Lista de medicamentos y medicamentos que favorece PHP Centennial Care

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1 Presbyterian Centennial Care Lista de medicamentos y medicamentos que favorece PHP Centennial Care La lista de medicamentos que favorece Centennial Care está sujeta a cambios. Esta lista está en orden alfabético. Para buscar un medicamento específico, utilice la aplicación de búsquedas que está a su disposición en Adobe Acrobat Reader (acceso directo: Ctrl+F). Los servicios son financiados en parte bajo contrato con el Estado de Nuevo México. La meta de Presbyterian es mejorar la salud de los pacientes, afiliados y comunidades que servimos.

2 PHP Centennial Care Se Convertira en Efectivo en 9/1/2018 letra minúscula cursiva = Medicamentos genéricos LETRA MAYÚSCULA GRUESA = Medicamentos de marca Nombre del medicamento *ADHD/ANTI-NARCOLEPSY/ANTI- OBESITY/ANOREXIANTS* *ADHD AGENT - SELECTIVE ALPHA ADRENERGIC AGONISTS*** guanfacine hcl er oral tablet extended release 24 hour 1, 2, 3, 4 *ADHD AGENT - SELECTIVE NOREPINEPHRINE REUPTAKE INHIBITOR*** atomoxetine hcl oral capsule 10, 100, 18, 25, 40, 60, 80 *AMPHETAMINE MIXTURES*** amphetamine-dextroamphet er oral capsule extended release 24 hour 10, 15, 5 amphetamine-dextroamphet er oral capsule extended release 24 hour 20, 25, 30 amphetamine-dextroamphetamine oral tablet 10, 12.5, 15, 20, 5, 7.5 amphetamine-dextroamphetamine oral tablet 30 *AMPHETAMINES*** dextroamphetamine sulfate er oral capsule extended release 24 hour 10, 15, 5 dextroamphetamine sulfate oral tablet 10, 5 QL (30 EA per 30 days) ST; QL (30 EA per 30 days) required for 19 years of age and older.; Schedule II medications are limited to a 34 day maximum.; QL (30 EA per 30 days); Min 6 Years and Max 18 Years required for 19 years of age and older.; Schedule II medications are limited to a 34 day maximum.; QL (60 EA per 30 days); Min 6 Years and Max 18 Years required for 19 years of age and older.; Schedule II medications are limited to a 34 day maximum.; QL (90 EA per 30 days); Min 3 Years and Max 18 Years required for 19 years of age and older.; Schedule II medications are limited to a 34 day maximum.; QL (60 EA per 30 days); Min 3 Years and Max 18 Years required for 19 years of age and older.; Schedule II medications are limited to a 34 day maximum.; QL (60 EA per 30 days); Min 6 Years and Max 18 Years required for 19 years of age and older.; Schedule II medications are limited to a 34 day maximum.; QL (90 EA per 30 days); Min 3 Years and Max 18 Years MPC /1/2018

3 VYVANSE ORAL CAPSULE 10 MG, 20 MG, 30 MG, 40 MG, 50 MG, 60 MG, 70 MG *ANALEPTICS*** caffeine citrate intravenous solution 60 /3ml caffeine citrate oral solution 20 /ml *STIMULANTS - MISC.*** ; Schedule II medications are limited to a 34 day maximum.; QL (30 EA per 30 days); Min 6 Years armodafinil oral tablet 200, 250 ; QL (30 EA per 30 days) armodafinil oral tablet 50 ; QL (90 EA per 30 days) dexmethylphenidate hcl er oral capsule extended release 24 hour 10, 15, 20, 30, 35, 40, 5 dexmethylphenidate hcl er oral capsule extended release 24 hour 25 dexmethylphenidate hcl oral tablet 10, 2.5 dexmethylphenidate hcl oral tablet 5 methylphenidate hcl er (cd) oral capsule extended release 10, 20, 30, 40, 50, 60 methylphenidate hcl er oral tablet extended release 10, 36 methylphenidate hcl er oral tablet extended release 18, 27, 54 methylphenidate hcl er oral tablet extended release 20 ST; required for patients 19 years of age and older.; Schedule II medications are limited to a 34 day maximum.; QL (30 EA per 30 days); Min 6 Years and Max 18 Years ST; required for patients 19 years of age and older.; Schedule II medications are limited to a 34 day maximum.; QL (30 EA per 30 days); Min 6 Years and Max 18 Years ST; required for patients 19 years of age and older.; Schedule II medications are limited to a 34 day maximum.; QL (60 EA per 30 days); Min 6 Years and Max 18 Years ST; required for patients 19 years of age and older.; Schedule II medications are limited to a 34 day maximum.; QL (60 EA per 60 days); Min 6 Years and Max 18 Years required for 19 years of age and older.; Schedule II medications are limited to a 34 day maximum.; QL (30 EA per 30 days); Min 6 Years and Max 18 Years required for 19 years of age and older.; Schedule II medications are limited to a 34 day maximum.; QL (60 EA per 30 days); Min 6 Years and Max 18 Years required for 19 years of age and older.; Schedule II medications are limited to a 34 day maximum.; QL (30 EA per 30 days); Min 6 Years and Max 18 Years required for 19 years of age and older.; Schedule II medications are limited to a 34 day maximum.; QL (90 EA per 30 days); Min 6 Years and Max 18 Years MPC /1/2018

4 methylphenidate hcl er oral tablet extended release 24 hour 18, 27, 54 methylphenidate hcl er oral tablet extended release 24 hour 36 methylphenidate hcl oral tablet 10, 20, 5 *AMINOGLYCOSIDES* *AMINOGLYCOSIDES*** neomycin sulfate oral tablet 500 tobramycin inhalation nebulization solution 300 /5ml *ANALGESICS - ANTI-INFLAMMATORY* *ANTIRHEUMATIC - JANUS KINASE (JAK) INHIBITORS*** required for 19 years of age and older.; Schedule II medications are limited to a 34 day maximum.; QL (30 EA per 30 days); Min 6 Years and Max 18 Years required for 19 years of age and older.; Schedule II medications are limited to a 34 day maximum.; QL (60 EA per 30 days); Min 6 Years and Max 18 Years required for 19 years of age and older.; Schedule II medications are limited to a 34 day maximum.; QL (90 EA per 30 days); Min 6 Years and Max 18 Years XELJANZ ORAL TABLET 10 MG ; SP; QL (60 EA per 30 Days) XELJANZ ORAL TABLET 5 MG ; SP; QL (60 EA per 30 days) XELJANZ XR ORAL TABLET EXTENDED RELEASE 24 HOUR 11 MG *ANTI-TNF-ALPHA - MONOCLONAL ANTIBODIES*** HUMIRA PEN-CROHNS STARTER SUBCUTANEOUS PEN-INJECTOR KIT 40 MG/0.8ML HUMIRA PEN-PSORIASIS STARTER SUBCUTANEOUS PEN-INJECTOR KIT 40 MG/0.8ML HUMIRA SUBCUTANEOUS PREFILLED SYRINGE KIT 10 MG/0.1ML, 10 MG/0.2ML, 20 MG/0.2ML, 20 MG/0.4ML, 40 MG/0.4ML, 40 MG/0.8ML *ANTI-TNF-ALPHA - MONOCLONOAL ANTIBODIES*** HUMIRA PEN SUBCUTANEOUS PEN-INJECTOR KIT 40 MG/0.8ML HUMIRA PEN-CROHNS STARTER SUBCUTANEOUS PEN-INJECTOR KIT 40 MG/0.8ML HUMIRA PEN-PSORIASIS STARTER SUBCUTANEOUS PEN-INJECTOR KIT 40 MG/0.8ML SP ; SP; QL (30 EA per 30 days) ; SP; Approve 1 box quantity of 6 to start initial therapy.; QL (6 EA per 30 days) ; Approve 1 box quantity of 4 to start initial therapy.; QL (4 EA per 30 days) ; SP; QL (2 EA per 28 days) ; SP; QL (2 EA per 28 days) ; SP; Approve 1 box quantity of 6 to start initial therapy.; QL (6 EA per 30 days) ; SP; Approve 1 box quantity of 4 to start initial therapy.; QL (4 EA per 30 days) MPC /1/2018

