2017 Elderplan FIDA Total Care (Medicare-Medicaid Plan) 本綜合處方藥一覽表自 2017 年 11 月 1 日起未作任何變更 如有問題, 請致電 Elderplan FIDA Total Care 參保者服務部聯絡我們, 電話 :

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1 2017 Elderplan FIDA Total Care (Medicare-Medicaid Plan) 本綜合處方藥一覽表自 2017 年 11 月 1 日起未作任何變更 如有問題, 請致電 Elderplan FIDA Total Care 參保者服務部聯絡我們, 電話 : , 聽障和語障人士可致電 711, 服務時間為 : 早上 8 點至晚上 8 點, 每週七天, 或瀏覽 Elderplan FIDA Total Care (Medicare-Medicaid Plan) 是一項與 Medicare 和紐約州衛生署 (Medicaid) 均簽有合約, 以便經由全面整合雙重利惠 (FIDA) 示範計劃向參保者提供兩項計劃之福利的管理式醫療保健計劃 承保藥物清單及藥房網絡在每年 1 月 1 日可能會有所調整, 在全年內也可能會不時變更 You can get this information for free in other languages. Call and 711 for TTY/TDD users during hours of 8:00 a.m. and 8:00 p.m., 7 days a week. The call is free. Puede obtener esta información de manera gratuita en otros idiomas.llame al y TTY/TDD 711 de lunes a domingos de 8:00 a.m. a 8:00 p.m. La llamada es gratuita. Ou ka jwenn enfòmasyon sa a gratis nan lòt lang.rele nan ak nan TTY/TDD (poumoun ki gen pwoblèm tande oswa moun ki bèbè) 711 de lendi a dimanch 8:00 a.m. - 8:00 p.m. Apèl la gratis. 이정보는다른언어로도제공됩니다 ( 무료 ). 월요일 - 일요일 8:00 a.m. 8:00 p.m. 중 나 TTY/TDD 711 로전화주십시오. 통화료는무료입니다.m 您可免費取得以其他語言撰寫的資訊 請於週一至週日上午 8 時至下午 8 時致電 ,TTY/TDD 使用者 :711 此為免付費電話 Данная информация доступна бесплатно на других языках.звоните по номеру или 711 (линия TTY/TDD) с понедельника по воскресенье с 8:00 до 20:00. Звонок бесплатный. È possibile ricevere queste informazioni in altre lingue gratuitamente.contatta il e TTY/TDD 711 dal lunedì alla domenica dalle ore 8:00 alle ore 20:00.Il servizio è gratuito. 請閱讀 : 本文件包含有關本計劃承保藥物的資訊 2017 年綜合處方藥一覽表 Elderplan FIDA Total Care (Medicare-Medicaid Plan) 本綜合處方藥一覽表自 2017 年 11 月 1 日起未作任何變更 如有問題, 請致電 Elderplan FIDA Total Care 參保者服務部聯絡我們, 電話 : , 聽障和語障人士可致電 711, 服務時間為 : 早上 8 點至晚上 8 點, 每週七天, 或瀏覽 i da.org HPMS Approved Formulary File Submission ID , Version Number 16 H8029_EPC15678_Accepted

2 I H8029_EPC15678_Accepted Elderplan FIDA Total Care (Medicare-Medicaid Plan) 2017 年承保藥物清單 ( 處方藥一覽表 ) 這是一份藥物清單, 參保者可從 Elderplan FIDA Total Care 獲取 Elderplan FIDA Total Care 是一項與 Medicare 和紐約州衛生署 (Medicaid) 均簽有合約, 以便 經由全面整合雙重利惠 (Fully Integrated Duals Advantage, 簡稱 FIDA) 示範計劃向參保者 提供兩項計劃之福利的管理式醫療保健計劃 承保藥物清單和 / 或藥房及醫療服務提供者網絡在全年內可能會有所變更 在做出會影響您的 變更之前, 我們將為您寄送通知 每年 1 月 1 日福利可能會發生變化 如需 Elderplan FIDA Total Care 的最新承保藥物清單, 您可以瀏覽網站 或致電 Elderplan FIDA Total Care 參保者服務部, 電話 : 可能會有適用的約束及限制 如需更多資訊, 請致電 Elderplan FIDA Total Care 參保者服務部 或細閱 Elderplan FIDA Total Care 參保者手冊 這意味著, 若要讓 Elderplan FIDA Total Care 償付您的服務, 您需要遵循某些規則 任何承保藥物均無需支付定額手續費 You can get this information for free in other languages. Call and TTY/TDD 711, 7 days a week, 8:00 A.M. to 8:00 P.M. The call is free. Puede obtener esta información en otros idiomas, en forma gratuita. Llame al , o al 711 para los usuarios de TTY/TDD, de 8:00 a.m. a 8:00 p.m., los 7 días de la semana. La llamada es gratuita. Ou ka jwenn enfòmasyon sa a gratis nan lòt lang. Rele nan ak moun ki itilize sistèm TTY/TDD rele nan 711, 7 jou sou 7, apatide 8:00 AM jiska 8:00 PM. Apèl la gratis. 이정보를다른언어로비용없이얻으실수있습니다 번및 TTY/TDD 711 번으로주 7 일오전 8 시 - 오후 8 시중에연락해주십시오. 통화는무료입니다. 您可免費取得此資訊的其他語言版本 請致電 , 聽障 / 語障人士可致電 711, 服 務時間為上午 8 時至晚上 8 時, 每週 7 天 此為免付費電話 Вы можете получить эту информацию бесплатно на других языках. Звоните по телефону (TTY/TDD: 711) в любой день недели с 8:00 до 20:00. Звонок бесплатный.? 如果您有疑問, 請致電 Elderplan FIDA Total Care: , 聽障 / 語障人士可致電 711, 服務時間為上午 8 點至晚上 8 點, 每週七天 此為免付費電話 如需更多資訊, 請瀏覽

3 II È possibile ricevere queste informazioni in altre lingue gratuitamente. Contatti il numero (non udenti: 711) 7 giorni su 7, dalle 8 alle 20. La chiamata è gratuita. 您可以免費取得此資訊的其他格式版本, 例如大號字體印刷版或音訊 請致電 , 聽障 / 語障人士可致電 711, 服務時間為上午 8 時至晚上 8 時, 每週 7 天 此為免付費 電話 紐約州設立了一個名為 Independent Consumer Advocacy Network (ICAN) 的參保者監察官計 劃, 就 Elderplan FIDA Total Care 提供的任何服務向參保者提供免費及保密的協助 您可撥打 免費電話 或瀏覽 icannys.org 聯絡 ICAN ( 聽障和語障人士可致電 711, 然 後按照提示撥打 )? 如果您有疑問, 請致電 Elderplan FIDA Total Care: , 聽障 / 語障人士可致電 711, 服務時間為上午 8 點至晚上 8 點, 每週七天 此為免付費電話 如需更多資訊, 請瀏覽

4 III 常見問題 (FAQ) 在此處查找您對本承保藥物清單的問題解答 您可以閱讀全部的常見問題以瞭解更多資訊, 或是 查找特定的問題和解答 1. 承保藥物清單上有哪些處方藥?( 我們將承保藥物清單簡稱為 藥物清單 ) 從第 1 頁開始的承保藥物清單上的藥物是 Elderplan FIDA Total Care 承保的藥物 這些藥物可在 我們網絡內的藥房購買 如果我們與一家藥房簽訂合作協議並向您提供服務, 這家藥房即屬於我們 的網絡內藥房 我們將這些藥房稱為 網絡內藥房 Elderplan FIDA Total Care 在以下情況中承保藥物清單上的所有藥物 : 您的醫生或其他處方醫師表示您需要這些藥物以恢復健康或保持健康, 藥物對您的病情具有醫療必要性, 及 您會在 Elderplan FIDA Total Care 網絡內藥房配取處方藥 Elderplan FIDA Total Care 可能要求採取額外行動才能獲得某些藥物 ( 請參見下文第 5 題 ) 在某些情況下, 您必須採取一些行動才能獲得藥物, 例如首先嘗試其他藥物 您也可以在我們的網站 或致電參保者服務部 查 詢最新的承保藥物清單 2. 藥物清單會變更嗎? 是的 Elderplan FIDA Total Care 可能會在一年之中增加或刪減藥物清單上的藥物 一般而言, 藥物清單只會在以下情況下變更 : 出現一種新藥物, 其藥效與目前藥物清單上的藥物相同, 或 我們得知一種藥物不安全 我們也可能更改有關藥物的規則 例如, 我們可能 : 決定要求或不要求某種藥物獲得事先批准 ( 事先批准是您在獲得藥物之前需要從 Elderplan FIDA Total Care 或您跨科團隊 (IDT) 處獲得的許可 ) 增加或改變您可以獲得的藥量 ( 稱為 數量限制 )? 如果您有疑問, 請致電 Elderplan FIDA Total Care: , 聽障 / 語障人士可致電 711, 服務時間為上午 8 點至晚上 8 點, 每週七天 此為免付費電話 如需更多資訊, 請瀏覽

5 IV 增加或改變藥物的階段療法限制 ( 階段療法指您必須先嘗試一種藥物, 我們才會承保另一種藥物 ) ( 有關這些藥物規則的更多資訊, 請參閱第 V 頁 ) 如果您使用的藥物從藥物清單上刪除, 我們會告訴您 當我們改變承保藥物的規則時, 我們也會告訴您 下文中的問題 3 4 和 7 會提供藥物清單變更時的更多相關資訊 您可以隨時在網站 查詢 Elderplan FIDA Total Care 的最新藥物清單 您也可以致電參保者服務部 , 查詢最新的藥物清單 3. 如果市面上出現一種比較便宜的藥物, 而且藥效與目前藥物清單上的藥物相同時會如何處理? 如果出現一種比較便宜的藥物, 且藥效與目前藥物清單上的藥物相同 : 您的藥劑師可能在您下次配取處方藥時向您提供這種比較便宜的藥物 如果您和您的提供 者認為這種較便宜的藥物不適合您, 您的提供者可以告知藥劑師, 繼續為您提供您目前使 用的藥物 Elderplan FIDA Total Care 可能會決定將價格較高的藥物從藥物清單中刪除 如果您使用 的藥物因為市面上出現價格較低且藥效相同的藥物而被我們撤出藥物清單, 我們會在撤 出藥物清單之前至少 60 天或是當您要求重新配藥時告訴您 然後, 您可以在藥物清單變 更之前獲得 60 天份的供藥 如果您目前正在使用的藥物即將被刪除,Elderplan FIDA Total Care 會在我們更改藥物清 單前至少 60 天為您來信說明 如果您決定使用將從藥物清單上刪除的價格較高的藥物, 您 的護理經理還會將您藥物治療方案的變化告知您的跨科團隊 (IDT) 4. 當我們發現一種藥物不安全時會怎麼辦? 如果食品藥物管理局 (FDA) 表示您正在使用的一種藥物不安全, 我們會立刻從藥物清單刪除 我們還會寄信並致電告知您, 不安全的藥物已從藥物清單中刪除 如果您收到我們參保者服務部寄出的此類信函, 請立刻透過致電參保者服務部 聯絡您的護理經理 您的護理經理將與您和您的處方醫生合作, 在藥物清單上尋找安全的替代藥物 您的護理經理還會告知您的跨科團隊 (IDT) 此事宜, 確保及時更新您的護理計劃? 如果您有疑問, 請致電 Elderplan FIDA Total Care: , 聽障 / 語障人士可致電 711, 服務時間為上午 8 點至晚上 8 點, 每週七天 此為免付費電話 如需更多資訊, 請瀏覽

