Addendum No. 18. Please provide Medicare supplement claims data . Answer: Medicare supplement claims data can be found in the attached file titled “Highmark Signature 65 Supplemental

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Addendum No. 1

RFP # 13-10380-4112

Medicare Advantage Plans

Prospective Respondents: You are hereby notified of the following information in regard to the referenced RFP: REVISION The response date referenced in Part I-11 of the RFP has been extended and revised as follows: I-11. Response. To be considered, proposals must be delivered to the Pennsylvania Turnpike Commission’s Contracts Administration Department, Attention: Wanda Metzger, on or before 12:00 PM local time on Thursday, November 29, 2012 Monday, April 29, 2013. The Pennsylvania Turnpike Commission is located at 700 South Eisenhower Boulevard, Middletown, PA 17057 (Street address). Our mailing Address is P. O. Box 67676, Harrisburg, PA 17106. QUESTIONS & ANSWERS

Following are the answers to questions submitted in response to the above referenced RFP as of April 2, 2013. All of the questions have been listed verbatim, as received by the Pennsylvania Turnpike Commission. 1. Please provide a monthly claims summary for all currently enrolled eligibles for all plan

designs offered, separated by plan. Please include medical and Rx claims as a separate line item with monthly membership corresponding to the claims provided.

Answer: Claims data for the Aetna Medicare plan cannot be provided since Aetna does not base their rates on the Commission’s retiree population due to the lower enrollment in their plan. Additional claims data for the other plans can be found in the attached files titled “Highmark FreedomBlue Claims” and “Highmark Signature 65 Supplement Claims”.

2. What is the intended offering environment? Will the new plan be in addition to the ones

currently offered, or will it be a total replacement to the current offerings and the only plan available to Medicare eligible retirees?

Answer: The new plan(s) selected will be offered in addition to the Highmark Medicare Supplement plan currently in place. The Highmark FreedomBlue Medicare Advantage plan and the Aetna Medicare Advantage PPO plan cannot be automatically extended; they would have to be awarded a new contract through this RFP process in order for either of those plans to be offered.

3. Please provide additional details as to how the Pennsylvania Turnpike Commission will

contribute towards the member premium (flat dollar amount or percentage) in 2014?

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Answer: The Commission contributes a flat dollar amount towards the premiums for each retiree (some retirees do not have a contribution). Contribution amounts vary based on retirement date and employee group.

4. Please provide retiree contributions.

Answer: Retirees contribute different amounts based on retirement date and employee group. Contribution amounts will not be provided.

5. Are the identifiers on the census informing us of the Health Plan they are on? If so can you

provide us a description of each code? If not can you provide us with a census of the retirees on the supplement plan?

Answer: Identifiers showing which plan the member is on were not on the original census. New census data showing persons on the Medicare Advantage plans has been provided in the attached files titled “Aetna Medicare PPO Census” and “Highmark FreedomBlue Census”. Persons on the original census that are under 65 are on a Highmark PPO plan; any persons on the original census that are not listed in the new Medicare Advantage census’, are on the Highmark Signature 65 Supplement plan.

6. Please provide current prescription formulary.

Answer: Prescription formularies can be found in the attached files titled “Aetna Medicare PPO RX Formulary” and “Highmark FreedomBlue RX Formulary”.

7. Do retirees have a choice between MA and supplement plans? Does the retiree have a choice

on what plan they can choose?

Answer: The retiree has a choice between Medicare Advantage and Medicare Supplement plans.

8. Please provide Medicare supplement claims data

Answer: Medicare supplement claims data can be found in the attached file titled “Highmark Signature 65 Supplemental Claims”.

9. Are benefits Union negotiated?

Answer: The Medicare Advantage plan benefits are not union negotiated.

10. Why is the Commission out to Bid?

Answer: The Commission can typically only contract with a vendor for up to 5 years before the service must go out to bid again.

11. Please consider an extension of at least two weeks for the due date so that bidders have time

to fully understand and work with the CMS recently released 2014 rates.

Answer: The Commission has extended the due date to April 29, 2013.

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12. Page 4 says “Each proposal page should be numbered for ease of reference.” Does this mean you would like the proposal to be sequentially numbered? If yes, is it ok to number by section? Or does this mean that just a page number is required.

Answer: A page number is required. The page numbers can be numbered by section.

13. Please provide a copy of your current contract for the Highmark plan.

Answer: Contracts can only be provided through the Right to Know Law process. It will not be provided as a part of this RFP.

14. Can you please clarify your plans for using SAP? We have heard of SAP being utilized as a

third party vendor for enrollment. Is this PA Turnpike’s intention as well?

Answer: The Commission currently uses SAP as its integrated software platform. Any interface files sent (if interface is utilized) would be sent to the selected vendor from SAP.

15. On Pg. 20, under Section H of the RFP, can we have this question clarified: “Describe your

experience with System, Applications and Products in Data Processing (SAP) system and confirm your ability to interface with SAP.”

Answer: The Commission currently uses SAP as its integrated software platform. Any interface files sent (if interface is utilized) would be sent to the selected vendor from SAP. We are asking if you have any experience with clients who have also used SAP.

16. Can you please clarify the following question: Are you referring to “exceptions or

restrictions” as our national network service area (which is question 1) OR the turnover rate for providers and facilities (which is question 2). Or something else?

Answer: In general, list any exceptions or restrictions to your network. Not available in certain areas? Restricted to only certain areas?

17. We noticed the census includes children and other eligibles under 65. Is it okay for these

eligibles to be removed from the census?

Answer: They can be removed; the under 65 category was included for the vendor’s use for future trending of the retiree population reaching age 65.

18. Should our quotes be based on the entire census for each of the plans? The census does not

include any indicators as to what carrier/plan the members are currently in (are they currently in the Highmark or Aetna plan and is the MA plan?)

Answer: It is impossible for the Commission to know which retiree may select which plan available each year. The entire census was provided so you could see the full group that would be eligible for the plan you are proposing (only the age 65 and over population listed on the census is eligible for the Medicare Advantage plans). Please see updated census data provided in the attached files titled “Aetna Medicare PPO Census” and “Highmark FreedomBlue Census”.

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19. Does the plan sponsor subsidize the cost of medical and Rx coverage for Medicare beneficiaries? Spouses? If so, what dollar amount or percentage of the cost is paid by the plan sponsor?


20. Is the PTC willing to consider a Medicare Advantage HMO alongside other Medicare Advantage plans (PPO or PFFS)?

Answer: Yes, the Commission will consider all Medicare Advantage plans proposed.

21. How many 65 years old or older participants covered under the Medicare Products are still

working? If any, can you break this down further into part-time versus full-time?

Answer: No persons over age 65 that are active employees are covered under the Medicare plans. They are covered under an active employee Highmark PPO. The Medicare plans are for retirees only.

22. Kindly provide current plan design(s) for the 2 Highmark Freedom Blue Plans and the 2

Aetna Medicare PPO plans. a. Please provide individual product rates for the past two years. b. Kindly provide the annual premium by product line for the past two years.

Answer: Plan designs were provided as Appendix B in the RFP. Plan rates are available as Appendix E in the RFP and are available by written request. Annual premium by product line can be derived using the monthly membership counts provided in Appendix C, in combination with the monthly premiums provided in Appendix E.

23. Is there any cost sharing for participants?


24. Please define the PA Turnpike Commission’s (“the Commission”) definition of eligibility.

Answer: Retirees will be eligible to enroll in Commission coverage if they retire with 20 years of service and are under age 60, or with 10 years of service and are age 60 or over. Regardless of age and years of service, the last 5 years of employment must be with the Commission. If this criterion is met, retirees and their eligible dependents are eligible for Commission coverage.

25. Please provide the percentage of retirees’ residence by state (and/or country if applicable).

Answer: This can be derived from the census data available in Appendix F, by written request.

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26. Please provide riders currently available to Medicare Products.

Answer: Riders that are on the plans are listed in the plan designs in Appendix B of the RFP.

27. Is the Commission also interested in providing a wellness program? Please identify which of

the following are currently in place and which the Commission would like to implement in the future:

a. Health risk assessment surveys b. Onsite Biometric Screenings c. Targeted Intervention/Health Coaching: Telephonic, Face to Face or Behavior

Change, Mail based interventions, Online coaching d. Self-Directed interventions (online and / or workbook) e. Gym membership discounts and Fitness f. Smoking cessation g. Nutrition education h. Disease prevention i. Mental health programs, Hypertension education, Alcohol and substance abuse

programs j. Stress Management

Answer: No.

28. Which Drug Subsidy program is the Commission currently using, Retiree Drug Subsidy

(RDS) model or Employer Group Waiver Plan (EGWP)?

Answer: RDS. 29. Please provide most recent census ( gender, date of birth, home zip, dependents, union retiree,

management retiree)

Answer: Census data was provided in Appendix F of the RFP, and is available by written request.

30. Kindly confirm that Highmark and Aetna are the only incumbent carriers for this group.

Answer: Confirmed.

31. Who are the current prescription drug carriers and dental carriers?

Answer: Aetna is the Commission’s current prescription carrier, and United Concordia is the Commission’s current dental carrier. Not all retirees are eligible for these prescription or dental plans; that is why the Commission offers Medicare Advantage plans with or without prescription coverage, and also is interested in any riders that would be available.

32. Is there a broker/consultant helping to evaluate this RFP? If yes, who is the

broker/consultant?

Answer: No.

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33. Is the current broker/consultant paid by fees, commissions, or both? a. If a broker is involved, please provide the commission in an annual dollar amount

and percentage. b. If a consultant is involved, kindly provide the annual dollar fee amount.

Answer: No broker or consultant is involved with this RFP.

34. What forms of benefits communications are currently provided to participants, i.e. print, e-

mail, IVR, internet/intranet, participant self-service? How many participants have access to e-mail?

Answer: The Commission communicates with the benefit participants via printed mail to their home address only. We do not have retiree email addresses.

35. We noted there are 110 locations and 3 administrative offices.

a. How many participants per worksite? b. How many of the worksites have facilities that could accommodate benefit fairs

and/or group meetings? (For example conference rooms, meeting rooms, auditorium, and etc.)

Answer: Number of participants per worksite varies greatly. There will not be benefit fairs for the retiree population; they are sent open enrollment information by mail annually.

36. How many benefit fairs per year do you expect carrier participation? a. What date(s) are the benefit fair(s) conducted? b. How many days and/or locations? c. How many participants typically attend per location? d. Any prominent secondary languages in your participant population (for example,

Spanish)? e. Are benefit meetings ever mandatory for participants to attend?

Answer: Carrier participation would be expected at our annual pre-retirement seminars. They are held in early fall and typically are 3 days. The 3 seminars are held at our administrative office; the Central Administration Building, Eastern Regional Office, and Western Regional Office. There is no prominent secondary language. It is not mandatory for participants to attend benefit meetings.

37. We noted that there are no specific DBE/MBE/WBE participation % goals listed. In the event

that there are two proposals with relatively equal technical and pricing, and one proposal has meaningful DBE/MBE/WBE participation and one does not, which proposal will receive more favorable overall scoring by The Commission?

Answer: DBE/MBE/WBE is a selection criteria factor and will be considered in the process of selection of the vendor(s).

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38. Page 15/21 of the RFP states that as of 2/19/13 there were 1116 retirees and spouses age 65 and over covered under the plans; however, appendix C shows there were only 329 contacts enrolled as of 1/1/13. Can you help us understand the discrepancy?

Answer: Appendix C shows ALL retirees and eligible dependents of the Commission. Some persons on the census are under age 65 (shown for your future trending purposes), some are enrolled on the Highmark Medicare Supplemental plan, some are enrolled on the Aetna Medicare PPO, and the remainder are the 329 contracts enrolled on the Highmark FreedomBlue plan, as listed in Appendix C.

39. Are the Medicare Advantage plans offered to all retirees, including those that have the

Medicare Supplemental plan?

Answer: Yes. 40. If the offering of our Medicare Advantage products is limited to the central 21 counties of

Pennsylvania, would the Turnpike still consider offering our products as an option to eligible retirees?

Answer: The Commission will consider all proposals submitted. However, if the Commission chooses one product that has limited network access, the Commission may choose another option as well so the retirees have an option that would cover their service area.

41. Due to the fact that plans and rates are not usually approved by CMS for the following plan

year until the June timeframe, is the Turnpike expecting firm rates in the RFP response on April 19 and if not, when will the Turnpike expect them?

