Magellan Rx Medicare Basic (PDP) 2019 Formulary

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1 Magellan Rx Medicare Basic (PDP) 2019 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE S WE COVER IN THIS PLAN Formulary File 19170, Version 19 This formulary was updated on 02/20/2019. For more recent information or other questions, please contact Magellan Rx Medicare Customer Service at or, for TTY users, 711, 24 hours a day, 7 days a week, 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. When this drug list (formulary) refers to we, us, or our, it means Magellan Rx Medicare. When it refers to plan or our plan, it means Magellan Rx Medicare Basic (PDP). This document includes a list of the drugs (formulary) for our plan which is current as of March 1, For an updated formulary, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy network, and/or copayments/coinsurance may change on January 1, 2020, and from time to time during the year. S4607_CLFMCM_2019_C Accepted

2 What is the Magellan Rx Medicare Basic (PDP) Formulary? A formulary is a list of covered drugs selected by Magellan Rx Medicare Basic (PDP) 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. Magellan Rx Medicare Basic (PDP) will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a Magellan Rx Medicare Basic (PDP) 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 2019 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2019 coverage year except when a new, less expensive generic drug becomes available, when new information about the safety or effectiveness of a drug is released, or the drug is removed from the market. (See bullets below for more information on changes that affect members currently taking the drug.) 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. Below are changes to the drug list that will also affect members currently taking a drug: New generic drugs. We may immediately remove a brand name drug on our Drug List if we are replacing it with a new generic drug that will appear on the same or lower cost sharing tier and with the same or fewer restrictions. Also, when adding the new generic drug, we may decide to keep the brand name drug on our Drug List, but immediately move it to a different cost-sharing tier or add new restrictions. If you are currently taking that brand name drug, we may not tell you in advance before we make that change, but we will later provide you with information about the specific change(s) we have made. o If we make such a change, you or your prescriber can ask us to make an exception and continue to cover the brand name drug for you. The notice we provide you will also include information on the steps you may take to request an exception, and you can also find information in the section below entitled How do I request an exception to the Magellan Rx Medicare Basic (PDP) Formulary? Drugs removed from the market. If the Food and Drug 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. Other changes. We may make other changes that affect members currently taking a drug. For instance, we may add a generic drug that is not new to market to replace a brand name drug currently on the formulary or add new restrictions to the brand name drug or move it to a different cost-sharing tier. Or we may make changes based on new clinical guidelines. If we remove drugs from our formulary, 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 30 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 30-day supply of the drug. I

3 The enclosed formulary is current as of March 1, To get updated information about the drugs covered by Magellan Rx Medicare Basic (PDP), please contact us. Our contact information appears on the front and back cover pages. If we have a mid-year non-maintenance formulary change (such as adding prior authorization requirements, quantity limits and/or step therapy restrictions on a drug, removing drugs from our formulary, or moving a drug to a higher cost-sharing tier), we will notify you by mail. We will also update our formulary with the information. The updated formulary will be available on our website or by calling Customer Service. Our contact information appears on the front and back cover pages of this document. 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 on 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 93. 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? Magellan Rx Medicare Basic (PDP) 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. II

4 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: Magellan Rx Medicare Basic (PDP) requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from Magellan Rx Medicare Basic (PDP) before you fill your prescriptions. If you don t get approval, Magellan Rx Medicare Basic (PDP) may not cover the drug. Quantity Limits: For certain drugs, Magellan Rx Medicare Basic (PDP) limits the amount of the drug that Magellan Rx Medicare Basic (PDP) will cover. For example, Magellan Rx Medicare Basic (PDP) provides 60 per prescription for PRADAXA. This may be in addition to a standard one-month or three-month supply. Step Therapy: In some cases, Magellan Rx Medicare Basic (PDP) requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, Magellan Rx Medicare Basic (PDP) may not cover Drug B unless you try Drug A first. If Drug A does not work for you, Magellan Rx Medicare Basic (PDP) will then cover Drug 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 on line 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 Magellan Rx Medicare Basic (PDP) 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 Magellan Rx Medicare Basic (PDP) formulary? on page IV for information about how to request an exception. III

5 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 Member Services and ask if your drug is covered. If you learn that Magellan Rx Medicare Basic (PDP) does not cover your drug, you have two options: You can ask Customer Service for a list of similar drugs that are covered by Magellan Rx Medicare Basic (PDP). When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by Magellan Rx Medicare Basic (PDP). You can ask Magellan Rx Medicare Basic (PDP) 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 Magellan Rx Medicare Basic (PDP) Formulary? You can ask Magellan Rx Medicare Basic (PDP) 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, Magellan Rx Medicare Basic (PDP) 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, Magellan Rx Medicare Basic (PDP) 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, or utilization restriction exception. When you request a formulary or utilization restriction exception you should submit a statement from your prescriber or physician supporting your request. Generally, we must make our decision within 72 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 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get a supporting statement from your doctor or other prescriber. IV

6 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 30-day supply. If your prescription is written for fewer days, we ll allow refills to provide up to a maximum 30 day supply of medication.after your first 30-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 and 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 31-day emergency supply of that drug while you pursue a formulary exception. Magellan Rx Management, a properly licensed affiliate of Magellan Health, Inc. (Magellan) implements and maintains an appropriate medication transition process consistent with Centers for Medicare and Medicaid Services (CMS) requirement for members whose current prescribed Part D drugs are not on Magellan s formulary. Magellan Rx Management (Magellan) implements and maintains an appropriate transition process in compliance with CMS rules and guidance. Transition supplies are available to members whose current drug therapy may not be covered by the plan, or that are on the formulary but subject to prior authorization (PA), step therapy (ST), or quantity limit (QL) edits based on Magellan s utilization management program. Transition supplies will allow members sufficient time to work with their medical provider to switch to a therapeutically appropriate formulary alternative or to request a coverage determination should the medication be medically necessary. Enrollees experiencing a level of care change may access a refill upon admission or discharge to a long term care facility. Enrollees in need of a one-time Transition Fill, or who are prescribed a Non-Formulary Drug as a result of a level of care change, can be placed in transition via a National Council for Prescription Drug Plans (NCPDP) pharmacy submission clarification code (SCC) via manual override at the pharmacy or by contacting Magellan Call Center for an override. For more information For more detailed information about your Magellan Rx Medicare Basic (PDP) prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about Magellan Rx Medicare Basic (PDP), 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 ( ), 24 hours a day/7 days a week. TTY users should call Or, visit V

7 Magellan Rx Medicare Basic (PDP) s Formulary The formulary that begins on the next page provides coverage information about the drugs covered by Magellan Rx Medicare Basic (PDP). If you have trouble finding your drug in the list, turn to the Index that begins on page 93. The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., LANOXIN) and generic drugs are listed in lower-case italics (e.g., digoxin). The information in the column tells you if Magellan Rx Medicare Basic (PDP) has any special requirements for coverage of your drug. VI

8 LEGEND NAME 1 Preferred Generic 2 Generic 3 Preferred Brand 4 Non-Preferred Drug 5 Specialty Tier SYMBOL NAME DESCRIPTION QL Quantity Limit There is a limit on the amount of this drug that is covered per prescription, or within a specific time frame. PA ST Prior Authorization Step Therapy You (or your physician) are required to get prior authorization before you fill your prescription for this drug. Without prior approval, we may not cover this drug. In some cases, you may be required to first try certain drugs to treat your medical condition before we will cover another drug for that condition. MO Mail Order This prescription may also be available via mail. 1