6 V 5. 藥物承保有任何限制嗎? 還是需要採取任何行動才能獲得某些藥物? 是的, 某些藥物有承保規則或是對您可以獲得的藥量有限制 在某些情況下, 您或您的醫生或其他處方醫師必須採取一些行動才能獲得藥物 例如 : 事先批准 ( 或事先授權 ): 就某些藥物而言, 您或您的醫生或其他處方醫師在您配取處方藥前必須取得 Elderplan FIDA Total Care 或您跨科團隊 (IDT) 的批准 若您未獲得批准, Elderplan FIDA Total Care 可能不會承保該藥物 數量限制 : 有時,Elderplan FIDA Total Care 會限制您可以獲得的藥量 階段療法 : 有時,Elderplan FIDA Total Care 要求您接受階段療法 這是指您必須按某種順序使用藥物來治療您的疾病 您可能必須先嘗試一種藥物, 我們才會承保另一種藥物 如果您的醫生認為第一種藥物對您無效, 我們才會承保第二種藥物 您可以透過第 1 頁開始的表格查詢您的藥物是否有額外的要求或限制 您也可以瀏覽我們的網站 瞭解更多資訊 我們已在線上刊載文件, 解釋我們事先授權和階段療法的限制 您也可以要求我們寄一份給您 您可以對這些限制提出 例外處理 要求 請參閱問題 11, 瞭解有關例外處理的更多資訊 如果您住在護理機構或其他長期護理機構, 而且需要一種不在藥物清單上的藥物, 或是您無法輕易取得需要的藥物, 我們可以為您提供幫助 無論您是否為 Elderplan FIDA Total Care 的新參保者, 我們都會為您需要的藥物承保 31 天份的緊急供藥 ( 除非處方開立更少天數 ), 以便您有時間與您的醫生或其他處方醫師討論 他們可以幫助您決定您是否可以使用藥物清單上的另一種類似藥物, 或是否要求例外處理 請參閱第 11 題有關例外處理的詳細資訊 6. 您如何知道您想要的藥物是否有限制或需要採取什麼行動來獲得藥物? 第 1 頁的承保藥物清單有 必要行動 限制或使用上限 一欄 7. 如果我們更改承保某些藥物的規則會如何處理? 例如, 如果我們新增某種藥物的事先授權 ( 批准 ) 數量限制及 / 或階段療法限制 我們會告訴您, 我們是否對某種藥物新增了事先批准 數量限制及 / 或階段療法限制 我們會在增 加限制之前至少 60 天或是在您下次要求重新配取時告訴您 然後, 您可以在藥物清單變更之前獲? 如果您有疑問, 請致電 Elderplan FIDA Total Care: , 聽障 / 語障人士可致電 711, 服務時間為上午 8 點至晚上 8 點, 每週七天 此為免付費電話 如需更多資訊, 請瀏覽

7 VI 得 60 天的藥量 這樣可以讓您有時間和醫生或其他處方醫師討論接下來該怎麼做 8. 如何查詢某種藥物是否列於藥物清單上? 有兩種方式可以查詢藥物 : 您可以按字母順序搜尋 ( 如果您知道如何拼寫藥物名稱 ), 或 您可以按照疾病搜尋 要按照字母順序搜尋, 請翻到第 73 頁的字母清單部分 然後在清單中查找藥物的名稱 要按疾病搜尋, 請翻到第 XII 頁的 按疾病排列的藥物清單 一節 本節所列藥物按照所治療的病症類型分類 例如, 如果您患有心臟病, 您應該查看 心血管 類別 您可以在該類別找到治療心臟病的藥物 9. 如果您想要使用的藥物不在藥物清單上怎麼辦? 如果您在藥物清單上沒有查到您的藥物, 請致電參保者服務部諮詢, 電話 : 如果您得知 Elderplan FIDA Total Care 不會承保該藥物, 您可以採取以下一種行動 : 向參保者服務部索取一份與您想要使用的藥物類似的清單 然後將該清單出示給您的醫生或其他處方醫師 他們可以開立藥物清單上與您想要使用的藥物類似的藥物 或 您可要求計劃或您的跨科團隊 (IDT) 破例承保您的藥物 請參閱第 11 題有關例外處理的詳細資訊 10. 如果您是 Elderplan FIDA Total Care 的新參保者, 而且在藥物清單上找不到您的藥物或是您在領取藥物時遇到困難該怎麼辦? 我們可以幫忙 我們會在您成為 Elderplan FIDA Total Care 參保者後的前 90 天按需要承保 90 天 的臨時性供藥, 以便您有時間與您的醫生或其他處方醫師討論 他們可以幫助您決定您是否可以使 用藥物清單上的另一種類似藥物, 或是否要求例外處理 如果您符合以下條件, 我們會承保 90 天的臨時性供藥 : 您正在使用未列於我們藥物清單上的藥物, 或 根據保健計劃的規則, 您無法取得處方醫師所開立的藥量, 或 藥物需要 Elderplan FIDA Total Care 或您跨科團隊 (IDT) 的事先批准, 或? 如果您有疑問, 請致電 Elderplan FIDA Total Care: , 聽障 / 語障人士可致電 711, 服務時間為上午 8 點至晚上 8 點, 每週七天 此為免付費電話 如需更多資訊, 請瀏覽

8 VII 您正在使用的藥物屬於階段療法限制中的藥物 如果您住在護理機構或其他長期護理機構, 您可以重新配取 91 天的處方藥, 最多可長達 98 天 在您參保本計劃的前 90 天內, 您可多次重新配取藥物 這樣, 您的處方醫師有時間將您的藥物改成藥物清單上的藥物或是申請例外處理 Elderplan FIDA Total Care 現有參保者的護理等級變更當參保者從一個治療機構轉到另一個治療機構時, 護理等級會發生變化 例如, 如果您從醫院或專業護理機構 (SNF) 或門診機構轉入長期護理 (LTC) 機構,Elderplan FIDA Total Care 將承保 31 天的過渡期臨時性供藥 ( 除非您的處方寫明更少的天數 ) 在您入住長期護理機構的前 90 天內, Elderplan FIDA Total Care 將承保這些藥物的多次重新配取 如果您離開長期護理機構或出院返家,Elderplan FIDA Total Care 將承保 30 天的臨時性供藥 ( 除非您的處方寫明更少的天數 ) 這適用於可能未列於 Elderplan FIDA Total Care 藥物清單上的藥物, 或受事先授權或數量限制等承保限制的藥物 您的護理經理將與您和您的處方醫師合作, 協助您申請例外處理, 以更好地適應護理等級變更 11. 我可以申請例外處理以獲得藥物承保嗎? 是的 您可以向 Elderplan FIDA Total Care 或您的跨科團隊 (IDT) 申請例外處理, 以承保不在藥物清單中的藥物 您也可以要求 Elderplan FIDA Total Care 或您的 IDT 更改針對藥物的相關規則 例如,Elderplan FIDA Total Care 可能會限制某種藥物的承保藥量 如果您的藥物有上限規定, 您可要求我們或您的 IDT 更改這項限制, 承保更多藥量 其他例子 : 您可要求我們或您的 IDT 撤銷階段療法限制或是事先批准要求 12. 取得例外處理需要多長時間? 首先,Elderplan FIDA Total Care 或您的跨科團隊 (IDT) 必須收到您的處方醫師支持您申請例外處理的聲明 我們收到聲明後, 會在 72 小時內對您的例外處理申請作出決定 如果您或您的處方醫師認為等候 72 小時作出決定會對您的健康造成危害, 您可以申請加急例外處理 這是更快速的決定 如果您的處方醫師支持您的申請, 我們會在收到處方醫師的支持聲明後 24 小時內作出決定? 如果您有疑問, 請致電 Elderplan FIDA Total Care: , 聽障 / 語障人士可致電 711, 服務時間為上午 8 點至晚上 8 點, 每週七天 此為免付費電話 如需更多資訊, 請瀏覽

9 VIII 13. 如何提出例外處理申請? 要提出例外處理申請, 請致電您的護理經理 您的護理經理將與您和您的提供者合作, 幫助您申請 例外處理 14. 什麼是副廠藥? 副廠藥的成份與原廠藥相同 副廠藥一般比原廠藥便宜, 而且副廠藥的名稱通常較不為人所知 副廠藥均已獲食品藥物管理局 (FDA) 批准 Elderplan FIDA Total Care 承保原廠藥和副廠藥 15. 什麼是 OTC 藥物? OTC 是指 非處方藥 Elderplan FIDA Total Care 承保部分 OTC 藥物 ( 若您的提供者開具該等藥物的處方 ) 您可以查閱 Elderplan FIDA Total Care 的藥物清單, 瞭解哪些 OTC 藥物可獲得承保 16. Elderplan FIDA Total Care 是否承保非藥物類 OTC 產品? Elderplan FIDA Total Care 承保部分非藥物類 OTC 產品 ( 若您的提供者開具該等產品的處方 ) 非藥物類 OTC 產品的例子包括紗布墊與敷料以及注射胰島素所用的針頭和注射器 您可以查閱 Elderplan FIDA Total Care 的藥物清單, 瞭解哪些非藥物類 OTC 產品可獲得承保 17. 您需支付多少定額手續費? 您無需為藥物清單上的藥物支付定額手續費? 如果您有疑問, 請致電 Elderplan FIDA Total Care: , 聽障 / 語障人士可致電 711, 服務時間為上午 8 點至晚上 8 點, 每週七天 此為免付費電話 如需更多資訊, 請瀏覽

10 IX 18. 什麼是藥物等級? 等級指藥物清單上的的藥物組別 藥物等級 承保藥物的類型 定額手續費 ( 分攤費用 ) 1 副廠藥 $0 2 原廠藥 $0 3 非 Medicare Rx( 處方 ) 和 OTC( 非處方 ) 藥物 $0 註 : 如上文定額手續費一欄所述, 參保者無需為藥物清單上第 1 至第 3 級的藥物支付分攤費用? 如果您有疑問, 請致電 Elderplan FIDA Total Care: , 聽障 / 語障人士可致電 711, 服務時間為上午 8 點至晚上 8 點, 每週七天 此為免付費電話 如需更多資訊, 請瀏覽

