PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN.

Transcription

1 01 Blue BCN Advantage HMO BCN Advantage HMO-POS Medicare and more Care Network of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association. BCN Advantage Formulary (List of covered drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN. This formulary was updated on 10/1/01. For more recent information or other questions, please contact BCN Advantage Customer Service at or, for TTY users, 711, 8 a.m. to 8 p.m. Monday through Friday, with weekend hours Oct. 1 through Feb. 1, or visit 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. Last updated: 10/1/01 Formulary 118, version BCN Advantage is an HMO POS plan and an HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal. DB 1991 OCT 1 H88_C_01FormularyR1 CMS Accepted

2 When this drug list (formulary) refers to we, us, or our, it means Blue Care Network. When it refers to plan or our plan, it means BCN Advantage. This document includes a list of the drugs (formulary) for our plan which is current as of 10/1/01. For an updated formulary, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy network, premium and/or copayments/coinsurance may change on January 1, 016.

3 What is the BCN Advantage Formulary? A formulary is a list of covered drugs selected by BCN Advantage 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. BCN Advantage will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a BCN Advantage network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage. Can the Formulary (drug list) change? Generally, if you are taking a drug on our 01 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 01 coverage year except when a new, less expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released. Other types of formulary changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug. It will remain available at the same cost-sharing for those members taking it for the remainder of the coverage year. We feel it is important that you have continued access for the remainder of the coverage year to the formulary drugs that were available when you chose our plan, except for cases in which you can save additional money or we can ensure your safety. If we remove drugs from our formulary, or add prior authorization, quantity limits and/or step therapy restrictions on a drug or move a drug to a higher cost-sharing tier, we must notify affected members of the change at least 60 days before the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 60-day supply of the drug. If the Food and Administration deems a drug on our formulary to be unsafe or the drug s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug. The enclosed formulary is current as of 10/1/01. To get updated information about the drugs covered by BCN Advantage, please contact us. Our contact information appears on the front and back cover pages. How do I use the Formulary? There are two ways to find your drug within the formulary: Medical Condition The formulary begins on page 1. The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category, Cardiovascular Agents. If you know what your drug is used for, look for the category name in the list that begins page 1. Then look under the category name for your drug. Alphabetical Listing If you are not sure what category to look under, you should look for your drug in the Index that begins on page Index 1. The Index provides an alphabetical list of all of the drugs included in this document. Both brand name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the Index and find the name of your drug in the first column of the list. What are generic drugs? BCN Advantage covers both brand name drugs and generic drugs. A generic drug is approved by the FDA as having the same active ingredient as the brand name drug. Generally, generic drugs cost less than brand name drugs. Are there any restrictions on my coverage? Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include: Prior Authorization: BCN Advantage requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from BCN Advantage before you fill your prescriptions. If you don t get approval, BCN Advantage may not cover the drug. Quantity Limits: For certain drugs, BCN Advantage limits the amount of the drug that BCN Advantage will cover. For example, BCN Advantage provides thirty four s per prescription for Crestor. This may be in addition to a standard one-month or three-month supply. i

4 Step Therapy: In some cases, BCN Advantage requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if A and B both treat your medical condition, BCN Advantage may not cover B unless you try A first. If A does not work for you, BCN Advantage will then cover B. You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 1. You can also get more information about the restrictions applied to specific covered drugs by visiting our Web site. 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 BCN Advantage to make an exception to these restrictions or limits or for a list of other, similar drugs that may treat your health condition. See the section, How do I request an exception to the BCN Advantage s formulary? on page ii for information about how to request an exception. What if my drug is not on the Formulary? If your drug is not included in this formulary (list of covered drugs), you should first contact Customer Service and ask if your drug is covered. If you learn that BCN Advantage does not cover your drug, you have two options: You can ask Customer Service for a list of similar drugs that are covered by BCN Advantage. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by BCN Advantage. You can ask BCN Advantage to make an exception and cover your drug. See below for information about how to request an exception. How do I request an exception to the BCN Advantage Formulary? You can ask BCN Advantage to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make. You can ask us to cover a drug even if it is not on our formulary. If approved, this drug will be covered at a pre-determined cost-sharing level, and you would not be able to ask us to provide the drug at a lower cost-sharing level. You can ask us to cover a formulary drug at a lower cost-sharing level if this drug is not on the specialty tier. If approved this would lower the amount you must pay for your drug. You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, BCN Advantage limits the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover a greater amount. Generally, BCN Advantage will only approve your request for an exception if the alternative drugs included on the plan s formulary, the lower cost-sharing drug or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects. You should contact us to ask us for an initial coverage decision for a formulary, tiering or utilization restriction exception. When you request a formulary, tiering or utilization restriction exception you should submit a statement from your prescriber or physician supporting your request. Generally, we must make our decision within 7 hours of getting your prescriber s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 7 hours for a decision. If your request to expedite is granted, we must give you a decision no later than hours after we get a supporting statement from your doctor or other prescriber. ii

5 What do I do before I can talk to my doctor about changing my drugs or requesting an exception? As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan. For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary -day supply (unless you have a prescription written for fewer when you go to a network pharmacy. After your first -day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days. If you are a resident of a long-term care facility, we will allow you to refill your prescription until we have provided you with a 91-day transition supply, consistent with dispensing increment, (unless you have a prescription written for fewer. We will cover more than one refill of these drugs for the first 90 days you are a member of our plan. If you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a -day emergency supply of that drug (unless you have a prescription for fewer while you pursue a formulary exception. Other times when we will cover a temporary -day transition supply (or less, if you have a prescription for fewer includes: When you enter a long-term care facility When you leave a long-term care facility When you are discharged from a hospital When you leave a skilled nursing facility When you cancel hospice care When you are discharged from a psychiatric hospital with a medication regimen that is highly individualized BCN Advantage will send you a letter within three business days of your filling a temporary transition supply, notifying you that this was a temporary supply and explaining your options. Note: Our transition policy applies only to those drugs that are Part D drugs and that are bought at a network pharmacy. The transition policy can t be used to buy a non-part D drug or a drug out-of-network, unless you qualify for out-of-network access. In addition to any exclusions or limitations described in the BCN Advantage 01 Formulary, or in the Evidence of Coverage, the following items and services aren t covered under Original Medicare or by our plan: Replacement prescriptions resulting from loss, theft or mishandling Reimbursement for prescriptions that are not approved by the FDA Reimbursement for prescriptions that are not purchased in the United States or its territories Out-of-state prescription refills are available to you when you spend time outside of Michigan; for example, if you travel to Florida in the winter months. Please call our Customer Service number located on the front and back covers of this booklet if you need help locating an out-of-state participating pharmacy. For more information For more detailed information about your BCN Advantage prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about BCN Advantage, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. If you have general questions about Medicare prescription drug coverage, please call Medicare at MEDICARE ( ) hours a day/7 days a week. TTY users call Or, visit iii

