Anthem Blue MedicareRx Standard (PDP) 2015 Formulary (List of Covered Drugs)

Transcription

1 Anthem Blue MedicareRx Standard (PDP) 0 Formulary (List of Covered s) Please read: This document contains information about some of the drugs we cover in this plan. This formulary was updated on August, 0. For more recent information or other questions, please contact Anthem Blue MedicareRx Standard (PDP) Customer Service at or, for TTY users, 7, 8 a.m. to 8 p.m., seven days a week (except Thanksgiving and Christmas) from October through February, and Monday to Friday (except holi from February through September 0, or visit Y007 0_U_0 CMS Accepted 08/09/0 979MUSENMUB_0 S96_06 Basic_7_v_09_

2 Note to existing members: This formulary has changed since last year. Please review this document to make sure that it still contains the drugs you take. When this drug list (formulary) refers to we, us or our, it means Anthem Blue Cross and Blue Shield. When it refers to plan or our plan, it means Anthem Blue MedicareRx Standard (PDP). This document includes a list of the drugs (formulary) for our plan which is current as of August, 0. For an updated formulary, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy network, and/or copayments/ coinsurance may change on January, 0 and from time to time during the year. Effective Date September, 0 Basic_7_v_09_

3 What is the Anthem Blue MedicareRx Standard (PDP) formulary? A formulary is a list of covered drugs selected by our plan in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. Our plan will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a plan network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage. Can the formulary (drug list) change? Generally, if you are taking a drug on our 0 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 0 coverage year except when a new, less expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released. Other types of formulary changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug. It will remain available at the same cost sharing for those members taking it for the remainder of the coverage year. We feel it is important that you have continued access for the remainder of the coverage year to the forumulary drugs that were available when you chose our plan, except for cases in which you can save additional money or we can ensure your safety. If we remove drugs from our formulary, or add prior authorization, quantity limits and/or step-therapy restrictions on a drug or move a drug to a higher cost-sharing tier, we must notify affected members of the change at least 60 days before the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 60-day supply of the drug. If the Food and Administration (FDA) deems a drug on our formulary to be unsafe or the drug s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug. The enclosed formulary is current as of January, 0. To get updated information about the drugs covered by our plan, please contact us. Our contact information appears on the front and back cover pages. If any other type of approved formulary change (nonmaintenance change) is made during the year, we will notify you by sending you a list of these changes, or by sending you an updated formulary. How do I use the formulary? There are two ways to find your drug within the formulary: Medical Condition The formulary begins on page 8. The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category, Cardiovascular Medications. If you know what your drug is used for, look for the category name in the list that begins on page 8. Then look under the category name for your drug. Alphabetical Listing If you are not sure what category to look under, you should look for your drug in the Index that begins on page 9. The Index provides an alphabetical list of all of the drugs included in this document. Both brand-name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the Index and find the name of your drug in the first column of the list. What are generic drugs? Our plan covers both brand-name drugs and generic drugs. A generic drug is approved by the FDA as having the same active ingredient as the brand-name drug. Generally, generic drugs cost less than brand-name drugs. Are there any restrictions on my coverage? Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include: Prior Authorization: Our plan requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from our plan before you fill your prescriptions. If you don't get approval, our plan may not cover the drug. Quantity : For certain drugs, our plan limits the amount of the drug that our plan will cover. For example, our plan provides 0 tablets per prescription for irbesartan 7mg tablets. This may be in addition to a standard one-month or three-month supply. Effective Date September, 0 Basic_7_v_09_

4 Step Therapy: In some cases, our plan requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if A and B both treat your medical condition, our plan may not cover B unless you try A first. If A does not work for you, our plan will then cover B. You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 8. You can also get more information about the restrictions applied to specific covered drugs by visiting our website. We have posted online documents that explain our prior authorization and step therapy restrictions. You may also ask us to send you a copy. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You can ask our plan to make an exception to these restrictions or limits or for a list of other, similar drugs that may treat your health condition. See the section, How do I request an exception to the Anthem Blue MedicareRx Standard (PDP)'s formulary? on page for information about how to request an exception. What if my drug is not on the formulary? If your drug is not included in this formulary (list of covered drugs), you should first contact Customer Service and ask if your drug is covered. If you learn that our plan does not cover your drug, you have two options: You can ask Customer Service for a list of similar drugs that are covered by our plan. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by our plan. You can ask our plan to make an exception and cover your drug. See below for information about how to request an exception. How do I request an exception to the Anthem Blue MedicareRx Standard (PDP)'s formulary? You can ask our plan to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make: You can ask us to cover a drug even if it is not on our formulary. If approved, this drug will be covered at a predetermined cost-sharing level, and you would not be able to ask us to provide the drug at a lower cost-sharing level. You can ask us to 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, our plan limits the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover a greater amount. Generally, our plan will only approve your request for an exception if the alternative drugs included on the plan s formulary, the lower cost-sharing drug or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects. You should contact us to ask us for an initial coverage decision for a formulary, tiering or utilization restriction exception. When you request a formulary, tiering or utilization restriction exception, you should submit a statement from your prescriber or physician supporting your request. Generally, we must make our decision within 7 hours of getting your prescriber s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 7 hours for a decision. If your request to expedite is granted, we must give you a decision no later than hours after we get a supporting statement from your doctor or other prescriber. Effective Date September, 0 Basic_7_v_09_

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 0-day supply (unless you have a prescription written for fewer when you go to a network pharmacy. After your first 0-day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days. If you are a resident of a long-term-care facility, we will allow you to refill your prescription until we have provided you with a 98-day transition supply, consistent with the dispensing increment (unless you have a prescription written for fewer. We will cover more than one refill of these drugs for the first 90 days you are a member of our plan. If you need a drug that is not on our formulary, or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a -day emergency supply of that drug (unless you have a prescription for fewer while you pursue a formulary exception. During the time when you are getting a temporary supply of a drug, you should talk to your prescriber or prescribing physician to decide what to do when your supply runs out. You can call Customer Service to ask for a list of covered drugs that treat the same medical condition. This list can help your doctor find a covered drug that might work for you while you pursue a formulary exception. Please refer to the Evidence of Coverage for more information about exceptions. For more information For more detailed information about our plan prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about our plan, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. If you have general questions about Medicare prescription drug coverage, please call Medicare at -800-MEDICARE ( ), hours a day/7 days a week. TTY users should call Or, visit Our plan s formulary The formulary on page 8 provides coverage information about some of the drugs covered by our plan. If you have trouble finding your drug in the list, turn to the Index that begins on page 9. The first column of the chart lists the drug name. Brand-name drugs are capitalized (e.g., CRESTOR) and generic drugs are listed in lowercase italics (e.g., atenolol). The information in the column tells you if our plan has any special requirements for coverage of your drug. QLL - Quantity : Restricts the frequency, amount or dosage of medication for which you can obtain benefits each time you get a prescription filled (most often set on a monthly basis). PAR - Prior Authorization: The process of obtaining approval for certain prescriptions before benefits will be approved. You, your doctor or other network provider will need to request prior authorization before you fill the prescription. ST - Step Therapy: The process of first trying a certain drug or drugs to determine if that drug or those drugs will treat your medical condition before your plan will cover another drug for that condition. B/D - Part B vs. Part D: This drug may be covered under either your Part D prescripton drug benefits or as a Part B drug under your medical benefits, as determined by Medicare. Effective Date September, 0 Basic_7_v_09_

