Blue MedicareRx Premier (PDP) 2015 Formulary (List of Covered Drugs)

Transcription

1 Blue MedicareRx Premier (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 October, 0. For more recent information or other questions, please contact Blue MedicareRx Premier (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_009 CMS Accepted 08/09/0 979MUSENMUB_009 S96_0 Premier_8_v

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 Blue MedicareRx Premier (PDP). This document includes a list of the drugs (formulary) for our plan which is current as of October, 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 November, 0 Premier_8_v

3 What is the Blue MedicareRx Premier (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 6. 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 November, 0 Premier_8_v

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 Blue MedicareRx Premier (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 Blue MedicareRx Premier (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 November, 0 Premier_8_v

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 6. 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 November, 0 Premier_8_v

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. CG Coverage Gap: 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. Effective Date November, 0 6 Premier_8_v

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 $.00 $7.00 $0.00 $.00 8% 0% % % 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 November, 0 7 Premier_8_v

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. CG Coverage Gap: 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. 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 ; ; CG ; CG ; ; QLL (80 per ; CG ; CG ; Name amikacin injection solution, 000 mg/ ml, 00 mg/ ml amoxicillin oral capsule 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 ; CG ; CG ; CG ; CG ; CG ; CG ; CG Premier_8_v 8 Effective Date November, 0

9 Name amphotericin b ampicillin oral capsule ampicillin oral suspension for reconstitution mg/ ml 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 AVELOX AVELOX ABC PACK AVELOX IN NACL (ISO- OSTIC) AZACTAM IN DEXTROSE (ISO-OSM) azithromycin intravenous azithromycin oral packet azithromycin oral suspension for reconstitution azithromycin oral tablet 0 mg (6 pack) azithromycin oral tablet 0 mg, 00 mg, 600 mg aztreonam baciim bacitracin intramuscular BACTRIM BACTRIM DS BARACLUDE BICILLIN C-R ; ; CG ; CG PAR; ; QLL ( per day) ; QLL ( per day) ; CG ; CG CG ; CG PAR; Name BICILLIN L-A BILTRICIDE CANCIDAS CAPASTAT CAYSTON CEDAX ORAL CAPSULE 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 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 cefixime cefotaxime injection recon soln gram, gram, 00 mg cefotetan cefoxitin in dextrose, iso-osm cefoxitin intravenous recon soln gram cefoxitin intravenous recon soln 0 gram, gram cefpodoxime ; PAR; ; LA ; CG ; CG ; CG ; CG ; CG Premier_8_v 9 Effective Date November, 0

10 Name 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 CEFTAZIDIME IN DW ceftazidime injection recon soln gram, gram ceftazidime injection recon soln 6 gram ceftibuten CEFTIN ORAL SUSPENSION FOR RECONSTITUTION 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 capsule 70 mg cephalexin oral suspension for reconstitution cephalexin oral tablet chloramphenicol sod succinate chloroquine phosphate oral cidofovir CIPRO IN DW INTRAVENOUS PIGGYBACK 00 MG/00 ML CIPRO ORAL SUSPENSION, MICROCAPSULE RECON CIPRO ORAL TABLET 0 MG, 00 MG ; CG ; CG ; CG ; CG ; CG ; CG ; Name ciprofloxacin (mixture) oral tablet, er multiphase hr, 000 mg ciprofloxacin (mixture) oral tablet, er multiphase hr 00 mg ciprofloxacin hcl oral tablet ciprofloxacin in % dextrose ciprofloxacin lactate intravenous solution 00 mg/ 0 ml ciprofloxacin lactate intravenous solution 00 mg/ 0 ml ciprofloxacin oral suspension, microcapsule recon CLAFORAN INJECTION RECON SOLN GRAM, 0 GRAM, GRAM CLAFORAN INJECTION RECON SOLN 00 MG CLAFORAN INTRAVENOUS RECON SOLN clarithromycin oral suspension for reconstitution clarithromycin oral tablet clarithromycin oral tablet extended release hr CLEOCIN ORAL 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 COARTEM colistin (colistimethate na) COLY-MYCIN M PARENTERAL COMPLERA ; QLL ( per day) ; QLL ( per day) ; CG ; QLL (8 per day) ; CG ; CG Premier_8_v 0 Effective Date November, 0

