Plan Year Allegian Advantage (HMO) Prior Authorization (PA) Criteria

Transcription

1 Plan Year 2016 Allegian Advantage (HMO) Prior Authorization (PA) Criteria Prior Authorization: Allegian Advantage requires you (or your physician) to get prior authorization for certain drugs. This means that you will need to get approval from Allegian Advantage before you fill your prescriptions. If you don t get approval, Allegian Advantage may not cover the drug. PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT OUR PRIOR AUTHORIZATION CRITERIA. Allegian Health Plans is an HMO plan with a Medicare contract. Enrollment in Allegian Health Plans depends on contract renewal. Formulary ID: Last updated 5/01/2016 Version: 10 H8554_ A

2 2016 Allegian Medicare Part D Formulary Products Affected ABILIFY 300MG MAINTENA INJ (New Starts Only) ABILIFY 400MG MAINTENA PF SYR (New Starts Only) ARIPIPRAZOLE 15MG ODT (New Starts Only) ABILIFY 300MG MAINTENA PF SYR (New Starts Only) ARIPIPRAZOLE 10MG ODT (New Starts Only) Patient has tried and failed or was intolerant to 1 of the following: olanzapine, quetiapine, risperidone or ziprasidone. If prescribed for schizoaffective disorder, member does not require trial of previous agent. 1

3 adapalene 0.1% cream adapalene 0.3% gel avita 0.025% cream AZELEX 20% CREAM DIFFERIN 0.1% GEL DIFFERIN 0.3% GEL EPIDUO % GEL RETIN-A 0.025% CREAM RETIN-A 0.04% GEL RETIN-A 0.08% GEL RETIN-A 0.1% GEL tretinoin 0.01% gel tretinoin 0.025% gel tretinoin 0.05% cream tretinoin 0.1% cream adapalene 0.1% gel ATRALIN 0.05% GEL avita 0.025% gel DIFFERIN 0.1% CREAM DIFFERIN 0.1% LOTION EPIDUO % GEL RETIN-A 0.01% GEL RETIN-A 0.025% GEL RETIN-A 0.05% CREAM RETIN-A 0.1% CREAM TRETIN X 0.038% CREAM tretinoin 0.025% cream tretinoin 0.04% gel tretinoin 0.05% gel tretinoin 0.1% gel All FDA-approved indications not otherwise excluded from Part D. 2

4 ACTEMRA 162MG/0.9ML SYR ACTEMRA 200MG/10ML INJ Patient has tried or was intolerant to Enbrel AND Humira Prescribed by a Rheumatology Specialist or in consultation with a Rheumatology Specialist. 3

5 ADAGEN 250UNIT/ML INJ 4

6 ADCIRCA 20MG TAB Primary Pulmonary Arterial Hypertension or Secondary Pulmonary Arterial Hypertension. 5

7 ADEMPAS 0.5MG TAB ADEMPAS 1MG TAB ADEMPAS 2MG TAB ADEMPAS 1.5MG TAB ADEMPAS 2.5MG TAB Diagnosis confirmed by right heart catheterization. Restricted to or in consult with Pulmonologist or Cardiologist. For diagnosis of Pulmonary Arterial Hypertension, trial of one (1) of the following: Letairis, Opsumit or Tracleer. For diagnosis of Persistent/recurrent Chronic Thromboembolic Pulmonary Hypertension (CTEPH) (WHO Group 4), trial of prior therapy is not required. 6

8 AFINITOR 10MG TAB (New Starts Only) AFINITOR 2MG SUSP (New Starts Only) AFINITOR 5MG SUSP (New Starts Only) AFINITOR 7.5MG TAB (New Starts Only) AFINITOR 2.5MG TAB (New Starts Only) AFINITOR 3MG SUSP (New Starts Only) AFINITOR 5MG TAB (New Starts Only) For the treatment of progressive neuroendocrine tumors of pancreatic origin in patients with unresectable, locally advanced, or metastatic disease. For the treatment of patients with advanced renal cell carcinoma after failure of treatment with Sutent or Nexavar. For the treatment of patients with subependymal giant cell astrocytoma associated with tuberous sclerosis who require therapeutic intervention but are not candidates for curative surgical resection. 7

9 ALECENSA 150MG CAP (New Starts Only) Prescribed by an Oncology Specialist or in consultation with an Oncology Specialist. 8

10 AMITIZA 24MCG CAP AMITIZA 8MCG CAP Patient has tried and failed Miralax (glycolax). Age 18 and above. 9

11 AMPYRA 10MG ER TAB Restricted to or in consult with Neurology Specialist. 10

12 ANDROID 10MG CAP FORTESTA 10MG/ACT GEL methyltestosterone 10mg cap TESTOSTERONE 1% (25MG) GEL TESTOSTERONE 1% GEL PUMP TESTRED 10MG CAP VOGELXO 1% GEL PUMP AXIRON 30MG/ACT TOPICAL SOLN METHITEST 10MG TAB TESTIM 1% GEL TESTOSTERONE 1% (50MG) GEL TESTOSTERONE 10MG/ACT GEL VOGELXO 1% (50MG) GEL Two morning testosterone levels fall below the normal range for a healthy adult male. Patient must have tried and failed ANDRODERM and ANDROGEL. For Android, Methitest, and Testred, if prescribed for delay in sexual development or metastasis from malignant tumor of breast, inoperable metastatic disease (skeletal) in women 1 to 5 years postmenopausal, testosterone levels and previous trial of ANDRODERM and ANDROGEL not required. 11

13 ANDRODERM 2MG/24HR PATCH ANDROGEL 1% (25MG) GEL ANDROGEL 1.62% (1.25GM) GEL ANDROGEL 1.62% GEL ANDRODERM 4MG/24HR PATCH ANDROGEL 1% (50MG) GEL ANDROGEL 1.62% (2.5GM) GEL Two morning testoterone levels fall below the normal range for a healthy adult male. 12

14 APTIOM 200MG TAB (New Starts Only) APTIOM 600MG TAB (New Starts Only) APTIOM 400MG TAB (New Starts Only) APTIOM 800MG TAB (New Starts Only) 13

15 ARCALYST 220MG INJ Restricted to Rheumatology Specialists or in consult with Rheumatology Specialist. 14

16 ARIXTRA 10MG/0.8ML SYR ARIXTRA 5MG/0.4ML SYR fondaparinux sodium 12.5mg/ml (0.4ml) syr fondaparinux sodium 12.5mg/ml (0.8ml) syr ARIXTRA 2.5MG/0.5ML SYR ARIXTRA 7.5MG/0.6ML SYR fondaparinux sodium 12.5mg/ml (0.6ml) syr fondaparinux sodium 5mg/ml syr Covered Uses All medically accepted indications not otherwise excluded from Part D. Body weight less than 50 kg (venous thromboembolism prophylaxis only) Patient has history of Heparin Induced Throbmocytopenia (HIT) or HIT is medically suspected. Or, prescribed for prevention or treatment of DVT in an orthopedic surgery patient. 15

17 FANAPT 10MG TAB (New Starts Only) FANAPT 1MG TAB (New Starts Only) FANAPT 4MG TAB (New Starts Only) FANAPT 8MG TAB (New Starts Only) INVEGA 1.5MG ER TAB (New Starts Only) INVEGA 156MG/ML SYR (New Starts Only) INVEGA 273MG/0.875ML SYR (New Starts Only) INVEGA 3MG ER TAB (New Starts Only) INVEGA 546MG/1.75ML SYR (New Starts Only) INVEGA 78MG/0.5ML SYR (New Starts Only) INVEGA 9MG ER TAB (New Starts Only) LATUDA 20MG TAB (New Starts Only) LATUDA 60MG TAB (New Starts Only) paliperidone 1.5mg er tab (New Starts Only) paliperidone 6mg er tab (New Starts Only) SAPHRIS 10MG SL TAB (New Starts Only) SAPHRIS 5MG SL TAB (New Starts Only) FANAPT 12MG TAB (New Starts Only) FANAPT 2MG TAB (New Starts Only) FANAPT 6MG TAB (New Starts Only) FANAPT TITRATION PACK (New Starts Only) INVEGA 117MG/0.75ML SYR (New Starts Only) INVEGA 234MG/1.5ML SYR (New Starts Only) INVEGA 39MG/0.25ML SYR (New Starts Only) INVEGA 410MG/1.315ML SYR (New Starts Only) INVEGA 6MG ER TAB (New Starts Only) INVEGA 819MG/2.625ML SYR (New Starts Only) LATUDA 120MG TAB (New Starts Only) LATUDA 40MG TAB (New Starts Only) LATUDA 80MG TAB (New Starts Only) paliperidone 3mg er tab (New Starts Only) paliperidone 9mg er tab (New Starts Only) SAPHRIS 2.5MG SL TAB (New Starts Only) Patient has tried and failed or was intolerant to 1 of the following: aripiprazole, olanzapine, quetiapine, risperidone or ziprasidone. If prescribed for schizoaffective disorder, member does not require trial of previous agent. 16

