Member Welcome Letter Template (Revised 2014)

P.O. Box 1039

Appleton, WI 54912-1039

Starting Your Mail Order and Specialty Prescription Service

S9701_2022_UCA_NEW_MAIL_V01_C

Dear University of California Retiree, Navitus MedicareRx (PDP) would like to inform you of some changes to your Medicare prescription drug coverage effective 1/1/2022. This will affect you if you get your medications through mail order or if you take specialty medications. Starting 1/1/2022, your mail order prescriptions will be available through your recommended pharmacy, Costco Mail Order. Also, Lumicera Specialty Pharmacy will be your recommended specialty pharmacies. The Select UC Pharmacies are still available in your network. On the following pages you will learn how to fill medications at your preferred mail order pharmacy or specialty pharmacy and ways to contact them. It is important to provide your new Navitus MedicareRx ID Card information to your pharmacies. Please refer to the following pages for help. Please note:

• Medicare guidelines require that members initiate any prescription mail order or specialty prescription refill transfers.

If you take prescription medications, you can help ensure a smooth transition to your new plan by having an adequate supply of your medication on hand prior to December 31, 2021. Important: Please dispose of your old card(s) as these will no longer be active as of 1/1/2022. If you try to fill a prescription using your old prescription ID card, the pharmacy may say that your prescription coverage has ended. Before filling a new prescription and/or refilling a current prescription, please provide your new Navitus MedicareRx ID card information to your pharmacy to avoid any delay. If you are not sure where to start, please call Navitus MedicareRx Customer Care at 1-866-270-3877 (TTY 711). Someone is always there to take your call every day except on Thanksgiving and Christmas Day.

Costco Mail Order Pharmacy

You can use any network mail order pharmacy you want; however, Costco Mail Order Pharmacy is the recommended mail order pharmacy and serves members nationwide. You do not need to be a member of Costco warehouse/club stores to utilize Costco mail order services. Both Costco mail order and retail locations are unable to fill Medicare Part B products - for example, diabetic testing strips. Costco can refer you to an affiliated provider that can fill these supplies or you can locate a participating retail pharmacy that can process Part B products. How do I register with Costco mail order? You will receive a new Navitus MedicareRx ID card in the mail from Navitus MedicareRx with updated prescription information. Since your Medicare Part D prescription drug benefits will be through Navitus MedicareRx as of 1/1/2022, please call and register your Costco patient profile information (Rx Member ID, BIN, PCN, and RxGroup). You can do so by calling Costco at 1-800-607-6861, or by going to www.pharmacy.costco.com. Registering with Costco.com allows you to manage your prescriptions online. How do I start a new prescription? You can mail original prescriptions to Costco Mail Order Pharmacy to start this service. It is important to allow at least 14 days before you will need your medications. Please include the following information with your prescriptions (no form required). Costco may need to contact you for additional information.

• Your Name Please send to: • Date of Birth Costco Mail Order Pharmacy • Phone Number 215 Deininger Circle • Shipping Address Corona, CA 92880

What if I already use Costco Mail Order Pharmacy? Will my mail order prescriptions automatically transfer? If you currently have a prescription on file with Costco, you can call Costco at 1-800-607-6861 to determine if a new prescription is necessary on or after 1/1/2022. You will need to provide Costco with your new Navitus MedicareRx ID card information. How can my physician reach Costco Mail Order Pharmacy or provide my prescriptions? You can also ask your provider to send the prescriptions directly to Costco Pharmacy. New prescriptions or order clarifications can be provided to Costco by your prescriber, using one of the following ways:

• Fax: 1-888-545-4615 • Call Costco’s Physician Line: 1-800-607-6861, option #3 • E-Prescribe: NCPDP# Corona: #5633753

http://www.pharmacy.costco.com/

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Costco calls you when new prescriptions are received and within 14 days of the date your prescriptions are eligible for refill. You may view your prescription order status and tracking information by logging onto www.pharmacy.costco.com. For questions about home delivery, call Costco at 1-800-607-6861. Their pharmacy agents are available Monday–Friday from 5:00 a.m. to 7:00 p.m. PST, and Saturday from 9:30 a.m. to 2:00 p.m. PST.

Lumicera Specialty Pharmacy

What should I do if I take a medication considered a specialty medication? You can use any specialty pharmacy you want; however, Lumicera Specialty Pharmacy is the recommended pharmacy for specialty medications. These medications usually:

• Have a high manufacturer cost. • Are hard to get locally. • Treat rare and complicated conditions. Examples of conditions include Rheumatoid

Arthritis, Hepatitis C, and Cancer. Note: If you decide to stay with your current specialty pharmacy and it is contracted with the pharmacy network, please call them and provide your new Navitus MedicareRx ID card information by 1/1/2022. The Select UC Pharmacies are still available in your network. Will my prescriptions automatically transfer to this new program? Lumicera will assist you with the transfer of your specialty prescription. If you are already on a specialty medication, you can call Lumicera’s Customer Care at 1-855-847-3553 (TTY 711), Monday through Thursday 6:00 a.m. to 5:00 p.m. and Friday from 6:00 a.m. to 4:00 p.m. PST, to set up an account and provide your new Navitus MedicareRx ID card information. It is important to call at least 14 days before you need your specialty mediation refill. Your prescriber can call Lumicera at 1-855-847-3554, or they can fax a prescription to 1-855-847-3558. What if I am not sure where to start or have questions about benefits or copays? You can get the answers you need by calling Navitus MedicareRx Customer Care at 1-866-270-3877 (TTY 711) 24 hours a day, 7 days a week, except on Thanksgiving and Christmas Day. Calls to these numbers are free. You can also visit our website at https://Memberportal.navitus.com for more information. Sincerely, The University of California and Navitus MedicareRx (PDP)

http://www.pharmacy.costco.com/

https://memberportal.navitus.com/

S9701_2022_UCA_FORM_Comp_V01.8_C This formulary was updated on 10/28/2021

Navitus MedicareRx (PDP) NAVITUS MEDICARERX (PDP) 2022 FORMULARY LIST OF COVERED DRUGS UNIVERSITY OF CALIFORNIA

PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN

HPMS Approved Formulary File Submission ID 00022105, Version Number 8

This formulary was updated on 10/28/2021. For more recent information or other questions, please contact Navitus MedicareRx Customer Care at 1-866-270-3877 (for TTY users, please call 711), available 24 hours a day, 7 days a week (except on Thanksgiving and Christmas Day) or visit the member portal at https://memberportal.navitus.com.


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When this formulary refers to “we,” “us”, “our”, “plan” or “our plan”, it means Navitus MedicareRx Prescription Drug Plan (PDP).

This document includes a list of the drugs (formulary) for our plan which is current as of 10/28/2021. For an updated formulary, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages.

You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy network, and/or copayments/coinsurance may change on January 1, 2023, and from time to time during the year.

What is the Navitus MedicareRx (PDP) Formulary? A formulary is a list of covered drugs selected by Navitus MedicareRx 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. Navitus MedicareRx will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a Navitus MedicareRx network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage.

Can the Formulary (drug list) change? Most changes in drug coverage happen on January 1, but we may add or remove drugs on the Formulary during the year, move them to different cost-sharing tiers, or add new restrictions. We must follow the Medicare rules in making these changes.

Changes that can affect you this year: In the below cases, you will be affected by coverage changes during the year:

• New generic drugs. We may immediately remove a brand name drug on our Formulary if weare replacing it with a new generic drug that will appear on the same or lower cost sharing tierand with the same or fewer restrictions. Also, when adding the new generic drug, we maydecide to keep the brand name drug on our Formulary, but immediately move it to a differentcost-sharing tier or add new restrictions. If you are currently taking that brand name drug, wemay not tell you in advance before we make that change, but we will later provide you withinformation about the specific change(s) we have made.

o If we make such a change, you or your prescriber can ask us to make an exception andcontinue to cover the brand name drug for you. The notice we provide you will alsoinclude information on how to request an exception, and you can find information inthe section below titled “How do I request an exception to the Navitus MedicareRxFormulary?”

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• Drugs removed from the market. If the Food and Drug Administration (FDA) deems a drugon 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 whotake the drug.

• Other changes. We may make other changes that affect members currently taking a drug. Forinstance, we may add a generic drug that is not new to market to replace a brand name drugcurrently on the formulary; or add new restrictions to the brand name drug or move it to adifferent cost sharing tier or both. Or we may make changes based on new clinical guidelines.If we remove drugs from our formulary, add prior authorization, quantity limits and/or steptherapy restrictions on a drug or move a drug to a higher cost-sharing tier, we must notifyaffected members of the change at least 30 days before the change becomes effective, or atthe time the member requests a refill of the drug, at which time the member will receive a30-day supply of the drug.

o If we make these other changes, you or your prescriber can ask us to make anexception and continue to cover the brand name drug for you. The notice we provideyou will also include information on how to request an exception, and you can also findinformation in the section below entitled “How do I request an exception to the NavitusMedicareRx Formulary?”

Changes that will not affect you if you are currently taking the drug. Generally, if you are taking a drug on our 2022 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2022 coverage year except as described above. This means these drugs will remain available at the same cost sharing and with no new restrictions for those members taking them for the remainder of the coverage year. You will not get direct notice this year about changes that do not affect you. However, on January 1 of the next year, such changes would affect you, and it is important to check the Formulary for the new benefit year for any changes to drugs.

The enclosed formulary is current as of 10/28/2021. The formulary is updated each month and is available on the Member Portal at https://memberportal.navitus.com. We update our online formulary on a regularly scheduled basis to include any changes that have occurred after the last update. When changes to the formulary occur during the year, we post the formulary on our Member Portal including those changes. In the event of CMS-approved non-maintenance changes to the formulary throughout the plan year, Navitus MedicareRx will notify you. To get updated information about the drugs covered by Navitus MedicareRx please contact us. Our contact information appears on the front and back cover pages.

How do I use the Formulary? There are two ways to find your drug within the formulary:


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Medical Condition The formulary begins on page 9. 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 9. 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 113. 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? Navitus MedicareRx 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: Navitus MedicareRx requires you or your physician to get priorauthorization for certain drugs. This means that you will need to get approval from NavitusMedicareRx before you fill your prescriptions. If you do not get approval, Navitus MedicareRxmay not cover the drug.

• Quantity Limits: For certain drugs, Navitus MedicareRx limits the amount of the drug thatNavitus MedicareRx will cover. For example, Navitus MedicareRx provides 18 tablets perprescription for Imitrex. This may be in addition to a standard one-month or three-monthsupply.

• Step Therapy: In some cases, Navitus MedicareRx requires you to first try certain drugs totreat your medical condition before we will cover another drug for that condition. Forexample, if Drug A and Drug B both treat your medical condition, Navitus MedicareRx maynot cover Drug B unless you try Drug A first. If Drug A does not work for you, NavitusMedicareRx will then cover Drug B.

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You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 9. You can also get more information about the restrictions applied to specific covered drugs by visiting the Member Portal. We have posted online documents that explain our prior authorization and step therapy restrictions. You may also ask us to send you a copy. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You can ask Navitus MedicareRx to make an exception to these restrictions or limits or for a list of other, similar drugs that may treat your health condition. See the section, “How do I request an exception to the Navitus MedicareRx formulary?” for information about how to request an exception.

Cost Sharing – Brand vs. Generic Drugs The Formulary indicates what you will pay for your drug. A generic drug is the same as a brand-name drug in dosage, safety and strength. If you and/or your prescriber specifies that a brand name drug must be dispensed and there is a lower tier generic equivalent available on the formulary, you must pay the applicable brand copay plus the difference between the cost of the brand-name drug and the generic equivalent. With prior authorization, exceptions for medical necessity can be made and you will pay the Tier 3 (non-preferred) copay. This Dispense as Written (DAW) cost-sharing penalty will not exceed the cost of the medication.

What are over-the-counter (OTC) drugs? OTC drugs are non-prescription drugs that are not normally covered by a Medicare Prescription Drug Plan. Navitus MedicareRx pays for certain OTC drugs. The covered OTC drugs are listed on your Formulary. Navitus MedicareRx will provide these OTC drugs at no cost to you. The cost to Navitus MedicareRx of these OTC drugs will not count toward your total Part D drug costs (that is, the cost of the OTC drugs does not count for the coverage gap). Your plan also covers certain prescribed Cough and Cold, or Vitamin and Mineral medications. The Formulary indicates what tier applies to these drugs.

What if my drug is not on the Formulary? If your drug is not included in this formulary (list of covered drugs), you should first contact Customer Care and ask if your drug is covered. If you learn that Navitus MedicareRx does not cover your drug, you have two options:

• You can ask Customer Care for a list of similar drugs that are covered by Navitus MedicareRx. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by Navitus MedicareRx.

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• You can ask Navitus MedicareRx 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 Navitus MedicareRx (PDP) Formulary? You can ask Navitus MedicareRx to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make.

• You can ask us to cover a drug even if it is not on our formulary. If approved, this drug will be covered at a pre-determined cost-sharing level, and you would not be able to ask us to provide the drug at a lower cost-sharing level.

• You can ask us to cover a formulary drug at lower cost-sharing level, unless the drug is on the specialty tier. If approved, this would lower the amount you must pay for your drug.

• You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, Navitus MedicareRx limits the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover a greater amount.

Generally, Navitus MedicareRx will only approve your request for an exception if the alternative drugs included on the plan’s formulary, the lower cost-sharing drug, or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects. You should contact us to ask us for an initial coverage decision for a formulary, tier, or utilization restriction exception. When you request a formulary, tier, or utilization restriction exception you should submit a statement from your prescriber or physician supporting your request. Generally, we must make our decision within 72 hours of getting your prescriber’s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get a supporting statement from your doctor or other prescriber.

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

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determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan. For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary 30-day supply. If your prescription is written for fewer days, we’ll allow refills to provide up to a maximum 30-day supply of medication. After your first 30-day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days. If you are a resident of a long-term care facility and you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 31-day emergency supply of that drug while you pursue a formulary exception.

Level of Care Changes Navitus MedicareRx’s level of care transition process accounts for unplanned changes for members. In some instances, these changes may result in the prescribed drug regimen(s) not being available on our formulary. These instances usually occur when a member moves from one treatment setting to another. This could include members who:

• Enter long-term care (LTC) facilities with a discharge list of medications from the hospital with very short-term planning taken into account (e.g., less than 8 hours).

• Are discharged from a hospital to a home with very short-term planning taken into account. • End their skilled nursing facility Medicare Part A stay (where payments include all pharmacy

charges) and who need to go back to their Part D plan formulary. • Give up hospice status to revert to standard Medicare Part A and Part B benefits. • End an LTC facility stay and return to their home. • Are discharged from psychiatric hospitals with drug regimens that are highly tailored to them.

These changes often result in members and/or prescribers using Navitus’ exceptions and/or appeals processes. For these types of changes, we will make coverage determinations and re-determinations as quickly as the member’s health requires. Navitus MedicareRx ensures proper medication continuance for members upon discharge from an LTC facility or other facilities to ensure an effective transition of care. This may include:

• A refill upon entrance to, or discharge from, an LTC facility. The current standard of care promotes caregivers receiving outpatient Part D prescriptions before discharge from a Part A stay. Members, through no fault of their own, may not have access to the balance of their prescription.

• Navitus MedicareRx allows the member to access a refill upon entrance to, or discharge from, an LTC facility.

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To process these transition refills, the pharmacy may need to call Navitus MedicareRx Customer Care (phone numbers are on the back cover of this booklet). Navitus MedicareRx Customer Care can help the pharmacy process an override.

For more information For more detailed information about your Navitus MedicareRx prescription drug coverage, please review your Evidence of Coverage and other plan materials.

If you have questions about Navitus MedicareRx, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. If you have general questions about Medicare prescription drug coverage, please call Medicare at 1-800-MEDICARE (1-800-633-4227) 24 hours a day/7 days a week. TTY users should call 1-877-486-2048. Or, visit www.medicare.gov.

Navitus MedicareRx (PDP) Formulary The formulary below provides coverage information about the drugs covered by Navitus MedicareRx.

If you have trouble finding your drug in the list, turn to the Index that begins on page 113.

The first column of the chart lists the drug name.

• Brand name drugs are capitalized (e.g., LIPITOR)• Generic drugs are listed in lower-case italics (e.g., atorvastatin).

The second column of the chart lists the Drug Tier. You can reference the Summary of Benefits booklet or Chapter 4 (Section 5.2) in the Evidence of Coverage booklet to learn what your copay or coinsurance will be.

• Tier 1: Preferred generics and certain lower cost brand products• Tier 2: Preferred brand products and some high cost non-preferred generics• Tier 3: Non-preferred products (could include some high cost non-preferred generics)• Tier 4: Specialty products

And • Tier $0: Select Generics (not all dosages of these drugs are covered at the Select Generics cost

share); certain over-the-counter drugs.

The third column of the chart lists information in the Requirements/Limits column which tells you if Navitus MedicareRx has any special requirements for coverage of your drug.

• Limited Distribution (LD): This prescription may be available only at certain pharmacies. Formore information consult your Pharmacy Directory or call Customer Care.

https://www.medicare.gov/

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• Non-Extended Day Supply (NDS): You may be able to receive greater than a 1-month supply of most of the drugs on your Formulary. Drugs noted with “NDS” are limited to a 1-month supply for both Retail and Mail Order.

• Prior Authorization (PA): The Plan requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from The Plan before you fill your prescriptions. If you don’t get approval, Navitus MedicareRx may not cover the drug.

• Prior Authorization Restriction for Part B vs Part D Determination (PA_BvD): This drug may be eligible for payment under Medicare Part B or Part D. You (or your physician) are required to get prior authorization from Navitus MedicareRx to determine that this drug is covered under Medicare Part D before you fill your prescription for this drug. Without prior approval, Navitus MedicareRx may not cover this drug.

• Prior Authorization Restriction for New Starts Only (PA_NSO): If this drug is new to you, you (or your physician) are required to get prior authorization from Navitus MedicareRx before you fill your prescription for this drug. Without prior approval, Navitus MedicareRx may not cover this drug.

• Step Therapy (ST): In some cases, Navitus MedicareRx 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, Navitus MedicareRx may not cover Drug B unless you try Drug A first. If Drug A does not work for you, Navitus MedicareRx will then cover Drug B.

• Step Therapy for New Starts Only (ST_NSO): If this drug is new to you, you are required to first try certain drugs to treat your medical condition before we will cover another drug for that condition.

• Quantity Limits (QL): For certain drugs, Navitus MedicareRx limits the amount of the drug that Navitus MedicareRx will cover. This could include a: per fill, daily, monthly, or yearly limitation.

• Rx Cents (RXC): This medication is offered at half the stated tier copay when your prescriber writes a prescription for half-tab daily. For example, if you take one 20mg tablet per day that is listed on the Formulary as a Tier 1 drug, the prescriber might write the prescription for half of a 40mg tab per day. Then you would pay $2.50 per month instead of $5 per month. For more information or to acquire a tablet splitter, contact Customer Care.

The * symbol after the Tier indicates these prescription drugs are not normally covered in a Medicare Prescription Drug Plan. The amount you pay when you fill a prescription for this drug does not count towards your total drug costs (that is, the amount you pay does not help you qualify for catastrophic coverage). In addition, if you are receiving extra help to pay for your prescriptions, you will not get any extra help to pay for these drugs.

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS

ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTSAMPHETAMINES

2amphetamine-dextroamphetamine 10mg ER cap

1amphetamine-dextroamphetamine 10mg tab

1amphetamine-dextroamphetamine 12.5mg tab










1amphetamine-dextroamphetamine 7.5mg tab

2dextroamphetamine sulfate 10mg er cap

2dextroamphetamine sulfate 10mg tab



2dextroamphetamine sulfate 5mg tab

2procentra 5mg/5ml oral solnATTENTION-DEFICIT/HYPERACTIVITY DISORDER (ADHD) AGENTS

2atomoxetine 100mg cap QL=60 Quantity/30 Days







2clonidine 0.1mg er tab

1guanfacine 1mg er tab



1guanfacine 4mg er tabDOPAMINE AND NOREPINEPHRINE REUPTAKE INHIBITORS (DNRIS)

2SUNOSI 150MG TAB PA QL=30 Quantity/30 Days

2SUNOSI 75MG TAB PA QL=30 Quantity/30 DaysHISTAMINE H3-RECEPTOR ANTAGONIST/INVERSE AGONISTS

4WAKIX 17.8MG TAB LD NDS PA QL=60 Quantity/30 Days

4WAKIX 4.45MG TAB LD NDS PA QL=60 Quantity/30 DaysSTIMULANTS - MISC.

2armodafinil 150mg tab PA QL=30 Quantity/30 Days




2dexmethylphenidate 10mg er cap

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

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1dexmethylphenidate 10mg tab


1dexmethylphenidate 2.5mg tab







1dexmethylphenidate 5mg tab

2methylphenidate 10mg chew tab

2methylphenidate 10mg cr cap

2methylphenidate 10mg er tab

2methylphenidate 10mg la cap

1methylphenidate 10mg tab

2METHYLPHENIDATE 18MG ER TAB


2methylphenidate 1mg/ml oral soln

2methylphenidate 2.5mg chew tab





1methylphenidate 27mg sr tab

2methylphenidate 2mg/ml oral soln








2methylphenidate 5mg chew tab




2methylphenidate ER osmotic 27mg tab



2modafinil 100mg tab PA QL=60 Quantity/30 Days

2modafinil 200mg tab PA QL=60 Quantity/30 Days

AMEBICIDESAMEBICIDES

3SOLOSEC 2GM GRANULES PA

AMINOGLYCOSIDESAMINOGLYCOSIDES


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2amikacin 250mg/ml inj

2amikacin sulfate 1gm/4ml inj

4ARIKAYCE 590MG/8.4ML INH SUSP LD NDS PA QL=252 Quantity/30 Days

2GENTAMICIN 0.8MG/ML INJ

2gentamicin 1.2mg/ml inj

2GENTAMICIN 1.6MG/ML INJ

2GENTAMICIN 1MG/ML INJ

2gentamicin 40mg/ml inj

1neomycin sulfate 500mg tab

3paromomycin 250mg cap

3STREPTOMYCIN 1000MG INJ

2tobramycin 1.2gm inj

2tobramycin 1.2gm/30ml inj

2TOBRAMYCIN 10MG/ML INJ

2TOBRAMYCIN 2GM/50ML INJ

2tobramycin 40mg/ml inj

4TOBRAMYCIN 60MG/ML INH SOLN NDS PA QL=300 Quantity/30 Days

4tobramycin 60mg/ml inh soln PA QL=300 Quantity/30 Days

ANALGESICS - ANTI-INFLAMMATORYANTIRHEUMATIC - ENZYME INHIBITORS

4OLUMIANT 1MG TAB NDS PA QL=30 Quantity/30 Days

4OLUMIANT 2MG TAB NDS PA QL=30 Quantity/30 Days

4RINVOQ 15MG ER TAB NDS PA QL=30 Quantity/30 Days

4XELJANZ 10MG TAB NDS PA QL=60 Quantity/30 Days

4XELJANZ 1MG/ML ORAL SOLN NDS PA QL=300 Quantity/30 Days

4XELJANZ 5MG TAB NDS PA QL=60 Quantity/30 Days

4XELJANZ XR 11MG TAB NDS PA QL=30 Quantity/30 Days

4XELJANZ XR 22MG TAB NDS PA QL=30 Quantity/30 DaysANTI-TNF-ALPHA - MONOCLONAL ANTIBODIES

4HUMIRA 10MG/0.1ML SYRINGE NDS PA QL=2 Quantity/28 Days




4HUMIRA 40MG/0.4ML AUTO-INJECTOR NDS PA QL=6 Quantity/28 Days





4HUMIRA PEDIATRIC CROHN'S STARTER PACK (3) 80MG/0.8ML SYRINGE

NDS PA QL=3 Quantity/180 Days

4HUMIRA PEDIATRIC CROHN'S STARTER PACK SYRINGE (2) 40MG/0.4ML, 80MG/0.8ML


4HUMIRA PEN - CROHN'S STARTER PACK 40MG/0.8ML INJ

PA QL=6 Quantity/180 Days

4HUMIRA PEN - PEDIATRIC UC STARTER PACK 80MG/0.8ML INJ



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4HUMIRA PEN - PSORIASIS STARTER PACK 40MG/0.8ML


4HUMIRA PEN - PSORIASIS STARTER PACK 80MG/0.8ML INJ


4HUMIRA PEN 80MG/0.8ML - STARTER PACK FOR CROHN'S DISEASE ULCERATIVE COLITIS OR HIDRADENITIS SUPPURAT


4SIMPONI 100MG/ML AUTO-INJECTOR NDS PA QL=1 Quantity/28 Days

4SIMPONI 100MG/ML SYRINGE NDS PA QL=1 Quantity/28 Days

4SIMPONI 50MG/0.5ML AUTO-INJECTOR NDS PA QL=.50 Quantity/28 Days

4SIMPONI 50MG/0.5ML SYRINGE NDS PA QL=.50 Quantity/28 DaysGOLD COMPOUNDS

2RIDAURA 3MG CAPINTERLEUKIN-1 BLOCKERS

4ARCALYST 220MG INJ NDS PAINTERLEUKIN-6 RECEPTOR INHIBITORS

4ACTEMRA 162MG/0.9ML AUTO-INJECTOR NDS PA QL=3.60 Quantity/28 Days

4ACTEMRA 162MG/0.9ML SYRINGE NDS PA QL=3.60 Quantity/28 Days

4KEVZARA 150MG/1.14ML AUTO-INJECTOR NDS PA QL=2.28 Quantity/28 Days

4KEVZARA 150MG/1.14ML SYRINGE NDS PA QL=2.28 Quantity/28 Days

4KEVZARA 200MG/1.14ML AUTO-INJECTOR NDS PA QL=1 Quantity/28 Days

4KEVZARA 200MG/1.14ML SYRINGE NDS PA QL=2.28 Quantity/28 DaysNONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)

1celecoxib 100mg cap QL=60 Quantity/30 Days




1diclofenac potassium 50mg tab

1diclofenac sodium 100mg er tab

1diclofenac sodium 25mg dr tab


2diclofenac sodium 50mg/misoprostol 0.2mg dr tab


2diclofenac sodium 75mg/misoprostol 0.2mg dr tab

1etodolac 200mg cap

1etodolac 300mg cap

2etodolac 400mg er tab

1etodolac 400mg tab


1etodolac 500mg tab


1flurbiprofen 100mg tab

1ibuprofen 20mg/ml susp

1ibuprofen 400mg tab




12


2INDOCIN 50MG RECTAL SUPP

2indomethacin 25mg cap

2indomethacin 50mg cap

2indomethacin 75mg er cap

3KETOPROFEN 200MG ER CAP

1ketorolac tromethamine 10mg tab QL=20 Quantity/5 Days

1meloxicam 15mg tab

1meloxicam 7.5mg tab

1nabumetone 500mg tab

1nabumetone 750mg tab

1naproxen 250mg tab

2naproxen 375mg dr tab

1naproxen 375mg tab

2naproxen 500mg dr tab

1naproxen 500mg tab

2naproxen sodium 275mg tab

2naproxen sodium 550mg tab

2oxaprozin 600mg tab

2piroxicam 10mg cap

2piroxicam 20mg cap

1sulindac 150mg tab

1sulindac 200mg tabPHOSPHODIESTERASE 4 (PDE4) INHIBITORS

4OTEZLA 28-DAY STARTER PACK NDS PA QL=55 Quantity/28 Days

4OTEZLA 30MG TAB NDS PA QL=60 Quantity/30 DaysPYRIMIDINE SYNTHESIS INHIBITORS

1leflunomide 10mg tab

1leflunomide 20mg tabSELECTIVE COSTIMULATION MODULATORS

4ORENCIA 125MG/ML AUTO-INJECTOR NDS PA QL=4 Quantity/28 Days

4ORENCIA 125MG/ML SYRINGE NDS PA QL=4 Quantity/28 Days

4ORENCIA 50MG/0.4ML SYRINGE NDS PA QL=1.60 Quantity/28 Days

4ORENCIA 87.5MG/0.7ML SYRINGE NDS PA QL=2.80 Quantity/28 DaysSOLUBLE TUMOR NECROSIS FACTOR RECEPTOR AGENTS

4ENBREL 25MG INJ NDS PA QL=8 Quantity/28 Days

4ENBREL 25MG/0.5ML INJ NDS PA QL=8 Quantity/28 Days

4ENBREL 25MG/0.5ML SYRINGE NDS PA QL=8.16 Quantity/28 Days

4ENBREL 50MG/ML AUTO-INJECTOR NDS PA QL=8 Quantity/28 Days

4ENBREL 50MG/ML CARTRIDGE NDS PA QL=8 Quantity/28 Days

4ENBREL 50MG/ML SYRINGE NDS PA QL=8 Quantity/28 Days

ANALGESICS - NONNARCOTICSALICYLATES

$0*aspirin 325mg EC tab

$0*aspirin 325mg tab

$0*aspirin 81mg chew tab

$0*aspirin 81mg EC tab


13


$0*aspirin 81mg tab

$0*ASPIRIN 81MG TAB

1diflunisal 500mg tab

2salsalate 500mg tab

2salsalate 750mg tab

ANALGESICS - OPIOIDOPIOID AGONISTS

2CODEINE SULFATE 15MG TAB QL=240 Quantity/30 Days


2codeine sulfate 30mg tab QL=240 Quantity/30 Days

2codeine sulfate 60mg tab QL=180 Quantity/30 Days


2fentanyl 0.012mg/hr patch QL=10 Quantity/30 Days





3FENTANYL 100MCG BUCCAL TAB PA QL=120 Quantity/30 Days

2fentanyl 1200mcg lozenge PA QL=120 Quantity/30 Days










2hydrocodone bitartrate 10mg er cap QL=60 Quantity/30 Days

2HYDROCODONE BITARTRATE 10MG ER CAP QL=60 Quantity/30 Days










2hydromorphone 1mg/ml oral soln QL=2400 Quantity/30 Days

1hydromorphone 2mg tab QL=450 Quantity/30 Days



1methadone 10mg tab QL=360 Quantity/30 Days

2methadone 10mg/5ml oral soln QL=1800 Quantity/30 Days

2METHADONE 1MG/ML ORAL SOLN QL=3600 Quantity/30 Days


14


2METHADONE 2MG/ML ORAL SOLN QL=1800 Quantity/30 Days

1methadone 5mg tab QL=360 Quantity/30 Days

2methadone 5mg/5ml oral soln QL=3600 Quantity/30 Days

1morphine sulfate 100mg er tab QL=120 Quantity/30 Days


1morphine sulfate 15mg tab QL=180 Quantity/30 Days

1MORPHINE SULFATE 15MG TAB QL=180 Quantity/30 Days


1morphine sulfate 20mg/ml oral soln QL=180 Quantity/30 Days



1morphine sulfate 30mg tab QL=180 Quantity/30 Days

1MORPHINE SULFATE 30MG TAB QL=180 Quantity/30 Days



2NUCYNTA 100MG ER TAB QL=60 Quantity/30 Days





1oxycodone 10mg tab QL=180 Quantity/30 Days


2oxycodone 1mg/ml oral soln QL=5400 Quantity/30 Days


2oxycodone 20mg/ml oral soln QL=270 Quantity/30 Days


1oxycodone 5mg cap QL=360 Quantity/30 Days


2oxymorphone 10mg tab QL=360 Quantity/30 Days

2oxymorphone 5mg tab QL=360 Quantity/30 Days

2tramadol 100mg er tab QL=60 Quantity/30 Days

2tramadol 100mg er tab (matrix delivery) QL=60 Quantity/30 Days





1tramadol 50mg tab QL=240 Quantity/30 Days

2XTAMPZA 13.5MG ER CAP QL=120 Quantity/30 Days

2XTAMPZA 18MG ER CAP QL=120 Quantity/30 Days



2XTAMPZA 9MG ER CAP QL=120 Quantity/30 DaysOPIOID COMBINATIONS

1acetaminophen 21.7mg/ml/hydrocodone bitartrate 0.5mg/ml oral soln

QL=5400 Quantity/30 Days


15


1acetaminophen 24mg/ml/codeine phosphate 2.4mg/ml oral soln


1acetaminophen 300mg/codeine phosphate 15mg tab QL=390 Quantity/30 Days



2acetaminophen 300mg/hydrocodone bitartrate 10mg tab




2acetaminophen 300mg/hydrocodone bitartrate 7.5mg tab




2acetaminophen 325mg/hydrocodone bitartrate 7.5mg tab


1acetaminophen 325mg/oxycodone 10mg tab QL=360 Quantity/30 Days

1acetaminophen 325mg/oxycodone 2.5mg tab QL=360 Quantity/30 Days

1acetaminophen 325mg/oxycodone 5mg tab QL=360 Quantity/30 Days

1acetaminophen 325mg/oxycodone 7.5mg tab QL=360 Quantity/30 Days

2acetaminophen 325mg/tramadol 37.5mg tab QL=360 Quantity/30 Days

2hydrocodone bitartrate 10mg/ibuprofen 200mg tab QL=480 Quantity/30 Days

2HYDROCODONE BITARTRATE 5MG/IBUPROFEN 200MG TAB


2hydrocodone bitartrate 7.5mg/ibuprofen 200mg tab QL=480 Quantity/30 Days

2hydrocodone/acetaminophen 10-325mg tab QL=360 Quantity/30 Days

2hydrocodone/ibuprofen 5-200mg tab QL=480 Quantity/30 DaysOPIOID PARTIAL AGONISTS

2buprenorphine 0.005mg/hr weekly patch QL=4 Quantity/28 Days





1buprenorphine 12mg/naloxone 3mg sublingual film QL=60 Quantity/30 Days

1buprenorphine 2mg sl tab QL=90 Quantity/30 Days

1buprenorphine 2mg/naloxone 0.5mg sl tab QL=90 Quantity/30 Days

1buprenorphine 2mg/naloxone 0.5mg sublingual film QL=90 Quantity/30 Days


1buprenorphine 8mg sl tab QL=90 Quantity/30 Days

1buprenorphine 8mg/naloxone 2mg sl tab QL=90 Quantity/30 Days


2butorphanol tartrate 1mg/act nasal inhaler QL=4 Quantity/30 Days

2ZUBSOLV 0.7-0.18MG SL TAB QL=60 Quantity/30 Days






16



ANDROGENS-ANABOLICANABOLIC STEROIDS

1oxandrolone 10mg tab PA QL=60 Quantity/30 Days

1oxandrolone 2.5mg tab PA QL=120 Quantity/30 DaysANDROGENS

2ANDRODERM 2MG/24HR PATCH PA QL=60 Quantity/30 Days

2ANDRODERM 4MG/24HR PATCH PA QL=30 Quantity/30 Days

2danazol 100mg cap

2danazol 200mg cap

2danazol 50mg cap

3METHITEST 10MG TAB PA

3METHYLTESTOSTERONE 10MG CAP PA

3testosterone 1% (12.5mg) gel pump bottle PA QL=4 Quantity/30 Days

3TESTOSTERONE 1% (12.5MG/ACT) GEL PUMP PA QL=4 Quantity/30 Days

2testosterone 1% (25mg) gel packet PA QL=120 Quantity/30 Days

2TESTOSTERONE 1% (50MG) GEL PACKET PA QL=60 Quantity/30 Days

2testosterone 1.62% (1.25gm) gel packet PA QL=60 Quantity/30 Days

2testosterone 1.62% (2.5gm) gel packet PA QL=60 Quantity/30 Days

2testosterone 20.25mg/act gel pump PA QL=2 Quantity/30 Days

2testosterone 30mg/act topical soln PA QL=2 Quantity/30 Days

1testosterone cypionate 100mg/ml inj

1testosterone cypionate 200mg/ml inj

2TESTOSTERONE ENANTHATE 200MG/ML INJ

2testosterone gel 1% (50mg) packet PA QL=60 Quantity/30 Days

ANORECTAL AGENTSINTRARECTAL STEROIDS

2hydrocortisone 1.67mg/ml enema

3UCERIS 2MG/ACT RECTAL FOAM PARECTAL COMBINATIONS

3*ANALPRAM-HC CREAM

2hydrocortisone/pramoxine 1-1% rectal cream

1*hydrocortisone/pramoxine 2.5-1% rectal cream

2*lidocaine/hydrocortisone creamRECTAL STEROIDS

3*ANUSOL-HC SUPP

1hydrocortisone 1% cream (RX Only) QL=240 Quantity/30 Days

2*hydrocortisone supp

1procto-med 2.5% cream

1procto-pak 1% rectal creamVASODILATING AGENTS

3RECTIV 0.4% RECTAL OINTMENT QL=30 Quantity/30 Days

ANTHELMINTICSANTHELMINTICS

2albendazole 200mg tab

2BENZNIDAZOLE 100MG TAB PA


17


2BENZNIDAZOLE 12.5MG TAB PA

2ivermectin 3mg tab

2praziquantel 600mg tab

ANTIANGINAL AGENTSANTIANGINALS-OTHER

2ranolazine 1000mg er tab

2ranolazine 500mg er tabNITRATES

1isosorbide dinitrate 10mg tab





1isosorbide mononitrate 10mg tab

1isosorbide mononitrate 120mg er tab

1isosorbide mononitrate 20mg tab



2NITRO-BID 2% OINTMENT

3NITRO-DUR 0.3MG/HR PATCH

3NITRO-DUR 0.8MG/HR PATCH

1nitroglycerin 0.1mg/hr patch


1nitroglycerin 0.3mg sl tab


2nitroglycerin 0.4mg/act spray




1*NITROGLYCERIN CAP

ANTIANXIETY AGENTSANTIANXIETY AGENTS - MISC.

1buspirone 10mg tab

1buspirone 15mg tab

1buspirone 30mg tab

1buspirone 5mg tab

1buspirone 7.5mg tab

1hydroxyzine 10mg tab


1hydroxyzine 2mg/ml oral soln


2HYDROXYZINE PAMOATE 100MG CAP

1hydroxyzine pamoate 25mg cap

1hydroxyzine pamoate 50mg capBENZODIAZEPINES

1alprazolam 0.25mg tab QL=120 Quantity/30 Days


18


2alprazolam 0.5mg er tab QL=30 Quantity/30 Days

1alprazolam 0.5mg tab QL=120 Quantity/30 Days

2alprazolam 1mg er tab QL=30 Quantity/30 Days

1alprazolam 1mg tab QL=120 Quantity/30 Days


1alprazolam 2mg tab QL=150 Quantity/30 Days


1chlordiazepoxide 10mg cap QL=120 Quantity/30 Days



2clorazepate dipotassium 15mg tab QL=180 Quantity/30 Days

2clorazepate dipotassium 3.75mg tab QL=180 Quantity/30 Days

2clorazepate dipotassium 7.5mg tab QL=180 Quantity/30 Days

1diazepam 10mg tab QL=120 Quantity/30 Days

2diazepam 1mg/ml oral soln QL=1200 Quantity/30 Days



1diazepam 5mg/ml oral soln QL=240 Quantity/30 Days

1lorazepam 0.5mg tab QL=150 Quantity/30 Days

1lorazepam 1mg tab QL=150 Quantity/30 Days

1lorazepam 2mg tab QL=150 Quantity/30 Days

1lorazepam 2mg/ml oral soln QL=150 Quantity/30 Days

ANTIARRHYTHMICSANTIARRHYTHMICS TYPE I-A

1disopyramide 100mg cap

1disopyramide 150mg cap

2NORPACE 100MG ER CAP

2NORPACE 150MG ER CAP

2quinidine gluconate 324mg er tab

2QUINIDINE SULFATE 200MG TAB

2QUINIDINE SULFATE 300MG TABANTIARRHYTHMICS TYPE I-B

2mexiletine 150mg cap

2mexiletine 200mg cap

2mexiletine 250mg capANTIARRHYTHMICS TYPE I-C

1flecainide acetate 100mg tab



1propafenone 150mg tab

2propafenone 225mg er cap



2propafenone 325mg er cap

2propafenone 425mg er capANTIARRHYTHMICS TYPE III


19


1amiodarone 100mg tab



2dofetilide 0.125mg cap



2MULTAQ 400MG TAB

ANTIASTHMATIC AND BRONCHODILATOR AGENTSANTIASTHMATIC - MONOCLONAL ANTIBODIES

4FASENRA 30MG/ML AUTO-INJECTOR PA

4FASENRA 30MG/ML SYRINGE PA

4NUCALA 100MG INJ NDS PA

4NUCALA 100MG/ML AUTO-INJECTOR NDS PA

4NUCALA 100MG/ML SYRINGE NDS PA

4XOLAIR 150MG INJ NDS PA

4XOLAIR 150MG/ML SYRINGE NDS PA

4XOLAIR 75MG/0.5ML SYRINGE NDS PABRONCHODILATORS - ANTICHOLINERGICS

2ATROVENT 17MCG INH

2INCRUSE 62.5MCG/INH INHALER

1ipratropium bromide 0.2mg/ml inh soln PA_BvD

2LONHALA 25MCG/ML INH SOLN ST QL=60 Quantity/30 Days

2SPIRIVA 1.25MCG INH ST QL=1 Quantity/30 DaysLEUKOTRIENE MODULATORS

1montelukast 10mg tab

1montelukast 4mg chew tab

2montelukast 4mg granules

1montelukast 5mg chew tab

2zafirlukast 10mg tab

2zafirlukast 20mg tabSELECTIVE PHOSPHODIESTERASE 4 (PDE4) INHIBITORS

3DALIRESP 250MCG TAB

3DALIRESP 500MCG TABSTEROID INHALANTS

2ARNUITY ELLIPTA 100MCG INHALER QL=1 Quantity/30 Days



2ASMANEX 100MCG INHALER QL=1 Quantity/30 Days



2ASMANEX 220MCG INH QL=1 Quantity/30 Days


2ASMANEX 50MCG HFA INHALER QL=1 Quantity/30 Days

1budesonide 0.125mg/ml inh susp PA_BvD QL=120 Quantity/30 Days




20


2FLOVENT 100MCG DISKUS QL=1 Quantity/30 Days

2FLOVENT 110MCG HFA INH QL=2 Quantity/30 Days


2FLOVENT 250MCG DISKUS QL=1 Quantity/30 Days


2FLOVENT 50MCG DISKUS QL=1 Quantity/30 DaysSYMPATHOMIMETICS

2ADVAIR 100-50MCG DISKUS QL=1 Quantity/30 Days

2ADVAIR 115-21MCG HFA INHALER QL=1 Quantity/30 Days

2ADVAIR 230-21MCG HFA INHALER QL=1 Quantity/30 Days


2ADVAIR 45-21MCG/ACT HFA INHALER QL=1 Quantity/30 Days


1albuterol 0.21mg/ml inh soln PA_BvD


1albuterol 0.4mg/ml oral soln


1albuterol 2mg tab

1albuterol 4mg tab

2albuterol 5mg/ml inh soln PA_BvD

1albuterol HFA inhaler (6.7gm) QL=2 Quantity/30 Days

1albuterol HFA inhaler (8.5gm) QL=2 Quantity/30 Days

2ANORO ELLIPTA 62.5-25MCG INHALER QL=1 Quantity/30 Days

2arformoterol tartrate 15mcg/2ml neb soln PA_BvD QL=120 Quantity/30 Days

2BREO ELLIPTA 100-25MCG INHALER QL=1 Quantity/30 Days

2BREO ELLIPTA 200-25MCG INHALER QL=1 Quantity/30 Days

2BREZTRI AEROSPHERE 160-9-4.8MCG/ACT INH QL=1 Quantity/30 Days

2COMBIVENT 20-100MCG/ACT INH

2DULERA 100-5MCG INHALER QL=1 Quantity/30 Days



1fluticasone propionate/salmeterol 100-50mcg/act dry powder inhaler, wixela 100-50mcg inhaler






2formoterol fumarate 20mcg/2ml neb soln PA_BvD QL=120 Quantity/30 Days

1ipratropium/albuterol 0.5-2.5mg/3ml inh soln PA_BvD

2levalbuterol 0.103mg/ml inh soln PA_BvD




2SEREVENT 50MCG/DOSE INH

2STIOLTO 2.5-2.5MCG/ACT INH QL=1 Quantity/30 Days

2SYMBICORT 160-4.5MCG/ACT INHALER QL=1 Quantity/30 Days


21


2SYMBICORT 80-4.5MCG/ACT INHALER QL=1 Quantity/30 Days

1terbutaline sulfate 2.5mg tab

1terbutaline sulfate 5mg tab

2TRELEGY ELLIPTA 100- 62.5-25MCG INHALER QL=1 Quantity/30 Days

2TRELEGY ELLIPTA 200-62.5-25MCG INHALER QL=1 Quantity/30 Days

2VENTOLIN 108MCG INH (18GM) QL=2 Quantity/30 Days

2VENTOLIN 108MCG INH (8GM) QL=5 Quantity/30 Days

3XOPENEX 45MCG INH, LEVALBUTEROL 45MCG INHALER

ST QL=2 Quantity/30 Days

XANTHINES

3THEO-24 100MG ER CAP




2THEOPHYLLINE 300MG ER TAB

1theophylline 400mg er tab

2THEOPHYLLINE 450MG ER TAB

1theophylline 5.33mg/ml oral soln

1theophylline 600mg er tab

ANTICOAGULANTSCOUMARIN ANTICOAGULANTS

1warfarin sodium 10mg tab


1warfarin sodium 2.5mg tab






1warfarin sodium 7.5mg tabDIRECT FACTOR XA INHIBITORS

2ELIQUIS 2.5MG TAB

2ELIQUIS 5MG TAB

2ELIQUIS 5MG TAB 30-DAY STARTER PACK

2XARELTO 10MG TAB

2XARELTO 15MG TAB

2XARELTO 2.5MG TAB

2XARELTO 20MG TAB

2XARELTO KIT PACKHEPARINS AND HEPARINOID-LIKE AGENTS

2enoxaparin 300mg/3ml inj QL=30 Quantity/30 Days

2enoxaparin sodium 100mg/ml (0.3ml) inj QL=60 Quantity/30 Days




2enoxaparin sodium 100mg/ml (1ml) inj QL=60 Quantity/30 Days


22



2enoxaparin sodium 150mg/ml (1ml) inj QL=60 Quantity/30 Days

2fondaparinux sodium 12.5mg/ml (0.4ml) inj



2fondaparinux sodium 5mg/ml (0.5mg) inj

3FRAGMIN 10000UNIT/ML INJ

3FRAGMIN 12500UNIT/0.5ML INJ


3FRAGMIN 18000UNT/0.72ML INJ





2heparin sodium 5000unit/0.5ml inj (PF)

2heparin sodium porcine 10000unit/ml inj



2heparin sodium porcine 5000unit/ml injTHROMBIN INHIBITORS

3PRADAXA 110MG CAP

3PRADAXA 150MG CAP

3PRADAXA 75MG CAP

ANTICONVULSANTSAMPA GLUTAMATE RECEPTOR ANTAGONISTS

3FYCOMPA 0.5MG/ML SUSP PA_NSO

3FYCOMPA 10MG TAB PA_NSO





3FYCOMPA 8MG TAB PA_NSOANTICONVULSANTS - BENZODIAZEPINES

2clobazam 10mg tab QL=60 Quantity/30 Days

2clobazam 2.5mg/ml susp QL=480 Quantity/30 Days

2clobazam 20mg tab QL=60 Quantity/30 Days

2clonazepam 0.125mg odt QL=90 Quantity/30 Days



1clonazepam 0.5mg tab QL=90 Quantity/30 Days

2clonazepam 1mg odt QL=90 Quantity/30 Days

1clonazepam 1mg tab QL=90 Quantity/30 Days

2clonazepam 2mg odt QL=300 Quantity/30 Days

1clonazepam 2mg tab QL=300 Quantity/30 Days

2DIAZEPAM 10MG/2ML RECTAL GEL QL=10 Quantity/30 Days

2DIAZEPAM 2.5MG/0.5ML RECTAL GEL QL=10 Quantity/30 Days


23


2DIAZEPAM 20MG/4ML RECTAL GEL QL=10 Quantity/30 Days

3NAYZILAM 5MG/0.1ML NASAL SPRAY QL=10 Quantity/30 Days

3SYMPAZAN 10MG ORAL FILM ST_NSO QL=60 Quantity/30 Days



3VALTOCO 10MG DOSE KIT 10MG/0.1ML PACK QL=10 Quantity/30 Days

3VALTOCO 15MG DOSE KIT 7.5MG/0.1ML PACK QL=10 Quantity/30 Days

3VALTOCO 20MG DOSE KIT 10MG/0.1ML PACK QL=10 Quantity/30 Days

3VALTOCO 5MG DOSE KIT 5MG/0.1ML PACK QL=10 Quantity/30 DaysANTICONVULSANTS - MISC.

3APTIOM 200MG TAB PA_NSO




3BRIVIACT 100MG TAB PA_NSO QL=60 Quantity/30 Days


3BRIVIACT 10MG/ML ORAL SOLN PA_NSO




1carbamazepine 100mg chew tab

2carbamazepine 100mg er cap

2carbamazepine 100mg er tab



1carbamazepine 200mg tab

1carbamazepine 20mg/ml susp



4DIACOMIT 250MG CAP LD NDS PA_NSO

4DIACOMIT 250MG POWDER FOR ORAL SUSP LD NDS PA_NSO

4DIACOMIT 500MG CAP LD NDS PA_NSO

4DIACOMIT 500MG POWDER FOR ORAL SUSP LD NDS PA_NSO

2EPIDIOLEX 100MG/ML ORAL SOLN LD PA_NSO

4FINTEPLA 2.2MG/ML ORAL SOLN LD NDS PA_NSO QL=360 Quantity/30 Days

1gabapentin 100mg cap



2gabapentin 50mg/ml oral soln

1gabapentin 600mg tab

1gabapentin 800mg tab

2lamotrigine 100mg er tab

2lamotrigine 100mg odt

1lamotrigine 100mg tab



24






1lamotrigine 25mg chew tab







1lamotrigine 5mg chew tab

1levetiracetam 1000mg tab

1levetiracetam 100mg/ml oral soln


1levetiracetam 500mg er tab


1levetiracetam 750mg er tab


1oxcarbazepine 150mg tab



1oxcarbazepine 60mg/ml susp

1pregabalin 100mg cap



2pregabalin 20mg/ml oral soln






1primidone 250mg tab

1primidone 50mg tab

2rufinamide 200mg tab PA_NSO

2rufinamide 40mg/ml susp PA_NSO

3SPRITAM 1000MG TAB FOR ORAL SUSP PA_NSO




1topiramate 100mg tab

1topiramate 15mg cap


1topiramate 25mg cap




25


2VIMPAT 100MG TAB QL=60 Quantity/30 Days

2VIMPAT 10MG/ML ORAL SOLN




1zonisamide 100mg cap

1zonisamide 25mg cap

1zonisamide 50mg capCARBAMATES

2felbamate 120mg/ml susp

2felbamate 400mg tab

2felbamate 600mg tab

2XCOPRI (250 MG DAILY DOSE) TAB PACK

2XCOPRI 100MG TAB

2XCOPRI 12.5/25MG TITRATION PACK

2XCOPRI 150/200MG TITRATION PACK

2XCOPRI 150MG TAB

2XCOPRI 200MG TAB

2XCOPRI 50/100MG TITRATION PACK

2XCOPRI 50MG TAB

2XCOPRI TAB 150/200MG PACKGABA MODULATORS

2tiagabine 12mg tab

2tiagabine 16mg tab

2tiagabine 2mg tab

2tiagabine 4mg tab

4vigabatrin 500mg powder for oral soln LD NDS PA_NSO

4vigabatrin 500mg tab LD NDS PA_NSOHYDANTOINS

3DILANTIN 100MG ER CAP

3DILANTIN 125MG/5ML SUSP

2DILANTIN 30MG ER CAP

3DILANTIN 50MG CHEW TAB

3PHENYTEK 200MG ER CAP

3PHENYTEK 300MG ER CAP

1phenytoin 25mg/ml susp

2phenytoin 50mg chew tab

1phenytoin sodium 100mg er cap

1phenytoin sodium 200mg er cap

1phenytoin sodium 300mg er capSUCCINIMIDES

2CELONTIN 300MG CAP

2ethosuximide 250mg cap

1ethosuximide 50mg/ml oral solnVALPROIC ACID

1divalproex sodium 125mg dr cap


26


1divalproex sodium 125mg dr tab


1divalproex sodium 250mg er tab


1divalproex sodium 500mg er tab

1valproic acid 250mg cap

1valproic acid 50mg/ml oral soln

ANTIDEPRESSANTSALPHA-2 RECEPTOR ANTAGONISTS (TETRACYCLICS)

1mirtazapine 15mg odt

1mirtazapine 15mg tab





1mirtazapine 7.5mg tabANTIDEPRESSANTS - MISC.

1bupropion 100mg er tab

1bupropion 100mg tab

1bupropion 150mg sr (12 hr) tab

1bupropion 150mg xl (24 hr) tab



1bupropion 75mg tabMODIFIED CYCLICS

1trazodone 100mg tab

1trazodone 150mg tab

1trazodone 50mg tab

2TRINTELLIX 10MG TAB ST_NSO QL=30 Quantity/30 Days



3VIIBRYD 10MG TAB ST_NSO QL=30 Quantity/30 Days

3VIIBRYD 20MG TAB ST_NSO QL=30 Quantity/30 Days

3VIIBRYD 40MG TAB ST_NSO QL=30 Quantity/30 DaysMONOAMINE OXIDASE INHIBITORS (MAOIS)

3EMSAM 12MG/24HR PATCH ST_NSO QL=30 Quantity/30 Days



2MARPLAN 10MG TAB

1phenelzine 15mg tab

2tranylcypromine 10mg tabSELECTIVE SEROTONIN REUPTAKE INHIBITORS (SSRIS)

1citalopram 10mg tab


1citalopram 2mg/ml oral soln



27


1escitalopram 10mg tab

2escitalopram 1mg/ml oral soln



1fluoxetine 10mg cap



1fluoxetine 4mg/ml oral soln

1fluvoxamine maleate 100mg tab



1paroxetine 10mg tab

3paroxetine 10mg/5ml susp

2paroxetine 12.5mg er tab


2paroxetine 25mg er tab


2paroxetine 37.5mg er tab


3PAXIL 10MG/5ML SUSP

1sertraline 100mg tab

1sertraline 20mg/ml oral soln

1sertraline 25mg tab

1sertraline 50mg tabSEROTONIN MODULATORS

3NEFAZODONE 100MG TAB





3VIIBRYD 10/20MG STARTER PACK ST_NSO QL=30 Quantity/30 DaysSEROTONIN-NOREPINEPHRINE REUPTAKE INHIBITORS (SNRIS)

2desvenlafaxine succinate 100mg er tab



3DRIZALMA 20MG DR CAP ST_NSO QL=60 Quantity/30 Days




1duloxetine 20mg dr cap



3FETZIMA 120MG ER CAP ST_NSO QL=30 Quantity/30 Days





28


3FETZIMA PACK ST_NSO QL=30 Quantity/30 Days

1venlafaxine 100mg tab

1venlafaxine 150mg er cap


1venlafaxine 37.5mg er cap

1venlafaxine 37.5mg tab


1venlafaxine 75mg er cap

1venlafaxine 75mg tabTRICYCLIC AGENTS

1amitriptyline 100mg tab






2AMOXAPINE 100MG TAB

2AMOXAPINE 150MG TAB

2AMOXAPINE 25MG TAB

2AMOXAPINE 50MG TAB

2clomipramine 25mg cap



2desipramine 100mg tab






1doxepin 100mg cap

1doxepin 10mg cap

1doxepin 10mg/ml oral soln

1doxepin 150mg cap

1doxepin 25mg cap

1doxepin 50mg cap

1doxepin 75mg cap

1imipramine 10mg tab



1nortriptyline 10mg cap


2NORTRIPTYLINE 2MG/ML ORAL SOLN



2protriptyline 10mg tab

2protriptyline 5mg tab


29


2trimipramine 100mg cap



ANTIDIABETICSALPHA-GLUCOSIDASE INHIBITORS

1acarbose 100mg tab

1acarbose 25mg tab

1acarbose 50mg tab

2miglitol 100mg tab

2miglitol 25mg tab

2miglitol 50mg tabANTIDIABETIC COMBINATIONS

$0glipizide 2.5mg/metformin 250mg tab

$0glipizide 2.5mg/metformin 500mg tab

$0glipizide 5mg/metformin 500mg tab

1glyburide 1.25mg/metformin 250mg tab

1glyburide 2.5mg/metformin 500mg tab

1glyburide 5mg/metformin 500mg tab

2GLYXAMBI 10-5MG TAB QL=30 Quantity/30 Days

2GLYXAMBI 25-5MG TAB QL=30 Quantity/30 Days

2JANUMET 1000-100MG ER TAB QL=30 Quantity/30 Days


2JANUMET 1000-50MG TAB QL=60 Quantity/30 Days


2JANUMET 500-50MG TAB QL=60 Quantity/30 Days

2JENTADUETO 2.5-1000MG ER TAB QL=30 Quantity/30 Days

2JENTADUETO 2.5-1000MG TAB QL=60 Quantity/30 Days



2JENTADUETO 5-1000MG ER TAB QL=30 Quantity/30 Days

2SOLIQUA PEN INJ PA QL=1 Quantity/25 Days

2SYNJARDY 10-1000MG ER TAB QL=30 Quantity/30 Days

2SYNJARDY 12.5-1000MG ER TAB QL=60 Quantity/30 Days

2SYNJARDY 12.5-1000MG TAB QL=60 Quantity/30 Days

2SYNJARDY 12.5-500MG TAB QL=60 Quantity/30 Days



2SYNJARDY 5-1000MG TAB QL=60 Quantity/30 Days

2SYNJARDY 5-500MG TAB QL=60 Quantity/30 Days

2TRIJARDY 10-5-1000MG ER TAB QL=30 Quantity/30 Days

2TRIJARDY 12.5-2.5-1000MG ER TAB QL=60 Quantity/30 Days

2TRIJARDY 25-5-1000MG ER TAB QL=30 Quantity/30 Days

2TRIJARDY 5-2.5-1000MG ER TAB QL=60 Quantity/30 Days

2XIGDUO 10-1000MG ER TAB QL=30 Quantity/30 Days


2XIGDUO 2.5-1000MG ER TAB QL=60 Quantity/30 Days


30




2XULTOPHY 100UNIT-3.6MG/ML PEN INJ PA QL=15 Quantity/30 DaysBIGUANIDES

$0metformin 1000mg tab

2metformin 100mg/ml soln

$0metformin 500mg er tab

$0metformin 500mg tab

$0metformin 750mg er tab

$0metformin 850mg tabDIABETIC OTHER

2BAQSIMI 3MG/DOSE NASAL POWDER QL=2 Quantity/7 Days

2diazoxide 50mg/ml susp

2GLUCAGEN 1MG INJ QL=2 Quantity/7 Days

2glucagon (rdna) 1mg inj kit QL=2 Quantity/7 Days

2GLUCAGON 1MG KIT QL=2 Quantity/7 Days

2GVOKE 0.5MG/0.1ML AUTO-INJECTOR QL=2 Quantity/7 Days

2GVOKE 0.5MG/0.1ML SYRINGE QL=2 Quantity/7 Days

2GVOKE 1MG/0.2ML AUTO-INJECTOR QL=2 Quantity/7 Days

2GVOKE 1MG/0.2ML SYRINGE QL=2 Quantity/7 Days

4KORLYM 300MG TAB LD NDS PADIPEPTIDYL PEPTIDASE-4 (DPP-4) INHIBITORS

2JANUVIA 100MG TAB RXC QL=30 Quantity/30 Days



2TRADJENTA 5MG TAB QL=30 Quantity/30 DaysDOPAMINE RECEPTOR AGONISTS - ANTIDIABETIC

3CYCLOSET 0.8MG TABINCRETIN MIMETIC AGENTS (GLP-1 RECEPTOR AGONISTS)

2BYDUREON 2MG PEN INJ QL=4 Quantity/28 Days

2BYDUREON 2MG/0.85ML AUTO-INJECTOR QL=4 Quantity/28 Days

2OZEMPIC 2MG/1.5ML PEN INJ QL=1 Quantity/28 Days

2OZEMPIC 2MG/1.5ML PEN INJ (1MG DOSE) QL=2 Quantity/28 Days

2OZEMPIC 4MG/3ML PEN INJ QL=1 Quantity/28 Days

2RYBELSUS 14MG TAB QL=30 Quantity/30 Days



2TRULICITY 0.75MG/0.5ML AUTO-INJECTOR QL=4 Quantity/28 Days


2TRULICITY 3MG/0.5ML AUTO-INJECTOR QL=4 Quantity/28 Days


2VICTOZA 18MG/3ML PEN INJ QL=9 Quantity/30 DaysINSULIN

2FIASP 100UNIT/ML CARTRIDGE

2FIASP 100UNIT/ML INJ PA_BvD

2FIASP 100UNIT/ML PEN INJ


31


2HUMULIN R 500UNIT/ML INJ PA_BvD

2HUMULIN R 500UNIT/ML PEN INJ

2LANTUS 100UNIT/ML INJ

2LANTUS SOLOSTAR 100UNIT/ML INJ

2LEVEMIR 100UNIT/ML INJ

2LEVEMIR 100UNIT/ML PEN INJ

2NOVOLIN MIX (70/30) 100UNIT/ML INJ

2NOVOLIN MIX (70/30) FLEXPEN 100UNIT/ML

2NOVOLIN N 100UNIT/ML INJ

2NOVOLIN N 100UNIT/ML PEN INJ

2NOVOLIN R 100UNIT/ML INJ

2NOVOLIN R FLEXPEN RELION

2NOVOLOG 100UNIT/ML CARTRIDGE, INSULIN ASPART HUMAN 100UNIT/ML CARTRIDGE

2NOVOLOG 100UNIT/ML INJ, INSULIN ASPART HUMAN 100UNIT/ML INJ

PA_BvD

2NOVOLOG 100UNIT/ML PEN INJ, INSULIN ASPART HUMAN 100UNIT/ML PEN INJ

2NOVOLOG MIX (70/30) 100UNIT/ML INJ, INSULIN ASPART MIX 70UNIT-30UNIT/ML INJ

2NOVOLOG MIX 70-30UNIT/ML PEN INJ, INSULIN ASPART MIX 70UNIT-30UNIT/ML PEN INJ

2TOUJEO 300UNIT/ML PEN INJ

2TOUJEO MAX 300UNIT/ML PEN INJ (3ML)

2TRESIBA 100UNIT/ML INJ

2TRESIBA 100UNIT/ML PEN INJ

2TRESIBA 200UNIT/ML PEN INJINSULIN SENSITIZING AGENTS

1pioglitazone 15mg tab

1pioglitazone 30mg tab

1pioglitazone 45mg tabMEGLITINIDE ANALOGUES

1nateglinide 120mg tab

1nateglinide 60mg tab

1repaglinide 0.5mg tab

1repaglinide 1mg tab

1repaglinide 2mg tabSODIUM-GLUCOSE CO-TRANSPORTER 2 (SGLT2) INHIBITORS

2FARXIGA 10MG TAB QL=30 Quantity/30 Days

2FARXIGA 5MG TAB QL=30 Quantity/30 Days

2JARDIANCE 10MG TAB QL=30 Quantity/30 Days

2JARDIANCE 25MG TAB QL=30 Quantity/30 DaysSULFONYLUREAS

$0glimepiride 1mg tab




32


$0glipizide 10mg er tab

$0glipizide 10mg tab

$0glipizide 2.5mg er tab

$0glipizide 5mg er tab

$0glipizide 5mg tab

2glyburide 1.25mg tab



2glyburide 3mg tab

2glyburide 5mg tab

2glyburide 6mg tab

ANTIDIARRHEAL/PROBIOTIC AGENTSANTIPERISTALTIC AGENTS

1ATROPINE SULFATE/DIPHENOXYLATE 2.5-0.025 MG/5ML ORAL SOLN

ANTIDIARRHEALSANTIPERISTALTIC AGENTS

1atropine sulfate 0.025mg/diphenoxylate 2.5mg tab

1loperamide 2mg cap (RX Only)

2opium 10mg/ml tincture

ANTIDOTESANTIDOTES - CHELATING AGENTS

2CHEMET 100MG CAP

4FERRIPROX 100MG/ML ORAL SOLN LD NDS PAOPIOID ANTAGONISTS

1naloxone 0.4mg/ml inj QL=2 Quantity/2 Days

4VIVITROL 380MG INJ NDS

ANTIDOTES AND SPECIFIC ANTAGONISTSANTIDOTES - CHELATING AGENTS

2deferasirox 125mg tab for oral susp

4deferasirox 180mg granules NDS

2deferasirox 180mg tab







4deferiprone 500mg tab LD NDS PA

4FERRIPROX (TWICE DAILY) 1000MG TAB LD NDS PA

4FERRIPROX 1000MG TAB LD NDS PAOPIOID ANTAGONISTS

2KLOXXADO 8MG/0.1ML NASAL SPRAY

1NALOXONE 0.4MG/ML CARTRIDGE QL=2 Quantity/2 Days

1naloxone 1mg/ml syringe

1naltrexone 50mg tab


33


1NARCAN 4MG/0.1ML NASAL SPRAY

ANTIEMETICS5-HT3 RECEPTOR ANTAGONISTS

1granisetron 1mg tab PA_BvD QL=60 Quantity/30 Days

1ondansetron 0.8mg/ml oral soln PA_BvD

1ONDANSETRON 24MG TAB PA_BvD

1ondansetron 4mg odt PA_BvD

1ondansetron 4mg tab PA_BvD

1ondansetron 8mg odt PA_BvD

1ondansetron 8mg tab PA_BvD

3SANCUSO 3.1MG/24HR PATCH QL=2 Quantity/14 DaysANTIEMETICS - ANTICHOLINERGIC

1meclizine 12.5mg tab

1meclizine 25mg tab (RX Only)

2scopolamine 0.0139mg/hr patch

1trimethobenzamide 300mg capANTIEMETICS - MISCELLANEOUS

2doxylamine succinate 10mg/pyridoxine 10mg dr tab QL=120 Quantity/30 Days

2dronabinol 10mg cap PA QL=60 Quantity/30 Days

2dronabinol 2.5mg cap PA QL=60 Quantity/30 Days

2dronabinol 5mg cap PA QL=60 Quantity/30 DaysSUBSTANCE P/NEUROKININ 1 (NK1) RECEPTOR ANTAGONISTS

2aprepitant 125mg cap PA_BvD QL=3 Quantity/2 Days

2aprepitant 125mg/aprepitant 80mg pack PA_BvD QL=6 Quantity/4 Days



3VARUBI 90MG TAB PA_BvD QL=4 Quantity/28 Days

ANTIFUNGALSANTIFUNGAL - GLUCAN SYNTHESIS INHIBITORS (ECHINOCANDINS)

4caspofungin acetate 50mg inj NDS

4CASPOFUNGIN ACETATE 50MG INJ NDS

2CASPOFUNGIN ACETATE 70MG INJ

2caspofungin acetate 70mg inj

2ERAXIS 100MG INJ

2ERAXIS 50MG INJ

2micafungin sodium 100mg inj

2micafungin sodium 50mg injANTIFUNGALS

3ABELCET 5MG/ML INJ PA_BvD

3AMBISOME 50MG INJ PA_BvD

3AMPHOTERICIN B 50MG INJ PA_BvD

2flucytosine 250mg cap

2flucytosine 500mg cap

2griseofulvin 125mg tab


2griseofulvin 25mg/ml susp


34



1nystatin 500000unit tab

1terbinafine 250mg tabIMIDAZOLE-RELATED ANTIFUNGALS

1fluconazole 100mg tab

1fluconazole 10mg/ml susp



2fluconazole 2mg/ml (100ml) inj

2fluconazole 2mg/ml (200ml) inj

1fluconazole 40mg/ml susp


2fluconazole/dextrose 200mg/100ml inj

2fluconazole/dextrose 400mg/200ml inj

2itraconazole 100mg cap PA

2itraconazole 10mg/ml oral soln PA

1ketoconazole 200mg tab

2NOXAFIL 40MG/ML SUSP PA

2posaconazole 100mg dr tab PA

2voriconazole 200mg inj PA

2voriconazole 200mg tab PA

2voriconazole 40mg/ml susp PA

2voriconazole 50mg tab PA

ANTIHISTAMINESANTIHISTAMINES - NON-SEDATING

2cetirizine 1mg/ml oral soln

2desloratadine 5mg tab

2levocetirizine 0.5mg/ml oral soln

1levocetirizine 5mg tabANTIHISTAMINES - PHENOTHIAZINES

1promethazine 1.25mg/ml oral soln

2promethazine 12.5mg rectal supp

1promethazine 12.5mg tab

1promethazine 25mg tab

1promethazine 50mg tab

2promethegan 25mg rectal supp

2PROMETHEGAN 50MG RECTAL SUPPANTIHISTAMINES - PIPERIDINES

2cyproheptadine 0.4mg/ml oral soln

2cyproheptadine 4mg tab

ANTIHYPERLIPIDEMICSANTIHYPERLIPIDEMICS - MISC.

1icosapent ethyl 1gm cap QL=120 Quantity/30 Days

2omega-3 acid ethyl esters (usp) 1000mg cap

2VASCEPA 0.5GM CAP QL=120 Quantity/30 Days

2VASCEPA 1GM CAP QL=120 Quantity/30 Days


35


BILE ACID SEQUESTRANTS

2cholestyramine 4gm bulk powder

2cholestyramine resin 4gm sf powder for oral susp

2cholestyramine resin 4gm sf powder for oral susp (sugar free)

2colesevelam 3750mg powder for oral susp

2colesevelam 625mg tab

1colestipol 1000mg tab

2colestipol 5000mg granules for oral susp

2colestipol 5gm granule

2prevalite 4gm powder for oral suspFIBRIC ACID DERIVATIVES

3ANTARA 30MG CAP

3ANTARA 90MG CAP

1fenofibrate 134mg cap

1fenofibrate 145mg tab

3FENOFIBRATE 150MG CAP




3FENOFIBRATE 50MG CAP



2fenofibric acid 135mg dr cap

2fenofibric acid 45mg dr cap

1gemfibrozil 600mg tabHMG COA REDUCTASE INHIBITORS

$0atorvastatin 10mg tab




2fluvastatin 20mg cap

2fluvastatin 40mg cap

2fluvastatin 80mg er tab

3LIVALO 1MG TAB ST

3LIVALO 2MG TAB ST

3LIVALO 4MG TAB ST

$0lovastatin 10mg tab



$0pravastatin sodium 10mg tab




$0rosuvastatin calcium 10mg tab



36




$0simvastatin 10mg tab




1simvastatin 80mg tabINTESTINAL CHOLESTEROL ABSORPTION INHIBITORS

2ezetimibe 10mg tab QL=30 Quantity/30 DaysMICROSOMAL TRIGLYCERIDE TRANSFER PROTEIN (MTP) INHIBITORS

4JUXTAPID 10MG CAP NDS PA



4JUXTAPID 5MG CAP NDS PANICOTINIC ACID DERIVATIVES

2niacin 1000mg er tab

2niacin 500mg er tab

2niacin 750mg er tabPROPROTEIN CONVERTASE SUBTILISIN/KEXIN TYPE 9 INHIBITORS

2PRALUENT 150MG/ML AUTO-INJECTOR PA QL=2 Quantity/28 Days

2PRALUENT 75MG/ML AUTO-INJECTOR PA QL=2 Quantity/28 Days

2REPATHA 140MG/ML AUTO-INJECTOR PA QL=2 Quantity/28 Days

2REPATHA 140MG/ML SYRINGE PA QL=2 Quantity/28 Days

2REPATHA 420MG/3.5ML CARTRIDGE PA QL=1 Quantity/28 Days

ANTIHYPERTENSIVESACE INHIBITORS

$0benazepril 10mg tab




2captopril 100mg tab

2captopril 12.5mg tab

2captopril 25mg tab

2captopril 50mg tab

$0enalapril maleate 10mg tab

$0enalapril maleate 2.5mg tab



1fosinopril sodium 10mg tab



$0lisinopril 10mg tab

$0lisinopril 2.5mg tab





37



1moexipril 15mg tab

1moexipril 7.5mg tab

1perindopril erbumine 2mg tab



3QBRELIS 1MG/ML ORAL SOLN PA

1quinapril 10mg tab

1quinapril 20mg tab

1quinapril 40mg tab

1quinapril 5mg tab

$0ramipril 1.25mg cap

$0ramipril 10mg cap

$0ramipril 2.5mg cap

$0ramipril 5mg cap

1trandolapril 1mg tab

1trandolapril 2mg tab

1trandolapril 4mg tabAGENTS FOR PHEOCHROMOCYTOMA

4metyrosine 250mg cap NDS

2phenoxybenzamine 10mg capANGIOTENSIN II RECEPTOR ANTAGONISTS

1candesartan cilexetil 16mg tab




$0irbesartan 150mg tab



$0losartan potassium 100mg tab



1olmesartan medoxomil 20mg tab



1telmisartan 20mg tab



$0valsartan 160mg tab



$0valsartan 80mg tabANTIADRENERGIC ANTIHYPERTENSIVES

2clonidine 0.00417mg/hr weekly patch




38


1clonidine 0.1mg tab



1doxazosin 1mg tab

1doxazosin 2mg tab

1doxazosin 4mg tab

1doxazosin 8mg tab

2guanfacine 1mg tab

2guanfacine 2mg tab

2methyldopa 250mg tab

2METHYLDOPA 250MG TAB

2METHYLDOPA 500MG TAB

2methyldopa 500mg tab

1prazosin 1mg cap

1prazosin 2mg cap

1prazosin 5mg cap

1terazosin 10mg cap

1terazosin 1mg cap

1terazosin 2mg cap

1terazosin 5mg capANTIHYPERTENSIVE COMBINATIONS

1amlodipine 10mg/benazepril 20mg cap


2amlodipine 10mg/hydrochlorothiazide 12.5mg/valsartan 160mg tab

2amlodipine 10mg/hydrochlorothiazide 25mg/valsartan 160mg tab


2amlodipine 10mg/olmesartan medoxomil 20mg tab


2amlodipine 10mg/valsartan 160mg tab


1amlodipine 2.5mg/benazepril 10mg cap




2amlodipine 5mg/hydrochlorothiazide 12.5mg/valsartan 160mg tab






$0atenolol 100mg/chlorthalidone 25mg tab


39


$0atenolol 50mg/chlorthalidone 25mg tab

$0benazepril 10mg/hydrochlorothiazide 12.5mg tab


$0benazepril 20mg/hydrochlorothiazide 25mg tab


1BENAZEPRIL-HYDROCHLOROTHIAZIDE 5-6.25MG TAB

$0bisoprolol fumarate 10mg/hydrochlorothiazide 6.25mg tab

$0bisoprolol fumarate 2.5mg/hydrochlorothiazide 6.25mg tab

$0bisoprolol fumarate 5mg/hydrochlorothiazide 6.25mg tab

$0enalapril maleate 10mg/hydrochlorothiazide 25mg tab

$0enalapril maleate 5mg/hydrochlorothiazide 12.5mg tab

1fosinopril sodium 10mg/hydrochlorothiazide 12.5mg tab

1fosinopril sodium 20mg/hydrochlorothiazide 12.5mg tab

$0hydrochlorothiazide 12.5mg/irbesartan 150mg tab

$0hydrochlorothiazide 12.5mg/irbesartan 300mg tab

$0hydrochlorothiazide 12.5mg/lisinopril 10mg tab

$0hydrochlorothiazide 12.5mg/lisinopril 20mg tab

$0hydrochlorothiazide 12.5mg/losartan potassium 100mg tab

$0hydrochlorothiazide 12.5mg/losartan potassium 50mg tab

1hydrochlorothiazide 12.5mg/olmesartan medoxomil 20mg tab

1hydrochlorothiazide 12.5mg/olmesartan medoxomil 40mg tab

1hydrochlorothiazide 12.5mg/quinapril 10mg tab

1hydrochlorothiazide 12.5mg/quinapril 20mg tab

$0hydrochlorothiazide 12.5mg/valsartan 160mg tab



$0hydrochlorothiazide 25mg/lisinopril 20mg tab

$0hydrochlorothiazide 25mg/losartan potassium 100mg tab

2hydrochlorothiazide 25mg/metoprolol tartrate 100mg tab

2hydrochlorothiazide 25mg/metoprolol tartrate 50mg tab


40


1hydrochlorothiazide 25mg/olmesartan medoxomil 40mg tab

1hydrochlorothiazide 25mg/quinapril 20mg tab

$0hydrochlorothiazide 25mg/valsartan 160mg tab

$0hydrochlorothiazide 25mg/valsartan 320mg tab

2HYDROCHLOROTHIAZIDE 50MG/METOPROLOL TARTRATE 100MG TAB

3TEKTURNA HCT 150-12.5MG TAB

3TEKTURNA HCT 150-25MG TAB

3TEKTURNA HCT 300-12.5MG TAB

3TEKTURNA HCT 300-25MG TAB

3TRANDOLAPRIL 1MG/VERAPAMIL 240MG ER TAB




2trandolapril 4mg/verapamil 240mg er tabDIRECT RENIN INHIBITORS

2aliskiren 150mg tab

2aliskiren 300mg tabSELECTIVE ALDOSTERONE RECEPTOR ANTAGONISTS (SARAS)

2eplerenone 25mg tab

2eplerenone 50mg tabVASODILATORS

1hydralazine 100mg tab




1minoxidil 10mg tab

1minoxidil 2.5mg tab

ANTI-INFECTIVE AGENTS - MISC.ANTI-INFECTIVE AGENTS - MISC.