5 HUMIRA SUBCUTANEOUS PREFILLED SYRINGE KIT 10 MG/0.1ML, 10 MG/0.2ML, 20 MG/0.2ML, 20 MG/0.4ML, 40 MG/0.4ML, 40 MG/0.8ML *CYCLOOXYGENASE 2 (COX-2) INHIBITORS*** celecoxib oral capsule 100, 200, 400, 50 *GOLD COMPOUNDS*** RIDAURA ORAL CAPSULE 3 MG *NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)*** childrens ibuprofen oral suspension 40 /ml diclofenac sodium er oral tablet extended release 24 hour 100 diclofenac sodium oral tablet delayed release 25, 50, 75 etodolac er oral tablet extended release 24 hour 400, 500, 600 etodolac oral capsule 200, 300 etodolac oral tablet 400, 500 flurbiprofen oral tablet 100, 50 ibuprofen junior strength oral tablet chewable 100 ibuprofen lysine intravenous solution 10 /ml ibuprofen oral suspension 100 /5ml ibuprofen oral tablet 200, 400, 600, 800 INDOCIN ORAL SUSPENSION 25 MG/5ML INDOCIN RECTAL SUPPOSITORY 50 MG indomethacin er oral capsule extended release 75 indomethacin oral capsule 25, 50 ketoprofen er oral capsule extended release 24 hour 200 meloxicam oral tablet 15, 7.5 MOTRIN IB ORAL TABLET 200 MG nabumetone oral tablet 500, 750 naproxen dr oral tablet delayed release 375, 500 naproxen oral suspension 125 /5ml naproxen oral tablet 250, 375, 500 naproxen sodium oral tablet 275, 550 oxaprozin oral tablet 600 piroxicam oral capsule 10, 20 ; SP; QL (2 EA per 28 days) QL (60 EA per 30 days) MPC /1/2018

6 sulindac oral tablet 150, 200 *PYRIMIDINE SYNTHESIS INHIBITORS*** leflunomide oral tablet 10, 20 *SELECTIVE COSTIMULATION MODULATORS*** ORENCIA CLICKJECT SUBCUTANEOUS SOLUTION AUTO-INJECTOR 125 MG/ML ORENCIA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 125 MG/ML ORENCIA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 50 MG/0.4ML ORENCIA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 87.5 MG/0.7ML *SOLUBLE TUMOR NECROSIS FACTOR RECEPTOR AGENTS*** ENBREL MINI SUBCUTANEOUS SOLUTION CARTRIDGE 50 MG/ML ENBREL SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 25 MG/0.5ML ENBREL SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 50 MG/ML ENBREL SURECLICK SUBCUTANEOUS SOLUTION AUTO-INJECTOR 50 MG/ML *ANALGESICS - NONNARCOTIC* *ANALGESICS OTHER*** ; SP; QL (4 ML per 30 days) ; SP; QL (4 ML per 28 days) ; SP; QL (1.6 ML per 28 days) ; SP; QL (2.8 ML per 28 days) ; SP; QL (3.92 ML per 28 days) ; SP; QL (4.08 ML per 28 days) ; SP; QL (7.84 ML per 28 days) ; SP; QL (7.84 ML per 28 days) ACEPHEN RECTAL SUPPOSITORY 325 MG QL (12 EA per 1 day) ACEPHEN RECTAL SUPPOSITORY 650 MG QL (6 EA per 1 day) acetaminophen extra strength oral liquid 500 /15ml QL (120 ML per 1 day) acetaminophen oral tablet 325 QL (12 EA per 1 day) acetaminophen oral tablet 500 QL (8 EA per 1 day) arthritis pain relief oral tablet extended release 650 QL (6 EA per 1 day) pain & fever childrens oral tablet chewable 80 *ANALGESICS-SEDATIVES*** butalbital-apap-caffeine oral tablet QL (180 EA per 30 days) butalbital-aspirin-caffeine oral tablet QL (6 EA per 1 day) *SALICYLATES*** aspirin ec oral tablet delayed release 81 $0 Copay per PCA guidelines. aspirin low dose oral tablet chewable 81 $0 Copay per PCA guidelines. aspirin low strength oral tablet chewable 81 aspirin oral tablet 325 $0 Copay per PCA guidelines. aspirin oral tablet chewable 81 $0 Copay per PCA guidelines. aspirin oral tablet delayed release 325 $0 Copay per PCA guidelines. childrens aspirin oral tablet chewable 81 $0 Copay per PCA guidelines. MPC /1/2018

7 diflunisal oral tablet 500 salsalate oral tablet 500, 750 *ANALGESICS - OPIOID* *CODEINE COMBINATIONS*** acetaminophen-codeine #2 oral tablet acetaminophen-codeine #3 oral tablet acetaminophen-codeine #4 oral tablet acetaminophen-codeine oral solution /5ml butalbital-apap-caff-cod oral capsule butalbital-asa-caff-codeine oral capsule *HYDROCODONE COMBINATIONS*** hydrocodone-acetaminophen oral solution /5ml, /10ml, /15ml hydrocodone-acetaminophen oral tablet , 5-325, hydrocodone-ibuprofen oral tablet *OPIOID AGONISTS*** codeine sulfate oral tablet 15, 30, 60 fentanyl transdermal patch 72 hour 100 mcg/hr, 12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr ; Not covered for patients under 12 years of age. Prior authorization required for patients 12 to 18 years.; QL (13 EA per 1 day); Min 12 Years ; Not covered for patients under 12 years of age. Prior authorization required for patients 12 to 18 years.; QL (13 EA per 1 day); Min 12 Years ; Not covered for patients under 12 years of age. Prior authorization required for patients 12 to 18 years of age.; QL (13 EA per 1 day); Min 12 Years ; Not covered for patients under 12 years of age. Prior authorization required for patients 12 to 18 years.; Min 12 Years ; Not covered for patients under 12 years of age. Prior authorization required for patients 12 to 18 years.; QL (180 EA per 30 days); Min 12 Years ; Not covered for patients under 12 years of age. Prior authorization required for patients 12 to 18 years of age.; QL (6 EA per 1 day); Min 12 Years Schedule II medications are limited to a 34 day maximum.; QL (12 EA per 1 day) Schedule II medications are limited to a 34 day maximum.; QL (5 EA per 1 day) ; Not covered for patients under 12 years of age. Prior authorization required for patients 12 to 18 years.; Schedule II medications are limited to a 34 day maximum.; QL (180 EA per 30 days); Min 12 Years ST; Schedule II medications are limited to a 34 day maximum.; QL (10 EA per 30 days) MPC /1/2018

8 hydromorphone hcl oral liquid 1 /ml hydromorphone hcl oral tablet 2, 4, 8 KADIAN ORAL CAPSULE EXTENDED RELEASE 24 HOUR 200 MG, 40 MG meperidine hcl oral solution 50 /5ml meperidine hcl oral tablet 100, 50 methadone hcl oral solution 10 /5ml, 5 /5ml methadone hcl oral tablet 10, 5 morphine sulfate (concentrate) oral solution 20 /ml morphine sulfate er beads oral capsule extended release 24 hour 120, 30, 45, 60, 75, 90 morphine sulfate er oral capsule extended release 24 hour 10, 100, 20, 30, 50, 60, 80 morphine sulfate er oral tablet extended release 100 morphine sulfate er oral tablet extended release 15, 200, 30, 60 morphine sulfate oral solution 10 /5ml, 20 /5ml morphine sulfate oral tablet 15, 30 oxycodone hcl oral concentrate 100 /5ml oxycodone hcl oral solution 5 /5ml oxycodone hcl oral tablet 10, 15, 20, 30, 5 Schedule II medications are limited to a 34 day maximum.; QL (50 ML per 1 day) Schedule II medications are limited to a 34 day maximum.; QL (6 EA per 1 day) ST; Schedule II medications are limited to a 34 day maximum.; QL (60 EA per 30 days) Schedule II medications are limited to a 34 day maximum.; QL (1200 ML per 30 days) Schedule II medications are limited to a 34 day maximum.; QL (180 EA per 30 days) ; Schedule II medications are limited to a 34 day maximum.; QL (900 ML per 30 days) ; Schedule II medications are limited to a 34 day maximum.; QL (180 EA per 30 days) Schedule II medications are limited to a 34 day maximum.; QL (180 ML per 30 days) ST; Schedule II medications are limited to a 34 day maximum.; QL (30 EA per 30 days) ST; Schedule II medications are limited to a 34 day maximum.; QL (60 EA per 30 days) Schedule II medications are limited to a 34 day maximum.; QL (180 EA per 30 days) Schedule II medications are limited to a 34 day maximum.; QL (90 EA per 30 days) Schedule II medications are limited to a 34 day maximum.; QL (900 ML per 30 days) Schedule II medications are limited to a 34 day maximum.; QL (180 EA per 30 days) Schedule II medications are limited to a 34 day maximum.; QL (180 ML per 30 days) Schedule II medications are limited to a 34 day maximum.; QL (2700 ML per 30 days) Schedule II medications are limited to a 34 day maximum.; QL (180 EA per 30 days) MPC /1/2018