18 AUBAGIO 14MG TAB AUBAGIO 7MG TAB For use in Multiple Sclerosis (MS), patient has a relapsing form of MS. Prescribed by a neurologist or an MS specialist. For use in MS, patient has a relapsing form of MS and patient has tried interferon beta-1a intramuscular (Avonex), interferon beta-1a subcutaneous (Rebif), interferon beta-1b (Betaseron or Extavia), or glatiramer acetate (Copaxone) AND dimethyl fumarate (Tecfidera). Exceptions to having tried an interferon beta-1a or -1b product (Avonex, Betaseron, Extavia, or Rebif) or glatiramer acetate (Copaxone) can be made if the patient is unable to administer injections due to dexterity issues or visual impairment. Patients who have tried natalizumab (Tysabri) for MS and have a relapsing form of MS will receive authorization, they are not required to try an interferon beta product or glatiramer acetate. 17

19 BUTISOL 30MG TAB (New Starts Only) PHENOBARBITAL 15MG TAB (New Starts Only) PHENOBARBITAL 30MG TAB (New Starts Only) phenobarbital 4mg/ml soln (New Starts Only) phenobarbital 64.8mg tab (New Starts Only) SECONAL SODIUM 100MG CAP (New Starts Only) PHENOBARBITAL 100MG TAB (New Starts Only) phenobarbital 16.2mg tab (New Starts Only) phenobarbital 32.4mg tab (New Starts Only) PHENOBARBITAL 60MG TAB (New Starts Only) phenobarbital 97.2mg tab (New Starts Only) Covered Uses All FDA approved indications not otherwise excluded from Part D. Prior Authorization required for members 65 years and older. 18

20 BELEODAQ 500MG INJ (New Starts Only) Prescribed by or in consult with Oncology Specialist. 19

21 BIVIGAM 10% INJ FLEBOGAMMA 10% INJ GAMMAGARD 2.5GM/25ML INJ GAMMAPLEX 10GM/200ML INJ OCTAGAM 25GM/500ML INJ PRIVIGEN 20GM/200ML INJ CARIMUNE 6GM INJ GAMASTAN 180UNIT/ML INJ GAMMAKED 1GM/10ML INJ GAMUNEX 1GM/10ML INJ OCTAGAM 2GM/20ML INJ 20

22 BOSULIF 100MG TAB (New Starts Only) BOSULIF 500MG TAB (New Starts Only) Prescribed by or in consult with Oncology Specialist. 21

23 CAPRELSA 100MG TAB (New Starts Only) CAPRELSA 300MG TAB (New Starts Only) Prescribed by an Oncologist or Endocrinologist or under the direct consultation of an Oncologist or Endocrinologist 22

24 CAYSTON 75MG INH SOLN Restricted to or in consult with Infectious Disease or Pulmonology Specialist. Approval will be based off BvD coverage determination. 23

25 CERVARIX SYR PA not required for members age 9-25 years. Approved for duration of plan year subject to formulary change and member eligibility. 24

26 CIMZIA 200MG INJ CIMZIA 200MG/ML SYR For moderate to severe RA requires intolerance to or failure of therapy with methotrexate (greater than 20mg/wk) AND etanercept (Enbrel) AND adalimumab (Humira). For Crohn's disease requires a trial of adalimumab (Humira) For RA must be prescribed by Rheumatology Specialist. For Crohn's Disease must be prescribed by Gastroenterology Specialist. For members with a diagnosis of early, severe-onset RA additional required medical information is not required. 25

27 BERINERT 500UNIT INJ FIRAZYR 30MG/3ML SYR CINRYZE 500UNIT INJ 26

28 COMETRIQ 100MG DAILY DOSE CARTON PACK (New Starts Only) COMETRIQ 140MG DAILY DOSE CARTON PACK (New Starts Only) COMETRIQ 60MG DAILY DOSE CARTON 20MG PACK (New Starts Only) Prescribed by or in consult with Oncology Specialist. 27

29 CORLANOR 5MG TAB CORLANOR 7.5MG TAB The patient is on a maximally tolerated dose of beta blocker or has a history of a documented intolerance, contraindication, or a hypersensitivity to beta blocker. Prescribed by, or in consultation with, a Cardiology Specialist. 28

30 COSENTYX 150MG/ML AUTO-INJECTOR COSENTYX 150MG/ML SYR Intolerance to or failure of therapy with Humira Psoriatic Arthritis and Ankylosing Spondylitis: Prescriber must be a Rheumatologist. Plaque Psoriasis: Prescriber must be a Dermatologist. 29

31 COTELLIC 20MG TAB (New Starts Only) Prescribed by an Oncology Specialist or in consultation with an Oncology Specialist. 30

32 CYRAMZA 100MG/10ML INJ (New Starts Only) CYRAMZA 500MG/50ML INJ (New Starts Only) Prescribed by an Oncology Specialist or in consultation with an Oncology Specialist. 31

33 CYSTARAN 0.44% OPHTH SOLN For the treatment of corneal cystine crystal accumulation in patients with cystinosis Prescribed by or in consultation with an Ophthalmologist or Geneticist. 32

34 DARZALEX 100MG/5ML INJ (New Starts Only) Prescribed by an Oncology Specialist or in consultation with an Oncology Specialist. 33

35 MARINOL 10MG CAP MARINOL 5MG CAP MARINOL 2.5MG CAP Diagnosis of loss of appetite due to AIDS OR chemotherapy induced nausea and vomiting This drug may be covered under Medicare Part B or D depending upon the circumstances. Information may need to be submitted describing the use and setting of the drug to make the determination. 34

36 DYMISTA MCG NASAL INHALER Covered Uses All FDA-approved indications not otherwise excluded by Part D. Requires trial of 2 formulary alternatives 35

37 EMPLICITI 300MG INJ (New Starts Only) EMPLICITI 400MG INJ (New Starts Only) Prescribed by an Oncology Specialist or Hematology Specialist, or in consultation with an Oncology Specialist or Hematology Specialist. 36

38 ENBREL 25MG INJ ENBREL 50MG/ML SURECLICK INJ ENBREL 25MG/0.5ML SYR ENBREL 50MG/ML SYR For moderate to severe RA or Psoriatic Arthritis requires Trial of or failure of therapy with methotrexate (greater than 20mg/wk). Plaque Psoriasis: Trial of, or intolerance to, methotrexate at a dose of 15mg/week or trial of, or intolerance to, soriatane. Rheumatoid Arthritis, Psoriatic Arthritis and Ankylosing Spondylitis: Prescriber must be a Rheumatologist. All Plaque Psoriasis: Prescriber must be a Dermatologist. Approved for the duration of contract year subject to formulary change and member eligibility. For members with a diagnosis of early, severe-onset RA, additional required medical information is not required. 37

39 ERIVEDGE 150MG CAP (New Starts Only) Covered Uses All FDA-approved indications not otherwise excluded from Part D. All medically accepted indications not otherwise excluded from Part D Restricted to or in consult with Oncology Specialist. Covered for duration of plan year subject to formulary change and member eligibility. 38

40 ERWINAZE 10000UNIT INJ (New Starts Only) Restricted to Oncology Specialists or in consult with Oncology Specialist. 39

41 FARYDAK 10MG CAP (New Starts Only) FARYDAK 20MG CAP (New Starts Only) FARYDAK 15MG CAP (New Starts Only) Prescribed by an Oncology or Hematology Specialist or in consultation with an Oncology or Hematology Specialist. 40

42 FERRIPROX 100MG/ML SOLN FERRIPROX 500MG TAB Restricted to Hematology Specialists or in consult with Hematology Specialist. 41

43 FIRMAGON 120MG INJ (New Starts Only) FIRMAGON 80MG INJ (New Starts Only) Prescribed by or in consultation with Oncologist or Urologist Approval subject to BvD determination 42

44 FLECTOR 1.3% PATCH Approved for duration of contract year subject to formulary change and member eligibility 43

45 FOLOTYN 40MG/2ML INJ (New Starts Only) Prescribed by or on consultation with Hematologist or Oncologist Approval subject to BvD determination. 44

46 FORTEO 600MCG/2.4ML SYR Member has had at least 1 fracture, OR member has BMD screening results of -2.5 or below, OR member has previously used and failed a bisphosphonate. 45

47 FYCOMPA 10MG TAB (New Starts Only) FYCOMPA 2MG TAB (New Starts Only) FYCOMPA 6MG TAB (New Starts Only) FYCOMPA 12MG TAB (New Starts Only) FYCOMPA 4MG TAB (New Starts Only) FYCOMPA 8MG TAB (New Starts Only) 46