4IMPAVIDO 50MG CAP NDS PA QL=84 Quantity/28 Days

1metronidazole 250mg tab

1metronidazole 500mg tab

2metronidazole 5mg/ml inj

2METRONIDAZOLE/NACL 0.74%-500MG/100ML INJ

2metronidazole/nacl 0.74%/500mg/100ml inj

2pentamidine isethionate 300mg inj

2pentamidine isethionate 50mg/ml inh soln PA_BvD QL=1 Quantity/28 Days

2tinidazole 250mg tab

2tinidazole 500mg tab

1trimethoprim 100mg tab

1TRIMETHOPRIM 100MG TAB

3XIFAXAN 200MG TAB QL=9 Quantity/3 Days

3XIFAXAN 550MG TAB PA QL=60 Quantity/30 DaysANTI-INFECTIVE MISC. - COMBINATIONS


41


1sulfamethoxazole 400mg/trimethoprim 80mg tab

1sulfamethoxazole 40mg/ml/trimethoprim 8mg/ml susp

1sulfamethoxazole 800mg/trimethoprim 160mg tabANTIPROTOZOAL AGENTS

2atovaquone 150mg/ml susp

2nitazoxanide 500mg tab PA QL=6 Quantity/3 DaysCARBAPENEMS

2CILASTATIN 250MG/IMIPENEM 250MG INJ

2cilastatin 500mg/imipenem 500mg inj

2ertapenem 1000mg inj

2MEROPENEM 0.9%-1GM-50ML INJ

2meropenem 1000mg inj

2meropenem 500mg inj

2MEROPENEM 500MG/50ML INJCYCLIC LIPOPEPTIDES

4daptomycin 500mg inj NDSGLYCOPEPTIDES

4DALVANCE 500MG INJ NDS

2FIRVANQ 25MG/ML ORAL SOLN

2FIRVANQ 50MG/ML ORAL SOLN

2VANCOMYCIN 1.25GM IV SOLN

2vancomycin 1000mg inj

2VANCOMYCIN 100GM INJ

2vancomycin 100mg/ml inj

2vancomycin 125mg cap QL=120 Quantity/30 Days

2vancomycin 250mg cap QL=120 Quantity/30 Days

2VANCOMYCIN 250MG INJ


2vancomycin 5gm inj


2VANCOMYCIN 750MG INJLEPROSTATICS

1dapsone 100mg tab

1dapsone 25mg tabLINCOSAMIDES

2clindamycin 12mg/ml inj

1clindamycin 150mg cap

2clindamycin 150mg/ml (2ml) inj



2clindamycin 15mg/ml oral soln





2clindamycin 9gm/60ml inj


42


2CLINDAMYCIN/NACL 300MG/50ML-9% IV SOLN

2CLINDAMYCIN/NACL 9%-600MG/50ML IV SOLN

2CLINDAMYCIN/NACL 9%-900MG/50ML IV SOLNMONOBACTAMS

2aztreonam 1000mg inj

4CAYSTON 75MG INH SOLN LD NDS PA QL=84 Quantity/28 DaysOXAZOLIDINONES

2linezolid 20mg/ml susp

2LINEZOLID 2MG/ML INJ

2linezolid 2mg/ml inj

2linezolid 600mg tab

4SIVEXTRO 200MG INJ NDS PA QL=6 Quantity/6 Days

4SIVEXTRO 200MG TAB NDS PA QL=6 Quantity/6 DaysPLEUROMUTILINS

2XENLETA 600MG TAB PA QL=14 Quantity/7 DaysPOLYMYXINS

2colistin 75mg/ml inj

2polymyxin b 250000unit/ml injURINARY ANTI-INFECTIVES

2fosfomycin 3000mg powder for oral soln

2methenamine hippurate 1gm tab

1*methenamine mandelate tab

1nitrofurantoin 100mg cap

1nitrofurantoin 50mg macro cap

1nitrofurantoin macro 100mg cap

ANTIMALARIALSANTIMALARIAL COMBINATIONS

2atovaquone 250mg/proguanil 100mg tab

2atovaquone 62.5mg/proguanil 25mg tab

2COARTEM 20-120MG TABANTIMALARIALS

2chloroquine phosphate 250mg tab

1CHLOROQUINE PHOSPHATE 500MG TAB

1hydroxychloroquine sulfate 200mg tab

2KRINTAFEL 150MG TAB

2mefloquine hcl 250mg tab

2primaquine phosphate 26.3mg tab

2PRIMAQUINE PHOSPHATE 26.3MG TAB

2quinine sulfate 324mg cap PA

ANTIMYASTHENIC AGENTSANTIMYASTHENIC AGENTS

1pyridostigmine bromide 60mg tab

ANTIMYASTHENIC/CHOLINERGIC AGENTSANTIMYASTHENIC/CHOLINERGIC AGENTS

2pyridostigmine bromide 12mg/ml oral soln

2pyridostigmine bromide 180mg er tab


43


4RUZURGI 10MG TAB LD NDS PA

ANTIMYCOBACTERIAL AGENTSANTIMYCOBACTERIAL AGENTS

2ethambutol 100mg tab

2ethambutol 400mg tab

1ISONIAZID 100MG TAB

2ISONIAZID 10MG/ML ORAL SOLN

1isoniazid 300mg tab

2PASER D/R 4GM GRANULES

2PRETOMANID 200MG TAB QL=30 Quantity/30 Days

3PRIFTIN 150MG TAB

1pyrazinamide 500mg tab

2rifabutin 150mg cap

2rifampin 150mg cap

2rifampin 300mg cap

2rifampin 600mg inj

4SIRTURO 100MG TAB NDS PA

4SIRTURO 20MG TAB NDS PA

3TRECATOR 250MG TAB

ANTINEOPLASTICS AND ADJUNCTIVE THERAPIESALKYLATING AGENTS

$0*ALKERAN TAB

2CYCLOPHOSPHAMIDE 25MG CAP PA_BvD

2cyclophosphamide 25mg cap PA_BvD

2CYCLOPHOSPHAMIDE 25MG TAB PA_BvD

2CYCLOPHOSPHAMIDE 50MG CAP PA_BvD

2cyclophosphamide 50mg cap PA_BvD

2CYCLOPHOSPHAMIDE 50MG TAB PA_BvD

2LEUKERAN 2MG TAB

$0*melphalan tab

$0*MYLERAN TAB

$0*temozolomide capANTIMETABOLITES

$0*capecitabine tab

2mercaptopurine 50mg tab

1methotrexate 2.5mg tab

1METHOTREXATE 250MG/10ML INJ

1methotrexate 25mg/ml (2ml) inj

1methotrexate 25mg/ml inj

4ONUREG 200MG TAB NDS PA_NSO QL=14 Quantity/28 Days

4ONUREG 300MG TAB NDS PA_NSO QL=14 Quantity/28 Days

3PURIXAN 2000MG/100ML SUSP

2TABLOID 40MG TAB

3XATMEP 2.5MG/ML ORAL SOLN PA


44


ANTINEOPLASTIC - ANGIOGENESIS INHIBITORS

4INLYTA 1MG TAB NDS PA_NSO

4INLYTA 5MG TAB NDS PA_NSO

4LENVIMA CAP THERAPY PACK (10MG) LD NDS PA_NSO QL=30 Quantity/30 Days








ANTINEOPLASTIC - ANTI-HER2 AGENTS

4TUKYSA 150MG TAB LD NDS PA_NSO QL=120 Quantity/30 Days

4TUKYSA 50MG TAB LD NDS PA_NSO QL=120 Quantity/30 Days

ANTINEOPLASTIC - BCL-2 INHIBITORS

4VENCLEXTA 100MG TAB LD NDS PA_NSO

2VENCLEXTA 10MG TAB LD PA_NSO

2VENCLEXTA 50MG TAB LD PA_NSO

4VENCLEXTA STARTING PACK LD NDS PA_NSOANTINEOPLASTIC - EGFR INHIBITORS

2erlotinib 100mg tab PA_NSO



4GILOTRIF 20MG TAB LD NDS PA_NSO QL=30 Quantity/30 Days



4IRESSA 250MG TAB LD NDS PA_NSO

4TAGRISSO 40MG TAB LD NDS PA_NSO

4TAGRISSO 80MG TAB LD NDS PA_NSO

4VIZIMPRO 15MG TAB NDS PA_NSO QL=30 Quantity/30 Days



45



ANTINEOPLASTIC - HEDGEHOG PATHWAY INHIBITORS

4DAURISMO 100MG TAB NDS PA_NSO

4DAURISMO 25MG TAB NDS PA_NSO

4ERIVEDGE 150MG CAP NDS PA_NSO

4ODOMZO 200MG CAP NDS PA_NSOANTINEOPLASTIC - HORMONAL AGENTS

$0anastrozole 1mg tab

1bicalutamide 50mg tab

3ELIGARD 22.5MG INJ QL=1 Quantity/84 Days

3ELIGARD 30MG INJ QL=1 Quantity/112 Days

3ELIGARD 45MG INJ QL=1 Quantity/168 Days

3ELIGARD 7.5MG INJ QL=1 Quantity/28 Days

2EMCYT 140MG CAP

$0exemestane 25mg tab

2flutamide 125mg cap

1letrozole 2.5mg tab

2leuprolide acetate 5mg/ml inj

4LUPRON 11.25MG INJ QL=1 Quantity/84 Days



4LUPRON 30MG INJ QL=1 Quantity/112 Days

4LUPRON 45MG INJ QL=1 Quantity/168 Days


2LYSODREN 500MG TAB LD

1megestrol acetate 20mg tab PA_NSO

1megestrol acetate 40mg tab PA_NSO

1megestrol acetate 40mg/ml susp PA

$0tamoxifen 10mg tab

$0tamoxifen 20mg tab

4TRELSTAR 11.25MG INJ QL=1 Quantity/84 Days

4TRELSTAR 22.5MG INJ QL=1 Quantity/168 Days

4TRELSTAR 3.75MG INJ QL=1 Quantity/28 DaysANTINEOPLASTIC - HORMONAL AND RELATED AGENTS

1abiraterone acetate 250mg tab QL=120 Quantity/30 Days

4ERLEADA 60MG TAB NDS PA_NSO QL=120 Quantity/30 Days

2FIRMAGON 120MG INJ PA_NSO

2FIRMAGON 80MG INJ PA_NSO

2FLUTAMIDE 125MG CAP

4nilutamide 150mg tab NDS

4NUBEQA 300MG TAB NDS PA_NSO QL=120 Quantity/30 Days

4ORGOVYX 120MG TAB LD NDS PA_NSO QL=30 Quantity/28 Days


46


3SOLTAMOX 10MG/5ML ORAL SOLN PA_NSO

2toremifene 60mg tab

4XTANDI 40MG CAP NDS PA_NSO QL=120 Quantity/30 Days

ANTINEOPLASTIC - IMMUNOMODULATORS

4POMALYST 1MG CAP NDS PA_NSO



4POMALYST 4MG CAP NDS PA_NSOANTINEOPLASTIC - PDGFR-ALPHA INHIBITORS

4AYVAKIT 100MG TAB LD NDS PA_NSO QL=30 Quantity/30 Days





ANTINEOPLASTIC - XPO1 INHIBITORS

4XPOVIO 100 MG ONCE WEEKLY LD NDS PA_NSO QL=20 Quantity/28 Days

4XPOVIO 100MG ONCE WEEKLY CARTON (8-PACK) LD NDS PA_NSO QL=8 Quantity/28 Days


4XPOVIO 40MG ONCE WEEKLY PACK LD NDS PA_NSO QL=8 Quantity/28 Days

4XPOVIO 40MG TWICE WEEKLY CARTON (8-PACK) LD NDS PA_NSO QL=8 Quantity/28 Days

4XPOVIO 40MG TWICE WEEKLY PACK LD NDS PA_NSO QL=16 Quantity/28 Days



4XPOVIO 60MG TWICE WEEKLY PACK LD NDS PA_NSO QL=24 Quantity/28 Days


4XPOVIO 80 MG TWICE WEEKLY LD NDS PA_NSO QL=32 Quantity/28 Days


ANTINEOPLASTIC COMBINATIONS


47


4INQOVI 5 TABLET PACK LD NDS PA_NSO QL=1 Quantity/28 Days

4KISQALI FEMARA CO-PACK 200 PACK NDS PA_NSO QL=49 Quantity/28 Days



4LONSURF 6.14-15MG TAB LD NDS PA_NSO

4LONSURF 8.19-20MG TAB LD NDS PA_NSOANTINEOPLASTIC ENZYME INHIBITORS

4ALECENSA 150MG CAP NDS PA_NSO QL=240 Quantity/30 Days

4ALUNBRIG 180MG TAB LD NDS PA_NSO QL=30 Quantity/30 Days



4ALUNBRIG TAB STARTER PACK NDS PA_NSO QL=30 Quantity/30 Days

4BALVERSA 3MG TAB LD NDS PA_NSO QL=60 Quantity/30 Days



4BOSULIF 100MG TAB NDS PA_NSO



4BRAFTOVI 75MG CAP LD NDS PA_NSO QL=180 Quantity/30 Days

4BRUKINSA 80MG CAP LD NDS PA_NSO QL=120 Quantity/30 Days

4CABOMETYX 20MG TAB NDS PA_NSO



4CALQUENCE 100MG CAP LD NDS PA_NSO QL=60 Quantity/30 Days

4CAPRELSA 100MG TAB LD NDS PA_NSO QL=60 Quantity/30 Days

4CAPRELSA 300MG TAB LD NDS PA_NSO QL=30 Quantity/30 Days

4COMETRIQ CAP (100MG) DOSE PACK LD NDS PA_NSO

4COMETRIQ CAP DOSE PACK (140MG) LD NDS PA_NSO

4COMETRIQ CAP DOSE PACK (60MG) LD NDS PA_NSO


48


4COPIKTRA 15MG CAP LD NDS PA_NSO QL=60 Quantity/30 Days

4COPIKTRA 25MG CAP LD NDS PA_NSO QL=60 Quantity/30 Days

4COTELLIC 20MG TAB NDS PA_NSO QL=63 Quantity/28 Days

4everolimus 10mg tab NDS PA_NSO QL=30 Quantity/30 Days

1everolimus 2.5mg tab PA_NSO QL=30 Quantity/30 Days

4everolimus 2mg tab for oral susp NDS PA_NSO


1everolimus 5mg tab PA_NSO QL=30 Quantity/30 Days


1everolimus 7.5mg tab PA_NSO QL=30 Quantity/30 Days

4FARYDAK 10MG CAP NDS PA_NSO



4FOTIVDA 0.89MG CAP NDS PA_NSO QL=21 Quantity/28 Days

4FOTIVDA 1.34MG CAP NDS PA_NSO QL=21 Quantity/28 Days

4GAVRETO 100MG CAP LD NDS PA_NSO QL=120 Quantity/30 Days

4IBRANCE 100MG CAP NDS PA_NSO QL=21 Quantity/28 Days

4IBRANCE 100MG TAB NDS PA_NSO QL=21 Quantity/28 Days





4ICLUSIG 10MG TAB LD NDS PA_NSO QL=30 Quantity/30 Days




4IDHIFA 100MG TAB NDS PA_NSO QL=30 Quantity/30 Days


49


4IDHIFA 50MG TAB NDS PA_NSO QL=30 Quantity/30 Days

1imatinib 100mg tab

1imatinib 400mg tab

4IMBRUVICA 140MG CAP LD NDS PA_NSO QL=90 Quantity/30 Days

4IMBRUVICA 140MG TAB LD NDS PA_NSO QL=30 Quantity/30 Days




4IMBRUVICA 70MG CAP LD NDS PA_NSO QL=30 Quantity/30 Days

4INREBIC 100MG CAP NDS PA_NSO QL=120 Quantity/30 Days

4JAKAFI 10MG TAB NDS PA_NSO QL=60 Quantity/30 Days





4KISQALI 200MG DAILY DOSE PACK NDS PA_NSO QL=21 Quantity/28 Days



4KOSELUGO 10MG CAP LD NDS PA_NSO QL=120 Quantity/30 Days

4KOSELUGO 25MG CAP LD NDS PA_NSO QL=120 Quantity/30 Days

4lapatinib ditosylate 250mg tab NDS PA_NSO

4LORBRENA 100MG TAB NDS PA_NSO QL=30 Quantity/30 Days

4LORBRENA 25MG TAB NDS PA_NSO QL=90 Quantity/30 Days

4LUMAKRAS 120MG TAB NDS PA_NSO QL=240 Quantity/30 Days


50


4LYNPARZA 100MG TAB LD NDS PA_NSO QL=120 Quantity/30 Days

4LYNPARZA 150MG TAB LD NDS PA_NSO QL=120 Quantity/30 Days

4MEKINIST 0.5MG TAB NDS PA_NSO QL=90 Quantity/30 Days

4MEKINIST 2MG TAB NDS PA_NSO QL=30 Quantity/30 Days

4MEKTOVI 15MG TAB LD NDS PA_NSO QL=180 Quantity/30 Days

4NERLYNX 40MG TAB LD NDS PA_NSO

4NEXAVAR 200MG TAB NDS PA_NSO

4NINLARO 2.3MG CAP NDS PA_NSO

4NINLARO 3MG CAP NDS PA_NSO

4NINLARO 4MG CAP NDS PA_NSO

4PEMAZYRE 13.5MG TAB LD NDS PA_NSO QL=14 Quantity/21 Days

4PEMAZYRE 4.5MG TAB LD NDS PA_NSO QL=14 Quantity/21 Days

4PEMAZYRE 9MG TAB LD NDS PA_NSO QL=14 Quantity/21 Days

4PIQRAY 200MG DAILY DOSE PACK NDS PA_NSO QL=30 Quantity/30 Days

4PIQRAY 250MG DAILY DOSE PACK NDS PA_NSO QL=60 Quantity/30 Days

4PIQRAY 300MG DAILY DOSE 150MG PACK NDS PA_NSO QL=60 Quantity/30 Days

4QINLOCK 50MG TAB LD NDS PA_NSO QL=90 Quantity/30 Days

4RETEVMO 40MG CAP NDS PA_NSO QL=120 Quantity/30 Days

4RETEVMO 80MG CAP NDS PA_NSO QL=120 Quantity/30 Days

4ROZLYTREK 100MG CAP NDS PA_NSO QL=150 Quantity/30 Days

4ROZLYTREK 200MG CAP NDS PA_NSO QL=90 Quantity/30 Days

4RUBRACA 200MG TAB LD NDS PA_NSO QL=120 Quantity/30 Days



4RYDAPT 25MG CAP NDS PA_NSO

4SPRYCEL 100MG TAB NDS PA_NSO



51






4STIVARGA 40MG TAB NDS PA_NSO QL=84 Quantity/28 Days

4sunitinib malate 12.5mg cap NDS PA_NSO

4sunitinib malate 25mg cap NDS PA_NSO

4sunitinib malate 37.5mg cap NDS PA_NSO

4sunitinib malate 50mg cap NDS PA_NSO

4TABRECTA 150MG TAB NDS PA_NSO QL=120 Quantity/30 Days

4TABRECTA 200MG TAB NDS PA_NSO QL=120 Quantity/30 Days

4TAFINLAR 50MG CAP NDS PA_NSO QL=120 Quantity/30 Days

4TAFINLAR 75MG CAP NDS PA_NSO QL=120 Quantity/30 Days

4TALZENNA 0.25MG CAP NDS PA_NSO QL=90 Quantity/30 Days

4TALZENNA 1MG CAP NDS PA_NSO QL=30 Quantity/30 Days

4TASIGNA 150MG CAP NDS PA_NSO



4TAZVERIK 200MG TAB LD NDS PA_NSO QL=240 Quantity/30 Days

4TEPMETKO 225MG TAB NDS PA_NSO QL=60 Quantity/30 Days

4TIBSOVO 250MG TAB LD NDS PA_NSO QL=60 Quantity/30 Days

4TURALIO 200MG CAP LD NDS PA_NSO QL=120 Quantity/30 Days

4UKONIQ 200MG TAB NDS PA_NSO QL=120 Quantity/30 Days

4VERZENIO 100MG TAB NDS PA_NSO QL=56 Quantity/28 Days




4VITRAKVI 100MG CAP LD NDS PA_NSO

4VITRAKVI 20MG/ML ORAL SOLN LD NDS PA_NSO

4VITRAKVI 25MG CAP LD NDS PA_NSO


52


4VOTRIENT 200MG TAB NDS PA_NSO

4XALKORI 200MG CAP NDS PA_NSO QL=60 Quantity/30 Days

4XALKORI 250MG CAP NDS PA_NSO QL=60 Quantity/30 Days

4XOSPATA 40MG TAB LD NDS PA_NSO

4ZEJULA 100MG CAP LD NDS PA_NSO QL=90 Quantity/30 Days

4ZELBORAF 240MG TAB NDS PA_NSO QL=240 Quantity/30 Days

4ZOLINZA 100MG CAP NDS PA_NSO

4ZYDELIG 100MG TAB LD NDS PA_NSO QL=60 Quantity/30 Days

4ZYDELIG 150MG TAB LD NDS PA_NSO QL=60 Quantity/30 Days

4ZYKADIA 150MG TAB NDS PA_NSO QL=90 Quantity/30 Days

ANTINEOPLASTICS MISC.

4ACTIMMUNE 2000000UNIT/0.5ML INJ LD NDS PA_NSO

2bexarotene 75mg cap PA_NSO

1hydroxyurea 500mg cap

2INTRON A 10MU INJ

2INTRON A 10MU/ML INJ

4INTRON A 18MU INJ NDS

4INTRON A 50MU INJ NDS

2INTRON A 6000000UNIT/ML INJ

4MATULANE 50MG CAP NDS

4SYNRIBO 3.5MG INJ NDS PA_NSO

1tretinoin 10mg capCHEMOTHERAPY RESCUE/ANTIDOTE AGENTS

2leucovorin 10mg tab



1leucovorin 5mg tab

2MESNEX 400MG TAB

ANTIPARKINSON AGENTSANTIPARKINSON ADJUVANTS

2carbidopa 25mg tabANTIPARKINSON ANTICHOLINERGICS

1benztropine mesylate 0.5mg tab

1benztropine mesylate 1mg tab

1benztropine mesylate 2mg tab

1trihexyphenidyl 2mg tab

1trihexyphenidyl 5mg tabANTIPARKINSON COMT INHIBITORS

2entacapone 200mg tab


53


2tolcapone 100mg tabANTIPARKINSON DOPAMINERGICS

1amantadine 100mg cap

2amantadine 100mg tab

1amantadine 10mg/ml oral soln

2bromocriptine 2.5mg tab

2bromocriptine 5mg cap

1carbidopa 10mg/levodopa 100mg tab

2CARBIDOPA 12.5MG/ENTACAPONE 200MG/LEVODOPA 50MG TAB

2CARBIDOPA 25MG/ENTACAPONE 200MG/LEVODOPA 100MG TAB, STALEVO 25-200-100MG TAB

1carbidopa 25mg/levodopa 100mg er tab



2CARBIDOPA 31.25MG/ENTACAPONE 200MG/LEVODOPA 125MG TAB, STALEVO 31.25-200-125MG TAB

2CARBIDOPA 37.5MG/ENTACAPONE 200MG/LEVODOPA 150MG TAB

1carbidopa 50mg/levodopa 200mg er tab

2CARBIDOPA/LEVODOPA/ENTACAPONE 50-200-200MG TAB

2CARBIDOPA/LEVODOPA/ENTACAPONE18.75-75-200MG TAB, STALEVO 12.5-200-50MG TAB

3NEUPRO 1MG/24HR PATCH






1pramipexole 0.125mg tab


2pramipexole 0.375mg er tab






1pramipexole 1mg tab



2pramipexole 3mg er tab


1ropinirole 0.25mg tab


54


1ropinirole 0.5mg tab

2ropinirole 12mg er tab

1ropinirole 1mg tab


1ropinirole 2mg tab

1ropinirole 3mg tab


1ropinirole 4mg tab

1ropinirole 5mg tab



3STALEVO 12.5-200-50MG TAB

3STALEVO 37.5-200-150MG TAB

3STALEVO 50-200-200MG TABANTIPARKINSON MONOAMINE OXIDASE INHIBITORS

2rasagiline 0.5mg tab RXC

2rasagiline 1mg tab RXC

1selegiline 5mg cap

2selegiline 5mg tab

ANTIPARKINSON AND RELATED THERAPY AGENTSANTIPARKINSON ADJUNCTIVE THERAPY

3NOURIANZ 20MG TAB LD PA QL=30 Quantity/30 Days

3NOURIANZ 40MG TAB LD PA QL=30 Quantity/30 DaysANTIPARKINSON ANTICHOLINERGICS

1trihexyphenidyl 0.4mg/ml oral solnANTIPARKINSON COMT INHIBITORS

3ONGENTYS 25MG CAP PA QL=30 Quantity/30 Days

3ONGENTYS 50MG CAP PA QL=30 Quantity/30 DaysANTIPARKINSON DOPAMINERGICS

1amantadine 10mg/ml oral soln

1CARBIDOPA/LEVODOPA 10-100MG ODT

1CARBIDOPA/LEVODOPA 10-250MG ODT TAB

1CARBIDOPA/LEVODOPA 25-100MG ODT TAB

4KYNMOBI 10MG SUBLINGUAL FILM NDS PA




4KYNMOBI 30MG SUBLINGUAL FILM NDS PAANTIPARKINSON MONOAMINE OXIDASE INHIBITORS

2SELEGILINE 5MG TAB

ANTIPSYCHOTICS/ANTIMANIC AGENTSANTIMANIC AGENTS

1LITHIUM CARBONATE 150MG CAP

1lithium carbonate 150mg cap




55


1lithium carbonate 300mg er tab

1lithium carbonate 300mg tab

1lithium carbonate 450mg er tab



1LITHIUM CITRATE 60MG/ML ORAL SOLNANTIPSYCHOTICS - MISC.

3CAPLYTA 42MG CAP PA_NSO QL=30 Quantity/30 Days

2LATUDA 120MG TAB ST_NSO RXC QL=30 Quantity/30 Days





3NUPLAZID 10MG TAB PA_NSO QL=30 Quantity/30 Days

3NUPLAZID 34MG CAP PA_NSO QL=30 Quantity/30 Days

3VRAYLAR 1.5/3MG MIXED PACK PA_NSO QL=30 Quantity/30 Days

3VRAYLAR 1.5MG CAP PA_NSO QL=30 Quantity/30 Days

3VRAYLAR 3MG CAP PA_NSO QL=30 Quantity/30 Days

3VRAYLAR 4.5MG CAP PA_NSO QL=30 Quantity/30 Days

3VRAYLAR 6MG CAP PA_NSO QL=30 Quantity/30 Days

1ziprasidone 20mg cap

2ziprasidone 20mg inj QL=60 Quantity/30 Days



1ziprasidone 80mg capBENZISOXAZOLES

3FANAPT 10MG TAB PA_NSO QL=60 Quantity/30 Days







3FANAPT TITRATION PACK PA_NSO QL=60 Quantity/30 Days

3INVEGA 117MG/0.75ML INJ QL=.75 Quantity/28 Days

3INVEGA 156MG/ML INJ QL=1 Quantity/28 Days

3INVEGA 234MG/1.5ML INJ QL=1.50 Quantity/28 Days






56




2paliperidone 1.5mg er tab QL=30 Quantity/30 Days

2paliperidone 3mg er tab QL=30 Quantity/30 Days



4PERSERIS 120MG INJ NDS QL=1 Quantity/28 Days

4PERSERIS 90MG INJ NDS QL=1 Quantity/28 Days

3RISPERDAL 12.5MG INJ QL=2 Quantity/28 Days

3RISPERDAL 25MG INJ QL=2 Quantity/28 Days

3RISPERDAL 37.5MG INJ QL=2 Quantity/28 Days

3RISPERDAL 50MG INJ QL=2 Quantity/28 Days

2RISPERIDONE 0.25MG ODT

1risperidone 0.25mg tab

2risperidone 0.5mg odt

1risperidone 0.5mg tab

2risperidone 1mg odt

1risperidone 1mg tab

1risperidone 1mg/ml oral soln






1risperidone 4mg tabBUTYROPHENONES

1haloperidol 0.5mg tab

1haloperidol 10mg tab




1haloperidol 2mg/ml oral soln


2haloperidol 5mg/ml inj

2haloperidol decanoate 100mg/ml inj

2haloperidol decanoate 50mg/ml injDIBENZAPINES

2asenapine 10mg sl tab PA_NSO QL=60 Quantity/30 Days

2asenapine 2.5mg sl tab PA_NSO QL=60 Quantity/30 Days

2asenapine 5mg sl tab PA_NSO QL=60 Quantity/30 Days

2clozapine 100mg odt

2clozapine 100mg tab

2CLOZAPINE 12.5MG ODT

3CLOZAPINE 150MG ODT

3CLOZAPINE 200MG ODT

2clozapine 200mg tab


57


2clozapine 25mg odt

2clozapine 25mg tab

2clozapine 50mg tab

1loxapine 10mg cap

1loxapine 25mg cap

1loxapine 50mg cap

1loxapine 5mg cap

2olanzapine 10mg inj

2olanzapine 10mg odt

1olanzapine 10mg tab



1olanzapine 2.5mg tab



2olanzapine 5mg odt

1olanzapine 5mg tab

1olanzapine 7.5mg tab

1quetiapine 100mg tab

1quetiapine 150mg er tab










3SECUADO 3.8MG/24HR PATCH PA_NSO QL=30 Quantity/30 Days



3VERSACLOZ 50MG/ML SUSP

3ZYPREXA RELPREVV 210MG INJ QL=2 Quantity/28 DaysDIHYDROINDOLONES

3MOLINDONE 10MG TAB

3MOLINDONE 25MG TAB

3MOLINDONE 5MG TABPHENOTHIAZINES

1chlorpromazine 100mg tab

3CHLORPROMAZINE 100MG/ML ORAL SOLN




3CHLORPROMAZINE 30MG/ML ORAL SOLN



58


2FLUPHENAZINE 0.5MG/ML ORAL SOLN

2fluphenazine 10mg tab


2fluphenazine 2.5mg tab

2FLUPHENAZINE 2.5MG/ML INJ


2FLUPHENAZINE 5MG/ML ORAL SOLN

2fluphenazine decanoate 25mg/ml inj

1perphenazine 16mg tab




1prochlorperazine 10mg tab

1prochlorperazine 25mg rectal supp

1prochlorperazine 5mg tab

1thioridazine 100mg tab




1trifluoperazine 10mg tab



1trifluoperazine 5mg tabQUINOLINONE DERIVATIVES

4ABILIFY 300MG INJ NDS QL=1 Quantity/28 Days

4ABILIFY 300MG SYRINGE NDS QL=1 Quantity/28 Days

4ABILIFY 400MG INJ NDS QL=1 Quantity/28 Days

4ABILIFY 400MG SYRINGE NDS QL=1 Quantity/28 Days

2aripiprazole 10mg odt QL=60 Quantity/30 Days

1aripiprazole 10mg tab

2aripiprazole 15mg odt QL=60 Quantity/30 Days


2aripiprazole 1mg/ml oral soln





4ARISTADA 1064MG/3.9ML INJ QL=3.90 Quantity/56 Days

4ARISTADA 441MG/1.6ML INJ NDS QL=1.60 Quantity/28 Days



4ARISTADA 882MG/3.2ML INJ QL=3.20 Quantity/28 Days

3REXULTI 0.25MG TAB PA_NSO QL=30 Quantity/30 Days

3REXULTI 0.5MG TAB PA_NSO QL=30 Quantity/30 Days

3REXULTI 1MG TAB PA_NSO QL=30 Quantity/30 Days



59



3REXULTI 4MG TAB PA_NSO QL=30 Quantity/30 DaysTHIOXANTHENES

1thiothixene 10mg cap




ANTIVIRALSANTIRETROVIRALS

2abacavir 20mg/ml oral soln

2abacavir 300mg tab

2abacavir 300mg/lamivudine 150mg/zidovudine 300mg tab

2abacavir 600mg/lamivudine 300mg tab

4APTIVUS 250MG CAP

2atazanavir 150mg cap



4BIKTARVY 50-200-25MG TAB

4CIMDUO 300-300MG TAB, TEMIXYS 300-300MG TAB

4COMPLERA 200-25-300MG TAB

2CRIXIVAN 200MG CAP

2CRIXIVAN 400MG CAP

4DELSTRIGO 100-300-300MG TAB

4DESCOVY 200-25MG TAB QL=30 Quantity/30 Days

4DOVATO 50-300MG TAB

4EDURANT 25MG TAB

2efavirenz 200mg cap

2efavirenz 400mg/lamivudine 300mg/tenofovir disoproxil fumarate 300mg tab

2efavirenz 50mg cap

2efavirenz 600mg tab

4efavirenz 600mg/emtricitabine 200mg/tenofovir disoproxil fumarate 300mg tab

2efavirenz/lamivudine/tenofovir disoproxil fumarate 600-300-300mg tab

$0emtricitabine 100mg/tenofovir disoproxil fumarate 150mg tab


2emtricitabine 200mg cap

$0emtricitabine 200mg/tenofovir disoproxil fumarate 300mg tab


$0emtricitabine/tenofovir disoproxil fumarate 133-200mg tab


$0emtricitabine/tenofovir disoproxil fumarate 167-250mg tab



60


2EMTRIVA 10MG/ML ORAL SOLN

2etravirine 100mg tab

2etravirine 200mg tab

4EVOTAZ 300-150MG TAB

4fosamprenavir 700mg tab

4FUZEON 90MG INJ

4GENVOYA 150-150-200-10MG TAB

3INTELENCE 25MG TAB

4INVIRASE 500MG TAB

2ISENTRESS 100MG CHEW TAB

2ISENTRESS 100MG GRANULES FOR ORAL SUSP

2ISENTRESS 25MG CHEW TAB

2ISENTRESS 400MG TAB

2ISENTRESS 600MG TAB

4JULUCA 50-25MG TAB

2lamivudine 10mg/ml oral soln

2lamivudine 150mg tab

2lamivudine 150mg/zidovudine 300mg tab


2LEXIVA 50MG/ML SUSP

2lopinavir 80mg/ml/ritonavir 20mg/ml oral solution

2lopinavir/ritonavir 100-25mg tab

2lopinavir/ritonavir 200-50mg tab

2NEVIRAPINE 100MG ER TAB

2NEVIRAPINE 10MG/ML SUSP

1nevirapine 200mg tab

2nevirapine 400mg er tab

2NORVIR 100MG ORAL POWDER

2NORVIR 80MG/ML ORAL SOLN

4ODEFSEY 200-25-25MG TAB

4PIFELTRO 100MG TAB

4PREZCOBIX 150-800MG TAB

2PREZISTA 100MG/ML SUSP

2PREZISTA 150MG TAB

4PREZISTA 600MG TAB

2PREZISTA 75MG TAB

4PREZISTA 800MG TAB

4REYATAZ 50MG ORAL POWDER

2ritonavir 100mg tab

4RUKOBIA 600MG ER TAB

4SELZENTRY 150MG TAB

4SELZENTRY 20MG/ML ORAL SOLN

2SELZENTRY 25MG TAB

4SELZENTRY 300MG TAB

4SELZENTRY 75MG TAB

4STRIBILD 150-150-200-300MG TAB


61


4SYMTUZA 800-150-200-10MG TAB

2tenofovir disoproxil fumarate 300mg tab

3TIVICAY 10MG TAB

3TIVICAY 25MG TAB

4TIVICAY 50MG TAB

2TIVICAY 5MG TAB FOR ORAL SUSP

4TRIUMEQ 600-50-300MG TAB

2TYBOST 150MG TAB

4VIRACEPT 250MG TAB

4VIRACEPT 625MG TAB

4VIREAD 150MG TAB

4VIREAD 200MG TAB

4VIREAD 250MG TAB

2VIREAD 40MG/GM ORAL POWDER

2zidovudine 100mg cap

2zidovudine 10mg/ml oral soln

2zidovudine 300mg tabCMV AGENTS

4PREVYMIS 240MG TAB NDS PA QL=30 Quantity/30 Days

4PREVYMIS 480MG TAB NDS PA QL=30 Quantity/30 Days

2valganciclovir 450mg tab

4valganciclovir 50mg/ml oral soln NDSHEPATITIS AGENTS

2adefovir dipivoxil 10mg tab

2entecavir 0.5mg tab

2entecavir 1mg tab

2EPIVIR HBV 5MG/ML ORAL SOLN


4MAVYRET 100-40MG TAB NDS PA QL=90 Quantity/30 Days

4PEGASYS 180MCG/0.5ML SYRINGE NDS

4PEGASYS 180MCG/ML INJ NDS

4PEGASYS PROCLICK 180MCG/0.5ML INJ NDS

1ribavirin 200mg cap

1ribavirin 200mg tab

4SOFOSBUVIR/VELPATASVIR 400-100MG TAB NDS PA QL=30 Quantity/30 Days

4VEMLIDY 25MG TAB NDS

4VOSEVI 400-100-100MG TAB NDS PA QL=30 Quantity/30 DaysHERPES AGENTS

1acyclovir 200mg cap

1acyclovir 400mg tab

1acyclovir 40mg/ml susp

2acyclovir 50mg/ml inj PA_BvD

1acyclovir 800mg tab

2famciclovir 125mg tab




62


1valacyclovir 1000mg tab

1valacyclovir 500mg tabINFLUENZA AGENTS

1oseltamivir 30mg cap QL=84 Quantity/180 Days


2oseltamivir 6mg/ml susp QL=540 Quantity/180 Days


2RELENZA 5MG/BLISTER INH QL=120 Quantity/30 Days

2RIMANTADINE 100MG TAB

3XOFLUZA 40MG THERAPY PACK QL=2 Quantity/30 Days

ASSORTED CLASSESIMMUNOMODULATORS

4REVLIMID 10MG CAP NDS PA_NSO QL=30 Quantity/30 Days


4REVLIMID 2.5MG CAP NDS PA_NSO QL=30 Quantity/30 Days




4THALOMID 100MG CAP NDS PA_NSO



4THALOMID 50MG CAP NDS PA_NSOIMMUNOSUPPRESSIVE AGENTS

3ASTAGRAF 0.5MG ER CAP PA_BvD

3ASTAGRAF 1MG ER CAP PA_BvD

3ASTAGRAF 5MG ER CAP PA_BvD

1azathioprine 50mg tab PA_BvD

3CELLCEPT 200MG/ML SUSP PA_BvD

3CELLCEPT 250MG CAP PA_BvD

3CELLCEPT 500MG TAB PA_BvD

2cyclosporine 100mg cap PA_BvD

2cyclosporine 25mg cap PA_BvD

2cyclosporine modified 100mg cap PA_BvD

2cyclosporine modified 100mg/ml oral soln PA_BvD



3ENVARSUS 0.75MG ER TAB PA_BvD

3ENVARSUS 1MG ER TAB PA_BvD

3ENVARSUS 4MG ER TAB PA_BvD

2mycophenolate mofetil 200mg/ml susp PA_BvD


63


1mycophenolate mofetil 250mg cap PA_BvD

1mycophenolate mofetil 500mg tab PA_BvD

2mycophenolic acid 180mg dr tab PA_BvD

2mycophenolic acid 360mg dr tab PA_BvD

3MYFORTIC 180MG DR TAB PA_BvD

3MYFORTIC 360MG DR TAB PA_BvD

3NEORAL 100MG CAP PA_BvD

3NEORAL 100MG/ML ORAL SOLN PA_BvD

3NEORAL 25MG CAP PA_BvD

3PROGRAF 0.5MG CAP PA_BvD

3PROGRAF 1MG CAP PA_BvD

3PROGRAF 5MG CAP PA_BvD

3RAPAMUNE 0.5MG TAB PA_BvD

3RAPAMUNE 1MG TAB PA_BvD

3RAPAMUNE 2MG TAB PA_BvD

3SANDIMMUNE 100MG CAP PA_BvD

3SANDIMMUNE 100MG/ML ORAL SOLN PA_BvD

3SANDIMMUNE 25MG CAP PA_BvD

2sirolimus 0.5mg tab PA_BvD

2sirolimus 1mg tab PA_BvD

2sirolimus 2mg tab PA_BvD

1tacrolimus 0.5mg cap PA_BvD

1tacrolimus 1mg cap PA_BvD

1tacrolimus 5mg cap PA_BvDPOTASSIUM REMOVING RESINS

2sodium polystyrene sulfonate 15000mg powder for oral susp

1SPS 15GM/60ML SUSP

2VELTASSA 16.8GM POWDER FOR ORAL SUSP PA



BETA BLOCKERSALPHA-BETA BLOCKERS

$0carvedilol 12.5mg tab

$0carvedilol 25mg tab



$0*carvedilol phosphate ER 10mg cap




1labetalol 100mg tab

1labetalol 200mg tab

1labetalol 300mg tabBETA BLOCKERS CARDIO-SELECTIVE

1acebutolol 200mg cap


64


1acebutolol 400mg cap

$0atenolol 100mg tab

$0atenolol 25mg tab

$0atenolol 50mg tab

1betaxolol 10mg tab

1betaxolol 20mg tab

1bisoprolol fumarate 10mg tab

1bisoprolol fumarate 5mg tab

3*FIRST ATENOLOL ORAL SOLN

3*FIRST METOPROLOL ORAL SOLN

1metoprolol succinate 100mg er tab




$0metoprolol tartrate 100mg tab



2nebivolol 10mg tab RXC

2nebivolol 2.5mg tab RXC

2nebivolol 20mg tab RXC

2nebivolol 5mg tab RXCBETA BLOCKERS NON-SELECTIVE

3INNOPRAN 120MG ER CAP

3INNOPRAN 80MG ER CAP

2nadolol 20mg tab

2nadolol 40mg tab

2nadolol 80mg tab

1pindolol 10mg tab

1pindolol 5mg tab

1propranolol 10mg tab

1propranolol 120mg er cap

1propranolol 160mg ER cap



2PROPRANOLOL 4MG/ML ORAL SOLN





2PROPRANOLOL 8MG/ML ORAL SOLN

1sorine 120mg tab

1sorine 160mg tab

1sorine 240mg tab

1sotalol 120mg tab

1sotalol 80mg tab

1sotalol AF 160mg tab


65


1sotalol AF 80mg tab

1timolol 10mg tab

1timolol 20mg tab

1timolol 5mg tab

CALCIUM CHANNEL BLOCKERSCALCIUM CHANNEL BLOCKERS

1amlodipine 10mg tab

1amlodipine 2.5mg tab

1amlodipine 5mg tab

3CARDIZEM 120MG ER TAB

1cartia 180mg er cap



1dilt 120mg er cap

1dilt 180mg er cap

1dilt 240mg er cap

1diltiazem 120mg er (12 hr) cap

1diltiazem 120mg er (24 hr) cap

1diltiazem 120mg tab

2diltiazem 180mg er tab


1diltiazem 30mg tab

1diltiazem 360mg cd cap


1diltiazem 420mg er cap


1diltiazem 60mg tab


1diltiazem 90mg tab

1felodipine 10mg er tab

1felodipine 2.5mg er tab

1felodipine 5mg er tab

1isradipine 2.5mg cap

1isradipine 5mg cap

2matzim 240mg er tab

2matzim 420mg er tab

1nicardipine 20mg cap

1nicardipine 30mg cap

2nifedipine 10mg cap

2nifedipine 20mg cap

1nifedipine 30mg er tab

1nifedipine 30mg osmotic er tab






66


2nimodipine 30mg cap

2nisoldipine 17mg er tab

2NISOLDIPINE 20MG ER TAB

2NISOLDIPINE 25.5MG ER TAB


2nisoldipine 34mg er tab


2nisoldipine 8.5mg er tab

1taztia 120mg er cap





2VERAPAMIL 100MG ER CAP

2verapamil 120mg er cap

1verapamil 120mg er tab

1verapamil 120mg tab








1verapamil 40mg tab

1verapamil 80mg tab

3VERELAN 100MG ER CAP




CARDIOTONICSCARDIAC GLYCOSIDES

1digox 125mcg tab

1digoxin 0.05mg/ml oral soln

1DIGOXIN 0.05 MG/ML ORAL SOLN

1digoxin 0.25mg tab

1DIGOXIN ORAL 0.05MG/ML SOLN

3LANOXIN 125MCG TAB

3LANOXIN 250MCG TAB

CARDIOVASCULAR AGENTS - MISC.CARDIOVASCULAR AGENTS MISC. - COMBINATIONS

2amlodipine 10mg/atorvastatin 10mg tab




2amlodipine 2.5mg/atorvastatin 10mg tab


67








2BIDIL 37.5-20MG TAB

2ENTRESTO 24-26MG TAB QL=60 Quantity/30 Days

2ENTRESTO 49-51MG TAB QL=60 Quantity/30 Days

2ENTRESTO 97-103MG TAB QL=60 Quantity/30 DaysIMPOTENCE AGENTS

2CAVERJECT INJ QL=6 Quantity/30 Days

2*CAVERJECT INJ QL=6 Quantity/30 Days

2*EDEX 10MCG INJ KIT QL=3 Quantity/30 Days





2*EDEX INJ QL=1 Quantity/30 Days

2*MUSE SUPP QL=6 Quantity/30 Days

2*sildenafil tab QL=6 Quantity/30 Days

2*STENDRA TAB QL=6 Quantity/30 Days

2*tadalafil 10mg tab QL=6 Quantity/30 Days

2*tadalafil 2.5mg tab QL=6 Quantity/30 Days

2*tadalafil 5mg tab QL=6 Quantity/30 Days

2*tadalafil tab 20mg QL=6 Quantity/30 Days

2*vardenafil ODT QL=6 Quantity/30 Days

2*vardenafil tab QL=6 Quantity/30 DaysPERIPHERAL VASODILATORS

3*isoxsuprine tab

3*ISOXSUPRINE TABPROSTAGLANDIN VASODILATORS

3ORENITRAM 0.125MG ER TAB PA

4ORENITRAM 0.25MG ER TAB NDS PA

4ORENITRAM 1MG ER TAB NDS PA

4ORENITRAM 2.5MG ER TAB NDS PA

4ORENITRAM 5MG ER TAB NDS PA

4VENTAVIS 10MCG/ML INH SOLN LD NDS PA QL=270 Quantity/30 Days

4VENTAVIS 20MCG/ML INH SOLN LD NDS PA QL=270 Quantity/30 DaysPULMONARY HYPERTENSION - ENDOTHELIN RECEPTOR ANTAGONISTS

2ambrisentan 10mg tab LD PA QL=30 Quantity/30 Days

2ambrisentan 5mg tab LD PA QL=30 Quantity/30 Days

2bosentan 125mg tab LD PA QL=60 Quantity/30 Days

2bosentan 62.5mg tab LD PA QL=60 Quantity/30 Days

4OPSUMIT 10MG TAB LD NDS PA QL=30 Quantity/30 Days

4TRACLEER 32MG TAB FOR ORAL SUSP LD NDS PA QL=120 Quantity/30 Days


68


PULMONARY HYPERTENSION - PHOSPHODIESTERASE INHIBITORS

1sildenafil 20mg tab PA

1tadalafil 20mg tab (PAH) PAPULMONARY HYPERTENSION - PROSTACYCLIN RECEPTOR AGONIST

4UPTRAVI 1000MCG TAB LD NDS PA








4UPTRAVI TITRATION PACK LD NDS PA QL=200 Quantity/28 DaysPULMONARY HYPERTENSION - SOL GUANYLATE CYCLASE STIMULATOR

4ADEMPAS 0.5MG TAB LD NDS PA


4ADEMPAS 1MG TAB LD NDS PA


4ADEMPAS 2MG TAB LD NDS PASINUS NODE INHIBITORS

3CORLANOR 5MG TAB PA

3CORLANOR 5MG/5ML ORAL SOLN PA

3CORLANOR 7.5MG TAB PATRANSTHYRETIN STABILIZERS

4VYNDAMAX 61MG CAP NDS PA QL=30 Quantity/30 Days

4VYNDAQEL 20MG CAP NDS PA QL=120 Quantity/30 DaysVASOACTIVE SOLUBLE GUANYLATE CYCLASE STIMULATOR (SGC)

2VERICIGUAT 10MG TAB PA QL=30 Quantity/30 Days

2VERICIGUAT 2.5MG TAB PA QL=30 Quantity/30 Days

2VERICIGUAT 5MG TAB PA QL=30 Quantity/30 Days

CEPHALOSPORINSCEPHALOSPORIN COMBINATIONS

4AVYCAZ 500-2000MG INJ NDS

4ZERBAXA 1000-500MG INJ NDSCEPHALOSPORINS - 1ST GENERATION

1cefadroxil 100mg/ml susp

1cefadroxil 1gm tab

1CEFADROXIL 1GM TAB

1cefadroxil 500mg cap

1cefadroxil 50mg/ml susp

2cefazolin 1000mg inj

2CEFAZOLIN 100GM INJ

2CEFAZOLIN 1GM INJ

2cefazolin 200mg/ml inj

2CEFAZOLIN 20GM INJ

2CEFAZOLIN 300GM INJ


69


2cefazolin 500mg inj

2CEFAZOLIN/DEXTROSE 1GM-4% IV SOLN

2CEFAZOLIN/DEXTROSE 1GM/50ML-4% IV SOLN

1cephalexin 250mg cap

1cephalexin 25mg/ml susp

1cephalexin 500mg cap

1cephalexin 50mg/ml suspCEPHALOSPORINS - 2ND GENERATION

2cefaclor 250mg cap

2CEFACLOR 250MG CAP

3CEFACLOR 25MG/ML SUSP

2cefaclor 500mg cap

2CEFACLOR 500MG CAP

3CEFACLOR 500MG ER TAB



2cefotetan 1000mg inj

2cefotetan 2000mg inj

2CEFOTETAN/DEXTROSE 1GM/3.58% INJ

2CEFOTETAN/DEXTROSE 2GM-2.08% INJ

2cefoxitin 1000mg inj

2cefoxitin 2000mg inj

2cefoxitin 200mg/ml inj

2CEFOXITIN/DEXTROSE 1GM-4% INJ

2CEFOXITIN/DEXTROSE 2GM/2.2% INJ

1cefprozil 250mg tab

1cefprozil 25mg/ml susp

1cefprozil 500mg tab

1cefprozil 50mg/ml susp

2cefuroxime 1500mg inj

1cefuroxime 250mg tab

1cefuroxime 500mg tab

2cefuroxime 750mg inj

2cefuroxime 95mg/ml injCEPHALOSPORINS - 3RD GENERATION

1cefdinir 25mg/ml susp

1cefdinir 300mg cap

1cefdinir 50mg/ml susp

2cefixime 20mg/ml susp

2cefixime 400mg cap

2cefixime 40mg/ml susp

2cefpodoxime 100mg tab

2cefpodoxime 10mg/ml susp

2cefpodoxime 200mg tab

2cefpodoxime 20mg/ml susp

2ceftazidime 1000mg inj


70


2ceftazidime 200mg/ml inj

2CEFTAZIDIME/D5W 1GM/50ML INJ

2CEFTAZIDIME/DEXTROSE 2GM/50ML/5% INJ

2ceftriaxone 1000mg inj

2ceftriaxone 100mg/ml inj




2CEFTRIAXONE SODIUM 100GM INJ

2ceftriaxone sodium 1gm inj

2ceftriaxone sodium 2gm inj

2CEFTRIAXONE/DEXTROSE 1GM-3.74% IV SOLN

2CEFTRIAXONE/DEXTROSE 20MG/ML INJ

2CEFTRIAXONE/DEXTROSE 2GM-2.22% IV SOLN

2CEFTRIAXONE/DEXTROSE 40MG/ML INJ

3SUPRAX 100MG CHEW TAB

3SUPRAX 200MG CHEW TAB

3SUPRAX 500MG/5ML SUSP

2TAZICEF 1GM INJ

2tazicef 2gm inj

2TAZICEF 6GM INJCEPHALOSPORINS - 4TH GENERATION

2cefepime 1000mg inj

2CEFEPIME 1GM/50ML IV SOLN

2cefepime 2000mg inj

2CEFEPIME 2GM/100ML IV SOLN

2CEFEPIME/DEXTROSE 1GM/50ML-5% INJ

2CEFEPIME/DEXTROSE 2GM/50ML-5% INJCEPHALOSPORINS - 5TH GENERATION

4TEFLARO 400MG INJ NDS

4TEFLARO 600MG INJ NDS

CONTRACEPTIVESCOMBINATION CONTRACEPTIVES - ORAL

$0altavera 28 day pack

$0apri 28 day pack

$0aranelle 28 pack

$0ashlyna 91 day pack

$0briellyn 28 day pack

$0camreselo 91 day pack

$0caziant 28 day pack

$0cyclafem 7/7/7 28 day pack

$0desogestrel/ethinyl estradiol pack

$0dolishale 28 day pack

$0estarylla 28 day pack

$0ethinyl estradiol 0.02mg/inert ingredients 1mg/levonorgestrel 0.1mg pack


71


$0ethinyl estradiol 0.035mg/ethynodiol 1mg 28 day pack

$0ethinyl estradiol 0.035mg/inert/norgestimate 0.18mg/0.215mg/0.25mg pack

$0ethinyl estradiol 0.03mg/inert ingredients 1mg/levonorgestrel 0.15mg pack

$0ethinyl estradiol 0.05mg/ethynodiol 1mg/inert ingredients 1mg 28 day pack

$0ethinyl estradiol/levonorgestrel 91 day pack

$0jasmiel 28 day pack

2junel fe 1.5/30 28 day pack

2larin 1.5/30 pack

2larin 1/20 pack

$0layolis fe 28 pack

3LO LOESTRIN FE 28 DAY PACK

$0low-ogestrel 28 day pack

2melodetta 24 fe chewable 28 day pack

2microgestin fe 1/20 28 day pack

3NATAZIA 28 DAY PACK

$0nortrel 0.5/35 28 day pack

$0ocella 28 day pack

$0pirmella 1/35 28 day pack

2tarina 24 fe 1/20 28 day pack

$0tri-legest 28 day pack

$0tri-lo-sprintec 28 day pack

$0trivora 28 day pack

2tydemy 28 day pack

$0wymzya fe 28 day packCOMBINATION CONTRACEPTIVES - TRANSDERMAL

$0xulane 150-35mcg/24hr patchCOMBINATION CONTRACEPTIVES - VAGINAL

$0eluryng 0.120-0.015mg/24hr vaginal systemCOPPER CONTRACEPTIVES - IUD

$0*PARAGARD IUDEMERGENCY CONTRACEPTIVES

$0*levonorgestrel tab

$0*PLAN B TAB PROGESTIN CONTRACEPTIVES - IMPLANTS

$0*IMPLANON IMPLANT, NEXPLANON IMPLANTPROGESTIN CONTRACEPTIVES - INJECTABLE

$0medroxyprogesterone acetate 150mg/ml inj

$0medroxyprogesterone acetate 150mg/ml syringePROGESTIN CONTRACEPTIVES - IUD

$0*MIRENA IUDPROGESTIN CONTRACEPTIVES - ORAL

$0norethindrone 0.35mg pack

3SLYND 4MG PACK


72


CORTICOSTEROIDSGLUCOCORTICOSTEROIDS

2budesonide 3mg dr cap

2budesonide 9mg er tab PA QL=30 Quantity/30 Days

1dexamethasone 0.1mg/ml oral soln

1dexamethasone 0.5mg tab

1DEXAMETHASONE 0.5MG/5ML ORAL SOLN



2DEXAMETHASONE 1MG TAB

2DEXAMETHASONE 2MG TAB

1dexamethasone 4mg tab

1dexamethasone 6mg tab

1hydrocortisone 10mg tab



2MEDROL 2MG TAB PA_BvD

1methylprednisolone 16mg tab PA_BvD


1methylprednisolone 4mg pack



3MILLIPRED 5MG TAB PA_BvD

2PREDNISOLONE 10MG ODT PA_BvD


1prednisolone 1mg/ml oral soln PA_BvD



2PREDNISOLONE 3MG/ML ORAL SOLN PA_BvD


3PREDNISOLONE 5MG/ML ORAL SOLN PA_BvD

1prednisolone sodium phosphate 15mg/5ml oral soln PA_BvD

1prednisone 10mg tab PA_BvD


2PREDNISONE 1MG/ML ORAL SOLN PA_BvD

1prednisone 2.5mg tab PA_BvD




2PREDNISONE 5MG/ML ORAL SOLN PA_BvDMINERALOCORTICOIDS

1fludrocortisone 0.1mg tab

COUGH/COLD/ALLERGYANTITUSSIVES

1*benzonatate 100mg cap, 200mg cap

3*HYCODAN SYRUP


73


1*hydrocodone/homatropine syrup

1*tussigon tabCOUGH/COLD/ALLERGY COMBINATIONS

1*GUAIFENESIN/CODEINE SYRUP QL=240 Quantity/ Per Dispensing

1*guaifenesin/codeine syrup QL=240 Quantity/ Per Dispensing

3*hydrocodone/chlorpheniramine susp QL=120 Quantity/ Per Dispensing

3*HYDROCODONE/CHLORPHENIRAMINE/PSE LIQUID

QL=120 Quantity/ Per Dispensing

1*promethazine DM syrup

1*promethazine VC w/codeine syrup

1*promethazine/codeine syrup

3*TUSNEL C SYRUP

3*TUSSIONEX SUSP QL=120 Quantity/ Per DispensingMUCOLYTICS

1acetylcysteine 100mg/ml inh soln PA_BvD

1acetylcysteine 200mg/ml inh soln PA_BvD

DERMATOLOGICALSACNE PRODUCTS

2adapalene 0.1% cream PA QL=45 Quantity/30 Days

2adapalene 0.1% gel PA QL=45 Quantity/30 Days

2adapalene 0.3% gel PA QL=45 Quantity/30 Days

2adapalene/benzoyl peroxide 0.1-2.5% gel PA QL=45 Quantity/30 Days

2benzoyl peroxide 5%/clindamycin phosphate 1.2% topical gel


1CLINDAGEL 1% QL=75 Quantity/30 Days

1clindamycin 1% gel QL=75 Quantity/30 Days

1clindamycin 1% lotion QL=60 Quantity/30 Days

1clindamycin 1% pad QL=120 Quantity/30 Days

1clindamycin 1% topical soln QL=60 Quantity/30 Days

2clindamycin/benzoyl peroxide 1-5% gel QL=100 Quantity/30 Days

2clindamycin/benzoyl peroxide 1.2-2.5% gel QL=100 Quantity/30 Days

3EPIDUO 0.3-2.5% GEL PA QL=60 Quantity/30 Days

1ERY 2% PAD QL=60 Quantity/30 Days

1erythromycin 2% gel QL=60 Quantity/30 Days

1erythromycin 2% topical soln QL=60 Quantity/30 Days

2erythromycin/benzoyl peroxide 5-3% gel QL=46.60 Quantity/30 Days

2isotretinoin 10mg cap




3*PLEXION SCT CREAM

2sulfacetamide sodium 10% lotion

2*sulfacetamide sodium/sulfur cream

2*sulfacetamide sodium/sulfur emulsion

2*sulfacleanse susp

3*SUMAXIN TS SUSP


74


3*SUMAXIN WASH

2tretinoin 0.01% gel PA QL=45 Quantity/30 Days

2tretinoin 0.025% cream PA QL=45 Quantity/30 Days






2tretinoin 0.1% gel PA QL=50 Quantity/30 DaysANTIBIOTICS - TOPICAL

1gentamicin 0.1% cream QL=30 Quantity/30 Days

1gentamicin 0.1% ointment QL=120 Quantity/30 Days

1mupirocin 2% ointment QL=220 Quantity/30 DaysANTIFUNGALS - TOPICAL

1betamethasone/clotrimazole 1-0.05% cream QL=90 Quantity/30 Days

2betamethasone/clotrimazole 1-0.05% lotion QL=60 Quantity/30 Days

1ciclopirox 0.77% cream QL=90 Quantity/30 Days

1ciclopirox 0.77% gel QL=100 Quantity/30 Days

1ciclopirox 0.77% lotion QL=60 Quantity/30 Days

2ciclopirox 1% shampoo QL=120 Quantity/30 Days

1ciclopirox 8% topical soln QL=13.20 Quantity/30 Days

2clotrimazole 1% cream QL=45 Quantity/30 Days

2clotrimazole 1% topical soln QL=30 Quantity/30 Days

1econazole nitrate 1% cream QL=85 Quantity/30 Days

3*iodoquinol/hydrocortisone cream

1ketoconazole 2% cream QL=120 Quantity/30 Days

1ketoconazole 2% shampoo QL=240 Quantity/30 Days

3NAFTIFINE 1% CREAM QL=60 Quantity/30 Days

2naftifine 2% cream QL=60 Quantity/30 Days

2NAFTIFINE 2% CREAM QL=60 Quantity/30 Days

3NAFTIN 2% GEL QL=60 Quantity/30 Days

1nystatin 100000unit/ml cream QL=30 Quantity/30 Days

1nystatin 100unit/mg ointment QL=30 Quantity/30 Days

1nystatin 100unit/mg topical powder QL=60 Quantity/30 DaysANTI-INFLAMMATORY AGENTS - TOPICAL

2diclofenac sodium 1% gel QL=10 Quantity/30 Days

2diclofenac sodium 1.5% topical soln QL=300 Quantity/30 Days

3FLECTOR 1.3% PATCH, DICLOFENAC 1.3% PATCH PA QL=60 Quantity/30 DaysANTINEOPLASTIC OR PREMALIGNANT LESION AGENTS - TOPICAL

2diclofenac sodium 3% gel PA QL=1 Quantity/30 Days

2FLUOROURACIL 2% TOPICAL SOLN QL=10 Quantity/30 Days

1fluorouracil 5% cream QL=1 Quantity/30 Days

2FLUOROURACIL 5% TOPICAL SOLN QL=10 Quantity/30 Days

4TARGRETIN 1% GEL NDS PA_NSO QL=60 Quantity/30 Days


75


4VALCHLOR 0.016% GEL LD NDS PA_NSO QL=240 Quantity/30 Days

ANTIPSORIATICS

2acitretin 10mg cap

2acitretin 17.5mg cap

2acitretin 25mg cap

2calcipotriene 0.005% cream PA QL=120 Quantity/30 Days

2calcipotriene 0.005% ointment PA QL=120 Quantity/30 Days

2calcipotriene 0.005% topical soln PA QL=120 Quantity/30 Days

2METHOXSALEN 10MG CAP

4SKYRIZI 150MG DOSE PACK (75MG/0.83ML) PA QL=7 Quantity/365 Days

4SKYRIZI 150MG/ML AUTO-INJECTOR PA QL=7 Quantity/365 Days

4SKYRIZI 150MG/ML SYRINGE PA QL=7 Quantity/365 Days

4STELARA 45MG/0.5ML INJ PA QL=.50 Quantity/28 Days

4STELARA 45MG/0.5ML SYRINGE PA QL=.50 Quantity/28 Days

4STELARA 90MG/ML SYRINGE PA QL=1 Quantity/28 Days

4TALTZ 80MG/ML AUTO-INJECTOR NDS PA QL=3 Quantity/28 Days

4TALTZ 80MG/ML SYRINGE NDS PA QL=3 Quantity/28 Days

2tazarotene 0.1% cream PA QL=60 Quantity/30 Days

3TAZORAC 0.05% CREAM PA QL=60 Quantity/30 Days

4TREMFYA 100MG/ML AUTO-INJECTOR NDS PA QL=2 Quantity/28 Days

4TREMFYA 100MG/ML SYRINGE NDS PA QL=2 Quantity/28 DaysANTISEBORRHEIC PRODUCTS

3*OVACE CREAM

3*OVACE PLUS SHAMPOO

3*OVACE PLUS WASH

3*OVACE WASH

3*seb-prev cream

2*selenium sulfide 2.25% shampoo

1selenium sulfide 2.5% shampoo

3*sulfacetamide sodium gel

3*sulfacetamide sodium shampoo

2*sulfacetamide sodium washANTIVIRALS - TOPICAL

2acyclovir 5% cream QL=5 Quantity/7 Days

2acyclovir 5% ointment QL=30 Quantity/30 DaysBURN PRODUCTS

1ssd 1% cream

2SULFAMYLON 85MG/GM CREAMCORTICOSTEROIDS - TOPICAL

1ala-cort 2.5% cream QL=454 Quantity/30 Days

2alclometasone dipropionate 0.05% cream QL=120 Quantity/30 Days

2alclometasone dipropionate 0.05% ointment QL=120 Quantity/30 Days

1betamethasone 0.05% aug cream QL=100 Quantity/30 Days

1betamethasone 0.05% aug lotion QL=120 Quantity/30 Days

1betamethasone 0.05% aug ointment QL=100 Quantity/30 Days


76


1betamethasone 0.05% cream QL=90 Quantity/30 Days

2BETAMETHASONE 0.05% GEL QL=100 Quantity/30 Days

1betamethasone 0.05% lotion QL=120 Quantity/30 Days

1betamethasone 0.05% ointment QL=90 Quantity/30 Days

1betamethasone 0.1% cream QL=180 Quantity/30 Days

1betamethasone 0.1% lotion QL=120 Quantity/30 Days

1betamethasone 0.1% ointment QL=180 Quantity/30 Days

2clobetasol propionate 0.05% cream QL=120 Quantity/30 Days

2clobetasol propionate 0.05% e cream QL=120 Quantity/30 Days

2clobetasol propionate 0.05% foam QL=100 Quantity/30 Days

2clobetasol propionate 0.05% gel QL=120 Quantity/30 Days

2clobetasol propionate 0.05% lotion QL=118 Quantity/30 Days

2clobetasol propionate 0.05% ointment QL=120 Quantity/30 Days

2clobetasol propionate 0.05% shampoo QL=2 Quantity/30 Days

2clobetasol propionate 0.05% spray QL=125 Quantity/30 Days

2clobetasol propionate 0.05% topical soln QL=100 Quantity/30 Days

2desonide 0.05% ointment QL=120 Quantity/30 Days

2desoximetasone 0.25% cream QL=120 Quantity/30 Days

2desoximetasone 0.25% ointment QL=120 Quantity/30 Days

2fluocinolone acetonide 0.01% body oil QL=120 Quantity/30 Days

1fluocinolone acetonide 0.01% cream QL=120 Quantity/30 Days

1fluocinolone acetonide 0.01% topical soln QL=90 Quantity/30 Days

1fluocinolone acetonide 0.025% cream QL=120 Quantity/30 Days

1fluocinolone acetonide 0.025% ointment QL=120 Quantity/30 Days

2fluocinolone acetonide 0.1mg/ml oil QL=120 Quantity/30 Days

2fluocinonide 0.05% cream QL=60 Quantity/30 Days

1fluocinonide 0.05% e cream QL=120 Quantity/30 Days

1fluocinonide 0.05% gel QL=60 Quantity/30 Days

1fluocinonide 0.05% ointment QL=60 Quantity/30 Days

1fluocinonide 0.05% topical soln QL=60 Quantity/30 Days

1fluocinonide 0.1% cream QL=60 Quantity/30 Days

1fluticasone propionate 0.005% ointment QL=240 Quantity/30 Days

1fluticasone propionate 0.05% cream QL=240 Quantity/30 Days

2halobetasol propionate 0.05% cream QL=50 Quantity/30 Days

2halobetasol propionate 0.05% ointment QL=50 Quantity/30 Days

1hydrocortisone 1% cream (RX Only) QL=240 Quantity/30 Days

1hydrocortisone 2.5% cream

1hydrocortisone 2.5% lotion QL=118 Quantity/30 Days

1hydrocortisone 2.5% ointment QL=240 Quantity/30 Days

1mometasone furoate 0.1% cream QL=180 Quantity/30 Days

1mometasone furoate 0.1% lotion QL=180 Quantity/30 Days

1mometasone furoate 0.1% ointment QL=180 Quantity/30 Days

3*NUCORT LOTION

2PREDNICARBATE 0.1% OINTMENT QL=120 Quantity/30 Days

1triamcinolone acetonide 0.025% cream QL=454 Quantity/30 Days

1triamcinolone acetonide 0.025% lotion QL=120 Quantity/30 Days


77


1triamcinolone acetonide 0.025% ointment QL=454 Quantity/30 Days

1triamcinolone acetonide 0.1% cream QL=454 Quantity/30 Days

1triamcinolone acetonide 0.1% lotion QL=120 Quantity/30 Days



1triderm 0.5% cream QL=454 Quantity/30 DaysECZEMA AGENTS

4DUPIXENT 200MG/1.14ML AUTO-INJECTOR NDS PA

4DUPIXENT 200MG/1.14ML SYRINGE NDS PA

4DUPIXENT 300MG/2ML AUTO-INJECTOR NDS PA

4DUPIXENT 300MG/2ML SYRINGE NDS PAEMOLLIENTS

1ammonium lactate 12% cream

1ammonium lactate 12% lotionENZYMES - TOPICAL

2SANTYL 250UNIT/GM OINTMENT QL=1 Quantity/30 DaysIMMUNOMODULATING AGENTS - TOPICAL

1imiquimod 5% cream QL=24 Quantity/30 DaysIMMUNOSUPPRESSIVE AGENTS - TOPICAL

2pimecrolimus 1% cream QL=100 Quantity/30 Days

2tacrolimus 0.03% ointment QL=100 Quantity/30 Days

2tacrolimus 0.1% ointment QL=100 Quantity/30 DaysKERATOLYTIC/ANTIMITOTIC AGENTS

3CONDYLOX 0.5% GEL QL=7 Quantity/30 Days

2*PODOCON SOLN

2podofilox 0.5% topical soln QL=7 Quantity/30 Days

3*SALEX SHAMPOO

2*salicylic acid shampooLOCAL ANESTHETICS - TOPICAL

1*lidocaine 3% cream (rx only)

1lidocaine 4% topical soln QL=50 Quantity/30 Days

1lidocaine 5% ointment PA QL=107 Quantity/30 Days

2lidocaine 5% patch PA QL=90 Quantity/30 Days

1lidocaine/prilocaine 2.5-2.5% cream QL=30 Quantity/30 DaysMISC. TOPICAL

2ALCOHOL SWAB 1"x1" (DIABETIC)

1*DRYSOL SOLNROSACEA AGENTS

2azelaic acid 15% gel QL=50 Quantity/30 Days

2FINACEA 15% FOAM QL=50 Quantity/30 Days

1metronidazole 0.75% cream QL=45 Quantity/30 Days

1metronidazole 0.75% gel QL=45 Quantity/30 Days

1metronidazole 0.75% lotion QL=59 Quantity/30 Days

2metronidazole 1% gel QL=60 Quantity/30 DaysSCABICIDES & PEDICULICIDES

2IVERMECTIN 0.5% LOTION QL=117 Quantity/15 Days


78


2LINDANE 1% SHAMPOO

2malathion 0.5% lotion

1permethrin 5% creamWOUND CARE PRODUCTS

2REGRANEX 0.01% GEL PA QL=2 Quantity/15 Days

DIAGNOSTIC PRODUCTSDIAGNOSTIC TESTS

1*CLINISTIX

1*KETO-DIASTIX

1*KETOSTIX

DIGESTIVE AIDSDIGESTIVE ENZYMES

2CREON 120000-76000-24000UNIT DR CAP

2CREON 15000-9500-3000UNIT DR CAP


2CREON 36000-114000-180000UNIT DR CAP


4SUCRAID 8500UNIT/ML ORAL SOLN NDS PA

3ZENPEP 105000-79000-25000UNIT DR CAP ST







DIURETICSCARBONIC ANHYDRASE INHIBITORS

2acetazolamide 125mg tab

2acetazolamide 250mg tab

2acetazolamide 500mg er cap

2methazolamide 25mg tab

2methazolamide 50mg tabDIURETIC COMBINATIONS

3ALDACTAZIDE 50-50MG TAB

1amiloride 5mg/hydrochlorothiazide 50mg tab

1hydrochlorothiazide 25mg/spironolactone 25mg tab

1hydrochlorothiazide 25mg/triamterene 37.5mg cap

1hydrochlorothiazide 25mg/triamterene 37.5mg tab

1hydrochlorothiazide 50mg/triamterene 75mg tabLOOP DIURETICS

2bumetanide 0.25mg/ml inj

1bumetanide 0.5mg tab

1bumetanide 1mg tab

1bumetanide 2mg tab

2ethacrynic acid 25mg tab

2furosemide 10mg/ml inj


79


1furosemide 10mg/ml oral soln

$0furosemide 20mg tab



2FUROSEMIDE 8MG/ML ORAL SOLN

1torsemide 100mg tab

1torsemide 10mg tab

1torsemide 20mg tab

1torsemide 5mg tabPOTASSIUM SPARING DIURETICS

1amiloride 5mg tab

1spironolactone 100mg tab



2triamterene 100mg cap

2triamterene 50mg capTHIAZIDES AND THIAZIDE-LIKE DIURETICS

$0chlorthalidone 25mg tab

$0chlorthalidone 50mg tab

2DIURIL 250MG/5ML SUSP

$0hydrochlorothiazide 12.5mg cap

$0hydrochlorothiazide 12.5mg tab

$0hydrochlorothiazide 25mg tab

$0hydrochlorothiazide 50mg tab

1indapamide 1.25mg tab

1indapamide 2.5mg tab

1metolazone 10mg tab

1metolazone 2.5mg tab

1metolazone 5mg tab

ENDOCRINE AND METABOLIC AGENTS - MISC.ADRENAL STEROID INHIBITORS

4ISTURISA 10MG TAB LD NDS PA QL=180 Quantity/30 Days

4ISTURISA 1MG TAB LD NDS PA QL=240 Quantity/30 Days

4ISTURISA 5MG TAB LD NDS PA QL=60 Quantity/30 DaysBONE DENSITY REGULATORS

$0alendronate 10mg tab



3alendronate 70mg/75ml oral soln

4FORTEO 600MCG/2.4ML PEN INJ NDS QL=1 Quantity/28 Days

1ibandronate 150mg tab QL=1 Quantity/30 Days

4NATPARA 100MCG CARTRIDGE LD NDS PA




3PROLIA 60MG/ML SYRINGE PA QL=1 Quantity/168 Days


80


2risedronate sodium 150mg tab




2salmon calcitonin 200unit/act nasal spray

4TYMLOS 3120MCG/1.56ML PEN INJ NDS QL=1.56 Quantity/30 Days

4XGEVA 120MG/1.7ML INJ NDS PA QL=1 Quantity/28 DaysGNRH/LHRH ANTAGONISTS

2ORILISSA 150MG TAB PA QL=30 Quantity/30 Days

2ORILISSA 200MG TAB PA QL=60 Quantity/30 DaysGROWTH HORMONE RECEPTOR ANTAGONISTS

4SOMAVERT 10MG INJ LD NDS PA




4SOMAVERT 30MG INJ LD NDS PAGROWTH HORMONES

4GENOTROPIN 0.2MG INJ NDS PA








4GENOTROPIN 12MG CARTRIDGE NDS PA

4GENOTROPIN 1MG INJ NDS PA

4GENOTROPIN 2MG INJ NDS PA

4GENOTROPIN 5MG CARTRIDGE NDS PAHORMONE RECEPTOR MODULATORS

3OSPHENA 60MG TAB PA

$0raloxifene 60mg tabINSULIN-LIKE GROWTH FACTORS (SOMATOMEDINS)

4INCRELEX 40MG/4ML INJ NDS PALHRH/GNRH AGONIST ANALOG PITUITARY SUPPRESSANTS

4LUPANETA 3-MONTH PACK PA QL=1 Quantity/84 Days

4LUPANETA PACK 1-MONTH PACK NDS PA QL=1 Quantity/28 Days

4LUPRON 11.25MG INJ PED KIT (3 MONTH) QL=1 Quantity/84 Days

4LUPRON 7.5MG INJ PED KIT (1 MONTH) QL=1 Quantity/28 Days

4SYNAREL 2MG/ML NASAL INHALER NDS PAMETABOLIC MODIFIERS

1calcitriol 0.00025mg cap

1calcitriol 0.0005mg cap

1calcitriol 0.001mg/ml oral soln

3CARBAGLU 200MG TAB FOR ORAL SUSP PA

2cinacalcet 30mg tab


81




2doxercalciferol 0.0005mg cap



4GALAFOLD 28 DAY WALLET 123MG PACK LD NDS PA QL=15 Quantity/30 Days

1levocarnitine 100mg/ml oral soln

1levocarnitine 330mg tab

4nitisinone 10mg cap NDS PA



4ORFADIN 20MG CAP NDS PA

4ORFADIN 4MG/ML SUSP NDS PA

4PALYNZIQ 10MG/0.5ML SYRINGE LD NDS PA

4PALYNZIQ 2.5MG/0.5ML SYRINGE LD NDS PA

4PALYNZIQ 20MG/ML SYRINGE LD NDS PA

2paricalcitol 0.001mg cap



4RAVICTI 1.1GM/ML ORAL SOLN NDS PA

4sapropterin 100mg powder for oral soln NDS PA

4sapropterin 500mg powder for oral soln NDS PA

4sapropterin dihydrochloride 100mg tab NDS PA

2sodium phenylbutyrate 0.94mg/mg oral powderPOSTERIOR PITUITARY HORMONES

2desmopressin 0.01% nasal spray

2desmopressin acetate 0.01mg/act nasal spray

2desmopressin acetate 0.1mg tab

2desmopressin acetate 0.2mg tabPROLACTIN INHIBITORS

1cabergoline 0.5mg tabSOMATOSTATIC AGENTS

1OCTREOTIDE 0.05MG/ML INJ PA

1octreotide 0.05mg/ml inj PA






1octreotide 1mg/ml inj PA

4SIGNIFOR 0.3MG/ML INJ LD NDS PA QL=60 Quantity/30 Days

4SIGNIFOR 0.6MG/ML INJ LD NDS PA QL=60 Quantity/30 Days

4SIGNIFOR 0.9MG/ML INJ LD NDS PA QL=60 Quantity/30 DaysVASOPRESSIN RECEPTOR ANTAGONISTS

4JYNARQUE 15MG TAB LD NDS PA QL=120 Quantity/30 Days

4JYNARQUE 30MG TAB LD NDS PA QL=120 Quantity/30 Days


82


4JYNARQUE 45/15 THERAPY PACK LD NDS PA QL=60 Quantity/30 Days



4JYNARQUE TAB 15/15 CARTON 15MG PACK LD NDS PA QL=60 Quantity/30 Days

4JYNARQUE TAB 30/15MG THERAPY PACK LD NDS PA QL=60 Quantity/30 Days

ESTROGENSESTROGEN COMBINATIONS

2amabelz 0.5/0.1mg 28 day pack

3ANGELIQ 0.25/0.5MG 28 DAY PACK

3ANGELIQ 0.5/1MG 28 DAY PACK

3CLIMARA PRO 0.00188-0.000625MG/HR PATCH

3COMBIPATCH 0.00208-0.00583MG/HR PATCH

3COMBIPATCH 0.00208-0.0104MG/HR PATCH

1*esterified estrogens/methyltestosterone tab

2ethinyl estradiol 0.005mg/norethindrone acetate 1mg pack

2fyavolv 0.0025-0.5mg tab

2mimvey pack

2ORIAHNN 28 DAY KIT PACK PA QL=56 Quantity/28 Days

3PREFEST 30 DAY PACK

2PREMPHASE 28 DAY PACK

2PREMPRO 0.3/1.5MG 28 DAY PACK

2PREMPRO 0.45/1.5 28 DAY PACK

2PREMPRO 0.625/2.5MG 28 DAY PACK

2PREMPRO 0.625/5MG 28 DAY PACKESTROGENS

3DELESTROGEN 10MG/ML INJ

3DEPO-ESTRADIOL 5MG/ML INJ

1estradiol 0.00104mg/hr weekly patch






2estradiol 0.025mg twice weekly patch

2estradiol 0.0375mg/24hr twice weekly patch




1estradiol 0.5mg tab

1estradiol 1mg tab

1estradiol 2mg tab

2estradiol valerate 20mg/ml inj

2estradiol valerate 40mg/ml inj

3EVAMIST 1.53MG/SPRAY SPRAY

3MENEST 0.3MG TAB


83


3MENEST 0.625MG TAB

3MENEST 1.25MG TAB

3MENOSTAR 14MCG/24HR PATCH

2PREMARIN 0.3MG TAB

2PREMARIN 0.45MG TAB


2PREMARIN 0.9MG TAB


FLUOROQUINOLONESFLUOROQUINOLONES

2BAXDELA 450MG TAB PA QL=60 Quantity/30 Days

3CIPRO 500MG/5ML SUSP

3CIPRO 5GM/100ML SUSP

1ciprofloxacin 250mg tab

2ciprofloxacin 2mg/ml inj



2ciprofloxacin/d5w 400mg/200ml inj

1levofloxacin 250mg tab

2levofloxacin 25mg/ml inj

2levofloxacin 25mg/ml oral soln


2levofloxacin 5mg/ml (100ml) inj

2levofloxacin 5mg/ml (150ml) inj


2levofloxacin/D5W 250mg/50ml inj

2MOXIFLOXACIN 1.6MG/ML INJ

2moxifloxacin 400mg tab

2MOXIFLOXACIN 400MG/250ML IV SOLN

1ofloxacin 400mg tab

GASTROINTESTINAL AGENTS - MISC.5-HT4 RECEPTOR AGONISTS

3MOTEGRITY 1MG TAB PA

3MOTEGRITY 2MG TAB PAAGENTS FOR CHRONIC IDIOPATHIC CONSTIPATION (CIC)

2TRULANCE 3MG TABBILE ACID SYNTHESIS DISORDER AGENTS

4CHOLBAM 250MG CAP LD NDS PA

4CHOLBAM 50MG CAP LD NDS PAFARNESOID X RECEPTOR (FXR) AGONISTS

4OCALIVA 10MG TAB LD NDS PA QL=30 Quantity/30 Days

4OCALIVA 5MG TAB LD NDS PA QL=30 Quantity/30 DaysGALLSTONE SOLUBILIZING AGENTS

4CHENODAL 250MG TAB NDS

1ursodiol 250mg tab

1ursodiol 300mg cap


84


1ursodiol 500mg tabGASTROINTESTINAL ANTIALLERGY AGENTS

2cromolyn sodium 20mg/ml oral solnGASTROINTESTINAL STIMULANTS

1metoclopramide 10mg tab

1metoclopramide 1mg/ml oral soln

1metoclopramide 5mg tabINFLAMMATORY BOWEL AGENTS

1balsalazide disodium 750mg cap

4CIMZIA 200MG INJ NDS PA QL=2 Quantity/28 Days

4CIMZIA 200MG/ML INJ NDS PA QL=2 Quantity/28 Days

4CIMZIA 200MG/ML INJ STARTER KIT NDS PA QL=2 Quantity/28 Days

3DIPENTUM 250MG CAP

2mesalamine 1000mg rectal supp

2mesalamine 1200mg dr tab

2mesalamine 375mg er cap

2mesalamine 400mg dr cap

2mesalamine 4gm enema

2mesalamine 66.7mg/ml enema

2mesalamine 800mg dr tab

1sulfasalazine 500mg dr tab

1sulfasalazine 500mg tabINTESTINAL ACIDIFIERS

1enulose 10gm/15ml oral solnIRRITABLE BOWEL SYNDROME (IBS) AGENTS

2alosetron 0.5mg tab

2alosetron 1mg tab

3VIBERZI 100MG TAB PA

3VIBERZI 75MG TAB PAPERIPHERAL OPIOID RECEPTOR ANTAGONISTS

2MOVANTIK 12.5MG TAB PA

2MOVANTIK 25MG TAB PA

3RELISTOR 12MG/0.6ML INJ PA

3RELISTOR 8MG/0.4ML INJ PA

2SYMPROIC 0.2MG TAB PAPHOSPHATE BINDER AGENTS

3AURYXIA 210MG TAB PA

1calcium acetate 667mg cap

1calcium acetate 667mg tab

2FOSRENOL 1000MG ORAL POWDER

2FOSRENOL 750MG ORAL POWDER

2lanthanum carbonate 1000mg chew tab



2PHOSLYRA 667MG/5ML ORAL SOLN

2SEVELAMER 400MG TAB


85


2sevelamer 800mg tab

2sevelamer carbonate 2400mg powder for oral susp

2sevelamer carbonate 800mg powder for oral susp

2sevelamer carbonate 800mg tab

3VELPHORO 500MG CHEW TABSHORT BOWEL SYNDROME (SBS) AGENTS

4GATTEX 5MG INJ NDS PATRYPTOPHAN HYDROXYLASE INHIBITORS

4XERMELO 250MG TAB LD NDS PA QL=90 Quantity/30 Days

GENITOURINARY AGENTS - MISCELLANEOUSALKALINIZERS

1*CYTRA K CRYSTALS

1*CYTRA-3 SYRUP

1*ORACIT SOLN

2potassium citrate 10meq er tab



1*potassium citrate/citric acid granule

1*potassium citrate/citric acid soln

1*sodium citrate/citric acid soln

1*tricitrates solnCYSTINOSIS AGENTS

2CYSTAGON 150MG CAP LD

2CYSTAGON 50MG CAP LDGENITOURINARY IRRIGANTS

2sodium chloride 0.154meq/ml solnINTERSTITIAL CYSTITIS AGENTS

2ELMIRON 100MG CAPPROSTATIC HYPERTROPHY AGENTS

1alfuzosin 10mg er tab

3CARDURA 4MG ER TAB

3CARDURA 8MG ER TAB

1dutasteride 0.5mg cap

2dutasteride 0.5mg/tamsulosin 0.4mg cap

1finasteride 5mg tab

2silodosin 4mg cap

2silodosin 8mg cap

1tamsulosin 0.4mg capURINARY ANALGESICS

1phenazopyridine 100mg tab

1phenazopyridine 200mg tab

2PYRIDIUM 100MG TAB

2PYRIDIUM 200MG TABURINARY STONE AGENTS

3LITHOSTAT 250MG TAB

3THIOLA 100MG DR TAB


86


3THIOLA 300MG DR TAB

2tiopronin 100mg tab

GOUT AGENTSGOUT AGENT COMBINATIONS

1colchicine 0.5mg/probenecid 500mg tabGOUT AGENTS

1allopurinol 100mg tab

1allopurinol 300mg tab

2colchicine 0.6mg tab

2febuxostat 40mg tab ST RXC

2febuxostat 80mg tab ST RXCURICOSURICS

1probenecid 500mg tab

HEMATOLOGICAL AGENTS - MISC.BRADYKININ B2 RECEPTOR ANTAGONISTS

4icatibant 10mg/ml inj NDS PACOMPLEMENT INHIBITORS

4BERINERT 500UNIT INJ LD NDS PA

4CINRYZE 500UNIT INJ LD NDS PA

4HAEGARDA 2000UNIT INJ LD NDS PA

4HAEGARDA 3000UNIT INJ LD NDS PA

4RUCONEST 2100UNIT INJ LD NDS PAHEMATAOLOGIC - TYROSINE KINASE INHIBITORS

4TAVALISSE 100MG TAB LD NDS PA QL=60 Quantity/30 Days

4TAVALISSE 150MG TAB LD NDS PA QL=60 Quantity/30 DaysHEMATORHEOLOGIC AGENTS

1pentoxifylline 400mg er tabPLASMA KALLIKREIN INHIBITORS

4TAKHZYRO 300MG/2ML INJ LD NDS PA QL=2 Quantity/28 DaysPLATELET AGGREGATION INHIBITORS

1anagrelide 0.5mg cap

1anagrelide 1mg cap

2aspirin 25mg/dipyridamole 200mg er cap

3BRILINTA 60MG TAB

3BRILINTA 90MG TAB

4CABLIVI 11MG INJ LD NDS PA QL=30 Quantity/30 Days

1cilostazol 100mg tab

1cilostazol 50mg tab

1clopidogrel 75mg tab

2dipyridamole 25mg tab



1prasugrel 10mg tab

1prasugrel 5mg tab

3ZONTIVITY 2.08MG TAB PA

HEMATOPOIETIC AGENTS


87


AGENTS FOR GAUCHER DISEASE

4CERDELGA 84MG CAP NDS PA QL=60 Quantity/30 Days

4miglustat 100mg cap LD NDS PAAGENTS FOR SICKLE CELL ANEMIA

2DROXIA 200MG CAP

2DROXIA 300MG CAP

2DROXIA 400MG CAP

4ENDARI 5GM POWDER FOR ORAL SOLN NDS PA QL=180 Quantity/30 DaysAGENTS FOR SICKLE CELL DISEASE

4OXBRYTA 500MG TAB LD NDS PA QL=150 Quantity/30 DaysCOBALAMINS

1*cyanocobalamin injFOLIC ACID/FOLATES

$0*folic acid tab (OTC) HEMATOPOIETIC GROWTH FACTORS

3ARANESP 100MCG/0.5ML SYRINGE PA

3ARANESP 100MCG/ML INJ PA











3ARANESP 500MCG/ML SYRINGE PA



4DOPTELET 20MG TAB LD NDS PA QL=60 Quantity/30 Days

4DOPTELET TAB 40MG DAILY DOSE PACK LD NDS PA QL=1 Quantity/5 Days

4DOPTELET TAB 60MG DAILY DOSE PACK LD NDS PA QL=1 Quantity/5 Days

4FULPHILA 6MG/0.6ML SYRINGE NDS

4NIVESTYM 300MCG/0.5ML SYRINGE NDS

4NIVESTYM 300MCG/ML INJ NDS

4NIVESTYM 480MCG/0.8ML SYRINGE NDS

4NIVESTYM 480MCG/1.6ML INJ NDS

4PROMACTA 12.5MG POWDER FOR ORAL SUSP NDS PA

4PROMACTA 12.5MG TAB NDS PA

4PROMACTA 25MG POWDER FOR ORAL SUSP NDS PA

4PROMACTA 25MG TAB NDS PA



2RETACRIT 20000UNIT/2ML INJ PA

2RETACRIT 20000UNIT/ML INJ PA


88






4ZARXIO 300MCG/0.5ML SYRINGE NDS

4ZARXIO 480MCG/0.8ML SYRINGE NDS

4ZIEXTENZO 6MG/0.6ML SYRINGE NDSHEMATOPOIETIC MIXTURES

1*ferrex forte cap

1*folbee tab

1*IRON POLYSACCH/THREONIC ACID/B12/FA CAP

3*IRON/VITAMIN C/VITAMIN B12/FOLIC ACID TAB

1*MULTIGEN FOLIC TAB

1*MULTIGEN PLUS TAB

1*MULTIGEN TAB

1*tricon capIRON

$0*ferrous sulfate elixir

$0*FERROUS SULFATE LIQUID

$0*ferrous sulfate soln

$0*ferrous sulfate syrup

$0*IRON SUSP

HEMOSTATICSHEMOSTATICS - SYSTEMIC

2tranexamic acid 650mg tab

HYPNOTICSBARBITURATE HYPNOTICS

1phenobarbital 4mg/ml oral solnNON-BARBITURATE HYPNOTICS

1estazolam 1mg tab QL=30 Quantity/30 Days

1estazolam 2mg tab QL=30 Quantity/30 Days

1eszopiclone 1mg tab QL=30 Quantity/30 Days



2FLURAZEPAM 15MG CAP QL=30 Quantity/30 Days

2FLURAZEPAM 30MG CAP QL=30 Quantity/30 Days

1temazepam 15mg cap QL=30 Quantity/30 Days

1temazepam 30mg cap QL=30 Quantity/30 Days

1zaleplon 10mg cap QL=30 Quantity/30 Days

1zaleplon 5mg cap QL=30 Quantity/30 Days

1zolpidem tartrate 10mg tab QL=30 Quantity/30 Days

1zolpidem tartrate 5mg tab QL=60 Quantity/30 DaysSELECTIVE MELATONIN RECEPTOR AGONISTS