9 oxymorphone hcl er oral tablet extended release 12 hour 10, 15, 20, 30, 40, 5, 7.5 tramadol hcl oral tablet 50 *OPIOID COMBINATIONS*** ENDOCET ORAL TABLET MG, MG, MG oxycodone-acetaminophen oral tablet , ST; Schedule II medications are limited to a 34 day maximum.; QL (60 EA per 30 days) ; Not covered for patients under 12 years of age. Prior authorization required for patients 12 to 18 years.; QL (240 EA per 30 days); Min 12 Years QL (12 EA per 1 day) QL (12 EA per 1 day) oxycodone-acetaminophen oral tablet QL (8 EA per 1 day) oxycodone-aspirin oral tablet *OPIOID RTIAL AGONISTS*** buprenorphine hcl sublingual tablet sublingual 2, 8 buprenorphine hcl-naloxone hcl sublingual tablet sublingual 2-0.5, 8-2 QL (90 EA per 30 days) QL (90 EA per 30 days) SUBOXONE SUBLINGUAL FILM 12-3 MG QL (60 EA per 30 days); Min 16 Years SUBOXONE SUBLINGUAL FILM MG, 4-1 MG, 8-2 MG *ANDROGENS-ANABOLIC* *ANDROGENS*** ANDRODERM TRANSDERMAL TCH 24 HOUR 2 MG/24HR ANDRODERM TRANSDERMAL TCH 24 HOUR 4 MG/24HR danazol oral capsule 100, 200, 50 testosterone cypionate intramuscular solution 100 /ml, 200 /ml testosterone enanthate intramuscular solution 200 /ml QL (90 EA per 30 days); Min 16 Years ; QL (60 EA per 30 days) ; QL (30 EA per 30 days) testosterone transdermal gel 10 /act (2%) ; QL (120 GM per 30 days) testosterone transdermal gel 12.5 /act (1%) ; QL (300 GM per 30 days) testosterone transdermal gel 25 /2.5gm (1%) ; QL (75 GM per 30 days) testosterone transdermal gel 50 /5gm (1%) *ANORECTAL AGENTS* *INTRARECTAL STEROIDS*** hydrocortisone rectal enema 100 /60ml *RECTAL ANESTHETIC/STEROIDS*** lidocaine-hydrocortisone ace rectal cream % PROCTOFOAM HC RECTAL FOAM 1-1 % MPC /1/2018 ; Generic for Androgel 1% only is covered.

10 *RECTAL LOCAL ANESTHETICS*** PROCTOFOAM RECTAL FOAM 1 % *RECTAL STEROIDS*** PROCTOSOL HC RECTAL CREAM 2.5 % *ANTHELMINTICS* *ANTHELMINTICS*** reeses pinworm medicine oral suspension 144 (50 base) /ml QL (60 ML per 30 days) reeses pinworm medicine oral tablet 180 QL (48 EA per 30 days) *ANTIANGINAL AGENTS* *ANTIANGINALS-OTHER*** RANEXA ORAL TABLET EXTENDED RELEASE 12 HOUR 1000 MG, 500 MG *NITRATES*** DILATRATE-SR ORAL CAPSULE EXTENDED RELEASE 40 MG isosorbide dinitrate er oral tablet extended release 40 isosorbide dinitrate oral tablet 10, 20, 30, 5 isosorbide mononitrate er oral tablet extended release 24 hour 120, 30, 60 isosorbide mononitrate oral tablet 10, 20 NITRO-BID TRANSDERMAL OINTMENT 2 % NITRO-DUR TRANSDERMAL TCH 24 HOUR 0.3 MG/HR, 0.8 MG/HR nitroglycerin er oral capsule extended release 9 nitroglycerin sublingual tablet sublingual 0.3, 0.4, 0.6 nitroglycerin transdermal patch 24 hour 0.1 /hr, 0.2 /hr, 0.4 /hr, 0.6 /hr *ANTIANXIETY AGENTS* *ANTIANXIETY AGENTS - MISC.*** buspirone hcl oral tablet 10, 15, 5, 7.5 QL (90 EA per 30 days) buspirone hcl oral tablet 30 QL (60 EA per 30 days) hydroxyzine hcl oral syrup 10 /5ml hydroxyzine hcl oral tablet 10, 25, 50 hydroxyzine pamoate oral capsule 100, 25, 50 meprobamate oral tablet 200, 400 *BENZODIAZEPINES*** alprazolam er oral tablet extended release 24 hour 0.5 QL (30 EA per 30 days), 1, 2 MPC /1/2018 ST

11 alprazolam er oral tablet extended release 24 hour 3 ALPRAZOLAM INTENSOL ORAL CONCENTRATE 1 MG/ML alprazolam oral tablet 0.25 QL (60 EA per 30 days) Max two Benzodiazepines.; QL (90 EA per 30 days) alprazolam oral tablet 0.5, 1 QL (90 EA per 30 days) alprazolam oral tablet 2 QL (135 EA per 30 days) chlordiazepoxide hcl oral capsule 10, 25, 5 QL (120 EA per 30 days) clorazepate dipotassium oral tablet 15 QL (180 EA per 30 days) clorazepate dipotassium oral tablet 3.75, 7.5 QL (90 EA per 30 days) diazepam oral tablet 10, 2, 5 QL (120 EA per 30 days) lorazepam oral concentrate 2 /ml lorazepam oral tablet 0.5, 1, 2 QL (90 EA per 30 days) *ANTIARRHYTHMICS* *ANTIARRHYTHMICS TYPE I-A*** disopyramide phosphate oral capsule 100, 150 NORCE CR ORAL CAPSULE EXTENDED RELEASE 12 HOUR 100 MG, 150 MG quinidine gluconate er oral tablet extended release 324 quinidine sulfate oral tablet 200, 300 *ANTIARRHYTHMICS TYPE I-B*** mexiletine hcl oral capsule 150, 200, 250 *ANTIARRHYTHMICS TYPE I-C*** propafenone hcl oral tablet 150, 225, 300 *ANTIARRHYTHMICS TYPE III*** amiodarone hcl oral tablet 200, 400 MULTAQ ORAL TABLET 400 MG ; QL (60 EA per 30 days) CERONE ORAL TABLET 100 MG *ANTIASTHMATIC AND BRONCHODILATOR AGENTS* *5-LIPOXYGENASE INHIBITORS*** zileuton er oral tablet extended release 12 hour 600 *ADRENERGIC COMBINATIONS*** ; SP; QL (120 EA per 30 days) MPC /1/2018

12 ADVAIR DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED MCG/DOSE, MCG/DOSE ADVAIR DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED MCG/DOSE COMBIVENT RESPIMAT INHALATION AEROSOL SOLUTION MCG/ACT DULERA INHALATION AEROSOL MCG/ACT, MCG/ACT fluticasone-salmeterol inhalation aerosol powder breath activated mcg/act, mcg/act, mcg/act ipratropium-albuterol inhalation solution (3) /3ml STIOLTO RESPIMAT INHALATION AEROSOL SOLUTION MCG/ACT SYMBICORT INHALATION AEROSOL MCG/ACT SYMBICORT INHALATION AEROSOL MCG/ACT *ANTI-INFLAMMATORY AGENTS*** cromolyn sodium inhalation nebulization solution 20 /2ml *BETA ADRENERGICS*** albuterol sulfate er oral tablet extended release 12 hour 4, 8 albuterol sulfate inhalation nebulization solution (2.5 /3ml) 0.083%, (5 /ml) 0.5%, 0.63 /3ml, 1.25 /3ml albuterol sulfate oral syrup 2 /5ml albuterol sulfate oral tablet 2, 4 metaproterenol sulfate oral syrup 10 /5ml metaproterenol sulfate oral tablet 10, 20 SEREVENT DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED 50 MCG/DOSE ; Step Edit Criteria applies to Dulera and Symbicort. Coverage of Dulera and Symbicort requires a prescription claim history of an orally inhaled corticosteroid or orally inhaled anticholinergic within the past 120 days OR FEV1 of less than 50%.; Advair Diskus 100/50 mcg and 250/50 mcg are covered for patients under 12 years of age only.; QL (60 EA per 30 days); Max 12 Years ; Step Edit Criteria applies to Dulera and Symbicort. Coverage of Dulera and Symbicort requires a prescription claim history of an orally inhaled corticosteroid or orally inhaled anticholinergic within the past 120 days OR FEV1 of less than 50%.; QL (60 EA per 30 days) QL (4 GM per 30 days) ST; QL (13 GM per 30 days) ST ST ST; QL (6 GM per 30 days) ST; QL (6.9 GM per 30 days) MPC /1/2018