48 GARDASIL 9 INJ GARDASIL INJ GARDASIL 9 SYR GARDASIL SYR PA not required for members age Approved for duration of plan year subject to formulary change and member eligibility. 47

49 GATTEX 5MG INJ Diagnosis of short bowel syndrome with less than 200cm of remnant functional intestine. Dependent on parenteral support for at least 12 months and at least 3 days per week. 48

50 GILENYA 0.5MG CAP For use in Multiple Sclerosis (MS), patient has a relapsing form of MS. Prescribed by a neurologist or an MS specialist. For use in MS, patient has a relapsing form of MS and patient has tried interferon beta-1a intramuscular (Avonex), interferon beta-1a subcutaneous (Rebif), interferon beta-1b (Betaseron or Extavia), or glatiramer acetate (Copaxone) AND dimethyl fumarate (Tecfidera). Exceptions to having tried an interferon beta-1a or -1b product (Avonex, Betaseron, Extavia, or Rebif) or glatiramer acetate (Copaxone) can be made if the patient is unable to administer injections due to dexterity issues or visual impairment. Patients who have tried natalizumab (Tysabri) for MS and have a relapsing form of MS will receive authorization, they are not required to try an interferon beta product or glatiramer acetate. 49

51 GILOTRIF 20MG TAB (New Starts Only) GILOTRIF 40MG TAB (New Starts Only) GILOTRIF 30MG TAB (New Starts Only) Prescribed by or in consultation with an Oncology Specialist 50

52 GLEEVEC 100MG TAB (New Starts Only) imatinib 100mg tab (New Starts Only) GLEEVEC 400MG TAB (New Starts Only) imatinib 400mg tab (New Starts Only) Prescribed by Oncologist or Hematologist, or under the direct consultation with an Oncologist or Hematologist. 51

53 NORDITROPIN 10MG/1.5ML SYR NORDITROPIN 30MG/3ML SYR NORDITROPIN 15MG/1.5ML SYR NORDITROPIN 5MG/1.5ML SYR The criteria for approval of growth hormones in adults require the diagnosis of Somatropin Deficiency Syndrome (defined by failure to stimulate Growth Hormone secretion (peak GH level of 10mcg/L or less) by one of the acceptable provocative tests). This may include adults who as children had Growth Hormone deficiency or adults with known pituitary disease. 52

54 HARVONI MG TAB 1) Patient is diagnosed with chronic HCV (greater than 6 months) with genotype indicated 2) Current HCV-RNA titer 3) Documentation that member does or does not have cirrhosis 4) Previous Hepatitis C Treatments Member must be 18 years of age or older Prescribed by, or in consultation with, a Gastroenterologist, Hepatologist, Infectious Disease or Transplant Specialist Coverage duration of weeks based on cirrhosis status and previous treatment. 1) Treatment-naïve without cirrhosis-approval for 12 weeks (patients with HCV RNA less than 6M IU/mL may be treated by physician for 8-week course if appropriate). 2)Treatment-naïve with compensated cirrhosis: approval for 12 weeks. 3) Treatment-experienced without cirrhosis: approval for 12 weeks. 4) Treatment-experienced with compensated cirrhosis: approval for 24 weeks (patients using in combination with ribavirin may be treated by physician with 12-week course if appropriate). 53

55 HETLIOZ 20MG CAP Patient is totally blind. 54

56 amitriptyline 100mg tab (New Starts Only) amitriptyline 150mg tab (New Starts Only) amitriptyline 50mg tab (New Starts Only) ANAFRANIL 25MG CAP (New Starts Only) ANAFRANIL 75MG CAP (New Starts Only) benztropine mesylate 1mg tab CHLORPROPAMIDE 100MG TAB clomipramine 25mg cap (New Starts Only) clomipramine 75mg cap (New Starts Only) DEMEROL 50MG TAB DIABETA 1.25MG TAB DIABETA 5MG TAB dipyridamole 50mg tab disopyramide 100mg cap doxepin 100mg cap (New Starts Only) doxepin 10mg/ml soln (New Starts Only) doxepin 25mg cap (New Starts Only) DOXEPIN 75MG CAP (New Starts Only) GLUCOVANCE MG TAB glyburide 1.25mg tab glyburide 1.5mg tab glyburide 2.5mg/metformin 500mg tab glyburide 5mg tab glyburide 6mg tab GLYNASE 3MG TAB guanfacine 1mg er tab guanfacine 2mg er tab guanfacine 3mg er tab hydrochlorothiazide 15mg/methyldopa 250mg tab amitriptyline 10mg tab (New Starts Only) amitriptyline 25mg tab (New Starts Only) amitriptyline 75mg tab (New Starts Only) ANAFRANIL 50MG CAP (New Starts Only) benztropine mesylate 0.5mg tab benztropine mesylate 2mg tab CHLORPROPAMIDE 250MG TAB clomipramine 50mg cap (New Starts Only) DEMEROL 100MG TAB DEMEROL 50MG/ML INJ DIABETA 2.5MG TAB dipyridamole 25mg tab dipyridamole 75mg tab disopyramide 150mg cap doxepin 10mg cap (New Starts Only) doxepin 150mg cap (New Starts Only) doxepin 50mg cap (New Starts Only) FURADANTIN 25MG/5ML SUSP GLUCOVANCE 5-500MG TAB glyburide 1.25mg/metformin 250mg tab glyburide 2.5mg tab glyburide 3mg tab glyburide 5mg/metformin 500mg tab GLYNASE 1.5MG TAB GLYNASE 6MG TAB guanfacine 1mg tab guanfacine 2mg tab guanfacine 4mg er tab hydrochlorothiazide 25mg/methyldopa 250mg tab 55

57 imipramine 10mg tab (New Starts Only) imipramine 50mg tab (New Starts Only) imipramine pamoate 125mg cap (New Starts Only) imipramine pamoate 75mg cap (New Starts Only) indomethacin 25mg cap indomethacin 75mg er cap INTUNIV 2MG ER TAB INTUNIV 4MG ER TAB ketorolac tromethamine 15mg/ml inj MEGACE 40MG/ML SUSP (New Starts Only) megestrol acetate 125mg/ml susp megestrol acetate 40mg tab (New Starts Only) meperidine 100mg tab MEPERIDINE 10MG/ML SOLN meperidine 50mg tab meprobamate 200mg tab methyldopa 250mg tab naloxone 0.5mg/pentazocine 50mg tab nifedipine 20mg cap NORPACE 100MG CAP NORPACE 150MG CAP PERSANTINE 25MG TAB PERSANTINE 75MG TAB RESERPINE 0.25MG TAB SURMONTIL 25MG CAP (New Starts Only) TENEX 1MG TAB thioridazine 100mg tab (New Starts Only) thioridazine 25mg tab (New Starts Only) TIGAN 100MG/ML INJ TOFRANIL 10MG TAB (New Starts Only) imipramine 25mg tab (New Starts Only) imipramine pamoate 100mg cap (New Starts Only) imipramine pamoate 150mg cap (New Starts Only) INDOCIN 25MG/5ML SUSP indomethacin 50mg cap INTUNIV 1MG ER TAB INTUNIV 3MG ER TAB ketorolac tromethamine 10mg tab ketorolac tromethamine 30mg/ml inj MEGACE 625MG/5ML SUSP megestrol acetate 20mg tab (New Starts Only) megestrol acetate 40mg/ml susp (New Starts Only) meperidine 100mg/ml inj meperidine 25mg/ml inj meperidine 50mg/ml inj meprobamate 400mg tab methyldopa 500mg tab nifedipine 10mg cap nitrofurantoin 5mg/ml susp NORPACE 100MG ER CAP NORPACE 150MG ER CAP PERSANTINE 50MG TAB PROCARDIA 10MG CAP SURMONTIL 100MG CAP (New Starts Only) SURMONTIL 50MG CAP (New Starts Only) TENEX 2MG TAB thioridazine 10mg tab (New Starts Only) thioridazine 50mg tab (New Starts Only) TIGAN 300MG CAP TOFRANIL 25MG TAB (New Starts Only) 56