4HETLIOZ 20MG CAP NDS PA QL=30 Quantity/30 Days

HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTSBARBITURATE HYPNOTICS


89


2phenobarbital 100mg tab


1phenobarbital 16.2mg tab





1phenobarbital 97.2mg tabNON-BARBITURATE HYPNOTICS

2triazolam 0.125mg tab QL=30 Quantity/30 Days

1triazolam 0.25mg tab QL=60 Quantity/30 DaysSELECTIVE MELATONIN RECEPTOR AGONISTS

4HETLIOZ 4MG/ML SUSP NDS PA QL=158 Quantity/30 Days

2ramelteon 8mg tab QL=30 Quantity/30 Days

LAXATIVESLAXATIVE COMBINATIONS

2CLENPIQ 75-21.9-0.0625MG/ML ORAL SOLN

$0GAVILYTE-C ORAL SOLN

$0gavilyte-g powder for oral soln

$0gavilyte-n powder for oral soln

$0peg 3350/electrolytes soln 240 gmLAXATIVES - MISCELLANEOUS

1constulose 10gm/15ml oral soln

3KRISTALOSE 10GM POWDER FOR ORAL SOLN

3KRISTALOSE 20GM POWDER FOR ORAL SOLN

MACROLIDESAZITHROMYCIN

3AZITHROMYCIN 1000MG POWDER FOR ORAL SUSP

1azithromycin 20mg/ml susp

1azithromycin 250mg pack

1azithromycin 40mg/ml susp

2azithromycin 500mg inj

1azithromycin 500mg tab

1azithromycin 600mg tabCLARITHROMYCIN

1clarithromycin 250mg tab

2CLARITHROMYCIN 25MG/ML SUSP

2clarithromycin 500mg er tab

1clarithromycin 500mg tab

2CLARITHROMYCIN 50MG/ML SUSPERYTHROMYCINS

3E.E.S. 400MG TAB

1ery-tab 250mg dr tab

3ERYTHROCIN 500MG INJ

2ERYTHROMYCIN 250MG DR CAP


90


2erythromycin 250mg dr cap

2erythromycin 250mg tab

1erythromycin 333mg dr tab

1erythromycin 500mg dr tab

2erythromycin 500mg tab

2erythromycin ethylsuccinate 40mg/ml susp

2erythromycin ethylsuccinate 80mg/ml suspFIDAXOMICIN

2DIFICID 200MG TAB PA QL=20 Quantity/10 Days

2DIFICID 40MG/ML SUSP PA QL=136 Quantity/10 Days

MEDICAL DEVICESBANDAGES-DRESSINGS-TAPE

2GAUZE PADS DRESSINGS - PADS 2 X 2 CONTRACEPTIVES

$0*CERVICAL CAP

$0*DIAPHRAGM

$0*FEMALE CONDOMS DIABETIC SUPPLIES

$0*ACCU-CHEK AVIVA PLUS METER

$0*CALIBRATION LIQUID

$0*FREESTYLE LITE METER

$0*LANCET DEVICE

$0*LANCET KIT

$0*LANCETS MISC. DEVICES

$0ALCOHOL SWAB 1"x1" (DIABETIC)

MEDICAL DEVICES AND SUPPLIESDIABETIC SUPPLIES

$0*CONTINUOUS BLOOD GLUCOSE SYSTEM RECEIVER

$0*CONTINUOUS BLOOD GLUCOSE SYSTEM SENSOR

$0*CONTINUOUS BLOOD GLUCOSE SYSTEM TRANSMITTER

$0*FREESTYLE LITE METER PARENTERAL THERAPY SUPPLIES

2INSULIN PEN NEEDLE

2INSULIN SYRINGE

2INSULIN SYRINGE U-500

2PEN NEEDLE

MIGRAINE PRODUCTSCALCITONIN GENE-RELATED PEPTIDE (CGRP) RECEPTOR ANTAG

2EMGALITY 120MG/ML AUTO-INJECTOR PA

2EMGALITY 120MG/ML INJ PA

2NURTEC 75MG ODT PA QL=16 Quantity/30 DaysMIGRAINE PRODUCTS

2dihydroergotamine mesylate 0.5mg/act nasal inhaler PA QL=16 Quantity/30 Days


91


MIGRAINE PRODUCTS - MONOCLONAL ANTIBODIES

2AIMOVIG 140MG/ML AUTO-INJECTOR PA

2AIMOVIG 70MG/ML AUTO-INJECTOR PA

2EMGALITY 100MG/ML INJ PA

2UBRELVY 100MG TAB PA QL=16 Quantity/30 Days

2UBRELVY 50MG TAB PA QL=16 Quantity/30 DaysSEROTONIN AGONISTS

2eletriptan 20mg tab QL=18 Quantity/30 Days

2eletriptan 40mg tab QL=18 Quantity/30 Days

2naratriptan 1mg tab QL=18 Quantity/30 Days

2naratriptan 2.5mg tab QL=18 Quantity/30 Days

2REYVOW 100MG TAB PA QL=8 Quantity/30 Days

2REYVOW 50MG TAB PA QL=8 Quantity/30 Days

1rizatriptan 10mg odt QL=36 Quantity/60 Days

1rizatriptan 10mg tab QL=36 Quantity/60 Days

1rizatriptan 5mg odt QL=36 Quantity/60 Days

1rizatriptan 5mg tab QL=36 Quantity/60 Days

1sumatriptan 100mg tab QL=18 Quantity/30 Days

2sumatriptan 12mg/ml auto-injector QL=10 Quantity/30 Days

2sumatriptan 12mg/ml inj QL=10 Quantity/30 Days

2sumatriptan 20mg/act nasal spray QL=12 Quantity/30 Days



2sumatriptan 5mg/act nasal spray QL=12 Quantity/30 Days

2sumatriptan 6mg/0.5ml refill inj QL=10 Quantity/30 Days

2sumatriptan 8mg/ml cartridge QL=10 Quantity/30 Days

2zolmitriptan 2.5mg odt QL=18 Quantity/30 Days

2zolmitriptan 2.5mg tab QL=18 Quantity/30 Days

2zolmitriptan 5mg odt QL=18 Quantity/30 Days

2zolmitriptan 5mg tab QL=18 Quantity/30 Days

3ZOMIG 2.5MG NASAL SPRAY QL=16 Quantity/30 Days

3ZOMIG 5MG NASAL SPRAY QL=12 Quantity/30 Days

MINERALS & ELECTROLYTESELECTROLYTE MIXTURES

2d2.5w/nacl 0.45% inj

2d5w/nacl 5%-0.33% inj

2DEXTROSE 10% W/ SODIUM CHLORIDE 0.2% PA_BvD

2DEXTROSE 10% W/ SODIUM CHLORIDE 0.45% PA_BvD

2DEXTROSE/SODIUM CHLORIDE 5-0.225% INJ

2dextrose/sodium chloride 5%-0.225% inj

2GLUCOSE 25MG/ML/SODIUM CHLORIDE 0.0769 MEQ/ML INJ

2glucose 50 mg/ml/potassium chloride 0.04meq/ml/sodium chloride 4.5mg/ml inj

2glucose 50mg/ml/potassium chloride 0.01 meq/ml/sodium chloride 0.0769 meq/ml inj


92


2glucose 50mg/ml/potassium chloride 0.02 meq/ml inj



2glucose 50mg/ml/potassium chloride 0.02meq/ml/sodium chloride 4.5mg/ml inj


2glucose 50mg/ml/sodium chloride 0.0342 meq/ml inj

2glucose 50mg/ml/sodium chloride 4.5mg/ml inj

2glucose 50mg/ml/sodium chloride 9mg/ml inj

2ISOLYTE P INJ

2ISOLYTE S INJ

2ISOLYTE-S (PH 7.4) INJ

2KCL 40 MEQ/L (0.3%) IN DEXTROSE 5% & NACL 0.9% INJ

2KCL 40 MEQ/L (0.3%) IN NACL 0.9% INJ

2KCL/D5W/LR 0.15% INJ

2KCL/D5W/NACL 20MEQ/5%/0.225% INJ

2KCL/NACL 20MEQ-0.45% INJ

2NORMOSOL-M/D5W INJ

2NORMOSOL-R (PH 7.4) INJ

2NORMOSOL-R INJ

2PLASMA-LYTE 148 INJ

2PLASMALYTE A INJ

2potassium chloride 0.02 meq/ml/sodium chloride 0.0769 meq/ml inj

2potassium chloride 0.02 meq/ml/sodium chloride 0.154 meq/ml inj

2TPN ELECTROLYTES INJ PA_BvDFLUORIDE

$0*FLUORABON SOLN

$0*LURIDE CHEW TAB

$0*LURIDE SOLN

$0*sodium fluoride chew tab

$0*SODIUM FLUORIDE LOZENGE

$0*sodium fluoride soln

$0*SODIUM FLUORIDE TABMAGNESIUM

2magnesium sulfate 500mg/ml injPHOSPHATE

2K-PHOS 500MG TAB

3*K-PHOS NEUTRAL TAB

1*phospha 250 neutral tabPOTASSIUM


93


2K-TAB 10MEQ ER TAB

2K-TAB 20MEQ ER TAB

2K-TAB ER 8MEQ TAB

1klor-con 10meq er tab

1klor-con 10meq micro er tab

2klor-con 20meq powder for oral soln

1klor-con 8meq er tab

1potassium bicarbonate 25meq effer tab

2POTASSIUM CHLORIDE 0.1MEQ/ML INJ



2potassium chloride 1.33meq/ml oral soln

1potassium chloride 10meq ER cap

2potassium chloride 10meq inj

2POTASSIUM CHLORIDE 10MEQ INJ

2POTASSIUM CHLORIDE 10MEQ/50ML INJ

2potassium chloride 10meq/50ml inj

2potassium chloride 15meq micro tab

2potassium chloride 2.67meq/ml oral soln

2potassium chloride 20meq er tab



1potassium chloride 20meq micro er tab

2potassium chloride 20meq/100ml inj

2POTASSIUM CHLORIDE 20MEQ/100ML INJ

1POTASSIUM CHLORIDE 25MEQ EFFER TAB

2potassium chloride 2meq/ml (20ml) inj



1potassium chloride 8meq er cap

1POTASSIUM CHLORIDE 8MEQ ER TABSODIUM

2sodium chloride 2.5meq/ml inj

2sodium chloride 23.4% inj

2sodium chloride 30mg/ml inj

2sodium chloride 4.5mg/ml inj

2sodium chloride 50mg/ml inj

2sodium chloride 9mg/ml injZINC

2*GALZIN CAP

MISCELLANEOUS THERAPEUTIC CLASSESCHELATING AGENTS

2penicillamine 250mg tab

2trientine 250mg cap PAIMMUNOSUPPRESSIVE AGENTS

4ENSPRYNG 120MG/ML SYRINGE NDS PA QL=2 Quantity/28 Days


94


2everolimus 0.25mg tab PA_BvD



4LUPKYNIS 7.9MG CAP LD NDS PA QL=180 Quantity/30 Days

3PROGRAF 0.2MG GRANULES FOR ORAL SUSP PA_BvD

3PROGRAF 1MG GRANULES FOR ORAL SUSP PA_BvD

3RAPAMUNE 1MG/ML ORAL SOLN PA_BvD

2sirolimus 1mg/ml oral soln PA_BvD

3ZORTRESS 1MG TAB PA_BvDPOTASSIUM REMOVING AGENTS

2LOKELMA 10GM POWDER FOR ORAL SUSP PA

2LOKELMA 5GM POWDER FOR ORAL SUSP PASYSTEMIC LUPUS ERYTHEMATOSUS AGENTS

4BENLYSTA 200MG/ML AUTO-INJECTOR NDS PA QL=4 Quantity/28 Days

4BENLYSTA 200MG/ML SYRINGE NDS PA QL=4 Quantity/28 Days

MOUTH/THROAT/DENTAL AGENTSANESTHETICS TOPICAL ORAL

3*FIRST MOUTHWASH BLM SUSP

1lidocaine 2% topical soln

1LIDOCAINE 4% ORAL SOLN QL=50 Quantity/30 DaysANTI-INFECTIVES - THROAT

1clotrimazole 10mg lozenge

1nystatin 100000unit/ml susp

3ORAVIG 50MG BUCCAL TABANTISEPTICS - MOUTH/THROAT

1chlorhexidine gluconate 0.12% mouthwashDENTAL PRODUCTS

2*PREVIDENT 5000 BOOSTER PASTE

2*PREVIDENT 5000 DRY MOUTH GEL

2*PREVIDENT 5000 PASTE

1*PREVIDENT 5000 PASTE

$0*PREVIDENT 5000 PLUS CREAM

2*PREVIDENT RINSE

$0*sodium fluoride cream

1*sodium fluoride gel

1*sodium fluoride paste

1*sodium fluoride rinse

1*sodium fluoride/potassium nitrate pasteSTEROIDS - MOUTH/THROAT

1triamcinolone acetonide 0.1% oral pasteTHROAT PRODUCTS - MISC.

2cevimeline 30mg cap

1pilocarpine 5mg tab

1pilocarpine 7.5mg tab

MULTIVITAMINSB-COMPLEX W/ FOLIC ACID


95


1*DIALYVITE TAB

1*dialyvite tab

1*DIALYVITE/ZINC TAB

1*FOLBEE PLUS CZ TAB

3*NEPHRO-VITE TAB

1*renaphro capMULTIPLE VITAMINS W/ MINERALS

1*multivitamin/minerals tab

3*STROVITE TAB

3*V-C FORTE CAPPED MULTI VITAMINS W/FL & FE

3*ESCAVITE CHEW TAB

1*pediatric multiple vitamins/fluoride/iron solnPED MV W/ FLUORIDE

2*FLORIVA PLUS DROPS

1*MULTI-VITAMIN/FLOURIDE 0.25MG CHEW TAB

1*MULTI-VITAMIN/FLOURIDE 0.5MG CHEW TAB

1*MULTI-VITAMIN/FLOURIDE 1MG CHEW TAB

1*pediatric multiple vitamins/fluoride chew tab

1*pediatric multiple vitamins/fluoride soln

3*QUFLORA PEDIATRIC CHEW TAB

MUSCULOSKELETAL THERAPY AGENTSCENTRAL MUSCLE RELAXANTS

1baclofen 10mg tab

1baclofen 20mg tab

1carisoprodol 350mg tab

2chlorzoxazone 500mg tab

1cyclobenzaprine 10mg tab

1cyclobenzaprine 5mg tab

2metaxalone 800mg tab

1methocarbamol 500mg tab

1methocarbamol 750mg tab

1orphenadrine citrate 100mg er tab

2tizanidine 2mg cap

1tizanidine 2mg tab

2tizanidine 4mg cap

1tizanidine 4mg tab

2tizanidine 6mg capDIRECT MUSCLE RELAXANTS

2dantrolene sodium 100mg cap



NASAL AGENTS - SYSTEMIC AND TOPICALNASAL ANTIALLERGY

1azelastine 0.137mg/act nasal inhaler

2azelastine 0.206mg/act nasal inhaler


96


2olopatadine 0.665mg/act nasal inhalerNASAL ANTICHOLINERGICS

1ipratropium 0.03% nasal spray

1ipratropium 0.06% nasal sprayNASAL STEROIDS

3FLUNISOLIDE 0.025MG/ACT NASAL INHALER QL=1 Quantity/30 Days

1fluticasone propionate 0.05mg/act nasal inhaler QL=2 Quantity/30 Days

NEUROMUSCULAR AGENTSALS AGENTS

2riluzole 50mg tabSPINAL MUSCULAR ATROPHY AGENTS (SMA)

4EVRYSDI 0.75MG/ML ORAL SOLN LD NDS PA QL=200 Quantity/30 Days

NUTRIENTSCARBOHYDRATES

2glucose 100mg/ml inj PA_BvD

2glucose 50mg/ml injLIPIDS

3INTRALIPID 30GM/100ML INJ PA_BvD

2NUTRILIPID 20GM/100ML INJ PA_BvDPROTEINS

3AMINOSYN-PF 7% INJ PA_BvD

2CLINIMIX 4.25/10 INJ PA_BvD

2CLINIMIX 4.25/5 INJ PA_BvD

2CLINIMIX 5/15 INJ PA_BvD

2CLINIMIX 5/20 INJ PA_BvD

2CLINIMIX E 2.75/5 INJ PA_BvD



2CLINIMIX E 5/15 INJ PA_BvD

2CLINIMIX E 5/20 INJ PA_BvD

2clinisol 15% inj PA_BvD

3FREAMINE HBC 6.9% INJ PA_BvD

2HEPATAMINE 8% INJ PA_BvD

3PROCALAMINE 3% INJ PA_BvD

3PROSOL 20% INJ PA_BvD

3TRAVASOL 10% INJ PA_BvD

OPHTHALMIC AGENTSBETA-BLOCKERS - OPHTHALMIC

1betaxolol 0.5% ophth soln

3BETIMOL 0.25% OPHTH SOLN

2BETIMOL 0.5% OPHTH SOLN

3BETOPTIC S 0.25% OPHTH SUSP

1CARTEOLOL 1% OPHTH SOLN

2COMBIGAN 2-5MG/ML OPHTH SOLN

1dorzolamide/timolol 22.3-6.8mg/ml ophth soln


97


2dorzolamide/timolol 22.3-6.8mg/ml ophth soln (preservative-free)

1LEVOBUNOLOL 0.5% OPHTH SOLN

2timolol 0.25% ophth gel

1timolol 0.25% ophth soln

2timolol 0.5% (pf) ophth soln

2timolol 0.5% ophth gel

1timolol 0.5% ophth soln

2timolol 5mg/ml ophth 24hr ophth soln

3TIMOPTIC 0.25% OPHTH SOLN (PRESERVATIVE-FREE)

CYCLOPLEGIC MYDRIATICS

2ATROPINE SULFATE 1% OPHTH SOLN

1*homatropine ophth soln

2*HOMATROPINE OPHTH SOLNMIOTICS

1pilocarpine 1% ophth soln

1pilocarpine 2% ophth soln

1pilocarpine 4% ophth solnOPHTHALMIC ADRENERGIC AGENTS

3ALPHAGAN 0.1% OPHTH SOLN

2apraclonidine 0.5% ophth soln

2brimonidine tartrate 0.15% ophth soln

1brimonidine tartrate 0.2% ophth soln

3IOPIDINE 1% OPHTH SOLN

2SIMBRINZA 0.2-1% OPHTH SUSPOPHTHALMIC ANTI-INFECTIVES

2AZASITE 1% OPHTH SOLN

2BACITRACIN 0.5UNIT/MG OPHTH OINTMENT

1bacitracin 0.5unit/mg/polymyxin b 10unit/mg ophth ointment


3CILOXAN 0.3% OPHTH OINTMENT QL=7 Quantity/7 Days

1ciprofloxacin 0.3% ophth soln QL=60 Quantity/30 Days

1erythromycin 0.5% ophth ointment QL=7 Quantity/7 Days

2gatifloxacin 0.5% ophth soln QL=2 Quantity/7 Days

2GENTAK 0.3% OPHTH OINTMENT QL=7 Quantity/7 Days

1gentamicin 0.3% ophth soln QL=10 Quantity/7 Days

1GRAMICIDIN 0.025MG/ML/NEOMYCIN 1.75MG/ML/POLYMYXIN B 10000UNIT/ML OPHTH SOLN


1levofloxacin 0.5% ophth soln QL=12 Quantity/30 Days

1moxifloxacin 0.5% ophth soln QL=2 Quantity/7 Days

1moxifloxacin 0.5% ophth soln QL=6 Quantity/7 Days

2NATACYN 5% OPHTH SUSP QL=1 Quantity/7 Days

1neomycin/bacitracin/polymyxin ophth ointment 5(3.5)mg-400unit-10000unit



98


1ofloxacin 0.3% ophth soln QL=60 Quantity/30 Days

1polymyxin b 10000unit/ml/trimethoprim 1mg/ml ophth soln


2SULFACETAMIDE SODIUM 10% OPHTH OINTMENT QL=7 Quantity/7 Days

1sulfacetamide sodium 10% ophth soln QL=15 Quantity/7 Days

1tobramycin 0.3% ophth soln QL=12 Quantity/30 Days

3TOBREX 0.3% OPHTH OINTMENT QL=7 Quantity/7 Days

2TRIFLURIDINE 1% OPHTH SOLN QL=2 Quantity/7 Days

2ZIRGAN 0.15% OPHTH GEL QL=10 Quantity/7 DaysOPHTHALMIC IMMUNOMODULATORS

2RESTASIS 0.05% OPHTH SUSPOPHTHALMIC KINASE INHIBITORS

2RHOPRESSA 0.02% OPHTH SOLN QL=2 Quantity/30 Days

2ROCKLATAN 0.05-0.2MG/ML OPHTH SOLN QL=2 Quantity/30 DaysOPHTHALMIC LOCAL ANESTHETICS

1proparacaine 0.5% ophth solnOPHTHALMIC NERVE GROWTH FACTORS

4OXERVATE 0.002% OPHTH SOLN LD NDS PA QL=112 Quantity/365 Days

OPHTHALMIC STEROIDS

2ALREX 0.2% OPHTH SUSP

3BLEPHAMIDE 0.2-10% OPHTH OINTMENT

3BLEPHAMIDE 0.2-10% OPHTH SUSP

2DEXAMETHASONE PHOSPHATE 0.1% OPHTH SOLN

1dexamethasone/neomycin/polymyxin b 0.1% ophth ointment

1dexamethasone/neomycin/polymyxin b 0.1% ophth susp

1dexamethasone/tobramycin 0.3-0.1% ophth susp

2difluprednate 0.05% ophth emulsion

3FLAREX 0.1% OPHTH SUSP

1fluorometholone 0.1% ophth susp

3FML 0.1% OPHTH OINTMENT

3FML FORTE LIQUIFILM 0.25% OPHTH SUSP

2LOTEMAX 0.5% OPHTH OINTMENT

2loteprednol etabonate 0.5% ophth gel

2loteprednol etabonate 0.5% ophth susp

2MAXIDEX 0.1% OPHTH SUSP

1NEOMYCIN-POLYMYXIN-HC OPHTH SUSP

1neomycin/polymyxin/bacitracin/hydrocortisone 1% ophth ointment

3PRED FORTE 1% OPHTH SUSP

2PRED MILD 0.12% OPHTH SUSP

3PRED-G 0.3-0.6% OPHTH OINTMENT

2PRED-G 0.3-1% OPHTH SUSP


99


2PREDNISOLONE 1% OPHTH SOLN

2PREDNISOLONE ACETATE 1% OPHTH SUSP

1PREDNISOLONE SODIUM PHOSPHATE 2.5MG/ML/SULFACETAMIDE SODIUM 100MG/ML OPHTH SOLN

3TOBRADEX 0.05-0.3% OPHTH SUSP

2TOBRADEX 0.1-0.3% OPHTH OINTMENT

2ZYLET 0.5-0.3% OPHTH SUSPOPHTHALMICS - MISC.

3ACUVAIL 0.45% OPHTH SOLN QL=60 Quantity/365 Days

2ALOCRIL 2% OPHTH SOLN

2ALOMIDE 0.1% OPHTH SOLN

1azelastine 0.05% ophth soln

2bepotastine besilate 1.5% ophth soln

2brinzolamide 1% ophth susp

1bromfenac 0.09% ophth soln QL=6.80 Quantity/365 Days

1cromolyn sodium 4% ophth soln

4CYSTADROPS 0.37% OPHTH SOLN LD NDS PA QL=4 Quantity/28 Days

4CYSTARAN 0.44% OPHTH SOLN LD NDS PA QL=60 Quantity/28 Days

1diclofenac sodium 0.1% ophth soln QL=20 Quantity/365 Days

1dorzolamide 2% ophth soln

2epinastine 0.05% ophth soln

2FLURBIPROFEN SODIUM 0.03% OPHTH SOLN

2ILEVRO 0.3% OPHTH SUSP QL=12 Quantity/365 Days

1ketorolac tromethamine 0.4% ophth soln QL=20 Quantity/365 Days

1ketorolac tromethamine 0.5% ophth soln

3LASTACAFT 0.25% OPHTH SOLN

2NEVANAC 0.1% OPHTH SUSP QL=12 Quantity/365 Days

1olopatadine 0.1% ophth soln

1olopatadine 0.2% ophth soln

3PROLENSA 0.07% OPHTH SOLN QL=12 Quantity/365 DaysPROSTAGLANDINS - OPHTHALMIC

2bimatoprost 0.03% ophth soln QL=5 Quantity/30 Days

1latanoprost 0.005% ophth soln QL=5 Quantity/30 Days

2LUMIGAN 0.01% OPHTH SOLN QL=5 Quantity/30 Days

2travoprost 0.004% ophth soln QL=5 Quantity/30 Days

3ZIOPTAN 0.015MG/ML OPHTH SOLN ST QL=30 Quantity/30 Days

OTIC AGENTSOTIC AGENTS - MISCELLANEOUS

1acetic acid 2% otic solnOTIC ANTI-INFECTIVES

2CIPROFLOXACIN 0.2% OTIC SOLN

1ofloxacin 0.3% otic solnOTIC COMBINATIONS

3CIPRO HC 0.2-1% OTIC SUSP

2ciprofloxacin/dexamethasone 0.3-0.1% otic susp


100


1hydrocortisone 10mg/ml/neomycin 3.5mg/ml/polymyxin b 10000unit/ml otic soln

1hydrocortisone 10mg/ml/neomycin 3.5mg/ml/polymyxin b 10000unit/ml otic susp

OTIC STEROIDS

1acetic acid/hydrocortisone 1-2% otic soln

2fluocinolone acetonide 0.01% otic soln

PASSIVE IMMUNIZING AGENTSIMMUNE SERUMS

4BIVIGAM 5GM/50ML INJ NDS PA

4FLEBOGAMMA 0.5GM/10ML INJ NDS PA

4GAMMAGARD 10GM INJ NDS PA

4GAMMAGARD 10GM/100ML INJ NDS PA

4GAMMAGARD 2.5GM/25ML INJ NDS PA



4GAMMAGARD 5GM INJ NDS PA


4GAMMAKED 1GM/10ML INJ NDS PA

4GAMMAPLEX 10GM/100ML INJ NDS PA



4GAMUNEX-C 40GM/400ML INJ NDS PA

4OCTAGAM 1GM/20ML INJ NDS PA

4OCTAGAM 2.5GM/50ML INJ NDS PA





4PRIVIGEN 20GM/200ML INJ NDS PA

4PRIVIGEN 40GM/400ML INJ NDS PA

PASSIVE IMMUNIZING AND TREATMENT AGENTSIMMUNE SERUMS

4PANZYGA 10GM/100ML INJ NDS PA


4PANZYGA 2.5GM/25ML INJ NDS PA




4VARIZIG 125UNIT/1.2ML INJ NDS

PENICILLINSAMINOPENICILLINS

1AMOXICILLIN 125MG CHEW TAB

1amoxicillin 250mg cap

2AMOXICILLIN 250MG CHEW TAB

1amoxicillin 25mg/ml susp


101



1amoxicillin 500mg cap

1amoxicillin 500mg tab



1amoxicillin 875mg tab

2ampicillin 1000mg inj

2ampicillin 100mg/ml inj

2AMPICILLIN 125MG INJ


2ampicillin 2gm inj

2AMPICILLIN 2GM INJ

1AMPICILLIN 500MG CAP


2AMPICILLIN SODIUM 1GM INJNATURAL PENICILLINS

2BICILLIN L-A 1200000UNIT/2ML INJ

2BICILLIN L-A 2400000UNIT/4ML INJ

2BICILLIN L-A 600000UNIT/ML INJ

2penicillin g potassium 1000000unit/ml inj

2PENICILLIN G POTASSIUM 40000UNIT/ML INJ

2PENICILLIN G POTASSIUM 60000UNIT/ML INJ

2PENICILLIN G PROCAINE 600000UNIT/ML INJ

2PENICILLIN G SODIUM 100000UNIT/ML INJ

2penicillin gk 5000000unit inj

1penicillin v potassium 250mg tab

1PENICILLIN V POTASSIUM 25MG/ML ORAL SOLN

1penicillin v potassium 500mg tab

1PENICILLIN V POTASSIUM 50MG/ML ORAL SOLNPENICILLIN COMBINATIONS

3AMOXICILLIN 1000MG/CLAVULANATE 62.5MG ER TAB

1amoxicillin 120mg/ml/clavulanate 8.58mg/ml susp

2AMOXICILLIN 200MG/CLAVULANATE 28.5MG CHEW TAB

1amoxicillin 250mg/clavulanate 125mg tab

2AMOXICILLIN 400MG/CLAVULANATE 57MG CHEW TAB






3amoxicillin/k clavulanate 1000-62.5mg er tab

2ampicillin 1000mg/sulbactam 500mg inj

2ampicillin 100mg/ml/sulbactam 50mg/ml inj


102


2ampicillin 2000mg/sulbactam 1000mg inj

2AMPICILLIN/SULBACTAM 1.5GM INJ

2AMPICILLIN/SULBACTAM 3GM INJ

2BICILLIN 300000-300000UNIT/ML INJ

2BICILLIN 450000-150000UNIT/ML INJ

2piperacillin 2000mg/tazobactam 250mg inj

2piperacillin 200mg/ml/tazobactam 25mg/ml inj



2piperacillin/tazobactam 12-1.5gm inj

3ZOSYN 2000-250MG INJ

3ZOSYN 3000-375MG INJ

3ZOSYN/DEXTROSE 4-0.5GM/100ML INJPENICILLINASE-RESISTANT PENICILLINS

1dicloxacillin 250mg cap

1dicloxacillin 500mg cap

2NAFCILLIN 1000MG INJ

2nafcillin 1000mg inj

2nafcillin 100mg/ml inj

2NAFCILLIN 1GM INJ

2NAFCILLIN 2000MG INJ

2nafcillin 2000mg inj

2NAFCILLIN 2GM INJ

2oxacillin 1000mg inj

2oxacillin 100mg/ml inj

2oxacillin 2000mg inj

2OXACILLIN 20MG/ML INJ

2OXACILLIN 40MG/ML INJ

PHARMACEUTICAL ADJUVANTSSEMI SOLID VEHICLES

2*POLYETHYLENE GLYCOL 8000 GRANULES

PROGESTINSPROGESTINS

1medroxyprogesterone acetate 10mg tab

1medroxyprogesterone acetate 2.5mg tab

1medroxyprogesterone acetate 5mg tab

2megestrol acetate 125mg/ml susp PA

1norethindrone acetate 5mg tab

2progesterone 100mg cap

2progesterone 200mg cap

PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.AGENTS FOR CHEMICAL DEPENDENCY

2acamprosate calcium 333mg dr tab

2disulfiram 250mg tab

2disulfiram 500mg tab

3LUCEMYRA 0.18MG TAB PA QL=168 Quantity/14 Days


103


ANTI-CATAPLECTIC AGENTS

4XYREM 500MG/ML ORAL SOLN LD NDS PA QL=540 Quantity/30 DaysANTIDEMENTIA AGENTS

1donepezil 10mg odt QL=30 Quantity/30 Days

1donepezil 10mg tab

2donepezil 23mg tab QL=30 Quantity/30 Days

1donepezil 5mg odt QL=30 Quantity/30 Days

1donepezil 5mg tab

1galantamine 12mg tab



2galantamine hydrobromide 16mg er cap


3GALANTAMINE HYDROBROMIDE 4MG/ML ORAL SOLN


1memantine 10mg tab

1memantine 10mg/memantine 5mg pack

2memantine 14mg er cap



2memantine 2mg/ml oral soln

1memantine 5mg tab


2rivastigmine 0.192mg/hr patch



1rivastigmine 1.5mg cap

1rivastigmine 3mg cap

1rivastigmine 4.5mg cap

1rivastigmine 6mg capFIBROMYALGIA AGENTS

2SAVELLA 100MG TAB QL=60 Quantity/30 Days

2SAVELLA 12.5MG TAB QL=60 Quantity/30 Days

2SAVELLA 25MG TAB QL=60 Quantity/30 Days

2SAVELLA 4-WEEK TITRATION PACK

2SAVELLA 50MG TAB QL=60 Quantity/30 DaysMOVEMENT DISORDER DRUG THERAPY

4AUSTEDO 12MG TAB NDS PA



4INGREZZA 40MG CAP LD NDS PA



2tetrabenazine 12.5mg tab PA

2tetrabenazine 25mg tab PA


104


MULTIPLE SCLEROSIS AGENTS

4AUBAGIO 14MG TAB NDS

4AUBAGIO 7MG TAB NDS

4AVONEX 30MCG/0.5ML AUTO-INJECTOR NDS

4AVONEX 30MCG/0.5ML SYRINGE NDS

1dalfampridine 10mg er tab QL=60 Quantity/30 Days

4dimethyl fumarate 120mg dr cap NDS

4dimethyl fumarate 120mg/dimethyl fumarate 240mg pack

NDS

4dimethyl fumarate 240mg dr cap NDS

4EXTAVIA 0.3MG INJ NDS

4GILENYA 0.25MG CAP NDS

4GILENYA 0.5MG CAP NDS

2glatiramer acetate 20mg/ml syringe

2glatiramer acetate 40mg/ml syringe

4KESIMPTA 20MG/0.4ML PEN INJ NDS

4MAYZENT 0.25MG STARTER PACK NDS

4MAYZENT 0.25MG TAB NDS

4MAYZENT 2MG TAB NDS

4PLEGRIDY 125MCG/0.5ML AUTO-INJECTOR NDS

4PLEGRIDY 125MCG/0.5ML SYRINGE NDS

4PLEGRIDY IM 125MCG/0.5ML INJ NDS

4PLEGRIDY INJ STARTER PACK NDS

4PLEGRIDY PEN STARTER PACK NDS

4REBIF 22MCG/0.5ML AUTO-INJECTOR NDS

4REBIF 22MCG/0.5ML INJ NDS

4REBIF 44MCG/0.5ML AUTO-INJECTOR NDS

4REBIF 44MCG/0.5ML INJ NDS

4REBIF REBIDOSE PACK NDS

4REBIF TITRATION PACK NDS

4ZEPOSIA 0.92MG CAP NDS PA

4ZEPOSIA 7-DAY STARTER PACK NDS PA

4ZEPOSIA STARTER KIT PACK NDS PAPSEUDOBULBAR AFFECT (PBA) AGENTS

2NUEDEXTA 20-10MG CAP PA QL=60 Quantity/30 DaysPSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.

3ERGOLOID MESYLATES USP 1MG TAB

2PIMOZIDE 1MG TAB

2PIMOZIDE 2MG TABSMOKING DETERRENTS

$0bupropion 150mg sr tab

$0CHANTIX 0.5MG TAB

$0CHANTIX 1MG TAB

$0CHANTIX FIRST MONTH OF THERAPY PACK

$0*COMMIT LOZENGE

$0*NICORETTE CQ PATCH


105


$0*NICORETTE GUM

$0*nicotine gum

$0*nicotine lozenge

$0*nicotine patch

$0*NICOTINE PATCH KIT

$0NICOTROL 10MG INH SOLN

$0NICOTROL 10MG/ML NASAL INHALERTRANSTHYRETIN AMYLOIDOSIS AGENTS

4TEGSEDI 284MG/1.5ML INJ LD NDS PA QL=4 Quantity/28 Days

RESPIRATORY AGENTS - MISC.ALPHA-PROTEINASE INHIBITOR (HUMAN)

4ARALAST NP 500MG INJ NDS PA

4GLASSIA 1000MG/50ML INJ NDS PA

4PROLASTIN-C 1000MG INJ NDS PA

4ZEMAIRA 1000MG INJ NDS PACYSTIC FIBROSIS AGENTS

4KALYDECO 150MG TAB LD NDS PA QL=60 Quantity/30 Days

4KALYDECO 25MG GRANULES LD NDS PA QL=60 Quantity/30 Days



4ORKAMBI 125-100MG GRANULES LD NDS PA QL=60 Quantity/30 Days

4ORKAMBI 125-100MG TAB LD NDS PA QL=120 Quantity/30 Days

4ORKAMBI 125-200MG TAB LD NDS PA QL=120 Quantity/30 Days

4ORKAMBI 188-150MG GRANULES LD NDS PA QL=60 Quantity/30 Days

4PULMOZYME 1MG/ML INH SOLN NDS PA_BvD QL=150 Quantity/30 Days

4SYMDEKO 50-75MG/75MG PACK LD NDS PA QL=60 Quantity/30 Days

4SYMDEKO TAB 4-WEEK PACK LD NDS PA QL=60 Quantity/30 Days

4TRIKAFTA 100-50-75MG/150MG PACK LD NDS PA QL=90 Quantity/30 Days

4TRIKAFTA 50-37.5-25MG/75MG TAB PACK LD NDS PA QL=84 Quantity/28 DaysPULMONARY FIBROSIS AGENTS

4ESBRIET 267MG CAP NDS PA

4ESBRIET 267MG TAB NDS PA

4ESBRIET 801MG TAB NDS PA

4OFEV 100MG CAP LD NDS PA

4OFEV 150MG CAP LD NDS PA

SULFONAMIDESSULFONAMIDES

2SULFADIAZINE 500MG TAB

TETRACYCLINESAMINOMETHYLCYCLINES

4NUZYRA 150MG TAB LD NDS PA QL=30 Quantity/14 DaysGLYCYLCYCLINES

4TIGECYCLINE 50MG INJ NDS

4tigecycline 50mg inj NDSTETRACYCLINES


106


2demeclocycline 150mg tab

2demeclocycline 300mg tab

2doxy 100mg inj

1doxycycline hyclate 100mg cap

1doxycycline hyclate 100mg tab

1doxycycline hyclate 20mg tab

1doxycycline hyclate 50mg cap

1doxycycline monohydrate 100mg tab

1doxycycline monohydrate 50mg cap

1doxycycline monohydrate 50mg tab

2doxycycline monohydrate 5mg/ml susp

1minocycline 100mg cap

2minocycline 100mg tab





1mondoxyne 100mg cap

1tetracycline 250mg cap

1tetracycline 500mg cap

3VIBRAMYCIN 50MG/5ML SUSP

THYROID AGENTSANTITHYROID AGENTS

1methimazole 10mg tab

1methimazole 5mg tab

1propylthiouracil 50mg tabTHYROID HORMONES

1ARMOUR THYROID 120MG TAB





3CYTOMEL 25MCG TAB

3CYTOMEL 50MCG TAB

3CYTOMEL 5MCG TAB

1levothyroxine sodium 100mcg tab












107



1liothyronine sodium 0.005mg tab



3SYNTHROID 100MCG TAB












TOXOIDSTOXOID COMBINATIONS

$0ADACEL INJ

$0BOOSTRIX INJ

$0DAPTACEL INJ

$0DIPHTHERIA/TETANUS TOXOID INJ PA_BvD

$0INFANRIX INJ

$0KINRIX INJ

$0KINRIX PF INJ

$0PEDIARIX INJ

$0PENTACEL INJ

$0TDVAX 4-4UNIT/ML INJ PA_BvD

$0TENIVAC 4-10UNIT/ML INJ PA_BvD

ULCER DRUGSANTISPASMODICS

3*ANASPAZ TAB

2*BELLADONNA ALKALOID/OPIUM SUPP

3CUVPOSA 1MG/5ML ORAL SOLN

1dicyclomine 10mg cap

1dicyclomine 20mg tab

2dicyclomine 2mg/ml oral soln

2glycopyrrolate 1mg tab

2glycopyrrolate 2mg tab

1*hyoscyamine sulfate CR tab

1*hyoscyamine sulfate elixir

1*hyoscyamine sulfate ODT

1*hyoscyamine sulfate SL tab

1*hyoscyamine sulfate tab

3*LEVBID TAB

3*LEVSIN SL TAB


108


3*LEVSIN TAB

2methscopolamine bromide 2.5mg tab

2methscopolamine bromide 5mg tab

3*SYMAX DUOTABH-2 ANTAGONISTS

1cimetidine 200mg tab


2cimetidine 300mg/5ml oral soln


2CIMETIDINE 60MG/ML ORAL SOLN


1famotidine 20mg tab

1famotidine 40mg tab

2famotidine 8mg/ml susp

1nizatidine 150mg capMISC. ANTI-ULCER

1sucralfate 1000mg tabPROTON PUMP INHIBITORS

2esomeprazole 20mg dr cap (rx only)

2esomeprazole 40mg dr cap

3*FIRST OMEPRAZOLE SUSP

3*LANSOPRAZOLE SUSP

1omeprazole 10mg dr cap



1pantoprazole 20mg dr tab

1pantoprazole 40mg dr tab

2rabeprazole sodium 20mg dr tabULCER DRUGS - PROSTAGLANDINS

1misoprostol 0.1mg tab

1misoprostol 0.2mg tabULCER THERAPY COMBINATIONS

2amoxicillin 500mg/clarithromycin 500mg/lansoprazole 30mg pack

3PYLERA 140-125-125MG CAP

ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICSH-2 ANTAGONISTS

1NIZATIDINE 150MG CAP

1NIZATIDINE 300MG CAPMISC. ANTI-ULCER

2sucralfate 100mg/ml susp

URINARY ANTISPASMODICSBETA-3 ADRENERGIC AGONISTS

2MYRBETRIQ 25MG ER TAB

2MYRBETRIQ 50MG ER TABURINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLIN) (NEW)


109


1oxybutynin chloride 10mg er tab


1oxybutynin chloride 1mg/ml oral soln


1oxybutynin chloride 5mg tab

1tolterodine tartrate 1mg tab

1tolterodine tartrate 2mg tab

1trospium chloride 20mg tab

2trospium chloride 60mg er capURINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)

2darifenacin 15mg er tab

2darifenacin 7.5mg er tab

1solifenacin succinate 10mg tab

1solifenacin succinate 5mg tab

2tolterodine tartrate 2mg er cap

2tolterodine tartrate 4mg er capURINARY ANTISPASMODICS - CHOLINERGIC AGONISTS (NEW)

1bethanechol chloride 10mg tab



1bethanechol chloride 5mg tabURINARY ANTISPASMODICS - DIRECT MUSCLE RELAXANTS

2flavoxate 100mg tab

VACCINESBACTERIAL VACCINES

$0ACTHIB INJ

$0BCG LIVE TICE STRAIN 50MG INJ

$0BEXSERO SYRINGE

$0HIBERIX 10MCG INJ

$0MENACTRA INJ

$0MENQUADFI INJ

$0MENVEO INJ

$0PEDVAXHIB 7.5MCG/0.5ML INJ

$0TRUMENBA INJ

$0TYPHIM VI 25MCG/0.5ML INJ

$0*VIVOTIF BERNA CAP QL=4 Quantity/ Per DispensingVIRAL VACCINES

$0ENGERIX-B 10MCG/0.5ML INJ PA_BvD

$0ENGERIX-B 20MCG/ML INJ PA_BvD

$0GARDASIL 9 INJ

$0GARDASIL 9 SYRINGE

$0HAVRIX 1440ELU/ML INJ

$0HAVRIX 720ELU/0.5ML INJ

$0IMOVAX 2.5UNIT/ML INJ PA_BvD

$0IPOL INJ

$0IXIARO 0.012MG/ML INJ


110


$0M-M-R II INJ

$0PROQUAD INJ

$0RABAVERT 2.5UNIT/ML INJ PA_BvD

$0RECOMBIVAX 10MCG/ML INJ PA_BvD

$0RECOMBIVAX 40MCG/ML INJ PA_BvD

$0RECOMBIVAX 5MCG/0.5ML INJ PA_BvD

$0ROTARIX SUSP

$0ROTATEQ SUSP

$0SHINGRIX 50MCG/0.5ML INJ QL=2 Quantity/365 Days

$0TWINRIX 720UNIT INJ

$0VAQTA 25UNIT/0.5ML INJ

$0VAQTA 50UNIT/ML INJ

$0VARIVAX 1350PFU/0.5ML INJ

$0YF-VAX 4000UNIT/ML INJ

VAGINAL PRODUCTSMISCELLANEOUS VAGINAL PRODUCTS

3*FEM PH GELSPERMICIDES

$0*CONTRACEPTIVE FILM

$0*CONTRACEPTIVE FOAM

$0*CONTRACEPTIVE GEL

$0*CONTRACEPTIVE SPONGE

$0*CONTRACEPTIVE SUPP VAGINAL ANTI-INFECTIVES

3CLEOCIN 100MG VAGINAL INSERT

1clindamycin 2% vaginal cream

3CLINDESSE 2% VAGINAL CREAM

1metronidazole 0.75% vaginal gel

3MICONAZOLE NITRATE 200MG VAGINAL INSERT

1terconazole 0.4% vaginal cream

2terconazole 0.8% vaginal cream

2TERCONAZOLE 0.8% VAGINAL CREAM

1terconazole 80mg vaginal insertVAGINAL ESTROGENS

2estradiol 0.01% vaginal cream

2estradiol 0.01mg vaginal insert

3ESTRING 2MG VAGINAL SYSTEM ST

3FEMRING 0.05MG/24HR VAGINAL SYSTEM ST

3FEMRING 0.1MG/24HR VAGINAL SYSTEM ST

2PREMARIN 0.625MG/GM VAGINAL CREAMVAGINAL PROGESTINS

2CRINONE 4% VAGINAL GEL PA

2CRINONE 8% VAGINAL GEL PA

VASOPRESSORSANAPHYLAXIS THERAPY AGENTS

2epinephrine 0.15mg/0.3ml auto-injector (2 pack) QL=2 Quantity/15 Days


111


2epinephrine 0.3mg/0.3ml auto-injector (2 pack) QL=2 Quantity/15 Days

2SYMJEPI 0.15MG/0.3ML SYRINGE QL=2 Quantity/15 Days

2SYMJEPI 0.3MG/0.3ML SYRINGE QL=2 Quantity/15 DaysNEUROGENIC ORTHOSTATIC HYPOTENSION (NOH) - AGENTS

2droxidopa 100mg cap PA

2droxidopa 200mg cap PA

2droxidopa 300mg cap PAVASOPRESSORS

1midodrine 10mg tab

1midodrine 2.5mg tab

1midodrine 5mg tab

VITAMINSOIL SOLUBLE VITAMINS

3*DRISDOL CAP

1*vitamin D 50000unit capWATER SOLUBLE VITAMINS

3*POTABA CAP


112

ALPHABETICAL LISTING OF DRUGS

A

abacavir 20mg/ml oral soln

60

abacavir 300mg tab 60 abacavir 300mg/lamivudine 150mg/zidovudine 300mg tab

60

abacavir 600mg/lamivudine 300mg tab

60

ABELCET 5MG/ML INJ 34 ABILIFY 300MG INJ 59 ABILIFY 300MG SYRINGE

59

ABILIFY 400MG INJ 59 ABILIFY 400MG SYRINGE

59

abiraterone acetate 250mg tab

46

acamprosate calcium 333mg dr tab

103

acarbose 100mg tab 30 acarbose 25mg tab 30 acarbose 50mg tab 30 ACCU-CHEK AVIVA PLUS METER

91

acebutolol 200mg cap 64 acebutolol 400mg cap 65 acetaminophen 21.7mg/ml/hydrocodone bitartrate 0.5mg/ml oral soln

15

acetaminophen 24mg/ml/codeine phosphate 2.4mg/ml oral soln

16

acetaminophen 300mg/codeine phosphate 15mg tab

16


16


16

acetaminophen 300mg/hydrocodone bitartrate 10mg tab

16


16

acetaminophen 300mg/hydrocodone bitartrate 7.5mg tab

16


16

acetaminophen 325mg/hydrocodone bitartrate 7.5mg tab

16

acetaminophen 325mg/oxycodone 10mg tab

16

acetaminophen 325mg/oxycodone 2.5mg tab

16

acetaminophen 325mg/oxycodone 5mg tab

16

acetaminophen 325mg/oxycodone 7.5mg tab

16

acetaminophen 325mg/tramadol 37.5mg tab

16

acetazolamide 125mg tab 79 acetazolamide 250mg tab 79 acetazolamide 500mg er cap

79

acetic acid 2% otic soln 100 acetic acid/hydrocortisone 1-2% otic soln

101

acetylcysteine 100mg/ml inh soln

74

acetylcysteine 200mg/ml inh soln

74

acitretin 10mg cap 76 acitretin 17.5mg cap 76 acitretin 25mg cap 76 ACTEMRA 162MG/0.9ML AUTO-INJECTOR

12

ACTEMRA 162MG/0.9ML SYRINGE

12

ACTHIB INJ 110 ACTIMMUNE 2000000UNIT/0.5ML INJ

53

ACUVAIL 0.45% OPHTH SOLN

100

acyclovir 200mg cap 62 acyclovir 400mg tab 62 acyclovir 40mg/ml susp 62 acyclovir 5% cream 76 acyclovir 5% ointment 76 acyclovir 50mg/ml inj 62 acyclovir 800mg tab 62 ADACEL INJ 108 adapalene 0.1% cream 74 adapalene 0.1% gel 74 adapalene 0.3% gel 74 adapalene/benzoyl peroxide 0.1-2.5% gel

74

adefovir dipivoxil 10mg tab

62

ADEMPAS 0.5MG TAB 69 ADEMPAS 1.5MG TAB 69 ADEMPAS 1MG TAB 69 ADEMPAS 2.5MG TAB 69 ADEMPAS 2MG TAB 69 ADVAIR 100-50MCG DISKUS

21

ADVAIR 115-21MCG HFA INHALER

21

ADVAIR 230-21MCG HFA INHALER

21

ADVAIR 250-50MCG DISKUS

21


113


ADVAIR 45-21MCG/ACT HFA INHALER

21

ADVAIR 500-50MCG DISKUS

21

AIMOVIG 140MG/ML AUTO-INJECTOR

92

AIMOVIG 70MG/ML AUTO-INJECTOR

92

ala-cort 2.5% cream 76 albendazole 200mg tab 17 albuterol 0.21mg/ml inh soln

21

albuterol 0.417mg/ml inh soln

21

albuterol 0.4mg/ml oral soln

21

albuterol 0.83mg/ml inh soln

21

albuterol 2mg tab 21 albuterol 4mg tab 21 albuterol 5mg/ml inh soln 21 albuterol HFA inhaler (6.7gm)

21

albuterol HFA inhaler (8.5gm)

21

alclometasone dipropionate 0.05% cream

76

alclometasone dipropionate 0.05% ointment

76

ALCOHOL SWAB 1"x1" (DIABETIC)

78

ALCOHOL SWAB 1"x1" (DIABETIC)

78

ALDACTAZIDE 50-50MG TAB

79

ALECENSA 150MG CAP 48 alendronate 10mg tab 80 alendronate 35mg tab 80 alendronate 70mg tab 80 alendronate 70mg/75ml oral soln

80

alfuzosin 10mg er tab 86 aliskiren 150mg tab 41

aliskiren 300mg tab 41 ALKERAN TAB 44 allopurinol 100mg tab 87 allopurinol 300mg tab 87 ALOCRIL 2% OPHTH SOLN

100

ALOMIDE 0.1% OPHTH SOLN

100

alosetron 0.5mg tab 85 alosetron 1mg tab 85 ALPHAGAN 0.1% OPHTH SOLN

98

alprazolam 0.25mg tab 18 alprazolam 0.5mg er tab 19 alprazolam 0.5mg tab 19 alprazolam 1mg er tab 19 alprazolam 1mg tab 19 alprazolam 2mg er tab 19 alprazolam 2mg tab 19 alprazolam 3mg er tab 19 ALREX 0.2% OPHTH SUSP

99

altavera 28 day pack 71 ALUNBRIG 180MG TAB 48 ALUNBRIG 30MG TAB 48 ALUNBRIG 90MG TAB 48 ALUNBRIG TAB STARTER PACK

48

amabelz 0.5/0.1mg 28 day pack

83

amantadine 100mg cap 54 amantadine 100mg tab 54 amantadine 10mg/ml oral soln

54

amantadine 10mg/ml oral soln

54

AMBISOME 50MG INJ 34 ambrisentan 10mg tab 68 ambrisentan 5mg tab 68 amikacin 250mg/ml inj 11 amikacin sulfate 1gm/4ml inj

11

amiloride 5mg tab 80

amiloride 5mg/hydrochlorothiazide 50mg tab

79

AMINOSYN-PF 7% INJ 97 amiodarone 100mg tab 20 amiodarone 200mg tab 20 amiodarone 400mg tab 20 amitriptyline 100mg tab 29 amitriptyline 10mg tab 29 amitriptyline 150mg tab 29 amitriptyline 25mg tab 29 amitriptyline 50mg tab 29 amitriptyline 75mg tab 29 amlodipine 10mg tab 66 amlodipine 10mg/atorvastatin 10mg tab

67

amlodipine 10mg/atorvastatin 20mg tab

67


67


67

amlodipine 10mg/benazepril 20mg cap

39


39

amlodipine 10mg/hydrochlorothiazide 12.5mg/valsartan 160mg tab

39

amlodipine 10mg/hydrochlorothiazide 25mg/valsartan 160mg tab

39


39


114


amlodipine 10mg/olmesartan medoxomil 20mg tab

39


39

amlodipine 10mg/valsartan 160mg tab

39


39

amlodipine 2.5mg tab 66 amlodipine 2.5mg/atorvastatin 10mg tab

67

amlodipine 2.5mg/atorvastatin 20mg tab

68

amlodipine 2.5mg/atorvastatin 40mg tab

68

amlodipine 2.5mg/benazepril 10mg cap

39

amlodipine 5mg tab 66 amlodipine 5mg/atorvastatin 10mg tab

68


68


68


68


39


39


39

amlodipine 5mg/hydrochlorothiazide 12.5mg/valsartan 160mg tab

39


39


39


39


39


39

ammonium lactate 12% cream

78

ammonium lactate 12% lotion

78

AMOXAPINE 100MG TAB

29

AMOXAPINE 150MG TAB

29

AMOXAPINE 25MG TAB 29 AMOXAPINE 50MG TAB 29 AMOXICILLIN 1000MG/CLAVULANATE 62.5MG ER TAB

102

amoxicillin 120mg/ml/clavulanate 8.58mg/ml susp

102

AMOXICILLIN 125MG CHEW TAB

101

AMOXICILLIN 200MG/CLAVULANATE 28.5MG CHEW TAB

102

amoxicillin 250mg cap 101 AMOXICILLIN 250MG CHEW TAB

101

amoxicillin 250mg/clavulanate 125mg tab

102

amoxicillin 25mg/ml susp 101 AMOXICILLIN 400MG/CLAVULANATE 57MG CHEW TAB

102

amoxicillin 40mg/ml susp 102 amoxicillin 40mg/ml/clavulanate 5.7mg/ml susp

102

amoxicillin 500mg cap 102 amoxicillin 500mg tab 102 amoxicillin 500mg/clarithromycin 500mg/lansoprazole 30mg pack

109

amoxicillin 500mg/clavulanate 125mg tab

102


102


102

amoxicillin 875mg tab 102 amoxicillin 875mg/clavulanate 125mg tab

102

amoxicillin/k clavulanate 1000-62.5mg er tab

102

amphetamine-dextroamphetamine 10mg ER cap

9

amphetamine-dextroamphetamine 10mg tab

9

amphetamine-dextroamphetamine 12.5mg tab

9


9


9


9


9


115



9


9


9


9


9

amphetamine-dextroamphetamine 7.5mg tab

9

AMPHOTERICIN B 50MG INJ

34

ampicillin 1000mg inj 102 ampicillin 1000mg/sulbactam 500mg inj

102

ampicillin 100mg/ml inj 102 ampicillin 100mg/ml/sulbactam 50mg/ml inj

102

AMPICILLIN 125MG INJ 102 ampicillin 2000mg/sulbactam 1000mg inj

103

ampicillin 250mg inj 102 ampicillin 2gm inj 102 AMPICILLIN 2GM INJ 102 AMPICILLIN 500MG CAP

102

ampicillin 500mg inj 102 AMPICILLIN SODIUM 1GM INJ

102

AMPICILLIN/SULBACTAM 1.5GM INJ

103

AMPICILLIN/SULBACTAM 3GM INJ

103

anagrelide 0.5mg cap 87 anagrelide 1mg cap 87 ANALPRAM-HC CREAM 17 ANASPAZ TAB 108 anastrozole 1mg tab 46 ANDRODERM 2MG/24HR PATCH

17

ANDRODERM 4MG/24HR PATCH

17

ANGELIQ 0.25/0.5MG 28 DAY PACK

83

ANGELIQ 0.5/1MG 28 DAY PACK

83

ANORO ELLIPTA 62.5-25MCG INHALER

21

ANTARA 30MG CAP 36 ANTARA 90MG CAP 36 ANUSOL-HC SUPP 17 apraclonidine 0.5% ophth soln

98

aprepitant 125mg cap 34 aprepitant 125mg/aprepitant 80mg pack

34

aprepitant 40mg cap 34 aprepitant 80mg cap 34 apri 28 day pack 71 APTIOM 200MG TAB 24 APTIOM 400MG TAB 24 APTIOM 600MG TAB 24 APTIOM 800MG TAB 24 APTIVUS 250MG CAP 60 ARALAST NP 500MG INJ 106 aranelle 28 pack 71 ARANESP 100MCG/0.5ML SYRINGE

88

ARANESP 100MCG/ML INJ

88

ARANESP 10MCG/0.4ML SYRINGE

88


88


88


88


88


88


88


88


88


88

ARANESP 500MCG/ML SYRINGE

88


88


88

ARCALYST 220MG INJ 12 arformoterol tartrate 15mcg/2ml neb soln

21

ARIKAYCE 590MG/8.4ML INH SUSP

11

aripiprazole 10mg odt 59 aripiprazole 10mg tab 59 aripiprazole 15mg odt 59 aripiprazole 15mg tab 59 aripiprazole 1mg/ml oral soln

59

aripiprazole 20mg tab 59 aripiprazole 2mg tab 59 aripiprazole 30mg tab 59 aripiprazole 5mg tab 59 ARISTADA 1064MG/3.9ML INJ

59

ARISTADA 441MG/1.6ML INJ

59


59


59


59

armodafinil 150mg tab 9 armodafinil 200mg tab 9 armodafinil 250mg tab 9


116


armodafinil 50mg tab 9 ARMOUR THYROID 120MG TAB

107

ARMOUR THYROID 15MG TAB

107


107


107


107

ARNUITY ELLIPTA 100MCG INHALER

20


20


20

asenapine 10mg sl tab 57 asenapine 2.5mg sl tab 57 asenapine 5mg sl tab 57 ashlyna 91 day pack 71 ASMANEX 100MCG INHALER

20

ASMANEX 110MCG INHALER

20

ASMANEX 200MCG INHALER

20

ASMANEX 220MCG INH 20 ASMANEX 220MCG INHALER

20

ASMANEX 50MCG HFA INHALER

20

aspirin 25mg/dipyridamole 200mg er cap

87

aspirin 325mg EC tab 13 aspirin 325mg tab 13 aspirin 81mg chew tab 13 aspirin 81mg EC tab 13 aspirin 81mg tab 14 ASPIRIN 81MG TAB 14 ASTAGRAF 0.5MG ER CAP

63

ASTAGRAF 1MG ER CAP 63 ASTAGRAF 5MG ER CAP 63

atazanavir 150mg cap 60 atazanavir 200mg cap 60 atazanavir 300mg cap 60 atenolol 100mg tab 65 atenolol 100mg/chlorthalidone 25mg tab

39

atenolol 25mg tab 65 atenolol 50mg tab 65 atenolol 50mg/chlorthalidone 25mg tab

40

atomoxetine 100mg cap 9 atomoxetine 10mg cap 9 atomoxetine 18mg cap 9 atomoxetine 25mg cap 9 atomoxetine 40mg cap 9 atomoxetine 60mg cap 9 atomoxetine 80mg cap 9 atorvastatin 10mg tab 36 atorvastatin 20mg tab 36 atorvastatin 40mg tab 36 atorvastatin 80mg tab 36 atovaquone 150mg/ml susp

42

atovaquone 250mg/proguanil 100mg tab

43

atovaquone 62.5mg/proguanil 25mg tab

43

atropine sulfate 0.025mg/diphenoxylate 2.5mg tab

33

ATROPINE SULFATE 1% OPHTH SOLN

98

ATROPINE SULFATE/DIPHENOXYLATE 2.5-0.025 MG/5ML ORAL SOLN

33

ATROVENT 17MCG INH 20 AUBAGIO 14MG TAB 105 AUBAGIO 7MG TAB 105 AURYXIA 210MG TAB 85 AUSTEDO 12MG TAB 104

AUSTEDO 6MG TAB 104 AUSTEDO 9MG TAB 104 AVONEX 30MCG/0.5ML AUTO-INJECTOR

105

AVONEX 30MCG/0.5ML SYRINGE

105

AVYCAZ 500-2000MG INJ

69

AYVAKIT 100MG TAB 47 AYVAKIT 200MG TAB 47 AYVAKIT 25MG TAB 47 AYVAKIT 300MG TAB 47 AYVAKIT 50MG TAB 47 AZASITE 1% OPHTH SOLN

98

azathioprine 50mg tab 63 azelaic acid 15% gel 78 azelastine 0.05% ophth soln

100

azelastine 0.137mg/act nasal inhaler

96

azelastine 0.206mg/act nasal inhaler

96

AZITHROMYCIN 1000MG POWDER FOR ORAL SUSP

90

azithromycin 20mg/ml susp

90

azithromycin 250mg pack 90 azithromycin 40mg/ml susp

90

azithromycin 500mg inj 90 azithromycin 500mg tab 90 azithromycin 600mg tab 90 aztreonam 1000mg inj 43

B

BACITRACIN 0.5UNIT/MG OPHTH OINTMENT

98

bacitracin 0.5unit/mg/polymyxin b 10unit/mg ophth ointment

98

baclofen 10mg tab 96 baclofen 20mg tab 96


117


balsalazide disodium 750mg cap

85

BALVERSA 3MG TAB 48 BALVERSA 4MG TAB 48 BALVERSA 5MG TAB 48 BAQSIMI 3MG/DOSE NASAL POWDER

31

BAXDELA 450MG TAB 84 BCG LIVE TICE STRAIN 50MG INJ

110

BELLADONNA ALKALOID/OPIUM SUPP

108

benazepril 10mg tab 37 benazepril 10mg/hydrochlorothiazide 12.5mg tab

40

benazepril 20mg tab 37 benazepril 20mg/hydrochlorothiazide 12.5mg tab

40

benazepril 20mg/hydrochlorothiazide 25mg tab

40

benazepril 40mg tab 37 benazepril 5mg tab 37 benazepril 5mg/hydrochlorothiazide 6.25mg tab

40

BENAZEPRIL-HYDROCHLOROTHIAZIDE 5-6.25MG TAB

40

BENLYSTA 200MG/ML AUTO-INJECTOR

95

BENLYSTA 200MG/ML SYRINGE

95

BENZNIDAZOLE 100MG TAB

17

BENZNIDAZOLE 12.5MG TAB

18

benzonatate 100mg cap, 200mg cap

73

benzoyl peroxide 5%/clindamycin phosphate 1.2% topical gel

74

benztropine mesylate 0.5mg tab

53

benztropine mesylate 1mg tab

53

benztropine mesylate 2mg tab

53

bepotastine besilate 1.5% ophth soln

100

BERINERT 500UNIT INJ 87 betamethasone 0.05% aug cream

76

betamethasone 0.05% aug lotion

76

betamethasone 0.05% aug ointment

76

betamethasone 0.05% cream

77

BETAMETHASONE 0.05% GEL

77

betamethasone 0.05% lotion

77

betamethasone 0.05% ointment

77

betamethasone 0.1% cream

77

betamethasone 0.1% lotion

77

betamethasone 0.1% ointment

77

betamethasone/clotrimazole 1-0.05% cream

75

betamethasone/clotrimazole 1-0.05% lotion

75

betaxolol 0.5% ophth soln

97

betaxolol 10mg tab 65 betaxolol 20mg tab 65 bethanechol chloride 10mg tab

110

bethanechol chloride 25mg tab

110


110


110

BETIMOL 0.25% OPHTH SOLN

97

BETIMOL 0.5% OPHTH SOLN

97

BETOPTIC S 0.25% OPHTH SUSP

97

bexarotene 75mg cap 53 BEXSERO SYRINGE 110 bicalutamide 50mg tab 46 BICILLIN 300000-300000UNIT/ML INJ

103

BICILLIN 450000-150000UNIT/ML INJ

103

BICILLIN L-A 1200000UNIT/2ML INJ

102

BICILLIN L-A 2400000UNIT/4ML INJ

102

BICILLIN L-A 600000UNIT/ML INJ

102

BIDIL 37.5-20MG TAB 68 BIKTARVY 50-200-25MG TAB

60

bimatoprost 0.03% ophth soln

100

bisoprolol fumarate 10mg tab

65

bisoprolol fumarate 10mg/hydrochlorothiazide 6.25mg tab

40

bisoprolol fumarate 2.5mg/hydrochlorothiazide 6.25mg tab

40

bisoprolol fumarate 5mg tab

65

bisoprolol fumarate 5mg/hydrochlorothiazide 6.25mg tab

40

BIVIGAM 5GM/50ML INJ

101


118


BLEPHAMIDE 0.2-10% OPHTH OINTMENT

99

BLEPHAMIDE 0.2-10% OPHTH SUSP

99

BOOSTRIX INJ 108 bosentan 125mg tab 68 bosentan 62.5mg tab 68 BOSULIF 100MG TAB 48 BOSULIF 400MG TAB 48 BOSULIF 500MG TAB 48 BRAFTOVI 75MG CAP 48 BREO ELLIPTA 100-25MCG INHALER

21

BREO ELLIPTA 200-25MCG INHALER

21

BREZTRI AEROSPHERE 160-9-4.8MCG/ACT INH

21

briellyn 28 day pack 71 BRILINTA 60MG TAB 87 BRILINTA 90MG TAB 87 brimonidine tartrate 0.15% ophth soln

98

brimonidine tartrate 0.2% ophth soln

98

brinzolamide 1% ophth susp

100

BRIVIACT 100MG TAB 24 BRIVIACT 10MG TAB 24 BRIVIACT 10MG/ML ORAL SOLN

24

BRIVIACT 25MG TAB 24 BRIVIACT 50MG TAB 24 BRIVIACT 75MG TAB 24 bromfenac 0.09% ophth soln

100

bromocriptine 2.5mg tab 54 bromocriptine 5mg cap 54 BRUKINSA 80MG CAP 48 budesonide 0.125mg/ml inh susp

20

budesonide 0.25mg/ml inh susp

20

budesonide 0.5mg/ml inh susp

20

budesonide 3mg dr cap 73

budesonide 9mg er tab 73 bumetanide 0.25mg/ml inj 79 bumetanide 0.5mg tab 79 bumetanide 1mg tab 79 bumetanide 2mg tab 79 buprenorphine 0.005mg/hr weekly patch

16

buprenorphine 0.0075mg/hr weekly patch

16


16


16


16

buprenorphine 12mg/naloxone 3mg sublingual film

16

buprenorphine 2mg sl tab 16 buprenorphine 2mg/naloxone 0.5mg sl tab

16

buprenorphine 2mg/naloxone 0.5mg sublingual film

16


16

buprenorphine 8mg sl tab 16 buprenorphine 8mg/naloxone 2mg sl tab

16


16

bupropion 100mg er tab 27 bupropion 100mg tab 27 bupropion 150mg sr (12 hr) tab

27

bupropion 150mg sr tab 105 bupropion 150mg xl (24 hr) tab

27

bupropion 200mg er tab 27 bupropion 300mg er tab 27 bupropion 75mg tab 27

buspirone 10mg tab 18 buspirone 15mg tab 18 buspirone 30mg tab 18 buspirone 5mg tab 18 buspirone 7.5mg tab 18 butorphanol tartrate 1mg/act nasal inhaler

16

BYDUREON 2MG PEN INJ

31

BYDUREON 2MG/0.85ML AUTO-INJECTOR

31

C

cabergoline 0.5mg tab 82 CABLIVI 11MG INJ 87 CABOMETYX 20MG TAB

48

CABOMETYX 40MG TAB

48

CABOMETYX 60MG TAB

48

calcipotriene 0.005% cream

76

calcipotriene 0.005% ointment

76

calcipotriene 0.005% topical soln

76

calcitriol 0.00025mg cap 81 calcitriol 0.0005mg cap 81 calcitriol 0.001mg/ml oral soln

81

calcium acetate 667mg cap

85

calcium acetate 667mg tab

85

CALIBRATION LIQUID 91 CALQUENCE 100MG CAP

48

camreselo 91 day pack 71 candesartan cilexetil 16mg tab

38

candesartan cilexetil 32mg tab

38


119



38


38

capecitabine tab 44 CAPLYTA 42MG CAP 56 CAPRELSA 100MG TAB 48 CAPRELSA 300MG TAB 48 captopril 100mg tab 37 captopril 12.5mg tab 37 captopril 25mg tab 37 captopril 50mg tab 37 CARBAGLU 200MG TAB FOR ORAL SUSP

81

carbamazepine 100mg chew tab

24

carbamazepine 100mg er cap

24

carbamazepine 100mg er tab

24


24


24

carbamazepine 200mg tab

24

carbamazepine 20mg/ml susp

24


24


24

carbidopa 10mg/levodopa 100mg tab

54

CARBIDOPA 12.5MG/ENTACAPONE 200MG/LEVODOPA 50MG TAB

54

carbidopa 25mg tab 53 CARBIDOPA 25MG/ENTACAPONE 200MG/LEVODOPA 100MG TAB, STALEVO 25-200-100MG TAB

54

carbidopa 25mg/levodopa 100mg er tab

54


54


54

CARBIDOPA 31.25MG/ENTACAPONE 200MG/LEVODOPA 125MG TAB, STALEVO 31.25-200-125MG TAB

54

CARBIDOPA 37.5MG/ENTACAPONE 200MG/LEVODOPA 150MG TAB

54

carbidopa 50mg/levodopa 200mg er tab

54

CARBIDOPA/LEVODOPA 10-100MG ODT

55

CARBIDOPA/LEVODOPA 10-250MG ODT TAB

55

CARBIDOPA/LEVODOPA 25-100MG ODT TAB

55

CARBIDOPA/LEVODOPA/ENTACAPONE 50-200-200MG TAB

54

CARBIDOPA/LEVODOPA/ENTACAPONE18.75-75-200MG TAB, STALEVO 12.5-200-50MG TAB

54

CARDIZEM 120MG ER TAB

66

CARDURA 4MG ER TAB 86 CARDURA 8MG ER TAB 86 carisoprodol 350mg tab 96 CARTEOLOL 1% OPHTH SOLN

97

cartia 180mg er cap 66 cartia 240mg er cap 66 cartia 300mg er cap 66 carvedilol 12.5mg tab 64

carvedilol 25mg tab 64 carvedilol 3.125mg tab 64 carvedilol 6.25mg tab 64 carvedilol phosphate ER 10mg cap

64

carvedilol phosphate ER 20mg cap

64


64


64

caspofungin acetate 50mg inj

34

CASPOFUNGIN ACETATE 50MG INJ

34

CASPOFUNGIN ACETATE 70MG INJ

34

caspofungin acetate 70mg inj

34

CAVERJECT INJ 68 CAVERJECT INJ 68 CAYSTON 75MG INH SOLN

43

caziant 28 day pack 71 cefaclor 250mg cap 70 CEFACLOR 250MG CAP 70 CEFACLOR 25MG/ML SUSP

70

cefaclor 500mg cap 70 CEFACLOR 500MG CAP 70 CEFACLOR 500MG ER TAB

70

CEFACLOR 50MG/ML SUSP

70

CEFACLOR 75MG/ML SUSP

70

cefadroxil 100mg/ml susp 69 cefadroxil 1gm tab 69 CEFADROXIL 1GM TAB 69 cefadroxil 500mg cap 69 cefadroxil 50mg/ml susp 69 cefazolin 1000mg inj 69 CEFAZOLIN 100GM INJ 69 CEFAZOLIN 1GM INJ 69 cefazolin 200mg/ml inj 69


120


CEFAZOLIN 20GM INJ 69 CEFAZOLIN 300GM INJ 69 cefazolin 500mg inj 70 CEFAZOLIN/DEXTROSE 1GM/50ML-4% IV SOLN

70

CEFAZOLIN/DEXTROSE 1GM-4% IV SOLN

70

cefdinir 25mg/ml susp 70 cefdinir 300mg cap 70 cefdinir 50mg/ml susp 70 cefepime 1000mg inj 71 CEFEPIME 1GM/50ML IV SOLN

71

cefepime 2000mg inj 71 CEFEPIME 2GM/100ML IV SOLN

71

CEFEPIME/DEXTROSE 1GM/50ML-5% INJ

71

CEFEPIME/DEXTROSE 2GM/50ML-5% INJ

71

cefixime 20mg/ml susp 70 cefixime 400mg cap 70 cefixime 40mg/ml susp 70 cefotetan 1000mg inj 70 cefotetan 2000mg inj 70 CEFOTETAN/DEXTROSE 1GM/3.58% INJ

70

CEFOTETAN/DEXTROSE 2GM-2.08% INJ

70

cefoxitin 1000mg inj 70 cefoxitin 2000mg inj 70 cefoxitin 200mg/ml inj 70 CEFOXITIN/DEXTROSE 1GM-4% INJ

70

CEFOXITIN/DEXTROSE 2GM/2.2% INJ

70

cefpodoxime 100mg tab 70 cefpodoxime 10mg/ml susp

70

cefpodoxime 200mg tab 70 cefpodoxime 20mg/ml susp

70

cefprozil 250mg tab 70 cefprozil 25mg/ml susp 70 cefprozil 500mg tab 70

cefprozil 50mg/ml susp 70 ceftazidime 1000mg inj 70 ceftazidime 200mg/ml inj 71 CEFTAZIDIME/D5W 1GM/50ML INJ

71

CEFTAZIDIME/DEXTROSE 2GM/50ML/5% INJ

71

ceftriaxone 1000mg inj 71 ceftriaxone 100mg/ml inj 71 ceftriaxone 2000mg inj 71 ceftriaxone 250mg inj 71 ceftriaxone 500mg inj 71 CEFTRIAXONE SODIUM 100GM INJ

71

ceftriaxone sodium 1gm inj

71

ceftriaxone sodium 2gm inj

71

CEFTRIAXONE/DEXTROSE 1GM-3.74% IV SOLN

71

CEFTRIAXONE/DEXTROSE 20MG/ML INJ

71

CEFTRIAXONE/DEXTROSE 2GM-2.22% IV SOLN

71

CEFTRIAXONE/DEXTROSE 40MG/ML INJ

71

cefuroxime 1500mg inj 70 cefuroxime 250mg tab 70 cefuroxime 500mg tab 70 cefuroxime 750mg inj 70 cefuroxime 95mg/ml inj 70 celecoxib 100mg cap 12 celecoxib 200mg cap 12 celecoxib 400mg cap 12 celecoxib 50mg cap 12 CELLCEPT 200MG/ML SUSP

63

CELLCEPT 250MG CAP 63 CELLCEPT 500MG TAB 63 CELONTIN 300MG CAP 26 cephalexin 250mg cap 70 cephalexin 25mg/ml susp 70 cephalexin 500mg cap 70 cephalexin 50mg/ml susp 70 CERDELGA 84MG CAP 88

CERVICAL CAP 91 cetirizine 1mg/ml oral soln

35

cevimeline 30mg cap 95 CHANTIX 0.5MG TAB 105 CHANTIX 1MG TAB 105 CHANTIX FIRST MONTH OF THERAPY PACK

105

CHEMET 100MG CAP 33 CHENODAL 250MG TAB 84 chlordiazepoxide 10mg cap

19

chlordiazepoxide 25mg cap

19

chlordiazepoxide 5mg cap

19

chlorhexidine gluconate 0.12% mouthwash

95

chloroquine phosphate 250mg tab

43

CHLOROQUINE PHOSPHATE 500MG TAB

43

chlorpromazine 100mg tab

58

CHLORPROMAZINE 100MG/ML ORAL SOLN

58

chlorpromazine 10mg tab 58 chlorpromazine 200mg tab

58

chlorpromazine 25mg tab 58 CHLORPROMAZINE 30MG/ML ORAL SOLN

58

chlorpromazine 50mg tab 58 chlorthalidone 25mg tab 80 chlorthalidone 50mg tab 80 chlorzoxazone 500mg tab 96 CHOLBAM 250MG CAP 84 CHOLBAM 50MG CAP 84 cholestyramine 4gm bulk powder

36

cholestyramine resin 4gm sf powder for oral susp

36


121


cholestyramine resin 4gm sf powder for oral susp (sugar free)

36

ciclopirox 0.77% cream 75 ciclopirox 0.77% gel 75 ciclopirox 0.77% lotion 75 ciclopirox 1% shampoo 75 ciclopirox 8% topical soln 75 CILASTATIN 250MG/IMIPENEM 250MG INJ

42

cilastatin 500mg/imipenem 500mg inj

42

cilostazol 100mg tab 87 cilostazol 50mg tab 87 CILOXAN 0.3% OPHTH OINTMENT

98

CIMDUO 300-300MG TAB, TEMIXYS 300-300MG TAB

60

cimetidine 200mg tab 109 cimetidine 300mg tab 109 cimetidine 300mg/5ml oral soln

109

cimetidine 400mg tab 109 CIMETIDINE 60MG/ML ORAL SOLN

109

cimetidine 800mg tab 109 CIMZIA 200MG INJ 85 CIMZIA 200MG/ML INJ 85 CIMZIA 200MG/ML INJ STARTER KIT

85

cinacalcet 30mg tab 81 cinacalcet 60mg tab 82 cinacalcet 90mg tab 82 CINRYZE 500UNIT INJ 87 CIPRO 500MG/5ML SUSP

84

CIPRO 5GM/100ML SUSP

84

CIPRO HC 0.2-1% OTIC SUSP

100

CIPROFLOXACIN 0.2% OTIC SOLN

100

ciprofloxacin 0.3% ophth soln

98

ciprofloxacin 250mg tab 84 ciprofloxacin 2mg/ml inj 84 ciprofloxacin 500mg tab 84 ciprofloxacin 750mg tab 84 ciprofloxacin/d5w 400mg/200ml inj

84

ciprofloxacin/dexamethasone 0.3-0.1% otic susp

100

citalopram 10mg tab 27 citalopram 20mg tab 27 citalopram 2mg/ml oral soln

27

citalopram 40mg tab 27 clarithromycin 250mg tab 90 CLARITHROMYCIN 25MG/ML SUSP

90

clarithromycin 500mg er tab

90

clarithromycin 500mg tab 90 CLARITHROMYCIN 50MG/ML SUSP

90

CLENPIQ 75-21.9-0.0625MG/ML ORAL SOLN

90

CLEOCIN 100MG VAGINAL INSERT

111

CLIMARA PRO 0.00188-0.000625MG/HR PATCH

83

CLINDAGEL 1% 74 clindamycin 1% gel 74 clindamycin 1% lotion 74 clindamycin 1% pad 74 clindamycin 1% topical soln

74

clindamycin 12mg/ml inj 42 clindamycin 150mg cap 42 clindamycin 150mg/ml (2ml) inj

42

clindamycin 150mg/ml (4ml) inj

42

clindamycin 150mg/ml (6ml) inj

42

clindamycin 15mg/ml oral soln

42

clindamycin 18mg/ml inj 42 clindamycin 2% vaginal cream

111

clindamycin 300mg cap 42 clindamycin 6mg/ml inj 42 clindamycin 75mg cap 42 clindamycin 9gm/60ml inj 42 clindamycin/benzoyl peroxide 1.2-2.5% gel

