Express Scripts Medicare (PDP) 2017 Formulary (List of Covered Drugs)

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1 Choice Plan Express Scripts Medicare (PDP) 017 Formulary (List of Covered s) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN Formulary File Submission ID: 17070, V18 This formulary was updated on 10/19/017. For more recent information or other questions, please contact Express Scripts Medicare (PDP) Customer Service at ; New York State residents: or, for TTY users, , 4 hours a day, 7 days a week, or visit ATTENTION: If you speak a language other than English, language assistance services, free of charge, are available to you. Call ; New York residents: (TTY: ). ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al ; para residentes de New York: (TTY: ). This information is available in braille, large print and other formats for people with disabilities. Please contact Customer Service if you need plan information in another format. Y0046_F00SNC7A Accepted F00SNC7BW4

2 Note to existing members: This formulary has changed since last year. Please review this document to make sure that it still contains the drugs you take. When this drug list (formulary) refers to we, us, or our, it means Medco Containment Life Insurance Company and Medco Containment Insurance Company of New York (for members located in New York State only). When it refers to plan or our plan, it means Express Scripts Medicare. This document includes a list of the drugs (formulary) for our plan, which is current as of October 19, 017. 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, 018, and from time to time during the year. What is the Express Scripts Medicare Formulary? A formulary is a list of covered drugs selected by Express Scripts Medicare in consultation with a team of healthcare providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. Express Scripts Medicare will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at an Express Scripts Medicare network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage. Can the Formulary (drug list) change? Generally, if you are taking a drug on our 017 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 017 coverage year except when a new, less expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released. Other types of formulary changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug. It will remain available at the same cost-sharing for those members taking it for the remainder of the coverage year. We feel it is important that you have continued access for the remainder of the coverage year to the formulary drugs that were available when you chose our plan, except for cases in which you can save additional money or we cannot ensure your safety. If we remove drugs from our formulary, or add prior authorization, quantity limits and/or step therapy restrictions on a drug, or move a drug to a higher cost-sharing tier, we must notify affected members of the change at least 60 days before the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 60-day supply of the drug. If the Food and Administration deems a drug on our formulary to be unsafe or the drug s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug. The enclosed formulary is current as of October 19, 017. To get updated information about the drugs covered by Express Scripts Medicare, please contact us. Our contact information appears on the front and back cover pages. If there are additional changes made to the formulary that affect you and are not mentioned above, you will be notified in writing of these changes within a reasonable period of time from when the changes are made. i

3 How do I use the Formulary? There are two ways to find your drug within the formulary: Medical Condition The formulary begins on page 1. The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category Cardiovascular, Hypertension/Lipids. If you know what your drug is used for, look for the category name in the list that begins on page 1. Then look under the category name for your drug. Alphabetical Listing If you are not sure what category to look under, you should look for your drug in the Index that begins on page 68. 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? Express Scripts Medicare covers both brand-name drugs and generic drugs. A generic drug is approved by the FDA as having the same active ingredient as the brand-name drug. Generally, generic drugs cost less than brand-name drugs. Are there any restrictions on my coverage? Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include: Prior Authorization: Express Scripts Medicare requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from Express Scripts Medicare before you fill your prescriptions. If you don t get approval, Express Scripts Medicare may not cover the drug. Quantity Limits: For certain drugs, Express Scripts Medicare limits the amount of the drug that Express Scripts Medicare will cover. For example, Express Scripts Medicare provides two inhalers (17 grams) for a 1-month supply per prescription for PROAIR HFA. This may be in addition to a standard 1-month or 3-month supply. Step Therapy: In some cases, Express Scripts Medicare requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if A and B both treat your medical condition, Express Scripts Medicare may not cover B unless you try A first. If A does not work for you, Express Scripts Medicare will then cover B. You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 1. You can also get more information about the restrictions applied to specific covered drugs by visiting our website. 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. ii

4 You can ask Express Scripts Medicare 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 Express Scripts Medicare Formulary? on page iii for information about how to request an exception. What if my drug is not on the Formulary? If your drug is not included in this formulary (list of covered drugs), you should first contact Customer Service and ask if your drug is covered. If you learn that Express Scripts Medicare does not cover your drug, you have two options: You can ask Customer Service for a list of similar drugs that are covered by Express Scripts Medicare. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by Express Scripts Medicare. You can ask Express Scripts Medicare to make an exception and cover your drug. See below for information about how to request an exception. How do I request an exception to the Express Scripts Medicare Formulary? You can ask Express Scripts Medicare to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make. You can ask us to cover a drug even if it is not on our formulary. If approved, this drug will be covered at a pre-determined cost-sharing level, and you would not be able to ask us to provide the drug at a lower cost-sharing level. You can ask us to cover a formulary drug at a lower cost-sharing level if this drug is not on the specialty tier. If approved, this would lower the amount you must pay for your drug. You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, Express Scripts Medicare limits the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover a greater amount. Generally, Express Scripts Medicare 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, tiering or utilization restriction exception. When you request a formulary, tiering or utilization restriction exception, you should submit a statement from your prescriber or physician supporting your request. Generally, we must make our decision within 7 hours of getting your prescriber s supporting statement. You can request an expedited (fast) exception if you or your doctor believes that your health could be seriously harmed by waiting up to 7 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 4 hours after we get a supporting statement from your doctor or other prescriber. iii

5 What do I do before I can talk to my doctor about changing my drugs or requesting an exception? As a new or continuing member in our plan, you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan. For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary 30-day supply (unless you have a prescription written for fewer when you go to a network pharmacy. 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, we will allow you to refill your prescription until we have provided you with a 91- to 98-day transition supply, consistent with dispensing increment (unless you have a prescription written for fewer. We will cover more than one refill of these drugs for the first 90 days you are a member of our plan. If you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 31-day emergency supply of that drug (unless you have a prescription for fewer while you pursue a formulary exception. Other times when we will cover a temporary 30-day transition supply (or less, if you have a prescription written for fewer include: When you leave a long-term care facility When you are discharged from a hospital When you leave a skilled nursing facility When you cancel hospice care When you are discharged from a psychiatric hospital with a medication regimen that is highly individualized If you are entering a long-term care facility, we will cover a 31-day transition supply. The plan will send you a letter within 3 business days of your filling a temporary transition supply, notifying you that this was a temporary supply and explaining your options. For more information For more detailed information about your Express Scripts Medicare prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about Express Scripts Medicare, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. If you have general questions about Medicare prescription drug coverage, please call Medicare at MEDICARE ( ), 4 hours a day, 7 days a week. TTY users should call Or, visit iv