11 Name CRIXIVAN ORAL CAPSULE 00 MG, 00 MG CUBICIN DAKLINZA DAPSONE DARAPRIM demeclocycline oral dicloxacillin didanosine DIFLUCAN DORIBAX DOXY-00 doxycycline hyclate intravenous doxycycline hyclate oral capsule doxycycline hyclate oral tablet 00 mg, 0 mg doxycycline hyclate oral tablet 0 mg doxycycline monohydrate oral capsule 7 mg doxycycline monohydrate oral suspension for reconstitution doxycycline monohydrate oral tablet 00 mg, 0 mg, 7 mg doxycycline monohydrate oral tablet 0 mg E.E.S. GRANULES EDURANT EMTRIVA entecavir EPIVIR HBV ORAL SOLUTION EPIVIR ORAL SOLUTION EPZICOM ery-tab oral tablet,delayed release (dr/ec) 0 mg, mg ERY-TAB ORAL TABLET, DELAYED RELEASE (DR/ EC) 00 MG ERYPED 00 ERYPED 00 erythrocin (as stearate) oral tablet 0 mg ; CG ; PAR; ; QLL (0 per 0 ; CG ; CG ; CG ; CG CG ; QLL (60 per day) ; CG PAR; ; CG Name 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 FLAGYL ER FLAGYL ORAL CAPSULE 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 foscarnet FUZEON SUBCUTANEOUS RECON SOLN ganciclovir sodium gentamicin in nacl (iso-osm) intravenous piggyback 00 mg/ 00 ml, 60 mg/0 ml GENTAMICIN IN NACL (ISO-OSM) INTRAVENOUS PIGGYBACK 00 MG/0 ML, 0 MG/00 ML gentamicin in nacl (iso-osm) intravenous piggyback 70 mg/ 0 ml, 80 mg/00 ml, 80 mg/ 0 ml, 90 mg/00 ml gentamicin injection gentamicin sulfate (ped) (pf) ; CG ; CG ; QLL (60 per 0 ; QLL ( per 7 ; CG ; ; QLL (60 per 0 Premier_8_v Effective Date November, 0

12 Name 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 microsize oral tablet griseofulvin ultramicrosize oral tablet mg griseofulvin ultramicrosize oral tablet 0 mg HARVONI HIPREX hydroxychloroquine oral imipenem-cilastatin INTELENCE ORAL TABLET 00 MG, 00 MG INTELENCE ORAL TABLET MG INVANZ INJECTION INVANZ INTRAVENOUS INVIRASE ISENTRESS ORAL POWDER IN PACKET ISENTRESS ORAL TABLET ISENTRESS ORAL TABLET,CHEWABLE 00 MG ISENTRESS ORAL TABLET,CHEWABLE MG isoniazid injection isoniazid oral solution isoniazid oral tablet itraconazole ivermectin oral KALETRA ORAL SOLUTION ; CG PAR; ; QLL (8 per 8 ; CG ; CG PAR; Name KALETRA ORAL TABLET 00- MG KALETRA ORAL TABLET 00-0 MG KEFLEX ORAL CAPSULE KETEK ketoconazole oral LAMISIL ORAL GRANULES IN PACKET LAMISIL ORAL TABLET 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 LINCOCIN linezolid intravenous linezolid oral linezolid-0.9% sodium chloride MALARONE MALARONE PEDIATRIC 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 ; CG; QLL (0 per day) ; CG ; QLL (0 per 0 ; CG; QLL ( per day) PAR; ; QLL (8 per day) ; CG PAR; ; CG ; CG ; CG ; CG Premier_8_v Effective Date November, 0

