MVP HEALTH CARE 2015 COMPREHENSIVE MEDICARE PART D FORMULARY

Transcription

1 MVP HEALTH CARE 2015 COMPREHENSIVE MEDICARE PART D FORMULARY (List of Covered Drugs) PLEASE READ: This document contains information about the drugs we cover in this plan. This Formulary was updated in August For more recent information or other questions, please contact MVP s Medicare Customer Care Center Monday Friday, 8 am 8 pm Eastern Time at: From Oct. 1 Feb. 14 call seven days a week from 8 am 8 pm. Or visit for the most up-to-date Formulary listing. TTY: 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 and to see if they have changed tiers since last year. When this drug list (Formulary) refers to we, us, or our it means MVP. When it refers to plan or our plan it means GoldValue HMO-POS, Preferred Gold HMO-POS, Gold PPO, BasiCare PPO, GoldAnywhere PPO, USA Care PPO or MVP RxCare PDP. This document includes a list of the drugs (Formulary) for our plans which is current as of August 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 access your prescription drug benefit. Benefits, formulary, pharmacy network, and/or copayments/coinsurance may change on January 1, 2016, and from time to time during the year. Y0051_2315 Approved 08/13/2014 Formulary ID15217, Version 8

2 PLEASE NOTE: Some of the abbreviations listed here have changed. Please review this list before looking up your drug. Abbreviations and Definitions of Formulary Terms You may find one or more of the following abbreviations in the Formulary under the Requirements/Limits column next to a drug name. Not Available at Mail Order (NM) Certain drugs are not allowed through the mail order pharmacy program. These prescriptions can only be filled at a retail pharmacy. Prior Authorization (PA) MVP Health Care requires you or your doctor to get prior authorization for certain drugs. This means that you will need to get approval from MVP before you fill your prescriptions. If you don t get approval first, MVP may not cover the drug. Quantity Limits (QL) For certain drugs, MVP Health Care limits the amount of the drug that we will cover. For example, MVP provides one tablet per day for ZETIA. This limit may be applied to a standard one-month or three-month supply. Step Therapy (ST) In some cases, MVP Health Care requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, MVP may not cover Drug B unless you try Drug A first. If Drug A does not work for you, MVP will then cover Drug B. Dispensing Limits (DL) Certain drugs are limited to a 30-day supply through a retail pharmacy and are not available through the mail order program. Limited Access (LA) Some drugs are available only through a designated Specialty Pharmacy because of manufacturer limited distribution. Part B versus Part D drug coverage (B/D) Some drugs could be covered under the Part B or Part D benefit, depending on certain criteria. This means that you or your doctor will need to submit a request to MVP Health Care so we can determine, based on Medicare guidelines, if your drug will be covered as Part B or Part D. Your cost sharing will be based on this determination. MVP RxCare PDP Members: because your MVP plan is Part D prescription drug coverage only, any drugs deemed Part B will not be covered. You will need to seek coverage from Original Medicare for Part B drugs. NOTE: Tier 1 and Tier 6 drugs are covered at the same copay ($0 or no more than $3) through all benefit stages all year long the Initial Coverage stage, the Coverage Gap stage, and the Catastrophic Coverage stage.

3 ATTENTION! Not all MVP Medicare Advantage plans are offered in all counties throughout New York and Vermont. Prescription drug copays may also vary by county. Please refer to the chart on the following pages that applies to you: Chart #1: If you live in Erie, Genesee, Livingston, Monroe, Niagara, Ontario, Orleans, Seneca, Steuben, Wayne, Wyoming, or Yates counties in New York. Chart #2: If you live in Albany, Broome, Cayuga, Chenango, Columbia, Cortland, Dutchess, Essex, Fulton, Greene, Montgomery, Orange, Putnam, Rensselaer, Saratoga, Schenectady, Schoharie, Tioga, Tompkins, Ulster, Warren, Washington, or Westchester counties in New York. Chart #3: If you live in Herkimer, Madison, Oneida, Onondaga, Oswego, or Otsego counties in New York; or Addison, Bennington, Chittenden, Lamoille, Rutland, or Washington counties in Vermont. ATTENTION! The costs in the charts that follow may be different for you if: 1. Your coverage is through an employer group. 2. You qualify for low income subsidy (Extra Help). If your coverage is through your former employer, or if you qualify for low income subsidy, the following information may not apply. Please check with your former employer, or read your Evidence of Coverage (your contract) and other plan materials for details. a

4 Chart #1 Refer to the list of counties at the beginning of this booklet to make sure you are looking at the right chart for the prescription drug copays and plans available to you based on where you live. The costs in the chart below show what you will pay for prescription drugs. Your costs may be different if your coverage is through a former employer or if you qualify for low income subsidy (Extra Help). Please read your Evidence of Coverage (your contract) and other plan materials for details. Coverage Level Stage 1: Yearly Deductible Stage Tier (Drug Cost-Sharing Level) GoldValue HMO-POS with Part D Because there is no deductible for the plan, this payment stage does not apply to you. Retail Pharmacy 30-day Supply Mail Order Pharmacy 90-day Supply Stage 2: Initial Coverage Stage During this stage, you pay your Tier copay or coinsurance for covered prescription drugs. Tier 1 Preferred Generic Drugs $0 $0 Tier 2 Non-Preferred Generic Drugs $10 $20 Tier 3 Preferred Brand Drugs $35 $70 Tier 4 Non-Preferred Brand Drugs $90 $180 Tier 5 Specialty Drugs 33% 33% Tier 6 Select Vaccines $0 $0 Stage 3: Coverage Gap Stage Once your total drug costs* reach $2,960, what you pay for your prescription drugs changes. Stage 4: Catastrophic Coverage Stage Once your out-of-pocket costs** (your payments) reach $4,700 the plan pays most of the cost for your covered drugs. Generic Drugs 65% Brand Name Drugs 45% Tier 1 Preferred Generic Drugs $0 Tier 6 Select Vaccines $0 Generic Drugs The greater of 5% or $2.65 Brand Name Drugs The greater of 5% or $6.60 Tier 1 Preferred Generic Drugs $0 Tier 6 Select Vaccines $0 *Total drug costs = your out-of-pocket costs for covered drugs (what you pay) plus what the plan pays for your covered drugs. **Out-of-pocket costs = your out-of-pocket costs for covered drugs (what you pay only - not what the plan pays). b

5 Chart #1, continued If you receive more than a 30-day supply at a retail pharmacy, you will pay more than the amounts listed above. Some drugs are limited to only a 30-day supply. If your doctor prescribes less than a full month s supply of a drug, you will only pay for the amount of the drug you receive. Some drugs are available by mail order you can receive a 90-day supply of your prescription for two copays (for example, if your Tier 2 copay is $10, you will receive a 90-day supply by mail for $20). Certain drugs are not allowed through the mail order pharmacy program. Gold PPO with Part D BasiCare PPO with Part D Because there is no deductible for the plan, this payment stage does not apply to you. $320 deductible. You will pay 100% of the cost of your drugs until you spend $320. Retail Pharmacy 30-day Supply Mail Order Pharmacy 90-day Supply $0 $0 25% $10 $20 25% $35 $70 25% $90 $180 25% 33% 33% 25% $0 $0 25% 65% 65% 45% 45% $0 $0 Generic Drugs: 65% Brand Name Drugs: 45% The greater of 5% or $2.65 The greater of 5% or $2.65 The greater of 5% or $6.60 The greater of 5% or $6.60 $0 Generic Drugs: The greater of 5% or $2.65 Brand Name Drugs: The greater of 5% or $6.60 $0 c