58 TOFRANIL 50MG TAB (New Starts Only) TOFRANIL-PM 125MG CAP (New Starts Only) TOFRANIL-PM 75MG CAP (New Starts Only) trihexyphenidyl 2mg tab trimethobenzamide 300mg cap trimipramine 25mg cap (New Starts Only) TOFRANIL-PM 100MG CAP (New Starts Only) TOFRANIL-PM 150MG CAP (New Starts Only) trihexyphenidyl 0.4mg/ml soln trihexyphenidyl 5mg tab trimipramine 100mg cap (New Starts Only) trimipramine 50mg cap (New Starts Only) No Prior Authorization required for members less than 65 years. If for pain (NSAID), trial or intolerance to ONE of the following: other NSAIDs such as ibuprofen, tramadol, hydrocodone/acetaminophen, oxycodone/acetaminophen. If for pain (opioid), trial or intolerance to ONE of the following: NSAIDs such as ibuprofen, tramadol, hydrocodone/acetaminophen, acetaminophen with codeine. If for ADHD, trial or intolerance to ONE of the following: stimulant. If for anxiety, trial or intolerance to ONE of the following: buspirone, SSRIs, SNRIs, bupropion. If for arrhythmia, trial or intolerance to ONE of the following: Beta-blockers, Calcium channel blockers, flecainide. If for depression, trial or intolerance to ONE of the following: Secondary Amine TCAs (nortriptyline, protriptyline, desipramine, amoxapine), SSRIs, SNRIs, bupropion. If for diabetes (sulfonylurea), trial or intolerance to ONE of the following: glipizide or glimepiride. If for emesis, trial or intolerance to ONE of the following: ondansetron. If for hypertension, trial or intolerance to ONE of the following: ACE inhibitors, ARBs, Beta-blockers, Calcium channel blockers, Thiazide diuretics. If for palliative treatment of advanced carcinoma of the breast or endometrium, anorexia, cachexia, or an unexplained, significant weight loss in patients with a diagnosis of acquired immunodeficiency syndrome, trial or intolerance to ONE of the following: medroxyprogesterone, dronabinol. If for Parkinson's, trial or intolerance to ONE of the following: Carbidopa/levodopa, pramipexole, ropinirole, bromocriptine, amantadine, selegiline. If for schizophrenia or psychosis, trial or intolerance to ONE of the following: Atypical antipsychotics: risperidone, olanzapine, ziprasidone, quetiapine. If for nifedipine IR, trial or intolerance to ONE of the following: amlodipine, felodipine, isradipine, nicardipine, nisoldipine, extended release nifedipine. If for stroke prevention, trial or intolerance to ONE of the following: clopidogrel, Aggrenox. If for Urinary Tract Infection (acute treatment), trial or intolerance to ONE of the following: ciprofloxacin, 57

59 trimethoprim/sulfamethoxazole (TMP/SMX), amoxicillin/clavulanate, cefdinir. If for Urinary Tract Infection (prevention of recurrent), trial or intolerance to ONE of the following: trimethoprim/sulfamethoxazole (TMP/SMX), Methenamine hippurate. 58

60 ACTIVELLA 0.5/0.1MG 28 DAY PACK ALORA 0.025MG/24HR PATCH ALORA 0.075MG/24HR PATCH AMITRIPTYLINE 10MG/PERPHENAZINE 2MG TAB (New Starts Only) amitriptyline 12.5mg/chlordiazepoxide 5mg tab (New Starts Only) AMITRIPTYLINE 25MG/PERPHENAZINE 2MG TAB (New Starts Only) AMITRIPTYLINE 50MG/PERPHENAZINE 4MG TAB (New Starts Only) ANGELIQ 0.5/1MG 28 DAY PACK arbinoxa 4mg/5ml soln aspirin 325mg/carisoprodol 200mg/codeine phosphate 16mg tab carbinoxamine maleate 4mg tab chlorzoxazone 500mg tab CLIMARA 0.025MG/24HR PATCH CLIMARA 0.06MG/24HR PATCH CLIMARA 0.1MG/24HR PATCH CLIMARA PRO MG PATCH COMBIPATCH MG PATCH cyclobenzaprine 5mg tab cyproheptadine 0.4mg/ml soln digitek 0.25mg tab digoxin 0.25mg tab diphenhydramine 2.5mg/ml soln ENJUVIA 0.45MG TAB ENJUVIA 1.25MG TAB ESTRACE 0.5MG TAB ESTRACE 2MG TAB estradiol mg/hr weekly patch estradiol mg/hr weekly patch estradiol mg/hr weekly patch ACTIVELLA 1/0.5MG 28 DAY PACK ALORA 0.05MG/24HR PATCH ALORA 0.1MG/24HR PATCH AMITRIPTYLINE 10MG/PERPHENAZINE 4MG TAB (New Starts Only) amitriptyline 25mg/chlordiazepoxide 10mg tab (New Starts Only) AMITRIPTYLINE 25MG/PERPHENAZINE 4MG TAB (New Starts Only) ANGELIQ 0.25/0.5MG 28 DAY PACK arbinoxa 4mg tab aspirin 325mg/carisoprodol 200mg tab carbinoxamine maleate 0.8mg/ml soln carisoprodol 350mg tab clemastine fumarate 2.68mg tab CLIMARA 0.05MG/24HR PATCH CLIMARA 0.075MG/24HR PATCH CLIMARA 37.5MCG/24HR PATCH COMBIPATCH MG PATCH cyclobenzaprine 10mg tab cyclobenzaprine 7.5mg tab cyproheptadine 4mg tab digoxin 0.05mg/ml soln digoxin 0.25mg/ml inj ENJUVIA 0.3MG TAB ENJUVIA 0.9MG TAB ERGOLOID MESYLATES 1MG TAB ESTRACE 1MG TAB estradiol mg/hr twice weekly patch estradiol mg/hr twice weekly patch estradiol mg/hr twice weekly patch estradiol mg/hr patch 59

61 estradiol mg/hr patch estradiol mg/hr twice weekly patch estradiol 0.5mg tab estradiol 1mg tab estradiol 2mg tab estropipate 1.5mg tab ethinyl estradiol mg/norethindrone acetate 0.5mg tab EVAMIST 1.53MG/SPRAY SPRAY FEXMID 7.5MG TAB fyavolv 1mg-5mcg tab hydroxyzine 25mg tab hydroxyzine 2mg/ml soln hydroxyzine 50mg/ml inj hydroxyzine pamoate 25mg cap jinteli tab LANOXIN 250MCG TAB lopreeza 1/0.5mg 28 day pack MENEST 0.625MG TAB MENEST 2.5MG TAB metaxall 800mg tab metaxalone 800mg tab methocarbamol 750mg tab mimvey pack MINIVELLE MG/24HR PATCH MINIVELLE 0.075MG/24HR PATCH orphenadrine citrate 100mg er tab PARAFON FORTE DSC 500MG TAB phenergan 12.5mg rectal supp PHENERGAN 25MG/ML INJ PHENERGAN 50MG/ML INJ estradiol mg/hr patch estradiol mg/hr weekly patch estradiol 0.5mg/norethindrone acetate 0.1mg pack estradiol 1mg/norethindrone acetate 0.5mg pack estropipate 0.75mg tab ESTROPIPATE 3MG TAB ethinyl estradiol 0.005mg/norethindrone acetate 1mg tab FEMHRT 0.5/2.5MG 28 DAY PACK fyavolv 0.5mg-2.5mcg tab hydroxyzine 10mg tab HYDROXYZINE 25MG/ML INJ hydroxyzine 50mg tab HYDROXYZINE PAMOATE 100MG CAP hydroxyzine pamoate 50mg cap LANOXIN 0.25MG/ML INJ lopreeza 0.5/0.1mg 28 day pack MENEST 0.3MG TAB MENEST 1.25MG TAB MENOSTAR 14MCG/24HR PATCH METAXALONE 400MG TAB methocarbamol 500mg tab mimvey lo 28 day pack MINIVELLE 0.025MG/24HR PATCH MINIVELLE 0.05MG/24HR PATCH MINIVELLE 0.1MG/24HR PATCH orphenadrine citrate 30mg/ml inj phenadoz 12.5mg rectal supp phenergan 25mg rectal supp phenergan 50mg rectal supp phenylephrine 1mg/ml/promethazine 1.25mg/ml soln 60

62 PREFEST 30 DAY PACK PREMARIN 0.45MG TAB PREMARIN 0.9MG TAB PREMPHASE 28 DAY PACK PREMPRO 0.45/ DAY PACK PREMPRO 0.625/5MG 28 DAY PACK promethazine 12.5mg rectal supp promethazine 25mg rectal supp promethazine 25mg/ml inj promethazine 50mg tab promethegan 25mg rectal supp SKELAXIN 800MG TAB VISTARIL 25MG CAP VIVELLE 0.025MG/24HR PATCH VIVELLE 0.05MG/24HR PATCH VIVELLE 0.1MG/24HR PATCH PREMARIN 0.3MG TAB PREMARIN 0.625MG TAB PREMARIN 1.25MG TAB PREMPRO 0.3/1.5MG 28 DAY PACK PREMPRO 0.625/2.5MG 28 DAY PACK promethazine 1.25mg/ml soln promethazine 12.5mg tab promethazine 25mg tab promethazine 50mg rectal supp promethazine 50mg/ml inj promethegan 50mg rectal supp SOMA 350MG TAB VISTARIL 50MG CAP VIVELLE MG/24HR PATCH VIVELLE 0.075MG/24HR PATCH Prior Authoration not required for members less than 65 years old. When a high-risk medication is identified, the provider is notified and allowed to attest that they wish to prescribe medication. 61