Answer: The due date for the RFP response has been extended to April 29, 2013. Vendors should propose firm rates. However, at its discretion, the Commission may request best and final offers in accordance with Section I-15 of the RFP.

All other terms, conditions and requirements of the original RFP dated March 19, 2013 remain unchanged unless modified by this Addendum.

Sheet1

Aetna Medicare PPO Census

DOBAgeSexZipPlan

02/09/3380M08094Med Only

12/31/4270M27513Med Only

10/31/4369F19138Med Only

08/04/4468M19138Med Only

01/03/3380M19363Med Only

11/05/4171M18974Med Only

07/16/3181F19144Med Only

05/09/4171F19462Med Only

09/19/4072F19380Med Only

04/19/4072M19301Med Only

01/26/3875F19401Med Only

11/28/2884M19132Med Only

11/22/4171F17241Med Only

10/10/3874F18347Med Only

10/02/4072M18518Med Only

08/31/4468F18518Med Only

12/14/3478F18433Med Only

01/26/3677M18433Med Only

09/29/2389F19406Med & Rx

09/24/2884M19460Med & Rx

10/18/2983F19115Med & Rx

07/23/2983F19064Med & Rx

11/15/3280F19520Med & Rx

04/12/4468F18940Med & Rx

12/30/2785F15223Med & Rx

10/29/4072F17233Med & Rx

07/22/4468M18421Med & Rx

02/01/4865F19971Med & Rx

2013 Aetna Comprehensive Formulary Drug List (Enhanced)This comprehensive drug list applies to Aetna Medicare members who are enrolled in or are considering any of our Aetna Medicare Advantage with Rx plans.

Quality health plans & benefitsHealthier livingFinancial well-beingIntelligent solutions

Y0001_M_PE_MM_20706_R1 CMS Accepted

READ THIS: This document contains information about the drugs we cover in this plan

1

Aetna Medicare

2013 Formulary

(List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS

WE COVER IN THIS PLAN Note to existing members: This formulary has changed since last year. Please review this document to make sure that it still contains the drugs you take. Beneficiaries must use network pharmacies to access their prescription drug benefit. Benefits, formulary, pharmacy network, premium and/or copayments/coinsurance may change on January 1, 2014.

Aetna Medicare is a Medicare Advantage organization with a Medicare contract. A Medicare-approved Part D sponsor.

This information is available for free in other languages. Please contact our Aetna Member Services at 1-877-238-6211 (TTY/TDD: 711) for additional information. Hours of operation: 7 days per week, 8 a.m. till 8 p.m. Esta información está disponible en otros idiomas de manera gratuita. Si desea más información, comuníquese con Servicios al Cliente al 1-877-238-6211 (TTY/TDD: 711). Horario de atención: los 7 días de la semana, de 8 a.m. a 8 p.m. This document may be available in an alternate format such as Braille, larger print or audio. Please contact Aetna Member Services at 1-877-238-6211 (TTY/TDD: 711) for more information. Formulary ID: 13639 Version 14 December, 2012

2

What is the Aetna Medicare formulary? A formulary is a list of covered drugs selected by Aetna Medicare in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. Aetna Medicare will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at an Aetna Medicare network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage. Can the formulary change? Generally, if you are taking a drug on our 2013 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2013 coverage year except when a new, less expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released. Other types of formulary changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug. It will remain available at the same cost-sharing for those members taking it for the remainder of the coverage year. We feel it is important that you have continued access for the remainder of the coverage year to the formulary drugs that were available when you chose our plan, except for cases in which you can save additional money or we can ensure your safety. If we remove drugs from our formulary, add prior authorization, quantity limits and/or step therapy restrictions on a drug or move a drug to a higher cost-sharing tier, we must notify affected members of the change at least 60 days before the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 60-day supply of the drug. If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug’s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug. The enclosed formulary is current as of December 1, 2012. To get updated information about the drugs covered by Aetna Medicare, please visit our website at www.aetnamedicare.com/2013formulary or call Aetna Member Services at 1-877-238-6211 (TTY/TDD: 711), 8 a.m. to 8 p.m., 7 days a week. In the event of any CMS-approved, mid-year non-maintenance formulary changes, you will be mailed an addendum to this printed formulary.

3

How do I use the formulary? There are two ways to find your drug within the formulary: Medical Condition The formulary begins on page 8. The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category, “Cardiovascular Agents.” If you know what your drug is used for, look for the category name in the list that begins on page 8. Then look under the category name for your drug. Alphabetical Listing If you are not sure what category to look under, you should look for your drug in the index that begins on page 89. The index provides an alphabetical list of all of the drugs included in this document. Both brand name drugs and generic drugs are listed in the index. Look in the index and find your drug. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the index and find the name of your drug in the first column of the list. What are generic drugs? Aetna Medicare covers both brand name drugs and generic drugs. A generic drug is approved by the FDA as having the same active ingredient as the brand name drug. Generally, generic drugs cost less than brand name drugs. Are there any restrictions on my coverage? Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include:

• Prior Authorization: Aetna Medicare requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from Aetna Medicare before you fill your prescriptions. If you don’t get approval, Aetna Medicare may not cover the drug. • Quantity Limits: For certain drugs, Aetna Medicare limits the amount of the drug that Aetna Medicare will cover. For example, Aetna Medicare provides 1 tablet per day per prescription for simvastatin. This may be in addition to a standard one month or three month supply. • Step Therapy: In some cases, Aetna Medicare requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, Aetna Medicare may not cover Drug B unless you try Drug A first. If Drug A does not work for you, Aetna Medicare will then cover Drug B.

4

You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 8. You can also get more information about the restrictions applied to specific covered drugs by visiting our website at www.aetnamedicare.com/2013formulary. You can ask Aetna Medicare to make an exception to these restrictions or limits. See the section, “How do I request an exception to the Aetna Medicare formulary?” on page 4, for information about how to request an exception. What if my drug is not on the formulary? If your drug is not included in this formulary, you should first contact Aetna Member Services and confirm that your drug is not covered. If you learn that Aetna Medicare does not cover your drug, you have two options:

• You can ask Aetna Member Services for a list of similar drugs that are covered by Aetna Medicare. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by Aetna Medicare. • You can ask Aetna Medicare to make an exception and cover your drug. See below for information about how to request an exception .

How do I request an exception to the Aetna Medicare formulary? You can ask Aetna Medicare to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make.

• You can ask us to cover your drug even if it is not on our formulary. • You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, Aetna Medicare limits the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover more. • You can ask us to provide a higher level of coverage for your drug. If your drug is contained in a non-preferred tier, you can ask us to cover it at the cost-sharing amount that applies to drugs in a preferred tier instead. This would lower the amount you must pay for your drug. Please note, if we grant your request to cover a drug that is not on our formulary, you may not ask us to provide a higher level of coverage for the drug. Also, you may not ask us to provide a higher level of coverage for drugs that are in the tier designated as the high cost/specialty drug tier.

Generally, Aetna Medicare will only approve your request for an exception if the alternative drugs included on the plan’s formulary, the lower-tiered drug or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects.

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You should contact us to ask us for an initial coverage decision for a formulary, tiering or utilization restriction exception. When you are requesting a formulary, tiering or utilization restriction exception you should submit a statement from your prescriber or physician supporting your request. Generally, we must make our decision within 72 hours of getting your prescriber’s or prescribing physician’s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get your prescriber’s or prescribing physician’s supporting statement. What do I do before I can talk to my doctor about changing my drugs or requesting an exception? As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan. For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary 31-day supply (unless you have a prescription written for fewer days) when you go to a network pharmacy. After your first 31-day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days. If you are a resident of a long-term care facility, we will allow you to refill your prescription until we have provided you with a 93-day (and may be up to a 98-day)transition supply, consistent with the dispensing increment, (unless you have a prescription written for fewer days). We will cover more than one refill of these drugs for the first 90 days you are a member of our plan. If you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 31-day emergency supply of that drug (unless you have a prescription for fewer days) while you pursue a formulary exception. If you experience a change in your setting of care (such as being discharged or admitted to a long term care facility), your physician or pharmacy can request a one-time prescription override. This one-time override will provide you with temporary coverage (up to a 31-day supply) for the applicable drug(s). For more information For more detailed information about your Aetna Medicare prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about Aetna Medicare, please call Aetna Member Services at 1-877-238-6211 (TTY/TDD: 711), 8 a.m. to 8 p.m., 7 days a week. Or, visit www.aetnamedicare.com. If you have general questions about Medicare prescription drug coverage, please call Medicare at 1-800-MEDICARE (1-800-633-4227) 24 hours a day/7 days a week. TTY/TDD users should call 1-877-486-2048.Or, visit www.medicare.gov.

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Aetna Medicare’s formulary The formulary that begins on page 8 provides coverage information about some of the drugs covered by Aetna Medicare. If you have trouble finding your drug in the list, turn to the index that begins on page 89. The first column of the chart lists the drug name. Brand-name drugs are capitalized (e.g.,NEXIUM) and generic drugs are listed in lower-case italics (e.g., simvastatin). The information in the “Requirements/Limits” column tells you if Aetna Medicare has any special requirements for coverage of your drug. The following abbreviations are used: QL Quantity Limits PA Prior Authorization ST Step Therapy LA Limited Availability MO Mail Order Delivery B/D Part B vs. D Prior Authorization QL: Quantity Limits. For certain drugs, Aetna Medicare limits the amount of the drug that we will cover. For example, Aetna Medicare provides coverage for 1 tablet per day per prescription for simvastatin. PA: Prior Authorization. Aetna Medicare requires you or your provider to get prior authorization for certain drugs. This means that for certain drugs you will need to get approval from Aetna Medicare before you fill your prescriptions. If you don't get approval, we may not cover the drug. ST: Step Therapy. In some cases, the Aetna Medicare plan requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, Aetna Medicare may not cover Drug B unless you try Drug A first. If Drug A does not work for you, Aetna Medicare will then cover Drug B. LA: Limited Availability. These prescriptions may be available only at certain pharmacies. For more information consult your Pharmacy Directory or call Aetna Member Services at 1-877-238-6211 (TTY/TDD: 711), 8 a.m. to 8 p.m., 7 days a week, for additional help. MO: Mail Order. For certain kinds of drugs, you can use Aetna Medicare network mail order services. Generally, the drugs available through mail order are drugs that you take on a regular basis, for a chronic or long-term medical condition. The drugs available through our plan’s mail order service are marked as “mail order” drugs in our Drug List or MO. For more information consult your Pharmacy Directory or call Aetna Member Services at 1-877-238-6211 (TTY/TDD: 711), 8 a.m. to 8 p.m., 7 days a week, for additional help. B/D: Part B versus Part D. This prescription drug has a Part B versus Part D administrative prior authorization requirement. This drug may be covered under Medicare Part B or Part D depending upon the circumstances. Your doctor may need to provide information to us describing the use and setting of the drug to make the determination.