6 BCN Advantage Formulary The formulary below provides coverage information about the drugs covered by BCN Advantage. If you have trouble finding your drug in the list, turn to the Index that begins on page Index 1. The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., Crestor ) and generic drugs are listed in lower-case italics (e.g., sumatriptan). The information in the column tells you if BCN Advantage has any special requirements for coverage of your drug. Your Costs (see copay tables below) The amount you pay for a covered drug will depend on: Your coverage stage. BCN Advantage has different stages of coverage. In each stage, the amount you pay for a drug may change. The drug tier for your drug. Each covered drug is in one of five drug tiers. Each tier may have a different copay or coinsurance amount. The s chart below explains what types of drugs are included in each tier and shows how costs may change with each tier. The pharmacy you use. You may go to any of our network pharmacies. However, you will usually pay less for your three-month supply of covered drugs if you use a preferred network pharmacy rather than a standard retail pharmacy. The Pharmacy Directory will tell you which of the pharmacies in our network are preferred network pharmacies. All drugs on our Formulary are available for mail order: Our plan s mail-order service requires you to order at least a -day supply of the drug and no more than a 90-day supply. specialty drugs are limited to -day supply via mail order. Description of our Formulary s s Includes Helpful Tips 1: Preferred Generic s : NonPreferred Generic s : Preferred Brand s : NonPreferred Brand s : Specialty s This tier includes many commonly prescribed low-cost drugs. This tier includes additional low-cost drugs. This tier includes preferred brand-name drugs This tier includes nonpreferred brand-name drugs. This tier includes very high-cost drugs. This tier includes commonly prescribed generic drugs and may include other low-cost drugs. Use 1 drugs for the lowest co-payments. This tier includes generic drugs and may include other low-cost drugs. Use drugs to keep your co-payments low. s in this tier will generally have lower co-payments than nonpreferred drugs. Many nonpreferred drugs have lower-cost alternatives in s 1, and. Ask your doctor if switching to a lower-cost generic or preferred brand drug may be right for you. Many Specialty drug prescriptions need prior authorization. Contact Customer Service at the numbers listed on the front and back cover of this booklet if you have questions regarding this tier. iv

7 BCN Advantage Prescription Costs* for Initial Coverage Stage *If you are eligible to receive a low-income subsidy for extra help, the copay and coinsurance amounts listed in this chart are not applicable. Refer to your Evidence of Coverage for cost-sharing details. The BCN Advantage Classic, Prestige, MyChoice and ConnectedCare plans have no deductible. You pay the amounts listed below until you reach your Initial Coverage Stage limit of $,960. This amount includes the total drug costs paid by you (copayments and coinsurance) and the plan. The BCN Advantage Basic plan has a deductible. After you (or others on your behalf) have met your deductible, the plan pays its share of the costs of your drugs and you pay your share. Up to a -day supply Up to a 90-day supply Description 1 Preferred Generic At long-term care, preferred and standard retail network pharmacies** At out-ofnetwork pharmacies At the plan s mail order service At preferred network pharmacies or the plan s mail order service At standard retail network pharmacies Basic: % Basic: % Basic: % Coinsurance Coinsurance Coinsurance Classic: $ Classic: $7.0 Classic: $9 Prestige: $ Prestige:$7.0 Prestige: $9 MyChoice: $ MyChoice: $1.0 MyChoice: $1 ConnectedCare: $ ConnectedCare: ConnectedCare: $1.0 $1 Basic: % Basic: % Basic: % Coinsurance Coinsurance Coinsurance Non Classic: $10 Classic: $ Classic: $0 Preferred Prestige: $10 Prestige: $ Prestige: $0 Generic MyChoice: $1 MyChoice: $7.0 MyChoice: $ ConnectedCare: $1 Preferred Brand ConnectedCare: $7.0 ConnectedCare: $ Basic: % Basic: % Basic: % Coinsurance Coinsurance Coinsurance Classic: $0 Classic: $100 Classic: $10 Prestige: $ Prestige: $87.0 Prestige: $10 MyChoice: $ MyChoice: $11.0 MyChoice: $1 ConnectedCare: $ ConnectedCare: ConnectedCare: $11.0 $1 Basic: % Basic: % Basic: % Coinsurance Coinsurance Coinsurance Non Classic: $80 Classic: $00 Classic: $0 Preferred Prestige: $7 Prestige: $187.0 Prestige: $ Brand MyChoice: $9 MyChoice: $7.0 MyChoice: $8 ConnectedCare: $9 ConnectedCare: $7.0 ConnectedCare: $8 Specialty Basic: % Coinsurance Classic/Prestige/MyChoice/ ConnectedCare: % Coinsurance A long-term supply is not available for drugs in **Brand-name solid oral dosage drugs are limited to a 1-day supply with prorated cost sharing. v