13 terbutaline sulfate oral tablet 2.5, 5 VENTOLIN HFA INHALATION AEROSOL SOLUTION 108 (90 BASE) MCG/ACT *BRONCHODILATORS - ANTICHOLINERGICS*** ATROVENT HFA INHALATION AEROSOL SOLUTION 17 MCG/ACT ipratropium bromide inhalation solution 0.02 % SPIRIVA RESPIMAT INHALATION AEROSOL SOLUTION 2.5 MCG/ACT *LEUKOTRIENE RECEPTOR ANTAGONISTS*** montelukast sodium oral tablet 10 QL (30 EA per 30 days) montelukast sodium oral tablet chewable 4, 5 QL (30 EA per 30 days) zafirlukast oral tablet 10, 20 *SELECTIVE PHOSPHODIESTERASE 4 (PDE4) INHIBITORS*** DALIRESP ORAL TABLET 500 MCG ; QL (30 EA per 30 days) *STEROID INHALANTS*** ASMANEX HFA INHALATION AEROSOL 100 MCG/ACT, 200 MCG/ACT budesonide inhalation suspension 0.25 /2ml, 0.5 /2ml FLOVENT DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED 100 MCG/BLIST, 250 MCG/BLIST, 50 MCG/BLIST FLOVENT HFA INHALATION AEROSOL 110 MCG/ACT, 220 MCG/ACT, 44 MCG/ACT QVAR INHALATION AEROSOL SOLUTION 40 MCG/ACT, 80 MCG/ACT QVAR REDIHALER INHALATION AEROSOL BREATH ACTIVATED 40 MCG/ACT, 80 MCG/ACT *XANTHINES*** ELIXOPHYLLIN ORAL ELIXIR 80 MG/15ML theophylline er oral tablet extended release 12 hour 100, 200, 300, 450 theophylline er oral tablet extended release 24 hour 400, 600 *ANTICOAGULANTS* *COUMARIN ANTICOAGULANTS*** JANTOVEN ORAL TABLET 1 MG, 10 MG, 2 MG, 2.5 MG, 3 MG, 4 MG, 5 MG, 6 MG, 7.5 MG warfarin sodium oral tablet 1, 10, 2, 2.5, 3, 4, 5, 6, 7.5 *DIRECT FACTOR XA INHIBITORS*** QL (13 GM per 30 days) QL (120 ML per 30 days); Max 12 Years MPC /1/2018 ST ST

14 XARELTO ORAL TABLET 10 MG ; QL (30 EA per 30 days) XARELTO ORAL TABLET 15 MG, 20 MG XARELTO STARTER CK ORAL TABLET THERAPY CK 15 & 20 MG *LOW MOLECULAR WEIGHT HERINS*** enoxaparin sodium injection solution 300 /3ml enoxaparin sodium subcutaneous solution 100 /ml, 120 /0.8ml, 150 /ml, 30 /0.3ml, 40 /0.4ml, 60 /0.6ml, 80 /0.8ml *SYNTHETIC HERINOID-LIKE AGENTS*** fondaparinux sodium subcutaneous solution 10 /0.8ml, 2.5 /0.5ml, 5 /0.4ml, 7.5 /0.6ml *ANTICONVULSANTS* *ANTICONVULSANTS - BENZODIAZEPINES*** ; QL (51 EA per 90 days) ; Maximum 30 syringes per 90 days. Prior authorization required for amounts exceeding plan quantity limits. ; Maximum 30 syringes per 90 days. Prior authorization required for amounts exceeding plan quantity limits. clonazepam oral tablet 0.5, 1, 2 QL (90 EA per 30 days) clonazepam oral tablet dispersible 0.125, 0.25, 0.5, 1, 2 diazepam rectal gel 10, 2.5, 20 *ANTICONVULSANTS - MISC.*** carbamazepine er oral capsule extended release 12 hour 100, 200, 300 carbamazepine er oral tablet extended release 12 hour 100, 200, 400 carbamazepine oral suspension 100 /5ml carbamazepine oral tablet 200 carbamazepine oral tablet chewable 100 gabapentin oral capsule 100, 300, 400 gabapentin oral solution 250 /5ml gabapentin oral tablet 600, 800 QL (90 EA per 30 days) ST; QL (5 EA per 30 days); Max 17 Years lamotrigine oral tablet 100, 150, 200 QL (60 EA per 30 days) lamotrigine oral tablet 25 QL (120 EA per 30 days) lamotrigine oral tablet chewable 25, 5 levetiracetam oral solution 100 /ml levetiracetam oral tablet 1000, 250, 500, 750 MPC /1/2018

15 LYRICA ORAL CAPSULE 100 MG, 150 MG, 200 MG, 25 MG, 50 MG, 75 MG ; QL (90 EA per 30 days) LYRICA ORAL CAPSULE 225 MG, 300 MG ; QL (60 EA per 30 days) oxcarbazepine oral suspension 300 /5ml oxcarbazepine oral tablet 150, 300, 600 primidone oral tablet 250, 50 topiramate oral capsule sprinkle 15, 25 topiramate oral tablet 100, 200, 25, 50 VIMT ORAL SOLUTION 10 MG/ML ; QL (1200 ML per 30 days) VIMT ORAL TABLET 100 MG, 150 MG, 200 MG, 50 MG zonisamide oral capsule 100, 25, 50 *HYDANTOINS*** DILANTIN ORAL CAPSULE 30 MG phenytoin oral suspension 125 /5ml phenytoin oral tablet chewable 50 phenytoin sodium extended oral capsule 100, 200, 300 *SUCCINIMIDES*** ethosuximide oral capsule 250 ethosuximide oral solution 250 /5ml *VALPROIC ACID*** divalproex sodium er oral tablet extended release 24 hour 250, 500 divalproex sodium oral tablet delayed release 125, 250, 500 valproic acid oral capsule 250 *ANTIDEPRESSANTS* *ALPHA-2 RECEPTOR ANTAGONISTS (TETRACYCLICS)*** ; QL (60 EA per 30 days) mirtazapine oral tablet 15, 30, 45 QL (30 EA per 30 days) mirtazapine oral tablet dispersible 15, 30, 45 *ANTIDEPRESSANTS - MISC.*** bupropion hcl er (sr) oral tablet extended release 12 hour 100, 150, 200 bupropion hcl er (xl) oral tablet extended release 24 hour 150 bupropion hcl er (xl) oral tablet extended release 24 hour 300 ; QL (30 EA per 30 days) QL (60 EA per 30 days) QL (90 EA per 30 days) QL (30 EA per 30 days) bupropion hcl oral tablet 100 QL (135 EA per 30 days) bupropion hcl oral tablet 75 QL (120 EA per 30 days) MPC /1/2018

16 maprotiline hcl oral tablet 25, 50, 75 *MODIFIED CYCLICS*** trazodone hcl oral tablet 100, 150, 300, 50 VIIBRYD ORAL TABLET 10 MG, 20 MG, 40 MG ; QL (30 EA per 30 days) *MONOAMINE OXIDASE INHIBITORS (MAOIS)*** EMSAM TRANSDERMAL TCH 24 HOUR 12 MG/24HR, 6 MG/24HR, 9 MG/24HR phenelzine sulfate oral tablet 15 tranylcypromine sulfate oral tablet 10 *SELECTIVE SEROTONIN REUPTAKE INHIBITORS (SSRIS)*** ; QL (30 EA per 30 days) citalopram hydrobromide oral solution 10 /5ml QL (600 ML per 30 days) citalopram hydrobromide oral tablet 10, 20 QL (60 EA per 30 days) citalopram hydrobromide oral tablet 40 QL (30 EA per 30 days) escitalopram oxalate oral solution 5 /5ml QL (600 ML per 30 days) escitalopram oxalate oral tablet 10 QL (45 EA per 30 days) escitalopram oxalate oral tablet 20, 5 QL (30 EA per 30 days) fluoxetine hcl oral capsule 10 QL (30 EA per 30 days) fluoxetine hcl oral capsule 20 QL (120 EA per 30 days) fluoxetine hcl oral capsule 40 QL (60 EA per 30 days) fluoxetine hcl oral solution 20 /5ml QL (600 ML per 30 days) fluvoxamine maleate er oral capsule extended release 24 hour 100, 150 ST; QL (30 EA per 30 days) fluvoxamine maleate oral tablet 100 QL (90 EA per 30 days) fluvoxamine maleate oral tablet 25 QL (30 EA per 30 days) fluvoxamine maleate oral tablet 50 QL (45 EA per 30 days) paroxetine hcl er oral tablet extended release 24 hour 12.5, 25, 37.5 paroxetine hcl oral tablet 10, 20, 30 QL (30 EA per 30 days) paroxetine hcl oral tablet 40 QL (45 EA per 30 days) XIL ORAL SUSPENSION 10 MG/5ML ; QL (900 ML per 30 days) sertraline hcl oral concentrate 20 /ml QL (300 ML per 30 days) sertraline hcl oral tablet 100, 25 QL (60 EA per 30 days) sertraline hcl oral tablet 50 QL (45 EA per 30 days) *SEROTONIN-NOREPINEPHRINE REUPTAKE INHIBITORS (SNRIS)*** duloxetine hcl oral capsule delayed release particles 20, 30, 60 venlafaxine hcl er oral capsule extended release 24 hour 150, 37.5 ST QL (60 EA per 30 days) QL (60 EA per 30 days) MPC /1/2018

