2015 List of Covered Drugs (Formulary)

Transcription

1 SecureBlue SM (HMO SNP) 205 List of Covered Drugs (Formulary) This is a list of drugs that members can get in SecureBlue. SecureBlue is a health plan that contracts with both Medicare and the Minnesota Medical Assistance (Medicaid) program to provide benefits of both programs to enrollees. Enrollment in SecureBlue depends on contract renewal. Benefits, List of Covered Drugs, pharmacies and provider networks, and copays may change from time to time throughout the year and on January of each year. You can always check SecureBlue s up-to-date List of Covered Drugs online at Limitations, copays, and restrictions may apply. For more information, call SecureBlue Member Services or read the SecureBlue Member Handbook. The Member Handbook is the name now being used for the document that was called the Evidence of Coverage in the past. Copays for prescription drugs may vary based on the level of Extra Help you receive. Please contact the plan for more details. You can ask for this information in other formats, such as Braille or large print. Call The call is free. You can speak to someone about getting this information for free in other languages. Call The call is free. H2425_00_0954_T0 Last updated: 0/2/205 Formulary ID: Version 7 Blue Cross and Blue Shield of Minnesota and Blue Plus are nonprofit independent licensees of the Blue Cross and Blue Shield Association. X202R26 (/5)

2 SecureBlue member services, (65) or toll free a.m. to 8 p.m., seven days a week, TTY users call 7. SecureBlue (HMO SNP) is a health plan with a Medicare contract and a contract with the Minnesota Medicaid program offered by Blue Plus. Enrollment in SecureBlue depends on contract renewal. This information is available in other forms to people with disabilities by calling Blue Plus Member Services at (65) (voice), or (toll free), or 7 (TTY), or through the Minnesota Relay direct access numbers at (TTY, voice, ASCII, hearing carry over), or (speech to speech relay service). American Indians can continue or begin to use tribal and Indian Health Services (IHS) clinics. We will not require prior approval or impose any conditions for you to get services at these clinics. For enrollees age 65 years and older this includes Elderly Waiver (EW) services accessed through the tribe. If a doctor or other provider in a tribal or IHS clinic refers you to a provider in our network, we will not require you to see your health plan primary care provider prior to the referral.? If you have questions, please call SecureBlue at (65) , , TTY 7, seven days a week, 8 a.m. to 8 p.m. The call is free. For more information, visit

3 Frequently Asked Questions (FAQ) Find answers to questions you have about this List of Covered Drugs. You can read all of the FAQ to learn more, or look for a question and answer.. What prescription drugs are on the List of Covered Drugs? (We call the List of Covered Drugs the Drug List for short.) The drugs on the Drug List that starts on page are the drugs covered by SecureBlue. These drugs are available at pharmacies within our network. A pharmacy is in our network if we have an agreement with them to work with us and provide you services. We refer to these pharmacies as network pharmacies. SecureBlue will cover all medically necessary drugs on the Drug List if: your doctor or other prescriber says you need them to get better or stay healthy, and you fill the prescription at a SecureBlue network pharmacy. SecureBlue may have additional steps to access certain drugs (see question 5 below). You can also see an up-to-date list of drugs that we cover on our website at or call Member Services at (65) Does the Drug List ever change? Yes. SecureBlue may add or remove drugs on the Drug List during the year. Generally, the Drug List will only change if: a cheaper drug comes along that works as well as a drug on the Drug List now, or we learn that a drug is not safe. We may also change our rules about drugs. For example, we could: Decide to require or not require prior authorization for a drug. (Prior authorization is permission from SecureBlue before you can get a drug.) Add or change the amount of a drug you can get (called quantity limits) Add or change step therapy restrictions on a drug. (Step therapy means you must try one drug before we will cover another drug) (For more information on these drug rules, see page II.)? If you have questions, please call SecureBlue at (65) , , TTY 7, seven days a week, 8 a.m. to 8 p.m. The call is free. For more information, visit I

4 We will tell you when a drug you are taking is removed from the Drug List. We will also tell you when we change our rules for covering a drug. Questions 3, 4, and 7 below have more information on what happens when the Drug List changes. You can always check SecureBlue s current Drug List online at You can also call Member Services to check the current Drug List at What happens when a cheaper drug comes along that works as well as a drug on the Drug List now? If you are taking a drug that is removed from the Drug List because a cheaper drug that works just as well comes along, we will tell you. We will tell you at least 60 days before we remove it from the Drug List or when you ask for a refill. Then you can get a 60-day supply of the drug before the change to the Drug List is made. 4. What happens when we find out a drug is not safe? If the Food and Drug Administration (FDA) says a drug you are taking is not safe, we will take it off the Drug List right away. We will also send you a letter telling you that. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover. 5. Are there any restrictions or limits on drug coverage? Or are there any actions required to get certain drugs? Yes, some drugs have coverage rules or have limits on the amount you can get. In some cases you must do something before you can get the drug. For example: Prior authorization: For some drugs, you or your health care provider must get authorization from SecureBlue before you fill your prescription. If you don t get authorization, SecureBlue may not cover the drug. Quantity limits: Sometimes SecureBlue limits the amount of a drug you can get. Step therapy: Sometimes SecureBlue requires you to do step therapy. This means you will have to try drugs in a certain order for your medical condition. You might have to try one drug before we will cover another drug. If your health care provider thinks the first drug doesn t work for you, then we will cover the second.? If you have questions, please call SecureBlue at (65) , , TTY 7, seven days a week, 8 a.m. to 8 p.m. The call is free. For more information, visit II

5 You can find out if your drug has any additional requirements or limits by looking in the tables on page 50. You can also get more information by visiting our website at We have posted online documents that explains our prior authorization and step therapy restrictions. You may also ask us to send you a copy. You can ask for an exception to these limits. Please see questions 9-3 for more information on exceptions. If you are in a nursing home or other long-term care facility and need a drug that is not on the Drug List, or if you cannot easily get the drug you need, we can help. We will cover a 3-day emergency supply of the drug you need (unless you have a prescription for fewer days), whether or not you are a new SecureBlue member. This will give you time to talk to your doctor or other prescriber. He or she can help you decide if there is a similar drug on the Drug List you can take instead or whether to request an exception. Please see questions 9-3 for more information about exceptions. 6. How will you know if the drug you want has limitations or if there are any actions required to get the drug? The Drug List on page has a column labeled Necessary actions, restrictions, or limits on use. 7. What happens if we change our rules on how we cover some drugs? For example, if we add prior authorization, quantity limits, and/or step therapy restrictions on a drug. We will tell you if we add prior authorization, quantity limits, and/or step therapy restrictions on a drug. We will tell you at least 60 days before the restriction is added or when you next ask for a refill. Then, you can get a 60-day supply of the drug before the change to the Drug List is made. This gives you time to talk to your doctor or other provider about what to do next. 8. How can you find a drug on the Drug List? There are two ways to find a drug: You can search alphabetically (if you know how to spell the drug), or You can search by medical condition.? If you have questions, please call SecureBlue at (65) , , TTY 7, seven days a week, 8 a.m. to 8 p.m. The call is free. For more information, visit III