8 BCN Advantage Costs* for Coverage Gap Stage *If you are eligible to receive a low-income subsidy for extra help, the copay and coinsurance amounts listed in this chart are not applicable. Refer to your Evidence of Coverage for cost-sharing details. After you leave the Initial Coverage Stage, we will continue to provide some prescription drug coverage until your yearly out-of-pocket costs reach a maximum of $,700 for 01. The BCN Advantage Classic, Prestige and MyChoice plans offer additional gap coverage. We provide additional drug coverage for 1 (Preferred Generic) drugs only; you will be required to pay the applicable copayment or coinsurance. Description 1 Preferred Generic & Non Preferred Generic Preferred and Non Preferred Brands Up to a -day supply At long-term care, preferred and standard retail network pharmacies** At out-ofnetwork pharmacies Basic: 6% of the approved total cost Classic: % of the approved total cost Prestige: the lesser of a $ copay or 6% of the approved total cost MyChoice: the lesser of a $7 copay or 6% of the approved total cost. ConnectedCare: 6% of the approved total cost Basic, Classic, Prestige, MyChoice and ConnectedCare: 6% of the approved total cost Basic, Classic, Prestige, MyChoice and ConnectedCare: % of the approved drug cost (plus a portion of the dispensing fee) At the plan s mail order service Up to a 90-day supply At preferred network pharmacies or the plan s mail order service Basic: 6% of the approved total cost Classic: 0% of the approved total cost Prestige: the lesser of a $1.0 copay or 6% of the approved total cost MyChoice: the lesser of $17.0 copay or 6% of the approved total cost ConnectedCare: 6% of the approved total cost Basic, Classic, Prestige, MyChoice and ConnectedCare: 6% of the approved total cost Basic, Classic, Prestige, MyChoice and ConnectedCare: % of the approved drug cost (plus a portion of the dispensing fee) At standard retail network pharmacies Basic: 6% of the approved total cost Classic: % of the approved total cost Prestige: the lesser of a $1 copay or 6% of the approved total cost MyChoice: the lesser of $1 copay or 6% of the approved total cost ConnectedCare: 6% of the approved total cost Basic, Classic, Prestige, MyChoice and ConnectedCare: 6% of the approved total cost Basic, Classic, Prestige, MyChoice and ConnectedCare: % of the approved drug cost (plus a portion of the dispensing fee) vi

9 Up to a -day supply Up to a 90-day supply Description Specialty At long-term care, preferred and standard retail network pharmacies** At out-ofnetwork pharmacies Basic, Classic, Prestige, MyChoice and ConnectedCare: Brands: % of the approved drug cost (plus a portion of the dispensing fee) Generics: 6% of the approved total cost At the plan s mail order service At preferred network pharmacies or the plan s mail order service Basic, Classic, Prestige, MyChoice and ConnectedCare: Brands: % of the approved drug cost (plus a portion of the dispensing fee) Generics: 6% of the approved total cost At standard retail network pharmacies Basic, Classic, Prestige, My Choice and ConnectedCare: Brands: % of the approved drug cost (plus a portion of the dispensing fee) Generics: 6% of the total approved drug cost It is important that you continue to use your BCN Advantage card when you are in the Coverage Gap Stage. Using your card assures you will pay the price your plan negotiated with the network pharmacy (usually less than retail prices) and, by tracking your spending, assures you will receive catastrophic coverage as soon as you are eligible. **Brand-name solid oral dosage drugs are limited to a 1-day supply with prorated cost sharing. BCN Advantage Costs* for Catastrophic Coverage Stage *If you are eligible to receive a low-income subsidy for extra help, the copay and coinsurance amounts listed in this chart are not applicable. Refer to your Evidence of Coverage for cost-sharing details. When your out-of-pocket costs have reached the $,700 Coverage Gap Stage limit, you move on to the Catastrophic Coverage Stage. The plan will pay for most of your drug costs for the rest of the calendar year. You will pay the following at network pharmacies: Description 1 Preferred Generic Non Preferred Generic Preferred Brand Non Preferred Brand Specialty Up to a -day supply at ALL retail pharmacies or the plan s mail order service Up to a 90-day supply at preferred and standard network retail pharmacies The greater of $.6 or % of the plan s approved amount The greater of $6.60 or % of the plan s approved amount The greater of $.6 (generics) $6.60 (brands) or % of the plan s approved amount A long-term supply is not available for drugs in vii

10 List of Abbreviations QL: Quantity Limit. For certain drugs, BCN Advantage limits the amount of the drug that we will cover. ST: Step Therapy. In some cases, BCN Advantage requires you to first try a certain drug to treat your medical condition before we will cover another drug for that condition. For example, if A and B both treat your medical condition, we may not cover B unless you try A first. If A does not work for you, we will then cover B. PA: Prior Authorization. BCN Advantage requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval before you fill your prescription. If you don t get approval, we may not cover the drug. B/D: This drug may be covered under Medicare Part B or D depending on the circumstances. Information may need to be submitted describing the use and setting of the drug to make the determination. HI: Home Infusion. This prescription drug is covered under our medical benefit. For more information, call Customer Service. GC: Gap Coverage. For members in Classic, Prestige, or My Choice we provide additional coverage of this prescription drug in the coverage gap. Please refer to your Evidence of Coverage for more information about this coverage. LA: Limited Availability. This prescription drug may be available only at certain pharmacies. For more information, call Customer Service at the numbers listed on the cover of this document. BRAND-NAME DRUGS ARE CAPITALIZED. Generic drugs are lower-case italics. viii

11 Name ANTI - INFECTIVES ANTIFUNGAL AGENTS ABELCET SUSPENSION AMBISOME SUSPENSION FOR RECONSTITUTIO N amphotericin b injection recon soln CANCIDAS clotrimazole mucous membrane troche ERAXIS(WATER DILUENT) fluconazole in dextrose(iso-o) intravenous piggyback fluconazole in nacl (iso-osm) intravenous piggyback fluconazole oral suspension for reconstitution fluconazole oral Name flucytosine oral griseofulvin microsize oral suspension griseofulvin microsize oral griseofulvin ultramicrosize oral itraconazole oral ketoconazole oral NOXAFIL NOXAFIL ORAL SUSPENSION NOXAFIL ORAL,DELAYE D RELEASE (DR/EC) nystatin oral suspension nystatin oral SPORANOX ORAL terbinafine hcl oral voriconazole intravenous QL (10 per : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part B vs. Part D only GC - Gap Coverage HI - 1

