Can the Formulary (drug list) change?

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1 CHRISTUS Health Plan Generations 018 Comprehensive Formulary List of Covered s PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN HPMS Approved Formulary File Submission ID , Version Number 1. This formulary was updated on 01/1/018. For more recent information or other questions, please contact CHRISTUS Health Plan Generations Member Services, at or, for TTY users, , 8 a.m. 8 p.m. local time, 7 days a week, or visit christushealthplan.org. H1189_MC438 Accepted 09/17/017 1

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 CHRISTUS Health Plan Generations. When it refers to plan or our plan, it means CHRISTUS Health Plan Generations. This document includes a list of the drugs (formulary) for our plan which is current as of 01/01/018. 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 CHRISTUS Health Plan Generations Formulary? A formulary is a list of covered drugs selected by CHRISTUS Health Plan Generations 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. We will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a CHRISTUS Health Plan Generations 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 018 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 018 coverage year except when a new, less expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released. Other types of formulary changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug. It will remain available at the same cost-sharing for those members taking it for the remainder of the coverage year. We feel it is important that you have continued access for the remainder of the coverage year to the formulary drugs that were available when you chose our plan, except for cases in which you can save additional money or we can ensure your safety. If we remove drugs from our formulary, 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 01/01/018. To get updated information about the drugs covered by CHRISTUS Health Plan Generations, 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: Medical Condition The formulary begins on page 7. 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

3 condition are listed under the category, antihypertensive therapy. If you know what your drug is used for, look for the category name in the list that begins on page 7. 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 79. 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? CHRISTUS Health Plan Generations 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: CHRISTUS Health Plan Generations requires your physician to get prior authorization for certain drugs. This means that you will need to get approval from us before you fill your prescriptions. If you don t get approval, CHRISTUS Health Plan Generations may not cover the drug. Quantity Limits: For certain drugs, CHRISTUS Health Plan Generations limits the amount of the drug that we will cover. For example, we provide 31 tablets per prescription for CRESTOR. This may be in addition to a standard one-month or three-month supply. Step Therapy: In some cases, CHRISTUS Health Plan Generations 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, we may not cover B unless you try A first. If A does not work for you, we 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 7. You can also get more information about the restrictions applied to specific covered drugs by visiting our Web site. We have posted on line 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 CHRISTUS Health Plan Generations 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 CHRISTUS Health Plan Generations formulary? on page 4 for information about how to request an exception. 3

4 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 Member Services and ask if your drug is covered. If you learn that we do not cover your drug, you have two options: You can ask Member Services for a list of similar drugs that are covered by CHRISTUS Health Plan Generations. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by us. You can ask CHRISTUS Health Plan Generations 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 CHRISTUS Health Plan Generations Formulary? You can ask us 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, we limit 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, we 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, or utilization restriction exception. When you request a formulary 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 believe 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. 4

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 91 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. Enrollees whose transition window has expired and are either being admitted to a LTC setting or being discharged from a long term care setting are provided an additional transition fill due to that level of care change. While the claim will initially reject as the member is no longer transition eligible according to plan enrollment dates, the pharmacist is instructed to enter an override code to allow the transition supply to process accordingly. Early refill edits are not applied in a long term care setting. For more information For more detailed information about your CHRISTUS Health Plan Generations prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about CHRISTUS Health Plan Generations 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 CHRISTUS Health Plan Generations Formulary The formulary below provides coverage information about the drugs covered by CHRISTUS Health Plan Generations (HMO). If you have trouble finding your drug in the list, turn to the Index that begins on page 79. The first column of the chart lists the drug name. Brand name drugs are capitalized (CRESTOR) and generic drugs are listed in lower-case italics (atorvastatin). 5

6 The information in the column tells you if we have any special requirements for coverage of your drug. Below is a list of abbreviations that may appear on the following pages in the column that tells you if there are any special requirements for coverage of your drug. List of Abbreviations B/D PA: This prescription drug may be covered under Medicare Part B or D depending upon the circumstances. Information may need to be submitted describing the use and setting of the drug to make the determination. GC: Gap Coverage. We provide coverage of this prescription drug in the Coverage Gap. Please refer to our Evidence of Coverage for more information about this coverage. LA: Limited Availability. This prescription may be available only at certain pharmacies. For more information, please call Customer Service. MO: Mail-Order. This prescription drug is available through our mail-order service, as well as through our retail network pharmacies. Consider using mail order for your long-term (maintenance) medications (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 physician to get prior authorization for certain drugs. This means that you will need to get approval before you fill your prescriptions. 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 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, we may not cover B unless you try A first. If A does not work for you, we will then cover B. Number Name Copay for a one-month supply filled at a network pharmacy with standard cost-sharing 1 Preferred Generic $4 Generic $10 3 Preferred Brand $35 4 Non-Preferred Brand $90 5 Specialty You pay 9% of the total cost 6