11 X 承保藥物清單 第 1 頁開始的承保藥物清單為您提供有關 Elderplan FIDA Total Care 承保藥物的資訊 若您難以在清單中找到所需的藥物, 請轉到第 73 頁開始的索引 表格的第一欄列出了藥物名稱 原廠藥用大寫字母表示 ( 如 LATUDA), 副廠藥則用小寫斜體字母表示 ( 如 losartan) 必要行動 限制或使用上限 一欄的資訊會說明 Elderplan FIDA Total Care 在承保您的藥物時是否有任何規定 符號 說明 * Medicaid 承保的非 D 部分藥物或 OTC 用品 B/D 由 Medicare B 部分或 D 部分承保 某些藥物可能由 Medicare B 部分或 D 部分承保 ( 視情況而定 ) 可能需要提交資訊, 描述藥物的用途與規定, 以便作出裁決 PA 需要事先授權 某些藥物需要您或您的醫師獲得事先授權才能配取 這表示您將需 要在配取處方藥前取得 Elderplan FIDA Total Care 或 IDT 的核准 ST QL 需要階段療法例外處理 您需要先嘗試藥物清單上的某些藥物, 我們才能承保此藥物 數量限制 Elderplan FIDA Total Care 會限制某些藥物的承保數量 除非另有說明, 數量限制指 30 天的供藥量 例如,Elderplan FIDA Total Care 規定 Fentanyl 貼片 30 天的數量限制為 10 片 LA NM 取藥限制 此藥物可能僅在某些藥房提供 如需更多資訊, 請致電參保者服 務部, 電話 : 不能在郵購藥房購買 註 : 藥物旁邊有 * 代表藥物不是 D 部分藥物 這些藥物有不同的上訴規則 上訴是指透過正式方式要求我們審查並更改您認為有誤的承保範圍決定 例如,Elderplan FIDA Total Care 或您的跨科團隊 (IDT) 可能裁決某種您想要的藥物是 Medicare 或 Medicaid 不承保或不再承保的藥物 如果您或您的醫生或其他處方醫師不同意該裁決, 您可提出上訴 如需瞭解如何提出上訴, 請致電參保者服務部, 電話 : 或 Independent Consumer Advocacy Network (ICAN),? 如果您有疑問, 請致電 Elderplan FIDA Total Care: , 聽障 / 語障人士可致電 711, 服務時間為上午 8 點至晚上 8 點, 每週七天 此為免付費電話 如需更多資訊, 請瀏覽

12 XI 電話 : ( 聽障和語障人士可致電 711, 然後按照提示撥打 ) 您 也可以參閱參保者手冊, 瞭解如何對裁決提出上訴? 如果您有疑問, 請致電 Elderplan FIDA Total Care: , 聽障 / 語障人士可致電 711, 服務時間為上午 8 點至晚上 8 點, 每週七天 此為免付費電話 如需更多資訊, 請瀏覽

13 XII 按疾病排列的藥物清單 本節所列藥物按照所治療的病症類型分類 例如, 如果您患有心臟病, 您應該查看 心血管 類別 您可以在該類別找到治療心臟病的藥物? 如果您有疑問, 請致電 Elderplan FIDA Total Care: , 聽障 / 語障人士可致電 711, 服務時間為上午 8 點至晚上 8 點, 每週七天 此為免付費電話 如需更多資訊, 請瀏覽

14 NY_CY17_2T_MMP effective 11/01/2017 ANALGESICS - DRUGS TO TREAT PAIN AND INFLAMMATION GOUT - DRUGS TO TREAT GOUT allopurinol tab 1 $0 colchicine w/ probenecid 1 $0 COLCRYS 2 $0 QL (120 tabs / 30 probenecid 1 $0 ULORIC 2 $0 ST MISCELLANEOUS acetaminophen CAPS 3 $0 NM; * acetaminophen CHEW 3 $0 NM; * acetaminophen LIQD 3 $0 NM; * acetaminophen SOLN 3 $0 NM; * acetaminophen SUPP 120mg, 3 $0 NM; * 325mg, 650mg ACETAMINOPHEN SUPP 120mg, 3 $0 NM; * 325mg, 650mg acetaminophen SUSP 3 $0 NM; * acetaminophen TABS 3 $0 NM; * acetaminophen TBCR 3 $0 NM; * acetaminophen TBDP 3 $0 NM; * aspirin CHEW 3 $0 NM; * aspirin SUPP 300mg, 600mg 3 $0 NM; * aspirin TABS 3 $0 NM; * aspirin TBEC 3 $0 NM; * aspirin buffered (cal carb-mag 3 $0 NM; * carb-mag oxide) FEVERALL INFANTS 3 $0 NM; * NSAIDS - DRUGS TO TREAT PAIN AND INFLAMMATION celecoxib CAPS 50mg 1 $0 QL (240 caps / 30 celecoxib CAPS 100mg 1 $0 QL (120 caps / 30 celecoxib CAPS 200mg 1 $0 QL (60 caps / 30 celecoxib CAPS 400mg 1 $0 QL (30 caps / 30 diclofenac potassium 1 $0 QL (120 tabs / 30 diclofenac sodium TB24 1 $0 diclofenac sodium TBEC 1 $0 diflunisal 1 $0 * - Non-Part D s, or OTC items that are covered by Medicaid 1

15 etodolac 1 $0 etodolac er 1 $0 flurbiprofen TABS 1 $0 ibuprofen CAPS 3 $0 NM; * ibuprofen SUSP 100mg/5ml 1 $0 ibuprofen SUSP 100mg/5ml 3 $0 NM; * ibuprofen TABS 200mg 3 $0 NM; * ibuprofen TABS 400mg, 600mg, 1 $0 800mg ketoprofen CAPS 1 $0 MELOXICAM SUSP 1 $0 meloxicam TABS 1 $0 nabumetone TABS 1 $0 naproxen SUSP; TABS; TBEC 1 $0 naproxen sodium TABS 275mg, 1 $0 550mg piroxicam CAPS 1 $0 sulindac TABS 1 $0 OPIOID ANALGESICS - DRUGS TO TREAT PAIN acetaminophen w/ codeine SOLN 1 $0 QL (5000 ml / 30 acetaminophen w/ codeine TABS 1 $0 QL (400 tabs / 30 butorphanol tartrate SOLN 1 $0 1mg/ml, 2mg/ml BUTRANS 5mcg/hr 2 $0 QL (16 patches / 28 BUTRANS 10mcg/hr 2 $0 QL (8 patches / 28 BUTRANS 15mcg/hr, 20mcg/hr 2 $0 QL (4 patches / 28 BUTRANS 7.5MCG/HR 2 $0 QL (8 patches / 28 nalbuphine hcl SOLN 1 $0 tramadol hcl TABS 1 $0 QL (240 tabs / 30 tramadol-acetaminophen 1 $0 QL (240 tabs / 30 OPIOID ANALGESICS, CII - DRUGS TO TREAT PAIN DURAMORPH 1 $0 B/D endocet 1 $0 QL (360 tabs / 30 * - Non-Part D s, or OTC items that are covered by Medicaid 2

16 fentanyl citrate LPOP 2 $0 QL (120 lozenges / 30, PA fentanyl patch 12 mcg/hr 1 $0 QL (10 patches / 30 fentanyl patch 25 mcg/hr 1 $0 QL (10 patches / 30 fentanyl patch 50 mcg/hr 1 $0 QL (10 patches / 30, PA fentanyl patch 75 mcg/hr 1 $0 QL (10 patches / 30, PA fentanyl patch 100 mcg/hr 1 $0 QL (10 patches / 30, PA FENTORA 2 $0 QL (120 tabs / 30, PA hydroco/apap tab 5-325mg 1 $0 QL (360 tabs / 30 hydroco/apap tab $0 QL (360 tabs / 30 hydroco/apap tab mg 1 $0 QL (360 tabs / 30 hydrocodone-acetaminophen mg/15ml 1 $0 QL (5400 ml / 30 hydrocodone-ibuprofen tab mg 1 $0 QL (150 tabs / 30 hydromorphone hcl LIQD 1 $0 hydromorphone hcl SOLN 1 $0 B/D 10mg/ml, 50mg/5ml, 500mg/50ml hydromorphone hcl TABS 1 $0 QL (270 tabs / 30 HYSINGLA ER 20mg, 30mg, 2 $0 QL (60 tabs / 30 40mg, 60mg HYSINGLA ER 80mg, 100mg, 2 $0 QL (30 tabs / mg lorcet hd tab mg 1 $0 QL (360 tabs / 30 lorcet plus tab $0 QL (360 tabs / 30 lorcet tab 5-325mg 1 $0 QL (360 tabs / 30 methadone hcl CONC 1 $0 QL (120 ml / 30 methadone hcl SOLN 5mg/5ml, 1 $0 QL (600 ml / 30 10mg/5ml methadone hcl 5mg 1 $0 QL (240 tabs / 30 * - Non-Part D s, or OTC items that are covered by Medicaid 3

17 methadone hcl 10mg 1 $0 QL (240 tabs / 30 morphine ext-rel tab 15mg, 1 $0 QL (90 tabs / 30 30mg, 60mg, 100mg morphine ext-rel tab 200mg 1 $0 QL (60 tabs / 30 MORPHINE SUL INJ 1MG/ML 1 $0 B/D MORPHINE SUL INJ 4MG/ML 1 $0 B/D MORPHINE SUL INJ 10MG/ML 1 $0 B/D MORPHINE SUL INJ 15MG/ML 1 $0 B/D MORPHINE SULFATE SOLN 2mg/ml, 8mg/ml, 150mg/30ml 1 $0 B/D morphine sulfate SOLN.5mg/ml, 1 $0 B/D 1mg/ml, 4mg/ml, 8mg/ml MORPHINE SULFATE TABS 1 $0 QL (180 tabs / 30 MORPHINE SULFATE ORAL SOL 1 $0 oxycodone hcl CAPS 1 $0 QL (180 caps / 30 oxycodone hcl CONC 1 $0 OXYCODONE HCL SOLN 1 $0 oxycodone hcl TABS 1 $0 QL (180 tabs / 30 oxycodone w/ acetaminophen $0 QL (360 tabs / mg oxycodone w/ acetaminophen 5-325mg 1 $0 QL (360 tabs / 30 oxycodone w/ acetaminophen $0 QL (360 tabs / mg oxycodone w/ acetaminophen mg 1 $0 QL (360 tabs / 30 oxycodone w/ acetaminophen soln 1 $0 QL (1800 ml / 30 OXYCONTIN 2 $0 QL (120 tabs / 30 ANESTHETICS - DRUGS FOR NUMBING LOCAL ANESTHETICS lidocaine hcl (local anesth.) 1 $0 B/D lidocaine inj 0.5% 1 $0 B/D lidocaine inj 1% 1 $0 B/D lidocaine inj 1.5% 1 $0 B/D lidocaine inj 2% 1 $0 B/D ANTI-INFECTIVES - DRUGS TO TREAT INFECTIONS ANTI-BACTERIALS - MISCELLANEOUS * - Non-Part D s, or OTC items that are covered by Medicaid 4

