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

Transcription

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

41 Name AMPYRA ORAL EXTENDED RELEASE 1 HR AUBAGIO ORAL COPAXONE SYRINGE PA PA donepezil oral QL (90 per 90 donepezil oral,disintegrating EXELON TRANSDERMAL PATCH HOUR galantamine oral,ext rel. pellets hr galantamine oral galantamine oral GILENYA ORAL CAPSULE glatopa subcutaneous syringe LEMTRADA memantine oral 10 mg QL (90 per 90 QL (90 per 90 QL ( per PA PA; QL (68 per Name memantine oral mg NAMENDA ORAL NAMENDA ORAL 10 MG NAMENDA ORAL MG NAMENDA TITRATION PAK ORAL S,DOSE PACK NAMENDA XR ORAL CAP,SPRINKLE,E R HR DOSE PACK NAMENDA XR ORAL CAPSULE,SPRINK LE,ER HR NUEDEXTA ORAL CAPSULE rivastigmine tartrate oral TECFIDERA ORAL CAPSULE,DELAY ED RELEASE(DR/EC) tetrabenazine oral TYSABRI PA; QL (10 per PA PA; QL (68 per PA; QL (10 per PA PA PA PA; QL (68 per PA; QL (68 per PA LA : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part B vs. Part D only GC - Gap Coverage HI - 1

42 Name XENAZINE ORAL PA MUSCLE RELAXANTS / ANTISPASMODIC THERAPY baclofen oral cyclobenzaprine oral DANTRIUM dantrolene oral enlon injection ENLON-PLUS LIORESAL INTRATHECAL MESTINON ORAL SYRUP MESTINON TIMESPAN ORAL EXTENDED RELEASE methocarbamol injection pyridostigmine bromide oral pyridostigmine bromide oral extended release PA B/D PA Name regonol injection revonto intravenous recon soln tizanidine oral tizanidine oral NARCOTIC ANALGESICS ABSTRAL SUBLINGUAL acetaminophencodeine oral 10 mg-1 mg / ml ( ml), 10-1 mg/ ml, 00 mg-0 mg /1. ml acetaminophencodeine oral BUPRENEX INJECTION buprenorphine hcl injection buprenorphine hcl injection syringe buprenorphine hcl sublingual butalbitalacetaminophen oral codeine sulfate oral PA; QL (16 per QL (000 per 0 QL (1080 per 90 HI HI : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part B vs. Part D only GC - Gap Coverage HI -

43 Name Name diskets oral,soluble duramorph (pf) injection endocet oral 10- mg,.- mg, - mg, 7.- mg fentanyl citrate (pf) injection QL (1080 per 90 hydrocodoneacetaminophen oral.-167 mg/ ml hydrocodoneacetaminophen oral mg, 10- mg,.- mg, -00 mg, - mg, mg, 7.- mg QL (1080 per 90 fentanyl citrate (pf) intravenous syringe 100 mcg/ ml (0 mcg/ml) fentanyl citrate buccal lozenge on a handle 1,00 mcg, 1,600 mcg, 00 mcg, 600 mcg, 800 mcg fentanyl citrate buccal lozenge on a handle 00 mcg PA; QL (10 per 0 PA; QL (10 per 0 hydrocodoneibuprofen oral hydromorphone (pf) injection hydromorphone injection HYDROMORPHO NE INJECTION SYRINGE hydromorphone oral mg QL (1080 per 90 QL (10 per 90 fentanyl transdermal patch 7 hour 100 mcg/hr, 1 mcg/hr, mcg/hr, 0 mcg/hr, 7 mcg/hr FENTORA BUCCAL, EFFERVESCENT hydrocodoneacetaminophen oral 10- mg/1 ml(1 ml), 7.- mg/1 ml QL (1 per PA; QL (10 per 0 QL (0 per 0 hydromorphone oral mg hydromorphone oral 8 mg ibuprofen-oxycodone oral INFUMORPH P/F INJECTION KADIAN ORAL CAPSULE,EXTEN D.RELEASE PELLETS 00 MG QL (70 per 90 QL (60 per 90 QL (70 per 90 QL (180 per 90 : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part B vs. Part D only GC - Gap Coverage HI -

44 Name LAZANDA NASAL SPRAY,NON- AEROSOL 100 MCG/SPRAY LAZANDA NASAL SPRAY,NON- AEROSOL 00 MCG/SPRAY levorphanol tartrate oral lorcet (hydrocodone) oral PA; QL (0 per 0 PA; QL (10 per 0 QL (1080 per 90 lorcet hd oral QL (1080 per 90 lorcet plus oral 7.- mg lortab 10- oral lortab - oral lortab 7.- oral marten-tab oral meperitab oral methadone injection methadone intensol oral concentrate methadone oral concentrate methadone oral QL (1080 per 90 QL (1080 per 90 QL (1080 per 90 Name methadone oral methadone oral,soluble methadose oral,soluble morphine (pf) injection 0. mg/ml, 1 mg/ml morphine (pf) intravenous patient control.analgesia soln morphine concentrate oral morphine injection syringe 10 mg/ml morphine intravenous cartridge 10 mg/ml, 1 mg/ml, mg/ml, mg/ml morphine intravenous MORPHINE SYRINGE 10 MG/ML, 8 MG/ML morphine intravenous syringe mg/ml, mg/ml morphine oral, er multiphase hr QL (90 per 90 : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part B vs. Part D only GC - Gap Coverage HI -

45 Name morphine oral,extend.relea se pellets morphine oral morphine oral morphine oral extended release morphine rectal suppository OPANA ER ORAL,ORAL ONLY,EXT.REL.1 HR 10 MG, 0 MG, 0 MG, 0 MG, MG OPANA INJECTION oxycodone oral oxycodone oral concentrate oxycodone oral oxycodone oral 10 mg, 1 mg, 0 mg, 0 mg oxycodone oral mg oxycodoneacetaminophen oral 10- mg,.- mg, - mg, 7.- mg QL ( per QL (70 per 90 QL (68 per QL (1080 per 90 QL (1800 per 90 QL (0 per 90 QL (1080 per 90 QL (1080 per 90 Name oxycodone-aspirin oral oxymorphone oral oxymorphone oral extended release 1 hr : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part B vs. Part D only GC - Gap Coverage HI - QL (1080 per 90 QL (0 per 90 QL (68 per reprexain oral QL (1080 per 90 sublimaze (pf) injection SUBSYS SUBLINGUAL SPRAY,NON- AEROSOL 100 MCG/SPRAY, 00 MCG/SPRAY, 00 MCG/SPRAY, 600 MCG/SPRAY, 800 MCG/SPRAY tencon oral 0- mg PA; QL (10 per 0 xylon 10 oral QL (1080 per 90 zamicet oral QL (0 per 0 NON-NARCOTIC ANALGESICS buprenorphinenaloxone sublingual butorphanol tartrate injection butorphanol tartrate nasal spray,nonaerosol

46 Name CELEBREX ORAL CAPSULE celecoxib oral clonidine (pf) epidural,000 mcg/10 ml diclofenac potassium oral diclofenac sodium oral extended release hr diclofenac sodium oral,delayed release (dr/ec) diclofenacmisoprostol oral,ir & delay rel,biphasic diflunisal oral etodolac oral etodolac oral etodolac oral extended release hr EVZIO INJECTION AUTO-INJECTOR fenoprofen oral flurbiprofen oral ibuprofen oral suspension QL (68 per QL (68 per Name ibuprofen oral 00 mg, 600 mg, 800 mg ketoprofen oral ketoprofen oral,ext rel. pellets hr 00 mg meclofenamate oral mefenamic acid oral meloxicam oral nabumetone oral nalbuphine injection naloxone injection naloxone injection syringe naltrexone oral naproxen oral suspension : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part B vs. Part D only GC - Gap Coverage HI - 6 HI naproxen oral naproxen oral,delayed release (dr/ec) naproxen sodium oral 7 mg, 0 mg

47 Name NUCYNTA ORAL oxaprozin oral piroxicam oral PRIALT INTRATHECAL salsalate oral SUBOXONE SUBLINGUAL FILM sulindac oral tolmetin oral tolmetin oral tramadol oral QL (70 per 90 tramadol oral extended release hr tramadol oral, er multiphase hr tramadolacetaminophen oral VIVITROL R SUSPENSION,EXT ENDED REL RECON VOLTAREN GEL TOPICAL GEL 1 % QL (90 per 90 QL (90 per 90 QL (1080 per 90 Name PSYCHOTHERAPEUTIC DRUGS ABILIFY MAINTENA R SUSPENSION,EXT ENDED REL RECON ABILIFY MAINTENA R SUSPENSION,EXT ENDED REL SYRING ABILIFY ORAL ADASUVE INHALATION AEROSOL POWDR BREATH ACTIVATED alprazolam intensol oral concentrate alprazolam oral amitriptyline oral amoxapine oral amphetamine salt combo oral 10 mg, 1. mg, 1 mg, 0 mg, mg, 7. mg ST ST ST ST PA QL (10 per : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part B vs. Part D only GC - Gap Coverage HI - 7

48 Name amphetamine salt combo oral 0 mg aripiprazole oral aripiprazole oral BRINTELLIX ORAL bupropion hcl oral bupropion hcl oral extended release bupropion hcl oral extended release hr buspirone oral chlorpromazine injection chlorpromazine oral citalopram oral citalopram oral clomipramine oral clonidine hcl oral extended release 1 hr clorazepate dipotassium oral QL (68 per ST PA Name clozapine oral clozapine oral,disintegrating 100 mg, 1. mg, mg CLOZAPINE ORAL,DISINTE GRATING 10 MG, 00 MG CYMBALTA ORAL CAPSULE,DELAY ED RELEASE(DR/EC) desipramine oral dexedrine oral dexmethylphenidate oral,er biphasic mg dexmethylphenidate oral,er biphasic mg, 0 mg, 0 mg dexmethylphenidate oral,er biphasic mg dexmethylphenidate oral 10 mg dexmethylphenidate oral. mg, mg : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part B vs. Part D only GC - Gap Coverage HI - 8 QL ( per QL (68 per QL (90 per 90 QL (16 per QL (10 per

49 Name dextroamphetamine oral, extended release 10 mg, mg dextroamphetamine oral, extended release 1 mg dextroamphetamine oral dextroamphetamine oral dextroamphetamineamphetamine oral,extended release hr 10 mg, 1 mg, 0 mg, mg, mg dextroamphetamineamphetamine oral,extended release hr 0 mg diazepam intensol oral concentrate diazepam oral concentrate diazepam oral diazepam oral doxepin oral PA doxepin oral concentrate duloxetine oral,delayed release(dr/ec) QL (10 per QL (16 per QL (10 per QL (68 per PA Name EMSAM TRANSDERMAL PATCH HOUR ergoloid oral escitalopram oxalate oral escitalopram oxalate oral FANAPT ORAL FANAPT ORAL S,DOSE PACK FAZACLO ORAL,DISINTE GRATING 10 MG, 00 MG FETZIMA ORAL CAPSULE,EXT REL HR DOSE PACK FETZIMA ORAL CAPSULE,EXTEN DED RELEASE HR fluoxetine oral fluoxetine oral,delayed release(dr/ec) fluoxetine oral fluoxetine oral 10 mg, 0 mg : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part B vs. Part D only GC - Gap Coverage HI - 9 ST ST ST ST

50 Name fluphenazine decanoate injection fluphenazine hcl injection fluphenazine hcl oral concentrate fluphenazine hcl oral elixir fluphenazine hcl oral fluvoxamine oral,extended release hr fluvoxamine oral GEODON R guanfacine oral extended release hr guanidine oral haloperidol decanoate intramuscular haloperidol lactate injection haloperidol lactate oral concentrate haloperidol oral ST ST; QL ( per Name HETLIOZ ORAL CAPSULE imipramine hcl oral imipramine pamoate oral INTUNIV ER ORAL EXTENDED RELEASE HR INVEGA ORAL EXTENDED RELEASE HR INVEGA SUSTENNA R SYRINGE 117 MG/0.7 ML, 16 MG/ML, MG/1. ML INVEGA SUSTENNA R SYRINGE 9 MG/0. ML, 78 MG/0. ML INVEGA TRINZA R SYRINGE KHEDEZLA ORAL EXTENDED RELEASE HR LATUDA ORAL PA; QL ( per PA PA ST; QL ( per ST ST ST ST ST ST : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part B vs. Part D only GC - Gap Coverage HI - 0

51 Name Name lithium carbonate oral lithium carbonate oral lithium carbonate oral extended release lithium citrate oral 8 meq/ ml lorazepam intensol oral concentrate methylphenidate oral, er biphasic mg, 0 mg, 60 mg methylphenidate oral, er biphasic mg methylphenidate oral, er biphasic mg, 0 mg QL (90 per 90 QL (70 per 90 QL (180 per 90 lorazepam oral concentrate lorazepam oral loxapine succinate oral maprotiline oral MARPLAN ORAL metadate er oral extended release methamphetamine oral METHYLIN ORAL,CHEWAB LE 10 MG METHYLIN ORAL,CHEWAB LE. MG, MG QL (0 per 90 QL (900 per 90 QL (70 per 90 methylphenidate oral,er biphasic mg methylphenidate oral,er biphasic mg methylphenidate oral,er biphasic mg methylphenidate oral methylphenidate oral 10 mg, mg methylphenidate oral 0 mg methylphenidate oral extended release 10 mg QL (0 per 90 QL (70 per 90 QL (180 per 90 QL (70 per 90 QL (0 per 90 QL (70 per 90 : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part B vs. Part D only GC - Gap Coverage HI - 1

52 Name methylphenidate oral extended release 0 mg methylphenidate oral extended release hr 18 mg methylphenidate oral extended release hr 7 mg, 6 mg, mg methylphenidate oral,chewable 10 mg methylphenidate oral,chewable. mg, mg mirtazapine oral mirtazapine oral,disintegrating QL (0 per 90 QL (90 per 90 QL (180 per 90 QL (900 per 90 QL (70 per 90 modafinil oral PA; QL (68 per nefazodone oral nortriptyline oral nortriptyline oral NUVIGIL ORAL olanzapine intramuscular recon soln PA; QL ( per Name olanzapine oral olanzapine oral,disintegrating olanzapinefluoxetine oral ORAP ORAL paroxetine hcl oral paroxetine hcl oral extended release hr PAXIL ORAL SUSPENSION perphenazine oral phenelzine oral PRISTIQ ORAL EXTENDED RELEASE HR protriptyline oral quetiapine oral REXULTI ORAL ST ST ST : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part B vs. Part D only GC - Gap Coverage HI -

53 Name RISPERDAL CONSTA R SYRINGE 1. MG/ ML, MG/ ML RISPERDAL CONSTA R SYRINGE 7. MG/ ML, 0 MG/ ML risperidone oral risperidone oral risperidone oral,disintegrating ROZEREM ORAL SAPHRIS (BLACK CHERRY) SUBLINGUAL SEROQUEL XR ORAL EXTENDED RELEASE HR sertraline oral concentrate sertraline oral STRATTERA ORAL CAPSULE 10 MG, 18 MG, MG, 0 MG, 60 MG ST ST QL ( per ST ST QL (68 per Name STRATTERA ORAL CAPSULE 100 MG, 80 MG SURMONTIL ORAL CAPSULE temazepam oral thioridazine oral thiothixene oral tranylcypromine oral QL ( per PA PA trazodone oral triazolam oral trifluoperazine oral venlafaxine oral,extended release hr venlafaxine oral VERSACLOZ ORAL SUSPENSION VIIBRYD ORAL VIIBRYD ORAL S,DOSE PACK 10 MG (7)- 0 MG () ST ST : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part B vs. Part D only GC - Gap Coverage HI -

54 Name VIIBRYD ORAL S,DOSE PACK 10 MG (7)- 0 MG (7)-0 MG (16) XYREM ORAL zaleplon oral ziprasidone hcl oral ZYPREXA RELPREVV R SUSPENSION FOR RECONSTITUTIO N ST PA; LA PA; QL ( per ST CARDIOVASCULAR, HYPERTENSION / LIPIDS ANTIARRHYTHMIC AGENTS adenosine intravenous adenosine intravenous syringe amiodarone intravenous amiodarone intravenous syringe amiodarone oral disopyramide phosphate oral Name flecainide oral ibutilide fumarate intravenous lidocaine (pf) in d7.w intrathecal lidocaine (pf) intravenous lidocaine (pf) intravenous syringe 100 mg/ ml ( %), 0 mg/ ml (1 %) mexiletine oral MULTAQ ORAL NORPACE CR ORAL CAPSULE, EXTENDED RELEASE pacerone oral 100 mg, 00 mg, 00 mg procainamide injection propafenone oral,extended release 1 hr propafenone oral quinidine gluconate injection : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part B vs. Part D only GC - Gap Coverage HI -

55 Name quinidine gluconate oral extended release quinidine sulfate oral sorine oral sotalol af oral sotalol oral TIKOSYN ORAL CAPSULE XYLOCAINE (CARDIAC) (PF) ANTIHYPERTENSIVE THERAPY acebutolol oral afeditab cr oral extended release amiloride oral amiloridehydrochlorothiazide oral amlodipine oral amlodipinebenazepril oral amlodipinevalsartan oral Name amlodipinevalsartan-hcthiazid oral atenolol oral atenololchlorthalidone oral AZOR ORAL benazepril oral benazeprilhydrochlorothiazide oral BENICAR HCT ORAL BENICAR ORAL QL ( per betaxolol oral BIDIL ORAL bisoprolol fumarate oral bisoprololhydrochlorothiazide oral BREVIBLOC 100 MG/10 ML (10 MG/ML) bumetanide injection : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part B vs. Part D only GC - Gap Coverage HI -

56 Name bumetanide oral candesartan oral candesartanhydrochlorothiazid oral captopril oral captoprilhydrochlorothiazide oral CARDIZEM LA ORAL EXTENDED RELEASE HR 10 MG CARDURA XL ORAL EXTENDED RELEASE HR cartia xt oral,extended release hr carvedilol oral chlorothiazide oral chlorothiazide sodium intravenous recon soln chlorthalidone oral mg, 0 mg clonidine (pf) epidural 1,000 mcg/10 ml (100 mcg/ml) Name clonidine hcl oral clonidine transdermal patch weekly COREG CR ORAL CAPSULE, ER MULTIPHASE HR CORLOPAM DEMSER ORAL CAPSULE diltiazem hcl intravenous recon soln diltiazem hcl intravenous diltiazem hcl oral, extended release diltiazem hcl oral,ext release degradable diltiazem hcl oral,extended release 1 hr diltiazem hcl oral,extended release hr diltiazem hcl oral : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part B vs. Part D only GC - Gap Coverage HI - 6 QL ( per