13 Name minocycline oral tablet 0 mg NUROL XATAG moxifloxacin MYAMBUTOL ORAL TABLET 00 MG MYCAMINE MYCOBUTIN nafcillin in dextrose iso-osm intravenous piggyback gram/ 0 ml nafcillin in dextrose iso-osm intravenous piggyback gram/ 00 ml nafcillin injection recon soln gram nafcillin injection recon soln 0 gram, gram nafcillin intravenous 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 ofloxacin oral tablet 00 mg OLYSIO ORACEA 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 ; CG ; CG; QLL ( per day) ; ; CG ; CG ; CG PAR; PAR; PAR; ; QLL (60 per 0 ; CG ; CG CG PAR; Name oxacillin injection recon soln 0 gram oxacillin intravenous recon soln gram oxacillin intravenous recon soln gram paromomycin PASER PCE PENICILLIN G POT IN DEXTROSE penicillin g potassium penicillin g procaine intramuscular syringe. million unit/ ml penicillin g procaine intramuscular syringe 600,000 unit/ml penicillin g sodium penicillin v potassium PENTAM pfizerpen-g piperacillin-tazobactam polymyxin b sulfate PREZCOBIX PREZISTA ORAL SUSPENSION PREZISTA ORAL TABLET 0 MG, 7 MG PREZISTA ORAL TABLET 600 MG, 800 MG PRIFTIN PRIMAQUINE PRIMSOL pyrazinamide QUALAQUIN quinine sulfate REBETOL ORAL SOLUTION RELENZA DISKHALER RESCRIPTOR RETROVIR INTRAVENOUS REYATAZ ORAL CAPSULE 0 MG, 00 MG, 00 MG ; CG ; CG ; CG ; CG PAR; PAR; PAR; ; CG; QLL (60 per 80 Premier_8_v Effective Date November, 0

14 Name REYATAZ ORAL POWDER IN PACKET ribasphere oral tablet 00 mg ribasphere oral tablet 00 mg ribasphere oral tablet 600 mg ribavirin oral capsule ribavirin oral tablet 00 mg rifabutin RIFADIN RIFAMATE rifampin intravenous rifampin oral RIFATER rimantadine SELZENTRY SOVALDI stavudine STREPTOMYCIN INTRAMUSCULAR STRIBILD STROMECTOL sulfadiazine oral sulfamethoxazole-trimethoprim intravenous sulfamethoxazole-trimethoprim oral suspension sulfamethoxazole-trimethoprim oral tablet mg sulfamethoxazole-trimethoprim oral tablet mg SUPRAX ORAL SUSPENSION FOR RECONSTITUTION 00 MG/ ML, 00 MG/ ML SUPRAX ORAL SUSPENSION FOR RECONSTITUTION 00 MG/ ML SUSTIVA SYNAGIS SYNERCID TAMIFLU ORAL CAPSULE 0 MG TAMIFLU ORAL CAPSULE MG PAR; PAR; PAR; PAR; PAR; ; CG ; CG PAR; ; CG ; CG ; CG ; CG ; CG PAR; ; LA ; CG; QLL (8 per day) ; CG; QLL ( per day) Name TAMIFLU ORAL CAPSULE 7 MG TAMIFLU ORAL SUSPENSION FOR RECONSTITUTION TEFLARO terbinafine hcl oral tetracycline tinidazole TIVICAY tobramycin in 0. % nacl tobramycin in 0.9 % nacl intravenous piggyback 80 mg/ 00 ml tobramycin sulfate injection recon soln tobramycin sulfate injection solution TRECATOR trimethoprim TRIUMEQ TRIZIVIR TRUVADA TYBOST TYGACIL TYZEKA valacyclovir oral tablet gram valacyclovir oral tablet 00 mg VALCYTE ORAL TABLET valganciclovir VANCOMYCIN IN DW INTRAVENOUS PIGGYBACK GRAM/00 ML VANCOMYCIN IN DW INTRAVENOUS PIGGYBACK 00 MG/00 ML VANCOMYCIN IN DEXTROSE ISO-OSM vancomycin intravenous ; CG; QLL (6 per 6 ; CG; QLL (60 per 80 ; CG; QLL (0 per 0 ; CG ; ; QLL (80 per 8 ; CG PAR; ; QLL (0 per day) ; CG; QLL (0 per day) ; ; Premier_8_v Effective Date November, 0