9 Analgesics Nonsteroidal Anti-inflammatory Drugs celecoxib (50 mg cap, 100 mg cap, 200 mg cap, 400 mg cap) 2 QL (60 PER 30 DAYS), MO (Mail diclofenac potassium 50 mg tab 3 MO (Mail diclofenac sodium (25 mg tab dr, 50 mg tab dr, 75 mg tab dr) 3 MO (Mail diflunisal 500 mg tab 2 MO (Mail ibu (400 mg tab, 600 mg tab, 800 mg tab) 1 MO (Mail ibuprofen (100 mg/5ml suspension, 400 mg tab, 600 mg tab, 800 mg tab) 1 MO (Mail indomethacin (25 mg cap, 50 mg cap) 4 MO (Mail ketorolac tromethamine 10 mg tab 4 QL (20 PER 30 OVER TIME), MO (Mail meloxicam (7.5 mg tab, 15 mg tab) 1 MO (Mail nabumetone (500 mg tab, 750 mg tab) 2 MO (Mail naproxen (125 mg/5ml suspension, 250 mg tab) 2 MO (Mail naproxen (375 mg tab, 500 mg tab) 1 MO (Mail Opioid Analgesics, Long-acting buprenorphine (5 mcg/hr patch wk, 10 mcg/hr patch wk, 15 mcg/hr patch wk, 20 mcg/hr patch wk) EMBEDA ( MG CAP ER, MG CAP ER, 50-2 MG CAP ER, MG CAP ER, MG CAP ER, MG CAP ER) fentanyl (12 mcg/hr patch 72hr, 25 mcg/hr patch 72hr, 37.5 mcg/hr patch 72hr, 50 mcg/hr patch 72hr, 62.5 mcg/hr patch 72hr, 75 mcg/hr patch 72hr, 100 mcg/hr patch 72hr) 4 QL (4 PER 28 DAYS), MO (Mail 3 QL (60 PER 30 DAYS), MO (Mail 4 QL (15 PER 30 DAYS), MO (Mail fentanyl 87.5 mcg/hr patch 72hr 5 QL (15 PER 30 DAYS), MO (Mail methadone hcl (5 mg/5ml solution, 10 mg/5ml solution) 4 QL (900 PER 30 DAYS), MO (Mail 2

10 methadone hcl 10 mg tab 3 QL (180 PER 30 DAYS), MO (Mail methadone hcl 5 mg tab 3 QL (90 PER 30 DAYS), MO (Mail morphine sulfate er (er 10 mg cap er 24h, er 20 mg cap er 24h, er 30 mg cap er 24h, er 40 mg cap er 24h, er 50 mg cap er 24h, er 60 mg cap er 24h, er 80 mg cap er 24h) 4 QL (30 PER 30 DAYS), MO (Mail morphine sulfate er (er 15 mg tab er, er 30 mg tab er, er 60 mg tab er, er 100 mg tab er) 2 QL (90 PER 30 DAYS), MO (Mail morphine sulfate er 100 mg cap er 24h 5 QL (30 PER 30 DAYS), MO (Mail morphine sulfate er 200 mg tab er 4 QL (90 PER 30 DAYS), MO (Mail Opioid Analgesics, Short-acting acetaminophen-codeine mg/5ml solution 2 QL (2700 PER 30 DAYS), MO (Mail acetaminophen-codeine mg tab 2 QL (360 PER 30 DAYS), MO (Mail acetaminophen-codeine mg tab 2 QL (360 PER 30 DAYS), MO (Mail acetaminophen-codeine mg tab 2 QL (180 PER 30 DAYS), MO (Mail butalbital-apap-caff-cod ( mg cap, mg cap) butalbital-asa-caff-codeine mg cap 4 QL (390 PER 30 DAYS), MO (Mail 4 QL (390 PER 30 DAYS), MO (Mail butorphanol tartrate 10 mg/ml solution 2 QL (60 PER 30 DAYS), MO (Mail codeine sulfate (15 mg tab, 30 mg tab, 60 mg tab) duramorph (0.5 mg/ml solution, 1 mg/ml solution) fentanyl citrate (200 mcg loz handle, 400 mcg loz handle, 600 mcg loz handle, 800 mcg loz handle, 1200 mcg loz handle, 1600 mcg loz handle) 2 QL (180 PER 30 DAYS), MO (Mail 2 MO (Mail 5 PA, QL (120 PER 30 DAYS), MO (Mail 3

11 hydrocodone-acetaminophen ( mg/5ml solution, mg/10ml solution, mg/15ml solution, mg/15ml solution) hydrocodone-acetaminophen ( mg tab, mg tab, mg tab, mg tab) hydrocodone-acetaminophen (5-300 mg tab, mg tab, mg tab) hydrocodone-ibuprofen ( mg tab, mg tab, mg tab, mg tab) hydromorphone hcl (2 mg tab, 4 mg tab, 8 mg tab) 3 QL (3600 PER 30 DAYS), MO (Mail 3 QL (180 PER 30 DAYS), MO (Mail 3 QL (390 PER 30 DAYS), MO (Mail 3 QL (180 PER 30 DAYS), MO (Mail 4 QL (180 PER 30 DAYS), MO (Mail hydromorphone hcl 1 mg/ml liquid 4 QL (1800 PER 30 DAYS), MO (Mail hydromorphone hcl 2 mg/ml solution 4 MO (Mail hydromorphone hcl pf (1 mg/ml solution, 4 mg/ml solution, 10 mg/ml solution, 50 mg/5ml solution, 500 mg/50ml solution) 4 MO (Mail morphine sulfate (15 mg tab, 30 mg tab) 3 QL (180 PER 30 DAYS), MO (Mail morphine sulfate (2 mg/ml solution, 4 mg/ml solution, 8 mg/ml solution, 10 mg/ml solution) morphine sulfate (concentrate) ((concentrate) 20 mg/ml solution, (concentrate) 100 mg/5ml solution) 4 MO (Mail 4 QL (450 PER 30 DAYS), MO (Mail morphine sulfate (pf) 2 mg/ml solution 4 MO (Mail morphine sulfate 10 mg/5ml solution 4 QL (1800 PER 30 DAYS), MO (Mail morphine sulfate 20 mg/5ml solution 4 QL (900 PER 30 DAYS), MO (Mail oxycodone hcl (5 mg cap, 5 mg tab, 10 mg tab, 15 mg tab, 20 mg tab, 30 mg tab) 3 QL (180 PER 30 DAYS), MO (Mail oxycodone hcl 100 mg/5ml conc 4 QL (180 PER 30 DAYS), MO (Mail oxycodone hcl 5 mg/5ml solution 3 QL (3600 PER 30 DAYS), MO (Mail oxycodone-acetaminophen ( mg tab, mg tab) 3 QL (180 PER 30 DAYS), MO (Mail 4

12 oxycodone-acetaminophen mg tab 3 QL (120 PER 30 DAYS), MO (Mail oxycodone-acetaminophen mg tab 3 QL (240 PER 30 DAYS), MO (Mail oxycodone-aspirin mg tab 3 QL (360 PER 30 DAYS), MO (Mail oxycodone-ibuprofen mg tab 3 QL (120 PER 30 DAYS), MO (Mail tramadol hcl 50 mg tab 2 QL (240 PER 30 DAYS), MO (Mail Anesthetics Local Anesthetics lidocaine 5 % patch 4 PA, MO (Mail lidocaine hcl 2 % gel 2 PA, QL (30 PER 30 DAYS), MO (Mail lidocaine hcl 4 % solution 2 PA, QL (50 PER 30 DAYS), MO (Mail lidocaine viscous 2 % solution 1 MO (Mail lidocaine-prilocaine % cream 4 PA, QL (30 PER 30 DAYS), MO (Mail lidocaine-prilocaine cream % 4 PA, QL (30 PER 30 DAYS), MO (Mail Anti-Addiction/Substance Abuse Treatment Agents Alcohol Deterrents/Anti-craving acamprosate calcium 333 mg tab dr 2 MO (Mail disulfiram (250 mg tab, 500 mg tab) 2 MO (Mail VIVITROL 380 MG RECON SUSP 5 MO (Mail Opioid Dependence Treatments buprenorphine hcl 2 mg sl tab 2 QL (360 PER 30 DAYS), MO (Mail buprenorphine hcl 8 mg sl tab 2 QL (90 PER 30 DAYS), MO (Mail 5