57 Name diltiazem hcl oral extended release hr dilt-xr oral,ext release degradable DIOVAN ORAL doxazosin oral EDARBYCLOR ORAL EDECRIN ORAL enalapril maleate oral enalaprilat intravenous injectable enalaprilhydrochlorothiazide oral eplerenone oral epoprostenol (glycine) intravenous recon soln eprosartan oral esmolol intravenous EXFORGE HCT ORAL Name EXFORGE ORAL felodipine oral extended release hr FLOLAN ; QL ( per fosinopril oral fosinoprilhydrochlorothiazide oral furosemide injection furosemide injection syringe furosemide oral 10 mg/ml, 0 mg/ ml furosemide oral hydralazine injection hydralazine oral hydrochlorothiazide oral hydrochlorothiazide oral indapamide oral : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part B vs. Part D only GC - Gap Coverage HI - 7

58 Name INNOPRAN XL ORAL CAPSULE,EXTEN DED RELEASE HR irbesartan oral irbesartanhydrochlorothiazide oral isradipine oral labetalol intravenous labetalol oral lisinopril oral lisinoprilhydrochlorothiazide oral losartan oral losartanhydrochlorothiazide oral matzim la oral extended release hr methyclothiazide oral methyldopahydrochlorothiazide oral methyldopate intravenous Name metolazone oral metoprolol succinate oral extended release hr metoprolol tahydrochlorothiaz oral metoprolol tartrate intravenous metoprolol tartrate intravenous syringe metoprolol tartrate oral minoxidil oral ; QL (180 per 90 moexipril oral moexiprilhydrochlorothiazide oral nadolol oral nadololbendroflumethiazide oral NICARDIPINE nicardipine oral nifedical xl oral extended release hr nifedipine oral extended release ; QL ( per : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part B vs. Part D only GC - Gap Coverage HI - 8

59 Name nifedipine oral extended release hr nimodipine oral nisoldipine oral extended release hr NYMALIZE ORAL ORENITRAM ORAL EXTENDED RELEASE 0.1 MG ORENITRAM ORAL EXTENDED RELEASE 0. MG, 1 MG,. MG perindopril erbumine oral PA PA pindolol oral prazosin oral propranolol intravenous propranolol oral,extended release hr propranolol oral propranolol oral Name propranololhydrochlorothiazid oral quinapril oral quinaprilhydrochlorothiazide oral ramipril oral REMODULIN INJECTION spironolactone oral spironolactonhydrochlorothiaz oral taztia xt oral, extended release TEKTURNA HCT ORAL TEKTURNA ORAL telmisartan oral telmisartanamlodipine oral telmisartanhydrochlorothiazid oral terazosin oral PA : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part B vs. Part D only GC - Gap Coverage HI - 9

60 Name TEVETEN HCT ORAL 600- MG timolol maleate oral torsemide oral trandolapril oral trandolaprilverapamil oral, ir & er, biphasic hr triamterenehydrochlorothiazid oral triamterenehydrochlorothiazid oral valsartan oral valsartanhydrochlorothiazide oral veletri intravenous recon soln verapamil intravenous verapamil intravenous syringe verapamil oral, hr er pellet ct verapamil oral,ext rel. pellets hr Name verapamil oral verapamil oral extended release CARDIAC GLYCOSIDES digitek oral 1 mcg digitek oral 0 mcg digox oral 1 mcg digox oral 0 mcg digoxin injection digoxin oral 0 mcg/ml digoxin oral 1 mcg digoxin oral 0 mcg LANOXIN PEDIATRIC INJECTION COAGULATION THERAPY AGGRENOX ORAL CAPSULE, ER MULTIPHASE 1 HR aminocaproic acid intravenous QL ( per QL ( per QL (90 per 90 : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part B vs. Part D only GC - Gap Coverage HI - 0

61 Name Name ARGATROBAN IN 0.9 % SOD CHLOR PARENTERAL enoxaparin subcutaneous syringe 100 mg/ml, 10 mg/0.8 ml, 10 mg/ml ARGATROBAN aspirin-dipyridamole oral, er multiphase 1 hr BRILINTA ORAL CEPROTIN (BLUE BAR) CEPROTIN (GREEN BAR) cilostazol oral enoxaparin subcutaneous syringe 0 mg/0. ml, 0 mg/0. ml, 60 mg/0.6 ml, 80 mg/0.8 ml fondaparinux subcutaneous syringe 10 mg/0.8 ml, mg/0. ml, 7. mg/0.6 ml fondaparinux subcutaneous syringe. mg/0. ml FRAGMIN clopidogrel oral EFFIENT ORAL ELIQUIS ORAL enoxaparin subcutaneous FRAGMIN SYRINGE 10,000 ANTI-XA UNIT/ML, 1,00 ANTI-XA UNIT/0. ML, 1,000 ANTI- XA UNIT/0.6 ML, 18,000 ANTI-XA UNIT/0.7 ML, 7,00 ANTI-XA UNIT/0. ML : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part B vs. Part D only GC - Gap Coverage HI - 1

62 Name FRAGMIN SYRINGE,00 ANTI-XA UNIT/0. ML,,000 ANTI- XA UNIT/0. ML heparin (porcine) in % dex intravenous parenteral 0,000 unit/00 ml (0 unit/ml) HEPARIN (PORCINE) IN % DEX PARENTERAL,000 UNIT/0 ML(100 UNIT/ML),,000 UNIT/00 ML (0 UNIT/ML) heparin (porcine) injection cartridge heparin (porcine) injection HEPARIN(PORCIN E) IN 0.% NACL PARENTERAL 1,00 UNIT/0 ML heparin, porcine (pf) injection heparin, porcine (pf) injection syringe HI jantoven oral Name NPLATE pentoxifylline oral extended release PRADAXA ORAL CAPSULE PROMACTA ORAL THROMBATE III 00 (+/-) UNIT ticlopidine oral tranexamic acid intravenous PA; LA warfarin oral XARELTO ORAL XARELTO ORAL S,DOSE PACK LIPID/CHOLESTEROL LOWERING AGENTS amlodipineatorvastatin oral atorvastatin oral cholestyramine (with sugar) oral powder : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part B vs. Part D only GC - Gap Coverage HI -

63 Name cholestyramine (with sugar) oral powder in packet cholestyramine light oral powder cholestyramine light oral powder in packet colestipol oral granules colestipol oral packet colestipol oral CRESTOR ORAL 10 MG, 0 MG, MG CRESTOR ORAL 0 MG fenofibrate micronized oral fenofibrate nanocrystallized oral fenofibrate oral 160 mg, mg fenofibric acid (choline) oral,delayed release(dr/ec) fenofibric acid oral fluvastatin oral ST; QL ( per QL ( per 1 ST; GC Name gemfibrozil oral JUXTAPID ORAL CAPSULE KYNAMRO SYRINGE LESCOL XL ORAL EXTENDED RELEASE HR LIPOFEN ORAL CAPSULE PA PA lovastatin oral LOVAZA ORAL CAPSULE niacin oral extended release hr NIASPAN EXTENDED- RELEASE ORAL EXTENDED RELEASE HR omega- acid ethyl esters oral pravastatin oral 10 mg, 0 mg, 80 mg pravastatin oral 0 mg prevalite oral powder QL ( per ; QL ( per ; QL (1 per : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part B vs. Part D only GC - Gap Coverage HI -

64 Name prevalite oral powder in packet simvastatin oral TRIGLIDE ORAL 160 MG VASCEPA ORAL CAPSULE VYTORIN ORAL VYTORIN 10-0 ORAL VYTORIN 10-0 ORAL VYTORIN ORAL WELCHOL ORAL POWDER IN PACKET WELCHOL ORAL ZETIA ORAL ; QL ( per ST; QL ( per ST; QL ( per ST; QL ( per ST; QL ( per QL ( per MISCELLANEOUS CARDIOVASCULAR AGENTS CORLANOR ORAL dobutamine intravenous QL (180 per 90 Name dopamine intravenous 00 mg/ ml (0 mg/ml), 00 mg/10 ml (0 mg/ml), 00 mg/ ml (80 mg/ml), 800 mg/10 ml (80 mg/ml) ISUPREL INJECTION LEVOPHED (BITARTRATE) norepinephrine bitartrate intravenous RANEXA ORAL EXTENDED RELEASE 1 HR VECAMYL ORAL NITRATES isosorbide dinitrate oral isosorbide dinitrate oral extended release isosorbide mononitrate oral PA : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part B vs. Part D only GC - Gap Coverage HI -

65 Name isosorbide mononitrate oral extended release hr nitro-bid transdermal ointment nitroglycerin intravenous nitroglycerin oral, extended release nitroglycerin transdermal patch hour nitroglycerin translingual aerosol,spray nitroglycerin translingual spray,non-aerosol NITROMIST TRANSLINGUAL AEROSOL,SPRAY NITROSTAT SUBLINGUAL DERMATOLOGICALS/TOPICA L THERAPY ANTIPSORIATIC / ANTISEBORRHEIC acitretin oral 10 mg Name acitretin oral 17. mg, mg calcipotriene topical cream calcipotriene topical ointment calcipotriene topical calcitrene topical ointment calcitriol topical ointment COSENTYX ( SYRINGES) SYRINGE COSENTYX PEN ( PENS) PEN INJECTOR COSENTYX PEN PEN INJECTOR COSENTYX SYRINGE EPIFOAM TOPICAL FOAM PRAMOSONE TOPICAL CREAM 1-1 % PRAMOSONE TOPICAL LOTION.-1 % : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part B vs. Part D only GC - Gap Coverage HI - PA PA PA PA

66 Name selenium sulfide topical suspension STELARA SYRINGE TACLONEX TOPICAL SUSPENSION BURN THERAPY silver sulfadiazine topical cream ssd topical cream MISCELLANEOUS DERMATOLOGICALS 8-MOP ORAL CAPSULE ammonium lactate topical cream ammonium lactate topical lotion CARAC TOPICAL CREAM CONDYLOX TOPICAL GEL diclofenac sodium topical gel ELIDEL TOPICAL CREAM FLUOROURACIL TOPICAL CREAM 0. % fluorouracil topical cream % PA Name fluorouracil topical imiquimod topical cream in packet METHOXSALEN RAPID ORAL CAPSULE OXSORALEN TOPICAL LOTION OXSORALEN ULTRA ORAL CAPSULE PANRETIN TOPICAL GEL PICATO TOPICAL GEL 0.01 % PICATO TOPICAL GEL 0.0 % podofilox topical PROTOPIC TOPICAL OINTMENT prudoxin topical cream REGRANEX TOPICAL GEL tacrolimus topical ointment UVADEX INJECTION VALCHLOR TOPICAL GEL : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part B vs. Part D only GC - Gap Coverage HI - 6 QL ( per QL ( per PA

67 Name THERAPY FOR ACNE adapalene topical cream adapalene topical gel adapalene topical gel with pump amnesteem oral AZELEX TOPICAL CREAM BENZACLIN PUMP TOPICAL GEL claravis oral 10 mg, 0 mg, 0 mg claravis oral 0 mg clindacin etz topical swab clindacin p topical swab clindamycin phosphate topical foam clindamycin phosphate topical gel clindamycin phosphate topical lotion clindamycin phosphate topical Name clindamycin phosphate topical swab clindamycin-benzoyl peroxide topical gel DIFFERIN TOPICAL LOTION ery pads topical swab erygel topical gel erythromycin with ethanol topical gel erythromycin with ethanol topical erythromycin with ethanol topical swab erythromycinbenzoyl peroxide topical gel FINACEA TOPICAL GEL metronidazole topical cream metronidazole topical gel 0.7 % metronidazole topical gel 1 % metronidazole topical gel with pump metronidazole topical lotion : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part B vs. Part D only GC - Gap Coverage HI - 7

68 Name Name neuac topical gel rosadan topical cream rosadan topical gel CARBOCAINE (PF) INJECTION 10 MG/ML (1 %), 0 MG/ML ( %) TAZORAC TOPICAL CREAM TAZORAC TOPICAL GEL tretinoin microspheres topical gel tretinoin microspheres topical gel with pump tretinoin topical cream tretinoin topical gel 0.01 %, 0.0 % TRETIN-X TOPICAL CREAM TOPICAL ANESTHETICS bupivacaine (pf) injection bupivacaine injection bupivacaineepinephrine (pf) injection bupivacaineepinephrine injection carbocaine (pf) injection 1 mg/ml (1. %) CARBOCAINE INJECTION glydo mucous membrane jelly in applicator lidocaine (pf) injection 10 mg/ml (1 %), 0 mg/ml ( %), mg/ml (0. %) lidocaine hcl injection 10 mg/ml (1 %), 0 mg/ml ( %) lidocaine hcl laryngotracheal lidocaine hcl mucous membrane gel lidocaine hcl mucous membrane jelly in applicator lidocaine hcl mucous membrane lidocaine hcl urethral gel : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part B vs. Part D only GC - Gap Coverage HI - 8

69 Name lidocaine topical adhesive patch,medicated lidocaine topical ointment lidocaine viscous mucous membrane lidocaineepinephrine (pf) injection LIDOCAINE- EPINEPHRINE BIT INJECTION CARTRIDGE %- 1:0,000 lidocaineepinephrine injection lidocaine-prilocaine topical cream lidocaine-prilocaine topical kit lta pre-attached laryngotracheal marcaine (pf) injection 0.7 % (7. mg/ml) MEPIVACAINE (PF) INJECTION CARTRIDGE NAROPIN (PF) INJECTION PA; QL (90 per 0 Name NESACAINE INJECTION 10 MG/ML (1 %) relador pak topical kit ropivacaine (pf) injection 10 mg/ml (1 %), mg/ml (0. %), 7. mg/ml (0.7 %) ropivacaine (pf) injection mg/ml (0. %) sensorcaine injection 0. % ( mg/ml) sensorcaine/epineph rine injection sensorcaine-mpf injection 0. % ( mg/ml) SENSORCAINE- MPF/EPINEPHRIN E INJECTION 0.7 %- 1:00,000 XYLOCAINE- MPF/EPINEPHRIN E INJECTION 1 %- 1:00,000 TOPICAL ANTIBACTERIALS : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part B vs. Part D only GC - Gap Coverage HI - 9

70 Name Name ALTABAX TOPICAL OINTMENT CENTANY TOPICAL OINTMENT gentamicin topical cream gentamicin topical ointment mupirocin calcium topical cream ciclopirox topical suspension clotrimazole topical cream clotrimazole topical clotrimazolebetamethasone topical cream clotrimazolebetamethasone topical lotion mupirocin topical ointment econazole topical cream sulfacetamide sodium (acne) topical suspension SULFAMYLON TOPICAL CREAM TOPICAL ANTIFUNGALS ciclodan topical cream ciclodan topical ciclopirox topical cream ciclopirox topical gel ciclopirox topical shampoo ciclopirox topical ERTACZO TOPICAL CREAM EXELDERM TOPICAL CREAM EXELDERM TOPICAL ketoconazole topical cream ketoconazole topical foam ketoconazole topical shampoo MENTAX TOPICAL CREAM NAFTIN TOPICAL CREAM NAFTIN TOPICAL GEL : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part B vs. Part D only GC - Gap Coverage HI - 60

71 Name Name nyamyc topical powder alclometasone topical ointment nystatin topical cream amcinonide topical cream nystatin topical ointment amcinonide topical lotion nystatin topical powder amcinonide topical ointment nystatintriamcinolone topical cream nystatintriamcinolone topical ointment nystop topical powder apexicon e topical cream betamethasone dipropionate topical cream betamethasone dipropionate topical lotion OXISTAT TOPICAL CREAM OXISTAT TOPICAL LOTION XOLEGEL TOPICAL GEL TOPICAL ANTIVIRALS acyclovir topical ointment DENAVIR TOPICAL CREAM betamethasone dipropionate topical ointment betamethasone valerate topical cream betamethasone valerate topical foam betamethasone valerate topical lotion ZOVIRAX TOPICAL CREAM TOPICAL CORTICOSTEROIDS alclometasone topical cream betamethasone valerate topical ointment betamethasone, augmented topical cream : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part B vs. Part D only GC - Gap Coverage HI - 61

72 Name Name betamethasone, augmented topical gel betamethasone, augmented topical lotion betamethasone, augmented topical ointment CAPEX TOPICAL SHAMPOO clobetasol topical cream clobetasol topical foam clobetasol topical gel clobetasol topical lotion clobetasol topical ointment clobetasol topical shampoo clobetasol topical clobetasol topical spray,non-aerosol clobetasol-emollient topical cream clobetasol-emollient topical foam clodan topical shampoo cormax topical CUTIVATE TOPICAL LOTION desonide topical cream desonide topical lotion desonide topical ointment desoximetasone topical cream desoximetasone topical gel desoximetasone topical ointment diflorasone topical cream diflorasone topical ointment fluocinolone topical cream fluocinolone topical oil fluocinolone topical ointment fluocinolone topical fluocinolone-shower cap topical oil fluocinonide topical cream : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part B vs. Part D only GC - Gap Coverage HI - 6

73 Name Name fluocinonide topical gel fluocinonide topical ointment fluocinonide topical fluocinonide-e topical cream fluticasone topical cream fluticasone topical lotion fluticasone topical ointment halobetasol propionate topical cream halobetasol propionate topical ointment HALOG TOPICAL CREAM HALOG TOPICAL OINTMENT hydrocortisone butyrate topical cream hydrocortisone butyrate topical ointment hydrocortisone butyrate topical hydrocortisone butyr-emollient topical cream hydrocortisone topical cream 1 %,. % hydrocortisone topical lotion. % hydrocortisone topical ointment 1 %,. % hydrocortisone valerate topical cream hydrocortisone valerate topical ointment hydrocortisone-min oil-wht pet topical ointment lokara topical lotion mometasone topical cream mometasone topical ointment mometasone topical PANDEL TOPICAL CREAM prednicarbate topical ointment PSORCON TOPICAL CREAM : 1-Preferred Generic -Non-Preferred Generic -Specialty s : B/D - Prior Authorization, Part B vs. Part D only Home Infusion LA - Limited Availability PA - Prior Authorization 6 -Preferred Brand -Non-Preferred Brand GC - Gap Coverage HI - QL - Quantity Limit