7 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 NOXAFIL ORAL nystatin oral suspension nystatin oral tablet ORAVIG Name SPORANOX ORAL SOLUTION terbinafine hcl oral voriconazole intravenous voriconazole oral ANTIVIRALS abacavir 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 APTIVUS ORAL CAPSULE APTIVUS ORAL SOLUTION ATRIPLA BARACLUDE ORAL SOLUTION 5 cidofovir 5 B/D PA; MO COMPLERA CRIXIVAN ORAL CAPSULE 00 MG, 400 MG 7

8 Name DAKLINZA (84 per 84 DESCOVY didanosine oral capsule,delayed release(dr/ec) 15 mg didanosine oral capsule,delayed release(dr/ec) 00 mg, 50 mg, 400 mg EDURANT EMTRIVA entecavir EPCLUSA (84 per 84 EPIVIR HBV ORAL SOLUTION EPZICOM EVOTAZ famciclovir 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 Name 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 lamivudinezidovudine LEXIVA ORAL SUSPENSION LEXIVA ORAL TABLET lopinavir-ritonavir moderiba moderiba dose pack oral tablets,dose pack 00 mg (7)- 400 mg (7), 400 mg (7)- 400 mg (7) moderiba dose pack oral tablets,dose pack 600 mg (7)- 400 mg (7), 600 mg (7)- 600 mg (7) 8

9 Name nevirapine oral suspension nevirapine oral tablet nevirapine oral tablet extended release 4 hr 100 mg nevirapine oral tablet extended release 4 hr 400 mg NORVIR ODEFSEY OLYSIO (168 per 168 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 Name ribasphere oral capsule ribasphere oral tablet 00 mg ribasphere oral tablet 400 mg ribasphere oral tablet 600 mg ribasphere ribapak oral tablets,dose pack 00 mg (7)- 400 mg (7) ribasphere ribapak oral tablets,dose pack mg (8)-mg (8), mg (8)-mg (8), mg (8)-mg (8) ribavirin oral capsule ribavirin oral tablet 00 mg 9 rimantadine SELZENTRY ORAL TABLET SOVALDI (168 per 168 stavudine oral capsule STRIBILD SUSTIVA ORAL CAPSULE 00 MG SUSTIVA ORAL CAPSULE 50 MG SUSTIVA ORAL TABLET

10 Name SYNAGIS INTRAMUSCULA R SOLUTION 50 MG/0.5 ML ; LA TAMIFLU TECHNIVIE (168 per 84 TIVICAY ORAL TABLET 10 MG TIVICAY ORAL TABLET 5 MG, 50 MG TRIUMEQ TRUVADA valacyclovir ; QL (30 VALCYTE ORAL RECON SOLN valganciclovir VEMLIDY VIDEX GRAM PEDIATRIC VIEKIRA PAK (67 per 168 VIEKIRA XR (504 per 168 VIRACEPT ORAL TABLET VIREAD ZEPATIER (11 per 11 ZERIT ORAL RECON SOLN Name ZIAGEN ORAL SOLUTION zidovudine CEPHALOSPORINS cefaclor oral capsule cefaclor oral suspension for reconstitution 15 mg/5 ml, 50 mg/5 ml cefaclor oral suspension for reconstitution 375 mg/5 ml cefaclor oral tablet extended release 1 hr 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 cefotetan injection 10

11 Name cefoxitin intravenous recon soln 1 gram, gram cefoxitin intravenous recon soln 10 gram cefpodoxime cefprozil ceftazidime injection recon soln 1 gram ceftazidime injection recon soln gram ceftazidime injection recon soln 6 gram 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 MAXIPIME INJECTION SUPRAX ORAL CAPSULE Name SUPRAX ORAL SUSPENSION FOR RECONSTITUTIO N 500 MG/5 ML SUPRAX ORAL TABLET,CHEWAB LE 4 TEFLARO ERYTHROMYCINS / OTHER MACROLIDES azithromycin clarithromycin e.e.s. 400 oral tablet E.E.S. GRANULES ery-tab oral tablet,delayed release (dr/ec) 50 mg ery-tab oral tablet,delayed release (dr/ec) 333 mg ERY-TAB ORAL TABLET,DELAYE D RELEASE (DR/EC) 500 MG erythrocin (as stearate) oral tablet 50 mg ERYTHROCIN INTRAVENOUS RECON SOLN 500 MG erythromycin ethylsuccinate oral suspension for reconstitution 11

12 Name erythromycin ethylsuccinate oral tablet erythromycin oral capsule,delayed release(dr/ec) erythromycin oral tablet 50 mg erythromycin oral tablet 500 mg MISCELLANEOUS ANTIINFECTIVES ALBENZA ALINIA amikacin injection solution 500 mg/ ml atovaquone atovaquoneproguanil AZACTAM IN DEXTROSE (ISO- OSM) aztreonam injection recon soln 1 gram baciim bacitracin intramuscular 3 BETHKIS 5 B/D PA; MO; QL (4 per 8 BILTRICIDE CAPASTAT 4 CAYSTON ; LA; QL (84 per 8 chloramphenicol sod succinate Name 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 gentamicin in nacl (iso-osm) intravenous piggyback 60 mg/50 ml, 80 mg/100 ml gentamicin injection solution 40 mg/ml 1