63 JUXTAPID 10MG CAP JUXTAPID 30MG CAP JUXTAPID 5MG CAP KYNAMRO 200MG/ML SYR JUXTAPID 20MG CAP JUXTAPID 40MG CAP JUXTAPID 60MG CAP Untreated LDL greater than 500 mg/dl OR treated LDL greater than or equal to 300 mg/dl. Concurrent use of maximum statin dose (atorvastatin or Crestor) and one other non-statin alternatives, including bile acid sequestrants, nicotinic acids, and fibric acid derivatives (include dates and reasons for discontinuation). Chart documentation showing the most recent full lipid panel, including Apo-B within the past 12 months. Prescriber is a lipidologist affiliated with or has consulted with a lipidologist at a Center for Excellence that manages patients with Homozygous Familial Hypercholesterolemia. 62

64 HUMIRA 10MG/0.2ML SYR HUMIRA 40MG/0.8ML AUTO-INJECTOR HUMIRA PEDIATRIC CROHN'S STARTER PACK (3) 40MG/0.8ML INJ HUMIRA PEN - CROHN'S STARTER PACK 40MG/0.8ML INJ HUMIRA 20MG/0.4ML SYR HUMIRA 40MG/0.8ML SYR HUMIRA PEDIATRIC CROHN'S STARTER PACK (6) 40MG/0.8ML INJ For moderate to severe RA or Psoriatic Arthritis requires intolerance to or failure of therapy with methotrexate (greater than 20mg/wk). Plaque Psoriasis: Failure of, or intolerance to, methotrexate at a dose of 15mg/week or failure of, or intolerance to, soriatane. Rheumatoid Arthritis, Psoriatic Arthritis and Ankylosing Spondylitis: Prescriber must be a Rheumatologist. All Plaque Psoriasis: Prescriber must be a Dermatologist. For members with a diagnosis of early, severe-onset RA, additional required medical information is not required. 63

65 IBRANCE 100MG CAP (New Starts Only) IBRANCE 75MG CAP (New Starts Only) IBRANCE 125MG CAP (New Starts Only) Prescribed by or in consultation with an Oncology Specialist Approved for duration of contract year subject to formulary change and member eligibility 64

66 ICLUSIG 15MG TAB (New Starts Only) ICLUSIG 45MG TAB (New Starts Only) Prescribed by or in consult with Oncology Specialist. 65

67 ILARIS 180MG INJ 66

68 IMBRUVICA 140MG CAP (New Starts Only) Prescribed by an Oncologist or Hemotologist or under the direct consultation of an Oncologist or Hemotologist 67

69 INCRELEX 40MG/4ML INJ For the long-term treatment of growth failure in children with severe primary insulin-like growth factor-1 (IGF-1) deficiency (primary IGFD) or with growth hormone (GH) gene deletion who have developed neutralizing antibodies to GH. 68

70 INLYTA 1MG TAB (New Starts Only) INLYTA 5MG TAB (New Starts Only) Covered Uses All FDA-approved indications not otherwise excluded from Part D. All medically accepted indications not otherwise excluded from Part D Restricted to or in consult with Oncology Specialist. Covered for duration of plan year subject to formulary change and member eligibility. 69

71 ESBRIET 267MG CAP OFEV 150MG CAP OFEV 100MG CAP Definitive diagnosis of idiopathic pulmonary fibrosis defined by the following: No known cause of lung fibrosis AND one of the following: A. Surgical lung biopsy revealing histopathological pattern of unspecified interstitial pneumonia (UIP) B. High-resolution computed tomography indicates definite UIP pattern C. High-resolution computed tomography indicates possible UIP pattern AND surgical lung biopsy reveals a histopathological pattern of probable UIP Prescribed by a Pulmonology Specialist or in consultation with a Pulmonology Specialist. The patient has a FVC less than or equal to 80% of predicted. The patient has a %DLco less than 80% of predicted. Will not be used in combination with other medications used to treat IPF. 70

72 IRESSA 250MG TAB (New Starts Only) Prescribed by an Oncology Specialist or in consultation with an Oncology Specialist. 71

73 ISTODAX 10MG INJ (New Starts Only) Prescribed by or consultation with Hematologist or Oncologist Approval subject to BvD determination 72

74 itraconazole 100mg cap SPORANOX 10MG/ML SOLN SPORANOX 100MG CAP SPORANOX PULSEPAK 100MG PACK For onychomycosis or diffuse dermatologic fungal infections: 1. If not prescribed by a Dermatologist or Podiatrist OR fungal infection is confirmed by a positive KOH test. 2. For onychomycosis, must fail terbinafine. For dermatologic infections, must fail one topical antifungal medication. Infectious Disease Specialists, Pulmonologist or Dermatologist or have consulted with an Infectious Disease Specialist, Pulmonologist or Dermatologist concerning the patient. Approved for 6 months. 73

75 JAKAFI 10MG TAB (New Starts Only) JAKAFI 20MG TAB (New Starts Only) JAKAFI 5MG TAB (New Starts Only) JAKAFI 15MG TAB (New Starts Only) JAKAFI 25MG TAB (New Starts Only) Covered Uses All FDA-approved indications not otherwise excluded from Part D. All medically accepted indications not otherwise excluded from Part D. Restricted to or in consult with Oncology or Hematology Specialist. 74

76 KADCYLA 100MG INJ (New Starts Only) Approval will be based off BvD coverage determination. 75

77 KALYDECO 150MG TAB KALYDECO 75MG PACKET KALYDECO 50MG PACKET Covered Uses All FDA-approved indications not otherwise excluded from Part D. All medically accepted indications not otherwise excluded from Part D Restricted to or in consult with Pulmonology Specialist. Covered for duration of plan year subject to formulary change and member eligibility. 76

78 KEYTRUDA 100MG/4ML INJ (New Starts Only) KEYTRUDA 50MG INJ (New Starts Only) Prescribed by or in consult with Oncology Specialist. 77

79 KINERET 100MG/0.67ML SYR Covered Uses All medically accepted indications not otherwise excluded from Part D. If for the treatment of RA, trial or contraindication to 1 TNF-inhibitor (Enbrel or Humira). Approval requires the prescriber to be a Rheumatologist. 78

80 KORLYM 300MG TAB Covered Uses All FDA-approved indications not otherwise excluded by Part D. 79

81 KUVAN 100MG TAB KUVAN 500MG POWDER For continuing therapy the patient must have shown a 20% drop in Phenylalanine levels after 2 months of Kuvan treatment. Prescribed by a Medical Genecist or other practitioner specialized in the treatment of Phenylketonuria (PKU). Initial = 3 month, then if critieria is met approved for the rest of the plan year 80

82 LENVIMA 10 10MG PACK (New Starts Only) LENVIMA 20 10MG PACK (New Starts Only) LENVIMA 14 PACK (New Starts Only) LENVIMA 24 PACK (New Starts Only) Prescribed by an Oncology Specialist or in consultation with an Oncology Specialist. 81

83 LETAIRIS 10MG TAB LETAIRIS 5MG TAB Diagnosis confirmed by right heart catheterization. Restricted to or in consult with Pulmonologist or Cardiologist. 82

84 lidocaine 5% patch LIDODERM 5% PATCH Covered Uses All FDA-approved indications not otherwise excluded from Part D. Management of neuropathic pain associated with diabetic peripheral neuropathy and postherpetic neuralgia. Trial and failure of gabapentin of four weeks or more 83

85 LINZESS 145MCG CAP LINZESS 290MCG CAP 84

86 LONSURF MG TAB (New Starts Only) LONSURF MG TAB (New Starts Only) Prescribed by an Oncology Specialist or in consultation with an Oncology Specialist. 85

87 LYNPARZA 50MG CAP (New Starts Only) Restricted to Oncology Specialist or in consult with Oncology Specialist. 86

88 LYRICA 100MG CAP (New Starts Only) LYRICA 200MG CAP (New Starts Only) LYRICA 225MG CAP (New Starts Only) LYRICA 300MG CAP (New Starts Only) LYRICA 75MG CAP (New Starts Only) LYRICA 150MG CAP (New Starts Only) LYRICA 20MG/ML SOLN (New Starts Only) LYRICA 25MG CAP (New Starts Only) LYRICA 50MG CAP (New Starts Only) For a diagnosis of diabetic peripheral neuropathy or post herpetic neuralgia. Members must have tried and failed a 4 week minimum trials of gabapentin at doses of at least 1800mg per day. Lyrica is covered when used for the treatment of neuropathic pain associated with spinal cord injury. 87