74 Name triamcinolone acetonide topical cream triamcinolone acetonide topical lotion triamcinolone acetonide topical ointment 0.0 %, 0.1 %, 0. % trianex topical ointment triderm topical cream TOPICAL ENZYMES SANTYL TOPICAL OINTMENT TOPICAL SCABICIDES / PEDICULICIDES EURAX TOPICAL CREAM EURAX TOPICAL LOTION lindane topical lotion lindane topical shampoo malathion topical lotion permethrin topical cream SKLICE TOPICAL LOTION Name DIAGNOSTICS / MISCELLANEOUS AGENTS ANTIDOTES acetylcysteine intravenous PROTOPAM CHLORIDE INJECTION IRRIGATING S lactated ringers irrigation neomycin-polymyxin b gu irrigation ringers irrigation SORBITOL IRRIGATION MISCELLANEOUS AGENTS acamprosate oral,delayed release (dr/ec) acetic acid irrigation ACTONEL ORAL 0 MG ADAGEN R alendronate oral 0 mg QL ( per QL ( per 8 : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part B vs. Part D only GC - Gap Coverage HI - 6

75 Name Name AMMONUL anagrelide oral ARALAST NP AURYXIA ORAL BUPHENYL ORAL bupivacainedextrose-water(pf) injection CAFCIT caffeine citrated intravenous caffeine citrated oral d. %-0. % sodium chloride intravenous parenteral d %-0. % sodium chloride intravenous parenteral deferoxamine injection recon soln DESFERAL INJECTION dextrose 10 % in water (d10w) intravenous parenteral dextrose 0 % in water (d0w) intravenous parenteral dextrose % in water (dw) intravenous syringe CARBAGLU ORAL, DISPERSIBLE cevimeline oral CHEMET ORAL CAPSULE d10 % & 0. % sodium chloride intravenous parenteral LA dextrose 0 % in water (d0w) intravenous parenteral dextrose 0 % in water (d0w) intravenous parenteral dextrose % in ringers intravenous parenteral : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part B vs. Part D only GC - Gap Coverage HI - 6

76 Name Name dextrose % in water (dw) intravenous parenteral dextrose % in water (dw) intravenous piggyback dextrose %- lactated ringers intravenous parenteral dextrose %-0. % sod chloride intravenous parenteral dextrose %-0. % sod.chloride intravenous parenteral dextrose 0 % in water (d0w) intravenous parenteral dextrose 0 % in water (d0w) intravenous syringe dextrose 70 % in water (d70w) intravenous parenteral dextrose with sodium chloride intravenous parenteral disulfiram oral etidronate disodium oral EXJADE ORAL, DISPERSIBLE 1 MG EXJADE ORAL, DISPERSIBLE 0 MG, 00 MG FOSRENOL ORAL POWDER IN PACKET FOSRENOL ORAL,CHEWAB LE INCRELEX JADENU ORAL kionex oral powder kionex oral suspension levocarnitine (with sugar) oral levocarnitine intravenous levocarnitine oral MARCAINE SPINAL (PF) INJECTION PA B/D PA B/D PA B/D PA : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part B vs. Part D only GC - Gap Coverage HI - 66

77 Name midodrine oral NORTHERA ORAL CAPSULE ORFADIN ORAL CAPSULE pilocarpine hcl oral PROLASTIN-C RAVICTI ORAL LIQUID RENAGEL ORAL RENVELA ORAL POWDER IN PACKET RENVELA ORAL riluzole oral risedronate oral 0 mg SENSORCAINE- MPF SPINAL INJECTION sodium chloride 0.9 % intravenous parenteral sodium chloride 0.9 % intravenous piggyback PA QL (90 per 90 Name sodium chloride irrigation sodium phenylbutyrate oral powder sodium polystyrene (sorb free) oral suspension sodium polystyrene sulfonate oral powder sodium polystyrene sulfonate oral suspension sodium polystyrene sulfonate rectal enema 0 gram/10 ml SODIUM POLYSTYRENE SULFONATE RECTAL ENEMA 0 GRAM/00 ML SOLIRIS sps oral suspension sps rectal enema SYPRINE ORAL CAPSULE water for irrigation, sterile irrigation : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part B vs. Part D only GC - Gap Coverage HI - 67

78 Name ZEMAIRA ZOLEDRONIC ACID-MANNITOL- WATER PIGGYBACK MG/100 ML zoledronic acidmannitol-water intravenous SMOKING DETERRENTS buproban oral extended release CHANTIX CONTINUING MONTH BOX ORAL CHANTIX ORAL CHANTIX STARTING MONTH BOX ORAL S,DOSE PACK NICOTROL INHALATION CARTRIDGE NICOTROL NS NASAL SPRAY,NON- AEROSOL QL (11 per 90 QL (60 per 60 Name EAR, NOSE / THROAT MEDICATIONS MISCELLANEOUS AGENTS azelastine nasal aerosol,spray azelastine nasal spray,non-aerosol BACTROBAN NASAL NASAL OINTMENT chlorhexidine gluconate mucous membrane mouthwash CLINPRO 000 DENTAL PASTE denta 000 plus dental cream dentagel dental gel ipratropium bromide nasal spray,nonaerosol olopatadine nasal spray,non-aerosol oralone dental paste paroex oral rinse mucous membrane mouthwash perio med dental periogard mucous membrane mouthwash : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part B vs. Part D only GC - Gap Coverage HI - 68

79 Name PREVIDENT 000 BOOSTER PLUS DENTAL PASTE PREVIDENT 000 DRY MOUTH DENTAL GEL PREVIDENT 000 ENAMEL PROTECT DENTAL PASTE PREVIDENT 000 PLUS DENTAL CREAM PREVIDENT 000 SENSITIVE DENTAL PASTE PREVIDENT DENTAL GEL PREVIDENT DENTAL sf 000 plus dental cream sf dental gel triamcinolone acetonide dental paste TYZINE NASAL DROPS 0.0 % MISCELLANEOUS OTIC PREPARATIONS acetasol hc otic drops Name acetic acid otic acetic acidaluminum acetate otic drops ciprofloxacin hcl otic dropperette fluocinolone acetonide oil otic drops hydrocortisoneacetic acid otic drops ofloxacin otic drops OTIC STEROID / ANTIBIOTIC CIPRO HC OTIC DROPS,SUSPENSI ON CIPRODEX OTIC DROPS,SUSPENSI ON COLY-MYCIN S OTIC DROPS,SUSPENSI ON CORTISPORIN-TC OTIC DROPS,SUSPENSI ON neomycinpolymyxin-hc otic drops,suspension neomycinpolymyxin-hc otic : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part B vs. Part D only GC - Gap Coverage HI - 69

80 Name ENDOCRINE/DIABETES ADRENAL HORMONES ACTHAR H.P. INJECTION GEL a-hydrocort injection recon soln ARISTOSPAN INTRA- ARTICULAR INJECTION SUSPENSION ARISTOSPAN INTRALESIONAL INJECTION SUSPENSION betamethasone acet,sod phos injection suspension CELESTONE SOLUSPAN INJECTION SUSPENSION cortisone oral deltasone oral 0 mg DEPO-MEDROL INJECTION SUSPENSION dexamethasone intensol oral drops dexamethasone oral elixir dexamethasone oral PA Name dexamethasone oral dexamethasone sodium phos (pf) injection dexamethasone sodium phosphate injection mg/ml DEXPAK 10 DAY ORAL S,DOSE PACK DEXPAK 1 DAY ORAL S,DOSE PACK DEXPAK 6 DAY ORAL S,DOSE PACK fludrocortisone oral hydrocortisone oral methylprednisolone acetate injection suspension methylprednisolone oral methylprednisolone oral s,dose pack : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part B vs. Part D only GC - Gap Coverage HI - 70

81 Name methylprednisolone sodium succ injection recon soln 1 mg, 0 mg methylprednisolone sodium succ intravenous recon soln prednisolone oral 1 mg/ ml prednisolone sodium phosphate oral 1 mg/ ml, mg/ ml ( mg/ml), mg base/ ml (6.7 mg/ ml) prednisolone sodium phosphate oral,disintegrating prednisone intensol oral concentrate prednisone oral prednisone oral prednisone oral s,dose pack SOLU-CORTEF (PF) INJECTION SOLU-MEDROL (PF) INJECTION Name SOLU-MEDROL (PF) SOLU-MEDROL triamcinolone acetonide injection suspension ANTITHYROID AGENTS methimazole oral 10 mg, mg propylthiouracil oral DIABETES THERAPY acarbose oral alcohol pads topical pads, medicated APIDRA SOLOSTAR INSULIN PEN APIDRA AVANDAMET ORAL - 1,000 MG, -00 MG AVANDIA ORAL ST; QL (68 per ST; QL (68 per : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part B vs. Part D only GC - Gap Coverage HI - 71

82 Name Name BYDUREON PEN INJECTOR BYDUREON SUSPENSION,EXT ENDED REL RECON BYETTA PEN INJECTOR CYCLOSET ORAL gauze pads x glimepiride oral PA; QL ( per 8 PA; QL ( per 8 PA; QL (. per 0 QL (0 per glipizide oral GLYSET ORAL HUMALOG KWIKPEN INSULIN PEN HUMALOG MIX 0-0 KWIKPEN INSULIN PEN HUMALOG MIX 0-0 SUSPENSION HUMALOG MIX 7- KWIKPEN INSULIN PEN glipizide oral extended release hr glipizide-metformin oral GLUCAGEN HYPOKIT INJECTION GLUCAGON EMERGENCY KIT (HUMAN) INJECTION KIT GLUMETZA ORAL,ER GAST.RETENTION HR 1 GC HUMALOG MIX 7- SUSPENSION HUMALOG CARTRIDGE HUMALOG HUMULIN 70/0 KWIKPEN INSULIN PEN HUMULIN 70/0 SUSPENSION : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part B vs. Part D only GC - Gap Coverage HI - 7

83 Name HUMULIN N KWIKPEN INSULIN PEN HUMULIN N SUSPENSION HUMULIN R INJECTION HUMULIN R U-00 "CONCENTRATED " insulin pen needle QL (00 per insulin syringe (disp) u ml insulin syringe (disp) u ml syringe insulin syringe (disp) u-100 1/ ml INVOKAMET ORAL INVOKANA ORAL JANUMET ORAL JANUMET XR ORAL, ER MULTIPHASE HR JANUVIA ORAL QL (00 per QL (00 per QL (00 per ST ST QL (180 per 90 QL ( per QL ( per Name KOMBIGLYZE XR ORAL, ER MULTIPHASE HR.-1,000 MG KOMBIGLYZE XR ORAL, ER MULTIPHASE HR -1,000 MG, -00 MG LANTUS SOLOSTAR INSULIN PEN LANTUS LEVEMIR FLEXTOUCH INSULIN PEN LEVEMIR metformin oral metformin oral extended release hr nateglinide oral needles, insulin disp.,safety NOVOFINE 0 NEEDLE : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part B vs. Part D only GC - Gap Coverage HI - 7 QL (68 per QL ( per QL (00 per

84 Name Name NOVOFINE NEEDLE ONGLYZA ORAL QL ( per NOVOFINE PLUS NEEDLE pioglitazone oral QL ( per NOVOLIN 70/0 SUSPENSION pioglitazoneglimepiride oral QL ( per NOVOLIN N SUSPENSION pioglitazonemetformin oral 1-00 mg QL (16 per NOVOLIN R INJECTION pioglitazonemetformin oral 1-80 mg QL (10 per NOVOLOG FLEXPEN INSULIN PEN NOVOLOG MIX 70-0 FLEXPEN INSULIN PEN NOVOLOG MIX 70-0 NOVOLOG PENFILL CARTRIDGE NOVOLOG NOVOTWIST NEEDLE PRANDIMET ORAL PROGLYCEM ORAL SUSPENSION repaglinide oral SYMLINPEN 10 PEN INJECTOR SYMLINPEN 60 PEN INJECTOR VICTOZA -PAK PEN INJECTOR VICTOZA -PAK PEN INJECTOR PA PA PA PA MISCELLANEOUS HORMONES : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part B vs. Part D only GC - Gap Coverage HI - 7

85 Name ALDURAZYME ANDRODERM TRANSDERMAL PATCH HOUR MG/ HOUR ANDRODERM TRANSDERMAL PATCH HOUR MG/ HR ANDROGEL TRANSDERMAL GEL IN METERED-DOSE PUMP ANDROGEL TRANSDERMAL GEL IN PACKET 1 % ( MG/.GRAM), 1.6 % (0. MG/1. GRAM), 1.6 % (0. MG/. GRAM) ANDROGEL TRANSDERMAL GEL IN PACKET 1 % (0 MG/ GRAM) ANDROID ORAL CAPSULE PA; QL (68 per PA; QL ( per PA; QL (10 per 0 PA; QL (60 per 0 PA; QL ( per androxy oral PA cabergoline oral Name calcitonin (salmon) nasal spray,nonaerosol calcitriol intravenous 1 mcg/ml calcitriol oral calcitriol oral CERDELGA ORAL CAPSULE CEREZYME 00 UNIT chorionic gonadotropin, human intramuscular recon soln danazol oral desmopressin injection desmopressin nasal aerosol,spray desmopressin nasal desmopressin nasal spray,non-aerosol desmopressin oral doxercalciferol intravenous B/D PA B/D PA B/D PA B/D PA : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part B vs. Part D only GC - Gap Coverage HI - 7

86 Name Name doxercalciferol oral ELAPRASE ELELYSO FABRAZYME B/D PA MYOZYME NAGLAZYME novarel intramuscular recon soln oxandrolone oral 10 mg PA fortical nasal spray,non-aerosol oxandrolone oral. mg PA HECTOROL MCG/ML (1 ML) KORLYM ORAL KUVAN ORAL POWDER IN PACKET KUVAN ORAL,SOLUBL E METHITEST ORAL MIACALCIN INJECTION MYALEPT PA PA PA B/D PA PA pamidronate intravenous recon soln pamidronate intravenous PARICALCITOL HEMODIALYSIS PORT INJECTION MCG/ML PARICALCITOL HEMODIALYSIS PORT INJECTION MCG/ML paricalcitol oral SAMSCA ORAL SENSIPAR ORAL 0 MG B/D PA B/D PA PA : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part B vs. Part D only GC - Gap Coverage HI - 76

87 Name SENSIPAR ORAL 60 MG, 90 MG SOMAVERT STIMATE NASAL SPRAY,NON- AEROSOL SYNAREL NASAL SPRAY,NON- AEROSOL TESTIM TRANSDERMAL GEL TESTOPEL IMPLANT PELLET testosterone cypionate intramuscular oil testosterone enanthate intramuscular oil TESTOSTERONE TRANSDERMAL GEL TESTOSTERONE TRANSDERMAL GEL IN METERED-DOSE PUMP 1. GRAM/ ACTUATION (1 %) PA PA; QL (00 per 0 PA; QL (0 per 0 PA; QL (10 per 0 Name TESTOSTERONE TRANSDERMAL GEL IN METERED-DOSE PUMP 10 MG/0. GRAM /ACTUATION TESTOSTERONE TRANSDERMAL GEL IN PACKET 1 % ( MG/.GRAM) TESTOSTERONE TRANSDERMAL GEL IN PACKET 1 % (0 MG/ GRAM) TESTRED ORAL CAPSULE vasopressin injection VPRIV ZAVESCA ORAL CAPSULE ZEMPLAR zoledronic acid intravenous recon soln zoledronic acid intravenous THYROID HORMONES PA; QL (60 per 0 PA; QL (60 per 0 PA; QL (00 per 0 B/D PA : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part B vs. Part D only GC - Gap Coverage HI - 77

88 Name levothyroxine intravenous recon soln 00 mcg, 00 mcg levothyroxine oral levoxyl oral 100 mcg, 11 mcg, 1 mcg, 17 mcg, 10 mcg, 17 mcg, 00 mcg, mcg, 0 mcg, 7 mcg, 88 mcg liothyronine intravenous liothyronine oral np thyroid oral unithroid oral GASTROENTEROLOGY ANTIDIARRHEALS / ANTISPASMODICS atropine injection syringe 0.0 mg/ml, 0.1 mg/ml dicyclomine oral dicyclomine oral dicyclomine oral diphenoxylateatropine oral liquid Name diphenoxylateatropine oral FULYZAQ ORAL,DELAYE D RELEASE (DR/EC) glycopyrrolate injection glycopyrrolate oral loperamide oral methscopolamine oral opium tincture oral tincture paregoric oral liquid PA MISCELLANEOUS GASTROINTESTINAL AGENTS AKYNZEO ORAL CAPSULE B/D PA alosetron oral QL (180 per 90 ALOXI AMITIZA ORAL CAPSULE ANALPRAM-HC RECTAL CREAM 1-1 % ANALPRAM-HC RECTAL LOTION PA; QL (180 per 90 : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part B vs. Part D only GC - Gap Coverage HI - 78

89 Name Name ANZEMET ANZEMET ORAL APRISO ORAL CAPSULE,EXTEN DED RELEASE HR ASACOL HD ORAL,DELAYE D RELEASE (DR/EC) balsalazide oral budesonide oral,delayed,exte nd.release CANASA RECTAL SUPPOSITORY CIMZIA POWDER FOR RECONST KIT B/D PA; QL (6 per 0 PA compro rectal suppository constulose oral CORTIFOAM RECTAL FOAM CREON ORAL CAPSULE,DELAY ED RELEASE(DR/EC) cromolyn oral concentrate CYSTADANE ORAL POWDER DELZICOL ORAL CAPSULE,DELAY ED RELEASE(DR/EC) dimenhydrinate injection DIPENTUM ORAL CAPSULE dronabinol oral B/D PA CIMZIA STARTER KIT SYRINGE KIT CIMZIA SYRINGE KIT colocort rectal enema PA PA droperidol injection EMEND EMEND ORAL CAPSULE 1 MG, 0 MG EMEND ORAL CAPSULE 80 MG B/D PA; QL ( per fill) B/D PA; QL ( per fill) : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part B vs. Part D only GC - Gap Coverage HI - 79

90 Name EMEND ORAL CAPSULE,DOSE PACK enulose oral GATTEX 0-VIAL KIT GATTEX ONE- VIAL KIT gavilyte-c oral recon soln gavilyte-g oral recon soln gavilyte-h and bisacodyl oral kit gavilyte-n oral recon soln generlac oral GOLYTELY ORAL POWDER IN PACKET granisetron (pf) intravenous 1 mg/ml (1 ml) granisetron (pf) intravenous 100 mcg/ml granisetron hcl intravenous 1 mg/ml B/D PA; QL (6 per fill) PA PA QL ( per 90 HI Name granisetron hcl intravenous 1 mg/ml (1 ml) granisetron hcl oral hydrocortisone rectal enema lactulose oral LIALDA ORAL,DELAYE D RELEASE (DR/EC) LINZESS ORAL CAPSULE LOTRONEX ORAL meclizine oral 1. mg, mg mesalamine rectal enema mesalamine with cleansing wipe rectal enema kit metoclopramide hcl injection metoclopramide hcl injection syringe metoclopramide hcl oral metoclopramide hcl oral MOVANTIK ORAL : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part B vs. Part D only GC - Gap Coverage HI - 80 HI B/D PA PA QL (68 per PA