15 Name VANCOMYCIN INTRAVENOUS 70 MG vancomycin oral capsule mg vancomycin oral capsule 0 mg VIBRAMYCIN ORAL CAPSULE 00 MG VIBRAMYCIN ORAL SUSPENSION FOR RECONSTITUTION VIBRAMYCIN ORAL SYRUP 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 XIFAXAN ORAL TABLET 00 MG ZIAGEN ORAL SOLUTION zidovudine oral capsule zidovudine oral syrup zidovudine oral tablet ZITHROMAX ZITHROMAX TRI-PAK ZITHROMAX Z-PAK ZMAX ; PAR; ; QLL (0 per day) PAR; ; QLL (80 per day) ; CG ; CG PAR; PAR; ; QLL (0 per 0 PAR; ; QLL (00 per 0 PAR; ; QLL (60 per 0 PAR; ; QLL (0 per 0 ; CG ; CG Name ZOVIRAX ORAL 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 INTRAVENOUS ALKERAN ORAL ; amifostine crystalline PAR; anastrozole ; CG ARRANON ARZERRA ; ASTAGRAF XL ; AVASTIN INTRAVENOUS SOLUTION MG/ML AVASTIN INTRAVENOUS SOLUTION MG/ML (6 ML) azacitidine PAR; PAR PAR; AZASAN ; azathioprine ; ; CG BELEODAQ PAR; bexarotene PAR; bicalutamide ; CG BICNU ; bleomycin ; BLINCYTO PAR; BOSULIF PAR; BUSULFEX Premier_8_v Effective Date November, 0

16 Name CAPRELSA carboplatin intravenous solution CASODEX CELLCEPT CELLCEPT INTRAVENOUS cisplatin cladribine CLOLAR COMETRIQ COSMEGEN cyclophosphamide oral capsule cyclosporine intravenous cyclosporine modified cyclosporine oral capsule 00 mg cyclosporine oral capsule mg CYRAMZA INTRAVENOUS SOLUTION 0 MG/ML CYRAMZA INTRAVENOUS SOLUTION 0 MG/ML (0 ML) 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 PAR; ; LA ; ; ; ; ; ; PAR; ; ; ; ; ; PAR; PAR ; ; ; ; ; ; ; Name 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 ELITEK ELLENCE 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 ; ; ; PAR; ; ; PAR; PAR; ; ; ; PAR; ; QLL (60 per 0 PAR; ; QLL (0 per 0 PAR; ; ; ; ; Premier_8_v 6 Effective Date November, 0

17 Name flutamide FOLOTYN FUSILEV GAZYVA gemcitabine intravenous recon soln gram, 00 mg gemcitabine intravenous recon soln gram gemcitabine intravenous solution gengraf GILOTRIF GLEEVEC GLEOSTINE HALAVEN HERCEPTIN HEXALEN HYDREA hydroxyurea IBRANCE ICLUSIG idarubicin ifosfamide intravenous recon soln gram ifosfamide intravenous recon soln gram ifosfamide intravenous solution IMBRUVICA INLYTA IRESSA 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) ; CG ; ; PAR; ; ; PAR; PAR; PAR; PAR; ; CG PAR; ; QLL (0 per 0 PAR; ; PAR; PAR; ; PAR; ; PAR; ; PAR; PAR; PAR; ; QLL (0 per 0 Name 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 LOMUSTINE LUPRON DEPOT INTRAMUSCULAR SYRINGE KIT.7 MG, 7. MG LUPRON DEPOT-PED INTRAMUSCULAR KIT 7. MG (PED) LYNPARZA LYSODREN MATULANE MEGACE 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 PAR; ; QLL (60 per 0 PAR; ; QLL (90 per 0 ; CG ; ; CG ; CG PAR; PAR; PAR; PAR; ; QLL (80 per 0 ; CG PAR; PAR PAR; PAR; PAR; ; CG ; Premier_8_v 7 Effective Date November, 0