6 Chart #2 Refer to the list of counties at the beginning of this booklet to make sure you are looking at the right chart for the prescription drug copays and plans available to you based on where you live. The costs in the chart below show what you will pay for prescription drugs. Your costs may be different if your coverage is through a former employer or if you qualify for low income subsidy (Extra Help). Please read your Evidence of Coverage (your contract) and other plan materials for details. Gold PPO with Part D and BasiCare PPO with Part D are not available in Columbia, Dutchess, Greene, Orange, Putnam, Ulster and Westchester counties. Coverage Level Stage 1: Yearly Deductible Stage Tier (Drug Cost-Sharing Level) GoldValue HMO-POS with Part D Because there is no deductible for the plan, this payment stage does not apply to you. Retail Pharmacy 30-day Supply Mail Order Pharmacy 90-day Supply Stage 2: Initial Coverage Stage During this stage, you pay your Tier copay or coinsurance for covered prescription drugs. Tier 1 Preferred Generic Drugs $3 $6 Tier 2 Non-Preferred Generic Drugs $15 $30 Tier 3 Preferred Brand Drugs $45 $90 Tier 4 Non-Preferred Brand Drugs $95 $190 Tier 5 Specialty Drugs 33% 33% Stage 3: Coverage Gap Stage Once your total drug costs* reach $2,960, what you pay for your prescription drugs changes. Stage 4: Catastrophic Coverage Stage Once your out-of-pocket costs** (your payments) reach $4,700 the plan pays most of the cost for your covered drugs. Tier 6 Select Vaccines $0 $0 Generic Drugs 65% Brand Name Drugs 45% Tier 1 Preferred Generic Drugs $3 Tier 6 Select Vaccines $0 Generic Drugs The greater of 5% or $2.65 Brand Name Drugs The greater of 5% or $6.60 Tier 1 Preferred Generic Drugs $3 Tier 6 Select Vaccines $0 *Total drug costs = your out-of-pocket costs for covered drugs (what you pay) plus what the plan pays for your covered drugs. d

7 Chart #2, continued If you receive more than a 30-day supply at a retail pharmacy, you will pay more than the amounts listed above. Some drugs are limited to only a 30-day supply. If your doctor prescribes less than a full month s supply of a drug, you will only pay for the amount of the drug you receive. Some drugs are available by mail order you can receive a 90-day supply of your prescription for two copays (for example, if your Tier 2 copay is $10, you will receive a 90-day supply by mail for $20). Certain drugs are not allowed through the mail order pharmacy program. Gold PPO with Part D and BasiCare PPO with Part D are not available in Columbia, Dutchess, Greene, Orange, Putnam, Ulster and Westchester counties. Preferred Gold HMO-POS with Part D Because there is no deductible for the plan, this payment stage does not apply to you. Gold PPO with Part D Because there is no deductible for the plan, this payment stage does not apply to you. BasiCare PPO with Part D $320 deductible. You will pay 100% of the cost of your drugs until you spend $320. Retail Pharmacy 30-day Supply Mail Order Pharmacy 90-day Supply Retail Pharmacy 30-day Supply Mail Order Pharmacy 90-day Supply $0 $0 $0 $0 25% $10 $20 $10 $20 25% $35 $70 $35 $70 25% $90 $180 $90 $180 25% 33% 33% 33% 33% 25% $0 $0 $0 $0 25% 65% 65% 65% 45% 45% 45% $0 $0 $0 $0 Generic Drugs: 65% Brand Name Drugs: 45% The greater of 5% or $2.65 The greater of 5% or $2.65 The greater of 5% or $2.65 The greater of 5% or $6.60 The greater of 5% or $2.65 The greater of 5% or $6.60 $0 $0 $0 $0 Generic Drugs: The greater of 5% or $2.65 Brand Name Drugs: The greater of 5% or $6.60 **Out-of-pocket costs = your out-of-pocket costs for covered drugs (what you pay only - not what the plan pays). e

8 Chart #3 Refer to the list of counties at the beginning of this booklet to make sure you are looking at the right chart for the prescription drug copays and plans available to you based on where you live. The costs in the chart below show what you will pay for prescription drugs. Your costs may be different if your coverage is through a former employer or if you qualify for low income subsidy (Extra Help). Please read your Evidence of Coverage (your contract) and other plan materials for details. Coverage Level Stage 1: Yearly Deductible Stage Tier (Drug Cost-Sharing Level) GoldValue HMO-POS with Part D Because there is no deductible for the plan, this payment stage does not apply to you. Retail Pharmacy 30-day Supply Mail Order Pharmacy 90-day Supply Stage 2: Initial Coverage Stage During this stage, you pay your Tier copay or coinsurance for covered prescription drugs. Tier 1 Preferred Generic Drugs $3 $6 Tier 2 Non-Preferred Generic Drugs $15 $30 Tier 3 Preferred Brand Drugs $45 $90 Tier 4 Non-Preferred Brand Drugs $95 $190 Tier 5 Specialty Drugs 33% 33% Tier 6 Select Vaccines $0 $0 Stage 3: Coverage Gap Stage Once your total drug costs* reach $2,960, what you pay for your prescription drugs changes. Stage 4: Catastrophic Coverage Stage Once your out-of-pocket costs** (your payments) reach $4,700 the plan pays most of the cost for your covered drugs. Generic Drugs 65% Brand Name Drugs 45% Tier 1 Preferred Generic Drugs $3 Tier 6 Select Vaccines $0 Generic Drugs The greater of 5% or $2.65 Brand Name Drugs The greater of 5% or $6.60 Tier 1 Preferred Generic Drugs $3 Tier 6 Select Vaccines $0 *Total drug costs = your out-of-pocket costs for covered drugs (what you pay) plus what the plan pays for your covered drugs. **Out-of-pocket costs = your out-of-pocket costs for covered drugs (what you pay only - not what the plan pays). f

9 Chart #3, continued If you receive more than a 30-day supply at a retail pharmacy, you will pay more than the amounts listed above. Some drugs are limited to only a 30-day supply. If your doctor prescribes less than a full month s supply of a drug, you will only pay for the amount of the drug you receive. Some drugs are available by mail order you can receive a 90-day supply of your prescription for two copays (for example, if your Tier 2 copay is $10, you will receive a 90-day supply by mail for $20). Certain drugs are not allowed through the mail order pharmacy program. Gold PPO with Part D BasiCare PPO with Part D Because there is no deductible for the plan, this payment stage does not apply to you. $320 deductible. You will pay 100% of the cost of your drugs until you spend $320. Retail Pharmacy 30-day Supply Mail Order Pharmacy 90-day Supply $0 $0 25% $10 $20 25% $35 $70 25% $90 $180 25% 33% 33% 25% $0 $0 25% 65% 65% 45% 45% $0 $0 Generic Drugs: 65% Brand Name Drugs: 45% The greater of 5% or $2.65 The greater of 5% or $2.65 The greater of 5% or $6.60 The greater of 5% or $6.60 $0 Generic Drugs: The greater of 5% or $2.65 Brand Name Drugs: The greater of 5% or $6.60 $0 g