17 venlafaxine hcl er oral capsule extended release 24 hour 75 venlafaxine hcl oral tablet 100, 25, 37.5, 50, 75 *TRICYCLIC AGENTS*** amitriptyline hcl oral tablet 10, 100, 150, 25, 50, 75 amoxapine oral tablet 100, 150, 25, 50 clomipramine hcl oral capsule 25, 50, 75 desipramine hcl oral tablet 10, 150, 25, 50 doxepin hcl oral capsule 10, 100, 150, 25, 50, 75 doxepin hcl oral concentrate 10 /ml imipramine hcl oral tablet 10, 25, 50 nortriptyline hcl oral capsule 10, 25, 50, 75 *ANTIDIABETICS* *ALPHA-GLUCOSIDASE INHIBITORS*** acarbose oral tablet 100, 25, 50 *ANTIDIABETIC - AMYLIN ANALOGS*** SYMLINPEN 120 SUBCUTANEOUS SOLUTION PEN-INJECTOR 2700 MCG/2.7ML SYMLINPEN 60 SUBCUTANEOUS SOLUTION PEN- INJECTOR 1500 MCG/1.5ML *BIGUANIDES*** metformin hcl er oral tablet extended release 24 hour 500, 750 metformin hcl oral tablet 1000, 500, 850 *DIABETIC OTHER*** GLUCAGON EMERGENCY INJECTION KIT 1 MG *DIPEPTIDYL PEPTIDASE-4 (DPP-4) INHIBITORS*** QL (90 EA per 30 days) QL (90 EA per 30 days) alogliptin benzoate oral tablet 12.5, 25 ST; QL (30 EA per 30 days) alogliptin benzoate oral tablet 6.25 ST; QL (30 EA per 1 day) *DIPEPTIDYL PEPTIDASE-4 INHIBITOR- BIGUANIDE COMBINATIONS*** alogliptin-metformin hcl oral tablet , *DPP-4 INHIBITOR-THIAZOLIDINEDIONE COMBINATIONS*** alogliptin-pioglitazone oral tablet , , , 25-15, 25-30, MPC /1/2018 ST; QL (60 EA per 30 days) ST; QL (30 EA per 30 days)

18 *HUMAN INSULIN*** BASAGLAR KWIKPEN SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML FIASP FLEXTOUCH SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML QL (45 ML per 30 days) QL (45 ML per 30 days) FIASP SUBCUTANEOUS SOLUTION 100 UNIT/ML QL (50 ML per 30 days) LEVEMIR FLEXTOUCH SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML LEVEMIR SUBCUTANEOUS SOLUTION 100 UNIT/ML NOVOLIN 70/30 RELION SUBCUTANEOUS SUSPENSION (70-30) 100 UNIT/ML NOVOLIN 70/30 SUBCUTANEOUS SUSPENSION (70-30) 100 UNIT/ML NOVOLIN N RELION SUBCUTANEOUS SUSPENSION 100 UNIT/ML NOVOLIN N SUBCUTANEOUS SUSPENSION 100 UNIT/ML ST; QL (45 ML per 30 days) ST; QL (50 ML per 30 days) QL (50 ML per 30 days) QL (50 ML per 30 days) QL (50 ML per 30 days) QL (50 ML per 30 days) NOVOLIN R INJECTION SOLUTION 100 UNIT/ML QL (50 ML per 30 days) NOVOLIN R RELION INJECTION SOLUTION 100 UNIT/ML NOVOLOG FLEXPEN SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML NOVOLOG MIX 70/30 FLEXPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR (70-30) 100 UNIT/ML NOVOLOG MIX 70/30 SUBCUTANEOUS SUSPENSION (70-30) 100 UNIT/ML NOVOLOG PENFILL SUBCUTANEOUS SOLUTION CARTRIDGE 100 UNIT/ML NOVOLOG SUBCUTANEOUS SOLUTION 100 UNIT/ML *INCRETIN MIMETIC AGENTS (GLP-1 RECEPTOR AGONISTS)*** TRULICITY SUBCUTANEOUS SOLUTION PEN- INJECTOR 0.75 MG/0.5ML, 1.5 MG/0.5ML VICTOZA SUBCUTANEOUS SOLUTION PEN- INJECTOR 18 MG/3ML *MEGLITINIDE ANALOGUES*** nateglinide oral tablet 120, 60 QL (50 ML per 30 days) QL (45 ML per 30 days) QL (45 ML per 30 days) QL (50 ML per 30 days) QL (45 ML per 30 days) QL (50 ML per 30 days) ; QL (2 ML per 28 days) ; QL (9 ML per 30 days) repaglinide oral tablet 0.5, 1 ST; QL (120 EA per 30 days) repaglinide oral tablet 2 ST; QL (240 EA per 30 days) *MEGLITINIDE-BIGUANIDE COMBINATIONS*** repaglinide-metformin hcl oral tablet ST *SODIUM-GLUCOSE CO-TRANSPORTER 2 (SGLT2) INHIBITORS*** MPC /1/2018

19 FARXIGA ORAL TABLET 10 MG, 5 MG ; QL (30 EA per 30 days) *SULFONYLUREA-BIGUANIDE COMBINATIONS*** glipizide-metformin hcl oral tablet , , glyburide-metformin oral tablet , QL (60 EA per 30 days) glyburide-metformin oral tablet QL (120 EA per 30 days) *SULFONYLUREAS*** chlorpropamide oral tablet 100, 250 glimepiride oral tablet 1, 2, 4 glipizide er oral tablet extended release 24 hour 10, 2.5, 5 glipizide oral tablet 10, 5 glyburide oral tablet 1.25, 2.5, 5 tolazamide oral tablet 250, 500 *SULFONYLUREA-THIAZOLIDINEDIONE COMBINATIONS*** pioglitazone hcl-glimepiride oral tablet 30-2, 30-4 *THIAZOLIDINEDIONE-BIGUANIDE COMBINATIONS*** pioglitazone hcl-metformin hcl oral tablet , *THIAZOLIDINEDIONES*** AVANDIA ORAL TABLET 2 MG, 4 MG ST; QL (60 EA per 30 days) pioglitazone hcl oral tablet 15, 30, 45 ST; QL (30 EA per 30 days) *ANTIDIARRHEALS* *ANTIPERISTALTIC AGENTS*** diphenoxylate-atropine oral liquid /5ml *ANTIDOTES* *OPIOID ANTAGONISTS*** naloxone hcl injection solution 0.4 /ml naltrexone hcl oral tablet 50 NARCAN NASAL LIQUID 4 MG/0.1ML VIVITROL INTRAMUSCULAR SUSPENSION RECONSTITUTED 380 MG *ANTIEMETICS* *5-HT3 RECEPTOR ANTAGONISTS*** MPC /1/2018 ST ST Naloxone injectable used with nasal atomizer is covered.; QL (2 ML per 30 days) ; SP; QL (1 EA per 30 days) ANZEMET ORAL TABLET 100 MG, 50 MG ; QL (4 EA per 28 days)

20 granisetron hcl intravenous solution 0.1 /ml, 4 /4ml granisetron hcl oral tablet 1 ST; QL (20 EA per 30 days) ondansetron hcl oral solution 4 /5ml Max 4 Years ondansetron hcl oral tablet 4, 8 QL (90 EA per 30 days) ondansetron oral tablet dispersible 4, 8 QL (90 EA per 30 days) *ANTIEMETICS - ANTICHOLINERGIC*** trimethobenzamide hcl oral capsule 300 *SUBSTANCE P/NEUROKININ 1 (NK1) RECEPTOR ANTAGONISTS*** aprepitant oral capsule 125, 40 ; QL (1 EA per 30 days) aprepitant oral capsule 80 & 125, 80 ; QL (3 EA per 30 days) EMEND ORAL SUSPENSION RECONSTITUTED 125 MG *ANTIFUNGALS* *ANTIFUNGALS*** bio-statin oral capsule unit, unit griseofulvin microsize oral suspension 125 /5ml griseofulvin ultramicrosize oral tablet 125, 250 nystatin oral tablet unit ; QL (6 EA per 28 days) terbinafine hcl oral tablet 250 QL (90 EA per 365 days) *IMIDAZOLES*** ketoconazole oral tablet 200 *TRIAZOLES*** fluconazole oral suspension reconstituted 10 /ml, 40 /ml fluconazole oral tablet 100, 150, 200, 50 itraconazole oral capsule 100 ST; QL (168 EA per 365 days) VFEND ORAL SUSPENSION RECONSTITUTED 40 MG/ML voriconazole oral tablet 200, 50 ; QL (60 EA per 30 days) *ANTIHISTAMINES* *ANTIHISTAMINES - NON-SEDATING*** allergy relief oral tablet dispersible 10 cetirizine hcl oral tablet 10, 5 OTC not covered for ABP plans cetirizine hcl oral tablet chewable 10, 5 OTC not covered for ABP plans childrens loratadine oral syrup 5 /5ml fexofenadine hcl oral tablet 180, 60 loratadine oral tablet 10 *ANTIHISTAMINES - PHENOTHIAZINES*** MPC /1/2018