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. Drug tier copay levels Aetna Medicare’s 2013 formulary covers most drugs identified by Medicare as Part D drugs, and your copay may differ depending upon the tier at which the drug resides. The copay tiers for covered prescription medications are listed below. Copay amounts and coinsurance percentages for each tier vary by Aetna Medicare plan. Consult your plan’s Summary of Benefits or Evidence of Coverage for your applicable copays and coinsurance amounts. Copay tier Type of drug Tier 1 (Lowest Copay Amount) Preferred generic prescription drugs Tier 2 Non-preferred generic prescription drugs Tier 3 Preferred brand name prescription drugs Tier 4 Non-preferred brand name prescription drugs Tier 5 Specialty tier brand and generic prescription drugs

8

KEY Drug Name UPPERCASE = Brand name prescription drugs Lower case italics = Generic medications

Drug Tier 1,2,3,4,5 = Copay tier level

Requirements/Limits QL= Quantity Limit ST = Step Therapy PA = Prior Authorization LA = Limited Availability MO = Mail order delivery B/D = Part B vs. Part D

Drug Name Drug Tier Requirements/Limits

ANALGESICS acetaminophen/caffeine/dihydrocodeine bitartrate 2 QL (5 per 1 day) acetaminophen/codeine #2 1 QL (13 per 1 day) acetaminophen/codeine #3 1 QL (13 per 1 day) acetaminophen/codeine oral solution 1 QL (150 per 1 day) acetaminophen/codeine tablet 1 QL (13 per 1 day) alfentanil 2 ascomp/codeine 2 QL (6 per 1 day) astramorph 2 B/D butalbital/aspirn/caffeine/codeine 2 QL (6 per 1 day) MO butorphanol tartrate injection 2mg/ml 2 butorphanol tartrate injection 1mg/ml 2 MO butorphanol tartrate nasal solution 2 QL (50 per 30 days) CAPITAL/CODEINE 4 QL (166.7 per 1 day) MO CELEBREX 4 MO co-gesic 1 QL (8 per 1 day) codeine sulfate tablet 2 QL (6 per 1 day) MO diclofenac potassium 1 diclofenac sodium dr tablet delayed release 50mg, 75mg

1

diclofenac sodium dr tablet delayed release 25mg 1 MO diclofenac sodium er 1 diclofenac sodium xr 1 MO diclofenac sodium/misoprostol 2 diflunisal 1 dolacet 1 QL (8 per 1 day) dolorex forte 1 QL (8 per 1 day) eth-oxydose 2 etodolac capsule 300mg 1 etodolac capsule 200mg 1 MO etodolac er tablet extended release 24 hour 600mg 1 etodolac er tablet extended release 24 hour 400mg, 500mg

1 MO

etodolac tablet 1 fenoprofen calcium 1 MO

9


fentanyl citrate 1 fentanyl citrate oral transmucosal 5 PA QL (4 per 1 day) fentanyl patch 72 hour 25mcg/hr, 50mcg/hr, 75mcg/hr 2 QL (15 per 30 days) fentanyl patch 72 hour 100mcg/hr, 12mcg/hr 2 QL (15 per 30 days) MO flurbiprofen tablet 100mg 1 flurbiprofen tablet 50mg 1 MO HYCET 4 QL (185 per 1 day) MO hydrocodone bitartrate/acetaminophen oral solution 2 QL (185 per 1 day) MO hydrocodone bitartrate/acetaminophen tablet 750mg; 10mg

1 QL (5 per 1 day) MO

hydrocodone bitartrate/acetaminophen tablet 325mg; 2.5mg

1 QL (12 per 1 day)

hydrocodone bitartrate/acetaminophen tablet 300mg; 10mg, 300mg; 5mg, 300mg; 7.5mg


hydrocodone/acetaminophen oral solution 500mg/15ml; 7.5mg/15ml

1 QL (90 per 1 day)

hydrocodone/acetaminophen oral solution 325mg/15ml; 10mg/15ml

2 QL (185 per 1 day)

hydrocodone/acetaminophen tablet 750mg; 7.5mg 1 QL (5 per 1 day) hydrocodone/acetaminophen tablet 650mg; 10mg, 650mg; 7.5mg, 660mg; 10mg

1 QL (6 per 1 day)

hydrocodone/acetaminophen tablet 500mg; 10mg, 500mg; 2.5mg, 500mg; 5mg

1 QL (8 per 1 day)

hydrocodone/acetaminophen tablet 500mg; 7.5mg 1 QL (8 per 1 day) MO hydrocodone/acetaminophen tablet 325mg; 10mg, 325mg; 5mg, 325mg; 7.5mg

1 QL (12 per 1 day)

hydrocodone/ibuprofen tablet 5mg; 200mg, 7.5mg; 200mg

1 QL (5 per 1 day)

hydrocodone/ibuprofen tablet 10mg; 200mg, 2.5mg; 200mg

2 QL (5 per 1 day)

hydrogesic 1 QL (8 per 1 day) MO hydromorphone hcl injection 1mg/ml 1 B/D hydromorphone hcl injection 10mg/ml, 2mg/ml, 4mg/ml, 500mg/50ml, 50mg/5ml

2 B/D

hydromorphone hcl liquid 1 QL (80 per 1 day) MO hydromorphone hcl tablet 4mg, 8mg 1 QL (8 per 1 day) hydromorphone hcl tablet 2mg 1 QL (16 per 1 day) ibu 1 ibuprofen suspension 1 MO ibuprofen tablet 400mg, 600mg, 800mg 1 INDOCIN SUPPOSITORY 4 MO indomethacin capsule 1 indomethacin cr 2 indomethacin er 2 ketoprofen 1 ketoprofen er 2 MO

10


ketorolac tromethamine injection 15mg/ml, 300mg/10ml, 30mg/ml

1 PA QL (20 per 5 days)

ketorolac tromethamine tablet 1 PA QL (20 per 5 days) MO LAZANDA 4 PA QL (1 per 1 day) levorphanol tartrate 2 QL (4.5 per 1 day) MO MAGNACET TABLET 400MG; 2.5MG 4 margesic-h 1 QL (8 per 1 day) MO meclofenamate sodium capsule 100mg 2 meclofenamate sodium capsule 50mg 2 MO mefenamic acid 2 meloxicam suspension 2 MO meloxicam tablet 1 meperidine hcl injection 10mg/ml, 25mg/ml, 75mg/ml 2 PA meperidine hcl injection 100mg/ml, 50mg/ml 2 PA MO meperidine hcl oral solution 2 PA QL (120 per 1 day) MO meperidine hcl tablet 2 PA QL (4 per 1 day) meperitab 2 PA QL (4 per 1 day) methadone hcl injection 2 methadone hcl oral solution 2 QL (100 per 1 day) methadone hcl tablet 10mg 2 QL (12 per 1 day) MO methadone hcl tablet 5mg 2 QL (20 per 1 day) MO methadose tablet 10mg 2 QL (12 per 1 day) methadose tablet 5mg 2 QL (20 per 1 day) MO morphine sulfate add-vantage 2 B/D morphine sulfate cr 2 QL (3 per 1 day) morphine sulfate er capsule extended release 24 hour 100mg

2

morphine sulfate er capsule extended release 24 hour 20mg, 30mg, 50mg, 60mg, 80mg

2 QL (6 per 1 day)

morphine sulfate er tablet extended release 12 hour 2 QL (3 per 1 day) morphine sulfate injection 0.5mg/ml, 10mg/ml, 150mg/30ml, 15mg/ml, 1mg/ml, 4mg/ml, 50mg/ml, 5mg/ml, 8mg/ml

2 B/D

morphine sulfate injection 2mg/ml 2 B/D MO morphine sulfate oral solution 10mg/0.5ml, 5mg/0.25ml

2

morphine sulfate oral solution 20mg/ml 2 MO morphine sulfate oral solution 20mg/5ml 2 QL (34 per 1 day) morphine sulfate oral solution 10mg/5ml, 20mg/10ml 2 QL (60 per 1 day) morphine sulfate tablet 2 QL (6 per 1 day) MO nabumetone tablet 500mg 1 nabumetone tablet 750mg 1 MO nalbuphine hcl 2 MO naproxen dr 1

11


naproxen sodium tablet 275mg, 550mg 1 naproxen suspension 2 MO naproxen tablet 250mg, 500mg 1 naproxen tablet 375mg 1 MO NUCYNTA 3 ST QL (6 per 1 day) NUCYNTA ER 3 MO OPANA ER (CRUSH RESISTANT) TABLET EXTENDED RELEASE 12 HOUR 10MG, 20MG, 30MG

4 ST QL (2 per 1 day)

OPANA ER (CRUSH RESISTANT) TABLET EXTENDED RELEASE 12 HOUR 5MG

4 ST QL (2 per 1 day) MO

OPANA ER (CRUSH RESISTANT) TABLET EXTENDED RELEASE 12 HOUR 40MG


OPANA ER TABLET EXTENDED RELEASE 12 HOUR 15MG, 7.5MG


OPANA ER TABLET EXTENDED RELEASE 12 HOUR 10MG, 20MG, 30MG, 5MG


OPANA ER TABLET EXTENDED RELEASE 12 HOUR 40MG


oxaprozin 1 MO oxycodone hcl capsule 2 QL (12 per 1 day) MO oxycodone hcl concentrate 2 MO oxycodone hcl cr 2 QL (4 per 1 day) oxycodone hcl er 2 QL (4 per 1 day) oxycodone hcl oral solution 1 oxycodone hcl tablet 10mg 1 QL (6 per 1 day) MO oxycodone hcl tablet 30mg 2 QL (6 per 1 day) oxycodone hcl tablet 15mg, 20mg 2 QL (6 per 1 day) MO oxycodone hcl tablet 5mg 2 QL (12 per 1 day) MO oxycodone/acetaminophen capsule 1 QL (8 per 1 day) oxycodone/acetaminophen tablet 650mg; 10mg 1 QL (6 per 1 day) oxycodone/acetaminophen tablet 500mg; 7.5mg 1 QL (8 per 1 day) oxycodone/acetaminophen tablet 325mg; 10mg, 325mg; 5mg

1 QL (12 per 1 day)

oxycodone/acetaminophen tablet 325mg; 2.5mg, 325mg; 7.5mg


oxycodone/aspirin 2 QL (12 per 1 day) MO oxycodone/ibuprofen 2 QL (4 per 1 day) oxymorphone hydrochloride 2 QL (6 per 1 day) MO oxymorphone hydrochloride er 2 QL (2 per 1 day) MO PANLOR DC 4 QL (11 per 1 day) pentazocine/naloxone hcl 2 PA QL (12 per 1 day) piroxicam 1 MO PRIMALEV 4 QL (13 per 1 day) REPREXAIN TABLET 2.5MG; 200MG 4 QL (5 per 1 day) MO

12


reprexain tablet 10mg; 200mg 2 QL (5 per 1 day) MO reprexain tablet 7.5mg; 200mg 1 QL (5 per 1 day) ROXANOL 4 ROXICODONE INTENSOL 4 salflex 1 salsalate 1 stagesic 1 QL (8 per 1 day) MO sulindac tablet 150mg 1 sulindac tablet 200mg 1 MO tolmetin sodium capsule 1 tolmetin sodium tablet 2 MO tramadol hcl 1 QL (8 per 1 day) tramadol hcl er capsule extended release 24 hour 2 QL (2 per 1 day) tramadol hcl er tablet extended release 24 hour 300mg

2 QL (1 per 1 day)

tramadol hcl er tablet extended release 24 hour 100mg, 300mg


tramadol hcl er tablet extended release 24 hour 200mg


tramadol hcl biphasic er tablet extended release 24 hour 100mg


tramadol hydrochloride/acetaminophen 1 QL (8 per 1 day) TREZIX 4 QL (11 per 1 day) MO vicodin es tablet 300mg; 7.5mg 1 QL (13 per 1 day) vicodin hp tablet 660mg; 10mg 1 QL (6 per 1 day) vicodin hp tablet 300mg; 10mg 1 QL (13 per 1 day) vicodin tablet 300mg; 5mg 1 QL (13 per 1 day) XODOL TABLET 300MG; 5MG, 300MG; 7.5MG 4 QL (13 per 1 day) XODOL TABLET 300MG; 10MG 4 QL (13 per 1 day) MO ZAMICET 4 QL (185 per 1 day) MO zerlor 2 QL (5 per 1 day) MO ZOLVIT 4 QL (68 per 1 day) ZYDONE 4 QL (10 per 1 day) MO

ANESTHETICS lidocaine cream 2 lidocaine hcl external solution 1 MO lidocaine hcl gel 1 MO lidocaine hcl injection 4% 1 MO lidocaine hcl injection 0.5%, 1%, 1.5%, 2% 1 B/D lidocaine hcl injection 1% 1 B/D MO lidocaine hcl jelly 1 MO lidocaine hcl mouth/throat solution 1 lidocaine ointment 1 lidocaine viscous 1

13


lidocaine/prilocaine cream 1 B/D MO lidocaine/prilocaine kit 2 B/D LIDODERM 3 PA ST QL (3 per 1 day) MO

ANTI-ADDICTION/SUBSTANCE ABUSE TREATMENT AGENTS ANTABUSE 4 buprenorphine hcl injection 1 MO buprenorphine hcl tablet sublingual 2 PA MO buproban 1 QL (2 per 1 day) bupropion hcl sr tablet extended release 12 hour 150mg


CAMPRAL 4 MO CHANTIX 4 ST QL (2 per 1 day) MO CHANTIX PAK 4 ST QL (2 per 1 day) depade 2 disulfiram tablet 250mg 2 disulfiram tablet 500mg 2 MO naloxone hcl 1 naltrexone hcl 1 nicotine 2 NICOTROL NS 4 QL (40 per 30 days) MO SUBOXONE FILM 2MG; 0.5MG, 8MG; 2MG 4 PA QL (3 per 1 day) MO SUBOXONE TABLET SUBLINGUAL 4 PA QL (3 per 1 day) MO