10 Table of Contents What is the MVP Health Care Comprehensive Medicare Part D Formulary?... i Can the Formulary change?...i MVP Health Care s Medicare Part D Formulary and Tiers...i How do I use the Formulary?...j What are generic drugs?... What programs are in place to promote cost savings and safety?... What if my drug is not on the Formulary?... How do I request an exception to MVP s Medicare Part D Formulary?...l What do I do before I talk to my doctor about changing my drugs or requesting an exception?... l For more information...m MVP s list of covered drugs by category...1 Alphabetical index of covered drugs k k k

11 What is the MVP Health Care Comprehensive Medicare Part D Formulary? A Formulary is a list of Medicare covered drugs selected by MVP Health Care 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. MVP Health Care will generally cover the drugs listed in our Formulary as long as the drug is medically necessary, the prescription is filled at an MVP Health Care network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage (your contract). Can the Formulary change? Generally, if you are taking a drug on our 2015 Formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2015 coverage year except when a new, less expensive generic drug becomes available or when information about concerns with 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 amount 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 need to make a change to ensure your safety. If we remove drugs from our Formulary, move a drug to a higher cost-sharing tier, or add prior authorization, quantity limits and/or step therapy restrictions on a drug, we must notify affected members of the change at least 60 days before the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 60-day supply of the drug. If the Food and Drug Administration deems a drug on our Formulary to be unsafe or a drug s manufacturer removes the drug from the market, we will immediately remove the drug from our Formulary and provide notice to members who take the drug. The enclosed Formulary is current as of August To get updated information about the drugs covered by MVP Health Care, please visit our website at www. mvphealthcare.com or contact us. Our contact information appears on the front and back cover pages. In the event of a change or changes to the Formulary during the year, the changes also will be posted on the MVP website: (This updated version of the Formulary will be posted on the MVP website on a monthly basis as needed.) To view the list of changes, start at our home page and: Click on Medicare Members. Click on the county you live in or the Employer Group Retirees Part D Coverage link at the top of the page. Under the Part D (Prescription Drug Coverage) heading click on Covered Formulary Drug List and Updates at the top of the list. Click on 2015 Formulary Changes. Or you may request an errata sheet (a copy of the 2015 Formulary changes) by calling MVP s Medicare Customer Care Center at the phone numbers on the back of your Member ID card. MVP Health Care s Medicare Part D Formulary and Tiers The Comprehensive Formulary that begins on page 1 provides coverage information about most of the drugs covered by MVP Health Care. To look for your drug, turn to the Index that begins on page 52. The first column of the Formulary chart lists the drug name. Brand-name drugs are capitalized (e.g., ZETIA) and generic drugs are listed in lower-case italics (e.g., allopurinol). The information in the Requirements/Limits column tells you if MVP Health Care has any special requirements for coverage of your drug. See inside front cover for abbreviations and definitions of Formulary terms. The 2015 Formulary is divided into six tiers (or cost groups) that correspond to the drug copays in your Evidence of Coverage (your contract) or prescription drug Rider. Copays may vary if you are in the Medicare Part D coverage gap, if you are in catastrophic coverage or if you have qualified for Extra Help. Refer to your Evidence of Coverage for more details about the different levels of coverage. i

12 Note for members with BasiCare PPO or the employer group Basic Prescription Drug Coverage Rider: the drug tiers in this Formulary do not apply to you. You will pay 25% for each medication you receive in the initial coverage phase of your benefit (after you meet your deductible) regardless of the tier on the Formulary. Here are the six tiers for 2015: Tier 1 Preferred Generic Drugs - $0 cost* *NOTE: GoldValue with Part D members who live in the counties listed for charts #2 and #3 at the front of this booklet pay a $3 copay for Tier 1 drugs. Tier 1 includes select drugs for diabetes, blood pressure control, glaucoma, gout, bone health, heartburn and ulcers, mental health conditions, pain management, cholesterol control, and thyroid conditions. Think about using a Tier 1 generic drug if you and your doctor decide it is right for you. Tier 2 Non-Preferred Generic Drugs Tier 2 includes non-preferred generic drugs. (Note: Not all generic drugs will be a Tier 2 drug.) Generic drugs have the same active ingredients, strength, and effectiveness as the brand-name versions, but generally at a much lower cost. Tier 3 - Preferred Brand Name Drugs Tier 3 includes preferred brand drugs that have the lowest cost sharing for brand name drugs. If you and your doctor decide that a brand name drug is right for you, try using a Tier 3 brand name drug to save money. Tier 4 - Non-Preferred Brand Drugs Tier 4 non-preferred brand name and non-preferred generic drugs are available at a higher cost. In addition, Part D drugs excluded from our Formulary must go through an exception process in order for MVP to cover them. If they are approved, they will be covered in Tier 4. Tier 5 Specialty Drugs Tier 5 includes drugs (brand name and generic) that cost $600 or more for a 30-day supply. Most drugs in this tier are restricted to a 30-day supply at retail, and are excluded from the mail order program and tier exception process. j Tier 6 Vaccines $0 cost The drugs in Tier 6 are provided at no cost to you! Tier 6 includes the most common Part D vaccines: the shingles vaccine (Zostavax), tetanus vaccines, and combination tetanus / diphtheria / pertussis vaccines (such as Tenivac, Adacel and Boostrix). Some of these vaccines can be given by a pharmacist. You will pay $0 if you receive your vaccination at the pharmacy. If you get your vaccine at a doctor s office, ask the doctor to process your vaccine claim through a service called TransactRx. If your doctor does not process your claim using TransactRx, you will have to pay out-of-pocket for your vaccine and submit the claim to CVS/caremark for reimbursement. MVP will reimburse vaccine claims up to MVP s allowed amount. If your doctor chooses to charge more than the allowed amount, you are responsible for paying the difference. Not all providers use the TransactRx service. Check with your doctor before getting your vaccine. NOTE: Tier 1 and Tier 6 drugs are available at $0 or no more than $3 through all benefit stages all year long in the Initial Coverage Stage, the Coverage Gap Stage, and the Catastrophic Coverage Stage. Refer to the drug copay charts at the front of this booklet to find the correct payment for your plan. How do I use the Formulary? There are two ways to find your covered drug within the Formulary: By Alphabetical Listing Look for your covered drug in the Index that begins on page 52. 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. 1. Look in the Index and find your drug. 2. Next to your drug, you will see the page number where you can find coverage information. 3. Turn to the page listed in the Index and find the name of your drug in the column of the list. By Medical Condition The drugs in this Formulary are grouped into categories depending on the type of medical condition that they are used to treat. For example, drugs used to treat high blood pressure are listed under the category, Ace Inhibitors. If you know the category of what your drug is used for, look in the list that begins on page 1.