6 LA - Limited Access: This prescription may be available only at certain pharmacies. For more information, consult your Pharmacy Directory or call Customer Service at , 8 a.m. to 8 p.m., seven days a week (except Thanksgiving and Christmas) from October through February, and Monday to Friday (except holi from February through September 0. TTY/TDD users should call 7. INJ - Injectable: The drug is available in injectable form. - Mail Orders: Prescription drugs available through mail order. Effective Date September, 0 6 Basic_7_v_09_

7 Cost-sharing for a one-month supply of a covered Part D prescription drug during the Initial Coverage Stage: Cost-Sharing : Preferred Generics Network Pharmacy with preferred cost-sharing (0-day supply) or Mail-Order Pharmacy** (0-day supply) Network Pharmacy with standard cost-sharing (0-day supply) or Long-Term-Care Pharmacy (-day supply) Cost-Sharing : Nonpreferred Generic Network Pharmacy with preferred cost-sharing (0-day supply) or Mail-Order Pharmacy** (0-day supply) Network Pharmacy with standard cost-sharing (0-day supply) or Long-Term-Care Pharmacy (-day supply) Cost-Sharing : Preferred Brand Network Pharmacy with preferred cost-sharing (0-day supply) or Mail-Order Pharmacy** (0-day supply) Network Pharmacy with standard cost-sharing (0-day supply) or Long-Term-Care Pharmacy (-day supply) Cost-Sharing : Nonpreferred Brand Network Pharmacy with preferred cost-sharing (0-day supply) or Mail-Order Pharmacy** (0-day supply) Network Pharmacy with standard cost-sharing (0-day supply) or Long-Term-Care Pharmacy (-day supply) Cost-Sharing : Specialty Network Pharmacy with preferred cost-sharing (0-day supply) or Mail-Order Pharmacy** (0-day supply) Network Pharmacy with standard cost-sharing (0-day supply) or Long-Term-Care Pharmacy (-day supply) $.00 $9.00 $6.00 $.00 $7.00 $.00 % % % % Please refer to our Evidence of Coverage for more information for cost sharing. Network Pharmacy with preferred cost-sharing A network pharmacy that offers covered drugs to members of our plan that may have lower cost-sharing levels than other network pharmacies with standard cost-sharing. ** Mail-Order Pharmacy Mail-order service allows you to order a 0 90-day supply of drugs. The drugs available through our plan s mail-order service are marked as mail-order drugs in our drug list. Effective Date September, 0 7 Basic_7_v_09_

8 Covered Medications by Therapeutic Category Legend Generic drugs are shown in lower-case italics (e.g. atenolol) Brand-name drugs are shown in capital letters (e.g. CRESTOR) QLL - Quantity : Restricts the frequency, amount or dosage of medication for which you can obtain benefits each time you get a prescription filled (most often set on a monthly basis). PAR - Prior Authorization: The process of obtaining approval for certain prescriptions before benefits will be approved. You, your doctor or other network provider will need to request prior authorization before you fill the prescription. ST - Step Therapy: The process of first trying a certain drug or drugs to determine if that drug or those drugs will treat your medical condition before your plan will cover another drug for that condition. B/D - Part B vs Part D: This drug may be covered under either your Part D prescription drug benefits or as a Part B drug under your medical benefits, as determined by Medicare. LA - Limited Access: This prescription may be available only at certain pharmacies. For more information, consult your Pharmacy Directory or call Customer Service , 8 a.m. to 8 p.m., seven days a week (except Thanksgiving and Christmas) from October through February, and Monday to Friday (except holi from February through September 0. TTY/TDD users should call 7. INJ - Injectable: The drug is available in injectable form. - Mail Order: Prescription drugs available through mail order. Name Anti - Infectives abacavir abacavir-lamivudinezidovudine ABELCET acyclovir oral capsule acyclovir oral suspension 00 mg/ ml acyclovir oral tablet acyclovir sodium intravenous recon soln 00 mg acyclovir sodium intravenous solution adefovir ALBENZA ALINIA ORAL SUSPENSION FOR RECONSTITUTION ALINIA ORAL TABLET amantadine hcl oral capsule amantadine hcl oral solution amantadine hcl oral tablet AMBISOME amikacin injection solution, 000 mg/ ml, 00 mg/ ml amoxicillin oral capsule ; ; ; QLL (80 per ; Name amoxicillin oral suspension for reconstitution mg/ ml amoxicillin oral suspension for reconstitution 00 mg/ ml, 0 mg/ ml, 00 mg/ ml amoxicillin oral tablet amoxicillin oral tablet,chewable mg, 0 mg amoxicillin-pot clavulanate oral suspension for reconstitution amoxicillin-pot clavulanate oral tablet 0- mg amoxicillin-pot clavulanate oral tablet 00- mg, 87- mg amoxicillin-pot clavulanate oral tablet extended release hr amoxicillin-pot clavulanate oral tablet,chewable mg amoxicillin-pot clavulanate oral tablet,chewable 00-7 mg amphotericin b ampicillin oral capsule ampicillin oral suspension for reconstitution mg/ ml ; Basic_7_v_09_ 8 Effective Date September, 0

9 Name ampicillin oral suspension for reconstitution 0 mg/ ml ampicillin sodium injection ampicillin sodium intravenous ampicillin-sulbactam injection recon soln. gram, gram ampicillin-sulbactam injection recon soln gram ampicillin-sulbactam intravenous recon soln. gram ampicillin-sulbactam intravenous recon soln gram APTIVUS ORAL CAPSULE APTIVUS ORAL SOLUTION atovaquone atovaquone-proguanil ATRIPLA azithromycin intravenous azithromycin oral aztreonam BARACLUDE BICILLIN C-R BICILLIN L-A CANCIDAS CAPASTAT CAYSTON cefaclor oral capsule 0 mg cefaclor oral capsule 00 mg cefaclor oral suspension for reconstitution mg/ ml, 0 mg/ ml, 7 mg/ ml cefaclor oral tablet extended release hr cefadroxil oral capsule cefadroxil oral suspension for reconstitution 0 mg/ ml, 00 mg/ ml cefadroxil oral tablet cefazolin in dextrose (iso-os) intravenous piggyback gram/ 0 ml, gram/0 ml cefazolin injection recon soln gram, 00 mg PAR; PAR; ; PAR; ; LA Name cefazolin injection recon soln 0 gram, 00 gram, 0 gram, 00 g cefazolin intravenous cefdinir cefepime cefepime in dextrose,iso-osm intravenous piggyback gram/ 0 ml cefepime in dextrose,iso-osm intravenous piggyback gram/ 00 ml cefotaxime injection recon soln gram, gram, 00 mg cefoxitin intravenous recon soln gram cefoxitin intravenous recon soln 0 gram, gram cefpodoxime cefprozil oral suspension for reconstitution mg/ ml cefprozil oral suspension for reconstitution 0 mg/ ml cefprozil oral tablet 0 mg cefprozil oral tablet 00 mg ceftriaxone in dextrose,iso-os ceftriaxone injection recon soln gram, gram, 0 mg, 00 mg ceftriaxone injection recon soln 0 gram ceftriaxone intravenous recon soln cefuroxime axetil oral tablet cefuroxime sodium injection recon soln. gram, 70 mg cefuroxime sodium intravenous cephalexin oral capsule 0 mg, 00 mg cephalexin oral suspension for reconstitution cephalexin oral tablet chloramphenicol sod succinate chloroquine phosphate oral cidofovir ciprofloxacin hcl oral tablet ; Basic_7_v_09_ 9 Effective Date September, 0