ANTIBACTERIALS ak-poly-bac 1 ALCOHOL PREPS PAD 4 MO ALTABAX 4 amikacin sulfate 1 amoxicillin capsule 1 amoxicillin suspension reconstituted 1 MO amoxicillin tablet 875mg 1 amoxicillin tablet 500mg 1 MO amoxicillin tablet chewable 200mg, 400mg 1 amoxicillin tablet chewable 125mg, 250mg 1 MO amoxicillin/clavulanate potassium er 1 amoxicillin/clavulanate potassium suspension reconstituted 200mg/5ml; 28.5mg/5ml, 400mg/5ml; 57mg/5ml, 600mg/5ml; 42.9mg/5ml

1

amoxicillin/clavulanate potassium suspension reconstituted 250mg/5ml; 62.5mg/5ml

1 MO

amoxicillin/clavulanate potassium tablet 250mg; 125mg

1

amoxicillin/clavulanate potassium tablet chewable 1 MO amoxicillin/potassium clavulanate tablet 875mg; 125mg

1

14


amoxicillin/potassium clavulanate tablet 500mg; 125mg

1 MO

amoxil capsule 1 amoxil suspension reconstituted 250mg/5ml 1 ampicillin capsule 1 ampicillin sodium injection 10gm, 125mg, 1gm, 250mg, 2gm, 500mg

2

ampicillin sodium injection 1gm 2 MO ampicillin suspension reconstituted 125mg/5ml 1 ampicillin suspension reconstituted 250mg/5ml 1 MO ampicillin-sulbactam 2 AVELOX ABC PACK 4 MO AVELOX INJECTION 4 AVELOX TABLET 4 MO avidoxy 2 PA AZASITE 3 MO azithromycin hydrogencitrate injection 2.5gm, 500mg 2 azithromycin injection 500mg 1 azithromycin packet 1 azithromycin suspension reconstituted 1 azithromycin tablet 1 aztreonam injection 2gm 2 aztreonam injection 1gm 2 MO baciim 1 bacitracin injection 1 MO bacitracin ophthalmic ointment 1 MO bacitracin/neomycin/polymyxin ointment 400unit/gm; 5mg/gm; 10000unit/gm

1

bacitracin/polymyxin b 1 MO BACTROBAN CREAM 4 MO BLEPH-10 4 MO BLEPHAMIDE S.O.P. 4 MO CAYSTON 5 QL (3 per 1 day) cefaclor 1 cefaclor er 2 MO cefadroxil capsule 2 cefadroxil suspension reconstituted 250mg/5ml 2 cefadroxil suspension reconstituted 500mg/5ml 2 MO cefadroxil tablet 2 MO cefazolin sodium 2 cefazolin sodium/dextrose 2 cefdinir capsule 2 cefdinir suspension reconstituted 250mg/5ml 2 cefdinir suspension reconstituted 125mg/5ml 2 MO

15


cefditoren pivoxil 2 MO cefepime 2 cefotaxime sodium 2 cefotetan 2 cefotetan/dextrose 2 cefoxitin sodium 2 cefpodoxime proxetil suspension reconstituted 2 MO cefpodoxime proxetil tablet 2 cefprozil 1 ceftazidime injection 1gm, 2gm, 500mg, 6gm 2 ceftriaxone in iso-osmotic dextrose 2 ceftriaxone sodium injection 100gm, 10gm, 1gm, 250mg, 2gm, 500mg

2

ceftriaxone sodium iv 2gm 2 MO ceftriaxone/dextrose 2 cefuroxime axetil suspension reconstituted 250mg/5ml 2 cefuroxime axetil suspension reconstituted 125mg/5ml 1 MO cefuroxime axetil tablet 1 cefuroxime sodium injection 1.5gm, 7.5gm, 75gm 2 cefuroxime sodium injection 750mg 2 MO cefuroxime/dextrose 2 cephalexin capsule 1 cephalexin suspension reconstituted 1 cephalexin tablet 1 MO chloramphenicol sodium succinate 2 CIPRODEX 4 MO ciprofloxacin er 2 MO ciprofloxacin hcl ophthalmic solution 1 MO ciprofloxacin hcl tablet 250mg, 500mg 1 ciprofloxacin hcl tablet 100mg, 750mg 1 MO ciprofloxacin i.v.-in d5w 2 ciprofloxacin injection 1200mg/120ml 1 ciprofloxacin injection 200mg/20ml, 400mg/40ml 2 MO clarithromycin er 2 MO clarithromycin suspension reconstituted 125mg/5ml 2 clarithromycin suspension reconstituted 250mg/5ml 2 MO clarithromycin tablet 2 clindamax 1 clindamycin hcl 1 clindamycin palmitate hcl 1 clindamycin phosphate add-vantage 2 clindamycin phosphate cream 2

16


clindamycin phosphate injection 150mg/ml, 300mg/2ml, 600mg/4ml, 9000mg/60ml, 900mg/6ml

2

colistimethate sodium 5 PA CORTISPORIN OINTMENT 4 MO demeclocycline hcl 2 PA dicloxacillin sodium 1 DIFICID 5 PA QL (2 per 1 day) MO doxycycline 2 PA MO doxycycline hyclate capsule 100mg 2 PA doxycycline hyclate capsule 50mg 2 PA MO doxycycline hyclate capsule delayed release particles 75mg

2 PA

doxycycline hyclate injection 2 PA doxycycline hyclate tablet 2 PA doxycycline hyclate tablet delayed release 2 PA MO doxycycline monohydrate capsule 100mg 2 PA doxycycline monohydrate capsule 50mg 2 PA MO doxycycline monohydrate suspension reconstituted 1 PA doxycycline monohydrate tablet 50mg, 75mg 2 PA doxycycline monohydrate tablet 100mg, 150mg 2 PA MO e.e.s. 400 tablet 1 MO E.E.S. GRANULES 4 e.s.p. 1 ery 1 MO eryderm 1 ERYPED 200 4 MO ERYPED 400 4 MO ERYTHROCIN LACTOBIONATE 4 ERYTHROCIN STEARATE TABLET 500MG 4 ERYTHROCIN STEARATE TABLET 250MG 4 MO erythromycin base 1 MO erythromycin capsule delayed release particles 1 MO erythromycin ethylsuccinate tablet 1 MO erythromycin external solution 1 MO erythromycin gel 1 MO erythromycin ointment 1 erythromycin pad 1 erythromycin/sulfisoxazole 1 MO FLAGYL ER 4 MO FURADANTIN 4 garamycin ointment 1 gentak ointment 1 MO gentak ophthalmic solution 1

17


gentamicin sulfate cream 1 MO gentamicin sulfate iv 10mg/ml 1 gentamicin sulfate injection 10mg/ml, 40mg/ml 1 MO gentamicin sulfate ointment 0.3% 1 gentamicin sulfate ointment 0.1% 1 MO gentamicin sulfate ophthalmic solution 1 MO gentamicin sulfate/0.9% sodium chloride injection 0.9mg/ml; 0.9%, 1.2mg/ml; 0.9%, 1.4mg/ml; 0.9%, 1.6mg/ml; 0.9%, 1mg/ml; 0.9%

1

gentamicin sulfate/0.9% sodium chloride injection 0.8mg/ml; 0.9%

1 MO

gentasol 1 ilotycin 1 imipenem/cilastatin 2 MO INVANZ IV 1GM 4 INVANZ INJECTION 1GM 4 MO isotonic gentamicin injection 0.6mg/ml; 0.9%, 0.8mg/ml; 0.9%, 1.2mg/ml; 0.9%, 2mg/ml; 0.9%

1

kanamycin sulfate 2 MO KETEK TABLET 300MG 4 KETEK TABLET 400MG 4 MO LEVAQUIN LEVA-PAK 4 levofloxacin in d5w 2 levofloxacin injection 2 levofloxacin ophthalmic solution 2 MO levofloxacin oral solution 2 levofloxacin tablet 2 MANDELAMINE 4 MEFOXIN 4 meropenem injection 1gm 2 meropenem injection 500mg 2 MO methenamine hippurate 2 methenamine mandelate tablet 0.5gm, 1gm 2 methenamine mandelate tablet 500mg, 1000mg 2 MO METRO IV 4 metronidazole capsule 1 MO metronidazole cream 2 metronidazole gel 1 metronidazole in nacl 0.79% 1 metronidazole lotion 2 metronidazole tablet 1 metronidazole vaginal 1 minocycline hcl capsule 2 PA minocycline hcl er 2 PA MO

18


minocycline hcl tablet 50mg 2 PA minocycline hcl tablet 100mg, 75mg 2 PA MO MONUROL 4 MO MOXATAG 4 MO MOXEZA 4 MO mupirocin 1 nafcillin sodium 2 NEO-FRADIN 4 neo-polycin 1 neocin 1 neocin-pg 1 neomycin sulfate 1 MO neomycin/bacitracin/polymyxin 1 MO neomycin/polymyxin b sulfates 2 neomycin/polymyxin/bacitracin/hydrocortisone 1 MO neomycin/polymyxin/gramicidin 1 neomycin/polymyxin/hydrocortisone ophthalmic suspension

1 MO

nitrofurantoin 2 nitrofurantoin macrocrystalline 2 nitrofurantoin monohydrate 2 ofloxacin ophthalmic solution 1 ofloxacin otic solution 1 ofloxacin tablet 200mg 1 ofloxacin tablet 300mg, 400mg 1 oxacillin sodium 2 paromomycin sulfate 2 PCE 4 MO penicillin g potassium in iso-osmotic dextrose 2 penicillin g potassium injection 5mu 2 penicillin g potassium injection 20mu 2 MO penicillin g procaine 2 MO penicillin g sodium 2 penicillin v potassium oral solution 1 MO penicillin v potassium tablet 1 pfizerpen-g injection 5mu 2 PFIZERPEN-G INJECTION 20MU 4 PHISOHEX 4 MO piperacillin sodium 2 piperacillin sodium/tazobactam sodium 2 polycin b 1 polymyxin b sulfate 1 polymyxin b sulfate/trimethoprim sulfate 1

19


PRIMAXIN I.M. 4 PRIMSOL 4 MO romycin 1 rosadan cream 2 rosadan gel 1 silver sulfadiazine 1 MO sodium sulfacetamide ophthalmic solution 1 MO ssd 1 ssd af 1 streptomycin sulfate 1 MO sulfacetamide sodium ointment 1 MO sulfacetamide sodium ophthalmic solution 1 sulfacetamide sodium/prednisolone sodium phosphate 1 sulfadiazine 2 sulfamethoxazole/trimethoprim ds 1 sulfamethoxazole/trimethoprim injection 1 sulfamethoxazole/trimethoprim suspension 1 MO sulfamethoxazole/trimethoprim tablet 1 SULFAMYLON 4 MO sulfatrim 1 SUPRAX SUSPENSION RECONSTITUTED 200MG/5ML

4

SUPRAX SUSPENSION RECONSTITUTED 100MG/5ML

4 MO

SUPRAX TABLET 4 MO SUPRAX TABLET CHEWABLE 4 tazicef injection 1gm, 2gm, 6gm 2 TEFLARO 4 tetracycline hcl 1 PA MO thermazene 1 TIMENTIN INJECTION 0.1GM/100ML; 3GM/100ML, 0.1GM; 3GM

4

TOBI 5 QL (10 per 1 day) B/D tobramycin sulfate add-vantage 1 tobramycin sulfate injection 1 tobramycin sulfate ophthalmic solution 1 MO tobramycin sulfate/sodium chloride 2 tobrasol 1 TOBREX OINTMENT 4 MO trimethoprim 1 MO trimethoprim sulfate/polymyxin b sulfate 1 MO trimox 1 TYGACIL 4 VANCOCIN HCL 5

20


vancomycin hcl capsule 2 vancomycin hcl in dextrose 2 B/D vancomycin hcl injection 10gm, 5000mg, 500mg, 750mg

2 B/D

vancomycin hcl injection 1000mg 2 B/D MO vandazole 1 MO veetids 1 VIBRAMYCIN SYRUP 4 PA MO VIGAMOX 4 MO vitazol 2 ZYLET 3 MO ZYVOX INJECTION 5 PA ZYVOX SUSPENSION RECONSTITUTED 5 PA QL (64.28 per 1 day)