13 What are generic drugs? MVP Health Care covers both brand name drugs and generic drugs. A generic drug is approved by the FDA as having the same active ingredient as the brand name drug. Generally, generic drugs cost less than brand name drugs. MVP Health Care covers select generic drugs for $0 or $3* through all benefit stages all year long in the Initial Coverage stage, the Coverage Gap stage, and the Catastrophic Coverage stage. Tier 1 includes select drugs for diabetes, blood pressure control, glaucoma, gout, bone health, heartburn and ulcers, mental health conditions, pain management, cholesterol control, and thyroid conditions. *NOTE: GoldValue with Part D members who live in the counties listed in Charts #2 and #3 at the front of this booklet pay a $3 copay for Tier 1 drugs. BasiCare PPO members and employer group members with the Basic Prescription Drug Coverage Rider pay 25% for all drugs after you meet your deductible. Refer to your Evidence of Coverage (your contract) and plan Riders for more information. What programs are in place to promote cost savings and safety? For safety reasons and/or cost savings, some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include: Prior Authorization: MVP Health Care requires you or your doctor to get prior authorization for certain drugs. For example, some compound prescriptions require Prior Authorization. This means that you will need to get approval from MVP before you fill your prescriptions. If you don t get approval first, MVP may not cover the drug. Quantity Limits: For certain drugs, MVP Health Care limits the amount of the drug that we will cover. For example, MVP provides one tablet per day for ZETIA. This limit may be applied to a standard one-month or three-month supply. Step Therapy: In some cases, MVP Health Care requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, MVP may not cover Drug B unless you try Drug A first. If Drug A does not work for you, MVP will then cover Drug B. You can find out if your drug has any additional requirements or limits by looking in the Requirements/ Limits column of the Formulary that begins on page 1. You also can get more information about the restrictions applied to specific covered drugs by visiting our website at We have posted online documents that explain our prior authorization and step therapy restrictions. You may also ask us to send you a copy. Our contact information, along with the date we last updated the Formulary, appears on the front and back cover pages. You can ask MVP Health Care to make an exception to these restrictions or limits. See the section, How do I request an exception to the MVP Health Care Formulary? on page L for information about how to request an exception. What if my drug is not on the Formulary? To find out if your drug is covered but is not listed in this Formulary (drug list), you should first contact MVP s Customer Care Center and ask if your drug is covered. If you learn that MVP Health Care does not cover your drug, you have two options: You can ask MVP s Medicare Customer Care Center for a list of similar drugs that are covered by MVP Health Care. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by MVP. You can ask MVP Health Care to make an exception and cover your drug. On this page is information about how to request an exception. Your drug may be available as a generic. Many popular brand name drugs have recently become available as generics. If you don t see your brand name medication on the formulary, a generic version may be available. If you have questions about the coverage of your brand name drug, please call MVP s Medicare Customer Care Center at the phone number on the back of your member ID card. Your drug may be a Part B drug, which means that the drug is not covered under your Medicare Part D pharmacy benefit, but under your medical benefit. If it is a Part B drug, you may be responsible to pay a coinsurance (a percentage). These drugs must still be obtained through an MVP network pharmacy. The following are examples of Part B drugs and supplies: k

14 Temodar (temozolomide) Xeloda (capecitabine) Vepesid (etoposide) Inhalation spacers Diabetic testing supplies like lancets, test strips* Insulin pump supplies *You pay a 10% coinsurance for OneTouch, FreeStyle and Precision test strips. You pay a 20% coinsurance for all other test strips. MVP RxCare PDP Members: Because your MVP plan is Part D prescription drug coverage only, any drugs deemed Part B will not be covered. You will need to seek coverage from Original Medicare for Part B drugs. How do I request an exception to MVP s Medicare Part D Formulary? You can ask MVP Health Care to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make. Formulary Exception: You can ask us to cover certain drugs even if they are not on our Formulary. If approved, these drugs will be covered at a Tier 4 copay and you would not be able to ask us to provide these drugs at a lower cost-sharing level. Generally, MVP Health Care will only approve your request for an exception if the alternative drugs included on the plan s Formulary, the lower costsharing drug or additional utilization restrictions, would not be as effective in treating your condition and/or would cause you to have negative medical effects. You should contact us to ask us for an initial coverage decision for a formulary, tiering, or utilization restriction exception. When you request a formulary, tiering, or utilization restriction exception you should submit a statement from your prescriber or doctor supporting your request. Generally, we must make our decision within 72 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 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get a supporting statement from your doctor or other prescriber. Please note that MVP can not approve a formulary exception request for a Medicare excluded drug. If you or your doctor believes it meets the definition of a covered Part D drug, you may request a coverage determination. Examples of Medicare excluded drugs include drugs used for weight loss, cough and colds, and erectile dysfunction. Also excluded are drugs not approved by the Food and Drug Administration and most vitamins. Tier Exception: You can ask us to cover a Formulary drug at a lower cost-sharing level. If approved, this would lower the amount you must pay for your drug. NOTE: You may not ask us to cover a Tier 5 (Specialty Tier) Formulary drug at a lower cost-sharing level. NOTE: Because BasiCare PPO members and employer group members with the Basic Prescription Drug Coverage Rider pay 25% for all drugs, Tier Exceptions do not apply. Quantity Limit Exception: You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, MVP Health Care 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. What do I do before I 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 that you are a member of our plan. l

15 For each of your drugs that is not on our Formulary or if your ability to get your drugs is limited, we will cover a temporary 30-day transition supply (unless you have a prescription written for fewer days) when you go to a network pharmacy. After your first 30-day supply, we will not pay for these drugs even if you have been a member of the plan less than 90 days unless your doctor submits a request for your drug and it is approved by the plan. 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 93-day transition supply, consistent with the dispensing increment (unless you have a prescription written for fewer days). We will cover more than one refill of these drugs for the first 90 days you are a member of our plan. If you need a drug that is not on our Formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 31-day emergency supply of that drug (unless you have a prescription for fewer days) while you pursue a Formulary exception. Members who are changing levels of care may be eligible for a transition supply of medication outside of their initial 90-day enrollment transition period. Level of care changes may include: entering or leaving a long-term care facility, discharge from hospital to home, and ending a skilled nursing facility stay and reverting to Part D Formulary coverage under your plan. For more information For more detailed information about your MVP Health Care Medicare Advantage prescription drug coverage, please review your Evidence of Coverage (your contract) and other plan materials. If you have questions about MVP Health Care, please contact us. Our contact information, along with the date we last updated the Formulary, appears on the front and back cover pages. Or, visit our website at for more information about Medicare Part D drug coverage. If you have general questions about Medicare prescription drug coverage, please call Medicare at MEDICARE ( ) 24 hours a day/7 days a week. TTY users should call Or, visit m

