Educators Rx Advantage (PDP) (List of Covered Drugs)

Transcription

1 Educators Rx Advantage (PDP) 2018 Formulary (List of Covered s) We have made changes to this formulary, the last update was 03/01/2018. For more recent information or other questions, please contact EMI Health Customer Service at or, for TTY users, , 24 hours a day, 7 days a week, or visit Please Read: This document contains information about the drugs we cover in this plan. Version #3 Effective 04/01/2018 Last Updated 03/27/2018 S5877_F00EDA7A CMS Accepted:

2 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. 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. 1

3 Name ANTI - INFECTIVES ANTIFUNGAL AGENTS ABELCET 4 B/D PA; MO AMBISOME 4 B/D PA; MO amphotericin b 3 B/D PA; MO ANCOBON CANCIDAS 4 B/D PA; MO caspofungin intravenous recon soln 50 mg CASPOFUNGIN INTRAVENOUS RECON SOLN 70 clotrimazole mucous membrane CRESEMBA INTRAVENOUS 4 B/D PA 4 B/D PA CRESEMBA ORAL DIFLUCAN ERAXIS(WATER DILUENT) INTRAVENOUS RECON SOLN 100 ERAXIS(WATER DILUENT) INTRAVENOUS RECON SOLN 50 4 fluconazole Name fluconazole in nacl (iso-osm) intravenous piggyback 200 mg/100 ml fluconazole in nacl (iso-osm) intravenous piggyback 400 mg/200 ml flucytosine griseofulvin microsize griseofulvin ultramicrosize GRIS-PEG (ULTRAMICROSIZ E) 1 itraconazole ketoconazole oral LAMISIL ORAL TABLET MYCAMINE NOXAFIL ORAL nystatin oral suspension nystatin oral tablet ONMEL ; QL (30 ORAVIG SPORANOX ORAL CAPSULE SPORANOX ORAL SOLUTION 2

4 Name terbinafine hcl oral VFEND VFEND IV voriconazole intravenous voriconazole oral ANTIVIRALS abacavir oral tablet abacavir-lamivudine abacavirlamivudinezidovudine acyclovir oral capsule acyclovir oral suspension 200 mg/5 ml acyclovir oral tablet acyclovir sodium intravenous solution 3 B/D PA; MO adefovir amantadine hcl APTIVUS ORAL CAPSULE APTIVUS ORAL SOLUTION atazanavir oral capsule 150 mg, 200 mg atazanavir oral capsule 300 mg 4 ATRIPLA Name BARACLUDE ORAL SOLUTION BARACLUDE ORAL TABLET cidofovir 4 B/D PA; MO COMBIVIR COMPLERA CRIXIVAN ORAL CAPSULE 200, 400 CYTOVENE 3 B/D PA; MO DAKLINZA (28 per 28 DESCOVY didanosine oral capsule,delayed release(dr/ec) 125 mg didanosine oral capsule,delayed release(dr/ec) 200 mg, 250 mg, 400 mg 1 EDURANT efavirenz oral capsule 50 mg EMTRIVA entecavir EPCLUSA (28 per 28 EPIVIR EPIVIR HBV ORAL SOLUTION 3

5 Name EPIVIR HBV ORAL TABLET EPZICOM EVOTAZ famciclovir FLUMADINE ORAL TABLET fosamprenavir FUZEON SUBCUTANEOUS RECON SOLN ganciclovir sodium 1 B/D PA; MO GENVOYA HARVONI (28 per 28 HEPSERA INTELENCE ORAL TABLET 100, 200 INTELENCE ORAL TABLET 25 INVIRASE ISENTRESS ORAL POWDER IN PACKET ISENTRESS ORAL TABLET ISENTRESS ORAL TABLET,CHEWAB LE 100 ISENTRESS ORAL TABLET,CHEWAB LE 25 Name JULUCA KALETRA ORAL SOLUTION KALETRA ORAL TABLET KALETRA ORAL TABLET lamivudine lamivudinezidovudine LEXIVA ORAL SUSPENSION LEXIVA ORAL TABLET lopinavir-ritonavir MAVYRET (84 per 28 moderiba moderiba dose pack oral tablets,dose pack 200 mg (28)- 400 mg (28), mg (28)-mg (28) moderiba dose pack oral tablets,dose pack mg (28)-mg (28), mg (28)-mg (28) nevirapine NORVIR ORAL CAPSULE NORVIR ORAL SOLUTION 4 2

6 Name NORVIR ORAL TABLET ODEFSEY OLYSIO (28 per 28 oseltamivir PREVYMIS INTRAVENOUS PREVYMIS ORAL PREZCOBIX PREZISTA ORAL SUSPENSION PREZISTA ORAL TABLET 150, 75 PREZISTA ORAL TABLET 600, 800 REBETOL ORAL SOLUTION RELENZA DISKHALER 4 RESCRIPTOR RETROVIR INTRAVENOUS RETROVIR ORAL CAPSULE RETROVIR ORAL SYRUP REYATAZ ORAL CAPSULE 150, 200, 300 Name REYATAZ ORAL POWDER IN PACKET ribasphere oral capsule ribasphere oral tablet 200 mg, 400 mg ribasphere oral tablet 600 mg ribasphere ribapak oral tablets,dose pack 200 mg (7)- 400 mg (7) ribasphere ribapak oral tablets,dose pack mg (28)-mg (28), mg (28)-mg (28), mg (28)-mg (28) ribavirin oral capsule ribavirin oral tablet 200 mg 1 rimantadine SELZENTRY SOVALDI (28 per 28 stavudine oral capsule STRIBILD SUSTIVA ORAL CAPSULE 200 5