10 Name ciprofloxacin in % dextrose ciprofloxacin lactate intravenous solution 00 mg/ 0 ml ciprofloxacin lactate intravenous solution 00 mg/ 0 ml clarithromycin oral suspension for reconstitution clarithromycin oral tablet clarithromycin oral tablet extended release hr clindamycin hcl clindamycin in % dextrose clindamycin phosphate injection clindamycin phosphate intravenous solution 00 mg/ ml, 900 mg/6 ml clindamycin phosphate intravenous solution 600 mg/ ml clotrimazole mucous membrane colistin (colistimethate na) COMPLERA CRIXIVAN ORAL CAPSULE 00 MG, 00 MG DAPSONE DARAPRIM demeclocycline oral dicloxacillin didanosine DOXY-00 doxycycline hyclate intravenous doxycycline hyclate oral capsule doxycycline hyclate oral tablet 00 mg, 0 mg doxycycline monohydrate oral tablet 00 mg EDURANT EMTRIVA entecavir EPIVIR HBV ORAL SOLUTION EPIVIR ORAL SOLUTION EPZICOM ; QLL (8 per day) PAR; Name erythrocin (as stearate) oral tablet 0 mg ERYTHROCIN INTRAVENOUS RECON SOLN 00 MG erythromycin ethylsuccinate oral tablet erythromycin oral capsule, delayed release(dr/ec) erythromycin oral tablet ethambutol EVOTAZ famciclovir oral tablet mg, 0 mg famciclovir oral tablet 00 mg fluconazole fluconazole in dextrose(iso-o) fluconazole in nacl (iso-osm) intravenous piggyback 00 mg/ 00 ml fluconazole in nacl (iso-osm) intravenous piggyback 00 mg/ 00 ml flucytosine FUZEON SUBCUTANEOUS RECON SOLN ganciclovir sodium gentamicin injection gentamicin sulfate (ped) (pf) gentamicin sulfate (pf) intravenous solution 00 mg/ 0 ml GENTAMICIN SULFATE (PF) INTRAVENOUS SOLUTION 60 MG/6 ML gentamicin sulfate (pf) intravenous solution 80 mg/8 ml griseofulvin microsize oral suspension griseofulvin ultramicrosize oral tablet mg griseofulvin ultramicrosize oral tablet 0 mg ; QLL (60 per 0 ; QLL ( per 7 ; QLL (60 per 0 Basic_7_v_09_ 0 Effective Date September, 0

11 Name HARVONI hydroxychloroquine oral imipenem-cilastatin INTELENCE ORAL TABLET 00 MG, 00 MG INTELENCE ORAL TABLET MG INVIRASE ISENTRESS ORAL POWDER IN PACKET ISENTRESS ORAL TABLET ISENTRESS ORAL TABLET,CHEWABLE 00 MG ISENTRESS ORAL TABLET,CHEWABLE MG isoniazid oral solution isoniazid oral tablet itraconazole ivermectin oral KALETRA ORAL SOLUTION KALETRA ORAL TABLET 00- MG KALETRA ORAL TABLET 00-0 MG ketoconazole oral lamivudine oral solution lamivudine oral tablet 00 mg, 0 mg lamivudine oral tablet 00 mg lamivudine-zidovudine levofloxacin in dw intravenous piggyback 0 mg/0 ml levofloxacin in dw intravenous piggyback 00 mg/00 ml, 70 mg/0 ml levofloxacin oral tablet LEXIVA ORAL SUSPENSION LEXIVA ORAL TABLET linezolid intravenous PAR; ; QLL (8 per 8 PAR; ; QLL ( per day) Name linezolid oral linezolid-0.9% sodium chloride mefloquine MEPRON meropenem methenamine hippurate methenamine mandelate metro i.v. metronidazole in nacl (iso-os) metronidazole oral minocycline oral capsule minocycline oral tablet 00 mg, 7 mg minocycline oral tablet 0 mg XATAG moxifloxacin MYCOBUTIN NEBUPENT neomycin nevirapine oral suspension nevirapine oral tablet nevirapine oral tablet extended release hr nitrofurantoin macrocrystal oral capsule 00 mg, 0 mg nitrofurantoin monohyd/mcryst NORVIR NOXAFIL ORAL SUSPENSION nystatin oral suspension nystatin oral tablet OLYSIO oxacillin in dextrose(iso-osm) intravenous piggyback gram/ 0 ml oxacillin in dextrose(iso-osm) intravenous piggyback gram/ 0 ml oxacillin injection recon soln gram, gram oxacillin injection recon soln 0 gram PAR; ; QLL (8 per day) PAR; ; QLL ( per day) ; PAR; PAR; PAR; ; QLL (60 per 0 PAR; Basic_7_v_09_ Effective Date September, 0

12 Name oxacillin intravenous recon soln gram oxacillin intravenous recon soln gram paromomycin PASER penicillin g potassium penicillin v potassium PENTAM pfizerpen-g piperacillin-tazobactam PREZCOBIX PREZISTA ORAL SUSPENSION PREZISTA ORAL TABLET 0 MG, 7 MG PREZISTA ORAL TABLET 600 MG, 800 MG PRIFTIN PRIMAQUINE pyrazinamide RELENZA DISKHALER RESCRIPTOR RETROVIR INTRAVENOUS REYATAZ ORAL CAPSULE 0 MG, 00 MG, 00 MG REYATAZ ORAL POWDER IN PACKET ribasphere oral tablet 00 mg ribavirin oral capsule ribavirin oral tablet 00 mg rifabutin rifampin intravenous rifampin oral rimantadine SELZENTRY SOVALDI stavudine STREPTOMYCIN INTRAMUSCULAR STRIBILD STROMECTOL sulfadiazine oral ; QLL (60 per 80 PAR; PAR; PAR; PAR; Name sulfamethoxazole-trimethoprim intravenous sulfamethoxazole-trimethoprim oral suspension sulfamethoxazole-trimethoprim oral tablet mg sulfamethoxazole-trimethoprim oral tablet mg SUSTIVA SYNAGIS SYNERCID TAMIFLU ORAL CAPSULE 0 MG TAMIFLU ORAL CAPSULE MG TAMIFLU ORAL CAPSULE 7 MG TAMIFLU ORAL SUSPENSION FOR RECONSTITUTION TEFLARO terbinafine hcl oral tetracycline tinidazole TIVICAY tobramycin in 0. % nacl tobramycin sulfate injection recon soln tobramycin sulfate injection solution TRECATOR trimethoprim TRIUMEQ TRIZIVIR TRUVADA TYBOST TYZEKA valacyclovir oral tablet gram valacyclovir oral tablet 00 mg VALCYTE ORAL TABLET valganciclovir PAR; ; LA ; QLL (8 per day) ; QLL ( per day) ; QLL (6 per 6 ; QLL (60 per 80 ; QLL (0 per 0 ; ; QLL (80 per 8 PAR; ; QLL (0 per day) ; QLL (0 per day) Basic_7_v_09_ Effective Date September, 0