16 5-HT3 RECEPTOR ANTAGONISTS ALOXI INJ 0.25MG/5 4 PA; DL ANZEMET INJ 20MG/ML 4 PA; DL ANZEMET TAB 50MG 4 B/D, QL (14 tabs / 30 days); DL ANZEMET TAB 100MG 4 B/D, QL (7 tabs / 30 days); DL granisetron inj 0.1mg/ml, 1mg/ml 2 PA; DL granisetron tab 1mg 2 B/D, QL (30 tabs / 30 days); DL GRANISOL SOL 2MG/10ML 2 B/D, QL (150 ml / 30 days); DL ondansetron inj 4mg/2ml 2 PA; DL ondansetron sol 4mg/5ml 2 B/D, QL (450 ml / 30 days); DL ondansetron tab 4mg, 4mg odt, 8mg, 8mg odt 2 B/D, QL (45 tabs / 30 days); DL ondansetron tab 24mg 2 B/D, QL (7 tabs / 30 days); DL SANCUSO DIS 3.1MG 4 ACE INHIBITORS benazepril tab 5mg, 10mg, 20mg, 40 mg 1 captopril tab 12.5mg, 25mg, 50 mg, 100mg 1 enalapril tab 2.5mg, 5mg, 10mb, 20mg 1 fosinopril tab 10mg, 20mg, 40mg 1 lisinopril tab 2.5mg, 5mg, 10mg, 20mg, 30mg, 40mg 1 moexipril tab 7.5mg, 15 mg 2 perindopril tab 2mg, 4mg, 8mg 2 quinapril tab 5mg, 10mg, 20mg, 40mg 1 ramipril cap 1.25mg, 2.5mg, 5mg 1 trandolapril tab 1mg, 2mg, 4mg 2 ACNE PRODUCTS ACANYA GEL % 4 adapalene 2 adapalene cre 0.1% 2 adapalene gel 0.1% 2 AKNE-MYCIN OIN 2% 4 amnesteem 2 AZELEX CRE 20% 4 claravis 2 clindamy/ben gel 1-5% 2 clindamycin aer 1% 2 clindamycin gel 1% 2 clindamycin lot 1% 2 clindamycin pad 1% 2 clindamycin sol 1% 2 DIFFERIN LOT 0.1% 4 ery 2 erythromycin gel 2% 2 erythromycin gel /benzoyl 2 erythromycin sol 2% 2 myorisan 2 sulfacetamid sus 10% 2 tretinoin cre 0.1%, 0.05%, 0.025% 2 PA; DL tretinoin gel 0.01%, 0.025% 2 PA; DL AGENTS FOR CHEMICAL DEPENDENCY acampro cal tab 333mg 2 CAMPRAL TAB 333MG 4 1

17 disulfiram tab 250mg, 500mg 2 AGENTS FOR EXTERNAL GENITAL AND PERIANAL WARTS VEREGEN OIN 15% 4 AGENTS FOR GAUCHER DISEASE CEREZYME INJ 400UNIT 5 NM, PA; DL VPRIV INJ 400UNIT 5 NM, PA; DL ZAVESCA CAP 100MG 5 NM, LA, PA; DL AGENTS FOR PHEOCHROMOCYTOMA DEMSER 5 DIBENZYLINE CAP 10MG 3 AGENTS FOR SICKLE CELL ANEMIA DROXIA CAP 200MG, 300MG, 400MG 3 ALKALINIZERS pot citrate tab 540mg, 1080mg 2 ALKYLATING AGENTS BICNU INJ 100MG 4 B/D; DL BUSULFEX INJ 6MG/ML 4 B/D; DL carboplatin inj 150/15ml 2 B/D; DL cisplatin inj 100mg 2 B/D; DL cyclophosphamide tab 25mg, 50mg 2 B/D; DL CYCLOPHOSPHAMIDE CAPS 3 B/D HEXALEN CAP 50MG 5 IFEX INJ 1GM 4 B/D; DL ifosfamide inj 1gm 2 B/D; DL LEUKERAN TAB 2MG 3 lomustine cap 10mg, 40mg, 100mg 4 melphalan inj 50mg 2 B/D; DL MUSTARGEN INJ 10MG 4 B/D; DL oxaliplatin inj 100mg 4 B/D; DL TREANDA INJ 100MG 5 B/D, NM; DL ZANOSAR INJ 1GM 4 B/D; DL ALPHA-2 RECEPTOR ANTAGONISTS (TETRACYCLICS) mirtazapine tab 7.5mg, 15mg, 30mg, 45mg 2 mirtazapine tab 15mg odt, 30mg odt, 45mg odt 2 ALPHA-BETA BLOCKERS carvedilol tab 3.125mg, 6.25mg, 12.5mg, 25mg 1 COREG CR CAP 10MG, 20MG, 40MG, 80MG 4 labetalol inj 5mg/ml 2 labetalol tab 100mg, 200mg, 300mg 2 ALPHA-GLUCOSIDASE INHIBITORS acarbose tab 25mg, 50mg, 100mg 2 GLYSET TAB 25MG, 50MG, 100MG 4 ALPHA-PROTEINASE INHIBITOR (HUMAN) ARALAST NP INJ 400MG 5 NM, LA, PA; DL GLASSIA INJ 5 NM, LA, PA; DL PROLASTIN-C INJ 1000MG 5 NM, LA, PA; DL ZEMAIRA INJ 1000MG 5 NM, LA, PA; DL ALS AGENTS riluzole tab 50mg 4 AMINOGLYCOSIDES 2

18 amikacin inj 500/2ml 2 GENTAMACIN/NACL INJ 0.9MG/ML, 1.4MG/ML 2 gentamacin/nacl inj 60mg, 80mg, 100mg 2 gentamicin inj 10mg/ml, 40mg/ml 2 neomycin tab 500mg 2 paromomycin cap 250mg 2 streptomycin inj 1gm 4 TOBI NEB 300/5ML 5 B/D, NM; DL TOBI PODHALR CAP 28MG 4 NM, PA; DL TOBRAMYCIN/NACL INJ 80/0.9 2 tobramycin inj 10mg/ml, 80mg/2ml 2 B/D; DL tobramycin neb 300/5ml 2 B/D, NM AMINOPENICILLINS amoxicillin cap 250mg, 500mg 2 amoxicillin chw 125mg, 250mg 2 amoxicillin sus 125/5ml, 200/5ml, 250/5ml, 400/ml 2 amoxicillin tab 500mg, 875mg 2 ampicillin cap 250mg, 500mg 2 ampicillin inj 1gm, 10gm, 125mg 2 ampicillin sus 125/5ml, 250/5ml 2 MOXATAG TAB 775MG 4 AMPA GLUTAMATE RECEPTOR ANTAGONISTS FYCOMPA TAB 2MG, 4MG, 6MG, 8MG, 10MG, 12MG 4 PA; DL AMPHETAMINES amphetamine cap 5mg er, 10mg er, 15mg er, 20mg er, 25mg er, 30mg 2 er amphetamine tab 5mg, 7.5mg, 10mg, 12.5mg, 15mg, 20mg, 30mg 2 dextroamphetamine cap 5mg er, 10mg er, 15mg er 4 dextroamphetamine tab 5mg, 10mg 2 methamphetamine tab 5mg 2 VYVANSE CAP 20MG, 30MG, 40MG, 50MG, 60MG, 70MG 4 ANALGESIC COMBINATIONS butalbital/apap/caf cap 2 QL (24 caps / 30 days) butalbital/apap/caf tab 2 QL (24 tabs / 30 days) butalbital/asa/caff cap 2 QL (24 caps / 30 days) butalbital/apap tab mg 2 QL (24 tabs / 30 days) ANAPHYLAXIS THERAPY AGENTS ADRENALIN INJ 1MG/ML 2 DL EPIPEN 2-PAK INJ 0.3MG 3 QL (1 / 30 days) EPIPEN-JR INJ 2-PAK 3 QL (1 / 30 days) ANDROGENS ANDRODERM DIS 2MG/24HR, 4MG/24HR 4 QL (30 patches / 30 days) ANDROGEL GEL 1%(50MG) 3 ANDROGEL GEL 1.62% 3 ANDROXY TAB 10MG 2 danazol cap 50mg, 100mg, 200mg 2 METHITEST TAB 10MG 4 oxandrolone TABS 2.5mg 2 QL (120 tabs / 30 days); DL oxandrolone TABS 10mg 4 DL testosterone cyp inj 100mg/ml, 200mg/ml 2 testosterone enan inj 200mg/ml 2 3