13 Name gentamicin sulfate (pf) intravenous solution 100 mg/10 ml hydroxychloroquine imipenem-cilastatin INVANZ INJECTION isoniazid injection isoniazid oral ivermectin lincomycin linezolid intravenous 5 linezolid oral mefloquine meropenem intravenous recon soln 500 mg metronidazole in nacl (iso-os) metronidazole oral NEBUPENT 3 B/D PA; MO; QL (1 per 8 neomycin paromomycin PASER PENTAM polymyxin b sulfate PRIFTIN PRIMAQUINE pyrazinamide quinine sulfate rifabutin Name 13 rifampin SIRTURO ; LA SIVEXTRO INTRAVENOUS STREPTOMYCIN SYNERCID 5 tinidazole TOBI PODHALER INHALATION CAPSULE, W/INHALATION DEVICE tobramycin in 0.5 % nacl tobramycin sulfate injection solution 5 ; QL (4 per 8 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 ; QL (9 per 30 ; QL (60 ampicillin

14 Name ampicillin sodium injection recon soln 1 gram, 10 gram, 15 mg 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 BICILLIN C-R BICILLIN L-A dicloxacillin nafcillin injection recon soln 1 gram nafcillin injection recon soln 10 gram oxacillin in dextrose(iso-osm) intravenous piggyback 1 gram/50 ml oxacillin in dextrose(iso-osm) intravenous piggyback gram/50 ml oxacillin injection recon soln 10 gram 5 Name PENICILLIN G POT IN DEXTROSE INTRAVENOUS PIGGYBACK MILLION UNIT/50 ML PENICILLIN G POT IN DEXTROSE INTRAVENOUS PIGGYBACK 3 MILLION UNIT/50 ML penicillin g potassium injection recon soln 5 million unit penicillin g procaine intramuscular syringe 1. million unit/ ml 3 penicillin g sodium penicillin v potassium piperacillintazobactam intravenous recon soln gram, 4.5 gram, 40.5 gram QUINOLONES ciprofloxacin ciprofloxacin (mixture) ciprofloxacin hcl oral ciprofloxacin in 5 % dextrose intravenous piggyback 00 mg/100 ml 14

15 Name 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 moxifloxacin oral ofloxacin oral tablet 300 mg ofloxacin oral tablet 400 mg SULFA'S / RELATED AGENTS sulfadiazine sulfamethoxazoletrimethoprim TETRACYCLINES demeclocycline oral tablet 150 mg demeclocycline oral tablet 300 mg doxy-100 doxycycline hyclate oral capsule doxycycline hyclate oral tablet 100 mg, 0 mg doxycycline hyclate oral tablet,delayed release (dr/ec) 100 mg, 150 mg, 75 mg Name doxycycline hyclate oral tablet,delayed release (dr/ec) 00 mg, 50 mg doxycycline monohydrate oral capsule 100 mg, 150 mg, 50 mg doxycycline monohydrate oral capsule 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 morgidox oral capsule 50 mg tetracycline oral capsule 50 mg tetracycline oral capsule 500 mg VIBRAMYCIN ORAL SYRUP URINARY TRACT AGENTS 15

16 Name methenamine hippurate nitrofurantoin nitrofurantoin macrocrystal nitrofurantoin monohyd/m-cryst PRIMSOL trimethoprim VANCOMYCIN vancomycin intravenous recon soln 1,000 mg, 10 gram, 500 mg vancomycin oral capsule VIBATIV INTRAVENOUS RECON SOLN 750 MG ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS ADJUNCTIVE AGENTS dexrazoxane hcl intravenous recon soln 50 mg ELITEK FUSILEV KEPIVANCE leucovorin calcium injection recon soln 100 mg, 350 mg leucovorin calcium oral 3 5 Name levoleucovorin intravenous recon soln 50 mg levoleucovorin intravenous solution mesna MESNEX ORAL XGEVA 5 5 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 (60 per 30 5 PA; MO ALECENSA (40 per 30 ALIMTA INTRAVENOUS RECON SOLN 500 MG ALUNBRIG 5 PA; MO; LA; QL (180 per 30 anastrozole ARRANON 5 16