6 Express Scripts Medicare s Formulary The formulary that begins on page 1 provides coverage information about the drugs covered by Express Scripts Medicare. If you have trouble finding your drug in the list, turn to the Index that begins on page 68. The first column of the chart lists the drug name. Brand-name drugs are capitalized (e.g., NEXIUM ) and generic drugs are listed in lowercase italics (e.g., omeprazole). The information in the column tells you if Express Scripts Medicare has any special requirements for coverage of your drug. B/D PA: Part B or Part D Prior Authorization. This drug may be covered under Medicare Part B or Part D depending upon the circumstances. Information may need to be submitted describing the use and setting of the drug to make the determination. LA: Limited Availability. This prescription may be available only at certain pharmacies. For more information, consult your Pharmacy Directory or call Customer Service at (New York State residents: ), 4 hours a day, 7 days a week. TTY users should call MO: Mail-Order. This prescription drug is available through our home delivery pharmacy service, as well as through our retail network pharmacies. Consider using mail order for your long-term medications (the ones you take regularly, such as high blood pressure medications). Retail network pharmacies may be more appropriate for short-term prescriptions (such as antibiotics). PA: Prior Authorization. The plan requires you or your doctor to get prior authorization for certain drugs. This means that you will need to get approval before you fill your prescription. If you don t get approval, we may not cover the drug. QL: Quantity Limit. For certain drugs, the plan limits the amount of the drug that we will cover. ST: Step Therapy. In some cases, the plan requires you to first try a certain drug to treat your medical condition before we will cover another drug for that condition. For example, if A and B both treat your medical condition, we may not cover B unless you try A first. If A does not work for you, we will then cover B. Your costs The amount you pay for a covered drug will depend on: Your coverage stage. Express Scripts Medicare has different stages of coverage. In each stage, the amount you pay for a drug may change. The drug tier for your drug. Each covered drug is in one of five drug tiers. Each tier may have a different copayment or coinsurance amount. The s chart on the following page explains what types of drugs are included in each tier and shows how costs may change with each tier. The Evidence of Coverage has more information about the plan s coverage stages and lists the copayment and coinsurance amounts for each tier. v

7 If you qualify for Extra Help If you qualify for Extra Help for your prescription drugs, your copayments and coinsurance may be lower. Please refer to the Evidence of Coverage Rider for People Who Get Extra Help Paying for Prescription s (LIS Rider) to find out what your costs are or you may contact Customer Service for more information. s 1: Preferred Generic s : Generic s 3: Preferred Brand s 4: Non-Preferred s 5: Specialty s Description This tier includes commonly prescribed generic drugs and may include other low-cost drugs. Use 1 drugs for the lowest copayments. This tier includes generic drugs and may include other low-cost drugs. Use drugs to keep your copayments low. This tier includes preferred brand-name drugs as well as some generic drugs. s in this tier will generally have lower copayments than non-preferred drugs. This tier includes non-preferred brand-name drugs as well as some generic drugs. Many drugs in 4 have lower-cost alternatives in s 1,, and 3. Ask your doctor if switching to a lower-cost generic or preferred brand drug may be right for you. s in this tier are limited to up to a 31-day supply. This tier includes very high-cost brand-name and generic drugs. To learn more about medications in this tier, you may contact a pharmacist at the numbers listed on the front and back covers of this document. s in this tier are limited to up to a 31-day supply. Key The abbreviations listed below may appear on the following pages in the column that tells you if there are any special requirements for coverage of your drug. You can find information on what the symbols and abbreviations on these tables mean by going to page v. B/D PA: Part B or Part D Prior Authorization LA: Limited Availability MO: Mail-Order PA: Prior Authorization QL: Quantity Limit ST: Step Therapy vi

8 Name ANTI - INFECTIVES ANTIFUNGAL AGENTS ABELCET 5 B/D PA; MO AMBISOME 5 B/D PA; MO amphotericin b 4 B/D PA; MO CANCIDAS 5 B/D PA; MO clotrimazole mucous membrane CRESEMBA INTRAVENOUS CRESEMBA ORAL fluconazole fluconazole in nacl (iso-osm) intravenous piggyback 00 mg/100 ml fluconazole in nacl (iso-osm) intravenous piggyback 400 mg/00 ml 5 flucytosine griseofulvin microsize griseofulvin ultramicrosize itraconazole ketoconazole oral MYCAMINE INTRAVENOUS RECON SOLN 100 MG Name MYCAMINE INTRAVENOUS RECON SOLN 50 MG NOXAFIL ORAL nystatin oral suspension nystatin oral tablet SPORANOX ORAL SOLUTION terbinafine hcl oral voriconazole intravenous voriconazole oral suspension for reconstitution voriconazole oral tablet ANTIVIRALS abacavir oral tablet abacavir-lamivudine abacavirlamivudinezidovudine acyclovir oral capsule acyclovir oral suspension 00 mg/5 ml acyclovir oral tablet acyclovir sodium intravenous solution B/D PA; MO adefovir amantadine hcl oral capsule 1

9 Name amantadine hcl oral solution amantadine hcl oral tablet APTIVUS ORAL CAPSULE APTIVUS ORAL SOLUTION ATRIPLA BARACLUDE ORAL SOLUTION 5 cidofovir 4 B/D PA; MO COMPLERA CRIXIVAN ORAL CAPSULE 00 MG, 400 MG DESCOVY didanosine oral capsule,delayed release(dr/ec) 15 mg didanosine oral capsule,delayed release(dr/ec) 00 mg, 50 mg, 400 mg 3 EDURANT EMTRIVA entecavir EPCLUSA (8 per 8 EPIVIR HBV ORAL SOLUTION EPZICOM EVOTAZ famciclovir Name FUZEON SUBCUTANEOUS RECON SOLN ganciclovir sodium B/D PA; MO GENVOYA HARVONI (168 per 168 INTELENCE ORAL TABLET 100 MG, 00 MG INTELENCE ORAL TABLET 5 MG INVIRASE ISENTRESS HD ISENTRESS ORAL POWDER IN PACKET ISENTRESS ORAL TABLET ISENTRESS ORAL TABLET,CHEWAB LE 100 MG ISENTRESS ORAL TABLET,CHEWAB LE 5 MG KALETRA ORAL SOLUTION KALETRA ORAL TABLET MG KALETRA ORAL TABLET MG lamivudine oral solution

10 Name lamivudine oral tablet 100 mg lamivudine oral tablet 150 mg, 300 mg lamivudinezidovudine LEXIVA ORAL SUSPENSION LEXIVA ORAL TABLET lopinavir-ritonavir moderiba moderiba dose pack oral tablets,dose pack 00 mg (7)- 400 mg (7), 600 mg (7)- 400 mg (7) moderiba dose pack oral tablets,dose pack 400 mg (7)- 400 mg (7), 600 mg (7)- 600 mg (7) nevirapine oral suspension nevirapine oral tablet nevirapine oral tablet extended release 4 hr NORVIR ORAL CAPSULE NORVIR ORAL SOLUTION NORVIR ORAL TABLET 3 ODEFSEY Name oseltamivir PREZCOBIX PREZISTA ORAL SUSPENSION PREZISTA ORAL TABLET 150 MG, 75 MG PREZISTA ORAL TABLET 600 MG, 800 MG REBETOL ORAL SOLUTION RELENZA DISKHALER RESCRIPTOR RETROVIR INTRAVENOUS REYATAZ ORAL CAPSULE 150 MG, 00 MG, 300 MG REYATAZ ORAL POWDER IN PACKET ribavirin oral capsule ribavirin oral tablet 00 mg rimantadine SELZENTRY ORAL TABLET SOVALDI (168 per 168 stavudine oral capsule STRIBILD 3

