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 Elde

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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 5 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 5 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 10 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 137 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 137 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 05/01/2017 Name ANALGESICS - S TO TREAT PAIN AND INFLAMMATION GOUT - S TO TREAT GOUT allopurinol tab 100 mg allopurinol tab 300 mg colchicine w/ probenecid tab mg COLCRYS TAB 0.6MG 2 $0 QL (120 tabs / 30 probenecid tab 500 mg ULORIC TAB 40MG 2 $0 ST ULORIC TAB 80MG 2 $0 ST MISCELLANEOUS ACEPHEN SUP 120MG 3 $0 NM; * acephen sup 325mg 3 $0 NM; * acephen sup 650mg 3 $0 NM; * acetamin tab 500mg 3 $0 NM; * acetaminophen liquid 160 mg/5ml 3 $0 NM; * acetaminophen soln 160 mg/5ml 3 $0 NM; * acetaminophen suppos 120 mg 3 $0 NM; * acetaminophen suppos 650 mg 3 $0 NM; * acetaminophen tab 325 mg 3 $0 NM; * acetaminophen tab cr 650 mg 3 $0 NM; * acetaminophn sus 160/5ml 3 $0 NM; * arthrts pain tab 650mg 3 $0 NM; * aspir-81 tab 81mg ec 3 $0 NM; * aspir-low tab 81mg ec 3 $0 NM; * aspirin chew tab 81 mg 3 $0 NM; * aspirin low chw 81mg 3 $0 NM; * aspirin low tab 81mg ec 3 $0 NM; * aspirin suppos 300 mg 3 $0 NM; * aspirin suppos 600 mg 3 $0 NM; * aspirin tab 325 mg 3 $0 NM; * aspirin tab 325mg ec 3 $0 NM; * aspirin tab delayed release 81 mg 3 $0 NM; * aspirin tab delayed release 325 mg 3 $0 NM; * child asa chw 81mg 3 $0 NM; * child asa ls chw 81mg 3 $0 NM; * D s, or OTC items that are covered by Medicaid 1

15 Name chld pain rl tab 80mg 3 $0 NM; * chld silapap liq 160/5ml 3 $0 NM; * ecpirin tab 325mg ec 3 $0 NM; * FEVERALL INF SUP 80MG 3 $0 NM; * FEVERALL SUP 120MG 3 $0 NM; * FEVERALL SUP 325MG 3 $0 NM; * FEVERALL SUP 650MG 3 $0 NM; * gnp aspirin chw 81mg 3 $0 NM; * gnp aspirin tab 325mg ec 3 $0 NM; * hm aspirin chw 81mg 3 $0 NM; * hm aspirin tab 325mg 3 $0 NM; * 8 hour pain tab 650mg 3 $0 NM; * mapap cap 500mg 3 $0 NM; * mapap child tab 80mg rt 3 $0 NM; * mapap chw 80mg 3 $0 NM; * mapap liq 160/5ml 3 $0 NM; * mapap tab 325mg 3 $0 NM; * mapap tab 500mg 3 $0 NM; * mapap tab 500mg/rr 3 $0 NM; * non-aspirin tab 325mg 3 $0 NM; * non-aspirin tab 500mg 3 $0 NM; * non-aspirin tab 500mg/rr 3 $0 NM; * pain & fever chw 80mg 3 $0 NM; * pain & fever sol 160/5ml 3 $0 NM; * pain & fever sus 160/5ml 3 $0 NM; * pain & fever tab 325mg 3 $0 NM; * pain & fever tab 500mg 3 $0 NM; * pain relief dro 80/0.8ml 3 $0 NM; * pain relief sus 160/5ml 3 $0 NM; * pain relief tab 325mg 3 $0 NM; * pain relief tab 500mg 3 $0 NM; * pain relieve tab 325mg 3 $0 NM; * pain relieve tab 500mg 3 $0 NM; * pain relieve tab 500mg/rr 3 $0 NM; * pharbetol tab 325mg 3 $0 NM; * pharbetol tab 500mg 3 $0 NM; * q-pap child sus 160/5ml 3 $0 NM; * q-pap infant dro 80/0.8ml 3 $0 NM; * q-pap liq 160/5ml 3 $0 NM; * D s, or OTC items that are covered by Medicaid 2

16 Name q-pap tab 325mg 3 $0 NM; * q-pap tab 500mg 3 $0 NM; * qc aspirin tab 325mg 3 $0 NM; * sb aspirin tab 325mg 3 $0 NM; * sm aspirin chw 81mg 3 $0 NM; * sm aspirin tab 325mg 3 $0 NM; * sm child asa chw 81mg 3 $0 NM; * sm pain rel cap 500mg 3 $0 NM; * tactinal tab 325mg 3 $0 NM; * tactinal tab 500mg 3 $0 NM; * tri-buff asa tab 325mg 3 $0 NM; * NSAIDS - S TO TREAT PAIN AND INFLAMMATION celecoxib cap 50 mg QL (240 caps / 30 celecoxib cap 100 mg QL (120 caps / 30 celecoxib cap 200 mg QL (60 caps / 30 celecoxib cap 400 mg QL (30 caps / 30 diclofenac potassium tab 50 mg QL (120 tabs / 30 diclofenac sodium tab delayed release 25 mg diclofenac sodium tab delayed release 50 mg diclofenac sodium tab delayed release 75 mg diclofenac sodium tab sr 24hr 100 mg diflunisal tab 500 mg etodolac cap 200 mg etodolac cap 300 mg etodolac tab 400 mg etodolac tab 500 mg etodolac tab sr 24hr 400 mg etodolac tab sr 24hr 500 mg etodolac tab sr 24hr 600 mg flurbiprofen tab 50 mg flurbiprofen tab 100 mg hm ibuprofen tab 200mg 3 $0 NM; * ibu-200 tab 200mg 3 $0 NM; * ibuprofen cap 200mg 3 $0 NM; * D s, or OTC items that are covered by Medicaid 3

17 Name ibuprofen sus 100/5ml 3 $0 NM; * ibuprofen susp 100 mg/5ml ibuprofen susp 100 mg/5ml 3 $0 NM; * ibuprofen tab 200 mg 3 $0 NM; * ibuprofen tab 200mg 3 $0 NM; * ibuprofen tab 400 mg ibuprofen tab 600 mg ibuprofen tab 800 mg ketoprofen cap 50 mg ketoprofen cap 75 mg MELOXICAM SUSP 7.5 MG/5ML meloxicam tab 7.5 mg meloxicam tab 15 mg nabumetone tab 500 mg nabumetone tab 750 mg naproxen dr tab 375mg naproxen dr tab 500mg naproxen sodium tab 275 mg naproxen sodium tab 550 mg naproxen susp 125 mg/5ml naproxen tab 250 mg naproxen tab 375 mg naproxen tab 500 mg piroxicam cap 10 mg piroxicam cap 20 mg provil tab 200mg 3 $0 NM; * qc ibuprofen tab 200mg 3 $0 NM; * sb ibuprofen tab 200mg 3 $0 NM; * sm ibuprofen tab 200mg 3 $0 NM; * sulindac tab 150 mg sulindac tab 200 mg OPIOID ANALGESICS - S TO TREAT PAIN acetaminophen w/ codeine soln QL (5000 ml / mg/5ml acetaminophen w/ codeine tab mg acetaminophen w/ codeine tab mg acetaminophen w/ codeine tab mg QL (400 tabs / 30 QL (400 tabs / 30 QL (400 tabs / 30 D s, or OTC items that are covered by Medicaid 4