89 MEKINIST 0.5MG TAB (New Starts Only) MEKINIST 2MG TAB (New Starts Only) Prescribed by or in consult with an Oncology Specialist. 88

90 MOVANTIK 12.5MG TAB MOVANTIK 25MG TAB Initial Therapy: Member must meet all criteria. 1. Opioid-induced constipation. 2. Failed two laxative/bowel therapies -- polyethylene glycol and lactulose. 4 Months 89

91 A-HYDROCORT 100MG INJ ABRAXANE 100MG INJ acetylcysteine 10% inh soln ACTIMMUNE UNIT/0.5ML INJ adrucil 500mg/10ml inj albuterol 0.21mg/ml (0.63mg/3ml) neb soln albuterol 0.83mg/ml (0.083%) neb soln ALDURAZYME 2.9MG/5ML INJ ALKERAN 50MG INJ amifostine 50mg/ml inj aminophylline 25mg/ml inj AMINOSYN 7% WITH ELECTROLYTES, SULFITE-FREE INJ AMINOSYN II 10% INJ AMINOSYN II 7%, SULFITE-FREE INJ AMINOSYN II 8.5%, SULFITE-FREE INJ AMINOSYN-PF 10%, SULFITE-FREE INJ AMINOSYN-RF 5.2%, SULFITE-FREE INJ AMMONIUM CHLORIDE 5 MEQ/ML INJ ampicillin 100mg/ml inj AMPICILLIN 125MG/ML INJ ampicillin 250mg/ml inj ANZEMET 100MG TAB ANZEMET 50MG TAB ARALAST 500MG INJ ARANESP 100MCG/ML INJ ARANESP 150MCG/0.3ML SYR ARANESP 200MCG/ML INJ ARANESP 25MCG/ML INJ ARANESP 300MCG/ML INJ ABELCET 5MG/ML INJ acetazolamide 100mg/ml inj acetylcysteine 20% inh soln acyclovir 50mg/ml inj AKYNZEO MG CAP albuterol 0.417mg/ml (1.25mg/3ml) neb soln albuterol 1mg/ml (0.5%) neb soln ALIMTA 500MG INJ AMBISOME 50MG INJ amikacin sulfate 250mg/ml inj AMINOSYN 3.5% M, SULFITE FREE INJ aminosyn 8.5% with electrolytes, sulfite-free inj AMINOSYN II 15% INJ aminosyn ii 8.5% with electrolytes, sulfite-free inj AMINOSYN-HBC 7%, SULFITE-FREE INJ AMINOSYN-PF 7% INJ amiodarone 50mg/ml inj AMPHOTERICIN B 5MG/ML INJ ampicillin 100mg/ml/sulbactam 50mg/ml inj ampicillin 20mg/ml/sulbactam 10mg/ml inj ampicillin 250mg/ml/sulbactam 125mg/ml inj ANZEMET 20MG/ML INJ APOKYN 10MG/ML SYR ARANESP 100MCG/0.5ML SYR ARANESP 10MCG/0.4ML SYR ARANESP 200MCG/0.4ML SYR ARANESP 25MCG/0.42ML SYR ARANESP 300MCG/0.6ML SYR ARANESP 40MCG/0.4ML SYR 90

92 ARANESP 40MCG/ML INJ ARANESP 500MCG/ML SYR ARANESP 60MCG/0.3ML SYR ARANESP 60MCG/ML INJ argatroban 100mg/ml inj ARGATROBAN 1MG/ML INJ ARRANON 5MG/ML INJ ASTAGRAF 0.5MG XL CAP ASTAGRAF 1MG XL CAP ASTAGRAF 5MG XL CAP ATGAM 50MG/ML INJ ATROPINE SULFATE 0.05MG/ML SYR atropine sulfate 0.1mg/ml syr AVASTIN 100MG/4ML INJ AVASTIN 400MG/16ML INJ AVELOX 400MG/250ML INJ azacitidine 25mg/ml inj AZACTAM 1GM INJ AZACTAM 1GM/50ML INJ AZACTAM 2GM/50ML INJ AZASAN 100MG TAB AZASAN 75MG TAB azathioprine 50mg tab azithromycin 100mg/ml inj azithromycin 2mg/ml inj aztreonam 333mg/ml inj baci-im 50000unit inj BACITRACIN 5000UNIT/ML INJ BCG, LIVE, TICE STRAIN 50MG/ML INJ BENLYSTA 120MG INJ BENTYL 10MG/ML INJ benztropine mesylate 1mg/ml inj BICILLIN UNIT/ML SYR BICILLIN UNIT/ML SYR BICILLIN L-A UNIT/2ML SYR BICILLIN L-A UNIT/4ML SYR BICNU 100MG INJ bleomycin 15unit/ml inj BONIVA 3MG/3ML SYR BROVANA 15MCG/2ML NEB SOLN budesonide 0.125mg/ml inh soln budesonide 0.25mg/ml inh soln budesonide 0.5mg/ml inh soln bumetanide 0.25mg/ml inj BUPRENEX 0.3MG/ML INJ buprenorphine 0.3mg/ml inj BUSULFEX 6MG/ML INJ butorphanol tartrate 1mg/ml inj butorphanol tartrate 2mg/ml inj calcitriol mg cap calcitriol mg cap calcitriol 0.001mg/ml inj calcitriol 0.001mg/ml soln calcium chloride meq/ml/potassium chloride meq/ml/sodium chlorid calcium chloride meq/ml/potassium chloride meq/ml/sodium chloride CAMPTOSAR meq/ml 100MG/5ML soln INJ CANCIDAS 50MG INJ CANCIDAS 70MG INJ CAPASTAT 1GM INJ carboplatin 10mg/ml inj 91

93 CARDENE 20MG/200ML INJ CARNITOR 1GM/10ML SOLN CARNITOR 330MG TAB CEFAZOLIN 20MG/ML INJ cefazolin 330mg/ml inj CEFEPIME 20MG/ML INJ CEFEPIME 40MG/ML INJ cefotaxime 300mg/ml inj CEFOTETAN 200MG/ML INJ CEFOTETAN 500MG/ML INJ cefoxitin 200mg/ml inj CEFOXITIN 40MG/ML INJ ceftazidime 170mg/ml inj CEFTAZIDIME 20MG/ML INJ CEFTAZIDIME 40MG/ML INJ ceftriaxone 20mg/ml inj ceftriaxone 350mg/ml inj cefuroxime 225mg/ml inj cefuroxime 95mg/ml inj CELLCEPT 250MG CAP CELLCEPT 500MG TAB CEREZYME 400UNIT INJ chlorothiazide 28mg/ml inj cidofovir 75mg/ml inj cilastatin 5mg/ml/imipenem 5mg/ml inj ciprofloxacin 10mg/ml inj cisplatin 1mg/ml inj CLAFORAN 10GM INJ CLAFORAN 1GM (300MG/ML) INJ CLAFORAN 2GM (40MG/ML) INJ CARDENE 40MG/200ML INJ CARNITOR 200MG/ML INJ cefazolin 200mg/ml inj cefazolin 225mg/ml inj cefepime 160mg/ml inj cefepime 280mg/ml inj cefotaxime 230mg/ml inj cefotaxime 330mg/ml inj CEFOTETAN 400MG/ML INJ cefoxitin 180mg/ml inj CEFOXITIN 20MG/ML INJ cefoxitin 95mg/ml inj ceftazidime 200mg/ml inj ceftazidime 280mg/ml inj ceftriaxone 100mg/ml inj ceftriaxone 250mg/ml inj ceftriaxone 40mg/ml inj cefuroxime 90mg/ml inj CELLCEPT 200MG/ML SUSP CELLCEPT 500MG INJ CEREBYX 500MG PE/10ML INJ CHLORAMPHENICOL 100MG/ML INJ CHLORPROMAZINE 25MG/ML INJ cilastatin 2.5mg/ml/imipenem 2.5mg/ml inj CIPRO 400MG/200ML INJ ciprofloxacin 2mg/ml inj cladribine 1mg/ml inj CLAFORAN 1GM (20MG/ML) INJ CLAFORAN 2GM (330MG/ML)INJ CLAFORAN 500MG INJ 92