17 Name AVASTIN azacitidine azathioprine B/D PA; MO azathioprine sodium 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 5 B/D PA; MO 5 PA; MO (30 per 30 CABOMETYX 5 PA; MO; LA CAPRELSA ORAL TABLET 100 MG CAPRELSA ORAL TABLET 300 MG carboplatin intravenous solution CELLCEPT INTRAVENOUS 5 PA; MO; LA; QL (90 per 30 5 PA; MO; LA; QL (30 per 30 3 B/D PA; MO cisplatin cladribine 5 B/D PA; MO clofarabine 5 CLOLAR 5 COMETRIQ 5 PA; MO Name 17 COSMEGEN COTELLIC 5 PA; MO; LA; QL (63 per 8 CYCLOPHOSPHA MIDE ORAL CAPSULE cyclosporine intravenous cyclosporine modified cyclosporine oral capsule 3 B/D PA; MO B/D PA B/D PA; MO 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 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 EMCYT

18 Name EMPLICITI 5 B/D PA; MO epirubicin intravenous solution 00 mg/100 ml ERBITUX INTRAVENOUS SOLUTION 100 MG/50 ML ERIVEDGE (30 per 30 ERWINAZE ETOPOPHOS etoposide intravenous exemestane FARESTON FARYDAK ORAL CAPSULE 10 MG FARYDAK ORAL CAPSULE 15 MG, 0 MG (1 per 1 FASLODEX FIRMAGON KIT W DILUENT SYRINGE SUBCUTANEOUS RECON SOLN 10 MG FIRMAGON KIT W DILUENT SYRINGE SUBCUTANEOUS RECON SOLN 80 MG fludarabine intravenous recon soln (6 per 1 Name fluorouracil intravenous solution.5 gram/50 ml 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 gengraf oral capsule 5 mg, 50 mg 4 B/D PA; MO 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 GLEEVEC ORAL TABLET 400 MG (60 per 30 (40 per 30 (30 per 30 5 PA; MO (60 per 30 GLEOSTINE HALAVEN HERCEPTIN INTRAVENOUS RECON SOLN 440 MG HEXALEN 18

19 Name hydroxyurea IBRANCE (1 per 8 ICLUSIG ORAL TABLET 15 MG ICLUSIG ORAL TABLET 45 MG idarubicin ifosfamide intravenous recon soln 1 gram imatinib oral tablet 100 mg imatinib oral tablet 400 mg 5 PA; QL (90 (30 per 30 5 PA; MO (60 per 30 IMBRUVICA (10 per 30 IMFINZI ; LA INLYTA ORAL TABLET 1 MG INLYTA ORAL TABLET 5 MG 5 PA; MO (10 per 30 IRESSA (30 per 30 irinotecan intravenous solution 100 mg/5 ml ISTODAX JAKAFI ORAL TABLET 10 MG, 15 MG, 0 MG, 5 MG 5 PA; MO Name JAKAFI ORAL TABLET 5 MG (60 per 30 JEVTANA KADCYLA INTRAVENOUS RECON SOLN 100 MG 5 PA; MO KEYTRUDA KISQALI 5 PA; MO KISQALI FEMARA CO-PACK 5 PA; MO KYPROLIS LARTRUVO ; LA LENVIMA 5 PA; MO letrozole LEUKERAN leuprolide subcutaneous kit LONSURF 5 PA; MO 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 19

20 Name 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 5 (10 per 30 (30 per 30 mercaptopurine methotrexate sodium B/D PA; MO methotrexate sodium (pf) injection recon soln methotrexate sodium (pf) injection solution mitomycin intravenous recon soln 0 mg, 5 mg mitomycin intravenous recon soln 40 mg B/D PA B/D PA; MO mitoxantrone MUSTARGEN mycophenolate mofetil hcl mycophenolate mofetil oral capsule mycophenolate mofetil oral suspension for reconstitution mycophenolate mofetil oral tablet B/D PA B/D PA; MO 5 B/D PA; MO B/D PA; MO Name mycophenolate sodium 0 B/D PA; MO 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 (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 ODOMZO 5 PA; MO; LA; QL (30 per 30 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

21 Name 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 (180 per 30 5 PA; MO; LA; QL (10 per 30 RYDAPT 5 PA; MO SANDIMMUNE ORAL SOLUTION SANDOSTATIN LAR DEPOT INTRAMUSCULA R SUSPENSION,EXT ENDED REL RECON 3 B/D PA; MO SIGNIFOR SIMULECT INTRAVENOUS RECON SOLN 0 MG sirolimus oral tablet 0.5 mg, 1 mg sirolimus oral tablet mg 3 B/D PA; MO B/D PA; MO 5 B/D PA; MO SOLTAMOX SOMATULINE DEPOT SPRYCEL ORAL TABLET 100 MG, 0 MG, 50 MG, 80 MG SPRYCEL ORAL TABLET 140 MG 5 PA; MO (30 per 30 Name SPRYCEL ORAL TABLET 70 MG 1 (60 per 30 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 (60 per 30 (30 per 30 SYNRIBO TABLOID tacrolimus oral B/D PA; MO TAFINLAR ORAL CAPSULE 50 MG TAFINLAR ORAL CAPSULE 75 MG TAGRISSO ORAL TABLET 40 MG TAGRISSO ORAL TABLET 80 MG (180 per 30 (10 per 30 5 PA; MO; LA; QL (60 per 30 5 PA; MO; LA; QL (30 per 30 tamoxifen TARCEVA ORAL TABLET 100 MG, 5 MG 5 PA; MO