18 Name butorphanol tartrate inj 1 mg/ml butorphanol tartrate inj 2 mg/ml BUTRANS DIS 5MCG/HR 2 $0 QL (16 patches / 28 BUTRANS DIS 7.5/HR 2 $0 QL (8 patches / 28 BUTRANS DIS 10MCG/HR 2 $0 QL (8 patches / 28 BUTRANS DIS 15MCG/HR 2 $0 QL (4 patches / 28 BUTRANS DIS 20MCG/HR 2 $0 QL (4 patches / 28 nalbuphine hcl inj 10 mg/ml nalbuphine hcl inj 20 mg/ml tramadol hcl tab 50 mg QL (240 tabs / 30 tramadol-acetaminophen tab mg QL (240 tabs / 30 OPIOID ANALGESICS, CII - S TO TREAT PAIN DURAMORPH INJ 0.5MG/ML B/D DURAMORPH INJ 1MG/ML B/D endocet tab 5-325mg QL (360 tabs / 30 endocet tab QL (360 tabs / 30 endocet tab mg QL (360 tabs / 30 fentanyl citrate lozenge on a handle 200 mcg fentanyl citrate lozenge on a handle 400 mcg fentanyl citrate lozenge on a handle 600 mcg fentanyl citrate lozenge on a handle 800 mcg fentanyl citrate lozenge on a handle 1200 mcg fentanyl citrate lozenge on a handle 1600 mcg 2 $0 QL (120 lozenges / 30, PA 2 $0 QL (120 lozenges / 30, PA 2 $0 QL (120 lozenges / 30, PA 2 $0 QL (120 lozenges / 30, PA 2 $0 QL (120 lozenges / 30, PA 2 $0 QL (120 lozenges / 30, PA fentanyl td patch 72hr 12 mcg/hr QL (10 patches / 30 fentanyl td patch 72hr 25 mcg/hr QL (10 patches / 30 D s, or OTC items that are covered by Medicaid 5

19 Name fentanyl td patch 72hr 50 mcg/hr QL (10 patches / 30, PA fentanyl td patch 72hr 75 mcg/hr QL (10 patches / 30, PA fentanyl td patch 72hr 100 mcg/hr QL (10 patches / 30, PA FENTORA TAB 100MCG 2 $0 QL (120 tabs / 30, PA FENTORA TAB 200MCG 2 $0 QL (120 tabs / 30, PA FENTORA TAB 400MCG 2 $0 QL (120 tabs / 30, PA FENTORA TAB 600MCG 2 $0 QL (120 tabs / 30, PA FENTORA TAB 800MCG 2 $0 QL (120 tabs / 30, PA hydrocodone-acetaminophen soln mg/15ml hydrocodone-acetaminophen tab mg hydrocodone-acetaminophen tab mg hydrocodone-acetaminophen tab mg hydrocodone-ibuprofen tab mg QL (5400 ml / 30 QL (360 tabs / 30 QL (360 tabs / 30 QL (360 tabs / 30 QL (150 tabs / 30 hydromorphone hcl liqd 1 mg/ml hydromorphone hcl preservative B/D free (pf) inj 10 mg/ml hydromorphone hcl tab 2 mg QL (270 tabs / 30 hydromorphone hcl tab 4 mg QL (270 tabs / 30 hydromorphone hcl tab 8 mg QL (270 tabs / 30 methadone con 10mg/ml QL (120 ml / 30 methadone hcl soln 5 mg/5ml QL (600 ml / 30 methadone hcl soln 10 mg/5ml QL (600 ml / 30 methadone hcl tab 5 mg QL (240 tabs / 30 methadone hcl tab 10 mg QL (240 tabs / 30 MORPHINE SUL INJ 2MG/ML B/D MORPHINE SUL INJ 4MG/ML B/D D s, or OTC items that are covered by Medicaid 6

20 Name MORPHINE SUL INJ 8MG/ML B/D MORPHINE SUL INJ 150/30ML B/D morphine sulfate inj pf 0.5 mg/ml B/D morphine sulfate inj pf 1 mg/ml B/D MORPHINE SULFATE IV SOLN 1 B/D MG/ML morphine sulfate iv soln pf 4 B/D mg/ml morphine sulfate iv soln pf 8 B/D mg/ml MORPHINE SULFATE IV SOLN PF B/D 10 MG/ML MORPHINE SULFATE IV SOLN PF B/D 15 MG/ML MORPHINE SULFATE ORAL SOLN 10 MG/5ML MORPHINE SULFATE ORAL SOLN 20 MG/5ML MORPHINE SULFATE ORAL SOLN 100 MG/5ML (20 MG/ML) MORPHINE SULFATE TAB 15 MG QL (180 tabs / 30 MORPHINE SULFATE TAB 30 MG QL (180 tabs / 30 morphine sulfate tab cr 15 mg QL (90 tabs / 30 morphine sulfate tab cr 30 mg QL (90 tabs / 30 morphine sulfate tab cr 60 mg QL (90 tabs / 30 morphine sulfate tab cr 100 mg QL (90 tabs / 30 morphine sulfate tab cr 200 mg QL (60 tabs / 30 oxycodone hcl cap 5 mg QL (180 caps / 30 oxycodone hcl conc 100 mg/5ml (20 mg/ml) OXYCODONE HCL SOLN 5 MG/5ML oxycodone hcl tab 5 mg QL (180 tabs / 30 oxycodone hcl tab 10 mg QL (180 tabs / 30 oxycodone hcl tab 15 mg QL (180 tabs / 30 oxycodone hcl tab 20 mg QL (180 tabs / 30 oxycodone hcl tab 30 mg QL (180 tabs / 30 D s, or OTC items that are covered by Medicaid 7

21 Name oxycodone w/ acetaminophen soln mg/5ml oxycodone w/ acetaminophen tab mg oxycodone w/ acetaminophen tab mg oxycodone w/ acetaminophen tab mg oxycodone w/ acetaminophen tab mg QL (1800 ml / 30 QL (360 tabs / 30 QL (360 tabs / 30 QL (360 tabs / 30 QL (360 tabs / 30 OXYCONTIN TAB 10MG CR 2 $0 QL (120 tabs / 30 OXYCONTIN TAB 15MG CR 2 $0 QL (120 tabs / 30 OXYCONTIN TAB 20MG CR 2 $0 QL (120 tabs / 30 OXYCONTIN TAB 30MG CR 2 $0 QL (120 tabs / 30 OXYCONTIN TAB 40MG CR 2 $0 QL (120 tabs / 30 OXYCONTIN TAB 60MG CR 2 $0 QL (120 tabs / 30 OXYCONTIN TAB 80MG CR 2 $0 QL (120 tabs / 30 ANESTHETICS - S FOR NUMBING LOCAL ANESTHETICS lidocaine hcl local inj 0.5% B/D lidocaine hcl local inj 1% B/D lidocaine hcl local inj 1.5% B/D lidocaine hcl local inj 2% B/D lidocaine hcl local preservative free 1 (pf) inj 0.5% $0 B/D lidocaine hcl local preservative free B/D (pf) inj 1% ANTI-INFECTIVES - S TO TREAT INFECTIONS ANTI-BACTERIALS - MISCELLANEOUS amikacin sulfate inj 1 gm/4ml (250 mg/ml) amikacin sulfate inj 500 mg/2ml (250 mg/ml) gentam/nacl inj 0.9mg/ml gentam/nacl inj 1.4mg/ml D s, or OTC items that are covered by Medicaid 8