11 Name SUSTIVA ORAL CAPSULE 00 MG SUSTIVA ORAL CAPSULE 50 MG SUSTIVA ORAL TABLET SYNAGIS INTRAMUSCULA R SOLUTION 50 MG/0.5 ML ; LA TAMIFLU TIVICAY ORAL TABLET 10 MG TIVICAY ORAL TABLET 5 MG, 50 MG TRIUMEQ TRUVADA valacyclovir ; QL (31 VALCYTE ORAL RECON SOLN valganciclovir oral recon soln valganciclovir oral tablet VEMLIDY VIDEX GRAM PEDIATRIC VIRACEPT ORAL TABLET VIREAD ZERIT ORAL RECON SOLN ZIAGEN ORAL SOLUTION Name zidovudine CEPHALOSPORINS cefaclor oral capsule cefadroxil oral capsule cefadroxil oral suspension for reconstitution 50 mg/5 ml, 500 mg/5 ml cefadroxil oral tablet cefazolin injection recon soln 1 gram, 500 mg cefazolin injection recon soln 10 gram cefdinir cefepime cefixime cefotaxime injection recon soln 1 gram, gram, 500 mg cefoxitin intravenous recon soln 1 gram cefoxitin intravenous recon soln 10 gram cefoxitin intravenous recon soln gram cefpodoxime ceftazidime injection recon soln 1 gram ceftazidime injection recon soln gram ceftazidime injection recon soln 6 gram 4

12 Name ceftriaxone injection recon soln 10 gram ceftriaxone injection recon soln 50 mg, 500 mg ceftriaxone intravenous cefuroxime axetil oral tablet cefuroxime sodium injection recon soln 750 mg cefuroxime sodium intravenous recon soln 1.5 gram cefuroxime sodium intravenous recon soln 7.5 gram cephalexin oral capsule 50 mg, 500 mg cephalexin oral suspension for reconstitution cephalexin oral tablet SUPRAX ORAL CAPSULE SUPRAX ORAL SUSPENSION FOR RECONSTITUTIO N 500 MG/5 ML TEFLARO ERYTHROMYCINS / OTHER MACROLIDES azithromycin clarithromycin 4 5 Name e.e.s. 400 oral tablet erythrocin (as stearate) oral tablet 50 mg ERYTHROCIN INTRAVENOUS RECON SOLN 500 MG erythromycin ethylsuccinate oral suspension for reconstitution erythromycin ethylsuccinate oral tablet erythromycin oral capsule,delayed release(dr/ec) erythromycin oral tablet MISCELLANEOUS ANTIINFECTIVES ALBENZA ALINIA amikacin injection solution 500 mg/ ml atovaquone atovaquoneproguanil oral tablet mg atovaquoneproguanil oral tablet mg AZACTAM IN DEXTROSE (ISO- OSM) aztreonam injection recon soln 1 gram 4

13 Name BILTRICIDE CAPASTAT 4 CAYSTON ; LA; QL (84 per 8 chloramphenicol sod succinate chloroquine phosphate clindamycin hcl clindamycin in 5 % dextrose clindamycin pediatric clindamycin phosphate injection clindamycin phosphate intravenous solution 600 mg/4 ml COARTEM colistin (colistimethate na) CUBICIN DAPSONE daptomycin DARAPRIM 3 PA; MO EMVERM ethambutol gentamicin in nacl (iso-osm) intravenous piggyback 100 mg/100 ml, 80 mg/50 ml Name gentamicin in nacl (iso-osm) intravenous piggyback 60 mg/50 ml, 80 mg/100 ml gentamicin injection solution 40 mg/ml gentamicin sulfate (pf) intravenous solution 100 mg/10 ml hydroxychloroquine imipenem-cilastatin isoniazid oral ivermectin linezolid intravenous 3 linezolid oral mefloquine meropenem metronidazole in nacl (iso-os) metronidazole oral NEBUPENT 3 B/D PA; MO; QL (1 per 8 neomycin paromomycin PASER PENTAM PRIFTIN PRIMAQUINE pyrazinamide quinine sulfate rifabutin 6

14 Name rifampin SIRTURO ; LA STREPTOMYCIN SYNERCID 5 tinidazole tobramycin in 0.5 % nacl tobramycin sulfate injection solution 5 B/D PA; MO; QL (80 per 8 TRECATOR TYGACIL XIFAXAN ORAL TABLET 00 MG XIFAXAN ORAL TABLET 550 MG PENICILLINS amoxicillin oral capsule amoxicillin oral suspension for reconstitution amoxicillin oral tablet amoxicillin oral tablet,chewable 15 mg, 50 mg amoxicillin-pot clavulanate ampicillin oral capsule ampicillin sodium injection recon soln 1 gram, 10 gram, 15 mg ; QL (9 per 30 ; QL (6 Name ampicillin-sulbactam injection recon soln 1.5 gram, 3 gram ampicillin-sulbactam injection recon soln 15 gram AUGMENTIN ORAL SUSPENSION FOR RECONSTITUTIO N MG/5 ML dicloxacillin nafcillin injection recon soln 1 gram nafcillin injection recon soln 10 gram penicillin g potassium injection recon soln 5 million unit penicillin g procaine intramuscular syringe 1. million unit/ ml penicillin g sodium penicillin v potassium piperacillintazobactam intravenous recon soln gram piperacillintazobactam intravenous recon soln 4.5 gram, 40.5 gram 7

15 Name ZOSYN IN DEXTROSE (ISO- OSM) INTRAVENOUS PIGGYBACK.5 GRAM/50 ML ZOSYN IN DEXTROSE (ISO- OSM) INTRAVENOUS PIGGYBACK GRAM/50 ML QUINOLONES ciprofloxacin ciprofloxacin hcl oral ciprofloxacin in 5 % dextrose intravenous piggyback 00 mg/100 ml ciprofloxacin lactate intravenous solution 400 mg/40 ml levofloxacin in d5w intravenous piggyback 500 mg/100 ml, 750 mg/150 ml levofloxacin intravenous levofloxacin oral solution levofloxacin oral tablet 3 moxifloxacin oral ofloxacin oral tablet 300 mg ofloxacin oral tablet 400 mg 8 Name SULFA'S / RELATED AGENTS sulfadiazine sulfamethoxazoletrimethoprim TETRACYCLINES demeclocycline doxy-100 doxycycline hyclate oral capsule doxycycline hyclate oral tablet 100 mg, 0 mg doxycycline hyclate oral tablet,delayed release (dr/ec) doxycycline monohydrate oral capsule 100 mg, 50 mg, 75 mg doxycycline monohydrate oral suspension for reconstitution doxycycline monohydrate oral tablet minocycline oral capsule minocycline oral tablet minocycline oral tablet extended release 4 hr 135 mg, 45 mg minocycline oral tablet extended release 4 hr 90 mg