18 amikacin sulfate SOLN 1 $0 gentamicin in saline 1 $0 gentamicin sulfate SOLN 1 $0 neomycin sulfate TABS 1 $0 paromomycin sulfate CAPS 1 $0 streptomycin sulfate SOLR 1 $0 sulfadiazine TABS 2 $0 tobramycin NEBU 2 $0 NM, PA tobramycin inj 1.2 gm/30ml 1 $0 tobramycin inj 1.2gm 2 $0 tobramycin inj 10mg/ml 1 $0 tobramycin inj 40mg/ml 1 $0 tobramycin inj 80mg/2ml 1 $0 ANTI-INFECTIVES - MISCELLANEOUS ALBENZA 2 $0 ALINIA 2 $0 atovaquone SUSP 2 $0 AZACTAM IN ISO-OSMOTIC DE 2 $0 AZACTAM/DEX INJ 2GM 2 $0 aztreonam 1 $0 BILTRICIDE 2 $0 CAYSTON 2 $0 NM, LA, PA clindamycin cap 75mg 1 $0 clindamycin cap 300mg 1 $0 clindamycin hcl cap 150 mg 1 $0 clindamycin phosphate SOLN 1 $0 clindamycin phosphate in d5w 1 $0 CLINDAMYCIN PHOSPHATE IN 2 $0 NACL clindamycin phosphate inj 1 $0 clindamycin sol 75mg/5ml 1 $0 colistimethate sodium SOLR 1 $0 CUBICIN 2 $0 dapsone TABS 1 $0 daptomycin 2 $0 emverm 2 $0 imipenem-cilastatin 1 $0 INVANZ 2 $0 ivermectin TABS 1 $0 linezolid SOLN 2 $0 LINEZOLID SUSR; TABS 2 $0 LINEZOLID IN SODIUM CHLORIDE 2 $0 * - Non-Part D s, or OTC items that are covered by Medicaid 5

19 meropenem 1 $0 methenamine hippurate 1 $0 metronidazole TABS 1 $0 metronidazole in nacl 1 $0 NEBUPENT 2 $0 B/D nitrofurantoin macrocrystal 50mg, 100mg 2 $0 PA; PA applies if 65 years and older after a 90 day supply in a calendar year nitrofurantoin monohyd macro 2 $0 PA; PA applies if 65 years and older after a 90 day supply in a calendar year PENTAM $0 SIVEXTRO 2 $0 sulfamethoxazole-trimethop ds 1 $0 sulfamethoxazole-trimethoprim 1 $0 sulfamethoxazole-trimethoprim inj 1 $0 SYNERCID 2 $0 TIGECYCLINE 2 $0 trimethoprim TABS 1 $0 TYGACIL 2 $0 vancomycin hcl CAPS 2 $0 vancomycin hcl SOLR 1 $0 VANCOMYCIN IN NACL 2 $0 ANTIFUNGALS - DRUGS TO TREAT FUNGAL INFECTIONS ABELCET 2 $0 B/D AMBISOME 2 $0 B/D amphotericin b SOLR 1 $0 B/D CANCIDAS 2 $0 CASPOFUNGIN ACETATE 2 $0 fluconazole SUSR; TABS 1 $0 fluconazole in dextrose 1 $0 fluconazole inj nacl $0 fluconazole inj nacl $0 fluconazole inj nacl $0 flucytosine CAPS 2 $0 griseofulvin microsize 1 $0 griseofulvin ultramicrosize 1 $0 itraconazole CAPS 1 $0 PA ketoconazole TABS 1 $0 PA MYCAMINE 2 $0 * - Non-Part D s, or OTC items that are covered by Medicaid 6

20 NOXAFIL SUSP; TBEC 2 $0 nystatin TABS 1 $0 terbinafine hcl TABS 1 $0 QL (90 tabs / 365 voriconazole SOLR 1 $0 voriconazole SUSR; TABS 2 $0 ANTIMALARIALS - DRUGS TO TREAT MALARIA atovaquone-proguanil hcl 1 $0 chloroquine phosphate TABS 1 $0 COARTEM 2 $0 mefloquine hcl 1 $0 PRIMAQUINE PHOSPHATE 2 $0 quinine sulfate CAPS 1 $0 PA ANTIRETROVIRAL AGENTS - DRUGS TO SUPPRESS HIV/AIDS INFECTION abacavir sulfate 1 $0 APTIVUS 2 $0 CRIXIVAN 2 $0 didanosine 1 $0 EDURANT 2 $0 EMTRIVA 2 $0 FUZEON 2 $0 NM INTELENCE 2 $0 INVIRASE 2 $0 ISENTRESS 2 $0 ISENTRESS HD 2 $0 lamivudine 1 $0 LEXIVA 2 $0 NEVIRAPINE SUSP 1 $0 nevirapine TABS; TB24 1 $0 NORVIR 2 $0 PREZISTA 2 $0 RESCRIPTOR 2 $0 RETROVIR IV INFUSION 2 $0 REYATAZ 2 $0 SELZENTRY 2 $0 stavudine 1 $0 SUSTIVA 2 $0 TIVICAY 2 $0 TYBOST 2 $0 VIDEX PEDIATRIC 2 $0 VIRACEPT 2 $0 * - Non-Part D s, or OTC items that are covered by Medicaid 7

21 VIRAMUNE SUSP 2 $0 VIREAD 2 $0 ZERIT SOLR 2 $0 ZIAGEN SOLN 2 $0 zidovudine 1 $0 ANTIRETROVIRAL COMBINATION AGENTS - DRUGS TO SUPPRESS HIV/AIDS INFECTION ABACAVIR SULFATE-LAMIVUDINE 2 $0 abacavir sulfate-lamivudinezidovudine 2 $0 ATRIPLA 2 $0 COMPLERA 2 $0 DESCOVY 2 $0 EVOTAZ 2 $0 GENVOYA 2 $0 KALETRA SOL 2 $0 KALETRA TAB MG 2 $0 KALETRA TAB MG 2 $0 lamivudine-zidovudine 1 $0 lopinavir-ritonavir 2 $0 ODEFSEY 2 $0 PREZCOBIX 2 $0 STRIBILD 2 $0 TRIUMEQ 2 $0 TRUVADA TAB $0 QL (60 tabs / 30 TRUVADA TAB $0 QL (30 tabs / 30 TRUVADA TAB $0 QL (30 tabs / 30 TRUVADA TAB $0 QL (30 tabs / 30 ANTITUBERCULAR AGENTS - DRUGS TO TREAT TUBERCULOSIS CAPASTAT SULFATE 2 $0 cycloserine CAPS 2 $0 ethambutol hcl TABS 1 $0 isoniazid TABS 1 $0 isoniazid inj 100 mg/ml 1 $0 isoniazid syp 50mg/5ml 1 $0 paser d/r 2 $0 PRIFTIN 2 $0 pyrazinamide TABS 1 $0 rifabutin 1 $0 rifampin CAPS; SOLR 1 $0 RIFATER 2 $0 SIRTURO 2 $0 LA, PA * - Non-Part D s, or OTC items that are covered by Medicaid 8

22 TRECATOR 2 $0 ANTIVIRALS - DRUGS TO TREAT VIRAL INFECTIONS acyclovir CAPS 1 $0 acyclovir SUSP 1 $0 acyclovir TABS 1 $0 acyclovir sodium 1 $0 B/D adefovir dipivoxil 2 $0 BARACLUDE SOLN 2 $0 DAKLINZA 2 $0 NM, PA entecavir 2 $0 EPCLUSA 2 $0 NM, PA EPIVIR HBV SOLN 2 $0 famciclovir TABS 1 $0 ganciclovir inj 500mg 1 $0 B/D HARVONI 2 $0 NM, PA lamivudine (hbv) 1 $0 MAVYRET 2 $0 NM, PA moderiba tab 200mg 1 $0 NM oseltamivir phosphate 1 $0 PEGASYS 2 $0 NM, PA PEGASYS PROCLICK 2 $0 NM, PA REBETOL SOLN 2 $0 NM RELENZA DISKHALER 2 $0 ribasphere CAPS 1 $0 NM ribasphere TABS 200mg 1 $0 NM ribasphere TABS 400mg, 600mg 2 $0 NM ribavirin 200mg 1 $0 NM rimantadine hydrochloride 1 $0 SOVALDI 2 $0 NM, PA TAMIFLU SUSR 2 $0 TYZEKA 2 $0 valacyclovir hcl TABS 1 $0 VALCYTE SOLR 2 $0 valganciclovir hcl 2 $0 VEMLIDY 2 $0 VOSEVI 2 $0 NM, PA ZEPATIER 2 $0 NM, PA CEPHALOSPORINS - DRUGS TO TREAT INFECTIONS cefaclor 1 $0 cefaclor monohydrate er 2 $0 cefadroxil 1 $0 * - Non-Part D s, or OTC items that are covered by Medicaid 9

23 CEFAZOLIN IN DEXTROSE 2 $0 2GM/100ML-4% cefazolin inj 1 $0 cefazolin sodium SOLR 1gm, 1 $0 20gm cefazolin sodium 1 gm/50ml 2 $0 cefdinir 1 $0 cefepime hcl 1 $0 cefixime 1 $0 cefotaxime sodium 1gm, 2gm, 1 $0 500mg cefoxitin sodium 1 $0 cefpodoxime proxetil 1 $0 cefprozil 1 $0 ceftazidime SOLR 1 $0 CEFTAZIDIME/DEXTROSE 2 $0 ceftriaxone sodium SOLR 1gm, 1 $0 2gm, 10gm, 250mg, 500mg cefuroxime axetil 1 $0 cefuroxime sodium 1 $0 cephalexin CAPS 250mg, 500mg 1 $0 cephalexin SUSR 1 $0 SUPRAX CAPS 2 $0 suprax CHEW 2 $0 SUPRAX SUSR 500mg/5ml 2 $0 tazicef SOLR 1 $0 tazicef vial 1 $0 TEFLARO 2 $0 ERYTHROMYCINS/MACROLIDES - DRUGS TO TREAT INFECTIONS AZITHROMYCIN PACK 1 $0 azithromycin SOLR; SUSR; TABS 1 $0 clarithromycin TABS 1 $0 clarithromycin er 1 $0 clarithromycin for susp 1 $0 DIFICID 2 $0 e.e.s. 1 $0 ery-tab 1 $0 erythrocin lactobionate 2 $0 erythrocin stearate 1 $0 erythromycin base 1 $0 erythromycin cap 250mg ec 1 $0 erythromycin ethylsuccinate TABS 1 $0 * - Non-Part D s, or OTC items that are covered by Medicaid 10