13 buprenorphine hcl-naloxone hcl mg sl tab 2 QL (360 PER 30 DAYS), MO (Mail buprenorphine hcl-naloxone hcl 8-2 mg film 3 QL (90 PER 30 DAYS), MO (Mail buprenorphine hcl-naloxone hcl 8-2 mg sl tab 2 QL (90 PER 30 DAYS), MO (Mail naltrexone hcl 50 mg tab 2 MO (Mail SUBOXONE 12-3 MG FILM 4 QL (60 PER 30 DAYS), MO (Mail SUBOXONE MG FILM 4 QL (360 PER 30 DAYS), MO (Mail SUBOXONE 4-1 MG FILM 4 QL (180 PER 30 DAYS), MO (Mail SUBOXONE 8-2 MG FILM 4 QL (90 PER 30 DAYS), MO (Mail Opioid Reversal Agents naloxone hcl (0.4 mg/ml solution, 0.4 mg/ml soln cart, 2 mg/2ml soln prsyr) 2 MO (Mail NARCAN 4 MG/0.1ML LIQUID 4 MO (Mail Smoking Cessation Agents bupropion hcl er (smoking det) tab er 12h 150 mg 3 QL (60 PER 30 DAYS), MO (Mail CHANTIX (0.5 MG TAB, 1 MG TAB) 3 QL (504 PER 365 OVER TIME), MO (Mail CHANTIX CONTINUING MONTH PAK 1 MG TAB 3 QL (504 PER 365 OVER TIME), MO (Mail CHANTIX STARTING MONTH PAK 3 QL (504 PER 365 OVER TIME), MO (Mail NICOTROL NS 10 MG/ML SOLUTION 3 QL (360 PER 365 OVER TIME), MO (Mail Antibacterials Aminoglycosides amikacin sulfate 500 mg/2ml solution 2 MO (Mail 6

14 gentamicin in saline ( mg/ml-% solution, mg/ml-% solution, mg/ml-% solution, mg/ml-% solution, mg/ml-% solution) gentamicin sulfate (0.1 % cream, 0.1 % ointment, 40 mg/ml solution) 2 MO (Mail 2 MO (Mail gentamicin sulfate 0.3 % solution 1 MO (Mail neomycin sulfate 500 mg tab 2 MO (Mail paromomycin sulfate 250 mg cap 4 MO (Mail streptomycin sulfate 1 gm recon soln 4 MO (Mail tobramycin 0.3 % solution 1 MO (Mail tobramycin sulfate (1.2 gm/30ml solution, 1.2 gm recon soln, 2 gm/50ml solution, 10 mg/ml solution, 80 mg/2ml solution) 2 MO (Mail TOBREX 0.3 % OINTMENT 4 MO (Mail Antibacterials, Other bacitra-neomycin-polymyxin-hc 1 % ointment 2 MO (Mail bacitracin 500 unit/gm ointment 2 MO (Mail BACTROBAN NASAL 2 % OINTMENT 4 MO (Mail clindamycin hcl (75 mg cap, 150 mg cap, 300 mg cap) clindamycin palmitate hcl 75 mg/5ml recon soln clindamycin phosphate (1 % lotion, 1 % gel, 2 % cream) clindamycin phosphate (1 % solution, 1 % swab, 300 mg/2ml solution, 600 mg/4ml solution, 900 mg/6ml solution) clindamycin phosphate in d5w ( 600 mg/50ml solution, 900 mg/50ml solution) clindamycin phosphate in d5w 300 mg/50ml solution 2 MO (Mail 2 MO (Mail 4 MO (Mail 2 MO (Mail 4 MO (Mail 2 MO (Mail colistimethate sodium (cba) 150 mg recon soln 4 MO (Mail daptomycin (350 mg recon soln, 500 mg recon soln) 5 MO (Mail 7

15 linezolid 100 mg/5ml recon susp 5 QL (1800 PER 28 DAYS), MO (Mail linezolid 600 mg tab 5 QL (56 PER 28 DAYS), MO (Mail linezolid 600 mg/300ml solution 5 MO (Mail methenamine hippurate tab 1 gm 4 MO (Mail metronidazole (0.75 % gel, 0.75 % cream) 2 MO (Mail metronidazole (0.75 % lotion, 1 % gel) 4 MO (Mail metronidazole (250 mg tab, 375 mg cap, 500 mg tab) metronidazole in nacl ( mg/ml-% solution, mg/100ml-% solution) 3 MO (Mail 3 MO (Mail mupirocin 2 % ointment 2 MO (Mail neomycin-polymyxin-hc suspension 3 MO (Mail nitrofurantoin 25 mg/5ml suspension 4 QL (7200 PER 365 OVER TIME), MO (Mail nitrofurantoin macrocrystal 100 mg cap 3 QL (360 PER 365 OVER TIME), MO (Mail nitrofurantoin macrocrystal 25 mg cap 3 QL (1440 PER 365 OVER TIME), MO (Mail nitrofurantoin macrocrystal 50 mg cap 3 QL (720 PER 365 OVER TIME), MO (Mail nitrofurantoin monohyd macro 100 mg cap 3 QL (180 PER 365 OVER TIME), MO (Mail polymyxin b sulfate unit recon soln 2 MO (Mail silver sulfadiazine 1 % cream 4 MO (Mail ssd 1 % cream 2 MO (Mail trimethoprim 100 mg tab 2 MO (Mail TYGACIL 50 MG RECON SOLN 5 MO (Mail vancomycin hcl (1 gm recon soln, 1.25 gm recon soln, 1.5 gm recon soln, 5 gm recon soln, 10 gm recon soln, 125 mg cap, 250 mg cap, 250 mg recon soln, 500 mg recon soln, 750 mg recon soln) 4 MO (Mail 8

16 vandazole 0.75 % gel 2 MO (Mail Beta-lactam, Cephalosporins cefaclor (250 mg cap, 500 mg cap) 4 MO (Mail cefaclor er 500 mg tab er 12h 4 MO (Mail cefadroxil (1 gm tab, 250 mg/5ml recon susp, 500 mg/5ml recon susp, 500 mg cap) cefazolin sodium (1 gm recon soln, 10 gm recon soln, 20 gm recon soln, 500 mg recon soln) cefdinir (125 mg/5ml recon susp, 250 mg/5ml recon susp, 300 mg cap) cefepime hcl (1 gm recon soln, 2 gm recon soln) cefixime (100 mg/5ml recon susp, 200 mg/5ml recon susp) cefotaxime sodium (1 gm recon soln, 2 gm recon soln, 500 mg recon soln) cefotetan disodium (1 gm recon soln, 2 gm recon soln) cefoxitin sodium (1 gm recon soln, 2 gm recon soln, 10 gm recon soln) cefpodoxime proxetil (50 mg/5ml recon susp, 100 mg/5ml recon susp, 100 mg tab, 200 mg tab) cefprozil (125 mg/5ml recon susp, 250 mg tab, 250 mg/5ml recon susp, 500 mg tab) ceftazidime (1 gm recon soln, 2 gm recon soln, 6 gm recon soln) ceftriaxone sodium (1 gm recon soln, 2 gm recon soln, 10 gm recon soln, 250 mg recon soln, 500 mg recon soln) 2 MO (Mail 2 MO (Mail 3 MO (Mail 4 MO (Mail 4 MO (Mail 2 MO (Mail 2 MO (Mail 2 MO (Mail 4 MO (Mail 2 MO (Mail 2 MO (Mail 4 MO (Mail cefuroxime axetil (250 mg tab, 500 mg tab) 3 MO (Mail cefuroxime sodium (1.5 gm recon soln, 7.5 gm recon soln, 750 mg recon soln) cephalexin (125 mg/5ml recon susp, 250 mg cap, 250 mg tab, 250 mg/5ml recon susp, 500 mg tab, 500 mg cap, 750 mg cap) 3 MO (Mail 2 MO (Mail 9