16 Name morgidox oral capsule 50 mg URINARY TRACT AGENTS methenamine hippurate nitrofurantoin nitrofurantoin macrocrystal oral capsule 100 mg, 5 mg nitrofurantoin macrocrystal oral capsule 50 mg nitrofurantoin monohyd/m-cryst PRIMSOL trimethoprim VANCOMYCIN vancomycin intravenous recon soln 1,000 mg vancomycin intravenous recon soln 10 gram, 500 mg vancomycin oral capsule VIBATIV INTRAVENOUS RECON SOLN 750 MG ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS ADJUNCTIVE AGENTS FUSILEV 5 Name KEPIVANCE leucovorin calcium injection recon soln 100 mg, 350 mg leucovorin calcium oral levoleucovorin intravenous recon soln 50 mg levoleucovorin intravenous solution mesna MESNEX ORAL XGEVA 3 3 ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS ABRAXANE adriamycin intravenous solution 0 mg/10 ml adrucil intravenous solution 500 mg/10 ml AFINITOR DISPERZ AFINITOR ORAL TABLET 10 MG AFINITOR ORAL TABLET.5 MG, 5 MG, 7.5 MG B/D PA; MO 5 PA; MO (6 per 31 5 PA; MO ALECENSA 3 PA; MO; QL (48 per 31 9

17 Name ALIMTA INTRAVENOUS RECON SOLN 500 MG ALUNBRIG 4 PA; MO; LA; QL (186 per 31 anastrozole ARRANON 3 AVASTIN azacitidine azathioprine B/D PA; MO azathioprine sodium 3 B/D PA BAVENCIO ; LA BELEODAQ bexarotene bicalutamide BICNU bleomycin injection recon soln 30 unit BOSULIF ORAL TABLET 100 MG BOSULIF ORAL TABLET 500 MG busulfan 5 BUSULFEX 4 B/D PA; MO 3 PA; MO 3 PA; MO; QL (31 per 31 CABOMETYX 4 PA; MO; LA CAPRELSA ORAL TABLET 100 MG CAPRELSA ORAL TABLET 300 MG 5 PA; MO; LA; QL (93 per 31 5 PA; MO; LA; QL (31 per 31 Name carboplatin intravenous solution CELLCEPT INTRAVENOUS 3 B/D PA; MO cisplatin cladribine 4 B/D PA; MO clofarabine 3 CLOLAR 4 COMETRIQ 5 PA; MO COTELLIC 4 PA; MO; LA; QL (63 per 8 CYCLOPHOSPHA MIDE ORAL CAPSULE cyclosporine intravenous cyclosporine modified cyclosporine oral capsule 3 B/D PA; MO 4 B/D PA 3 B/D PA; MO 3 B/D PA; MO CYRAMZA 5 B/D PA; MO cytarabine B/D PA; MO cytarabine (pf) injection solution gram/0 ml (100 mg/ml) dacarbazine intravenous recon soln 00 mg B/D PA; MO DARZALEX ; LA daunorubicin intravenous solution decitabine 10

18 Name docetaxel intravenous solution 80 mg/4 ml (0 mg/ml), 80 mg/8 ml (10 mg/ml) doxorubicin intravenous solution 50 mg/5 ml doxorubicin, pegliposomal DROXIA ELLENCE INTRAVENOUS SOLUTION 00 MG/100 ML EMCYT EMPLICITI 4 B/D PA; MO epirubicin intravenous solution 00 mg/100 ml ERBITUX INTRAVENOUS SOLUTION 100 MG/50 ML ERIVEDGE (31 per 31 ERWINAZE ETOPOPHOS etoposide intravenous exemestane FARESTON FARYDAK ORAL CAPSULE 10 MG (1 per 1 Name FARYDAK ORAL CAPSULE 15 MG, 0 MG FASLODEX FIRMAGON KIT W DILUENT SYRINGE fludarabine intravenous recon soln fluorouracil intravenous solution.5 gram/50 ml (6 per 1 B/D PA; MO flutamide FOLOTYN INTRAVENOUS SOLUTION 40 MG/ ML (0 MG/ML) gemcitabine intravenous recon soln 1 gram gengraf oral capsule 100 mg, 5 mg gengraf oral capsule 50 mg 4 B/D PA; MO 3 B/D PA; MO gengraf oral solution 4 B/D PA; MO GILOTRIF ORAL TABLET 0 MG GILOTRIF ORAL TABLET 30 MG GILOTRIF ORAL TABLET 40 MG GLEEVEC ORAL TABLET 100 MG (6 per 31 (4 per 31 (31 per 31 5 PA; MO 11

19 Name GLEEVEC ORAL TABLET 400 MG (6 per 31 GLEOSTINE HALAVEN HERCEPTIN INTRAVENOUS RECON SOLN 440 MG HEXALEN hydroxyurea IBRANCE (1 per 8 ICLUSIG ORAL TABLET 15 MG ICLUSIG ORAL TABLET 45 MG idarubicin IDHIFA ORAL TABLET 100 MG IDHIFA ORAL TABLET 50 MG ifosfamide intravenous recon soln 1 gram imatinib oral tablet 100 mg imatinib oral tablet 400 mg 5 PA; QL (93 (31 per 31 5 PA; MO; LA; QL (31 per 31 5 PA; MO; LA; QL (6 per 31 5 PA; MO (6 per 31 IMBRUVICA (14 per 31 Name IMFINZI ; LA INLYTA ORAL TABLET 1 MG INLYTA ORAL TABLET 5 MG 5 PA; MO (14 per 31 IRESSA 4 PA; MO; QL (31 per 31 irinotecan intravenous solution 100 mg/5 ml ISTODAX JAKAFI ORAL TABLET 10 MG, 15 MG, 0 MG, 5 MG JAKAFI ORAL TABLET 5 MG 5 PA; MO (6 per 31 JEVTANA KADCYLA INTRAVENOUS RECON SOLN 100 MG 5 PA; MO KEYTRUDA KISQALI 4 PA; MO KISQALI FEMARA CO-PACK 4 PA; MO KYPROLIS LARTRUVO ; LA LENVIMA 5 PA; MO letrozole LEUKERAN leuprolide subcutaneous kit LONSURF 5 PA; MO 1

20 Name LUPRON DEPOT 5 PA; MO LUPRON DEPOT (NTH) LUPRON DEPOT (NTH) LUPRON DEPOT (6 MONTH) LUPRON DEPOT- PED INTRAMUSCULA R KIT 11.5 MG, 15 MG 5 PA; MO 5 PA; MO 5 PA; MO 5 PA; MO LYNPARZA 5 PA; MO LYSODREN MATULANE megestrol oral suspension 400 mg/10 ml (40 mg/ml), 65 mg/5 ml PA; MO megestrol oral tablet PA; MO MEKINIST ORAL TABLET 0.5 MG MEKINIST ORAL TABLET MG melphalan hcl 3 (14 per 31 (31 per 31 mercaptopurine methotrexate sodium B/D PA; MO methotrexate sodium (pf) injection recon soln methotrexate sodium (pf) injection solution 3 B/D PA B/D PA; MO mitomycin mitoxantrone 13 Name MUSTARGEN mycophenolate mofetil mycophenolate mofetil hcl mycophenolate sodium oral tablet,delayed release (dr/ec) 180 mg mycophenolate sodium oral tablet,delayed release (dr/ec) 360 mg B/D PA; MO 3 B/D PA B/D PA; MO 3 B/D PA; MO NERLYNX 5 PA; MO; LA NEXAVAR 5 PA; MO; LA; QL (10 per 30 NILANDRON nilutamide NINLARO ORAL CAPSULE.3 MG NINLARO ORAL CAPSULE 3 MG NINLARO ORAL CAPSULE 4 MG NIPENT (6 per 8 (4 per 8 (3 per 8 NULOJIX 5 B/D PA; MO octreotide acetate injection solution 1,000 mcg/ml, 500 mcg/ml octreotide acetate injection solution 100 mcg/ml, 00 mcg/ml, 50 mcg/ml