22 Name gentamicin in saline inj 0.8 mg/ml gentamicin in saline inj 1 mg/ml gentamicin in saline inj 1.2 mg/ml gentamicin in saline inj 1.6 mg/ml gentamicin in saline inj 2 mg/ml gentamicin sulfate inj 10 mg/ml gentamicin sulfate inj 40 mg/ml gentamicin sulfate iv soln 10 mg/ml neomycin sulfate tab 500 mg paromomycin sulfate cap 250 mg streptomycin sulfate for inj 1 gm sulfadiazine tab 500mg 2 $0 tobramycin nebu soln 300 mg/5ml 2 $0 NM, PA tobramycin sulfate for inj 1.2 gm 2 $0 tobramycin sulfate inj 1.2 gm/30ml (40 mg/ml) (base equiv) tobramycin sulfate inj 2 gm/50ml (40 mg/ml) (base equiv) tobramycin sulfate inj 10 mg/ml (base equivalent) tobramycin sulfate inj 80 mg/2ml (40 mg/ml) (base equiv) ANTI-INFECTIVES - MISCELLANEOUS ALBENZA TAB 200MG 2 $0 ALINIA SUS 100/5ML 2 $0 ALINIA TAB 500MG 2 $0 atovaquone susp 750 mg/5ml 2 $0 AZACTAM/DEX INJ 1GM 2 $0 AZACTAM/DEX INJ 2GM 2 $0 aztreonam for inj 1 gm aztreonam for inj 2 gm BILTRICIDE TAB 600MG 2 $0 CAYSTON INH 75MG 2 $0 NM, LA, PA clindamycin hcl cap 75 mg clindamycin hcl cap 150 mg clindamycin hcl cap 300 mg clindamycin palmitate hcl for soln 75 mg/5ml (base equiv) clindamycin phosphate in d5w iv soln 300 mg/50ml D s, or OTC items that are covered by Medicaid 9

23 Name clindamycin phosphate in d5w iv soln 600 mg/50ml clindamycin phosphate in d5w iv soln 900 mg/50ml clindamycin phosphate inj 9 gm/60ml clindamycin phosphate inj 300 mg/2ml clindamycin phosphate inj 600 mg/4ml clindamycin phosphate inj 900 mg/6ml clindamycin phosphate iv soln 300 mg/2ml clindamycin phosphate iv soln 900 mg/6ml colistimethate sodium for inj 150 mg CUBICIN SOL 500MG 2 $0 dapsone tab 25 mg dapsone tab 100 mg daptomycin for iv soln 500 mg 2 $0 emverm chw 100mg 2 $0 imipenem-cilastatin intravenous for soln 250 mg imipenem-cilastatin intravenous for soln 500 mg INVANZ INJ 1GM 2 $0 ivermectin tab 3 mg LINEZOLID FOR SUSP 100 MG/5ML 2 $0 LINEZOLID IN SODIUM CHLORIDE 2 $0 IV SOLN 600 MG/300ML-0.9% linezolid iv soln 600 mg/300ml (2 2 $0 mg/ml) LINEZOLID TAB 600 MG 2 $0 meropenem iv for soln 1 gm meropenem iv for soln 500 mg methenamine hippurate tab 1 gm metronidazole in nacl 0.79% iv soln 500 mg/100ml metronidazole tab 250 mg metronidazole tab 500 mg NEBUPENT INH 300MG 2 $0 B/D D s, or OTC items that are covered by Medicaid 10

24 Name nitrofurantoin macrocrystalline cap 50 mg nitrofurantoin macrocrystalline cap 100 mg nitrofurantoin monohydrate macrocrystalline cap 100 mg 2 $0 PA; PA applies if 65 years and after a 90 day supply in a calendar year 2 $0 PA; PA applies if 65 years and after a 90 day supply in a calendar year 2 $0 PA; PA applies if 65 years and after a 90 day supply in a calendar year PENTAM 300 INJ 300MG 2 $0 SIVEXTRO INJ 200MG 2 $0 SIVEXTRO TAB 200MG 2 $0 sulfamethoxazole-trimethoprim iv soln mg/5ml sulfamethoxazole-trimethoprim susp mg/5ml sulfamethoxazole-trimethoprim tab mg sulfamethoxazole-trimethoprim tab mg SYNERCID INJ 500MG 2 $0 TIGECYCLINE INJ 50MG 2 $0 trimethoprim tab 100 mg TYGACIL INJ 50MG 2 $0 vancomycin hcl cap 125 mg 2 $0 vancomycin hcl cap 250 mg 2 $0 vancomycin hcl for inj 10 gm vancomycin hcl for inj 500 mg vancomycin hcl for inj 750 mg vancomycin hcl for inj 1000 mg vancomycin hcl for inj 5000 mg VANCOMYCIN INJ 1 GM 2 $0 VANCOMYCIN INJ 500MG 2 $0 VANCOMYCIN INJ 750MG 2 $0 ANTIFUNGALS - S TO TREAT FUNGAL INFECTIONS ABELCET INJ 5MG/ML 2 $0 B/D AMBISOME INJ 50MG 2 $0 B/D amphotericin b for inj 50 mg B/D CANCIDAS INJ 50MG 2 $0 D s, or OTC items that are covered by Medicaid 11

25 Name CANCIDAS INJ 70MG 2 $0 fluconazole for susp 10 mg/ml fluconazole for susp 40 mg/ml fluconazole in dextrose inj 200 mg/100ml fluconazole in dextrose inj 400 mg/200ml fluconazole in nacl 0.9% inj 200 mg/100ml fluconazole in nacl 0.9% inj 400 mg/200ml fluconazole tab 50 mg fluconazole tab 100 mg fluconazole tab 150 mg fluconazole tab 200 mg fluconazole/ inj nacl 100 flucytosine cap 250 mg 2 $0 flucytosine cap 500 mg 2 $0 griseofulvin microsize susp 125 mg/5ml griseofulvin microsize tab 500 mg griseofulvin ultramicrosize tab 125 mg griseofulvin ultramicrosize tab 250 mg itraconazole cap 100 mg PA ketoconazole tab 200 mg PA MYCAMINE INJ 50MG 2 $0 MYCAMINE INJ 100MG 2 $0 NOXAFIL SUS 40MG/ML 2 $0 NOXAFIL TAB 100MG 2 $0 nystatin tab unit terbinafine hcl tab 250 mg QL (90 tabs / 365 voriconazole for inj 200 mg voriconazole for susp 40 mg/ml 2 $0 voriconazole tab 50 mg 2 $0 voriconazole tab 200 mg 2 $0 ANTIMALARIALS - S TO TREAT MALARIA atovaquone-proguanil hcl tab mg D s, or OTC items that are covered by Medicaid 12