17 SUPRAX (100 MG CHEW TAB, 200 MG CHEW TAB, 400 MG CAP) 3 MO (Mail SUPRAX 500 MG/5ML RECON SUSP 5 MO (Mail TEFLARO (400 MG RECON SOLN, 600 MG RECON SOLN) 5 MO (Mail Beta-lactam, Other AZACTAM (1 GM RECON SOLN, 2 GM RECON SOLN) 4 MO (Mail aztreonam 1 gm recon soln 4 MO (Mail ertapenem sodium 1 gm recon soln 2 MO (Mail imipenem-cilastatin (250 mg recon soln, 500 mg recon soln) 4 MO (Mail INVANZ 1 GM RECON SOLN 4 MO (Mail meropenem (1 gm recon soln, 500 mg recon soln) Beta-lactam, Penicillins amoxicillin (125 mg chew tab, 125 mg/5ml recon susp, 200 mg/5ml recon susp, 250 mg/5ml recon susp, 250 mg chew tab, 250 mg cap, 400 mg/5ml recon susp, 500 mg cap, 500 mg tab, 875 mg tab) amoxicillin-pot clavulanate ( mg/5ml recon susp, mg chew tab, mg tab, mg/5ml recon susp, mg chew tab, mg/5ml recon susp, mg tab, mg/5ml recon susp, mg tab) amoxicillin-pot clavulanate er mg tab er 12h 2 MO (Mail 2 MO (Mail 2 MO (Mail 2 MO (Mail ampicillin 500 mg cap 2 MO (Mail ampicillin sodium (1 gm recon soln, 2 gm recon soln, 10 gm recon soln) 2 MO (Mail ampicillin sodium 125 mg recon soln 4 MO (Mail ampicillin-sulbactam sodium (1.5 (1-0.5) gm recon soln, 3 (2-1) gm recon soln, 15 (10-5) gm recon soln) 2 MO (Mail 10

18 AUGMENTIN MG/5ML RECON SUSP BICILLIN C-R UNIT/2ML SUSPENSION BICILLIN C-R 900/ UNIT/2ML SUSPENSION BICILLIN L-A ( UNIT/ML SUSPENSION, UNIT/2ML SUSPENSION, UNIT/4ML SUSPENSION) 5 MO (Mail 4 MO (Mail 4 MO (Mail 4 MO (Mail dicloxacillin sodium (250 mg cap, 500 mg cap) 2 MO (Mail nafcillin sodium (1 gm recon soln, 2 gm recon soln) 4 MO (Mail nafcillin sodium 10 gm recon soln 5 MO (Mail oxacillin sodium 10 gm recon soln 5 MO (Mail oxacillin sodium 2 gm recon soln 4 MO (Mail penicillin g pot in dextrose (20000 unit/ml solution, unit/ml solution, unit/ml solution) penicillin g potassium ( recon soln, recon soln) 4 MO (Mail 4 MO (Mail penicillin g sodium unit recon soln 5 MO (Mail penicillin v potassium (125 mg/5ml recon soln, 250 mg/5ml recon soln) penicillin v potassium (250 mg tab, 500 mg tab) piperacillin sod-tazobactam so (d-tazobactam 2.25 (2-0.25) gm recon ln, d-tazobactam ( ) gm recon ln, d-tazobactam 4.5 (4-0.5) gm recon ln, d-tazobactam 40.5 (36-4.5) gm recon ln) Macrolides azithromycin (1 gm packet, 100 mg/5ml recon susp, 200 mg/5ml recon susp, 250 mg tab, 500 mg recon soln, 500 mg tab, 600 mg tab) clarithromycin (125 mg/5ml recon susp, 250 mg/5ml recon susp, 250 mg tab, 500 mg tab) 1 MO (Mail 2 MO (Mail 4 MO (Mail 2 MO (Mail 4 MO (Mail 11

19 clarithromycin er 500 mg tab er 24h 4 MO (Mail DIFICID 200 MG TAB 5 MO (Mail ERY-TAB (250 MG TAB DR, 333 MG TAB DR, 500 MG TAB DR) ERYTHROCIN LACTOBIONATE 500 MG RECON SOLN 4 MO (Mail 4 MO (Mail ERYTHROCIN STEARATE 250 MG TAB 4 MO (Mail erythromycin (2 % gel, 2 % solution, 5 mg/gm ointment) erythromycin base (250 mg tab, 250 mg cp dr part, 500 mg tab) erythromycin ethylsuccinate (200 mg/5ml recon susp, 400 mg tab) 2 MO (Mail 4 MO (Mail 4 MO (Mail Quinolones BAXDELA (300 MG RECON SOLN, 450 MG TAB) 5 MO (Mail BESIVANCE 0.6 % SUSPENSION 4 MO (Mail ciprofloxacin (250 mg/5ml (5%) recon susp, 500 mg/5ml (10%) recon susp) ciprofloxacin hcl (0.3 % solution, 100 mg tab, 250 mg tab, 500 mg tab, 750 mg tab) ciprofloxacin in d5w (200 mg/100ml solution, 400 mg/200ml solution) ciprofloxacin-ciproflox hcl er (er 500 mg tab er 24h, er 1000 mg tab er 24h) 2 MO (Mail 2 MO (Mail 2 MO (Mail 2 MO (Mail gatifloxacin 0.5 % solution 2 MO (Mail levofloxacin (0.5 % solution, 250 mg tab, 500 mg tab, 750 mg tab) 4 MO (Mail levofloxacin 25 mg/ml oral solution 4 MO (Mail levofloxacin 25 mg/ml solution inj 4 MO (Mail levofloxacin in d5w ( 250 mg/50ml solution, 500 mg/100ml solution, 750 mg/150ml solution) 4 MO (Mail ofloxacin (300 mg tab, 400 mg tab) 4 MO (Mail 12

20 ofloxacin 0.3 % ophthalmic solution 4 MO (Mail ofloxacin 0.3 % otic solution 4 MO (Mail Sulfonamides sulfadiazine 500 mg tab 4 MO (Mail sulfamethoxazole-trimethoprim ( mg/5ml suspension, mg tab, mg tab) 2 MO (Mail sulfatrim pediatric mg/5ml suspension 2 MO (Mail Tetracyclines demeclocycline hcl (150 mg tab, 300 mg tab) 4 MO (Mail doxy mg recon soln 4 MO (Mail doxycycline hyclate (20 mg tab, 50 mg tab, 50 mg cap, 75 mg tab, 100 mg tab, 100 mg cap, 150 mg tab) 3 MO (Mail doxycycline hyclate 100 mg recon soln 4 MO (Mail doxycycline monohydrate (25 mg/5ml recon susp, 50 mg tab, 50 mg cap, 75 mg tab, 75 mg cap, 100 mg cap, 100 mg tab, 150 mg tab, 150 mg cap) minocycline hcl (50 mg cap, 75 mg cap, 100 mg cap) 3 MO (Mail 2 MO (Mail okebo 75 mg cap 3 MO (Mail tetracycline hcl (250 mg cap, 500 mg cap) 4 MO (Mail Anticonvulsants Anticonvulsants, Other APTIOM (200 MG TAB, 400 MG TAB, 600 MG TAB, 800 MG TAB) BRIVIACT (10 MG TAB, 10 MG/ML SOLUTION, 25 MG TAB, 50 MG TAB, 75 MG TAB, 100 MG TAB) 5 MO (Mail 5 MO (Mail EPIDIOLEX 100 MG/ML SOLUTION 5 PA - FOR NEW STARTS ONLY, MO (Mail FYCOMPA (0.5 MG/ML SUSPENSION, 2 MG TAB, 8 MG TAB) 4 MO (Mail 13