74

clindamycin/benzoyl peroxide 1-5% gel

74

CLINDAMYCIN/NACL 300MG/50ML-9% IV SOLN

43

CLINDAMYCIN/NACL 9%-600MG/50ML IV SOLN

43

CLINDAMYCIN/NACL 9%-900MG/50ML IV SOLN

43

CLINDESSE 2% VAGINAL CREAM

111

CLINIMIX 4.25/10 INJ 97 CLINIMIX 4.25/5 INJ 97 CLINIMIX 5/15 INJ 97 CLINIMIX 5/20 INJ 97 CLINIMIX E 2.75/5 INJ 97 CLINIMIX E 4.25/10 INJ 97 CLINIMIX E 4.25/5 INJ 97 CLINIMIX E 5/15 INJ 97 CLINIMIX E 5/20 INJ 97 clinisol 15% inj 97 CLINISTIX 79 clobazam 10mg tab 23 clobazam 2.5mg/ml susp 23 clobazam 20mg tab 23 clobetasol propionate 0.05% cream

77

clobetasol propionate 0.05% e cream

77

clobetasol propionate 0.05% foam

77


122


clobetasol propionate 0.05% gel

77

clobetasol propionate 0.05% lotion

77

clobetasol propionate 0.05% ointment

77

clobetasol propionate 0.05% shampoo

77

clobetasol propionate 0.05% spray

77

clobetasol propionate 0.05% topical soln

77

clomipramine 25mg cap 29 clomipramine 50mg cap 29 clomipramine 75mg cap 29 clonazepam 0.125mg odt 23 clonazepam 0.25mg odt 23 clonazepam 0.5mg odt 23 clonazepam 0.5mg tab 23 clonazepam 1mg odt 23 clonazepam 1mg tab 23 clonazepam 2mg odt 23 clonazepam 2mg tab 23 clonidine 0.00417mg/hr weekly patch

38

clonidine 0.00833mg/hr weekly patch

38

clonidine 0.0125mg/hr weekly patch

38

clonidine 0.1mg er tab 9 clonidine 0.1mg tab 39 clonidine 0.2mg tab 39 clonidine 0.3mg tab 39 clopidogrel 75mg tab 87 clorazepate dipotassium 15mg tab

19

clorazepate dipotassium 3.75mg tab

19

clorazepate dipotassium 7.5mg tab

19

clotrimazole 1% cream 75 clotrimazole 1% topical soln

75

clotrimazole 10mg lozenge

95

clozapine 100mg odt 57 clozapine 100mg tab 57 CLOZAPINE 12.5MG ODT

57

CLOZAPINE 150MG ODT

57

CLOZAPINE 200MG ODT

57

clozapine 200mg tab 57 clozapine 25mg odt 58 clozapine 25mg tab 58 clozapine 50mg tab 58 COARTEM 20-120MG TAB

43

CODEINE SULFATE 15MG TAB

14

CODEINE SULFATE 30MG TAB

14

codeine sulfate 30mg tab 14 codeine sulfate 60mg tab 14 CODEINE SULFATE 60MG TAB

14

colchicine 0.5mg/probenecid 500mg tab

87

colchicine 0.6mg tab 87 colesevelam 3750mg powder for oral susp

36

colesevelam 625mg tab 36 colestipol 1000mg tab 36 colestipol 5000mg granules for oral susp

36

colestipol 5gm granule 36 colistin 75mg/ml inj 43 COMBIGAN 2-5MG/ML OPHTH SOLN

97

COMBIPATCH 0.00208-0.00583MG/HR PATCH

83

COMBIPATCH 0.00208-0.0104MG/HR PATCH

83

COMBIVENT 20-100MCG/ACT INH

21

COMETRIQ CAP (100MG) DOSE PACK

48

COMETRIQ CAP DOSE PACK (140MG)

48

COMETRIQ CAP DOSE PACK (60MG)

48

COMMIT LOZENGE 105 COMPLERA 200-25-300MG TAB

60

CONDYLOX 0.5% GEL 78 constulose 10gm/15ml oral soln

90

CONTINUOUS BLOOD GLUCOSE SYSTEM RECEIVER

91

CONTINUOUS BLOOD GLUCOSE SYSTEM SENSOR

91

CONTINUOUS BLOOD GLUCOSE SYSTEM TRANSMITTER

91

CONTRACEPTIVE FILM 111 CONTRACEPTIVE FOAM 111 CONTRACEPTIVE GEL 111 CONTRACEPTIVE SPONGE

111

CONTRACEPTIVE SUPP 111 COPIKTRA 15MG CAP 49 COPIKTRA 25MG CAP 49 CORLANOR 5MG TAB 69 CORLANOR 5MG/5ML ORAL SOLN

69

CORLANOR 7.5MG TAB 69 COTELLIC 20MG TAB 49 CREON 120000-76000-24000UNIT DR CAP

79

CREON 15000-9500-3000UNIT DR CAP

79


79


123


CREON 36000-114000-180000UNIT DR CAP

79


79

CRINONE 4% VAGINAL GEL

111

CRINONE 8% VAGINAL GEL

111

CRIXIVAN 200MG CAP 60 CRIXIVAN 400MG CAP 60 cromolyn sodium 20mg/ml oral soln

85

cromolyn sodium 4% ophth soln

100

CUVPOSA 1MG/5ML ORAL SOLN

108

cyanocobalamin inj 88 cyclafem 7/7/7 28 day pack

71

cyclobenzaprine 10mg tab

96

cyclobenzaprine 5mg tab 96 CYCLOPHOSPHAMIDE 25MG CAP

44

cyclophosphamide 25mg cap

44

CYCLOPHOSPHAMIDE 25MG TAB

44

CYCLOPHOSPHAMIDE 50MG CAP

44

cyclophosphamide 50mg cap

44

CYCLOPHOSPHAMIDE 50MG TAB

44

CYCLOSET 0.8MG TAB 31 cyclosporine 100mg cap 63 cyclosporine 25mg cap 63 cyclosporine modified 100mg cap

63

cyclosporine modified 100mg/ml oral soln

63

cyclosporine modified 25mg cap

63

cyclosporine modified 50mg cap

63

cyproheptadine 0.4mg/ml oral soln

35

cyproheptadine 4mg tab 35 CYSTADROPS 0.37% OPHTH SOLN

100

CYSTAGON 150MG CAP 86 CYSTAGON 50MG CAP 86 CYSTARAN 0.44% OPHTH SOLN

100

CYTOMEL 25MCG TAB 107 CYTOMEL 50MCG TAB 107 CYTOMEL 5MCG TAB 107 CYTRA K CRYSTALS 86 CYTRA-3 SYRUP 86

D

d2.5w/nacl 0.45% inj 92 d5w/nacl 5%-0.33% inj 92 dalfampridine 10mg er tab

105

DALIRESP 250MCG TAB 20 DALIRESP 500MCG TAB 20 DALVANCE 500MG INJ 42 danazol 100mg cap 17 danazol 200mg cap 17 danazol 50mg cap 17 dantrolene sodium 100mg cap

96

dantrolene sodium 25mg cap

96

dantrolene sodium 50mg cap

96

dapsone 100mg tab 42 dapsone 25mg tab 42 DAPTACEL INJ 108 daptomycin 500mg inj 42 darifenacin 15mg er tab 110 darifenacin 7.5mg er tab 110 DAURISMO 100MG TAB 46 DAURISMO 25MG TAB 46 deferasirox 125mg tab for oral susp

33

deferasirox 180mg granules

33

deferasirox 180mg tab 33 deferasirox 250mg tab for oral susp

33


33

deferasirox 360mg tab 33 deferasirox 500mg tab for oral susp

33


33

deferasirox 90mg tab 33 deferiprone 500mg tab 33 DELESTROGEN 10MG/ML INJ

83

DELSTRIGO 100-300-300MG TAB

60

demeclocycline 150mg tab

107

demeclocycline 300mg tab

107

DEPO-ESTRADIOL 5MG/ML INJ

83

DESCOVY 200-25MG TAB

60

desipramine 100mg tab 29 desipramine 10mg tab 29 desipramine 150mg tab 29 desipramine 25mg tab 29 desipramine 50mg tab 29 desipramine 75mg tab 29 desloratadine 5mg tab 35 desmopressin 0.01% nasal spray

82

desmopressin acetate 0.01mg/act nasal spray

82

desmopressin acetate 0.1mg tab

82

desmopressin acetate 0.2mg tab

82

desogestrel/ethinyl estradiol pack

71

desonide 0.05% ointment 77


124


desoximetasone 0.25% cream

77

desoximetasone 0.25% ointment

77

desvenlafaxine succinate 100mg er tab

28


28


28

dexamethasone 0.1mg/ml oral soln

73

dexamethasone 0.5mg tab 73 DEXAMETHASONE 0.5MG/5ML ORAL SOLN

73

dexamethasone 0.75mg tab

73

dexamethasone 1.5mg tab 73 DEXAMETHASONE 1MG TAB

73

DEXAMETHASONE 2MG TAB

73

dexamethasone 4mg tab 73 dexamethasone 6mg tab 73 DEXAMETHASONE PHOSPHATE 0.1% OPHTH SOLN

99

dexamethasone/neomycin/polymyxin b 0.1% ophth ointment

99

dexamethasone/neomycin/polymyxin b 0.1% ophth susp

99

dexamethasone/tobramycin 0.3-0.1% ophth susp

99

dexmethylphenidate 10mg er cap

9

dexmethylphenidate 10mg tab

10


10

dexmethylphenidate 2.5mg tab

10


10


10


10


10


10


10

dexmethylphenidate 5mg tab

10

dextroamphetamine sulfate 10mg er cap

9

dextroamphetamine sulfate 10mg tab

9


9


9

dextroamphetamine sulfate 5mg tab

9

DEXTROSE 10% W/ SODIUM CHLORIDE 0.2%

92

DEXTROSE 10% W/ SODIUM CHLORIDE 0.45%

92

DEXTROSE/SODIUM CHLORIDE 5-0.225% INJ

92

dextrose/sodium chloride 5%-0.225% inj

92

DIACOMIT 250MG CAP 24 DIACOMIT 250MG POWDER FOR ORAL SUSP

24

DIACOMIT 500MG CAP 24 DIACOMIT 500MG POWDER FOR ORAL SUSP

24

DIALYVITE TAB 96 dialyvite tab 96 DIALYVITE/ZINC TAB 96 DIAPHRAGM 91

diazepam 10mg tab 19 DIAZEPAM 10MG/2ML RECTAL GEL

23

diazepam 1mg/ml oral soln

19

DIAZEPAM 2.5MG/0.5ML RECTAL GEL

23

DIAZEPAM 20MG/4ML RECTAL GEL

24

diazepam 2mg tab 19 diazepam 5mg tab 19 diazepam 5mg/ml oral soln

19

diazoxide 50mg/ml susp 31 diclofenac potassium 50mg tab

12

diclofenac sodium 0.1% ophth soln

100

diclofenac sodium 1% gel 75 diclofenac sodium 1.5% topical soln

75

diclofenac sodium 100mg er tab

12

diclofenac sodium 25mg dr tab

12

diclofenac sodium 3% gel 75 diclofenac sodium 50mg dr tab

12

diclofenac sodium 50mg/misoprostol 0.2mg dr tab

12

diclofenac sodium 75mg dr tab

12

diclofenac sodium 75mg/misoprostol 0.2mg dr tab

12

dicloxacillin 250mg cap 103 dicloxacillin 500mg cap 103 dicyclomine 10mg cap 108 dicyclomine 20mg tab 108 dicyclomine 2mg/ml oral soln

108

DIFICID 200MG TAB 91 DIFICID 40MG/ML SUSP 91


125


diflunisal 500mg tab 14 difluprednate 0.05% ophth emulsion

99

digox 125mcg tab 67 digoxin 0.05mg/ml oral soln

67

DIGOXIN 0.05 MG/ML ORAL SOLN

67

digoxin 0.25mg tab 67 DIGOXIN ORAL 0.05MG/ML SOLN

67

dihydroergotamine mesylate 0.5mg/act nasal inhaler

91

DILANTIN 100MG ER CAP

26

DILANTIN 125MG/5ML SUSP

26

DILANTIN 30MG ER CAP

26

DILANTIN 50MG CHEW TAB

26

dilt 120mg er cap 66 dilt 180mg er cap 66 dilt 240mg er cap 66 diltiazem 120mg er (12 hr) cap

66

diltiazem 120mg er (24 hr) cap

66

diltiazem 120mg tab 66 diltiazem 180mg er tab 66 diltiazem 300mg er tab 66 diltiazem 30mg tab 66 diltiazem 360mg cd cap 66 diltiazem 360mg er tab 66 diltiazem 420mg er cap 66 diltiazem 60mg er cap 66 diltiazem 60mg tab 66 diltiazem 90mg er cap 66 diltiazem 90mg tab 66 dimethyl fumarate 120mg dr cap

105

dimethyl fumarate 120mg/dimethyl fumarate 240mg pack

105

dimethyl fumarate 240mg dr cap

105

DIPENTUM 250MG CAP 85 DIPHTHERIA/TETANUS TOXOID INJ

108

dipyridamole 25mg tab 87 dipyridamole 50mg tab 87 dipyridamole 75mg tab 87 disopyramide 100mg cap 19 disopyramide 150mg cap 19 disulfiram 250mg tab 103 disulfiram 500mg tab 103 DIURIL 250MG/5ML SUSP

80

divalproex sodium 125mg dr cap

26

divalproex sodium 125mg dr tab

27


27

divalproex sodium 250mg er tab

27


27

divalproex sodium 500mg er tab

27

dofetilide 0.125mg cap 20 dofetilide 0.25mg cap 20 dofetilide 0.5mg cap 20 dolishale 28 day pack 71 donepezil 10mg odt 104 donepezil 10mg tab 104 donepezil 23mg tab 104 donepezil 5mg odt 104 donepezil 5mg tab 104 DOPTELET 20MG TAB 88 DOPTELET TAB 40MG DAILY DOSE PACK

88

DOPTELET TAB 60MG DAILY DOSE PACK

88

dorzolamide 2% ophth soln

100

dorzolamide/timolol 22.3-6.8mg/ml ophth soln

97

dorzolamide/timolol 22.3-6.8mg/ml ophth soln (preservative-free)

98

DOVATO 50-300MG TAB 60 doxazosin 1mg tab 39 doxazosin 2mg tab 39 doxazosin 4mg tab 39 doxazosin 8mg tab 39 doxepin 100mg cap 29 doxepin 10mg cap 29 doxepin 10mg/ml oral soln

29

doxepin 150mg cap 29 doxepin 25mg cap 29 doxepin 50mg cap 29 doxepin 75mg cap 29 doxercalciferol 0.0005mg cap

82

doxercalciferol 0.001mg cap

82

doxercalciferol 0.0025mg cap

82

doxy 100mg inj 107 doxycycline hyclate 100mg cap

107

doxycycline hyclate 100mg tab

107

doxycycline hyclate 20mg tab

107

doxycycline hyclate 50mg cap

107

doxycycline monohydrate 100mg tab

107

doxycycline monohydrate 50mg cap

107

doxycycline monohydrate 50mg tab

107

doxycycline monohydrate 5mg/ml susp

107

doxylamine succinate 10mg/pyridoxine 10mg dr tab

34

DRISDOL CAP 112 DRIZALMA 20MG DR CAP

28


126


DRIZALMA 30MG DR CAP

28


28


28

dronabinol 10mg cap 34 dronabinol 2.5mg cap 34 dronabinol 5mg cap 34 DROXIA 200MG CAP 88 DROXIA 300MG CAP 88 DROXIA 400MG CAP 88 droxidopa 100mg cap 112 droxidopa 200mg cap 112 droxidopa 300mg cap 112 DRYSOL SOLN 78 DULERA 100-5MCG INHALER

21

DULERA 200-5MCG INHALER

21

DULERA 50-5MCG INHALER

21

duloxetine 20mg dr cap 28 duloxetine 30mg dr cap 28 duloxetine 60mg dr cap 28 DUPIXENT 200MG/1.14ML AUTO-INJECTOR

78

DUPIXENT 200MG/1.14ML SYRINGE

78

DUPIXENT 300MG/2ML AUTO-INJECTOR

78

DUPIXENT 300MG/2ML SYRINGE

78

dutasteride 0.5mg cap 86 dutasteride 0.5mg/tamsulosin 0.4mg cap

86

E

E.E.S. 400MG TAB 90 econazole nitrate 1% cream

75

EDEX 10MCG INJ KIT 68

EDEX 10MCG INJ KIT 68 EDEX 20MCG INJ KIT 68 EDEX 20MCG INJ KIT 68 EDEX 40MCG INJ KIT 68 EDEX INJ 68 EDURANT 25MG TAB 60 efavirenz 200mg cap 60 efavirenz 400mg/lamivudine 300mg/tenofovir disoproxil fumarate 300mg tab

60

efavirenz 50mg cap 60 efavirenz 600mg tab 60 efavirenz 600mg/emtricitabine 200mg/tenofovir disoproxil fumarate 300mg tab

60

efavirenz/lamivudine/tenofovir disoproxil fumarate 600-300-300mg tab

60

eletriptan 20mg tab 92 eletriptan 40mg tab 92 ELIGARD 22.5MG INJ 46 ELIGARD 30MG INJ 46 ELIGARD 45MG INJ 46 ELIGARD 7.5MG INJ 46 ELIQUIS 2.5MG TAB 22 ELIQUIS 5MG TAB 22 ELIQUIS 5MG TAB 30-DAY STARTER PACK

22

ELMIRON 100MG CAP 86 eluryng 0.120-0.015mg/24hr vaginal system

72

EMCYT 140MG CAP 46 EMGALITY 100MG/ML INJ

92

EMGALITY 120MG/ML AUTO-INJECTOR

91

EMGALITY 120MG/ML INJ

91

EMSAM 12MG/24HR PATCH

27


27


27

emtricitabine 100mg/tenofovir disoproxil fumarate 150mg tab

60

emtricitabine 200mg cap 60 emtricitabine 200mg/tenofovir disoproxil fumarate 300mg tab

60

emtricitabine/tenofovir disoproxil fumarate 133-200mg tab

60

emtricitabine/tenofovir disoproxil fumarate 167-250mg tab

60

EMTRIVA 10MG/ML ORAL SOLN

61

enalapril maleate 10mg tab

37

enalapril maleate 10mg/hydrochlorothiazide 25mg tab

40

enalapril maleate 2.5mg tab

37


37


37

enalapril maleate 5mg/hydrochlorothiazide 12.5mg tab

40

ENBREL 25MG INJ 13 ENBREL 25MG/0.5ML INJ

13

ENBREL 25MG/0.5ML SYRINGE

13

ENBREL 50MG/ML AUTO-INJECTOR

13


127


ENBREL 50MG/ML CARTRIDGE

13

ENBREL 50MG/ML SYRINGE

13

ENDARI 5GM POWDER FOR ORAL SOLN

88

ENGERIX-B 10MCG/0.5ML INJ

110

ENGERIX-B 20MCG/ML INJ

110

enoxaparin 300mg/3ml inj

22

enoxaparin sodium 100mg/ml (0.3ml) inj

22


22


22


22

enoxaparin sodium 100mg/ml (1ml) inj

22


23

enoxaparin sodium 150mg/ml (1ml) inj

23

ENSPRYNG 120MG/ML SYRINGE

94

entacapone 200mg tab 53 entecavir 0.5mg tab 62 entecavir 1mg tab 62 ENTRESTO 24-26MG TAB

68

ENTRESTO 49-51MG TAB

68

ENTRESTO 97-103MG TAB

68

enulose 10gm/15ml oral soln

85

ENVARSUS 0.75MG ER TAB

63

ENVARSUS 1MG ER TAB 63 ENVARSUS 4MG ER TAB 63 EPIDIOLEX 100MG/ML ORAL SOLN

24

EPIDUO 0.3-2.5% GEL 74 epinastine 0.05% ophth soln

100

epinephrine 0.15mg/0.3ml auto-injector (2 pack)

111

epinephrine 0.3mg/0.3ml auto-injector (2 pack)

112

EPIVIR HBV 5MG/ML ORAL SOLN

62

eplerenone 25mg tab 41 eplerenone 50mg tab 41 ERAXIS 100MG INJ 34 ERAXIS 50MG INJ 34 ERGOLOID MESYLATES USP 1MG TAB

105

ERIVEDGE 150MG CAP 46 ERLEADA 60MG TAB 46 erlotinib 100mg tab 45 erlotinib 150mg tab 45 erlotinib 25mg tab 45 ertapenem 1000mg inj 42 ERY 2% PAD 74 ery-tab 250mg dr tab 90 ERYTHROCIN 500MG INJ

90

erythromycin 0.5% ophth ointment

98

erythromycin 2% gel 74 erythromycin 2% topical soln

74

ERYTHROMYCIN 250MG DR CAP

90

erythromycin 250mg dr cap

90

erythromycin 250mg tab 91 erythromycin 333mg dr tab

91

erythromycin 500mg dr tab

91

erythromycin 500mg tab 91 erythromycin ethylsuccinate 40mg/ml susp

91

erythromycin ethylsuccinate 80mg/ml susp

91

erythromycin/benzoyl peroxide 5-3% gel

74

ESBRIET 267MG CAP 106 ESBRIET 267MG TAB 106 ESBRIET 801MG TAB 106 ESCAVITE CHEW TAB 96 escitalopram 10mg tab 28 escitalopram 1mg/ml oral soln

28

escitalopram 20mg tab 28 escitalopram 5mg tab 28 esomeprazole 20mg dr cap (rx only)

109

esomeprazole 40mg dr cap

109

estarylla 28 day pack 71 estazolam 1mg tab 89 estazolam 2mg tab 89 esterified estrogens/methyltestosterone tab

83

estradiol 0.00104mg/hr weekly patch

83


83


83


83


83


83

estradiol 0.01% vaginal cream

111

estradiol 0.01mg vaginal insert

111

estradiol 0.025mg twice weekly patch

83

estradiol 0.0375mg/24hr twice weekly patch

83


128



83


83


83

estradiol 0.5mg tab 83 estradiol 1mg tab 83 estradiol 2mg tab 83 estradiol valerate 20mg/ml inj

83

estradiol valerate 40mg/ml inj

83

ESTRING 2MG VAGINAL SYSTEM

111

eszopiclone 1mg tab 89 eszopiclone 2mg tab 89 eszopiclone 3mg tab 89 ethacrynic acid 25mg tab 79 ethambutol 100mg tab 44 ethambutol 400mg tab 44 ethinyl estradiol 0.005mg/norethindrone acetate 1mg pack

83

ethinyl estradiol 0.02mg/inert ingredients 1mg/levonorgestrel 0.1mg pack

71

ethinyl estradiol 0.035mg/ethynodiol 1mg 28 day pack

72

ethinyl estradiol 0.035mg/inert/norgestimate 0.18mg/0.215mg/0.25mg pack

72

ethinyl estradiol 0.03mg/inert ingredients 1mg/levonorgestrel 0.15mg pack

72

ethinyl estradiol 0.05mg/ethynodiol 1mg/inert ingredients 1mg 28 day pack

72

ethinyl estradiol/levonorgestrel 91 day pack

72

ethosuximide 250mg cap 26 ethosuximide 50mg/ml oral soln

26

etodolac 200mg cap 12 etodolac 300mg cap 12 etodolac 400mg er tab 12 etodolac 400mg tab 12 etodolac 500mg er tab 12 etodolac 500mg tab 12 etodolac 600mg er tab 12 etravirine 100mg tab 61 etravirine 200mg tab 61 EVAMIST 1.53MG/SPRAY SPRAY

83

everolimus 0.25mg tab 95 everolimus 0.5mg tab 95 everolimus 0.75mg tab 95 everolimus 10mg tab 49 everolimus 2.5mg tab 49 everolimus 2mg tab for oral susp

49

everolimus 3mg tab for oral susp

49

everolimus 5mg tab 49 everolimus 5mg tab for oral susp

49

everolimus 7.5mg tab 49 EVOTAZ 300-150MG TAB

61

EVRYSDI 0.75MG/ML ORAL SOLN

97

exemestane 25mg tab 46 EXTAVIA 0.3MG INJ 105 ezetimibe 10mg tab 37

F

famciclovir 125mg tab 62 famciclovir 250mg tab 62 famciclovir 500mg tab 62 famotidine 20mg tab 109 famotidine 40mg tab 109 famotidine 8mg/ml susp 109

FANAPT 10MG TAB 56 FANAPT 12MG TAB 56 FANAPT 1MG TAB 56 FANAPT 2MG TAB 56 FANAPT 4MG TAB 56 FANAPT 6MG TAB 56 FANAPT 8MG TAB 56 FANAPT TITRATION PACK

56

FARXIGA 10MG TAB 32 FARXIGA 5MG TAB 32 FARYDAK 10MG CAP 49 FARYDAK 15MG CAP 49 FARYDAK 20MG CAP 49 FASENRA 30MG/ML AUTO-INJECTOR

20

FASENRA 30MG/ML SYRINGE

20

febuxostat 40mg tab 87 febuxostat 80mg tab 87 felbamate 120mg/ml susp 26 felbamate 400mg tab 26 felbamate 600mg tab 26 felodipine 10mg er tab 66 felodipine 2.5mg er tab 66 felodipine 5mg er tab 66 FEM PH GEL 111 FEMALE CONDOMS 91 FEMRING 0.05MG/24HR VAGINAL SYSTEM

111

FEMRING 0.1MG/24HR VAGINAL SYSTEM

111

fenofibrate 134mg cap 36 fenofibrate 145mg tab 36 FENOFIBRATE 150MG CAP

36

fenofibrate 160mg tab 36 fenofibrate 200mg cap 36 fenofibrate 48mg tab 36 FENOFIBRATE 50MG CAP

36

fenofibrate 54mg tab 36 fenofibrate 67mg cap 36 fenofibric acid 135mg dr cap

36


129


fenofibric acid 45mg dr cap

36

fentanyl 0.012mg/hr patch

14

fentanyl 0.025mg/hr patch

14

fentanyl 0.05mg/hr patch 14 fentanyl 0.075mg/hr patch

14

fentanyl 0.1mg/hr patch 14 FENTANYL 100MCG BUCCAL TAB

14

fentanyl 1200mcg lozenge 14 fentanyl 1600mcg lozenge 14 FENTANYL 200MCG BUCCAL TAB

14

fentanyl 200mcg lozenge 14 FENTANYL 400MCG BUCCAL TAB

14


14


14

fentanyl 800mcg lozenge 14 ferrex forte cap 89 FERRIPROX (TWICE DAILY) 1000MG TAB

33

FERRIPROX 1000MG TAB

33

FERRIPROX 100MG/ML ORAL SOLN

33

ferrous sulfate elixir 89 FERROUS SULFATE LIQUID

89

ferrous sulfate soln 89 ferrous sulfate syrup 89 FETZIMA 120MG ER CAP

28

FETZIMA 20MG ER CAP 28 FETZIMA 40MG ER CAP 28 FETZIMA 80MG ER CAP 28 FETZIMA PACK 29

FIASP 100UNIT/ML CARTRIDGE

31

FIASP 100UNIT/ML INJ 31 FIASP 100UNIT/ML PEN INJ

31

FINACEA 15% FOAM 78 finasteride 5mg tab 86 FINTEPLA 2.2MG/ML ORAL SOLN

24

FIRMAGON 120MG INJ 46 FIRMAGON 80MG INJ 46 FIRST ATENOLOL ORAL SOLN

65

FIRST METOPROLOL ORAL SOLN

65

FIRST MOUTHWASH BLM SUSP

95

FIRST OMEPRAZOLE SUSP

109

FIRVANQ 25MG/ML ORAL SOLN

42

FIRVANQ 50MG/ML ORAL SOLN

42

FLAREX 0.1% OPHTH SUSP

99

flavoxate 100mg tab 110 FLEBOGAMMA 0.5GM/10ML INJ

101

flecainide acetate 100mg tab

19


19


19

FLECTOR 1.3% PATCH, DICLOFENAC 1.3% PATCH

75

FLORIVA PLUS DROPS 96 FLOVENT 100MCG DISKUS

21

FLOVENT 110MCG HFA INH

21


21

FLOVENT 250MCG DISKUS

21


21

FLOVENT 50MCG DISKUS

21

fluconazole 100mg tab 35 fluconazole 10mg/ml susp 35 fluconazole 150mg tab 35 fluconazole 200mg tab 35 fluconazole 2mg/ml (100ml) inj

35

fluconazole 2mg/ml (200ml) inj

35

fluconazole 40mg/ml susp 35 fluconazole 50mg tab 35 fluconazole/dextrose 200mg/100ml inj

35

fluconazole/dextrose 400mg/200ml inj

35

flucytosine 250mg cap 34 flucytosine 500mg cap 34 fludrocortisone 0.1mg tab 73 FLUNISOLIDE 0.025MG/ACT NASAL INHALER

97

fluocinolone acetonide 0.01% body oil

77

fluocinolone acetonide 0.01% cream

77

fluocinolone acetonide 0.01% otic soln

101

fluocinolone acetonide 0.01% topical soln

77

fluocinolone acetonide 0.025% cream

77

fluocinolone acetonide 0.025% ointment

77

fluocinolone acetonide 0.1mg/ml oil

77

fluocinonide 0.05% cream 77 fluocinonide 0.05% e cream

77

fluocinonide 0.05% gel 77


130


fluocinonide 0.05% ointment

77

fluocinonide 0.05% topical soln

77

fluocinonide 0.1% cream 77 FLUORABON SOLN 93 fluorometholone 0.1% ophth susp

99

FLUOROURACIL 2% TOPICAL SOLN

75

fluorouracil 5% cream 75 FLUOROURACIL 5% TOPICAL SOLN

75

fluoxetine 10mg cap 28 fluoxetine 20mg cap 28 fluoxetine 40mg cap 28 fluoxetine 4mg/ml oral soln

28

FLUPHENAZINE 0.5MG/ML ORAL SOLN

59

fluphenazine 10mg tab 59 fluphenazine 1mg tab 59 fluphenazine 2.5mg tab 59 FLUPHENAZINE 2.5MG/ML INJ

59

fluphenazine 5mg tab 59 FLUPHENAZINE 5MG/ML ORAL SOLN

59

fluphenazine decanoate 25mg/ml inj

59

FLURAZEPAM 15MG CAP

89

FLURAZEPAM 30MG CAP

89

flurbiprofen 100mg tab 12 FLURBIPROFEN SODIUM 0.03% OPHTH SOLN

100

flutamide 125mg cap 46 FLUTAMIDE 125MG CAP

46

fluticasone propionate 0.005% ointment

77

fluticasone propionate 0.05% cream

77

fluticasone propionate 0.05mg/act nasal inhaler

97

fluticasone propionate/salmeterol 100-50mcg/act dry powder inhaler, wixela 100-50mcg inhaler

21


21


21

fluvastatin 20mg cap 36 fluvastatin 40mg cap 36 fluvastatin 80mg er tab 36 fluvoxamine maleate 100mg tab

28

fluvoxamine maleate 25mg tab

28

fluvoxamine maleate 50mg tab

28

FML 0.1% OPHTH OINTMENT

99

FML FORTE LIQUIFILM 0.25% OPHTH SUSP

99

FOLBEE PLUS CZ TAB 96 folbee tab 89 folic acid tab (OTC) 88 fondaparinux sodium 12.5mg/ml (0.4ml) inj

23

fondaparinux sodium 12.5mg/ml (0.6ml) inj

23

fondaparinux sodium 12.5mg/ml (0.8ml) inj

23

fondaparinux sodium 5mg/ml (0.5mg) inj

23

formoterol fumarate 20mcg/2ml neb soln

21

FORTEO 600MCG/2.4ML PEN INJ

80

fosamprenavir 700mg tab 61 fosfomycin 3000mg powder for oral soln

43

fosinopril sodium 10mg tab

37

fosinopril sodium 10mg/hydrochlorothiazide 12.5mg tab

40


37

fosinopril sodium 20mg/hydrochlorothiazide 12.5mg tab

40


37

FOSRENOL 1000MG ORAL POWDER

85

FOSRENOL 750MG ORAL POWDER

85

FOTIVDA 0.89MG CAP 49 FOTIVDA 1.34MG CAP 49 FRAGMIN 10000UNIT/ML INJ

23

FRAGMIN 12500UNIT/0.5ML INJ

23


23

FRAGMIN 18000UNT/0.72ML INJ

23


23


23


23


23

FREAMINE HBC 6.9% INJ

97

FREESTYLE LITE METER

91

FREESTYLE LITE METER

91

FULPHILA 6MG/0.6ML SYRINGE

88


131


furosemide 10mg/ml inj 79 furosemide 10mg/ml oral soln

80

furosemide 20mg tab 80 furosemide 40mg tab 80 furosemide 80mg tab 80 FUROSEMIDE 8MG/ML ORAL SOLN

80

FUZEON 90MG INJ 61 fyavolv 0.0025-0.5mg tab 83 FYCOMPA 0.5MG/ML SUSP

23

FYCOMPA 10MG TAB 23 FYCOMPA 12MG TAB 23 FYCOMPA 2MG TAB 23 FYCOMPA 4MG TAB 23 FYCOMPA 6MG TAB 23 FYCOMPA 8MG TAB 23

G

gabapentin 100mg cap 24 gabapentin 300mg cap 24 gabapentin 400mg cap 24 gabapentin 50mg/ml oral soln

24

gabapentin 600mg tab 24 gabapentin 800mg tab 24 GALAFOLD 28 DAY WALLET 123MG PACK

82

galantamine 12mg tab 104 galantamine 4mg tab 104 galantamine 8mg tab 104 galantamine hydrobromide 16mg er cap

104

galantamine hydrobromide 24mg er cap

104

GALANTAMINE HYDROBROMIDE 4MG/ML ORAL SOLN

104

galantamine hydrobromide 8mg er cap

104

GALZIN CAP 94

GAMMAGARD 10GM INJ

101

GAMMAGARD 10GM/100ML INJ

101

GAMMAGARD 2.5GM/25ML INJ

101


101


101

GAMMAGARD 5GM INJ 101 GAMMAGARD 5GM/50ML INJ

101

GAMMAKED 1GM/10ML INJ

101

GAMMAPLEX 10GM/100ML INJ

101


101


101

GAMUNEX-C 40GM/400ML INJ

101

GARDASIL 9 INJ 110 GARDASIL 9 SYRINGE 110 gatifloxacin 0.5% ophth soln

98

GATTEX 5MG INJ 86 GAUZE PADS DRESSINGS - PADS 2 X 2

91

GAVILYTE-C ORAL SOLN

90

gavilyte-g powder for oral soln

90

gavilyte-n powder for oral soln

90

GAVRETO 100MG CAP 49 gemfibrozil 600mg tab 36 GENOTROPIN 0.2MG INJ

81

GENOTROPIN 0.4MG INJ

81


81


81


81


81


81


81

GENOTROPIN 12MG CARTRIDGE

81

GENOTROPIN 1MG INJ 81 GENOTROPIN 2MG INJ 81 GENOTROPIN 5MG CARTRIDGE

81

GENTAK 0.3% OPHTH OINTMENT

98

gentamicin 0.1% cream 75 gentamicin 0.1% ointment 75 gentamicin 0.3% ophth soln

98

GENTAMICIN 0.8MG/ML INJ

11

gentamicin 1.2mg/ml inj 11 GENTAMICIN 1.6MG/ML INJ

11

GENTAMICIN 1MG/ML INJ

11

gentamicin 40mg/ml inj 11 GENVOYA 150-150-200-10MG TAB

61

GILENYA 0.25MG CAP 105 GILENYA 0.5MG CAP 105 GILOTRIF 20MG TAB 45 GILOTRIF 30MG TAB 45 GILOTRIF 40MG TAB 45 GLASSIA 1000MG/50ML INJ

106

glatiramer acetate 20mg/ml syringe

105

glatiramer acetate 40mg/ml syringe

105

glimepiride 1mg tab 32 glimepiride 2mg tab 32


132


glimepiride 4mg tab 32 glipizide 10mg er tab 33 glipizide 10mg tab 33 glipizide 2.5mg er tab 33 glipizide 2.5mg/metformin 250mg tab

30

glipizide 2.5mg/metformin 500mg tab

30

glipizide 5mg er tab 33 glipizide 5mg tab 33 glipizide 5mg/metformin 500mg tab

30

GLUCAGEN 1MG INJ 31 glucagon (rdna) 1mg inj kit

31

GLUCAGON 1MG KIT 31 glucose 100mg/ml inj 97 GLUCOSE 25MG/ML/SODIUM CHLORIDE 0.0769 MEQ/ML INJ

92

glucose 50 mg/ml/potassium chloride 0.04meq/ml/sodium chloride 4.5mg/ml inj

92

glucose 50mg/ml inj 97 glucose 50mg/ml/potassium chloride 0.01 meq/ml/sodium chloride 0.0769 meq/ml inj

92

glucose 50mg/ml/potassium chloride 0.02 meq/ml inj

93

glucose 50mg/ml/potassium chloride 0.02 meq/ml/sodium chloride 0.0342 meq/ml inj

93


93

glucose 50mg/ml/potassium chloride 0.02meq/ml/sodium chloride 4.5mg/ml inj

93


93

glucose 50mg/ml/sodium chloride 0.0342 meq/ml inj

93

glucose 50mg/ml/sodium chloride 4.5mg/ml inj

93

glucose 50mg/ml/sodium chloride 9mg/ml inj

93

glyburide 1.25mg tab 33 glyburide 1.25mg/metformin 250mg tab

30

glyburide 1.5mg tab 33 glyburide 2.5mg tab 33 glyburide 2.5mg/metformin 500mg tab

30

glyburide 3mg tab 33 glyburide 5mg tab 33 glyburide 5mg/metformin 500mg tab

30

glyburide 6mg tab 33 glycopyrrolate 1mg tab 108 glycopyrrolate 2mg tab 108 GLYXAMBI 10-5MG TAB

30

GLYXAMBI 25-5MG TAB

30

GRAMICIDIN 0.025MG/ML/NEOMYCIN 1.75MG/ML/POLYMYXIN B 10000UNIT/ML OPHTH SOLN

98

granisetron 1mg tab 34 griseofulvin 125mg tab 34 griseofulvin 250mg tab 34 griseofulvin 25mg/ml susp

34

griseofulvin 500mg tab 35 GUAIFENESIN/CODEINE SYRUP

74

guaifenesin/codeine syrup

74

guanfacine 1mg er tab 9 guanfacine 1mg tab 39 guanfacine 2mg er tab 9 guanfacine 2mg tab 39 guanfacine 3mg er tab 9 guanfacine 4mg er tab 9 GVOKE 0.5MG/0.1ML AUTO-INJECTOR

31

GVOKE 0.5MG/0.1ML SYRINGE

31

GVOKE 1MG/0.2ML AUTO-INJECTOR

31

GVOKE 1MG/0.2ML SYRINGE

31

H

HAEGARDA 2000UNIT INJ

87

HAEGARDA 3000UNIT INJ

87

halobetasol propionate 0.05% cream

77

halobetasol propionate 0.05% ointment

77

haloperidol 0.5mg tab 57 haloperidol 10mg tab 57 haloperidol 1mg tab 57 haloperidol 20mg tab 57 haloperidol 2mg tab 57


133


haloperidol 2mg/ml oral soln

57

haloperidol 5mg tab 57 haloperidol 5mg/ml inj 57 haloperidol decanoate 100mg/ml inj

57

haloperidol decanoate 50mg/ml inj

57

HAVRIX 1440ELU/ML INJ

110

HAVRIX 720ELU/0.5ML INJ

110

heparin sodium 5000unit/0.5ml inj (PF)

23

heparin sodium porcine 10000unit/ml inj

23


23


23


23

HEPATAMINE 8% INJ 97 HETLIOZ 20MG CAP 89 HETLIOZ 4MG/ML SUSP 90 HIBERIX 10MCG INJ 110 homatropine ophth soln 98 HOMATROPINE OPHTH SOLN

98

HUMIRA 10MG/0.1ML SYRINGE

11


11


11


11

HUMIRA 40MG/0.4ML AUTO-INJECTOR

11


11


11


11


11

HUMIRA PEDIATRIC CROHN'S STARTER PACK (3) 80MG/0.8ML SYRINGE

11

HUMIRA PEDIATRIC CROHN'S STARTER PACK SYRINGE (2) 40MG/0.4ML, 80MG/0.8ML

11

HUMIRA PEN - CROHN'S STARTER PACK 40MG/0.8ML INJ

11

HUMIRA PEN - PEDIATRIC UC STARTER PACK 80MG/0.8ML INJ

11

HUMIRA PEN - PSORIASIS STARTER PACK 40MG/0.8ML

12

HUMIRA PEN - PSORIASIS STARTER PACK 80MG/0.8ML INJ

12

HUMIRA PEN 80MG/0.8ML - STARTER PACK FOR CROHN'S DISEASE ULCERATIVE COLITIS OR HIDRADENITIS SUPPURAT

12

HUMULIN R 500UNIT/ML INJ

32

HUMULIN R 500UNIT/ML PEN INJ

32

HYCODAN SYRUP 73 hydralazine 100mg tab 41 hydralazine 10mg tab 41 hydralazine 25mg tab 41 hydralazine 50mg tab 41 hydrochlorothiazide 12.5mg cap

80

hydrochlorothiazide 12.5mg tab

80

hydrochlorothiazide 12.5mg/irbesartan 150mg tab

40

hydrochlorothiazide 12.5mg/irbesartan 300mg tab

40

hydrochlorothiazide 12.5mg/lisinopril 10mg tab

40

hydrochlorothiazide 12.5mg/lisinopril 20mg tab

40

hydrochlorothiazide 12.5mg/losartan potassium 100mg tab

40

hydrochlorothiazide 12.5mg/losartan potassium 50mg tab

40

hydrochlorothiazide 12.5mg/olmesartan medoxomil 20mg tab

40

hydrochlorothiazide 12.5mg/olmesartan medoxomil 40mg tab

40

hydrochlorothiazide 12.5mg/quinapril 10mg tab

40

hydrochlorothiazide 12.5mg/quinapril 20mg tab

40

hydrochlorothiazide 12.5mg/valsartan 160mg tab

40


40


40

hydrochlorothiazide 25mg tab

80

hydrochlorothiazide 25mg/lisinopril 20mg tab

40


134


hydrochlorothiazide 25mg/losartan potassium 100mg tab

40

hydrochlorothiazide 25mg/metoprolol tartrate 100mg tab

40

hydrochlorothiazide 25mg/metoprolol tartrate 50mg tab

40

hydrochlorothiazide 25mg/olmesartan medoxomil 40mg tab

41

hydrochlorothiazide 25mg/quinapril 20mg tab

41

hydrochlorothiazide 25mg/spironolactone 25mg tab

79

hydrochlorothiazide 25mg/triamterene 37.5mg cap

79

hydrochlorothiazide 25mg/triamterene 37.5mg tab

79

hydrochlorothiazide 25mg/valsartan 160mg tab

41

hydrochlorothiazide 25mg/valsartan 320mg tab

41

hydrochlorothiazide 50mg tab

80

HYDROCHLOROTHIAZIDE 50MG/METOPROLOL TARTRATE 100MG TAB

41

hydrochlorothiazide 50mg/triamterene 75mg tab

79

hydrocodone bitartrate 10mg er cap

14

HYDROCODONE BITARTRATE 10MG ER CAP

14

hydrocodone bitartrate 10mg/ibuprofen 200mg tab

16


14


14


14


14


14


14


14


14


14

HYDROCODONE BITARTRATE 5MG/IBUPROFEN 200MG TAB

16

hydrocodone bitartrate 7.5mg/ibuprofen 200mg tab

16

hydrocodone/acetaminophen 10-325mg tab

16

hydrocodone/chlorpheniramine susp

74

HYDROCODONE/CHLORPHENIRAMINE/PSE LIQUID

74

hydrocodone/homatropine syrup

74

hydrocodone/ibuprofen 5-200mg tab

16

hydrocortisone 1% cream (RX Only)

17

hydrocortisone 1% cream (RX Only)

17

hydrocortisone 1.67mg/ml enema

17

hydrocortisone 10mg tab 73 hydrocortisone 10mg/ml/neomycin 3.5mg/ml/polymyxin b 10000unit/ml otic soln

101

hydrocortisone 10mg/ml/neomycin 3.5mg/ml/polymyxin b 10000unit/ml otic susp

101

hydrocortisone 2.5% cream

77

hydrocortisone 2.5% lotion

77

hydrocortisone 2.5% ointment

77

hydrocortisone 20mg tab 73 hydrocortisone 5mg tab 73 hydrocortisone supp 17 hydrocortisone/pramoxine 1-1% rectal cream

17

hydrocortisone/pramoxine 2.5-1% rectal cream

17

hydromorphone 1mg/ml oral soln

14

hydromorphone 2mg tab 14 hydromorphone 4mg tab 14 hydromorphone 8mg tab 14 hydroxychloroquine sulfate 200mg tab

43

hydroxyurea 500mg cap 53 hydroxyzine 10mg tab 18 hydroxyzine 25mg tab 18 hydroxyzine 2mg/ml oral soln

18

hydroxyzine 50mg tab 18 HYDROXYZINE PAMOATE 100MG CAP

18

hydroxyzine pamoate 25mg cap

18


135


hydroxyzine pamoate 50mg cap

18

hyoscyamine sulfate CR tab

108

hyoscyamine sulfate elixir 108 hyoscyamine sulfate ODT 108 hyoscyamine sulfate SL tab

108

hyoscyamine sulfate tab 108

I

ibandronate 150mg tab 80 IBRANCE 100MG CAP 49 IBRANCE 100MG TAB 49 IBRANCE 125MG CAP 49 IBRANCE 125MG TAB 49 IBRANCE 75MG CAP 49 IBRANCE 75MG TAB 49 ibuprofen 20mg/ml susp 12 ibuprofen 400mg tab 12 ibuprofen 600mg tab 12 ibuprofen 800mg tab 12 icatibant 10mg/ml inj 87 ICLUSIG 10MG TAB 49 ICLUSIG 15MG TAB 49 ICLUSIG 30MG TAB 49 ICLUSIG 45MG TAB 49 icosapent ethyl 1gm cap 35 IDHIFA 100MG TAB 49 IDHIFA 50MG TAB 50 ILEVRO 0.3% OPHTH SUSP

100

imatinib 100mg tab 50 imatinib 400mg tab 50 IMBRUVICA 140MG CAP

50

IMBRUVICA 140MG TAB 50 IMBRUVICA 280MG TAB 50 IMBRUVICA 420MG TAB 50 IMBRUVICA 560MG TAB 50 IMBRUVICA 70MG CAP 50 imipramine 10mg tab 29 imipramine 25mg tab 29 imipramine 50mg tab 29 imiquimod 5% cream 78

IMOVAX 2.5UNIT/ML INJ

110

IMPAVIDO 50MG CAP 41 IMPLANON IMPLANT, NEXPLANON IMPLANT

72

INCRELEX 40MG/4ML INJ

81

INCRUSE 62.5MCG/INH INHALER

20

indapamide 1.25mg tab 80 indapamide 2.5mg tab 80 INDOCIN 50MG RECTAL SUPP

13

indomethacin 25mg cap 13 indomethacin 50mg cap 13 indomethacin 75mg er cap

13

INFANRIX INJ 108 INGREZZA 40MG CAP 104 INGREZZA 60MG CAP 104 INGREZZA 80MG CAP 104 INLYTA 1MG TAB 45 INLYTA 5MG TAB 45 INNOPRAN 120MG ER CAP

65

INNOPRAN 80MG ER CAP

65

INQOVI 5 TABLET PACK 48 INREBIC 100MG CAP 50 INSULIN PEN NEEDLE 91 INSULIN SYRINGE 91 INSULIN SYRINGE U-500

91

INTELENCE 25MG TAB 61 INTRALIPID 30GM/100ML INJ

97

INTRON A 10MU INJ 53 INTRON A 10MU/ML INJ 53 INTRON A 18MU INJ 53 INTRON A 50MU INJ 53 INTRON A 6000000UNIT/ML INJ

53

INVEGA 117MG/0.75ML INJ

56

INVEGA 156MG/ML INJ 56


56


56


56


56


56


57


57

INVIRASE 500MG TAB 61 iodoquinol/hydrocortisone cream

75

IOPIDINE 1% OPHTH SOLN

98

IPOL INJ 110 ipratropium 0.03% nasal spray

97

ipratropium 0.06% nasal spray

97

ipratropium bromide 0.2mg/ml inh soln

20

ipratropium/albuterol 0.5-2.5mg/3ml inh soln

21

irbesartan 150mg tab 38 irbesartan 300mg tab 38 irbesartan 75mg tab 38 IRESSA 250MG TAB 45 IRON POLYSACCH/THREONIC ACID/B12/FA CAP

89

IRON SUSP 89 IRON/VITAMIN C/VITAMIN B12/FOLIC ACID TAB

89

ISENTRESS 100MG CHEW TAB

61

ISENTRESS 100MG GRANULES FOR ORAL SUSP

61


136


ISENTRESS 25MG CHEW TAB

61

ISENTRESS 400MG TAB 61 ISENTRESS 600MG TAB 61 ISOLYTE P INJ 93 ISOLYTE S INJ 93 ISOLYTE-S (PH 7.4) INJ 93 ISONIAZID 100MG TAB 44 ISONIAZID 10MG/ML ORAL SOLN

44

isoniazid 300mg tab 44 isosorbide dinitrate 10mg tab

18

isosorbide dinitrate 20mg tab

18


18


18


18

isosorbide mononitrate 10mg tab

18

isosorbide mononitrate 120mg er tab

18

isosorbide mononitrate 20mg tab

18


18


18

isotretinoin 10mg cap 74 isotretinoin 20mg cap 74 isotretinoin 30mg cap 74 isotretinoin 40mg cap 74 isoxsuprine tab 68 ISOXSUPRINE TAB 68 isradipine 2.5mg cap 66 isradipine 5mg cap 66 ISTURISA 10MG TAB 80 ISTURISA 1MG TAB 80 ISTURISA 5MG TAB 80 itraconazole 100mg cap 35 itraconazole 10mg/ml oral soln

35

IVERMECTIN 0.5% LOTION

78

ivermectin 3mg tab 18 IXIARO 0.012MG/ML INJ 110

J

JAKAFI 10MG TAB 50 JAKAFI 15MG TAB 50 JAKAFI 20MG TAB 50 JAKAFI 25MG TAB 50 JAKAFI 5MG TAB 50 JANUMET 1000-100MG ER TAB

30

JANUMET 1000-50MG ER TAB

30

JANUMET 1000-50MG TAB

30

JANUMET 500-50MG ER TAB

30

JANUMET 500-50MG TAB

30

JANUVIA 100MG TAB 31 JANUVIA 25MG TAB 31 JANUVIA 50MG TAB 31 JARDIANCE 10MG TAB 32 JARDIANCE 25MG TAB 32 jasmiel 28 day pack 72 JENTADUETO 2.5-1000MG ER TAB

30

JENTADUETO 2.5-1000MG TAB

30


30


30

JENTADUETO 5-1000MG ER TAB

30

JULUCA 50-25MG TAB 61 junel fe 1.5/30 28 day pack

72

JUXTAPID 10MG CAP 37 JUXTAPID 20MG CAP 37 JUXTAPID 30MG CAP 37 JUXTAPID 5MG CAP 37 JYNARQUE 15MG TAB 82

JYNARQUE 30MG TAB 82 JYNARQUE 45/15 THERAPY PACK

83

JYNARQUE 60/30 THERAPY PACK

83

JYNARQUE 90/30 THERAPY PACK

83

JYNARQUE TAB 15/15 CARTON 15MG PACK

83

JYNARQUE TAB 30/15MG THERAPY PACK

83

K

KALYDECO 150MG TAB 106 KALYDECO 25MG GRANULES

106

KALYDECO 50MG GRANULES

106

KALYDECO 75MG GRANULES

106

KCL 40 MEQ/L (0.3%) IN DEXTROSE 5% & NACL 0.9% INJ

93

KCL 40 MEQ/L (0.3%) IN NACL 0.9% INJ

93

KCL/D5W/LR 0.15% INJ 93 KCL/D5W/NACL 20MEQ/5%/0.225% INJ

93

KCL/NACL 20MEQ-0.45% INJ

93

KESIMPTA 20MG/0.4ML PEN INJ

105

ketoconazole 2% cream 75 ketoconazole 2% shampoo

75

ketoconazole 200mg tab 35 KETO-DIASTIX 79 KETOPROFEN 200MG ER CAP

13

ketorolac tromethamine 0.4% ophth soln

100

ketorolac tromethamine 0.5% ophth soln

100


137


ketorolac tromethamine 10mg tab

13

KETOSTIX 79 KEVZARA 150MG/1.14ML AUTO-INJECTOR

12

KEVZARA 150MG/1.14ML SYRINGE

12

KEVZARA 200MG/1.14ML AUTO-INJECTOR

12

KEVZARA 200MG/1.14ML SYRINGE

12

KINRIX INJ 108 KINRIX PF INJ 108 KISQALI 200MG DAILY DOSE PACK

50

KISQALI 400MG DAILY DOSE PACK

50

KISQALI 600MG DAILY DOSE PACK

50

KISQALI FEMARA CO-PACK 200 PACK

48


48


48

klor-con 10meq er tab 94 klor-con 10meq micro er tab

94

klor-con 20meq powder for oral soln

94

klor-con 8meq er tab 94 KLOXXADO 8MG/0.1ML NASAL SPRAY

33

KORLYM 300MG TAB 31 KOSELUGO 10MG CAP 50 KOSELUGO 25MG CAP 50 K-PHOS 500MG TAB 93 K-PHOS NEUTRAL TAB 93 KRINTAFEL 150MG TAB 43

KRISTALOSE 10GM POWDER FOR ORAL SOLN

90

KRISTALOSE 20GM POWDER FOR ORAL SOLN

90

K-TAB 10MEQ ER TAB 94 K-TAB 20MEQ ER TAB 94 K-TAB ER 8MEQ TAB 94 KYNMOBI 10MG SUBLINGUAL FILM

55

KYNMOBI 15MG SUBLINGUAL FILM

55


55


55


55

L

labetalol 100mg tab 64 labetalol 200mg tab 64 labetalol 300mg tab 64 lamivudine 100mg tab 62 lamivudine 10mg/ml oral soln

61

lamivudine 150mg tab 61 lamivudine 150mg/zidovudine 300mg tab

61

lamivudine 300mg tab 61 lamotrigine 100mg er tab 24 lamotrigine 100mg odt 24 lamotrigine 100mg tab 24 lamotrigine 150mg tab 24 lamotrigine 200mg er tab 25 lamotrigine 200mg odt 25 lamotrigine 200mg tab 25 lamotrigine 250mg er tab 25 lamotrigine 25mg chew tab

25

lamotrigine 25mg er tab 25 lamotrigine 25mg odt 25 lamotrigine 25mg tab 25

lamotrigine 300mg er tab 25 lamotrigine 50mg er tab 25 lamotrigine 50mg odt 25 lamotrigine 5mg chew tab 25 LANCET DEVICE 91 LANCET KIT 91 LANCETS 91 LANOXIN 125MCG TAB 67 LANOXIN 250MCG TAB 67 LANSOPRAZOLE SUSP 109 lanthanum carbonate 1000mg chew tab

85

lanthanum carbonate 500mg chew tab

85

lanthanum carbonate 750mg chew tab

85

LANTUS 100UNIT/ML INJ

32

LANTUS SOLOSTAR 100UNIT/ML INJ

32

lapatinib ditosylate 250mg tab

50

larin 1.5/30 pack 72 larin 1/20 pack 72 LASTACAFT 0.25% OPHTH SOLN

100

latanoprost 0.005% ophth soln

100

LATUDA 120MG TAB 56 LATUDA 20MG TAB 56 LATUDA 40MG TAB 56 LATUDA 60MG TAB 56 LATUDA 80MG TAB 56 layolis fe 28 pack 72 leflunomide 10mg tab 13 leflunomide 20mg tab 13 LENVIMA CAP THERAPY PACK (10MG)

45

LENVIMA CAP THERAPY PACK (12MG)

45


45


45


138



45


45


45


45

letrozole 2.5mg tab 46 leucovorin 10mg tab 53 leucovorin 15mg tab 53 leucovorin 25mg tab 53 leucovorin 5mg tab 53 LEUKERAN 2MG TAB 44 leuprolide acetate 5mg/ml inj

46

levalbuterol 0.103mg/ml inh soln

21


21


21


21

LEVBID TAB 108 LEVEMIR 100UNIT/ML INJ

32

LEVEMIR 100UNIT/ML PEN INJ

32

levetiracetam 1000mg tab 25 levetiracetam 100mg/ml oral soln

25

levetiracetam 250mg tab 25 levetiracetam 500mg er tab

25

levetiracetam 500mg tab 25 levetiracetam 750mg er tab

25

levetiracetam 750mg tab 25 LEVOBUNOLOL 0.5% OPHTH SOLN

98

levocarnitine 100mg/ml oral soln

82

levocarnitine 330mg tab 82

levocetirizine 0.5mg/ml oral soln

35

levocetirizine 5mg tab 35 levofloxacin 0.5% ophth soln

98

levofloxacin 250mg tab 84 levofloxacin 25mg/ml inj 84 levofloxacin 25mg/ml oral soln

84

levofloxacin 500mg tab 84 levofloxacin 5mg/ml (100ml) inj

84

levofloxacin 5mg/ml (150ml) inj

84

levofloxacin 750mg tab 84 levofloxacin/D5W 250mg/50ml inj

84

levonorgestrel tab 72 levothyroxine sodium 100mcg tab

107

levothyroxine sodium 112mcg tab

107


107


107


107


107


107


107


107


107


107


108

LEVSIN SL TAB 108 LEVSIN TAB 109 LEXIVA 50MG/ML SUSP 61

lidocaine 2% topical soln 95 lidocaine 3% cream (rx only)

78

LIDOCAINE 4% ORAL SOLN

95

lidocaine 4% topical soln 78 lidocaine 5% ointment 78 lidocaine 5% patch 78 lidocaine/hydrocortisone cream

17

lidocaine/prilocaine 2.5-2.5% cream

78

LINDANE 1% SHAMPOO 79 linezolid 20mg/ml susp 43 LINEZOLID 2MG/ML INJ 43 linezolid 2mg/ml inj 43 linezolid 600mg tab 43 liothyronine sodium 0.005mg tab

108

liothyronine sodium 0.025mg tab

108

liothyronine sodium 0.05mg tab

108

lisinopril 10mg tab 37 lisinopril 2.5mg tab 37 lisinopril 20mg tab 37 lisinopril 30mg tab 37 lisinopril 40mg tab 37 lisinopril 5mg tab 38 LITHIUM CARBONATE 150MG CAP

55

lithium carbonate 150mg cap

55


55

LITHIUM CARBONATE 300MG CAP

55

lithium carbonate 300mg er tab

56

lithium carbonate 300mg tab

56

lithium carbonate 450mg er tab

56


56


139


LITHIUM CARBONATE 600MG CAP

56

LITHIUM CITRATE 60MG/ML ORAL SOLN

56

LITHOSTAT 250MG TAB 86 LIVALO 1MG TAB 36 LIVALO 2MG TAB 36 LIVALO 4MG TAB 36 LO LOESTRIN FE 28 DAY PACK

72

LOKELMA 10GM POWDER FOR ORAL SUSP

95

LOKELMA 5GM POWDER FOR ORAL SUSP

95

LONHALA 25MCG/ML INH SOLN

20

LONSURF 6.14-15MG TAB

48

LONSURF 8.19-20MG TAB

48

loperamide 2mg cap (RX Only)

33

lopinavir 80mg/ml/ritonavir 20mg/ml oral solution

61

lopinavir/ritonavir 100-25mg tab

61

lopinavir/ritonavir 200-50mg tab

61

lorazepam 0.5mg tab 19 lorazepam 1mg tab 19 lorazepam 2mg tab 19 lorazepam 2mg/ml oral soln

19

LORBRENA 100MG TAB 50 LORBRENA 25MG TAB 50 losartan potassium 100mg tab

38

losartan potassium 25mg tab

38

losartan potassium 50mg tab

38

LOTEMAX 0.5% OPHTH OINTMENT

99

loteprednol etabonate 0.5% ophth gel

99

loteprednol etabonate 0.5% ophth susp

99

lovastatin 10mg tab 36 lovastatin 20mg tab 36 lovastatin 40mg tab 36 low-ogestrel 28 day pack 72 loxapine 10mg cap 58 loxapine 25mg cap 58 loxapine 50mg cap 58 loxapine 5mg cap 58 LUCEMYRA 0.18MG TAB

103

LUMAKRAS 120MG TAB 50 LUMIGAN 0.01% OPHTH SOLN

100

LUPANETA 3-MONTH PACK

81

LUPANETA PACK 1-MONTH PACK

81

LUPKYNIS 7.9MG CAP 95 LUPRON 11.25MG INJ 46 LUPRON 11.25MG INJ PED KIT (3 MONTH)

81

LUPRON 22.5MG INJ 46 LUPRON 3.75MG INJ 46 LUPRON 30MG INJ 46 LUPRON 45MG INJ 46 LUPRON 7.5MG INJ 46 LUPRON 7.5MG INJ PED KIT (1 MONTH)

81

LURIDE CHEW TAB 93 LURIDE SOLN 93 LYNPARZA 100MG TAB 51 LYNPARZA 150MG TAB 51 LYSODREN 500MG TAB 46

M

magnesium sulfate 500mg/ml inj

93

malathion 0.5% lotion 79 MARPLAN 10MG TAB 27

MATULANE 50MG CAP 53 matzim 240mg er tab 66 matzim 420mg er tab 66 MAVYRET 100-40MG TAB

62

MAXIDEX 0.1% OPHTH SUSP

99

MAYZENT 0.25MG STARTER PACK

105

MAYZENT 0.25MG TAB 105 MAYZENT 2MG TAB 105 meclizine 12.5mg tab 34 meclizine 25mg tab (RX Only)

34

MEDROL 2MG TAB 73 medroxyprogesterone acetate 10mg tab

103

medroxyprogesterone acetate 150mg/ml inj

72

medroxyprogesterone acetate 150mg/ml syringe

72

medroxyprogesterone acetate 2.5mg tab

103

medroxyprogesterone acetate 5mg tab

103

mefloquine hcl 250mg tab 43 megestrol acetate 125mg/ml susp

103

megestrol acetate 20mg tab

46

megestrol acetate 40mg tab

46

megestrol acetate 40mg/ml susp

46

MEKINIST 0.5MG TAB 51 MEKINIST 2MG TAB 51 MEKTOVI 15MG TAB 51 melodetta 24 fe chewable 28 day pack

72

meloxicam 15mg tab 13 meloxicam 7.5mg tab 13 melphalan tab 44 memantine 10mg tab 104


140


memantine 10mg/memantine 5mg pack

104

memantine 14mg er cap 104 memantine 21mg er cap 104 memantine 28mg er cap 104 memantine 2mg/ml oral soln

104

memantine 5mg tab 104 memantine 7mg er cap 104 MENACTRA INJ 110 MENEST 0.3MG TAB 83 MENEST 0.625MG TAB 84 MENEST 1.25MG TAB 84 MENOSTAR 14MCG/24HR PATCH

84

MENQUADFI INJ 110 MENVEO INJ 110 mercaptopurine 50mg tab 44 MEROPENEM 0.9%-1GM-50ML INJ

42

meropenem 1000mg inj 42 meropenem 500mg inj 42 MEROPENEM 500MG/50ML INJ

42

mesalamine 1000mg rectal supp

85

mesalamine 1200mg dr tab

85

mesalamine 375mg er cap 85 mesalamine 400mg dr cap 85 mesalamine 4gm enema 85 mesalamine 66.7mg/ml enema

85

mesalamine 800mg dr tab 85 MESNEX 400MG TAB 53 metaxalone 800mg tab 96 metformin 1000mg tab 31 metformin 100mg/ml soln 31 metformin 500mg er tab 31 metformin 500mg tab 31 metformin 750mg er tab 31 metformin 850mg tab 31 methadone 10mg tab 14

methadone 10mg/5ml oral soln

14

METHADONE 1MG/ML ORAL SOLN

14

METHADONE 2MG/ML ORAL SOLN

15

methadone 5mg tab 15 methadone 5mg/5ml oral soln

15

methazolamide 25mg tab 79 methazolamide 50mg tab 79 methenamine hippurate 1gm tab

43

methenamine mandelate tab

43

methimazole 10mg tab 107 methimazole 5mg tab 107 METHITEST 10MG TAB 17 methocarbamol 500mg tab

96

methocarbamol 750mg tab

96

methotrexate 2.5mg tab 44 METHOTREXATE 250MG/10ML INJ

44

methotrexate 25mg/ml (2ml) inj

44

methotrexate 25mg/ml inj 44 METHOXSALEN 10MG CAP

76

methscopolamine bromide 2.5mg tab

109

methscopolamine bromide 5mg tab

109

methyldopa 250mg tab 39 METHYLDOPA 250MG TAB

39

METHYLDOPA 500MG TAB

39

methyldopa 500mg tab 39 methylphenidate 10mg chew tab

10

methylphenidate 10mg cr cap

10

methylphenidate 10mg er tab

10

methylphenidate 10mg la cap

10

methylphenidate 10mg tab

10

METHYLPHENIDATE 18MG ER TAB

10


10

methylphenidate 1mg/ml oral soln

10

methylphenidate 2.5mg chew tab

10


10


10


10

methylphenidate 20mg tab

10

methylphenidate 27mg sr tab

10

methylphenidate 2mg/ml oral soln

10


10


10


10


10


10


10


10

methylphenidate 5mg chew tab

10

methylphenidate 5mg tab 10 methylphenidate 60mg cr cap

10


141



10

methylphenidate ER osmotic 27mg tab

10


10


10

methylprednisolone 16mg tab

73


73

methylprednisolone 4mg pack

73


73


73

METHYLTESTOSTERONE 10MG CAP

17

metoclopramide 10mg tab 85 metoclopramide 1mg/ml oral soln

85

metoclopramide 5mg tab 85 metolazone 10mg tab 80 metolazone 2.5mg tab 80 metolazone 5mg tab 80 metoprolol succinate 100mg er tab

65

metoprolol succinate 200mg er tab

65


65


65

metoprolol tartrate 100mg tab

65


65


65

metronidazole 0.75% cream

78

metronidazole 0.75% gel 78

metronidazole 0.75% lotion

78

metronidazole 0.75% vaginal gel

111

metronidazole 1% gel 78 metronidazole 250mg tab 41 metronidazole 500mg tab 41 metronidazole 5mg/ml inj 41 METRONIDAZOLE/NACL 0.74%-500MG/100ML INJ

41

metronidazole/nacl 0.74%/500mg/100ml inj

41

metyrosine 250mg cap 38 mexiletine 150mg cap 19 mexiletine 200mg cap 19 mexiletine 250mg cap 19 micafungin sodium 100mg inj

34

micafungin sodium 50mg inj

34

MICONAZOLE NITRATE 200MG VAGINAL INSERT

111

microgestin fe 1/20 28 day pack

72

midodrine 10mg tab 112 midodrine 2.5mg tab 112 midodrine 5mg tab 112 miglitol 100mg tab 30 miglitol 25mg tab 30 miglitol 50mg tab 30 miglustat 100mg cap 88 MILLIPRED 5MG TAB 73 mimvey pack 83 minocycline 100mg cap 107 minocycline 100mg tab 107 minocycline 50mg cap 107 minocycline 50mg tab 107 minocycline 75mg cap 107 minocycline 75mg tab 107 minoxidil 10mg tab 41 minoxidil 2.5mg tab 41 MIRENA IUD 72 mirtazapine 15mg odt 27

mirtazapine 15mg tab 27 mirtazapine 30mg odt 27 mirtazapine 30mg tab 27 mirtazapine 45mg odt 27 mirtazapine 45mg tab 27 mirtazapine 7.5mg tab 27 misoprostol 0.1mg tab 109 misoprostol 0.2mg tab 109 M-M-R II INJ 111 modafinil 100mg tab 10 modafinil 200mg tab 10 moexipril 15mg tab 38 moexipril 7.5mg tab 38 MOLINDONE 10MG TAB 58 MOLINDONE 25MG TAB 58 MOLINDONE 5MG TAB 58 mometasone furoate 0.1% cream

77

mometasone furoate 0.1% lotion

77

mometasone furoate 0.1% ointment

77

mondoxyne 100mg cap 107 montelukast 10mg tab 20 montelukast 4mg chew tab

20

montelukast 4mg granules

20

montelukast 5mg chew tab

20

morphine sulfate 100mg er tab

15


15

morphine sulfate 15mg tab

15

MORPHINE SULFATE 15MG TAB

15


15

morphine sulfate 20mg/ml oral soln

15


15


142



15

morphine sulfate 30mg tab

15

MORPHINE SULFATE 30MG TAB

15


15


15

MOTEGRITY 1MG TAB 84 MOTEGRITY 2MG TAB 84 MOVANTIK 12.5MG TAB 85 MOVANTIK 25MG TAB 85 moxifloxacin 0.5% ophth soln

98

moxifloxacin 0.5% ophth soln

98

MOXIFLOXACIN 1.6MG/ML INJ

84

moxifloxacin 400mg tab 84 MOXIFLOXACIN 400MG/250ML IV SOLN

84

MULTAQ 400MG TAB 20 MULTIGEN FOLIC TAB 89 MULTIGEN PLUS TAB 89 MULTIGEN TAB 89 MULTI-VITAMIN/FLOURIDE 0.25MG CHEW TAB

96

MULTI-VITAMIN/FLOURIDE 0.5MG CHEW TAB

96

MULTI-VITAMIN/FLOURIDE 1MG CHEW TAB

96

multivitamin/minerals tab 96 mupirocin 2% ointment 75 MUSE SUPP 68 mycophenolate mofetil 200mg/ml susp

63

mycophenolate mofetil 250mg cap

64

mycophenolate mofetil 500mg tab

64

mycophenolic acid 180mg dr tab

64

mycophenolic acid 360mg dr tab

64

MYFORTIC 180MG DR TAB

64

MYFORTIC 360MG DR TAB

64

MYLERAN TAB 44 MYRBETRIQ 25MG ER TAB

109

MYRBETRIQ 50MG ER TAB

109

N

nabumetone 500mg tab 13 nabumetone 750mg tab 13 nadolol 20mg tab 65 nadolol 40mg tab 65 nadolol 80mg tab 65 NAFCILLIN 1000MG INJ 103 nafcillin 1000mg inj 103 nafcillin 100mg/ml inj 103 NAFCILLIN 1GM INJ 103 NAFCILLIN 2000MG INJ 103 nafcillin 2000mg inj 103 NAFCILLIN 2GM INJ 103 NAFTIFINE 1% CREAM 75 naftifine 2% cream 75 NAFTIFINE 2% CREAM 75 NAFTIN 2% GEL 75 NALOXONE 0.4MG/ML CARTRIDGE

33

naloxone 0.4mg/ml inj 33 naloxone 1mg/ml syringe 33 naltrexone 50mg tab 33 naproxen 250mg tab 13 naproxen 375mg dr tab 13 naproxen 375mg tab 13 naproxen 500mg dr tab 13 naproxen 500mg tab 13 naproxen sodium 275mg tab

13

naproxen sodium 550mg tab

13

naratriptan 1mg tab 92 naratriptan 2.5mg tab 92

NARCAN 4MG/0.1ML NASAL SPRAY

34

NATACYN 5% OPHTH SUSP

98

NATAZIA 28 DAY PACK 72 nateglinide 120mg tab 32 nateglinide 60mg tab 32 NATPARA 100MCG CARTRIDGE

80

NATPARA 25MCG CARTRIDGE

80


80


80

NAYZILAM 5MG/0.1ML NASAL SPRAY

24

nebivolol 10mg tab 65 nebivolol 2.5mg tab 65 nebivolol 20mg tab 65 nebivolol 5mg tab 65 NEFAZODONE 100MG TAB

28

NEFAZODONE 150MG TAB

28


28


28

NEFAZODONE 50MG TAB

28

neomycin sulfate 500mg tab

11

neomycin/bacitracin/polymyxin ophth ointment 5(3.5)mg-400unit-10000unit

98

neomycin/polymyxin/bacitracin/hydrocortisone 1% ophth ointment

99

NEOMYCIN-POLYMYXIN-HC OPHTH SUSP

99

NEORAL 100MG CAP 64 NEORAL 100MG/ML ORAL SOLN

64


143


NEORAL 25MG CAP 64 NEPHRO-VITE TAB 96 NERLYNX 40MG TAB 51 NEUPRO 1MG/24HR PATCH

54

NEUPRO 2MG/24HR PATCH

54


54


54


54


54

NEVANAC 0.1% OPHTH SUSP

100

NEVIRAPINE 100MG ER TAB

61

NEVIRAPINE 10MG/ML SUSP

61

nevirapine 200mg tab 61 nevirapine 400mg er tab 61 NEXAVAR 200MG TAB 51 niacin 1000mg er tab 37 niacin 500mg er tab 37 niacin 750mg er tab 37 nicardipine 20mg cap 66 nicardipine 30mg cap 66 NICORETTE CQ PATCH 105 NICORETTE GUM 106 nicotine gum 106 nicotine lozenge 106 nicotine patch 106 NICOTINE PATCH KIT 106 NICOTROL 10MG INH SOLN

106

NICOTROL 10MG/ML NASAL INHALER

106

nifedipine 10mg cap 66 nifedipine 20mg cap 66 nifedipine 30mg er tab 66 nifedipine 30mg osmotic er tab

66

nifedipine 60mg er tab 66

nifedipine 60mg osmotic er tab

66

nifedipine 90mg er tab 66 nifedipine 90mg osmotic er tab

66

nilutamide 150mg tab 46 nimodipine 30mg cap 67 NINLARO 2.3MG CAP 51 NINLARO 3MG CAP 51 NINLARO 4MG CAP 51 nisoldipine 17mg er tab 67 NISOLDIPINE 20MG ER TAB

67

NISOLDIPINE 25.5MG ER TAB

67

NISOLDIPINE 30MG ER TAB

67

nisoldipine 34mg er tab 67 NISOLDIPINE 40MG ER TAB

67

nisoldipine 8.5mg er tab 67 nitazoxanide 500mg tab 42 nitisinone 10mg cap 82 nitisinone 2mg cap 82 nitisinone 5mg cap 82 NITRO-BID 2% OINTMENT

18

NITRO-DUR 0.3MG/HR PATCH

18

NITRO-DUR 0.8MG/HR PATCH

18

nitrofurantoin 100mg cap 43 nitrofurantoin 50mg macro cap

43

nitrofurantoin macro 100mg cap

43

nitroglycerin 0.1mg/hr patch

18


18

nitroglycerin 0.3mg sl tab 18 nitroglycerin 0.4mg sl tab 18 nitroglycerin 0.4mg/act spray

18


18

nitroglycerin 0.6mg sl tab 18 nitroglycerin 0.6mg/hr patch

18

NITROGLYCERIN CAP 18 NIVESTYM 300MCG/0.5ML SYRINGE

88

NIVESTYM 300MCG/ML INJ

88

NIVESTYM 480MCG/0.8ML SYRINGE

88

NIVESTYM 480MCG/1.6ML INJ

88

nizatidine 150mg cap 109 NIZATIDINE 150MG CAP 109 NIZATIDINE 300MG CAP 109 norethindrone 0.35mg pack

72

norethindrone acetate 5mg tab

103

NORMOSOL-M/D5W INJ 93 NORMOSOL-R (PH 7.4) INJ

93

NORMOSOL-R INJ 93 NORPACE 100MG ER CAP

19

NORPACE 150MG ER CAP

19

nortrel 0.5/35 28 day pack

72

nortriptyline 10mg cap 29 nortriptyline 25mg cap 29 NORTRIPTYLINE 2MG/ML ORAL SOLN

29

nortriptyline 50mg cap 29 nortriptyline 75mg cap 29 NORVIR 100MG ORAL POWDER

61

NORVIR 80MG/ML ORAL SOLN

61

NOURIANZ 20MG TAB 55 NOURIANZ 40MG TAB 55


144


NOVOLIN MIX (70/30) 100UNIT/ML INJ

32

NOVOLIN MIX (70/30) FLEXPEN 100UNIT/ML

32

NOVOLIN N 100UNIT/ML INJ

32

NOVOLIN N 100UNIT/ML PEN INJ

32

NOVOLIN R 100UNIT/ML INJ

32

NOVOLIN R FLEXPEN RELION

32

NOVOLOG 100UNIT/ML CARTRIDGE, INSULIN ASPART HUMAN 100UNIT/ML CARTRIDGE

32

NOVOLOG 100UNIT/ML INJ, INSULIN ASPART HUMAN 100UNIT/ML INJ

32

NOVOLOG 100UNIT/ML PEN INJ, INSULIN ASPART HUMAN 100UNIT/ML PEN INJ

32

NOVOLOG MIX (70/30) 100UNIT/ML INJ, INSULIN ASPART MIX 70UNIT-30UNIT/ML INJ

32

NOVOLOG MIX 70-30UNIT/ML PEN INJ, INSULIN ASPART MIX 70UNIT-30UNIT/ML PEN INJ

32

NOXAFIL 40MG/ML SUSP

35

NUBEQA 300MG TAB 46 NUCALA 100MG INJ 20 NUCALA 100MG/ML AUTO-INJECTOR

20

NUCALA 100MG/ML SYRINGE

20

NUCORT LOTION 77 NUCYNTA 100MG ER TAB

15

NUCYNTA 150MG ER TAB

15


15


15

NUCYNTA 50MG ER TAB

15

NUEDEXTA 20-10MG CAP

105

NUPLAZID 10MG TAB 56 NUPLAZID 34MG CAP 56 NURTEC 75MG ODT 91 NUTRILIPID 20GM/100ML INJ

97

NUZYRA 150MG TAB 106 nystatin 100000unit/ml cream

75

nystatin 100000unit/ml susp

95

nystatin 100unit/mg ointment

75

nystatin 100unit/mg topical powder

75

nystatin 500000unit tab 35

O

OCALIVA 10MG TAB 84 OCALIVA 5MG TAB 84 ocella 28 day pack 72 OCTAGAM 1GM/20ML INJ

101

OCTAGAM 2.5GM/50ML INJ

101

OCTAGAM 25GM/500ML INJ

101


101


101


101

OCTREOTIDE 0.05MG/ML INJ

82

octreotide 0.05mg/ml inj 82

OCTREOTIDE 0.1MG/ML INJ

82

octreotide 0.1mg/ml inj 82 octreotide 0.2mg/ml inj 82 OCTREOTIDE 0.5MG/ML INJ

82

octreotide 0.5mg/ml inj 82 octreotide 1mg/ml inj 82 ODEFSEY 200-25-25MG TAB

61

ODOMZO 200MG CAP 46 OFEV 100MG CAP 106 OFEV 150MG CAP 106 ofloxacin 0.3% ophth soln 99 ofloxacin 0.3% otic soln 100 ofloxacin 400mg tab 84 olanzapine 10mg inj 58 olanzapine 10mg odt 58 olanzapine 10mg tab 58 olanzapine 15mg odt 58 olanzapine 15mg tab 58 olanzapine 2.5mg tab 58 olanzapine 20mg odt 58 olanzapine 20mg tab 58 olanzapine 5mg odt 58 olanzapine 5mg tab 58 olanzapine 7.5mg tab 58 olmesartan medoxomil 20mg tab

38

olmesartan medoxomil 40mg tab

38

olmesartan medoxomil 5mg tab

38

olopatadine 0.1% ophth soln

100

olopatadine 0.2% ophth soln

100

olopatadine 0.665mg/act nasal inhaler

97

OLUMIANT 1MG TAB 11 OLUMIANT 2MG TAB 11 omega-3 acid ethyl esters (usp) 1000mg cap

35

omeprazole 10mg dr cap 109 omeprazole 20mg dr cap 109


145


omeprazole 40mg dr cap 109 ondansetron 0.8mg/ml oral soln

34

ONDANSETRON 24MG TAB

34

ondansetron 4mg odt 34 ondansetron 4mg tab 34 ondansetron 8mg odt 34 ondansetron 8mg tab 34 ONGENTYS 25MG CAP 55 ONGENTYS 50MG CAP 55 ONUREG 200MG TAB 44 ONUREG 300MG TAB 44 opium 10mg/ml tincture 33 OPSUMIT 10MG TAB 68 ORACIT SOLN 86 ORAVIG 50MG BUCCAL TAB

95

ORENCIA 125MG/ML AUTO-INJECTOR

13

ORENCIA 125MG/ML SYRINGE

13

ORENCIA 50MG/0.4ML SYRINGE

13

ORENCIA 87.5MG/0.7ML SYRINGE

13

ORENITRAM 0.125MG ER TAB

68


68

ORENITRAM 1MG ER TAB

68


68

ORENITRAM 5MG ER TAB

68

ORFADIN 20MG CAP 82 ORFADIN 4MG/ML SUSP

82

ORGOVYX 120MG TAB 46 ORIAHNN 28 DAY KIT PACK

83

ORILISSA 150MG TAB 81 ORILISSA 200MG TAB 81

ORKAMBI 125-100MG GRANULES

106

ORKAMBI 125-100MG TAB

106

ORKAMBI 125-200MG TAB

106

ORKAMBI 188-150MG GRANULES

106

orphenadrine citrate 100mg er tab

96

oseltamivir 30mg cap 63 oseltamivir 45mg cap 63 oseltamivir 6mg/ml susp 63 oseltamivir 75mg cap 63 OSPHENA 60MG TAB 81 OTEZLA 28-DAY STARTER PACK

13

OTEZLA 30MG TAB 13 OVACE CREAM 76 OVACE PLUS SHAMPOO 76 OVACE PLUS WASH 76 OVACE WASH 76 oxacillin 1000mg inj 103 oxacillin 100mg/ml inj 103 oxacillin 2000mg inj 103 OXACILLIN 20MG/ML INJ

103

OXACILLIN 40MG/ML INJ

103

oxandrolone 10mg tab 17 oxandrolone 2.5mg tab 17 oxaprozin 600mg tab 13 OXBRYTA 500MG TAB 88 oxcarbazepine 150mg tab 25 oxcarbazepine 300mg tab 25 oxcarbazepine 600mg tab 25 oxcarbazepine 60mg/ml susp

25

OXERVATE 0.002% OPHTH SOLN

99

oxybutynin chloride 10mg er tab

110


110

oxybutynin chloride 1mg/ml oral soln

110


110

oxybutynin chloride 5mg tab

110

oxycodone 10mg tab 15 oxycodone 15mg tab 15 oxycodone 1mg/ml oral soln

15

oxycodone 20mg tab 15 oxycodone 20mg/ml oral soln

15

oxycodone 30mg tab 15 oxycodone 5mg cap 15 oxycodone 5mg tab 15 oxymorphone 10mg tab 15 oxymorphone 5mg tab 15 OZEMPIC 2MG/1.5ML PEN INJ

31

OZEMPIC 2MG/1.5ML PEN INJ (1MG DOSE)