94 CLEOCIN 300MG/50ML INJ CLEOCIN 900MG/50ML INJ clindamycin 12mg/ml inj clindamycin 18mg/ml inj CLINIMIX 2.75/5 INJ CLINIMIX 4.25/20 INJ CLINIMIX 4.25/5 INJ CLINIMIX 5/20 INJ CLINIMIX E 2.75/10 INJ CLINIMIX E 4.25/10 INJ CLINIMIX E 4.25/5 INJ CLINIMIX E 5/20 INJ clinisol 15% inj COGENTIN 1MG/ML INJ COSMEGEN 0.5MG INJ CUBICIN 500MG INJ CYCLOPHOSPHAMIDE 50MG CAP cyclosporine 25mg cap cyclosporine, modified 100mg cap cyclosporine, modified 25mg cap CYKLOKAPRON 100MG/ML INJ cytarabine 20mg/ml inj d5w/lactated ringers inj DACOGEN 50MG INJ daunorubicin 5mg/ml inj DDAVP 4MCG/ML INJ DELESTROGEN 10MG/ML INJ DELESTROGEN 40MG/ML INJ DEPO-ESTRADIOL 5MG/ML INJ DEPO-MEDROL 40MG/ML INJ CLEOCIN 600MG/50ML INJ CLEOCIN 900MG/6ML INJ clindamycin 150mg/ml inj clindamycin 6mg/ml inj CLINIMIX 4.25/10 INJ CLINIMIX 4.25/25 INJ CLINIMIX 5/15 INJ CLINIMIX 5/25 INJ CLINIMIX E 2.75/5 INJ CLINIMIX E 4.25/25 INJ CLINIMIX E 5/15 INJ CLINIMIX E 5/25 INJ CLOLAR 1MG/ML INJ colistin 75mg/ml inj CROMOLYN SODIUM 10MG/ML NEB SOLN CYCLOPHOSPHAMIDE 25MG CAP cyclosporine 100mg cap cyclosporine 50mg/ml inj cyclosporine, modified 100mg/ml soln CYCLOSPORINE, MODIFIED 50MG CAP cytarabine 100mg/ml inj CYTOVENE 500MG INJ dacarbazine 10mg/ml inj DALVANCE 500MG INJ DAUNOXOME 2MG/ML INJ decitabine 5mg/ml inj DELESTROGEN 20MG/ML INJ DEPACON 100MG/ML INJ DEPO-MEDROL 20MG/ML INJ DEPO-MEDROL 80MG/ML INJ 93

95 DEPO-TESTOSTERONE 100MG/ML INJ desmopressin acetate 0.004mg/ml inj dexamethasone phosphate 4mg/ml inj dihydroergotamine mesylate 1mg/ml inj DILAUDID 4MG/ML INJ diltiazem 5mg/ml inj DIURIL 500MG INJ DOCETAXEL 10MG/ML INJ DORIBAX 500MG INJ doxercalciferol 0.001mg cap doxercalciferol 0.002mg/ml inj doxorubicin 2mg/ml inj doxycycline 10mg/ml inj duramorph 1mg/ml inj ELIGARD 22.5MG SYR ELIGARD 45MG SYR ELITEK 1.5MG INJ EMEND 125MG CAP EMEND 80MG CAP ENGERIX-B 10MCG/0.5ML INJ ENGERIX-B 20MCG/ML SYR ENVARSUS 1MG ER TAB epirubicin 2mg/ml inj EPOGEN 20000UNIT/ML INJ EPOGEN 3000UNIT/ML INJ ERAXIS 100MG INJ ERYTHROCIN LACTOBIONATE 500MG INJ esomeprazole 8mg/ml inj estradiol 40mg/ml inj etoposide 20mg/ml inj DEPO-TESTOSTERONE 200MG/ML INJ DEXAMETHASONE 10MG/ML INJ dexrazoxane 10mg/ml inj DILAUDID 2MG/ML INJ DILTIAZEM 1MG/ML INJ diphenhydramine 50mg/ml inj DOCEFREZ 20MG INJ DOCETAXEL 20MG/ML INJ doxercalciferol mg cap doxercalciferol mg cap DOXIL 2MG/ML INJ doxy 100mg inj duramorph 0.5mg/ml inj ELAPRASE 6MG/3ML INJ ELIGARD 30MG SYR ELIGARD 7.5MG SYR ELLENCE 200MG/100ML INJ EMEND 40MG CAP EMEND TRI-FOLD PACK ENGERIX-B 10MCG/0.5ML SYR ENVARSUS 0.75MG ER TAB ENVARSUS 4MG ER TAB EPOGEN 10000UNIT/ML INJ EPOGEN 2000UNIT/ML INJ EPOGEN 4000UNIT/ML INJ ERBITUX 100MG/50ML INJ ESOMEPRAZOLE 4MG/ML INJ estradiol 20mg/ml inj ETOPOFOS 100MG INJ FABRAZYME 35MG INJ 94

96 FAMOTIDINE 0.4MG/ML INJ famotidine 10mg/ml inj FASLODEX 250MG/5ML SYR fat emulsion 20% iv soln fluconazole 2mg/ml inj fludarabine phosphate 25mg/ml inj fluorouracil 50mg/ml inj FLUPHENAZINE 2.5MG/ML INJ fluphenazine decanoate 25mg/ml inj fomepizole 1000mg/ml inj FORTAZ 1GM INJ FORTAZ 2GM (170MG/ML) INJ FORTAZ 2GM (40MG/ML) INJ FORTAZ 6GM INJ fosphenytoin sodium 75mg/ml inj FRAGMIN 10000UNIT/ML SYR FRAGMIN 12500UNIT/0.5ML SYR FRAGMIN 15000UNIT/0.6ML SYR FRAGMIN 18000UNIT/0.72ML SYR FRAGMIN 2500UNIT/0.2ML SYR FRAGMIN 5000UNIT/0.2ML SYR FREAMINE 6.9% INJ furosemide 10mg/ml inj furosemide 10mg/ml syr FUSILEV 50MG INJ ganciclovir 50mg/ml inj gemcitabine 38mg/ml inj GEMZAR 1GM INJ gengraf 100mg cap gengraf 100mg/ml soln gengraf 25mg cap gentamicin sulfate 0.8mg/ml inj GENTAMICIN SULFATE 0.9MG/ML INJ gentamicin sulfate 1.2mg/ml inj GENTAMICIN SULFATE 1.4MG/ML INJ gentamicin sulfate 1.6mg/ml inj gentamicin sulfate 10mg/ml inj gentamicin sulfate 1mg/ml inj gentamicin sulfate 40mg/ml inj GEODON 20MG INJ GLASSIA 1000MG/50ML INJ glucose 10% inj GLUCOSE 100MG/ML/SODIUM CHLORIDE MEQ/ML INJ GLUCOSE 100MG/ML/SODIUM CHLORIDE MEQ/ML INJ glucose 25mg/ml/sodium chloride meq/ml inj glucose 5% inj glucose 50mg/ml/potassium chloride 0.01 meq/ml/sodium chloride meq/ml glucose inj 50mg/ml/potassium chloride 0.02 meq/ml inj glucose 50mg/ml/potassium chloride 0.02 meq/ml/sodium chloride meq/ml GLUCOSE inj 50MG/ML/POTASSIUM CHLORIDE 0.02 MEQ/ML/SODIUM CH glucose 50mg/ml/potassium chloride 0.02 meq/ml/sodium chloride meq/ml glucose inj 50mg/ml/potassium chloride 0.02 meq/ml/sodium chloride meq/m glucose 50mg/ml/potassium chloride 0.02 meq/ml/sodium chloride meq/ml glucose inj 50mg/ml/potassium chloride 0.03 meq/ml/sodium chloride meq/m glucose 50mg/ml/potassium chloride 0.04 meq/ml inj glucose 50mg/ml/potassium chloride 0.04 meq/ml/sodium chloride meq/m GLUCOSE 50MG/ML/POTASSIUM CHLORIDE 0.04 MEQ/ML/SODIUM CHLORIDE glucose 50mg/ml/sodium MEQ/ML chloride INJ meq/ml inj GLUCOSE 50MG/ML/SODIUM CHLORIDE MEQ/ML INJ glucose 50mg/ml/sodium chloride meq/ml inj 95