21 FYCOMPA (4 MG TAB, 6 MG TAB, 10 MG TAB, 12 MG TAB) levetiracetam (100 mg/ml solution, 250 mg tab, 500 mg tab, 750 mg tab, 1000 mg tab) levetiracetam er (er 500 mg tab er 24h, er 750 mg tab er 24h) SPRITAM (250 MG TAB, 500 MG TAB, 750 MG TAB, 1000 MG TAB) 5 MO (Mail 3 MO (Mail 4 MO (Mail 4 MO (Mail Calcium Channel Modifying Agents CELONTIN 300 MG CAP 4 MO (Mail ethosuximide (250 mg/5ml solution, 250 mg cap) LYRICA (25 MG CAP, 50 MG CAP, 75 MG CAP, 100 MG CAP, 150 MG CAP, 200 MG CAP, 225 MG CAP) 2 MO (Mail 3 QL (90 PER 30 DAYS), MO (Mail LYRICA 20 MG/ML SOLUTION 3 QL (900 PER 30 DAYS), MO (Mail LYRICA 300 MG CAP 3 QL (60 PER 30 DAYS), MO (Mail zonisamide (25 mg cap, 50 mg cap, 100 mg cap) 2 MO (Mail Gamma-aminobutyric Acid (GABA) Augmenting Agents clobazam (2.5 mg/ml suspension, 10 mg tab, 20 mg tab) clonazepam (0.125 mg tab disp, 0.25 mg tab disp, 0.5 mg tab disp, 1 mg tab disp) 4 PA - FOR NEW STARTS ONLY, MO (Mail 4 QL (90 PER 30 DAYS), MO (Mail clonazepam (0.5 mg tab, 1 mg tab) 2 QL (90 PER 30 DAYS), MO (Mail clonazepam 2 mg tab 2 QL (300 PER 30 DAYS), MO (Mail clonazepam 2 mg tab disp 4 QL (300 PER 30 DAYS), MO (Mail DIASTAT ACUDIAL (10 MG GEL, 20 MG GEL) 4 MO (Mail DIASTAT PEDIATRIC 2.5 MG GEL 4 MO (Mail 14

22 divalproex sodium (125 mg tab dr, 250 mg tab dr, 500 mg tab dr) 3 MO (Mail divalproex sodium 125 mg dr sprinkle cap 3 MO (Mail divalproex sodium er (er 250 mg tab er 24h, er 500 mg tab er 24h) 3 MO (Mail gabapentin (100 mg cap, 300 mg cap) 2 QL (360 PER 30 DAYS), MO (Mail gabapentin (250 mg/5ml solution, 300 mg/6ml solution) 2 QL (2160 PER 30 DAYS), MO (Mail gabapentin 400 mg cap 2 QL (270 PER 30 DAYS), MO (Mail gabapentin 600 mg tab 2 QL (180 PER 30 DAYS), MO (Mail gabapentin 800 mg tab 2 QL (150 PER 30 DAYS), MO (Mail GABITRIL (12 MG TAB, 16 MG TAB) 4 MO (Mail phenobarbital (15 mg tab, 16.2 mg tab, 20 mg/5ml elixir, 20 mg/5ml solution, 30 mg tab, 32.4 mg tab, 60 mg tab, 64.8 mg tab, 97.2 mg tab, 100 mg tab) 4 MO (Mail primidone (50 mg tab, 250 mg tab) 2 MO (Mail SABRIL 500 MG TAB 5 PA - FOR NEW STARTS ONLY, MO (Mail tiagabine hcl (2 mg tab, 4 mg tab, 12 mg tab, 16 mg tab) 4 MO (Mail valproate sodium 250 mg/5ml solution 2 MO (Mail valproic acid (250 mg cap, 250 mg/5ml solution) 2 MO (Mail vigabatrin (500 mg tab, 500 mg packet) 5 PA - FOR NEW STARTS ONLY, MO (Mail Glutamate Reducing Agents felbamate (400 mg tab, 600 mg tab) 4 MO (Mail felbamate 600 mg/5ml suspension 5 MO (Mail lamotrigine (5 mg chew tab, 25 mg tab, 25 mg chew tab, 100 mg tab, 150 mg tab, 200 mg tab) 2 MO (Mail 15

23 topiramate (15 mg cap sprink, 25 mg cap sprink, 25 mg tab, 50 mg tab, 100 mg tab, 200 mg tab) 2 MO (Mail Sodium Channel Agents BANZEL (40 MG/ML SUSPENSION, 200 MG TAB, 400 MG TAB) carbamazepine (100 mg chew tab, 100 mg/5ml suspension, 200 mg tab) carbamazepine er (er 100 mg tab er 12h, er 100 mg cap er 12h, er 200 mg tab er 12h, er 200 mg cap er 12h, er 300 mg cap er 12h, er 400 mg tab er 12h) 5 PA - FOR NEW STARTS ONLY, MO (Mail 2 MO (Mail 4 MO (Mail DILANTIN 30 MG CAP 4 MO (Mail epitol 200 mg tab 4 MO (Mail oxcarbazepine (150 mg tab, 300 mg tab, 600 mg tab) 3 MO (Mail oxcarbazepine 300 mg/5ml suspension 4 MO (Mail PEGANONE 250 MG TAB 4 MO (Mail phenytoin (50 mg chew tab, 125 mg/5ml suspension) 2 MO (Mail phenytoin infatabs 50 mg chew tab 2 MO (Mail phenytoin sodium extended (100 mg cap, 200 mg cap, 300 mg cap) VIMPAT (10 MG/ML SOLUTION, 50 MG TAB, 100 MG TAB, 150 MG TAB, 200 MG TAB, 200 MG/20ML SOLUTION) Antidementia Agents Antidementia Agents, Other 2 MO (Mail 4 MO (Mail ergoloid mesylates 1 mg tab 4 MO (Mail Cholinesterase Inhibitors donepezil hcl (5 mg tab, 5 mg tab disp, 10 mg tab disp, 10 mg tab) galantamine hydrobromide (4 mg tab, 4 mg/ml solution, 8 mg tab, 12 mg tab) 2 MO (Mail 4 MO (Mail 16