6 To search alphabetically, go to the Index. You can find it on page 63. The Index is an alphabetical list of all of the drugs included in the Drug List. Both brand name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. To search by medical condition, find the section labeled List of drugs by medical condition on page. Then find your medical condition. For example, if you have a heart condition, you should look in that category. That is where you will find drugs that treat heart conditions. 9. What if the drug you want to take is not on the Drug List? If you don t see your drug on the Drug List, call Member Services at and ask about it. If you learn that SecureBlue will not cover the drug, you can do one of these things: Ask Member Services for a list of drugs like the one you want to take. Then show the list to your doctor or other prescriber. He or she can prescribe a drug on the Drug List that is like the one you want to take. Or You can ask the health plan to make an exception to cover your drug. Please see questions 0-3 for more information about exceptions. 0. What if you are a new SecureBlue member and can t find your drug on the Drug List or have a problem getting your drug? We can help. We may cover a temporary 30-day supply of your drug during the first 90 days you are a member of SecureBlue. This will give you time to talk to your doctor or other prescriber. He or she can help you decide if there is a similar drug on the Drug List you can take instead or whether to request an exception. We will cover a 30-day supply of your drug if: you are taking a drug that is not on our Drug List, or health plan rules do not let you get the amount ordered by your prescriber, or the drug requires prior authorization by SecureBlue, or you are taking a drug that is part of a step therapy restriction. If you live in a nursing home or other long-term care facility, you may refill your prescription for as long as 9 and may be up to 98 days. You may refill the drug multiple times during the 9 and may be up to 98 days. This gives your prescriber time to change your drugs to ones on the Drug List or ask for an exception.? If you have questions, please call SecureBlue at (65) , , TTY 7, seven days a week, 8 a.m. to 8 p.m. The call is free. For more information, visit IV

7 Circumstances exist in which unplanned transitions for current members could arise and in which prescribed drug regimens may not be on the formulary. These circumstances usually involve level of care changes in which a member is changing from one treatment setting to another. For these unplanned transitions, you must use our exceptions and appeals process. Coverage determinations and redeterminations will be processed as expeditiously as your health condition requires. In order to prevent a temporary gap in care when a member is discharged to home, members are permitted to have a full outpatient supply available to continue therapy once their limited supply provided at discharge is exhausted. This outpatient supply is available in advance of discharge from a Part A stay. When a member is admitted to or discharged from a LTC facility, he or she does not have access to the remainder of the previously dispensed prescription. We will ensure you have a refill upon admission or discharge. A one-time override of the refill too soon edits, are provided, for each medication which would be impacted due to a member being admitted to or discharged from a LTC facility. Early refill edits are not used to limit appropriate and necessary access to a member s Part D benefit, and such members are allowed to access a refill upon admission or discharge.. Can you ask for an exception to cover your drug? Yes. You can ask SecureBlue to make an exception to cover a drug that is not on the Drug List. You can also ask us to change the rules on your drug. For example, SecureBlue may limit the amount of a drug we will cover. If your drug has a limit, you can ask us to change the limit and cover more. Other examples: You can ask us to drop step therapy restrictions or prior approval requirements. 2. How long does it take to get an exception? First, we must receive a statement from your prescriber supporting your request for an exception. After we receive the statement, we will give you a decision on your exception request within 72 hours. If you or your prescriber think your health may be harmed if you have to wait 72 hours for a decision, you can ask for an expedited exception. This is a faster decision. If your prescriber? If you have questions, please call SecureBlue at (65) , , TTY 7, seven days a week, 8 a.m. to 8 p.m. The call is free. For more information, visit V

8 supports your request, we will give you a decision within 24 hours of receiving your prescriber s supporting statement. 3. How can you ask for an exception? To ask for an exception, call your care coordinator. Your care coordinator will work with you and your provider to help you ask for an exception. 4. What are generic drugs? Generic drugs are made up of the same ingredients as brand name drugs. They usually cost less than the brand name drug and usually don t have well-known names. Generic drugs are approved by the Food and Drug Administration (FDA). SecureBlue covers both brand name drugs and generic drugs. 5. What are OTC drugs? OTC stands for over-the-counter. SecureBlue offers some OTC drugs at no cost to you and without a prescription. SecureBlue covers some additional OTC drugs through Medical Assistance (Medicaid). These OTC drugs are not included in this Drug List. For a complete list of OTC drugs, please go to or call Member Services at , seven days a week, 8 a.m. to 8 p.m. TTY users should call Does SecureBlue cover non-drug OTC products? SecureBlue covers some non-drug OTC products through Medical Assistance (Medicaid). Non-drug OTC products are not listed in this Drug List. For a complete list of non-drug OTC products, please go to or call Member Services at , seven days a week, 8 a.m. to 8 p.m. TTY users should call What is your copay? You can read the SecureBlue Drug List to learn about the copay for each drug.? If you have questions, please call SecureBlue at (65) , , TTY 7, seven days a week, 8 a.m. to 8 p.m. The call is free. For more information, visit VI

9 A copay is an amount you may be required to pay as your share of the cost of a prescription drug. A copay is usually a set amount, rather than a percentage. For example, you might pay $ or $6 for a prescription drug. SecureBlue members living in nursing homes or other long-term care facilities will have no copays. Some members getting long-term care in the community will also have no copays. The Drug List has copays listed by tiers. Tier Generic drugs have the lowest copay. They are generic drugs. The copay will be from $0 to $2.65, depending on your level of Medicaid eligibility. Tier Brand drugs have a higher copay. They are brand name drugs. The copay will be from $0 to $6.60, depending on your level of Medicaid eligibility. List of Covered Drugs The list of covered that begins on the next page gives you information about the drugs covered by SecureBlue. If you have trouble finding your drug in the list, turn to the Index that begins on page 63. The first column of the chart lists the name of the drug. Generic drugs are listed in lower-case italics (e.g., metformin), and brand name drugs are capitalized (e.g., LANTUS). The information in the Necessary actions, restrictions, or limits on use column tells you if SecureBlue has any rules for covering your drug. Note: The X next to a drug means the drug is not a Part D drug. The amount you pay when you fill a prescription for this drug does not count towards your total drug costs (that is, the amount you pay does not help you qualify for catastrophic coverage). In addition, if you are receiving extra help to pay for your prescriptions, you will not get any extra help to pay for these drugs.? If you have questions, please call SecureBlue at (65) , , TTY 7, seven days a week, 8 a.m. to 8 p.m. The call is free. For more information, visit VII

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11 205 Quantity Analgesics acetaminophen/codeine soln, 20-2 mg/5ml; tab, mg, mg, mg butorphanol tartrate inj, mg/ml, 2 mg/ml; nasal soln, 0 mg/ml codeine sulfate tab, 5 mg, 30 mg, 60 mg diclofenac potassium tab, 50 mg diclofenac sodium tab sr 24hr, 00 mg diclofenac sodium tab delayed release, 25 mg, 50 mg, 75 mg diclofenac/misoprostol tab delayed release, mg, mg etodolac cap, 200 mg, 300 mg; tab, 400 mg, 500 mg etodolac tab sr 24hr, 400 mg, 500 mg, 600 mg fentanyl citrate lozenge on a handle, 200 mcg, 400 mcg, 600 mcg, 800 mcg, 200 mcg, 600 mcg fentanyl td patch 72hr, 2 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/ hr, 00 mcg/hr flurbiprofen tab, 50 mg, 00 mg hydrocodone/acetaminophen soln, mg/5ml; tab, mg, mg, mg, mg, mg, mg Quantity hydrocodone/ibuprofen tab, mg, mg, mg, mg hydromorphone hcl liqd, mg/ml; tab, 2 mg, 4 mg, 8 mg hydromorphone hcl preservative X free (pf) inj, 0 mg/ml ibuprofen susp, 00 mg/5ml; tab, 400 mg, 600 mg, 800 mg ketoprofen cap, 50 mg, 75 mg LAZANDA - fentanyl citrate nasal spray 00 mcg/act, 400 mcg/act meloxicam tab, 7.5 mg, 5 mg methadone hcl tab, 5 mg, 0 mg MORPHINE SULFATE - morphine sulfate tab 5 mg, 30 mg morphine sulfate tab cr, 5 mg, 30 mg, 60 mg, 00 mg, 200 mg morphine sulfate inj pf, 0.5 mg/ml, X mg/ml morphine sulfate oral soln, 0 mg/5ml, 20 mg/5ml, 00 mg/5ml (20 mg/ml) nabumetone tab, 500 mg, 750 mg naproxen susp, 25 mg/5ml; tab ec, 375 mg, 500 mg; tab, 250 mg, 375 mg, 500 mg naproxen sodium tab, 275 mg, 550 mg oxaprozin tab, 600 mg oxycodone hcl tab, 5 mg, 0 mg, 5 mg, 20 mg, 30 mg You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. = Generic and Brand Drugs = Utilization Management (UM) * = Limited Distribution Drug X = Drugs that may be covered by Medicare Part B or Medicare Part D depending on the circumstance = Quantity limit restrictions for these drugs are listed beginning on page 50 # = High Risk Medication (HRM)