26 Name atovaquone-proguanil hcl tab mg chloroquine phosphate tab 250 mg chloroquine phosphate tab 500 mg COARTEM TAB MG 2 $0 mefloquine hcl tab 250 mg PRIMAQUINE TAB 26.3MG 2 $0 quinine sulfate cap 324 mg PA ANTIRETROVIRAL AGENTS - S TO SUPPRESS HIV/AIDS INFECTION abacavir sulfate tab 300 mg (base equiv) APTIVUS CAP 250MG 2 $0 APTIVUS SOL 2 $0 CRIXIVAN CAP 200MG 2 $0 CRIXIVAN CAP 400MG 2 $0 didanosine delayed release capsule 125 mg didanosine delayed release capsule 200 mg didanosine delayed release capsule 250 mg didanosine delayed release capsule 400 mg EDURANT TAB 25MG 2 $0 EMTRIVA CAP 200MG 2 $0 EMTRIVA SOL 10MG/ML 2 $0 FUZEON INJ 90MG 2 $0 NM INTELENCE TAB 25MG 2 $0 INTELENCE TAB 100MG 2 $0 INTELENCE TAB 200MG 2 $0 INVIRASE CAP 200MG 2 $0 INVIRASE TAB 500MG 2 $0 ISENTRESS CHW 25MG 2 $0 ISENTRESS CHW 100MG 2 $0 ISENTRESS POW 100MG 2 $0 ISENTRESS TAB 400MG 2 $0 lamivudine oral soln 10 mg/ml lamivudine tab 150 mg lamivudine tab 300 mg D s, or OTC items that are covered by Medicaid 13

27 Name LEXIVA SUS 50MG/ML 2 $0 LEXIVA TAB 700MG 2 $0 NEVIRAPINE SUSP 50 MG/5ML nevirapine tab 200 mg nevirapine tab sr 24hr 100 mg nevirapine tab sr 24hr 400 mg NORVIR CAP 100MG 2 $0 NORVIR SOL 80MG/ML 2 $0 NORVIR TAB 100MG 2 $0 PREZISTA SUS 100MG/ML 2 $0 PREZISTA TAB 75MG 2 $0 PREZISTA TAB 150MG 2 $0 PREZISTA TAB 600MG 2 $0 PREZISTA TAB 800MG 2 $0 RESCRIPTOR TAB 100 MG 2 $0 RESCRIPTOR TAB 200MG 2 $0 RETROVIR INJ 10MG/ML 2 $0 REYATAZ CAP 150MG 2 $0 REYATAZ CAP 200MG 2 $0 REYATAZ CAP 300MG 2 $0 REYATAZ POW 50MG 2 $0 SELZENTRY TAB 25MG 2 $0 SELZENTRY TAB 75MG 2 $0 SELZENTRY TAB 150MG 2 $0 SELZENTRY TAB 300MG 2 $0 stavudine cap 15 mg stavudine cap 20 mg stavudine cap 30 mg stavudine cap 40 mg SUSTIVA CAP 50MG 2 $0 SUSTIVA CAP 200MG 2 $0 SUSTIVA TAB 600MG 2 $0 TIVICAY TAB 10MG 2 $0 TIVICAY TAB 25MG 2 $0 TIVICAY TAB 50MG 2 $0 TYBOST TAB 150MG 2 $0 VIDEX SOL 2GM 2 $0 VIDEX SOL 4GM 2 $0 VIRACEPT TAB 250MG 2 $0 D s, or OTC items that are covered by Medicaid 14

28 Name VIRACEPT TAB 625MG 2 $0 VIREAD POW 40MG/GM 2 $0 VIREAD TAB 150MG 2 $0 VIREAD TAB 200MG 2 $0 VIREAD TAB 250MG 2 $0 VIREAD TAB 300MG 2 $0 ZERIT SOL 1MG/ML 2 $0 ZIAGEN SOL 20MG/ML 2 $0 zidovudine cap 100 mg zidovudine syrup 10 mg/ml zidovudine tab 300 mg ANTIRETROVIRAL COMBINATION AGENTS - S TO SUPPRESS HIV/AIDS INFECTION ABACAVIR SULFATE-LAMIVUDINE 2 $0 TAB MG abacavir sulfate-lamivudinezidovudine 2 $0 tab mg ATRIPLA TAB 2 $0 COMPLERA TAB 2 $0 DESCOVY TAB 200/25 2 $0 EPZICOM TAB $0 EVOTAZ TAB $0 GENVOYA TAB 2 $0 KALETRA SOL 2 $0 KALETRA TAB MG 2 $0 KALETRA TAB MG 2 $0 lamivudine-zidovudine tab mg lopinavir-ritonavir soln $0 mg/5ml (80-20 mg/ml) ODEFSEY TAB 2 $0 PREZCOBIX TAB $0 STRIBILD TAB 2 $0 TRIUMEQ TAB 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 - S TO TREAT TUBERCULOSIS CAPASTAT SUL INJ 1GM 2 $0 D s, or OTC items that are covered by Medicaid 15

29 Name cycloserine cap 250 mg 2 $0 ethambutol hcl tab 100 mg ethambutol hcl tab 400 mg isoniazid inj 100 mg/ml isoniazid syrup 50 mg/5ml isoniazid tab 100 mg isoniazid tab 300 mg paser gra 4gm 2 $0 PRIFTIN TAB 150MG 2 $0 pyrazinamide tab 500 mg rifabutin cap 150 mg rifampin cap 150 mg rifampin cap 300 mg rifampin for inj 600 mg RIFATER TAB 2 $0 SIRTURO TAB 100MG 2 $0 LA, PA TRECATOR TAB 250MG 2 $0 ANTIVIRALS - S TO TREAT VIRAL INFECTIONS acyclovir cap 200 mg acyclovir sodium for inj 500 mg B/D acyclovir sodium iv soln 50 mg/ml B/D acyclovir susp 200 mg/5ml acyclovir tab 400 mg acyclovir tab 800 mg adefovir dipivoxil tab 10 mg 2 $0 BARACLUDE SOL.05MG/ML 2 $0 DAKLINZA TAB 30MG 2 $0 NM, PA DAKLINZA TAB 60MG 2 $0 NM, PA DAKLINZA TAB 90MG 2 $0 NM, PA entecavir tab 0.5 mg 2 $0 entecavir tab 1 mg 2 $0 EPIVIR HBV SOL 5MG/ML 2 $0 famciclovir tab 125 mg famciclovir tab 250 mg famciclovir tab 500 mg ganciclovir sodium for inj 500 mg B/D lamivudine tab 100 mg (hbv) oseltamivir phosphate cap 30 mg (base equiv) D s, or OTC items that are covered by Medicaid 16

30 Name oseltamivir phosphate cap 45 mg (base equiv) oseltamivir phosphate cap 75 mg (base equiv) PEGASYS INJ 2 $0 NM, PA PEGASYS INJ 180MCG/M 2 $0 NM, PA PEGASYS INJ PROCLICK 2 $0 NM, PA REBETOL SOL 40MG/ML 2 $0 NM RELENZA MIS DISKHALE 2 $0 ribasphere cap 200mg NM ribasphere tab 200mg NM ribasphere tab 400mg 2 $0 NM ribasphere tab 600mg 2 $0 NM ribavirin cap 200 mg NM ribavirin tab 200 mg NM rimantadine hydrochloride tab 100 mg SOVALDI TAB 400MG 2 $0 NM, PA TAMIFLU CAP 30MG 2 $0 TAMIFLU CAP 45MG 2 $0 TAMIFLU CAP 75MG 2 $0 TAMIFLU SUS 6MG/ML 2 $0 TYZEKA TAB 600MG 2 $0 valacyclovir hcl tab 1 gm valacyclovir hcl tab 500 mg VALCYTE SOL 50MG/ML 2 $0 valganciclovir hcl for soln 50 mg/ml (base equiv) 2 $0 valganciclovir hcl tab 450 mg (base2 $0 equivalent) VEMLIDY TAB 25MG 2 $0 ZEPATIER TAB MG 2 $0 NM, PA CEPHALOSPORINS - S TO TREAT INFECTIONS cefaclor cap 250 mg cefaclor cap 500 mg cefaclor er tab 500mg 2 $0 cefaclor for susp 125 mg/5ml cefaclor for susp 250 mg/5ml cefaclor for susp 375 mg/5ml cefadroxil cap 500 mg D s, or OTC items that are covered by Medicaid 17