18 Name methotrexate sodium injection methotrexate sodium oral mitomycin mitoxantrone MUSTARGEN mycophenolate mofetil oral capsule mycophenolate mofetil oral suspension for reconstitution mycophenolate mofetil oral tablet mycophenolate sodium MYFORTIC ORAL TABLET,DELAYED RELEASE (DR/EC) 80 MG MYFORTIC ORAL TABLET,DELAYED RELEASE (DR/EC) 60 MG NEORAL NEXAVAR NILANDRON NIPENT NULOJIX octreotide acetate injection solution,000 mcg/ml 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 ; CG ; ; ; ; CG ; ; ; CG ; ; ; ; PAR; ; LA; QLL (0 per 0 ; ; PAR; PAR; PAR; PAR; ; PAR; ; ; ; PAR; PAR; ; Name 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 RHEUMATREX ORAL TABLETS,DOSE PACK. MG RHEUMATREX ORAL TABLETS,DOSE PACK. MG (DOSE PACK ),. MG (DOSE PACK 6),. MG (DOSE PACK 0),. MG (DOSE PACK 8) RITUXAN SANDIMMUNE SANDOSTATIN LAR DEPOT SIMULECT INTRAVENOUS RECON SOLN 0 MG SIMULECT INTRAVENOUS RECON SOLN 0 MG sirolimus SOLTAX SOMATULINE DEPOT SPRYCEL STIVARGA SUTENT SYNRIBO TABLOID tacrolimus oral capsule 0. mg, mg tacrolimus oral capsule mg TAFINLAR PAR; ; ; CG ; ; CG ; PAR; ; LA; QLL (60 per 0 PAR; ; LA; QLL (0 per 0 PAR; ; LA; QLL (0 per 0 PAR; ; PAR; ; ; PAR; PAR; ; QLL (0 per 0 PAR; PAR; ; ; PAR; Premier_8_v 8 Effective Date November, 0

19 Name tamoxifen TARCEVA TARGRETIN TASIGNA THALOMID ORAL CAPSULE 00 MG, 0 MG THALOMID ORAL CAPSULE 0 MG, 00 MG thiotepa toposar topotecan TORISEL TREANDA TRELSTAR TRELSTAR DEPOT TRELSTAR LA tretinoin (chemotherapy) TREXALL TRISENOX TYKERB UNITUXIN 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 ZOLINZA ZORTRESS ORAL TABLET 0. MG ZORTRESS ORAL TABLET 0. MG, 0.7 MG ; CG 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; PAR; ; ; Name 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 alprazolam oral tablet amitriptyline amoxapine (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 ; QLL (90 per 0 PAR; ; CG Premier_8_v 9 Effective Date November, 0