12 Name Name voriconazole oral suspension for reconstitution voriconazole oral ANTIVIRALS abacavir oral abacavirlamivudinezidovudine oral acyclovir oral ATRIPLA ORAL BARACLUDE ORAL BARACLUDE ORAL cidofovir intravenous COMPLERA ORAL CRIXIVAN ORAL CAPSULE 00 MG, 00 MG acyclovir oral suspension 00 mg/ ml didanosine oral,delayed release(dr/ec) acyclovir oral acyclovir sodium intravenous recon soln EDURANT ORAL EMTRIVA ORAL CAPSULE acyclovir sodium intravenous EMTRIVA ORAL adefovir oral entecavir oral amantadine hcl oral EPIVIR HBV ORAL amantadine hcl oral EPIVIR ORAL amantadine hcl oral EPZICOM ORAL APTIVUS ORAL CAPSULE EVOTAZ ORAL APTIVUS ORAL famciclovir oral : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part B vs. Part D only GC - Gap Coverage HI -

13 Name foscarnet intravenous FUZEON ganciclovir sodium intravenous recon soln HARVONI ORAL INTELENCE ORAL 100 MG, 00 MG INTELENCE ORAL MG INVIRASE ORAL CAPSULE INVIRASE ORAL ISENTRESS ORAL POWDER IN PACKET ISENTRESS ORAL ISENTRESS ORAL,CHEWAB LE 100 MG ISENTRESS ORAL,CHEWAB LE MG KALETRA ORAL PA Name KALETRA ORAL 100- MG KALETRA ORAL 00-0 MG lamivudine oral lamivudine oral lamivudinezidovudine oral LEXIVA ORAL SUSPENSION LEXIVA ORAL moderiba dose pack oral s,dose pack moderiba oral nevirapine oral suspension nevirapine oral nevirapine oral extended release hr NORVIR ORAL CAPSULE NORVIR ORAL NORVIR ORAL : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part B vs. Part D only GC - Gap Coverage HI -

14 Name OLYSIO ORAL CAPSULE PREZCOBIX ORAL PREZISTA ORAL SUSPENSION PREZISTA ORAL 10 MG, 7 MG PREZISTA ORAL 600 MG, 800 MG REBETOL ORAL RELENZA DISKHALER INHALATION BLISTER WITH DEVICE RESCRIPTOR ORAL RESCRIPTOR ORAL, DISPERSIBLE RETROVIR REYATAZ ORAL CAPSULE 10 MG, 00 MG, 00 MG REYATAZ ORAL POWDER IN PACKET ribasphere oral PA QL (68 per Name ribasphere oral 00 mg, 00 mg ribasphere oral 600 mg ribasphere ribapak oral s,dose pack ribavirin oral ribavirin oral 00 mg rimantadine oral SELZENTRY ORAL SOVALDI ORAL stavudine oral stavudine oral recon soln STRIBILD ORAL SUSTIVA ORAL CAPSULE SUSTIVA ORAL SYNAGIS R 0 MG/0. ML TAMIFLU ORAL CAPSULE 0 MG : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part B vs. Part D only GC - Gap Coverage HI - PA QL (6 per 180

15 Name Name TAMIFLU ORAL CAPSULE MG, 7 MG TAMIFLU ORAL SUSPENSION FOR RECONSTITUTIO N QL (8 per 180 QL (60 per 180 VIRACEPT ORAL VIRAMUNE XR ORAL EXTENDED RELEASE HR 100 MG TIVICAY ORAL TRIUMEQ ORAL TRUVADA ORAL TYBOST ORAL TYZEKA ORAL valacyclovir oral VALCYTE ORAL valganciclovir oral VIDEX GRAM PEDIATRIC ORAL VIDEX GRAM PEDIATRIC ORAL VIEKIRA PAK ORAL S,DOSE PACK PA VIRAZOLE INHALATION VIREAD ORAL POWDER VIREAD ORAL VITEKTA ORAL ZIAGEN ORAL zidovudine oral zidovudine oral syrup zidovudine oral CEPHALOSPORINS CEDAX ORAL CAPSULE CEDAX ORAL SUSPENSION FOR RECONSTITUTIO N 90 MG/ ML cefaclor oral : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part B vs. Part D only GC - Gap Coverage HI -

16 Name cefaclor oral suspension for reconstitution 1 mg/ ml, 0 mg/ ml, 7 mg/ ml cefaclor oral extended release 1 hr cefadroxil oral cefadroxil oral suspension for reconstitution 0 mg/ ml, 00 mg/ ml cefadroxil oral cefazolin in dextrose (iso-os) intravenous piggyback 1 gram/0 ml cefazolin injection recon soln 1 gram, 10 gram, 00 mg cefazolin injection recon soln 100 gram, 00 g cefazolin intravenous recon soln cefdinir oral cefdinir oral suspension for reconstitution HI HI Name CEFEPIME IN DEXTROSE % PIGGYBACK cefepime in dextrose,iso-osm intravenous piggyback cefepime injection recon soln cefixime oral suspension for reconstitution cefotaxime injection recon soln 1 gram, gram, 00 mg CEFOTETAN IN DEXTROSE, ISO- OSM PIGGYBACK cefotetan intravenous recon soln cefoxitin in dextrose, iso-osm intravenous piggyback cefoxitin intravenous recon soln cefpodoxime oral suspension for reconstitution cefpodoxime oral HI HI HI HI HI : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part B vs. Part D only GC - Gap Coverage HI - 6

17 Name cefprozil oral suspension for reconstitution cefprozil oral CEFTAZIDIME IN DW PIGGYBACK ceftazidime injection recon soln ceftibuten oral ceftibuten oral suspension for reconstitution ceftriaxone in dextrose,iso-os intravenous piggyback ceftriaxone injection recon soln 1 gram, gram ceftriaxone injection recon soln 10 gram, 0 mg, 00 mg ceftriaxone intravenous recon soln cefuroxime axetil oral cefuroxime sodium injection recon soln 1. gram, 70 mg HI HI HI HI HI Name cefuroxime sodium intravenous recon soln cephalexin oral cephalexin oral suspension for reconstitution cephalexin oral CLAFORAN GRAM FORTAZ IN DEXTROSE % PIGGYBACK FORTAZ INJECTION 1 GRAM FORTAZ MAXIPIME 1 GRAM MEFOXIN IN DEXTROSE (ISO- OSM) PIGGYBACK SUPRAX ORAL CAPSULE : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part B vs. Part D only GC - Gap Coverage HI - 7 HI HI HI