21 promethazine hcl oral syrup 6.25 /5ml promethazine hcl oral tablet 12.5, 25, 50 promethazine hcl rectal suppository 12.5, 25 PROMETHEGAN RECTAL SUPPOSITORY 50 MG *ANTIHISTAMINES - PIPERIDINES*** cyproheptadine hcl oral syrup 2 /5ml cyproheptadine hcl oral tablet 4 *ANTIHYPERLIPIDEMICS* *BILE ACID SEQUESTRANTS*** cholestyramine light oral packet 4 gm cholestyramine light oral powder 4 gm/dose cholestyramine oral packet 4 gm cholestyramine oral powder 4 gm/dose colesevelam hcl oral tablet 625 PREVALITE ORAL POWDER 4 GM/DOSE WELCHOL ORAL CKET 3.75 GM *FIBRIC ACID DERIVATIVES*** fenofibrate micronized oral capsule 134, 200, 67 fenofibrate oral tablet 145, 160, 48, 54 gemfibrozil oral tablet 600 *HMG COA REDUCTASE INHIBITORS*** atorvastatin calcium oral tablet 10, 20, 40, 80 lovastatin oral tablet 10, 20, 40 pravastatin sodium oral tablet 10, 20, 40, 80 rosuvastatin calcium oral tablet 10, 20, 40, 5 simvastatin oral tablet 10, 20, 40, 5, 80 *INTEST CHOLEST ABSORP INHIB-HMG COA REDUCTASE INHIB COMB*** ezetimibe-simvastatin oral tablet 10-10, 10-20, 10-40, *INTESTINAL CHOLESTEROL ABSORPTION INHIBITORS*** ezetimibe oral tablet 10 *NICOTINIC ACID DERIVATIVES*** niacin er (antihyperlipidemic) oral tablet extended release 1000, 500, 750 QL (30 EA per 30 days) QL (30 EA per 30 days) MPC /1/2018 ST

22 NIACOR ORAL TABLET 500 MG *ANTIHYPERTENSIVES* *ACE INHIBITOR & CALCIUM CHANNEL BLOCKER COMBINATIONS*** amlodipine besy-benazepril hcl oral capsule 10-20, 10-40, , 5-10, 5-20, 5-40 *ACE INHIBITORS & THIAZIDE/THIAZIDE- LIKE*** benazepril-hydrochlorothiazide oral tablet , , 20-25, captopril-hydrochlorothiazide oral tablet 25-15, 25-25, 50-15, enalapril-hydrochlorothiazide oral tablet 10-25, fosinopril sodium-hctz oral tablet , lisinopril-hydrochlorothiazide oral tablet , , moexipril-hydrochlorothiazide oral tablet , 15-25, quinapril-hydrochlorothiazide oral tablet , , *ACE INHIBITORS*** benazepril hcl oral tablet 10, 20, 40, 5 captopril oral tablet 100, 12.5, 25, 50 enalapril maleate oral tablet 10, 2.5, 20, 5 fosinopril sodium oral tablet 10, 20, 40 lisinopril oral tablet 10, 2.5, 20, 30, 40, 5 moexipril hcl oral tablet 15, 7.5 quinapril hcl oral tablet 10, 20, 40, 5 ramipril oral capsule 1.25, 10, 2.5, 5 *ANGIOTENSIN II RECEPTOR ANTAG & THIAZIDE/THIAZIDE-LIKE*** candesartan cilexetil-hctz oral tablet ST; QL (60 EA per 30 days) candesartan cilexetil-hctz oral tablet , ST; QL (30 EA per 30 days) irbesartan-hydrochlorothiazide oral tablet ST; QL (60 EA per 30 days) irbesartan-hydrochlorothiazide oral tablet ST; QL (30 EA per 30 days) losartan potassium-hctz oral tablet , , valsartan-hydrochlorothiazide oral tablet , , , , MPC /1/2018 ST

23 *ANGIOTENSIN II RECEPTOR ANTAGONISTS*** candesartan cilexetil oral tablet 16, 4, 8 ST; QL (60 EA per 30 days) candesartan cilexetil oral tablet 32 ST; QL (30 EA per 30 days) irbesartan oral tablet 150, 300, 75 ST; QL (30 EA per 30 days) losartan potassium oral tablet 100, 25, 50 *ANTIADRENERGICS - CENTRALLY ACTING*** clonidine hcl oral tablet 0.1, 0.2, 0.3 guanfacine hcl oral tablet 1, 2 methyldopa oral tablet 250, 500 *ANTIADRENERGICS - PERIPHERALLY ACTING*** doxazosin mesylate oral tablet 1, 2, 4, 8 prazosin hcl oral capsule 1, 2, 5 terazosin hcl oral capsule 1, 10, 2, 5 *BETA BLOCKER & DIURETIC COMBINATIONS*** atenolol-chlorthalidone oral tablet , bisoprolol-hydrochlorothiazide oral tablet , , metoprolol-hydrochlorothiazide oral tablet , , *VASODILATORS*** hydralazine hcl oral tablet 10, 100, 25, 50 minoxidil oral tablet 10, 2.5 *ANTI-INFECTIVE AGENTS - MISC.* *ANTI-INFECTIVE AGENTS - MISC.*** metronidazole oral tablet 250, 500 NEBUPENT INHALATION SOLUTION RECONSTITUTED 300 MG trimethoprim oral tablet 100 vancomycin hcl intravenous solution reconstituted 1000, 500 SP; QL (1 vial per 28 days) vancomycin hcl oral capsule 125 ST; QL (40 EA per 30 days) vancomycin hcl oral capsule 250 ; QL (80 EA per 30 days) XIFAXAN ORAL TABLET 200 MG ; QL (9 EA per 30 days) XIFAXAN ORAL TABLET 550 MG ; QL (60 EA per 30 days) MPC /1/2018

24 *ANTI-INFECTIVE MISC. - COMBINATIONS*** sulfamethoxazole-trimethoprim oral suspension /5ml sulfamethoxazole-trimethoprim oral tablet *ANTIPROTOZOAL AGENTS*** atovaquone oral suspension 750 /5ml *CYCLIC LIPOPEPTIDES*** daptomycin intravenous solution reconstituted 500 *LEPROSTATICS*** dapsone oral tablet 100, 25 *LINCOSAMIDES*** clindamycin hcl oral capsule 150, 300, 75 clindamycin palmitate hcl oral solution reconstituted 75 /5ml *OXAZOLIDINONES*** linezolid in sodium chloride intravenous solution /300ml-% MPC /1/2018 linezolid intravenous solution 600 /300ml linezolid oral suspension reconstituted 100 /5ml linezolid oral tablet 600 ZYVOX INTRAVENOUS SOLUTION 200 MG/100ML *ANTIMALARIALS* *ANTIMALARIALS*** chloroquine phosphate oral tablet 250, 500 hydroxychloroquine sulfate oral tablet 200 primaquine phosphate oral tablet 26.3 *ANTIMYASTHENIC AGENTS* *ANTIMYASTHENIC AGENTS*** MESTINON ORAL SYRUP 60 MG/5ML pyridostigmine bromide oral tablet 60 *ANTIMYCOBACTERIAL AGENTS* *ANTIMYCOBACTERIAL AGENTS*** cycloserine oral capsule 250 ethambutol hcl oral tablet 100, 400 isoniazid oral syrup 50 /5ml isoniazid oral tablet 100, 300 SER ORAL CKET 4 GM PRIFTIN ORAL TABLET 150 MG

25 pyrazinamide oral tablet 500 rifabutin oral capsule 150 rifampin oral capsule 150, 300 *ANTINEOPLASTIC - BCL-2 INHIBITORS*** *ANTINEOPLASTIC - BCL-2 INHIBITORS*** VENCLEXTA ORAL TABLET 10 MG ; QL (60 EA per 30 days) VENCLEXTA ORAL TABLET 100 MG ; QL (120 EA per 30 days) VENCLEXTA ORAL TABLET 50 MG ; QL (30 EA per 30 days) VENCLEXTA STARTING CK ORAL TABLET THERAPY CK 10 & 50 & 100 MG *ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES* *ALKYLATING AGENTS*** HEXALEN ORAL CAPSULE 50 MG ; SP MYLERAN ORAL TABLET 2 MG ; SP *ANDROGEN BIOSYNTHESIS INHIBITORS*** ; QL (1 CK per 28 days) ZYTIGA ORAL TABLET 250 MG ; SP; QL (120 EA per 30 days) ZYTIGA ORAL TABLET 500 MG ; SP; QL (60 EA per 30 days) *ANTIADRENALS*** LYSODREN ORAL TABLET 500 MG *ANTIANDROGENS*** bicalutamide oral tablet 50 ST ERLEADA ORAL TABLET 60 MG ; QL (120 EA per 30 days) flutamide oral capsule 125 XTANDI ORAL CAPSULE 40 MG ; SP; QL (120 EA per 30 days) *ANTIESTROGENS*** FARESTON ORAL TABLET 60 MG ; SP; QL (30 EA per 30 days) tamoxifen citrate oral tablet 10, 20 *ANTIMETABOLITES*** capecitabine oral tablet 150, 500 ; SP mercaptopurine oral tablet 50 methotrexate oral tablet 2.5 methotrexate sodium (pf) injection solution 1 gm/40ml, 250 /10ml, 50 /2ml methotrexate sodium injection solution reconstituted 1 gm TABLOID ORAL TABLET 40 MG ; SP TREXALL ORAL TABLET 5 MG MPC /1/2018