20 Name 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 solution aripiprazole oral tablet 0 mg aripiprazole oral tablet mg, 0 mg aripiprazole oral tablet mg aripiprazole oral tablet 0 mg aripiprazole oral tablet mg ARTHROTEC 0 ARTHROTEC 7 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 injection benztropine oral BRINTELLIX ORAL TABLET 0 MG BRINTELLIX ORAL TABLET 0 MG BRINTELLIX ORAL TABLET MG bromocriptine BUPRENEX buprenorphine hcl injection solution buprenorphine hcl injection syringe PAR; ; QLL (90 per 0 PAR; ; QLL (60 per 0 PAR; ; LA; QLL (60 per 0 PAR; ; LA ST; ; QLL (900 per 0 ; QLL (90 per 0 ; QLL (60 per 0 ; QLL (0 per 0 ; QLL (0 per 0 ; QLL (80 per 0 ; CG ; CG PAR; ; QLL (00 per 0 PAR; ; QLL (80 per 0 PAR; ; QLL (0 per 0 PAR; PAR; ST; ; QLL (60 per 0 ST; ; QLL (0 per 0 ST; ; QLL (0 per 0 Name buprenorphine hcl sublingual tablet mg buprenorphine hcl sublingual tablet 8 mg buprenorphine-naloxone sublingual tablet -0. mg 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 butalbital-acetaminop-caf-cod oral capsule mg butorphanol tartrate injection butorphanol tartrate nasal CAPITAL WITH CODEINE 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 CARBATROL carbidopa carbidopa-levodopa carbidopa-levodopa-entacapone CELEBREX celecoxib PAR; ; QLL (0 per 0 PAR; ; QLL (60 per 0 PAR; ; QLL (60 per 0 PAR; ; QLL (90 per 0 ; CG; QLL ( per 0 ; CG; QLL (80 per 0 ; CG; QLL (0 per 0 ; CG; QLL (60 per 0 ; CG; QLL (90 per 0 ; CG; QLL ( per 0 ; CG PAR; ; QLL (80 per 0 ; QLL ( per 8 ; QLL (700 per 0 ST; PAR; ; QLL (60 per 0 PAR; ; QLL (60 per 0 Premier_8_v 0 Effective Date November, 0

21 Name 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 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 PAR; PAR; ; CG PAR; ; CG; QLL (600 per 0 ; CG; QLL (0 per 0 ; CG; QLL (60 per 0 ; CG; QLL (0 per 0 PAR; PAR; ; QLL (00 per 0 PAR; ; QLL (600 per 0 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 ; CG; 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 Name clozapine oral tablet, disintegrating 0 mg clozapine oral tablet, disintegrating 00 mg clozapine oral tablet, disintegrating mg codeine sulfate oral tablet mg, 0 mg codeine sulfate oral tablet 60 mg COGENTIN COPAXONE SUBCUTANEOUS SYRINGE 0 MG/ML COPAXONE SUBCUTANEOUS SYRINGE 0 MG/ML cyclobenzaprine oral tablet CYMBALTA ORAL CAPSULE,DELAYED RELEASE(DR/EC) 0 MG CYMBALTA ORAL CAPSULE,DELAYED RELEASE(DR/EC) 0 MG CYMBALTA ORAL CAPSULE,DELAYED RELEASE(DR/EC) 60 MG dantrolene DEPACON DEPAKENE 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 DESVENLAFAXINE FUMARATE ORAL TABLET EXTENDED RELEASE HR 0 MG DESVENLAFAXINE ORAL TABLET EXTENDED RELEASE HR 00 MG QLL (80 per 0 QLL ( per 0 QLL (080 per 0 ; CG; QLL (60 per 0 ; CG; QLL (80 per 0 PAR; PAR; ; QLL (0 per 0 PAR; ; QLL ( per 8 PAR; ; CG ; QLL (80 per 0 ; QLL (0 per 0 ; QLL (60 per 0 ; ; CG ; QLL (0 per 0 ; QLL (0 per 0 ; QLL (0 per 0 Premier_8_v Effective Date November, 0

22 Name 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 diclofenac-misoprostol diflunisal dihydrocodeine-aspirin-caff dihydroergotamine injection dihydroergotamine nasal DILANTIN 0 MG CAPSULE DILANTIN EXTENDED DILANTIN INFATABS DILANTIN- diskets divalproex DOLOPHINE ORAL TABLET 0 MG ; 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) ; CG ; CG ; CG QLL (0 per 0 ; QLL (8 per 8 QLL (0 per 0 ; CG ; QLL (80 per 0 Name DOLOPHINE ORAL TABLET MG donepezil oral tablet 0 mg, mg donepezil oral tablet mg 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 EC-NAPROSYN 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 ERGOMAR escitalopram oxalate oral solution ; QLL (60 per 0 ; CG; QLL (0 per 0 ST; ; QLL (0 per 0 ; CG; 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 ; CG ; QLL (80 per 0 ; QLL (0 per 0 ; QLL (80 per 0 PAR; ; QLL (600 per 0 Premier_8_v Effective Date November, 0