18 Name SUPRAX ORAL SUSPENSION FOR RECONSTITUTIO N SUPRAX ORAL,CHEWAB LE TAZICEF INJECTION TAZICEF TEFLARO ZERBAXA ERYTHROMYCINS / OTHER MACROLIDES azithromycin intravenous recon soln azithromycin oral packet azithromycin oral suspension for reconstitution azithromycin oral clarithromycin oral suspension for reconstitution HI Name clarithromycin oral clarithromycin oral extended release hr DIFICID ORAL e.e.s. 00 oral ery-tab oral,delayed release (dr/ec) 0 mg, mg ERY-TAB ORAL,DELAYE D RELEASE (DR/EC) 00 MG erythrocin (as stearate) oral 0 mg ERYTHROCIN erythromycin ethylsuccinate oral erythromycin oral,delayed release(dr/ec) erythromycin oral PCE ORAL, PARTICLES/CRYS TALS : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part B vs. Part D only GC - Gap Coverage HI - 8

19 Name ZMAX ORAL SUSPENSION,EXT ENDED REL RECON MISCELLANEOUS ANTIINFECTIVES ALBENZA ORAL ALINIA ORAL SUSPENSION FOR RECONSTITUTIO N ALINIA ORAL amikacin injection 1,000 mg/ ml amikacin injection 00 mg/ ml atovaquone oral suspension atovaquoneproguanil oral AZACTAM IN DEXTROSE (ISO- OSM) PIGGYBACK aztreonam injection recon soln 1 gram aztreonam injection recon soln gram baciim intramuscular recon soln HI HI Name bacitracin intramuscular recon soln BETHKIS INHALATION FOR NEBULIZATION BILTRICIDE ORAL CAPASTAT INJECTION chloramphenicol sod succinate intravenous recon soln chloroquine phosphate oral clindamycin hcl oral clindamycin in % dextrose intravenous piggyback clindamycin palmitate hcl oral recon soln clindamycin pediatric oral recon soln clindamycin phosphate injection : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part B vs. Part D only GC - Gap Coverage HI - 9 B/D PA

20 Name Name clindamycin phosphate intravenous COARTEM ORAL colistin (colistimethate na) injection recon soln CUBICIN CYCLOSERINE ORAL CAPSULE DALVANCE DAPSONE ORAL HI B/D PA; HI gentamicin in nacl (iso-osm) intravenous piggyback 60 mg/0 ml, 80 mg/100 ml gentamicin injection gentamicin sulfate (ped) (pf) injection gentamicin sulfate (pf) intravenous 100 mg/10 ml GENTAMICIN SULFATE (PF) 60 MG/6 ML HI DARAPRIM ORAL ethambutol oral gentamicin in nacl (iso-osm) intravenous piggyback 100 mg/100 ml, 70 mg/0 ml, 90 mg/100 ml GENTAMICIN IN NACL (ISO-OSM) PIGGYBACK 100 MG/0 ML, 10 MG/100 ML gentamicin sulfate (pf) intravenous 80 mg/8 ml hydroxychloroquine oral imipenem-cilastatin intravenous recon soln INVANZ INJECTION INVANZ isoniazid injection : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part B vs. Part D only GC - Gap Coverage HI - 10

21 Name isoniazid oral isoniazid oral ivermectin oral KETEK ORAL linezolid intravenous parenteral linezolid oral linezolid-0.9% sodium chloride intravenous parenteral mefloquine oral meropenem intravenous recon soln metro i.v. intravenous piggyback metronidazole in nacl (iso-os) intravenous piggyback metronidazole oral metronidazole oral NEBUPENT INHALATION neomycin oral HI B/D PA Name paromomycin oral PASER ORAL GRANULES DR FOR SUSP IN PACKET PENTAM INJECTION polymyxin b sulfate injection recon soln PRIFTIN ORAL PRIMAQUINE ORAL pyrazinamide oral quinine sulfate oral rifabutin oral rifampin intravenous recon soln rifampin oral RIFATER ORAL RIMSO-0 INTRAVESICAL SIRTURO ORAL SIVEXTRO ORAL : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part B vs. Part D only GC - Gap Coverage HI - 11 PA

22 Name STREPTOMYCIN R STROMECTOL ORAL SYNERCID tinidazole oral TOBI PODHALER INHALATION CAPSULE TOBI PODHALER INHALATION CAPSULE, W/INHALATION DEVICE tobramycin in 0. % nacl inhalation for nebulization tobramycin in 0.9 % nacl intravenous piggyback 80 mg/100 ml tobramycin sulfate injection recon soln tobramycin sulfate injection TRECATOR ORAL TYGACIL B/D PA HI HI Name XIFAXAN ORAL 00 MG XIFAXAN ORAL 0 MG ZYVOX PARENTERAL ZYVOX ORAL SUSPENSION FOR RECONSTITUTIO N ZYVOX ORAL PENICILLINS amoxicillin oral amoxicillin oral suspension for reconstitution amoxicillin oral amoxicillin oral,chewable 1 mg, 0 mg amoxicillin-pot clavulanate oral suspension for reconstitution amoxicillin-pot clavulanate oral QL (9 per QL (68 per : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part B vs. Part D only GC - Gap Coverage HI - 1

23 Name Name amoxicillin-pot clavulanate oral extended release 1 hr amoxicillin-pot clavulanate oral,chewable ampicillin oral BICILLIN L-A R SYRINGE dicloxacillin oral nafcillin in dextrose iso-osm intravenous piggyback 1 gram/0 ml ampicillin oral suspension for reconstitution ampicillin sodium injection recon soln 1 gram, 1 mg HI nafcillin in dextrose iso-osm intravenous piggyback gram/100 ml nafcillin injection recon soln ampicillin sodium injection recon soln gram, 0 mg, 00 mg ampicillin sodium intravenous recon soln ampicillin-sulbactam injection recon soln 1. gram ampicillin-sulbactam injection recon soln 1 gram, gram HI nafcillin intravenous recon soln oxacillin in dextrose(iso-osm) intravenous piggyback oxacillin injection recon soln 1 gram, gram OXACILLIN INJECTION 10 GRAM HI ampicillin-sulbactam intravenous recon soln BICILLIN C-R R SYRINGE oxacillin intravenous recon soln 1 gram OXACILLIN GRAM HI : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part B vs. Part D only GC - Gap Coverage HI - 1