21 Name ODOMZO 5 PA; MO; LA; QL (31 per 31 OPDIVO INTRAVENOUS SOLUTION 40 MG/4 ML oxaliplatin intravenous solution 100 mg/0 ml paclitaxel PERJETA POMALYST PROGRAF INTRAVENOUS 3 B/D PA; MO PURIXAN RAPAMUNE ORAL SOLUTION 5 B/D PA; MO REVLIMID 5 PA; MO; LA RITUXAN 5 PA; MO RUBRACA ORAL TABLET 00 MG RUBRACA ORAL TABLET 300 MG 5 PA; MO; LA; QL (186 per 31 5 PA; MO; LA; QL (14 per 31 RYDAPT 5 PA; MO SIGNIFOR SIMULECT INTRAVENOUS RECON SOLN 0 MG sirolimus oral tablet 0.5 mg sirolimus oral tablet 1 mg, mg 3 B/D PA; MO B/D PA; MO 3 B/D PA; MO SOLTAMOX 14 Name SOMATULINE DEPOT SPRYCEL ORAL TABLET 100 MG, 0 MG, 50 MG, 80 MG SPRYCEL ORAL TABLET 140 MG SPRYCEL ORAL TABLET 70 MG 5 PA; MO (31 per 31 (6 per 31 STIVARGA (84 per 8 SUTENT ORAL CAPSULE 1.5 MG SUTENT ORAL CAPSULE 5 MG, 37.5 MG SUTENT ORAL CAPSULE 50 MG SYLVANT INTRAVENOUS RECON SOLN 100 MG 5 PA; MO (6 per 31 (31 per 31 SYNRIBO TABLOID tacrolimus oral 3 B/D PA; MO TAFINLAR ORAL CAPSULE 50 MG TAFINLAR ORAL CAPSULE 75 MG (186 per 31 (14 per 31

22 Name TAGRISSO ORAL TABLET 40 MG TAGRISSO ORAL TABLET 80 MG 5 PA; MO; LA; QL (6 per 31 5 PA; MO; LA; QL (31 per 31 tamoxifen TARCEVA ORAL TABLET 100 MG, 5 MG TARCEVA ORAL TABLET 150 MG TARGRETIN TOPICAL TASIGNA ORAL CAPSULE 150 MG TASIGNA ORAL CAPSULE 00 MG 5 PA; MO (31 per 31 5 PA; MO (11 per 8 TECENTRIQ ; LA THALOMID 5 PA; MO thiotepa toposar topotecan intravenous recon soln TORISEL TREANDA INTRAVENOUS RECON SOLN 100 MG 4 TRELSTAR tretinoin (chemotherapy) TRISENOX Name TYKERB 5 PA; MO; LA; QL (186 per 31 VECTIBIX INTRAVENOUS SOLUTION 100 MG/5 ML (0 MG/ML) 5 B/D PA; MO VELCADE VENCLEXTA 4 PA; MO; LA VENCLEXTA STARTING PACK vinblastine intravenous solution vincasar pfs intravenous solution 1 mg/ml vincristine intravenous solution 1 mg/ml vinorelbine intravenous solution 50 mg/5 ml 4 PA; MO; LA; QL (4 per 8 B/D PA; MO B/D PA B/D PA; MO VOTRIENT (14 per 31 VYXEOS 5 B/D PA; MO XALKORI ORAL CAPSULE 00 MG XALKORI ORAL CAPSULE 50 MG 5 PA; MO (6 per 31 XATMEP 4 B/D PA; MO XERMELO 5 PA; MO; LA; QL (93 per 31 15

23 Name XTANDI 4 PA; MO; QL (14 per 31 YERVOY INTRAVENOUS SOLUTION 50 MG/10 ML (5 MG/ML) YONDELIS ZALTRAP INTRAVENOUS SOLUTION 100 MG/4 ML (5 MG/ML) ZANOSAR ZEJULA 5 PA; MO; LA; QL (93 per 31 ZELBORAF 4 PA; MO; QL (48 per 31 ZOLINZA ZORTRESS 5 B/D PA; MO ZYDELIG (93 per 31 ZYKADIA (155 per 31 ZYTIGA ORAL TABLET 50 MG ZYTIGA ORAL TABLET 500 MG (14 per 31 (6 per 31 AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH ANTICONVULSANTS 16 Name APTIOM ORAL TABLET 00 MG, 400 MG, 800 MG APTIOM ORAL TABLET 600 MG BANZEL ORAL SUSPENSION BANZEL ORAL TABLET 00 MG BANZEL ORAL TABLET 400 MG BRIVIACT INTRAVENOUS BRIVIACT ORAL carbamazepine oral capsule, er multiphase 1 hr carbamazepine oral suspension 100 mg/5 ml carbamazepine oral tablet carbamazepine oral tablet extended release 1 hr carbamazepine oral tablet,chewable CELONTIN ORAL CAPSULE 300 MG 4 clonazepam PA; MO DIASTAT DIASTAT ACUDIAL diazepam rectal kit.5 mg, mg DILANTIN 30 MG

24 Name divalproex oral capsule, delayed rel sprinkle divalproex oral tablet extended release 4 hr divalproex oral tablet,delayed release (dr/ec) epitol ethosuximide felbamate fosphenytoin injection solution 100 mg pe/ ml FYCOMPA ORAL SUSPENSION FYCOMPA ORAL TABLET gabapentin oral capsule gabapentin oral solution 50 mg/5 ml gabapentin oral tablet 600 mg, 800 mg GABITRIL ORAL TABLET 1 MG, 16 MG LAMICTAL STARTER (BLUE) KIT LAMICTAL STARTER (GREEN) KIT LAMICTAL STARTER (ORANGE) KIT 17 Name LAMICTAL XR STARTER (BLUE) LAMICTAL XR STARTER (GREEN) LAMICTAL XR STARTER (ORANGE) lamotrigine oral tablet lamotrigine oral tablet extended release 4hr lamotrigine oral tablet, chewable dispersible lamotrigine oral tablet,disintegrating levetiracetam in nacl (iso-os) intravenous piggyback 1,000 mg/100 ml, 1,500 mg/100 ml levetiracetam in nacl (iso-os) intravenous piggyback 500 mg/100 ml levetiracetam intravenous levetiracetam oral solution 100 mg/ml levetiracetam oral tablet levetiracetam oral tablet extended release 4 hr 3 LYRICA