MO ZYVOX TABLET 5 PA QL (56 per 28 days) MO

ANTICONVULSANTS BANZEL SUSPENSION 5 PA QL (80 per 1 day) MO BANZEL TABLET 200MG 4 PA QL (3 per 1 day) MO BANZEL TABLET 400MG 4 PA QL (8 per 1 day) MO carbamazepine 1 carbamazepine er capsule extended release 12 hour 2 carbamazepine er tablet extended release 12 hour 2 MO CELONTIN 4 MO clonazepam odt tablet dispersible 0.25mg, 0.5mg 2 PA QL (2 per 1 day) clonazepam odt tablet dispersible 0.125mg 2 PA QL (3 per 1 day) clonazepam odt tablet dispersible 1mg 2 PA QL (4 per 1 day) clonazepam odt tablet dispersible 2mg 2 PA QL (10 per 1 day) clonazepam tablet 0.5mg 2 PA QL (3 per 1 day) clonazepam tablet 1mg 2 PA QL (4 per 1 day) clonazepam tablet 2mg 2 PA QL (10 per 1 day) clorazepate dipotassium tablet 3.75mg, 7.5mg 1 QL (3 per 1 day) MO clorazepate dipotassium tablet 15mg 1 QL (6 per 1 day) diazepam gel 2.5mg 2 PA QL (15 per 1 day) MO diazepam gel 10mg 2 PA QL (60 per 1 day) MO diazepam gel 20mg 2 PA QL (120 per 1 day) MO DILANTIN CAPSULE 30MG 4 MO DILANTIN INFATABS 4 MO divalproex sodium 1 divalproex sodium dr 1 divalproex sodium er 1 epitol 1 EQUETRO CAPSULE EXTENDED RELEASE 12 HOUR 100MG


21


EQUETRO CAPSULE EXTENDED RELEASE 12 HOUR 300MG


EQUETRO CAPSULE EXTENDED RELEASE 12 HOUR 200MG


ethosuximide capsule 2 ethosuximide oral solution 2 MO felbamate suspension 2 felbamate tablet 400mg 2 felbamate tablet 600mg 2 MO FELBATOL SUSPENSION 4 MO FELBATOL TABLET 4 fosphenytoin sodium injection 100mg pe/2ml 2 fosphenytoin sodium injection 500mg pe/10ml 1 gabapentin capsule 100mg, 300mg 1 QL (6 per 1 day) gabapentin capsule 400mg 1 QL (9 per 1 day) gabapentin oral solution 2 QL (72 per 1 day) gabapentin tablet 800mg 1 QL (4.5 per 1 day) gabapentin tablet 600mg 1 QL (6 per 1 day) GABITRIL TABLET 4MG 4 PA ST MO GABITRIL TABLET 2MG 4 PA ST QL (2 per 1 day) MO GABITRIL TABLET 12MG, 16MG 4 PA ST QL (4 per 1 day) MO KEPPRA INJECTION 4 LAMICTAL ODT TABLET DISPERSIBLE 4 ST MO LAMICTAL TABLET CHEWABLE 4 lamotrigine starter kit 2 lamotrigine tablet 2 lamotrigine tablet chewable 5mg 2 lamotrigine tablet chewable 25mg 2 MO levetiracetam injection 500mg/5ml 2 MO levetiracetam oral solution 2 levetiracetam tablet 1 LYRICA CAPSULE 225MG, 300MG 4 QL (2 per 1 day) MO LYRICA CAPSULE 100MG, 150MG, 200MG, 25MG, 50MG, 75MG


LYRICA ORAL SOLUTION 4 QL (30 per 1 day) magnesium sulfate in d5w injection 5%; 10mg/ml 1 ONFI 4 PA QL (2 per 1 day) MO oxcarbazepine suspension 300mg/5ml 2 MO oxcarbazepine tablet 300mg, 600mg 2 oxcarbazepine tablet 150mg 2 MO PEGANONE 4 MO phenobarbital tablet 64.8mg 2 PA QL (3 per 1 day) phenobarbital tablet 16.2mg, 97.2mg 2 PA QL (4 per 1 day) phenobarbital tablet 30mg 2 PA QL (11 per 1 day)

22


phenobarbital tablet 32.4mg 2 PA QL (12 per 1 day) phenytoin 1 phenytoin sodium 1 phenytoin sodium extended capsule 100mg 1 phenytoin sodium extended capsule 200mg 2 phenytoin sodium extended capsule 300mg 2 MO POTIGA TABLET 50MG 4 PA ST MO POTIGA TABLET 400MG 4 PA ST QL (3 per 1 day) POTIGA TABLET 200MG, 300MG 4 PA ST QL (3 per 1 day) MO primidone 1 SABRIL PACKET 5 PA QL (6.67 per 1 day) SABRIL TABLET 5 PA ST QL (6 per 1 day) TEGRETOL-XR TABLET EXTENDED RELEASE 12 HOUR 100MG

4 MO

tiagabine hydrochloride tablet 4mg 2 PA tiagabine hydrochloride tablet 2mg 2 PA QL (2 per 1 day) topiragen 2 topiramate capsule sprinkle 2 topiramate tablet 2 MO TRILEPTAL SUSPENSION 4 MO valproate sodium 2 valproic acid capsule 1 valproic acid syrup 1 MO VIMPAT INJECTION 4 PA ST QL (40 per 1 day) VIMPAT ORAL SOLUTION 4 PA QL (40 per 1 day) MO VIMPAT TABLET 100MG, 150MG, 200MG 4 PA ST QL (2 per 1 day) MO VIMPAT TABLET 50MG 4 PA ST QL (6 per 1 day) MO ZARONTIN ORAL SOLUTION 4 zonisamide 1

ANTIDEMENTIA AGENTS donepezil hcl tablet 5mg 2 QL (1 per 1 day) donepezil hcl tablet 10mg 2 QL (2 per 1 day) donepezil hcl tablet dispersible 5mg 2 QL (1 per 1 day) donepezil hcl tablet dispersible 10mg 2 QL (2 per 1 day) ergoloid mesylates 2 MO EXELON ORAL SOLUTION 4 MO EXELON PATCH 24 HOUR 13.3MG/24HR 3 EXELON PATCH 24 HOUR 4.6MG/24HR, 9.5MG/24HR

3 MO

galantamine hydrobromide capsule extended release 24 hour

2

galantamine hydrobromide oral solution 2 MO galantamine hydrobromide tablet 2 NAMENDA 3 MO

23


NAMENDA TITRATION PAK 3 MO rivastigmine tartrate 2

ANTIDEPRESSANTS amitriptyline hcl 1 amitriptyline/chlordiazepoxide 1 amoxapine 1 MO budeprion sr 1 QL (2 per 1 day) budeprion xl 1 QL (1 per 1 day) bupropion hcl 1 QL (6 per 1 day) bupropion hcl er 1 QL (2 per 1 day) bupropion hcl sr tablet extended release 12 hour 100mg, 150mg

1 QL (2 per 1 day)

bupropion hcl sr tablet extended release 12 hour 200mg


bupropion hcl xl 1 QL (1 per 1 day) chlordiazepoxide/amitriptyline tablet 12.5mg; 5mg 1 chlordiazepoxide/amitriptyline tablet 25mg; 10mg 1 MO citalopram hydrobromide oral solution 2 QL (30 per 1 day) citalopram hydrobromide tablet 1 QL (1 per 1 day) clomipramine hcl 1 MO CYMBALTA CAPSULE DELAYED RELEASE PARTICLES 30MG

4

CYMBALTA CAPSULE DELAYED RELEASE PARTICLES 20MG, 60MG

4 MO

desipramine hcl tablet 100mg, 150mg, 25mg, 50mg 1 desipramine hcl tablet 10mg, 75mg 1 MO doxepin hcl capsule 100mg, 10mg, 25mg, 50mg, 75mg 1 doxepin hcl capsule 150mg 1 MO doxepin hcl concentrate 1 MO EMSAM 4 PA ST QL (1 per 1 day) MO escitalopram oxalate oral solution 2 QL (20 per 1 day) MO escitalopram oxalate tablet 10mg, 5mg 2 QL (1 per 1 day) escitalopram oxalate tablet 20mg 2 QL (1 per 1 day) MO fluoxetine capsule 10mg 1 QL (1 per 1 day) MO fluoxetine capsule 20mg 1 QL (4 per 1 day) MO fluoxetine dr 2 QL (4 per 28 days) MO fluoxetine hcl capsule 10mg 1 QL (1 per 1 day) MO fluoxetine hcl capsule 40mg 1 QL (2 per 1 day) fluoxetine hcl capsule 20mg 1 QL (4 per 1 day) fluoxetine hcl oral solution 1 QL (20 per 1 day) fluoxetine hcl tablet 10mg 1 QL (1 per 1 day) fluoxetine hcl tablet 60mg 1 QL (1 per 1 day) MO fluoxetine hcl tablet 20mg 1 QL (4 per 1 day) MO fluvoxamine maleate tablet 25mg, 50mg 1 QL (1 per 1 day)

24


fluvoxamine maleate tablet 100mg 1 QL (3 per 1 day) FORFIVO XL 4 QL (1 per 1 day) imipramine hcl 1 imipramine pamoate 1 MO LEXAPRO ORAL SOLUTION 4 ST QL (20 per 1 day) LEXAPRO TABLET 5MG 4 ST QL (1 per 1 day) LEXAPRO TABLET 10MG, 20MG 4 ST QL (1 per 1 day) MO maprotiline hcl 1 MO MARPLAN 4 MO mirtazapine 1 QL (1 per 1 day) mirtazapine odt tablet dispersible 30mg, 45mg 1 QL (1 per 1 day) NARDIL 4 nefazodone hcl tablet 250mg, 50mg 1 QL (2 per 1 day) MO nefazodone hcl tablet 100mg, 150mg, 200mg 1 QL (3 per 1 day) MO nortriptyline hcl capsule 10mg, 25mg, 75mg 1 nortriptyline hcl capsule 50mg 1 MO nortriptyline hcl oral solution 1 MO paroxetine hcl er tablet extended release 24 hour 37.5mg


paroxetine hcl er tablet extended release 24 hour 25mg


paroxetine hcl er tablet extended release 24 hour 12.5mg


paroxetine hcl suspension 2 QL (30 per 1 day) paroxetine hcl tablet 10mg, 20mg 1 QL (1 per 1 day) paroxetine hcl tablet 30mg, 40mg 1 QL (2 per 1 day) PAXIL SUSPENSION 4 QL (30 per 1 day) MO perphenazine/amitriptyline tablet 25mg; 4mg 1 perphenazine/amitriptyline tablet 10mg; 2mg, 10mg; 4mg, 25mg; 2mg, 50mg; 4mg

1 MO

phenelzine sulfate 2 PRISTIQ 4 ST QL (1 per 1 day) MO protriptyline hcl 2 selfemra capsule 10mg 2 QL (1 per 1 day) MO selfemra capsule 20mg 2 QL (4 per 1 day) MO sertraline hcl concentrate 2 QL (10 per 1 day) sertraline hcl tablet 25mg 1 QL (1 per 1 day) sertraline hcl tablet 50mg 1 QL (1.5 per 1 day) sertraline hcl tablet 100mg 1 QL (2 per 1 day) SURMONTIL 4 tranylcypromine sulfate 2 MO trazodone hcl tablet 100mg, 150mg, 50mg 1 trazodone hcl tablet 300mg 1 MO trimipramine maleate 2

25


venlafaxine hcl er capsule extended release 24 hour 37.5mg

2 QL (1 per 1 day)

venlafaxine hcl er capsule extended release 24 hour 75mg


venlafaxine hcl er capsule extended release 24 hour 150mg


venlafaxine hcl er tablet extended release 24 hour 37.5mg

2 QL (1 per 1 day)

venlafaxine hcl er tablet extended release 24 hour 225mg, 75mg


venlafaxine hcl er tablet extended release 24 hour 150mg


venlafaxine hcl tablet 100mg, 25mg 1 QL (3 per 1 day) MO venlafaxine hcl tablet 37.5mg 1 QL (4 per 1 day) MO venlafaxine hcl tablet 75mg 1 QL (5 per 1 day) MO venlafaxine hcl tablet 50mg 1 QL (6 per 1 day) MO VIIBRYD KIT 4 QL (1 per 1 day) VIIBRYD TABLET 4 QL (1 per 1 day) MO VIVACTIL 4

ANTIEMETICS CESAMET 5 QL (6 per 1 day) B/D MO dronabinol capsule 10mg 5 PA QL (2 per 1 day) dronabinol capsule 2.5mg, 5mg 2 PA QL (2 per 1 day) EMEND PAK 4 QL (6 per 30 days) EMEND CAPSULE 125MG, 40MG 4 QL (5 per 30 days) B/D EMEND CAPSULE 80MG 4 QL (6 per 30 days) B/D EMEND INJECTION 4 B/D granisetron hcl injection 1mg/ml 2 B/D granisetron hcl injection 0.1mg/ml 2 B/D MO granisetron hcl tablet 2 QL (2 per 1 day) B/D GRANISOL 4 QL (10 per 1 day) B/D MO meclizine hcl 1 ondansetron hcl injection 32mg/50ml; 450mg/50ml, 40mg/20ml, 4mg/2ml