24 Name Name PENICILLIN G POT IN DEXTROSE PIGGYBACK piperacillintazobactam intravenous recon soln. gram, 0. gram penicillin g potassium injection recon soln 0 million unit penicillin g potassium injection recon soln million unit penicillin g procaine intramuscular syringe 1. million unit/ ml penicillin g procaine intramuscular syringe 600,000 unit/ml penicillin g sodium injection recon soln HI HI piperacillintazobactam intravenous recon soln.7 gram,. gram ZOSYN IN DEXTROSE (ISO- OSM) PIGGYBACK. GRAM/0 ML,.7 GRAM/0 ML ZOSYN IN DEXTROSE (ISO- OSM) PIGGYBACK. GRAM/100 ML HI HI penicillin v potassium oral recon soln penicillin v potassium oral pfizerpen-g injection recon soln 0 million unit pfizerpen-g injection recon soln million unit HI QUINOLONES ciprofloxacin (mixture) oral, er multiphase hr ciprofloxacin hcl oral ciprofloxacin in % dextrose intravenous piggyback 00 mg/100 ml ciprofloxacin lactate intravenous QL (1 per fill) : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part B vs. Part D only GC - Gap Coverage HI - 1

25 Name ciprofloxacin oral suspension,microcap sule recon levofloxacin in dw intravenous piggyback 00 mg/100 ml levofloxacin intravenous levofloxacin oral levofloxacin oral moxifloxacin oral ofloxacin oral 00 mg HI SULFA'S / RELATED AGENTS sulfadiazine oral sulfamethoxazoletrimethoprim intravenous sulfamethoxazoletrimethoprim oral suspension sulfamethoxazoletrimethoprim oral sulfatrim oral suspension TETRACYCLINES demeclocycline oral Name doxy-100 intravenous recon soln doxycycline hyclate intravenous recon soln doxycycline hyclate oral doxycycline hyclate oral doxycycline hyclate oral,delayed release (dr/ec) doxycycline monohydrate oral doxycycline monohydrate oral suspension for reconstitution doxycycline monohydrate oral minocycline oral minocycline oral minocycline oral extended release hr morgidox oral tetracycline oral : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part B vs. Part D only GC - Gap Coverage HI - 1

26 Name URINARY TRACT AGENTS methenamine hippurate oral methenamine mandelate oral nitrofurantoin macrocrystal oral 100 mg, 0 mg nitrofurantoin monohyd/m-cryst oral nitrofurantoin oral suspension PRIMSOL ORAL trimethoprim oral VANCOMYCIN VANCOMYCIN IN DW PIGGYBACK 1 GRAM/00 ML VANCOMYCIN IN DEXTROSE ISO- OSM PIGGYBACK vancomycin intravenous recon soln 1,000 mg, 10 gram, 00 mg B/D PA Name vancomycin intravenous recon soln gram VANCOMYCIN 70 MG vancomycin oral ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS ADJUNCTIVE AGENTS amifostine crystalline intravenous recon soln dexrazoxane hcl intravenous recon soln ELITEK FUSILEV KEPIVANCE leucovorin calcium injection recon soln leucovorin calcium oral : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part B vs. Part D only GC - Gap Coverage HI - 16

27 Name LEVOLEUCOVORI N CALCIUM mesna intravenous MESNEX ORAL XGEVA PA ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS ABRAXANE SUSPENSION FOR RECONSTITUTIO N adrucil intravenous AFINITOR DISPERZ ORAL FOR SUSPENSION AFINITOR ORAL ALIMTA anastrozole oral ARRANON PA PA Name ARZERRA 1,000 MG/0 ML ARZERRA 100 MG/ ML ASTAGRAF XL ORAL CAPSULE,EXTEN DED RELEASE HR AVASTIN MG/ML AVASTIN MG/ML (16 ML) azacitidine injection recon soln AZASAN ORAL azathioprine oral BELEODAQ bexarotene oral bicalutamide oral B/D PA PA B/D PA B/D PA PA PA : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part B vs. Part D only GC - Gap Coverage HI - 17

28 Name Name BICNU cyclophosphamide intravenous recon soln B/D PA bleomycin injection recon soln BLINCYTO KIT B/D PA CYCLOPHOSPHA MIDE ORAL CAPSULE cyclosporine intravenous B/D PA B/D PA BOSULIF ORAL BUSULFEX CAPRELSA ORAL carboplatin intravenous CELLCEPT PA B/D PA cyclosporine modified oral cyclosporine modified oral cyclosporine oral CYRAMZA cytarabine (pf) injection B/D PA B/D PA B/D PA PA CELLCEPT ORAL SUSPENSION FOR RECONSTITUTIO N cisplatin intravenous cladribine intravenous CLOLAR COMETRIQ ORAL CAPSULE B/D PA PA cytarabine injection dacarbazine intravenous recon soln daunorubicin intravenous DAUNOXOME decitabine intravenous recon soln : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part B vs. Part D only GC - Gap Coverage HI - 18

29 Name Name DEPOCYT (PF) INTRATHECAL SUSPENSION epirubicin intravenous recon soln 0 mg DOCEFREZ 0 MG docetaxel intravenous 10 mg/ml, 160 mg/16 ml (10 mg/ml), 0 mg/ ml (10 mg/ml), 0 mg/ml (1 ml), 80 mg/ ml (0 mg/ml), 80 mg/8 ml (10 mg/ml) docetaxel intravenous 10 mg/7 ml (0 mg/ml) doxorubicin intravenous recon soln doxorubicin intravenous doxorubicin, pegliposomal intravenous suspension DROXIA ORAL CAPSULE ELLENCE EMCYT ORAL CAPSULE epirubicin intravenous ERBITUX ERIVEDGE ORAL CAPSULE ERWINAZE R ETOPOPHOS etoposide intravenous exemestane oral FARESTON ORAL FARYDAK ORAL CAPSULE FASLODEX R SYRINGE floxuridine injection recon soln fludarabine intravenous recon soln fludarabine intravenous PA PA; QL (6 per 1 : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part B vs. Part D only GC - Gap Coverage HI - 19