31

OZEMPIC 4MG/3ML PEN INJ

31

P

paliperidone 1.5mg er tab 57 paliperidone 3mg er tab 57 paliperidone 6mg er tab 57 paliperidone 9mg er tab 57 PALYNZIQ 10MG/0.5ML SYRINGE

82

PALYNZIQ 2.5MG/0.5ML SYRINGE

82

PALYNZIQ 20MG/ML SYRINGE

82

pantoprazole 20mg dr tab 109 pantoprazole 40mg dr tab 109 PANZYGA 10GM/100ML INJ

101

PANZYGA 1GM/10ML INJ

101

PANZYGA 2.5GM/25ML INJ

101


146



101


101


101

PARAGARD IUD 72 paricalcitol 0.001mg cap 82 paricalcitol 0.002mg cap 82 paricalcitol 0.004mg cap 82 paromomycin 250mg cap 11 paroxetine 10mg tab 28 paroxetine 10mg/5ml susp

28

paroxetine 12.5mg er tab 28 paroxetine 20mg tab 28 paroxetine 25mg er tab 28 paroxetine 30mg tab 28 paroxetine 37.5mg er tab 28 paroxetine 40mg tab 28 PASER D/R 4GM GRANULES

44

PAXIL 10MG/5ML SUSP 28 PEDIARIX INJ 108 pediatric multiple vitamins/fluoride chew tab

96

pediatric multiple vitamins/fluoride soln

96

pediatric multiple vitamins/fluoride/iron soln

96

PEDVAXHIB 7.5MCG/0.5ML INJ

110

peg 3350/electrolytes soln 240 gm

90

PEGASYS 180MCG/0.5ML SYRINGE

62

PEGASYS 180MCG/ML INJ

62

PEGASYS PROCLICK 180MCG/0.5ML INJ

62

PEMAZYRE 13.5MG TAB 51 PEMAZYRE 4.5MG TAB 51

PEMAZYRE 9MG TAB 51 PEN NEEDLE 91 penicillamine 250mg tab 94 penicillin g potassium 1000000unit/ml inj

102

PENICILLIN G POTASSIUM 40000UNIT/ML INJ

102

PENICILLIN G POTASSIUM 60000UNIT/ML INJ

102

PENICILLIN G PROCAINE 600000UNIT/ML INJ

102

PENICILLIN G SODIUM 100000UNIT/ML INJ

102

penicillin gk 5000000unit inj

102

penicillin v potassium 250mg tab

102

PENICILLIN V POTASSIUM 25MG/ML ORAL SOLN

102

penicillin v potassium 500mg tab

102

PENICILLIN V POTASSIUM 50MG/ML ORAL SOLN

102

PENTACEL INJ 108 pentamidine isethionate 300mg inj

41

pentamidine isethionate 50mg/ml inh soln

41

pentoxifylline 400mg er tab

87

perindopril erbumine 2mg tab

38


38


38

permethrin 5% cream 79 perphenazine 16mg tab 59 perphenazine 2mg tab 59 perphenazine 4mg tab 59

perphenazine 8mg tab 59 PERSERIS 120MG INJ 57 PERSERIS 90MG INJ 57 phenazopyridine 100mg tab

86

phenazopyridine 200mg tab

86

phenelzine 15mg tab 27 phenobarbital 100mg tab 90 phenobarbital 15mg tab 90 phenobarbital 16.2mg tab 90 phenobarbital 30mg tab 90 phenobarbital 32.4mg tab 90 phenobarbital 4mg/ml oral soln

89

phenobarbital 60mg tab 90 phenobarbital 64.8mg tab 90 phenobarbital 97.2mg tab 90 phenoxybenzamine 10mg cap

38

PHENYTEK 200MG ER CAP

26

PHENYTEK 300MG ER CAP

26

phenytoin 25mg/ml susp 26 phenytoin 50mg chew tab 26 phenytoin sodium 100mg er cap

26

phenytoin sodium 200mg er cap

26

phenytoin sodium 300mg er cap

26

PHOSLYRA 667MG/5ML ORAL SOLN

85

phospha 250 neutral tab 93 PIFELTRO 100MG TAB 61 pilocarpine 1% ophth soln

98

pilocarpine 2% ophth soln

98

pilocarpine 4% ophth soln

98

pilocarpine 5mg tab 95 pilocarpine 7.5mg tab 95 pimecrolimus 1% cream 78


147


PIMOZIDE 1MG TAB 105 PIMOZIDE 2MG TAB 105 pindolol 10mg tab 65 pindolol 5mg tab 65 pioglitazone 15mg tab 32 pioglitazone 30mg tab 32 pioglitazone 45mg tab 32 piperacillin 2000mg/tazobactam 250mg inj

103

piperacillin 200mg/ml/tazobactam 25mg/ml inj

103

piperacillin 3000mg/tazobactam 375mg inj

103

piperacillin 4000mg/tazobactam 500mg inj

103

piperacillin/tazobactam 12-1.5gm inj

103

PIQRAY 200MG DAILY DOSE PACK

51

PIQRAY 250MG DAILY DOSE PACK

51

PIQRAY 300MG DAILY DOSE 150MG PACK

51

pirmella 1/35 28 day pack 72 piroxicam 10mg cap 13 piroxicam 20mg cap 13 PLAN B TAB 72 PLASMA-LYTE 148 INJ 93 PLASMALYTE A INJ 93 PLEGRIDY 125MCG/0.5ML AUTO-INJECTOR

105

PLEGRIDY 125MCG/0.5ML SYRINGE

105

PLEGRIDY IM 125MCG/0.5ML INJ

105

PLEGRIDY INJ STARTER PACK

105

PLEGRIDY PEN STARTER PACK

105

PLEXION SCT CREAM 74 PODOCON SOLN 78 podofilox 0.5% topical soln

78

POLYETHYLENE GLYCOL 8000 GRANULES

103

polymyxin b 10000unit/ml/trimethoprim 1mg/ml ophth soln

99

polymyxin b 250000unit/ml inj

43

POMALYST 1MG CAP 47 POMALYST 2MG CAP 47 POMALYST 3MG CAP 47 POMALYST 4MG CAP 47 posaconazole 100mg dr tab

35

POTABA CAP 112 potassium bicarbonate 25meq effer tab

94

potassium chloride 0.02 meq/ml/sodium chloride 0.0769 meq/ml inj

93

potassium chloride 0.02 meq/ml/sodium chloride 0.154 meq/ml inj

93

POTASSIUM CHLORIDE 0.1MEQ/ML INJ

94


94


94

potassium chloride 1.33meq/ml oral soln

94

potassium chloride 10meq ER cap

94

potassium chloride 10meq inj

94

POTASSIUM CHLORIDE 10MEQ INJ

94

POTASSIUM CHLORIDE 10MEQ/50ML INJ

94

potassium chloride 10meq/50ml inj

94

potassium chloride 15meq micro tab

94

potassium chloride 2.67meq/ml oral soln

94

potassium chloride 20meq er tab

94


94


94

potassium chloride 20meq micro er tab

94

potassium chloride 20meq/100ml inj

94

POTASSIUM CHLORIDE 20MEQ/100ML INJ

94

POTASSIUM CHLORIDE 25MEQ EFFER TAB

94

potassium chloride 2meq/ml (20ml) inj

94


94


94

potassium chloride 8meq er cap

94

POTASSIUM CHLORIDE 8MEQ ER TAB

94

potassium citrate 10meq er tab

86


86


86

potassium citrate/citric acid granule

86

potassium citrate/citric acid soln

86

PRADAXA 110MG CAP 23 PRADAXA 150MG CAP 23 PRADAXA 75MG CAP 23 PRALUENT 150MG/ML AUTO-INJECTOR

37

PRALUENT 75MG/ML AUTO-INJECTOR

37


148


pramipexole 0.125mg tab 54 pramipexole 0.25mg tab 54 pramipexole 0.375mg er tab

54

pramipexole 0.5mg tab 54 pramipexole 0.75mg er tab

54

pramipexole 0.75mg tab 54 pramipexole 1.5mg er tab 54 pramipexole 1.5mg tab 54 pramipexole 1mg tab 54 pramipexole 2.25mg er tab

54

pramipexole 3.75mg er tab

54

pramipexole 3mg er tab 54 pramipexole 4.5mg er tab 54 prasugrel 10mg tab 87 prasugrel 5mg tab 87 pravastatin sodium 10mg tab

36

pravastatin sodium 20mg tab

36


36


36

praziquantel 600mg tab 18 prazosin 1mg cap 39 prazosin 2mg cap 39 prazosin 5mg cap 39 PRED FORTE 1% OPHTH SUSP

99

PRED MILD 0.12% OPHTH SUSP

99

PRED-G 0.3-0.6% OPHTH OINTMENT

99

PRED-G 0.3-1% OPHTH SUSP

99

PREDNICARBATE 0.1% OINTMENT

77

PREDNISOLONE 1% OPHTH SOLN

100

PREDNISOLONE 10MG ODT

73


73

prednisolone 1mg/ml oral soln

73


73


73

PREDNISOLONE 3MG/ML ORAL SOLN

73


73

PREDNISOLONE 5MG/ML ORAL SOLN

73

PREDNISOLONE ACETATE 1% OPHTH SUSP

100

prednisolone sodium phosphate 15mg/5ml oral soln

73

PREDNISOLONE SODIUM PHOSPHATE 2.5MG/ML/SULFACETAMIDE SODIUM 100MG/ML OPHTH SOLN

100

prednisone 10mg tab 73 prednisone 1mg tab 73 PREDNISONE 1MG/ML ORAL SOLN

73

prednisone 2.5mg tab 73 prednisone 20mg tab 73 prednisone 50mg tab 73 prednisone 5mg tab 73 PREDNISONE 5MG/ML ORAL SOLN

73

PREFEST 30 DAY PACK 83 pregabalin 100mg cap 25 pregabalin 150mg cap 25 pregabalin 200mg cap 25 pregabalin 20mg/ml oral soln

25

pregabalin 225mg cap 25 pregabalin 25mg cap 25 pregabalin 300mg cap 25

pregabalin 50mg cap 25 pregabalin 75mg cap 25 PREMARIN 0.3MG TAB 84 PREMARIN 0.45MG TAB 84 PREMARIN 0.625MG TAB

84

PREMARIN 0.625MG/GM VAGINAL CREAM

111

PREMARIN 0.9MG TAB 84 PREMARIN 1.25MG TAB 84 PREMPHASE 28 DAY PACK

83

PREMPRO 0.3/1.5MG 28 DAY PACK

83

PREMPRO 0.45/1.5 28 DAY PACK

83

PREMPRO 0.625/2.5MG 28 DAY PACK

83

PREMPRO 0.625/5MG 28 DAY PACK

83

PRETOMANID 200MG TAB

44

prevalite 4gm powder for oral susp

36

PREVIDENT 5000 BOOSTER PASTE

95

PREVIDENT 5000 DRY MOUTH GEL

95

PREVIDENT 5000 PASTE 95 PREVIDENT 5000 PASTE 95 PREVIDENT 5000 PLUS CREAM

95

PREVIDENT RINSE 95 PREVYMIS 240MG TAB 62 PREVYMIS 480MG TAB 62 PREZCOBIX 150-800MG TAB

61

PREZISTA 100MG/ML SUSP

61

PREZISTA 150MG TAB 61 PREZISTA 600MG TAB 61 PREZISTA 75MG TAB 61 PREZISTA 800MG TAB 61 PRIFTIN 150MG TAB 44


149


primaquine phosphate 26.3mg tab

43

PRIMAQUINE PHOSPHATE 26.3MG TAB

43

primidone 250mg tab 25 primidone 50mg tab 25 PRIVIGEN 20GM/200ML INJ

101

PRIVIGEN 40GM/400ML INJ

101

probenecid 500mg tab 87 PROCALAMINE 3% INJ 97 procentra 5mg/5ml oral soln

9

prochlorperazine 10mg tab

59

prochlorperazine 25mg rectal supp

59

prochlorperazine 5mg tab 59 procto-med 2.5% cream 17 procto-pak 1% rectal cream

17

progesterone 100mg cap 103 progesterone 200mg cap 103 PROGRAF 0.2MG GRANULES FOR ORAL SUSP

95

PROGRAF 0.5MG CAP 64 PROGRAF 1MG CAP 64 PROGRAF 1MG GRANULES FOR ORAL SUSP

95

PROGRAF 5MG CAP 64 PROLASTIN-C 1000MG INJ

106

PROLENSA 0.07% OPHTH SOLN

100

PROLIA 60MG/ML SYRINGE

80

PROMACTA 12.5MG POWDER FOR ORAL SUSP

88

PROMACTA 12.5MG TAB

88

PROMACTA 25MG POWDER FOR ORAL SUSP

88

PROMACTA 25MG TAB 88 PROMACTA 50MG TAB 88 PROMACTA 75MG TAB 88 promethazine 1.25mg/ml oral soln

35

promethazine 12.5mg rectal supp

35

promethazine 12.5mg tab 35 promethazine 25mg tab 35 promethazine 50mg tab 35 promethazine DM syrup 74 promethazine VC w/codeine syrup

74

promethazine/codeine syrup

74

promethegan 25mg rectal supp

35

PROMETHEGAN 50MG RECTAL SUPP

35

propafenone 150mg tab 19 propafenone 225mg er cap

19

propafenone 225mg tab 19 propafenone 300mg tab 19 propafenone 325mg er cap

19

propafenone 425mg er cap

19

proparacaine 0.5% ophth soln

99

propranolol 10mg tab 65 propranolol 120mg er cap

65

propranolol 160mg ER cap

65

propranolol 20mg tab 65 propranolol 40mg tab 65 PROPRANOLOL 4MG/ML ORAL SOLN

65

propranolol 60mg er cap 65 propranolol 60mg tab 65 propranolol 80mg er cap 65

propranolol 80mg tab 65 PROPRANOLOL 8MG/ML ORAL SOLN

65

propylthiouracil 50mg tab

107

PROQUAD INJ 111 PROSOL 20% INJ 97 protriptyline 10mg tab 29 protriptyline 5mg tab 29 PULMOZYME 1MG/ML INH SOLN

106

PURIXAN 2000MG/100ML SUSP

44

PYLERA 140-125-125MG CAP

109

pyrazinamide 500mg tab 44 PYRIDIUM 100MG TAB 86 PYRIDIUM 200MG TAB 86 pyridostigmine bromide 12mg/ml oral soln

43

pyridostigmine bromide 180mg er tab

43

pyridostigmine bromide 60mg tab

43

Q

QBRELIS 1MG/ML ORAL SOLN

38

QINLOCK 50MG TAB 51 quetiapine 100mg tab 58 quetiapine 150mg er tab 58 quetiapine 200mg er tab 58 quetiapine 200mg tab 58 quetiapine 25mg tab 58 quetiapine 300mg er tab 58 quetiapine 300mg tab 58 quetiapine 400mg er tab 58 quetiapine 400mg tab 58 quetiapine 50mg er tab 58 quetiapine 50mg tab 58 QUFLORA PEDIATRIC CHEW TAB

96

quinapril 10mg tab 38 quinapril 20mg tab 38 quinapril 40mg tab 38


150


quinapril 5mg tab 38 quinidine gluconate 324mg er tab

19

QUINIDINE SULFATE 200MG TAB

19

QUINIDINE SULFATE 300MG TAB

19

quinine sulfate 324mg cap

43

R

RABAVERT 2.5UNIT/ML INJ

111

rabeprazole sodium 20mg dr tab

109

raloxifene 60mg tab 81 ramelteon 8mg tab 90 ramipril 1.25mg cap 38 ramipril 10mg cap 38 ramipril 2.5mg cap 38 ramipril 5mg cap 38 ranolazine 1000mg er tab 18 ranolazine 500mg er tab 18 RAPAMUNE 0.5MG TAB 64 RAPAMUNE 1MG TAB 64 RAPAMUNE 1MG/ML ORAL SOLN

95

RAPAMUNE 2MG TAB 64 rasagiline 0.5mg tab 55 rasagiline 1mg tab 55 RAVICTI 1.1GM/ML ORAL SOLN

82

REBIF 22MCG/0.5ML AUTO-INJECTOR

105

REBIF 22MCG/0.5ML INJ

105

REBIF 44MCG/0.5ML AUTO-INJECTOR

105

REBIF 44MCG/0.5ML INJ

105

REBIF REBIDOSE PACK 105 REBIF TITRATION PACK 105 RECOMBIVAX 10MCG/ML INJ

111

RECOMBIVAX 40MCG/ML INJ

111

RECOMBIVAX 5MCG/0.5ML INJ

111

RECTIV 0.4% RECTAL OINTMENT

17

REGRANEX 0.01% GEL 79 RELENZA 5MG/BLISTER INH

63

RELISTOR 12MG/0.6ML INJ

85

RELISTOR 8MG/0.4ML INJ

85

renaphro cap 96 repaglinide 0.5mg tab 32 repaglinide 1mg tab 32 repaglinide 2mg tab 32 REPATHA 140MG/ML AUTO-INJECTOR

37

REPATHA 140MG/ML SYRINGE

37

REPATHA 420MG/3.5ML CARTRIDGE

37

RESTASIS 0.05% OPHTH SUSP

99

RETACRIT 20000UNIT/2ML INJ

88

RETACRIT 20000UNIT/ML INJ

88


89


89


89


89

RETEVMO 40MG CAP 51 RETEVMO 80MG CAP 51 REVLIMID 10MG CAP 63 REVLIMID 15MG CAP 63 REVLIMID 2.5MG CAP 63 REVLIMID 20MG CAP 63 REVLIMID 25MG CAP 63 REVLIMID 5MG CAP 63

REXULTI 0.25MG TAB 59 REXULTI 0.5MG TAB 59 REXULTI 1MG TAB 59 REXULTI 2MG TAB 59 REXULTI 3MG TAB 60 REXULTI 4MG TAB 60 REYATAZ 50MG ORAL POWDER

61

REYVOW 100MG TAB 92 REYVOW 50MG TAB 92 RHOPRESSA 0.02% OPHTH SOLN

99

ribavirin 200mg cap 62 ribavirin 200mg tab 62 RIDAURA 3MG CAP 12 rifabutin 150mg cap 44 rifampin 150mg cap 44 rifampin 300mg cap 44 rifampin 600mg inj 44 riluzole 50mg tab 97 RIMANTADINE 100MG TAB

63

RINVOQ 15MG ER TAB 11 risedronate sodium 150mg tab

81

risedronate sodium 30mg tab

81


81


81

RISPERDAL 12.5MG INJ 57 RISPERDAL 25MG INJ 57 RISPERDAL 37.5MG INJ 57 RISPERDAL 50MG INJ 57 RISPERIDONE 0.25MG ODT

57

risperidone 0.25mg tab 57 risperidone 0.5mg odt 57 risperidone 0.5mg tab 57 risperidone 1mg odt 57 risperidone 1mg tab 57 risperidone 1mg/ml oral soln

57

risperidone 2mg odt 57


151


risperidone 2mg tab 57 risperidone 3mg odt 57 risperidone 3mg tab 57 risperidone 4mg odt 57 risperidone 4mg tab 57 ritonavir 100mg tab 61 rivastigmine 0.192mg/hr patch

104

rivastigmine 0.396mg/hr patch

104

rivastigmine 0.554mg/hr patch

104

rivastigmine 1.5mg cap 104 rivastigmine 3mg cap 104 rivastigmine 4.5mg cap 104 rivastigmine 6mg cap 104 rizatriptan 10mg odt 92 rizatriptan 10mg tab 92 rizatriptan 5mg odt 92 rizatriptan 5mg tab 92 ROCKLATAN 0.05-0.2MG/ML OPHTH SOLN

99

ropinirole 0.25mg tab 54 ropinirole 0.5mg tab 55 ropinirole 12mg er tab 55 ropinirole 1mg tab 55 ropinirole 2mg er tab 55 ropinirole 2mg tab 55 ropinirole 3mg tab 55 ropinirole 4mg er tab 55 ropinirole 4mg tab 55 ropinirole 5mg tab 55 ropinirole 6mg er tab 55 ropinirole 8mg er tab 55 rosuvastatin calcium 10mg tab

36

rosuvastatin calcium 20mg tab

36


37


37

ROTARIX SUSP 111 ROTATEQ SUSP 111

ROZLYTREK 100MG CAP

51

ROZLYTREK 200MG CAP

51

RUBRACA 200MG TAB 51 RUBRACA 250MG TAB 51 RUBRACA 300MG TAB 51 RUCONEST 2100UNIT INJ

87

rufinamide 200mg tab 25 rufinamide 40mg/ml susp 25 RUKOBIA 600MG ER TAB

61

RUZURGI 10MG TAB 44 RYBELSUS 14MG TAB 31 RYBELSUS 3MG TAB 31 RYBELSUS 7MG TAB 31 RYDAPT 25MG CAP 51

S

SALEX SHAMPOO 78 salicylic acid shampoo 78 salmon calcitonin 200unit/act nasal spray

81

salsalate 500mg tab 14 salsalate 750mg tab 14 SANCUSO 3.1MG/24HR PATCH

34

SANDIMMUNE 100MG CAP

64

SANDIMMUNE 100MG/ML ORAL SOLN

64

SANDIMMUNE 25MG CAP

64

SANTYL 250UNIT/GM OINTMENT

78

sapropterin 100mg powder for oral soln

82

sapropterin 500mg powder for oral soln

82

sapropterin dihydrochloride 100mg tab

82

SAVELLA 100MG TAB 104 SAVELLA 12.5MG TAB 104

SAVELLA 25MG TAB 104 SAVELLA 4-WEEK TITRATION PACK

104

SAVELLA 50MG TAB 104 scopolamine 0.0139mg/hr patch

34

seb-prev cream 76 SECUADO 3.8MG/24HR PATCH

58

SECUADO 5.7MG/24HR PATCH

58

SECUADO 7.6MG/24HR PATCH

58

selegiline 5mg cap 55 selegiline 5mg tab 55 SELEGILINE 5MG TAB 55 selenium sulfide 2.25% shampoo

76

selenium sulfide 2.5% shampoo

76

SELZENTRY 150MG TAB 61 SELZENTRY 20MG/ML ORAL SOLN

61

SELZENTRY 25MG TAB 61 SELZENTRY 300MG TAB 61 SELZENTRY 75MG TAB 61 SEREVENT 50MCG/DOSE INH

21

sertraline 100mg tab 28 sertraline 20mg/ml oral soln

28

sertraline 25mg tab 28 sertraline 50mg tab 28 SEVELAMER 400MG TAB

85

sevelamer 800mg tab 86 sevelamer carbonate 2400mg powder for oral susp

86

sevelamer carbonate 800mg powder for oral susp

86

sevelamer carbonate 800mg tab

86


152


SHINGRIX 50MCG/0.5ML INJ

111

SIGNIFOR 0.3MG/ML INJ

82


82


82

sildenafil 20mg tab 69 sildenafil tab 68 silodosin 4mg cap 86 silodosin 8mg cap 86 SIMBRINZA 0.2-1% OPHTH SUSP

98

SIMPONI 100MG/ML AUTO-INJECTOR

12

SIMPONI 100MG/ML SYRINGE

12

SIMPONI 50MG/0.5ML AUTO-INJECTOR

12

SIMPONI 50MG/0.5ML SYRINGE

12

simvastatin 10mg tab 37 simvastatin 20mg tab 37 simvastatin 40mg tab 37 simvastatin 5mg tab 37 simvastatin 80mg tab 37 sirolimus 0.5mg tab 64 sirolimus 1mg tab 64 sirolimus 1mg/ml oral soln

95

sirolimus 2mg tab 64 SIRTURO 100MG TAB 44 SIRTURO 20MG TAB 44 SIVEXTRO 200MG INJ 43 SIVEXTRO 200MG TAB 43 SKYRIZI 150MG DOSE PACK (75MG/0.83ML)

76

SKYRIZI 150MG/ML AUTO-INJECTOR

76

SKYRIZI 150MG/ML SYRINGE

76

SLYND 4MG PACK 72 sodium chloride 0.154meq/ml soln

86

sodium chloride 2.5meq/ml inj

94

sodium chloride 23.4% inj

94

sodium chloride 30mg/ml inj

94

sodium chloride 4.5mg/ml inj

94


94


94

sodium citrate/citric acid soln

86

sodium fluoride chew tab 93 sodium fluoride cream 95 sodium fluoride gel 95 SODIUM FLUORIDE LOZENGE

93

sodium fluoride paste 95 sodium fluoride rinse 95 sodium fluoride soln 93 SODIUM FLUORIDE TAB 93 sodium fluoride/potassium nitrate paste

95

sodium phenylbutyrate 0.94mg/mg oral powder

82

sodium polystyrene sulfonate 15000mg powder for oral susp

64

SOFOSBUVIR/VELPATASVIR 400-100MG TAB

62

solifenacin succinate 10mg tab

110

solifenacin succinate 5mg tab

110

SOLIQUA PEN INJ 30 SOLOSEC 2GM GRANULES

10

SOLTAMOX 10MG/5ML ORAL SOLN

47

SOMAVERT 10MG INJ 81 SOMAVERT 15MG INJ 81 SOMAVERT 20MG INJ 81

SOMAVERT 25MG INJ 81 SOMAVERT 30MG INJ 81 sorine 120mg tab 65 sorine 160mg tab 65 sorine 240mg tab 65 sotalol 120mg tab 65 sotalol 80mg tab 65 sotalol AF 160mg tab 65 sotalol AF 80mg tab 66 SPIRIVA 1.25MCG INH 20 spironolactone 100mg tab

80

spironolactone 25mg tab 80 spironolactone 50mg tab 80 SPRITAM 1000MG TAB FOR ORAL SUSP

25

SPRITAM 250MG TAB FOR ORAL SUSP

25


25


25

SPRYCEL 100MG TAB 51 SPRYCEL 140MG TAB 51 SPRYCEL 20MG TAB 52 SPRYCEL 50MG TAB 52 SPRYCEL 70MG TAB 52 SPRYCEL 80MG TAB 52 SPS 15GM/60ML SUSP 64 ssd 1% cream 76 STALEVO 12.5-200-50MG TAB

55

STALEVO 37.5-200-150MG TAB

55

STALEVO 50-200-200MG TAB

55

STELARA 45MG/0.5ML INJ

76

STELARA 45MG/0.5ML SYRINGE

76

STELARA 90MG/ML SYRINGE

76

STENDRA TAB 68 STIOLTO 2.5-2.5MCG/ACT INH

21


153


STIVARGA 40MG TAB 52 STREPTOMYCIN 1000MG INJ

11

STRIBILD 150-150-200-300MG TAB

61

STROVITE TAB 96 SUCRAID 8500UNIT/ML ORAL SOLN

79

sucralfate 1000mg tab 109 sucralfate 100mg/ml susp 109 sulfacetamide sodium 10% lotion

74

SULFACETAMIDE SODIUM 10% OPHTH OINTMENT

99

sulfacetamide sodium 10% ophth soln

99

sulfacetamide sodium gel 76 sulfacetamide sodium shampoo

76

sulfacetamide sodium wash

76

sulfacetamide sodium/sulfur cream

74

sulfacetamide sodium/sulfur emulsion

74

sulfacleanse susp 74 SULFADIAZINE 500MG TAB

106

sulfamethoxazole 400mg/trimethoprim 80mg tab

42

sulfamethoxazole 40mg/ml/trimethoprim 8mg/ml susp

42

sulfamethoxazole 800mg/trimethoprim 160mg tab

42

SULFAMYLON 85MG/GM CREAM

76

sulfasalazine 500mg dr tab

85

sulfasalazine 500mg tab 85 sulindac 150mg tab 13

sulindac 200mg tab 13 sumatriptan 100mg tab 92 sumatriptan 12mg/ml auto-injector

92

sumatriptan 12mg/ml inj 92 sumatriptan 20mg/act nasal spray

92

sumatriptan 25mg tab 92 sumatriptan 50mg tab 92 sumatriptan 5mg/act nasal spray

92

sumatriptan 6mg/0.5ml refill inj

92

sumatriptan 8mg/ml cartridge

92

SUMAXIN TS SUSP 74 SUMAXIN WASH 75 sunitinib malate 12.5mg cap

52

sunitinib malate 25mg cap

52

sunitinib malate 37.5mg cap

52

sunitinib malate 50mg cap

52

SUNOSI 150MG TAB 9 SUNOSI 75MG TAB 9 SUPRAX 100MG CHEW TAB

71

SUPRAX 200MG CHEW TAB

71

SUPRAX 500MG/5ML SUSP

71

SYMAX DUOTAB 109 SYMBICORT 160-4.5MCG/ACT INHALER

21

SYMBICORT 80-4.5MCG/ACT INHALER

22

SYMDEKO 50-75MG/75MG PACK

106

SYMDEKO TAB 4-WEEK PACK

106

SYMJEPI 0.15MG/0.3ML SYRINGE

112

SYMJEPI 0.3MG/0.3ML SYRINGE

112

SYMPAZAN 10MG ORAL FILM

24


24


24

SYMPROIC 0.2MG TAB 85 SYMTUZA 800-150-200-10MG TAB

62

SYNAREL 2MG/ML NASAL INHALER

81

SYNJARDY 10-1000MG ER TAB

30

SYNJARDY 12.5-1000MG ER TAB

30

SYNJARDY 12.5-1000MG TAB

30

SYNJARDY 12.5-500MG TAB

30


30


30

SYNJARDY 5-1000MG TAB

30

SYNJARDY 5-500MG TAB

30

SYNRIBO 3.5MG INJ 53 SYNTHROID 100MCG TAB

108

SYNTHROID 112MCG TAB

108


108


108


108


108


154



108

SYNTHROID 25MCG TAB

108


108

SYNTHROID 50MCG TAB

108

SYNTHROID 75MCG TAB

108

SYNTHROID 88MCG TAB

108

T

TABLOID 40MG TAB 44 TABRECTA 150MG TAB 52 TABRECTA 200MG TAB 52 tacrolimus 0.03% ointment

78

tacrolimus 0.1% ointment 78 tacrolimus 0.5mg cap 64 tacrolimus 1mg cap 64 tacrolimus 5mg cap 64 tadalafil 10mg tab 68 tadalafil 2.5mg tab 68 tadalafil 20mg tab (PAH) 69 tadalafil 5mg tab 68 tadalafil tab 20mg 68 TAFINLAR 50MG CAP 52 TAFINLAR 75MG CAP 52 TAGRISSO 40MG TAB 45 TAGRISSO 80MG TAB 45 TAKHZYRO 300MG/2ML INJ

87

TALTZ 80MG/ML AUTO-INJECTOR

76

TALTZ 80MG/ML SYRINGE

76

TALZENNA 0.25MG CAP 52 TALZENNA 1MG CAP 52 tamoxifen 10mg tab 46 tamoxifen 20mg tab 46 tamsulosin 0.4mg cap 86 TARGRETIN 1% GEL 75

tarina 24 fe 1/20 28 day pack

72

TASIGNA 150MG CAP 52 TASIGNA 200MG CAP 52 TASIGNA 50MG CAP 52 TAVALISSE 100MG TAB 87 TAVALISSE 150MG TAB 87 tazarotene 0.1% cream 76 TAZICEF 1GM INJ 71 tazicef 2gm inj 71 TAZICEF 6GM INJ 71 TAZORAC 0.05% CREAM

76

taztia 120mg er cap 67 taztia 180mg er cap 67 taztia 240mg er cap 67 taztia 300mg er cap 67 taztia 360mg er cap 67 TAZVERIK 200MG TAB 52 TDVAX 4-4UNIT/ML INJ 108 TEFLARO 400MG INJ 71 TEFLARO 600MG INJ 71 TEGSEDI 284MG/1.5ML INJ

106

TEKTURNA HCT 150-12.5MG TAB

41

TEKTURNA HCT 150-25MG TAB

41

TEKTURNA HCT 300-12.5MG TAB

41

TEKTURNA HCT 300-25MG TAB

41

telmisartan 20mg tab 38 telmisartan 40mg tab 38 telmisartan 80mg tab 38 temazepam 15mg cap 89 temazepam 30mg cap 89 temozolomide cap 44 TENIVAC 4-10UNIT/ML INJ

108

tenofovir disoproxil fumarate 300mg tab

62

TEPMETKO 225MG TAB 52 terazosin 10mg cap 39 terazosin 1mg cap 39

terazosin 2mg cap 39 terazosin 5mg cap 39 terbinafine 250mg tab 35 terbutaline sulfate 2.5mg tab

22

terbutaline sulfate 5mg tab

22

terconazole 0.4% vaginal cream

111

terconazole 0.8% vaginal cream

111

TERCONAZOLE 0.8% VAGINAL CREAM

111

terconazole 80mg vaginal insert

111

testosterone 1% (12.5mg) gel pump bottle

17

TESTOSTERONE 1% (12.5MG/ACT) GEL PUMP

17

testosterone 1% (25mg) gel packet

17

TESTOSTERONE 1% (50MG) GEL PACKET

17

testosterone 1.62% (1.25gm) gel packet

17

testosterone 1.62% (2.5gm) gel packet

17

testosterone 20.25mg/act gel pump

17

testosterone 30mg/act topical soln

17

testosterone cypionate 100mg/ml inj

17

testosterone cypionate 200mg/ml inj

17

TESTOSTERONE ENANTHATE 200MG/ML INJ

17

testosterone gel 1% (50mg) packet

17

tetrabenazine 12.5mg tab 104 tetrabenazine 25mg tab 104 tetracycline 250mg cap 107 tetracycline 500mg cap 107


155


THALOMID 100MG CAP 63 THALOMID 150MG CAP 63 THALOMID 200MG CAP 63 THALOMID 50MG CAP 63 THEO-24 100MG ER CAP

22

THEO-24 200MG ER CAP

22


22


22

THEOPHYLLINE 300MG ER TAB

22

theophylline 400mg er tab

22

THEOPHYLLINE 450MG ER TAB

22

theophylline 5.33mg/ml oral soln

22

theophylline 600mg er tab

22

THIOLA 100MG DR TAB 86 THIOLA 300MG DR TAB 87 thioridazine 100mg tab 59 thioridazine 10mg tab 59 thioridazine 25mg tab 59 thioridazine 50mg tab 59 thiothixene 10mg cap 60 thiothixene 1mg cap 60 thiothixene 2mg cap 60 thiothixene 5mg cap 60 tiagabine 12mg tab 26 tiagabine 16mg tab 26 tiagabine 2mg tab 26 tiagabine 4mg tab 26 TIBSOVO 250MG TAB 52 TIGECYCLINE 50MG INJ 106 tigecycline 50mg inj 106 timolol 0.25% ophth gel 98 timolol 0.25% ophth soln 98 timolol 0.5% (pf) ophth soln

98

timolol 0.5% ophth gel 98 timolol 0.5% ophth soln 98

timolol 10mg tab 66 timolol 20mg tab 66 timolol 5mg tab 66 timolol 5mg/ml ophth 24hr ophth soln

98

TIMOPTIC 0.25% OPHTH SOLN (PRESERVATIVE-FREE)

98

tinidazole 250mg tab 41 tinidazole 500mg tab 41 tiopronin 100mg tab 87 TIVICAY 10MG TAB 62 TIVICAY 25MG TAB 62 TIVICAY 50MG TAB 62 TIVICAY 5MG TAB FOR ORAL SUSP

62

tizanidine 2mg cap 96 tizanidine 2mg tab 96 tizanidine 4mg cap 96 tizanidine 4mg tab 96 tizanidine 6mg cap 96 TOBRADEX 0.05-0.3% OPHTH SUSP

100

TOBRADEX 0.1-0.3% OPHTH OINTMENT

100

tobramycin 0.3% ophth soln

99

tobramycin 1.2gm inj 11 tobramycin 1.2gm/30ml inj

11

TOBRAMYCIN 10MG/ML INJ

11

TOBRAMYCIN 2GM/50ML INJ

11

tobramycin 40mg/ml inj 11 TOBRAMYCIN 60MG/ML INH SOLN

11

tobramycin 60mg/ml inh soln

11

TOBREX 0.3% OPHTH OINTMENT

99

tolcapone 100mg tab 54 tolterodine tartrate 1mg tab

110

tolterodine tartrate 2mg er cap

110

tolterodine tartrate 2mg tab

110

tolterodine tartrate 4mg er cap

110

topiramate 100mg tab 25 topiramate 15mg cap 25 topiramate 200mg tab 25 topiramate 25mg cap 25 topiramate 25mg tab 25 topiramate 50mg tab 25 toremifene 60mg tab 47 torsemide 100mg tab 80 torsemide 10mg tab 80 torsemide 20mg tab 80 torsemide 5mg tab 80 TOUJEO 300UNIT/ML PEN INJ

32

TOUJEO MAX 300UNIT/ML PEN INJ (3ML)

32

TPN ELECTROLYTES INJ 93 TRACLEER 32MG TAB FOR ORAL SUSP

68

TRADJENTA 5MG TAB 31 tramadol 100mg er tab 15 tramadol 100mg er tab (matrix delivery)

15

tramadol 200mg er tab 15 tramadol 200mg er tab (matrix delivery)

15

tramadol 300mg er tab 15 tramadol 300mg er tab (matrix delivery)

15

tramadol 50mg tab 15 trandolapril 1mg tab 38 TRANDOLAPRIL 1MG/VERAPAMIL 240MG ER TAB

41

trandolapril 2mg tab 38 TRANDOLAPRIL 2MG/VERAPAMIL 180MG ER TAB

41


156


TRANDOLAPRIL 2MG/VERAPAMIL 240MG ER TAB

41

trandolapril 4mg tab 38 TRANDOLAPRIL 4MG/VERAPAMIL 240MG ER TAB

41

trandolapril 4mg/verapamil 240mg er tab

41

tranexamic acid 650mg tab

89

tranylcypromine 10mg tab

27

TRAVASOL 10% INJ 97 travoprost 0.004% ophth soln

100

trazodone 100mg tab 27 trazodone 150mg tab 27 trazodone 50mg tab 27 TRECATOR 250MG TAB 44 TRELEGY ELLIPTA 100- 62.5-25MCG INHALER

22

TRELEGY ELLIPTA 200-62.5-25MCG INHALER

22

TRELSTAR 11.25MG INJ 46 TRELSTAR 22.5MG INJ 46 TRELSTAR 3.75MG INJ 46 TREMFYA 100MG/ML AUTO-INJECTOR

76

TREMFYA 100MG/ML SYRINGE

76

TRESIBA 100UNIT/ML INJ

32

TRESIBA 100UNIT/ML PEN INJ

32

TRESIBA 200UNIT/ML PEN INJ

32

tretinoin 0.01% gel 75 tretinoin 0.025% cream 75 tretinoin 0.025% gel 75 tretinoin 0.04% gel 75 tretinoin 0.05% cream 75 tretinoin 0.05% gel 75

tretinoin 0.1% cream 75 tretinoin 0.1% gel 75 tretinoin 10mg cap 53 triamcinolone acetonide 0.025% cream

77

triamcinolone acetonide 0.025% lotion

77

triamcinolone acetonide 0.025% ointment

78

triamcinolone acetonide 0.1% cream

78

triamcinolone acetonide 0.1% lotion

78


78

triamcinolone acetonide 0.1% oral paste

95


78

triamterene 100mg cap 80 triamterene 50mg cap 80 triazolam 0.125mg tab 90 triazolam 0.25mg tab 90 tricitrates soln 86 tricon cap 89 triderm 0.5% cream 78 trientine 250mg cap 94 trifluoperazine 10mg tab 59 trifluoperazine 1mg tab 59 trifluoperazine 2mg tab 59 trifluoperazine 5mg tab 59 TRIFLURIDINE 1% OPHTH SOLN

99

trihexyphenidyl 0.4mg/ml oral soln

55

trihexyphenidyl 2mg tab 53 trihexyphenidyl 5mg tab 53 TRIJARDY 10-5-1000MG ER TAB

30

TRIJARDY 12.5-2.5-1000MG ER TAB

30

TRIJARDY 25-5-1000MG ER TAB

30

TRIJARDY 5-2.5-1000MG ER TAB

30

TRIKAFTA 100-50-75MG/150MG PACK

106

TRIKAFTA 50-37.5-25MG/75MG TAB PACK

106

tri-legest 28 day pack 72 tri-lo-sprintec 28 day pack

72

trimethobenzamide 300mg cap

34

trimethoprim 100mg tab 41 TRIMETHOPRIM 100MG TAB

41

trimipramine 100mg cap 30 trimipramine 25mg cap 30 trimipramine 50mg cap 30 TRINTELLIX 10MG TAB 27 TRINTELLIX 20MG TAB 27 TRINTELLIX 5MG TAB 27 TRIUMEQ 600-50-300MG TAB

62

trivora 28 day pack 72 trospium chloride 20mg tab

110

trospium chloride 60mg er cap

110

TRULANCE 3MG TAB 84 TRULICITY 0.75MG/0.5ML AUTO-INJECTOR

31

TRULICITY 1.5MG/0.5ML AUTO-INJECTOR

31

TRULICITY 3MG/0.5ML AUTO-INJECTOR

31

TRULICITY 4.5MG/0.5ML AUTO-INJECTOR

31

TRUMENBA INJ 110 TUKYSA 150MG TAB 45 TUKYSA 50MG TAB 45 TURALIO 200MG CAP 52


157


TUSNEL C SYRUP 74 tussigon tab 74 TUSSIONEX SUSP 74 TWINRIX 720UNIT INJ 111 TYBOST 150MG TAB 62 tydemy 28 day pack 72 TYMLOS 3120MCG/1.56ML PEN INJ

81

TYPHIM VI 25MCG/0.5ML INJ

110

U

UBRELVY 100MG TAB 92 UBRELVY 50MG TAB 92 UCERIS 2MG/ACT RECTAL FOAM

17

UKONIQ 200MG TAB 52 UPTRAVI 1000MCG TAB 69 UPTRAVI 1200MCG TAB 69 UPTRAVI 1400MCG TAB 69 UPTRAVI 1600MCG TAB 69 UPTRAVI 200MCG TAB 69 UPTRAVI 400MCG TAB 69 UPTRAVI 600MCG TAB 69 UPTRAVI 800MCG TAB 69 UPTRAVI TITRATION PACK

69

ursodiol 250mg tab 84 ursodiol 300mg cap 84 ursodiol 500mg tab 85

V

valacyclovir 1000mg tab 63 valacyclovir 500mg tab 63 VALCHLOR 0.016% GEL 76 valganciclovir 450mg tab 62 valganciclovir 50mg/ml oral soln

62

valproic acid 250mg cap 27 valproic acid 50mg/ml oral soln

27

valsartan 160mg tab 38 valsartan 320mg tab 38 valsartan 40mg tab 38 valsartan 80mg tab 38

VALTOCO 10MG DOSE KIT 10MG/0.1ML PACK

24

VALTOCO 15MG DOSE KIT 7.5MG/0.1ML PACK

24


24


24

VANCOMYCIN 1.25GM IV SOLN

42

vancomycin 1000mg inj 42 VANCOMYCIN 100GM INJ

42

vancomycin 100mg/ml inj 42 vancomycin 125mg cap 42 vancomycin 250mg cap 42 VANCOMYCIN 250MG INJ

42

vancomycin 500mg inj 42 vancomycin 5gm inj 42 vancomycin 750mg inj 42 VANCOMYCIN 750MG INJ

42

VAQTA 25UNIT/0.5ML INJ

111

VAQTA 50UNIT/ML INJ 111 vardenafil ODT 68 vardenafil tab 68 VARIVAX 1350PFU/0.5ML INJ

111

VARIZIG 125UNIT/1.2ML INJ

101

VARUBI 90MG TAB 34 VASCEPA 0.5GM CAP 35 VASCEPA 1GM CAP 35 V-C FORTE CAP 96 VELPHORO 500MG CHEW TAB

86

VELTASSA 16.8GM POWDER FOR ORAL SUSP

64


64


64

VEMLIDY 25MG TAB 62 VENCLEXTA 100MG TAB

45

VENCLEXTA 10MG TAB 45 VENCLEXTA 50MG TAB 45 VENCLEXTA STARTING PACK

45

venlafaxine 100mg tab 29 venlafaxine 150mg er cap 29 venlafaxine 25mg tab 29 venlafaxine 37.5mg er cap

29

venlafaxine 37.5mg tab 29 venlafaxine 50mg tab 29 venlafaxine 75mg er cap 29 venlafaxine 75mg tab 29 VENTAVIS 10MCG/ML INH SOLN

68

VENTAVIS 20MCG/ML INH SOLN

68

VENTOLIN 108MCG INH (18GM)

22

VENTOLIN 108MCG INH (8GM)

22

VERAPAMIL 100MG ER CAP

67

verapamil 120mg er cap 67 verapamil 120mg er tab 67 verapamil 120mg tab 67 verapamil 180mg er cap 67 verapamil 180mg er tab 67 VERAPAMIL 200MG ER CAP

67

verapamil 240mg er cap 67 verapamil 240mg er tab 67 VERAPAMIL 300MG ER CAP

67

VERAPAMIL 360MG ER CAP

67

verapamil 40mg tab 67 verapamil 80mg tab 67


158


VERELAN 100MG ER CAP

67


67


67


67

VERICIGUAT 10MG TAB 69 VERICIGUAT 2.5MG TAB 69 VERICIGUAT 5MG TAB 69 VERSACLOZ 50MG/ML SUSP

58

VERZENIO 100MG TAB 52 VERZENIO 150MG TAB 52 VERZENIO 200MG TAB 52 VERZENIO 50MG TAB 52 VIBERZI 100MG TAB 85 VIBERZI 75MG TAB 85 VIBRAMYCIN 50MG/5ML SUSP

107

VICTOZA 18MG/3ML PEN INJ

31

vigabatrin 500mg powder for oral soln

26

vigabatrin 500mg tab 26 VIIBRYD 10/20MG STARTER PACK

28

VIIBRYD 10MG TAB 27 VIIBRYD 20MG TAB 27 VIIBRYD 40MG TAB 27 VIMPAT 100MG TAB 26 VIMPAT 10MG/ML ORAL SOLN

26

VIMPAT 150MG TAB 26 VIMPAT 200MG TAB 26 VIMPAT 50MG TAB 26 VIRACEPT 250MG TAB 62 VIRACEPT 625MG TAB 62 VIREAD 150MG TAB 62 VIREAD 200MG TAB 62 VIREAD 250MG TAB 62 VIREAD 40MG/GM ORAL POWDER

62

vitamin D 50000unit cap 112

VITRAKVI 100MG CAP 52 VITRAKVI 20MG/ML ORAL SOLN

52

VITRAKVI 25MG CAP 52 VIVITROL 380MG INJ 33 VIVOTIF BERNA CAP 110 VIZIMPRO 15MG TAB 45 VIZIMPRO 30MG TAB 45 VIZIMPRO 45MG TAB 46 voriconazole 200mg inj 35 voriconazole 200mg tab 35 voriconazole 40mg/ml susp

35

voriconazole 50mg tab 35 VOSEVI 400-100-100MG TAB

62

VOTRIENT 200MG TAB 53 VRAYLAR 1.5/3MG MIXED PACK

56

VRAYLAR 1.5MG CAP 56 VRAYLAR 3MG CAP 56 VRAYLAR 4.5MG CAP 56 VRAYLAR 6MG CAP 56 VYNDAMAX 61MG CAP 69 VYNDAQEL 20MG CAP 69

W

WAKIX 17.8MG TAB 9 WAKIX 4.45MG TAB 9 warfarin sodium 10mg tab

22

warfarin sodium 1mg tab 22 warfarin sodium 2.5mg tab

22

warfarin sodium 2mg tab 22 warfarin sodium 3mg tab 22 warfarin sodium 4mg tab 22 warfarin sodium 5mg tab 22 warfarin sodium 6mg tab 22 warfarin sodium 7.5mg tab

22

wymzya fe 28 day pack 72

X

XALKORI 200MG CAP 53 XALKORI 250MG CAP 53

XARELTO 10MG TAB 22 XARELTO 15MG TAB 22 XARELTO 2.5MG TAB 22 XARELTO 20MG TAB 22 XARELTO KIT PACK 22 XATMEP 2.5MG/ML ORAL SOLN

44

XCOPRI (250 MG DAILY DOSE) TAB PACK

26

XCOPRI 100MG TAB 26 XCOPRI 12.5/25MG TITRATION PACK

26

XCOPRI 150/200MG TITRATION PACK

26

XCOPRI 150MG TAB 26 XCOPRI 200MG TAB 26 XCOPRI 50/100MG TITRATION PACK

26

XCOPRI 50MG TAB 26 XCOPRI TAB 150/200MG PACK

26

XELJANZ 10MG TAB 11 XELJANZ 1MG/ML ORAL SOLN

11

XELJANZ 5MG TAB 11 XELJANZ XR 11MG TAB 11 XELJANZ XR 22MG TAB 11 XENLETA 600MG TAB 43 XERMELO 250MG TAB 86 XGEVA 120MG/1.7ML INJ

81

XIFAXAN 200MG TAB 41 XIFAXAN 550MG TAB 41 XIGDUO 10-1000MG ER TAB

30

XIGDUO 10-500MG ER TAB

30

XIGDUO 2.5-1000MG ER TAB

30


31


31

XOFLUZA 40MG THERAPY PACK

63


159


XOLAIR 150MG INJ 20 XOLAIR 150MG/ML SYRINGE

20

XOLAIR 75MG/0.5ML SYRINGE

20

XOPENEX 45MCG INH, LEVALBUTEROL 45MCG INHALER

22

XOSPATA 40MG TAB 53 XPOVIO 100 MG ONCE WEEKLY

47

XPOVIO 100MG ONCE WEEKLY CARTON (8-PACK)

47


47

XPOVIO 40MG ONCE WEEKLY PACK

47

XPOVIO 40MG TWICE WEEKLY CARTON (8-PACK)

47

XPOVIO 40MG TWICE WEEKLY PACK

47

XPOVIO 60 MG ONCE WEEKLY

47


47

XPOVIO 60MG TWICE WEEKLY PACK

47

XPOVIO 80 MG ONCE WEEKLY

47

XPOVIO 80 MG TWICE WEEKLY

47


47

XTAMPZA 13.5MG ER CAP

15

XTAMPZA 18MG ER CAP

15

XTAMPZA 27MG ER CAP

15

XTAMPZA 36MG ER CAP

15

XTAMPZA 9MG ER CAP 15 XTANDI 40MG CAP 47 xulane 150-35mcg/24hr patch

72

XULTOPHY 100UNIT-3.6MG/ML PEN INJ

31

XYREM 500MG/ML ORAL SOLN

104

Y

YF-VAX 4000UNIT/ML INJ

111

Z

zafirlukast 10mg tab 20 zafirlukast 20mg tab 20 zaleplon 10mg cap 89 zaleplon 5mg cap 89 ZARXIO 300MCG/0.5ML SYRINGE

89

ZARXIO 480MCG/0.8ML SYRINGE

89

ZEJULA 100MG CAP 53 ZELBORAF 240MG TAB 53 ZEMAIRA 1000MG INJ 106 ZENPEP 105000-79000-25000UNIT DR CAP

79

ZENPEP 14000-10000-3000UNIT DR CAP

79


79


79


79


79


79

ZEPOSIA 0.92MG CAP 105 ZEPOSIA 7-DAY STARTER PACK

105

ZEPOSIA STARTER KIT PACK

105

ZERBAXA 1000-500MG INJ

69

zidovudine 100mg cap 62 zidovudine 10mg/ml oral soln

62

zidovudine 300mg tab 62 ZIEXTENZO 6MG/0.6ML SYRINGE

89

ZIOPTAN 0.015MG/ML OPHTH SOLN

100

ziprasidone 20mg cap 56 ziprasidone 20mg inj 56 ziprasidone 40mg cap 56 ziprasidone 60mg cap 56 ziprasidone 80mg cap 56 ZIRGAN 0.15% OPHTH GEL

99

ZOLINZA 100MG CAP 53 zolmitriptan 2.5mg odt 92 zolmitriptan 2.5mg tab 92 zolmitriptan 5mg odt 92 zolmitriptan 5mg tab 92 zolpidem tartrate 10mg tab

89

zolpidem tartrate 5mg tab 89 ZOMIG 2.5MG NASAL SPRAY

92

ZOMIG 5MG NASAL SPRAY

92

zonisamide 100mg cap 26 zonisamide 25mg cap 26 zonisamide 50mg cap 26 ZONTIVITY 2.08MG TAB 87 ZORTRESS 1MG TAB 95 ZOSYN 2000-250MG INJ 103 ZOSYN 3000-375MG INJ 103


160


ZOSYN/DEXTROSE 4-0.5GM/100ML INJ

103

ZUBSOLV 0.7-0.18MG SL TAB

16


16


16


16


16


17

ZYDELIG 100MG TAB 53 ZYDELIG 150MG TAB 53 ZYKADIA 150MG TAB 53 ZYLET 0.5-0.3% OPHTH SUSP

100

ZYPREXA RELPREVV 210MG INJ

58


161

S9701_2022_UCA_FORM_Comp_V01.8_C

This formulary was updated on 10/28/2021. For more recent information or other questions, please contact Navitus MedicareRx Customer Care at 1-866-270-3877 (TTY users should call 711), available 24 hours a day, 7 days a week (except on Thanksgiving and Christmas Day) or visit the member portal at https://memberportal.navitus.com.

Pharmacies can reach Navitus Customer Care 24 hours a day, 7 days a week.

This formulary was updated on 10/28/2021


NAVITUS MEDICARERX (PDP) JANUARY 1 – DECEMBER 31, 2022 EVIDENCE OF COVERAGE UNIVERSITY OF CALIFORNIA High Option Supplement to Medicare and Medicare PPO

Your Medicare Prescription Drug Coverage as a Member of Navitus MedicareRx Prescription Drug Plan (PDP) This booklet gives you the details about your Medicare prescription drug coverage from January 1 – December 31, 2022. It explains how to get coverage for the prescription drugs you need. This is an important legal document. Please keep it in a safe place.

This plan, Navitus MedicareRx (PDP), offered by Dean Health Insurance, Inc., is a Federally-Qualified Medicare Contracting Prescription Drug Plan.

(When this Evidence of Coverage says “we,” “us,” or “our,” “plan,” or “our plan,” it means Navitus MedicareRx.)

The University of California has implemented an Employer Group Waiver Plan (EGWP) for Medicare-eligible retirees. This plan is administered by Navitus Health Solutions. This means that Medicare-eligible retirees and/or dependents are enrolled in a Group Medicare Part D Plan. Your employer group plan also includes supplemental coverage that wraps around the benefits provided by this plan. Please contact our Customer Care number at 1-866-270-3877 for additional information. (TTY/TDD users should call 711.) Hours are 24 hours a day, 7 days a week, except on Thanksgiving and Christmas Day. Calls to these numbers are free.

Customer Care has free language interpreter services available for non-English speakers if needed. This booklet is also available in different formats, including braille and large print. Please call Customer Care if you need plan information in another format.

For plan premium or enrollment questions, please contact the UC Retirement Administration Service Center (RASC) at (800) 888-8267 (in U.S.) or (510) 987-0200 (from outside the U.S.). Representatives are available Monday through Friday, 8:30 a.m. to 4:30 p.m. (Pacific).

Benefits, premium, deductible, and/or copayments/coinsurance may change on January 1, 2023.

The formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary.

S9701_2022_UCA_EOC_V01_C

2022 Evidence of Coverage for Navitus MedicareRx (PDP) 1 Table of Contents

2022 Evidence of Coverage

Table of Contents

This list of chapters and page numbers is your starting point. For more help in finding information you need, go to the first page of a chapter. You will find a detailed list of topics at the beginning of each chapter.

Chapter 1. Getting started as a member ...................................................................... 4 Explains what it means to be in a Medicare prescription drug plan and how to use this booklet. Tells about materials we will send you, your plan premium, the Part D late enrollment penalty, your plan membership card, and keeping your membership record up to date.

Chapter 2. Important phone numbers and resources.............................................. 21 Tells you how to get in touch with our plan (Navitus MedicareRx) and with other organizations including Medicare, the State Health Insurance Assistance Program (SHIP), the Quality Improvement Organization, Social Security, Medicaid (the state health insurance program for people with low incomes), programs that help people pay for their prescription drugs, and the Railroad Retirement Board.

Chapter 3. Using the plan’s coverage for your Part D prescription drugs .......... 36 Explains rules you need to follow when you get your Part D drugs. Tells how to use the plan’s List of Covered Drugs (Formulary) to find out which drugs are covered. Tells which kinds of drugs are not covered. Explains several kinds of restrictions that apply to coverage for certain drugs. Explains where to get your prescriptions filled. Tells about the plan’s programs for drug safety and managing medications.

Chapter 4. What you pay for your Part D prescription drugs ................................. 62 Tells about the four stages of drug coverage (Deductible Stage, Initial Coverage Stage, Coverage Gap Stage, Catastrophic Coverage Stage) and how these stages affect what you pay for your drugs. Explains the four cost-sharing tiers for your Part D drugs and tells what you must pay for a drug in each cost-sharing tier.

Chapter 5. Asking us to pay our share of the costs for covered drugs ............... 86 Explains when and how to send a bill to us when you want to ask us to pay you back for our share of the cost for your covered drugs.

2022 Evidence of Coverage for Navitus MedicareRx (PDP) 2 Table of Contents

Chapter 6. Your rights and responsibilities............................................................... 93 Explains the rights and responsibilities you have as a member of our plan. Tells what you can do if you think your rights are not being respected.

Chapter 7. What to do if you have a problem or complaint (coverage decisions, appeals, complaints) ......................................... 103 Tells you step-by-step what to do if you are having problems or concerns as a member of our plan.

• Explains how to ask for coverage decisions and make appeals if you are having trouble getting the prescription drugs you think are covered by our plan. This includes asking us to make exceptions to the rules and/or extra restrictions on your coverage.

• Explains how to make complaints about quality of care, waiting times, customer care, and other concerns.

Chapter 8. Ending your membership in the plan .................................................... 129 Explains when and how you can end your membership in the plan. Explains situations in which our plan is required to end your membership.

Chapter 9. Legal notices ............................................................................................. 140 Includes notices about governing law and about non-discrimination.

Chapter 10. Definitions of important words ............................................................... 143 Explains key terms used in this booklet.

Exhibit A - Listing of State Health Insurance Assistance Programs (SHIPs)…....149

Exhibit B - Listing of Quality Improvement Organizations (QIOs)…………………156

Exhibit C - Listing of State Medical Assistance Offices (Medicaid)……………….157

Exhibit D - Listing of State Pharmaceutical Assistance Programs (SPAPs)…….162

Exhibit E - Listing of State AIDS Drug Assistance Programs (ADAPs) ………….164

CHAPTER 1 Getting started as a member

2022 Evidence of Coverage for Navitus MedicareRx (PDP) 4 Chapter 1. Getting started as a member

Chapter 1. Getting started as a member

SECTION 1 Introduction.............................................................................................. 6

Section 1.1 You are enrolled in Navitus MedicareRx, which is a Medicare Prescription Drug Plan (PDP) ......................................................................6

Section 1.2 What is the Evidence of Coverage booklet about? ........................................6

Section 1.3 Legal information about the Evidence of Coverage.......................................6

SECTION 2 What makes you eligible to be a plan member?................................ 7

Section 2.1 Your eligibility requirements .......................................................................7

Section 2.2 What are Medicare Part A and Medicare Part B? ..........................................7

Section 2.3 Here is the plan service area for Navitus MedicareRx ...................................8

Section 2.4 U.S. Citizen or Lawful Presence ..................................................................8

SECTION 3 What other materials will you get from us? ....................................... 8

Section 3.1 Your plan membership card – Use it to get all covered prescription drugs .....8

Section 3.2 The Pharmacy Directory: Your guide to pharmacies in our network .............9

Section 3.3 The plan’s List of Covered Drugs (Formulary)........................................... 10

Section 3.4 The Part D Explanation of Benefits (the “Part D EOB”): Reports with a summary of payments made for your Part D prescription drugs .................. 10

SECTION 4 Your monthly premium for Navitus MedicareRx (PDP) .................. 10

Section 4.1 How much is your plan premium? ............................................................. 10

SECTION 5 Do you have to pay the Part D “late enrollment penalty”? ............ 12

Section 5.1 What is the Part D “late enrollment penalty”? ............................................ 12

Section 5.2 How much is the Part D late enrollment penalty? ....................................... 12

Section 5.3 In some situations, you can enroll late and not have to pay the penalty........ 13

Section 5.4 What can you do if you disagree about your Part D late enrollment penalty? .................................................................................................... 14

SECTION 6 Do you have to pay an extra Part D amount because of your income? .................................................................................................. 14

Section 6.1 Who pays an extra Part D amount because of income? ............................... 14

Section 6.2 How much is the extra Part D amount? ...................................................... 15

Section 6.3 What can you do if you disagree about paying an extra Part D amount? ...... 15

Section 6.4 What happens if you do not pay the extra Part D amount? .......................... 15


SECTION 7 More information about your monthly premium ............................. 15

Section 7.1 Many members are required to pay other Medicare premiums .................... 15

Section 7.2 There are several ways you can pay your plan premium ............................. 16

Section 7.3 Can we change your monthly plan premium during the year? ..................... 16

SECTION 8 Please keep your plan membership record up to date .................. 17

Section 8.1 How to help make sure that we have accurate information about you .......... 17

SECTION 9 We protect the privacy of your personal health information ........ 18

Section 9.1 We make sure that your health information is protected.............................. 18

SECTION 10 How other insurance works with our plan ........................................ 18

Section 10.1 Which plan pays first when you have other insurance? ............................... 18


SECTION 1 Introduction

Section 1.1 You are enrolled in Navitus MedicareRx, which is a Medicare Prescription Drug Plan (PDP)

You are covered by Original Medicare for your health care coverage, and you have chosen to get your Medicare prescription drug coverage through our plan, Navitus MedicareRx.

There are different types of Medicare plans. Navitus MedicareRx is a Medicare prescription drug plan (PDP). Like all Medicare plans, this Medicare prescription drug plan is approved by Medicare and run by a private company. In addition, your retiree drug coverage includes non-Medicare supplemental drug coverage provided by your Navitus MedicareRx benefits.

Section 1.2 What is the Evidence of Coverage booklet about?

This Evidence of Coverage booklet explains how to get your Medicare prescription drug coverage through our plan. This booklet explains your rights and responsibilities, what is covered, and what you pay as a member of the plan.

The word “coverage” or “covered drugs” refers to the prescription drug coverage available to you as a member of Navitus MedicareRx.

It’s important for you to learn what your plan’s rules are and what coverage is available to you. We encourage you to set aside some time to look through this Evidence of Coverage booklet.

If you are confused or concerned or just have a question, please contact our plan’s Customer Care (phone numbers are printed on the back cover of this booklet).

Section 1.3 Legal information about the Evidence of Coverage

It’s part of our contract with you

This Evidence of Coverage is part of our contract with you about how Navitus MedicareRx covers your care. Other parts of this contract include your enrollment form, the List of Covered Drugs (Formulary), and any notices you receive from us about changes to your coverage or conditions that affect your coverage. These notices are sometimes called “riders” or “amendments.”

The contract is in effect for months in which you are enrolled in Navitus MedicareRx between January 1, 2022 and December 31, 2022.

Each calendar year, Medicare allows us to make changes to the plans that we offer. This means we can change the costs and benefits of Navitus MedicareRx after December 31, 2022. We can


also choose to stop offering the plan, or to offer it in a different service area, after December 31, 2022.

Medicare must approve our plan each year

Medicare (the Centers for Medicare & Medicaid Services) must approve Navitus MedicareRx each year. You can continue to get Medicare coverage as a member of our plan as long as we choose to continue to offer the plan and Medicare renews its approval of the plan.

SECTION 2 What makes you eligible to be a plan member?

Section 2.1 Your eligibility requirements

You are eligible for membership in our plan as long as:

• You have Medicare Part A and Medicare Part B (Section 2.2 tells you about Medicare Part A and Medicare Part B)

• -- and -- you are a United States citizen or are lawfully present in the United States

• -- and -- you live in our geographic service area (Section 2.3 below describes our service area)

• -- and -- you are eligible for coverage under your group sponsored health plan retiree benefits.

Section 2.2 What are Medicare Part A and Medicare Part B?

As discussed in Section 1.1 above, you have chosen to get your prescription drug coverage (sometimes called Medicare Part D) through our plan. Our plan has contracted with Medicare to provide you with most of these Medicare benefits. We describe the drug coverage you receive under your Medicare Part D coverage in Chapter 3.

When you first signed up for Medicare, you received information about what services are covered under Medicare Part A and Medicare Part B. Remember:

• Medicare Part A generally helps cover services provided by hospitals (for inpatient services, skilled nursing facilities, or home health agencies).

• Medicare Part B is for most other medical services (such as physician’s services, home infusion therapy, and other outpatient services) and certain items (such as durable medical equipment (DME) and supplies).


Section 2.3 Here is the plan service area for Navitus MedicareRx

Although Medicare is a Federal program, Navitus MedicareRx is available only to individuals who live in our plan service area. To remain a member of our plan, you must continue to reside in the plan service area. The service area is described as all 50 states and Puerto Rico. The service area excludes most U.S. Territories, such as the U.S. Virgin Islands, Guam, American Samoa, and the Northern Mariana Islands.

If you move outside of our service area, you cannot remain a member of our plan. If you plan to move out of the service area, please contact the UC Retirement Administration Service Center (RASC) at (800) 888-8267 (in U.S.) or (510) 987-0200 (from outside the U.S.). Representatives are available Monday through Friday, 8:30 a.m. to 4:30 p.m. (Pacific).

It is also important that you call Social Security if you move or change your mailing address. You can find phone numbers and contact information for Social Security in Chapter 2, Section 5.

Section 2.4 U.S. Citizen or Lawful Presence

A member of a Medicare health plan must be a U.S. citizen or lawfully present in the United States. Medicare (the Centers for Medicare & Medicaid Services) will notify Navitus MedicareRx if you are not eligible to remain a member on this basis. Navitus MedicareRx must disenroll you if you do not meet this requirement.

SECTION 3 What other materials will you get from us?

Section 3.1 Your plan membership card – Use it to get all covered prescription drugs

While you are a member of our plan, you must use your membership card for our plan for prescription drugs you get at network pharmacies. You should also show the pharmacy your Medicaid card, if applicable. Here’s a sample membership card to show you what yours will look like:


Please carry your membership card with you at all times and remember to show your card when you get covered drugs. If your plan membership card is damaged, lost, or stolen, call Customer Care right away and we will send you a new card. (Phone numbers for Customer Care are printed on the back cover of this booklet.)

You may need to use your red, white, and blue Medicare card to get covered medical care and services under Original Medicare.

Section 3.2 The Pharmacy Directory: Your guide to pharmacies in our network

What are “network pharmacies”?

Network pharmacies are all of the pharmacies that have agreed to fill covered prescriptions for our plan members.

Why do you need to know about network pharmacies?

You can use the pharmacy search tool to find the network pharmacy you want to use. You can find a pharmacy search tool on our Member Portal at https://memberportal.navitus.com. There are changes to our network of pharmacies for next year. Also, an updated Pharmacy Directory is located on our Member Portal at https://memberportal.navitus.com. You may also call Customer Care for updated pharmacy information or to ask us to mail you a Pharmacy Directory. Please review your pharmacies to see which pharmacies are in our network.

If you don’t have the Pharmacy Directory, you can get a copy from Customer Care (phone numbers are printed on the back cover of this booklet). At any time, you can call Customer Care to get up-to-date information about changes in the pharmacy network. You can also find a pharmacy search tool on our Member Portal at https://memberportal.navitus.com.





Section 3.3 The plan’s List of Covered Drugs (Formulary)

The plan has a List of Covered Drugs (Formulary). It tells which Part D prescription drugs are covered by Navitus MedicareRx. The drugs on this list are selected by the plan with the help of a team of doctors and pharmacists. The list must meet requirements set by Medicare. Medicare has approved the Navitus MedicareRx Formulary.

The Formulary also explains if there are any rules that restrict coverage for your drugs.

A copy of the Formulary is located on our Member Portal at https://memberportal.navitus.com. If one of your drugs is not listed in the Formulary, you should visit our Member Portal or contact Customer Care to find out if we cover it. To get the most complete and current information about which drugs are covered, you can visit the plan’s Member Portal (https://memberportal.navitus.com) or call Customer Care (phone numbers are printed on the back cover of this booklet).

Section 3.4 The Part D Explanation of Benefits (the “Part D EOB”): Reports with a summary of payments made for your Part D prescription drugs

When you use your Part D prescription drug benefits, we will send you a summary report to help you understand and keep track of payments for your Part D prescription drugs. This summary report is called the Part D Explanation of Benefits (or the “Part D EOB”).

A Part D Explanation of Benefits explains the total amount you, or others on your behalf, have spent on your Part D prescription drugs and the total amount your retiree drug coverage has paid for each of your Part D prescription drugs during each month the Part D benefit is used. The Part D EOB is not a bill. The Part D EOB provides more information about the drugs you take, such as increases in price and other drugs with lower cost sharing that may be available. You should consult with your prescriber about these lower cost options. Chapter 4 (What you pay for your Part D prescription drugs) gives more information about the Part D Explanation of Benefits and how it can help you keep track of your drug coverage.

The Part D Explanation of Benefits is also available upon request. To get a copy, please contact Customer Care (phone numbers are printed on the back cover of this booklet).

SECTION 4 Your monthly premium for Navitus MedicareRx (PDP)

Section 4.1 How much is your plan premium?

As a member of our plan, you pay a monthly plan premium. In addition, you must continue to pay your Medicare Part B premium (unless your Part B premium is paid for you by Medicaid or another third party).




Your coverage is provided through a contract with your current employer or former employer. Please contact the UC Retirement Administration Service Center (RASC) at (800) 888-8267 (in U.S.) or (510) 987-0200 (from outside the U.S.) for information about your plan premium amounts. Representatives are available Monday through Friday, 8:30 a.m. to 4:30 p.m. (Pacific).

In some situations, your plan premium could be less There are programs to help people with limited resources pay for their drugs. These include “Extra Help” and State Pharmaceutical Assistance Programs. The “Extra Help” program helps people with limited resources pay for their drugs. Chapter 2, Section 7 tells more about these programs. If you qualify, enrolling in the program might lower your monthly plan premium.

If you are already enrolled and getting help from one of these programs, the information about premiums in this Evidence of Coverage may not apply to you. We have included a separate insert, called the “Evidence of Coverage Rider for People Who Get Extra Help Paying for Prescription Drugs” (also known as the “Low Income Subsidy Rider” or the “LIS Rider”), which explains your drug coverage. If you didn’t receive this insert and it applies to you, please call Customer Care and ask for the “LIS Rider.” (Phone numbers for Customer Care are printed on the back cover of this booklet.) In most cases, because you’re enrolled in a group sponsored plan, we’ll credit the amount of “Extra Help” received to your group’s bill on your behalf. If your group plan pays 100% of the premium for your retiree coverage, then the group sponsor plan is entitled to keep these funds. However, if you contribute to the premium, your group must apply the subsidy toward the amount you contribute to this plan.

In some situations, your plan premium could be more In some situations, you may owe additional money because of your income or when you enrolled in Part D. Some members are required to pay a Part D late enrollment penalty because they did not join a Medicare drug plan when they first became eligible or because they had a continuous period of 63 days or more when they didn’t have “creditable” prescription drug coverage. (“Creditable” means the drug coverage is expected to pay, on average, at least as much as Medicare’s standard prescription drug coverage. If applicable to you, Navitus MedicareRx will bill you directly each month.

• If you are required to pay the Part D late enrollment penalty, the cost of the late enrollment penalty depends on how long you went without Part D or other creditable prescription drug coverage. Chapter 1, Section 5 explains the Part D late enrollment penalty.

If you have a Part D late enrollment penalty and do not pay it, you could be disenrolled from your plan. Some members may be required to pay an extra charge, known as the Part D Income Related Monthly Adjustment Amount, also known as IRMAA, because, 2 years ago, they had a modified adjusted gross income, above a certain amount, on their IRS tax return. Members subject to an IRMAA will have to pay the standard premium amount and this extra charge, which will be added to their premium. Chapter 1, Section 6 explains the IRMAA in further detail.


SECTION 5 Do you have to pay the Part D “late enrollment penalty”?

Section 5.1 What is the Part D “late enrollment penalty”?

Note: If you receive “Extra Help” from Medicare to pay for your prescription drugs, you will not pay a late enrollment penalty.

You may owe a Part D late enrollment penalty if you did not enroll in a plan offering Medicare Part D drug coverage when you first became eligible for this drug coverage, or if there is a period of 63 days or more in a row when you did not have Part D or other creditable prescription drug coverage. (“Creditable prescription drug coverage” is coverage that meets Medicare’s minimum standards since it is expected to pay, on average, at least as much as Medicare’s standard prescription drug coverage.) The cost of the late enrollment penalty depends on how long you went without Part D or other creditable prescription drug coverage. You will have to pay this penalty for as long as you have Part D coverage.

When you first enroll in Navitus MedicareRx, we will let you know the amount of the penalty. Navitus MedicareRx will directly bill you for any applicable late enrollment penalties. If you do not pay your Part D late enrollment penalty, you could be disenrolled from the plan.

Section 5.2 How much is the Part D late enrollment penalty?

Medicare determines the amount of the penalty. Here is how it works:

• First count the number of full months that you delayed enrolling in a Medicare drug plan after you were eligible to enroll. Or count the number of full months in which you did not have creditable prescription drug coverage, if the break in coverage was 63 days or more. The penalty is 1% for every month that you didn’t have creditable coverage. For example, if you go 14 months without coverage, the penalty will be 14%.

• Then Medicare determines the amount of the average monthly premium for Medicare drug plans in the nation from the previous year. For 2022, the average premium amount is $33.37.

• To calculate your monthly penalty, you multiply the penalty percentage and the average monthly premium and then round it to the nearest 10 cents. In the example here, it would be 14% times $33.37, which equals $4.67. This rounds to $4.70. This amount would be added to the monthly premium for someone with a Part D late enrollment penalty.

There are three important things to note about this monthly Part D late enrollment penalty:


• First, the penalty may change each year, because the average monthly premium can change each year. If the national average premium (as determined by Medicare) increases, your penalty will increase.

• Second, you will continue to pay a penalty every month for as long as you are enrolled in a plan that has Medicare Part D drug benefits, even if you change plans.

• Third, if you are under 65 and currently receiving Medicare benefits, the Part D late enrollment penalty will reset when you turn 65. After age 65, your Part D late enrollment penalty will be based only on the months that you don’t have coverage after your initial enrollment period for aging into Medicare.

Section 5.3 In some situations, you can enroll late and not have to pay the penalty

Even if you have delayed enrolling in a plan offering Medicare Part D coverage when you were first eligible, sometimes you do not have to pay the Part D late enrollment penalty.

You will not have to pay a penalty for late enrollment if you are in any of these situations:

• If you already have prescription drug coverage that is expected to pay, on average, at least as much as Medicare’s standard prescription drug coverage. Medicare calls this “creditable drug coverage.” Please note:

o Creditable coverage could include drug coverage from a group sponsor, TRICARE, or the Department of Veterans Affairs. Your insurer or your human resources department will tell you each year if your drug coverage is creditable coverage. This information may be sent to you in a letter or included in a newsletter from the plan. Keep this information, because you may need it if you join a Medicare drug plan later. Please note: If you receive a “certificate of creditable coverage” when

your health coverage ends, it may not mean your prescription drug coverage was creditable. The notice must state that you had “creditable” prescription drug coverage that expected to pay as much as Medicare’s standard prescription drug plan pays.

o The following are not creditable prescription drug coverage: prescription drug discount cards, free clinics, and drug discount websites.

o For additional information about creditable coverage, please look in your Medicare & You 2022 handbook or call Medicare at 1-800-MEDICARE (1-800-633-4227). TTY/TDD users call 1-877-486-2048. You can call these numbers for free, 24 hours a day, 7 days a week.

• If you were without creditable coverage, but you were without it for less than 63 days in a row.

• If you are receiving “Extra Help” from Medicare.


Section 5.4 What can you do if you disagree about your Part D late enrollment penalty?

If you disagree about your Part D late enrollment penalty, you or your representative can ask for a review of the decision about your late enrollment penalty. Generally, you must request this review within 60 days from the date on the first letter you receive stating you have to pay a late enrollment penalty. If you were paying a penalty before joining our plan, you may not have another chance to request a review of that late enrollment penalty. Call Customer Care to find out more about how to do this (phone numbers are printed on the back cover of this booklet).

Important: Do not stop paying your Part D late enrollment penalty while you’re waiting for a review of the decision about your late enrollment penalty. If you do, you could be disenrolled for failure to pay your plan premiums.

SECTION 6 Do you have to pay an extra Part D amount because of your income?

Section 6.1 Who pays an extra Part D amount because of income?

If your modified adjusted gross income as reported on your IRS tax return from 2 years ago is above a certain amount, you’ll pay the standard premium amount and an Income Related Monthly Adjustment Amount, also known as IRMAA. IRMAA is an extra charge added to your premium.

Part D-IRMAA is assessed to all Medicare beneficiaries with Part D coverage whose incomes exceed the federal government established threshold amounts. Failure by a Medicare beneficiary to pay the Part D-IRMAA will result in involuntary disenrollment from their Part D plan and, thus, the loss of retiree drug and/or health coverage through their group sponsor.

Please carefully review all communications you receive from Medicare. As a Part D group sponsor, your group sponsor will not be billing or collecting the Part D-IRMAA; however, as a group sponsor we must be prepared to effectuate accurate disenrollments in situations where individuals fail to pay the income-related adjustment.

If you have to pay an extra amount, Social Security, not your Medicare plan, will send you a letter telling you what that extra amount will be and how to pay it. The extra amount will be withheld from your Social Security, Railroad Retirement Board, or Office of Personnel Management benefit check, no matter how you usually pay your plan premium, unless your monthly benefit isn’t enough to cover the extra amount owed. If your benefit check isn’t enough to cover the extra amount, you will get a bill from Medicare. You must pay the extra amount to the government. It cannot be paid with your monthly plan premium.


Section 6.2 How much is the extra Part D amount?

If your modified adjusted gross income (MAGI) as reported on your IRS tax return is above a certain amount, you will pay an extra amount in addition to your monthly plan premium. For more information on the extra amount you may have to pay based on your income, visit www.medicare.gov/part-d/costs/premiums/drug-plan-premiums.html.

Section 6.3 What can you do if you disagree about paying an extra Part D amount?

If you disagree about paying an extra amount because of your income, you can ask Social Security to review the decision. To find out more about how to do this, contact Social Security at 1-800-772-1213 (TTY/TDD 1-800-325-0778).

Section 6.4 What happens if you do not pay the extra Part D amount?

The extra amount is paid directly to the government (not your Medicare plan) for your Medicare Part D coverage. If you are required by law to pay the extra amount and you do not pay it, you will be disenrolled from retiree drug and/or health coverage through the group sponsor.

SECTION 7 More information about your monthly premium

Section 7.1 Many members are required to pay other Medicare premiums

In addition to paying the monthly plan premium, many members are required to pay other Medicare premiums. Some plan members (those who aren’t eligible for premium-free Part A) pay a premium for Medicare Part A. Most plan members pay a premium for Medicare Part B. You must continue to pay your Medicare premiums for you to remain a member of your plan.

If your modified adjusted gross income as reported on your IRS tax return from 2 years ago is above a certain amount, you’ll pay the standard premium amount and an Income Related Monthly Adjustment Amount, also known as IRMAA. IRMAA is an extra charge added to your premium.

• If you are required to pay the extra amount and you do not pay it, you will be disenrolled from your plan and lose prescription drug coverage.

• If you have to pay an extra amount, Social Security, not your Medicare plan, will send you a letter telling you what that extra amount will be.

• For more information about Part D premiums based on income, go to Chapter 1, Section 6 of this booklet. You can also visit www.medicare.gov on the Web or call 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY/TDD users should

http://www.medicare.gov/part-d/costs/premiums/drug-plan-premiums.html

http://www.medicare.gov/


call 1-877-486-2048. Or you may call Social Security at 1-800-772-1213. TTY/TDD users should call 1-800-325-0778.

Your copy of the Medicare & You 2022 handbook gives information about the Medicare premiums in the section called “2022 Medicare Costs.” This explains how the Medicare Part B and Part D premiums differ for people with different incomes. Everyone with Medicare receives a copy of the Medicare & You 2022 handbook each year in the fall. Those new to Medicare receive it within a month after first signing up. You can also download a copy of the Medicare & You 2022 handbook from the Medicare website (www.medicare.gov). Or, you can order a printed copy by phone at 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY/TDD users call 1-877-486-2048.

Section 7.2 There are several ways you can pay your plan premium Please contact the UC Retirement Administration Service Center (RASC) at (800) 888-8267 (in U.S.) or (510) 987-0200 (from outside the U.S.). Representatives are available Monday through Friday, 8:30 a.m. to 4:30 p.m. (Pacific) to find out what your plan premium is and how you are required to pay for it. Your benefits administrator can discuss different payment options with you. If you think we have wrongfully ended your enrollment in the Part D plan, you have a right to ask us to reconsider this decision by making a complaint. Chapter 7, Section 7 of this booklet tells how to make a complaint. If you had an emergency circumstance that was out of your control and it caused you to not be able to pay your plan premium within the grace period, you can ask us to reconsider this decision by calling the RASC. TTY/TDD users should call 711. You must make your request no later than 60 days after the date your membership ends.

Section 7.3 Can we change your monthly plan premium during the year?

Medicare Part D Coverage: No. Generally, your plan premium won’t change during the benefit year. You will be notified, in advance, if there will be any changes for the next benefit year in your plan premiums or in the amounts you will have to pay when you get your prescriptions covered.

However, in some cases the part of the premium that you have to pay can change during the year. This happens if you become eligible for the “Extra Help” program or if you lose your eligibility for the “Extra Help” program during the year. If you qualify for “Extra Help” with their prescription drug costs, the “Extra Help” program will pay part of the member’s monthly plan premium. If Medicare pays only a portion of this premium, we will bill you for the amount Medicare doesn’t cover. A member who loses their eligibility during the year, will need to start paying their full monthly premium. You can find out more about the “Extra Help” program in Chapter 2, Section 7.

If you lose Extra Help, you may be subject to the late enrollment penalty if you go 63 days or more in a row without Part D or other creditable prescription drug coverage.



SECTION 8 Please keep your plan membership record up to date

Section 8.1 How to help make sure that we have accurate information about you

Your membership record has information including your address and telephone number. It shows your specific plan coverage.

The pharmacists in your plan’s network need to have correct information about you. These network providers use your membership record to know what drugs are covered and the cost sharing amounts for you. Because of this, it is very important that you help us keep your information up to date.