13 Name VANCOMYCIN IN DW INTRAVENOUS PIGGYBACK GRAM/00 ML VANCOMYCIN IN DW INTRAVENOUS PIGGYBACK 00 MG/00 ML VANCOMYCIN IN DEXTROSE ISO-OSM vancomycin intravenous VANCOMYCIN INTRAVENOUS 70 MG vancomycin oral capsule mg vancomycin oral capsule 0 mg VIDEX GRAM PEDIATRIC VIDEX GRAM PEDIATRIC VIEKIRA PAK VIRACEPT ORAL TABLET VIRAMUNE XR VIRAZOLE VIREAD ORAL POWDER VIREAD ORAL TABLET 0 MG, 00 MG VIREAD ORAL TABLET 00 MG, 0 MG VITEKTA voriconazole intravenous voriconazole oral suspension for reconstitution voriconazole oral tablet 00 mg voriconazole oral tablet 0 mg ZIAGEN ORAL SOLUTION zidovudine oral capsule zidovudine oral syrup zidovudine oral tablet ; ; ; PAR; ; QLL (0 per day) PAR; ; QLL (80 per day) PAR; PAR; ; QLL (0 per 0 PAR; ; QLL (00 per 0 PAR; ; QLL (60 per 0 PAR; ; QLL (0 per 0 Name ZYVOX INTRAVENOUS PARENTERAL SOLUTION 00 MG/00 ML ZYVOX INTRAVENOUS PARENTERAL SOLUTION 600 MG/00 ML ZYVOX ORAL SUSPENSION FOR RECONSTITUTION ZYVOX ORAL TABLET PAR; ; QLL (800 per day) PAR; ; QLL (8 per day) Antineoplastic / Immunosuppressant s ABRAXANE ; adrucil intravenous solution. gram/0 ml adrucil intravenous solution ; gram/00 ml, 00 mg/0 ml AFINITOR PAR; AFINITOR DISPERZ PAR; ALIMTA PAR; ALKERAN ORAL ; amifostine crystalline PAR; anastrozole ARRANON ARZERRA ; ASTAGRAF XL ; AVASTIN PAR; azacitidine PAR; azathioprine ; BELEODAQ PAR; bexarotene PAR; bicalutamide BICNU ; bleomycin ; BLINCYTO PAR; BOSULIF PAR; BUSULFEX CAPRELSA PAR; ; LA carboplatin intravenous ; solution CELLCEPT ; INTRAVENOUS CELLCEPT ORAL ; SUSPENSION FOR RECONSTITUTION Basic_7_v_09_ Effective Date September, 0

14 Name cisplatin cladribine CLOLAR COMETRIQ COSMEGEN cyclophosphamide oral capsule cyclosporine intravenous cyclosporine modified cyclosporine oral capsule 00 mg cyclosporine oral capsule mg CYRAMZA cytarabine cytarabine (pf) injection solution 00 mg/ ml (0 mg/ ml), gram/0 ml (00 mg/ ml) cytarabine (pf) injection solution 0 mg/ml dacarbazine DACOGEN daunorubicin intravenous solution DAUNOXOME decitabine dexrazoxane hcl intravenous recon soln 0 mg dexrazoxane hcl intravenous recon soln 00 mg DOCEFREZ INTRAVENOUS RECON SOLN 0 MG docetaxel intravenous solution 0 mg/ml, 0 mg/7 ml (0 mg/ml), 60 mg/6 ml (0 mg/ ml), 0 mg/ ml (0 mg/ml) docetaxel intravenous solution 0 mg/ml ( ml), 80 mg/ ml (0 mg/ml), 80 mg/8 ml (0 mg/ml) DOXIL doxorubicin intravenous recon soln doxorubicin intravenous solution DROXIA ; ; ; PAR; ; ; ; ; ; PAR; ; ; ; ; ; ; ; ; ; ; Name ELITEK EMCYT epirubicin intravenous solution 00 mg/00 ml epirubicin intravenous solution 0 mg/ ml ERBITUX ERIVEDGE ERWINAZE ETOPOPHOS etoposide intravenous exemestane FARESTON FARYDAK ORAL CAPSULE 0 MG FARYDAK ORAL CAPSULE MG, 0 MG FASLODEX FIRMAGON KIT W DILUENT SYRINGE SUBCUTANEOUS RECON SOLN 0 MG FIRMAGON KIT W DILUENT SYRINGE SUBCUTANEOUS RECON SOLN 80 MG fludarabine intravenous recon soln fludarabine intravenous solution fluorouracil intravenous flutamide FOLOTYN FUSILEV GAZYVA gemcitabine intravenous recon soln gram, 00 mg gemcitabine intravenous recon soln gram gemcitabine intravenous solution gengraf GILOTRIF GLEEVEC GLEOSTINE HALAVEN PAR ; PAR; PAR; ; ; ; PAR; ; QLL (60 per 0 PAR; ; QLL (0 per 0 PAR; ; ; ; ; ; ; PAR; ; ; PAR; PAR; PAR; Basic_7_v_09_ Effective Date September, 0

15 Name HERCEPTIN HEXALEN hydroxyurea IBRANCE ICLUSIG idarubicin ifosfamide intravenous recon soln gram ifosfamide intravenous recon soln gram ifosfamide intravenous solution IMBRUVICA INLYTA irinotecan intravenous solution 00 mg/ ml, 0 mg/ ml irinotecan intravenous solution 00 mg/ ml ISTODAX IXEMPRA JAKAFI JEVTANA KADCYLA KEYTRUDA LENVIMA ORAL CAPSULE 0 MG/DAY (0 MG []/DAY) LENVIMA ORAL CAPSULE MG (0 MG[] - MG[])/DAY, 0 MG/DAY (0 MG []/DAY) LENVIMA ORAL CAPSULE MG (0 MG[] - MG[])/DAY letrozole leucovorin calcium injection recon soln 00 mg, 00 mg, 0 mg, 0 mg leucovorin calcium injection recon soln 00 mg leucovorin calcium oral tablet 0 mg, mg leucovorin calcium oral tablet mg, mg LEUKERAN leuprolide PAR; PAR; ; QLL (0 per 0 PAR; ; PAR; PAR; ; PAR; ; PAR; ; PAR; PAR; PAR; ; QLL (0 per 0 PAR; ; QLL (60 per 0 PAR; ; QLL (90 per 0 ; PAR; Name LOMUSTINE LUPRON DEPOT INTRAMUSCULAR SYRINGE KIT.7 MG, 7. MG LUPRON DEPOT-PED INTRAMUSCULAR KIT 7. MG (PED) LYNPARZA LYSODREN MATULANE megestrol oral suspension 00 mg/0 ml (0 ml) megestrol oral suspension 00 mg/0 ml (0 mg/ml) megestrol oral tablet MEKINIST melphalan hcl mercaptopurine mesna MESNEX ORAL methotrexate sodium (pf) injection recon soln methotrexate sodium (pf) injection solution methotrexate sodium injection methotrexate sodium oral mitomycin mitoxantrone MUSTARGEN mycophenolate mofetil oral capsule mycophenolate mofetil oral suspension for reconstitution mycophenolate mofetil oral tablet NEXAVAR NILANDRON NIPENT NULOJIX octreotide acetate injection solution,000 mcg/ml PAR; PAR; PAR; ; QLL (80 per 0 PAR PAR; PAR; PAR; ; ; ; ; ; ; PAR; ; LA; QLL (0 per 0 ; ; PAR; Basic_7_v_09_ Effective Date September, 0