25 Name ONFI ORAL SUSPENSION ONFI ORAL TABLET 10 MG ONFI ORAL TABLET 0 MG 3 PA; MO 3 PA; MO 5 PA; MO oxcarbazepine PEGANONE phenobarbital phenytoin oral suspension 15 mg/5 ml phenytoin oral tablet,chewable phenytoin sodium extended phenytoin sodium intravenous solution primidone roweepra oral tablet 1,000 mg, 750 mg roweepra oral tablet 500 mg 3 SABRIL ; LA SPRITAM tiagabine topiramate oral capsule, sprinkle topiramate oral tablet 3 PA; MO 1 PA; MO valproate sodium valproic acid valproic acid (as sodium salt) oral solution 50 mg/5 ml Name vigabatrin ; LA VIMPAT INTRAVENOUS VIMPAT ORAL SOLUTION VIMPAT ORAL TABLET 3 zonisamide PA; MO ANTIPARKINSONISM AGENTS APOKYN ; LA AZILECT benztropine bromocriptine carbidopa carbidopa-levodopa carbidopa-levodopaentacapone entacapone NEUPRO pramipexole oral tablet pramipexole oral tablet extended release 4 hr mg,.5 mg, 3 mg, 3.75 mg, 4.5 mg pramipexole oral tablet extended release 4 hr 0.75 mg, 1.5 mg ropinirole oral tablet ropinirole oral tablet extended release 4 hr selegiline hcl 18

26 Name tolcapone trihexyphenidyl ZELAPAR MIGRAINE / CLUSTER HEADACHE THERAPY dihydroergotamine injection dihydroergotamine nasal ; QL (8 per 8 eletriptan hbr ; QL (18 per 8 ergotamine-caffeine migergot naratriptan ; QL (18 per 8 RELPAX ; QL (18 per 8 rizatriptan ; QL (36 per 8 sumatriptan nasal spray,non-aerosol 0 mg/actuation sumatriptan nasal spray,non-aerosol 5 mg/actuation sumatriptan succinate oral sumatriptan succinate subcutaneous cartridge sumatriptan succinate subcutaneous pen injector ; QL (18 per 8 ; QL (36 per 8 ; QL (18 per 8 ; QL (8 per 8 ; QL (8 per 8 Name sumatriptan succinate subcutaneous solution sumatriptan succinate subcutaneous syringe 6 mg/0.5 ml ; QL (8 per 8 ; QL (8 per 8 zolmitriptan ; QL (18 per 8 MISCELLANEOUS NEUROLOGICAL THERAPY AMPYRA 5 PA; MO; LA COPAXONE SUBCUTANEOUS SYRINGE 40 MG/ML donepezil oral tablet 10 mg, 5 mg donepezil oral tablet 3 mg donepezil oral tablet,disintegrating galantamine oral capsule,ext rel. pellets 4 hr galantamine oral solution galantamine oral tablet (1 per 8 glatopa (30 per 30 memantine oral solution memantine oral tablet PA; MO PA; MO 19

27 Name MEMANTINE ORAL TABLETS,DOSE PACK NAMENDA ORAL TABLET NAMENDA TITRATION PAK 3 PA; MO 3 PA; MO 3 PA; MO NAMENDA XR 3 PA; MO NAMZARIC 3 PA; MO NUEDEXTA RADICAVA 5 PA; MO rivastigmine rivastigmine tartrate TECFIDERA 5 PA; MO tetrabenazine 5 PA; MO TYSABRI 5 PA; MO; LA MUSCLE RELAXANTS / ANTISPASMODIC THERAPY baclofen cyclobenzaprine oral tablet dantrolene LIORESAL INTRATHECAL SOLUTION,000 MCG/ML LIORESAL INTRATHECAL SOLUTION 500 MCG/ML MESTINON ORAL SYRUP pyridostigmine bromide oral tablet 5 B/D PA; MO 3 B/D PA; MO 0 Name pyridostigmine bromide oral tablet extended release tizanidine oral capsule tizanidine oral tablet NARCOTIC ANALGESICS acetaminophencodeine oral solution 10-1 mg/5 ml acetaminophencodeine oral tablet mg, mg acetaminophencodeine oral tablet mg ; QL (4650 ; QL (37 ; QL (186 BUPRENEX ; QL (76 per 30 buprenorphine hcl injection solution buprenorphine hcl injection syringe buprenorphine hcl sublingual ; QL (76 QL (76 per 31 BUTRANS ; QL (4 per 8 codeine sulfate oral tablet duramorph (pf) injection solution 0.5 mg/ml duramorph (pf) injection solution 1 mg/ml endocet oral tablet mg, 5-35 mg, mg ; QL (186 ; QL (4134 per 30 QL (067 per 30 ; QL (37

28 Name fentanyl citrate buccal lozenge on a handle 1,00 mcg fentanyl citrate buccal lozenge on a handle 1,600 mcg fentanyl citrate buccal lozenge on a handle 00 mcg fentanyl citrate buccal lozenge on a handle 400 mcg fentanyl citrate buccal lozenge on a handle 600 mcg fentanyl citrate buccal lozenge on a handle 800 mcg fentanyl transdermal patch 7 hour 100 mcg/hr fentanyl transdermal patch 7 hour 1 mcg/hr, 5 mcg/hr, 50 mcg/hr, 75 mcg/hr hydrocodoneacetaminophen oral solution mg/15 ml hydrocodoneacetaminophen oral tablet mg, mg,.5-35 mg, mg, 5-35 mg, mg, mg 3 PA; MO; QL (40 per 31 3 PA; MO; QL (30 per 31 3 PA; MO; QL (14 per 31 3 PA; MO; QL (10 per 31 3 PA; MO; QL (80 per 31 3 PA; MO; QL (60 per 31 ; QL (9 per 30 ; QL (10 per 30 ; QL (5735 ; QL (37 Name hydrocodoneibuprofen oral tablet mg, 5-00 mg, mg ; QL (5 hydromorphone (pf) ; QL (48 hydromorphone injection syringe mg/ml hydromorphone oral liquid hydromorphone oral tablet 4 QL (140 per 31 ; QL (1550 ; QL (186 levorphanol tartrate ; QL (14 methadone injection solution methadone oral solution 10 mg/5 ml methadone oral solution 5 mg/5 ml methadone oral tablet 10 mg methadone oral tablet 5 mg morphine concentrate oral solution morphine intravenous syringe mg/ml morphine intravenous syringe 4 mg/ml morphine oral capsule, er multiphase 4 hr 10 mg QL (160 per 31 ; QL (60 ; QL (140 ; QL (14 ; QL (48 ; QL (310 QL (1034 per 31 QL (517 per 31 ; QL (5 1

29 Name morphine oral capsule, er multiphase 4 hr 30 mg, 45 mg, 60 mg, 75 mg morphine oral capsule, er multiphase 4 hr 90 mg morphine oral capsule,extend.relea se pellets 10 mg, 0 mg, 30 mg, 50 mg, 60 mg morphine oral capsule,extend.relea se pellets 100 mg morphine oral capsule,extend.relea se pellets 80 mg morphine oral solution ; QL (6 ; QL (6 ; QL (93 ; QL (6 ; QL (78 ; QL (930 morphine oral tablet ; QL (186 morphine oral tablet extended release 100 mg morphine oral tablet extended release 15 mg, 30 mg morphine oral tablet extended release 00 mg morphine oral tablet extended release 60 mg oxycodone oral capsule ; QL (6 ; QL (14 ; QL (31 ; QL (103 ; QL (37 Name oxycodone oral concentrate oxycodone oral solution oxycodone oral tablet 10 mg, 15 mg, 0 mg oxycodone oral tablet 30 mg oxycodone oral tablet 5 mg oxycodoneacetaminophen oral tablet mg,.5-35 mg, 5-35 mg, mg ; QL (186 ; QL (140 ; QL (186 ; QL (139 ; QL (37 ; QL (37 oxycodone-aspirin ; QL (37 oxymorphone oral tablet extended release 1 hr 10 mg, 15 mg, 0 mg, 5 mg, 7.5 mg oxymorphone oral tablet extended release 1 hr 30 mg oxymorphone oral tablet extended release 1 hr 40 mg ; QL (93 ; QL (70 ; QL (5 vicodin ; QL (37 vicodin es ; QL (37 vicodin hp ; QL (37 zamicet QL (5735 per 31 NON-NARCOTIC ANALGESICS