19 ANESTHETICS TOPICAL ORAL lidocaine sol 2% visc 2 ANGIOTENSIN II RECEPTOR ANTAGONISTS BENICAR TAB 5MG, 20MG, 40MG 4 candesartan tab 4mg, 8mg, 16mg, 32mg 2 DIOVAN TAB 40MG, 80MG, 160MG, 320MG 4 EDARBI TAB 40MG 4 EDARBI TAB 80MG 4 eprosartan mes tab 600mg 2 irbesartan tab 75mg, 150mg, 300mg 2 losartan pot tab 25mg, 50mg, 100mg 1 telmisartan tab 20mg, 40mg, 80mg 2 ANTI TB COMBINATIONS rifamate 4 RIFATER TAB 4 ANTI-CATAPLECTIC AGENTS XYREM SOL 500MG/ML 5 QL (540 ml / 30 days), LA, PA; DL ANTI-INFECTIVE AGENTS - MISC. AZACTAM/DEX INJ 1GM, 2GM 4 aztreonam inj 1gm 2 baci-im 2 BACITRACIN INJ 50000UNT 2 colistimethate inj 150mg 4 FLAGYL ER TAB 750MG 4 metronidazole/nacl inj 500mg 2 metronidazole cap 375mg 2 metronidazole tab 250mg, 500mg 2 NEBUPENT INH 300MG 4 B/D; DL PENTAM 300 INJ 300MG 4 DL PRIMSOL SOL 50MG/5ML 4 TEFLARO 4 tinidazole tab 250mg, 500mg 2 trimethoprim tab 100mg 2 vancomycin cap 125mg, 250mg 5 vancomycin inj 10gm, 500mg, 1000mg 2 XIFAXAN TAB 200MG 4 QL (9 tabs / 30 days), PA; DL XIFAXAN TAB 550MG 4 ANTI-INFECTIVE MISC. - COMBINATIONS smz-tmp inj /5 2 smz-tmp sus /5 2 smz-tmp tab mg 2 smz/tmp ds tab ANTI-INFECTIVES - THROAT clotrimazole tro 10mg 2 nystatin sus ANTI-INFLAMMATORY AGENTS cromolyn sod neb 20mg/2ml 2 B/D ANTI-INFLAMMATORY AGENTS - TOPICAL diclofenac sodium 1.5% (topical) 2 VOLTAREN GEL 1% 4 4

20 ANTI-TNF-ALPHA - MONOCLONAL ANTIBODIES HUMIRA KIT 20MG/0.4, 40MG/0.8 5 NM, PA; DL HUMIRA PEN KIT CROHNS 5 NM, PA; DL SIMPONI 5 NM, PA; DL SIMPONI ARIA SOL 50MG/4ML 5 NM, PA; DL SIMPONI INJ 50MG 5 NM, PA; DL ANTIADRENERGIC ANTIHYPERTENSIVES clonidine dis 0.1/24hr, 0.2/24hr, 0.3/24hr 2 clonidine tab 0.1mg, 0.2mg, 0.3mg 2 doxazosin tab 1mg, 2mg, 4mg, 8mg 2 methyldopa tab 250mg, 500mg 4 prazosin hcl cap 1mg, 2mg, 5mg 2 reserpine tab 0.1mg, 0.25mg 2 terazosin cap 1mg, 2mg, 5mg, 10mg 2 ANTIANGINALS-OTHER RANEXA TAB 500MG, 1000MG 4 ANTIANXIETY AGENTS - MISC. buspirone tab 5mg, 7.5mg, 10mg, 15mg, 30mg 1 ANTIARRHYTHMICS TYPE I-A disopyramide cap 100mg, 150mg 2 NORPACE CAP 100MG CR, 150MG CR 4 procainamide inj 100mg/ml 2 PROCAINAMIDE INJ 500MG/ML 2 QUINIDINE GL INJ 80MG/ML 2 quinidine gl tab 324mg cr 2 quinidine su tab 200mg, 300mg, 300mg er 2 ANTIARRHYTHMICS TYPE I-B mexiletine cap 150mg, 200mg, 250mg 2 ANTIARRHYTHMICS TYPE I-C flecainide tab 50mg, 100mg, 150mg 2 propafenone cap 225mg er, 325mg er, 425mg er 3 propafenone tab 150mg, 225mg, 300mg 2 ANTIARRHYTHMICS TYPE III amiodarone inj 50mg/ml 2 amiodarone tab 200mg, 400mg 2 MULTAQ TAB 400MG 4 pacerone 2 TIKOSYN CAP 125MCG, 250MCG, 500MCG 4 NM ANTIASTHMATIC - MONOCLONAL ANTIBODIES XOLAIR SOL 150MG 5 NM, LA; DL ANTIBIOTICS - TOPICAL ALTABAX OIN 1% 4 CORTISPORIN CRE 0.5% 4 CORTISPORIN OIN 1% 4 gentamicin cre 0.1% 2 gentamicin oin 0.1% 2 mupirocin cre 2% 2 mupirocin oin 2% 2 ANTICOAGULANTS COUMADIN INJ 5 MG 4 5