16 Name octreotide acetate injection solution 00 mcg/ml, 00 mcg/ ml, 0 mcg/ml, 00 mcg/ml octreotide acetate injection syringe 00 mcg/ml ( ml), 0 mcg/ml ( ml) octreotide acetate injection syringe 00 mcg/ml ( ml) ONCASPAR OPDIVO oxaliplatin intravenous recon soln 00 mg oxaliplatin intravenous recon soln 0 mg oxaliplatin intravenous solution paclitaxel PERJETA POMALYST PROGRAF INTRAVENOUS PURIXAN RAPAMUNE ORAL SOLUTION RAPAMUNE ORAL TABLET 0. MG RAPAMUNE ORAL TABLET MG, MG REVLIMID ORAL CAPSULE 0 MG REVLIMID ORAL CAPSULE MG,. MG, 0 MG, MG REVLIMID ORAL CAPSULE MG RITUXAN SIMULECT INTRAVENOUS RECON SOLN 0 MG SIMULECT INTRAVENOUS RECON SOLN 0 MG sirolimus SOLTAX SOMATULINE DEPOT SPRYCEL PAR; PAR; PAR; ; PAR; ; ; ; PAR; PAR; ; PAR; ; ; ; PAR; ; LA; QLL (60 per 0 PAR; ; LA; QLL (0 per 0 PAR; ; LA; QLL (0 per 0 PAR; ; ; PAR; Name STIVARGA SUTENT SYNRIBO TABLOID tacrolimus oral capsule 0. mg, mg tacrolimus oral capsule mg TAFINLAR tamoxifen TARCEVA TARGRETIN TASIGNA THALOMID ORAL CAPSULE 00 MG, 0 MG THALOMID ORAL CAPSULE 0 MG, 00 MG toposar topotecan TORISEL TREANDA TRELSTAR TRELSTAR DEPOT TRELSTAR LA tretinoin (chemotherapy) TRISENOX TYKERB VECTIBIX VELCADE vinblastine intravenous solution vincasar pfs intravenous solution mg/ml vincasar pfs intravenous solution mg/ ml vincristine vinorelbine VOTRIENT XALKORI XGEVA XTANDI YERVOY ZALTRAP ZANOSAR ZELBORAF PAR; ; QLL (0 per 0 PAR; PAR; ; ; PAR; PAR; PAR; PAR; PAR; ; QLL (0 per 0 PAR; ; QLL (60 per 0 ; ; ; ; ; PAR; ; LA PAR; PAR; ; ; ; ; PAR; PAR; PAR; ; QLL (.7 per 8 PAR; PAR; PAR; ; PAR; Basic_7_v_09_ 6 Effective Date September, 0

17 Name ZOLINZA PAR; ZORTRESS ORAL TABLET 0. MG ZORTRESS ORAL TABLET 0. MG, 0.7 MG ZYDELIG ; ; PAR; ; QLL (60 per 0 ZYKADIA PAR; ZYTIGA PAR; Autonomic / Cns s, Neurology / Psych ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING ABILIFY ORAL TABLET 0 MG ABILIFY ORAL TABLET MG, 0 MG ABILIFY ORAL TABLET MG ABILIFY ORAL TABLET 0 MG ABILIFY ORAL TABLET MG ABSTRAL ; QLL ( per 8 QLL ( per 8 ; QLL (90 per 0 ; QLL (60 per 0 ; QLL (0 per 0 ; QLL (0 per 0 ; QLL (80 per 0 PAR; ; QLL acetaminophen-codeine oral solution 0 mg- mg / ml ( ml), 0 mg- mg /0 ml (0 ml), 00 mg-0 mg /. ml acetaminophen-codeine oral solution 0- mg/ ml acetaminophen-codeine oral tablet 00- mg acetaminophen-codeine oral tablet 00-0 mg acetaminophen-codeine oral tablet mg ACTIQ ADASUVE (0 per 0 QLL (00 per 0 ; QLL (00 per 0 ; QLL (90 per 0 ; QLL (60 per 0 ; QLL (80 per 0 PAR; ; QLL (0 per 0 Name alprazolam oral tablet amitriptyline amoxapine amphetamine salt combo oral tablet 0 mg,. mg, mg, 0 mg, mg, 7. mg amphetamine salt combo oral tablet 0 mg AMPYRA APOKYN APTIOM aripiprazole oral tablet 0 mg aripiprazole oral tablet mg, 0 mg aripiprazole oral tablet mg aripiprazole oral tablet 0 mg aripiprazole oral tablet mg AZILECT baclofen oral tablet 0 mg baclofen oral tablet 0 mg BANZEL ORAL SUSPENSION BANZEL ORAL TABLET 00 MG BANZEL ORAL TABLET 00 MG benztropine oral BRINTELLIX ORAL TABLET 0 MG BRINTELLIX ORAL TABLET 0 MG BRINTELLIX ORAL TABLET MG bromocriptine buprenorphine hcl sublingual tablet mg buprenorphine hcl sublingual tablet 8 mg buprenorphine-naloxone sublingual tablet -0. mg ; QLL (90 per 0 PAR; PAR; ; QLL (90 per 0 PAR; ; QLL (60 per 0 PAR; ; LA; QLL (60 per 0 PAR; ; LA ST; ; QLL (90 per 0 ; QLL (60 per 0 ; QLL (0 per 0 ; QLL (0 per 0 ; QLL (80 per 0 PAR; ; QLL (00 per 0 PAR; ; QLL (80 per 0 PAR; ; QLL (0 per 0 PAR; ST; ; QLL (60 per 0 ST; ; QLL (0 per 0 ST; ; QLL (0 per 0 PAR; ; QLL (0 per 0 PAR; ; QLL (60 per 0 PAR; ; QLL (60 per 0 Basic_7_v_09_ 7 Effective Date September, 0

18 Name buprenorphine-naloxone sublingual tablet 8- mg bupropion hcl oral tablet 00 mg bupropion hcl oral tablet 7 mg bupropion hcl oral tablet extended release 00 mg bupropion hcl oral tablet extended release 0 mg, 00 mg bupropion hcl oral tablet extended release hr 0 mg bupropion hcl oral tablet extended release hr 00 mg buspirone carbamazepine oral capsule, er multiphase hr carbamazepine oral suspension 00 mg/ ml carbamazepine oral tablet carbamazepine oral tablet extended release hr carbamazepine oral tablet, chewable carbidopa-levodopa CELONTIN ORAL CAPSULE 00 MG chlorpromazine injection chlorpromazine oral tablet 0 mg, mg, 0 mg chlorpromazine oral tablet 00 mg, 00 mg citalopram oral solution citalopram oral tablet 0 mg citalopram oral tablet 0 mg citalopram oral tablet 0 mg clomipramine clonazepam oral tablet 0. mg clonazepam oral tablet mg PAR; ; QLL (90 per 0 ; QLL ( per 0 ; QLL (80 per 0 ; QLL (0 per 0 ; QLL (60 per 0 ; QLL (90 per 0 ; QLL ( per 0 PAR; PAR; PAR; ; QLL (600 per 0 ; QLL (0 per 0 ; QLL (60 per 0 ; QLL (0 per 0 PAR; PAR; ; QLL (00 per 0 PAR; ; QLL (600 per 0 Name clonazepam oral tablet mg clonazepam oral tablet, disintegrating 0. mg clonazepam oral tablet, disintegrating 0. mg clonazepam oral tablet, disintegrating 0. mg clonazepam oral tablet, disintegrating mg clonazepam oral tablet, disintegrating mg clorazepate dipotassium clozapine oral tablet 00 mg clozapine oral tablet 00 mg clozapine oral tablet mg clozapine oral tablet 0 mg clozapine oral tablet, disintegrating 00 mg clozapine oral tablet, disintegrating. mg clozapine oral tablet, disintegrating 0 mg clozapine oral tablet, disintegrating 00 mg clozapine oral tablet, disintegrating mg COPAXONE SUBCUTANEOUS SYRINGE 0 MG/ML COPAXONE SUBCUTANEOUS SYRINGE 0 MG/ML cyclobenzaprine oral tablet desipramine oral tablet 0 mg, 00 mg, mg, 0 mg, 7 mg desipramine oral tablet 0 mg DESVENLAFAXINE FUMARATE ORAL TABLET EXTENDED RELEASE HR 00 MG PAR; ; QLL (00 per 0 PAR; ; QLL (800 per 0 PAR; ; QLL (00 per 0 PAR; ; QLL (00 per 0 PAR; ; QLL (600 per 0 PAR; ; QLL (00 per 0 ; QLL (0 per 0 ; QLL (70 per 0 QLL ( per 0 ; QLL (080 per 0 ; QLL (0 per 0 QLL (70 per 0 QLL (60 per 0 QLL (80 per 0 QLL ( per 0 QLL (080 per 0 PAR; ; QLL (0 per 0 PAR; ; QLL ( per 8 PAR; ; QLL (0 per 0 Basic_7_v_09_ 8 Effective Date September, 0