12 205 Quantity oxycodone/acetaminophen tab, mg, mg, mg, mg OXYCONTIN - oxycodone hcl tab er 2hr deter 0 mg, 5 mg, 20 mg, 30 mg, 40 mg, 60 mg, 80 mg piroxicam cap, 0 mg, 20 mg sulindac tab, 50 mg, 200 mg tolmetin sodium cap, 400 mg tramadol hcl tab, 50 mg tramadol/acetaminophen tab, mg VOLTAREN - diclofenac sodium gel % ZOHYDRO ER - hydrocodone bitartrate cap sr 2hr abusedeterrent 0 mg, 5 mg, 20 mg, 30 mg, 40 mg, 50 mg ZOHYDRO ER - hydrocodone bitartrate cap sr 2hr 0 mg, 5 mg, 20 mg, 30 mg, 40 mg, 50 mg Anesthetics lidocaine oint, 5% lidocaine patch, 5% lidocaine hcl gel, 2%; local inj, %; local preservative free (pf) inj, %; soln, 4%; viscous soln, 2% lidocaine/prilocaine cream, % Quantity Anti-Addiction/Substance Abuse Treatment Agents acamprosate calcium tab delayed release, 333 mg buprenorphine hcl/naloxone hcl sl tab, mg, 8-2 mg buprenorphine hcl sl tab, 2 mg, 8 mg bupropion hcl (smoking deterrent) tab sr 2hr, 50 mg CHANTIX - varenicline tartrate tab 0.5 mg, mg CHANTIX CONTINUING MONTH - varenicline tartrate tab mg CHANTIX STARTING MONTH PACK - varenicline tartrate tab 0.5 mg x & tab mg x 42 pack disulfiram tab, 250 mg, 500 mg naloxone hcl inj, 0.4 mg/ml, mg/ ml naltrexone hcl tab, 50 mg NICOTROL INHALER - nicotine inhaler system 0 mg (4 mg delivered) NICOTROL NS - nicotine nasal spray 0 mg/ml (0.5 mg/spray) Antibacterials amikacin sulfate inj, 500 mg/2ml (250 mg/ml), gm/4ml (250 mg/ ml) amoxicillin (trihydrate) cap, 250 mg, 500 mg; for susp, 25 mg/5ml, 200 mg/5ml, You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. = Generic and Brand Drugs = Utilization Management (UM) * = Limited Distribution Drug X = Drugs that may be covered by Medicare Part B or Medicare Part D depending on the circumstance = Quantity limit restrictions for these drugs are listed beginning on page 50 # = High Risk Medication (HRM) 2

13 mg/5 ml, 400 mg/5 ml; tab, 500 mg, 875 mg amoxicillin/k clavulanate chew tab, mg, mg; for susp, mg/5ml, mg/5ml, mg/5ml; tab, mg, mg, mg AMPICILLIN - ampicillin for susp 25 mg/5ml, 250 mg/5ml AMPICILLIN SODIUM - ampicillin sodium for iv soln gm, 2 gm ampicillin/sulbactam sodium for inj, 2- gm ampicillin cap, 250 mg, 500 mg; for inj, 250 mg, 500 mg, gm, 2 gm; for iv soln, 0 gm AZACTAM - aztreonam in dextrose inj gm/50 ml, 2 gm/50 ml azithromycin for susp, 00 mg/5ml, 200 mg/5ml; iv for soln, 500 mg; tab, 250 mg, 500 mg, 600 mg aztreonam for inj, gm, 2 gm BICILLIN L-A - penicillin g benzathine intramuscular susp unit/ml, unit/2ml, unit/4ml cefaclor cap, 250 mg, 500 mg cefadroxil cap, 500 mg; for susp, 250 mg/5ml, 500 mg/5ml; tab, gm Quantity cefazolin sodium for inj, 500 mg, gm, 0 gm, 20 gm cefdinir cap, 300 mg; for susp, 25 mg/5ml, 250 mg/5ml cefepime hcl for inj, gm, 2 gm cefotaxime sodium for inj, 500 mg, gm, 2 gm, 0 gm cefoxitin sodium for inj, 0 gm; for iv soln, gm, 2 gm cefpodoxime proxetil for susp, 50 mg/5ml, 00 mg/5ml; tab, 00 mg, 200 mg cefprozil for susp, 25 mg/5ml, 250 mg/5ml; tab, 250 mg, 500 mg ceftazidime for inj, gm, 2 gm, 6 gm; for iv soln, gm, 2 gm CEFTRIAXONE IN ISO- OSMOTIC - ceftriaxone sodium in dextrose inj 20 mg/ml, 40 mg/ ml ceftriaxone sodium for inj, 250 mg, 500 mg, gm, 2 gm, 0 gm; for iv soln, gm, 2 gm CEFTRIAXONE/DEXTROSE - ceftriaxone sodium for iv soln gm and dextrose 3.74%, 2 gm and dextrose 2.22% cefuroxime axetil tab, 250 mg, 500 mg cefuroxime sodium for inj, 750 mg,.5 gm, 7.5 gm; for iv soln,.5 gm Quantity You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. = Generic and Brand Drugs = Utilization Management (UM) * = Limited Distribution Drug X = Drugs that may be covered by Medicare Part B or Medicare Part D depending on the circumstance = Quantity limit restrictions for these drugs are listed beginning on page 50 # = High Risk Medication (HRM) 3