22 Name TARCEVA ORAL TABLET 150 MG TARGRETIN TOPICAL TASIGNA ORAL CAPSULE 150 MG TASIGNA ORAL CAPSULE 00 MG (30 per 30 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 5 TRELSTAR tretinoin (chemotherapy) TRISENOX TYKERB 5 PA; MO; LA; QL (180 per 30 VECTIBIX INTRAVENOUS SOLUTION 100 MG/5 ML (0 MG/ML) 5 B/D PA; MO VELCADE VENCLEXTA ORAL TABLET 10 MG, 50 MG 3 PA; MO; LA Name VENCLEXTA ORAL TABLET 100 MG 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 5 PA; MO; LA 5 PA; MO; LA; QL (4 per 180 B/D PA; MO B/D PA B/D PA; MO VOTRIENT (10 per 30 XALKORI ORAL CAPSULE 00 MG XALKORI ORAL CAPSULE 50 MG 5 PA; MO (60 per 30 XATMEP 5 B/D PA XERMELO ; LA XTANDI (10 per 30 YERVOY INTRAVENOUS SOLUTION 50 MG/10 ML (5 MG/ML) YONDELIS

23 Name ZALTRAP INTRAVENOUS SOLUTION 100 MG/4 ML (5 MG/ML) ZANOSAR ZEJULA 5 PA; MO; LA; QL (90 per 30 ZELBORAF (40 per 30 ZOLINZA ZORTRESS 5 B/D PA; MO ZYDELIG (90 per 30 ZYKADIA (150 per 30 ZYTIGA ORAL TABLET 50 MG (10 per 30 AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH ANTICONVULSANTS 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 Name 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 diazepam rectal DILANTIN 30 MG divalproex oral capsule, delayed rel sprinkle divalproex oral tablet extended release 4 hr divalproex oral tablet,delayed release (dr/ec) epitol ethosuximide felbamate oral suspension felbamate oral tablet 400 mg 3

24 Name felbamate oral tablet 600 mg 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 GRALISE 3 PA; MO GRALISE 30-DAY STARTER PACK lamotrigine oral tablet lamotrigine oral tablet extended release 4hr 100 mg, 00 mg, 5 mg, 50 mg lamotrigine oral tablet extended release 4hr 50 mg, 300 mg lamotrigine oral tablet, chewable dispersible lamotrigine oral tablet,disintegrating 3 PA; MO Name 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 4 LYRICA 3 PA; MO ONFI ORAL SUSPENSION ONFI ORAL TABLET 10 MG, 0 MG 3 PA; MO 3 PA; MO oxcarbazepine PEGANONE phenobarbital phenytoin oral suspension 15 mg/5 ml phenytoin oral tablet,chewable phenytoin sodium extended phenytoin sodium intravenous solution POTIGA primidone

25 Name roweepra oral tablet 1,000 mg, 750 mg roweepra oral tablet 500 mg SABRIL ; LA SPRITAM tiagabine topiramate oral capsule, sprinkle topiramate oral tablet PA; MO 1 PA; MO valproate sodium valproic acid valproic acid (as sodium salt) oral solution 50 mg/5 ml VIMPAT INTRAVENOUS VIMPAT ORAL SOLUTION VIMPAT ORAL TABLET 3 zonisamide PA; MO ANTIPARKINSONISM AGENTS APOKYN ; LA AZILECT benztropine bromocriptine oral capsule bromocriptine oral tablet carbidopa carbidopa-levodopa carbidopa-levodopaentacapone Name entacapone NEUPRO pramipexole oral tablet pramipexole oral tablet extended release 4 hr mg, 0.75 mg,.5 mg, 3 mg, 3.75 mg, 4.5 mg pramipexole oral tablet extended release 4 hr 1.5 mg rasagiline ropinirole oral tablet ropinirole oral tablet extended release 4 hr 1 mg ropinirole oral tablet extended release 4 hr mg, 4 mg, 6 mg, 8 mg selegiline hcl tolcapone MIGRAINE / CLUSTER HEADACHE THERAPY almotriptan malate oral tablet 1.5 mg almotriptan malate oral tablet 6.5 mg dihydroergotamine injection dihydroergotamine nasal ; QL (4 per 8 ; QL (18 per 8 ergotamine-caffeine ; QL (8 per 8 frovatriptan ; QL (7 per 8 5