19 Name DESVENLAFAXINE FUMARATE ORAL TABLET EXTENDED RELEASE HR 0 MG DESVENLAFAXINE ORAL TABLET EXTENDED RELEASE HR 00 MG DESVENLAFAXINE ORAL TABLET EXTENDED RELEASE HR 0 MG DESVENLAFAXINE ORAL TABLET EXTENDED RELEASE HR 00 MG DESVENLAFAXINE ORAL TABLET EXTENDED RELEASE HR 0 MG dextroamphetamine oral tablet 0 mg dextroamphetamine oral tablet mg diazepam intensol diazepam oral concentrate diazepam oral solution mg/ ml diazepam oral tablet 0 mg diazepam oral tablet mg diazepam oral tablet mg diazepam rectal diclofenac potassium diclofenac sodium oral diflunisal dihydroergotamine injection DILANTIN 0 MG CAPSULE DILANTIN INFATABS diskets divalproex donepezil oral tablet 0 mg, mg ; QLL (0 per 0 ; QLL (0 per 0 ; QLL (0 per 0 QLL (0 per 0 QLL (0 per 0 PAR; ; QLL (80 per 0 PAR; ; QLL (90 per 0 PAR; ; QLL (0 per 0 PAR; QLL (0 per 0 ; QLL (00 per 0 PAR; ; QLL (0 per 0 PAR; ; QLL (600 per 0 PAR; ; QLL (0 per 0 ; QLL ( per day) QLL (0 per 0 ; QLL (0 per 0 Name donepezil oral tablet, disintegrating doxepin oral duloxetine oral capsule,delayed release(dr/ec) 0 mg duloxetine oral capsule,delayed release(dr/ec) 0 mg duloxetine oral capsule,delayed release(dr/ec) 0 mg duloxetine oral capsule,delayed release(dr/ec) 60 mg duramorph (pf) injection solution 0. mg/ml duramorph (pf) injection solution mg/ml EMSAM endocet oral tablet 0- mg, - mg, 7.- mg endodan entacapone epitol EQUETRO ORAL CAPSULE, ER MULTIPHASE HR 00 MG EQUETRO ORAL CAPSULE, ER MULTIPHASE HR 00 MG EQUETRO ORAL CAPSULE, ER MULTIPHASE HR 00 MG ergoloid escitalopram oxalate oral solution escitalopram oxalate oral tablet 0 mg escitalopram oxalate oral tablet 0 mg escitalopram oxalate oral tablet mg ethosuximide etodolac oral capsule ; QLL (0 per 0 PAR; ; QLL (80 per 0 ; QLL (0 per 0 ; QLL (90 per 0 ; QLL (60 per 0 ; PAR; ; QLL (0 per 0 ; QLL (60 per 0 ; QLL (60 per 0 ; QLL (80 per 0 ; QLL (0 per 0 ; QLL (80 per 0 PAR; ; QLL (600 per 0 ; QLL (60 per 0 ; QLL (0 per 0 ; QLL (0 per 0 Basic_7_v_09_ 9 Effective Date September, 0

20 Name etodolac oral tablet FANAPT ORAL TABLET MG FANAPT ORAL TABLET 0 MG FANAPT ORAL TABLET MG FANAPT ORAL TABLET MG FANAPT ORAL TABLET MG FANAPT ORAL TABLET 6 MG FANAPT ORAL TABLET 8 MG FANAPT ORAL TABLETS, DOSE PACK FAZACLO ORAL TABLET, DISINTEGRATING 00 MG FAZACLO ORAL TABLET, DISINTEGRATING. MG FAZACLO ORAL TABLET, DISINTEGRATING 0 MG FAZACLO ORAL TABLET, DISINTEGRATING 00 MG FAZACLO ORAL TABLET, DISINTEGRATING MG felbamate oral suspension felbamate oral tablet 00 mg felbamate oral tablet 600 mg fentanyl citrate fentanyl transdermal patch 7 hour 00 mcg/hr, mcg/hr, mcg/hr, 0 mcg/hr, 7 mcg/ hr FENTORA FETZIMA ORAL CAPSULE,EXT REL HR DOSE PACK ; QLL (70 per 0 ; QLL (7 per 0 ; QLL (60 per 0 ; QLL (60 per 0 ; QLL (80 per 0 ; QLL (0 per 0 ; QLL (90 per 0 ; QLL (8 per 0 QLL (70 per 0 QLL (60 per 0 QLL (80 per 0 QLL ( per 0 QLL (080 per 0 PAR; ; QLL (0 per 0 ST; ; QLL ( per 0 PAR; ; QLL (0 per 0 PAR; ; QLL (8 per 6 Name FETZIMA ORAL CAPSULE,EXTENDED RELEASE HR 0 MG, 80 MG FETZIMA ORAL CAPSULE,EXTENDED RELEASE HR 0 MG FETZIMA ORAL CAPSULE,EXTENDED RELEASE HR 0 MG fluoxetine oral capsule 0 mg fluoxetine oral capsule 0 mg fluoxetine oral capsule 0 mg fluoxetine oral solution fluoxetine oral tablet 0 mg fluoxetine oral tablet 0 mg FLUOXETINE ORAL TABLET 60 MG fluphenazine decanoate fluphenazine hcl injection fluphenazine hcl oral flurbiprofen fluvoxamine oral tablet 00 mg fluvoxamine oral tablet mg fluvoxamine oral tablet 0 mg fosphenytoin FYCOMPA ORAL TABLET 0 MG, MG FYCOMPA ORAL TABLET MG FYCOMPA ORAL TABLET MG FYCOMPA ORAL TABLET 6 MG FYCOMPA ORAL TABLET 8 MG PAR; ; QLL (0 per 0 PAR; ; QLL (80 per 0 PAR; ; QLL (90 per 0 ; QLL (0 per 0 ; QLL (0 per 0 ; QLL (60 per 0 ; QLL (600 per 0 ; QLL (0 per 0 ; QLL (0 per 0 ; QLL (0 per 0 ; QLL (90 per 0 ; QLL (60 per 0 ; QLL (80 per 0 ; ; QLL (0 per 0 ; QLL (80 per 0 ; QLL (90 per 0 ; QLL (60 per 0 ; QLL ( per 0 Basic_7_v_09_ 0 Effective Date September, 0