91 Name MOVIPREP ORAL POWDER IN PACKET ondansetron hcl (pf) injection ondansetron hcl (pf) injection syringe ondansetron hcl intravenous ondansetron hcl oral ondansetron hcl oral ondansetron oral,disintegrating OSMOPREP ORAL PANCREAZE ORAL CAPSULE,DELAY ED RELEASE(DR/EC) pancrelipase 000 oral,delayed release(dr/ec) peg 0- electrolytes oral recon soln gram peg-0 with flavor packs oral recon soln peg-electrolyte soln oral recon soln HI B/D PA B/D PA B/D PA Name peg-prep oral kit QL ( per 90 PENTASA ORAL CAPSULE, EXTENDED RELEASE polyethylene glycol 0 oral powder polyethylene glycol 0 oral powder in packet prochlorperazine edisylate injection prochlorperazine maleate oral prochlorperazine rectal suppository PROCTOFOAM HC RECTAL FOAM proctosol hc rectal cream RELISTOR RELISTOR SYRINGE 1 MG/0.6 ML RELISTOR SYRINGE 8 MG/0. ML : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part B vs. Part D only GC - Gap Coverage HI - 81 PA; QL (16.8 per 8 PA; QL (16.8 per 8 PA; QL (11. per 8

92 Name REMICADE SANCUSO TRANSDERMAL PATCH WEEKLY sulfasalazine oral sulfasalazine oral,delayed release (dr/ec) sulfazine ec oral,delayed release (dr/ec) PA PA; QL ( per 8 sulfazine oral TRANSDERM- SCOP TRANSDERMAL PATCH DAY trilyte with flavor packets oral recon soln ursodiol oral ursodiol oral ZENPEP ORAL CAPSULE,DELAY ED RELEASE(DR/EC) ULCER THERAPY carafate oral suspension famotidine (pf) intravenous Name famotidine (pf)-nacl (iso-os) intravenous piggyback famotidine intravenous famotidine oral suspension famotidine oral 0 mg, 0 mg lansoprazole oral,delayed release(dr/ec) misoprostol oral nizatidine oral nizatidine oral omeprazole oral,delayed release(dr/ec) pantoprazole oral,delayed release (dr/ec) PYLERA ORAL CAPSULE ranitidine hcl injection ranitidine hcl oral ranitidine hcl oral syrup : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part B vs. Part D only GC - Gap Coverage HI - 8

93 Name ranitidine hcl oral 10 mg, 00 mg sucralfate oral IMMUNOLOGY, VACCINES / BIOTECHNOLOGY BIOTECHNOLOGY DRUGS ACTIMMUNE ARANESP (IN POLYSORBATE) INJECTION 100 MCG/ML, 10 MCG/0.7 ML, 00 MCG/ML, 00 MCG/ML ARANESP (IN POLYSORBATE) INJECTION MCG/ML, 0 MCG/ML, 60 MCG/ML ARANESP (IN POLYSORBATE) INJECTION SYRINGE 10 MCG/0. ML, 100 MCG/0. ML, MCG/0. ML, 0 MCG/0. ML, 60 MCG/0. ML PA PA PA Name ARANESP (IN POLYSORBATE) INJECTION SYRINGE 10 MCG/0. ML, 00 MCG/0. ML, 00 MCG/0.6 ML, 00 MCG/ML ARCALYST AVONEX (WITH ALBUMIN) R KIT AVONEX R PEN INJECTOR KIT AVONEX R SYRINGE AVONEX R SYRINGE KIT BETASERON KIT EGRIFTA MG PA PA ST : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part B vs. Part D only GC - Gap Coverage HI - 8

94 Name Name EPOGEN INJECTION 10,000 UNIT/ML,,000 UNIT/ML, 0,000 UNIT/ ML, 0,000 UNIT/ML,,000 UNIT/ML,,000 UNIT/ML EXTAVIA KIT EXTAVIA GENOTROPIN MINIQUICK SYRINGE 0. MG/0. ML GENOTROPIN MINIQUICK SYRINGE 0. MG/0. ML, 0.6 MG/0. ML, 0.8 MG/0. ML, 1 MG/0. ML, 1. MG/0. ML, 1. MG/0. ML, 1.6 MG/0. ML, 1.8 MG/0. ML, MG/0. ML GENOTROPIN CARTRIDGE PA PA PA PA GRANIX SYRINGE HUMATROPE INJECTION CARTRIDGE 1 MG (6 UNIT), MG (7 UNIT) HUMATROPE INJECTION CARTRIDGE 6 MG (18 UNIT) HUMATROPE INJECTION ILARIS (PF) INTRON A INJECTION 10 MILLION UNIT (1 ML) INTRON A INJECTION 18 MILLION UNIT (1 ML), 0 MILLION UNIT (1 ML) INTRON A INJECTION LEUKINE INJECTION PA PA PA : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part B vs. Part D only GC - Gap Coverage HI - 8

95 Name Name MOZOBIL PA OMNITROPE PA NEULASTA SYRINGE NEULASTA SYRINGE, W/ WEARABLE INJECTOR NEUMEGA NEUPOGEN INJECTION NEUPOGEN INJECTION SYRINGE NORDITROPIN FLEXPRO PEN INJECTOR QL ( per 0 QL ( per 0 PA PEGASYS PROCLICK PEN INJECTOR PEGASYS PEGASYS SYRINGE PEGINTRON REDIPEN PEN INJECTOR KIT PEGINTRON KIT PLEGRIDY PEN INJECTOR PA; QL ( per 8 PA; QL ( per 8 PA; QL ( per 8 PA; QL ( per 8 PA; QL ( per 8 NUTROPIN AQ NUSPIN CARTRIDGE PA PLEGRIDY SYRINGE 1 MCG/0. ML NUTROPIN AQ CARTRIDGE OMNITROPE CARTRIDGE PA PA PROCRIT INJECTION 10,000 UNIT/ML,,000 UNIT/ML, 0,000 UNIT/ ML,,000 UNIT/ML,,000 UNIT/ML PA : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part B vs. Part D only GC - Gap Coverage HI - 8

96 Name PROCRIT INJECTION 0,000 UNIT/ML, 0,000 UNIT/ML PROLEUKIN REBIF (WITH ALBUMIN) SYRINGE REBIF REBIDOSE PEN INJECTOR REBIF TITRATION PACK SYRINGE SAIZEN CLICK.EASY CARTRIDGE SAIZEN SEROSTIM MG, MG, 6 MG SYLATRON KIT ZORBTIVE PA PA PA PA PA PA Name VACCINES / MISCELLANEOUS IMMUNOLOGICALS ACTHIB (PF) R ADACEL(TDAP ADOLESN/ADULT )(PF) R SUSPENSION ADACEL(TDAP ADOLESN/ADULT )(PF) R SYRINGE BCG VACCINE, LIVE (PF) PERCUTANEOUS SUSPENSION FOR RECONSTITUTIO N BEXSERO (PF) R SYRINGE BIVIGAM BOOSTRIX TDAP R SUSPENSION BOOSTRIX TDAP R SYRINGE B/D PA : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part B vs. Part D only GC - Gap Coverage HI - 86

97 Name Name CARIMUNE NF NANOFILTERED 1 GRAM, 6 GRAM CERVARIX VACCINE (PF) R SYRINGE COMVAX (PF) R SUSPENSION CYTOGAM 0 MG/ML DAPTACEL (DTAP PEDIATRIC) (PF) R SUSPENSION DYSPORT R ENGERIX-B (PF) R SUSPENSION ENGERIX-B (PF) R SYRINGE ENGERIX-B PEDIATRIC (PF) R SUSPENSION B/D PA PA B/D PA B/D PA B/D PA ENGERIX-B PEDIATRIC (PF) R SYRINGE FLEBOGAMMA DIF fomepizole intravenous GAMASTAN S/D R GAMMAGARD LIQUID INJECTION GAMMAGARD S- D (IGA < 1 MCG/ML) GAMMAPLEX GAMUNEX-C INJECTION GARDASIL (PF) R SUSPENSION GARDASIL (PF) R SYRINGE B/D PA B/D PA B/D PA B/D PA B/D PA B/D PA B/D PA : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part B vs. Part D only GC - Gap Coverage HI - 87

98 Name GARDASIL 9 (PF) R SUSPENSION GARDASIL 9 (PF) R SYRINGE GRASTEK SUBLINGUAL HAVRIX (PF) R SUSPENSION HAVRIX (PF) R SYRINGE HEPAGAM B INJECTION HIZENTRA HYPERHEP B S/D R HYPERHEP B S/D R SYRINGE HYPERHEP B S-D NEONATAL R SYRINGE HYPERRAB S/D (PF) R B/D PA Name HYPERTET S/D (PF) R SYRINGE HYQVIA IMOGAM RABIES- HT (PF) R IMOVAX RABIES VACCINE (PF) R INFANRIX (DTAP) (PF) R SUSPENSION INFANRIX (DTAP) (PF) R SYRINGE IPOL INJECTION SUSPENSION IPOL INJECTION SYRINGE IXIARO (PF) R SYRINGE KINRIX (PF) R SUSPENSION KINRIX (PF) R SYRINGE : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part B vs. Part D only GC - Gap Coverage HI - 88 B/D PA B/D PA

99 Name MENACTRA (PF) R MENOMUNE - A/C/Y/W-1 (PF) MENOMUNE - A/C/Y/W-1 MENVEO A-C-Y- W-1-DIP (PF) R KIT M-M-R II (PF) NABI-HB R OCTAGAM PEDIARIX (PF) R SYRINGE PEDVAX HIB (PF) R PENTACEL (PF) R KIT PRIVIGEN B/D PA B/D PA Name PROQUAD (PF) SUSPENSION FOR RECONSTITUTIO N QUADRACEL (PF) R SUSPENSION RABAVERT (PF) R SUSPENSION FOR RECONSTITUTIO N RAGWITEK SUBLINGUAL RECOMBIVAX HB (PF) R SUSPENSION RECOMBIVAX HB (PF) R SYRINGE RHOPHYLAC INJECTION SYRINGE ROTARIX ORAL SUSPENSION FOR RECONSTITUTIO N ROTATEQ VACCINE ORAL SUSPENSION : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part B vs. Part D only GC - Gap Coverage HI - 89 B/D PA B/D PA

100 Name Name TENIVAC (PF) R SUSPENSION TWINRIX (PF) R SYRINGE TENIVAC (PF) R SYRINGE TYPHIM VI R TETANUS,DIPHTH ERIA TOX PED(PF) R SUSPENSION TETANUS- DIPHTHERIA TOXOIDS-TD R SUSPENSION THERACYS INTRAVESICAL SUSPENSION FOR RECONSTITUTIO N THYMOGLOBULI N TICE BCG INTRAVESICAL SUSPENSION FOR RECONSTITUTIO N TRUMENBA R SYRINGE TWINRIX (PF) R SUSPENSION B/D PA TYPHIM VI R SYRINGE VAQTA (PF) R SUSPENSION VAQTA (PF) R SYRINGE VARIVAX (PF) SUSPENSION FOR RECONSTITUTIO N VARIZIG R VARIZIG R YF-VAX (PF) SUSPENSION FOR RECONSTITUTIO N ZOSTAVAX (PF) SUSPENSION FOR RECONSTITUTIO N : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part B vs. Part D only GC - Gap Coverage HI - 90

101 Name MUSCULOSKELETAL / RHEUMATOLOGY GOUT THERAPY allopurinol oral COLCHICINE ORAL CAPSULE COLCHICINE ORAL colchicineprobenecid oral COLCRYS ORAL KRYSTEXXA probenecid oral ULORIC ORAL QL (60 per 90 ST OSTEOPOROSIS THERAPY ACTONEL ORAL 10 MG ACTONEL ORAL MG ACTONEL ORAL MG alendronate oral alendronate oral 10 mg, mg QL (1 per QL ( per 8 QL ( per Name alendronate oral mg, 70 mg BONIVA SYRINGE FORTEO PEN INJECTOR FOSAMAX PLUS D ORAL ibandronate intravenous ibandronate intravenous syringe ibandronate oral PROLIA SYRINGE QL ( per 8 B/D PA PA QL ( per 8 QL (1 per 8 PA raloxifene oral ; QL (90 per 90 risedronate oral 10 mg risedronate oral mg, mg (1 pack) risedronate oral mg QL (1 per QL (1 per 8 QL (90 per 90 OTHER RHEUMATOLOGICALS : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part B vs. Part D only GC - Gap Coverage HI - 91

102 Name Name ACTEMRA 00 MG/0 ML (0 MG/ML), 80 MG/ ML (0 MG/ML) HUMIRA PSORIASIS STARTER PACK PEN INJECTOR KIT ACTEMRA SYRINGE HUMIRA SYRINGE KIT DEPEN TITRATABS ORAL KINERET SYRINGE PA; QL ( per ENBREL ENBREL SYRINGE ENBREL SURECLICK PEN INJECTOR HUMIRA CROHN'S DIS START PCK PEN INJECTOR KIT HUMIRA PEN PEN INJECTOR KIT leflunomide oral ORENCIA SYRINGE OTEZLA ORAL OTEZLA STARTER ORAL S,DOSE PACK RASUVO (PF) AUTO-INJECTOR RIDAURA ORAL CAPSULE SAVELLA ORAL SAVELLA ORAL S,DOSE PACK QL ( per PA PA PA : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part B vs. Part D only GC - Gap Coverage HI - 9

103 Name SIMPONI ARIA SIMPONI PEN INJECTOR SIMPONI SYRINGE XELJANZ ORAL PA PA PA PA OBSTETRICS / GYNECOLOGY ESTROGENS / PROGESTINS camila oral CRINONE VAGINAL GEL deblitane oral DEPO-ESTRADIOL R OIL DEPO-PROVERA R DEPO-SUBQ PROVERA 10 SYRINGE DIVIGEL TRANSDERMAL GEL IN PACKET 0. MG (0.1 %), 1 MG (0.1 %) errin oral Name ESTRACE VAGINAL CREAM estradiol valerate intramuscular oil 0 mg/ml ESTRING VAGINAL RING EVAMIST TRANSDERMAL SPRAY,NON- AEROSOL FEMRING VAGINAL RING heather oral jencycla oral lyza oral MAKENA R OIL medroxyprogesteron e intramuscular suspension medroxyprogesteron e intramuscular syringe medroxyprogesteron e oral MENEST ORAL 1. MG,. MG norethindrone (contraceptive) oral QL (1 per 90 QL (1 per 90 PA : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part B vs. Part D only GC - Gap Coverage HI - 9

104 Name norethindrone acetate oral norlyroc oral PREMARIN VAGINAL CREAM progesterone micronized oral sharobel oral VAGIFEM VAGINAL MISCELLANEOUS OB/GYN AVC VAGINAL VAGINAL CREAM CLEOCIN VAGINAL SUPPOSITORY clindamycin phosphate vaginal cream CLINDESSE VAGINAL CREAM,EXTENDE D RELEASE GYNAZOLE-1 VAGINAL CREAM metronidazole vaginal gel miconazole- vaginal suppository NUVARING VAGINAL RING QL (1 per 8 Name ORTHO EVRA TRANSDERMAL PATCH WEEKLY terconazole vaginal cream terconazole vaginal suppository tranexamic acid oral vandazole vaginal gel zazole vaginal cream 0. % ORAL CONTRACEPTIVES / RELATED AGENTS altavera (8) oral alyacen 1/ (8) oral alyacen 7/7/7 (8) oral amethia lo oral s,dose pack, month amethia oral s,dose pack, month amethyst oral apri oral aranelle (8) oral QL ( per 8 QL (0 per 1 QL (91 per 91 QL (91 per 91 : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part B vs. Part D only GC - Gap Coverage HI - 9

105 Name ashlyna oral s,dose pack, month aubra oral aviane oral azurette (8) oral balziva (8) oral briellyn oral camrese lo oral s,dose pack, month camrese oral s,dose pack, month caziant (8) oral chateal oral cryselle (8) oral cyclafem 1/ (8) oral cyclafem 7/7/7 (8) oral cyred oral dasetta 1/ (8) oral dasetta 7/7/7 (8) oral daysee oral s,dose pack, month QL (91 per 91 QL (91 per 91 QL (91 per 91 QL (91 per 91 Name delyla (8) oral desoge.estradiol/e.estradio l oral desogestrel-ethinyl estradiol oral drospirenone-ethinyl estradiol oral elinest oral ELLA ORAL emoquette oral enpresse oral enskyce oral estarylla oral falmina (8) oral gildagia oral gildess fe oral gildess fe oral gildess oral introvale oral s,dose pack, month jolessa oral s,dose pack, month junel 1./0 (1) oral : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part B vs. Part D only GC - Gap Coverage HI - 9 QL ( per QL (91 per 91 QL (91 per 91

106 Name junel 1/0 (1) oral junel fe 1./0 (8) oral junel fe 1/0 (8) oral junel fe oral kariva (8) oral kelnor 1/ (8) oral kimidess (8) oral kurvelo oral l norgest/e.estradiole.estrad oral s,dose pack, month larin 1./0 (1) oral larin 1/0 (1) oral larin fe oral larin fe oral layolis fe oral,chewable lessina oral levonest (8) oral levonorgestrel oral 1. mg QL (91 per 91 Name levonorgestrelethinyl estrad oral levonorgestrelethinyl estrad oral s,dose pack, month levora-8 oral loryna (8) oral low-ogestrel (8) oral lutera (8) oral marlissa oral microgestin 1./0 (1) oral microgestin 1/0 (1) oral microgestin fe 1./0 (8) oral microgestin fe 1/0 (8) oral mono-linyah oral myzilra oral necon 0./ (8) oral necon 1/ (8) oral necon 10/11 (8) oral : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part B vs. Part D only GC - Gap Coverage HI - 96 nikki (8) oral

107 Name noreth-ethinyl estradiol-iron oral,chewable 0.8mg-mcg() and 7 mg () norethindrone ac-eth estradiol oral 1-0 mg-mcg norethindronee.estradiol-iron oral norgestimate-ethinyl estradiol oral nortrel 0./ (8) oral nortrel 1/ (1) oral nortrel 1/ (8) oral nortrel 7/7/7 (8) oral ogestrel (8) oral orsythia oral philith oral pimtrea (8) oral pirmella oral portia oral previfem oral quasense oral s,dose pack, month QL (91 per 91 Name reclipsen (8) oral sprintec (8) oral sronyx oral syeda oral tarina fe oral tri-estarylla oral tri-legest fe oral tri-linyah oral tri-previfem (8) oral tri-sprintec (8) oral trivora (8) oral velivet triphasic regimen (8) oral vestura (8) oral viorele (8) oral wera (8) oral wymzya fe oral,chewable zarah oral zenchent (8) oral : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part B vs. Part D only GC - Gap Coverage HI - 97