31 Name cefadroxil for susp 250 mg/5ml cefadroxil for susp 500 mg/5ml cefadroxil tab 1 gm cefazolin inj 1gm/50ml 2 $0 cefazolin sodium for inj 1 gm cefazolin sodium for inj 10 gm cefazolin sodium for inj 20 gm cefazolin sodium for inj 500 mg cefazolin sodium for iv soln 1 gm CEFAZOLIN SOL 2 $0 cefdinir cap 300 mg cefdinir for susp 125 mg/5ml cefdinir for susp 250 mg/5ml cefepime hcl for inj 1 gm cefepime hcl for inj 2 gm cefixime for susp 100 mg/5ml cefixime for susp 200 mg/5ml cefotaxime sodium for inj 1 gm cefotaxime sodium for inj 2 gm cefotaxime sodium for inj 500 mg cefoxitin sodium for inj 10 gm cefoxitin sodium for iv soln 1 gm cefoxitin sodium for iv soln 2 gm cefpodoxime proxetil for susp 50 mg/5ml cefpodoxime proxetil for susp 100 mg/5ml cefpodoxime proxetil tab 100 mg cefpodoxime proxetil tab 200 mg cefprozil for susp 125 mg/5ml cefprozil for susp 250 mg/5ml cefprozil tab 250 mg cefprozil tab 500 mg ceftazidime for inj 1 gm ceftazidime for inj 2 gm ceftazidime for inj 6 gm CEFTAZIDIME/ SOL D5W 1GM 2 $0 CEFTAZIDIME/ SOL D5W 2GM 2 $0 ceftriaxone sodium for inj 1 gm D s, or OTC items that are covered by Medicaid 18

32 Name ceftriaxone sodium for inj 2 gm ceftriaxone sodium for inj 10 gm ceftriaxone sodium for inj 250 mg ceftriaxone sodium for inj 500 mg ceftriaxone sodium for iv soln 1 gm ceftriaxone sodium for iv soln 2 gm cefuroxime axetil tab 250 mg cefuroxime axetil tab 500 mg cefuroxime sodium for inj 1.5 gm cefuroxime sodium for inj 7.5 gm cefuroxime sodium for inj 750 mg cefuroxime sodium for iv soln 1.5 gm cephalexin cap 250 mg cephalexin cap 500 mg cephalexin for susp 125 mg/5ml cephalexin for susp 250 mg/5ml SUPRAX CAP 400MG 2 $0 suprax chw 100mg 2 $0 suprax chw 200mg 2 $0 SUPRAX SUS 500/5ML 2 $0 tazicef inj 1gm tazicef inj 2gm tazicef inj 6gm TEFLARO INJ 400MG 2 $0 TEFLARO INJ 600MG 2 $0 ERYTHROMYCINS/MACROLIDES - S TO TREAT INFECTIONS azithromycin for susp 100 mg/5ml azithromycin for susp 200 mg/5ml azithromycin iv for soln 500 mg AZITHROMYCIN POWD PACK FOR SUSP 1 GM azithromycin tab 250 mg azithromycin tab 500 mg azithromycin tab 600 mg clarithromycin for susp 125 mg/5ml clarithromycin for susp 250 mg/5ml clarithromycin tab 250 mg D s, or OTC items that are covered by Medicaid 19

33 Name clarithromycin tab 500 mg clarithromycin tab sr 24hr 500 mg DIFICID TAB 200MG 2 $0 e.e.s. 400 tab 400mg ery-tab tab 250mg ec ery-tab tab 333mg ec ery-tab tab 500mg ec erythrocin inj 500mg 2 $0 erythrocin tab 250mg erythromycin ethylsuccinate tab 400 mg erythromycin tab 250 mg erythromycin tab 500 mg erythromycin w/ delayed release particles cap 250 mg FLUOROQUINOLONES - S TO TREAT INFECTIONS ciprofloxacin 200 mg/100ml in d5w ciprofloxacin 400 mg/200ml in d5w ciprofloxacin for oral susp 250 mg/5ml (5%) (5 gm/100ml) ciprofloxacin for oral susp 500 mg/5ml (10%) (10 gm/100ml) ciprofloxacin hcl tab 100 mg (base equiv) ciprofloxacin hcl tab 250 mg (base equiv) ciprofloxacin hcl tab 500 mg (base equiv) ciprofloxacin hcl tab 750 mg (base equiv) ciprofloxacin iv soln 200 mg/20ml (1%) ciprofloxacin iv soln 400 mg/40ml (1%) ciprofloxacin-ciprofloxacin hcl tab sr 24hr 500 mg (base eq) ciprofloxacin-ciprofloxacin hcl tab sr 24hr 1000 mg(base eq) levofloxacin in d5w iv soln 250 mg/50ml levofloxacin in d5w iv soln 500 mg/100ml D s, or OTC items that are covered by Medicaid 20

34 Name levofloxacin in d5w iv soln 750 mg/150ml levofloxacin iv soln 25 mg/ml levofloxacin oral soln 25 mg/ml levofloxacin tab 250 mg levofloxacin tab 500 mg levofloxacin tab 750 mg moxifloxacin hcl tab 400 mg (base equiv) PENICILLINS - S TO TREAT INFECTIONS amoxicillin & k clavulanate chew tab mg amoxicillin & k clavulanate chew tab mg amoxicillin & k clavulanate for susp mg/5ml amoxicillin & k clavulanate for susp mg/5ml amoxicillin & k clavulanate for susp mg/5ml amoxicillin & k clavulanate for susp mg/5ml amoxicillin & k clavulanate tab mg amoxicillin & k clavulanate tab mg amoxicillin & k clavulanate tab mg amoxicillin & k clavulanate tab sr 12hr mg amoxicillin (trihydrate) cap 250 mg amoxicillin (trihydrate) cap 500 mg amoxicillin (trihydrate) chew tab 125 mg amoxicillin (trihydrate) chew tab 250 mg amoxicillin (trihydrate) for susp 125 mg/5ml amoxicillin (trihydrate) for susp 200 mg/5ml amoxicillin (trihydrate) for susp 250 mg/5ml amoxicillin (trihydrate) for susp 400 mg/5ml D s, or OTC items that are covered by Medicaid 21

35 Name amoxicillin (trihydrate) tab 500 mg amoxicillin (trihydrate) tab 875 mg ampicillin & sulbactam sodium for inj 1.5 (1-0.5) gm ampicillin & sulbactam sodium for inj 3 (2-1) gm ampicillin & sulbactam sodium for inj 15 (10-5) gm ampicillin & sulbactam sodium for iv soln 15 (10-5) gm ampicillin cap 250 mg ampicillin cap 500 mg ampicillin for susp 125 mg/5ml ampicillin for susp 250 mg/5ml ampicillin sodium for inj 1 gm ampicillin sodium for inj 2 gm ampicillin sodium for inj 10 gm ampicillin sodium for inj 125 mg ampicillin sodium for inj 250 mg ampicillin sodium for inj 500 mg ampicillin sodium for iv soln 1 gm ampicillin sodium for iv soln 2 gm ampicillin sodium for iv soln 10 gm BICILLIN L-A INJ $0 BICILLIN L-A INJ $0 BICILLIN L-A INJ $0 dicloxacillin sodium cap 250 mg dicloxacillin sodium cap 500 mg nafcillin sodium for inj 1 gm nafcillin sodium for inj 2 gm nafcillin sodium for inj 10 gm nafcillin sodium for iv soln 1 gm nafcillin sodium for iv soln 2 gm oxacillin sodium for inj 1 gm oxacillin sodium for inj 2 gm oxacillin sodium for inj 10 gm 2 $0 pen g proc inj $0 PENICILL GK/ INJ DEX 2MU 2 $0 PENICILL GK/ INJ DEX 3MU 2 $0 D s, or OTC items that are covered by Medicaid 22