Let us and RASC know about these changes:

• Changes to your name, your address, or your phone number

• Changes in any other medical or drug insurance coverage you have (such as from a group sponsor, your spouse’s employer, workers’ compensation, or Medicaid)

• If you have any liability claims, such as claims from an automobile accident

• If you have been admitted to a nursing home

• If your designated responsible party (such as a caregiver) changes/

If any of this information changes, please let us know by calling Customer Care (phone numbers are printed on the back cover of this booklet). Please remember to also notify the RASC so they will have your most up-to-date contact information on file.

It is also important to contact Social Security if you move or change your mailing address. You can find phone numbers and contact information for Social Security in Chapter 2, Section 5.

Read over the information we send you about any other insurance coverage you have

Medicare requires that we collect information from you about any medical or drug insurance coverage that you have in addition to this retiree drug coverage. That’s because we must coordinate any other coverage you have with your benefits under our plan. (For more information about how our coverage works when you have other insurance, see Section 10 in this chapter.)

Once each year, we will send you a letter that lists any other medical or drug insurance coverage that we know about. Please read over this information carefully. If it is correct, you don’t need to do anything. If the information is incorrect, or if you have other coverage that is not listed, please call Customer Care (phone numbers are printed on the back cover of this booklet).


SECTION 9 We protect the privacy of your personal health information

Section 9.1 We make sure that your health information is protected

Federal and state laws protect the privacy of your medical records and personal health information. We protect your personal health information as required by these laws.

For more information about how we protect your personal health information, please go to Chapter 6, Section 1.3 of this booklet.

SECTION 10 How other insurance works with our plan

Section 10.1 Which plan pays first when you have other insurance?

When you have other insurance (like employer group health coverage), there are rules set by Medicare that decide whether our plan or your other insurance pays first. The insurance that pays first is called the “primary payer” and pays up to the limits of its coverage. The one that pays second, called the “secondary payer,” only pays if there are costs left uncovered by the primary coverage. The secondary payer may not pay all of the uncovered costs. Your retiree drug coverage includes basic coverage provided by Group Part D benefits and additional coverage provided by your Navitus MedicareRx supplemental benefits.

These rules apply for employer or union group health plan coverage:

• If you have retiree coverage, Medicare pays first.

• If your group health plan coverage is based on your or a family member’s current employment, who pays first depends on your age, the number of people employed by your employer, and whether you have Medicare based on age, disability, or End-Stage Renal Disease (ESRD):

o If you’re under 65 and disabled and you or your family member is still working, your group health plan pays first if the employer has 100 or more employees or at least one employer in a multiple employer plan that has more than 100 employees.

o If you’re over 65 and you or your spouse/domestic partner is still working, your group health plan pays first if the employer has 20 or more employees or at least one employer in a multiple employer plan that has more than 20 employees.

• If you have Medicare because of ESRD, your group sponsored health plan will pay first for the first 30 months after you become eligible for Medicare.

These types of coverage usually pay first for services related to each type:


• No-fault insurance (including automobile insurance)

• Liability (including automobile insurance)

• Black lung benefits

• Workers’ compensation

Medicaid and TRICARE never pay first for Medicare-covered services. They only pay after Medicare, group sponsored health plans, and/or Medigap have paid.

If you have other insurance, tell your doctor, hospital, and pharmacy. If you have questions about who pays first, or you need to update your other insurance information, call Customer Care (phone numbers are printed on the back cover of this booklet). You may need to give your plan member ID number to your other insurers (once you have confirmed their identity) so your bills are paid correctly and on time.

CHAPTER 2 Important phone numbers and

resources

2022 Evidence of Coverage for Navitus MedicareRx (PDP) 21 Chapter 2. Important phone numbers and resources

Chapter 2. Important phone numbers and resources

SECTION 1 Navitus MedicareRx (PDP) contacts (how to contact us, including how to reach Customer Care at the plan) ............................. 22

SECTION 2 Medicare (how to get help and information directly from the Federal Medicare program) .................................................................... 27

SECTION 3 State Health Insurance Assistance Program (free help, information, and answers to your questions about Medicare) ............. 28

SECTION 4 Quality Improvement Organization (paid by Medicare to check on the quality of care for people with Medicare) ........................ 29

SECTION 5 Social Security ...................................................................................... 29

SECTION 6 Medicaid (a joint Federal and state program that helps with medical costs for some people with limited income and resources) ................................................................................................ 30

SECTION 7 Information about programs to help people pay for their prescription drugs ................................................................................ 31

SECTION 8 How to contact the Railroad Retirement Board ............................... 34

SECTION 9 Do you have “group insurance” or other health insurance from another employer? ...................................................................... 34


SECTION 1 Navitus MedicareRx (PDP) contacts (how to contact us, including how to reach Customer Care at the plan)

How to contact our plan’s Customer Care

For assistance with claims, billing, or member card questions, please call or write to Navitus MedicareRx Customer Care. We will be happy to help you.

Method Customer Care – Contact Information

CALL 1-866-270-3877 Calls to this number are free. We are available 24 hours a day, 7 days a week, except on Thanksgiving and Christmas Day. Pharmacies can also reach Navitus Customer Care 24 hours a day, 7 days a week. Customer Care also has free language interpreter services available for non-English speakers.

TTY/TDD 711 This number requires special telephone equipment and is only for people who have difficulties with hearing or speaking. Calls to this number are free. Members can reach Navitus Customer Care 24 hours a day, 7 days a week, except on Thanksgiving and Christmas Day.

WRITE Navitus MedicareRx (PDP) Customer Care P.O. Box 1039 Appleton, WI 54912-1039

WEBSITE https://memberportal.navitus.com



How to contact us when you are asking for a coverage decision about your Part D prescription drugs

A coverage decision is a decision we make about your benefits and coverage or about the amount we will pay for your prescription drugs covered under the Part D benefit included in your plan. For more information on asking for coverage decisions about your Part D prescription drugs, see Chapter 7 (What to do if you have a problem or complaint (coverage decisions, appeals, complaints)).

You may call us if you have questions about our coverage decision process your request against both your Group Part D and Navitus MedicareRx coverage.

Method Coverage Decisions for Part D Prescription Drugs – Contact Information



FAX 1-855-668-8552

WRITE Navitus MedicareRx (PDP) Prior Authorization P.O. Box 1039 Appleton, WI 54912-1039




How to contact us when you are making an appeal about your Part D prescription drugs

An appeal is a formal way of asking us to review and change a coverage decision we have made. For more information on making an appeal about your Part D prescription drugs, see Chapter 7 (What to do if you have a problem or complaint (coverage decisions, appeals, complaints)). We will process your request against both your Group Part D and Navitus MedicareRx coverage.

Method Appeals for Part D Prescription Drugs – Contact Information


TTY/TDD 711 This number requires special telephone equipment and is only for people who have difficulties with hearing or speaking. Calls to this number are free We are available 24 hours a day, 7 days a week, except on Thanksgiving and Christmas Day. Customer Care also has free language interpreter services available for non-English speakers.

FAX 1-844-268-9791

WRITE Navitus MedicareRx (PDP) Grievances & Appeals P.O. Box 1039 Appleton, WI 54912-1039




How to contact us when you are making a complaint about your Part D prescription drugs

You can make a complaint about us or one of our network pharmacies, including a complaint about the quality of your care. This type of complaint does not involve coverage or payment disputes. (If your problem is about the plan’s coverage or payment, you should look at the section above about making an appeal.) For more information on making a complaint about your Part D prescription drugs, see Chapter 7 (What to do if you have a problem or complaint (coverage decisions, appeals, complaints)).

Method Complaints about Part D prescription drugs – Contact Information



FAX 1-844-268-9791

WRITE Navitus MedicareRx (PDP) Grievances & Appeals P.O. Box 1039 Appleton, WI 54912-1039

MEDICARE WEBSITE

You can submit a complaint about Navitus MedicareRx directly to Medicare. To submit an online complaint to Medicare go to www.medicare.gov/MedicareComplaintForm/home.aspx.

http://www.medicare.gov/MedicareComplaintForm/home.aspx


Where to send a request asking us to pay for our share of the cost of a drug you have received

The coverage determination process includes determining requests to pay for our share of the costs of a drug that you have received. For more information on situations in which you may need to ask the plan for reimbursement or to pay a bill you have received from a pharmacy, see Chapter 5 (Asking us to pay our share of the costs for covered drugs).

Please note: If you send us a payment request and we deny any part of your request, you can appeal our decision. See Chapter 7 (What to do if you have a problem or complaint (coverage decisions, appeals, complaints)) for more information.

Method Payment Requests – Contact Information



FAX 1-855-668-8550

WRITE Navitus MedicareRx (PDP) Manual Claims P.O. Box 1039 Appleton, WI 54912-1039




SECTION 2 Medicare (how to get help and information directly from the Federal Medicare program)

Medicare is the Federal health insurance program for people 65 years of age or older, some people under age 65 with disabilities, and people with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a kidney transplant).

The Federal agency in charge of Medicare is the Centers for Medicare & Medicaid Services (sometimes called “CMS”). This agency contracts with Medicare Prescription Drug Plans, including us.

Method Medicare – Contact Information

CALL 1-800-MEDICARE, or 1-800-633-4227 Calls to this number are free. 24 hours a day, 7 days a week.

TTY/TDD 1-877-486-2048 This number requires special telephone equipment and is only for people who have difficulties with hearing or speaking. Calls to this number are free.

WEBSITE www.medicare.gov This is the official government website for Medicare. It gives you up-to-date information about Medicare and current Medicare issues. It also has information about hospitals, nursing homes, physicians, home health agencies, and dialysis facilities. It includes booklets you can print directly from your computer. You can also find Medicare contacts in your state. The Medicare website also has detailed information about your Medicare eligibility and enrollment options with the following tools:

• Medicare Eligibility Tool: Provides Medicare eligibility status information.

• Medicare Plan Finder: Provides personalized information about available Medicare prescription drug plans, Medicare health plans, and Medigap (Medicare Supplement Insurance) policies in your area. These tools provide an estimate of what your out-of-pocket costs might be in different Medicare plans.



Method Medicare – Contact Information

WEBSITE (continued)

You can also use the website to tell Medicare about any complaints you have about Navitus MedicareRx:

• Tell Medicare about your complaint: You can submit a complaint about Navitus MedicareRx directly to Medicare. To submit a complaint to Medicare, go to www.medicare.gov/MedicareComplaintForm/home.aspx. Medicare takes your complaints seriously and will use this information to help improve the quality of the Medicare program.

If you don’t have a computer, your local library or senior center may be able to help you visit this website using its computer. Or, you can call Medicare and tell them what information you are looking for. They will find the information on the website, print it out, and send it to you. (You can 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.)

SECTION 3 State Health Insurance Assistance Program (free help, information, and answers to your questions about Medicare)

The State Health Insurance Assistance Program (SHIP) is a government program with trained counselors in every state. Please refer to Exhibit A for the name and contact information of the specific SHIP in your state.

SHIP is independent (not connected with any insurance company or health plan). It is a state program that gets money from the Federal government to give free local health insurance counseling to people with Medicare.

SHIP counselors can help you with your Medicare questions or problems. They can help you understand your Medicare rights, help you make complaints about your medical care or treatment, and help you straighten out problems with your Medicare bills. SHIP counselors can also help you understand your Medicare plan choices and answer questions about switching plans.



METHOD TO ACCESS SHIP and OTHER RESOURCES:

Visit www.medicare.gov Click on “Forms, Help, and Resources” on far right of menu on top In the drop down click on “Phone Numbers & Websites” You now have several options

o Option #1: You can have a live chat o Option #2: You can click on any of the “TOPICS” in the menu

on bottom o Option #3: You can select your STATE from the dropdown

menu and click GO. This will take you to a page with phone numbers and resources specific to your state.

SECTION 4 Quality Improvement Organization (paid by Medicare to check on the quality of care for people with Medicare)

There is a designated Quality Improvement Organization (QIO) for serving Medicare beneficiaries in each state. Please refer to Exhibit B for the name and contact information of the specific Quality Improvement Organization in your area.

The QIO has a group of doctors and other health care professionals who are paid by the Federal government. This organization is paid by Medicare to check on and help improve the quality of care for people with Medicare. The QIO is an independent organization. It is not connected with our plan.

You should contact the QIO if you have a complaint about the quality of care you have received. For example, you can contact the QIO if you were given the wrong medication or if you were given medications that interact in a negative way.

SECTION 5 Social Security

Social Security is responsible for determining eligibility and handling enrollment for Medicare. U.S. citizens and lawful permanent residents who are 65 or older, or who have a disability or End-Stage Renal Disease and meet certain conditions, are eligible for Medicare. If you are already getting Social Security checks, enrollment into Medicare is automatic. If you are not getting Social Security checks, you have to enroll in Medicare. To apply for Medicare, you can call Social Security or visit your local Social Security office.

Social Security is also responsible for determining who has to pay an extra amount for their Part D drug coverage because they have a higher income. If you got a letter from Social Security telling you that you have to pay the extra amount and have questions about the



amount or if your income went down because of a life-changing event, you can call Social Security to ask for reconsideration.

If you move or change your mailing address, it is important that you contact Social Security to let them know.

Method Social Security – Contact Information

CALL 1-800-772-1213 Calls to this number are free. Available 7:00 am to 7:00 pm, Monday through Friday. You can use Social Security’s automated telephone services to get recorded information and conduct some business 24 hours a day.

TTY/TDD 1-800-325-0778 This number requires special telephone equipment and is only for people who have difficulties with hearing or speaking. Calls to this number are free. Available 7:00 am ET to 7:00 pm, Monday through Friday.

WEBSITE www.ssa.gov/

SECTION 6 Medicaid (a joint Federal and state program that helps with medical costs for some people with limited income and resources)

Medicaid is a joint Federal and state government program that helps with medical costs for certain people with limited incomes and resources. Some people with Medicare are also eligible for Medicaid.

In addition, there are programs offered through Medicaid that help people with Medicare pay their Medicare costs, such as their Medicare premiums. These “Medicare Savings Programs” help people with limited income and resources save money each year:

• Qualified Medicare Beneficiary (QMB): Helps pay Medicare Part A and Part B premiums, and other cost sharing (like deductibles, coinsurance, and copayments). (Some people with QMB are also eligible for full Medicaid benefits (QMB+).)

• Specified Low-Income Medicare Beneficiary (SLMB): Helps pay Part B premiums. (Some people with SLMB are also eligible for full Medicaid benefits (SLMB+).)

• Qualifying Individual (QI): Helps pay Part B premiums.

• Qualified Disabled & Working Individuals (QDWI): Helps pay Part A premiums.

http://www.ssa.gov/


To find out more about Medicaid and its programs, please refer to Exhibit C for the name and contact information of your state specific Medicaid program.

SECTION 7 Information about programs to help people pay for their prescription drugs

Medicare’s “Extra Help” Program

Medicare provides “Extra Help” to pay prescription drug costs for people who have limited income and resources. Resources include your savings and stocks, but not your home or car. If you qualify, you get help paying for any Medicare drug plan’s monthly premium, and prescription copayments or coinsurance. This “Extra Help” also counts toward your out-of-pocket costs.

Some people automatically qualify for “Extra Help” and don’t need to apply. Medicare mails a letter to people who automatically qualify for “Extra Help.”

You may be able to get “Extra Help” to pay for your prescription drug premiums and costs. To see if you qualify for getting “Extra Help,” call:

• 1-800-MEDICARE (1-800-633-4227). TTY/TDD users should call 1-877-486-2048, 24 hours a day, 7 days a week;

• The Social Security Office at 1-800-772-1213, between 7 am to 7 pm, Monday through Friday. TTY/TDD users should call 1-800-325-0778 (applications); or

• Your State Medicaid Office (applications). (See Section 6 of this chapter for contact information.)

If you believe you have qualified for “Extra Help” and you believe that you are paying an incorrect cost-sharing amount when you get your prescription at a pharmacy, our plan has established a process that allows you to either request assistance in obtaining evidence of your proper copayment level, or, if you already have the evidence, to provide this evidence to us.

• If you do not have evidence of “Extra Help”, notify the pharmacy when you pick up your prescription. The pharmacy will contact us and we will work with Medicare to get this evidence for you.

• When we receive the evidence showing your copayment level, we will update our system so that you can pay the correct copayment when you get your next prescription at the pharmacy. If you overpay your copayment, we will reimburse you.

• When we receive the evidence showing your copayment level, we will update our system so that you can pay the correct copayment when you get your next prescription at the pharmacy. If you overpay your copayment, we will reimburse you. We will forward a check to you in the amount of your overpayment. Please contact Customer Care if you have questions (phone numbers are printed on the back cover of this booklet).


There are programs in Puerto Rico to help people with limited income and resources pay their Medicare costs. Programs vary in these areas. Call your local Medical Assistance (Medicaid) office to find out more about their rules (phone numbers are in Section 6 of this chapter). Or call 1-800-MEDICARE (1-800-633-4227) 24 hours a day, 7 days a week and say “Medicaid” for more information. TTY/TDD users should call 1-877-486-2048. You can also visit www.medicare.gov for more information.

Medicare Coverage Gap Discount Program

The plan continues to cover your drugs at your regular cost-sharing amount through the Gap Coverage Stage.

The Medicare Coverage Gap Discount Program provides manufacturer discounts on brand name drugs to Part D members who have reached the coverage gap and are not receiving “Extra Help.” For brand name drugs, the 70% discount provided by manufacturers excludes any dispensing fee for costs in the gap. Members pay 25% of the negotiated price which includes a portion of the dispensing fee for brand name drugs.

If you reach the coverage gap, we will automatically apply the discount when your pharmacy bills you for your prescription and your Part D Explanation of Benefits (EOB) will show any discount provided. It will also reflect the coverage provided by your Navitus MedicareRx supplemental coverage after the discount is applied. Both the amount you pay and the amount discounted by the manufacturer count toward your out-of-pocket costs as if you had paid them and move you through the coverage gap. The amount paid by the plan (5%) does not count toward your out-of-pocket costs.

You also receive some coverage for generic drugs. For generic drugs, the amount paid by the plan (75%) does not count toward your out-of-pocket costs. Only the amount you pay counts and moves you through the coverage gap. Also, the dispensing fee is included as part of the cost of the drug.

The Medicare Coverage Gap Discount Program is available nationwide. Because Navitus MedicareRx offers additional gap coverage during the Coverage Gap Stage. Please go to Chapter 4, Section 6 for more information about your coverage during the Coverage Gap Stage.

If you have any questions about the availability of discounts for the drugs you are taking or about the Medicare Coverage Gap Discount Program in general, please contact Customer Care (phone numbers are printed on the back cover of this booklet).

What if you have coverage from a State Pharmaceutical Assistance Program (SPAP)?

If you are enrolled in a State Pharmaceutical Assistance Program (SPAP), or any other program that provides coverage for Part D drugs (other than “Extra Help”), you still get the 70% discount on covered brand name drugs. Also, the plan pays 5% of the costs of brand drugs in the coverage gap. The 70% discount and the 5% paid by the plan are both applied to the price of the drug before any SPAP or other coverage.



What if you have coverage from an AIDS Drug Assistance Program (ADAP)? What is the AIDS Drug Assistance Program (ADAP)?

The AIDS Drug Assistance Program (ADAP) helps ADAP-eligible individuals living with HIV/AIDS have access to life-saving HIV medications. Medicare Part D prescription drugs that are also covered by ADAP qualify for prescription cost-sharing assistance. Note: To be eligible for the ADAP operating in your State, individuals must meet certain criteria, including proof of State residence and HIV status, low income as defined by the State, and uninsured/under-insured status.

If you are currently enrolled in an ADAP, it can continue to provide you with Medicare Part D prescription cost-sharing assistance for drugs on the ADAP formulary. In order to be sure you continue receiving this assistance, please notify your local ADAP enrollment worker of any changes in your Medicare Part D plan name or policy number.

For information on eligibility criteria, covered drugs, or how to enroll in the program, refer to Exhibit E for the name and contact information of your state specific ADAP.

What if you get “Extra Help” from Medicare to help pay your prescription drug costs? Can you get the discounts?

No. If you get “Extra Help,” you already get coverage for your prescription drug costs during the coverage gap.

What if you don’t get a discount, and you think you should have?

If you think that you have reached the coverage gap and did not get a discount when you paid for your brand name drug, you should review your next Part D Explanation of Benefits (Part D EOB) notice. If the discount doesn’t appear on your Part D Explanation of Benefits, you should contact us to make sure that your prescription records are correct and up-to-date. If we don’t agree that you are owed a discount, you can appeal. You can get help filing an appeal from your State Health Insurance Assistance Program (SHIP) (refer to Exhibit A for the name and contact information of the specific SHIP in your state) or by calling 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY/TDD users should call 1-877-486-2048.

State Pharmaceutical Assistance Programs Many states have State Pharmaceutical Assistance Programs that help some people pay for prescription drugs based on financial need, age, medical condition, or disabilities. Each state has different rules to provide drug coverage to its members.

To find out more about a State Pharmaceutical Assistance Program (SPAP), please refer to Exhibit D for the name and contact information of your state specific SPAP.


SECTION 8 How to contact the Railroad Retirement Board

The Railroad Retirement Board is an independent Federal agency that administers comprehensive benefit programs for the nation’s railroad workers and their families. If you have questions regarding your benefits from the Railroad Retirement Board, contact the agency.

If you receive your Medicare through the Railroad Retirement Board, it is important that you let them know if you move or change your mailing address.

Method Railroad Retirement Board – Contact Information

CALL 1-877-772-5772 Calls to this number are free. If you press “0,” you may speak with an RRB representative from 9:00 am to 3:30 pm, Monday, Tuesday, Thursday, and Friday, and from 9:00 am to 12:00 pm on Wednesday. If you press “1”, you may access the automated RRB HelpLine and recorded information 24 hours a day, including weekends and holidays.

TTY/TDD 1-312-751-4701 This number requires special telephone equipment and is only for people who have difficulties with hearing or speaking. Calls to this number are not free.

WEBSITE rrb.gov/

SECTION 9 Do you have “group insurance” or other health insurance from another employer?

If you (or your spouse) get benefits from your (or your spouse’s) employer or retiree group as part of this plan, you may call the RASC or Customer Care if you have any questions. You can ask about your (or your spouse’s) employer or retiree health benefits, premiums, or the enrollment period. (Phone numbers for Customer Care are printed on the back cover of this booklet.) You may also call 1-800-MEDICARE (1-800-633-4227; TTY/TDD: 1-877-486-2048) with questions related to your Medicare coverage under this plan.

If you have other prescription drug coverage through your (or your spouse’s) employer or retiree group, please contact that group’s benefits administrator. That benefits administrator can help you determine how your current prescription drug coverage will work with our plan.

https://rrb.gov/

CHAPTER 3 Using the plan’s coverage for your

Part D prescription drugs

2022 Evidence of Coverage for Navitus MedicareRx (PDP) 36 Chapter 3. Using the plan’s coverage for your Part D prescription drugs

Chapter 3. Using the plan’s coverage for your Part D prescription drugs

SECTION 1 Introduction............................................................................................ 38

Section 1.1 This chapter describes your coverage for Part D drugs ............................... 38

Section 1.2 Basic rules for the plan’s Part D drug coverage .......................................... 38

SECTION 2 Fill your prescription at a network pharmacy or through the plan’s mail-order service ..................................................................... 39

Section 2.1 To have your prescription covered, use a network pharmacy ...................... 39

Section 2.2 Finding network pharmacies ...................................................................... 39

Section 2.3 Using the plan’s mail-order services .......................................................... 40

Section 2.4 How can you get a long-term supply of drugs? ........................................... 42

Section 2.5 When can you use a pharmacy that is not in the plan’s network? ................ 43

SECTION 3 Your drugs need to be on the plan’s “Formulary” .......................... 44

Section 3.1 The “Formulary” tells which Part D drugs are covered ............................... 44

Section 3.2 There are four “cost-sharing tiers” for drugs on the Formulary ................... 44

Section 3.3 How can you find out if a specific drug is on the Formulary? ..................... 45

SECTION 4 There are restrictions on coverage for some drugs ....................... 45

Section 4.1 Why do some drugs have restrictions? ....................................................... 45

Section 4.2 What kinds of restrictions? ........................................................................ 46

Section 4.3 Do any of these restrictions apply to your drugs? ....................................... 47

SECTION 5 What if one of your drugs is not covered in the way you’d like it to be covered? ............................................................................ 48

Section 5.1 There are things you can do if your drug is not covered in the way you’d like it to be covered ................................................................................... 48

Section 5.2 What can you do if your drug is not on the Formulary or if the drug is restricted in some way? ............................................................................. 48

Section 5.3 What can you do if your drug is in a cost-sharing tier you think is too high? ......................................................................................................... 50

SECTION 6 What if your coverage changes for one of your drugs? ................ 51

Section 6.1 The Formulary can change during the year ................................................. 51

Section 6.2 What happens if coverage changes for a drug you are taking?..................... 51

SECTION 7 What types of drugs are not covered by the plan? ......................... 53

Section 7.1 Types of drugs we do not cover ................................................................. 53


SECTION 8 Show your plan membership card when you fill a prescription ............................................................................................ 55

Section 8.1 Show your membership card...................................................................... 55

Section 8.2 What if you don’t have your membership card with you? ........................... 55

SECTION 9 Part D drug coverage in special situations ...................................... 55

Section 9.1 What if you’re in a hospital or a skilled nursing facility for a stay that is covered by Original Medicare? .................................................................. 55

Section 9.2 What if you’re a resident in a long-term care (LTC) facility? ...................... 56

Section 9.3 What if you are taking drugs covered by Original Medicare? ...................... 56

Section 9.4 What if you have a Medigap (Medicare Supplement Insurance) policy with prescription drug coverage? ............................................................... 57

Section 9.5 What if you’re also getting drug coverage from an employer or retiree group plan? ............................................................................................... 57

Section 9.6 What if you are in Medicare-certified Hospice?.......................................... 58

SECTION 10 Programs on drug safety and managing medications ................... 58

Section 10.1 Programs to help members use drugs safely ............................................... 58

Section 10.2 Drug Management Program (DMP) to help members safely use their opioid medications .................................................................................... 59

Section 10.3 Medication Therapy Management (MTM) program to help members manage their medications .......................................................................... 59


Did you know there are programs to help people pay for their drugs?

There are programs to help people with limited resources pay for their drugs. These include “Extra Help” and State Pharmaceutical Assistance Programs. For more information, see Chapter 2, Section 7.

Are you currently getting help to pay for your drugs?

If you are in a program that helps pay for your drugs, some information in this Evidence of Coverage about the costs for Part D prescription drugs may not apply to you. If you qualify, we have included a separate insert, called the “Evidence of Coverage Rider for People Who Get Extra Help Paying for Prescription Drugs” (also known as the “Low Income Subsidy Rider” or the “LIS Rider”), which explains your drug coverage. If you don’t have this insert and it is applicable to you, please call Customer Care and ask for the “LIS Rider.” (Phone numbers for Customer Care are printed on the back cover of this booklet.)


Section 1.1 This chapter describes your coverage for Part D drugs

This chapter explains rules for using your coverage for Part D drugs. The next chapter tells what you pay for Part D drugs (Chapter 4, What you pay for your Part D prescription drugs).

In addition to your coverage for Part D drugs through your plan, Original Medicare (Medicare Part A and Part B) also covers some drugs:

• Medicare Part A covers drugs you are given during Medicare-covered stays in the hospital or in a skilled nursing facility.

• Medicare Part B also provides benefits for some drugs. Part B drugs include certain chemotherapy drugs, certain drug injections you are given during an office visit, drugs you are given at a dialysis facility, and certain drugs you receive via medical equipment such as nebulizers.

The two examples of drugs described above are covered by Original Medicare. (To find out more about this coverage, see your Medicare & You 2022 handbook.) Your Part D prescription drugs are covered under our plan.

Section 1.2 Basic rules for the plan’s Part D drug coverage

The plan will generally cover your drugs as long as you follow these basic rules:

• You must have a provider (a doctor, dentist, or other prescriber) write your prescription.


• Your prescriber must either accept Medicare or file documentation with CMS showing that they are qualified to write prescriptions, or your Part D claim will be denied. You should ask your prescribers the next time you call or visit if they meet this condition. If not, please be aware it takes time for your prescriber to submit the necessary paperwork to be processed.

• You generally must use a network pharmacy to fill your prescription. (See Section 2, Fill your prescriptions at a network pharmacy or through your plan’s mail-order service.)

• Your drug must be on the plan’s List of Covered Drugs (Formulary). (See Section 3, Your drugs need to be on the plan’s “Formulary”.)

• Your drug must be used for a medically accepted indication. A “medically accepted indication” is a use of the drug that is either approved by the Food and Drug Administration or supported by certain reference books. (See Section 3 for more information about a medically accepted indication.)

SECTION 2 Fill your prescription at a network pharmacy or through the plan’s mail-order service

Section 2.1 To have your prescription covered, use a network pharmacy

In most cases, your prescriptions are covered only if they are filled at your plan’s network pharmacies. (See Section 2.5 for information about when we would cover prescriptions filled at out-of-network pharmacies.)

A network pharmacy is a pharmacy that has a contract with us to provide your covered prescription drugs. The term “covered drugs” means all of the Part D prescription drugs that are covered on the plan’s Formulary.

Section 2.2 Finding network pharmacies

How do you find a network pharmacy in your area?

To find a network pharmacy, you can look in your Pharmacy Directory, visit our Member Portal (https://memberportal.navitus.com), or call Customer Care (phone numbers are printed on the back cover of this booklet). You can also find a pharmacy search tool on our Member Portal.

You may go to any of our network pharmacies. If you switch from one network pharmacy to another, and you need a refill of a drug you have been taking, you can ask either to have a new prescription written by a prescriber or to have your prescription transferred to your new network pharmacy.



What if the pharmacy you have been using leaves the network?

If the pharmacy you have been using leaves your plan’s network, you will have to find a new pharmacy that is in the network. To find another network pharmacy in your area, you can get help from Customer Care (phone numbers are printed on the back cover of this booklet) or use the Pharmacy Directory. You can find information on our Member Portal at https://memberportal.navitus.com. You can also find a pharmacy search tool on our Member Portal.

What if you need a specialized pharmacy?

Sometimes prescriptions must be filled at a specialized pharmacy. Specialized pharmacies include:

• Pharmacies that supply drugs for home infusion therapy.

• Pharmacies that supply drugs for residents of a long-term care (LTC) facility. Usually, a long-term care facility (such as a nursing home) has its own pharmacy. If you are in an LTC facility, we must ensure that you are able to routinely receive your Part D benefits through our network of LTC pharmacies, which is typically the pharmacy that the LTC facility uses. If you have any difficulty accessing your Part D benefits in an LTC facility, please contact Customer Care.

• Pharmacies that serve the Indian Health Service / Tribal / Urban Indian Health Program (not available in Puerto Rico). Except in emergencies, only Native Americans or Alaska Natives have access to these pharmacies in our network.

• Pharmacies that dispense drugs that are restricted by the FDA to certain locations or that require special handling, pharmacy coordination, or education on their use. (Note: This scenario should happen rarely.)

To locate a specialized pharmacy, look in your Pharmacy Directory or call Customer Care (phone numbers are printed on the back cover of this booklet). You can find information on our Member Portal at https://memberportal.navitus.com. You can also find a pharmacy search tool on our Member Portal.

Section 2.3 Using the plan’s mail-order services

You can use the plan’s network mail-order services. Generally, the drugs provided through mail order are drugs that you take on a regular basis, for a chronic or long-term medical condition.

Our plan’s mail-order service allows you to order up to a 90-day supply for most drugs. Specialty drugs are only available for up to a 30-day supply.

To get order forms and information about filling your prescriptions by mail call Customer Care (phone numbers are on the back cover of this booklet).




You may use any contracted pharmacy you like, currently the recommended mail order pharmacy is Costco Mail Order Pharmacy. Note: Costco Mail Order is not to be confused with Costco Warehouse/Club Stores. You do not need to be a member of Costco Warehouse/Club Stores to utilize Costco Mail Order Pharmacy services.

Costco Mail Order can be reached at 1-800-607-6861. Costco representatives are available Monday through Friday, 5am to 7pm PST and Saturdays 9:30am to 2pm PST. Refill orders can be placed and tracked 24 hours a day, 7 days a week. Your physician can send new prescriptions in by calling (1-800-607-6861) or by fax at 1-888-545-4615.

Usually a mail-order pharmacy order will get to you in no more than 14 days.

New prescriptions the pharmacy receives directly from your doctor’s office. After the pharmacy receives a prescription from a health care provider, it will contact you to see if you want the medication filled immediately or at a later time. This will give you an opportunity to make sure that the pharmacy is delivering the correct drug (including strength, amount, and form) and, if needed, allow you to stop or delay the order before you are billed and it is shipped. It is important that you respond each time you are contacted by the pharmacy, to let them know what to do with the new prescription and to prevent any delays in shipping.

Refills on mail-order prescriptions. For refills, please contact your pharmacy 14 days before you think the drugs you have on hand will run out to make sure your next order is shipped to you in time.

Note: Both Costco mail order and retail locations are unable to fill Medicare Part B products, for example, Diabetic Testing Strips. Costco can either refer you to an affiliated provider that can fill these supplies, or you can locate a participating retail pharmacy that can process Part B products.

What should I do if I need my mail order prescription urgently from Costco?

Usually Costco Mail Order will get to you within 14 days. If the medication does not arrive in that timeframe, you should contact Costco to report that you did not receive your prescription. Costco will verify how many days of medication you have left.

If you have 5 days or less of medication left, you should contact your doctor to ask for a two-week supply to be called into your local pharmacy.

If you have more than 6 days remaining, Costco will continue to process your order. Costco can expedite shipping your order at an additional cost to you. The overnight shipping happens after the usual processing time of 24 to 96 hours.

In an emergency circumstance where Costco failed to comply with their protocol, they will expedite the patient medication at Costco’s cost. If Costco provided unrealistic expectations to


you which results in you not getting your medication in time, Costco will investigate and immediately resolve the situation to prevent gaps in therapy.

So the pharmacy can reach you to confirm your order before shipping, please make sure to let the pharmacy know the best ways to contact you. Communication preferences can be updated by contacting our recommended mail order partner, Costco Mail Order Pharmacy.

Section 2.4 How can you get a long-term supply of drugs?

When you get a long-term supply of drugs, your cost sharing may be lower. Your plan offers two ways to get a long-term supply (also called an “extended supply”) of “maintenance” drugs on your plan’s Formulary. (Maintenance drugs are drugs that you take on a regular basis, for a chronic or long-term medical condition.) You may order this supply through mail order (see Section 2.3) or you may go to a retail pharmacy.

1. Some retail pharmacies in our network allow you to get a long-term supply of maintenance drugs. Some of these retail pharmacies agree to accept the mail-order cost-sharing amount for a long-term supply of maintenance drugs. Other retail pharmacies may not agree to accept the mail-order cost-sharing amounts for a long-term supply of maintenance drugs. In this case you may be responsible for the difference in price. Your Pharmacy Directory tells you which pharmacies in our network can give you a long-term supply of maintenance drugs. You can find a pharmacy search tool on our Member Portal at https://memberportal.navitus.com. You can also call Customer Care for more information (phone numbers are printed on the back cover of this booklet).

2. Select Retail pharmacies in our network allow you to get a long-term supply of drugs for a reduced copayment. For these Select Retail pharmacies, you will only be charged twice your 1-month retail copayment for a 90-day supply. You can take advantage of this benefit by visiting one of the participating Select Retail pharmacies which include the UC Medical Center retail pharmacies, Costco, CVS, Vons/Safeway, Walmart or Walgreens.

3. You can use the plan’s network mail-order services. Our plan’s mail-order service allows you to order up to a 90-day supply. See Section 2.3 for more information about using our mail-order services.

You may be able to receive greater than a 1-month supply for most of the drugs on your formulary. Drugs noted with “NDS” (Non-extended Day Supply) on the list are limited to a 1-month supply for retail, mail-order and specialty pharmacies.



Section 2.5 When can you use a pharmacy that is not in the plan’s network?

Your prescription may be covered in certain situations

Generally, we cover drugs filled at an out-of-network pharmacy only when you are not able to use a network pharmacy. If you cannot use a network pharmacy, here are the circumstances when we would cover prescriptions filled at an out-of-network pharmacy:

• If you are unable to get a covered drug in a timely manner within your area because there are no network pharmacies within a reasonable driving distance that provides 24-hour services.

• If you are trying to fill a covered drug that is not regularly stocked at an eligible network retail pharmacy or mail order pharmacy. (These drugs include orphan drugs or other specialty pharmaceuticals.)

• Please note that out-of-network prescriptions are limited to reimbursement for a single refill of up to a 30-day supply. If you are planning an extended stay in an area without a network pharmacy, please call Customer Care for assistance in signing up for mail order service.

• If you are filling prescriptions at an out-of-network pharmacy related to a medical emergency.

• Additionally, the pharmacy is not located outside the United States or its territories.

In these situations, please check first with Customer Care to see if there is a network pharmacy nearby. (Phone numbers for Customer Care are printed on the back cover of this booklet.) You may be required to pay the difference between what you pay for the drug at the out-of-network pharmacy and the cost that we would cover at an in-network pharmacy.

How do you ask for reimbursement from your plan?

If you must use an out-of-network pharmacy, you will generally have to pay the full cost (rather than your normal share of the cost) at the time you fill your prescription. You can ask us to reimburse you for our share of the cost. (Chapter 5, Section 2.1 explains how to ask your plan to pay you back.)

After all benefits are provided under your retiree drug coverage, in addition to paying your copayments/coinsurances, you will be required to pay the difference between what we would pay for a prescription filled at an in-network pharmacy and what the out-of-network pharmacy charged for your prescriptions.


SECTION 3 Your drugs need to be on the plan’s “Formulary”

Section 3.1 The “Formulary” tells which Part D drugs are covered

The plan has a “List of Covered Drugs (Formulary)”.

The drugs on this list are selected by your plan with the help of a team of doctors and pharmacists. The list must meet requirements set by Medicare. Medicare has approved the plan’s Formulary.

The drugs on the Formulary are only those covered under Medicare Part D (earlier in this chapter, Section 1.1 explains about Part D drugs).

We will generally cover a drug on your plan’s Formulary as long as you follow the other coverage rules explained in this chapter and the use of the drug is a medically accepted indication. A “medically accepted indication” is a use of the drug that is either:

• Approved by the Food and Drug Administration. (That is, the Food and Drug Administration has approved the drug for the diagnosis or condition for which it is being prescribed.)

• -- or -- Supported by certain references, such as the American Hospital Formulary Service Drug Information and the DRUGDEX Information System.

The Formulary includes both brand name and generic drugs

A generic drug is a prescription drug that has the same active ingredients as the brand name drug. Generally, it works just as well as the brand name drug and usually costs less. There are generic drug substitutes available for many brand name drugs.

What is not on the Formulary?

Your plan does not cover all prescription drugs.

• In some cases, the law does not allow any Medicare plan to cover certain types of drugs (for more about this, see Section 7.1 in this chapter).

• In other cases, we have decided not to include a particular drug on our Formulary.

Section 3.2 There are four “cost-sharing tiers” for drugs on the Formulary

Every drug on your plan’s Formulary is in one of four cost-sharing tiers. In general, the higher the cost-sharing tier, the higher your cost for the drug.

To find out which cost-sharing tier your drug is in, look it up in the Formulary.


The amount you pay for drugs in each cost-sharing tier is shown in Chapter 4 (What you pay for your Part D prescription drugs).

• Tier $0: Select generics (not all dosages of these drugs are covered at the Select Generics cost share)

• Tier 1: Preferred generics and certain lower cost brand products

• Tier 2: Preferred brand products and some high cost non-preferred generics

• Tier 3: Non-preferred products (could include some high cost non-preferred generics)

• Tier 4: Specialty products

Section 3.3 How can you find out if a specific drug is on the Formulary?

You have two ways to find out:

1. Check the most recent Formulary provided electronically on the Navitus MedicareRx Member Portal (https://memberportal.navitus.com). (Please note: If one of your drugs is not listed in the Formulary, you should visit our Member Portal or contact Customer Care to find out if we cover it.) The Formulary on the Member Portal is always the most current.

2. Call Customer Care to find out if a particular drug is on the plan’s Formulary or to ask for a copy of the list. (Phone numbers for Customer Care are printed on the back cover of this booklet.)

SECTION 4 There are restrictions on coverage for some drugs

Section 4.1 Why do some drugs have restrictions?

For certain prescription drugs, special rules restrict how and when your plan covers them. A team of doctors and pharmacists developed these rules to help our members use drugs in the most effective ways. These special rules also help control overall drug costs, which keeps your drug coverage more affordable.

In general, our rules encourage you to get a drug that works for your medical condition and is safe and effective. Whenever a safe, lower-cost drug will work just as well medically as a higher-cost drug, your plan’s rules are designed to encourage you and your prescriber to use that lower-cost option. We also need to comply with Medicare’s rules and regulations for drug coverage and cost sharing.

If there is a restriction for your drug, it usually means that you or your prescriber will have to take extra steps in order for us to cover the drug. If you want us to waive the restriction for you, you will need to use the coverage decision process and ask us to make an exception. We



may or may not agree to waive the restriction for you. (See Chapter 7, Section 5.2 for information about asking for exceptions.)

Please note that sometimes a drug may appear more than once in our Formulary. This is because different restrictions or cost sharing may apply based on factors such as the strength, amount, or form of the drug prescribed by your health care provider (for instance, 10 mg versus 100 mg; one per day versus two per day; tablet versus liquid).

Section 4.2 What kinds of restrictions?

Our plan uses different types of restrictions to help our members use drugs in the most effective ways. The sections below tell you more about the types of restrictions we use for certain drugs.

Restricting brand name drugs when a generic version is available

Generally, a “generic” drug works the same as a brand name drug and usually costs less. In most cases, when a generic version of a brand name drug is available, our network pharmacies will provide you the generic version. We usually will not cover the brand name drug when a generic version is available.

The Formulary indicates what you will pay for your drug. A generic drug is the same as a brand-name drug in dosage, safety and strength. When a generic drug is available and you or your prescriber choose the brand-name drug, you must pay the applicable brand copay plus the difference between the cost of the brand-name drug and the generic equivalent. With a prior authorization request, an exception for medical necessity may be made and you will pay the Tier 3 (non-preferred) applicable copay.

Note: The difference between the cost of the brand drug and the generic (DAW penalty) does not accumulate toward the UC High Option Supplement to Medicare Annual Prescription Maximum Out-of-Pocket.

This Dispense as Written (DAW) cost-sharing penalty will not exceed the cost of the medication.

Coverage for out-of-country drugs

Outpatient prescription drugs are not covered by Medicare Part D plans when they are filled by pharmacies outside of the United States.

Your UC plan provides coverage for outpatient prescription drugs when all of the following apply:

• You remain a permanent resident of the United States while you are out of country, • The drug is approved by the Food and Drug Administration (FDA), and • The drug would be a covered drug by your plan if the drug was filled by a pharmacy

located within the United States.


When you receive coverage for outpatient prescription drugs filled at a pharmacy outside the United States, you will need to pay the full cost of the drug and request that we reimburse you for our share. Your share of a covered outpatient drug will be your coinsurance or copayment amount. Please see “How to ask us to pay you back” in Chapter 5, Section 2, for detailed instructions.

Getting plan approval in advance

For certain drugs, you or your prescriber need to get approval from us before we will agree to cover the drug for you. This is called “prior authorization.” Sometimes the requirement for getting approval in advance helps guide appropriate use of certain drugs. If you do not get this approval, your drug might not be covered by the plan.

Trying a different drug first

This requirement encourages you to try less costly but usually just as effective drugs before your plan covers another drug. For example, if Drug A and Drug B treat the same medical condition, your plan may require you to try Drug A first. If Drug A does not work for you, your plan will then cover Drug B. This requirement to try a different drug first is called “step therapy.”

Quantity limits

For certain drugs, we limit the amount of the drug that you can have by limiting how much of a drug you can get each time you fill your prescription. For example, if it is normally considered safe to take only one pill per day for a certain drug, we may limit coverage for your prescription to no more than one pill per day.

Section 4.3 Do any of these restrictions apply to your drugs?

The plan’s Formulary includes information about the restrictions described above. To find out if any of these restrictions apply to a drug you take or want to take, check the Formulary. For the most up-to-date information, call Customer Care (phone numbers are printed on the back cover of this booklet) or check our Member Portal (https://memberportal.navitus.com).

If there is a restriction for your drug, it usually means that you or your prescriber will have to take extra steps in order for us to cover the drug. If there is a restriction on the drug you want to take, you should contact Customer Care to learn what you or your prescriber would need to do to get coverage for the drug. If you want us to waive the restriction for you, you will need to use the coverage decision process and ask us to make an exception. We may or may not agree to waive the restriction for you. (See Chapter 7, Section 5.2 for information about asking for exceptions.)



SECTION 5 What if one of your drugs is not covered in the way you’d like it to be covered?

Section 5.1 There are things you can do if your drug is not covered in the way you’d like it to be covered

We hope that your drug coverage will work well for you. But it’s possible that there could be a prescription drug you are currently taking, or one that you and your prescriber think you should be taking that is not on our formulary or is on our formulary with restrictions. For example:

• The drug might not be covered at all. Or maybe a generic version of the drug is covered but the brand name version you want to take is not covered.

• The drug is covered, but there are extra rules or restrictions on coverage for that drug. As explained in Section 4, some of the drugs covered by your plan have extra rules to restrict their use. For example, you might be required to try a different drug first, to see if it will work, before the drug you want to take will be covered for you. Or there might be limits on what amount of the drug (number of pills, etc.) is covered during a particular time period. In some cases, you may want us to waive the restriction for you.

• The drug is covered, but it is in a cost-sharing tier that makes your cost sharing more expensive than you think it should be. Your plan puts each covered drug into one of four different cost-sharing tiers. How much you pay for your prescription depends in part on which cost-sharing tier your drug is in.

There are things you can do if your drug is not covered in the way that you’d like it to be covered. Your options depend on what type of problem you have:

• If your drug is not on the Formulary or if your drug is restricted, go to Section 5.2 to learn what you can do.

• If your drug is in a cost-sharing tier that makes your cost more expensive than you think it should be, go to Section 5.3 to learn what you can do.

Section 5.2 What can you do if your drug is not on the Formulary or if the drug is restricted in some way?

If your drug is not on the Formulary or is restricted, here are things you can do:

• You may be able to get a temporary supply of the drug (only members in certain situations can get a temporary supply). This will give you and your prescriber time to change to another drug or to file a request to have the drug covered.

• You can change to another drug.

• You can request an exception and ask your plan to cover the drug or remove restrictions from the drug.


You may be able to get a temporary supply

Under certain circumstances, your plan must offer a temporary supply of a drug to you when your drug is not on the Formulary or when it is restricted in some way. Doing this gives you time to talk with your prescriber about the change in coverage and figure out what to do.

To be eligible for a temporary supply, you must meet the two requirements below:

1. The change to your drug coverage must be one of the following types of changes:

• The drug you have been taking is no longer on your plan’s Formulary.

• -- or -- The drug you have been taking is now restricted in some way (Section 4 in this chapter explains restrictions).

2. You must be in one of the situations described below:

• For those members who are new or who were in the plan last year: We will cover a temporary supply of your drug during the first 90 days of your membership in the plan if you were new and during the first 90 days of the calendar year if you were in the plan last year. This temporary supply will be for a maximum of a 30-day supply. If your prescription is written for fewer days, we will allow multiple fills to provide up to a maximum of a 30-day supply of medication. The prescription must be filled at a network pharmacy. (Please note that the long-term care pharmacy may provide the drug in smaller amounts at a time to prevent waste.)

• For those members who have been in the plan for more than 90 days and reside in a long-term care (LTC) facility and need a supply right away: We will cover one 31-day supply of a particular drug, or less if your prescription is written for fewer days. This is in addition to the above temporary supply situation.

Level of Care Changes

We will provide a one-time 31-day transition supply per drug, which will cover a temporary supply if you have a change in your medications due to a level-of-care change. A level of care change may include:

• Entering or leaving a LTC facility • Being discharged from a hospital to a home • Ending a Medicare Part A skilled nursing facility stay • Giving up hospice status and reverting back to standard Medicare benefits • Ending an LTC facility stay and return home

To ask for a temporary supply, call Customer Care (phone numbers are printed on the back cover of this booklet).


During the time when you are getting a temporary supply of a drug, you should talk with your prescriber to decide what to do when your temporary supply runs out. You can either switch to a different drug covered by your plan or ask your plan to make an exception for you and cover your current drug. The sections below tell you more about these options.

You can change to another drug

Start by talking with your prescriber. Perhaps there is a different drug covered by your plan that might work just as well for you. You can call Customer Care to ask for a list of covered drugs that treat the same medical condition. This list can help your prescriber find a covered drug that might work for you. (Phone numbers for Customer Care are printed on the back cover of this booklet.)

You can ask for an exception

You and your prescriber can ask us to make an exception for you and cover the drug in the way you would like it to be covered. If your prescriber says that you have medical reasons that justify asking us for an exception, your prescriber can help you request an exception to the rule. For example, you can ask us to cover a drug even though it is not on your plan’s Formulary. Or you can ask us to make an exception and cover the drug without restrictions.

If you are a current member and a drug you are taking will be removed from the formulary or restricted in some way for next year, we will allow you to request a formulary exception in advance for next year. We will explain any change in the coverage for your drug for next year. You can ask for an exception before next year, and we will give you an answer within 72 hours after we receive your request (or your prescriber’s supporting statement). If we approve your request, we will authorize the coverage before the change takes effect.

If you and your prescriber want to ask for an exception, Chapter 7, Section 5.4 tells what to do. It explains the procedures and deadlines that have been set by Medicare to make sure your request is handled promptly and fairly.

Section 5.3 What can you do if your drug is in a cost-sharing tier you think is too high?

If your drug is in a cost-sharing tier you think is too high, here are things you can do:

You can change to another drug

If your drug is in a cost-sharing tier you think is too high, start by talking with your prescriber. Perhaps there is a different drug in a lower cost-sharing tier that might work just as well for you. You can call Customer Care to ask for a list of covered drugs that treat the same medical condition. This list can help your prescriber find a covered drug that might work for you. (Phone numbers for Customer Care are printed on the back cover of this booklet.)


You can ask for an exception

You and your prescriber can ask us to make an exception in the cost-sharing tier for the drug so that you pay less for it. If your prescriber says that you have medical reasons that justify asking us for an exception, your prescriber can help you request an exception to the rule.

If you and your prescriber want to ask for an exception, Chapter 7, Section 5.4 tells what to do. It explains the procedures and deadlines that have been set by Medicare to make sure your request is handled promptly and fairly.

Drugs of our Tier 4 (Specialty products) are not eligible for this type of exception. We do not lower the cost-sharing amount for drugs in this tier.

SECTION 6 What if your coverage changes for one of your drugs?

Section 6.1 The Formulary can change during the year

Most of the changes in drug coverage happen at the beginning of each year (January 1). However, during the year, your plan might make changes to the Formulary. For example, the plan might:

• Add or remove drugs from the Formulary. New drugs become available, including new generic drugs. Perhaps the government has given approval to a new use for an existing drug. Sometimes, a drug gets recalled and we decide not to cover it. Or we might remove a drug from the list because it has been found to be ineffective.

• Move a drug to a higher or lower cost-sharing tier.

• Add or remove a restriction on coverage for a drug (for more information about restrictions to coverage, see Section 4 in this chapter).

• Replace a brand name drug with a generic drug.

We must follow Medicare requirements before we change your plan’s Formulary.

Section 6.2 What happens if coverage changes for a drug you are taking?

Information on changes to drug coverage

When changes to the Formulary occur during the year, we post information on our Member Portal about those changes. We will update our online Formulary on a regularly scheduled basis to include any changes that have occurred after the last update. Below we point out the times that you would get direct notice if changes are made to a drug that you are then taking. You can also call Customer Care for more information (phone numbers are printed on the back cover of this booklet).


Do changes to your drug coverage affect you right away?

Changes that can affect you this year: In the below cases, you will be affected by the coverage changes during the current year:

Advance General Notice that Navitus MedicareRx may immediately substitute new generic drugs:

• A new generic drug replaces a brand name drug on the Formulary (or we change the cost-sharing tier or add new restrictions to the brand name drug or both)

o We may immediately remove a brand name drug on our Formulary if we are replacing it with a newly approved generic version of the same drug that will appear on the same or lower cost-sharing tier and with the same or fewer restrictions. Also, when adding the new generic drug, we may decide to keep the brand name drug on our Formulary, but immediately move it to a higher cost-sharing tier or add new restrictions or both.

o We may not tell you in advance before we make that change—even if you are currently taking the brand name drug,

o You or your prescriber can ask us to make an exception and continue to cover the brand name drug for you. For information on how to ask for an exception, see Chapter 7 (What to do if you have a problem or complaint (coverage decisions, appeals, complaints)).

o If you are taking the brand name drug at the time we make the change, we will provide you with information about the specific change(s) we made. This will also include information on the steps you may take to request an exception to cover the brand name drug. You may not get this notice before we make the change.

• Unsafe drugs and other drugs on the Formulary that are withdrawn from the market

o Once in a while, a drug may be suddenly withdrawn because it has been found to be unsafe or removed from the market for another reason. If this happens, we will immediately remove the drug from the Formulary. If you are taking that drug, we will let you know of this change right away.

o Your prescriber will also know about this change, and can work with you to find another drug for your condition.

• Other changes to drugs on the Formulary o We may make other changes once the year has started that affect drugs you are

taking. For instance, we might add a generic drug that is not new to the market to replace a brand name drug or change the cost-sharing tier or add new restrictions to the brand name drug or both. We also might make changes based on FDA boxed warnings or new clinical guidelines recognized by Medicare. We must give


you at least 30 days’ advance notice of the change or give you notice of the change and a 30-day refill of the drug you are taking at a network pharmacy.

o After you receive notice of the change, you should be working with your prescriber to switch to a different drug that we cover.

o Or you or your prescriber can ask us to make an exception and continue to cover the drug for you. For information on how to ask for an exception, see Chapter 7 (What to do if you have a problem or complaint (coverage decisions, appeals, complaints)).

Changes to drugs on the Formulary that will not affect people currently taking the drug: For changes to the Formulary that are not described above, if you are currently taking the drug, the following types of changes will not affect you until January 1 of the next year if you stay in your plan:

• If we move your drug into a higher cost-sharing tier.

• If we put a new restriction on your use of the drug.

• If we remove your drug from the Formulary.

If any of these changes happen for a drug you are taking (but not because of a market withdrawal, a generic drug replacing a brand name drug, a Part D status change or other change noted in the sections above), then the change won’t affect your use or what you pay as your share of the cost until January 1 of the next year. Until that date, you probably won’t see any increase in your payments or any added restriction to your use of the drug. You will not get direct notice this year about changes that do not affect you. However, on January 1 of the next year, the changes will affect you, and it is important to check the Formulary in the new benefit year for any changes to drugs.

SECTION 7 What types of drugs are not covered by the plan?

Section 7.1 Types of drugs we do not cover

This section tells you what kinds of prescription drugs are “excluded.” This means Medicare does not pay for these drugs.

If you get drugs that are excluded and not on the formulary, you must pay for them yourself. We won’t pay for the drugs that are listed in this section (except for certain excluded drugs covered under our supplemental drug coverage). In some cases, excluded drugs may be covered under your medical plan. The only exception: If the requested drug is found upon appeal to be a drug that is not excluded under Part D and we should have paid for or covered it because of your specific situation. (For information about appealing a decision we have made to not cover a drug, go to Chapter 7, Section 5.5 in this booklet.)


Here are a few general rules about drugs that Medicare drug plans will not cover under Part D:

• Our plan’s Part D drug coverage cannot cover a drug that would be covered under Medicare Part A or Part B.

• Our plan cannot cover a drug purchased outside the United States and its territories.

• Our plan usually cannot cover off-label use. “Off-label use” is any use of the drug other than those indicated on a drug’s label as approved by the Food and Drug Administration.

o Generally, coverage for “off-label use” is allowed only when the use is supported by certain references, such as the American Hospital Formulary Service Drug Information and the DRUGDEX Information System. If the use is not supported by any of these references, then our plan cannot cover its “off-label use.”

• Your plan does cover drugs listed on your Formulary, including when these drugs are ingredients in a compound drug.

Also, by law, these categories of drugs are not covered by Medicare drug plans unless your plan covers them as “Extra Covered Drugs”. Please see the “Extra Covered Drugs” section of the benefits chart located in Chapter 4 to find out which of the drugs listed below are covered under your group sponsored plan.

• Non-prescription drugs (also called over-the-counter drugs)

• Drugs when used to promote fertility

• Drugs when used for the relief of cough or cold symptoms

• Drugs when used for cosmetic purposes or to promote hair growth

• Prescription vitamins and mineral products, except prenatal vitamins and fluoride preparations

• Drugs when used for the treatment of sexual or erectile dysfunction

• Drugs when used for treatment of anorexia, weight loss, or weight gain, unless used to treat HIV or cancer wasting

• Outpatient drugs for which the manufacturer seeks to require that associated tests or monitoring services be purchased exclusively from the manufacturer as a condition of sale

We offer additional coverage of some prescription drugs not normally covered in a Medicare prescription drug plan (supplemental drug coverage). These drugs can be found on the Formulary. The amount you pay when you fill a prescription for these drugs does not count toward qualifying you for the Catastrophic Coverage Stage. (The Catastrophic Coverage Stage is described in Chapter 4, Section 7 of this booklet.)

In addition, if you are receiving “Extra Help” from Medicare to pay for your prescriptions, the “Extra Help” program will not pay for the drugs not normally covered. (Please refer to the plan’s Formulary or call Customer Care for more information. Phone numbers for Customer Care are printed on the back cover of this booklet.) However, if you have drug coverage through


Medicaid, your state Medicaid program may cover some prescription drugs not normally covered in a Medicare drug plan. Please contact your state Medicaid program to determine what drug coverage may be available to you. (You can find phone numbers and contact information for Medicaid in Chapter 2, Section 6.)

SECTION 8 Show your plan membership card when you fill a prescription

Section 8.1 Show your membership card

To fill your prescription, show your plan membership card at the network pharmacy you choose. When you show your plan membership card, the network pharmacy will automatically bill your plan for our share of your covered prescription drug cost. You will need to pay the pharmacy your share of the cost when you pick up your prescription.

Section 8.2 What if you don’t have your membership card with you?

If you don’t have your plan membership card with you when you fill your prescription, ask the pharmacy to contact Customer Care to get the necessary information (phone numbers are printed on the back cover of this booklet).

If the pharmacy is not able to get the necessary information, you may have to pay the full cost of the prescription when you pick it up. (You can then ask us to reimburse you for our share. See Chapter 5, Section 2.1 for information about how to ask the plan for reimbursement.)

SECTION 9 Part D drug coverage in special situations

Section 9.1 What if you’re in a hospital or a skilled nursing facility for a stay that is covered by Original Medicare?

If you are admitted to a hospital for a stay covered by Original Medicare, Medicare Part A will generally cover the cost of your prescription drugs during your stay. Once you leave the hospital, our plan will cover your drugs as long as the drugs meet all of our rules for coverage. See the previous parts of this chapter that tell about the rules for getting drug coverage.

If you are admitted to a skilled nursing facility for a stay covered by Original Medicare, Medicare Part A will generally cover your prescription drugs during all or part of your stay. If you are still in the skilled nursing facility, and Part A is no longer covering your drugs, our plan will cover your drugs as long as the drugs meet all of our rules for coverage. See the previous parts of this chapter that tell about the rules for getting drug coverage.

Please Note: When you enter, live in, or leave a skilled nursing facility, you are entitled to a Special Enrollment Period. During this time period, you can switch plans or change your


coverage. (Chapter 8, Ending your membership in the plan, tells when you can leave our plan and join a different Medicare plan.)

Section 9.2 What if you’re a resident in a long-term care (LTC) facility?

Usually, a long-term care facility (LTC) (such as a nursing home) has its own pharmacy, or a pharmacy that supplies drugs for all of its residents. If you are a resident of a long-term care facility, you may get your prescription drugs through the facility’s pharmacy as long as it is part of our network.

Check your Pharmacy Directory to find out if your LTC facility’s pharmacy is part of our network. There is also a pharmacy search tool on our Member Portal at https://memberportal.navitus.com. If the LTC pharmacy isn’t in our network, or if you need more information, please contact Customer Care (phone numbers are printed on the back cover of this booklet).

What if you’re a resident in a long-term care (LTC) facility and become a new member of the plan?

If you need a drug that is not on our Formulary or is restricted in some way, the plan will cover a temporary supply of your drug during the first 90 days of your membership. The total supply will be for a maximum of a 31-day supply, or less if your prescription is written for fewer days. (Please note that the long-term care pharmacy may provide the drug in smaller amounts at a time to prevent waste.) If you have been a member of the plan for more than 90 days and need a drug that is not on our Formulary or if the plan has any restriction on the drug’s coverage, we will cover one 31-day supply, or less if your prescription is written for fewer days.

During the time when you are getting a temporary supply of a drug, you should talk with your prescriber to decide what to do when your temporary supply runs out. Perhaps there is a different drug covered by the plan that might work just as well for you. Or you and your prescriber can ask the plan to make an exception for you and cover the drug in the way you would like it to be covered. If you and your prescriber want to ask for an exception, Chapter 7, Section 5.4 tells what to do.

Section 9.3 What if you are taking drugs covered by Original Medicare?

Your enrollment in Navitus MedicareRx doesn’t affect your coverage for drugs covered under Medicare Part A or Part B. If you meet Medicare’s coverage requirements, your drug will still be covered under Medicare Part A or Part B, even though you are enrolled in this plan. In addition, if your drug would be covered by Medicare Part A or Part B, our plan can’t cover it, even if you choose not to enroll in Part A or Part B.

Some drugs may be covered under Medicare Part B in some situations and through Navitus MedicareRx in other situations. But drugs are never covered by both Part B and our plan at the



same time. In general, your pharmacist or prescriber will determine whether to bill Medicare Part B or Navitus MedicareRx for the drug.

Section 9.4 What if you have a Medigap (Medicare Supplement Insurance) policy with prescription drug coverage?

If you currently have a Medigap policy that includes coverage for prescription drugs, you must contact your Medigap issuer and tell them you have enrolled in our plan. If you decide to keep your current Medigap policy, your Medigap issuer will remove the prescription drug coverage portion of your Medigap policy and lower your premium.

Each year your Medigap insurance company should send you a notice that tells if your prescription drug coverage is “creditable,” and the choices you have for drug coverage. (If the coverage from the Medigap policy is “creditable,” it means that it is expected to pay, on average, at least as much as Medicare’s standard prescription drug coverage.) The notice will also explain how much your premium would be lowered if you remove the prescription drug coverage portion of your Medigap policy. If you didn’t get this notice, or if you can’t find it, contact your Medigap insurance company and ask for another copy.

Section 9.5 What if you’re also getting drug coverage from an employer or retiree group plan?

Do you currently have other prescription drug coverage through your (or your spouse’s) employer or retiree group? If so, please contact that group’s sponsor. They can help you determine how your current prescription drug coverage will work with our plan.

In general, if you are currently employed, the prescription drug coverage you get from us will be secondary to your employer or retiree group coverage. That means your group coverage would pay first.

Special note about ‘creditable coverage’:

Each year your employer or retiree group should provide you a notice that tells if your prescription drug coverage for the next calendar year is “creditable” and the choices you have for drug coverage.

If the coverage from the group plan is “creditable,” it means that the plan has drug coverage that is expected to pay, on average, at least as much as Medicare’s standard prescription drug coverage.

Keep these notices about creditable coverage, because you may need them later. If you enroll in a Medicare plan that includes Part D drug coverage, you may need these notices to show that you have maintained creditable coverage. If you didn’t get a notice about creditable coverage from your employer or retiree group plan, you can get a copy from the employer or retiree group’s benefits administrator or the employer.


Section 9.6 What if you are in Medicare-certified Hospice?

Drugs are never covered by both hospice and our plan at the same time. If you are enrolled in Medicare hospice and require an anti-nausea, laxative, pain medication, or anti-anxiety drug that is not covered by your hospice because it is unrelated to your terminal illness and related conditions, our plan must receive notification from either the prescriber or your hospice provider that the drug is unrelated before our plan can cover the drug. To prevent delays in receiving any unrelated drugs that should be covered by our plan, you can ask your hospice provider or prescriber to make sure we have the notification that the drug is unrelated before you ask a pharmacy to fill your prescription.

In the event you either revoke your hospice election or are discharged from hospice, our plan should cover all your drugs. To prevent any delays at a pharmacy when your Medicare hospice benefit ends, you should bring documentation to the pharmacy to verify your revocation or discharge. See the previous parts of this section that tell about the rules for getting drug coverage under Part D. Chapter 4 (What you pay for your Part D prescription drugs) gives more information about drug coverage and what you pay.

SECTION 10 Programs on drug safety and managing medications

Section 10.1 Programs to help members use drugs safely

We conduct drug use reviews for our members to help make sure that they are getting safe and appropriate care. These reviews are especially important for members who have more than one prescriber who prescribes their drugs.

We do a review each time you fill a prescription. We also review our records on a regular basis. During these reviews, we look for potential problems such as:

• Possible medication errors

• Drugs that may not be necessary because you are taking another drug to treat the same medical condition

• Drugs that may not be safe or appropriate because of your age or gender

• Certain combinations of drugs that could harm you if taken at the same time

• Prescriptions written for drugs that have ingredients you are allergic to

• Possible errors in the amount (dosage) of a drug you are taking

• Unsafe amounts of opioid pain medications

If we see a possible problem in your use of medications, we will work with your prescriber to correct the problem.


Section 10.2 Drug Management Program (DMP) to help members safely use their opioid medications

We have a program that can help make sure our members safely use their prescription opioid medications, and other medications that are frequently abused. This program is called a Drug Management Program (DMP). If you use opioid medications that you get from several doctors or pharmacies, or if you had a recent opioid overdose, we may talk to your doctors to make sure your use of opioid medications is appropriate and medically necessary. Working with your doctors, if we decide your use of prescription opioid or benzodiazepine medications is not safe, we may limit how you can get those medications. The limitations may be:

• Requiring you to get all your prescriptions for opioid or benzodiazepine medications from a certain pharmacy(ies)

• Requiring you to get all your prescriptions for opioid or benzodiazepine medications from a certain doctor(s)

• Limiting the amount of opioid or benzodiazepine medications we will cover for you

If we think that one or more of these limitations should apply to you, we will send you a letter in advance. The letter will have information explaining the limitations we think should apply to you. You will also have an opportunity to tell us which doctors or pharmacies you prefer to use, and about any other information you think is important for us to know. After you have had the opportunity to respond, if we decide to limit your coverage for these medications, we will send you another letter confirming the limitation. If you think we made a mistake or you disagree with our determination that you are at-risk for prescription drug misuse or with the limitation, you and your prescriber have the right to ask us for an appeal. If you choose to appeal, we will review your case and give you a decision. If we continue to deny any part of your request related to the limitations that apply to your access to medications, we will automatically send your case to an independent reviewer outside of our plan for review and resolution. See Chapter 7 for information about how to ask for an appeal.

The DMP may not apply to you if you have certain medical conditions, such as cancer or sickle cell disease, you are receiving hospice, palliative, or end-of-life care, or live in a long-term care facility.

Section 10.3 Medication Therapy Management (MTM) program to help members manage their medications

We have a program that can help our members with complex health needs.

This program is voluntary and free to members. A team of pharmacists and doctors developed the program for us. This program can help make sure that our members get the most benefit from the drugs they take. Our program is called a Medication Therapy Management (MTM) program.

Some members who take medications for different medical conditions and have high drug costs, or are in a Drug Management Program (DMP) to help members use their opioids safely, may be able to get services through an MTM program. A pharmacist or other health professional will


give you a comprehensive review of all your medications. You can talk about how best to take your medications, your costs, and any problems or questions you have about your prescription and over-the-counter medications. You’ll get a written summary of this discussion. The summary has a medication action plan that recommends what you can do to make the best use of your medications, with space for you to take notes or write down any follow-up questions. You’ll also get a personal medication list that will include all the medications you’re taking and why you take them. In addition, members in the MTM program will receive information on the safe disposal of prescription medications that are controlled substances.

It’s a good idea to have your medication review before your yearly “Wellness” visit, so you can talk to your doctor about your action plan and medication list. Bring your action plan and medication list with you to your visit or anytime you talk with your doctors, pharmacists, and other health care prescribers. Also, keep your medication list with you (for example, with your ID) in case you go to the hospital or emergency room.

If we have a program that fits your needs, we will automatically enroll you in the program and send you information. If you decide not to participate, please notify us and we will withdraw you from the program. If you have any questions about these programs, please contact Customer Care (phone numbers are printed on the back cover of this booklet).

If you have specific questions about this program, please contact the Medication Therapy Management (MTM) program team. You can call us at 1-833-837-4304, Monday through Thursday 9 am to 6 pm Central Standard Time and on Friday 9 am to 4 pm Central Standard Time. TTY/TDD users should call 711.

CHAPTER 4 What you pay for your Part D

prescription drugs

2022 Evidence of Coverage for Navitus MedicareRx (PDP) 62 Chapter 4. What you pay for your Part D prescription drugs

Chapter 4. What you pay for your Part D prescription drugs

SECTION 1 Introduction............................................................................................ 64

Section 1.1 Use this chapter together with other materials that explain your drug coverage ................................................................................................... 64

Section 1.2 Types of out-of-pocket costs you may pay for covered drugs ...................... 65

SECTION 2 What you pay for a drug depends on which “drug payment stage” you are in when you get the drug.......................................... 65

Section 2.1 What are the drug payment stages for Navitus MedicareRx (PDP) members?.................................................................................................. 65

SECTION 3 We send you reports that explain payments for your drugs and which payment stage you are in ................................................. 66

Section 3.1 We send you a monthly summary called the “Part D Explanation of Benefits” (the “Part D EOB”) .................................................................... 66

Section 3.2 Help us keep our information about your drug payments up to date ............ 67

SECTION 4 There is no deductible for Navitus MedicareRx .............................. 68

Section 4.1 You do not pay a deductible for your Part D drugs. .................................... 68

SECTION 5 During the Initial Coverage Stage, the plan pays its share of your drug costs and you pay your share.......................................... 68

Section 5.1 What you pay for a drug depends on the drug and where you fill your prescription ............................................................................................... 68

Section 5.2 A table that shows your costs for a one-month supply of a drug .................. 69

Section 5.3 If your doctor prescribes less than a full month’s supply, you may not have to pay the cost of the entire month’s supply........................................ 73

Section 5.4 A table that shows your costs for a long-term (up to a 90-day) supply of a drug .......................................................................................................... 73

Section 5.5 You stay in the Initial Coverage Stage until total drug costs for the year reach $4,430.............................................................................................. 77

SECTION 6 During the Coverage Gap Stage, the plan provides some drug coverage........................................................................................ 77

Section 6.1 You stay in the Coverage Gap Stage until your out-of-pocket costs reach $7,050 ....................................................................................................... 77

Section 6.2 How Medicare calculates your out-of-pocket costs for prescription drugs ... 78


SECTION 7 During the Catastrophic Coverage Stage, the plan pays most of the cost for your drugs.......................................................... 80

Section 7.1 Once you are in the Catastrophic Coverage Stage, you will stay in this stage for the rest of the year ....................................................................... 80

SECTION 8 What you pay for vaccinations covered by Part D depends on how and where you get them ........................................................ 83

Section 8.1 Our plan may have separate coverage for the Part D vaccine medication itself and for the cost of giving you the vaccine .......................................... 83

Section 8.2 You may want to call us at Customer Care before you get a vaccination ..... 84


Did you know there are programs to help people pay for their drugs?

There are programs to help people with limited resources pay for their drugs. These include “Extra Help” and State Pharmaceutical Assistance Programs. For more information, see Chapter 2, Section 7.

Are you currently getting help to pay for your drugs?

If you are in a program that helps pay for your drugs, some information in this Evidence of Coverage about the costs for Part D prescription drugs may not apply to you. We will provide a separate insert, called the “Evidence of Coverage Rider for People Who Get Extra Help Paying for Prescription Drugs” (also known as the “Low Income Subsidy Rider” or the “LIS Rider”), which tells you about your drug coverage. If you are eligible and don’t have this insert, please call Customer Care and ask for the “LIS Rider.” (Phone numbers for Customer Care are printed on the back cover of this booklet.)


Section 1.1 Use this chapter together with other materials that explain your drug coverage

This chapter focuses on what you pay for your Part D prescription drugs. To keep things simple, we use “drug” in this chapter to mean a Part D prescription drug. As explained in Chapter 3, not all drugs are Part D drugs – some drugs are covered under Medicare Part A or Part B and other drugs are excluded from Medicare coverage by law. Some excluded drugs may be covered by our plan because of your supplemental (wrap) drug coverage, and will be included on our Formulary.

To understand the payment information, we give you in this chapter, you need to know the basics of what drugs are covered, where to fill your prescriptions, and what rules to follow when you get your covered drugs. Here are materials that explain these basics:

• The plan’s List of Covered Drugs (Formulary). o This Formulary tells which drugs are covered for you. o It also tells which of the four “cost-sharing tiers” the drug is in and whether there

are any restrictions on your coverage for the drug.

o If you need a copy of the Formulary, call Customer Care (phone numbers are printed on the back cover of this booklet). You can also find the Formulary on our Member Portal at https://memberportal.navitus.com. The Formulary on the Member Portal is always the most current.

• Chapter 3 of this booklet. Chapter 3 gives the details about your prescription drug coverage, including rules you need to follow when you get your covered drugs. Chapter 3 also tells which types of prescription drugs are not covered by our plan.



The plan’s Pharmacy Directory. In most situations you must use a network pharmacy to get your covered drugs (see Chapter 3 for the details). The Pharmacy Directory has a list of pharmacies in the plan’s network. It also tells you which pharmacies in our network can give you a long-term supply of a drug (such as filling a prescription for a three-month’s supply). You can also find a pharmacy search tool on our Member Portal at https://memberportal.navitus.com.

Section 1.2 Types of out-of-pocket costs you may pay for covered drugs

To understand the payment information we give you in this chapter, you need to know about the types of out-of-pocket costs you may pay for your covered services. The amount that you pay for a drug is called “cost sharing,” and there are three ways you may be asked to pay.

• The “deductible” (if your plan has one) is the amount you must pay for drugs before our plan begins to pay its share.

• “Copayment” means that you pay a fixed amount each time you fill a prescription.

• “Coinsurance” means that you pay a percent of the total cost of the drug each time you fill a prescription.

Maximum Out-of-Pocket

Prescription Maximum Out-of-Pocket (Supplement to Medicare)

UC Medicare PPO with Rx Plan Not Applicable

UC High Option Supplement to Medicare Plan $1000 *

* Once you reach the $1000 UC High Option Maximum Out-of-Pocket, the plan covers 100% of the cost of covered drugs until next year. (If the UC Maximum Out-Of-Pocket has not been met, the payment responsibility changes after Part D (PDP) TrOOP of $7,050 is met.)

SECTION 2 What you pay for a drug depends on which “drug payment stage” you are in when you get the drug

Section 2.1 What are the drug payment stages for Navitus MedicareRx (PDP) members?

As shown in the table below, there are four “drug payment stages” for your prescription drug coverage under Navitus MedicareRx. How much you pay for a drug depends on which of these stages you are in at the time you get a prescription filled or refilled. Keep in mind you are always responsible for the plan’s monthly premium regardless of the drug payment stage.



Stage 1 Yearly Deductible

Stage

Stage 2 Initial Coverage

Stage

Stage 3 Coverage Gap

Stage

Stage 4 Catastrophic

Coverage Stage

Because there is no deductible for the plan, this payment stage does not apply to you.

You begin in this stage when you fill your first prescription of the year. During this stage, your plan pays its share of the cost of your drugs and you pay your share of the cost. You stay in this stage until your year-to-date “total drug costs” (your payments plus any Part D plan’s payments) total $4,430. (Details are in Section 5 of this chapter.)

Your plan will continue to pay for your drug costs when the Medicare plan does not; you will be responsible for your copayment/ coinsurance if applicable. You stay in this stage until your year-to-date “out-of-pocket costs” (your payments) reach a total of $7,050. This amount and rules for counting costs toward this amount have been set by Medicare. (Details are in Section 6 of this chapter.)

During this stage, the plan will pay most of the cost of your drugs for the rest of the calendar year (through December 31, 2022). (Details are in Section 7 of this chapter.)

SECTION 3 We send you reports that explain payments for your drugs and which payment stage you are in

Section 3.1 We send you a monthly summary called the “Part D Explanation of Benefits” (the “Part D EOB”)

Our plan keeps track of the costs of your prescription drugs and the payments you have made when you get your prescriptions filled or refilled at the pharmacy. This way, we can tell you when you have moved from one drug payment stage to the next. In particular, there are two types of costs we keep track of:

• We keep track of how much you have paid. This is called your “out-of-pocket” cost.

• We keep track of your “total drug costs.” This is the amount you pay out-of-pocket or others pay on your behalf plus the amount paid by the plan.

Our plan will prepare a written summary called the Part D Explanation of Benefits (it is sometimes called the “EOB”) when you have had one or more prescriptions filled through the


plan during the previous month. The Part D EOB provides more information about the drugs you take, such as increases in price and other drugs with lower cost sharing that may be available. You should consult with your prescriber about these lower cost options. The Part D EOB includes:

• Information for that month. This report gives the payment details about the prescriptions you have filled during the previous month. It shows the total drugs costs, what your plan paid, and what you and others on your behalf paid.

• Totals for the year since January 1. This is called “year-to-date” information. It shows you the total drug costs and total payments for your drugs since the year began.

• Drug price information. This information will display the total drug price, and any percentage change from the first fill for each prescription claim of the same quantity.

• Available lower cost alternative prescriptions. This will include information about other drugs with lower cost sharing for each prescription claim that may be available.

Section 3.2 Help us keep our information about your drug payments up to date

To keep track of your drug costs and the payments you make for drugs, we use records we get from pharmacies. Here is how you can help us keep your information correct and up to date:

• Show your membership ID card when you get a prescription filled. To make sure we know about the prescriptions you are filling and what you are paying, show your plan membership card every time you get a prescription filled.

• Make sure we have the information we need. There are times you may pay for prescription drugs when we will not automatically get the information we need to keep track of your out-of-pocket costs. To help us keep track of your out-of-pocket costs, you may give us copies of receipts for drugs that you have purchased. (If you are billed for a covered drug, you can ask our plan to pay our share of the cost. For instructions on how to do this, go to Chapter 5, Section 2 of this booklet.) Here are some types of situations when you may want to give us copies of your drug receipts to be sure we have a complete record of what you have spent for your drugs:

o When you purchase a covered drug at a network pharmacy at a special price or using a discount card that is not part of our plan’s benefit.

o When you made a copayment for drugs that are provided under a drug manufacturer patient assistance program.

o Any time you have purchased covered drugs at out-of-network pharmacies or other times you have paid the full price for a covered drug under special circumstances.

• Send us information about the payments others have made for you. Payments made by certain other individuals and organizations also count toward your out-of-pocket costs and help qualify you for catastrophic coverage. For example, payments made by a State Pharmaceutical Assistance Program, an AIDS drug assistance program (ADAP), the


Indian Health Service, and most charities count toward your out-of-pocket costs. You should keep a record of these payments and send them to us so we can track your costs.

• Check the written report we send you. When you receive the Part D Explanation of Benefits (an EOB) in the mail, please look it over to be sure the information is complete and correct. If you think something is missing from the report, or you have any questions, please call us at Customer Care (phone numbers are printed on the back cover of this booklet). Be sure to keep these reports. They are an important record of your drug expenses.

SECTION 4 There is no deductible for Navitus MedicareRx

Section 4.1 You do not pay a deductible for your Part D drugs.

There is no deductible for Navitus MedicareRx. You begin in the Initial Coverage Stage when you fill your first prescription of the year. See Section 5 for information about your coverage in the Initial Coverage Stage.

SECTION 5 During the Initial Coverage Stage, the plan pays its share of your drug costs and you pay your share

Section 5.1 What you pay for a drug depends on the drug and where you fill your prescription

During the Initial Coverage Stage, the plan pays its share of the cost of your covered prescription drugs, and you pay your share (your copayment or coinsurance amount). Your share of the cost will vary depending on the drug and where you fill your prescription.

The plan has four Cost-Sharing Tiers To find out which cost-sharing tier your drug is in, please check our plan’s Formulary. Every drug on the plan’s Formulary is in one of four cost-sharing tiers. In general, the higher the cost-sharing tier number, the higher your cost for the drug:

• Tier $0 includes select generics

• Tier 1 includes preferred generics and certain lower cost brand products

• Tier 2 includes preferred brand products and some high cost non-preferred generics

• Tier 3 includes non-preferred products (could include some high cost non-preferred generics)

• Tier 4 includes specialty products


Your pharmacy choices

How much you pay for a drug depends on whether you get the drug from:

• A retail pharmacy that is in our plan’s network

• A pharmacy that is not in the plan’s network

• The plan’s mail-order pharmacy

• The plan’s specialty pharmacy

For more information about these pharmacy choices and filling your prescriptions, see Chapter 3 in this booklet and the plan’s Pharmacy Directory.

Section 5.2 A table that shows your costs for a one-month supply of a drug

During the Initial Coverage Stage, your share of the cost of a covered drug will be either a copayment or coinsurance.

• “Copayment” means that you pay a fixed amount each time you fill a prescription.

• “Coinsurance” means that you pay a percent of the total cost of the drug each time you fill a prescription.

As shown in the table below, the amount of the copayment or coinsurance depends on which tier your drug is in. Please note:

• If your covered drug costs less than the copayment amount listed in the chart, you will pay that lower price for the drug. You pay either the full price of the drug or the copayment amount, whichever is lower.

• We cover prescriptions filled at out-of-network pharmacies in only limited situations. Please see Chapter 3, Section 2.5 for information about when we will cover a prescription filled at an out-of-network pharmacy.


Your share of the cost when you get a one-month supply of a covered Part D prescription drug:

Cost-Sharing

Retail cost sharing (in-network)

(up to a 30-day supply)

Mail-order cost sharing (in network)


Long-term care (LTC) cost

sharing (up to a 31-day

supply)

Out-of-network cost sharing

(Coverage is limited to certain situations;

see Chapter 3 for details.) (up to a 30-

day supply) Tier $0 (Select generics; diabetic supplies after Part B pays primary)

$0 copayment

$0 copayment

$0 copayment

$0 copayment

Tier 1 (Preferred generics and certain lower cost brand products; insulin & Part D diabetic supplies)

$10 copayment

$10 copayment

$10 copayment

$10 copayment

Tier 2 (Preferred brand products and some high cost non-preferred generics; insulin & Part D diabetic supplies)

$30 copayment

$30 copayment

$30 copayment

$30 copayment

Tier 3 (Non-preferred products (could include some high cost non-preferred generics); insulin & Part D diabetic supplies)

$45 copayment

$45 copayment

$45 copayment

$45 copayment

Tier 4 (Specialty products)

$30 copayment

$30 copayment

$30 copayment

$30 copayment

Your drug copay or coinsurance may be less, based upon the cost of the drug.