2 B/D

ondansetron hcl oral solution 2 QL (30 per 1 day) B/D MO ondansetron hcl tablet 8mg 1 QL (3 per 1 day) B/D ondansetron hcl tablet 24mg 1 QL (5 per 30 days) B/D ondansetron hcl tablet 4mg 1 QL (6 per 1 day) B/D ondansetron hcl/dextrose 2 B/D ondansetron odt tablet dispersible 8mg 2 QL (3 per 1 day) B/D ondansetron odt tablet dispersible 4mg 2 QL (6 per 1 day) B/D MO phenadoz suppository 25mg 1 PA phenadoz suppository 12.5mg 1 PA MO promethazine hcl suppository 12.5mg, 50mg 1 PA promethazine hcl suppository 25mg 1 PA MO

26


promethegan suppository 12.5mg, 25mg 1 PA promethegan suppository 50mg 1 PA MO trimethobenzamide hcl injection 2 PA

ANTIFUNGALS amphotericin b 2 B/D MO bio-statin powder 2 ciclodan cream 2 ciclodan external solution 2 PA ciclopirox 2 ciclopirox nail lacquer 1 PA ciclopirox olamine 2 clotrimazole external cream 1 MO clotrimazole external solution 1 clotrimazole troche 1 MO econazole nitrate 1 MO ERAXIS 5 PA fluconazole in dextrose 2 fluconazole in nacl 2 fluconazole suspension reconstituted 40mg/ml 1 fluconazole suspension reconstituted 10mg/ml 1 MO fluconazole tablet 100mg, 200mg, 50mg 1 fluconazole tablet 150mg 1 QL (0.14 per 1 day) MO flucytosine capsule 250mg 2 flucytosine capsule 500mg 2 MO GRIFULVIN V TABLET 4 MO GRIS-PEG 4 MO griseofulvin microsize 1 itraconazole 2 PA ketoconazole cream 1 ketoconazole shampoo 1 MO ketoconazole tablet 1 kuric 1 LAMISIL PACKET 187.5MG 4 PA LAMISIL PACKET 125MG 4 PA MO MENTAX 4 MO miconazole 3 1 MO MYCAMINE 5 PA MO nuzole 2 nyamyc 2 nystatin cream 1 MO nystatin ointment 1 MO nystatin powder 100000unit/gm 2 nystatin powder 2 MO

27


nystatin suspension 1 nystatin tablet 2 nystatin vaginal 1 MO nystatin/triamcinolone 1 MO nystop 2 MO pedi-dri 2 MO SPORANOX ORAL SOLUTION 5 PA MO terbinafine hcl tablet 1 PA QL (1 per 1 day) terconazole cream 0.4% 1 MO terconazole cream 0.8% 2 MO terconazole suppository 2 MO VFEND IV 4 PA VFEND SUSPENSION RECONSTITUTED 5 PA MO VFEND TABLET 5 PA voriconazole injection 2 PA voriconazole tablet 5 PA zazole 1

ANTIGOUT AGENTS allopurinol sodium 1 allopurinol tablet 300mg 1 allopurinol tablet 100mg 1 MO COLCRYS 3 QL (4 per 1 day) MO probenecid 1 MO probenecid/colchicine 1 ULORIC 3 MO

ANTIMIGRAINE AGENTS dihydroergotamine mesylate 2 MAXALT 4 QL (12 per 30 days) MAXALT-MLT 4 QL (12 per 30 days) MIGERGOT 4 MO naratriptan hcl 2 QL (0.3 per 1 day) sumatriptan 2 QL (6 per 30 days) MO sumatriptan succinate injection 6mg/0.5ml 2 QL (4 per 30 days) sumatriptan succinate refill injection 4mg/0.5ml 2 QL (4 per 30 days) MO sumatriptan succinate tablet 2 QL (9 per 30 days)

ANTIMYASTHENIC AGENTS guanidine hcl 1 MESTINON SYRUP 4 MO MESTINON TIMESPAN 4 MO MYTELASE 4 MO pyridostigmine bromide 1

ANTIMYCOBACTERIALS CAPASTAT SULFATE 4

28


cycloserine 2 dapsone 1 MO ethambutol hcl tablet 400mg 2 ethambutol hcl tablet 100mg 2 MO isonarif 2 MO isoniazid injection 2 isoniazid syrup 2 MO isoniazid tablet 2 MYCOBUTIN 4 MO PASER 4 MO PRIFTIN 4 MO pyrazinamide 2 rifampin capsule 1 rifampin injection 2 RIFATER 4 MO TRECATOR 4 MO

ANTINEOPLASTICS adriamycin injection 10mg 2 B/D adriamycin injection 2mg/ml 2 B/D AFINITOR 5 PA QL (1 per 1 day) ALIMTA 5 PA ALKERAN TABLET 4 B/D amifostine 5 B/D anastrozole 2 QL (1 per 1 day) ARRANON 5 B/D ARZERRA 5 PA AVASTIN 5 PA BICNU 4 B/D bleomycin sulfate 2 B/D BOSULIF 5 PA BUSULFEX 5 B/D calcium folinate 2 B/D CAMPATH 5 B/D CAPRELSA TABLET 300MG 5 PA CAPRELSA TABLET 100MG 5 PA QL (2 per 1 day) carboplatin injection 150mg/15ml, 450mg/45ml, 50mg/5ml, 600mg/60ml

2 B/D

CEENU CAPSULE 100MG, 10MG, 40MG 4 cisplatin 2 B/D cladribine 2 B/D CLOLAR 5 B/D cyclophosphamide injection 2 B/D cyclophosphamide tablet 2 B/D MO

29


cytarabine aqueous 2 B/D cytarabine injection 100mg, 1gm, 500mg 2 B/D dacarbazine 2 B/D DACOGEN 4 B/D daunorubicin hcl 2 B/D dexrazoxane 2 B/D DOCEFREZ 5 B/D docetaxel injection 160mg/16ml, 20mg/0.5ml, 20mg/2ml, 20mg/ml, 80mg/2ml, 80mg/4ml, 80mg/8ml

5 B/D

doxorubicin hcl 2 B/D DROXIA 4 MO ELITEK 5 PA ELOXATIN INJECTION 100MG/20ML 5 B/D ELSPAR 4 B/D EMCYT 4 epirubicin hcl 2 B/D ERBITUX 5 PA ERIVEDGE 5 PA QL (1 per 1 day) etoposide injection 1 B/D exemestane 2 MO FARESTON 4 MO FASLODEX INJECTION 125MG/2.5ML 5 QL (0.36 per 1 day) FASLODEX INJECTION 250MG/5ML 5 QL (10 per 28 days) floxuridine 2 B/D fludarabine phosphate 2 B/D fluorouracil injection 2 B/D FUSILEV 4 B/D gemcitabine hcl injection 200mg, 2gm 2 B/D gemcitabine hcl injection 1gm 5 B/D gemcitabine injection 200mg/5.26ml, 2gm/52.6ml 2 B/D gemcitabine injection 1gm/26.3ml 5 B/D GEMZAR INJECTION 200MG 5 B/D GLEEVEC TABLET 400MG 5 PA QL (2 per 1 day) GLEEVEC TABLET 100MG 5 PA QL (3 per 1 day) HALAVEN 5 PA HERCEPTIN 5 B/D HEXALEN 5 PA hydroxyurea 1 idarubicin hcl injection 20mg/20ml, 5mg/5ml 2 B/D idarubicin hcl injection 10mg/10ml 5 B/D ifosfamide 2 B/D ifosfamide/mesna 2 B/D INLYTA TABLET 5MG 5 PA QL (4 per 1 day)

30


INLYTA TABLET 1MG 5 PA QL (8 per 1 day) IRESSA 5 PA QL (2 per 1 day) irinotecan 2 B/D ISTODAX 5 PA IXEMPRA KIT 5 B/D JAKAFI 5 PA QL (2 per 1 day) JEVTANA 5 PA letrozole 2 QL (1 per 1 day) leucovorin calcium injection 1 B/D leucovorin calcium tablet 5mg 1 leucovorin calcium tablet 10mg, 15mg, 25mg 1 MO LEUKERAN 4 MO MATULANE 5 melphalan hydrochloride 5 B/D MENEST 4 PA MO mercaptopurine 2 mesna 2 B/D MESNEX TABLET 4 mitomycin 2 B/D mitoxantrone hcl 2 B/D MUSTARGEN 4 B/D NEXAVAR 5 PA QL (4 per 1 day) ONCASPAR 5 B/D ONTAK 5 B/D onxol 2 B/D paclitaxel 2 B/D PANRETIN 5 MO pentostatin 2 B/D PERJETA 5 PA PHOTOFRIN 5 PROLEUKIN 5 B/D REVLIMID CAPSULE 2.5MG 5 PA QL (1 per 1 day) REVLIMID CAPSULE 10MG, 15MG, 25MG, 5MG 5 PA QL (1 per 1 day) LA RITUXAN 5 PA SOLTAMOX 4 SPRYCEL TABLET 100MG, 140MG 5 PA QL (1 per 1 day) SPRYCEL TABLET 20MG, 50MG, 70MG, 80MG 5 PA QL (2 per 1 day) STIVARGA 5 PA SUTENT CAPSULE 50MG 5 PA QL (1 per 1 day) SUTENT CAPSULE 25MG 5 PA QL (2 per 1 day) SUTENT CAPSULE 12.5MG 5 PA QL (3 per 1 day) SYLATRON 5 PA TABLOID 4 MO

31


tamoxifen citrate tablet 20mg 1 tamoxifen citrate tablet 10mg 1 MO TARCEVA TABLET 25MG 5 PA QL (2 per 1 day) TARCEVA TABLET 100MG, 150MG 5 PA QL (3 per 1 day) TARGRETIN 5 PA TASIGNA 5 PA QL (4 per 1 day) THALOMID CAPSULE 100MG, 150MG, 50MG 5 PA QL (28 per 28 days) THALOMID CAPSULE 200MG 5 PA QL (56 per 28 days) THERACYS 4 B/D thiotepa 2 B/D TICE BCG 4 B/D toposar 1 B/D topotecan hcl 5 B/D TREANDA 5 B/D tretinoin capsule 2 PA MO TRISENOX 4 B/D TYKERB 5 PA QL (6 per 1 day) VALSTAR 5 B/D VECTIBIX 5 PA VELCADE 5 B/D VIDAZA 5 B/D MO vinblastine sulfate 2 B/D vincasar pfs 2 B/D vincristine sulfate 2 B/D vinorelbine tartrate 2 B/D VOTRIENT 5 PA QL (4 per 1 day) VUMON 4 B/D XALKORI 5 PA QL (2 per 1 day) YERVOY 5 PA ZALTRAP 5 PA ZANOSAR 4 B/D ZELBORAF 5 PA QL (8 per 1 day) ZOLINZA 5 PA QL (4 per 1 day) ZYTIGA 5

ANTIPARASITICS acticin 1 ALBENZA 3 ALINIA SUSPENSION RECONSTITUTED 4 QL (50 per 1 day) MO ALINIA TABLET 4 QL (6 per 3 days) MO chloroquine phosphate 2 MO DARAPRIM 4 MO EURAX 4 MO hydroxychloroquine sulfate 1

32


lindane 2 QL (2 per 1 day) malathion 2 mebendazole 1 MO mefloquine hcl 1 MEPRON 5 MO NEBUPENT 4 B/D MO permethrin cream 1 MO primaquine phosphate 1 MO QUALAQUIN 4 PA MO STROMECTOL 4 MO tinidazole tablet 250mg 2 tinidazole tablet 500mg 2 MO

ANTIPARKINSON AGENTS amantadine hcl capsule 1 MO amantadine hcl syrup 2 amantadine hcl tablet 1 MO APOKYN 5 PA atamet 1 AZILECT 3 MO benztropine mesylate injection 2 benztropine mesylate tablet 2mg 1 benztropine mesylate tablet 0.5mg, 1mg 1 MO bromocriptine mesylate 2 carbidopa/levodopa 1 carbidopa/levodopa er 2 carbidopa/levodopa odt 1 MO carbidopa/levodopa sr 2 carbidopa/levodopa/entacapone 2 MO COMTAN 4 MO entacapone 2 LODOSYN 4 MIRAPEX ER 3 QL (1 per 1 day) MO PARCOPA TABLET DISPERSIBLE 10MG; 100MG 4 PARCOPA TABLET DISPERSIBLE 25MG; 100MG, 25MG; 250MG