14 205 cephalexin cap, 250 mg, 500 mg, 750 mg; for susp, 25 mg/5ml, 250 mg/5ml CHLORAMPHENICOL SODIUM SUCCINATE - chloramphenicol sodium succinate for iv inj gm ciprofloxacin hcl tab, 00 mg, 250 mg, 500 mg, 750 mg ciprofloxacin in d5w, 200 mg/00ml, 400 mg/200ml; iv soln, 200 mg/20ml (%), 400 mg/40ml (%) CLAFORAN/D5W - cefotaxime sodium in d5w iv soln gm/50ml, 2 gm/50ml clarithromycin tab sr 24hr, 500 mg clarithromycin for susp, 25 mg/5ml, 250 mg/5ml; tab, 250 mg, 500 mg clindamycin hcl cap, 75 mg, 50 mg, 300 mg clindamycin phosphate inj, 300 mg/2ml, 600 mg/4ml, 900 mg/6ml, 9 gm/60ml; iv soln, 600 mg/4ml, 900 mg/6ml; vaginal cream, 2% colistimethate sodium for inj, 50 mg dicloxacillin sodium cap, 250 mg, 500 mg doxycycline hyclate cap, 50 mg, 00 mg; for inj, 00 mg; tab, 20 mg, 00 mg Quantity doxycycline monohydrate cap, 50 mg, 75 mg, 00 mg, 50 mg; tab, 50 mg, 75 mg, 00 mg, 50 mg ERYTHROCIN LACTOBIONATE - erythromycin lactobionate for inj 500 mg, 000 mg ERYTHROCIN STEARATE - erythromycin stearate tab 250 mg ERYTHROMYCIN BASE - erythromycin tab 250 mg, 500 mg FORTAZ - ceftazidime for inj 500 mg FORTAZ - ceftazidime sodium in d5w inj gm/50ml, 2 gm/50ml gentamicin sulfate inj, 0 mg/ml, 40 mg/ml; iv soln, 0 mg/ml imipenem/cilastatin intravenous for soln, 250 mg, 500 mg INVANZ - ertapenem sodium for inj gm; for iv inj, gm levofloxacin in d5w iv soln, 250 mg/50ml, 500 mg/00ml, 750 mg/50ml; iv soln, 25 mg/ ml; oral soln, 25 mg/ml; tab, 250 mg, 500 mg, 750 mg linezolid iv soln, 2 mg/ml linezolid tab, 600 mg MEFOXIN - cefoxitin sodium iv soln gm/50ml in dextrose 2 gm/50ml, 2 gm/50ml in dextrose. gm/50ml Quantity You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. = Generic and Brand Drugs = Utilization Management (UM) * = Limited Distribution Drug X = Drugs that may be covered by Medicare Part B or Medicare Part D depending on the circumstance = Quantity limit restrictions for these drugs are listed beginning on page 50 # = High Risk Medication (HRM) 4

15 205 meropenem iv for soln, 500 mg, mg methenamine hippurate tab, gm metronidazole cap, 375 mg; in nacl 0.79% iv soln, 500 mg/00ml; tab, 250 mg, 500 mg; vaginal gel, 0.75% minocycline hcl cap, 50 mg, 75 mg, 00 mg; tab, 50 mg, 75 mg, 00 mg moxifloxacin hcl tab, 400 mg NAFCILLIN SODIUM - nafcillin sodium for iv soln gm, 2 gm nafcillin sodium for inj, gm, 2 gm, 0 gm neomycin sulfate tab, 500 mg Quantity neomycin/polymyxin b gu irrigation soln nitrofurantoin monohydrate macrocrystalline cap, 00 mg# paromomycin sulfate cap, 250 mg PENICILLIN G POTASSIUM IN DEXTROSE - penicillin g potassium inj unit/ml in dextrose, unit/ml in dextrose, unit/ml in dextrose penicillin g potassium for inj, unit, unit PENICILLIN G SODIUM - penicillin g sodium for inj unit penicillin v potassium for soln, 25 mg/5ml, 250 mg/5ml; tab, 250 mg, 500 mg piperacillin sodium/tazobactam sodium for inj, gm, gm, gm SIVEXTRO - tedizolid phosphate for iv soln 200 mg SIVEXTRO - tedizolid phosphate tab 200 mg STREPTOMYCIN SULFATE - streptomycin sulfate for inj gm SULFADIAZINE - sulfadiazine tab 500 mg SULFAMETHOXAZOLE/ TRIMETHOPRIM - sulfamethoxazole-trimethoprim iv soln mg/5ml sulfamethoxazole/trimethoprim susp, mg/5ml; tab, mg, mg SUPRAX - cefixime cap 400 mg; chew tab, 00 mg, 200 mg SYNERCID - quinupristindalfopristin for inj 500 mg ( mg) TEFLARO - ceftaroline fosamil for iv soln 400 mg, 600 mg TETRACYCLINE HCL - tetracycline hcl cap 250 mg, 500 mg tobramycin sulfate for inj,.2 gm; inj, 0 mg/ml, 80 mg/2ml (40 mg/ml),.2 gm/30ml Quantity You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. = Generic and Brand Drugs = Utilization Management (UM) * = Limited Distribution Drug X = Drugs that may be covered by Medicare Part B or Medicare Part D depending on the circumstance = Quantity limit restrictions for these drugs are listed beginning on page 50 # = High Risk Medication (HRM) 5

16 205 (40 mg/ml), 2 gm/50ml (40 mg/ ml) trimethoprim tab, 00 mg TYGACIL - tigecycline for iv soln 50 mg VANCOMYCIN HCL IN DEXTROSE - vancomycin hcl in dextrose inj 500 mg/00ml, 750 mg/50ml, gm/200ml vancomycin hcl cap, 25 mg, 250 mg; for inj, 500 mg, 000 mg, 5000 mg, 0 gm XIFAXAN - rifaximin tab 550 mg ZINACEF - cefuroxime in sterile water inj.5 gm/50ml ZOSYN - piperacillin sodtazobactam sod in dex iv soln gm/50ml, gm/50ml, 4-0.5gm/00ml ZYVOX - linezolid for susp 00 mg/5ml; tab, 600 mg ZYVOX - linezolid iv soln 2 mg/ml Anticonvulsants APTIOM - eslicarbazepine acetate tab 200 mg, 400 mg, 600 mg, 800 mg BANZEL - rufinamide susp 40 mg/ml; tab, 200 mg, 400 mg carbamazepine chew tab, 00 mg; susp, 00 mg/5ml; tab, 200 mg Quantity Quantity carbamazepine cap sr 2hr, 00 mg, 200 mg, 300 mg; tab sr 2hr, 200 mg, 400 mg CELONTIN - methsuximide cap 300 mg clonazepam orally disintegrating tab, 0.25 mg, 0.25 mg, 0.5 mg, mg, 2 mg; tab, 0.5 mg, mg, 2 mg clorazepate dipotassium tab, 3.75 mg, 7.5 mg, 5 mg DIAZEPAM - diazepam rectal gel delivery system 2.5 mg, 0 mg, 20 mg DIAZEPAM - diazepam soln mg/ml diazepam conc, 5 mg/ml; tab, 2 mg, 5 mg, 0 mg DILANTIN - phenytoin sodium extended cap 30 mg divalproex sodium cap sprinkle, 25 mg divalproex sodium tab delayed release, 25 mg, 250 mg, 500 mg divalproex sodium tab sr 24 hr, 250 mg, 500 mg ethosuximide cap, 250 mg; soln, 250 mg/5ml felbamate susp, 600 mg/5ml; tab, 400 mg, 600 mg fosphenytoin sodium inj, 00 mg/2ml, 500 mg/0ml You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. = Generic and Brand Drugs = Utilization Management (UM) * = Limited Distribution Drug X = Drugs that may be covered by Medicare Part B or Medicare Part D depending on the circumstance = Quantity limit restrictions for these drugs are listed beginning on page 50 # = High Risk Medication (HRM) 6