30 Name fluorouracil intravenous flutamide oral GAZYVA gemcitabine intravenous recon soln gemcitabine intravenous B/D PA gengraf oral B/D PA gengraf oral GILOTRIF ORAL GLEEVEC ORAL HALAVEN HERCEPTIN HEXALEN ORAL CAPSULE hydroxyurea oral IBRANCE ORAL CAPSULE ICLUSIG ORAL 1 MG PA PA PA B/D PA Name ICLUSIG ORAL MG idarubicin intravenous ifosfamide intravenous recon soln ifosfamide intravenous ifosfamide-mesna intravenous kit 1-1 gram IMBRUVICA ORAL CAPSULE INLYTA ORAL IRESSA ORAL irinotecan intravenous IXEMPRA JAKAFI ORAL JEVTANA KADCYLA KEYTRUDA PA; QL (6 per 1 PA PA PA B/D PA : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part B vs. Part D only GC - Gap Coverage HI - 0

31 Name KEYTRUDA LENVIMA ORAL CAPSULE letrozole oral LEUKERAN ORAL leuprolide subcutaneous kit lipodox 0 intravenous suspension lipodox intravenous suspension LOMUSTINE ORAL CAPSULE LUPRON DEPOT ( MONTH) R SYRINGE KIT LUPRON DEPOT ( MONTH) R SYRINGE KIT LUPRON DEPOT (6 MONTH) R SYRINGE KIT LUPRON DEPOT R SYRINGE KIT.7 MG PA; QL (90 per 90 Name LUPRON DEPOT R SYRINGE KIT 7. MG LUPRON DEPOT- PED ( MONTH) R SYRINGE KIT LUPRON DEPOT- PED R KIT LYNPARZA ORAL CAPSULE LYSODREN ORAL MATULANE ORAL CAPSULE MEGACE ES ORAL SUSPENSION megestrol oral suspension 00 mg/10 ml (10 ml), 00 mg/10 ml (0 mg/ml), 6 mg/ ml PA PA PA megestrol oral PA MEKINIST ORAL melphalan hcl intravenous recon soln mercaptopurine oral PA : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part B vs. Part D only GC - Gap Coverage HI - 1

32 Name methotrexate sodium (pf) injection recon soln methotrexate sodium (pf) injection methotrexate sodium injection methotrexate sodium oral mitomycin intravenous recon soln mitoxantrone intravenous concentrate MUSTARGEN INJECTION mycophenolate mofetil oral mycophenolate mofetil oral suspension for reconstitution mycophenolate mofetil oral mycophenolate sodium oral,delayed release (dr/ec) NEXAVAR ORAL NILANDRON ORAL B/D PA B/D PA B/D PA B/D PA B/D PA PA Name NIPENT NULOJIX octreotide acetate injection 1,000 mcg/ml, 00 mcg/ml octreotide acetate injection 100 mcg/ml, 00 mcg/ml, 0 mcg/ml octreotide acetate injection syringe 100 mcg/ml (1 ml), 0 mcg/ml (1 ml) octreotide acetate injection syringe 00 mcg/ml (1 ml) ONCASPAR INJECTION OPDIVO oxaliplatin intravenous recon soln oxaliplatin intravenous paclitaxel intravenous concentrate : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part B vs. Part D only GC - Gap Coverage HI - B/D PA

33 Name PERJETA POMALYST ORAL CAPSULE PROGRAF PURIXAN ORAL SUSPENSION RAPAMUNE ORAL RAPAMUNE ORAL 1 MG, MG REVLIMID ORAL CAPSULE RHEUMATREX ORAL S,DOSE PACK RITUXAN CONCENTRATE SANDIMMUNE SANDOSTATIN LAR DEPOT R KIT PA; QL ( per B/D PA B/D PA B/D PA PA; LA B/D PA B/D PA Name SANDOSTATIN LAR DEPOT R SUSPENSION,EXT ENDED REL RECON SIGNIFOR LAR R SUSPENSION FOR RECONSTITUTIO N SIGNIFOR SIMULECT sirolimus oral B/D PA SOLTAMOX ORAL SOMATULINE DEPOT SYRINGE SPRYCEL ORAL STIVARGA ORAL SUPPRELIN LA IMPLANT KIT SUTENT ORAL CAPSULE PA PA : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part B vs. Part D only GC - Gap Coverage HI -

34 Name SYLVANT 100 MG SYNRIBO TABLOID ORAL tacrolimus oral 0. mg, 1 mg tacrolimus oral mg TAFINLAR ORAL CAPSULE tamoxifen oral TARCEVA ORAL TARGRETIN ORAL CAPSULE TARGRETIN TOPICAL GEL TASIGNA ORAL CAPSULE TEMODAR THALOMID ORAL CAPSULE thiotepa injection recon soln toposar intravenous PA PA B/D PA B/D PA PA PA PA PA PA PA Name topotecan intravenous recon soln topotecan intravenous TORISEL TREANDA TREANDA TRELSTAR DEPOT R SUSPENSION FOR RECONSTITUTIO N TRELSTAR R SUSPENSION FOR RECONSTITUTIO N TRELSTAR R SYRINGE TRELSTAR LA R SUSPENSION FOR RECONSTITUTIO N PA PA : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part B vs. Part D only GC - Gap Coverage HI -