4 MO

pramipexole dihydrochloride tablet 0.125mg, 0.5mg, 1.5mg, 1mg

2

pramipexole dihydrochloride tablet 0.25mg, 0.75mg 2 MO ropinirole er tablet extended release 24 hour 2mg 2 QL (1 per 1 day) MO ropinirole er tablet extended release 24 hour 12mg 2 QL (2 per 1 day) MO ropinirole er tablet extended release 24 hour 8mg 2 QL (3 per 1 day) MO ropinirole er tablet extended release 24 hour 6mg 2 QL (4 per 1 day) ropinirole er tablet extended release 24 hour 4mg 2 QL (5 per 1 day) MO

33


ropinirole hcl 1 selegiline hcl 1 STALEVO 4 trihexyphenidyl hcl elixir 1 MO trihexyphenidyl hcl tablet 1

ANTIPSYCHOTICS ABILIFY DISCMELT 4 QL (2 per 1 day) MO ABILIFY INJECTION 4 MO ABILIFY ORAL SOLUTION 4 QL (30 per 1 day) MO ABILIFY TABLET 4 QL (1 per 1 day) MO chlorpromazine hcl injection 1 chlorpromazine hcl tablet 100mg, 200mg, 25mg, 50mg 1 chlorpromazine hcl tablet 10mg 1 MO clozapine odt tablet dispersible 12.5mg 2 QL (2 per 1 day) clozapine odt tablet dispersible 25mg 2 QL (3 per 1 day) clozapine odt tablet dispersible 100mg 2 QL (9 per 1 day) clozapine tablet 25mg, 50mg 2 QL (3 per 1 day) clozapine tablet 200mg 2 QL (4 per 1 day) clozapine tablet 100mg 2 QL (9 per 1 day) compro 1 MO FANAPT 4 PA ST QL (2 per 1 day) MO FANAPT TITRATION PACK 4 PA ST QL (16 per 365 days) FAZACLO TABLET DISPERSIBLE 12.5MG 4 ST QL (2 per 1 day) FAZACLO TABLET DISPERSIBLE 25MG 4 ST QL (3 per 1 day) FAZACLO TABLET DISPERSIBLE 200MG 4 ST QL (4 per 1 day) FAZACLO TABLET DISPERSIBLE 150MG 4 ST QL (6 per 1 day) FAZACLO TABLET DISPERSIBLE 100MG 4 ST QL (9 per 1 day) fluphenazine decanoate 1 MO fluphenazine hcl concentrate 1 MO fluphenazine hcl elixir 1 fluphenazine hcl injection 2 MO fluphenazine hcl tablet 10mg, 1mg, 5mg 1 fluphenazine hcl tablet 2.5mg 1 MO GEODON CAPSULE 4 PA ST QL (2 per 1 day) GEODON INJECTION 4 MO haloperidol concentrate 1 MO haloperidol decanoate 2 haloperidol lactate 1 haloperidol tablet 0.5mg, 1mg, 20mg, 5mg 1 haloperidol tablet 10mg, 2mg 1 MO INVEGA SUSTENNA INJECTION 39MG/0.25ML 4 QL (0.25 per 30 days) MO INVEGA SUSTENNA INJECTION 78MG/0.5ML 4 QL (0.5 per 30 days) MO INVEGA SUSTENNA INJECTION 117MG/0.75ML 5 QL (0.75 per 30 days) MO

34


INVEGA SUSTENNA INJECTION 156MG/ML 5 QL (1 per 30 days) MO INVEGA SUSTENNA INJECTION 234MG/1.5ML 5 QL (1.5 per 30 days) MO INVEGA TABLET EXTENDED RELEASE 24 HOUR 1.5MG, 9MG


INVEGA TABLET EXTENDED RELEASE 24 HOUR 3MG, 6MG


LATUDA TABLET 120MG, 20MG, 40MG 4 QL (1 per 1 day) LATUDA TABLET 80MG 4 QL (2 per 1 day) loxapine succinate 2 LOXITANE 4 NAVANE CAPSULE 20MG 4 olanzapine injection 2 olanzapine odt 2 QL (1 per 1 day) olanzapine tablet 10mg, 15mg, 20mg, 5mg, 7.5mg 2 QL (1 per 1 day) olanzapine tablet 2.5mg 2 QL (2 per 1 day) olanzapine/fluoxetine 2 QL (1 per 1 day) ORAP 4 MO perphenazine tablet 4mg 1 perphenazine tablet 16mg, 2mg, 8mg 1 MO prochlorperazine 1 prochlorperazine edisylate 1 MO prochlorperazine maleate tablet 5mg 1 prochlorperazine maleate tablet 10mg 1 MO quetiapine fumarate tablet 300mg, 400mg 2 QL (2 per 1 day) quetiapine fumarate tablet 100mg, 50mg 2 QL (3 per 1 day) quetiapine fumarate tablet 200mg 2 QL (4 per 1 day) quetiapine fumarate tablet 25mg 2 QL (6 per 1 day) RISPERDAL CONSTA INJECTION 12.5MG, 25MG 4 QL (75 per 30 days) MO RISPERDAL CONSTA INJECTION 37.5MG, 50MG 5 QL (75 per 30 days) MO risperidone odt tablet dispersible 1mg 2 risperidone odt tablet dispersible 0.5mg, 2mg 2 QL (2 per 1 day) risperidone odt tablet dispersible 0.25mg, 3mg 2 QL (2 per 1 day) MO risperidone odt tablet dispersible 4mg 2 QL (4 per 1 day) MO risperidone oral solution 2 risperidone tablet 0.25mg, 0.5mg, 1mg, 2mg, 3mg 1 QL (2 per 1 day) risperidone tablet 4mg 1 QL (4 per 1 day) SAPHRIS 4 QL (2 per 1 day) MO SEROQUEL TABLET 300MG, 400MG 4 QL (2 per 1 day) SEROQUEL TABLET 100MG, 50MG 4 QL (3 per 1 day) MO SEROQUEL TABLET 200MG 4 QL (4 per 1 day) SEROQUEL TABLET 25MG 4 QL (6 per 1 day) MO SEROQUEL XR TABLET EXTENDED RELEASE 24 HOUR 150MG, 200MG

3 QL (1 per 1 day)

35


SEROQUEL XR TABLET EXTENDED RELEASE 24 HOUR 400MG

3 QL (2 per 1 day)




3 QL (6 per 1 day)

thioridazine hcl tablet 10mg, 25mg, 50mg 2 thioridazine hcl tablet 100mg 2 MO thiothixene capsule 1mg 1 thiothixene capsule 10mg, 2mg, 5mg 1 MO trifluoperazine hcl tablet 1mg 1 trifluoperazine hcl tablet 10mg, 2mg, 5mg 1 MO ziprasidone hcl capsule 60mg, 80mg 2 PA QL (2 per 1 day) ziprasidone hcl capsule 20mg, 40mg 2 PA QL (2 per 1 day) MO ZYPREXA INJECTION 4 ZYPREXA TABLET 10MG, 15MG, 7.5MG 4 QL (1 per 1 day) ZYPREXA TABLET 20MG, 5MG 4 QL (1 per 1 day) MO ZYPREXA TABLET 2.5MG 4 QL (2 per 1 day) ZYPREXA ZYDIS 4 QL (1 per 1 day)

ANTISPASTICITY AGENTS baclofen 1 dantrolene sodium capsule 2 MO ed baclofen 1 GABLOFEN INJECTION 10000MCG/20ML, 20000MCG/20ML, 50MCG/ML

4 B/D

GABLOFEN INJECTION 40000MCG/20ML 5 B/D LIORESAL INTRATHECAL INJECTION 10MG/5ML, 40MG/20ML

5 B/D

LIORESAL INTRATHECAL INJECTION 0.05MG/ML, 10MG/20ML

4 B/D

revonto 2 tizanidine hcl capsule 1 tizanidine hcl tablet 2mg 1 tizanidine hcl tablet 4mg 1 MO

ANTIVIRALS abacavir 2 acyclovir 1 acyclovir sodium injection 1000mg, 50mg/ml 2 B/D acyclovir sodium injection 500mg 2 B/D MO APTIVUS CAPSULE 5 MO APTIVUS ORAL SOLUTION 5 ATRIPLA 5 MO BARACLUDE ORAL SOLUTION 3 PA QL (21 per 1 day) MO BARACLUDE TABLET 0.5MG 5 PA QL (1 per 1 day)

36


BARACLUDE TABLET 1MG 5 PA QL (1 per 1 day) MO COMPLERA 5 MO CRIXIVAN CAPSULE 100MG, 333MG, 400MG 3 CRIXIVAN CAPSULE 200MG 3 MO DENAVIR 4 didanosine capsule delayed release 250mg, 400mg 2 didanosine capsule delayed release 125mg, 200mg 2 MO EDURANT 5 MO EMTRIVA 3 MO EPIVIR HBV 4 MO EPIVIR ORAL SOLUTION 4 MO EPZICOM 5 MO famciclovir tablet 125mg, 250mg 2 QL (2 per 1 day) MO famciclovir tablet 500mg 2 QL (30 per 10 days) MO foscarnet sodium 2 B/D FUZEON 5 ganciclovir capsule 500mg 5 ganciclovir capsule 250mg 2 ganciclovir injection 2 HEPSERA 4 PA QL (1 per 1 day) MO INCIVEK 5 PA QL (6 per 1 day) INTELENCE TABLET 100MG, 200MG 5 MO INTELENCE TABLET 25MG 4 INTRON-A INJECTION 10MU/0.2ML, 6000000UNIT/ML

4 PA

INTRON-A INJECTION 10MU/ML, 3MU/0.2ML, 5MU/0.2ML

5 PA

INTRON-A W/DILUENT 5 PA INVIRASE CAPSULE 4 MO INVIRASE TABLET 5 MO ISENTRESS TABLET 5 MO ISENTRESS TABLET CHEWABLE 4 KALETRA ORAL SOLUTION 5 MO KALETRA TABLET 200MG; 50MG 5 MO KALETRA TABLET 100MG; 25MG 4 MO lamivudine 2 MO lamivudine/zidovudine 5 LEXIVA SUSPENSION 4 MO LEXIVA TABLET 5 MO nevirapine 2 NORVIR 4 MO PEG-INTRON 5 PA PEG-INTRON REDIPEN 5 PA

37


PEGASYS 5 PA PEGASYS PROCLICK 5 PA PREZISTA TABLET 400MG, 600MG 5 MO PREZISTA TABLET 300MG, 75MG 4 PREZISTA TABLET 150MG 4 MO REBETOL ORAL SOLUTION 4 PA RELENZA DISKHALER 4 QL (120 per 365 days) MO RESCRIPTOR TABLET 100MG 3 RESCRIPTOR TABLET 200MG 3 MO RETROVIR IV INFUSION 4 REYATAZ CAPSULE 100MG 4 MO REYATAZ CAPSULE 150MG, 200MG, 300MG 5 MO RIBAPAK MISCELLANEOUS 5 PA ribasphere capsule 2 PA ribasphere tablet 200mg 2 PA RIBATAB MISCELLANEOUS 4 PA RIBATAB TABLET 5 PA ribavirin tablet 400mg, 600mg 2 PA rimantadine hcl 1 MO SELZENTRY 5 MO stavudine capsule 2 stavudine oral solution 2 MO STRIBILD 5 SUSTIVA 4 MO TAMIFLU CAPSULE 45MG, 75MG 4 QL (84 per 365 days) MO TAMIFLU CAPSULE 30MG 4 QL (168 per 365 days) MO TAMIFLU SUSPENSION RECONSTITUTED 12MG/ML

4 QL (525 per 365 days) MO

TAMIFLU SUSPENSION RECONSTITUTED 6MG/ML

4 QL (1080 per 365 days) MO

trifluridine 2 MO TRIZIVIR 5 MO TRUVADA 5 MO TYZEKA 4 PA QL (1 per 1 day) MO valacyclovir hcl 1 VALCYTE TABLET 5 MO VICTRELIS 5 PA QL (12 per 1 day) VIDEX PEDIATRIC 4 MO VIRACEPT POWDER 4 MO VIRACEPT TABLET 5 MO VIRAMUNE 4 VIRAMUNE XR 4 MO VIRAZOLE 5