17 205 FYCOMPA - perampanel tab 2 mg, 4 mg, 6 mg, 8 mg, 0 mg, 2 mg gabapentin cap, 00 mg, 300 mg, 400 mg; oral soln, 250 mg/5ml; tab, 600 mg, 800 mg LAMICTAL ODT - lamotrigine orally disintegrating tab 25 mg, 50 mg, 00 mg, 200 mg lamotrigine orally disintegrating tab, 25 mg, 50 mg, 00 mg, 200 mg; tab chewable dispersible, 5 mg, 25 mg; tab, 25 mg, 00 mg, 50 mg, 200 mg LEVETIRACETAM - levetiracetam in sodium chloride iv soln 500 mg/00ml, 000 mg/00ml, 500 mg/00ml levetiracetam inj, 500 mg/5ml (00 mg/ml); oral soln, 00 mg/ ml; tab, 250 mg, 500 mg, 750 mg, 000 mg LYRICA - pregabalin cap 25 mg, 50 mg, 75 mg, 00 mg, 50 mg, 200 mg, 225 mg, 300 mg; soln, 20 mg/ml ONFI - clobazam suspension 2.5 mg/ml; tab, 5 mg, 0 mg, 20 mg oxcarbazepine susp, 300 mg/5ml (60 mg/ml); tab, 50 mg, 300 mg, 600 mg PEGANONE - ethotoin tab 250 mg Quantity phenobarbital elixir, 20 mg/5ml; tab, 6.2 mg, 32.4 mg, 64.8 mg, 97.2 mg# PHENOBARBITAL - phenobarbital tab 5 mg, 30 mg, 60 mg, 00 mg# phenobarbital sodium inj, 30 mg/ ml# PHENOBARBITAL SODIUM - phenobarbital sodium inj 65 mg/ ml# phenytoin chew tab, 50 mg; susp, 25 mg/5ml phenytoin sodium extended cap, 00 mg, 200 mg, 300 mg POTIGA - ezogabine tab 50 mg, 200 mg, 300 mg, 400 mg primidone tab, 50 mg, 250 mg SABRIL - vigabatrin powd pack 500 mg; tab, 500 mg TEGRETOL-XR - carbamazepine tab sr 2hr 00 mg tiagabine hcl tab, 2 mg, 4 mg topiramate sprinkle cap, 5 mg, 25 mg; tab, 25 mg, 50 mg, 00 mg, 200 mg valproate sodium inj, 00 mg/ml; syrup, 250 mg/5ml valproic acid cap, 250 mg VIMPAT - lacosamide iv inj 200 mg/20ml (0 mg/ml); oral solution, 0 mg/ml; tab, 50 mg, 00 mg, 50 mg, 200 mg Quantity You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. = Generic and Brand Drugs = Utilization Management (UM) * = Limited Distribution Drug X = Drugs that may be covered by Medicare Part B or Medicare Part D depending on the circumstance = Quantity limit restrictions for these drugs are listed beginning on page 50 # = High Risk Medication (HRM) 7

18 205 zonisamide cap, 25 mg, 50 mg, 00 mg Antidementia Agents donepezil hydrochloride orally disintegrating tab, 5 mg, 0 mg; tab, 5 mg, 0 mg ergoloid mesylates tab, mg# EXELON - rivastigmine td patch 24 hr 4.6 mg/24hr, 9.5 mg/24hr, 3.3 mg/24hr galantamine hydrobromide oral soln, 4 mg/ml; tab, 4 mg, 8 mg, 2 mg galantamine hydrobromide cap sr 24hr, 8 mg, 6 mg, 24 mg memantine hcl oral solution, 2 mg/ml; tab, 5 mg, 0 mg memantine hcl tab (titration pak), 5 mg (28) & 0 mg (2) NAMENDA - memantine hcl oral solution 2 mg/ml NAMENDA XR - memantine hcl cap sr 24hr 7 mg, 4 mg, 2 mg, 28 mg NAMENDA XR TITRATION PACK - memantine hcl cap sr 24hr 7 mg & 4 mg & 2 mg & 28 mg pack rivastigmine tartrate cap,.5 mg, 3 mg, 4.5 mg, 6 mg rivastigmine td patch 24hr, 4.6 mg/24hr, 9.5 mg/24hr, 3.3 mg/24hr Quantity Quantity Antidepressants ABILIFY - aripiprazole tab 2 mg, 5 mg, 0 mg, 5 mg, 20 mg, 30 mg ABILIFY MAINTENA - aripiprazole im for extended release susp 300 mg, 400 mg amitriptyline hcl tab, 0 mg, 25 mg, 50 mg, 75 mg, 00 mg, 50 mg# AMOXAPINE - amoxapine tab 25 mg, 50 mg, 00 mg, 50 mg ARIPIPRAZOLE ODT - aripiprazole orally disintegrating tab 0 mg, 5 mg aripiprazole oral solution, mg/ ml; tab, 2 mg, 5 mg, 0 mg, 5 mg, 20 mg, 30 mg BRINTELLIX - vortioxetine hbr tab 5 mg, 0 mg, 20 mg bupropion hcl tab, 75 mg, 00 mg bupropion hcl tab sr 2hr, 00 mg, 50 mg, 200 mg; tab sr 24hr, 50 mg, 300 mg citalopram hydrobromide oral soln, 0 mg/5ml; tab, 0 mg, 20 mg, 40 mg clomipramine hcl cap, 25 mg, 50 mg, 75 mg# desipramine hcl tab, 0 mg, 25 mg, 50 mg, 75 mg, 00 mg, 50 mg DOXEPIN HCL - doxepin hcl cap 75 mg# You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. = Generic and Brand Drugs = Utilization Management (UM) * = Limited Distribution Drug X = Drugs that may be covered by Medicare Part B or Medicare Part D depending on the circumstance = Quantity limit restrictions for these drugs are listed beginning on page 50 # = High Risk Medication (HRM) 8

19 205 doxepin hcl cap, 0 mg, 25 mg, 50 mg, 00 mg, 50 mg; conc, 0 mg/ml# duloxetine hcl enteric coated pellets cap, 20 mg, 30 mg, 60 mg EMSAM - selegiline td patch 24hr 6 mg/24hr, 9 mg/24hr, 2 mg/24hr escitalopram oxalate soln, 5 mg/5ml; tab, 5 mg, 0 mg, 20 mg FETZIMA - levomilnacipran hcl cap sr 24hr 20 mg, 40 mg, 80 mg, 20 mg FETZIMA TITRATION PACK - levomilnacipran hcl cap sr 24hr 20 & 40 mg therapy pack fluoxetine hcl cap delayed release, 90 mg fluoxetine hcl cap, 0 mg, 20 mg, 40 mg; solution, 20 mg/5ml; tab, 0 mg, 20 mg fluvoxamine maleate tab, 25 mg, 50 mg, 00 mg imipramine hcl tab, 0 mg, 25 mg, 50 mg# MAPROTILINE HCL - maprotiline hcl tab 25 mg, 50 mg, 75 mg MARPLAN - isocarboxazid tab 0 mg mirtazapine orally disintegrating tab, 5 mg, 30 mg, 45 mg; tab, 7.5 mg, 5 mg, 30 mg, 45 mg Quantity Quantity NEFAZODONE HCL - nefazodone hcl tab 00 mg, 50 mg, 200 mg nefazodone hcl tab, 50 mg, 250 mg NORTRIPTYLINE HCL - nortriptyline hcl soln 0 mg/5ml nortriptyline hcl cap, 0 mg, 25 mg, 50 mg, 75 mg paroxetine hcl tab, 0 mg, 20 mg, 30 mg, 40 mg paroxetine hcl tab sr 24hr, 2.5 mg, 25 mg, 37.5 mg PAXIL - paroxetine hcl oral susp 0 mg/5ml phenelzine sulfate tab, 5 mg PRISTIQ - desvenlafaxine succinate tab sr 24hr 25 mg, 50 mg, 00 mg protriptyline hcl tab, 5 mg, 0 mg quetiapine fumarate tab, 25 mg, 50 mg, 00 mg, 200 mg, 300 mg, 400 mg REXULTI - brexpiprazole tab 0.25 mg, 0.5 mg, mg, 2 mg, 3 mg, 4 mg SEROQUEL XR - quetiapine fumarate tab sr 24hr 50 mg, 50 mg, 200 mg, 300 mg, 400 mg sertraline hcl oral conc, 20 mg/ml; tab, 25 mg, 50 mg, 00 mg You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. = Generic and Brand Drugs = Utilization Management (UM) * = Limited Distribution Drug X = Drugs that may be covered by Medicare Part B or Medicare Part D depending on the circumstance = Quantity limit restrictions for these drugs are listed beginning on page 50 # = High Risk Medication (HRM) 9