97 glucose 50mg/ml/sodium chloride meq/ml inj glycopyrrolate 0.2mg/ml inj granisetron 1mg tab GRANIX 300MCG/0.5ML SYR HALAVEN 1MG/2ML INJ HALDOL 50MG/ML INJ haloperidol 5mg/ml inj haloperidol decanoate 50mg/ml inj HECTOROL 1MCG CAP HECTOROL 4MCG/2ML INJ heparin sodium, porcine 1000unit/ml inj heparin sodium, porcine 20000unit/ml inj heparin sodium, porcine 5000unit/ml inj hepatamine 8% inj HYCAMTIN 4MG INJ hydromorphone 10mg/ml inj IDAMYCIN 20MG/20ML INJ IFEX 1GM INJ IMOVAX RABIES 2.5UNIT/ML INJ intralipid 20% inj INTRON A 10MU INJ INTRON A 50MU INJ INVANZ 1GM INJ IONOSOL-MB INJ ipratropium/albuterol mg/3ml neb soln ISOLYTE P INJ IXEMPRA 45MG INJ KCL/D5W/LR INJ 0.15% KENALOG 40MG/ML INJ labetalol 5mg/ml inj glucose 50mg/ml/sodium chloride meq/ml inj granisetron 0.1mg/ml inj granisetron 1mg/ml inj GRANIX 480MCG/0.8ML SYR HALDOL 100MG/ML INJ HALDOL 5MG/ML INJ haloperidol decanoate 100mg/ml inj HECTOROL 0.5MCG CAP HECTOROL 2.5MCG CAP heparin sodium, porcine 10000unit/ml inj HEPARIN SODIUM, PORCINE 100UNIT/ML INJ heparin sodium, porcine 40unit/ml inj heparin sodium, porcine 50unit/ml inj HERCEPTIN 440MG INJ hydralazine 20mg/ml inj ibandronic acid 1mg/ml inj idarubicin 1mg/ml inj ifosfamide 50mg/ml inj IMURAN 50MG TAB INTRALIPID 30% INJ INTRON A 18MU INJ INTRON A UNIT/ML INJ IONOSOL-B INJ ipratropium bromide 0.02% inh soln irinotecan 20mg/ml inj ISOLYTE S INJ JEVTANA 60MG/1.5ML INJ KENALOG 10MG/ML INJ KEPIVANCE 6.25MG INJ lactated ringers inj 96

98 lactated ringers irrigation leucovorin 20mg/ml inj leuprolide acetate 5mg/ml inj levalbuterol 0.63mg neb soln levetiracetam 100mg/ml inj LEVETIRACETAM 15MG/ML INJ levocarnitine 100mg/ml soln levocarnitine 330mg tab levofloxacin 5mg/ml (150ml) inj levoleucovorin 10mg/ml inj lidocaine 2% inj lincomycin 300mg/ml inj LUMIZYME 50MG INJ LUPRON 11.25MG (1ML) SYR LUPRON 22.5MG SYR LUPRON 30MG SYR LUPRON 7.5MG SYR magnesium sulfate 50% syr MAXIPIME 2GM INJ meropenem 50mg/ml inj mesna 100mg/ml inj METHADONE 10MG/ML INJ methylprednisolone 62.5mg/ml inj methylprednisolone acetate 80mg/ml inj metoprolol tartrate 1mg/ml inj MIACALCIN 200UNIT/ML INJ mitoxantrone 2mg/ml inj MORPHINE SULFATE 2MG/ML SYR MORPHINE SULFATE 8MG/ML SYR MOZOBIL 24MG/1.2ML INJ leucovorin 10mg/ml inj LEUKINE 250MCG INJ levalbuterol 0.31mg neb soln levalbuterol 1.25mg neb soln LEVETIRACETAM 10MG/ML INJ LEVETIRACETAM 5MG/ML INJ levocarnitine 200mg/ml inj levofloxacin 25mg/ml inj levofloxacin 5mg/ml inj lidocaine 0.5% inj LINCOCIN 300MG/ML INJ liothyronine sodium 0.01mg/ml inj LUPRON 11.25MG (1.5ML) SYR LUPRON 15MG SYR LUPRON 3.75MG SYR LUPRON 45MG SYR magnesium sulfate 50% inj MAXIPIME 1GM INJ melphalan 5mg/ml inj MERREM 500MG INJ MESNEX 100MG/ML INJ methylprednisolone 40mg/ml inj methylprednisolone acetate 40mg/ml inj metoclopramide 5mg/ml inj metronidazole 5mg/ml inj mitomycin 0.5mg/ml inj MORPHINE SULFATE 10MG/ML SYR MORPHINE SULFATE 4MG/ML SYR MOXIFLOXACIN 1.6MG/ML INJ MUSTARGEN 10MG INJ 97

99 MYCAMINE 100MG INJ mycophenolate mofetil 200mg/ml susp mycophenolate mofetil 500mg tab mycophenolic acid 360mg dr tab MYFORTIC 360MG DR TAB nafcillin 100mg/ml inj nafcillin 250mg/ml inj NEBUPENT 300MG INH SOLN NEORAL 100MG/ML SOLN NEPHRAMINE 5.4% INJ NEUPOGEN 300MCG/0.5ML SYR NEUPOGEN 480MCG/0.8ML SYR NEXIUM 40MG INJ NEXTERONE 360MG/200ML INJ NIPENT 10MG INJ NORMOSOL-R IN 5% DEXTROSE INJ NULOJIX 250MG INJ octreotide 0.05mg/ml inj octreotide 0.2mg/ml inj octreotide 1mg/ml inj ONCASPAR 750UNIT/ML INJ ondansetron 24mg tab ondansetron 2mg/ml syr ondansetron 4mg tab ondansetron 8mg tab oxacillin 167mg/ml inj OXACILLIN 40MG/ML INJ paclitaxel 6mg/ml inj PAMIDRONATE DISODIUM 6MG/ML INJ paricalcitol 0.001mg cap MYCAMINE 50MG INJ mycophenolate mofetil 250mg cap mycophenolic acid 180mg dr tab MYFORTIC 180MG DR TAB MYOZYME 50MG INJ NAFCILLIN 20MG/ML INJ NAGLAZYME 1MG/ML INJ NEORAL 100MG CAP NEORAL 25MG CAP NEULASTA 6MG/0.6ML SYR NEUPOGEN 300MCG/ML INJ NEUPOGEN 480MCG/1.6ML INJ NEXTERONE 150MG/100ML INJ nicardipine 2.5mg/ml inj NORMOSOL-M INJ NORMOSOL-R INJ nutrilipid 20gm/100ml inj octreotide 0.1mg/ml inj octreotide 0.5mg/ml inj olanzapine 5mg/ml inj ondansetron 0.8mg/ml soln ondansetron 2mg/ml inj ondansetron 4mg odt ondansetron 8mg odt oxacillin 100mg/ml inj OXACILLIN 20MG/ML INJ oxaliplatin 5mg/ml inj pamidronate disodium 3mg/ml inj pamidronate disodium 9mg/ml inj paricalcitol 0.002mg cap 98

100 paricalcitol 0.002mg/ml inj paricalcitol 0.004mg cap paricalcitol 0.005mg/ml inj penicillin g potassium unit/ml inj PENICILLIN G POTASSIUM 40000UNIT/ML INJ PENICILLIN G POTASSIUM 60000UNIT/ML INJ PENICILLIN G PROCAINE UNIT/ML SYR PENICILLIN G SODIUM UNIT/ML INJ PENTAM 300MG INJ PERFOROMIST 20MCG/2ML NEB SOLN phenytoin sodium 50mg/ml inj physiolyte soln physiosol soln piperacillin 200mg/ml/tazobactam 25mg/ml inj piperacillin 80mg/ml/tazobactam 10mg/ml inj PLASMA-LYTE 148 INJ PLASMA-LYTE 56 IN 5% DEXTROSE INJ PLASMALYTE A INJ plenamine 15% inj polymyxin b unit/ml inj potassium chloride 0.02 meq/ml/sodium chloride meq/ml inj POTASSIUM CHLORIDE 0.02 MEQ/ML/SODIUM CHLORIDE MEQ/ POTASSIUM CHLORIDE 0.04 MEQ/ML/SODIUM CHLORIDE MEQ/ML POTASSIUM INJ CHLORIDE 0.1 MEQ/ML INJ POTASSIUM CHLORIDE 0.2 MEQ/ML INJ POTASSIUM CHLORIDE 0.4 MEQ/ML INJ potassium chloride 2 meq/ml inj PREMARIN 25MG INJ PREMASOL 10% INJ premasol 6% inj PRIMAXIN 250MG INJ PRIMAXIN 500MG INJ PROCAINAMIDE 100MG/ML INJ PROCAINAMIDE 500MG/ML INJ PROCALAMINE 3% INJ prochlorperazine 5mg/ml inj PROCRIT 10000UNIT/ML INJ PROCRIT 20000UNIT/ML INJ PROCRIT 2000UNIT/ML INJ PROCRIT 3000UNIT/ML INJ PROCRIT 40000UNIT/ML INJ PROCRIT 4000UNIT/ML INJ PROGRAF 0.5MG CAP PROGRAF 1MG CAP PROGRAF 5MG CAP PROGRAF 5MG/ML INJ PROLASTIN 1000MG INJ PROLEUKIN UNIT INJ PROLIA 60MG/ML SYR propranolol 1mg/ml inj PROSOL 20% INJ PULMICORT 0.25MG/2ML INH SOLN PULMICORT 0.5MG/2ML INH SOLN PULMICORT 1MG/2ML INH SOLN PULMOZYME 1MG/ML INH SOLN QUINIDINE GLUCONATE 80MG/ML INJ RABAVERT 2.5UNIT/ML INJ ranitidine 25mg/ml inj RAPAMUNE 0.5MG TAB RAPAMUNE 1MG TAB 99