24 galantamine hydrobromide er (er 8 mg cap er 24h, er 16 mg cap er 24h, er 24 mg cap er 24h) rivastigmine (4.6 mg/24hr patch 24hr, 9.5 mg/24hr patch 24hr, 13.3 mg/24hr patch 24hr) rivastigmine tartrate (1.5 mg cap, 3 mg cap, 4.5 mg cap, 6 mg cap) 4 MO (Mail 4 MO (Mail 2 MO (Mail N-methyl-D-aspartate (NMDA) Receptor Antagonist memantine hcl (5 mg tab, 10 mg tab) 3 MO (Mail memantine hcl 2 mg/ml solution 4 MO (Mail memantine hcl 5-10 mg titration pack 4 MO (Mail memantine hcl er (er 7 mg cap er 24h, er 14 mg cap er 24h, er 21 mg cap er 24h, er 28 mg cap er 24h) Antidepressants Antidepressants, Other 4 QL (30 PER 30 DAYS), MO (Mail bupropion hcl (75 mg tab, 100 mg tab) 3 MO (Mail bupropion hcl er (sr) (er (sr) 100 mg tab er 12h, er (sr) 150 mg tab er 12h, er (sr) 200 mg tab er 12h) bupropion hcl er (xl) (er (xl) 300 mg tab er 24h, er (xl) 450 mg tab er 24h) 3 QL (90 PER 30 DAYS), MO (Mail 3 QL (30 PER 30 DAYS), MO (Mail bupropion hcl er (xl) 150 mg tab er 24h 3 QL (90 PER 30 DAYS), MO (Mail mirtazapine (7.5 mg tab, 15 mg tab disp, 15 mg tab, 30 mg tab, 30 mg tab disp, 45 mg tab, 45 mg tab disp) Monoamine Oxidase Inhibitors EMSAM (6 MG/24HR PATCH 24HR, 9 MG/24HR PATCH 24HR, 12 MG/24HR PATCH 24HR) 2 MO (Mail 5 ST, QL (30 PER 30 DAYS), MO (Mail MARPLAN 10 MG TAB 4 MO (Mail phenelzine sulfate 15 mg tab 2 MO (Mail tranylcypromine sulfate 10 mg tab 4 MO (Mail 17

25 SSRIs/SNRIs (Selective Serotonin Reuptake Inhibitors/Serotonin and Norepinephrine Reuptake Inhibitor citalopram hydrobromide (10 mg tab, 20 mg tab, 40 mg tab) 1 MO (Mail citalopram hydrobromide 10 mg/5ml solution 2 MO (Mail desvenlafaxine succinate er (er 25 mg tab er 24h, er 50 mg tab er 24h, er 100 mg tab er 24h) duloxetine hcl (20 mg cp dr part, 60 mg cp dr part) duloxetine hcl (30 mg cp dr part, 40 mg cp dr part) escitalopram oxalate (5 mg/5ml solution, 5 mg tab, 10 mg tab, 20 mg tab) FETZIMA (20 MG CAP ER 24H, 40 MG CAP ER 24H, 80 MG CAP ER 24H, 120 MG CAP ER 24H) 4 QL (30 PER 30 DAYS), MO (Mail 3 QL (60 PER 30 DAYS), MO (Mail 3 QL (90 PER 30 DAYS), MO (Mail 2 MO (Mail 4 ST, QL (30 PER 30 DAYS), MO (Mail FETZIMA 20 & 40 MG TITRATION PACK 4 ST, QL (56 PER 365 OVER TIME), MO (Mail fluoxetine hcl (10 mg cap, 20 mg cap, 40 mg cap) fluoxetine hcl (10 mg tab, 20 mg/5ml solution, 20 mg tab, 60 mg tab) 1 MO (Mail 2 MO (Mail fluoxetine hcl 90 mg cap dr 2 QL (4 PER 28 DAYS), MO (Mail fluvoxamine maleate (25 mg tab, 50 mg tab, 100 mg tab) maprotiline hcl (25 mg tab, 50 mg tab, 75 mg tab) nefazodone hcl (50 mg tab, 100 mg tab, 150 mg tab, 200 mg tab, 250 mg tab) paroxetine hcl (10 mg tab, 20 mg tab, 30 mg tab, 40 mg tab) 4 MO (Mail 2 MO (Mail 4 MO (Mail 2 MO (Mail PAXIL 10 MG/5ML SUSPENSION 4 MO (Mail sertraline hcl (25 mg tab, 50 mg tab, 100 mg tab) 1 MO (Mail 18

26 sertraline hcl 20 mg/ml conc 2 MO (Mail trazodone hcl (50 mg tab, 100 mg tab, 150 mg tab, 300 mg tab) 2 MO (Mail TRINTELLIX (5 MG TAB, 10 MG TAB, 20 MG TAB) venlafaxine hcl (25 mg tab, 37.5 mg tab, 50 mg tab, 75 mg tab, 100 mg tab) venlafaxine hcl er (er 37.5 mg cap er 24h, er 75 mg cap er 24h, er 150 mg cap er 24h) venlafaxine hcl er (er 37.5 mg tab er 24h, er 75 mg tab er 24h, er 150 mg tab er 24h, er 225 mg tab er 24h) VIIBRYD (10 MG TAB, 20 MG TAB, 40 MG TAB) 4 QL (30 PER 30 DAYS), MO (Mail 3 MO (Mail 3 MO (Mail 4 MO (Mail 4 QL (30 PER 30 DAYS), MO (Mail VIIBRYD STARTER PACK 10 & 20 MG KIT 4 QL (60 PER 365 OVER TIME), MO (Mail Tricyclics amitriptyline hcl (10 mg tab, 25 mg tab, 50 mg tab, 75 mg tab, 100 mg tab, 150 mg tab) amoxapine (25 mg tab, 50 mg tab, 100 mg tab, 150 mg tab) chlordiazepoxide-amitriptyline ( mg tab, mg tab) clomipramine hcl (25 mg cap, 50 mg cap, 75 mg cap) desipramine hcl (10 mg tab, 25 mg tab, 50 mg tab, 75 mg tab, 100 mg tab, 150 mg tab) doxepin hcl (10 mg cap, 10 mg/ml conc, 25 mg cap, 50 mg cap, 75 mg cap, 100 mg cap, 150 mg cap) imipramine hcl (10 mg tab, 25 mg tab, 50 mg tab) nortriptyline hcl (10 mg/5ml solution, 10 mg cap, 25 mg cap, 50 mg cap, 75 mg cap) perphenazine-amitriptyline (2-10 mg tab, 2-25 mg tab, 4-50 mg tab, 4-25 mg tab, 4-10 mg tab) 4 MO (Mail 2 MO (Mail 4 MO (Mail 4 MO (Mail 4 MO (Mail 4 MO (Mail 4 MO (Mail 2 MO (Mail 4 MO (Mail 19

27 protriptyline hcl (5 mg tab, 10 mg tab) 2 MO (Mail trimipramine maleate (25 mg cap, 50 mg cap, 100 mg cap) 4 MO (Mail Antiemetics Antiemetics, Other compro 25 mg suppos 2 MO (Mail meclizine hcl (12.5 mg tab, 25 mg tab) 2 MO (Mail prochlorperazine 25 mg suppos 2 MO (Mail prochlorperazine maleate (5 mg tab, 10 mg tab) promethazine hcl (6.25 mg/5ml solution, 6.25 mg/5ml syrup, 12.5 mg tab, 12.5 mg suppos, 25 mg tab, 25 mg suppos, 50 mg suppos, 50 mg tab) 1 MO (Mail 4 MO (Mail promethegan 50 mg suppos 4 MO (Mail scopolamine 1 mg/3days patch 72hr 2 MO (Mail Emetogenic Therapy Adjuncts aprepitant 125 mg cap 2 PA - Part B vs D Determination, QL (2 PER 30 OVER TIME), MO (Mail aprepitant 40 mg cap 2 PA - Part B vs D Determination, QL (1 PER 30 OVER TIME), MO (Mail aprepitant 80 & 125 mg cap 2 PA - Part B vs D Determination, QL (6 PER 30 OVER TIME), MO (Mail aprepitant 80 mg cap 2 PA - Part B vs D Determination, QL (8 PER 30 OVER TIME), MO (Mail dronabinol (2.5 mg cap, 5 mg cap) 4 PA, QL (60 PER 30 OVER TIME), MO (Mail dronabinol 10 mg cap 5 PA, QL (60 PER 30 OVER TIME), MO (Mail EMEND 125 MG RECON SUSP 4 PA - Part B vs D Determination, QL (6 PER 30 OVER TIME), MO (Mail 20