26 *ANTINEOPLASTIC - BRAF KINASE INHIBITORS*** BRAFTOVI ORAL CAPSULE 50 MG ; QL (120 EA per 30 days) BRAFTOVI ORAL CAPSULE 75 MG ; QL (180 EA per 30 days) TAFINLAR ORAL CAPSULE 50 MG, 75 MG ; SP; QL (120 EA per 30 days) ZELBORAF ORAL TABLET 240 MG ; SP; QL (240 EA per 30 days) *ANTINEOPLASTIC - HEDGEHOG THWAY INHIBITORS*** ERIVEDGE ORAL CAPSULE 150 MG ; SP; QL (30 EA per 30 days) ODOMZO ORAL CAPSULE 200 MG ; QL (30 EA per 30 days) *ANTINEOPLASTIC - HISTONE DEACETYLASE INHIBITORS*** FARYDAK ORAL CAPSULE 10 MG, 15 MG, 20 MG ; QL (6 EA per 21 days) ZOLINZA ORAL CAPSULE 100 MG ; SP; QL (120 EA per 30 days) *ANTINEOPLASTIC - IMMUNOMODULATORS*** POMALYST ORAL CAPSULE 1 MG, 2 MG, 3 MG, 4 MG *ANTINEOPLASTIC - MEK INHIBITORS*** ; SP; QL (21 EA per 28 days) MEKINIST ORAL TABLET 0.5 MG ; SP; QL (90 EA per 30 days) MEKINIST ORAL TABLET 2 MG ; SP; QL (30 EA per 30 days) MEKTOVI ORAL TABLET 15 MG ; QL (180 EA per 30 days) *ANTINEOPLASTIC - MONOCLONAL ANTIBODIES*** RITUXAN INTRAVENOUS SOLUTION 100 MG/10ML, 500 MG/50ML TECENTRIQ INTRAVENOUS SOLUTION 1200 MG/20ML *ANTINEOPLASTIC - MTOR KINASE INHIBITORS*** AFINITOR DISPERZ ORAL TABLET SOLUBLE 2 MG, 3 MG, 5 MG AFINITOR ORAL TABLET 10 MG, 2.5 MG, 5 MG, 7.5 MG *ANTINEOPLASTIC - MULTIKINASE INHIBITORS*** ; SP ; SP NEXAVAR ORAL TABLET 200 MG ; SP; QL (120 EA per 30 days) MPC /1/2018

27 RYDAPT ORAL CAPSULE 25 MG ; Quantity limit for acute myeloid leukemia (AML) is 120 capsules per 30; Quantity limit for aggressive systemic mastocytosis (ASM),systemic mastocytosis w/assosicated hematological neoplasm (SM-AHN), and mast cell leukemia (MCL) is 240 capsules per 30; QL (120 EA per 30 days) STIVARGA ORAL TABLET 40 MG ; SP; QL (120 EA per 30 days) SUTENT ORAL CAPSULE 12.5 MG, 25 MG, 37.5 MG, 50 MG *ANTINEOPLASTIC - TYROSINE KINASE INHIBITORS*** ; SP ALECENSA ORAL CAPSULE 150 MG ; QL (240 EA per 30 days) ALUNBRIG ORAL TABLET 180 MG, 90 MG ; QL (30 EA per 30 days) ALUNBRIG ORAL TABLET 30 MG ; QL (60 EA per 30 days) ALUNBRIG ORAL TABLET THERAPY CK 90 & 180 MG ; QL (30 EA per 30 days) BOSULIF ORAL TABLET 100 MG ; SP; QL (90 EA per 30 days) BOSULIF ORAL TABLET 400 MG, 500 MG ; SP; QL (30 EA per 30 days) CABOMETYX ORAL TABLET 20 MG, 40 MG, 60 MG ; SP; QL (30 EA per 30 days) CALQUENCE ORAL CAPSULE 100 MG ; QL (60 EA per 30 days) CAPRELSA ORAL TABLET 100 MG ; SP; QL (60 EA per 30 days) CAPRELSA ORAL TABLET 300 MG ; SP; QL (30 EA per 30 days) COMETRIQ (100 MG DAILY DOSE) ORAL KIT 1 X 80 & 1 X 20 MG COMETRIQ (140 MG DAILY DOSE) ORAL KIT 1 X 80 & 3 X 20 MG COMETRIQ (60 MG DAILY DOSE) ORAL KIT 20 MG GILOTRIF ORAL TABLET 20 MG, 30 MG, 40 MG ICLUSIG ORAL TABLET 15 MG ; SP; QL (60 EA per 30 days) ICLUSIG ORAL TABLET 45 MG ; SP; QL (30 EA per 30 days) imatinib mesylate oral tablet 100, 400 ; SP; QL (60 EA per 30 days) IMBRUVICA ORAL TABLET 140 MG, 280 MG, 420 MG, 560 MG ; QL (28 EA per 28 days) INLYTA ORAL TABLET 1 MG, 5 MG ; SP; QL (4 EA per 1 day) IRESSA ORAL TABLET 250 MG ; QL (30 EA per 30 days) LENVIMA 10 MG DAILY DOSE ORAL CAPSULE THERAPY CK 10 MG LENVIMA 14 MG DAILY DOSE ORAL CAPSULE THERAPY CK 10 & 4 MG LENVIMA 20 MG DAILY DOSE ORAL CAPSULE THERAPY CK 10 (2) MG LENVIMA 24 MG DAILY DOSE ORAL CAPSULE THERAPY CK 10 (2) & 4 MG ; QL (30 EA per 30 days) ; QL (60 EA per 30 days) ; QL (60 EA per 30 days) ; QL (90 EA per 30 days) MPC /1/2018

28 SPRYCEL ORAL TABLET 100 MG, 140 MG, 20 MG, 50 MG, 70 MG, 80 MG ; SP; QL (30 EA per 30 days) TAGRISSO ORAL TABLET 40 MG, 80 MG ; QL (30 EA per 30 days) TARCEVA ORAL TABLET 100 MG, 150 MG, 25 MG ; SP; QL (60 EA per 30 days) TASIGNA ORAL CAPSULE 150 MG, 200 MG, 50 MG ; SP; QL (120 EA per 30 days) TYKERB ORAL TABLET 250 MG ; SP; QL (180 EA per 30 days) VOTRIENT ORAL TABLET 200 MG ; SP; QL (120 EA per 30 days) XALKORI ORAL CAPSULE 200 MG, 250 MG ; SP; QL (60 EA per 30 days) ZYKADIA ORAL CAPSULE 150 MG ; SP; QL (150 EA per 30 days) *ANTINEOPLASTIC COMBINATIONS*** KISQALI FEMARA 200 DOSE ORAL TABLET THERAPY CK 200 & 2.5 MG KISQALI FEMARA 400 DOSE ORAL TABLET THERAPY CK 200 & 2.5 MG KISQALI FEMARA 600 DOSE ORAL TABLET THERAPY CK 200 & 2.5 MG ; QL (49 EA per 28 days) ; QL (70 EA per 28 days) ; QL (91 EA per 28 days) LONSURF ORAL TABLET MG, MG ; QL (40 EA per 28 days) *ANTINEOPLASTICS MISC.*** ALFERON N INJECTION SOLUTION UNIT/ML hydroxyurea oral capsule 500 INTRON A INJECTION SOLUTION UNIT/ML, UNIT/ML MATULANE ORAL CAPSULE 50 MG ; SP SYLATRON SUBCUTANEOUS KIT 200 MCG, 300 MCG, 600 MCG *AROMATASE INHIBITORS*** anastrozole oral tablet 1 letrozole oral tablet 2.5 *ESTROGENS-ANTINEOPLASTIC*** ; SP EMCYT ORAL CAPSULE 140 MG ; SP *FOLIC ACID ANTAGONISTS RESCUE AGENTS*** leucovorin calcium oral tablet 10, 15, 25, 5 *IMIDAZOTETRAZINES*** temozolomide oral capsule 100, 140, 180, 20, 250, 5 *JANUS ASSOCIATED KINASE (JAK) INHIBITORS*** JAKAFI ORAL TABLET 10 MG, 15 MG, 20 MG, 25 MG, 5 MG *LHRH ANALOGS*** ; SP ; SP; QL (60 EA per 30 days) MPC /1/2018