36 Name penicillin g potassium for inj unit penicillin g potassium for inj unit penicillin g sodium for inj unit penicillin v potassium for soln 125 mg/5ml penicillin v potassium for soln 250 mg/5ml penicillin v potassium tab 250 mg penicillin v potassium tab 500 mg piper/tazoba inj gm piperacillin sod-tazobactam na for inj gm ( gm) piperacillin sod-tazobactam sod for inj 2.25 gm ( gm) piperacillin sod-tazobactam sod for inj 4.5 gm (4-0.5 gm) piperacillin sod-tazobactam sod for inj 40.5 gm ( gm) TETRACYCLINES - S TO TREAT INFECTIONS doxy 100 inj 100mg doxycycline hyclate cap 50 mg doxycycline hyclate cap 100 mg doxycycline hyclate for inj 100 mg doxycycline hyclate tab 20 mg doxycycline hyclate tab 100 mg doxycycline monohydrate cap 50 mg doxycycline monohydrate cap 100 mg doxycycline monohydrate tab 50 mg doxycycline monohydrate tab 75 mg doxycycline monohydrate tab 100 mg doxycycline monohydrate tab 150 mg minocycline hcl cap 50 mg minocycline hcl cap 75 mg minocycline hcl cap 100 mg D s, or OTC items that are covered by Medicaid 23

37 Name ANTINEOPLASTIC AGENTS - S TO TREAT CANCER ALKYLATING AGENTS BENDEKA INJ 100/4ML 2 $0 B/D, NM BICNU INJ 100MG 2 $0 B/D BUSULFEX INJ 6MG/ML 2 $0 B/D CYCLOPHOSPH CAP 25MG 2 $0 B/D CYCLOPHOSPH CAP 50MG 2 $0 B/D cyclophosphamide for inj 1 gm 2 $0 B/D cyclophosphamide for inj 2 gm 2 $0 B/D cyclophosphamide for inj 500 mg 2 $0 B/D dacarbazine for inj 100 mg B/D dacarbazine for inj 200 mg B/D EMCYT CAP 140MG 2 $0 GLEOSTINE CAP 5MG 2 $0 GLEOSTINE CAP 10MG 2 $0 GLEOSTINE CAP 40MG 2 $0 GLEOSTINE CAP 100MG 2 $0 HEXALEN CAP 50MG 2 $0 IFEX INJ 3GM 2 $0 B/D ifosfamide for inj 1 gm B/D IFOSFAMIDE INJ 3GM 2 $0 B/D ifosfamide iv inj 1 gm/20ml (50 B/D mg/ml) ifosfamide iv inj 3 gm/60ml (50 B/D mg/ml) LEUKERAN TAB 2MG 2 $0 melphalan hcl for inj 50 mg (base 2 $0 B/D equiv) MUSTARGEN INJ 10MG 2 $0 B/D TREANDA INJ 25MG 2 $0 B/D, NM TREANDA INJ 100MG 2 $0 B/D, NM ANTHRACYCLINES adriamycin inj 20mg B/D daunorubicin hcl inj 5 mg/ml (base B/D equiv) doxorubicin hcl for inj 50 mg B/D doxorubicin hcl inj 2 mg/ml B/D doxorubicin hcl liposomal inj (for iv 2 $0 B/D infusion) 2 mg/ml D s, or OTC items that are covered by Medicaid 24

38 Name epirubicin hcl iv soln 50 mg/25ml (2 mg/ml) epirubicin hcl iv soln 200 mg/100ml (2 mg/ml) idarubicin hcl iv inj 5 mg/5ml (1 mg/ml) idarubicin hcl iv inj 10 mg/10ml (1 mg/ml) idarubicin hcl iv inj 20 mg/20ml (1 mg/ml) B/D B/D 2 $0 B/D 2 $0 B/D 2 $0 B/D ANTIBIOTICS bleomycin sulfate for inj 15 unit B/D bleomycin sulfate for inj 30 unit B/D mitomycin for iv soln 5 mg 2 $0 B/D mitomycin for iv soln 20 mg 2 $0 B/D mitomycin for iv soln 40 mg 2 $0 B/D ANTIMETABOLITES adrucil inj 2.5g/50m B/D adrucil inj 5gm/100m B/D adrucil inj 500/10ml B/D ALIMTA INJ 100MG 2 $0 B/D ALIMTA INJ 500MG 2 $0 B/D azacitidine for inj 100 mg 2 $0 B/D, NM cladribine iv soln 10 mg/10ml (1 2 $0 B/D mg/ml) cytarabine inj 20 mg/ml B/D fludarabine phosphate for inj 50 B/D mg fludarabine phosphate inj 25 B/D mg/ml fluorouracil inj 1 gm/20ml (50 B/D mg/ml) fluorouracil inj 2.5 gm/50ml (50 B/D mg/ml) fluorouracil inj 5 gm/100ml (50 B/D mg/ml) fluorouracil inj 500 mg/10ml (50 B/D mg/ml) gemcitabine hcl for inj 1 gm 2 $0 B/D gemcitabine hcl for inj 2 gm 2 $0 B/D gemcitabine hcl for inj 200 mg 2 $0 B/D D s, or OTC items that are covered by Medicaid 25

39 Name GEMCITABINE HCL INJ 1 GM/26.3ML (38 MG/ML) (BASE EQUIV) GEMCITABINE HCL INJ 2 GM/52.6ML (38 MG/ML) (BASE EQUIV) GEMCITABINE HCL INJ 200 MG/5.26ML (38 MG/ML) (BASE EQUIV) 2 $0 B/D 2 $0 B/D 2 $0 B/D mercaptopurine tab 50 mg methotrexate sodium for inj 1 gm B/D METHOTREXATE SODIUM INJ 50 B/D MG/2ML (25 MG/ML) methotrexate sodium inj 250 B/D mg/10ml (25 mg/ml) methotrexate sodium inj pf 50 B/D mg/2ml (25 mg/ml) methotrexate sodium inj pf 100 B/D mg/4ml (25 mg/ml) methotrexate sodium inj pf 200 B/D mg/8ml (25 mg/ml) methotrexate sodium inj pf 250 B/D mg/10ml (25 mg/ml) methotrexate sodium inj pf 1000 B/D mg/40ml (25 mg/ml) NIPENT INJ 10MG 2 $0 B/D PURIXAN SUS 20MG/ML 2 $0 NM TABLOID TAB 40MG 2 $0 ANTIMITOTIC, TAXOIDS ABRAXANE INJ 100MG 2 $0 B/D DOCEFREZ INJ 20MG 2 $0 B/D DOCETAXEL FOR INJ CONC 20 2 $0 B/D MG/ML docetaxel for inj conc 80 mg/4ml 2 $0 B/D (20 mg/ml) DOCETAXEL INJ 20MG/2ML 2 $0 B/D DOCETAXEL INJ 80MG/4ML 2 $0 B/D DOCETAXEL INJ 80MG/8ML 2 $0 B/D DOCETAXEL INJ 160/8ML 2 $0 B/D DOCETAXEL INJ 160/16ML 2 $0 B/D DOCETAXEL INJ 200MG/20 2 $0 B/D paclitaxel iv conc 30 mg/5ml (6 mg/ml) B/D D s, or OTC items that are covered by Medicaid 26