30 Name butorphanol tartrate nasal celecoxib diclofenac potassium diclofenac sodium oral diclofenac sodium topical drops diclofenac sodium topical gel 1 % ; QL (5 per 8 diflunisal etodolac fenoprofen oral tablet flurbiprofen ibuprofen oral suspension ibuprofen oral tablet 400 mg, 600 mg, 800 mg ketoprofen oral capsule ketoprofen oral capsule,ext rel. pellets 4 hr 00 mg meclofenamate oral capsule 100 mg meclofenamate oral capsule 50 mg mefenamic acid meloxicam oral tablet 15 mg meloxicam oral tablet 7.5 mg ; QL (31 nabumetone Name naloxone injection solution naloxone injection syringe 1 mg/ml naltrexone naproxen oral suspension naproxen oral tablet naproxen oral tablet,delayed release (dr/ec) naproxen sodium oral tablet 75 mg, 550 mg naproxen sodium oral tablet, er multiphase 4 hr NARCAN NASAL SPRAY,NON- AEROSOL 4 MG/ACTUATION oxaprozin piroxicam SUBOXONE SUBLINGUAL FILM 1-3 MG SUBOXONE SUBLINGUAL FILM -0.5 MG SUBOXONE SUBLINGUAL FILM 4-1 MG, 8- MG ; QL ( per 8 ; QL (6 ; QL (37 ; QL (93 sulindac tolmetin oral capsule tolmetin oral tablet 600 mg 3

31 Name tramadol oral tablet ; QL (48 VOLTAREN GEL TOPICAL GEL 1 % PSYCHOTHERAPEUTIC DRUGS ABILIFY MAINTENA amitriptyline PA; MO amoxapine aripiprazole oral tablet 10 mg aripiprazole oral tablet 15 mg aripiprazole oral tablet mg aripiprazole oral tablet 0 mg aripiprazole oral tablet 30 mg aripiprazole oral tablet 5 mg aripiprazole oral tablet,disintegrating 10 mg aripiprazole oral tablet,disintegrating 15 mg ; QL (93 ; QL (6 ; QL (465 ; QL (6 ; QL (31 ; QL (186 ; QL (93 ; QL (6 atomoxetine bupropion hcl oral tablet bupropion hcl oral tablet extended release 1 hr 100 mg bupropion hcl oral tablet extended release 1 hr 150 mg ; QL (14 ; QL (93 Name bupropion hcl oral tablet extended release 1 hr 00 mg bupropion hcl oral tablet extended release 4 hr 150 mg bupropion hcl oral tablet extended release 4 hr 300 mg ; QL (6 ; QL (93 ; QL (6 buspirone chlorpromazine citalopram oral solution citalopram oral tablet 10 mg citalopram oral tablet 0 mg citalopram oral tablet 40 mg ; QL (14 ; QL (6 ; QL (31 clomipramine 4 PA; MO clorazepate dipotassium PA; MO clozapine oral tablet clozapine oral tablet,disintegrating 100 mg, 1.5 mg, 5 mg CYMBALTA ORAL CAPSULE,DELAY ED RELEASE(DR/EC) 0 MG ; QL (186 4

32 Name CYMBALTA ORAL CAPSULE,DELAY ED RELEASE(DR/EC) 30 MG CYMBALTA ORAL CAPSULE,DELAY ED RELEASE(DR/EC) 60 MG ; QL (14 ; QL (6 desipramine desvenlafaxine succinate oral tablet extended release 4 hr 100 mg desvenlafaxine succinate oral tablet extended release 4 hr 5 mg desvenlafaxine succinate oral tablet extended release 4 hr 50 mg dextroamphetamine oral capsule, extended release dextroamphetamine oral tablet dextroamphetamineamphetamine oral capsule,extended release 4hr ; QL (14 ; QL (496 ; QL (48 diazepam intensol PA; MO diazepam oral solution 5 mg/5 ml (1 mg/ml) PA; MO diazepam oral tablet PA; MO Name doxepin oral PA; MO duloxetine oral capsule,delayed release(dr/ec) 0 mg duloxetine oral capsule,delayed release(dr/ec) 30 mg duloxetine oral capsule,delayed release(dr/ec) 40 mg duloxetine oral capsule,delayed release(dr/ec) 60 mg ; QL (186 ; QL (14 ; QL (93 ; QL (6 EMSAM ergoloid escitalopram oxalate oral solution escitalopram oxalate oral tablet 10 mg escitalopram oxalate oral tablet 0 mg escitalopram oxalate oral tablet 5 mg FANAPT ORAL TABLET 1 MG FANAPT ORAL TABLET 10 MG, 8 MG FANAPT ORAL TABLET 1 MG FANAPT ORAL TABLET MG FANAPT ORAL TABLET 4 MG FANAPT ORAL TABLET 6 MG ; QL (6 ; QL (31 ; QL (14 ; QL (744 ; QL (93 ; QL (6 ; QL (37 ; QL (186 ; QL (14 5

33 Name FANAPT ORAL TABLETS,DOSE PACK FAZACLO ORAL TABLET,DISINTE GRATING 150 MG, 00 MG FETZIMA ORAL CAPSULE,EXT REL 4HR DOSE PACK FETZIMA ORAL CAPSULE,EXTEN DED RELEASE 4 HR 10 MG FETZIMA ORAL CAPSULE,EXTEN DED RELEASE 4 HR 0 MG FETZIMA ORAL CAPSULE,EXTEN DED RELEASE 4 HR 40 MG FETZIMA ORAL CAPSULE,EXTEN DED RELEASE 4 HR 80 MG fluoxetine oral capsule 10 mg fluoxetine oral capsule 0 mg fluoxetine oral capsule 40 mg fluoxetine oral solution fluoxetine oral tablet 10 mg fluoxetine oral tablet 0 mg ; QL (8 per 8 4 ; QL (8 per 8 ; QL (31 ; QL (186 ; QL (93 ; QL (47 ; QL (48 ; QL (6 ; QL (48 Name fluphenazine decanoate fluphenazine hcl fluvoxamine oral capsule,extended release 4hr 100 mg fluvoxamine oral capsule,extended release 4hr 150 mg fluvoxamine oral tablet 100 mg fluvoxamine oral tablet 5 mg fluvoxamine oral tablet 50 mg ; QL (93 ; QL (6 ; QL (93 ; QL (37 ; QL (186 FORFIVO XL ; QL (31 GEODON INTRAMUSCULA R guanfacine oral tablet extended release 4 hr haloperidol haloperidol decanoate haloperidol lactate HETLIOZ (31 per 31 imipramine hcl PA; MO imipramine pamoate 4 PA; MO INVEGA ORAL TABLET EXTENDED RELEASE 4HR 1.5 MG ; QL (48 6