28 granisetron hcl 1 mg tab 2 PA - Part B vs D Determination, QL (30 PER 30 OVER TIME), MO (Mail ondansetron (4 mg tab disp, 8 mg tab disp) 4 PA - Part B vs D Determination, MO (Mail ondansetron hcl (4 mg tab, 8 mg tab) 3 PA - Part B vs D Determination, MO (Mail ondansetron hcl 24 mg tab 3 PA - Part B vs D Determination, QL (14 PER 28 OVER TIME), MO (Mail ondansetron hcl 4 mg/5ml solution 3 PA - Part B vs D Determination, QL (450 PER 30 DAYS), MO (Mail Antifungals ABELCET 5 MG/ML SUSPENSION 5 PA - Part B vs D Determination, MO (Mail AMBISOME 50 MG RECON SUSP 5 PA - Part B vs D Determination, MO (Mail amphotericin b 50 mg recon soln 4 PA - Part B vs D Determination, MO (Mail caspofungin acetate (50 mg recon soln, 70 mg recon soln) 5 MO (Mail ciclopirox (0.77 % gel, 1 % shampoo) 2 MO (Mail ciclopirox 8 % solution 2 PA, MO (Mail ciclopirox olamine (0.77 % cream, 0.77 % suspension) clotrimazole (1 % solution, 1 % cream, 10 mg troche, 10 mg lozenge) fluconazole (10 mg/ml recon susp, 40 mg/ml recon susp, 50 mg tab, 100 mg tab, 150 mg tab, 200 mg tab) fluconazole in dextrose (200 mg/100ml solution, 400 mg/200ml solution) fluconazole in sodium chloride ( mg/100ml-% solution, mg/200ml-% solution) 2 MO (Mail 2 MO (Mail 2 MO (Mail 2 MO (Mail 2 MO (Mail 21

29 flucytosine (250 mg cap, 500 mg cap) 5 MO (Mail griseofulvin microsize 125 mg/5ml suspension 2 MO (Mail griseofulvin microsize 500 mg tab 4 MO (Mail griseofulvin ultramicrosize (125 mg tab, 250 mg tab) 4 MO (Mail itraconazole 10 mg/ml solution 5 PA, MO (Mail itraconazole 100 mg cap 4 PA, MO (Mail ketoconazole (2 % cream, 2 % shampoo, 200 mg tab) 2 MO (Mail MICONAZOLE MG SUPPOS 3 MO (Mail NATACYN 5 % SUSPENSION 4 MO (Mail NOXAFIL (40 MG/ML SUSPENSION, 100 MG TAB DR) 5 MO (Mail nyamyc unit/gm powder 3 MO (Mail nystatin ( unit/gm powder, unit/ml suspension, unit/gm ointment, unit/gm cream, unit tab) 3 MO (Mail nystop unit/gm powder 3 MO (Mail terbinafine hcl 250 mg tab 2 QL (90 PER 180 OVER TIME), MO (Mail terconazole (0.4 % cream, 0.8 % cream, 80 mg suppos) voriconazole (40 mg/ml recon susp, 50 mg tab, 200 mg recon soln, 200 mg tab) Antigout Agents 2 MO (Mail 5 MO (Mail allopurinol (100 mg tab, 300 mg tab) 2 MO (Mail colchicine (0.6 mg tab, 0.6 mg cap) 3 MO (Mail colchicine-probenecid mg tab 2 MO (Mail probenecid 500 mg tab 2 MO (Mail ULORIC (40 MG TAB, 80 MG TAB) 3 ST, MO (Mail 22

30 Antimigraine Agents Ergot Alkaloids dihydroergotamine mesylate 4 mg/ml solution 5 PA, QL (8 PER 30 OVER TIME), MO (Mail ergotamine-caffeine mg tab 2 MO (Mail MIGERGOT MG SUPPOS 5 MO (Mail Serotonin (5-HT) 1b/1d Receptor Agonists rizatriptan benzoate (5 mg tab disp, 10 mg tab disp) 4 QL (18 PER 30 OVER TIME), MO (Mail rizatriptan benzoate (5 mg tab, 10 mg tab) 3 QL (18 PER 30 OVER TIME), MO (Mail sumatriptan (5 mg/act solution, 20 mg/act solution) sumatriptan succinate (25 mg tab, 50 mg tab, 100 mg tab) sumatriptan succinate (6 mg/0.5ml soln a-inj, 6 mg/0.5ml solution) 4 QL (12 PER 30 OVER TIME), MO (Mail 2 QL (9 PER 30 OVER TIME), MO (Mail 4 QL (5 PER 30 OVER TIME), MO (Mail sumatriptan succinate 4 mg/0.5ml soln a-inj 4 QL (8 PER 30 OVER TIME), MO (Mail sumatriptan succinate 6 mg/0.5ml soln prsyr 4 QL (5 PER 30 DAYS), MO (Mail sumatriptan succinate refill 4 mg/0.5ml soln cart sumatriptan succinate refill 6 mg/0.5ml soln cart Antimyasthenic Agents Parasympathomimetics 4 QL (8 PER 30 OVER TIME), MO (Mail 4 QL (5 PER 30 OVER TIME), MO (Mail guanidine hcl 125 mg tab 4 MO (Mail pyridostigmine bromide 60 mg tab 3 MO (Mail 23

31 Antimycobacterials Antimycobacterials, Other dapsone (25 mg tab, 100 mg tab) 2 MO (Mail rifabutin 150 mg cap 4 MO (Mail Antituberculars ethambutol hcl (100 mg tab, 400 mg tab) 2 MO (Mail isoniazid (100 mg tab, 300 mg tab) 2 MO (Mail isoniazid 50 mg/5ml syrup 4 MO (Mail PASER 4 GM PACKET 4 MO (Mail PRIFTIN 150 MG TAB 4 MO (Mail pyrazinamide 500 mg tab 2 MO (Mail rifampin (150 mg cap, 300 mg cap) 2 MO (Mail rifampin 600 mg recon soln 4 MO (Mail RIFATER MG TAB 4 MO (Mail SIRTURO 100 MG TAB 5 MO (Mail TRECATOR 250 MG TAB 4 MO (Mail Antineoplastics Alkylating Agents carmustine 100 mg recon soln 5 MO (Mail cyclophosphamide (25 mg cap, 50 mg cap) 4 PA - Part B vs D Determination, MO (Mail GLEOSTINE (5 MG CAP, 10 MG CAP, 40 MG CAP, 100 MG CAP) 4 MO (Mail HEXALEN 50 MG CAP 5 MO (Mail LEUKERAN 2 MG TAB 5 MO (Mail MATULANE 50 MG CAP 5 MO (Mail VALCHLOR % GEL 5 PA - FOR NEW STARTS ONLY, MO (Mail 24