21 ANTICONVULSANTS - BENZODIAZEPINES clonazepam odt tab 0.5mg, 0.25, 0.125, 1mg, 2mg 2 clonazepam tab 0.5mg, 1mg, 2mg 2 diazepam gel (anticonvulsant) 3 ONFI SUS 2.5MG/ML 4 DL ONFI TAB 10MG, 20MG 4 DL ANTICONVULSANTS - MISC. APTIOM 4 PA BANZEL SUS 40MG/ML 5 BANZEL TAB 200MG 4 BANZEL TAB 400MG 5 carbamazepine cap 100mg er, 200mg er, 300mg er 2 carbamazepine chw 100mg 2 carbamazepine sus 100/5ml 2 carbamazepine tab 200mg, 200mg er, 400mg er 2 epitol 2 gabapentin cap 100mg, 300mg, 400mg 2 gabapentin sol 250/5ml 2 gabapentin tab 600mg, 800mg 2 lamotrigine chw 5mg, 25mg 2 lamotrigine tab 25mg 2 lamotrigine tab 25mg er, 50mg er 4 lamotrigine tab 100mg 2 lamotrigine tab 100mg er 4 lamotrigine tab 150mg, 200 mg 2 lamotrigine tab 200mg er, 250mg er, 300mg er 4 levetiracetam sol 100mg/ml 2 levetiracetam tab 250mg, 500mg, 500mg er, 750mg, 750mg er, mg levetiracetam inj 500/5ml 2 LYRICA CAP 25MG, 50MG, 75MG, 100MG, 150MG, 200MG, 225MG, 4 QL (90 caps / 30 days) 300MG LYRICA SOL 20MG/ML 4 PA; DL oxcarbazepine sus 300mg/5m 2 oxcarbazepine tab 150mg, 300mg, 600mg 2 POTIGA TAB 50MG, 200MG, 300MG, 400MG 4 primidone tab 50mg, 250mg 2 TEGRETOL-XR TAB 100MG 3 topiramate cap 15mg, 25mg 2 topiramate tab 25mg, 50mg, 100mg, 200mg 2 TRILEPTAL SUS 300MG/5M 4 VIMPAT INJ 200MG/20 4 VIMPAT SOL 10MG/ML 4 VIMPAT TAB 50MG, 100MG, 150MG, 200MG 4 zonisamide cap 25mg, 50mg, 100mg 2 ANTIDEMENTIA AGENTS donepezil tab 5mg, 5mg odt, 10mg, 10mg odt 2 donepezil tab hcl 23mg 2 EXELON DIS 4.6MG/24, 9.5MG/24, 13.3/24 4 galantamine cap 8mg er, 16mg er, 24mg er 2 galantamine sol 4mg/ml 2 galantamine tab 4mg, 8mg, 12mg 2 6

22 NAMENDA SOL 10MG/5ML 3 NAMENDA XR CAP 7MG, 14MG, 21MG, 28MG 3 NAMENDA XR CAP TITRATIO 3 rivastigmine cap 1.5mg, 3mg, 4.5mg, 6mg 2 ANTIDEPRESSANTS - MISC. APLENZIN TAB 174MG, 348MG, 522MG 4 bupropion tab 75mg, 100mg, 100mg sr, 150mg sr, 200mg sr 2 bupropion hcl tab 150mg xl, 300mg xl 2 maprotiline tab 25mg, 50mg, 75mg 2 ANTIDIABETIC - AMYLIN ANALOGS SYMLINPEN 60 INJ 1000MCG 4 SYMLNPEN 120 INJ 1000MCG 4 ANTIDIABETIC COMBINATIONS AVANDAMET TAB 2-500MG, 1000MG 4 AVANDAMET TAB 4-500MG, 1000MG 4 AVANDARYL TAB 4-1MG, 2MG, 4MG 4 AVANDARYL TAB 8-2MG, 4MG 4 glipizide/metform tab m, 500m 2 glipizide/metform tab 5-500mg 2 glyburide-metformin 4 PA JANUMET TAB MG, 100MG 3 JANUMET XR TAB MG, 1000MG 3 JANUMET XR TAB JENTADUETO 3 pioglitazone/glimepiride tab 30-2mg, 4mg 2 pioglitazone/metformin tab mg, 850mg 2 ANTIDOTES fomepizole inj 1gm/ml 2 ANTIDOTES - CHELATING AGENTS CHEMET CAP 100MG 4 EXJADE TAB 125MG 4 NM, LA; DL EXJADE TAB 250MG, 500MG 5 NM, LA; DL ANTIEMETICS - ANTICHOLINERGIC meclizine tab 12.5mg, 25mg 2 TRANSDERM-SCOP 4 ANTIEMETICS - MISCELLANEOUS CESAMET CAP 1MG 4 dronabinol cap 2.5mg, 5mg, 10mg 2 QL (60 caps / 30 days) ANTIFUNGAL - GLUCAN SYNTHESIS INHIBITORS (ECHINOCANDINS) ALBENZA TAB 200MG 4 BILTRICIDE TAB 600MG 3 CANCIDAS INJ 50MG, 70MG 5 DL ERAXIS INJ 100MG 4 STROMECTOL TAB 3MG 4 ANTIFUNGALS ABELCET INJ 5MG/ML 5 B/D; DL amphotericin inj 50mg 2 B/D; DL flucytosine cap 250mg, 500mg 2 GRIS-PEG TAB 125MG, 250MG 4 griseofulvin sus 125/5ml 2 7

23 griseofulvin tab micr griseofulvin tab ultr griseofulvin tab ultr nystatin tab terbinafine tab 250mg 2 QL (84 tabs/ 365 days) ANTIFUNGALS - TOPICAL ciclopirox cre 0.77% 2 ciclopirox gel 0.77% 2 ciclopirox sha 1% 2 ciclopirox sol 8% 2 PA; DL ciclopirox sus 0.77% 2 clotrim/beta cre diprop 2 clotrim/beta lot diprop 2 econazole cre 1% 2 EXELDERM CRE 1% 4 EXELDERM SOL 1% 4 ketoconazole cre 2% 2 ketoconazole sha 2% 2 KETODAN KIT 2% 2 NAFTIN CRE 1% 4 NAFTIN GEL 1%, 2% 4 nyamyc 2 nystat/triam cre 2 nystat/triam oin 2 nystatin cre nystatin oin nystatin pow nystop 2 OXISTAT CRE 1% 4 OXISTAT LOT 1% 4 pedi-dri 2 ANTIHISTAMINES - ETHANOLAMINES carbinoxamine sol 4mg/5ml 2 carbinoxamine tab 4mg 2 clemastine syp 0.5/5ml 2 clemastine tab 2.68mg 2 PALGIC TAB 4MG 2 ANTIHISTAMINES - NON-SEDATING CLARINEX SYP 0.5MG/ML 4 desloratadine tab 2.5 odt 2 desloratadine tab 5mg, 5mg odt 2 levocetirizine sol 2.5/5ml 2 levocetirizine tab 5mg 2 ANTIHISTAMINES - PHENOTHIAZINES phenadoz 2 promethazine inj 25mg/ml, 50mg/ml 2 promethazine sup 12.5mg, 25mg 2 promethazine syp 6.25/5ml 2 promethazine tab 12.5mg, 25mg, 50mg 2 promethegan 2 ANTIHYPERLIPIDEMICS - COMBINATIONS 8