35 Name Name tretinoin (chemotherapy) oral TREXALL ORAL TRISENOX TYKERB ORAL VALSTAR INTRAVESICAL VECTIBIX VELCADE INJECTION vinblastine intravenous vincasar pfs intravenous B/D PA PA YERVOY 00 MG/0 ML ( MG/ML) YERVOY 0 MG/10 ML ( MG/ML) ZALTRAP ZANOSAR ZELBORAF ORAL ZOLADEX IMPLANT 10.8 MG ZOLADEX IMPLANT.6 MG PA PA; QL (0 per 0 vincristine intravenous ZOLINZA ORAL CAPSULE PA vinorelbine intravenous ZORTRESS ORAL 0. MG B/D PA VOTRIENT ORAL XALKORI ORAL CAPSULE XTANDI ORAL CAPSULE PA PA; QL (68 per PA ZORTRESS ORAL 0. MG, 0.7 MG ZYDELIG ORAL ZYKADIA ORAL CAPSULE B/D PA PA PA : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part B vs. Part D only GC - Gap Coverage HI -

36 Name ZYTIGA ORAL PA AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH ANTICONVULSANTS APTIOM ORAL BANZEL ORAL SUSPENSION BANZEL ORAL carbamazepine oral, er multiphase 1 hr carbamazepine oral suspension 100 mg/ ml carbamazepine oral carbamazepine oral extended release 1 hr carbamazepine oral,chewable carbatrol oral, er multiphase 1 hr CELONTIN ORAL CAPSULE 00 MG CEREBYX INJECTION Name clonazepam oral clonazepam oral,disintegrating diazepam rectal kit DILANTIN 0 MG ORAL CAPSULE divalproex oral, sprinkle divalproex oral extended release hr divalproex oral,delayed release (dr/ec) epitol oral ethosuximide oral ethosuximide oral felbamate oral suspension felbamate oral fosphenytoin injection FYCOMPA ORAL gabapentin oral gabapentin oral : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part B vs. Part D only GC - Gap Coverage HI - 6

37 Name Name gabapentin oral 600 mg, 800 mg GABITRIL ORAL 1 MG, 16 MG LAMICTAL ODT ORAL,DISINTE GRATING LAMICTAL ODT STARTER (BLUE) ORAL DISINTEGRATING, DOSE PK LAMICTAL ODT STARTER (GREEN) ORAL DISINTEGRATING, DOSE PK LAMICTAL ODT STARTER (ORANGE) ORAL DISINTEGRATING, DOSE PK LAMICTAL STARTER (BLUE) KIT ORAL S,DOSE PACK LAMICTAL STARTER (GREEN) KIT ORAL S,DOSE PACK LAMICTAL STARTER (ORANGE) KIT ORAL S,DOSE PACK lamotrigine oral lamotrigine oral extended release hr lamotrigine oral, chewable dispersible lamotrigine oral,disintegrating lamotrigine oral s,dose pack mg () LEVETIRACETAM IN NACL (ISO-OS) PIGGYBACK levetiracetam intravenous levetiracetam oral levetiracetam oral : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part B vs. Part D only GC - Gap Coverage HI - 7

38 Name levetiracetam oral extended release hr LYRICA ORAL CAPSULE LYRICA ORAL ONFI ORAL SUSPENSION ONFI ORAL 10 MG ONFI ORAL 0 MG oxcarbazepine oral suspension oxcarbazepine oral PEGANONE ORAL phenobarbital oral elixir phenobarbital oral phenytoin oral suspension phenytoin oral,chewable phenytoin sodium extended oral phenytoin sodium intravenous QL ( per QL (16 per QL (68 per Name phenytoin sodium intravenous syringe POTIGA ORAL primidone oral SABRIL ORAL POWDER IN PACKET SABRIL ORAL TEGRETOL XR ORAL EXTENDED RELEASE 1 HR 100 MG tiagabine oral topiramate oral, sprinkle topiramate oral valproate sodium intravenous valproic acid (as sodium salt) oral valproic acid oral VIMPAT VIMPAT ORAL PA PA : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part B vs. Part D only GC - Gap Coverage HI - 8

39 Name VIMPAT ORAL zonisamide oral PA ANTIPARKINSONISM AGENTS APOKYN CARTRIDGE AZILECT ORAL benztropine injection benztropine oral bromocriptine oral bromocriptine oral carbidopa oral carbidopa-levodopa oral carbidopa-levodopa oral extended release carbidopa-levodopa oral,disintegrating carbidopa-levodopaentacapone oral Name DUOPA J-TUBE INTESTINAL PUMP SUSPENSION entacapone oral LODOSYN ORAL NEUPRO TRANSDERMAL PATCH HOUR pramipexole oral pramipexole oral extended release hr 0.7 mg, 0.7 mg, 1. mg,. mg ropinirole oral ropinirole oral extended release hr selegiline hcl oral selegiline hcl oral TASMAR ORAL 100 MG tolcapone oral trihexyphenidyl oral elixir trihexyphenidyl oral PA : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part B vs. Part D only GC - Gap Coverage HI - 9

40 Name ZELAPAR ORAL,DISINTE GRATING MIGRAINE / CLUSTER HEADACHE THERAPY almotriptan malate oral AXERT ORAL dihydroergotamine nasal spray,nonaerosol ERGOMAR SUBLINGUAL FROVA ORAL migergot rectal suppository MIGRANAL NASAL SPRAY,NON- AEROSOL naratriptan oral RELPAX ORAL rizatriptan oral rizatriptan oral,disintegrating sumatriptan nasal spray,non-aerosol ST; QL (1 per 0 ST; QL (1 per 0 QL (16 per 0 QL (0 per 8 ST; QL (1 per 0 QL (16 per 0 QL (9 per 0 ST; QL (6 per 0 QL (1 per 8 QL (1 per 8 Name sumatriptan succinate oral sumatriptan succinate subcutaneous cartridge sumatriptan succinate subcutaneous pen injector sumatriptan succinate subcutaneous sumatriptan succinate subcutaneous syringe 6 mg/0. ml TREXIMET ORAL zolmitriptan oral zolmitriptan oral,disintegrating ZOMIG NASAL SPRAY,NON- AEROSOL. MG ZOMIG NASAL SPRAY,NON- AEROSOL MG QL (10 per 0 QL (6 per 0 QL (6 per 0 MISCELLANEOUS NEUROLOGICAL THERAPY ST; QL (6 per ST; QL (18 per 90 : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part B vs. Part D only GC - Gap Coverage HI - 0