32 Antiandrogens abiraterone acetate 250 mg tab 5 PA - FOR NEW STARTS ONLY, MO (Mail bicalutamide 50 mg tab 3 MO (Mail ERLEADA 60 MG TAB 5 PA - FOR NEW STARTS ONLY, QL (120 PER 30 DAYS), MO (Mail flutamide 125 mg cap 2 MO (Mail nilutamide 150 mg tab 5 MO (Mail XTANDI 40 MG CAP 5 PA - FOR NEW STARTS ONLY, MO (Mail YONSA 125 MG TAB 5 PA - FOR NEW STARTS ONLY, MO (Mail ZYTIGA (250 MG TAB, 500 MG TAB) 5 PA - FOR NEW STARTS ONLY, MO (Mail Antiangiogenic Agents POMALYST (1 MG CAP, 2 MG CAP, 3 MG CAP, 4 MG CAP) REVLIMID (2.5 MG CAP, 5 MG CAP, 10 MG CAP, 15 MG CAP, 20 MG CAP, 25 MG CAP) THALOMID (50 MG CAP, 100 MG CAP, 150 MG CAP, 200 MG CAP) 5 PA - FOR NEW STARTS ONLY, MO (Mail 5 PA - FOR NEW STARTS ONLY, MO (Mail 5 PA - FOR NEW STARTS ONLY, MO (Mail Antiestrogens/Modifiers EMCYT 140 MG CAP 5 MO (Mail FARESTON 60 MG TAB 5 MO (Mail SOLTAMOX 10 MG/5ML SOLUTION 5 MO (Mail tamoxifen citrate (10 mg tab, 20 mg tab) 2 MO (Mail toremifene citrate 60 mg tab 5 MO (Mail Antimetabolites DROXIA (200 MG CAP, 300 MG CAP, 400 MG CAP) 4 MO (Mail hydroxyurea 500 mg cap 2 MO (Mail LONSURF MG TAB 5 PA - FOR NEW STARTS ONLY, QL (100 PER 28 DAYS), MO (Mail 25

33 LONSURF MG TAB 5 PA - FOR NEW STARTS ONLY, QL (80 PER 28 DAYS), MO (Mail mercaptopurine 50 mg tab 3 MO (Mail PURIXAN 2000 MG/100ML SUSPENSION 5 MO (Mail TABLOID 40 MG TAB 4 MO (Mail Antineoplastics, Other COPIKTRA (15 MG CAP, 25 MG CAP) 5 PA - FOR NEW STARTS ONLY, MO (Mail COTELLIC 20 MG TAB 5 PA - FOR NEW STARTS ONLY, MO (Mail DAURISMO (25 MG TAB, 100 MG TAB) 5 PA - FOR NEW STARTS ONLY, MO (Mail FARYDAK (10 MG CAP, 15 MG CAP, 20 MG CAP) IBRANCE (75 MG CAP, 100 MG CAP, 125 MG CAP) KHAPZORY (175 MG RECON SOLN, 300 MG RECON SOLN) 5 PA - FOR NEW STARTS ONLY, QL (6 PER 21 OVER TIME), MO (Mail 5 PA - FOR NEW STARTS ONLY, MO (Mail 5 PA - Part B vs D Determination, MO (Mail KISQALI FEMARA 200 MG CO-PACK 5 PA - FOR NEW STARTS ONLY, QL (91 PER 28 DAYS), MO (Mail KISQALI FEMARA 400 MG CO-PACK 5 PA - FOR NEW STARTS ONLY, QL (91 PER 28 DAYS), MO (Mail KISQALI FEMARA 600 MG CO-PACK 5 PA - FOR NEW STARTS ONLY, QL (91 PER 28 DAYS), MO (Mail leucovorin calcium (100 mg/10ml solution, 500 mg/50ml solution) leucovorin calcium (5 mg tab, 10 mg tab, 15 mg tab, 25 mg tab) 4 PA - Part B vs D Determination, MO (Mail 2 MO (Mail LIBTAYO 350 MG/7ML SOLUTION 5 PA - FOR NEW STARTS ONLY, MO (Mail LORBRENA (25 MG TAB, 100 MG TAB) 5 PA - FOR NEW STARTS ONLY, MO (Mail 26

34 LUMOXITI 1 MG RECON SOLN 5 PA - FOR NEW STARTS ONLY, MO (Mail LYNPARZA (50 MG CAP, 100 MG TAB, 150 MG TAB) 5 PA - FOR NEW STARTS ONLY, MO (Mail NERLYNX 40 MG TAB 5 PA - FOR NEW STARTS ONLY, QL (180 PER 30 DAYS), MO (Mail NINLARO (2.3 MG CAP, 3 MG CAP, 4 MG CAP) 5 PA - FOR NEW STARTS ONLY, MO (Mail POTELIGEO 20 MG/5ML SOLUTION 5 PA - FOR NEW STARTS ONLY, MO (Mail RUBRACA (200 MG TAB, 250 MG TAB, 300 MG TAB) 5 PA - FOR NEW STARTS ONLY, QL (120 PER 30 DAYS), MO (Mail RYDAPT 25 MG CAP 5 PA - FOR NEW STARTS ONLY, QL (240 PER 30 DAYS), MO (Mail SYLATRON (200 MCG KIT, 300 MCG KIT, 600 MCG KIT) 5 PA - FOR NEW STARTS ONLY, MO (Mail SYNRIBO 3.5 MG RECON SOLN 5 PA - FOR NEW STARTS ONLY, MO (Mail TALZENNA (0.25 MG CAP, 1 MG CAP) 5 PA - FOR NEW STARTS ONLY, MO (Mail VERZENIO (50 MG TAB, 100 MG TAB, 150 MG TAB, 200 MG TAB) VITRAKVI (20 MG/ML SOLUTION, 25 MG CAP, 100 MG CAP) 5 PA - FOR NEW STARTS ONLY, QL (60 PER 30 DAYS), MO (Mail 5 PA - FOR NEW STARTS ONLY, MO (Mail ZEJULA 100 MG CAP 5 PA - FOR NEW STARTS ONLY, QL (90 PER 30 DAYS), MO (Mail ZOLINZA 100 MG CAP 5 PA - FOR NEW STARTS ONLY, MO (Mail Aromatase Inhibitors, 3rd Generation anastrozole 1 mg tab 4 MO (Mail exemestane 25 mg tab 4 MO (Mail letrozole 2.5 mg tab 2 MO (Mail 27

35 Enzyme Inhibitors ZYDELIG (100 MG TAB, 150 MG TAB) 5 PA - FOR NEW STARTS ONLY, MO (Mail Molecular Target Inhibitors AFINITOR (2.5 MG TAB, 5 MG TAB, 7.5 MG TAB, 10 MG TAB) AFINITOR DISPERZ (2 MG TAB SOL, 3 MG TAB SOL, 5 MG TAB SOL) 5 PA - FOR NEW STARTS ONLY, QL (30 PER 30 DAYS), MO (Mail 5 PA - FOR NEW STARTS ONLY, MO (Mail ALECENSA 150 MG CAP 5 PA - FOR NEW STARTS ONLY, QL (240 PER 30 DAYS), MO (Mail ALUNBRIG (90 MG TAB, 180 MG TAB) 5 PA - FOR NEW STARTS ONLY, QL (30 PER 30 DAYS), MO (Mail ALUNBRIG 30 MG TAB 5 PA - FOR NEW STARTS ONLY, QL (120 PER 30 DAYS), MO (Mail ALUNBRIG 90 & 180 MG TAB THPK 5 PA - FOR NEW STARTS ONLY, QL (60 PER 365 OVER TIME), MO (Mail BOSULIF (100 MG TAB, 400 MG TAB, 500 MG TAB) 5 PA - FOR NEW STARTS ONLY, MO (Mail BRAFTOVI (50 MG CAP, 75 MG CAP) 5 PA - FOR NEW STARTS ONLY, MO (Mail CABOMETYX (20 MG TAB, 40 MG TAB, 60 MG TAB) 5 PA - FOR NEW STARTS ONLY, MO (Mail CALQUENCE 100 MG CAP 5 PA - FOR NEW STARTS ONLY, QL (60 PER 30 DAYS), MO (Mail CAPRELSA 100 MG TAB 5 PA - FOR NEW STARTS ONLY, QL (60 PER 30 DAYS), MO (Mail CAPRELSA 300 MG TAB 5 PA - FOR NEW STARTS ONLY, MO (Mail COMETRIQ 100 MG DAILY-DOSE PACK 5 PA - FOR NEW STARTS ONLY, MO (Mail 28

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