21 Name gabapentin oral capsule 00 mg gabapentin oral capsule 00 mg gabapentin oral capsule 00 mg gabapentin oral solution 0 mg/ ml gabapentin oral solution 0 mg/ ml ( ml), 00 mg/6 ml (6 ml) gabapentin oral tablet 600 mg gabapentin oral tablet 800 mg GABITRIL ORAL TABLET MG, 6 MG galantamine oral capsule,ext rel. pellets hr galantamine oral solution galantamine oral tablet GEODON INTRAMUSCULAR GILENYA GLATOPA guanfacine oral tablet extended release hr guanidine haloperidol haloperidol decanoate haloperidol lactate injection haloperidol lactate oral hydrocodone-acetaminophen oral solution.-67 mg/ ml hydrocodone-acetaminophen oral solution 7.- mg/ ml hydrocodone-acetaminophen oral tablet 0- mg, - mg, 7.- mg hydrocodone-ibuprofen ; QLL (080 per 0 ; QLL (60 per 0 ; QLL (70 per 0 ; QLL (60 per 0 QLL (60 per 0 ; QLL (80 per 0 ; QLL ( per 0 ; QLL (0 per 0 ; QLL (80 per 0 ; QLL (60 per 0 PAR; ; QLL (0 per 0 PAR; ; QLL (0 per 0 PAR; ; QLL (0 per 0 QLL (700 per 0 ; QLL (700 per 0 ; QLL (60 per 0 ; QLL (80 per 0 Name hydromorphone oral tablet mg, mg hydromorphone oral tablet 8 mg ibuprofen oral suspension ibuprofen oral tablet 00 mg, 600 mg, 800 mg ibuprofen-oxycodone imipramine hcl INTUNIV ER INVEGA ORAL TABLET EXTENDED RELEASE HR. MG INVEGA ORAL TABLET EXTENDED RELEASE HR MG INVEGA ORAL TABLET EXTENDED RELEASE HR 6 MG INVEGA ORAL TABLET EXTENDED RELEASE HR 9 MG INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 7 MG/0.7 ML, 6 MG/ML, MG/. ML INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 9 MG/0. ML, 78 MG/0. ML INVEGA TRINZA INTRAMUSCULAR SYRINGE 7 MG/0.87 ML INVEGA TRINZA INTRAMUSCULAR SYRINGE 0 MG/. ML INVEGA TRINZA INTRAMUSCULAR SYRINGE 6 MG/.7 ML INVEGA TRINZA INTRAMUSCULAR ; QLL (60 per 0 ; QLL (80 per 0 ; QLL (8 per day) PAR; PAR; ; QLL (0 per 0 ; QLL (0 per 0 ; QLL (0 per 0 ; QLL (60 per 0 ; QLL (0 per 0 ; QLL ( per 8 ; QLL ( per 8 ; QLL (0.87 per 90 ; QLL (. per 90 ; QLL (.7 per 90 ; QLL (.6 per 90 Basic_7_v_09_ Effective Date September, 0

22 Name SYRINGE 89 MG/.6 ML KHEDEZLA ORAL TABLET EXTENDED RELEASE HR 00 MG KHEDEZLA ORAL TABLET EXTENDED RELEASE HR 0 MG lamotrigine oral tablet lamotrigine oral tablet, chewable dispersible LATUDA ORAL TABLET 0 MG LATUDA ORAL TABLET 0 MG LATUDA ORAL TABLET 0 MG LATUDA ORAL TABLET 60 MG LATUDA ORAL TABLET 80 MG LAZANDA levetiracetam in nacl (iso-os) intravenous piggyback,000 mg/00 ml,,00 mg/00 ml levetiracetam in nacl (iso-os) intravenous piggyback 00 mg/ 00 ml levetiracetam intravenous levetiracetam oral solution 00 mg/ml levetiracetam oral solution 00 mg/ ml ( ml) levetiracetam oral tablet levetiracetam oral tablet extended release hr 00 mg levetiracetam oral tablet extended release hr 70 mg lithium carbonate oral capsule 0 mg, 00 mg lithium carbonate oral capsule 600 mg lithium carbonate oral tablet lithium carbonate oral tablet extended release ; QLL (0 per 0 ; QLL (0 per 0 ; QLL (0 per 0 ; QLL (0 per 0 ; QLL (0 per 0 ; QLL (7 per 0 ; QLL (60 per 0 PAR; ; QLL (0 per 0 ; ; ; QLL (80 per 0 ; QLL (0 per 0 Name lithium citrate oral solution 8 meq/ ml lorazepam oral tablet loxapine succinate LYRICA ORAL CAPSULE 00 MG LYRICA ORAL CAPSULE 0 MG LYRICA ORAL CAPSULE 00 MG LYRICA ORAL CAPSULE MG, 00 MG LYRICA ORAL CAPSULE MG LYRICA ORAL CAPSULE 0 MG LYRICA ORAL CAPSULE 7 MG LYRICA ORAL SOLUTION maprotiline oral tablet mg maprotiline oral tablet 0 mg maprotiline oral tablet 7 mg MARPLAN meloxicam oral tablet methadone intensol methadone oral concentrate methadone oral solution 0 mg/ ml methadone oral solution mg/ ml methadone oral tablet 0 mg methadone oral tablet mg methadone oral tablet,soluble methadose oral concentrate ; QLL (90 per 0 PAR; ; QLL (80 per 0 PAR; ; QLL (0 per 0 PAR; ; QLL (90 per 0 PAR; ; QLL (60 per 0 PAR; ; QLL (70 per 0 PAR; ; QLL (60 per 0 PAR; ; QLL (0 per 0 PAR; ; QLL (900 per 0 ; QLL (70 per 0 ; QLL ( per 0 ; QLL (0 per 0 ; QLL (80 per 0 ; QLL (80 per 0 ; QLL (900 per 0 ; QLL (800 per 0 ; QLL (80 per 0 ; QLL (60 per 0 QLL (0 per 0 ; QLL (80 per 0 Basic_7_v_09_ Effective Date September, 0