24 FLUOROQUINOLONES - DRUGS TO TREAT INFECTIONS ciprofloxacin SUSR 1 $0 ciprofloxacin er 1 $0 ciprofloxacin hcl tab 1 $0 ciprofloxacin in d5w 1 $0 ciprofloxacin inj 1 $0 levofloxacin TABS 1 $0 levofloxacin in d5w 1 $0 levofloxacin inj 25mg/ml 1 $0 levofloxacin oral soln 25 mg/ml 1 $0 moxifloxacin hcl TABS 1 $0 PENICILLINS - DRUGS TO TREAT INFECTIONS amoxicillin 1 $0 amoxicillin & pot clavulanate 1 $0 ampicillin & sulbactam sodium 1 $0 ampicillin cap 250 mg 1 $0 ampicillin cap 500 mg 1 $0 ampicillin inj 1 $0 ampicillin sodium 1 $0 ampicillin susp 1 $0 BICILLIN L-A 2 $0 dicloxacillin sodium 1 $0 nafcillin sodium 1 $0 oxacillin sodium 1gm, 2gm 1 $0 oxacillin sodium 10gm 2 $0 PENICILLIN G POT IN DEXTROSE 2 $0 penicillin g procaine 2 $0 penicillin g sodium 1 $0 penicillin v potassium 1 $0 penicilln gk inj 5mu 1 $0 penicilln gk inj 20mu 1 $0 pfizerpen-g 1 $0 piperacillin sodium-tazobactam 1 $0 sodium piperacillin/tazobactam 1 $0 TETRACYCLINES - DRUGS TO TREAT INFECTIONS doxy 1 $0 doxycycline (monohydrate) CAPS 1 $0 50mg, 100mg doxycycline (monohydrate) TABS 1 $0 doxycycline hyclate CAPS 1 $0 doxycycline hyclate SOLR 1 $0 * - Non-Part D s, or OTC items that are covered by Medicaid 11

25 doxycycline hyclate TABS 20mg, 1 $0 100mg minocycline hcl CAPS 1 $0 morgidox cap 1x50mg 1 $0 ANTINEOPLASTIC AGENTS - DRUGS TO TREAT CANCER ALKYLATING AGENTS BENDEKA 2 $0 B/D, NM BICNU 2 $0 B/D busulfan 2 $0 B/D BUSULFEX 2 $0 B/D CYCLOPHOSPHAMIDE CAPS 2 $0 B/D cyclophosphamide SOLR 2 $0 B/D dacarbazine 1 $0 B/D EMCYT 2 $0 GLEOSTINE 2 $0 HEXALEN 2 $0 IFEX INJ 3GM 2 $0 B/D ifosfamide inj 1gm 1 $0 B/D ifosfamide inj 1gm/20ml 1 $0 B/D IFOSFAMIDE INJ 3GM 2 $0 B/D ifosfamide inj 3gm/60ml 1 $0 B/D LEUKERAN 2 $0 melphalan hcl 2 $0 B/D MUSTARGEN 2 $0 B/D TREANDA 2 $0 B/D, NM ANTHRACYCLINES adriamycin 1 $0 B/D daunorubicin hcl 1 $0 B/D doxorubicin hcl 1 $0 B/D doxorubicin hcl liposomal inj 2 $0 B/D 2mg/ml doxorubicin inj 50mg 1 $0 B/D epirubicin hcl 1 $0 B/D idarubicin hcl 2 $0 B/D ANTIBIOTICS bleomycin sulfate 1 $0 B/D mitomycin SOLR 2 $0 B/D ANTIMETABOLITES adrucil 1 $0 B/D ALIMTA 2 $0 B/D azacitidine 2 $0 B/D, NM * - Non-Part D s, or OTC items that are covered by Medicaid 12

26 cladribine 2 $0 B/D cytarabine 20mg/ml 1 $0 B/D fludarabine phosphate 1 $0 B/D fluorouracil SOLN 1 $0 B/D GEMCITABINE HCL SOLN 2 $0 B/D gemcitabine hcl SOLR 2 $0 B/D mercaptopurine TABS 1 $0 METHOTREXATE SODIUM 50mg/2ml 1 $0 B/D methotrexate sodium 50mg/2ml, 1 $0 B/D 100mg/4ml, 200mg/8ml, 250mg/10ml methotrexate sodium inj 1 $0 B/D NIPENT 2 $0 B/D PURIXAN 2 $0 NM TABLOID 2 $0 ANTIMITOTIC, TAXOIDS ABRAXANE 2 $0 B/D DOCEFREZ 2 $0 B/D DOCETAXEL 20mg/ml, 80mg/4ml, 2 $0 B/D 160mg/8ml docetaxel 80mg/4ml, 2 $0 B/D 200mg/10ml DOCETAXEL 20MG/2ML 2 $0 B/D DOCETAXEL 160MG/16ML 2 $0 B/D DOCETAXEL SOLN 80MG/8ML 2 $0 B/D paclitaxel 1 $0 B/D TAXOTERE 80mg/4ml 2 $0 B/D ANTIMITOTIC, VINCA ALKALOIDS vinblastine sulfate 2 $0 B/D vincasar 1 $0 B/D vincristine sulfate 1 $0 B/D vinorelbine tartrate 1 $0 B/D BIOLOGIC RESPONSE MODIFIERS AVASTIN 2 $0 NM, LA, PA BELEODAQ 2 $0 NM, PA ERIVEDGE 2 $0 NM, LA, PA FARYDAK 2 $0 NM, LA, PA HERCEPTIN 2 $0 NM, PA IBRANCE 2 $0 NM, LA, PA IDHIFA 2 $0 NM, LA, PA ISTODAX (OVERFILL) 2 $0 B/D, NM * - Non-Part D s, or OTC items that are covered by Medicaid 13

27 KADCYLA 2 $0 B/D, NM KEYTRUDA 2 $0 NM, PA KISQALI 2 $0 NM, PA KISQALI FEMARA 200 DOSE 2 $0 NM, PA KISQALI FEMARA 400 DOSE 2 $0 NM, PA KISQALI FEMARA 600 DOSE 2 $0 NM, PA LYNPARZA CAPS 2 $0 NM, LA, PA NINLARO 2 $0 NM, PA PROLEUKIN 2 $0 B/D, NM RITUXAN 2 $0 NM, LA, PA RITUXAN HYCELA 2 $0 NM, LA, PA RUBRACA 2 $0 NM, LA, PA TECENTRIQ 2 $0 NM, LA, PA VELCADE 2 $0 NM, PA VENCLEXTA 2 $0 NM, LA, PA VENCLEXTA STARTING PACK 2 $0 NM, LA, PA YERVOY 2 $0 NM, PA ZEJULA 2 $0 NM, LA, PA ZOLINZA 2 $0 NM, PA HORMONAL ANTINEOPLASTIC AGENTS anastrozole TABS 1 $0 bicalutamide 1 $0 DEPO-PROVERA INJ 400/ML 2 $0 B/D exemestane 1 $0 FARESTON 2 $0 FASLODEX 2 $0 B/D flutamide 1 $0 hydroxyprogesterone caproate 2 $0 B/D (antineoplastic) letrozole TABS 1 $0 leuprolide acetate KIT 1 $0 NM, PA LUPRON DEPOT (1-MONTH) 2 $0 NM, PA 3.75mg LUPRON DEPOT INJ 11.25MG (3-2 $0 NM, PA MONTH) LYSODREN 2 $0 megestrol ac sus 40mg/ml 2 $0 PA; PA if 65 years and older megestrol ac tab 20mg 2 $0 PA; PA if 65 years and older megestrol ac tab 40mg 2 $0 PA; PA if 65 years and older * - Non-Part D s, or OTC items that are covered by Medicaid 14

28 MEGESTROL SUS 625MG/5ML 2 $0 PA nilutamide 2 $0 SOLTAMOX 2 $0 tamoxifen citrate TABS 1 $0 TRELSTAR DEP INJ 3.75MG 2 $0 NM, PA TRELSTAR LA INJ 11.25MG 2 $0 NM, PA XTANDI 2 $0 NM, LA, PA ZYTIGA 2 $0 NM, LA, PA KINASE INHIBITORS AFINITOR 2 $0 NM, PA AFINITOR DISPERZ 2 $0 NM, PA ALECENSA 2 $0 NM, LA, PA ALUNBRIG 2 $0 NM, LA, PA BOSULIF 2 $0 NM, PA CABOMETYX 2 $0 NM, LA, PA CAPRELSA 2 $0 NM, LA, PA COMETRIQ 2 $0 NM, LA, PA COTELLIC 2 $0 NM, LA, PA GILOTRIF TAB 20MG 2 $0 NM, LA, PA GILOTRIF TAB 30MG 2 $0 NM, LA, PA GILOTRIF TAB 40MG 2 $0 NM, LA, PA ICLUSIG 2 $0 NM, LA, PA imatinib mesylate 100mg 2 $0 QL (90 tabs / 30, NM, PA imatinib mesylate 400mg 2 $0 QL (60 tabs / 30, NM, PA IMBRUVICA CAP 140MG 2 $0 NM, LA, PA INLYTA 2 $0 NM, LA, PA IRESSA 2 $0 NM, LA, PA JAKAFI 2 $0 NM, LA, PA LENVIMA 8 MG DAILY DOSE 2 $0 NM, LA, PA LENVIMA 10 MG DAILY DOSE 2 $0 NM, LA, PA LENVIMA 14 MG DAILY DOSE 2 $0 NM, LA, PA LENVIMA 18 MG DAILY DOSE 2 $0 NM, LA, PA LENVIMA 20 MG DAILY DOSE 2 $0 NM, LA, PA LENVIMA 24 MG DAILY DOSE 2 $0 NM, LA, PA MEKINIST 2 $0 NM, LA, PA NERLYNX 2 $0 NM, LA, PA NEXAVAR 2 $0 NM, LA, PA RYDAPT 2 $0 NM, PA SPRYCEL 2 $0 NM, PA STIVARGA 2 $0 NM, LA, PA * - Non-Part D s, or OTC items that are covered by Medicaid 15

29 SUTENT 2 $0 NM, PA TAFINLAR 2 $0 NM, LA, PA TAGRISSO 2 $0 NM, LA, PA TARCEVA 2 $0 NM, LA, PA TASIGNA 2 $0 NM, PA TYKERB 2 $0 NM, LA, PA VOTRIENT 2 $0 NM, LA, PA XALKORI 2 $0 NM, LA, PA ZELBORAF 2 $0 NM, LA, PA ZYDELIG 2 $0 NM, LA, PA ZYKADIA 2 $0 NM, LA, PA MISCELLANEOUS bexarotene 2 $0 NM, PA DROXIA 2 $0 hydroxyurea CAPS 1 $0 LONSURF 2 $0 NM, PA MATULANE 2 $0 LA mitoxantrone hcl 1 $0 B/D, NM ODOMZO 2 $0 NM, LA, PA SYLATRON KIT 200MCG 2 $0 NM, PA SYLATRON KIT 300MCG 2 $0 NM, PA SYLATRON KIT 600MCG 2 $0 NM, PA SYNRIBO 2 $0 NM, PA tretinoin (chemotherapy) 2 $0 TRISENOX 2 $0 B/D PLATINUM-BASED AGENTS carboplatin 1 $0 B/D cisplatin 1 $0 B/D oxaliplatin 1 $0 B/D PROTECTIVE AGENTS AMIFOSTINE 2 $0 B/D dexrazoxane 2 $0 B/D ELITEK 2 $0 B/D FUSILEV 2 $0 B/D, NM leucovorin calcium SOLR 1 $0 B/D leucovorin calcium TABS 1 $0 leucovorin calcium for inj 500 mg 1 $0 B/D levoleucovorin calcium SOLN 2 $0 B/D, NM levoleucovorin calcium SOLR 2 $0 B/D, NM 50mg LEVOLEUCOVORIN CALCIUM SOLR 175mg 2 $0 B/D, NM * - Non-Part D s, or OTC items that are covered by Medicaid 16