38


VIREAD POWDER 4 VIREAD TABLET 150MG, 200MG, 250MG 4 VIREAD TABLET 300MG 4 MO ZERIT ORAL SOLUTION 4 ZIAGEN 4 MO zidovudine 2 MO ZIRGAN 4 MO ZOVIRAX OINTMENT 4 MO

ANXIOLYTICS buspirone hcl 1 diazepam oral solution 2 QL (40 per 1 day) MO diazepam tablet 10mg, 2mg 1 QL (4 per 1 day) diazepam tablet 5mg 1 QL (8 per 1 day)

BIPOLAR AGENTS lithium carbonate 1 lithium carbonate er 1 lithium citrate oral solution 1 MO lithium citrate syrup 1

BLOOD GLUCOSE REGULATORS acarbose 1 QL (3 per 1 day) ACTOPLUS MET 4 QL (3 per 1 day) MO ACTOPLUS MET XR 4 MO ACTOS TABLET 30MG 4 QL (1 per 1 day) ACTOS TABLET 15MG, 45MG 4 QL (1 per 1 day) MO alcohol 5%/dextrose 5% 1 AMINOSYN II 3.5/DEXTROSE 25% 4 B/D AMINOSYN II 4.25/DEXTROSE20% 4 B/D AMINOSYN II 4.25/DEXTROSE25% 4 B/D AVANDAMET TABLET 1000MG; 2MG, 1000MG; 4MG, 500MG; 4MG

4 QL (2 per 1 day)

AVANDAMET TABLET 500MG; 2MG 4 QL (4 per 1 day) AVANDARYL TABLET 2MG; 8MG, 4MG; 4MG, 4MG; 8MG

4 QL (1 per 1 day)

AVANDARYL TABLET 1MG; 4MG, 2MG; 4MG 4 QL (2 per 1 day) AVANDIA TABLET 8MG 4 QL (1 per 1 day) AVANDIA TABLET 2MG, 4MG 4 QL (2 per 1 day) BYDUREON 3 MO BYETTA INJECTION 5MCG/0.02ML 4 QL (0.04 per 1 day) MO BYETTA INJECTION 10MCG/0.04ML 4 QL (0.08 per 1 day) MO CYCLOSET 4 PA QL (6 per 1 day) MO dextrose 10%/nacl 0.45% 1 dextrose 2.5% 1 dextrose 10% flex container 1 B/D

39


dextrose 10%/nacl 0.2% 1 dextrose 10%/nacl 0.225% 1 dextrose 10%/sodium chloride 0.9% 1 dextrose 2.5%/sodium chloride 0.45% 1 dextrose 20% 1 B/D dextrose 25% 1 B/D dextrose 30% partial fill 1 B/D dextrose 40% 1 B/D dextrose 5% 1 MO dextrose 5%/nacl 0.2% 1 dextrose 5%/nacl 0.225% 1 dextrose 5%/nacl 0.3% 2 dextrose 5%/nacl 0.33% 1 dextrose 5%/nacl 0.45% 1 dextrose 5%/nacl 0.9% 1 dextrose 50% 2 B/D dextrose 70% 1 B/D DUETACT 4 QL (1 per 1 day) MO glimepiride tablet 1mg, 2mg 1 QL (1 per 1 day) glimepiride tablet 4mg 1 QL (2 per 1 day) glipizide er tablet extended release 24 hour 2.5mg, 5mg

1 QL (1 per 1 day)

glipizide er tablet extended release 24 hour 10mg 1 QL (2 per 1 day) glipizide tablet 10mg 1 QL (4 per 1 day) glipizide tablet 5mg 1 QL (8 per 1 day) glipizide xl tablet extended release 24 hour 2.5mg, 5mg


glipizide xl tablet extended release 24 hour 10mg 1 QL (2 per 1 day) MO glipizide/metformin hcl tablet 2.5mg; 500mg 1 QL (4 per 1 day) glipizide/metformin hcl tablet 5mg; 500mg 1 QL (4 per 1 day) MO glipizide/metformin hcl tablet 2.5mg; 250mg 1 QL (8 per 1 day) GLUCAGEN 4 QL (2 per 1 day) MO GLUCAGEN HYPOKIT 4 QL (2 per 1 day) MO GLUCAGON EMERGENCY KIT 3 QL (2 per 1 day) MO glyburide micronized tablet 3mg 1 QL (1 per 1 day) glyburide micronized tablet 1.5mg 1 QL (1 per 1 day) MO glyburide micronized tablet 6mg 1 QL (2 per 1 day) glyburide tablet 2.5mg 1 QL (3 per 1 day) glyburide tablet 1.25mg 1 QL (3 per 1 day) MO glyburide tablet 5mg 1 QL (4 per 1 day) glyburide/metformin hcl tablet 2.5mg; 500mg, 5mg; 500mg

1 QL (4 per 1 day)

glyburide/metformin hcl tablet 1.25mg; 250mg 1 QL (8 per 1 day) MO glycron tablet 1.5mg, 3mg 1 QL (1 per 1 day)

40


glycron tablet 6mg 1 QL (2 per 1 day) GLYCRON TABLET 4.5MG 4 QL (2 per 1 day) HUMALOG MIX 50/50 4 MO HUMALOG MIX 50/50 KWIKPEN 4 MO HUMULIN R U-500 (CONCENTRATED) 4 MO JANUMET 3 MO JANUMET XR 3 MO JANUVIA TABLET 100MG, 25MG 3 JANUVIA TABLET 50MG 3 MO JENTADUETO TABLET 2.5MG; 500MG 4 JENTADUETO TABLET 2.5MG; 1000MG, 2.5MG; 850MG

4 MO

JUVISYNC 3 kcl 0.075%/d5w/nacl 0.45% 2 kcl 0.15%/d10w/nacl 0.2% 1 kcl 0.15%/d5w/lr 2 kcl 0.15%/d5w/nacl 0.2% 2 kcl 0.15%/d5w/nacl 0.225% 2 kcl 0.15%/d5w/nacl 0.45% 2 kcl 0.15%/d5w/nacl 0.9% 2 kcl 0.224%/d5w/nacl 0.2% 2 kcl 0.3%/d5w/lr iv lac ring 2 kcl 0.3%/d5w/nacl 0.2% 2 kcl 0.3%/d5w/nacl 0.45% 2 kcl 0.3%/d5w/nacl 0.9% 2 LEVEMIR 3 MO LEVEMIR FLEXPEN 3 MO metformin hcl er tablet extended release 24 hour 1000mg, 500mg

1 MO

metformin hcl er tablet extended release 24 hour 750mg

1 QL (2 per 1 day)

metformin hcl er tablet extended release 24 hour 500mg

1 QL (4 per 1 day)

metformin hcl tablet 1000mg, 850mg 1 QL (3 per 1 day) metformin hcl tablet 500mg 1 QL (5 per 1 day) nateglinide 1 NORMOSOL-R IN D5W 4 NOVOLIN 70/30 3 MO NOVOLIN 70/30 INNOLET 3 NOVOLIN 70/30 PENFILL 3 NOVOLIN N 3 MO NOVOLIN N INNOLET 3 NOVOLIN N U-100 PENFILL 3 NOVOLIN R 3 MO

41


NOVOLIN R INNOLET 3 NOVOLIN R U-100 PENFILL 3 MO NOVOLOG 3 MO NOVOLOG FLEXPEN 3 MO NOVOLOG MIX 70/30 3 MO NOVOLOG MIX 70/30 PREFILLED FLEXPEN 3 MO NOVOLOG PENFILL 3 MO pioglitazone hcl 1 QL (1 per 1 day) pioglitazone hcl/metformin hcl 1 QL (3 per 1 day) plasma-lyte-r/d5w 2 potassium chloride 0.075%/d5w/nacl 0.225% 2 potassium chloride 0.15% d5w/nacl 0.33% 2 potassium chloride 0.15% d5w/nacl 0.45% viaflex 2 potassium chloride 0.22% d5w/nacl 0.45% 2 potassium chloride 0.224%d5w/nacl 0.33% 1 potassium chloride 0.224%d5w/nacl 0.45% viaflex 2 PROGLYCEM 4 MO SYMLIN 4 QL (0.66 per 1 day) SYMLINPEN 120 4 QL (0.78 per 1 day) MO SYMLINPEN 60 4 QL (0.78 per 1 day) MO tolazamide tablet 250mg 1 QL (2 per 1 day) MO tolazamide tablet 500mg 1 QL (3 per 1 day) MO tolbutamide 1 QL (6 per 1 day) TRADJENTA 4 VICTOZA 3 QL (1.8 per 1 day) MO

BLOOD PRODUCTS/MODIFIERS/ VOLUME EXPANDERS clopidogrel tablet 75mg 2 QL (1 per 1 day) clopidogrel tablet 300mg 2 QL (2 per 365 days)

BLOOD PRODUCTS/MODIFIERS/VOLUME EXPANDERS AGGRENOX 3 QL (2 per 1 day) MO AMICAR SYRUP 4 aminocaproic acid injection 2 aminocaproic acid syrup 2 aminocaproic acid tablet 1000mg 2 aminocaproic acid tablet 500mg 2 MO anagrelide hydrochloride capsule 1mg 2 anagrelide hydrochloride capsule 0.5mg 2 MO ARANESP ALBUMIN FREE INJECTION 100MCG/ML, 25MCG/0.42ML, 25MCG/ML, 40MCG/0.4ML, 40MCG/ML, 60MCG/0.3ML, 60MCG/ML

3 PA

42


ARANESP ALBUMIN FREE INJECTION 100MCG/0.5ML, 150MCG/0.3ML, 150MCG/0.75ML, 200MCG/0.4ML, 200MCG/ML, 300MCG/0.6ML, 300MCG/ML, 500MCG/ML

5 PA

cilostazol 1 CINRYZE 5 dipyridamole tablet 2 EFFIENT 4 enoxaparin sodium injection 100mg/ml, 120mg/0.8ml, 150mg/ml, 300mg/3ml

5

enoxaparin sodium injection 30mg/0.3ml, 40mg/0.4ml, 60mg/0.6ml, 80mg/0.8ml

2

fondaparinux sodium 2 heparin sodium 2 B/D heparin sodium/d5w injection 5%; 50unit/ml 2 heparin sodium/d5w injection 5%; 100unit/ml 2 B/D heparin sodium/d5w injection 5%; 40unit/ml 1 heparin sodium/nacl 0.45% 2 heparin sodium/nacl 0.9% 1 heparin sodium/sodium chloride 0.9% 1 heparin sodium/sodium chloride 0.9% premix 1 jantoven 1 LEUKINE 5 PA LYSTEDA 4 PA QL (30 per 5 days) MOZOBIL 5 PA NEUMEGA 5 PA NEUPOGEN 5 PA PLAVIX TABLET 75MG 4 QL (1 per 1 day) MO PLAVIX TABLET 300MG 4 QL (2 per 365 days) PRADAXA 3 QL (2 per 1 day) MO PROCRIT INJECTION 10000UNIT/ML 3 PA PROCRIT INJECTION 2000UNIT/ML, 3000UNIT/ML, 4000UNIT/ML

3 PA QL (12 per 30 days)

PROCRIT INJECTION 20000UNIT/ML, 40000UNIT/ML

5 PA

PROMACTA TABLET 12.5MG, 75MG 5 PA QL (1 per 1 day) PROMACTA TABLET 50MG 5 PA QL (1.5 per 1 day) PROMACTA TABLET 25MG 5 PA QL (3 per 1 day) ticlopidine hcl 1 QL (2 per 1 day) tranexamic acid 2 warfarin sodium tablet 10mg, 1mg, 2.5mg, 2mg, 5mg, 6mg, 7.5mg

1

warfarin sodium tablet 3mg, 4mg 1 MO XARELTO 3 QL (1 per 1 day)

43


CARDIOVASCULAR AGENTS acebutolol hcl 1 acetazolamide sodium 2 acetazolamide tablet 250mg 1 acetazolamide tablet 125mg 1 MO afeditab cr tablet extended release 24 hour 30mg 1 QL (1 per 1 day) afeditab cr tablet extended release 24 hour 60mg 1 QL (2 per 1 day) amiloride hcl 1 amiloride/hydrochlorothiazide 1 amiodarone hcl injection

Documents

Addendum No. 18. Please provide Medicare supplement claims data . Answer: Medicare supplement claims data can be found in the attached file titled “Highmark Signature 65 Supplemental