26 Name migergot naratriptan ; 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 sumatriptan succinate subcutaneous solution sumatriptan succinate subcutaneous syringe 6 mg/0.5 ml ; QL (18 per 8 ; QL (36 per 8 ; QL (18 per 8 ; QL (8 per 8 ; QL (8 per 8 ; QL (8 per 8 ; QL (8 per 8 zolmitriptan ; QL (18 per 8 MISCELLANEOUS NEUROLOGICAL THERAPY AMPYRA 5 PA; MO; LA AUBAGIO 5 PA; MO COPAXONE SUBCUTANEOUS SYRINGE 40 MG/ML (1 per 8 Name donepezil oral tablet 10 mg, 5 mg donepezil oral tablet 3 mg donepezil oral tablet,disintegrating 6 galantamine GILENYA 5 PA; MO glatopa (30 per 30 memantine oral solution memantine oral tablet PA; MO PA; MO NAMENDA XR 3 PA; MO NAMZARIC 3 PA; MO NUEDEXTA rivastigmine rivastigmine tartrate TECFIDERA 5 PA; MO tetrabenazine 5 PA; MO TYSABRI 5 PA; MO; LA MUSCLE RELAXANTS / ANTISPASMODIC THERAPY baclofen cyclobenzaprine oral tablet PA; MO dantrolene LIORESAL INTRATHECAL SOLUTION,000 MCG/ML, 500 MCG/ML 3 B/D PA; MO

27 Name LIORESAL INTRATHECAL SOLUTION 50 MCG/ML MESTINON ORAL SYRUP pyridostigmine bromide tizanidine oral capsule mg, 4 mg tizanidine oral capsule 6 mg 3 B/D PA tizanidine oral tablet NARCOTIC ANALGESICS acetaminophencodeine oral solution 10-1 mg/5 ml acetaminophencodeine oral tablet mg, mg acetaminophencodeine oral tablet mg buprenorphine hcl injection solution buprenorphine hcl injection syringe buprenorphine hcl sublingual tablet mg buprenorphine hcl sublingual tablet 8 mg ; QL (4500 ; QL (360 ; QL (180 ; QL (67 QL (67 per 30 ; QL (300 ; QL (75 BUTRANS ; QL (4 per 8 codeine sulfate oral tablet ; QL (180 Name duramorph (pf) injection solution 0.5 mg/ml duramorph (pf) injection solution 1 mg/ml endocet oral tablet mg, 5-35 mg, mg ; QL (4000 QL (000 per 30 ; QL (360 fentanyl citrate (10 per 30 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 hydrocodoneibuprofen oral tablet mg, 5-00 mg, mg ; QL (9 per 30 ; QL (10 ; QL (5550 ; QL (360 ; QL (50 hydromorphone (pf) ; QL (40 hydromorphone injection syringe mg/ml QL (100 per 30 7

28 Name hydromorphone oral liquid hydromorphone oral tablet hydromorphone oral tablet extended release 4 hr 1 mg, 8 mg hydromorphone oral tablet extended release 4 hr 16 mg hydromorphone oral tablet extended release 4 hr 3 mg ; QL (1500 ; QL (180 ; QL (60 ; QL (60 ; QL (47 ibuprofen-oxycodone ; QL (8 levorphanol tartrate ; QL (10 lorcet (hydrocodone) QL (360 per 30 lorcet hd QL (360 per 30 lorcet plus oral tablet mg QL (360 per 30 lortab QL (360 per 30 lortab 5-35 QL (360 per 30 lortab QL (360 per 30 methadone injection QL (160 per 30 methadone oral solution 10 mg/5 ml methadone oral solution 5 mg/5 ml methadone oral tablet 10 mg ; QL (600 ; QL (100 ; QL (10 Name 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 morphine oral capsule, er multiphase 4 hr 30 mg, 60 mg, 90 mg morphine oral capsule, er multiphase 4 hr 45 mg, 75 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 (40 ; QL (300 QL (1000 per 30 QL (500 per 30 ; QL (50 ; QL (60 ; QL (60 ; QL (90 ; QL (60 ; QL (75 ; QL (900 morphine oral tablet ; QL (180 8

29 Name 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 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 solution oxycodoneacetaminophen oral tablet mg,.5-35 mg, 5-35 mg, mg ; QL (60 ; QL (10 ; QL (30 ; QL (100 ; QL (360 ; QL (180 ; QL (100 ; QL (180 ; QL (134 ; QL (360 QL (1846 per 30 ; QL (360 oxycodone-aspirin ; QL (360 Name OXYCONTIN ORAL TABLET,ORAL ONLY,EXT.REL.1 HR 10 MG, 15 MG, 0 MG, 30 MG, 40 MG OXYCONTIN ORAL TABLET,ORAL ONLY,EXT.REL.1 HR 60 MG OXYCONTIN ORAL TABLET,ORAL ONLY,EXT.REL.1 HR 80 MG oxymorphone oral tablet 10 mg oxymorphone oral tablet 5 mg oxymorphone oral tablet extended release 1 hr 10 mg, 5 mg, 7.5 mg oxymorphone oral tablet extended release 1 hr 15 mg, 0 mg oxymorphone oral tablet extended release 1 hr 30 mg oxymorphone oral tablet extended release 1 hr 40 mg reprexain oral tablet mg, 5-00 mg ; QL (90 ; QL (67 ; QL (60 ; QL (00 ; QL (180 ; QL (90 ; QL (90 ; QL (67 ; QL (50 ; QL (50 vicodin ; QL (360 9