20 205 SURMONTIL - trimipramine maleate cap 25 mg, 50 mg, 00 mg# tranylcypromine sulfate tab, 0 mg trazodone hcl tab, 50 mg, 00 mg, 50 mg, 300 mg trimipramine maleate cap, 25 mg, 50 mg, 00 mg# venlafaxine hcl tab, 25 mg, 37.5 mg, 50 mg, 75 mg, 00 mg venlafaxine hcl cap sr 24hr, 37.5 mg, 75 mg, 50 mg; tab sr 24hr, 37.5 mg, 75 mg, 50 mg VIIBRYD - vilazodone hcl tab starter kit 0 (7) & 20 (7) & 40 (6) mg; tab, 0 mg, 20 mg, 40 mg VIIBRYD STARTER PACK - vilazodone hcl tab starter kit 0 (7) & 20 (23) mg Antiemetics ALOXI - palonosetron hcl iv soln 0.25 mg/5ml CHLORPROMAZINE HCL - chlorpromazine hcl inj 25 mg/ ml, 50 mg/2ml chlorpromazine hcl tab, 0 mg, 25 mg, 50 mg, 00 mg, 200 mg diphenhydramine hcl inj, 50 mg/ ml dronabinol cap, 2.5 mg, 5 mg, 0 mg Quantity X EMEND - aprepitant capsule X therapy pack 80 & 25 mg; cap, 40 mg, 80 mg, 25 mg EMEND - fosaprepitant dimeglumine for iv infusion 50 mg granisetron hcl tab, mg X meclizine hcl tab, 2.5 mg, 25 mg metoclopramide hcl soln, 5 mg/5ml (0 mg/0ml); tab, 5 mg, 0 mg ondansetron hcl inj, 4 mg/2ml (2 mg/ml), 40 mg/20ml (2 mg/ ml) ondansetron orally disintegrating tab, 4 mg, 8 mg; oral soln, 4 mg/5 ml; tab, 4 mg, 8 mg, 24 mg X perphenazine tab, 2 mg, 4 mg, 8 mg, 6 mg prochlorperazine suppos, 25 mg prochlorperazine edisylate inj, 5 mg/ml prochlorperazine maleate tab, 5 mg, 0 mg Antifungals AMBISOME - amphotericin b X liposome iv for susp 50 mg AMPHOTERICIN B - X amphotericin b for inj 50 mg CANCIDAS - caspofungin acetate for iv soln 50 mg, 70 mg clotrimazole troche, 0 mg Quantity You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. = Generic and Brand Drugs = Utilization Management (UM) * = Limited Distribution Drug X = Drugs that may be covered by Medicare Part B or Medicare Part D depending on the circumstance = Quantity limit restrictions for these drugs are listed beginning on page 50 # = High Risk Medication (HRM) 0

21 205 CRESEMBA - isavuconazonium sulfate cap 86 mg; for iv soln, 372 mg fluconazole in dextrose inj, 200 mg/00ml, 400 mg/200ml FLUCONAZOLE IN NACL - fluconazole in nacl 0.9% inj 00 mg/50ml fluconazole in nacl 0.9% inj, 200 mg/00ml, 400 mg/200ml fluconazole tab, 50 mg, 00 mg, 50 mg, 200 mg flucytosine cap, 250 mg, 500 mg griseofulvin microsize susp, 25 mg/5ml griseofulvin ultramicrosize tab, 25 mg, 250 mg itraconazole cap, 00 mg ketoconazole tab, 200 mg MYCAMINE - micafungin sodium for iv soln 50 mg, 00 mg NOXAFIL - posaconazole iv soln 300 mg/6.7ml (8 mg/ml); susp 40 mg/ml nystatin susp, unit/ml; tab, unit terbinafine hcl tab, 250 mg terconazole vaginal cream, 0.4%, 0.8%; vaginal suppos, 80 mg voriconazole for inj, 200 mg; for susp, 40 mg/ml; tab, 50 mg, 200 mg Quantity Antigout Agents allopurinol tab, 00 mg, 300 mg ALOPRIM - allopurinol sodium for inj 500 mg colchicine/probenecid tab, mg COLCRYS - colchicine tab 0.6 mg probenecid tab, 500 mg ULORIC - febuxostat tab 40 mg Anti-Inflammatory Agents diclofenac potassium tab, 50 mg diclofenac sodium tab sr 24hr, 00 mg diclofenac sodium tab delayed release, 25 mg, 50 mg, 75 mg diclofenac/misoprostol tab delayed release, mg, mg etodolac cap, 200 mg, 300 mg; tab, 400 mg, 500 mg etodolac tab sr 24hr, 400 mg, 500 mg, 600 mg flurbiprofen tab, 50 mg, 00 mg ibuprofen susp, 00 mg/5ml; tab, 400 mg, 600 mg, 800 mg ketoprofen cap, 50 mg, 75 mg meloxicam tab, 7.5 mg, 5 mg nabumetone tab, 500 mg, 750 mg naproxen susp, 25 mg/5ml; tab ec, 375 mg, 500 mg; tab, 250 mg, 375 mg, 500 mg naproxen sodium tab, 275 mg, 550 mg Quantity You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. = Generic and Brand Drugs = Utilization Management (UM) * = Limited Distribution Drug X = Drugs that may be covered by Medicare Part B or Medicare Part D depending on the circumstance = Quantity limit restrictions for these drugs are listed beginning on page 50 # = High Risk Medication (HRM)

22 205 oxaprozin tab, 600 mg piroxicam cap, 0 mg, 20 mg sulindac tab, 50 mg, 200 mg Quantity tolmetin sodium cap, 400 mg VOLTAREN - diclofenac sodium gel % Antimigraine Agents divalproex sodium cap sprinkle, 25 mg divalproex sodium tab delayed release, 25 mg, 250 mg, 500 mg divalproex sodium tab sr 24 hr, 250 mg, 500 mg MIGERGOT - ergotamine w/ caffeine suppos 2-00 mg MIGRANAL - dihydroergotamine mesylate nasal spray 4 mg/ml naratriptan hcl tab, mg, 2.5 mg propranolol hcl inj, mg/ml; tab, 0 mg, 20 mg, 40 mg, 60 mg, 80 mg propranolol hcl cap sr 24hr, 60 mg, 80 mg, 20 mg, 60 mg rizatriptan benzoate orally disintegrating tab, 5 mg, 0 mg; tab, 5 mg, 0 mg SUMATRIPTAN - sumatriptan nasal spray 5 mg/act, 20 mg/act sumatriptan succinate inj, 6 mg/0.5ml; solution autoinjection, 4 mg/0.5ml, 6mg/ Quantity ml0.5ml; solution cartridge, 4 mg/0.5ml, 6 mg/0.5ml SUMATRIPTAN SUCCINATE - sumatriptan succinate solution prefilled syringe 6 mg/0.5ml sumatriptan succinate tab, 25 mg, 50 mg, 00 mg topiramate sprinkle cap, 5 mg, 25 mg; tab, 25 mg, 50 mg, 00 mg, 200 mg Antimyasthenic Agents GUANIDINE HCL - guanidine hcl tab 25 mg MESTINON - pyridostigmine bromide syrup 60 mg/5ml pyridostigmine bromide tab, 60 mg Antimycobacterials CAPASTAT SULFATE - capreomycin sulfate for inj gm CYCLOSERINE - cycloserine cap 250 mg DAPSONE - dapsone tab 25 mg, 00 mg ethambutol hcl tab, 00 mg, 400 mg ISONIAZID - isoniazid inj 00 mg/ ml isoniazid tab, 00 mg, 300 mg PASER - aminosalicylic acid cr granules packet 4 gm PRIFTIN - rifapentine tab 50 mg pyrazinamide tab, 500 mg You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. = Generic and Brand Drugs = Utilization Management (UM) * = Limited Distribution Drug X = Drugs that may be covered by Medicare Part B or Medicare Part D depending on the circumstance = Quantity limit restrictions for these drugs are listed beginning on page 50 # = High Risk Medication (HRM) 2