30 mesna 1 $0 B/D MESNEX TABS 2 $0 TOPOISOMERASE INHIBITORS etoposide SOLN 1 $0 B/D irinotecan inj 40mg/2ml 1 $0 B/D irinotecan inj 100/5ml 1 $0 B/D irinotecan inj 500mg/25ml 1 $0 B/D toposar 1 $0 B/D TOPOTECAN HCL SOLN 2 $0 B/D topotecan hcl SOLR 2 $0 B/D CARDIOVASCULAR - DRUGS TO TREAT HEART AND CIRCULATION CONDITIONS ACE INHIBITOR COMBINATIONS - DRUGS TO TREAT HIGH BLOOD PRESSURE amlodipine--benazepril hcl cap 10-1 $0 20 mg amlodipine-benazepril hcl cap mg 1 $0 amlodipine-benazepril hcl cap $0 mg amlodipine-benazepril hcl cap $0 mg amlodipine-benazepril hcl cap $0 mg amlodipine-benazepril hcl cap 10-1 $0 40mg benazepril & hydrochlorothiazide 1 $0 captopril & hydrochlorothiazide 1 $0 enalapril maleate & 1 $0 hydrochlorothiazide fosinopril sodium & 1 $0 hydrochlorothiazide lisinopril & hydrochlorothiazide 1 $0 moexipril-hydrochlorothiazide 1 $0 quinapril-hydrochlorothiazide 1 $0 ACE INHIBITORS - DRUGS TO TREAT HIGH BLOOD PRESSURE benazepril hcl TABS 1 $0 captopril TABS 1 $0 enalapril maleate TABS 1 $0 fosinopril sodium 1 $0 lisinopril TABS 1 $0 moexipril hcl 1 $0 * - Non-Part D s, or OTC items that are covered by Medicaid 17

31 perindopril erbumine 1 $0 quinapril hcl 1 $0 ramipril 1 $0 trandolapril 1 $0 ALDOSTERONE RECEPTOR ANTAGONISTS - DRUGS TO TREAT HIGH BLOOD PRESSURE eplerenone 1 $0 spironolactone TABS 1 $0 ALPHA BLOCKERS - DRUGS TO TREAT HIGH BLOOD PRESSURE doxazosin mesylate 1mg, 2mg, 1 $0 QL (30 tabs / 30 4mg doxazosin mesylate 8mg 1 $0 prazosin hcl 1 $0 terazosin hcl 1 $0 ANGIOTENSIN II RECEPTOR ANTAGONIST COMBINATIONS - DRUGS TO TREAT HIGH BLOOD PRESSURE amlodipine besylate-olmesartan 1 $0 medoxomil amlodipine besylate-valsartan tab 1 $ mg amlodipine besylate-valsartan tab 1 $ mg amlodipine besylate-valsartan tab 1 $ mg amlodipine besylate-valsartan tab 1 $ mg amlodipine-valsartanhydrochlorothiazide 1 $ mg amlodipine-valsartanhydrochlorothiazide 1 $ mg amlodipine-valsartanhydrochlorothiazide 1 $ mg amlodipine-valsartanhydrochlorothiazide 1 $ mg amlodipine-valsartanhydrochlorothiazide 1 $ mg candesartan cilexetilhydrochlorothiazide 1 $0 ENTRESTO 2 $0 irbesartan-hydrochlorothiazide 1 $0 losartan-hydrochlorothiazide 1 $0 * - Non-Part D s, or OTC items that are covered by Medicaid 18

32 olmesartan medoxomil-amlodipine-hydrochlorothiazide $0 olmesartan medoxomilhydrochlorothiazide 1 $0 telmisartan-hydrochlorothiazide 1 $0 valsartan & hctz tab mg 1 $0 valsartan & hctz tab mg 1 $0 valsartan & hctz tab mg 1 $0 valsartan & hctz tab mg 1 $0 valsartan & hctz tab mg 1 $0 ANGIOTENSIN II RECEPTOR ANTAGONISTS - DRUGS TO TREAT HIGH BLOOD PRESSURE candesartan cilexetil 1 $0 irbesartan 1 $0 losartan potassium 1 $0 olmesartan medoxomil TABS 1 $0 telmisartan 1 $0 valsartan 1 $0 ANTIARRHYTHMICS - DRUGS TO CONTROL HEART RHYTHM amiodarone hcl 1 $0 disopyramide phosphate 2 $0 PA; PA if 65 years and older DOFETILIDE 1 $0 NM flecainide acetate 1 $0 mexiletine hcl 1 $0 MULTAQ 2 $0 NORPACE CR 2 $0 PA; PA if 65 years and older pacerone 1 $0 propafenone hcl 1 $0 propafenone hcl 12hr 1 $0 quinidine gluconate TBCR 1 $0 quinidine sulfate TABS 1 $0 sorine 1 $0 sotalol hcl 1 $0 sotalol hcl (afib/afl) 1 $0 ANTILIPEMICS, HMG-CoA REDUCTASE INHIBITORS - DRUGS TO TREAT HIGH CHOLESTEROL atorvastatin calcium TABS 1 $0 lovastatin 1 $0 pravastatin sodium 1 $0 rosuvastatin calcium 1 $0 QL (30 tabs / 30 * - Non-Part D s, or OTC items that are covered by Medicaid 19

33 simvastatin TABS 5mg, 10mg, 1 $0 20mg, 40mg simvastatin TABS 80mg 1 $0 QL (30 tabs / 30 ANTILIPEMICS, MISCELLANEOUS - DRUGS TO TREAT HIGH CHOLESTEROL cholestyramine 1 $0 cholestyramine light 1 $0 colestipol hcl 1 $0 ezetimibe 1 $0 fenofibrate TABS 48mg, 54mg, 1 $0 145mg, 160mg fenofibrate micronized 67mg, 1 $0 134mg, 200mg gemfibrozil TABS 1 $0 JUXTAPID 2 $0 NM, LA, PA KYNAMRO 2 $0 NM, PA niacin er (antihyperlipidemic) 1 $0 QL (90 tabs / mg niacin er (antihyperlipidemic) 1 $0 750mg, 1000mg niacor 1 $0 omega-3-acid ethyl esters 1 $0 PRALUENT 2 $0 NM, PA prevalite 1 $0 triklo 1 $0 VASCEPA 2 $0 WELCHOL 2 $0 BETA-BLOCKER/DIURETIC COMBINATIONS - DRUGS TO TREAT HIGH BLOOD PRESSURE AND HEART CONDITIONS atenolol & chlorthalidone 1 $0 bisoprolol & hydrochlorothiazide 1 $0 metoprolol & hctz tab 50-25mg 1 $0 metoprolol & hctz tab mg 1 $0 metoprolol & hctz tab mg 1 $0 propranolol & hydrochlorothiazide 1 $0 BETA-BLOCKERS - DRUGS TO TREAT HIGH BLOOD PRESSURE AND HEART CONDITIONS acebutolol hcl CAPS 1 $0 atenolol TABS 1 $0 bisoprolol fumarate 1 $0 BYSTOLIC 2 $0 carvedilol 1 $0 * - Non-Part D s, or OTC items that are covered by Medicaid 20

34 labetalol hcl TABS 1 $0 metoprolol succinate 1 $0 metoprolol tartrate SOCT 1 $0 metoprolol tartrate SOLN 1 $0 metoprolol tartrate TABS 25mg, 1 $0 50mg, 100mg nadolol TABS 1 $0 pindolol 1 $0 propranolol cap er 1 $0 propranolol hcl SOLN; TABS 1 $0 propranolol oral sol 1 $0 timolol maleate TABS 1 $0 CALCIUM CHANNEL BLOCKERS - DRUGS TO TREAT HIGH BLOOD PRESSURE AND HEART CONDITIONS afeditab cr 1 $0 amlodipine besylate TABS 1 $0 cartia xt cap 120/24hr 1 $0 cartia xt cap 180/24hr 1 $0 cartia xt cap 240/24hr 1 $0 cartia xt cap 300/24hr 1 $0 dilt-xr cap 1 $0 diltiazem cap 120mg cd 1 $0 diltiazem cap 180mg cd 1 $0 diltiazem cap 240mg cd 1 $0 diltiazem cap 300mg cd 1 $0 DILTIAZEM CAP 360MG CD 1 $0 diltiazem cap er/12hr 1 $0 diltiazem hcl SOLN; TABS 1 $0 diltiazem hcl cap sr 24hr 1 $0 diltiazem hcl coated beads cap sr 1 $0 24hr diltiazem hcl extended release 1 $0 beads cap sr felodipine 1 $0 isradipine 1 $0 nicardipine hcl CAPS 1 $0 nifedical xl 1 $0 nifedipine TB24 1 $0 nifedipine er 1 $0 nimodipine CAPS 2 $0 NYMALIZE 2 $0 taztia 1 $0 * - Non-Part D s, or OTC items that are covered by Medicaid 21

35 verapamil cap er 100mg, 120mg, 1 $0 180mg, 200mg, 240mg, 300mg VERAPAMIL CAP ER 360mg 1 $0 verapamil hcl SOLN; TABS; TBCR 1 $0 verapamil tab er 1 $0 DIGITALIS GLYCOSIDES - DRUGS TO TREAT HEART CONDITIONS digitek.25mg 1 $0 PA; PA if 65 years and older digitek.125mg 1 $0 QL (30 tabs / 30 digox 125mcg 1 $0 QL (30 tabs / 30 digox 250mcg 1 $0 PA; PA if 65 years and older digoxin TABS 125mcg 1 $0 QL (30 tabs / 30 digoxin TABS 250mcg 1 $0 PA; PA if 65 years and older digoxin inj 1 $0 DIGOXIN SOL 50MCG/ML 1 $0 PA; PA if 65 years and older DIURETICS - DRUGS TO TREAT HEART CONDITIONS acetazolamide CP12; TABS 1 $0 amiloride & hydrochlorothiazide 1 $0 amiloride hcl TABS 1 $0 bumetanide 1 $0 chlorothiazide tabs 1 $0 chlorthalidone 1 $0 furosemide SOLN; TABS 1 $0 furosemide inj 10mg/ml 1 $0 FUROSEMIDE INJ 10mg/ml 1 $0 hydrochlorothiazide CAPS; TABS 1 $0 indapamide 1 $0 methazolamide TABS 1 $0 methyclothiazide 1 $0 metolazone 1 $0 spironolactone & 1 $0 hydrochlorothiazide torsemide tabs 1 $0 triamterene & hydrochlorothiazide 1 $0 TABS triamterene & hydrochlorothiazide 1 $0 cap mg MISCELLANEOUS clonidine hcl PTWK; TABS 1 $0 * - Non-Part D s, or OTC items that are covered by Medicaid 22