108 Name zenchent fe oral,chewable zeosa oral,chewable zovia 1/e (8) oral zovia 1/0e (8) oral OXYTOCICS HEMABATE R METHYLERGONO VINE INJECTION methylergonovine oral OPHTHALMOLOGY ANTIBIOTICS ak-poly-bac ophthalmic ointment AZASITE OPHTHALMIC DROPS bacitracin ophthalmic ointment bacitracinpolymyxin b ophthalmic ointment BESIVANCE OPHTHALMIC DROPS,SUSPENSI ON Name CILOXAN OPHTHALMIC OINTMENT ciprofloxacin hcl ophthalmic drops erythromycin ophthalmic ointment garamycin ophthalmic drops gatifloxacin ophthalmic drops gentak ophthalmic ointment gentamicin ophthalmic drops gentamicin ophthalmic ointment levofloxacin ophthalmic drops MOXEZA OPHTHALMIC DROPS, VISCOUS NATACYN OPHTHALMIC DROPS,SUSPENSI ON neomycinbacitracinpolymyxin ophthalmic ointment neomycinpolymyxingramicidin ophthalmic drops : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part B vs. Part D only GC - Gap Coverage HI - 98

109 Name neo-polycin ophthalmic ointment ofloxacin ophthalmic drops polycin ophthalmic ointment polymyxin b sulftrimethoprim ophthalmic drops tobramycin ophthalmic drops VIGAMOX OPHTHALMIC DROPS ANTIVIRALS trifluridine ophthalmic drops ZIRGAN OPHTHALMIC GEL BETA-BLOCKERS betaxolol ophthalmic drops BETIMOL OPHTHALMIC DROPS 0. % BETOPTIC S OPHTHALMIC DROPS,SUSPENSI ON carteolol ophthalmic drops Name levobunolol ophthalmic drops 0. % metipranolol ophthalmic drops timolol maleate ophthalmic drops timolol maleate ophthalmic gel forming TIMOPTIC OCUDOSE (PF) OPHTHALMIC DROPPERETTE CHOLINESTERASE INHIBITOR MIOTICS PHOSPHOLINE IODIDE OPHTHALMIC DROPS CYCLOPLEGIC MYDRIATICS atropine ophthalmic drops cyclopentolate ophthalmic drops tropicamide ophthalmic drops DIRECT ACTING MIOTICS pilocarpine hcl ophthalmic drops 1 %, %, % MISCELLANEOUS OPHTHALMOLOGICS : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part B vs. Part D only GC - Gap Coverage HI - 99

110 Name Name AKTEN (PF) OPHTHALMIC GEL ALOCRIL OPHTHALMIC DROPS ALOMIDE OPHTHALMIC DROPS altacaine ophthalmic drops altafluor ophthalmic drops azelastine ophthalmic drops BEPREVE OPHTHALMIC DROPS cromolyn ophthalmic drops CYSTARAN OPHTHALMIC DROPS flurox ophthalmic drops LACRISERT OPHTHALMIC INSERT PATADAY PATANOL OPHTHALMIC DROPS PAZEO OPHTHALMIC DROPS proparacaine ophthalmic drops RESTASIS OPHTHALMIC DROPPERETTE tetracaine hcl ophthalmic drops TETRAVISC OPHTHALMIC DROPPERETTE,VI SCOUS EMADINE OPHTHALMIC DROPS TETRAVISC OPHTHALMIC DROPS, VISCOUS epinastine ophthalmic drops fluoresceinbenoxinate ophthalmic drops fluoresceinproparacaine ophthalmic drops NON-STEROIDAL ANTI- INFLAMMATORY AGENTS ACUVAIL (PF) OPHTHALMIC DROPPERETTE bromfenac ophthalmic drops : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part B vs. Part D only GC - Gap Coverage HI - 100

111 Name diclofenac sodium ophthalmic drops flurbiprofen sodium ophthalmic drops ILEVRO OPHTHALMIC DROPS,SUSPENSI ON ketorolac ophthalmic drops NEVANAC OPHTHALMIC DROPS,SUSPENSI ON ORAL DRUGS FOR GLAUCOMA acetazolamide oral, extended release acetazolamide oral acetazolamide sodium injection recon soln methazolamide oral OTHER GLAUCOMA DRUGS AZOPT OPHTHALMIC DROPS,SUSPENSI ON bimatoprost ophthalmic drops Name COMBIGAN OPHTHALMIC DROPS dorzolamide ophthalmic drops dorzolamide-timolol ophthalmic drops latanoprost ophthalmic drops LUMIGAN OPHTHALMIC DROPS 0.01 % SIMBRINZA OPHTHALMIC DROPS,SUSPENSI ON TRAVATAN Z OPHTHALMIC DROPS travoprost (benzalkonium) ophthalmic drops ZIOPTAN (PF) OPHTHALMIC DROPPERETTE STEROID-ANTIBIOTIC COMBINATIONS neomycinbacitracin-poly-hc ophthalmic ointment neomycin-polymyxin b-dexameth ophthalmic drops,suspension : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part B vs. Part D only GC - Gap Coverage HI - 101

112 Name neomycin-polymyxin b-dexameth ophthalmic ointment neomycinpolymyxin-hc ophthalmic drops,suspension neo-polycin hc ophthalmic ointment PRED-G OPHTHALMIC DROPS,SUSPENSI ON PRED-G S.O.P. OPHTHALMIC OINTMENT TOBRADEX OPHTHALMIC OINTMENT TOBRADEX ST OPHTHALMIC DROPS,SUSPENSI ON tobramycindexamethasone ophthalmic drops,suspension ZYLET OPHTHALMIC DROPS,SUSPENSI ON STEROIDS ALREX OPHTHALMIC DROPS,SUSPENSI ON Name dexamethasone sodium phosphate ophthalmic drops DUREZOL OPHTHALMIC DROPS FLAREX OPHTHALMIC DROPS,SUSPENSI ON fluorometholone ophthalmic drops,suspension FML FORTE OPHTHALMIC DROPS,SUSPENSI ON FML S.O.P. OPHTHALMIC OINTMENT LOTEMAX OPHTHALMIC DROPS,GEL LOTEMAX OPHTHALMIC DROPS,SUSPENSI ON LOTEMAX OPHTHALMIC OINTMENT MAXIDEX OPHTHALMIC DROPS,SUSPENSI ON : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part B vs. Part D only GC - Gap Coverage HI - 10

113 Name OZURDEX INTRAVITREAL IMPLANT PRED MILD OPHTHALMIC DROPS,SUSPENSI ON prednisolone acetate ophthalmic drops,suspension prednisolone sodium phosphate ophthalmic drops RETISERT INTRAVITREAL IMPLANT VEXOL OPHTHALMIC DROPS,SUSPENSI ON STEROID-SULFONAMIDE COMBINATIONS BLEPHAMIDE OPHTHALMIC DROPS,SUSPENSI ON BLEPHAMIDE S.O.P. OPHTHALMIC OINTMENT sulfacetamideprednisolone ophthalmic drops SULFONAMIDES Name bleph-10 ophthalmic drops sulfacetamide sodium ophthalmic drops sulfacetamide sodium ophthalmic ointment SYMPATHOMIMETICS ALPHAGAN P OPHTHALMIC DROPS 0.1 % apraclonidine ophthalmic drops brimonidine ophthalmic drops IOPIDINE OPHTHALMIC DROPPERETTE VASOCONSTRICTOR DECONGESTANTS naphazoline ophthalmic drops RESPIRATORY AND ALLERGY ANTIHISTAMINE / ANTIALLERGENIC AGENTS adrenalin injection AUVI-Q INJECTION AUTO- INJECTOR : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part B vs. Part D only GC - Gap Coverage HI - 10

114 Name cetirizine oral 1 mg/ml cyproheptadine oral syrup cyproheptadine oral desloratadine oral desloratadine oral,disintegrating diphenhydramine hcl injection 0 mg/ml diphenhydramine hcl injection syringe epinephrine injection autoinjector epinephrine injection syringe 0.1 mg/ml (1:10,000) EPIPEN -PAK INJECTION AUTO- INJECTOR EPIPEN JR -PAK INJECTION AUTO- INJECTOR levocetirizine oral levocetirizine oral PULMONARY AGENTS acetylcysteine PA PA QL ( per QL ( per PA PA QL (90 per 90 B/D PA Name ADCIRCA ORAL ADEMPAS ORAL ADVAIR DISKUS INHALATION BLISTER WITH DEVICE ADVAIR HFA INHALATION HFA AEROSOL INHALER albuterol sulfate inhalation for nebulization 0.6 mg/ ml, 1. mg/ ml,. mg / ml (0.08 %), mg/ml albuterol sulfate inhalation for nebulization. mg/0. ml albuterol sulfate oral syrup albuterol sulfate oral albuterol sulfate oral extended release 1 hr ALVESCO INHALATION HFA AEROSOL INHALER aminophylline intravenous : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part B vs. Part D only GC - Gap Coverage HI - 10 PA PA QL (180 per 90 QL (6 per 90 1 B/D PA; GC QL (7 per 90

115 Name Name ARCAPTA NEOHALER INHALATION CAPSULE, W/INHALATION DEVICE ARNUITY ELLIPTA INHALATION BLISTER WITH DEVICE ASMANEX HFA INHALATION HFA AEROSOL INHALER ASMANEX TWISTHALER INHALATION AEROSOL POWDR BREATH ACTIVATED ATROVENT HFA INHALATION HFA AEROSOL INHALER BECONASE AQ NASAL SPRAY,NON- AEROSOL BERINERT KIT BROVANA INHALATION FOR NEBULIZATION QL (90 per 90 QL ( per 90 B/D PA budesonide inhalation suspension for nebulization budesonide nasal spray,non-aerosol CINRYZE COMBIVENT RESPIMAT INHALATION MIST cromolyn inhalation for nebulization DALIRESP ORAL DULERA INHALATION HFA AEROSOL INHALER ELIXOPHYLLIN ORAL ELIXIR 80 MG/1 ML ESBRIET ORAL CAPSULE FIRAZYR SYRINGE FLOVENT DISKUS INHALATION BLISTER WITH DEVICE B/D PA PA 1 B/D PA; GC PA QL (9 per 90 PA QL (60 per 90 : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part B vs. Part D only GC - Gap Coverage HI - 10

116 Name Name FLOVENT HFA INHALATION HFA AEROSOL INHALER QL (7 per 90 levalbuterol hcl inhalation for nebulization 1. mg/ ml flunisolide nasal spray,non-aerosol mcg (0.0 %) fluticasone nasal spray,suspension FORADIL AEROLIZER INHALATION CAPSULE, W/INHALATION DEVICE QL (180 per 90 metaproterenol oral syrup metaproterenol oral montelukast oral granules in packet montelukast oral montelukast oral,chewable QL ( per QL ( per QL ( per ipratropium bromide inhalation ipratropiumalbuterol inhalation for nebulization KALYDECO ORAL GRANULES IN PACKET KALYDECO ORAL LETAIRIS ORAL levalbuterol hcl inhalation for nebulization 0.1 mg/ ml, 0.6 mg/ ml, 1. mg/0. ml 1 B/D PA; GC PA PA PA B/D PA NASONEX NASAL SPRAY,NON- AEROSOL OFEV ORAL CAPSULE OMNARIS NASAL SPRAY,NON- AEROSOL OPSUMIT ORAL PROAIR HFA INHALATION HFA AEROSOL INHALER PROAIR RESPICLICK INHALATION AEROSOL POWDR BREATH ACTIVATED PA ST PA QL (10 per 90 QL (1 per 90 : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part B vs. Part D only GC - Gap Coverage HI - 106

117 Name PULMICORT FLEXHALER INHALATION AEROSOL POWDR BREATH ACTIVATED PULMICORT INHALATION SUSPENSION FOR NEBULIZATION 1 MG/ ML PULMOZYME INHALATION QVAR INHALATION AEROSOL REVATIO ORAL SUSPENSION FOR RECONSTITUTIO N RUCONEST SEREVENT DISKUS INHALATION BLISTER WITH DEVICE sildenafil intravenous B/D PA B/D PA PA PA QL (180 per 90 PA sildenafil oral PA; QL (10 per Name SPIRIVA RESPIMAT INHALATION MIST SPIRIVA WITH HANDIHALER INHALATION CAPSULE, W/INHALATION DEVICE STRIVERDI RESPIMAT INHALATION MIST SYMBICORT INHALATION HFA AEROSOL INHALER MCG/ACTUATION SYMBICORT INHALATION HFA AEROSOL INHALER 80-. MCG/ACTUATION terbutaline oral terbutaline subcutaneous theochron oral extended release 1 hr theophylline oral elixir QL (0 per 0 QL (90 per 90 QL (1 per 0 QL (0.6 per 90 QL (9 per 90 : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part B vs. Part D only GC - Gap Coverage HI - 107

118 Name theophylline oral extended release theophylline oral extended release 1 hr TRACLEER ORAL TUDORZA PRESSAIR INHALATION AEROSOL POWDR BREATH ACTIVATED TYVASO INHALATION FOR NEBULIZATION TYVASO INSTITUTIONAL START KIT INHALATION FOR NEBULIZATION TYVASO REFILL KIT INHALATION FOR NEBULIZATION TYVASO STARTER KIT INHALATION FOR NEBULIZATION VENTAVIS INHALATION FOR NEBULIZATION PA; LA QL (1 per 0 PA PA PA PA PA Name VENTOLIN HFA INHALATION HFA AEROSOL INHALER VERAMYST NASAL SPRAY,SUSPENSI ON XOLAIR XOPENEX HFA INHALATION HFA AEROSOL INHALER zafirlukast oral ZYFLO CR ORAL, ER MULTIPHASE 1 HR ZYFLO ORAL UROLOGICALS : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part B vs. Part D only GC - Gap Coverage HI ANTICHOLINERGICS / ANTISPASMODICS QL (10 per 90 ST PA QL (90 per 90 ; QL (68 per flavoxate oral oxybutynin chloride oral syrup oxybutynin chloride oral QL (16 per QL (60 per 90

119 Name oxybutynin chloride oral extended release hr 10 mg, 1 mg oxybutynin chloride oral extended release hr mg tolterodine oral,extended release hr tolterodine oral TOVIAZ ORAL EXTENDED RELEASE HR trospium oral,extended release hr trospium oral VESICARE ORAL QL (180 per 90 QL (90 per 90 QL ( per BENIGN PROSTATIC HYPERPLASIA(BPH) THERAPY alfuzosin oral extended release hr AVODART ORAL CAPSULE finasteride oral mg tamsulosin oral,extended release hr QL (90 per 90 Name CHOLINERGIC STIMULANTS bethanechol chloride oral MISCELLANEOUS UROLOGICALS CYSTAGON ORAL CAPSULE cytra k crystals oral packet cytra-k oral ELMIRON ORAL CAPSULE K-PHOS NO ORAL K-PHOS ORIGINAL ORAL,SOLUBL E potassium citrate oral extended release potassium citratecitric acid oral packet potassium citratecitric acid oral PROCYSBI ORAL CAPSULE, DELAYED REL SPRINKLE RENACIDIN IRRIGATION PA : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part B vs. Part D only GC - Gap Coverage HI - 109

120 Name sodium citrate-citric acid oral UROCIT-K 1 ORAL EXTENDED RELEASE VITAMINS, HEMATINICS / ELECTROLYTES BLOOD DERIVATIVES albumin, human % intravenous parenteral albumin, human % intravenous parenteral albuminar % intravenous parenteral albuminar % intravenous parenteral alburx (human) % intravenous parenteral alburx (human) % intravenous parenteral albutein % intravenous parenteral albutein % intravenous parenteral Name buminate % intravenous parenteral buminate % intravenous parenteral plasbumin % intravenous parenteral plasbumin % intravenous parenteral ELECTROLYTES calcium acetate oral calcium acetate oral 667 mg calcium chloride intravenous calcium chloride intravenous syringe calcium gluconate intravenous dextrose-kcl-nacl intravenous effer-k oral, effervescent meq eliphos oral HYPERLYTE CR k-effervescent oral, effervescent : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part B vs. Part D only GC - Gap Coverage HI - 110

121 Name klor-con 10 oral extended release klor-con 8 oral extended release klor-con m10 oral,er particles/crystals klor-con m1 oral,er particles/crystals klor-con m0 oral,er particles/crystals 1 GC klor-con oral packet klor-con/ef oral, effervescent k-phos-neutral oral k-sol oral liquid k-tab oral extended release 8 meq lactated ringers intravenous parenteral magnesium sulfate in water intravenous parenteral magnesium sulfate in water intravenous piggyback Name magnesium sulfate injection syringe NEUT NORMOSOL-R PARENTERAL phospha 0 neutral oral potassium acetate intravenous meq/ml potassium bicarb and chloride oral, effervescent potassium bicarbcitric acid oral, effervescent potassium chloridd-0.%nacl intravenous parenteral potassium chloride in 0.9%nacl intravenous parenteral 0 meq/l, 0 meq/l potassium chloride in % dex intravenous parenteral 0 meq/l, 0 meq/l : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part B vs. Part D only GC - Gap Coverage HI - 111

122 Name Name potassium chloride in lr-d intravenous parenteral 0 meq/l potassium chloride intravenous piggyback 10 meq/100 ml, 0 meq/100 ml, 0 meq/100 ml HI potassium chlorided-0.%nacl intravenous parenteral 0 meq/l, 0 meq/l potassium chlorided-0.%nacl intravenous parenteral 0 meq/l potassium chloride intravenous piggyback 0 meq/100 ml potassium chlorided-0.9%nacl intravenous parenteral potassium chloride oral, extended release potassium phosphate dibasic intravenous potassium chloride oral liquid ringers intravenous parenteral potassium chloride oral packet sodium acetate intravenous potassium chloride oral extended release potassium chloride oral,er particles/crystals potassium chloride- 0. % nacl intravenous parenteral potassium chlorided-0.%nacl intravenous parenteral 0 meq/l sodium bicarbonate intravenous sodium bicarbonate intravenous syringe sodium chloride 0. % intravenous parenteral sodium chloride 0. % intravenous piggyback sodium chloride % intravenous parenteral HI : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part B vs. Part D only GC - Gap Coverage HI - 11