23 205 rifabutin cap, 50 mg rifampin cap, 50 mg, 300 mg; for inj, 600 mg SEROMYCIN - cycloserine cap 250 mg TRECATOR - ethionamide tab 250 mg Antineoplastics ABRAXANE - paclitaxel proteinbound particles for iv susp 00 mg AFINITOR - everolimus tab 2.5 mg, 5 mg, 7.5 mg, 0 mg AFINITOR DISPERZ - everolimus tab for oral susp 2 mg, 3 mg, 5 mg ALIMTA - pemetrexed disodium for iv soln 00 mg, 500 mg amifostine crystalline for inj, 500 mg anastrozole tab, mg ARRANON - nelarabine iv soln 5 mg/ml ARZERRA - ofatumumab conc for iv infusion 00 mg/5ml, 000 mg/50ml* AVASTIN - bevacizumab iv soln 00 mg/4ml (for infusion), 400 mg/6ml (for infusion)* azacitidine for inj, 00 mg Quantity BELEODAQ - belinostat for iv inj 500 mg bexarotene cap, 75 mg bicalutamide tab, 50 mg BICNU - carmustine for inj 00 mg bleomycin sulfate for inj, 5 unit, X 30 unit BLINCYTO - blinatumomab for iv infusion 35 mcg BOSULIF - bosutinib tab 00 mg, 500 mg BUSULFEX - busulfan inj 6 mg/ml CAPRELSA - vandetanib tab 00 mg, 300 mg* carboplatin iv soln, 50 mg/5ml, 50 mg/5ml, 450 mg/45ml, 600 mg/60ml CISPLATIN - cisplatin inj 200 mg/200ml ( mg/ml) cisplatin inj, 50 mg/50ml ( mg/ ml), 00 mg/00ml ( mg/ml) cladribine inj, mg/ml X CLOLAR - clofarabine iv soln mg/ml COMETRIQ - cabozantinib s- malate cap 3 x 20 mg (60 mg dose) kit, x80 mg & x 20 mg (00 dose) kit, x 80 mg & 3 x 20 mg (40 dose) kit* COSMEGEN - dactinomycin for inj 0.5 mg CYCLOPHOSPHAMIDE - cyclophosphamide cap 25 mg, 50 mg cyclophosphamide for inj, 500 mg, gm, 2 gm Quantity X You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. = Generic and Brand Drugs = Utilization Management (UM) * = Limited Distribution Drug X = Drugs that may be covered by Medicare Part B or Medicare Part D depending on the circumstance = Quantity limit restrictions for these drugs are listed beginning on page 50 # = High Risk Medication (HRM) 3

24 205 CYRAMZA - ramucirumab iv soln 00 mg/0ml (for infusion), 500 mg/50ml (for infusion) cytarabine inj pf, 20 mg/ml, X 00 mg/ml; inj, 20 mg/ml dacarbazine for inj, 200 mg DACARBAZINE - dacarbazine for inj 00 mg daunorubicin hcl for inj, 20 mg; inj, 5 mg/ml DAUNOXOME - daunorubicin citrate liposome inj 2 mg/ml decitabine for inj, 50 mg dexrazoxane for inj, 250 mg, 500 mg DOCEFREZ - docetaxel for inj 20 mg, 80 mg DOCETAXEL - docetaxel for inj conc 20 mg/ml, 80 mg/4ml (20 mg/ml), 40 mg/7ml (20 mg/ml); soln for iv infusion, 20 mg/2ml, 80 mg/8ml, 60 mg/6ml, 200 mg/20 ml docetaxel for inj conc, 20 mg/ml, 80 mg/4ml (20 mg/ml) doxorubicin hcl for inj, 0 mg, 50 mg; inj, 2 mg/ml; liposomal inj (for iv infusion), 2 mg/ml ELITEK - rasburicase for iv soln.5 mg, 7.5 mg EMCYT - estramustine phosphate sodium cap 40 mg X Quantity epirubicin hcl iv soln, 50 mg/25ml (2 mg/ml), 200 mg/00ml (2 mg/ ml) ERBITUX - cetuximab iv soln 00 mg/50ml (2 mg/ml), 200 mg/00ml (2 mg/ml) ERIVEDGE - vismodegib cap 50 mg* ERWINAZE - asparaginase erwinia chrysanthemi for inj 0000 unit ETOPOPHOS - etoposide phosphate iv for inj 00 mg etoposide inj, 00 mg/5ml (20 mg/ ml), 500 mg/25ml (20 mg/ml), gm/50ml (20 mg/ml) exemestane tab, 25 mg FARESTON - toremifene citrate tab 60 mg FARYDAK - panobinostat lactate cap 0 mg, 5 mg, 20 mg FASLODEX - fulvestrant inj 250 mg/5ml fludarabine phosphate for inj, 50 mg; inj, 25 mg/ml FLUDARABINE PHOSPHATE - fludarabine phosphate inj 25 mg/ml fluorouracil inj, 500 mg/0ml X (50 mg/ml), gm/20ml (50 mg/ ml), 2.5 gm/50ml (50 mg/ml), 5 gm/00ml (50 mg/ml) flutamide cap, 25 mg Quantity You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. = Generic and Brand Drugs = Utilization Management (UM) * = Limited Distribution Drug X = Drugs that may be covered by Medicare Part B or Medicare Part D depending on the circumstance = Quantity limit restrictions for these drugs are listed beginning on page 50 # = High Risk Medication (HRM) 4