23 Name escitalopram oxalate oral tablet 0 mg escitalopram oxalate oral tablet 0 mg escitalopram oxalate oral tablet mg ethosuximide etodolac 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 FELDENE fenoprofen oral tablet fentanyl citrate ; CG; QLL (60 per 0 ; CG; QLL (0 per 0 ; CG; QLL (0 per 0 ; CG ; 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 ; CG PAR; ; QLL (0 per 0 Name 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 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 FIORICET WITH CODEINE ORAL CAPSULE MG fluoxetine oral capsule 0 mg fluoxetine oral capsule 0 mg fluoxetine oral capsule 0 mg fluoxetine oral capsule,delayed release(dr/ec) 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 ST; ; QLL ( per 0 PAR; ; QLL (0 per 0 PAR; ; QLL (8 per 6 PAR; ; QLL (0 per 0 PAR; ; QLL (80 per 0 PAR; ; QLL (90 per 0 PAR; ; QLL (80 per 0 ; CG; QLL (0 per 0 ; CG; QLL (0 per 0 ; CG; QLL (60 per 0 ; QLL ( per 8 ; CG; QLL (600 per 0 ; CG; QLL (0 per 0 ; CG; QLL (0 per 0 ; QLL (0 per 0 ; CG ; CG ; CG; QLL (90 per 0 Premier_8_v Effective Date November, 0

24 Name 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 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 ; CG; QLL (60 per 0 ; CG; QLL (80 per 0 ; ; QLL (0 per 0 ; QLL (80 per 0 ; QLL (90 per 0 ; QLL (60 per 0 ; QLL ( per 0 ; CG; QLL (080 per 0 ; CG; QLL (60 per 0 ; CG; QLL (70 per 0 ; QLL (60 per 0 QLL (60 per 0 ; CG; QLL (80 per 0 ; CG; 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 Name guanidine haloperidol haloperidol decanoate haloperidol lactate injection haloperidol lactate oral HORIZANT ORAL TABLET EXTENDED RELEASE 00 MG HORIZANT ORAL TABLET EXTENDED RELEASE 600 MG HYCET 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 hydromorphone (pf) injection solution mg/ml hydromorphone (pf) injection solution 0 mg/ml, mg/ml hydromorphone injection solution hydromorphone injection syringe mg/ml hydromorphone injection syringe mg/ml hydromorphone injection syringe mg/ml hydromorphone oral liquid 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 ; CG ; CG ; CG PAR; ; QLL (0 per 0 PAR; ; QLL (60 per 0 ; QLL (700 per 0 QLL (700 per 0 ; QLL (700 per 0 ; QLL (60 per 0 ; QLL (80 per 0 ; QLL (80 per 0 QLL (80 per 0 ; QLL (70 per 0 ; QLL (60 per 0 ; QLL (80 per 0 ; CG ; CG ; QLL (8 per day) PAR; ; CG Premier_8_v Effective Date November, 0

25 Name 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 SYRINGE 89 MG/.6 ML ketoprofen oral capsule ketoprofen oral capsule,ext rel. pellets hr 00 mg KHEDEZLA ORAL TABLET EXTENDED RELEASE HR 00 MG 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 ; CG ; QLL (0 per 0 Name KHEDEZLA ORAL TABLET EXTENDED RELEASE HR 0 MG LAMICTAL ORAL TABLET LAMICTAL ORAL TABLET, CHEWABLE DISPERSIBLE MG, MG LAMICTAL STARTER (BLUE) KIT LAMICTAL STARTER (GREEN) KIT LAMICTAL STARTER (ORANGE) KIT 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 ; QLL (0 per 0 ; CG ; 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 ; ; ; CG ; QLL (80 per 0 ; QLL (0 per 0 Premier_8_v Effective Date November, 0