30 Name vicodin es ; QL (360 vicodin hp ; QL (360 zamicet QL (5550 per 30 NON-NARCOTIC ANALGESICS buprenorphinenaloxone sublingual tablet -0.5 mg buprenorphinenaloxone sublingual tablet 8- mg butorphanol tartrate injection solution 1 mg/ml butorphanol tartrate injection solution mg/ml butorphanol tartrate nasal ; QL (360 ; QL (90 ; QL (70 ; QL (360 celecoxib diclofenac potassium diclofenac sodium oral diclofenac sodium topical drops diclofenac sodium topical gel 1 % diclofenacmisoprostol ; QL (5 per 8 diflunisal etodolac fenoprofen oral tablet Name FLECTOR 4 PA; MO; QL (60 per 30 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 (30 nabumetone nalbuphine injection solution 10 mg/ml nalbuphine injection solution 0 mg/ml naloxone injection solution naloxone injection syringe 1 mg/ml ; QL (00 ; QL (100 naltrexone naproxen oral suspension naproxen oral tablet 30

31 Name 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 (60 ; QL (360 ; QL (90 sulindac tolmetin oral capsule tolmetin oral tablet 600 mg tramadol oral tablet ; QL (40 tramadol oral tablet extended release 4 hr 100 mg, 00 mg tramadol oral tablet, er multiphase 4 hr 300 mg tramadolacetaminophen ; QL (30 ; QL (30 ; QL (40 Name VOLTAREN GEL TOPICAL GEL 1 % 31 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 ARISTADA INTRAMUSCULA R SUSPENSION,EXT ENDED REL SYRING 441 MG/1.6 ML, 66 MG/.4 ML, 88 MG/3. ML ; QL (90 ; QL (60 ; QL (450 ; QL (60 ; QL (30 ; QL (180 ; QL (90 ; QL (60 armodafinil PA; MO bupropion hcl oral tablet

32 Name bupropion hcl oral tablet extended release 1 hr 100 mg bupropion hcl oral tablet extended release 1 hr 150 mg 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 (10 ; QL (90 ; QL (60 ; QL (90 ; QL (60 buspirone chlorpromazine injection chlorpromazine oral tablet 10 mg, 00 mg, 5 mg, 50 mg chlorpromazine oral tablet 100 mg citalopram oral solution citalopram oral tablet 10 mg citalopram oral tablet 0 mg citalopram oral tablet 40 mg clomipramine oral capsule 5 mg, 50 mg clomipramine oral capsule 75 mg clonidine hcl oral tablet extended release 1 hr ; QL (10 ; QL (60 ; QL (30 PA; MO 4 PA; MO Name clorazepate dipotassium 3 PA; MO clozapine oral tablet clozapine oral tablet,disintegrating 100 mg, 1.5 mg, 5 mg 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 dexmethylphenidate oral capsule,er biphasic mg, 0 mg, 5 mg dexmethylphenidate oral capsule,er biphasic mg, 5 mg, 30 mg, 35 mg, 40 mg dexmethylphenidate oral tablet dextroamphetamine oral capsule, extended release 10 mg, 15 mg dextroamphetamine oral capsule, extended release 5 mg ; QL (10 ; QL (480 ; QL (40

33 Name dextroamphetamine oral tablet dextroamphetamineamphetamine diazepam intensol PA; MO diazepam oral solution 5 mg/5 ml (1 mg/ml) PA; MO diazepam oral tablet PA; MO 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 (180 ; QL (10 ; QL (90 ; QL (60 EMSAM ergoloid escitalopram oxalate oral solution escitalopram oxalate oral tablet 10 mg escitalopram oxalate oral tablet 0 mg escitalopram oxalate oral tablet 5 mg ; QL (60 ; QL (30 ; QL (10 eszopiclone ST; MO; QL (30 per 30 FANAPT ORAL TABLET 1 MG ; QL (70 Name 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 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 33 ; QL (90 ; QL (60 ; QL (360 ; QL (180 ; QL (10 ; QL (8 per 8 4 ; QL (8 per 8 ; QL (30 ; QL (180 ; QL (90 ; QL (45 ; QL (40