25 205 FOLOTYN - pralatrexate iv inj 20 mg/ml, 40 mg/2ml GAZYVA - obinutuzumab soln for iv infusion 000 mg/40ml (25 mg/ml) gemcitabine hcl for inj, 200 mg, gm, 2 gm GILOTRIF - afatinib dimaleate tab 20 mg, 30 mg, 40 mg GLEEVEC - imatinib mesylate tab 00 mg, 400 mg GLEOSTINE - lomustine cap 0 mg, 40 mg, 00 mg HALAVEN - eribulin mesylate inj mg/2ml (0.5 mg/ml) HERCEPTIN - trastuzumab for iv soln 440 mg HEXALEN - altretamine cap 50 mg hydroxyurea cap, 500 mg IBRANCE - palbociclib cap 75 mg, 00 mg, 25 mg ICLUSIG - ponatinib hcl tab 5 mg, 45 mg idarubicin hcl iv inj, 5 mg/5ml ( mg/ml), 0 mg/0ml ( mg/ ml), 20 mg/20ml ( mg/ml) ifosfamide for inj, gm IFOSFAMIDE - ifosfamide for inj 3 gm IMBRUVICA - ibrutinib cap 40 mg Quantity INLYTA - axitinib tab mg, 5 mg* IRESSA - gefitinib tab 250 mg IRINOTECAN - irinotecan hcl inj 500 mg/25ml (20 mg/ml) irinotecan hcl inj, 40 mg/2ml (20 mg/ml), 00 mg/5ml (20 mg/ ml) ISTODAX - romidepsin for iv inj 0 mg IXEMPRA KIT - ixabepilone for iv infusion 5 mg, 45 mg JAKAFI - ruxolitinib phosphate tab 5 mg, 0 mg, 5 mg, 20 mg, 25 mg* JEVTANA - cabazitaxel inj 60 mg/.5ml (for iv infusion) KADCYLA - ado-trastuzumab emtansine for iv soln 00 mg, 60 mg KEYTRUDA - pembrolizumab for iv soln 50 mg; iv soln, 00 mg/4ml (25 mg/ml) LENVIMA 0MG DAILY DOSE - lenvatinib cap therapy pack 0 mg LENVIMA 4MG DAILY DOSE - lenvatinib cap therapy pack 0 & 4 mg LENVIMA 20MG DAILY DOSE - lenvatinib cap therapy pack 0 (2) mg LENVIMA 24MG DAILY DOSE - lenvatinib cap therapy pack 0 (2) & 4 mg letrozole tab, 2.5 mg Quantity You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. = Generic and Brand Drugs = Utilization Management (UM) * = Limited Distribution Drug X = Drugs that may be covered by Medicare Part B or Medicare Part D depending on the circumstance = Quantity limit restrictions for these drugs are listed beginning on page 50 # = High Risk Medication (HRM) 5

26 205 LEUCOVORIN CALCIUM - leucovorin calcium for inj 500 mg; tab, 0 mg, 5 mg leucovorin calcium for inj, 50 mg, 00 mg, 200 mg, 350 mg; tab, 5 mg, 25 mg LEUKERAN - chlorambucil tab 2 mg LOMUSTINE - lomustine cap 0 mg, 40 mg, 00 mg LONSURF - trifluridine-tipiracil tab mg, mg Quantity LYNPARZA - olaparib cap 50 mg MATULANE - procarbazine hcl cap 50 mg* MEKINIST - trametinib dimethyl sulfoxide tab 0.5 mg, 2 mg melphalan hcl for inj, 50 mg mercaptopurine tab, 50 mg mesna inj, 00 mg/ml MESNEX - mesna tab 400 mg methotrexate sodium for inj, gm; inj pf, 25 mg/ml; inj, 25 mg/ml methotrexate sodium tab, 2.5 mg X mitomycin for iv soln, 5 mg, 20 mg, 40 mg mitoxantrone hcl inj conc, 20 mg/0ml (2 mg/ml), 25 mg/2.5ml (2 mg/ml), 30 mg/5ml (2 mg/ml) MUSTARGEN - mechlorethamine hcl for inj 0 mg NEXAVAR - sorafenib tosylate tab 200 mg* NILANDRON - nilutamide tab 50 mg NIPENT - pentostatin for inj 0 mg ODOMZO - sonidegib phosphate cap 200 mg ONCASPAR - pegaspargase inj 750 unit/ml OPDIVO - nivolumab iv soln 40 mg/4ml, 00 mg/0ml oxaliplatin for iv inj, 50 mg, 00 mg; iv soln, 50 mg/0ml, 00 mg/20ml paclitaxel iv conc, 30 mg/5ml (6 mg/ml), 00 mg/6.7ml (6 mg/ml), 300 mg/50ml (6 mg/ ml) PANRETIN - alitretinoin gel 0.% PERJETA - pertuzumab soln for iv infusion 420 mg/4ml (30 mg/ ml)* POMALYST - pomalidomide cap mg, 2 mg, 3 mg, 4 mg* PROLEUKIN - aldesleukin for iv soln unit PURIXAN - mercaptopurine susp 2000 mg/00ml (20 mg/ml) REVLIMID - lenalidomide cap 2.5 mg, 5 mg, 0 mg, 5 mg, 20 mg, 25 mg* RITUXAN - rituximab iv soln 00 mg/0ml, 500 mg/50ml* Quantity You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. = Generic and Brand Drugs = Utilization Management (UM) * = Limited Distribution Drug X = Drugs that may be covered by Medicare Part B or Medicare Part D depending on the circumstance = Quantity limit restrictions for these drugs are listed beginning on page 50 # = High Risk Medication (HRM) 6

27 205 SOLTAMOX - tamoxifen citrate oral soln 0 mg/5ml SPRYCEL - dasatinib tab 20 mg, 50 mg, 70 mg, 80 mg, 00 mg, 40 mg STIVARGA - regorafenib tab 40 mg* SUTENT - sunitinib malate cap 2.5 mg, 25 mg, 37.5 mg, 50 mg SYLATRON - peginterferon alfa-2b for inj kit 200 mcg, 300 mcg, 600 mcg, 4 x 200 mcg, 4 x 300 mcg, 4 x 600 mcg SYLVANT - siltuximab for iv infusion 00 mg, 400 mg SYNRIBO - omacetaxine mepesuccinate for inj 3.5 mg TABLOID - thioguanine tab 40 mg Quantity TAFINLAR - dabrafenib mesylate cap 50 mg, 75 mg tamoxifen citrate tab, 0 mg, 20 mg TARCEVA - erlotinib hcl tab 25 mg, 00 mg, 50 mg TARGRETIN - bexarotene cap 75 mg TARGRETIN - bexarotene gel % TASIGNA - nilotinib hcl cap 50 mg, 200 mg TAXOTERE - docetaxel for inj conc 20 mg/ml, 80 mg/4ml (20 mg/ml) TEMODAR - temozolomide for iv soln 00 mg THALOMID - thalidomide cap 50 mg, 00 mg, 50 mg, 200 mg THIOTEPA - thiotepa for inj 5 mg topotecan hcl for inj, 4 mg Quantity TORISEL - temsirolimus soln for iv infusion 25 mg/ml TREANDA - bendamustine hcl for iv soln 25 mg, 00 mg; iv soln, 45 mg/0.5ml (90 mg/ml), 80 mg/2ml (90 mg/ml) tretinoin cap, 0 mg TRISENOX - arsenic trioxide inj 0 mg/0ml ( mg/ml) TYKERB - lapatinib ditosylate tab 250 mg* UNITUXIN - dinutuximab iv soln 7.5 mg/5ml (3.5 mg/ml) UVADEX - methoxsalen soln 20 mcg/ml VECTIBIX - panitumumab iv soln 00 mg/5ml, 400 mg/20ml VELCADE - bortezomib for inj 3.5 mg VINBLASTINE SULFATE - X vinblastine sulfate inj mg/ml vincristine sulfate iv soln, mg/ml vinorelbine tartrate inj, 0 mg/ml, 50 mg/5ml (0 mg/ml) VOTRIENT - pazopanib hcl tab 200 mg* You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. = Generic and Brand Drugs = Utilization Management (UM) * = Limited Distribution Drug X = Drugs that may be covered by Medicare Part B or Medicare Part D depending on the circumstance = Quantity limit restrictions for these drugs are listed beginning on page 50 # = High Risk Medication (HRM) 7