34 Name INVEGA ORAL TABLET EXTENDED RELEASE 4HR 3 MG INVEGA ORAL TABLET EXTENDED RELEASE 4HR 6 MG INVEGA ORAL TABLET EXTENDED RELEASE 4HR 9 MG INVEGA SUSTENNA INTRAMUSCULA R SYRINGE 117 MG/0.75 ML, 156 MG/ML, 39 MG/0.5 ML, 78 MG/0.5 ML INVEGA SUSTENNA INTRAMUSCULA R SYRINGE 34 MG/1.5 ML ; QL (14 ; QL (6 ; QL (4 INVEGA TRINZA LATUDA ORAL TABLET 10 MG LATUDA ORAL TABLET 0 MG LATUDA ORAL TABLET 40 MG LATUDA ORAL TABLET 60 MG, 80 MG ; QL (31 ; QL (48 ; QL (14 ; QL (6 lithium carbonate Name lithium citrate oral solution 8 meq/5 ml lorazepam intensol PA; MO lorazepam oral tablet PA; MO loxapine succinate maprotiline MARPLAN methylphenidate hcl oral capsule, er biphasic methylphenidate hcl oral capsule,er biphasic mg, 40 mg, 60 mg methylphenidate hcl oral solution 10 mg/5 ml methylphenidate hcl oral solution 5 mg/5 ml methylphenidate hcl oral tablet mirtazapine oral tablet mirtazapine oral tablet,disintegrating modafinil 3 PA; MO nefazodone nortriptyline NUPLAZID olanzapine intramuscular olanzapine oral tablet 10 mg ; QL (6 7

35 Name olanzapine oral tablet 15 mg, 0 mg olanzapine oral tablet.5 mg olanzapine oral tablet 5 mg olanzapine oral tablet 7.5 mg olanzapine oral tablet,disintegrating 10 mg olanzapine oral tablet,disintegrating 15 mg, 0 mg olanzapine oral tablet,disintegrating 5 mg olanzapinefluoxetine ; QL (31 ; QL (48 ; QL (14 ; QL (83 ; QL (6 ; QL (31 ; QL (14 oxazepam PA; MO paliperidone oral tablet extended release 4hr 1.5 mg paliperidone oral tablet extended release 4hr 3 mg paliperidone oral tablet extended release 4hr 6 mg paliperidone oral tablet extended release 4hr 9 mg paroxetine hcl oral tablet 10 mg paroxetine hcl oral tablet 0 mg paroxetine hcl oral tablet 30 mg ; QL (48 ; QL (14 ; QL (6 ; QL (4 ; QL (186 ; QL (93 ; QL (6 8 Name paroxetine hcl oral tablet 40 mg PAXIL ORAL SUSPENSION ; QL (47 perphenazine phenelzine pimozide PRISTIQ ORAL TABLET EXTENDED RELEASE 4 HR 100 MG PRISTIQ ORAL TABLET EXTENDED RELEASE 4 HR 5 MG PRISTIQ ORAL TABLET EXTENDED RELEASE 4 HR 50 MG ; QL (14 ; QL (496 ; QL (48 procentra protriptyline quetiapine oral tablet 100 mg quetiapine oral tablet 00 mg quetiapine oral tablet 5 mg quetiapine oral tablet 300 mg quetiapine oral tablet 400 mg quetiapine oral tablet 50 mg ; QL (48 ; QL (14 ; QL (93 ; QL (83 ; QL (6 ; QL (496

36 Name Name quetiapine oral tablet extended release 4 hr 150 mg quetiapine oral tablet extended release 4 hr 00 mg quetiapine oral tablet extended release 4 hr 300 mg quetiapine oral tablet extended release 4 hr 400 mg quetiapine oral tablet extended release 4 hr 50 mg ; QL (166 ; QL (14 ; QL (83 ; QL (6 ; QL (496 risperidone oral solution risperidone oral tablet 0.5 mg risperidone oral tablet 0.5 mg risperidone oral tablet 1 mg risperidone oral tablet mg risperidone oral tablet 3 mg risperidone oral tablet 4 mg ; QL (496 ; QL (1984 ; QL (99 ; QL (496 ; QL (48 ; QL (166 ; QL (14 REXULTI ORAL TABLET 0.5 MG REXULTI ORAL TABLET 0.5 MG REXULTI ORAL TABLET 1 MG REXULTI ORAL TABLET MG REXULTI ORAL TABLET 3 MG REXULTI ORAL TABLET 4 MG RISPERDAL CONSTA INTRAMUSCULA R SYRINGE 1.5 MG/ ML, 5 MG/ ML RISPERDAL CONSTA INTRAMUSCULA R SYRINGE 37.5 MG/ ML, 50 MG/ ML ; QL (496 ; QL (48 ; QL (14 ; QL (6 ; QL (4 ; QL (31 risperidone oral tablet,disintegrating 0.5 mg risperidone oral tablet,disintegrating 0.5 mg risperidone oral tablet,disintegrating 1 mg risperidone oral tablet,disintegrating mg risperidone oral tablet,disintegrating 3 mg risperidone oral tablet,disintegrating 4 mg RITALIN LA ORAL CAPSULE,ER BIPHASIC MG ; QL (1984 ; QL (99 ; QL (496 ; QL (48 ; QL (166 ; QL (14 9

37 Name ROZEREM ; QL (31 SAPHRIS (BLACK CHERRY) SUBLINGUAL TABLET 10 MG SAPHRIS (BLACK CHERRY) SUBLINGUAL TABLET.5 MG SAPHRIS (BLACK CHERRY) SUBLINGUAL TABLET 5 MG SEROQUEL XR ORAL TABLET EXTENDED RELEASE 4 HR 150 MG SEROQUEL XR ORAL TABLET EXTENDED RELEASE 4 HR 00 MG SEROQUEL XR ORAL TABLET EXTENDED RELEASE 4 HR 300 MG SEROQUEL XR ORAL TABLET EXTENDED RELEASE 4 HR 400 MG SEROQUEL XR ORAL TABLET EXTENDED RELEASE 4 HR 50 MG sertraline oral concentrate ; QL (6 ; QL (48 ; QL (14 ; QL (166 ; QL (14 ; QL (83 ; QL (6 ; QL ( Name sertraline oral tablet 100 mg sertraline oral tablet 5 mg sertraline oral tablet 50 mg ; QL (6 ; QL (48 ; QL (14 STRATTERA SURMONTIL 4 PA; MO temazepam PA; MO thioridazine thiothixene tranylcypromine trazodone trifluoperazine trimipramine PA; MO TRINTELLIX ORAL TABLET 10 MG TRINTELLIX ORAL TABLET 0 MG TRINTELLIX ORAL TABLET 5 MG venlafaxine oral capsule,extended release 4hr 150 mg venlafaxine oral capsule,extended release 4hr 37.5 mg venlafaxine oral capsule,extended release 4hr 75 mg venlafaxine oral tablet 100 mg, 75 mg ; QL (6 ; QL (31 ; QL (14 ; QL (6 ; QL (186 ; QL (93 ; QL (93

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