34 Name fluoxetine oral capsule 0 mg fluoxetine oral capsule 40 mg fluoxetine oral capsule,delayed release(dr/ec) fluoxetine oral solution fluoxetine oral tablet 10 mg fluoxetine oral tablet 0 mg fluphenazine decanoate ; QL (60 ; QL (4 per 8 ; QL (40 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 (90 ; QL (60 ; QL (90 ; QL (360 ; QL (180 FORFIVO XL ; QL (30 GEODON INTRAMUSCULA R guanidine haloperidol haloperidol decanoate Name 34 haloperidol lactate HETLIOZ (30 per 30 imipramine hcl PA; MO imipramine pamoate 4 PA; MO INVEGA SUSTENNA INTRAMUSCULA R SYRINGE 117 MG/0.75 ML, 156 MG/ML, 34 MG/1.5 ML, 78 MG/0.5 ML INVEGA SUSTENNA INTRAMUSCULA R SYRINGE 39 MG/0.5 ML 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 (30 ; QL (40 ; QL (10 ; QL (60 lithium carbonate lithium citrate oral solution 8 meq/5 ml lorazepam intensol PA; MO lorazepam oral tablet PA; MO loxapine succinate maprotiline MARPLAN

35 Name metadate er methamphetamine PA; MO methylphenidate oral capsule, er biphasic methylphenidate oral capsule,er biphasic mg, 40 mg, 60 mg methylphenidate oral solution 10 mg/5 ml methylphenidate oral solution 5 mg/5 ml methylphenidate oral tablet methylphenidate oral tablet extended release methylphenidate oral tablet extended release 4hr methylphenidate oral tablet,chewable mirtazapine oral tablet mirtazapine oral tablet,disintegrating modafinil PA; MO molindone nefazodone nortriptyline NUPLAZID olanzapine intramuscular Name olanzapine oral tablet 10 mg 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 oral capsule 1-5 mg, 3-5 mg olanzapinefluoxetine oral capsule 1-50 mg, 6-5 mg, 6-50 mg ; QL (60 ; QL (30 ; QL (40 ; QL (10 ; QL (81 ; QL (60 ; QL (30 ; QL (10 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 ; QL (40 ; QL (10 ; QL (60 35

36 Name 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 paroxetine hcl oral tablet 40 mg paroxetine hcl oral tablet extended release 4 hr 1.5 mg paroxetine hcl oral tablet extended release 4 hr 5 mg paroxetine hcl oral tablet extended release 4 hr 37.5 mg PAXIL ORAL SUSPENSION ; QL (41 ; QL (180 ; QL (90 ; QL (60 ; QL (45 ; QL (180 ; QL (90 ; QL (60 perphenazine phenelzine pimozide PRISTIQ ORAL TABLET EXTENDED RELEASE 4 HR 100 MG PRISTIQ ORAL TABLET EXTENDED RELEASE 4 HR 5 MG ; QL (10 ; QL (480 Name PRISTIQ ORAL TABLET EXTENDED RELEASE 4 HR 50 MG ; QL (40 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 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 REXULTI ORAL TABLET 0.5 MG REXULTI ORAL TABLET 0.5 MG ; QL (40 ; QL (10 ; QL (90 ; QL (81 ; QL (60 ; QL (480 ; QL (161 ; QL (10 ; QL (81 ; QL (60 ; QL (480 ; QL (480 ; QL (40 36

37 Name 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 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 risperidone oral tablet,disintegrating 0.5 mg ; QL (10 ; QL (60 ; QL (40 ; QL (30 ; QL (480 ; QL (190 ; QL (960 ; QL (480 ; QL (40 ; QL (161 ; QL (10 ; QL (190 Name 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 ; QL (960 ; QL (480 ; QL (40 ; QL (161 ; QL (10 ROZEREM ; QL (30 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 ; QL (60 ; QL (40 ; QL (10 ; QL (161 ; QL (10 37

38 Name 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 sertraline oral tablet 100 mg sertraline oral tablet 5 mg sertraline oral tablet 50 mg ; QL (81 ; QL (60 ; QL (480 ; QL (60 ; QL (40 ; QL (10 STRATTERA temazepam PA; MO thioridazine thiothixene tranylcypromine trazodone trifluoperazine trimipramine PA; MO TRINTELLIX ORAL TABLET 10 MG TRINTELLIX ORAL TABLET 0 MG ; QL (60 ; QL (30 Name 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 venlafaxine oral tablet 5 mg venlafaxine oral tablet 37.5 mg venlafaxine oral tablet 50 mg VERSACLOZ 5 VIIBRYD ORAL TABLET 10 MG VIIBRYD ORAL TABLET 0 MG VIIBRYD ORAL TABLET 40 MG VIIBRYD ORAL TABLETS,DOSE PACK 10 MG (7)- 0 MG (3) VRAYLAR ORAL CAPSULE 1.5 MG VRAYLAR ORAL CAPSULE 3 MG VRAYLAR ORAL CAPSULE 4.5 MG ; QL (10 ; QL (60 ; QL (180 ; QL (90 ; QL (90 ; QL (70 ; QL (180 ; QL (150 ; QL (10 ; QL (60 ; QL (30 ; QL (30 per 180 ; QL (10 ; QL (60 ; QL (40 38

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