The Formulary indicates what you will pay for your drug. A generic drug is the same as a brand-name drug in dosage, safety and strength. When a generic drug is available and you or your prescriber choose the brand-name drug, you must pay the applicable brand copay plus the difference between the cost of the brand-name drug and the generic equivalent. With a prior authorization request, an exception for medical necessity may be made and you will pay the Tier 3 (non-preferred) applicable copay. Note: The difference between the cost of the brand drug and the generic (DAW penalty) does not accumulate toward the UC High Option Supplement to Medicare Annual Prescription Maximum Out-of-Pocket.






* Once you reach the $1000 UC High Option Maximum Out-of-Pocket, the plan covers 100% of the cost of covered drugs until next year. (If the UC Maximum Out-of-Pocket has not been met, the payment responsibility changes after Part D (PDP) TrOOP of $7,050 is met.)

Extra Covered Drug Benefits (Non-Medicare Part D) – Prescription Required

Formulary Cost Sharing Select Retail (up to 90 days)

Part B Diabetic Supplies (Navitus MedicareRx will coordinate benefits, if submitted after Medicare Part B pays primary, including lancets, blood sugar diagnostics, calibration solutions and glucometers)

$0 copay

Certain drugs that are excluded by law from coverage by Medicare Part D, may be included in the supplemental coverage of your drug plan. Drugs covered under the “Extra Covered Drugs” benefit, will be listed in the Formulary.


Extra covered drug benefits (non-Medicare Part D) – prescription required

Extra Covered Drugs Cost Sharing

Retail & Mail Order

(up to 30 days)

Retail (31-60 days)

Retail (61-90 days)

Mail Order (31-90 days)

Tier 1 non-Medicare covered drugs

$10 copay $20 copay $30 copay $20 copay





Note: These Extra Covered Drugs do not count towards the Medicare TrOOP ($7,050) expenses and they do not qualify for lower catastrophic copays.

Member cost share per tier values in the above table, for:

• Cough and Cold Prescriptions • Erectile Disfunction (ED) – with quantity limit (QL) • Vitamins and Minerals Prescriptions

Coverage for Out of Country Drugs: Outpatient prescription drugs are not covered by Medicare Part D plans when they are filled by pharmacies outside of the United States. Your UC plan provides coverage for outpatient prescription drugs when all of the following apply:

You remain a permanent resident of the United States while you are out of country, and The drug is approved by the Food and Drug Administration (FDA), and The drug would be a covered drug by your plan if the drug was filled by a pharmacy

located within the United States. When you receive coverage for outpatient prescription drugs filled at a pharmacy outside the United States, you will need to pay the full cost of the drug and request that we reimburse you for our share. Your share of a covered outpatient drug will be your coinsurance or copayment amount. Please see “How to ask us to pay you back” for detailed instructions, which can be found in the Evidence of Coverage, Chapter 5, Section 2.


Section 5.3 If your doctor prescribes less than a full month’s supply, you may not have to pay the cost of the entire month’s supply

Typically, the amount you pay for a prescription drug covers a full month’s supply of a covered drug. However, your doctor can prescribe less than a month’s supply of drugs. There may be times when you want to ask your doctor about prescribing less than a month’s supply of a drug (for example, when you are trying a medication for the first time that is known to have serious side effects). If your doctor prescribes less than a full month’s supply, you may not have to pay for the full month’s supply for certain drugs.

The amount you pay when you get less than a full month’s supply will depend on whether you are responsible for paying coinsurance (a percentage of the total cost) or a copayment (a flat dollar amount).

• If you are responsible for coinsurance, you pay a percentage of the total cost of the drug. You pay the same percentage regardless of whether the prescription is for a full month’s supply or for fewer days. However, because the entire drug cost will be lower if you get less than a full month’s supply, the amount you pay will be less.

Section 5.4 A table that shows your costs for a long-term (up to a 90-day) supply of a drug

For some drugs, you can get a long-term supply (also called an “extended supply”) when you fill your prescription. A long-term supply is up to a 90-day supply. (For details on where and how to get a long-term supply of a drug, see Chapter 3, Section 2.4.)

The table below shows what you pay when you get a long-term (up to a 90-day) supply of a drug.

• Please note: If your covered drug costs less than the copayment amount listed in the chart, you will pay that lower price for the drug. You pay either the full price of the drug or the copayment amount, whichever is lower.


Your share of the cost when you get a long-term supply of a covered Part D prescription drug:

Cost Sharing


(31-60 day supply)


(61-90 day supply)

Mail-order cost sharing (in-network)

(61-90 day supply)

Tier $0 (Select generics; diabetic supplies after Part B pays primary)

$0 copayment

$0 copayment

$0 copayment


$20 copayment

$30 copayment

$20 copayment


$60 copayment

$90 copayment

$60 copayment


$90 copayment

$135 copayment

$90 copayment


A long-term supply is not available for

drugs in Tier 4


drugs in Tier 4


drugs in Tier 4

Extended supplies (greater than a 1-month supply) may not be available for all medications. To verify if your medication is excluded from extended supplies, check the Formulary. Medications which do not qualify for extended supplies will be marked with “NDS” on the formulary.

The Formulary indicates what you will pay for your drug. A generic drug is the same as a brand-name drug in dosage, safety and strength. When a generic drug is available and you or your prescriber choose the brand-name drug, you must pay the applicable brand copay plus the difference between the cost of the brand-name drug and the generic equivalent. With a prior authorization request, an exception for medical necessity may be made and you will pay the Tier 3 (non-preferred) applicable copay.


Note: The difference between the cost of the brand drug and the generic (DAW penalty) does not accumulate toward the UC High Option Supplement to Medicare Annual Prescription Maximum Out-of-Pocket.







“Select Retail” Pharmacies

Select Retail Pharmacy Cost Sharing * Select Retail (up to 90 days)

Tier 1 Drugs from Select Retail Pharmacies $20 copay



* Select Retail pharmacies includes the following retail pharmacies: UC Medical Center retail pharmacies, Costco, CVS, Vons/Safeway, Walmart and Walgreens.


Extra Covered Drug Benefits (Non-Medicare Part D) – Prescription Required

Formulary Cost Sharing Select Retail (up to 90 days)

Part B Diabetic Supplies (Navitus MedicareRx will coordinate benefits, if submitted after Medicare Part B pays primary, including lancets, blood sugar diagnostics, calibration solutions and glucometers)

$0 copay

Certain drugs that are excluded by law from coverage by Medicare Part D, may be included in the supplemental coverage of your drug plan. Drugs covered under the “Extra Covered Drugs” benefit, will be listed in the Formulary.


Retail & Mail Order

(up to 30 days)

Retail (31-60 days)

Retail (61-90 days)








Note: These Extra Covered Drugs do not count towards the Medicare TrOOP ($7,050) expenses and they do not qualify for lower catastrophic copays.

Member cost share per tier values in the above table, for:


Coverage for Out of Country Drugs: Outpatient prescription drugs are not covered by Medicare Part D plans when they are filled by pharmacies outside of the United States. Your UC plan provides coverage for outpatient prescription drugs when all of the following apply:

You remain a permanent resident of the United States while you are out of country, and The drug is approved by the Food and Drug Administration (FDA), and The drug would be a covered drug by your plan if the drug was filled by a pharmacy

located within the United States.


When you receive coverage for outpatient prescription drugs filled at a pharmacy outside the United States, you will need to pay the full cost of the drug and request that we reimburse you for our share. Your share of a covered outpatient drug will be your coinsurance or copayment amount. Please see “How to ask us to pay you back” for detailed instructions, which can be found in the Evidence of Coverage, Chapter 5, Section 2.

Section 5.5 You stay in the Initial Coverage Stage until total drug costs for the year reach $4,430

You stay in the Initial Coverage Stage until the total amount for the prescription drugs you have filled and refilled reaches the $4,430 limit for the Initial Coverage Stage.

Your total drug cost is based on adding together what you have paid and what any Part D plan has paid:

• What you have paid for all the covered drugs you have gotten since you started with your first drug purchase of the year. (See Section 6.2 for more information about how Medicare calculates your out-of-pocket costs.) This includes:

o The total you paid as your share of the cost for your drugs during the Initial Coverage Stage.

• What the plan has paid as its share of the cost for your drugs during the Initial Coverage Stage. (If you were enrolled in a different Part D plan at any time during 2022, the amount that plan paid during the Initial Coverage Stage also counts toward your total drug costs.)

We offer additional coverage on some prescription drugs that are not normally covered in a Medicare Prescription Drug Plan. Payments made for these drugs will not count toward your initial coverage limit or total out-of-pocket costs.

The Explanation of Benefits (EOB) that we send to you will help you keep track of how much you and the plan, as well as any third parties, have spent on your behalf during the year. Many people do not reach the $4,430 limit in a year.

We will let you know if you reach this $4,430 amount. If you do reach this amount, you will leave the Initial Coverage Stage and move on to the Coverage Gap Stage.

SECTION 6 During the Coverage Gap Stage, the plan provides some drug coverage

Section 6.1 You stay in the Coverage Gap Stage until your out-of-pocket costs reach $7,050

When you are in the Coverage Gap Stage, the Medicare Coverage Gap Discount Program provides manufacturer discounts on brand name drugs. Your plan will continue to pay for your


drug costs at the Initial Coverage Stage copayments, when the Medicare plan does not; you will be responsible for your formulary copayment as applicable.

Medicare has rules about what counts and what does not count as your out-of-pocket costs. When you reach an out-of-pocket limit of $7,050, you leave the Coverage Gap Stage and move on to the Catastrophic Coverage Stage.

Section 6.2 How Medicare calculates your out-of-pocket costs for prescription drugs

Here are Medicare’s rules that we must follow when we keep track of your out-of-pocket (TrOOP) costs for your drugs.

These payments are included in your out-of-pocket costs

When you add up your out-of-pocket costs, you can include the payments listed below (as long as they are for Part D covered drugs and you followed the rules for drug coverage that are explained in Chapter 3 of this booklet):

• The amount you pay for drugs when you are in any of the following drug payment stages:

o The Initial Coverage Stage o The Coverage Gap Stage

• Any payments you made during this calendar year as a member of a different Medicare prescription drug plan before you joined our plan.

It matters who pays:

• If you make these payments yourself, they are included in your out-of-pocket costs.

• These payments are also included if they are made on your behalf by certain other individuals or organizations. This includes payments for your drugs made by a friend or relative, by most charities, by AIDS drug assistance programs, by a State Pharmaceutical Assistance Program that is qualified by Medicare, or by the Indian Health Service. Payments made by Medicare’s “Extra Help” Program are also included.

• Some of the payments made by the Medicare Coverage Gap Discount Program are included. The amount the manufacturer pays for your brand name drugs is included. But the amount the plan pays for your generic drugs is not included.


Moving on to the Catastrophic Coverage Stage:

When the amount you (or those paying on your behalf) have paid for covered drugs reaches $7,050 in out-of-pocket costs within the calendar year, you will move from the Coverage Gap Stage to the Catastrophic Coverage Stage.

These payments are not included in your out-of-pocket costs

When you add up your out-of-pocket costs, you are not allowed to include any of these types of payments for prescription drugs:

• The amount you pay for your monthly premium.

• Drugs you buy outside the United States and Puerto Rico.

• Drugs that are not covered by our plan.

• Drugs you get at an out-of-network pharmacy that do not meet the plan’s requirements for out-of-network coverage.

• Non-Part D drugs, including prescription drugs covered by Part A or Part B and other drugs excluded from coverage by Medicare.

• Prescription drugs covered by Part A or Part B. • Payments you make toward drugs covered under our additional coverage but not

normally covered in a Medicare Prescription Drug Plan (for example, the “Extra Covered Drugs” benefit).

• Payments you make toward prescription drugs not normally covered in a Medicare Prescription Drug Plan.

• Payments made by the plan for your brand or generic drugs while in the Coverage Gap. • Payments for your drugs that are made by group health plans including employer health

plans. • Payments for your drugs that are made by certain insurance plans and government-funded

health programs such as TRICARE and Veterans Affairs. • Payments for your drugs made by a third-party with a legal obligation to pay for

prescription costs (for example, Workers’ Compensation). Reminder: If any other organization such as the ones listed above pays part or all of your out-of-pocket costs for drugs, you are required to tell our plan. Call Customer Care to let us know (phone numbers are printed on the back cover of this booklet).


How can you keep track of your out-of-pocket total? • We will help you. The Part D Explanation of Benefits (Part D EOB) summary we send

to you includes the current amount of your out-of-pocket costs (Section 3 in this chapter tells about this report). When you reach a total of $7,050 in out-of-pocket costs for the year, this report will tell you that you have left the Coverage Gap Stage and have moved on to the Catastrophic Coverage Stage.

• Make sure we have the information we need. Section 3.2 tells what you can do to help make sure that our records of what you have spent are complete and up to date.

SECTION 7 During the Catastrophic Coverage Stage, the plan pays most of the cost for your drugs

Section 7.1 Once you are in the Catastrophic Coverage Stage, you will stay in this stage for the rest of the year

You qualify for the Catastrophic Coverage Stage when your out-of-pocket costs have reached the $7,050 limit for the calendar year. Once you are in the Catastrophic Coverage Stage, you will stay in this payment stage until the end of the calendar year.

During this stage, the plan will pay most of the cost for your drugs.

Cost-Sharing

Retail cost sharing



(31-90 day supply)





supply)

Tier $0 (Select generics; diabetic supplies after Part B pays primary)

$0 copayment

$0 copayment

$0 copayment

$0 copayment


$0 copayment

$0 copayment

$0 copayment

$0 copayment


$0 copayment

$0 copayment

$0 copayment

$0 copayment


Cost-Sharing

Retail cost sharing



(31-90 day supply)





supply)


$0 copayment

$0 copayment

$0 copayment

$0 copayment


$0 copayment


drugs in Tier 4


drugs in Tier 4

$0 copayment

The Formulary indicates what you will pay for your drug. A generic drug is the same as a brand-name drug in dosage, safety and strength. When a generic drug is available and you or your prescriber choose the brand-name drug, you must pay the applicable brand copay plus the difference between the cost of the brand-name drug and the generic equivalent. With a prior authorization request, an exception for medical necessity may be made and you will pay the Tier 3 (non-preferred) applicable copay. Note: The difference between the cost of the brand drug and the generic (DAW penalty) does not accumulate toward the UC High Option Supplement to Medicare Annual Prescription Maximum Out-of-Pocket.








For UC High Option Supplement to Medicare – once members reach the $1000 UC Maximum Out-of-Pocket, the plan covers 100% of the cost of covered drugs until next year.

• Out-of-pocket costs for Extra Covered Drugs apply toward the $1,000 out-of-pocket maximum, but not the Medicare TrOOP of $7,050.

• Members qualifying for the Coverage Gap Discount could reach Medicare TrOOP before the $1,000 out-of-pocket maximum because out-of-pocket expenses covered by the Coverage Gap Discount apply only toward the Medicare TrOOP, but not the UC out-of-pocket maximum. If this happens, members will continue to pay a copayment for Extra Covered Drugs until reaching the $1,000 out-of-pocket maximum. After that, the plan will pay 100% for all covered drugs (including Extra Covered Drugs).

For PPO Plan Members – members continue to pay the cost of Extra Covered Drugs, even after the CMS TrOOP is met.

Extra Covered Drug Benefits (Non-Medicare Part D) – Prescription Required Certain drugs that are excluded by law from coverage by Medicare Part D, may be included in the supplemental coverage of your drug plan. Drugs covered under the “Extra Covered Drugs” benefit, will be listed in the Formulary.


Retail & Mail Order

(up to 30 days)

Retail (31-60 days)

Retail (61-90 days)








Note: These Extra Covered Drugs do not count towards the Medicare TrOOP ($7,050) expenses and they do not qualify for lower catastrophic copays. Member cost share per tier values in the above table, for:



SECTION 8 What you pay for vaccinations covered by Part D depends on how and where you get them

Section 8.1 Our plan may have separate coverage for the Part D vaccine medication itself and for the cost of giving you the vaccine

Our plan provides coverage of a number of Part D vaccines. There are two parts to our coverage of vaccinations:

• The first part of coverage is the cost of the vaccine medication itself. The vaccine is a prescription medication.

• The second part of coverage is for the cost of giving you the vaccine. (This is sometimes called the “administration” of the vaccine.)

What do you pay for a Part D vaccination?

What you pay for a Part D vaccination depends on three things: 1. The type of vaccine (what you are being vaccinated for).

o Some vaccines are considered Part D drugs. You can find these vaccines listed in the plan’s List of Covered Drugs (Formulary).

o Other vaccines are considered medical benefits. They are covered under Original Medicare.

2. Where you get the vaccine medication. 3. Who gives you the vaccine.

What you pay at the time you get the Part D vaccination can vary depending on the circumstances. For example:

• Sometimes when you get your vaccine, you will have to pay the entire cost for both the vaccine medication and for getting the vaccine. You can ask our plan to pay you back for our share of the cost.

• Other times, when you get the vaccine medication or the vaccine, you will pay only your share of the cost.

To show how this works, here are three common ways you might get a Part D vaccine.

Situation 1: You buy the Part D vaccine at the pharmacy and you get your vaccine at the network pharmacy. (Whether you have this choice depends on where you live. Some states do not allow pharmacies to administer a vaccination.)

• You will have to pay the pharmacy the amount of your coinsurance or copayment for the vaccine and the cost of giving you the vaccine.

• Our plan will pay the remainder of the costs.


Situation 2: You get the Part D vaccination at your doctor’s office.

• When you get the vaccination, you will pay for the entire cost of the vaccine and its administration.

• You can then ask our plan to pay our share of the cost by using the procedures that are described in Chapter 5 of this booklet (Asking us to pay our share of the costs for covered drugs).

• You will be reimbursed the amount you paid, less your normal coinsurance or copayment for the vaccine (including administration) and less any difference between the amount the doctor charges and what we normally pay, up to the plan limits. (If you get “Extra Help”, we will reimburse you for this difference.)

Situation 3: You buy the Part D vaccine at your pharmacy, and then take it to your doctor’s office where they give you the vaccine.

• You will have to pay the pharmacy the amount of your coinsurance or copayment for the vaccine itself.

• When your doctor gives you the vaccine, you will pay the entire cost for this service. You can then ask our plan to pay our share of the cost by using the procedures described in Chapter 5 of this booklet.

• You will be reimbursed the amount charged by the doctor for administering the vaccine, less any difference between the amount the doctor charges and what we normally pay, up to the plan limits. (If you get “Extra Help”, we will reimburse you for this difference.)

Section 8.2 You may want to call us at Customer Care before you get a vaccination

The rules for coverage of vaccinations are complicated. We are here to help. We recommend that you call us first at Customer Care whenever you are planning to get a vaccination. (Phone numbers for Customer Care are printed on the back cover of this booklet.)

• We can tell you about how your vaccination is covered by our plan and explain your share of the cost.

• We can tell you how to keep your own cost down by using providers and pharmacies in the network.

• If you are not able to use a network provider or pharmacy, we can tell you what you need to do to get payment from us for our share of the cost.

CHAPTER 5 Asking us to pay our share of the

costs for covered drugs

2022 Evidence of Coverage for Navitus MedicareRx (PDP) 86 Chapter 5. Asking us to pay our share of the costs for covered drugs

Chapter 5. Asking us to pay our share of the costs for covered drugs

SECTION 1 Situations in which you should ask us to pay our share of the cost of your covered drugs .......................................................... 87

Section 1.1 If you pay our plan’s share of the cost of your covered drugs, you can ask us for payment .......................................................................................... 87

SECTION 2 How to ask us to pay you back........................................................... 88

Section 2.1 How and where to send us your request for payment .................................. 88

SECTION 3 We will consider your request for payment and say yes or no ............................................................................................................. 89

Section 3.1 We check to see whether we should cover the drug and how much we owe ........................................................................................................... 89

Section 3.2 If we tell you that we will not pay for all or part of the drug, you can make an appeal .......................................................................................... 89

SECTION 4 Other situations in which you should save your receipts and send copies to us .......................................................................... 90

Section 4.1 In some cases, you should send copies of your receipts to us to help us track your out-of-pocket drug costs ............................................................ 90


SECTION 1 Situations in which you should ask us to pay our share of the cost of your covered drugs

Section 1.1 If you pay our plan’s share of the cost of your covered drugs, you can ask us for payment

Sometimes when you get a prescription drug, you may need to pay the full cost right away. Other times, you may find that you have paid more than you expected under the coverage rules of the plan. In either case, you can ask our plan to pay you back (paying you back is often called “reimbursing” you). Please note that depending on the coverage rules for your specific drug, there may be a difference in the amount you are reimbursed and the total amount you paid.

Here are examples of situations in which you may need to ask our plan to pay you back. All of these examples are types of coverage decisions (for more information about coverage decisions, go to Chapter 7 of this booklet).

1. When you use an out-of-network pharmacy to get a prescription filled If you go to an out-of-network pharmacy and try to use your membership card to fill a prescription, the pharmacy may not be able to submit the claim directly to us. When that happens, you will have to pay the full cost of your prescription. (We cover prescriptions filled at out-of-network pharmacies only in a few special situations. Please go to Chapter 3, Section 2.5 to learn more.)

Save your receipt and send a copy to us when you ask us to pay you back for our share of the cost.

2. When you pay the full cost for a prescription because you don’t have your plan membership card with you If you do not have your plan membership card with you, you can ask the pharmacy to call the plan or look up your enrollment information. However, if the pharmacy cannot get the enrollment information they need right away, you may need to pay the full cost of the prescription yourself. Save your receipt and send a copy to us when you ask us to pay you back for our share of the cost.

3. When you pay the full cost for a prescription in other situations You may pay the full cost of the prescription because you find that the drug is not covered for some reason.

• For example, the drug may not be on the plan’s List of Covered Drugs (Formulary); or it could have a requirement or restriction that you didn’t know about or don’t think should apply to you. If you decide to get the drug immediately, you may need to pay the full cost for it.


• Save your receipt and send a copy to us when you ask us to pay you back. In some situations, we may need to get more information from your doctor in order to pay you back for our share of the cost.

4. If you are retroactively enrolled in our plan Sometimes a person’s enrollment in the plan is retroactive. (Retroactive means that the first day of their enrollment has already passed. The enrollment date may even have occurred last year.) If you were retroactively enrolled in our plan and you paid out-of-pocket for any of your drugs after your enrollment date, you can ask us to pay you back for our share of the costs. You will need to submit paperwork for us to handle the reimbursement. Please call Customer Care for additional information about how to ask us to pay you back and deadlines for making your request. (Phone numbers for Customer Care are printed on the back cover of this booklet.)

All of the examples above are types of coverage decisions. This means that if we deny your request for payment, you can appeal our decision. Chapter 7 of this booklet (What to do if you have a problem or complaint (coverage decisions, appeals, complaints)) has information about how to make an appeal.

SECTION 2 How to ask us to pay you back

Section 2.1 How and where to send us your request for payment

Send us your request for payment, along with your receipt documenting the payment you have made. It’s a good idea to make a copy of your receipts for your records.

To make sure you are giving us all the information we need to make a decision, you can fill out our claim form to make your request for payment.

• You don’t have to use the form, but it will help us process the information faster.

• Either download a copy of the form from our Member Portal (https://memberportal.navitus.com) or call Customer Care and ask for the form. (Phone numbers for Customer Care are printed on the back cover of this booklet.)

Mail your request for payment together with any bills and paid receipts to us at this address:

Navitus MedicareRx Manual Claims P.O. Box 1039 Appleton, WI 54912-1039



You must submit your claim to us within 36 months of the date you received the service, item, or drug.

Contact Customer Care if you have any questions (phone numbers are printed on the back cover of this booklet). If you don’t know what you should have paid, we can help. You can also call if you want to give us more information about a request for payment you have already sent to us.

SECTION 3 We will consider your request for payment and say yes or no

Section 3.1 We check to see whether we should cover the drug and how much we owe

When we receive your request for payment, we will let you know if we need any additional information from you. Otherwise, we will consider your request and make a coverage decision.

• If we decide that the drug is covered and you followed all the rules for getting the drug, we will pay for our share of the cost. We will mail your reimbursement of our share of the cost to you. (Chapter 3 explains the rules you need to follow for getting your Part D prescription drugs covered.) We will send payment within 30 days after your request was received.

• If we decide that the drug is not covered, or you did not follow all the rules, we will not pay for our share of the cost. Instead, we will send you a letter that explains the reasons why we are not sending the payment you have requested and your rights to appeal that decision.

Section 3.2 If we tell you that we will not pay for all or part of the drug, you can make an appeal

If you think we have made a mistake in turning down your request for payment or you don’t agree with the amount we are paying, you can make an appeal. If you make an appeal, it means you are asking us to change the decision we made when we turned down your request for payment.

For the details on how to make this appeal, go to Chapter 7 of this booklet (What to do if you have a problem or complaint (coverage decisions, appeals, complaints)). The appeals process is a formal process with detailed procedures and important deadlines. If making an appeal is new to you, you will find it helpful to start by reading Section 4 of Chapter 7. Section 4 is an introductory section that explains the process for coverage decisions and appeals and gives definitions of terms such as “appeal.” Then after you have read Section 4, you can go to Section 5.5 in Chapter 7 for a step-by-step explanation of how to file an appeal.


SECTION 4 Other situations in which you should save your receipts and send copies to us

Section 4.1 In some cases, you should send copies of your receipts to us to help us track your out-of-pocket drug costs

There are some situations when you should let us know about payments you have made for your drugs. In these cases, you are not asking us for payment. Instead, you are telling us about your payments so that we can calculate your out-of-pocket costs correctly. This may help you to qualify for the Catastrophic Coverage Stage more quickly.

Here are two situations when you should send us copies of receipts to let us know about payments you have made for your drugs:

1. When you buy the drug for a price that is lower than our price Sometimes you can buy your drug at a network pharmacy for a price that is lower than our price.

• For example, a pharmacy might offer a special price on the drug. Or you may have a discount card that is outside our benefit that offers a lower price.

• Unless special conditions apply, you must use a network pharmacy in these situations and your drug must be on our Formulary.

• Save your receipt and send a copy to us so that we can have your out-of-pocket expenses count toward qualifying you for the Catastrophic Coverage Stage.

• Please note: We may not pay for any share of these drug costs. But sending a copy of the receipt allows us to calculate your out-of-pocket costs correctly and may help you qualify for the Catastrophic Coverage Stage more quickly.

2. When you get a drug through a patient assistance program offered by a drug manufacturer Some members are enrolled in a patient assistance program offered by a drug manufacturer that is outside your Part D plan benefits. If you get any drugs through a program offered by a drug manufacturer, you may pay a copayment to the patient assistance program.

• Save your receipt and send a copy to us so that we can have your out-of-pocket expenses count toward qualifying you for the Catastrophic Coverage Stage.

• Please note: Because you are getting your drug through the patient assistance program and not through your Part D plan’s benefits, will not pay for any share of these drug costs. But sending a copy of the receipt allows us to calculate your out-of-pocket costs correctly and may help you qualify for the Catastrophic Coverage Stage more quickly.


Since you are not asking for payment in the two cases described above, these situations are not considered coverage decisions. Therefore, you cannot make an appeal if you disagree with our decision.

CHAPTER 6 Your rights and responsibilities

2022 Evidence of Coverage for Navitus MedicareRx (PDP) 93 Chapter 6. Your rights and responsibilities

Chapter 6. Your rights and responsibilities

SECTION 1 Our plan must honor your rights as a member of the plan ........... 94

Section 1.1 We must provide information in a way that works for you (in languages other than English, in braille, in large print, or other alternate formats, etc.)........................................................................................................... 94

Section 1.2 We must ensure that you get timely access to your covered drugs ............... 94

Section 1.3 We must protect the privacy of your personal health information ................ 94

Section 1.4 We must give you information about the plan, its network of pharmacies, and your covered drugs.............................................................................. 95

Section 1.5 We must support your right to make decisions about your care ................... 97

Section 1.6 You have the right to make complaints and to ask us to reconsider decisions we have made ............................................................................ 98

Section 1.7 What can you do if you believe you are being treated unfairly or your rights are not being respected? ................................................................... 98

Section 1.8 How to get more information about your rights .......................................... 99

SECTION 2 You have some responsibilities as a member of the plan ............. 99

Section 2.1 What are your responsibilities? .................................................................. 99


SECTION 1 Our plan must honor your rights as a member of the plan

Section 1.1 We must provide information in a way that works for you (in languages other than English, in braille, in large print, or other alternate formats, etc.)

To get information from us in a way that works for you, please call Customer Care (phone numbers are printed on the back cover of this booklet).

Our plan has people and free interpreter services available to answer questions from disabled and non-English speaking members. We can also give you information in braille, in large print, or other alternate formats at no cost if you need it. We are required to give you information about the plan’s benefits in a format that is accessible and appropriate for you. To get information from us in a way that works for you, please call Customer Care (phone numbers are printed on the back cover of this booklet).

If you have any trouble getting information from our plan in a format that is accessible and appropriate for you, please call to file a grievance with Navitus MedicareRx Customer Care (phone numbers are printed on the back cover of this booklet). You may also file a complaint with Medicare by calling 1-800-MEDICARE (1-800-633-4227) or directly with the Office for Civil Rights. Contact information is included in this Evidence of Coverage or with this mailing, or you may contact Navitus MedicareRx Customer Care for additional information (phone numbers are printed on the back cover of this booklet).

Section 1.2 We must ensure that you get timely access to your covered drugs

As a member of our plan, you have the right to get your prescriptions filled or refilled at any of our network pharmacies without long delays. If you think that you are not getting your Part D drugs within a reasonable amount of time, Chapter 7, Section 7 of this booklet tells what you can do. (If we have denied coverage for your prescription drugs and you don’t agree with our decision, Chapter 7, Section 4 tells what you can do.)

Section 1.3 We must protect the privacy of your personal health information

Federal and state laws protect the privacy of your medical records and personal health information. We protect your personal health information as required by these laws.

• Your “personal health information” includes the personal information you gave us when you enrolled in this plan as well as your medical records and other medical and health information.


• The laws that protect your privacy give you rights related to getting information and controlling how your health information is used. We give you a written notice, called a “Notice of Privacy Practice,” that tells about these rights and explains how we protect the privacy of your health information.

How do we protect the privacy of your health information? • We make sure that unauthorized people don’t see or change your records.

• In most situations, if we give your health information to anyone who isn’t providing your care or paying for your care, we are required to get written permission from you first. Written permission can be given by you or by someone you have given legal power to make decisions for you.

• There are certain exceptions that do not require us to get your written permission first. These exceptions are allowed or required by law.

o For example, we are required to release health information to government agencies that are checking on quality of care.

o Because you are a member of our plan through Medicare, we are required to give Medicare your health information including information about your Part D prescription drugs. If Medicare releases your information for research or other uses, this will be done according to Federal statutes and regulations.

You can see the information in your records and know how it has been shared with others

You have the right to look at your medical records held at the plan, and to get a copy of your records. We are allowed to charge you a fee for making copies. You also have the right to ask us to make additions or corrections to your medical records. If you ask us to do this, we will work with your healthcare provider to decide whether the changes should be made.

You have the right to know how your health information has been shared with others for any purposes that are not routine.

If you have questions or concerns about the privacy of your personal health information, please call Customer Care (phone numbers are printed on the back cover of this booklet).

Section 1.4 We must give you information about the plan, its network of pharmacies, and your covered drugs

As a member of Navitus MedicareRx, you have the right to get several kinds of information from us. (As explained above in Section 1.1, you have the right to get information from us in a way that works for you. This includes getting the information in languages other than English and in large print or other alternate formats.)


If you want any of the following kinds of information, please call Customer Care (phone numbers are printed on the back cover of this booklet):

• Information about our plan. This includes, for example, information about your plan’s financial condition, the number of appeals made by members and the plan’s Star Ratings, including how it has been rated by plan members and how it compares to other Medicare prescription drug plans.

• Information about our network pharmacies. o For example, you have the right to get information from us about the pharmacies

in our network. o For a list of the pharmacies in the plan’s network, see the Pharmacy Directory. o For more detailed information about our pharmacies, you can call Customer Care

(phone numbers are printed on the back cover of this booklet) or visit our Member Portal at https://memberportal.navitus.com. There is also a pharmacy search tool on our Member Portal at https://memberportal.navitus.com.

• Information about your coverage and the rules you must follow when using your coverage.

o To get the details on your Part D prescription drug coverage, see Chapters 3 and 4 of this booklet plus the plan’s List of Covered Drugs (Formulary). These chapters, together with the List of Covered Drugs (Formulary), tell you what drugs are covered and explain the rules you must follow and the restrictions to your coverage for certain drugs.

o If you have questions about the rules or restrictions, please call Customer Care (phone numbers are printed on the back cover of this booklet).

• Information about why something is not covered and what you can do about it. o If a Part D drug is not covered for you, or if your coverage is restricted in some

way, you can ask us for a written explanation. You have the right to this explanation even if you received the drug from an out-of-network pharmacy.

o If you are not happy or if you disagree with a decision we make about what Part D drug is covered for you, you have the right to ask us to change the decision. You can ask us to change the decision by making an appeal. For details on what to do if something is not covered for you in the way you think it should be covered, see Chapter 7 of this booklet. It gives you the details about how to make an appeal if you want us to change our decision. (Chapter 7 also tells about how to make a complaint about quality of care, waiting times, and other concerns.)

o If you want to ask our plan to pay our share of the cost for a Part D prescription drug, see Chapter 5 of this booklet.




Section 1.5 We must support your right to make decisions about your care

You have the right to give instructions about what is to be done if you are not able to make medical decisions for yourself

Sometimes people become unable to make health care decisions for themselves due to accidents or serious illness. You have the right to say what you want to happen if you are in this situation. This means that, if you want to, you can:

• Fill out a written form to give someone the legal authority to make medical decisions for you if you ever become unable to make decisions for yourself.

• Give your doctors written instructions about how you want them to handle your medical care if you become unable to make decisions for yourself.

The legal documents that you can use to give your directions in advance in these situations are called “advance directives.” There are different types of advance directives and different names for them. Documents called “living will” and “power of attorney for health care” are examples of advance directives.

If you want to use an “advance directive” to give your instructions, here is what to do:

• Get the form. If you want to have an advance directive, you can get a form from your lawyer, from a social worker, or from some office supply stores. You can sometimes get advance directive forms from organizations that give people information about Medicare.

• Fill it out and sign it. Regardless of where you get this form, keep in mind that it is a legal document. You should consider having a lawyer help you prepare it.

• Give copies to appropriate people. You should give a copy of the form to your doctor and to the person you name on the form as the one to make decisions for you if you can’t. You may want to give copies to close friends or family members as well. Be sure to keep a copy at home.

If you know ahead of time that you are going to be hospitalized, and you have signed an advance directive, take a copy with you to the hospital.

• If you are admitted to the hospital, they will ask you whether you have signed an advance directive form and whether you have it with you.

• If you have not signed an advance directive form, the hospital has forms available and will ask if you want to sign one.

Remember, it is your choice whether you want to fill out an advance directive (including whether you want to sign one if you are in the hospital). According to law, no one can deny you care or discriminate against you based on whether or not you have signed an advance directive.


What if your instructions are not followed?

If you have signed an advance directive, and you believe that a doctor or hospital did not follow the instructions in it, you may file a complaint with the state agency. For contact information on the State Medical Assistance Office in your state, please refer to Exhibit C or call Customer Care (phone numbers are printed on the back cover of this booklet).

Section 1.6 You have the right to make complaints and to ask us to reconsider decisions we have made

If you have any problems or concerns about your covered services or care, Chapter 7 of this booklet tells what you can do. It gives the details about how to deal with all types of problems and complaints. What you need to do to follow up on a problem or concern depends on the situation. You might need to ask our plan to make a coverage decision for you, make an appeal to us to change a coverage decision, or make a complaint. Whatever you do – ask for a coverage decision, make an appeal, or make a complaint – we are required to treat you fairly.

You have the right to get a summary of information about the appeals and complaints that other members have filed against our plan in the past. To get this information, please call Customer Care (phone numbers are printed on the back cover of this booklet).

Section 1.7 What can you do if you believe you are being treated unfairly or your rights are not being respected?

If it is about discrimination, call the Office for Civil Rights

If you believe you have been treated unfairly or your rights have not been respected due to your race, disability, religion, sex, health, ethnicity, creed (beliefs), age, or national origin, you should call the Department of Health and Human Services’ Office for Civil Rights at 1-800-368-1019 or TTY/TDD 1-800-537-7697, or call your local Office for Civil Rights.

Is it about something else?

If you believe you have been treated unfairly or your rights have not been respected, and it’s not about discrimination, you can get help dealing with the problem you are having:

• You can call Customer Care (phone numbers are printed on the back cover of this booklet).

• You can call the State Health Insurance Assistance Program. For details about this organization and how to contact it, go to Chapter 2, Section 3.

• Or, you can 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.


Section 1.8 How to get more information about your rights

There are several places where you can get more information about your rights:


• You can call the State Health Insurance Assistance Program. For details about this organization and how to contact it, go to Chapter 2, Section 3.

• You can contact Medicare. o You can visit the Medicare website to read or download the publication

“Medicare Rights & Protections.” (The publication is available at: www.medicare.gov/Pubs/pdf/11534-Medicare-Rights-and-Protections.pdf.)

o Or, you can call 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY/TDD users should call 1-877-486-2048.

SECTION 2 You have some responsibilities as a member of the plan

Section 2.1 What are your responsibilities?

Things you need to do as a member of the plan are listed below. If you have any questions, please call Customer Care (phone numbers are printed on the back cover of this booklet). We’re here to help.

• Get familiar with your covered drugs and the rules you must follow to get these covered drugs. Use this Evidence of Coverage booklet to learn what is covered for you and the rules you need to follow to get your covered drugs.

o Chapters 3 and 4 give the details about your coverage for Part D prescription drugs.

• If you have any other prescription drug coverage in addition to our plan, you are required to tell us. Please call Customer Care to let us know (phone numbers are printed on the back cover of this booklet).

o We are required to follow rules set by Medicare to make sure that you are using all of your coverage in combination when you get your covered drugs from our plan. This is called “coordination of benefits” because it involves coordinating the drug benefits you get from our plan with any other drug benefits available to you. We’ll help you coordinate your benefits. (For more information about coordination of benefits, go to Chapter 1, Section 10.)

• Tell your doctor and pharmacist that you are enrolled in our plan. Show your plan membership card whenever you get your Part D prescription drugs.

http://www.medicare.gov/Pubs/pdf/11534-Medicare-Rights-and-Protections.pdf


• Help your doctors and other prescribers help you, by giving them information, asking questions, and following through on your care.

o To help your doctors and other health providers give you the best care, learn as much as you are able to about your health problems and give them the information they need about you and your health. Follow the treatment plans and instructions that you and your doctors agree upon.

o Make sure your doctors know all of the drugs you are taking, including over-the-counter drugs, vitamins, and supplements.

o If you have any questions, be sure to ask. Your doctors and other health care providers are supposed to explain things in a way you can understand. If you ask a question and you don’t understand the answer you are given, ask again.

• Pay what you owe. As a plan member, you are responsible for these payments: o Your plan premiums must be paid to continue being a member of our plan. o For most of your drugs covered by the plan, you must pay your share of the cost

when you get the drug. This will be a copayment (a fixed amount) or coinsurance (a percentage of the total cost). Chapter 4 tells what you must pay for your Part D prescription drugs.

o If you get any drugs that are not covered by our plan or by other insurance you may have, you must pay the full cost. If you disagree with our decision to deny coverage for a drug, you can

make an appeal. Please see Chapter 7 of this booklet for information about how to make an appeal.

o If you are required to pay a late enrollment penalty, you must pay the penalty to remain a member of the plan.

o If you are required to pay the extra amount for Part D because of your yearly income, you must pay the extra amount directly to the government to remain a member of the plan.

Tell us if you move. If you are going to move, it’s important to tell us right away. Please remember to also notify UC Retirement Administration Service Center (RASC) at (800) 888-8267 (in U.S.) or (510) 987-0200 (from outside the U.S.), so they will have your most up-to-date contact information on file. Representatives are available Monday through Friday, 8:30 a.m. to 4:30 p.m. (Pacific). We need to keep your membership record up to date and know how to contact you.

o If you move outside of the United States or Puerto Rico, you cannot remain a member of our plan. (Chapter 1 tells about our service area.) We can help you figure out whether you are moving outside our service area.

o If you move within our service area, we still need to know so we can keep your membership record up to date and know how to contact you.


o If you move, it is also important to tell Social Security (or the Railroad Retirement Board). You can find phone numbers and contact information for these organizations in Chapter 2.

• Call Customer Care for help if you have questions or concerns. We also welcome any suggestions you may have for improving our plan.

o Phone numbers and calling hours for Customer Care are printed on the back cover of this booklet.

o For more information on how to reach us, including our mailing address, please see Chapter 2.

CHAPTER 7 What to do if you have a problem or

complaint (coverage decisions, appeals, complaints)

2022 Evidence of Coverage for Navitus MedicareRx (PDP) 103 Chapter 7. What to do if you have a problem or complaint

(coverage decisions, appeals, complaints)

Chapter 7. What to do if you have a problem or complaint (coverage decisions, appeals, complaints)

SECTION 1 Introduction.......................................................................................... 105

Section 1.1 What to do if you have a problem or concern ........................................... 105

Section 1.2 What about the legal terms? ..................................................................... 105

SECTION 2 You can get help from government organizations that are not connected with us ........................................................................ 106

Section 2.1 Where to get more information and personalized assistance ...................... 106

SECTION 3 To deal with your problem, which process should you use? ..... 106

Section 3.1 Should you use the process for coverage decisions and appeals? Or should you use the process for making complaints? .................................. 106

COVERAGE DECISIONS AND APPEALS .................................................................... 107

SECTION 4 A guide to the basics of coverage decisions and appeals .......... 107

Section 4.1 Asking for coverage decisions and making appeals: the big picture .......... 107

Section 4.2 How to get help when you are asking for a coverage decision or making an appeal ................................................................................................. 108

SECTION 5 Your Part D prescription drugs: How to ask for a coverage decision or make an appeal .............................................................. 109

Section 5.1 This section tells you what to do if you have problems getting a Part D drug or you want us to pay you back for a Part D drug ............................. 109

Section 5.2 What is an exception? .............................................................................. 111

Section 5.3 Important things to know about asking for exceptions .............................. 113

Section 5.4 Step-by-step: How to ask for a coverage decision, including an exception 113

Section 5.5 Step-by-step: How to make a Level 1 Appeal (how to ask for a review of a coverage decision made by our plan) ..................................................... 117

Section 5.6 Step-by-step: How to make a Level 2 Appeal ........................................... 120

SECTION 6 Taking your appeal to Level 3 and beyond .................................... 122

Section 6.1 Appeal Levels 3, 4 and 5 for Part D Drug Requests .................................. 122

MAKING COMPLAINTS................................................................................................... 123

SECTION 7 How to make a complaint about quality of care, waiting times, customer service, or other concerns .................................. 123

Section 7.1 What kinds of problems are handled by the complaint process? ................ 123



Section 7.2 The formal name for “making a complaint” is “filing a grievance” ........... 125

Section 7.3 Step-by-step: Making a complaint............................................................ 125

Section 7.4 You can also make complaints about quality of care to the Quality Improvement Organization ...................................................................... 126

Section 7.5 You can also tell Medicare about your complaint ..................................... 127




Section 1.1 What to do if you have a problem or concern

Please call us first

Your health and satisfaction are important to us. When you have a problem or concern, we hope you’ll try an informal approach first. Please call Navitus MedicareRx Customer Care, our phone numbers are printed on the back cover of this booklet. We will work with you on a mutually satisfactory solution to your concern. We pledge to honor your rights, to take your problems and concerns seriously, and to treat you with respect.

This chapter explains two types of processes for handling problems and concerns:

• For some types of problems, you need to use the process for coverage decisions and appeals.

• For other types of problems, you need to use the process for making complaints.

Both of these processes have been approved by Medicare. To ensure fairness and prompt handling of your problems, each process has a set of rules, procedures, and deadlines that must be followed by us and by you.

Which one do you use? That depends on the type of problem you are having. The guide in Section 3 will help you identify the right process to use.

Section 1.2 What about the legal terms?

There are technical legal terms for some of the rules, procedures, and types of deadlines explained in this chapter. Many of these terms are unfamiliar to most people and can be hard to understand.

To keep things simple, this chapter explains the legal rules and procedures using simpler words in place of certain legal terms. For example, this chapter generally says “making a complaint” rather than “filing a grievance,” “coverage decision” rather than “coverage determination” or “at-risk determination,” and “Independent Review Organization” instead of “Independent Review Entity.” It also uses abbreviations as little as possible.

However, it can be helpful – and sometimes quite important – for you to know the correct legal terms for the situation you are in. Knowing which terms to use will help you communicate more clearly and accurately when you are dealing with your problem and get the right help or information for your situation. To help you know which terms to use, we include legal terms when we give the details for handling specific types of situations.



SECTION 2 You can get help from government organizations that are not connected with us

Section 2.1 Where to get more information and personalized assistance

Sometimes it can be confusing to start or follow through the process for dealing with a problem. This can be especially true if you do not feel well or have limited energy. Other times, you may not have the knowledge you need to take the next step.

Get help from an independent government organization

We are always available to help you. But in some situations you may also want help or guidance from someone who is not connected with us. You can always contact your State Health Insurance Assistance Program (SHIP). This government program has trained counselors in every state. The program is not connected with us or with any insurance company or health plan. The counselors at this program can help you understand which process you should use to handle a problem you are having. They can also answer your questions, give you more information, and offer guidance on what to do.

The services of SHIP counselors are free You will find contact information for the SHIP program in your state in Exhibit A (located in the back of this booklet).

You can also get help and information from Medicare

For more information and help in handling a problem, you can also contact Medicare. Here are two ways to get information directly from Medicare:

• You can call 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY/TDD users should call 1-877-486-2048.

• You can visit the Medicare website (www.medicare.gov).

SECTION 3 To deal with your problem, which process should you use?

Section 3.1 Should you use the process for coverage decisions and appeals? Or should you use the process for making complaints?

If you have a problem or concern, you only need to read the parts of this chapter that apply to your situation. The guide that follows will help.




To figure out which part of this chapter will help with your specific problem or concern, START HERE

Is your problem or concern about your benefits or coverage?

(This includes problems about whether particular medical care or prescription drugs are covered or not, the way in which they are covered, and problems related to payment for medical care or prescription drugs.)

Yes. My problem is about benefits or coverage.

Go on to the next section of this chapter, Section 4, “A guide to the basics of coverage decisions and appeals.”

No. My problem is not about benefits or coverage.

Skip ahead to Section 7 at the end of this chapter: “How to make a complaint about quality of care, waiting times, customer service or other concerns.”

COVERAGE DECISIONS AND APPEALS

SECTION 4 A guide to the basics of coverage decisions and appeals

Section 4.1 Asking for coverage decisions and making appeals: the big picture

The process for coverage decisions and appeals deals with problems related to your benefits and coverage for prescription drugs, including problems related to payment. This is the process you use for issues such as whether a drug is covered or not and the way in which the drug is covered.

Asking for coverage decisions

A coverage decision is a decision we make about your benefits and coverage or about the amount we will pay for your prescription drugs.

We are making a coverage decision for you whenever we decide what is covered for you and how much we pay. In some cases, we might decide a drug is not covered or is no longer covered by Medicare for you. If you disagree with this coverage decision, you can make an appeal.



Making an appeal

If we make a coverage decision and you are not satisfied with this decision, you can “appeal” the decision. An appeal is a formal way of asking us to review and change a coverage decision we have made.

When you appeal a decision for the first time, this is called a Level 1 Appeal. In this appeal, we review the coverage decision we made to check to see if we were following all of the rules properly. Your appeal is handled by different reviewers than those who made the original unfavorable decision. When we have completed the review, we give you our decision. Under certain circumstances, which we discuss later, you can request an expedited or “fast coverage decision” or fast appeal of a coverage decision. In limited circumstances a request for a coverage decision will be dismissed, which means we won’t review the request. Examples of when a request will be dismissed include if the request is incomplete, if someone makes the request on your behalf but isn’t legally authorized to do so or if you ask for your request to be withdrawn. If we dismiss a request for a coverage decision, we will send a notice explaining why the request was dismissed and how to ask for a review of the dismissal.

If we say no to all or part of your Level 1 Appeal, you can ask for a Level 2 Appeal. The Level 2 Appeal is conducted by an Independent Review Organization that is not connected to us. If you are not satisfied with the decision at the Level 2 Appeal, you may be able to continue through additional levels of appeal.

Section 4.2 How to get help when you are asking for a coverage decision or making an appeal

Would you like some help? Here are resources you may wish to use if you decide to ask for any kind of coverage decision or appeal a decision:

• You can call us at Customer Care (phone numbers are printed on the back cover of this booklet).

• You can get free help from your State Health Insurance Assistance Program (SHIP) (see Section 2 of this chapter).

• Your doctor or other prescriber can make a request for you. For Part D prescription drugs, your doctor or other prescriber can request a coverage decision or a Level 1 or Level 2 Appeal on your behalf. To request any appeal after Level 2, your doctor or other prescriber must be appointed as your representative.

• You can ask someone to act on your behalf. If you want to, you can name another person to act for you as your “representative” to ask for a coverage decision or make an appeal.

o There may be someone who is already legally authorized to act as your representative under State law.



o If you want a friend, relative, your doctor or other prescriber, or other person to be your representative, call Customer Care (phone numbers are printed on the back cover of this booklet) and ask for the “Appointment of Representative” form. (The form is also available on Medicare’s website at www.cms.gov/Medicare/CMS-Forms/CMS-Forms/downloads/cms1696.pdf or on our Member Portal at https://memberportal.navitus.com.) The form gives that person permission to act on your behalf. It must be signed by you and by the person who you would like to act on your behalf. You must give us a copy of the signed form.

• You also have the right to hire a lawyer to act for you. You may contact your own lawyer, or get the name of a lawyer from your local bar association or other referral service. There are also groups that will give you free legal services if you qualify. However, you are not required to hire a lawyer to ask for any kind of coverage decision or appeal a decision.

SECTION 5 Your Part D prescription drugs: How to ask for a coverage decision or make an appeal

Have you read Section 4 of this chapter (A guide to “the basics” of coverage decisions and appeals)? If not, you may want to read it before you start this section.

Section 5.1 This section tells you what to do if you have problems getting a Part D drug or you want us to pay you back for a Part D drug

Your benefits as a member of our plan include coverage for many prescription drugs. Please refer to our plan’s List of Covered Drugs (Formulary). To be covered, the drug must be used for a medically accepted indication. (A “medically accepted indication” is a use of the drug that is either approved by the Food and Drug Administration or supported by certain reference books. See Chapter 3, Section 3 for more information about a medically accepted indication.)

• This section is about your Part D drugs only. To keep things simple, we generally say “drug” in the rest of this section, instead of repeating “covered outpatient prescription drug” or “Part D drug” every time.

• For details about what we mean by Part D drugs, the List of Covered Drugs (Formulary), rules and restrictions on coverage, and cost information, see Chapter 3 (Using our plan’s coverage for your Part D prescription drugs) and Chapter 4 (What you pay for your Part D prescription drugs).

http://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/downloads/cms1696.pdf




Part D coverage decisions and appeals

As discussed in Section 4 of this chapter, a coverage decision is a decision we make about your benefits and coverage or about the amount we will pay for your drugs.

Legal Terms

An initial coverage decision about your Part D drugs is called a “coverage determination.”

Here are examples of coverage decisions you ask us to make about your Part D drugs:

• You ask us to make an exception, including: o Asking us to cover a Part D drug that is not on the plan’s List of Covered Drugs

(Formulary) o Asking us to waive a restriction on the plan’s coverage for a drug (such as limits

on the amount of the drug you can get) o Asking to pay a lower cost-sharing amount for a covered drug on a higher cost-

sharing tier

• You ask us whether a drug is covered for you and whether you satisfy any applicable coverage rules. (For example, when your drug is on the plan’s List of Covered Drugs (Formulary) but we require you to get approval from us before we will cover it for you.)

o Please note: If your pharmacy tells you that your prescription cannot be filled as written, the pharmacy will give you a written notice explaining how to contact us to ask for a coverage decision.

• You ask us to pay for a prescription drug you already bought. This is a request for a coverage decision about payment.

If you disagree with a coverage decision we have made, you can appeal our decision.



This section tells you both how to ask for coverage decisions and how to request an appeal. Use the chart below to help you determine which part has information for your situation:

Which of these situations are you in?

If you are in this situation: This is what you can do:

If you need a drug that is not on our Formulary or need us to waive a rule or restriction on a drug we cover.

You can ask us to make an exception. (This is a type of coverage decision.) Start with Section 5.2 of this chapter

If you want us to cover a drug on our Formulary and you believe you meet any plan rules or restrictions (such as getting approval in advance) for the drug you need.

You can ask us for a coverage decision. Skip ahead to Section 5.4 of this chapter.

If you want to ask us to pay you back for a drug you have already received and paid for.

You can ask us to pay you back. (This is a type of coverage decision.) Skip ahead to Section 5.4 of this chapter.

If we already told you that we will not cover or pay for a drug in the way that you want it to be covered or paid for.

You can make an appeal. (This means you are asking us to reconsider.) Skip ahead to Section 5.5 of this chapter.

Section 5.2 What is an exception?

If a drug is not covered in the way you would like it to be covered, you can ask us to make an “exception.” An exception is a type of coverage decision. Similar to other types of coverage decisions, if we turn down your request for an exception, you can appeal our decision.

When you ask for an exception, your doctor or other prescriber will need to explain the medical reasons why you need the exception approved. We will then consider your request. Here are three examples of exceptions that you or your doctor or other prescriber can ask us to make:

1. Covering a Part D drug for you that is not on our List of Covered Drugs (Formulary).

Legal Terms

Asking for coverage of a drug that is not on the Formulary is sometimes called asking for a “formulary exception.” • If we agree to make an exception and cover a drug that is not on the Formulary, you will

need to pay the cost-sharing amount that applies to drugs in Tier 3. You cannot ask for an exception to the copayment or coinsurance amount we require you to pay for the drug.



2. Removing a restriction on our coverage for a covered drug. There are extra rules or restrictions that apply to certain drugs on our List of Covered Drugs (Formulary) (for more information, go to Chapter 3).

Legal Terms

Asking for removal of a restriction on coverage for a drug is sometimes called asking for a “formulary exception.”

• The extra rules and restrictions on coverage for certain drugs include: o Being required to use the generic version of a drug instead of the brand name

drug. o Getting plan approval in advance before we will agree to cover the drug for you.

(This is sometimes called “prior authorization.”) o Being required to try a different drug first before we will agree to cover the drug

you are asking for. (This is sometimes called “step therapy.”) o Quantity limits. For some drugs, there are restrictions on the amount of the drug

you can have.

• If we agree to make an exception and waive a restriction for you, you can ask for an exception to the copayment or coinsurance amount we require you to pay for the drug.

3. Changing coverage of a drug to a lower cost-sharing tier. Every drug on our Formulary is in one of four cost-sharing tiers. In general, the lower the cost-sharing tier number, the less you will pay as your share of the cost of the drug.

Legal Terms

Asking to pay a lower price for a covered non-preferred drug is sometimes called asking for a “tiering exception.”

• If our Formulary contains alternative drug(s) for treating your medical condition that are in a lower cost-sharing tier than your drug, you can ask us to cover your drug at the cost-sharing amount that applies to the alternative drug(s). This would lower your share of the cost for the drug.

o If the drug you’re taking is a biological product you can ask us to cover your drug at the cost-sharing amount that applies to the lowest tier that contains biological product alternatives for treating your condition.

o If the drug you’re taking is a brand name drug you can ask us to cover your drug at the cost-sharing amount that applies to the lowest tier that contains brand name alternatives for treating your condition.



o If the drug you’re taking is a generic drug you can ask us to cover your drug at the cost-sharing amount that applies to the lowest tier that contains either brand or generic alternatives for treating your condition.

• You cannot ask us to change the cost-sharing tier for any drug in Tier 4 (Specialty products).

• If we approve your request for a tiering exception and there is more than one lower cost-sharing tier with alternative drugs you can’t take, you will usually pay the lowest amount. Please contact Customer Care with any questions (phone numbers are printed on the back cover of this booklet).

Section 5.3 Important things to know about asking for exceptions

Your doctor must tell us the medical reasons Your doctor or other prescriber must give us a statement that explains the medical reasons for requesting an exception. For a faster decision, include this medical information from your doctor or other prescriber when you ask for the exception.

Typically, our Formulary includes more than one drug for treating a particular condition. These different possibilities are called “alternative” drugs. If an alternative drug would be just as effective as the drug you are requesting and would not cause more side effects or other health problems, we will generally not approve your request for an exception. If you ask us for a tiering exception, we will generally not approve your request for an exception unless all the alternative drugs in the lower cost-sharing tier(s) won’t work as well for you or are likely to cause an adverse reaction or other harm.

We can say yes or no to your request

• If we approve your request for an exception, our approval usually is valid until the end of the calendar year. This is true as long as your doctor continues to prescribe the drug for you and that drug continues to be safe and effective for treating your condition.

• If we say no to your request for an exception, you can ask for a review of our decision by making an appeal. Section 5.5 tells you how to make an appeal if we say no.

The next section tells you how to ask for a coverage decision, including an exception.

Section 5.4 Step-by-step: How to ask for a coverage decision, including an exception

Step 1: You ask us to make a coverage decision about the drug(s) or payment you need. If your health requires a quick response, you must ask us to make a



“fast coverage decision.” You cannot ask for a fast coverage decision if you are asking us to pay you back for a drug you already bought.

What to do

• Request the type of coverage decision you want. Start by calling, writing, or faxing us to make your request. You, your representative, or your doctor (or other prescriber) can do this. You can also access the coverage decision process through our Member Portal. For the details, go to Chapter 2, Section 1 and look for the section called How to contact us when you are asking for a coverage decision about your Part D prescription drugs. Or if you are asking us to pay you back for a drug, go to the section called Where to send a request asking us to pay for our share of the cost of a drug you have received.

• You or your doctor or someone else who is acting on your behalf can ask for a coverage decision. Section 4 of this chapter tells how you can give written permission to someone else to act as your representative. You can also have a lawyer act on your behalf.

• If you want to ask us to pay you back for a drug, start by reading Chapter 5 of this booklet: Asking us to pay our share of the costs for covered drugs. Chapter 5 describes the situations in which you may need to ask for reimbursement. It also tells how to send us the paperwork that asks us to pay you back for our share of the cost of a drug you have paid for.

• If you are requesting an exception, provide the “supporting statement.” Your doctor or other prescriber must give us the medical reasons for the drug exception you are requesting. (We call this the “supporting statement.”) Your doctor or other prescriber can fax or mail the statement to us. Or your doctor or other prescriber can tell us on the phone and follow up by faxing or mailing a written statement if necessary. See Sections 5.2 and 5.3 for more information about exception requests.

• We must accept any written request, including a request submitted on the CMS Model Coverage Determination Request Form, which is available on our Member Portal.

• For electronic submission, you can go to our website (https://memberportal.navitus.com) to sign into your Member Portal and complete the Request for Coverage Determination form. Note that if attachments need to be submitted, please fax or mail the form and supporting documentation.

If your health requires it, ask us to give you a “fast coverage decision”

Legal Terms

A “fast coverage decision” is called an “expedited coverage determination.”

• When we give you our decision, we will use the “standard” deadlines unless we have agreed to use the “fast” deadlines. A standard coverage decision means we will give you




an answer within 72 hours after we receive your doctor’s statement. A fast coverage decision means we will answer within 24 hours after we receive your doctor’s statement.

• To get a fast coverage decision, you must meet two requirements: o You can get a fast coverage decision only if you are asking for a drug you have

not yet received. (You cannot ask for a fast coverage decision if you are asking us to pay you back for a drug you have already bought.)

o You can get a fast coverage decision only if using the standard deadlines could cause serious harm to your health or hurt your ability to function.

• If your doctor or other prescriber tells us that your health requires a “fast coverage decision,” we will automatically agree to give you a fast coverage decision.

• If you ask for a fast coverage decision on your own (without your doctor’s or other prescriber’s support), we will decide whether your health requires that we give you a fast coverage decision.

o If we decide that your medical condition does not meet the requirements for a fast coverage decision, we will send you a letter that says so (and we will use the standard deadlines instead).

o This letter will tell you that if your doctor or other prescriber asks for the fast coverage decision, we will automatically give a fast coverage decision.

o The letter will also tell how you can file a complaint about our decision to give you a standard coverage decision instead of the fast coverage decision you requested. It tells how to file a “fast” complaint, which means you would get our answer to your complaint within 24 hours of receiving the complaint. (The process for making a complaint is different from the process for coverage decisions and appeals. For more information about the process for making complaints, see Section 7 of this chapter.)

Step 2: We consider your request and we give you our answer.

Deadlines for a “fast” coverage decision

• If we are using the fast deadlines, we must give you our answer within 24 hours. o Generally, this means within 24 hours after we receive your request. If you are

requesting an exception, we will give you our answer within 24 hours after we receive your doctor’s statement supporting your request. We will give you our answer sooner if your health requires us to.

o If we do not meet this deadline, we are required to send your request on to Level 2 of the appeals process, where it will be reviewed by an Independent Review Organization. Later in this section, we talk about this review organization and explain what happens at Appeal Level 2.



• If our answer is yes to part or all of what you requested, we must provide the coverage we have agreed to provide within 24 hours after we receive your request or doctor’s statement supporting your request.

• If our answer is no to part or all of what you requested, we will send you a written statement that explains why we said no. We will also tell you how you can appeal.

Deadlines for a “standard” coverage decision about a drug you have not yet received

• If we are using the standard deadlines, we must give you our answer within 72 hours. o Generally, this means within 72 hours after we receive your request. If you are

requesting an exception, we will give you our answer within 72 hours after we receive your doctor’s statement supporting your request. We will give you our answer sooner if your health requires us to.

o If we do not meet this deadline, we are required to send your request on to Level 2 of the appeals process, where it will be reviewed by an Independent Review Organization. Later in this section, we talk about this review organization and explain what happens at Appeal Level 2.

• If our answer is yes to part or all of what you requested – o If we approve your request for coverage, we must provide the coverage we have

agreed to provide within 72 hours after we receive your request or doctor’s statement supporting your request.


Deadlines for a “standard” coverage decision about payment for a drug you have already bought

• We must give you our answer within 14 calendar days after we receive your request. o If we do not meet this deadline, we are required to send your request on to Level 2

of the appeals process, where it will be reviewed by an Independent Review Organization. Later in this section, we talk about this review organization and explain what happens at Appeal Level 2.

• If our answer is yes to part or all of what you requested, we are also required to make payment to you within 14 calendar days after we receive your request.


Step 3: If we say no to your coverage request, you decide if you want to make an appeal.

• If we say no, you have the right to request an appeal. Requesting an appeal means asking us to reconsider – and possibly change – the decision we made.



Section 5.5 Step-by-step: How to make a Level 1 Appeal (how to ask for a review of a coverage decision made by our plan)

Legal Terms

An appeal to the plan about a Part D drug coverage decision is called a plan “redetermination.”

Step 1: You contact us and make your Level 1 Appeal. If your health requires a quick response, you must ask for a “fast appeal.”

What to do

• To start your appeal, you (or your representative or your doctor or other prescriber) must contact us.

o For details on how to reach us by phone, fax, or mail, or on our Member Portal, for any purpose related to your appeal, go to Chapter 2, Section 1, and look for the section called How to contact us when you are making an appeal about your Part D prescription drugs.

• If you are asking for a standard appeal, make your appeal by submitting a written request. You may also ask for an appeal by calling us at the phone number shown in Chapter 2, Section 1 (How to contact us when you are making an appeal about your Part D prescription drugs).

• If you are asking for a fast appeal, you may make your appeal in writing or you may call us at the phone number shown in Chapter 2, Section 1 (How to contact us when you are making an appeal about your Part D prescription drugs).

• We must accept any written request, including a request submitted on the CMS Model Coverage Determination Request Form, which is available on our Member Portal.

• For electronic submission, you can go to our Member Portal (https://memberportal.navitus.com) to sign into your Member Portal and complete the Request for Redetermination of Medicare Prescription Drug Denial form. Note that if attachments need to be submitted, please fax or mail the form and supporting documentation.

• You must make your appeal request within 60 calendar days from the date on the written notice we sent to tell you our answer to your request for a coverage decision. If you miss this deadline and have a good reason for missing it, we may give you more time to make your appeal. Examples of good cause for missing the deadline may include if you had a serious illness that prevented you from contacting us or if we provided you with incorrect or incomplete information about the deadline for requesting an appeal.




• You can ask for a copy of the information in your appeal and add more information.

o You have the right to ask us for a copy of the information regarding your appeal. o If you wish, you and your doctor or other prescriber may give us additional

information to support your appeal.

If your health requires it, ask for a “fast appeal”

Legal Terms

A “fast appeal” is also called an “expedited redetermination.”

• If you are appealing a decision we made about a drug you have not yet received, you and your doctor or other prescriber will need to decide if you need a “fast appeal.”

• The requirements for getting a “fast appeal” are the same as those for getting a “fast coverage decision” in Section 5.4 of this chapter.

Step 2: We consider your appeal and we give you our answer.

• When we are reviewing your appeal, we take another careful look at all of the information about your coverage request. We check to see if we were following all the rules when we said no to your request. We may contact you or your doctor or other prescriber to get more information.

Deadlines for a “fast appeal”

• If we are using the fast deadlines, we must give you our answer within 72 hours after we receive your appeal. We will give you our answer sooner if your health requires it.

o If we do not give you an answer within 72 hours, we are required to send your request on to Level 2 of the appeals process, where it will be reviewed by an Independent Review Organization. (Later in this section, we talk about this review organization and explain what happens at Level 2 of the appeals process.)

• If our answer is yes to part or all of what you requested, we must provide the coverage we have agreed to provide within 72 hours after we receive your appeal.

• If our answer is no to part or all of what you requested, we will send you a written statement that explains why we said no and how you can appeal our decision.

Deadlines for a “standard” appeal

• If we are using the standard deadlines, we must give you our answer within 7 calendar days after we receive your appeal for a drug you have not received yet. We will give you our decision sooner if you have not received the drug yet and your health condition requires us to do so. If you believe your health requires it, you should ask for “fast” appeal.



o If we do not give you a decision within 7 calendar days, we are required to send your request on to Level 2 of the appeals process, where it will be reviewed by an Independent Review Organization. Later in this section, we talk about this review organization and explain what happens at Level 2 of the appeals process.

• If our answer is yes to part or all of what you requested – o If we approve a request for coverage, we must provide the coverage we have

agreed to provide as quickly as your health requires, but no later than 7 calendar days after we receive your appeal.

o If we approve a request to pay you back for a drug you already bought, we are required to send payment to you within 30 calendar days after we receive your appeal request.

• If our answer is no to part or all of what you requested, we will send you a written statement that explains why we said no and how you can appeal our decision.

• If you are requesting that we pay you back for a drug you have already bought, we must give you our answer within 14 calendar days after we receive your request.

o If we do not give you a decision within 14 calendar days, we are required to send your request on to Level 2 of the appeals process, where it will be reviewed by an Independent Review Organization. Later in this section, we talk about this review organization and explain what happens at Appeal Level 2.

• If our answer is yes to part or all of what you requested, we are also required to make payment to you within 30 calendar days after we receive your request.

• If our answer is no to part or all of what you requested, we will send you a written statement that explains why we said no. We will also tell you how you can appeal our decision.

Step 3: If we say no to your appeal, you decide if you want to continue with the appeals process and make another appeal.

• If we say no to your appeal, you then choose whether to accept this decision or continue by making another appeal.

• If you decide to make another appeal, it means your appeal is going on to Level 2 of the appeals process (see below).



Section 5.6 Step-by-step: How to make a Level 2 Appeal

If we say no to your appeal, you then choose whether to accept this decision or continue by making another appeal. If you decide to go on to a Level 2 Appeal, the Independent Review Organization reviews the decision we made when we said no to your first appeal. This organization decides whether the decision we made should be changed.

Legal Terms

The formal name for the “Independent Review Organization” is the “Independent Review Entity.” It is sometimes called the “IRE.”

Step 1: To make a Level 2 Appeal, you (or your representative or your doctor or other prescriber) must contact the Independent Review Organization and ask for a review of your case.

• If we say no to your Level 1 Appeal, the written notice we send you will include instructions on how to make a Level 2 Appeal with the Independent Review Organization. These instructions will tell who can make this Level 2 Appeal, what deadlines you must follow, and how to reach the review organization.

• When you make an appeal to the Independent Review Organization, we will send the information we have about your appeal to this organization. This information is called your “case file.” You have the right to ask us for a copy of your case file.

• You have a right to give the Independent Review Organization additional information to support your appeal.

Step 2: The Independent Review Organization does a review of your appeal and gives you an answer.

• The Independent Review Organization is an independent organization that is hired by Medicare. This organization is not connected with us and it is not a government agency. This organization is a company chosen by Medicare to review our decisions about your Part D benefits with us.

• Reviewers at the Independent Review Organization will take a careful look at all of the information related to your appeal. The organization will tell you its decision in writing and explain the reasons for it.

Deadlines for “fast appeal” at Level 2

• If your health requires it, ask the Independent Review Organization for a “fast appeal.”

• If the review organization agrees to give you a “fast appeal,” the review organization must give you an answer to your Level 2 Appeal within 72 hours after it receives your appeal request.



• If the Independent Review Organization says yes to part or all of what you requested, we must provide the drug coverage that was approved by the review organization within 24 hours after we receive the decision from the review organization.

Deadlines for “standard appeal” at Level 2

• If you have a standard appeal at Level 2, the review organization must give you an answer to your Level 2 Appeal within 7 calendar days after it receives your appeal if it is for a drug you have not received yet. If you are requesting that we pay you back for a drug you have already bought, the review organization must give you an answer to your level 2 appeal within 14 calendar days after it receives your request.

• If the Independent Review Organization says yes to part or all of what you requested

• If the Independent Review Organization approves a request for coverage, we must provide the drug coverage that was approved by the review organization within 72 hours after we receive the decision from the review organization.

• If the Independent Review Organization approves a request to pay you back for a drug you already bought, we are required to send payment to you within 30 calendar days after we receive the decision from the review organization.

What if the review organization says no to your appeal?

If this organization says no to your appeal, it means the organization agrees with our decision not to approve your request. (This is called “upholding the decision.” It is also called “turning down your appeal.”)

If the Independent Review Organization “upholds the decision” you have the right to a Level 3 Appeal. However, to make another appeal at Level 3, the dollar value of the drug coverage you are requesting must meet a minimum amount. If the dollar value of the drug coverage you are requesting is too low, you cannot make another appeal and the decision at Level 2 is final. The notice you get from the Independent Review Organization will tell you the dollar value that must be in dispute to continue with the appeals process.

Step 3: If the dollar value of the coverage you are requesting meets the requirement, you choose whether you want to take your appeal further.

• There are three additional levels in the appeals process after Level 2 (for a total of five levels of appeal).

• If your Level 2 Appeal is turned down and you meet the requirements to continue with the appeals process, you must decide whether you want to go on to Level 3 and make a third appeal. If you decide to make a third appeal, the details on how to do this are in the written notice you got after your second appeal.

• The Level 3 Appeal is handled by an Administrative Law Judge or attorney adjudicator. Section 6 in this chapter tells more about Levels 3, 4, and 5 of the appeals process.



SECTION 6 Taking your appeal to Level 3 and beyond

Section 6.1 Appeal Levels 3, 4 and 5 for Part D Drug Requests

This section may be appropriate for you if you have made a Level 1 Appeal and a Level 2 Appeal, and both of your appeals have been turned down.

If the value of the drug you have appealed meets a certain dollar amount, you may be able to go on to additional levels of appeal. If the dollar amount is less, you cannot appeal any further. The written response you receive to your Level 2 Appeal will explain who to contact and what to do to ask for a Level 3 Appeal.

For most situations that involve appeals, the last three levels of appeal work in much the same way. Here is who handles the review of your appeal at each of these levels.

Level 3 Appeal A judge (called an Administrative Law Judge) or an attorney adjudicator who works for the Federal government will review your appeal and give you an answer.

• If the answer is yes, the appeals process is over. What you asked for in the appeal has been approved. We must authorize or provide the drug coverage that was approved by the Administrative Law Judge or attorney adjudicator within 72 hours (24 hours for expedited appeals) or make payment no later than 30 calendar days after we receive the decision.

• If the Administrative Law Judge or attorney adjudicator says no to your appeal, the appeals process may or may not be over.

o If you decide to accept this decision that turns down your appeal, the appeals process is over.

o If you do not want to accept the decision, you can continue to the next level of the review process. If the Administrative Law Judge or attorney adjudicator says no to your appeal, the notice you get will tell you what to do next if you choose to continue with your appeal.

Level 4 Appeal The Medicare Appeals Council (Council) will review your appeal and give you an answer. The Council is part of the Federal government.

• If the answer is yes, the appeals process is over. What you asked for in the appeal has

been approved. We must authorize or provide the drug coverage that was approved by the Council within 72 hours (24 hours for expedited appeals) or make payment no later than 30 calendar days after we receive the decision.



• If the answer is no, the appeals process may or may not be over. o If you decide to accept this decision that turns down your appeal, the appeals

process is over. o If you do not want to accept the decision, you might be able to continue to the

next level of the review process. If the Council says no to your appeal or denies your request to review the appeal, the notice you get will tell you whether the rules allow you to go on to a Level 5 Appeal. If the rules allow you to go on, the written notice will also tell you who to contact and what to do next if you choose to continue with your appeal.

Level 5 Appeal A judge at the Federal District Court will review your appeal.

• This is the last step of the appeals process.

MAKING COMPLAINTS

SECTION 7 How to make a complaint about quality of care, waiting times, customer service, or other concerns

If your problem is about decisions related to benefits, coverage, or payment, then this section is not for you. Instead, you need to use the process for coverage decisions and appeals. Go to Section 4 of this chapter.

Section 7.1 What kinds of problems are handled by the complaint process?

This section explains how to use the process for making complaints. The complaint process is used for certain types of problems only. This includes problems related to quality of care, waiting times, and the customer service you receive. Here are examples of the kinds of problems handled by the complaint process.

If you have any of these kinds of problems, you can “make a complaint”

Complaint Example

Quality of your medical care

• Are you unhappy with the quality of the care you have received?

Respecting your privacy

• Do you believe that someone did not respect your right to privacy or shared information about you that you feel should be confidential?



Complaint Example

Disrespect, poor customer service, or other negative behaviors

• Has someone been rude or disrespectful to you? • Are you unhappy with how our Customer Care has treated you? • Do you feel you are being encouraged to leave the plan?

Waiting times • Have you been kept waiting too long by pharmacists? Or by our Customer Care or other staff at the plan? o Examples include waiting too long on the phone or when

getting a prescription.

Cleanliness • Are you unhappy with the cleanliness or condition of a pharmacy?

Information you get from us

• Do you believe we have not given you a notice that we are required to give?

• Do you think written information we have given you is hard to understand?

Timeliness (These types of complaints are all related to the timeliness of our actions related to coverage decisions and appeals)

The process of asking for a coverage decision and making appeals is explained in sections 4-6 of this chapter. If you are asking for a coverage decision or making an appeal, you use that process, not the complaint process. However, if you have already asked us for a coverage decision or made an appeal, and you think that we are not responding quickly enough, you can also make a complaint about our slowness. Here are examples: • If you have asked us to give you a “fast coverage decision” or a

“fast appeal,” and we have said we will not, you can make a complaint.

• If you believe we are not meeting the deadlines for giving you a coverage decision or an answer to an appeal you have made, you can make a complaint.

• When a coverage decision we made is reviewed and we are told that we must cover or reimburse you for certain drugs, there are deadlines that apply. If you think we are not meeting these deadlines, you can make a complaint.

• When we do not give you a decision on time, we are required to forward your case to the Independent Review Organization. If we do not do that within the required deadline, you can make a complaint.



Section 7.2 The formal name for “making a complaint” is “filing a grievance”

Legal Terms

• What this section calls a “complaint” is also called a “grievance.”

• Another term for “making a complaint” is “filing a grievance.” Another way to say “using the process for complaints” is “using the process for filing a grievance.”

Section 7.3 Step-by-step: Making a complaint

Step 1: Contact us promptly – either by phone or in writing.

• Usually, calling Customer Care is the first step. If there is anything else you need to do, Customer Care will let you know. Please contact our Customer Care number at 1-866-270-3877. TTY users should call 711. Navitus MedicareRx Customer Care are available 24 hours a day, 7 days a week, except on Thanksgiving and Christmas Day.

• If you do not wish to call (or you called and were not satisfied), you can put your complaint in writing and send it to us. If you put your complaint in writing, we will respond to your complaint in writing.

• When a complaint is received in any department of Navitus Health Solutions, it is immediately forwarded to the Navitus MedicareRx Grievance and Appeals Department. All information related to the complaint is collected. You will be advised of the decision no later than 30 calendar days after the date the oral or written complaint is received. Navitus MedicareRx may extend the 30-calendar day timeframe by up to an additional 14 calendar days. Extensions may be given if you request the extension, or if the Grievance and Appeals Department justifies a need for more information. We must inform you of the status of the grievance within 30 days of receipt of the complaint.

o You may file for a faster response time when sending an expedited complaint. This request may be filed either verbally or in writing. The same procedures apply for documentation as with standard complaints. However, the Grievance and Appeals Department must notify the member of the decision within 24 hours of receipt of the complaint. The decision is usually presented verbally to the member. Navitus MedicareRx then sends written notice of the decision within three (3) calendar days of the oral notification.

• Whether you call or write, you should contact Customer Care right away (phone numbers are printed on the back cover of this booklet). The complaint must be made within 60 calendar days after you had the problem you want to complain about.



• If you are making a complaint because we denied your request for a “fast coverage decision” or a “fast appeal,” we will automatically give you a “fast” complaint. If you have a “fast” complaint, it means we will give you an answer within 24 hours.

Legal Terms

What this section calls a “fast complaint” is also called an “expedited grievance.”

Step 2: We look into your complaint and give you our answer.

• If possible, we will answer you right away. If you call us with a complaint, we may be able to give you an answer on the same phone call. If your health condition requires us to answer quickly, we will do that.

• Most complaints are answered within 30 calendar days. If we need more information and the delay is in your best interest or if you ask for more time, we can take up to 14 more calendar days (44 calendar days total) to answer your complaint. If we decide to take extra days, we will tell you in writing.

• If we do not agree with some or all of your complaint or don’t take responsibility for the problem you are complaining about, we will let you know. Our response will include our reasons for this answer. We must respond whether we agree with the complaint or not.

Section 7.4 You can also make complaints about quality of care to the Quality Improvement Organization

You can make your complaint about the quality of care you received by using the step-by-step process outlined above.

When your complaint is about quality of care, you also have two extra options:

• You can make your complaint to the Quality Improvement Organization. If you prefer, you can make your complaint about the quality of care you received directly to this organization (without making the complaint to us).

o The Quality Improvement Organization is a group of practicing doctors and other health care experts paid by the Federal government to check and improve the care given to Medicare patients.

o You will find the name, address, and phone number of the Quality Improvement Organization for your state in Exhibit B (located in the back of this booklet). If you make a complaint to this organization, we will work with them to resolve your complaint.

• Or you can make your complaint to both at the same time. If you wish, you can make your complaint about quality of care to us and also to the Quality Improvement Organization.



Section 7.5 You can also tell Medicare about your complaint

You can submit a complaint about Navitus MedicareRx directly to Medicare. To submit a complaint to Medicare, go to www.medicare.gov/MedicareComplaintForm/home.aspx. Medicare takes your complaints seriously and will use this information to help improve the quality of the Medicare program.

If you have any other feedback or concerns, or if you feel the plan is not addressing your issue, please call 1-800-MEDICARE (1-800-633-4227). TTY/TDD users can call 1-877-486-2048.


CHAPTER 8 Ending your membership in the plan

2022 Evidence of Coverage for Navitus MedicareRx (PDP) 129 Chapter 8. Ending your membership in the plan

Chapter 8. Ending your membership in the plan

SECTION 1 Introduction.......................................................................................... 130

Section 1.1 This chapter focuses on ending your membership in our plan ................... 130

SECTION 2 When can you end your membership in our plan? ....................... 130

Section 2.1 You can end your membership during the Annual Enrollment Period ....... 130

Section 2.2 In certain situations, you can end your membership during a Special Enrollment Period ................................................................................... 132

Section 2.3 Where can you get more information about when you can end your membership? ........................................................................................... 133

SECTION 3 How do you end your membership in our plan? ........................... 134

Section 3.1 Usually, you end your membership by enrolling in another plan ............... 134

SECTION 4 Until your membership ends, you must keep getting your drugs through our plan ...................................................................... 136

Section 4.1 Until your membership ends, you are still a member of our plan ............... 136

SECTION 5 Navitus MedicareRx must end your membership in the plan in certain situations ............................................................................ 136

Section 5.1 When must we end your membership in the plan? .................................... 136

Section 5.2 We cannot ask you to leave our plan for any reason related to your health 137

Section 5.3 You have the right to make a complaint if we end your membership in our plan ................................................................................................... 138



Section 1.1 This chapter focuses on ending your membership in our plan

Ending your membership in Navitus MedicareRx may be voluntary (your own choice) or involuntary (not your own choice):

• You might leave our plan because you have decided that you want to leave. o There are only certain times during the year, or certain situations, when you may

voluntarily end your membership in the plan. Section 2 tells you when you can end your membership in the plan.

o The process for voluntarily ending your membership varies depending on what type of new coverage you are choosing. Section 3 tells you how to end your membership in each situation.

• There are also limited situations where you do not choose to leave, but we are required to end your membership. Section 5 tells you about situations when we must end your membership.

If you are leaving our plan, you must continue to get your Part D prescription drugs through our plan until your membership ends.

SECTION 2 When can you end your membership in our plan?

You may end your membership in our plan anytime during the year. Ending your group sponsored Medicare Part D plan may impact your eligibility for other coverage sponsored by your group. You may not be able to re-enroll in your plan in the future. If you end your group Medicare Part D coverage, your Navitus MedicareRx coverage will end on the same date. Before ending your group sponsored Medicare Part D coverage, please contact your group sponsor.

Note: If you disenroll from Medicare prescription drug coverage and go without creditable prescription drug coverage for 63 days or more in a row, you may need to pay a late penalty if you join a Medicare drug plan later. “Creditable” coverage means the coverage is expected to pay, on average, at least as much as Medicare’s standard prescription drug coverage. See Chapter 1, Section 5 for more information about the late enrollment penalty.

Section 2.1 You can end your membership during the Annual Enrollment Period

You can end your membership and enroll in a different plan during the Annual Enrollment Period (also known as the “Annual Open Enrollment Period”). This is the time when you should review your health and drug coverage and make a decision about your coverage for the upcoming year.