123 Name sodium chloride % intravenous parenteral sodium chloride intravenous parenteral sodium lactate intravenous sodium phosphate intravenous virt-phos 0 neutral oral MISCELLANEOUS NUTRITION PRODUCTS amino acids 1 % intravenous parenteral AMINOSYN 7 % WITH ELECTROLYTES PARENTERAL AMINOSYN II 1 % PARENTERAL AMINOSYN II 7 % PARENTERAL B/D PA B/D PA B/D PA B/D PA Name AMINOSYN-HBC 7% PARENTERAL AMINOSYN-PF 10 % PARENTERAL AMINOSYN-PF 7 % (SULFITE- FREE) PARENTERAL AMINOSYN-RF. % PARENTERAL BAL IN OIL R CALCIUM DISODIUM VERSENATE INJECTION CLINIMIX E.%/D10W SUL FREE PARENTERAL cysteine (l-cysteine) intravenous B/D PA B/D PA B/D PA B/D PA B/D PA : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part B vs. Part D only GC - Gap Coverage HI - 11

124 Name Name FREAMINE HBC 6.9 % PARENTERAL freamine iii 10 % intravenous parenteral B/D PA B/D PA liposyn iii intravenous emulsion 10 %, 0 % NEPHRAMINE. % PARENTERAL B/D PA B/D PA intralipid intravenous emulsion 0 % INTRALIPID EMULSION 0 % ISOLYTE S PH 7. PARENTERAL ISOLYTE-P IN % DEXTROSE PARENTERAL ISOLYTE-S PARENTERAL KABIVEN EMULSION LIPOSYN II EMULSION B/D PA B/D PA B/D PA B/D PA NORMOSOL-R PH 7. PARENTERAL NUTRILIPID EMULSION PERIKABIVEN EMULSION PLASMA-LYTE 18 PARENTERAL PLASMA-LYTE A PARENTERAL PLASMA-LYTE-6 IN % DEXTROSE PARENTERAL plasmanate intravenous parenteral B/D PA B/D PA : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part B vs. Part D only GC - Gap Coverage HI - 11

125 Name premasol 10 % intravenous parenteral PREMASOL 6 % PARENTERAL PROSOL 0 % PARENTERAL THAM travasol 10 % intravenous parenteral TROPHAMINE 10 % PARENTERAL B/D PA B/D PA B/D PA B/D PA B/D PA VITAMINS / HEMATINICS fluor-a-day (with xylitol) oral,chewable fluoritab oral,chewable ludent fluoride oral,chewable multi-vit with fluoride & iron oral drops multi-vitamin with fluoride oral drops Name multivitamin with fluoride oral,chewable multi-vitamin with fluoride oral,chewable 0. mg multivitamins with fluoride oral,chewable mvc-fluoride oral,chewable prenatal vitamin oral sodium fluoride oral drops sodium fluoride oral sodium fluoride oral,chewable triple vitamin with fluoride oral drops tri-vit with fluoride & iron oral drops tri-vitamin with fluoride oral drops vitamins a,c,d & fluoride oral drops : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part B vs. Part D only GC - Gap Coverage HI - 11

126 Index 8 8-MOP...6 A abacavir... abacavir-lamivudinezidovudine... ABELCET...1 ABILIFY...7 ABILIFY MAINTENA...7 ABRAXANE...17 ABSTRAL... acamprosate...6 acarbose...71 acebutolol... acetaminophen-codeine... acetasol hc...69 acetazolamide acetazolamide sodium acetic acid... 6, 69 acetic acid-aluminum acetate 69 acetylcysteine...6, 10 acitretin... ACTEMRA...9 ACTHAR H.P ACTHIB (PF)...86 ACTIMMUNE...8 ACTONEL... 6, 91 ACUVAIL (PF) acyclovir..., 61 acyclovir sodium... ADACEL(TDAP ADOLESN/ADULT)(PF) 86 ADAGEN...6 adapalene...7 ADASUVE...7 ADCIRCA...10 adefovir... ADEMPAS...10 adenosine... adrenalin...10 adrucil...17 ADVAIR DISKUS...10 ADVAIR HFA...10 afeditab cr... AFINITOR...17 AFINITOR DISPERZ...17 AGGRENOX...0 a-hydrocort...70 ak-poly-bac...98 AKTEN (PF) AKYNZEO...78 ALBENZA...9 albumin, human % albumin, human % albuminar % albuminar % alburx (human) % alburx (human) % albutein % albutein % albuterol sulfate...10 alclometasone...61 alcohol pads...71 ALDURAZYME...7 alendronate...6, 91 alfuzosin ALIMTA...17 ALINIA...9 allopurinol...91 almotriptan malate...0 ALOCRIL ALOMIDE alosetron...78 ALOXI...78 ALPHAGAN P...10 alprazolam...7 alprazolam intensol...7 ALREX...10 ALTABAX...60 altacaine altafluor altavera (8)...9 ALVESCO...10 alyacen 1/ (8)...9 alyacen 7/7/7 (8)...9 amantadine hcl... AMBISOME...1 amcinonide...61 amethia...9 amethia lo...9 amethyst...9 amifostine crystalline...16 amikacin...9 amiloride... amiloride-hydrochlorothiazide amino acids 1 %...11 aminocaproic acid...0 aminophylline...10 AMINOSYN 7 % WITH ELECTROLYTES...11 AMINOSYN II 1 %...11 AMINOSYN II 7 %...11 AMINOSYN-HBC 7%...11 AMINOSYN-PF 10 %...11 AMINOSYN-PF 7 % (SULFITE-FREE)...11 AMINOSYN-RF. %...11 amiodarone... AMITIZA...78 amitriptyline...7 amlodipine... amlodipine-atorvastatin... amlodipine-benazepril... amlodipine-valsartan... amlodipine-valsartan-hcthiazid... ammonium lactate...6 AMMONUL...6 amnesteem...7 amoxapine...7 amoxicillin...1 amoxicillin-pot clavulanate.1, 1 amphetamine salt combo 7, 8 amphotericin b...1 ampicillin...1 ampicillin sodium...1 ampicillin-sulbactam...1 AMPYRA...1 anagrelide...6 ANALPRAM-HC...78 anastrozole...17 ANDRODERM...7 ANDROGEL...7 ANDROID...7 androxy...7 ANZEMET...79 apexicon e...61 APIDRA...71 APIDRA SOLOSTAR...71 APOKYN...9 apraclonidine...10 apri...9

127 APRISO...79 APTIOM...6 APTIVUS... ARALAST NP...6 aranelle (8)...9 ARANESP (IN POLYSORBATE)...8 ARCALYST...8 ARCAPTA NEOHALER...10 ARGATROBAN...1 ARGATROBAN IN 0.9 % SOD CHLOR...1 aripiprazole...8 ARISTOSPAN INTRA- ARTICULAR...70 ARISTOSPAN INTRALESIONAL...70 ARNUITY ELLIPTA...10 ARRANON...17 ARZERRA...17 ASACOL HD...79 ashlyna...9 ASMANEX HFA...10 ASMANEX TWISTHALER...10 aspirin-dipyridamole...1 ASTAGRAF XL...17 atenolol... atenolol-chlorthalidone... atorvastatin... atovaquone...9 atovaquone-proguanil...9 ATRIPLA... atropine... 78, 99 ATROVENT HFA...10 AUBAGIO...1 aubra...9 AURYXIA...6 AUVI-Q...10 AVANDAMET...71 AVANDIA...71 AVASTIN...17 AVC VAGINAL...9 aviane...9 AVODART AVONEX...8 AVONEX (WITH ALBUMIN)...8 AXERT...0 azacitidine...17 AZACTAM IN DEXTROSE (ISO-OSM)...9 AZASAN...17 AZASITE...98 azathioprine...17 azelastine...68, 100 AZELEX...7 AZILECT...9 azithromycin...8 AZOPT AZOR... aztreonam...9 azurette (8)...9 B baciim...9 bacitracin...9, 98 bacitracin-polymyxin b...98 baclofen... BACTROBAN NASAL...68 BAL IN OIL...11 balsalazide...79 balziva (8)...9 BANZEL...6 BARACLUDE... BCG VACCINE, LIVE (PF) 86 BECONASE AQ...10 BELEODAQ...17 benazepril... benazepril-hydrochlorothiazide... BENICAR... BENICAR HCT... BENZACLIN PUMP...7 benztropine...9 BEPREVE BERINERT...10 BESIVANCE...98 betamethasone acet,sod phos70 betamethasone dipropionate.61 betamethasone valerate...61 betamethasone, augmented..61, 6 BETASERON...8 betaxolol..., 99 bethanechol chloride BETHKIS...9 BETIMOL...99 BETOPTIC S...99 bexarotene...17 BEXSERO (PF) bicalutamide...17 BICILLIN C-R...1 BICILLIN L-A...1 BICNU...18 BIDIL... BILTRICIDE...9 bimatoprost bisoprolol fumarate... bisoprolol-hydrochlorothiazide... BIVIGAM...86 bleomycin...18 bleph BLEPHAMIDE...10 BLEPHAMIDE S.O.P BLINCYTO...18 BONIVA...91 BOOSTRIX TDAP...86 BOSULIF...18 BREVIBLOC... briellyn...9 BRILINTA...1 brimonidine...10 BRINTELLIX...8 bromfenac bromocriptine...9 BROVANA...10 budesonide...79, 10 bumetanide..., 6 buminate % buminate % BUPHENYL...6 bupivacaine...8 bupivacaine (pf)...8 bupivacaine-dextrose-water(pf)...6 bupivacaine-epinephrine...8 bupivacaine-epinephrine (pf)8 BUPRENEX... buprenorphine hcl... buprenorphine-naloxone... buproban...68 bupropion hcl...8 buspirone...8 BUSULFEX...18 butalbital-acetaminophen... butorphanol tartrate... BYDUREON...7 BYETTA...7

128 C cabergoline...7 CAFCIT...6 caffeine citrated...6 calcipotriene... calcitonin (salmon)...7 calcitrene... calcitriol..., 7 calcium acetate calcium chloride CALCIUM DISODIUM VERSENATE...11 calcium gluconate camila...9 camrese...9 camrese lo...9 CANASA...79 CANCIDAS...1 candesartan...6 candesartan-hydrochlorothiazid...6 CAPASTAT...9 CAPEX...6 CAPRELSA...18 captopril...6 captopril-hydrochlorothiazide...6 CARAC...6 carafate...8 CARBAGLU...6 carbamazepine...6 carbatrol...6 carbidopa...9 carbidopa-levodopa...9 carbidopa-levodopaentacapone...9 CARBOCAINE...8 carbocaine (pf)...8 CARBOCAINE (PF)...8 carboplatin...18 CARDIZEM LA...6 CARDURA XL...6 CARIMUNE NF NANOFILTERED...87 carteolol...99 cartia xt...6 carvedilol...6 caziant (8)...9 CEDAX... cefaclor..., 6 cefadroxil...6 cefazolin...6 cefazolin in dextrose (iso-os).6 cefdinir...6 cefepime...6 CEFEPIME IN DEXTROSE %...6 cefepime in dextrose,iso-osm.6 cefixime...6 cefotaxime...6 cefotetan...6 CEFOTETAN IN DEXTROSE, ISO-OSM...6 cefoxitin...6 cefoxitin in dextrose, iso-osm 6 cefpodoxime...6 cefprozil...7 ceftazidime...7 CEFTAZIDIME IN DW...7 ceftibuten...7 ceftriaxone...7 ceftriaxone in dextrose,iso-os.7 cefuroxime axetil...7 cefuroxime sodium...7 CELEBREX...6 celecoxib...6 CELESTONE SOLUSPAN.70 CELLCEPT...18 CELLCEPT...18 CELONTIN...6 CENTANY...60 cephalexin...7 CEPROTIN (BLUE BAR)...1 CEPROTIN (GREEN BAR) 1 CERDELGA...7 CEREBYX...6 CEREZYME...7 CERVARIX VACCINE (PF)...87 cetirizine...10 cevimeline...6 CHANTIX...68 CHANTIX CONTINUING MONTH BOX...68 CHANTIX STARTING MONTH BOX...68 chateal...9 CHEMET chloramphenicol sod succinate...9 chlorhexidine gluconate...68 chloroquine phosphate...9 chlorothiazide...6 chlorothiazide sodium...6 chlorpromazine...8 chlorthalidone...6 cholestyramine (with sugar), cholestyramine light... chorionic gonadotropin, human...7 ciclodan...60 ciclopirox...60 cidofovir... cilostazol...1 CILOXAN...98 CIMZIA...79 CIMZIA POWDER FOR RECONST...79 CIMZIA STARTER KIT...79 CINRYZE...10 CIPRO HC...69 CIPRODEX...69 ciprofloxacin...1 ciprofloxacin (mixture)...1 ciprofloxacin hcl...1, 69, 98 ciprofloxacin in % dextrose...1 ciprofloxacin lactate...1 cisplatin...18 citalopram...8 cladribine...18 CLAFORAN...7 claravis...7 clarithromycin...8 CLEOCIN...9 clindacin etz...7 clindacin p...7 clindamycin hcl...9 clindamycin in % dextrose..9 clindamycin palmitate hcl...9 clindamycin pediatric...9 clindamycin phosphate...9, 10, 7, 9 clindamycin-benzoyl peroxide...7 CLINDESSE...9

129 CLINIMIX E.%/D10W SUL FREE...11 CLINPRO clobetasol...6 clobetasol-emollient...6 clodan...6 CLOLAR...18 clomipramine...8 clonazepam...6 clonidine...6 clonidine (pf)...6, 6 clonidine hcl...8, 6 clopidogrel...1 clorazepate dipotassium...8 clotrimazole...1, 60 clotrimazole-betamethasone.60 clozapine...8 CLOZAPINE...8 COARTEM...10 codeine sulfate... COLCHICINE...91 colchicine-probenecid...91 COLCRYS...91 colestipol... colistin (colistimethate na)...10 colocort...79 COLY-MYCIN S...69 COMBIGAN COMBIVENT RESPIMAT10 COMETRIQ...18 COMPLERA... compro...79 COMVAX (PF)...87 CONDYLOX...6 constulose...79 COPAXONE...1 COREG CR...6 CORLANOR... CORLOPAM...6 cormax...6 CORTIFOAM...79 cortisone...70 CORTISPORIN-TC...69 COSENTYX... COSENTYX ( SYRINGES)... COSENTYX PEN... COSENTYX PEN ( PENS) CREON...79 CRESTOR... CRINONE...9 CRIXIVAN... cromolyn...79, 100, 10 cryselle (8)...9 CUBICIN...10 CUTIVATE...6 cyclafem 1/ (8)...9 cyclafem 7/7/7 (8)...9 cyclobenzaprine... cyclopentolate...99 cyclophosphamide...18 CYCLOPHOSPHAMIDE...18 CYCLOSERINE...10 CYCLOSET...7 cyclosporine...18 cyclosporine modified...18 CYMBALTA...8 cyproheptadine...10 CYRAMZA...18 cyred...9 CYSTADANE...79 CYSTAGON CYSTARAN cysteine (l-cysteine)...11 cytarabine...18 cytarabine (pf)...18 CYTOGAM...87 cytra k crystals cytra-k D d10 % & 0. % sodium chloride...6 d. %-0. % sodium chloride...6 d %-0. % sodium chloride...6 dacarbazine...18 DALIRESP...10 DALVANCE...10 danazol...7 DANTRIUM... dantrolene... DAPSONE...10 DAPTACEL (DTAP PEDIATRIC) (PF)...87 DARAPRIM...10 dasetta 1/ (8)...9 dasetta 7/7/7 (8)...9 daunorubicin...18 DAUNOXOME daysee...9 deblitane...9 decitabine...18 deferoxamine...6 deltasone...70 delyla (8)...9 DELZICOL...79 demeclocycline...1 DEMSER...6 DENAVIR...61 denta 000 plus...68 dentagel...68 DEPEN TITRATABS...9 DEPOCYT (PF)...19 DEPO-ESTRADIOL...9 DEPO-MEDROL...70 DEPO-PROVERA...9 DEPO-SUBQ PROVERA DESFERAL...6 desipramine...8 desloratadine...10 desmopressin...7 desog-e.estradiol/e.estradiol.9 desogestrel-ethinyl estradiol.9 desonide...6 desoximetasone...6 dexamethasone...70 dexamethasone intensol...70 dexamethasone sodium phos (pf)...70 dexamethasone sodium phosphate...70, 10 dexedrine...8 dexmethylphenidate...8 DEXPAK 10 DAY...70 DEXPAK 1 DAY...70 DEXPAK 6 DAY...70 dexrazoxane hcl...16 dextroamphetamine...9 dextroamphetamineamphetamine...9 dextrose 10 % in water (d10w)...6 dextrose 0 % in water (d0w)...6 dextrose % in water (dw)...6 dextrose 0 % in water (d0w)...6

130 dextrose 0 % in water (d0w)...6 dextrose % in ringers...6 dextrose % in water (dw) 66 dextrose %-lactated ringers66 dextrose %-0. % sod chloride...66 dextrose %-0. % sod.chloride...66 dextrose 0 % in water (d0w)...66 dextrose 70 % in water (d70w)...66 dextrose with sodium chloride...66 dextrose-kcl-nacl diazepam... 6, 9 diazepam intensol...9 diclofenac potassium...6 diclofenac sodium..6, 6, 101 diclofenac-misoprostol...6 dicloxacillin...1 dicyclomine...78 didanosine... DIFFERIN...7 DIFICID...8 diflorasone...6 diflunisal...6 digitek...0 digox...0 digoxin...0 dihydroergotamine...0 DILANTIN 0 MG...6 diltiazem hcl...6, 7 dilt-xr...7 dimenhydrinate...79 DIOVAN...7 DIPENTUM...79 diphenhydramine hcl...10 diphenoxylate-atropine...78 diskets... disopyramide phosphate... disulfiram...66 divalproex...6 DIVIGEL...9 dobutamine... DOCEFREZ...19 docetaxel...19 donepezil...1 dopamine... dorzolamide dorzolamide-timolol doxazosin...7 doxepin...9 doxercalciferol...7, 76 doxorubicin...19 doxorubicin, peg-liposomal..19 doxy doxycycline hyclate...1 doxycycline monohydrate...1 dronabinol...79 droperidol...79 drospirenone-ethinyl estradiol...9 DROXIA...19 DULERA...10 duloxetine...9 DUOPA...9 duramorph (pf)... DUREZOL...10 DYSPORT...87 E e.e.s econazole...60 EDARBYCLOR...7 EDECRIN...7 EDURANT... effer-k EFFIENT...1 EGRIFTA...8 ELAPRASE...76 ELELYSO...76 ELIDEL...6 elinest...9 eliphos ELIQUIS...1 ELITEK...16 ELIXOPHYLLIN...10 ELLA...9 ELLENCE...19 ELMIRON EMADINE EMCYT...19 EMEND...79, 80 emoquette...9 EMSAM...9 EMTRIVA... enalapril maleate...7 enalaprilat enalapril-hydrochlorothiazide...7 ENBREL...9 ENBREL SURECLICK...9 endocet... ENGERIX-B (PF)...87 ENGERIX-B PEDIATRIC (PF)...87 enlon... ENLON-PLUS... enoxaparin...1 enpresse...9 enskyce...9 entacapone...9 entecavir... enulose...80 EPIFOAM... epinastine epinephrine...10 EPIPEN -PAK...10 EPIPEN JR -PAK...10 epirubicin...19 epitol...6 EPIVIR... EPIVIR HBV... eplerenone...7 EPOGEN...8 epoprostenol (glycine)...7 eprosartan...7 EPZICOM... ERAXIS(WATER DILUENT)...1 ERBITUX...19 ergoloid...9 ERGOMAR...0 ERIVEDGE...19 errin...9 ERTACZO...60 ERWINAZE...19 ery pads...7 erygel...7 ery-tab...8 ERY-TAB...8 ERYTHROCIN...8 erythrocin (as stearate)...8 erythromycin...8, 98 erythromycin ethylsuccinate...8 erythromycin with ethanol...7 erythromycin-benzoyl peroxide...7