40 Name paclitaxel iv conc 100 mg/16.7ml (6 mg/ml) paclitaxel iv conc 150 mg/25ml (6 mg/ml) paclitaxel iv conc 300 mg/50ml (6 mg/ml) B/D B/D B/D TAXOTERE INJ 80MG/4ML 2 $0 B/D ANTIMITOTIC, VINCA ALKALOIDS vinblastine sulfate inj 1 mg/ml 2 $0 B/D vincasar pfs inj 1mg/ml B/D vincristine sulfate iv soln 1 mg/ml B/D vinorelbine tartrate inj 10 mg/ml B/D (base equiv) vinorelbine tartrate inj 50 mg/5ml (10 mg/ml) (base equiv) B/D BIOLOGIC RESPONSE MODIFIERS AVASTIN INJ 2 $0 NM, LA, PA AVASTIN INJ 400/16ML 2 $0 NM, LA, PA BELEODAQ INJ 500MG 2 $0 NM, PA ERIVEDGE CAP 150MG 2 $0 NM, LA, PA FARYDAK CAP 10MG 2 $0 NM, LA, PA FARYDAK CAP 15MG 2 $0 NM, LA, PA FARYDAK CAP 20MG 2 $0 NM, LA, PA HERCEPTIN INJ 440MG 2 $0 NM, PA IBRANCE CAP 75MG 2 $0 NM, LA, PA IBRANCE CAP 100MG 2 $0 NM, LA, PA IBRANCE CAP 125MG 2 $0 NM, LA, PA ISTODAX OVR INJ 10MG 2 $0 B/D, NM KADCYLA INJ 100MG 2 $0 B/D, NM KADCYLA INJ 160MG 2 $0 B/D, NM KEYTRUDA INJ 100MG/4M 2 $0 NM, PA KEYTRUDA SOL 50MG 2 $0 NM, PA LYNPARZA CAP 50MG 2 $0 NM, LA, PA NINLARO CAP 2.3MG 2 $0 NM, PA NINLARO CAP 3MG 2 $0 NM, PA NINLARO CAP 4MG 2 $0 NM, PA PROLEUKIN INJ 22MU 2 $0 B/D, NM RITUXAN INJ 100MG 2 $0 NM, LA, PA RITUXAN INJ 500MG 2 $0 NM, LA, PA RUBRACA TAB 200MG 2 $0 NM, LA, PA D s, or OTC items that are covered by Medicaid 27

41 Name RUBRACA TAB 300MG 2 $0 NM, LA, PA TECENTRIQ INJ 1200/20 2 $0 NM, LA, PA VELCADE INJ 3.5MG 2 $0 NM, PA VENCLEXTA TAB 10MG 2 $0 NM, LA, PA VENCLEXTA TAB 50MG 2 $0 NM, LA, PA VENCLEXTA TAB 100MG 2 $0 NM, LA, PA VENCLEXTA TAB START PK 2 $0 NM, LA, PA YERVOY INJ 50MG 2 $0 NM, PA YERVOY INJ 200MG 2 $0 NM, PA ZOLINZA CAP 100MG 2 $0 NM, PA HORMONAL ANTINEOPLASTIC AGENTS anastrozole tab 1 mg bicalutamide tab 50 mg DEPO-PROVERA INJ 400/ML 2 $0 B/D exemestane tab 25 mg FARESTON TAB 60MG 2 $0 FASLODEX INJ 250MG 2 $0 B/D flutamide cap 125 mg hydroxyprogesterone caproate im 2 $0 B/D in oil 1.25 gm/5ml letrozole tab 2.5 mg leuprolide acetate inj kit 5 mg/ml NM, PA LUPRON DEPOT INJ 3.75MG 2 $0 NM, PA LUPRON DEPOT INJ 11.25MG 2 $0 NM, PA LYSODREN TAB 500MG 2 $0 megestrol acetate susp 40 mg/ml 2 $0 PA; PA if 65 years and MEGESTROL ACETATE SUSP $0 PA MG/5ML megestrol acetate tab 20 mg 2 $0 PA; PA if 65 years and megestrol acetate tab 40 mg 2 $0 PA; PA if 65 years and NILANDRON TAB 150MG 2 $0 nilutamide tab 150 mg 2 $0 SOLTAMOX SOL 10MG/5ML 2 $0 tamoxifen citrate tab 10 mg (base equivalent) tamoxifen citrate tab 20 mg (base equivalent) TRELSTAR MIX INJ 3.75MG 2 $0 NM, PA D s, or OTC items that are covered by Medicaid 28

42 Name TRELSTAR MIX INJ 11.25MG 2 $0 NM, PA XTANDI CAP 40MG 2 $0 NM, LA, PA ZYTIGA TAB 250MG 2 $0 NM, LA, PA KINASE INHIBITORS AFINITOR DIS TAB 2MG 2 $0 NM, PA AFINITOR DIS TAB 3MG 2 $0 NM, PA AFINITOR DIS TAB 5MG 2 $0 NM, PA AFINITOR TAB 2.5MG 2 $0 NM, PA AFINITOR TAB 5MG 2 $0 NM, PA AFINITOR TAB 7.5MG 2 $0 NM, PA AFINITOR TAB 10MG 2 $0 NM, PA ALECENSA CAP 150MG 2 $0 NM, LA, PA BOSULIF TAB 100MG 2 $0 NM, PA BOSULIF TAB 500MG 2 $0 NM, PA CABOMETYX TAB 20MG 2 $0 NM, LA, PA CABOMETYX TAB 40MG 2 $0 NM, LA, PA CABOMETYX TAB 60MG 2 $0 NM, LA, PA CAPRELSA TAB 100MG 2 $0 NM, LA, PA CAPRELSA TAB 300MG 2 $0 NM, LA, PA COMETRIQ KIT 60MG 2 $0 NM, LA, PA COMETRIQ KIT 100MG 2 $0 NM, LA, PA COMETRIQ KIT 140MG 2 $0 NM, LA, PA COTELLIC TAB 20MG 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 TAB 15MG 2 $0 NM, LA, PA ICLUSIG TAB 45MG 2 $0 NM, LA, PA imatinib mesylate tab 100 mg (base equivalent) imatinib mesylate tab 400 mg (base equivalent) 2 $0 QL (90 tabs / 30, NM, PA 2 $0 QL (60 tabs / 30, NM, PA IMBRUVICA CAP 140MG 2 $0 NM, LA, PA INLYTA TAB 1MG 2 $0 NM, LA, PA INLYTA TAB 5MG 2 $0 NM, LA, PA IRESSA TAB 250MG 2 $0 NM, LA, PA JAKAFI TAB 5MG 2 $0 NM, LA, PA JAKAFI TAB 10MG 2 $0 NM, LA, PA JAKAFI TAB 15MG 2 $0 NM, LA, PA D s, or OTC items that are covered by Medicaid 29