• When is the Medicare Annual Enrollment Period? This happens for Medicare from October 15 to December 7. The University of California’s Open Enrollment Period is from October 28 through November 18, 2021.

• What type of plan can you switch to during the Medicare Annual Enrollment Period? You can choose to keep your current coverage or make changes to your coverage for the upcoming year. If you decide to change to a new plan, you can choose any of the following types of plans:

o Another Medicare prescription drug plan. o Original Medicare without a separate Medicare prescription drug plan.

If you receive “Extra Help” from Medicare to pay for your prescription drugs: If you do not enroll in a separate Medicare prescription drug plan, Medicare may enroll you in a drug plan, unless you have opted out of automatic enrollment.

o – or – A Medicare health plan. A Medicare health plan is a plan offered by a private company that contracts with Medicare to provide all of the Medicare Part A (Hospital) and Part B (Medical) benefits. Some Medicare health plans also include Part D prescription drug coverage. Note: Ending your group sponsored Medicare Part D plan may impact your eligibility for other coverage sponsored by your group, or mean that you will not be able to re-enroll in your plan in the future. Before ending your group sponsored Medicare Part D coverage, please contact your group sponsor. If you end your group Medicare Part D coverage, your Navitus MedicareRx coverage will end on the same date.

• If you enroll in most Medicare health plans, you will be disenrolled from Navitus MedicareRx when your new plan’s coverage begins. However, if you choose a Private Fee-for-Service plan without Part D drug coverage, a Medicare Medical Savings Account plan, or a Medicare Cost Plan, you can enroll in that new plan, however enrollment in the new plan will not end your membership in our plan. Your group benefits administrator can best explain your options, the implications of leaving this plan (such as if there would be loss of medical or dental benefits) and the process to follow to disenroll. If you do not want to keep our plan, you can choose to enroll in another Medicare prescription drug plan or drop Medicare prescription drug coverage.

Note: If you disenroll from Medicare prescription drug coverage and go without creditable prescription drug coverage for 63 or more days in a row, you may have to pay a late enrollment penalty if you join a Medicare drug plan later. (“Creditable” coverage means the coverage is expected to pay, on average, at least as much as Medicare’s standard prescription drug coverage.) See Chapter 1, Section 5 for more information about the late enrollment penalty.

• When will your membership end? Your membership will end when your new plan’s coverage begins on January 1.


Section 2.2 In certain situations, you can end your membership during a Special Enrollment Period

In certain situations, members of Navitus MedicareRx may be eligible to end their membership at other times of the year. This is known as a Special Enrollment Period.

• Who is eligible for a Special Enrollment Period? If any of the following situations apply to you, you may be eligible to end your membership during a Special Enrollment Period. These are just examples, for the full list you can contact the plan, call Medicare, or visit the Medicare website (www.medicare.gov):

o If you have moved out of your plan’s service area. o If you have Medicaid. o If you are eligible for “Extra Help” with paying for your Medicare prescriptions. o If we violate our contract with you. o If you are getting care in an institution, such as a nursing home or long-term care

(LTC) hospital. o If you enroll in the Program of All-inclusive Care for the Elderly (PACE). PACE

is not available in all states. If you would like to know if PACE is available in your state, please contact Customer Care (phone numbers are printed on the back cover of this booklet).

o Note: If you are in a drug management program, you may not be able to change plans. Chapter 3, Section 10 tells you more about drug management programs.

• When are Special Enrollment Periods? The enrollment periods vary depending on your situation.

• What can you do? To find out if you are eligible for a Special Enrollment Period, please call Medicare at 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY/TDD users call 1-877-486-2048. If you are eligible to end your membership because of a special situation, you can choose to change both your Medicare health coverage and prescription drug coverage. This means you can choose any of the following types of plans:

o Another Medicare prescription drug plan. o Original Medicare without a separate Medicare prescription drug plan.

If you receive “Extra Help” from Medicare to pay for your prescription drugs: If you switch to Original Medicare and do not enroll in a separate Medicare prescription drug plan, Medicare may enroll you in a drug plan, unless you have opted out of automatic enrollment.

o – or – A Medicare health plan. A Medicare health plan is a plan offered by a private company that contracts with Medicare to provide all of the Medicare Part A (Hospital) and Part B (Medical) benefits. Some Medicare health plans also include Part D prescription drug coverage.



Note: Ending your group sponsored Medicare Part D plan may impact your eligibility for other coverage sponsored by your group, or mean that you will not be able to re-enroll in your plan in the future. Before ending your group sponsored Medicare Part D coverage, please contact your group sponsor. If you end your group Medicare Part D coverage, your Navitus MedicareRx coverage will end on the same date. If you enroll in most Medicare health plans, you will automatically be

disenrolled from Navitus MedicareRx when your new plan’s coverage begins. However, if you choose a Private Fee-for-Service plan without Part D drug coverage, a Medicare Medical Savings Account plan, or a Medicare Cost Plan, you can enroll in that new plan, however enrollment in the new plan will not end your membership in our plan. Contact your group benefits administrator for information about disenrolling from this plan. Your group benefits administrator can best explain your options, the implications of leaving this plan (such as if there would be loss of medical or dental benefits) and the process to follow to disenroll. If you do not want to keep our plan, you can choose to enroll in another Medicare prescription drug plan or to drop Medicare prescription drug coverage.

Note: If you disenroll from Medicare prescription drug coverage and go without creditable prescription drug coverage for a continuous period of 63 days or more, you may have to pay a Part D late enrollment penalty if you join a Medicare drug plan later. (“Creditable” coverage means the coverage is expected to pay, on average, at least as much as Medicare’s standard prescription drug coverage.) See Chapter 1, Section 5 for more information about the late enrollment penalty.

• When will your membership end? Your membership will usually end on the first day of the month after we receive your request to change your plan.

Section 2.3 Where can you get more information about when you can end your membership?

If you have any questions or would like more information on when you can end your membership:


• You can find the information in the Medicare & You 2022 handbook. o Everyone with Medicare receives a copy of the Medicare & You 2022 handbook

each fall. Those new to Medicare receive it within a month after first signing up. o You can also download a copy from the Medicare website (www.medicare.gov).

Or, you can order a printed copy by calling Medicare at the number below.

• You can contact 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.



SECTION 3 How do you end your membership in our plan?

Section 3.1 Usually, you end your membership by enrolling in another plan

If you are considering ending your Part D membership with Navitus MedicareRx, please first contact RASC at (800) 888-8267 (in U.S.) or (510) 987-0200 (from outside the U.S.), to talk about how this may affect your UC Medicare Supplement PPO plan coverage.

Usually, to end your membership in our plan, you simply enroll in another Medicare plan during one of the enrollment periods (see Section 2 in this chapter for information about the enrollment periods). However, there are two situations in which you will need to end your membership in a different way:

• If you want to switch from our plan to Original Medicare without a Medicare prescription drug plan, you must ask to be disenrolled from our plan.

• If you join a Private Fee-for-Service plan without prescription drug coverage, a Medicare Medical Savings Account Plan, or a Medicare Cost Plan, you can enroll in that new plan, however your enrollment in that new plan will not end your membership in our plan. Contact your group benefits administrator for information about disenrolling from this plan. Your group benefits administrator can best explain your options, the implications of leaving this plan (such as loss of medical or dental benefits) and the process to follow to disenroll. If you do not want to keep our plan, you can choose to enroll in another Medicare prescription drug plan or ask to be disenrolled from our plan.

If you are in one of these two situations and want to leave our plan, there are two ways you can ask to be disenrolled:

• You can make a request in writing to us. Contact Customer Care if you need more information on how to do this (phone numbers are printed on the back cover of this booklet).

• --or--You can contact 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.

Ending your group sponsored Medicare Part D plan may impact your eligibility for other coverage sponsored by your group, or mean that you will not be able to re-enroll in your plan in the future. Before ending your group sponsored Medicare Part D coverage, please contact your group sponsor. If you end your group Medicare Part D coverage, your Navitus MedicareRx coverage will end on the same date.

Note: If you disenroll from Medicare prescription drug coverage and go without creditable prescription drug coverage for 63 days or more in a row, you may have to pay a Part D late enrollment penalty if you join a Medicare drug plan later. (“Creditable” coverage means the


coverage is expected to pay, on average, at least as much as Medicare’s standard prescription drug coverage.) See Chapter 1, Section 5 for more information about the late enrollment penalty.

The table below explains how you should end your membership in our plan.

If you would like to switch from our plan to: This is what you should do:

• Another Medicare prescription drug plan.

• Enroll in the new Medicare prescription drug plan between October 15 and December 7. You will automatically be disenrolled from Navitus MedicareRx when your new plan’s coverage begins.

• A Medicare health plan. • Enroll in the Medicare health plan by December 7. With most Medicare health plans, you will automatically be disenrolled from Navitus MedicareRx when your new plan’s coverage begins. However, if you choose a Private Fee-For-Service plan without Part D drug coverage, a Medicare Medical Savings Account plan, or a Medicare Cost Plan, you can enroll in that new plan, however enrollment in the new plan will not end your membership in our plan. Contact your group benefits administrator for information about dis-enrolling from this plan. Your group benefits administrator can best explain your options, the implications of leaving this plan (such as if there would be loss of medical or dental benefits) and the process to follow to dis-enroll. If you want to leave our plan, you must either enroll in another Medicare prescription drug plan or ask to be disenrolled. To ask to be disenrolled, you must send us a written request (contact Customer Care (phone numbers are printed on the back cover of this booklet) if you need more information on how to do this) or contact 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).


If you would like to switch from our plan to: This is what you should do:

• Original Medicare without a separate Medicare prescription drug plan.

Note: If you disenroll from a Medicare prescription drug plan and go without creditable prescription drug coverage for 63 days or more in a row, you may have to pay a late enrollment penalty if you join a Medicare drug plan later. See Chapter 1, Section 5 for more information about the late enrollment penalty.

• Send us a written request to disenroll. Contact Customer Care if you need more information on how to do this (phone numbers are printed on the back cover of this booklet).

• You can also contact Medicare at 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week, and ask to be disenrolled. TTY/TDD users should call 1-877-486-2048.

• – or – Contact your group benefits administrator.

SECTION 4 Until your membership ends, you must keep getting your drugs through our plan

Section 4.1 Until your membership ends, you are still a member of our plan

If you leave Navitus MedicareRx, it may take time before your membership ends and your new Medicare coverage goes into effect. (See Section 2 for information on when your new coverage begins.) During this time, you must continue to get your prescription drugs through our plan.

• You should continue to use our network pharmacies to get your prescriptions filled until your membership in our plan ends. Usually, your prescription drugs are only covered if they are filled at a network pharmacy including through our mail-order pharmacy services.

SECTION 5 Navitus MedicareRx must end your membership in the plan in certain situations

Section 5.1 When must we end your membership in the plan?

Navitus MedicareRx must end your membership in the plan if any of the following happen:

• If you no longer have Medicare Part A and Medicare Part B.

• If you move out of our service area.


• If you are away from our service area for more than 12 months. o If you move or take a long trip, you need to call Customer Care to find out if the

place you are moving or traveling to is in our plan’s area. (Phone numbers for Customer Care are printed on the back cover of this booklet.)

• If you become incarcerated (go to prison).

• If you are not a United States citizen or lawfully present in the United States.

• If you lie about or withhold information about other insurance you have that provides prescription drug coverage.

• If you intentionally give us incorrect information when you are enrolling in our plan and that information affects your eligibility for our plan. (We cannot make you leave our plan for this reason unless we get permission from Medicare first.)

• If you continuously behave in a way that is disruptive and makes it difficult for us to provide care for you and other members of our plan. (We cannot make you leave our plan for this reason unless we get permission from Medicare first.)

• If you let someone else use your membership card to get prescription drugs. (We cannot make you leave our plan for this reason unless we get permission from Medicare first.)

o If we end your membership because of this reason, Medicare may have your case investigated by the Inspector General.

• If plan premiums are not paid. o We must notify you in writing that you have 3 months to pay the plan premium

before we end your membership. • If you are required to pay the extra Part D amount because of your income and you do not

pay it, Medicare will disenroll you from our plan and you will lose prescription drug coverage.

Where can you get more information?

If you have questions or would like more information on when we can end your membership:

• You can call Customer Care for more information (phone numbers are printed on the back cover of this booklet).

Section 5.2 We cannot ask you to leave our plan for any reason related to your health

Navitus MedicareRx is not allowed to ask you to leave our plan for any reason related to your health.


What should you do if this happens?

If you feel that you are being asked to leave our plan because of a health-related reason, you should call Medicare at 1-800-MEDICARE (1-800-633-4227). TTY/TDD users should call 1-877-486-2048. You may call 24 hours a day, 7 days a week.

Section 5.3 You have the right to make a complaint if we end your membership in our plan

If we end your membership in our plan, we must tell you our reasons in writing for ending your membership. We must also explain how you file a grievance or can make a complaint about our decision to end your membership. You can also look in Chapter 7, Section 7 for information about how to make a complaint.

CHAPTER 9 Legal notices

2022 Evidence of Coverage for Navitus MedicareRx (PDP) 140 Chapter 9. Legal notices

Chapter 9. Legal notices

SECTION 1 Notice about governing law .............................................................. 141

SECTION 2 Notice about non-discrimination ...................................................... 141

SECTION 3 Notice about Medicare Secondary Payer subrogation rights ..... 141

2022 Evidence of Coverage for Navitus MedicareRx (PDP) 141 Chapter 9. Legal notices

SECTION 1 Notice about governing law

Many laws apply to this Evidence of Coverage and some additional provisions may apply because they are required by law. This may affect your rights and responsibilities even if the laws are not included or explained in this document. The principal law that applies to this document is Title XVIII of the Social Security Act and the regulations created under the Social Security Act by the Centers for Medicare & Medicaid Services, or CMS. In addition, other Federal laws may apply and, under certain circumstances, the laws of the state you live in.

SECTION 2 Notice about non-discrimination

Our plan must obey laws that protect you from discrimination or unfair treatment. We don’t discriminate based on race, ethnicity, national origin, color, religion, sex, gender, age, mental or physical disability, health status, claims experience, medical history, genetic information, evidence of insurability, or geographic location within the service area. All organizations that provide Medicare prescription drug plans, like our plan, must obey Federal laws against discrimination, including Title VI of the Civil Rights Act of 1964, the Rehabilitation Act of 1973, the Age Discrimination Act of 1975, the Americans with Disabilities Act, Section 1557 of the Affordable Care Act, all other laws that apply to organizations that get Federal funding, and any other laws and rules that apply for any other reason.

If you want more information or have concerns about discrimination or unfair treatment, please call the Department of Health and Human Services’ Office for Civil Rights at 1-800-368-1019 (TTY/TDD 1-800-537-7697) or your local Office for Civil Rights.

If you have a disability and need help with access to care, please call us at Customer Care (phone numbers are printed on the back cover of this booklet). If you have a complaint, such as a problem with wheelchair access, Customer Care can help.

SECTION 3 Notice about Medicare Secondary Payer subrogation rights

We have the right and responsibility to collect for covered Medicare prescription drugs for which Medicare is not the primary payer. According to CMS regulations at 42 CFR sections 422.108 and 423.462, Navitus MedicareRx (PDP), as a Medicare prescription drug plan sponsor, will exercise the same rights of recovery that the Secretary exercises under CMS regulations in subparts B through D of part 411 of 42 CFR and the rules established in this section supersede any State laws.

CHAPTER 10 Definitions of important words

2022 Evidence of Coverage for Navitus MedicareRx (PDP) 143 Chapter 10. Definitions of important words

Chapter 10. Definitions of important words

Appeal – An appeal is something you do if you disagree with our decision to deny a request for coverage of prescription drugs or payment for drugs you already received. For example, you may ask for an appeal if we don’t pay for a drug you think you should be able to receive. Chapter 7 explains appeals, including the process involved in making an appeal.

Annual Enrollment Period (Original Medicare) – A set time each fall when members can change their health or drug plans or switch to Original Medicare. The Medicare Annual Enrollment Period is from October 15 until December 7.

Brand Name Drug – A prescription drug that is manufactured and sold by the pharmaceutical company that originally researched and developed the drug. Brand name drugs have the same active-ingredient formula as the generic version of the drug. However, generic drugs are manufactured and sold by other drug manufacturers and are generally not available until after the patent on the brand name drug has expired.

Catastrophic Coverage Stage – The stage in the Part D Drug Benefit where you pay a low copayment or coinsurance for your drugs after you or other qualified parties on your behalf have spent $7,050 in covered drugs during the covered year.

Centers for Medicare & Medicaid Services (CMS) – The Federal agency that administers Medicare. Chapter 2 explains how to contact CMS.

Coinsurance – An amount you may be required to pay as your share of the cost for prescription drugs (after you pay any deductibles, if applicable). Coinsurance is usually a percentage (for example, 20%).

Complaint – The formal name for “making a complaint” is “filing a grievance.” The complaint process is used for certain types of problems only. This includes problems related to quality of care, waiting times, and the customer service you receive. See also “Grievance,” in this list of definitions.

Copayment (or “copay”) – An amount you may be required to pay as your share of the cost for a prescription drug. A copayment is a set amount, rather than a percentage. For example, you might pay $10 or $20 for a prescription drug.

Cost Sharing – Cost sharing refers to amounts that a member has to pay when drugs are received. (This is in addition to the plan’s monthly premium.) Cost sharing includes any combination of the following three types of payments: (1) any deductible amount a plan may impose before drugs are covered; (2) any fixed “copayment” amount that a plan requires when a specific drug is received; or (3) any “coinsurance” amount, a percentage of the total amount paid for a drug, that a plan requires when a specific drug is received.

Cost-Sharing Tier – Every drug on the list of covered drugs is in one of four cost-sharing tiers. In general, the higher the cost-sharing tier, the higher your cost for the drug.


Coverage Determination – A decision about whether a drug prescribed for you is covered by the plan and the amount, if any, you are required to pay for the prescription. In general, if you bring your prescription to a pharmacy and the pharmacy tells you the prescription isn’t covered under your plan, that isn’t a coverage determination. You need to call or write to your plan to ask for a formal decision about the coverage. Coverage determinations are called “coverage decisions” in this booklet. Chapter 7 explains how to ask us for a coverage decision.

Covered Drugs – The term we use to mean all of the prescription drugs covered by our plan.

Creditable Prescription Drug Coverage – Prescription drug coverage (for example, from an employer or union) that is expected to pay, on average, at least as much as Medicare’s standard prescription drug coverage. People who have this kind of coverage when they become eligible for Medicare can generally keep that coverage without paying a penalty, if they decide to enroll in Medicare prescription drug coverage later.

Customer Care – A department within our plan responsible for answering your questions about your membership, benefits, grievances, and appeals. See Chapter 2 for information about how to contact Customer Care.

Deductible – The amount you must pay for prescriptions before our plan begins to pay (if applicable).

Disenroll or Disenrollment – The process of ending your membership in our plan. Disenrollment may be voluntary (your own choice) or involuntary (not your own choice).

Dispensing Fee – A fee charged each time a covered drug is dispensed to pay for the cost of filling a prescription. The dispensing fee covers costs such as the pharmacist’s time to prepare and package the prescription.

Emergency – A medical emergency is when you, or any other prudent layperson with an average knowledge of health and medicine, believe that you have medical symptoms that require immediate medical attention to prevent loss of life, loss of a limb, or loss of function of a limb. The medical symptoms may be an illness, injury, severe pain, or a medical condition that is quickly getting worse.

Evidence of Coverage (EOC) and Disclosure Information – This document along with any other attachments, riders, or other optional coverage selected, which explains your coverage, what we must do, your rights, and what you have to do as a member of our plan.

Exception – A type of coverage decision that, if approved, allows you to get a drug that is not on your plan sponsor’s formulary (a formulary exception), or get a non-preferred drug at a lower cost-sharing level (a tiering exception). You may also request an exception if your plan sponsor requires you to try another drug before receiving the drug you are requesting, or the plan limits the quantity or dosage of the drug you are requesting (a formulary exception).


Extra Covered Drugs – Certain drugs that are excluded by law from coverage by Medicare Part D, may be included in the supplemental coverage of your drug plan. Drugs covered under the “Extra Covered Drugs” benefit, will be listed in the Formulary.

Extra Help – A Medicare program to help people with limited income and resources pay Medicare prescription drug program costs, such as premiums, deductibles, and coinsurance.

Formulary – A list of covered drugs provided by your plan.

Generic Drug – A prescription drug that is approved by the Food and Drug Administration (FDA) as having the same active ingredient(s) as the brand name drug. Generally, a “generic” drug works the same as a brand name drug and usually costs less.

Grievance – A type of complaint you make about us or one of our network pharmacies, including a complaint concerning the quality of your care. This type of complaint does not involve coverage or payment disputes.

Income Related Monthly Adjustment Amount (IRMAA) – If your modified adjusted gross income as reported on your IRS tax return from 2 years ago is above a certain amount, you’ll pay the standard premium amount and an Income Related Monthly Adjustment Amount, also known as IRMAA. IRMAA is an extra charge added to your premium. Less than 5% of people with Medicare are affected, so most people will not pay a higher premium.

Initial Coverage Limit – The maximum limit of coverage under the Initial Coverage Stage.

Initial Coverage Stage – This is the stage before your total drug costs including amounts you have paid and what your plan has paid on your behalf for the year have reached $4,430.

Initial Enrollment Period – When you are first eligible for Medicare, the period of time when you can sign up for Medicare Part A and Part B. For example, if you’re eligible for Medicare when you turn 65, your Initial Enrollment Period is the 7-month period that begins 3 months before the month you turn 65, includes the month you turn 65, and ends 3 months after the month you turn 65.

List of Covered Drugs (Formulary) – A list of prescription drugs covered by the plan. The drugs on this list are selected by the plan with the help of doctors and pharmacists. The list includes both brand name and generic drugs.

Low Income Subsidy (LIS) – See “Extra Help.”

Medicaid (or Medical Assistance) – A joint Federal and state program that helps with medical costs for some people with low incomes and limited resources. Medicaid programs vary from state to state, but most health care costs are covered if you qualify for both Medicare and Medicaid. See Chapter 2, Section 6 for information about how to contact Medicaid in your state.


Medically Accepted Indication – A use of a drug that is either approved by the Food and Drug Administration or supported by certain reference books. See Chapter 3, Section 3 for more information about a medically accepted indication.

Medicare – The Federal health insurance program for people 65 years of age or older, some people under age 65 with certain disabilities, and people with End-Stage Renal Disease (generally those with permanent kidney failure who need dialysis or a kidney transplant). People with Medicare can get their Medicare health coverage through Original Medicare, a Medicare Cost Plan, a PACE plan, or a Medicare Advantage Plan.

Medicare Advantage (MA) Plan – Sometimes called Medicare Part C. A plan offered by a private company that contracts with Medicare to provide you with all your Medicare Part A and Part B benefits. A Medicare Advantage Plan can be an HMO, PPO, a Private Fee-for-Service (PFFS) plan, or a Medicare Medical Savings Account (MSA) plan. If you are enrolled in a Medicare Advantage Plan, Medicare services are covered through the plan, and are not paid for under Original Medicare. In most cases, Medicare Advantage Plans also offer Medicare Part D (prescription drug coverage). These plans are called Medicare Advantage Plans with Prescription Drug Coverage. Everyone who has Medicare Part A and Part B is eligible to join any Medicare Advantage health plan that is offered in their area.

Medicare Cost Plan – A Medicare Cost Plan is a plan operated by a Health Maintenance Organization (HMO) or Competitive Medical Plan (CMP) in accordance with a cost-reimbursed contract under section 1876(h) of the Act.

Medicare Coverage Gap Discount Program – A program that provides discounts on most covered Part D brand name drugs to Part D members who have reached the Coverage Gap Stage and who are not already receiving “Extra Help.” Discounts are based on agreements between the Federal government and certain drug manufacturers. For this reason, most, but not all, brand name drugs are discounted.

Medicare-Covered Services – Services covered by Medicare Part A and Part B.

Medicare Health Plan – A Medicare health plan is offered by a private company that contracts with Medicare to provide Part A and Part B benefits to people with Medicare who enroll in the plan. This term includes all Medicare Advantage Plans, Medicare Cost Plans, Demonstration/Pilot Programs, and Programs of All-inclusive Care for the Elderly (PACE).

Medicare Prescription Drug Coverage (Medicare Part D) – Insurance to help pay for outpatient prescription drugs, vaccines, biologicals, and some supplies not covered by Medicare Part A or Part B.

“Medigap” (Medicare Supplement Insurance) Policy – Medicare supplement insurance sold by private insurance companies to fill “gaps” in Original Medicare. Medigap policies only work with Original Medicare. (A Medicare Advantage Plan is not a Medigap policy.)


Member (Member of our Plan, or “Plan Member”) – A person with Medicare who is eligible to get covered services, who has enrolled in our plan and whose enrollment has been confirmed by the Centers for Medicare & Medicaid Services (CMS).

Network Pharmacy – A network pharmacy is a pharmacy where members of our plan can get their prescription drug benefits. We call them “network pharmacies” because they contract with our plan. In most cases, your prescriptions are covered only if they are filled at one of our network pharmacies.

Original Medicare (“Traditional Medicare” or “Fee-for-service” Medicare) – Original Medicare is offered by the government, and not a private health plan like Medicare Advantage Plans and prescription drug plans. Under Original Medicare, Medicare services are covered by paying doctors, hospitals, and other health care providers payment amounts established by Congress. You can see any doctor, hospital, or other health care provider that accepts Medicare. You must pay the deductible. Medicare pays its share of the Medicare-approved amount, and you pay your share. Original Medicare has two parts: Part A (Hospital Insurance) and Part B (Medical Insurance) and is available everywhere in the United States.

Out-of-Network Pharmacy – A pharmacy that doesn’t have a contract with our plan to coordinate or provide covered drugs to members of our plan. As explained in this Evidence of Coverage, most drugs you get from out-of-network pharmacies are not covered by our plan unless certain conditions apply.

Out-of-Pocket Costs – See the definition for “cost sharing” above. A member’s cost-sharing requirement to pay for a portion of drugs received is also referred to as the member’s “out-of-pocket” cost requirement.

PACE Plan – A PACE (Program of All-Inclusive Care for the Elderly) plan combines medical, social, and long-term care (LTC) services for frail people to help people stay independent and living in their community (instead of moving to a nursing home) as long as possible, while getting the high-quality care they need. People enrolled in PACE plans receive both their Medicare and Medicaid benefits through the plan. PACE is not available in all states. If you would like to know if PACE is available in your state, please contact Customer Care (phone numbers are printed on the back cover of this booklet).

Part C – see “Medicare Advantage (MA) Plan.”

Part D – The voluntary Medicare Prescription Drug Benefit Program. (For ease of reference, we will refer to the prescription drug benefit program as Part D.)

Part D Drugs – Drugs that can be covered under Part D. We may or may not offer all Part D drugs. (See your formulary for a specific list of covered drugs.) Certain categories of drugs were specifically excluded by Congress from being covered as Part D drugs.

Part D Late Enrollment Penalty – An amount added to your monthly premium for Medicare drug coverage if you go without creditable coverage (coverage that is expected to pay, on average, at least as much as standard Medicare prescription drug coverage) for a continuous


period of 63 days or more after you are first eligible to join a Part D plan. You pay this higher amount as long as you have a Medicare drug plan. There are some exceptions. For example, if you receive “Extra Help” from Medicare to pay your prescription drug plan costs, the late enrollment penalty rules do not apply to you. If you receive “Extra Help,” you do not pay a late enrollment penalty.

Premium – The periodic payment to Medicare, an insurance company, or a health care plan for health or prescription drug coverage.

Prior Authorization – Approval in advance to get certain drugs that may or may not be on our formulary. Some drugs are covered only if your doctor or other network prescriber gets “prior authorization” from us. Covered drugs that need prior authorization are marked in the formulary.

Quality Improvement Organization (QIO) – A group of practicing doctors and other health care experts paid by the Federal government to check and improve the care given to Medicare patients. See Chapter 2, Section 4 for information about how to contact the QIO for your state.

Quantity Limits – A management tool that is designed to limit the use of selected drugs for quality, safety, or utilization reasons. Limits may be on the amount of the drug that we cover per prescription or for a defined period of time.

Select Generics - A specific list of generic drugs that have been on the market long enough to have a proven track record for effectiveness and value. Your plan has reduced copayments for “Select Generics”.

Service Area – A geographic area where a prescription drug plan accepts members if it limits membership based on where people live. The plan may disenroll you if you permanently move out of the plan’s service area.

Specialty Drugs - The Centers for Medicare & Medicaid Services (CMS) defines specialty drugs as any drug that costs $830 or more per unit.

Special Enrollment Period – A set time when members can change their health or drug plans or return to Original Medicare. Situations in which you may be eligible for a Special Enrollment Period include: if you are getting “Extra Help” with your prescription drug costs, if you move into a nursing home, or if we violate our contract with you.

Step Therapy – A utilization tool that requires you to first try another drug to treat your medical condition before we will cover the drug your physician may have initially prescribed.

Supplemental Security Income (SSI) – A monthly benefit paid by Social Security to people with limited income and resources who are disabled, blind, or age 65 and older. SSI benefits are not the same as Social Security benefits.

2022 Evidence of Coverage for Navitus MedicareRx (PDP) 149 Exhibit A – Listing of State Health Assistance Programs (SHIPs)

Exhibit A - Listing of State Health Insurance Assistance Programs (SHIPs) SHIP is a state program that gets money from the Federal government to give free local health insurance counseling to people with Medicare. TTY numbers require special telephone equipment and are only for people who have difficulties with hearing or speaking. If there is no TTY number indicated, you may try 711.

State Agency Name/Address Contact Information Alabama State Health Insurance Assistance

Program (SHIP) 201 Monroe St, Ste 350 Montgomery AL 36104

Toll Free: 1-800-243-5463 Local: 1-334-242-5743

Fax: 1-334-242-5594

Website: http://www.alabamaageline.gov/ Alaska Alaska Medicare Information

Office (SHIP) 550 W. 8th Ave Anchorage AK 99501

Toll Free (within AK): 1-800-478-6065 Local (in Anchorage): 1-907-269-3680

Outside AK: Call Anchorage TTY: 1-800-770-8973

Website: http://www.medicare.alaska.gov Arizona State Health Insurance Assistance

Program (SHIP) 1789 W. Jefferson St #950A Phoenix AZ 85007

Toll Free: 1-800-432-4040 (leave message)

Local: 1-602-542-4446

Website: https://des.az.gov/services/older-adults/medicare-assistance Arkansas Senior Health Insurance Information

Program (SHIP) 1200 W. 3rd St Little Rock AR 72201-1904

Toll Free: 1-800-224-6330 Local: 1-501-371-2782 TTY: 1-501-371-2782

Website: https://insurance.arkansas.gov/pages/consumer-services/senior-health/ California California Health Insurance

Counseling and Advocacy Program (HICAP) 1300 National Dr, Ste 200 Sacramento CA 95834

Toll Free (within CA): 1-800-434-0222 Toll Free (outside CA): 1-800-677-1116

TTY: 1-800-735-2929

Website: https://www.aging.ca.gov/hicap/ Colorado State Health Insurance Assistance

Program 1560 Broadway, Ste 850 Denver CO 80202


Spanish: 1-866-665-9668 Website: https://www.colorado.gov/dora/senior-healthcare-medicare

http://www.alabamaageline.gov/

http://www.medicare.alaska.gov/

https://des.az.gov/services/older-adults/medicare-assistance

https://insurance.arkansas.gov/pages/consumer-services/senior-health/

https://www.aging.ca.gov/hicap/

https://www.colorado.gov/dora/senior-healthcare-medicare


State Agency Name/Address Contact Information Connecticut Connecticut’s Program for Health

Insurance Assistance, Outreach, Information and Referral, Counseling, Eligibility Screening (CHOICES) 55 Farmington Ave Hartford CT 06105-3730

Toll Free (within CT): 1-800-994-9422 Outside CT: 1-860-424-5274

Website: http://www.ct.gov/agingservices Delaware Delaware Medicare Assistance

Bureau (DMAB) 841 Silverlake Blvd Dover DE 19904

Toll Free: 1-800-336-9500 Local: 1-302-674-7364

Website: https://insurance.delaware.gov/divisions/dmab/ District of Columbia

Health Insurance Counseling Project (HICP) 500 K Street NE Washington DC 20002

Local: 1-202-727-8370 Fax: 1-202-741-5885

Website: https://dcoa.dc.gov/service/health-insurance-counseling Florida Serving Health Insurance Needs of

Elders (SHINE) 4040 Esplanade Way, Ste 270 Tallahassee FL 32399

Toll Free: 1-800-963-5337 TDD/TYY:1-800-955-8770

Fax: 1-850-414-2150

Website: www.floridashine.org Georgia GeorgiaCares

2 Peachtree St NW, 33rd Floor Atlanta GA 30303

Toll free: 1-866-552-4464 (Option 4)

Website: www.mygeorgiacares.org Hawaii Hawaii State Health

Insurance Assistance Program (SHIP) No 1 Capitol District 250 South Hotel St, Ste 406 Honolulu HI 96813-2831

On the island of Oahu: 1-808-586-7299 Neighbor islands Toll Free: 1-888-875-9229

TTY: 1-866-810-4379

Website: www.hawaiiship.org Idaho Senior Health Insurance Benefits

Advisors (SHIBA) PO Box 83720 Boise ID 83720-0043

Toll Free: 1-800-247-4422 Local: 1-208-334-4250

Fax: 1-208-334-4389

Website: https://doi.idaho.gov/SHIBA/default Illinois Senior Health Insurance Program

(SHIP) One Natural Resources Way #100 Springfield IL 62702-1271

Toll Free: 1-800-252-8966 TTY: 1-888-206-1327

Website: www.illinois.gov/aging/ship/Pages/default.aspx

http://www.ct.gov/agingservices

https://insurance.delaware.gov/divisions/dmab/

https://dcoa.dc.gov/service/health-insurance-counseling

http://www.floridashine.org/

http://www.mygeorgiacares.org/

http://www.hawaiiship.org/

https://doi.idaho.gov/SHIBA/default

http://www.illinois.gov/aging/ship/Pages/default.aspx


State Agency Name/Address Contact Information Indiana State Health Insurance Assistance

Program (SHIP) 311 W. Washington St, Ste 300 Indianapolis IN 46204-2787

Toll Free: 1-800-452-4800 TDD/TYY: 1-866-846-0139

Website: www.in.gov/idoi/2495.htm Iowa Senior Health Insurance Information

Program (SHIIP) 601 Locust St, 4th Floor Des Moines IA 50309-3738

Toll Free: 1-800-351-4664 TTY: 1-800-735-2942

Website: https://shiip.iowa.gov/ Kansas Senior Health Insurance

Counseling for Kansas (SHICK) 503 S. Kansas Ste 612 Topeka KS 66603

Toll Free: 1-800-860-5260 TTY: 1-800-766-3777 Fax: 1-785-296-0256

Website: https://www.kdads.ks.gov/commissions/commission-on-aging/medicare-programs/shick Kentucky State Health Insurance

Assistance Program (SHIP) 275 E. Main St 3E-E Frankfort KY 40621

Toll Free: 1-877-293-7447 (Option #2) Local (DAIL): 1-502-564-6930

(Ask for a SHIP counselor) TTY: 1-888-642-1137

Website: https://chfs.ky.gov/agencies/dail/Pages/ship.aspx Louisiana Senior Health Insurance

Information Program (SHIIP) 1702 N 3rd Baton Rouge LA 70802

Toll Free: 1-800-259-5300 Local: 1-225-342-5301

Website: www.ldi.la.gov/consumers/senior-health-shiip Maine Office of Aging and Disability

Services 41 Anthony Ave Augusta ME 04333

Toll Free: 1-800-262-2232

Website: http://www.maine.gov/dhhs/oads/community-support/ship.html Maryland Senior Health Insurance

Assistance Program (SHIP) 301 W. Preston St, Ste 1007 Baltimore MD 21201

Toll Free: 1-800-243-3425 Local: 1-410-767-1100

Website: http://www.aging.maryland.gov/Pages/StateHealthInsuranceProgram.aspx Massachusetts Serving Health Insurance Needs

of Elders (SHINE) 1 Ashburton Pl, 5th Floor Boston MA 02108

Toll Free: 1-800-243-4636 TTY: 1-877-610-0241

Website: https://www.mass.gov/health-insurance-counseling

http://www.in.gov/idoi/2495.htm

https://shiip.iowa.gov/

https://www.kdads.ks.gov/commissions/commission-on-aging/medicare-programs/shick

https://www.kdads.ks.gov/commissions/commission-on-aging/medicare-programs/shick

https://chfs.ky.gov/agencies/dail/Pages/ship.aspx

http://www.ldi.la.gov/consumers/senior-health-shiip

http://www.maine.gov/dhhs/oads/community-support/ship.html

https://www.mass.gov/health-insurance-counseling


State Agency Name/Address Contact Information Michigan Medicare/Medicaid Assistance

Program (MMAP) 6105 W. St Joseph Hwy, Ste 204 Lansing MI 48917

Toll Free: 1-800-803-7174

Website: http://mmapinc.org/ Minnesota Minnesota State Health

Insurance Assistance Program/Senior LinkAge Line 540 Cedar St St. Paul MN 55155

Toll Free: 1-800-333-2433 TTY: 1-800-627-3529

Website: https://www.minnesotahelp.info/index Mississippi State Health Insurance Assistance Program

200 S Lamar St. Jackson, MS 39201

Toll Free: 1-844-822-4622 Local: 1-601-359-4500

Website: http://www.mdhs.ms.gov/adults-seniors/services-for-seniors/state-health-insurance-assistance-program/ Missouri CLAIM, State Health Insurance

Assistance Program (SHIP) 200 N. Keene St., Ste. 101 Columbia, MO 65201

Toll Free: 1-800-390-3330 Local: 1-573-817-8320

Website: www.missouriclaim.org Montana Montana State Health Insurance Assistance

Program (SHIP) 2030 11th Ave Helena MT 59604

Toll Free: 1-800-551-3191 1-406-444-2590

Website: http://dphhs.mt.gov/SLTC/aging/SHIP Nebraska Nebraska Senior Health Insurance Information

Program 1033 O St. Suite 307 Lincoln, NE 68508


Website: www.doi.nebraska.gov/shiip/ Nevada State Health Insurance Assistance Program

3416 Goni Road Suite D-132 Carson City NV 89706

Toll Free: 1-800-307-4444 Local: 1-775-687-4210

Website: http://adsd.nv.gov/Programs/Seniors/SHIP/SHIP_Prog/ New Hampshire

NH ServiceLink Resource Center 2nd Industrial Park Drive Concord, NH 03302


Website: https://www.servicelink.nh.gov/ New Jersey State Health Insurance Assistance Program

PO Box 715 Trenton NJ 08625-0715

Toll Free: 1-877-222-3737 TTY: 1-877-486-2048

Website: www.state.nj.us/humanservices/doas/services/ship/

http://mmapinc.org/

https://www.minnesotahelp.info/index

http://www.mdhs.ms.gov/adults-seniors/services-for-seniors/state-health-insurance-assistance-program

http://www.mdhs.ms.gov/adults-seniors/services-for-seniors/state-health-insurance-assistance-program

http://www.missouriclaim.org/

http://dphhs.mt.gov/SLTC/aging/SHIP

http://www.doi.nebraska.gov/shiip/

http://adsd.nv.gov/Programs/Seniors/SHIP/SHIP_Prog/

https://www.servicelink.nh.gov/

http://www.state.nj.us/humanservices/doas/services/ship/


State Agency Name/Address Contact Information New Mexico New Mexico ADRC

2550 Cerrillos Rd Santa Fe NM 87505


Website: http://www.nmaging.state.nm.us/ New York Health Insurance Information Counseling and

Assistance Program (HIICAP) 2 Empire State Plaza 4th Floor Albany NY 12223

Toll Free: 1-800-701-0501 Local: 1-800-342-9871

Website: www.aging.ny.gov/HealthBenefits/Index.cfm North Carolina

Seniors’ Health Insurance Information Program 325 N Salisbury St Raleigh, NC 27603


Website: www.ncdoi.com/SHIIP/Default.aspx North Dakota State Health Insurance Counseling Program

600 E Boulevard Ave Bismarck, ND 58505


Website: www.nd.gov/ndins/shic Ohio Ohio Senior Health Insurance Information

Program 50 W. Town St 3rd Floor, Ste 300 Columbus OH 43215

Toll Free:1-800-686-1578 Local: 1-614-644-2658 TTY: 1-614-644-3745

Website: http://www.insurance.ohio.gov/Pages/default.aspx Oklahoma Medicare Assistance Program

5 Corporate Plaza 3625 NW 56th St, Ste 100 Oklahoma City, OK 73112

Toll Free: 1-800-763-2828 Local: 1-405-521-2828

Website: www.ok.gov/oid/Consumers/Information_for_Seniors/SHIP.html Oregon Senior Health Insurance Benefits Assistance

(SHIBA) 350 Winter St NE Salem OR 97309-2555

Toll Free: 1-800-722-4134 TTY: 1-800-735-2900

Website: https://healthcare.oregon.gov/shiba/pages/index.aspx Pennsylvania APPRISE Pennsylvania State Health

Assistance Program 600 S Wycombe Ave, Yeadon, PA 19050

Toll Free: 1-800-783-7067 Local: 1-484-494-3769

Website: http://www.aging.pa.gov/aging-services/insurance/Pages/default.aspx Puerto Rico State Health Insurance Assistance Program

San Juan PR 00907 Toll Free: 1-877-725-4300

TTY: 1-787-919-7291 Website: http://www.oppea.pr.gov/

http://www.nmaging.state.nm.us/

http://www.aging.ny.gov/HealthBenefits/Index.cfm

http://www.ncdoi.com/SHIIP/Default.aspx

http://www.nd.gov/ndins/shic

http://www.insurance.ohio.gov/Pages/default.aspx

http://www.ok.gov/oid/Consumers/Information_for_Seniors/SHIP.html

https://healthcare.oregon.gov/shiba/pages/index.aspx

http://www.aging.pa.gov/aging-services/insurance/Pages/default.aspx

http://www.oppea.pr.gov/


State Agency Name/Address Contact Information Rhode Island Senior Health Insurance Program

57 Howard Ave Louis Pasteur Bldg. 2nd Floor Cranston RI 02920


Website: www.dea.ri.gov/insurance/ South Carolina

State Health Insurance Assistance Program (SHIP) 1301 Gervais St, Ste 350 Columbus SC 29201

Toll Free: 1-800-868-9095 Local: 1-803-734-9900

Website: https://aging.sc.gov/programs-and-initiatives South Dakota Senior Health Information & Insurance

Education (SHIINE) 2300 W 46th St Sioux Falls SD 57105

Toll Free: 1-800-536-8197 Local: 1-605-333-3314

Website: www.shiine.net

Tennessee State Health Insurance Assistance Program 502 Deaderick St, 9th Floor Nashville TN, 37243-0860


Website: http://tnmedicarehelp.com/ Texas Health Information Counseling and Advocacy

Program (HICAP) 701 W. 51st St Austin TX 78751

Toll Free: 1-800-252-9240 TTY: 1-800-735-2989

Website: https://hhs.texas.gov/services/health/medicare Utah Senior Health Insurance Information Program

195 N. 1950 W Salt Lake City UT 84116

Toll Free: 1-800-541-7735 Local: 1-801-538-4171

Website: https://daas.utah.gov/seniors/ Vermont State Health Insurance Assistance Program

476 Main St Ste #3 Winooski VT 05404

Toll Free: 1-800-642-5119 Local: 1-802-578-7094

Website: https://www.vermont4a.org/ Virginia Virginia Insurance Counseling and Assistance

Program (VICAP) 1610 Forest Ave, Ste 100 Henrico VA 23229

Toll Free: 1-800-552-3402 Local: 1-804-662-9333

Website: www.vda.virginia.gov/vicap.asp Washington Statewide Health Insurance Benefits Advisors

(SHIBA) PO Box 40255 Olympia WA 98504-0255

Toll Free: 1-800-562-6900 TDD: 1-360-586-0241

Website: www.insurance.wa.gov/about-oic/what-we-do/advocate-for-consumers/shiba/

http://www.dea.ri.gov/insurance/

http://www.shiine.net/

http://tnmedicarehelp.com/

https://hhs.texas.gov/services/health/medicare

https://daas.utah.gov/seniors/

https://www.vermont4a.org/

http://www.vda.virginia.gov/vicap.asp

http://www.insurance.wa.gov/about-oic/what-we-do/advocate-for-consumers/shiba/


State Agency Name/Address Contact Information West Virginia West Virginia State Health Insurance

Assistance Program 1900 Kanawha Blvd E Charleston WV 25305

Toll Free: 1-877-987-4463 Local: 1-304-558-3317

Website: www.wvship.org/AboutWVSHIP/tabid/132/Default.aspx Wisconsin Wisconsin State Health Insurance Assistance

Program (SHIP) 1 W. Wilson St Madison WI 53703


Website: www.dhs.wisconsin.gov/benefit-specialists/ship.htm Wyoming Wyoming State Health Insurance Assistance

Program 106 West Adams Ave Riverton WY 82501

Toll Free: 1-800-856-4398 Local: 1-307-856-6880

Website: www.wyomingseniors.com/services/wyoming-state-health-insurance-information-program

http://www.wvship.org/AboutWVSHIP/tabid/132/Default.aspx

http://www.dhs.wisconsin.gov/benefit-specialists/ship.htm

http://www.wyomingseniors.com/services/wyoming-state-health-insurance-information-program

http://www.wyomingseniors.com/services/wyoming-state-health-insurance-information-program

2022 Evidence of Coverage for Navitus MedicareRx (PDP) 156 Exhibit B – Listing of Quality Improvement Organizations (QIOs)

Exhibit B - Listing of Quality Improvement Organizations (QIOs)

Region Address Contact 1 KEPRO 888-319-8452

(CT, ME, MA, NH, RI, VT) 5700 Lombardo Center Dr., Suite 100 833-868-4055 (fax) Seven Hills, OH 44131 855-843-4776 TTY 2 Livanta BFCC-QIO Program 866-815-5440

(NJ, NY, PR, VI) 10820 Guilford Road, Suite 202 833-868-4056 (fax) Annapolis Junction, MD 20701 866-868-2289 TTY 3 Livanta BFCC-QIO Program 888-396-4646

(DE, DC, MD, PA, VA, WV) 10820 Guilford Road, Suite 202 833-868-4057 (fax) Annapolis Junction, MD 20701 888-985-2660 TTY 4 KEPRO 888-317-0751

(AL, FL, GA, KY, MS, NC, SC, TN) 5201 W. Kennedy Blvd., Suite 900 833-868-4058 (fax) Tampa, FL 33609 855-843-4776 TTY 5 Livanta BFCC-QIO Program 888-524-9900

(IL, IN, MI, MN, OH, WI) 10820 Guilford Road, Suite 202 833-868-4059 (fax) Annapolis Junction, MD 20701 888-985-8775 TTY 6 KEPRO 888-315-0636

(AR, LA, NM, OK, TX) 5201 W. Kennedy Blvd., Suite 900 833-868-4060 (fax) Tampa, FL 33609 855-843-4776 TTY 7 Livanta BFCC-QIO Program 888-755-5580

(IA, KS, MO, NE) 10820 Guilford Road, Suite 202 833-868-4061 (fax) Annapolis Junction, MD 20701 888-985-9295 TTY 8 KEPRO 888-317-0891

(CO, MT, ND, SD, UT, WY) 5700 Lombardo Center Dr., Suite 100 833-868-4062 (fax) Seven Hills, OH 44131 855-843-4776 TTY 9 Livanta BFCC-QIO Program 877-588-1123

(AZ, CA, HI, NV) 10820 Guilford Road, Suite 202 833-868-4063 (fax) Annapolis Junction, MD 20701 855-887-6668 TTY

10 KEPRO 888-305-6759 (AK, ID, OR, WA) 5700 Lombardo Center Dr., Suite 100 833-868-4064 (fax)

Seven Hills, OH 44131 855-843-4776 TTY TTY numbers require special telephone equipment and are only for people who have difficulties with hearing or speaking

2022 Evidence of Coverage for Navitus MedicareRx (PDP) 157 Exhibit C – Listing of State Medical Assistance Offices (Medicaid)

Exhibit C - Listing of State Medical Assistance Offices (Medicaid) STATE PROGRAM

NAME ADDRESS PHONE NUMBERS/WEBSITES

Alabama Medicaid Agency of Alabama

501 Dexter Ave PO Box 5624 Montgomery AL 36103-5624

1-800-362-1504 www.medicaid.alabama.gov

Alaska

Alaska Department of Health and Social Services

350 Main St Rm 304 PO Box 110640 Juneau AK 99811-0640

1-800-780-9972 http://dhss.alaska.gov

Arizona

Arizona Health Care Cost Containment System (AHCCCS)

801 E. Jefferson St Phoenix AZ 85034

1-855-432-7587 www.azahcccs.gov

Arkansas Arkansas Medicaid

PO Box 1437 Slot S401 Little Rock AR 72203-1437

1-800-482-8988 1-800-285-1131 x26789 (TDD) * https://medicaid.mmis.arkansas.gov

California Medi-Cal PO Box 997417

MS 4607 Sacramento CA 95899-7417

1-800-541-5555 1-916-636-1980 (outside California) www.dhca.ca.gov

Colorado Health First Colorado

1570 Grant St Denver CO 80203-1818

1-800-221-3943 TTY: 711 www.colorado.gov/hcpf

Connecticut Husky Health 55 Farmington Ave Hartford CT 06105-3730

1-877-284-8759 1-866-492-5276 (TDD/TTY) * http://www.ct.gov/hh/

Delaware Diamond State Health

1901 N. Dupont Hwy New Castle DE 19720

1-866-843-7212 1-302-571-4900 http://www.dhss.delaware.gov/dss/medicaid.html

District of Columbia

DC Medicaid 441 4th St NW 900S Washington DC 20001

1-202-727-5355 www.dc-medicaid.com

Florida Statewide Medicaid Managed Care

2727 Mahan Dr Mail Stop #8 Tallahassee FL 32308

1-877-254-1055 1-866-467-4970 (TDD) * www.fdhc.state.fl.us/Medicaid

Georgia Georgia Medicaid

2 Peachtree St NW Atlanta GA 30303

1-866-211-0950 https://dch.georgia.gov/medicaid

http://www.medicaid.alabama.gov/

http://dhss.alaska.gov/

http://www.azahcccs.gov/

https://medicaid.mmis.arkansas.gov/

http://www.dhca.ca.gov/

http://www.colorado.gov/hcpf

http://www.ct.gov/hh/

http://www.dhss.delaware.gov/dss/medicaid.html

http://www.dhss.delaware.gov/dss/medicaid.html

http://www.dc-medicaid.com/

http://www.fdhc.state.fl.us/Medicaid/index.shtml

https://dch.georgia.gov/medicaid


STATE PROGRAM NAME ADDRESS PHONE NUMBERS/WEBSITES

Hawaii Hawaii QUEST

801 Dillingham Blvd 3rd Floor Honolulu HI 96817

Oahu: 1-808-524-3370 TTY/TDD: 1-808-692-7182* Neighbor Islands: 1-800-316-8005 TTY/TDD 1-800-603-1201 * https://medquest.hawaii.gov

Idaho Idaho Medicaid

1720 N Westgate Dr Boise ID 83704

1-877-456-1233 1-208-334-6801 (TTY) * http://www.medicaid.idaho.gov/

Illinois HFS Medical Benefits

201 S. Grand Ave E. 2nd Springfield IL 62704-0001

1-800-843-6154 1-800-447-6404 (TTY) * http://www.illinois.gov/hfs/

Indiana Hoosier Healthwise

PO Box 1810 Marion IN 46952

1-800-457-4584 https://fssabenefits.in.gov

Iowa IA Health Link 1305 E Walnut St Des Moines IA 50319

1-800-338-8366 1-800-735-2942 (TTY) * http://dhs.iowa.gov/iahealthlink

Kansas KanCare 900 SW Jackson St Ste 900N Topeka KS 66612

1-800-792-4884 www.kancare.ks.gov

Kentucky Kentucky Medicaid

275 E Main St 6W-A Frankfurt KY 40602

1-855-306-8959 https://chfs.ky.gov/

Louisiana Healthy Louisiana

PO Box 629 Baton Rouge LA 70821-0629

1-888-342-6207 1-855-526-3346 (TTY) * www.bayouhealth.com

Maine MaineCare 114 Corn Shop Ln Farmington ME 04938

1-855-797-4357 TTY: 711 * https://www.maine.gov/DHHS/oms

Maryland Maryland Medicaid

201 W Preston St Baltimore MD 21201

1-877-463-3464 1-410-767-6500 mmcp.dhmh.maryland.gov

Massachusetts MassHealth PO Box 290794 Charleston MA 02129

1-800-841-2900 1-800-497-4648 (TTY) * www.mass.gov/masshealth

Michigan Michigan Medicaid Program

333 S Grand Ave PO Box 30195 Lansing MI 48909

1-800-642-3195 1-800-649-3777 (TTY) * www.michigan.gov/medicaid

Minnesota MinnesotaCare PO Box 64838 St Paul MN 55164

1-800-657-3672 http://mn.gov/dhs

Mississippi Mississippi Medicaid

550 High St Ste 1000 Jackson MS 39201-1399

1-800-421-2408 www.medicaid.ms.gov

https://medquest.hawaii.gov/

http://www.medicaid.idaho.gov/

http://www.illinois.gov/hfs/

https://fssabenefits.in.gov/

http://dhs.iowa.gov/iahealthlink

http://www.kancare.ks.gov/

https://chfs.ky.gov/

http://www.bayouhealth.com/

https://www.maine.gov/DHHS/oms

https://mmcp.health.maryland.gov/Pages/home.aspx

http://www.mass.gov/masshealth

http://www.michigan.gov/medicaid

http://mn.gov/dhs

http://www.medicaid.ms.gov/



Missouri MO HealthNet

615 Howerton Ct PO Box 6500 Jefferson City MO 65102-6500

1-800-392-2161 www.dss.mo.gov/fsd

Montana Montana Medicaid

1400 Broadway Cogswell Bldg Helena MT 59620

1-800-362-8312 https://apply.mt.gov

Nebraska Access Nebraska

301 Centennial Mall S. PO Box 95026 Lincoln NE 68509

1-855-632-7633 1-402-471-9570 (TTY) * www.accessnebraska.ne.gov

Nevada Nevada Medicaid

1210 S. Valley View Ste 104 Las Vegas NV 89102

1-800-992-0900 https://dwss.nv.gov/

New Hampshire

NH Health Protection Program

129 Pleasant St Concord NH 03301-3852

1-888-901-4999 1-800-735-2964 (TTY) * http://www.dhhs.nh.gov/ombp/

New Jersey NJ FamilyCare 7 Quakerbridge Plaza PO Box 712 Trenton NJ 08619

1-800-356-1561 http://www.state.nj.us/humanservices

New Mexico Centennial Care

PO Box 2348 Santa Fe NM 87504-2348

1-800-283-4465 http://www.hsd.state.nm.us/

New York New York Medicaid

1466 Corning Tower Albany NY 12237

1-800-541-2831 www.health.ny.gov

North Carolina North Carolina Medicaid

220 Swinburne St PO Box 46833 Raleigh NC 27620

1-800-662-7030 1-877-733-4851 (TTY) * https://dma.ncdhhs.gov/medicaid/

North Dakota North Dakota Medicaid

600 E. Boulevard Ave Dept 325 Bismarck, ND 58505-0250

1-844-854-4825 1-800-366-6888 (TTY) * http://www.nd.gov/dhs/eligibility/

Ohio Ohio Medicaid 50 W. Town St Ste 400 Columbus OH 43215

1-800-324-8680 http://www.medicaid.ohio.gov

Oklahoma SoonerCare 4345 N. Lincoln Blvd Oklahoma City OK 73105

1-800-987-7767 http://www.okhca.org/

http://www.dss.mo.gov/fsd

https://apply.mt.gov/

http://www.accessnebraska.ne.gov/

https://dwss.nv.gov/

http://www.dhhs.nh.gov/ombp/

http://www.state.nj.us/humanservices

http://www.hsd.state.nm.us/

http://www.health.ny.gov/

https://dma.ncdhhs.gov/medicaid/

http://www.nd.gov/dhs/eligibility/

http://www.medicaid.ohio.gov/

http://www.okhca.org/



Oregon Oregon Health Plan

500 Summer St NE Salem OR 97301

1-800-699-9075 http://healthcare.oregon.gov/

Pennsylvania Pennsylvania Medicaid

625 Forester St Rm 515 PO Box 2675 Harrisburg PA 17105

1-800-692-7462 1-717-705-7103 (TTY) * http://www.dhs.pa.gov/citizens/healthcaremedicalassistance/

Puerto Rico Puerto Rico Medicaid

PO Box 70184 San Juan PR 00936

1-787-765-6000 www.medicaid.pr.gov

Rhode Island Rhody Health Options

57 Howard Ave Cranston RI 02920

1-800-984-8989 1-401-462-0740 (TTY) * http://www.eohhs.ri.gov/

South Carolina Healthy Connections

PO Box 100101 Columbia SC 29202

1-888-549-0820 www.scdhhs.gov

South Dakota South Dakota Medicaid

700 Governors Dr Pierre SD 57501

1-800-226-1033 http://dss.sd.gov/medicaid/

Tennessee TennCare 310 Great Circle Rd Nashville TN 37243

1-800-342-3145 1-877-779-3103 (TTY) * www.tn.gov/tenncare/

Texas Texas Medicaid

4900 N. Lamar Blvd Austin TX 78751

1-800-252-8263 1-512-424-6597 (TTY) * www.yourtexasbenefits.com

Utah Utah Medicaid 288 N. 1460 West PO Box 143106 Salt Lake City UT 84114

1-800-662-9651 https://medicaid.utah.gov/

Vermont Vermont Medicaid

103 S. Main St Waterbury VT 05671-0204

1-800-250-8427 http://dcf.vermont.gov/benefits/MABD

Virginia Virginia Medicaid

600 E. Broad St Ste 1300 Richmond VA 23219

1-804-786-7933 1-800-343-0634 (TTY) * http://www.dmas.virginia.gov/

Washington Washington Apple Health

PO Box 45502 Olympia WA 98504-5502

1-800-562-3022 1-360-586-0226 (TTY) * http://www.hca.wa.gov/Medicaid

http://healthcare.oregon.gov/

http://www.dhs.pa.gov/citizens/healthcaremedicalassistance/

http://www.dhs.pa.gov/citizens/healthcaremedicalassistance/

http://www.medicaid.pr.gov/

http://www.eohhs.ri.gov/

http://www.scdhhs.gov/

http://dss.sd.gov/medicaid/

http://www.tn.gov/tenncare/

http://www.yourtexasbenefits.com/

https://medicaid.utah.gov/

http://dcf.vermont.gov/benefits/MABD

http://www.dmas.virginia.gov/

http://www.hca.wa.gov/Medicaid



West Virginia WV Medicaid 350 Capitol St Rm 251 Charleston WV 25301

1-888-483-0797 http://www.dhhr.wv.gov/

Wisconsin ForwardHealth 1 West Wilson St Madison WI 53703

1-800-362-3002 1-888-701-1251 (TTY) * www.forwardhealth.wi.gov

Wyoming Wyoming Medicaid

401 Hathaway Bldg Cheyenne WY 82002

1-866-571-0944 https://health.wyo.gov

*.This number requires special telephone equipment and is only for people who have difficulties with hearing or speaking.

http://www.dhhr.wv.gov/

http://www.forwardhealth.wi.gov/

https://health.wyo.gov/

2021 Evidence of Coverage for Navitus MedicareRx (PDP) 162 Exhibit D – Listing of State Pharmaceutal Assistance Programs (SPAPs)

Exhibit D - Listing of State Pharmaceutical Assistance Programs (SPAPs) STATE AGENCY ADDRESS PHONE NUMBERS

Colorado Colorado Bridging the Gap

Colorado Department of Public Health and Environment 4300 Cherry Creek Drive South Denver, CO 80246

1-303-692-2716

1-303-692-2783

https://www.colorado.gov

Connecticut

Connecticut Pharmaceutical Assistance Contract to the Elderly and the Disabled Program (ConnPACE)

PO Box 5011 Harford CT 06102

1-860-269-2029 (Hartford/Farmington and

out-of-state) 1-800-423-5026

(in-state only)

https://portal.ct.gov/dors

Delaware Delaware Prescription Assistance Program

PO Box 950 New Castle DE 19720 1-800-996-9969 Ext:2

https://www.dhss.delaware.gov/dhss/dmma/dpap.html

Idaho IdaGAP PO Box 83720 Boise ID 83720

1-208-334-5612

http://healthandwelfare.idaho.gov/Health/FamilyPlanningSTDHIV/HIVCareandTreatment

Indiana HoosierRx 402 W. Washington St Room W374, MS07 Indianapolis IN 46204

1-866-267-4679

https://www.payingforseniorcare.com/pharmaceutical-assistance/in-hoosierrx.html

Massachusetts Massachusetts Prescription Advantage

PO Box 15153 Worcester MA 01615 1-800-243-4636 Ext: 2

TTY (877) 610-0241 https://www.mass.gov/prescription-drug-assistance

Maryland Maryland SPAP c/o Pool Administrators 628 Hebron Ave Ste 502 Glastonbury CT 06033

1-800-551-5995 TTY/TDD 1-800-877-

5156 http://marylandspdap.com/

Maine MaineCare Services 242 State St Augusta ME 04333 1-866-796-2463

https://www.maine.gov/dhhs/oads/community-support/medicare-assistance.html

Missouri Missouri Rx Plan PO Box 6500 Jefferson City MO 65102

1-800-375-1406

https://www.payingforseniorcare.com/pharmaceutical-assistance/mo-missouri-rx-plan.html

https://www.colorado.gov/pacific/cdphe/colorado-aids-drug-assistance-program-adap

https://portal.ct.gov/dors

https://www.dhss.delaware.gov/dhss/dmma/dpap.html

http://healthandwelfare.idaho.gov/Health/FamilyPlanningSTDHIV/HIVCareandTreatment/tabid/391/Default.aspx

https://www.payingforseniorcare.com/pharmaceutical-assistance/in-hoosierrx.html

https://www.mass.gov/prescription-drug-assistance

http://marylandspdap.com/

https://www.maine.gov/dhhs/oads/community-support/medicare-assistance.html

https://www.payingforseniorcare.com/pharmaceutical-assistance/mo-missouri-rx-plan.html

2021 Evidence of Coverage for Navitus MedicareRx (PDP) 163 Exhibit D – Listing of State Pharmaceutal Assistance Programs (SPAPs)

STATE AGENCY ADDRESS PHONE NUMBERS

Montana Montana Big Sky Rx Program

PO Box 202915 Helena MT 59620

1-866-369-1233

https://dphhs.mt.gov/MontanaHealthcarePrograms/BigSky

North Carolina North Carolina SPAP 1902 Mail Service Center

Raleigh NC 27699 1-877-466-2232

https://epi.dph.ncdhhs.gov/cd/hiv/hmap.html

New Jersey NJ Senior Gold Prescription Discount Program

PO Box 715 Trenton NJ 08625

1-800-792-9745

https://www.state.nj.us/humanservices/doas/services/seniorgold/

Nevada Nevada Senior Rx 3416 Goni Road Ste D-132 Carson City NV 89706

1-866-303-6323 Option 2 702-486-4307

http://adsd.nv.gov/Programs/Seniors/SeniorRx/SrRxProg/

New York New York EPIC PO Box 15018 Albany NY 12212

1-800-332-3742

https://www.health.ny.gov/health_care/epic/

Pennsylvania PACE PO Box 8806 Harrisburg PA 17105 1-800-225-7223

https://www.aging.pa.gov/aging-services/prescriptions/Pages/default.aspx

Rhode Island RIPAE 74 West Rd Cranston RI 02920 1-401-462-3000

https://www.payingforseniorcare.com/pharmaceutical-assistance/ri-ripae.html

Texas Texas KHC PO Box 149347 Austin TX 78714 1-800-222-3986

https://hhs.texas.gov/services/health/kidney-health-care

Virginia Virginia SPAP 109 Governor St Richmond VA 23219 1-855-362-0658

http://www.vdh.virginia.gov/disease-prevention/virginia-aids-drug-assistance-program-adap/

Vermont VPharm 312 Hurricane Ln Ste 201 Williston VT 05495

1-800-250-8427

https://www.payingforseniorcare.com/pharmaceutical-assistance/vt-vpharm-vhap-vscript.html

Washington Washington State Health Insurance Pool

PO Box 1090 Great Bend KS 67530 1-800-877-5187

https://www.wship.org/Default.asp

Wisconsin SeniorCare PO Box 6710 Madison WI 53716 1-800-657-2038

https://www.dhs.wisconsin.gov/seniorcare/index.htm

https://dphhs.mt.gov/MontanaHealthcarePrograms/BigSky

https://epi.dph.ncdhhs.gov/cd/hiv/hmap.html

https://www.state.nj.us/humanservices/doas/services/seniorgold/

http://adsd.nv.gov/Programs/Seniors/SeniorRx/SrRxProg/

https://www.health.ny.gov/health_care/epic/

https://www.aging.pa.gov/aging-services/prescriptions/Pages/default.aspx

https://www.payingforseniorcare.com/pharmaceutical-assistance/ri-ripae.html

https://hhs.texas.gov/services/health/kidney-health-care

http://www.vdh.virginia.gov/disease-prevention/virginia-aids-drug-assistance-program-adap/

https://www.payingforseniorcare.com/pharmaceutical-assistance/vt-vpharm-vhap-vscript.html

https://www.wship.org/Default.asp

https://www.dhs.wisconsin.gov/seniorcare/index.htm

2022 Evidence of Coverage for Navitus MedicareRx (PDP) 164 Exhibit E – Listing of State AIDS Drug Assistance Programs (ADAPs)

Exhibit E - Listing of State AIDS Drug Assistance Programs (ADAPs) STATE AGENCY ADDRESS PHONE

NUMBERS Alabama

http://www.adph.org/aids/index.asp

Alabama ADAP 201 Monroe St Ste 1400 Montgomery AL 36104

1-866-574-9964

Alaska Alaska ADAP 3601 C Street Ste 540 Anchorage AK 99503

1-907-269-8058

http://www.adph.org/aids/index.asp Arizona Arizona ADAP 150 N. 18th

Ave, Ste 110 Phoenix AZ 85007

1-800-334-1540

http://www.azdhs.gov/phs/hiv/adap/ Arkansas Arkansas ADAP 4815 W.

Markham Little Rock AR 72205

1-800-232-4636

http://www.healthy.arkansas.gov/programsServices/infectiousDisease/ California California ADAP 1616 Capitol

Ave Ste 616 Sacramento CA 95814

1-888-311-7632

http://www.cdph.ca.gov/programs/aids/Pages/toaADAPIndiv.aspx Colorado Colorado ADAP 4300 Cherry

Creek Dr South Denver CO 80246

1-303-692-2716

https://www.colorado.gov/pacific/cdphe/colorado-aids-drug-assistance-program-adap Connecticut Connecticut

ADAP 25 Sigourney St Hartford CT 06106

1-800-233-2503

http://www.ct.gov/dss/lib/dss/PDFs/CADAPapp03.pdf Delaware Delaware ADAP 540 DuPoint

Hwy Dover DE 19901

1-302-739-3032

http://www.dhss.delaware.gov/dph/dpc/hivtreatment.html



http://www.azdhs.gov/phs/hiv/adap/

http://www.healthy.arkansas.gov/programsServices/infectiousDisease/

http://www.cdph.ca.gov/programs/aids/Pages/toaADAPIndiv.aspx

https://www.colorado.gov/pacific/cdphe/colorado-aids-drug-assistance-program-adap

http://www.ct.gov/dss/lib/dss/PDFs/CADAPapp03.pdf

http://www.dhss.delaware.gov/dph/dpc/hivtreatment.html



District of Columbia DC ADAP 899 North Capitol St NE Washington DC 20002

1-202-671-4900

http://doh.dc.gov/service/dc-aids-drug-assistance-program Florida Florida ADAP 4052 Bald

Cypress Way Tallahassee FL 32399

1-850-245-4335

http://www.floridahealth.gov/diseases-and-conditions/aids/adap/index.html Georgia Georgia ADAP 2 Peachtree St

NW Ste 12-235 Atlanta GA 30303

1-404-657-3127

https://dph.georgia.gov/adap-program Hawaii Hawaii ADAP 3627 Kilauea

Ave Ste 306 Honolulu HI 96816

1-808-732-0026

http://www.idph.state.il.us/health/aids/adap.htm Illinois Illinois ADAP 525 West

Jefferson St 1st Floor Springfield IL 62761

1-800-547-0466

http://www.idph.state.il.us/health/aids/adap.htm Idaho Idaho ADAP 450 W. State St

PO Box 837220 Boise ID 83720

1-800-926-2588

http://healthandwelfare.idaho.gov/Health/HIV,STD,HepatitisPrograms/HIVCare Indiana Ryan White

Program 2 N Meridan St Indianapolis IN 46204

1-866-588-4948

https://www.in.gov/isdh/17740.htm Iowa Iowa ADAP 321 E 12th St

Des Moines IA 50319

1-888-346-9562

http://idph.iowa.gov/hivstdhep/hiv/support

http://doh.dc.gov/service/dc-aids-drug-assistance-program

http://www.floridahealth.gov/diseases-and-conditions/aids/adap/index.html

https://dph.georgia.gov/adap-program

http://www.idph.state.il.us/health/aids/adap.htm

http://www.idph.state.il.us/health/aids/adap.htm

http://healthandwelfare.idaho.gov/Health/HIV,STD,HepatitisPrograms/HIVCare/tabid/391/Default.aspx

https://www.in.gov/isdh/17740.htm

http://idph.iowa.gov/hivstdhep/hiv/support



Kansas Kansas ADAP 1000 SW Jackson Ste 210 Topeka KS 66612

1-785-296-8701

http://www.kdheks.gov/sti_hiv/ryan_white_care.htm Kentucky Kentucky ADAP 275 E. Main St

1E-B Frankfort KY 40621

1-800-420-7431

http://chfs.ky.gov/dph/epi/hivaids/services.htm Louisiana Louisiana Health

Access Program 1450 Poydras St Ste 2136 New Orleans LA 70112

1-504-568-7474

http://new.dhh.louisiana.gov/index.cfm/page/1118 Maine Maine ADAP 221 State St

Augusta ME 04333

1-800-851-8437

http://www.maine.gov/dhhs/mecdc/infectious-disease/hiv-std/contacts/adap.shtml Maryland Maryland ADAP 201 W. Preston

St Baltimore MD 21201

1-800-205-6308

http://phpa.dhmh.maryland.gov/OIDPCS/CHCS/pages/madap.aspx Massachusetts Community

Research Initiative of New England/HDAP

38 Chauncy St Ste 500 Boston MA 02111

1-800-228-2714

http://crine.org/hdap/contact-us/ Michigan MiDAP 109 Michigan

Ave 9th Floor Lansing MI 48913

1-888-826-6565

http://www.michigan.gov/mdhhs/0,5885,7-339-71550_2955_2982---,00.html Minnesota MN ADAP PO Box 64972

St Paul MN 55164

1-800-657-3761

1-800-627-3529 (TTY) *

https://mn.gov/dhs/people-we-serve/adults/health-care/hiv-aids/

http://www.kdheks.gov/sti_hiv/ryan_white_care.htm

http://chfs.ky.gov/dph/epi/hivaids/services.htm

http://new.dhh.louisiana.gov/index.cfm/page/1118

http://www.maine.gov/dhhs/mecdc/infectious-disease/hiv-std/contacts/adap.shtml

http://phpa.dhmh.maryland.gov/OIDPCS/CHCS/pages/madap.aspx

http://crine.org/hdap/contact-us/

http://www.michigan.gov/mdhhs/0,5885,7-339-71550_2955_2982---,00.html

https://mn.gov/dhs/people-we-serve/adults/health-care/hiv-aids/



Mississippi Mississippi ADAP 570 E. Woodrow Wilson PO Box 1700 Jackson MS 39215-1700

1-888-343-7373

http://msdh.ms.gov/msdhsite/_static/14,13047,150.html Missouri Missouri

HIV/AIDS Case Management Program

PO Box 570 Jefferson City MO 65102-0570

1-800-785-2437

https://health.mo.gov/living/healthcondiseases/communicable/hivaids/casemgmt.php Montana Montana ADAP 1400

Broadway Room C-211 Helena MT 59620

1-406-444-3565

http://dphhs.mt.gov/publichealth/hivstd/treatmentprogram.aspx Nebraska Nebraska

ADAP/CARE 301 Centennial Mall S. Lincoln NE 68509

1-800-782-2437

http://dhhs.ne.gov/publichealth/Pages/dpc_ryan_white.aspx Nevada Nevada Ryan

White 4126 Technology Way Ste 200 Carson City NV 89706

1-877-385-2345

http://dpbh.nv.gov/Programs/HIV-Ryan/Ryan_White_Part_B_-_Home/ New Hampshire New Hampshire

Ryan White CARE

129 Pleasant St Concord NH

03301-3852

1-800-852-3345

http://www.dhhs.nh.gov/dphs/bchs/std/care.htm New Jersey NJ AIDS Drug

Distribution Program

PO Box 722 Trenton NJ 08625-0722

1-877-613-4533

http://www.state.nj.us/health/aids/freemeds.shtml New Mexico NM AIDS Drug

Assistance PO Box 830 Bernalillo NM 87004

1-855-637-6574

https://nmhealth.org/about/phd/idb/hats/

http://msdh.ms.gov/msdhsite/_static/14,13047,150.html

https://health.mo.gov/living/healthcondiseases/communicable/hivaids/casemgmt.php

http://dphhs.mt.gov/publichealth/hivstd/treatmentprogram.aspx

http://dhhs.ne.gov/publichealth/Pages/dpc_ryan_white.aspx

http://dpbh.nv.gov/Programs/HIV-Ryan/Ryan_White_Part_B_-_Home/

http://www.dhhs.nh.gov/dphs/bchs/std/care.htm

http://www.state.nj.us/health/aids/freemeds.shtml

https://nmhealth.org/about/phd/idb/hats/



New York HIV Uninsured CARE

PO Box 2052 Albany NY 12220-0052

1-800-542-2437

1-518-459-0121 (TTY) *

http://www.health.ny.gov/diseases/aids/general/resources/adap/ North Carolina NC ADAP 1902 Mail

Service Center Raleigh NC 27699

1-877-466-2232

http://epi.publichealth.nc.gov/cd/hiv/adap.html North Dakota Ryan White

HIV/AIDS Program

2635 E. Main Ave Bismarck ND 58506

1-800-472-2180

https://www.ndhealth.gov/HIV/HIV%20Care/ADAP/ADAP.htm Ohio Ohio HIV Drug

Assistance Program

246 N. High St Columbus OH 43215

1-800-777-4775

https://www.odh.ohio.gov/odhprograms/hastpac/hivcare/OHDAP/drgasst1.aspx Oklahoma Oklahoma ADAP 1000 NE Tenth

Rm 614 Oklahoma City OK 73117

1-800-884-1572

https://www.ok.gov/health2/documents/HIV-HDAPbrochure14.pdf Oregon CAREassist PO Box 14450

Portland OR 97293

1-800-805-2313

https://www.oregon.gov/oha/ph/DiseasesConditions/HIVSTDViralHepatitis/HIVCareTreatment/CAREAssist Pennsylvania Special

Pharmaceutical Benefits Program

PO Box 8808 Harrisburg PA 17105-8808

1-800-922-9384

https://www.health.pa.gov/topics/programs/HIV/Pages/Special-Pharmaceutical-Benefits.aspx Puerto Rico Ryan White

Program PO Box 70184 San Juan PR 00936-8184

1-787-765-2929

http://www.salud.gov.pr/Servicios-al-Ciudadano/Pages/default.aspx Rhode Island Ryan White

Program 74 West Rd Ste 60 Cranston RI 02920

1-401-462-3294

http://www.eohhs.ri.gov/Portals/0/Uploads/Documents/ADAPEnrollmentForm.pdf

http://www.health.ny.gov/diseases/aids/general/resources/adap/

http://epi.publichealth.nc.gov/cd/hiv/adap.html

https://www.ndhealth.gov/HIV/HIV%20Care/ADAP/ADAP.htm

https://www.odh.ohio.gov/odhprograms/hastpac/hivcare/OHDAP/drgasst1.aspx

https://www.ok.gov/health2/documents/HIV-HDAPbrochure14.pdf

https://www.oregon.gov/oha/ph/DiseasesConditions/HIVSTDViralHepatitis/HIVCareTreatment/CAREAssist/Pages/index.aspx

https://www.oregon.gov/oha/ph/DiseasesConditions/HIVSTDViralHepatitis/HIVCareTreatment/CAREAssist/Pages/index.aspx

https://www.health.pa.gov/topics/programs/HIV/Pages/Special-Pharmaceutical-Benefits.aspx

http://www.salud.gov.pr/Servicios-al-Ciudadano/Pages/default.aspx

http://www.eohhs.ri.gov/Portals/0/Uploads/Documents/ADAPEnrollmentForm.pdf



South Carolina SC ADAP PO Box 101106 Columbia SC 29211

1-800-856-9954

http://www.scdhec.gov/Health/DiseasesandConditions/InfectiousDiseases/HIVandSTDs/ South Dakota Ryan White

Program 615 E. 4th St Pierre SD 57501

1-800-592-1861

http://doh.sd.gov/diseases/infectious/ryanwhite/ Tennessee Ryan White

Program 425 5th Ave N. 3rd Fl Nashville TN 37243

1-800- 525-2437

http://www.tn.gov/health/topic/STD-ryanwhite

Texas Texas HIV Medication Program

PO Box 149347 MC 1873 Austin TX 78714

1-800-255-1090

https://www.dshs.texas.gov/hivstd/meds/document.shtm Utah Utah ADAP PO Box

142104 Salt Lake City UT 84114-2104

1-801-538-6197

http://health.utah.gov/epi/treatment/ Vermont VT Medication

Assistance Program

108 Cherry St Burlington VT 05402

1-802-863-7245

http://healthvermont.gov/prevent/aids/aids_index.aspx Virginia Virginia ADAP VA Dept of

Health 109 Governor St 1st Floor Richmond VA 23219

1-855-362-0658

http://166.67.66.226/epidemiology/DiseasePrevention/Programs/ADAP/ Washington Early Intervention

Program PO Box 47841 Olympia WA 98504-7841

1-877-376-9316

http://www.doh.wa.gov/portals/1/documents/pubs/430-025-EIPBrochure.pdf

http://www.scdhec.gov/Health/DiseasesandConditions/InfectiousDiseases/HIVandSTDs/

http://doh.sd.gov/diseases/infectious/ryanwhite/

http://www.tn.gov/health/topic/STD-ryanwhite

https://www.dshs.texas.gov/hivstd/meds/document.shtm

http://health.utah.gov/epi/treatment/

http://healthvermont.gov/prevent/aids/aids_index.aspx

http://166.67.66.226/epidemiology/DiseasePrevention/Programs/ADAP/

http://www.doh.wa.gov/portals/1/documents/pubs/430-025-EIPBrochure.pdf



West Virginia WV ADAP PO Box 6360 Wheeling WV 26003

1-304-232-6822

http://www.dhhr.wv.gov/oeps/std-hiv-hep/HIV_AIDS/caresupport/Pages/ADAP.aspx Wisconsin WI ADAP PO Box 2659

Madison WI 53701-2659

1-800-991-5532

https://www.dhs.wisconsin.gov/aids-hiv/adap.htm Wyoming Communicable

Disease Services Program

401 Hathaway Building Cheyenne WY 82002

1-307-777-7529

https://health.wyo.gov/publichealth/communicable-disease-unit/hivaids/forms/

http://www.dhhr.wv.gov/oeps/std-hiv-hep/HIV_AIDS/caresupport/Pages/ADAP.aspx

https://www.dhs.wisconsin.gov/aids-hiv/adap.htm

https://health.wyo.gov/publichealth/communicable-disease-unit/hivaids/forms/

Navitus MedicareRx (PDP) Customer Care

Method Customer Care – Contact Information

CALL 1-866-270-3877 Calls to this number are free. We are available 24 hours a day, 7 days a week except on Thanksgiving and Christmas Day. Pharmacies can also reach Customer Care 24 hours a day, 7 days a week. Customer Care also has free language interpreter services available for non-English speakers.

TTY/TDD 711 This number requires special telephone equipment and is only for people who have difficulties with hearing or speaking. Calls to this number are free. We are available 24 hours a day, 7 days a week except on Thanksgiving and Christmas Day. Customer Care also has free language interpreter services available for non-English speakers.

WRITE Navitus MedicareRx (PDP) Customer Care P.O. Box 1039 Appleton, WI 54912-1039


SHIP (State Health Insurance Assistance Program) is a state program that gets money from the Federal government to give free local health insurance counseling to people with Medicare. Refer to Exhibit A in this Evidence of Coverage.

PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1051. If you have comments or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

S9701_2022_UCA_EOC_V01_C


S9701_2022_UCA_VACC_V01_C

Your Vaccine Coverage

Navitus MedicareRx (PDP) is committed to your health. Your prescription benefit covers

Medicare Part D vaccinations to prevent illness. Navitus covers the following common vaccines,

which are available at a $0 cost to you at a participating pharmacy. It is always recommended to

check with your prescriber to see which vaccinations are right for you.

• Shingles

• Hepatitis A and Hepatitis B (for members at low risk)

• Travel vaccines (including typhoid, yellow fever, Rabies, Japanese Encephalitis, and

Polio)

• Tetanus (for preventative use)

• Meningitis

Please note that some common vaccines are covered by your Medicare Part B benefit. These

include influenza (flu), pneumonia, COVID-19, tetanus (for injury or exposure) and hepatitis

B (for members at medium or high risk of hepatitis). Please contact your Medicare Part B

plan for more information.

How to Receive Your Part D Vaccinations

We recommend scheduling your Part D vaccinations at an in-network pharmacy. These

pharmacies can bill directly to Navitus MedicareRx for a quick, easy, no-cost appointment.

Part D vaccinations may also be covered by Medicare at your provider’s office. However, you

may have to pay additional out-of-pocket costs. You can ask us to reimburse you for our share of

the cost. To do this, submit vaccination records along with payment receipts to Navitus

MedicareRx.

Questions?

If you have questions, please call Navitus MedicareRx Customer Care. We can be reached toll-

free at 1-866-270-3877. For the hearing impaired, please call TTY at 711. Members can reach

Navitus MedicareRx Customer Care 24 hours a day, 7 days a week, except on Thanksgiving and

Christmas Day.

Our online portal can help you find an in-network pharmacy and manage your pharmacy benefit.

You can find the Member Portal at https://memberportal.navitus.com to get started.