24 LIPTRUZET 3 VYTORIN TAB 10-10MG, 20MG, 40MG, 80MG 4 ANTIHYPERLIPIDEMICS - MISC. KYNAMRO INJ 200MG/ML 5 NM, PA; DL omega-3-acid ethyl esters 2 ANTIHYPERTENSIVE COMBINATIONS amlodipine/benazapril cap mg 2 amlodipine/benazapril cap 5-10mg, 20mg, 40mg 2 amlodipine/benazapril cap 10-20mg, 40mg 2 atenol/chlor tab 50-25mg 1 atenol/chlor tab mg 1 AZOR TAB 5-20MG, 40MG 4 AZOR TAB 10-20MG, 40MG 4 benazepril/hctz tab benazepril/hctz tab benazepril/hctz tab , 25mg 1 BENICAR HCT TAB BENICAR HCT TAB MG, 25MG 4 bisoprolol/hctz tab 2.5/ bisoprolol/hctz tab mg 1 bisoprolol/hctz tab 10/ candesartan/hctz tab candesartan/hctz tab , 25mg 2 captopril/hctz tab 25-15mg, 25mg 1 captopril/hctz tab 50-15mg, 25mg 1 EDARBYCLOR TAB MG, 25MG 4 enalapril/hctz tab mg 1 enalapril/hctz tab 10-25mg 1 EXFORGE TAB 5-160MG, 320MG 4 EXFORGE TAB MG, 320MG 4 EXFORGE HCT/ , EXFORGE HCT/ , , fosinopril/hctz tab 10/ fosinopril/hctz tab 20/ irbesartan/hctz tab , lisinopril/hctz tab lisinopril/hctz tab lisinopril/hctz tab 20-25mg 1 losartan/hct tab losartan/hct tab , methyldopa/hctz tab 250/15, 250/25 4 metoprolol/hctz tab 50-25mg, mg 1 metoprl/hctz tab mg 1 moexipril/hctz tab , , 15-25mg 2 nadolol/bend tab 40-5mg, 80-5mg 2 propranolol/hctz tab 40/25, 80/25 1 quinapril/hctz tab quinapril/hctz tab , 20-25mg 1 TEKTURNA HCT TAB MG, 25MG 4 TEKTURNA HCT TAB MG, 25MG 4 telmisartan/amlodipine tab 40-5mg, 10mg 2 telmisartan/amlodipine tab 80-5mg, 10mg 2 9

25 telmisartan/hctz tab telmisartan/hctz tab mg, 25mg 2 TRIBENZOR20- TAB MG 4 TRIBENZOR40- TAB MG, 5-25MG 4 TRIBENZOR40- TAB MG, 10-25MG 4 valsartan/hctz tab valsartan/hctz tab mg, mg 2 valsartan/hctz tab mg, mg 2 ANTIMALARIAL COMBINATIONS atovaq/progu tab DL COARTEM TAB MG 4 DL ANTIMALARIALS chloroquine tab 250mg, 500mg 2 DL DARAPRIM TAB 25MG 4 DL hydroxychloroquine tab 200mg 2 mefloquine tab 250mg 2 DL PRIMAQUINE TAB 26.3MG 4 DL QUALAQUIN CAP 324MG 4 DL quinine sulf cap 324mg 2 DL ANTIMANIC AGENTS lithium carb cap 150mg, 300mg, 600mg 2 lithium carb tab 300mg 2 lithium carb tab 300mg er, 450mg er 2 LITHIUM CITR SOL 8MEQ/5ML 2 ANTIMETABOLITES ALIMTA INJ 500MG 5 B/D; DL ARRANON INJ 5MG/ML 5 B/D; DL azacitidine inj 100mg 5 B/D, NM; DL cladribine inj 1mg/ml 4 B/D; DL cytarabine inj 20mg/ml, 100mg/ml 2 B/D; DL decitabine inj 50mg 5 B/D, NM; DL fludarabine inj 50mg 2 B/D; DL fluorouracil inj 2.5g/50m 2 B/D; DL gemcitabine inj 1gm 2 B/D; DL mercaptopur tab 50mg 2 methotrexate inj 1gm 2 B/D; DL methotrexate inj 1gm/40ml 2 methotrexate tab 2.5mg 2 TABLOID TAB 40MG 4 TREXALL TAB 5MG, 7.5MG, 10MG, 15MG 4 VIDAZA INJ 100MG 5 B/D, NM; DL ANTIMYASTHENIC/CHOLINERGIC AGENTS GUANIDINE HCL 2 MESTINON SYP 60MG/5ML 4 MESTINON TAB TIMESPAN 4 pyridostigmine tab 60mg 2 ANTIMYCOBACTERIAL AGENTS CAPASTAT SUL INJ 1GM 4 ethambutol tab 100mg, 400mg 2 isoniazid inj 100mg/ml 2 isoniazid syp 50mg/5ml 2 10

26 isoniazid tab 100mg, 300mg 2 MYCOBUTIN CAP 150MG 4 PASER GRA 4GM 4 PRIFTIN TAB 150MG 4 pyrazinamide tab 500mg 2 rifabutin 2 rifampin cap 150mg, 300mg 2 rifampin inj 600 mg 2 SIRTURO TAB 100MG 5 LA, PA; DL TRECATOR TAB 250MG 4 ANTINEOPLASTIC - ANGIOGENESIS INHIBITORS AVASTIN INJ 5 B/D, NM; DL ZALTRAP INJ 100/4ML 5 NM, PA; DL ANTINEOPLASTIC - ANTIBODIES ARZERRA CON 100/5ML 5 B/D, NM; DL ERBITUX INJ 100MG 5 B/D, NM; DL HERCEPTIN INJ 440MG 5 B/D, NM; DL KADCYLA INJ 100MG 5 NM, PA; DL PERJETA INJ 420/14ML 5 NM, PA; DL RITUXAN INJ 500MG 5 NM; DL VECTIBIX INJ 100MG 5 B/D, NM; DL YERVOY INJ 50MG 5 NM, PA; DL ANTINEOPLASTIC - HEDGEHOG PATHWAY INHIBITORS ERIVEDGE CAP 150MG 5 NM, LA, PA; DL ANTINEOPLASTIC - HORMONAL AND RELATED AGENTS anastrozole tab 1mg 2 bicalutamide tab 50mg 2 DEPO-PROVERA INJ 400/ML 4 ELIGARD INJ 7.5MG, 22.5MG, 30MG, 45MG 4 B/D, NM; DL EMCYT CAP 140MG 3 exemestane tab 25mg 2 FARESTON TAB 60MG 3 FASLODEX INJ 250MG 5 B/D; DL FIRMAGON INJ 80MG 4 B/D, QL (4 / 28 days), NM; DL FIRMAGON INJ 120MG 5 B/D, NM; DL flutamide cap 125mg 2 letrozole tab 2.5mg 2 leuprolide inj 1mg/0.2 2 NM LUPRON DEPOT INJ 3.75MG 4 QL (1 box / 30 days), NM; DL LUPRON DEPOT INJ 7.5MG, 1125MG, 22.5MG, 30MG, 45MG 5 NM; DL LYSODREN TAB 500MG 3 megestrol ac sus 40mg/ml 2 PA; DL megestrol ac tab 20mg, 40mg 2 PA; DL NILANDRON TAB 150MG 3 SOLTAMOX SOL 10MG/5ML 4 tamoxifen tab 10mg, 20mg 2 TRELSTAR DEP INJ 3.75MG 4 NM; DL TRELSTAR LA INJ 11.25MG 4 NM; DL TRELSTAR MIX INJ 22.5MG 5 NM; DL XTANDI CAP 40MG 5 NM, LA, PA; DL ZYTIGA TAB 250MG 5 NM, PA; DL ANTINEOPLASTIC - IMMUNOMODULATORS 11