131 ESBRIET...10 escitalopram oxalate...9 esmolol...7 estarylla...9 ESTRACE...9 estradiol valerate...9 ESTRING...9 ethambutol...10 ethosuximide...6 etidronate disodium...66 etodolac...6 ETOPOPHOS...19 etoposide...19 EURAX...6 EVAMIST...9 EVOTAZ... EVZIO...6 EXELDERM...60 EXELON...1 exemestane...19 EXFORGE...7 EXFORGE HCT...7 EXJADE...66 EXTAVIA...8 F FABRAZYME...76 falmina (8)...9 famciclovir... famotidine...8 famotidine (pf)...8 famotidine (pf)-nacl (iso-os)8 FANAPT...9 FARESTON...19 FARYDAK...19 FASLODEX...19 FAZACLO...9 felbamate...6 felodipine...7 FEMRING...9 fenofibrate... fenofibrate micronized... fenofibrate nanocrystallized. fenofibric acid... fenofibric acid (choline)... fenoprofen...6 fentanyl... fentanyl citrate... fentanyl citrate (pf)... FENTORA... FETZIMA...9 FINACEA...7 finasteride FIRAZYR...10 FLAREX...10 flavoxate FLEBOGAMMA DIF...87 flecainide... FLOLAN...7 FLOVENT DISKUS...10 FLOVENT HFA floxuridine...19 fluconazole...1 fluconazole in dextrose(iso-o) 1 fluconazole in nacl (iso-osm).1 flucytosine...1 fludarabine...19 fludrocortisone...70 flunisolide fluocinolone...6 fluocinolone acetonide oil...69 fluocinolone-shower cap...6 fluocinonide...6, 6 fluocinonide-e...6 fluor-a-day (with xylitol)...11 fluorescein-benoxinate fluorescein-proparacaine fluoritab...11 fluorometholone...10 fluorouracil...0, 6 FLUOROURACIL...6 fluoxetine...9 fluphenazine decanoate...0 fluphenazine hcl...0 flurbiprofen...6 flurbiprofen sodium flurox flutamide...0 fluticasone...6, 106 fluvastatin... fluvoxamine...0 FML FORTE...10 FML S.O.P fomepizole...87 fondaparinux...1 FORADIL AEROLIZER FORTAZ...7 FORTAZ IN DEXTROSE %...7 FORTEO...91 fortical FOSAMAX PLUS D...91 foscarnet... fosinopril...7 fosinopril-hydrochlorothiazide...7 fosphenytoin...6 FOSRENOL...66 FRAGMIN...1, FREAMINE HBC 6.9 %...11 freamine iii 10 %...11 FROVA...0 FULYZAQ...78 furosemide...7 FUSILEV...16 FUZEON... FYCOMPA...6 G gabapentin...6, 7 GABITRIL...7 galantamine...1 GAMASTAN S/D...87 GAMMAGARD LIQUID...87 GAMMAGARD S-D (IGA < 1 MCG/ML)...87 GAMMAPLEX...87 GAMUNEX-C...87 ganciclovir sodium... garamycin...98 GARDASIL (PF)...87 GARDASIL 9 (PF)...88 gatifloxacin...98 GATTEX 0-VIAL...80 GATTEX ONE-VIAL...80 gauze pads...7 gavilyte-c...80 gavilyte-g...80 gavilyte-h and bisacodyl...80 gavilyte-n...80 GAZYVA...0 gemcitabine...0 gemfibrozil... generlac...80 gengraf...0 GENOTROPIN...8 GENOTROPIN MINIQUICK...8 gentak...98 gentamicin...10, 60, 98 gentamicin in nacl (iso-osm) 10

132 GENTAMICIN IN NACL (ISO-OSM)...10 gentamicin sulfate (ped) (pf) 10 gentamicin sulfate (pf)...10 GENTAMICIN SULFATE (PF)...10 GEODON...0 gildagia...9 gildess...9 gildess fe...9 gildess fe...9 GILENYA...1 GILOTRIF...0 glatopa...1 GLEEVEC...0 glimepiride...7 glipizide...7 glipizide-metformin...7 GLUCAGEN HYPOKIT...7 GLUCAGON EMERGENCY KIT (HUMAN)...7 GLUMETZA...7 glycopyrrolate...78 glydo...8 GLYSET...7 GOLYTELY...80 granisetron (pf)...80 granisetron hcl...80 GRANIX...8 GRASTEK...88 griseofulvin microsize...1 griseofulvin ultramicrosize...1 guanfacine...0 guanidine...0 GYNAZOLE H HALAVEN...0 halobetasol propionate...6 HALOG...6 haloperidol...0 haloperidol decanoate...0 haloperidol lactate...0 HARVONI... HAVRIX (PF)...88 heather...9 HECTOROL...76 HEMABATE...98 HEPAGAM B...88 heparin (porcine)... heparin (porcine) in % dex HEPARIN (PORCINE) IN % DEX... HEPARIN(PORCINE) IN 0.% NACL... heparin, porcine (pf)... HERCEPTIN...0 HETLIOZ...0 HEXALEN...0 HIZENTRA...88 HUMALOG...7 HUMALOG KWIKPEN...7 HUMALOG MIX HUMALOG MIX 0-0 KWIKPEN...7 HUMALOG MIX HUMALOG MIX 7- KWIKPEN...7 HUMATROPE...8 HUMIRA...9 HUMIRA CROHN'S DIS START PCK...9 HUMIRA PEN...9 HUMIRA PSORIASIS STARTER PACK...9 HUMULIN 70/0...7 HUMULIN 70/0 KWIKPEN...7 HUMULIN N...7 HUMULIN N KWIKPEN...7 HUMULIN R...7 HUMULIN R U hydralazine...7 hydrochlorothiazide...7 hydrocodone-acetaminophen hydrocodone-ibuprofen... hydrocortisone...6, 70, 80 hydrocortisone butyrate...6 hydrocortisone butyr-emollient...6 hydrocortisone valerate...6 hydrocortisone-acetic acid...69 hydrocortisone-min oil-wht pet...6 hydromorphone... HYDROMORPHONE... hydromorphone (pf)... hydroxychloroquine...10 hydroxyurea...0 HYPERHEP B S/D HYPERHEP B S-D NEONATAL...88 HYPERLYTE CR HYPERRAB S/D (PF)...88 HYPERTET S/D (PF)...88 HYQVIA...88 I ibandronate...91 IBRANCE...0 ibuprofen...6 ibuprofen-oxycodone... ibutilide fumarate... ICLUSIG...0 idarubicin...0 ifosfamide...0 ifosfamide-mesna...0 ILARIS (PF)...8 ILEVRO IMBRUVICA...0 imipenem-cilastatin...10 imipramine hcl...0 imipramine pamoate...0 imiquimod...6 IMOGAM RABIES-HT (PF)...88 IMOVAX RABIES VACCINE (PF)...88 INCRELEX...66 indapamide...7 INFANRIX (DTAP) (PF)...88 INFUMORPH P/F... INLYTA...0 INNOPRAN XL...8 insulin pen needle...7 insulin syringe (disp) u ml...7 insulin syringe (disp) u ml...7 insulin syringe (disp) u-100 1/ ml...7 INTELENCE... intralipid...11 INTRALIPID...11 INTRON A...8 introvale...9 INTUNIV ER...0 INVANZ...10 INVEGA...0 INVEGA SUSTENNA...0 INVEGA TRINZA...0

133 INVIRASE... INVOKAMET...7 INVOKANA...7 IOPIDINE...10 IPOL...88 ipratropium bromide...68, 106 ipratropium-albuterol irbesartan...8 irbesartan-hydrochlorothiazide...8 IRESSA...0 irinotecan...0 ISENTRESS... ISOLYTE S PH ISOLYTE-P IN % DEXTROSE...11 ISOLYTE-S...11 isoniazid... 10, 11 isosorbide dinitrate... isosorbide mononitrate..., isradipine...8 ISUPREL... itraconazole...1 ivermectin...11 IXEMPRA...0 IXIARO (PF)...88 J JADENU...66 JAKAFI...0 jantoven... JANUMET...7 JANUMET XR...7 JANUVIA...7 jencycla...9 JEVTANA...0 jolessa...9 junel 1./0 (1)...9 junel 1/0 (1)...96 junel fe 1./0 (8)...96 junel fe 1/0 (8)...96 junel fe...96 JUXTAPID... K KABIVEN...11 KADCYLA...0 KADIAN... KALETRA... KALYDECO kariva (8)...96 k-effervescent kelnor 1/ (8)...96 KEPIVANCE...16 KETEK...11 ketoconazole...1, 60 ketoprofen...6 ketorolac KEYTRUDA...0, 1 KHEDEZLA...0 kimidess (8)...96 KINERET...9 KINRIX (PF)...88 kionex...66 klor-con klor-con klor-con klor-con m klor-con m klor-con m klor-con/ef KOMBIGLYZE XR...7 KORLYM...76 K-PHOS NO K-PHOS ORIGINAL k-phos-neutral KRYSTEXXA...91 k-sol k-tab kurvelo...96 KUVAN...76 KYNAMRO... L l norgest/e.estradiol-e.estrad.96 labetalol...8 LACRISERT lactated ringers...6, 111 lactulose...80 LAMICTAL ODT...7 LAMICTAL ODT STARTER (BLUE)...7 LAMICTAL ODT STARTER (GREEN)...7 LAMICTAL ODT STARTER (ORANGE)...7 LAMICTAL STARTER (BLUE) KIT...7 LAMICTAL STARTER (GREEN) KIT...7 LAMICTAL STARTER (ORANGE) KIT...7 lamivudine... 1 lamivudine-zidovudine... lamotrigine...7 LANOXIN PEDIATRIC...0 lansoprazole...8 LANTUS...7 LANTUS SOLOSTAR...7 larin 1./0 (1)...96 larin 1/0 (1)...96 larin fe...96 larin fe...96 latanoprost LATUDA...0 layolis fe...96 LAZANDA... leflunomide...9 LEMTRADA...1 LENVIMA...1 LESCOL XL... lessina...96 LETAIRIS letrozole...1 leucovorin calcium...16 LEUKERAN...1 LEUKINE...8 leuprolide...1 levalbuterol hcl LEVEMIR...7 LEVEMIR FLEXTOUCH...7 levetiracetam...7, 8 LEVETIRACETAM IN NACL (ISO-OS)...7 levobunolol...99 levocarnitine...66 levocarnitine (with sugar)...66 levocetirizine...10 levofloxacin...1, 98 levofloxacin in dw...1 LEVOLEUCOVORIN CALCIUM...17 levonest (8)...96 levonorgestrel...96 levonorgestrel-ethinyl estrad 96 LEVOPHED (BITARTRATE)... levora levorphanol tartrate... levothyroxine...78 levoxyl...78 LEXIVA... LIALDA...80

134 lidocaine...9 lidocaine (pf) in d7.w... lidocaine (pf)..., 8 lidocaine hcl...8 lidocaine viscous...9 lidocaine-epinephrine...9 lidocaine-epinephrine (pf)...9 LIDOCAINE-EPINEPHRINE BIT...9 lidocaine-prilocaine...9 lindane...6 linezolid...11 linezolid-0.9% sodium chloride...11 LINZESS...80 LIORESAL... liothyronine...78 lipodox...1 lipodox LIPOFEN... LIPOSYN II...11 liposyn iii...11 lisinopril...8 lisinopril-hydrochlorothiazide...8 lithium carbonate...1 lithium citrate...1 LODOSYN...9 lokara...6 LOMUSTINE...1 loperamide...78 lorazepam...1 lorazepam intensol...1 lorcet (hydrocodone)... lorcet hd... lorcet plus... lortab lortab -... lortab loryna (8)...96 losartan...8 losartan-hydrochlorothiazide8 LOTEMAX...10 LOTRONEX...80 lovastatin... LOVAZA... low-ogestrel (8)...96 loxapine succinate...1 lta pre-attached...9 ludent fluoride...11 LUMIGAN LUPRON DEPOT...1 LUPRON DEPOT ( MONTH)...1 LUPRON DEPOT ( MONTH)...1 LUPRON DEPOT (6 MONTH)...1 LUPRON DEPOT-PED...1 LUPRON DEPOT-PED ( MONTH)...1 lutera (8)...96 LYNPARZA...1 LYRICA...8 LYSODREN...1 lyza...9 M magnesium sulfate magnesium sulfate in water 111 MAKENA...9 malathion...6 maprotiline...1 marcaine (pf)...9 MARCAINE SPINAL (PF)..66 marlissa...96 MARPLAN...1 marten-tab... MATULANE...1 matzim la...8 MAXIDEX...10 MAXIPIME...7 meclizine...80 meclofenamate...6 medroxyprogesterone...9 mefenamic acid...6 mefloquine...11 MEFOXIN IN DEXTROSE (ISO-OSM)...7 MEGACE ES...1 megestrol...1 MEKINIST...1 meloxicam...6 melphalan hcl...1 memantine...1 MENACTRA (PF)...89 MENEST...9 MENOMUNE - A/C/Y/W MENOMUNE - A/C/Y/W-1 (PF) MENTAX...60 MENVEO A-C-Y-W-1-DIP (PF)...89 meperitab... MEPIVACAINE (PF)...9 mercaptopurine...1 meropenem...11 mesalamine...80 mesalamine with cleansing wipe...80 mesna...17 MESNEX...17 MESTINON... MESTINON TIMESPAN... metadate er...1 metaproterenol metformin...7 methadone... methadone intensol... methadose... methamphetamine...1 methazolamide methenamine hippurate...16 methenamine mandelate...16 methimazole...71 METHITEST...76 methocarbamol... methotrexate sodium... methotrexate sodium (pf)... METHOXSALEN RAPID...6 methscopolamine...78 methyclothiazide...8 methyldopahydrochlorothiazide...8 methyldopate...8 methylergonovine...98 METHYLERGONOVINE...98 METHYLIN...1 methylphenidate...1, methylprednisolone...70 methylprednisolone acetate..70 methylprednisolone sodium succ...71 metipranolol...99 metoclopramide hcl...80 metolazone...8 metoprolol succinate...8 metoprolol ta-hydrochlorothiaz...8 metoprolol tartrate...8

135 metro i.v metronidazole...11, 7, 9 metronidazole in nacl (iso-os)...11 mexiletine... MIACALCIN...76 miconazole-...9 microgestin 1./0 (1)...96 microgestin 1/0 (1)...96 microgestin fe 1./0 (8)...96 microgestin fe 1/0 (8)...96 midodrine...67 migergot...0 MIGRANAL...0 minocycline...1 minoxidil...8 mirtazapine... misoprostol...8 mitomycin... mitoxantrone... M-M-R II (PF)...89 modafinil... moderiba... moderiba dose pack... moexipril...8 moexipril-hydrochlorothiazide...8 mometasone...6 mono-linyah...96 montelukast morgidox...1 morphine..., MORPHINE... morphine (pf)... morphine concentrate... MOVANTIK...80 MOVIPREP...81 MOXEZA...98 moxifloxacin...1 MOZOBIL...8 MULTAQ... multi-vit with fluoride & iron...11 multivitamin with fluoride.11 multi-vitamin with fluoride 11 multi-vitamin with fluoride 11 multivitamins with fluoride 11 mupirocin...60 mupirocin calcium...60 MUSTARGEN... mvc-fluoride...11 MYALEPT...76 mycophenolate mofetil... mycophenolate sodium... MYOZYME...76 myzilra...96 N NABI-HB...89 nabumetone...6 nadolol...8 nadolol-bendroflumethiazide8 nafcillin...1 nafcillin in dextrose iso-osm 1 NAFTIN...60 NAGLAZYME...76 nalbuphine...6 naloxone...6 naltrexone...6 NAMENDA...1 NAMENDA TITRATION PAK...1 NAMENDA XR...1 naphazoline...10 naproxen...6 naproxen sodium...6 naratriptan...0 NAROPIN (PF)...9 NASONEX NATACYN...98 nateglinide...7 NEBUPENT...11 necon 0./ (8)...96 necon 1/ (8)...96 necon 10/11 (8)...96 needles, insulin disp.,safety..7 nefazodone... neomycin...11 neomycin-bacitracin-poly-hc neomycin-bacitracinpolymyxin...98 neomycin-polymyxin b gu...6 neomycin-polymyxin b- dexameth...101, 10 neomycin-polymyxingramicidin...98 neomycin-polymyxin-hc...69, 10 neo-polycin...99 neo-polycin hc NEPHRAMINE. %...11 NESACAINE...9 neuac...8 NEULASTA...8 NEUMEGA...8 NEUPOGEN...8 NEUPRO...9 NEUT NEVANAC nevirapine... NEXAVAR... niacin... NIASPAN EXTENDED- RELEASE... nicardipine...8 NICARDIPINE...8 NICOTROL...68 NICOTROL NS...68 nifedical xl...8 nifedipine...8, 9 nikki (8)...96 NILANDRON... nimodipine...9 NIPENT... nisoldipine...9 nitro-bid... nitrofurantoin...16 nitrofurantoin macrocrystal..16 nitrofurantoin monohyd/mcryst...16 nitroglycerin... NITROMIST... NITROSTAT... nizatidine...8 NORDITROPIN FLEXPRO 8 norepinephrine bitartrate... noreth-ethinyl estradiol-iron.97 norethindrone (contraceptive)...9 norethindrone acetate...9 norethindrone ac-eth estradiol...97 norethindrone-e.estradiol-iron...97 norgestimate-ethinyl estradiol...97 norlyroc...9 NORMOSOL-R NORMOSOL-R PH NORPACE CR...