43 Name JAKAFI TAB 20MG 2 $0 NM, LA, PA JAKAFI TAB 25MG 2 $0 NM, LA, PA LENVIMA CAP 8 MG 2 $0 NM, LA, PA LENVIMA CAP 10 MG 2 $0 NM, LA, PA LENVIMA CAP 14 MG 2 $0 NM, LA, PA LENVIMA CAP 18 MG 2 $0 NM, LA, PA LENVIMA CAP 20 MG 2 $0 NM, LA, PA LENVIMA CAP 24 MG 2 $0 NM, LA, PA MEKINIST TAB 0.5MG 2 $0 NM, LA, PA MEKINIST TAB 2MG 2 $0 NM, LA, PA NEXAVAR TAB 200MG 2 $0 NM, LA, PA SPRYCEL TAB 20MG 2 $0 NM, PA SPRYCEL TAB 50MG 2 $0 NM, PA SPRYCEL TAB 70MG 2 $0 NM, PA SPRYCEL TAB 80MG 2 $0 NM, PA SPRYCEL TAB 100MG 2 $0 NM, PA SPRYCEL TAB 140MG 2 $0 NM, PA STIVARGA TAB 40MG 2 $0 NM, LA, PA SUTENT CAP 12.5MG 2 $0 NM, PA SUTENT CAP 25MG 2 $0 NM, PA SUTENT CAP 37.5MG 2 $0 NM, PA SUTENT CAP 50MG 2 $0 NM, PA TAFINLAR CAP 50MG 2 $0 NM, LA, PA TAFINLAR CAP 75MG 2 $0 NM, LA, PA TAGRISSO TAB 40MG 2 $0 NM, LA, PA TAGRISSO TAB 80MG 2 $0 NM, LA, PA TARCEVA TAB 25MG 2 $0 NM, LA, PA TARCEVA TAB 100MG 2 $0 NM, LA, PA TARCEVA TAB 150MG 2 $0 NM, LA, PA TASIGNA CAP 150MG 2 $0 NM, PA TASIGNA CAP 200MG 2 $0 NM, PA TYKERB TAB 250MG 2 $0 NM, LA, PA VOTRIENT TAB 200MG 2 $0 NM, LA, PA XALKORI CAP 200MG 2 $0 NM, LA, PA XALKORI CAP 250MG 2 $0 NM, LA, PA ZELBORAF TAB 240MG 2 $0 NM, LA, PA ZYDELIG TAB 100MG 2 $0 NM, LA, PA ZYDELIG TAB 150MG 2 $0 NM, LA, PA ZYKADIA CAP 150MG 2 $0 NM, LA, PA D s, or OTC items that are covered by Medicaid 30

44 Name MISCELLANEOUS bexarotene cap 75 mg 2 $0 NM, PA DROXIA CAP 200MG 2 $0 DROXIA CAP 300MG 2 $0 DROXIA CAP 400MG 2 $0 hydroxyurea cap 500 mg LONSURF TAB $0 NM, PA LONSURF TAB $0 NM, PA MATULANE CAP 50MG 2 $0 LA mitoxantrone hcl inj conc 20 B/D, NM mg/10ml (2 mg/ml) mitoxantrone hcl inj conc 25 B/D, NM mg/12.5ml (2 mg/ml) mitoxantrone hcl inj conc 30 B/D, NM mg/15ml (2 mg/ml) ODOMZO CAP 200MG 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 INJ 3.5MG 2 $0 NM, PA tretinoin cap 10 mg 2 $0 TRISENOX SOL 10MG/10M 2 $0 B/D PLATINUM-BASED AGENTS carboplatin iv soln 50 mg/5ml B/D carboplatin iv soln 150 mg/15ml B/D carboplatin iv soln 450 mg/45ml B/D carboplatin iv soln 600 mg/60ml B/D cisplatin inj 50 mg/50ml (1 mg/ml) B/D cisplatin inj 100 mg/100ml (1 B/D mg/ml) cisplatin inj 200 mg/200ml (1 B/D mg/ml) oxaliplatin for iv inj 50 mg B/D oxaliplatin for iv inj 100 mg B/D oxaliplatin iv soln 50 mg/10ml B/D oxaliplatin iv soln 100 mg/20ml B/D PROTECTIVE AGENTS AMIFOSTINE FOR INJ 500 MG 2 $0 B/D dexrazoxane for inj 250 mg 2 $0 B/D dexrazoxane for inj 500 mg 2 $0 B/D D s, or OTC items that are covered by Medicaid 31

45 Name ELITEK INJ 1.5MG 2 $0 B/D ELITEK INJ 7.5MG 2 $0 B/D FUSILEV INJ 50MG 2 $0 B/D, NM leucovorin calcium for inj 50 mg B/D leucovorin calcium for inj 100 mg B/D leucovorin calcium for inj 200 mg B/D leucovorin calcium for inj 350 mg B/D leucovorin calcium for inj 500 mg B/D leucovorin calcium tab 5 mg leucovorin calcium tab 10 mg leucovorin calcium tab 15 mg leucovorin calcium tab 25 mg levoleucovor sol 250mg/25 2 $0 B/D, NM levoleucovorin calcium for iv inj 50 2 $0 B/D, NM mg (base equiv) levoleucovorin calcium inj $0 B/D, NM mg/17.5ml (base equiv) mesna inj 100 mg/ml B/D MESNEX TAB 400MG 2 $0 TOPOISOMERASE INHIBITORS etoposide inj 100 mg/5ml (20 B/D mg/ml) etoposide inj 500 mg/25ml (20 B/D mg/ml) irinotecan hcl inj 40 mg/2ml (20 B/D mg/ml) irinotecan hcl inj 100 mg/5ml (20 B/D mg/ml) irinotecan hcl inj 500 mg/25ml (20 B/D mg/ml) toposar inj 1gm/50ml B/D toposar inj 100/5ml B/D topotecan hcl for inj 4 mg 2 $0 B/D TOPOTECAN INJ 4MG/4ML 2 $0 B/D CARDIOVASCULAR - S TO TREAT HEART AND CIRCULATION CONDITIONS ACE INHIBITOR COMBINATIONS - S TO TREAT HIGH BLOOD PRESSURE amlodipine besylate-benazepril hcl cap mg D s, or OTC items that are covered by Medicaid 32

46 Name amlodipine besylate-benazepril hcl cap 5-10 mg amlodipine besylate-benazepril hcl cap 5-20 mg amlodipine besylate-benazepril hcl cap 5-40 mg amlodipine besylate-benazepril hcl cap mg amlodipine besylate-benazepril hcl cap mg benazepril & hydrochlorothiazide tab mg benazepril & hydrochlorothiazide tab mg benazepril & hydrochlorothiazide tab mg benazepril & hydrochlorothiazide tab mg captopril & hydrochlorothiazide tab mg captopril & hydrochlorothiazide tab mg captopril & hydrochlorothiazide tab mg captopril & hydrochlorothiazide tab mg enalapril maleate & hydrochlorothiazide tab mg enalapril maleate & hydrochlorothiazide tab mg fosinopril sodium & hydrochlorothiazide tab mg fosinopril sodium & hydrochlorothiazide tab mg lisinopril & hydrochlorothiazide tab mg lisinopril & hydrochlorothiazide tab mg lisinopril & hydrochlorothiazide tab mg moexipril-hydrochlorothiazide tab mg moexipril-hydrochlorothiazide tab mg D s, or OTC items that are covered by Medicaid 33