36 DEMSER 2 $0 hydralazine hcl SOLN; TABS 1 $0 midodrine hcl 1 $0 minoxidil TABS 1 $0 NORTHERA 2 $0 NM, LA, PA RANEXA 2 $0 NITRATES - DRUGS TO TREAT HEART CONDITIONS isosorb mononitrate tab 1 $0 isosorbide dinitrate 1 $0 isosorbide dinitrate er 1 $0 isosorbide mononitrate er 1 $0 minitran 1 $0 nitro-bid 2 $0 NITRO-DUR DIS 0.3MG/HR 2 $0 NITRO-DUR DIS 0.8MG/HR 2 $0 nitroglycerin SUBL 1 $0 nitroglycerin td patch 1 $0 PULMONARY ARTERIAL HYPERTENSION - DRUGS TO TREAT PULMONARY HYPERTENSION ADCIRCA 2 $0 NM, PA ADEMPAS 2 $0 QL (90 tabs / 30, NM, LA, PA LETAIRIS 2 $0 QL (30 tabs / 30, NM, LA, PA OPSUMIT 2 $0 NM, LA, PA REMODULIN 2 $0 NM, LA, PA REVATIO SUSR 2 $0 QL (224 ml / 30, NM, PA sildenafil citrate (pulmonary hypertension) TABS 1 $0 QL (90 tabs / 30, NM, PA TRACLEER 62.5mg 2 $0 QL (120 tabs / 30, NM, LA, PA TRACLEER 125mg 2 $0 QL (60 tabs / 30, NM, LA, PA UPTRAVI TABS 200mcg 2 $0 QL (480 tabs / 30, NM, LA, PA UPTRAVI TABS 400mcg 2 $0 QL (240 tabs / 30, NM, LA, PA UPTRAVI TABS 600mcg 2 $0 QL (150 tabs / 30, NM, LA, PA UPTRAVI TABS 800mcg 2 $0 QL (120 tabs / 30, NM, LA, PA * - Non-Part D s, or OTC items that are covered by Medicaid 23

37 UPTRAVI TABS 1000mcg 2 $0 QL (90 tabs / 30, NM, LA, PA UPTRAVI TABS 1200mcg, 1400mcg, 1600mcg 2 $0 QL (60 tabs / 30, NM, LA, PA UPTRAVI TBPK 2 $0 NM, LA, PA VENTAVIS 2 $0 NM, PA CENTRAL NERVOUS SYSTEM - DRUGS TO TREAT NERVOUS SYSTEM DISORDERS ANTIANXIETY - DRUGS TO TREAT ANXIETY alprazolam tab 0.5mg 1 $0 QL (240 tabs / 30 alprazolam tab 0.25mg 1 $0 QL (480 tabs / 30 alprazolam tab 1mg 1 $0 QL (120 tabs / 30 alprazolam tab 2mg 1 $0 QL (150 tabs / 30 buspirone hcl TABS 1 $0 fluvoxamine maleate TABS 25mg, 1 $0 QL (45 tabs / 30 50mg fluvoxamine maleate TABS 1 $0 100mg lorazepam CONC 1 $0 QL (150 ml / 30 lorazepam SOLN 1 $0 lorazepam TABS 1 $0 QL (150 tabs / 30 ANTICONVULSANTS - DRUGS TO TREAT SEIZURES APTIOM 200mg 2 $0 QL (180 tabs / 30 APTIOM 400mg 2 $0 QL (90 tabs / 30 APTIOM 600mg, 800mg 2 $0 QL (60 tabs / 30 BANZEL SUS 40MG/ML 2 $0 PA BANZEL TAB 200MG 2 $0 PA BANZEL TAB 400MG 2 $0 PA BRIVIACT 2 $0 PA carbamazepine CHEW; CP12; 1 $0 SUSP; TABS; TB12 CELONTIN 2 $0 clonazepam TABS 1mg 1 $0 QL (120 tabs / 30 clonazepam TABS 2mg 1 $0 QL (300 tabs / 30 * - Non-Part D s, or OTC items that are covered by Medicaid 24

38 clonazepam TABS.5mg 1 $0 QL (240 tabs / 30 clonazepam TBDP 1mg 1 $0 QL (120 tabs / 30 clonazepam TBDP 2mg 1 $0 QL (300 tabs / 30 clonazepam TBDP.5mg 1 $0 QL (240 tabs / 30 clonazepam TBDP.25mg 1 $0 QL (480 tabs / 30 clonazepam TBDP.125mg 1 $0 QL (960 tabs / 30 clorazepate dipotassium 3.75mg, 7.5mg 1 $0 QL (120 tabs / 30, PA; PA if 65 years and older clorazepate dipotassium 15mg 1 $0 QL (180 tabs / 30, PA; PA if 65 years and older DIASTAT ACUDIAL 2 $0 DIASTAT PEDIATRIC 2 $0 diazepam CONC 1 $0 QL (240 ml / 30, PA; PA if 65 years and older diazepam SOLN 1mg/ml 1 $0 QL (1200 ml / 30, PA; PA if 65 years and older diazepam SOLN 5mg/ml 1 $0 diazepam TABS 1 $0 QL (120 tabs / 30, PA; PA if 65 years and older DIAZEPAM GEL 1 $0 dilantin 2 $0 DILANTIN-125 SUS 125/5ML 2 $0 divalproex sodium CSDR; TB24; 1 $0 TBEC epitol 1 $0 ethosuximide CAPS; SOLN 1 $0 felbamate SUSP 2 $0 felbamate TABS 1 $0 FYCOMPA SUSP 2 $0 QL (720 ml / 30, PA FYCOMPA TABS 2mg 2 $0 QL (180 tabs / 30, PA * - Non-Part D s, or OTC items that are covered by Medicaid 25

39 FYCOMPA TABS 4mg 2 $0 QL (90 tabs / 30, PA FYCOMPA TABS 6mg 2 $0 QL (60 tabs / 30, PA FYCOMPA TABS 8mg, 10mg, 12mg 2 $0 QL (30 tabs / 30, PA gabapentin CAPS 100mg 1 $0 QL (1080 caps / 30 gabapentin CAPS 300mg 1 $0 QL (360 caps / 30 gabapentin CAPS 400mg 1 $0 QL (270 caps / 30 gabapentin SOLN 1 $0 QL (2160 ml / 30 gabapentin TABS 600mg 1 $0 QL (180 tabs / 30 gabapentin TABS 800mg 1 $0 QL (120 tabs / 30 GABITRIL 12mg, 16mg 2 $0 lamotrigine CHEW; TABS; TB24 1 $0 levetiracetam SOLN; TABS; TB24 1 $0 LEVETIRACETAM IN SODIUM 2 $0 CHLORIDE LEVETIRACETAM IV 1 $0 levetiracetam oral soln 100 mg/ml 1 $0 LYRICA CAPS 25mg, 50mg, 75mg, 100mg, 150mg 2 $0 QL (120 caps / 30 LYRICA CAPS 200mg 2 $0 QL (90 caps / 30 LYRICA CAPS 225mg, 300mg 2 $0 QL (60 caps / 30 LYRICA SOLN 2 $0 QL (946 ml / 30 ONFI 2 $0 PA oxcarbazepine 1 $0 PEGANONE 2 $0 phenobarbital ELIX; TABS 2 $0 PA; PA if 65 years and older PHENOBARBITAL SODIUM SOLN 65mg/ml 2 $0 PA; PA if 65 years and older phenobarbital sodium SOLN 130mg/ml 2 $0 PA; PA if 65 years and older phenytek 2 $0 phenytoin CHEW; SUSP 1 $0 phenytoin sodium SOLN 1 $0 phenytoin sodium extended 1 $0 * - Non-Part D s, or OTC items that are covered by Medicaid 26

40 POTIGA 50mg 2 $0 POTIGA 200mg 2 $0 QL (180 tabs / 30 POTIGA 300mg, 400mg 2 $0 QL (90 tabs / 30 primidone TABS 1 $0 roweepra 1 $0 SABRIL PACK 2 $0 QL (180 packets / 30, NM, LA, PA SABRIL TABS 2 $0 QL (180 tabs / 30, NM, LA, PA SPRITAM 2 $0 TEGRETOL 2 $0 TEGRETOL-XR 2 $0 tiagabine hcl 1 $0 topiramate CPSP; TABS 1 $0 valproate sodium SOLN 1 $0 valproic acid 1 $0 vigabatrin powd pack 2 $0 QL (180 packets / 30, NM, LA, PA VIMPAT SOLN 10mg/ml 2 $0 QL (1200 ml / 30 VIMPAT SOLN 200mg/20ml 2 $0 VIMPAT TABS 50mg 2 $0 QL (180 tabs / 30 VIMPAT TABS 100mg, 150mg, 2 $0 QL (60 tabs / mg zonisamide CAPS 1 $0 ANTIDEMENTIA - DRUGS TO TREAT DEMENTIA AND MEMORY LOSS donepezil hydrochloride TABS 1 $0 QL (60 tabs / 30 5mg donepezil hydrochloride TABS 1 $0 10mg, 23mg donepezil hydrochloride TBDP 1 $0 QL (60 tabs / 30 5mg donepezil hydrochloride TBDP 10mg 1 $0 galantamine hydrobromide SOLN 1 $0 galantamine hydrobromide TABS 1 $0 QL (180 tabs / 30 4mg galantamine hydrobromide TABS 1 $0 QL (90 tabs / 30 8mg galantamine hydrobromide TABS 1 12mg $0 * - Non-Part D s, or OTC items that are covered by Medicaid 27

41 galantamine hydrobromide er 1 $0 QL (30 caps / 30 8mg, 16mg galantamine hydrobromide er 1 $0 24mg memantine hcl SOLN 1 $0 PA; PA if < 30 yrs memantine hcl TABS 5mg 1 $0 PA; PA if < 30 yrs MEMANTINE HCL TABS 10mg 1 $0 PA; PA if < 30 yrs NAMENDA XR 2 $0 PA; PA if < 30 yrs NAMENDA XR TITRATION PACK 2 $0 PA; PA if < 30 yrs NAMZARIC 2 $0 rivastigmine tartrate 1 $0 rivastigmine td patch 24hr 4.6 mg/24hr 1 $0 QL (30 patches / 30 rivastigmine td patch 24hr 9.5 mg/24hr 1 $0 QL (30 patches / 30 rivastigmine td patch 24hr 13.3 mg/24hr 1 $0 QL (30 patches / 30 ANTIDEPRESSANTS - DRUGS TO TREAT DEPRESSION amitriptyline hcl TABS 2 $0 PA; PA if 65 years and older amoxapine tab 25mg 1 $0 amoxapine tab 50mg 1 $0 amoxapine tab 100mg 1 $0 amoxapine tab 150mg 1 $0 bupropion hcl TABS 1 $0 bupropion hcl TB12 1 $0 bupropion hcl TB24 150mg 1 $0 QL (90 tabs / 30 bupropion hcl TB24 300mg 1 $0 QL (30 tabs / 30 citalopram hydrobromide SOLN 1 $0 citalopram hydrobromide TABS 1 $0 QL (45 tabs / 30 10mg, 20mg citalopram hydrobromide TABS 1 $0 QL (30 tabs / 30 40mg clomipramine hcl CAPS 2 $0 PA; PA if 65 years and older desipramine hcl TABS 1 $0 desvenlafaxine succinate 1 $0 QL (30 tabs / 30 doxepin hcl CAPS; CONC 2 $0 PA; PA if 65 years and older duloxetine hcl CPEP 20mg 1 $0 QL (180 caps / 30 duloxetine hcl CPEP 30mg 1 $0 QL (120 caps / 30 * - Non-Part D s, or OTC items that are covered by Medicaid 28