136 NORTHERA...67 nortrel 0./ (8)...97 nortrel 1/ (1)...97 nortrel 1/ (8)...97 nortrel 7/7/7 (8)...97 nortriptyline... NORVIR... novarel...76 NOVOFINE NOVOFINE...7 NOVOFINE PLUS...7 NOVOLIN 70/0...7 NOVOLIN N...7 NOVOLIN R...7 NOVOLOG...7 NOVOLOG FLEXPEN...7 NOVOLOG MIX NOVOLOG MIX 70-0 FLEXPEN...7 NOVOLOG PENFILL...7 NOVOTWIST...7 NOXAFIL...1 np thyroid...78 NPLATE... NUCYNTA...7 NUEDEXTA...1 NULOJIX... NUTRILIPID...11 NUTROPIN AQ...8 NUTROPIN AQ NUSPIN...8 NUVARING...9 NUVIGIL... nyamyc...61 NYMALIZE...9 nystatin... 1, 61 nystatin-triamcinolone...61 nystop...61 O OCTAGAM...89 octreotide acetate... OFEV ofloxacin... 1, 69, 99 ogestrel (8)...97 olanzapine... olanzapine-fluoxetine... olopatadine...68 OLYSIO... omega- acid ethyl esters... omeprazole...8 OMNARIS OMNITROPE...8 ONCASPAR... ondansetron...81 ondansetron hcl...81 ondansetron hcl (pf)...81 ONFI...8 ONGLYZA...7 OPANA... OPANA ER... OPDIVO... opium tincture...78 OPSUMIT oralone...68 ORAP... ORENCIA...9 ORENITRAM...9 ORFADIN...67 orsythia...97 ORTHO EVRA...9 OSMOPREP...81 OTEZLA...9 OTEZLA STARTER...9 oxacillin...1 OXACILLIN...1 oxacillin in dextrose(iso-osm)...1 oxaliplatin... oxandrolone...76 oxaprozin...7 oxcarbazepine...8 OXISTAT...61 OXSORALEN...6 OXSORALEN ULTRA...6 oxybutynin chloride...108, 109 oxycodone... oxycodone-acetaminophen... oxycodone-aspirin... oxymorphone... OZURDEX...10 P pacerone... paclitaxel... pamidronate...76 PANCREAZE...81 pancrelipase PANDEL...6 PANRETIN...6 pantoprazole...8 paregoric...78 paricalcitol PARICALCITOL...76 paroex oral rinse...68 paromomycin...11 paroxetine hcl... PASER...11 PATADAY PATANOL PAXIL... PAZEO PCE...8 PEDIARIX (PF)...89 PEDVAX HIB (PF)...89 peg 0-electrolytes...81 peg-0 with flavor packs..81 PEGANONE...8 PEGASYS...8 PEGASYS PROCLICK...8 peg-electrolyte soln...81 PEGINTRON...8 PEGINTRON REDIPEN...8 peg-prep...81 PENICILLIN G POT IN DEXTROSE...1 penicillin g potassium...1 penicillin g procaine...1 penicillin g sodium...1 penicillin v potassium...1 PENTACEL (PF)...89 PENTAM...11 PENTASA...81 pentoxifylline... PERIKABIVEN...11 perindopril erbumine...9 perio med...68 periogard...68 PERJETA... permethrin...6 perphenazine... pfizerpen-g...1 phenelzine... phenobarbital...8 phenytoin...8 phenytoin sodium...8 phenytoin sodium extended..8 philith...97 phospha 0 neutral PHOSPHOLINE IODIDE...99 PICATO...6 pilocarpine hcl...67, 99 pimtrea (8)...97

137 pindolol...9 pioglitazone...7 pioglitazone-glimepiride...7 pioglitazone-metformin...7 piperacillin-tazobactam...1 pirmella...97 piroxicam...7 plasbumin % plasbumin % PLASMA-LYTE PLASMA-LYTE A...11 PLASMA-LYTE-6 IN % DEXTROSE...11 plasmanate...11 PLEGRIDY...8 podofilox...6 polycin...99 polyethylene glycol polymyxin b sulfate...11 polymyxin b sulf-trimethoprim...99 POMALYST... portia...97 potassium acetate potassium bicarb and chloride potassium bicarb-citric acid111 potassium chlorid-d- 0.%nacl potassium chloride...11 potassium chloride in 0.9%nacl potassium chloride in % dex potassium chloride in lr-d.11 potassium chloride-0. % nacl...11 potassium chloride-d- 0.%nacl...11 potassium chloride-d- 0.%nacl...11 potassium chloride-d- 0.9%nacl...11 potassium citrate potassium citrate-citric acid109 potassium phosphate dibasic...11 POTIGA...8 PRADAXA... pramipexole...9 PRAMOSONE... PRANDIMET...7 pravastatin... prazosin...9 PRED MILD...10 PRED-G...10 PRED-G S.O.P prednicarbate...6 prednisolone...71 prednisolone acetate...10 prednisolone sodium phosphate...71, 10 prednisone...71 prednisone intensol...71 PREMARIN...9 premasol 10 %...11 PREMASOL 6 %...11 prenatal vitamin oral.11 prevalite..., PREVIDENT...69 PREVIDENT 000 BOOSTER PLUS...69 PREVIDENT 000 DRY MOUTH...69 PREVIDENT 000 ENAMEL PROTECT...69 PREVIDENT 000 PLUS...69 PREVIDENT 000 SENSITIVE...69 previfem...97 PREZCOBIX... PREZISTA... PRIALT...7 PRIFTIN...11 PRIMAQUINE...11 primidone...8 PRIMSOL...16 PRISTIQ... PRIVIGEN...89 PROAIR HFA PROAIR RESPICLICK probenecid...91 procainamide... prochlorperazine...81 prochlorperazine edisylate...81 prochlorperazine maleate...81 PROCRIT...8, 86 PROCTOFOAM HC...81 proctosol hc...81 PROCYSBI progesterone micronized...9 PROGLYCEM...7 PROGRAF... PROLASTIN-C...67 PROLEUKIN...86 PROLIA...91 PROMACTA... propafenone... proparacaine propranolol...9 propranolol-hydrochlorothiazid...9 propylthiouracil...71 PROQUAD (PF)...89 PROSOL 0 %...11 PROTOPAM CHLORIDE...6 PROTOPIC...6 protriptyline... prudoxin...6 PSORCON...6 PULMICORT PULMICORT FLEXHALER PULMOZYME PURIXAN... PYLERA...8 pyrazinamide...11 pyridostigmine bromide... Q QUADRACEL (PF)...89 quasense...97 quetiapine... quinapril...9 quinapril-hydrochlorothiazide...9 quinidine gluconate..., quinidine sulfate... quinine sulfate...11 QVAR R RABAVERT (PF)...89 RAGWITEK...89 raloxifene...91 ramipril...9 RANEXA... ranitidine hcl...8, 8 RAPAMUNE... RASUVO (PF)...9 RAVICTI...67 REBETOL...

138 REBIF (WITH ALBUMIN).86 REBIF REBIDOSE...86 REBIF TITRATION PACK 86 reclipsen (8)...97 RECOMBIVAX HB (PF)...89 regonol... REGRANEX...6 relador pak...9 RELENZA DISKHALER... RELISTOR...81 RELPAX...0 REMICADE...8 REMODULIN...9 RENACIDIN RENAGEL...67 RENVELA...67 repaglinide...7 reprexain... RESCRIPTOR... RESTASIS RETISERT...10 RETROVIR... REVATIO REVLIMID... revonto... REXULTI... REYATAZ... RHEUMATREX... RHOPHYLAC...89 ribasphere... ribasphere ribapak... ribavirin... RIDAURA...9 rifabutin...11 rifampin...11 RIFATER...11 riluzole...67 rimantadine... RIMSO ringers... 6, 11 risedronate... 67, 91 RISPERDAL CONSTA... risperidone... RITUXAN... rivastigmine tartrate...1 rizatriptan...0 ropinirole...9 ropivacaine (pf)...9 rosadan...8 ROTARIX...89 ROTATEQ VACCINE...89 ROZEREM... RUCONEST S SABRIL...8 SAIZEN...86 SAIZEN CLICK.EASY...86 salsalate...7 SAMSCA...76 SANCUSO...8 SANDIMMUNE... SANDOSTATIN LAR DEPOT... SANTYL...6 SAPHRIS (BLACK CHERRY)... SAVELLA...9 selegiline hcl...9 selenium sulfide...6 SELZENTRY... SENSIPAR...76, 77 sensorcaine...9 sensorcaine/epinephrine...9 sensorcaine-mpf...9 SENSORCAINE-MPF SPINAL...67 SENSORCAINE- MPF/EPINEPHRINE...9 SEREVENT DISKUS SEROQUEL XR... SEROSTIM...86 sertraline... sf 69 sf 000 plus...69 sharobel...9 SIGNIFOR... SIGNIFOR LAR... sildenafil silver sulfadiazine...6 SIMBRINZA SIMPONI...9 SIMPONI ARIA...9 SIMULECT... simvastatin... sirolimus... SIRTURO...11 SIVEXTRO...11 SKLICE...6 sodium acetate...11 sodium bicarbonate sodium chloride...67, 11 sodium chloride 0. %...11 sodium chloride 0.9 %...67 sodium chloride %...11 sodium chloride %...11 sodium citrate-citric acid sodium fluoride...11 sodium lactate...11 sodium phenylbutyrate...67 sodium phosphate...11 sodium polystyrene (sorb free)...67 sodium polystyrene sulfonate...67 SODIUM POLYSTYRENE SULFONATE...67 SOLIRIS...67 SOLTAMOX... SOLU-CORTEF (PF)...71 SOLU-MEDROL...71 SOLU-MEDROL (PF)...71 SOMATULINE DEPOT... SOMAVERT...77 SORBITOL...6 sorine... sotalol... sotalol af... SOVALDI... SPIRIVA RESPIMAT SPIRIVA WITH HANDIHALER spironolactone...9 spironolacton-hydrochlorothiaz...9 SPORANOX...1 sprintec (8)...97 SPRYCEL... sps...67 sronyx...97 ssd...6 stavudine... STELARA...6 STIMATE...77 STIVARGA... STRATTERA... STREPTOMYCIN...1 STRIBILD... STRIVERDI RESPIMAT..107 STROMECTOL...1 sublimaze (pf)...

139 SUBOXONE...7 SUBSYS... sucralfate...8 sulfacetamide sodium...10 sulfacetamide sodium (acne) 60 sulfacetamide-prednisolone 10 sulfadiazine...1 sulfamethoxazole-trimethoprim...1 SULFAMYLON...60 sulfasalazine...8 sulfatrim...1 sulfazine...8 sulfazine ec...8 sulindac...7 sumatriptan...0 sumatriptan succinate...0 SUPPRELIN LA... SUPRAX... 7, 8 SURMONTIL... SUSTIVA... SUTENT... syeda...97 SYLATRON...86 SYLVANT... SYMBICORT SYMLINPEN SYMLINPEN SYNAGIS... SYNAREL...77 SYNERCID...1 SYNRIBO... SYPRINE...67 T TABLOID... TACLONEX...6 tacrolimus..., 6 TAFINLAR... TAMIFLU..., tamoxifen... tamsulosin TARCEVA... TARGRETIN... tarina fe...97 TASIGNA... TASMAR...9 TAZICEF...8 TAZORAC...8 taztia xt...9 TECFIDERA...1 TEFLARO...8 TEGRETOL XR...8 TEKTURNA...9 TEKTURNA HCT...9 telmisartan...9 telmisartan-amlodipine...9 telmisartan-hydrochlorothiazid...9 temazepam... TEMODAR... tencon... TENIVAC (PF)...90 terazosin...9 terbinafine hcl...1 terbutaline terconazole...9 TESTIM...77 TESTOPEL...77 TESTOSTERONE...77 testosterone cypionate...77 testosterone enanthate...77 TESTRED...77 TETANUS,DIPHTHERIA TOX PED(PF)...90 TETANUS-DIPHTHERIA TOXOIDS-TD...90 tetrabenazine...1 tetracaine hcl tetracycline...1 TETRAVISC TEVETEN HCT...0 THALOMID... THAM...11 theochron theophylline...107, 108 THERACYS...90 thioridazine... thiotepa... thiothixene... THROMBATE III... THYMOGLOBULIN...90 tiagabine...8 TICE BCG...90 ticlopidine... TIKOSYN... timolol maleate...0, 99 TIMOPTIC OCUDOSE (PF)...99 tinidazole...1 TIVICAY tizanidine... TOBI PODHALER...1 TOBRADEX...10 TOBRADEX ST...10 tobramycin...99 tobramycin in 0. % nacl..1 tobramycin in 0.9 % nacl...1 tobramycin sulfate...1 tobramycin-dexamethasone 10 tolcapone...9 tolmetin...7 tolterodine topiramate...8 toposar... topotecan... TORISEL... torsemide...0 TOVIAZ TRACLEER tramadol...7 tramadol-acetaminophen...7 trandolapril...0 trandolapril-verapamil...0 tranexamic acid..., 9 TRANSDERM-SCOP...8 tranylcypromine... travasol 10 %...11 TRAVATAN Z travoprost (benzalkonium)..101 trazodone... TREANDA... TRECATOR...1 TRELSTAR... TRELSTAR DEPOT... TRELSTAR LA... tretinoin...8 tretinoin (chemotherapy)... tretinoin microspheres...8 TRETIN-X...8 TREXALL... TREXIMET...0 triamcinolone acetonide.6, 69, 71 triamterene-hydrochlorothiazid...0 trianex...6 triazolam... triderm...6 tri-estarylla...97 trifluoperazine...

140 trifluridine...99 TRIGLIDE... trihexyphenidyl...9 tri-legest fe...97 tri-linyah...97 trilyte with flavor packets...8 trimethoprim...16 triple vitamin with fluoride 11 tri-previfem (8)...97 TRISENOX... tri-sprintec (8)...97 TRIUMEQ... tri-vit with fluoride & iron.11 tri-vitamin with fluoride...11 trivora (8)...97 TROPHAMINE 10 %...11 tropicamide...99 trospium TRUMENBA...90 TRUVADA... TUDORZA PRESSAIR TWINRIX (PF)...90 TYBOST... TYGACIL...1 TYKERB... TYPHIM VI...90 TYSABRI...1 TYVASO TYVASO INSTITUTIONAL START KIT TYVASO REFILL KIT TYVASO STARTER KIT.108 TYZEKA... TYZINE...69 U ULORIC...91 unithroid...78 UROCIT-K ursodiol...8 UVADEX...6 V VAGIFEM...9 valacyclovir... VALCHLOR...6 VALCYTE... valganciclovir... valproate sodium...8 valproic acid...8 valproic acid (as sodium salt)...8 valsartan...0 valsartan-hydrochlorothiazide...0 VALSTAR... vancomycin...16 VANCOMYCIN...16 VANCOMYCIN IN DW...16 VANCOMYCIN IN DEXTROSE ISO-OSM...16 vandazole...9 VAQTA (PF)...90 VARIVAX (PF)...90 VARIZIG...90 VASCEPA... vasopressin...77 VECAMYL... VECTIBIX... VELCADE... veletri...0 velivet triphasic regimen (8)...97 venlafaxine... VENTAVIS VENTOLIN HFA VERAMYST verapamil...0 VERSACLOZ... VESICARE vestura (8)...97 VEXOL...10 VICTOZA -PAK...7 VICTOZA -PAK...7 VIDEX GRAM PEDIATRIC... VIDEX GRAM PEDIATRIC... VIEKIRA PAK... VIGAMOX...99 VIIBRYD..., VIMPAT...8, 9 vinblastine... vincasar pfs... vincristine... vinorelbine... viorele (8)...97 VIRACEPT... VIRAMUNE XR... VIRAZOLE... VIREAD... virt-phos 0 neutral vitamins a,c,d & fluoride...11 VITEKTA... VIVITROL...7 VOLTAREN GEL...7 voriconazole...1, VOTRIENT... VPRIV...77 VYTORIN VYTORIN VYTORIN VYTORIN W warfarin... water for irrigation, sterile...67 WELCHOL... wera (8)...97 wymzya fe...97 X XALKORI... XARELTO... XELJANZ...9 XENAZINE... XGEVA...17 XIFAXAN...1 XOLAIR XOLEGEL...61 XOPENEX HFA XTANDI... XYLOCAINE (CARDIAC) (PF)... XYLOCAINE- MPF/EPINEPHRINE...9 xylon XYREM... Y YERVOY... YF-VAX (PF)...90 Z zafirlukast zaleplon... ZALTRAP... zamicet... ZANOSAR... zarah...97 ZAVESCA...77 zazole...9 ZELAPAR...0 ZELBORAF... ZEMAIRA...68 ZEMPLAR...77

141 zenchent (8)...97 zenchent fe ZENPEP... 8 zeosa...98 ZERBAXA... 8 ZETIA... ZIAGEN... zidovudine... ZIOPTAN (PF) ziprasidone hcl... ZIRGAN ZMAX...9 ZOLADEX... zoledronic acid...77 zoledronic acid-mannitol-water...68 ZOLEDRONIC ACID- MANNITOL-WATER...68 ZOLINZA... zolmitriptan...0 ZOMIG...0 zonisamide...9 ZORBTIVE...86 ZORTRESS... ZOSTAVAX (PF)...90 ZOSYN IN DEXTROSE (ISO- OSM)...1 zovia 1/e (8)...98 zovia 1/0e (8)...98 ZOVIRAX...61 ZYDELIG... ZYFLO ZYFLO CR ZYKADIA... ZYLET...10 ZYPREXA RELPREVV... ZYTIGA...6 ZYVOX

142 BCN Advantage SM Service Area MEDICARE ADVANTAGE DEEMED You are always covered for emergency and urgent care anywhere in Michigan, the nation or the world. Benzie Leelanau Grand Traverse Emmet Charlevoix Antrim Cheboygan Presque Isle Otsego Shiawassee Montmorency Alpena Kalkaska Crawford Oscoda Alcona Manistee Wexford MissaukeeRoscommon Ogemaw Iosco Mason Lake Osceola Clare Gladwin Arenac Huron Oceana Muskegon Newaygo Mecosta Isabella Midland Bay Montcalm Gratiot Saginaw Tuscola Sanilac St. Joseph ZIP Codes Served Ottawa Allegan Van Buren Kent Barry Ionia Eaton Clinton Genesee Ingham Livingston Oakland Lapeer Kalamazoo Calhoun Jackson Washtenaw Wayne Macomb St. Clair St. Joseph Branch Hillsdale Lenawee Monroe This formulary was updated on 10/1/01. For more recent information or other questions, please contact BCN Advantage Customer Service at or, for TTY users, 711, 8 a.m. to 8 p.m. Monday through Friday, with weekend hours Oct. 1 through Feb. 1, or visit Medicare Customer Service: MEDICARE (TTY/TDD ) hours a day seven days a week Blue Care Network Corporate Offices P.O. Box 0 Southfield, MI R071