29 leuprolide acetate injection kit 1 /0.2ml LUPRON DEPOT (1-MONTH) INTRAMUSCULAR KIT 3.75 MG, 7.5 MG LUPRON DEPOT (3-MONTH) INTRAMUSCULAR KIT MG, 22.5 MG LUPRON DEPOT (4-MONTH) INTRAMUSCULAR KIT 30 MG LUPRON DEPOT (6-MONTH) INTRAMUSCULAR KIT 45 MG *MITOTIC INHIBITORS*** etoposide oral capsule 50 *NITROGEN MUSTARDS*** cyclophosphamide oral capsule 25, 50 EVOMELA INTRAVENOUS SOLUTION RECONSTITUTED 50 MG MPC /1/2018 LEUKERAN ORAL TABLET 2 MG ; SP melphalan oral tablet 2 *PROGESTINS-ANTINEOPLASTIC*** megestrol acetate oral suspension 40 /ml megestrol acetate oral tablet 20, 40 *SELECTIVE RETINOID X RECEPTOR AGONISTS*** bexarotene oral capsule 75 ; SP *TOPOISOMERASE I INHIBITORS*** HYCAMTIN ORAL CAPSULE 0.25 MG, 1 MG ; SP *ANTIRKINSON AGENTS* *ANTIRKINSON ANTICHOLINERGICS*** benztropine mesylate oral tablet 0.5, 1, 2 COGENTIN INJECTION SOLUTION 1 MG/ML trihexyphenidyl hcl oral elixir 0.4 /ml trihexyphenidyl hcl oral tablet 2, 5 *ANTIRKINSON DOMINERGICS*** amantadine hcl oral capsule 100 amantadine hcl oral syrup 50 /5ml amantadine hcl oral tablet 100 bromocriptine mesylate oral capsule 5 bromocriptine mesylate oral tablet 2.5 *ANTIRKINSON MONOAMINE OXIDASE INHIBITORS*** required if billed with Dx codes F F64.9. required if billed with Dx codes F F64.9. required if billed with Dx codes F F64.9. required if billed with Dx codes F F64.9. required if billed with Dx codes F F64.9.

30 selegiline hcl oral capsule 5 selegiline hcl oral tablet 5 *LEVODO COMBINATIONS*** carbidopa-levodopa er oral tablet extended release , carbidopa-levodopa oral tablet , , carbidopa-levodopa oral tablet dispersible , , *NONERGOLINE DOMINE RECEPTOR AGONISTS*** pramipexole dihydrochloride oral tablet 0.125, 0.25, 0.5, 0.75, 1, 1.5 ropinirole hcl oral tablet 0.25, 0.5, 1, 2, 3, 4, 5 *PERIPHERAL COMT INHIBITORS*** entacapone oral tablet 200 *ANTIPSYCHOTICS/ANTIMANIC AGENTS* *ANTIMANIC AGENTS*** lithium carbonate er oral tablet extended release 300, 450 lithium carbonate oral capsule 150, 300, 600 lithium carbonate oral tablet 300 lithium oral solution 8 meq/5ml *ANTIPSYCHOTICS - MISC.*** ziprasidone hcl oral capsule 20, 40, 60, 80 *BENZISOXAZOLES*** risperidone oral solution 1 /ml risperidone oral tablet 0.25, 0.5, 1, 2, 3 QL (60 EA per 30 days); Min 6 Years QL (480 ML per 30 days); Min 6 Years QL (60 EA per 30 days); Min 6 Years risperidone oral tablet 4 QL (120 EA per 30 days); Min 6 Years risperidone oral tablet dispersible 0.25, 0.5, 1, 2, 3 ; QL (60 EA per 30 days) risperidone oral tablet dispersible 4 ; QL (120 EA per 30 days) *BUTYROPHENONES*** haloperidol decanoate intramuscular solution 100 /ml, 50 /ml haloperidol oral tablet 0.5, 1, 10, 2, 5 *DIBENZODIAZEPINES*** clozapine oral tablet 100 QL (270 EA per 30 days) MPC /1/2018

31 clozapine oral tablet 200 QL (135 EA per 30 days) clozapine oral tablet 25, 50 QL (60 EA per 30 days) clozapine oral tablet dispersible 100 ; QL (270 EA per 30 days) clozapine oral tablet dispersible 12.5 ; QL (60 EA per 30 days) clozapine oral tablet dispersible 25 ; QL (180 EA per 30 days) *DIBENZOTHIAZEPINES*** quetiapine fumarate oral tablet 100, 200, 25, 50 QL (90 EA per 30 days); Min 6 Years quetiapine fumarate oral tablet 300, 400 QL (60 EA per 30 days); Min 6 Years *DIBENZOXAZEPINES*** loxapine succinate oral capsule 10, 25, 5, 50 *PHENOTHIAZINES*** chlorpromazine hcl oral tablet 10, 100, 200, 25, 50 COMPRO RECTAL SUPPOSITORY 25 MG fluphenazine hcl oral concentrate 5 /ml fluphenazine hcl oral elixir 2.5 /5ml fluphenazine hcl oral tablet 1, 10, 2.5, 5 perphenazine oral tablet 16, 2, 4, 8 prochlorperazine edisylate injection solution 5 /ml prochlorperazine maleate oral tablet 10, 5 prochlorperazine rectal suppository 25 thioridazine hcl oral tablet 10, 100, 25, 50 trifluoperazine hcl oral tablet 1, 10, 2, 5 *QUINOLINONE DERIVATIVES*** aripiprazole oral solution 1 /ml ; QL (750 ML per 30 days) aripiprazole oral tablet 10, 15, 2, 20, 30, 5 QL (30 EA per 30 days) aripiprazole oral tablet dispersible 10, 15 ; QL (30 EA per 30 days) ARISTADA INTRAMUSCULAR PREFILLED SYRINGE 1064 MG/3.9ML, 441 MG/1.6ML, 662 MG/2.4ML, 882 MG/3.2ML *THIENBENZODIAZEPINES*** olanzapine oral tablet 10, 15, 2.5, 20, 5, 7.5 olanzapine oral tablet dispersible 10, 15, 20, 5 *THIOXANTHENES*** thiothixene oral capsule 1, 10, 2, 5 SP required for patients younger than 6 years of age.; QL (30 EA per 30 days); Min 6 Years QL (30 EA per 30 days); Min 6 Years MPC /1/2018

32 *ANTIRETROVIRALS ADJUVANTS*** *ANTIRETROVIRALS ADJUVANTS*** TYBOST ORAL TABLET 150 MG QL (30 EA per 30 days) *ANTISEPTICS & DISINFECTANTS* *CHLORINE ANTISEPTICS*** BETASEPT SURGICAL SCRUB EXTERNAL LIQUID 4 % *ANTIVIRALS* *ANTIRETROVIRAL COMBINATIONS*** abacavir sulfate-lamivudine oral tablet QL (30 EA per 30 days) abacavir-lamivudine-zidovudine oral tablet QL (60 EA per 30 days) ATRIPLA ORAL TABLET MG QL (30 EA per 30 days) BIKTARVY ORAL TABLET MG QL (30 EA per 30 days) CIMDUO ORAL TABLET MG QL (30 EA per 30 Days) COMPLERA ORAL TABLET MG QL (30 EA per 30 days) DESCOVY ORAL TABLET MG QL (30 EA per 30 days) EVOTAZ ORAL TABLET MG QL (30 EA per 30 days) GENVOYA ORAL TABLET MG QL (30 EA per 30 days) JULUCA ORAL TABLET MG QL (30 EA per 30 days) KALETRA ORAL TABLET MG QL (60 EA per 30 days) KALETRA ORAL TABLET MG QL (120 EA per 30 days) lamivudine-zidovudine oral tablet QL (60 EA per 30 days) lopinavir-ritonavir oral solution /5ml QL (300 ML per 30 days) ODEFSEY ORAL TABLET MG QL (30 EA per 30 days) PREZCOBIX ORAL TABLET MG QL (30 EA per 30 days) STRIBILD ORAL TABLET MG QL (30 EA per 30 days) SYMFI LO ORAL TABLET MG QL (30 EA per 30 days) TRIUMEQ ORAL TABLET MG QL (30 EA per 30 days) TRUVADA ORAL TABLET MG, MG, MG, MG *ANTIRETROVIRALS - CCR5 ANTAGONISTS (ENTRY INHIBITOR)*** QL (30 EA per 30 days) SELZENTRY ORAL TABLET 150 MG, 300 MG QL (120 EA per 30 days) *ANTIRETROVIRALS - FUSION INHIBITORS*** FUZEON SUBCUTANEOUS SOLUTION RECONSTITUTED 90 MG *ANTIRETROVIRALS - INTEGRASE INHIBITORS*** QL (60 EA per 30 days) ISENTRESS HD ORAL TABLET 600 MG QL (60 EA per 30 days) ISENTRESS ORAL CKET 100 MG QL (60 EA per 30 days) MPC /1/2018