42 duloxetine hcl CPEP 60mg 1 $0 QL (60 caps / 30 EMSAM 2 $0 QL (30 patches / 30, PA escitalopram oxalate SOLN 1 $0 QL (600 ml / 30 escitalopram oxalate TABS 5mg, 10mg 1 $0 QL (45 tabs / 30 escitalopram oxalate TABS 20mg 1 $0 QL (60 tabs / 30 FETZIMA 20mg 2 $0 QL (180 caps / 30 FETZIMA 40mg 2 $0 QL (90 caps / 30 FETZIMA 80mg, 120mg 2 $0 QL (30 caps / 30 FETZIMA TITRATION PACK 2 $0 fluoxetine cap 10mg 1 $0 QL (30 caps / 30 fluoxetine cap 20mg 1 $0 QL (120 caps / 30 fluoxetine cap 40mg 1 $0 fluoxetine hcl SOLN 1 $0 fluoxetine hcl TABS 10mg 1 $0 QL (45 tabs / 30 fluoxetine hcl TABS 20mg 1 $0 imipramine hcl TABS 2 $0 PA; PA if 65 years and older maprotiline hcl 1 $0 MARPLAN TAB 10MG 2 $0 QL (180 tabs / 30 mirtazapine TABS 7.5mg, 15mg 1 $0 QL (45 tabs / 30 mirtazapine TABS 30mg, 45mg 1 $0 mirtazapine TBDP 15mg 1 $0 QL (30 tabs / 30 mirtazapine TBDP 30mg, 45mg 1 $0 nefazodone hcl 1 $0 nortriptyline hcl CAPS; SOLN 1 $0 paroxetine hcl tabs 10mg, 20mg, 1 $0 QL (45 tabs / 30 40mg paroxetine hcl tabs 30mg 1 $0 QL (60 tabs / 30 PAXIL SUSP 2 $0 QL (900 ml / 30 phenelzine sulfate TABS 1 $0 PRISTIQ 2 $0 QL (30 tabs / 30 protriptyline hcl 1 $0 sertraline hcl CONC 1 $0 sertraline hcl TABS 25mg, 50mg 1 $0 QL (45 tabs / 30 sertraline hcl TABS 100mg 1 $0 tranylcypromine sulfate 1 $0 trazodone hcl TABS 50mg, 100mg, 150mg 1 $0 * - Non-Part D s, or OTC items that are covered by Medicaid 29

43 trimipramine maleate CAPS 25mg 2 $0 QL (240 caps / 30, PA; PA if 65 years and older trimipramine maleate CAPS 50mg 2 $0 QL (120 caps / 30, PA; PA if 65 years and older trimipramine maleate CAPS 100mg 2 $0 QL (60 caps / 30, PA; PA if 65 years and older TRINTELLIX 5mg 2 $0 QL (120 tabs / 30 TRINTELLIX 10mg 2 $0 QL (60 tabs / 30 TRINTELLIX 20mg 2 $0 QL (30 tabs / 30 venlafaxine hcl CP mg, 1 $0 QL (30 caps / 30 75mg venlafaxine hcl CP24 150mg 1 $0 QL (60 caps / 30 venlafaxine hcl TABS 1 $0 VIIBRYD STARTER PACK 2 $0 VIIBRYD TAB 2 $0 QL (30 tabs / 30 ANTIPARKINSONIAN AGENTS - DRUGS TO TREAT PARKINSONS DISEASE amantadine hcl CAPS 1 $0 QL (120 caps / 30 amantadine hcl SYRP; TABS 1 $0 APOKYN 2 $0 NM, LA, PA BENZTROPINE MESYLATE SOLN 1 $0 benztropine mesylate TABS 2 $0 PA; PA if 65 years and older bromocriptine mesylate CAPS; 1 $0 TABS carbidopa-levodopa 1 $0 CARBIDOPA/LEVODOPA/ENTACAPO1 $0 NE ENTACAPONE 1 $0 NEUPRO 2 $0 pramipexole tab 0.5mg 1 $0 pramipexole tab 0.25mg 1 $0 pramipexole tab 0.75mg 1 $0 pramipexole tab 0.125mg 1 $0 pramipexole tab 1.5mg 1 $0 pramipexole tab 1mg 1 $0 rasagiline mesylate TABS 1 $0 ropinirole tab 0.5mg 1 $0 * - Non-Part D s, or OTC items that are covered by Medicaid 30

44 ropinirole tab 0.25mg 1 $0 ropinirole tab 1mg 1 $0 ropinirole tab 2mg 1 $0 ropinirole tab 3mg 1 $0 ropinirole tab 4mg 1 $0 ropinirole tab 5mg 1 $0 selegiline hcl CAPS; TABS 1 $0 trihexyphenidyl hcl 2 $0 PA; PA if 65 years and older ANTIPSYCHOTICS - DRUGS TO TREAT PSYCHOSES ABILIFY MAINTENA PRSY 2 $0 QL (1 syringe / 28 ABILIFY MAINTENA SRER 2 $0 QL (1 vial / 28 aripiprazole odt 2 $0 QL (60 tabs / 30 aripiprazole oral solution 1 mg/ml 2 $0 QL (900 ml / 30 aripiprazole tab 2mg, 5mg, 10mg, 1 $0 QL (30 tabs / 30 15mg aripiprazole tab 20mg, 30mg 2 $0 QL (30 tabs / 30 ARISTADA 441mg/1.6ml, 662mg/2.4ml, 882mg/3.2ml 2 $0 QL (1 syringe / 28 ARISTADA 1064mg/3.9ml 2 $0 QL (1 syringe / 56 chlorpromazine hcl TABS 1 $0 chlorpromazine inj 2 $0 CLOZAPINE ODT 12.5mg, 25mg 1 $0 PA CLOZAPINE ODT 100mg 1 $0 QL (270 tabs / 30, PA CLOZAPINE ODT 150mg 1 $0 QL (180 tabs / 30, PA CLOZAPINE ODT 200mg 2 $0 QL (135 tabs / 30, PA clozapine tab 25mg 1 $0 clozapine tab 50mg 1 $0 clozapine tab 100mg 1 $0 QL (270 tabs / 30 clozapine tab 200mg 1 $0 QL (135 tabs / 30 FANAPT 2 $0 QL (60 tabs / 30 FANAPT TITRATION PACK 2 $0 fluphenazine decanoate SOLN 1 $0 fluphenazine hcl 1 $0 GEODON SOLR 2 $0 QL (6 ml / 3 haloperidol TABS 1 $0 * - Non-Part D s, or OTC items that are covered by Medicaid 31

45 haloperidol decanoate SOLN 1 $0 haloperidol lactate inj 5 mg/ml 1 $0 haloperidol lactate oral conc 2 mg/ml 1 $0 INVEGA SUST INJ 39 MG/0.25 ML 2 $0 QL (1 injection / 28 INVEGA SUST INJ 78 MG/0.5 ML 2 $0 QL (1 injection / 28 INVEGA SUST INJ 117 MG/0.75 ML 2 $0 QL (1 injection / 28 INVEGA SUST INJ 156MG/ML 2 $0 QL (1 injection / 28 INVEGA SUST INJ 234 MG/1.5 ML 2 $0 QL (1 injection / 28 INVEGA TRINZA 2 $0 QL (1 syringe / 90 LATUDA 20mg 2 $0 QL (240 tabs / 30 LATUDA 40mg, 120mg 2 $0 QL (30 tabs / 30 LATUDA 60mg, 80mg 2 $0 QL (60 tabs / 30 loxapine succinate 1 $0 molindone hcl 10mg 1 $0 molindone hcl 25mg 1 $0 NUPLAZID 2 $0 QL (60 tabs / 30, NM, LA, PA olanzapine SOLR 1 $0 QL (3 vials / 1 day) olanzapine TABS 2.5mg 1 $0 QL (240 tabs / 30 olanzapine TABS 5mg 1 $0 QL (120 tabs / 30 olanzapine TABS 7.5mg 1 $0 QL (30 tabs / 30 olanzapine TABS 10mg, 15mg, 1 $0 QL (60 tabs / 30 20mg olanzapine TBDP 5mg 1 $0 QL (30 tabs / 30 olanzapine TBDP 10mg, 15mg, 1 $0 QL (60 tabs / 30 20mg paliperidone 1.5mg, 3mg, 9mg 2 $0 QL (30 tabs / 30 paliperidone 6mg 2 $0 QL (60 tabs / 30 perphenazine TABS 1 $0 pimozide 1 $0 quetiapine fumarate TABS 1 $0 QL (90 tabs / 30 quetiapine fumarate TB24 50mg 1 $0 QL (120 tabs / 30 * - Non-Part D s, or OTC items that are covered by Medicaid 32

46 quetiapine fumarate TB24 1 $0 QL (30 tabs / mg, 200mg quetiapine fumarate TB24 1 $0 QL (60 tabs / mg, 400mg REXULTI 1mg 2 $0 QL (90 tabs / 30 REXULTI 2mg 2 $0 QL (60 tabs / 30 REXULTI 3mg, 4mg 2 $0 QL (30 tabs / 30 REXULTI.5mg 2 $0 QL (180 tabs / 30 REXULTI.25mg 2 $0 QL (360 tabs / 30 RISPERDAL INJ 12.5MG 2 $0 QL (2 injections / 28 RISPERDAL INJ 25MG 2 $0 QL (2 injections / 28 RISPERDAL INJ 37.5MG 2 $0 QL (2 injections / 28 RISPERDAL INJ 50MG 2 $0 QL (2 injections / 28 risperidone SOLN 1 $0 QL (240 ml / 30 risperidone TABS 1mg, 2mg, 3mg 1 $0 QL (60 tabs / 30 risperidone TABS 4mg 1 $0 QL (120 tabs / 30 risperidone TABS.25mg,.5mg 1 $0 QL (90 tabs / 30 risperidone TBDP 1mg, 2mg, 3mg 1 $0 QL (60 tabs / 30 risperidone TBDP 4mg 1 $0 QL (120 tabs / 30 risperidone TBDP.25mg,.5mg 1 $0 QL (90 tabs / 30 SAPHRIS 2.5mg 2 $0 QL (240 tabs / 30 SAPHRIS 5mg 2 $0 QL (120 tabs / 30 SAPHRIS 10mg 2 $0 QL (60 tabs / 30 thioridazine hcl TABS 2 $0 PA; PA if 65 years and older thiothixene 1 $0 trifluoperazine hcl 1 $0 VERSACLOZ 2 $0 QL (600 ml / 30, PA VRAYLAR 1.5mg 2 $0 QL (120 caps / 30 VRAYLAR 3mg 2 $0 QL (60 caps / 30 VRAYLAR 4.5mg, 6mg 2 $0 QL (30 caps / 30 VRAYLAR THERAPY PACK 2 $0 * - Non-Part D s, or OTC items that are covered by Medicaid 33