23 Name methadose oral tablet,soluble methylphenidate oral tablet mirtazapine oral tablet mg mirtazapine oral tablet 0 mg mirtazapine oral tablet mg mirtazapine oral tablet 7. mg mirtazapine oral tablet, disintegrating mg mirtazapine oral tablet, disintegrating 0 mg mirtazapine oral tablet, disintegrating mg modafinil oral tablet 00 mg modafinil oral tablet 00 mg morphine (pf) injection solution 0. mg/ml morphine (pf) injection solution mg/ml morphine (pf) intravenous patient control.analgesia soln 0 mg/0 ml morphine (pf) intravenous patient control.analgesia soln 0 mg/0 ml morphine concentrate oral solution morphine intravenous cartridge RPHINE INTRAVENOUS CARTRIDGE morphine intravenous pt controlled analgesia syring morphine intravenous solution 00 mg/ ml, mg/ml, 0 mg/0 ml morphine intravenous solution 0 mg/ml ; QLL (0 per 0 PAR; ; QLL (90 per 0 ; QLL (90 per 0 ; QLL ( per 0 ; QLL (0 per 0 ; QLL (80 per 0 ; QLL (90 per 0 ; QLL ( per 0 ; QLL (0 per 0 PAR; ; QLL (0 per 0 PAR; ; QLL (60 per 0 ; ; QLL (70 per 0 Name morphine intravenous syringe mg/ml, mg/ml morphine oral solution 0 mg/ ml morphine oral solution 0 mg/ ml morphine oral tablet mg morphine oral tablet 0 mg morphine oral tablet extended release 00 mg, mg, 0 mg, 60 mg morphine oral tablet extended release 00 mg morphine rectal nabumetone nalbuphine injection naloxone injection solution naloxone injection syringe 0. mg/ml naloxone injection syringe mg/ ml naltrexone oral NAMENDA ORAL SOLUTION NAMENDA ORAL TABLET 0 MG NAMENDA ORAL TABLET MG NAMENDA TITRATION PAK NAMENDA XR ORAL CAP,SPRINKLE,ER HR DOSE PACK NAMENDA XR ORAL CAPSULE,SPRINKLE,ER HR naproxen oral suspension naproxen oral tablet 0 mg naproxen oral tablet 7 mg, 00 mg naproxen oral tablet,delayed release (dr/ec) ; QLL (700 per 0 ; QLL (0 per 0 ; QLL (60 per 0 ; QLL (80 per 0 ; QLL (90 per 0 ; QLL (60 per 0 ; QLL (80 per 0 PAR; ; QLL (00 per 0 ; QLL (60 per 0 ; QLL (90 per 0 ; QLL (60 per 0 PAR; ; QLL (8 per 6 PAR; ; QLL (0 per 0 Basic_7_v_09_ Effective Date September, 0

24 Name naproxen sodium oral tablet 7 mg, 0 mg naratriptan oral tablet mg naratriptan oral tablet. mg nefazodone oral tablet 00 mg nefazodone oral tablet 0 mg nefazodone oral tablet 00 mg nefazodone oral tablet 0 mg nefazodone oral tablet 0 mg NEUPRO nortriptyline oral capsule 0 mg, mg nortriptyline oral capsule 0 mg, 7 mg nortriptyline oral solution NUEDEXTA olanzapine intramuscular olanzapine oral tablet 0 mg olanzapine oral tablet mg olanzapine oral tablet. mg olanzapine oral tablet 0 mg olanzapine oral tablet mg olanzapine oral tablet 7. mg olanzapine oral tablet, disintegrating 0 mg olanzapine oral tablet, disintegrating mg olanzapine oral tablet, disintegrating 0 mg ; QLL (9 per 0 ; QLL (9 per 0 ; QLL (80 per 0 ; QLL (0 per 0 ; QLL (90 per 0 ; QLL (7 per 0 ; QLL (60 per 0 PAR; ; QLL (0 per 0 ; QLL (60 per 0 ; QLL (60 per 0 ; QLL (60 per 0 ; QLL (0 per 0 ; QLL (0 per 0 ; QLL (0 per 0 ; QLL (0 per 0 ; QLL (80 per 0 ; QLL (60 per 0 ; QLL (0 per 0 ; QLL (0 per 0 Name olanzapine oral tablet, disintegrating mg ONFI ORAL SUSPENSION ONFI ORAL TABLET 0 MG ONFI ORAL TABLET 0 MG ORAP oxazepam oxcarbazepine OXTELLAR XR ORAL TABLET EXTENDED RELEASE HR 0 MG OXTELLAR XR ORAL TABLET EXTENDED RELEASE HR 00 MG OXTELLAR XR ORAL TABLET EXTENDED RELEASE HR 600 MG oxycodone oral capsule oxycodone oral solution oxycodone oral tablet 0 mg, mg oxycodone oral tablet mg oxycodone oral tablet 0 mg, 0 mg oxycodone-acetaminophen oral tablet 0- mg,.- mg, - mg, 7.- mg oxycodone-aspirin paroxetine hcl oral tablet 0 mg paroxetine hcl oral tablet 0 mg paroxetine hcl oral tablet 0 mg paroxetine hcl oral tablet 0 mg PAXIL ORAL SUSPENSION ; QLL (0 per 0 PAR; ; QLL (80 per 0 PAR; ; QLL (0 per 0 PAR; ; QLL (60 per 0 PAR; ; QLL (0 per 0 ; QLL (80 per 0 ; QLL (0 per 0 ; QLL (0 per 0 ; QLL (60 per 0 ; QLL (800 per 0 ; QLL (60 per 0 ; QLL (0 per 0 ; QLL (80 per 0 ; QLL (60 per 0 ; QLL (60 per 0 ; QLL (80 per 0 ; QLL (90 per 0 ; QLL (60 per 0 ; QLL ( per 0 ; QLL (900 per 0 Basic_7_v_09_ Effective Date September, 0

25 Name PEGANONE perphenazine phenelzine phenobarbital oral elixir phenobarbital oral tablet 00 mg phenobarbital oral tablet mg phenobarbital oral tablet 6. mg phenobarbital oral tablet 0 mg phenobarbital oral tablet. mg phenobarbital oral tablet 60 mg phenobarbital oral tablet 6.8 mg phenobarbital oral tablet 97. mg phenytoin oral suspension 00 mg/ ml phenytoin oral suspension mg/ ml phenytoin oral tablet,chewable phenytoin sodium extended phenytoin sodium intravenous solution phenytoin sodium intravenous syringe POTIGA ORAL TABLET 00 MG, 00 MG POTIGA ORAL TABLET 00 MG POTIGA ORAL TABLET 0 MG pramipexole oral tablet primidone PRISTIQ ORAL TABLET EXTENDED RELEASE HR 00 MG PRISTIQ ORAL TABLET EXTENDED RELEASE HR MG PAR; ; QLL (000 per 0 PAR; QLL (0 per 0 PAR; ; QLL (800 per 0 PAR; ; QLL (7 per 0 PAR; ; QLL (00 per 0 PAR; ; QLL (70 per 0 PAR; ; QLL (00 per 0 PAR; ; QLL (8 per 0 PAR; ; QLL ( per 0 ; ; QLL (90 per 0 ; QLL (90 per 0 ; QLL (70 per 0 ; QLL (0 per 0 ; QLL (80 per 0 Name PRISTIQ ORAL TABLET EXTENDED RELEASE HR 0 MG protriptyline oral tablet 0 mg protriptyline oral tablet mg pyridostigmine bromide oral tablet quetiapine oral tablet 00 mg quetiapine oral tablet 00 mg quetiapine oral tablet mg quetiapine oral tablet 00 mg quetiapine oral tablet 00 mg quetiapine oral tablet 0 mg RISPERDAL CONSTA INTRAMUSCULAR SYRINGE. MG/ ML, MG/ ML RISPERDAL CONSTA INTRAMUSCULAR SYRINGE 7. MG/ ML RISPERDAL CONSTA INTRAMUSCULAR SYRINGE 0 MG/ ML risperidone oral solution risperidone oral tablet 0. mg risperidone oral tablet 0. mg risperidone oral tablet mg risperidone oral tablet mg risperidone oral tablet mg risperidone oral tablet mg risperidone oral tablet, disintegrating 0. mg ; QLL (0 per 0 ; QLL (0 per 0 ; QLL (0 per 0 ; QLL (960 per 0 ; QLL (80 per 0 ; QLL (60 per 0 ; QLL (80 per 0 ; QLL ( per 8 ; QLL ( per 8 ; QLL (80 per 0 ; QLL (90 per 0 ; QLL (960 per 0 ; QLL (80 per 0 ; QLL (0 per 0 ; QLL (60 per 0 ; QLL (0 per 0 ; QLL (90 per 0 Basic_7_v_09_ Effective Date September, 0