7 Name SUSTIVA ORAL CAPSULE 50 SUSTIVA ORAL TABLET SYNAGIS INTRAMUSCULA R SOLUTION 50 /0.5 ML ; LA TAMIFLU TECHNIVIE (56 per 28 tenofovir disoproxil fumarate TIVICAY ORAL TABLET 10 TIVICAY ORAL TABLET 25, 50 TRIUMEQ TRIZIVIR TRUVADA TYBOST valacyclovir oral tablet 1 gram valacyclovir oral tablet 500 mg ; QL (120 ; QL (60 VALCYTE valganciclovir VALTREX ORAL TABLET 1 GRAM VALTREX ORAL TABLET 500 ; QL (120 ; QL (60 VEMLIDY Name VIDEX 4 GRAM PEDIATRIC VIDEX EC VIEKIRA PAK (112 per 28 VIEKIRA XR (84 per 28 VIRACEPT ORAL TABLET VIRAMUNE VIRAMUNE XR VIREAD VOSEVI (28 per 28 ZEPATIER (28 per 28 ZERIT ZIAGEN ORAL SOLUTION ZIAGEN ORAL TABLET zidovudine ZOVIRAX ORAL CAPSULE ZOVIRAX ORAL SUSPENSION ZOVIRAX ORAL TABLET 800 CEPHALOSPORINS AVYCAZ 6

8 Name cefaclor oral capsule cefaclor oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml cefaclor oral suspension for reconstitution 375 mg/5 ml cefaclor oral tablet extended release 12 hr cefadroxil oral capsule cefadroxil oral suspension for reconstitution 250 mg/5 ml, 500 mg/5 ml 1 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, 2 gram, 500 mg cefotetan injection 1 cefoxitin intravenous recon soln 1 gram, 2 gram 1 1 Name cefoxitin intravenous recon soln 10 gram cefpodoxime cefprozil ceftazidime injection recon soln 1 gram, 2 gram ceftazidime injection recon soln 6 gram CEFTIN ORAL SUSPENSION FOR RECONSTITUTIO N ceftriaxone injection recon soln 1 gram, 2 gram, 250 mg, 500 mg ceftriaxone injection recon soln 10 gram 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 1 7

9 Name SUPRAX ORAL SUSPENSION FOR RECONSTITUTIO N 100 /5 ML, 200 /5 ML SUPRAX ORAL SUSPENSION FOR RECONSTITUTIO N 500 /5 ML SUPRAX ORAL TABLET,CHEWAB LE TAZICEF INJECTION RECON SOLN 1 GRAM TAZICEF INJECTION RECON SOLN 2 GRAM, 6 GRAM 3 3 TEFLARO ZERBAXA 4 ERYTHROMYCINS / OTHER MACROLIDES azithromycin clarithromycin DIFICID e.e.s. 400 oral tablet E.E.S. GRANULES ERYPED 200 ERYPED 400 ery-tab oral tablet,delayed release (dr/ec) 250 mg, 333 mg Name ERY-TAB ORAL TABLET,DELAYE D RELEASE (DR/EC) 500 erythrocin (as stearate) oral tablet 250 mg ERYTHROCIN INTRAVENOUS RECON SOLN 500 erythromycin ethylsuccinate oral suspension for reconstitution erythromycin ethylsuccinate oral tablet erythromycin oral capsule,delayed release(dr/ec) erythromycin oral tablet PCE ZITHROMAX ZITHROMAX TRI- PAK ZITHROMAX Z- PAK ZMAX MISCELLANEOUS ANTIINFECTIVES ALBENZA 8

10 Name ALINIA ORAL SUSPENSION FOR RECONSTITUTIO N ALINIA ORAL TABLET amikacin injection solution 500 mg/2 ml atovaquone atovaquoneproguanil AZACTAM aztreonam injection recon soln 1 gram baciim 1 bacitracin intramuscular BETHKIS 4 B/D PA; MO; QL (224 per 28 BILTRICIDE CAPASTAT 3 CAYSTON ; LA; QL (84 per 28 chloramphenicol sod succinate chloroquine phosphate 1 CLEOCIN HCL Name CLEOCIN IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK 300 /50 ML, 600 /50 ML CLEOCIN IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK 900 /50 ML CLEOCIN INJECTION CLEOCIN PEDIATRIC 3 clindamycin hcl clindamycin in 5 % dextrose clindamycin palmitate hcl clindamycin phosphate injection clindamycin phosphate intravenous solution 600 mg/4 ml COARTEM colistin (colistimethate na) 1 CUBICIN DALVANCE dapsone oral daptomycin DARAPRIM 4 PA; MO 9

11 Name DORIPENEM INTRAVENOUS RECON SOLN 500 EMVERM ethambutol FLAGYL 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 gentamicin sulfate (pf) intravenous solution 100 mg/10 ml 3 1 hydroxychloroquine imipenem-cilastatin INVANZ INJECTION isoniazid injection 1 isoniazid oral ivermectin KITABIS PAK LINCOCIN lincomycin 1 linezolid intravenous 4 Name linezolid oral MALARONE MALARONE PEDIATRIC mefloquine MEPRON meropenem MERREM INTRAVENOUS RECON SOLN 500 metronidazole in nacl (iso-os) metronidazole oral MYAMBUTOL ORAL TABLET 400 MYCOBUTIN NEBUPENT 2 B/D PA; MO; QL (1 per 28 neomycin ORBACTIV paromomycin PASER PENTAM PLAQUENIL polymyxin b sulfate PRIFTIN PRIMAQUINE 10

12 Name PRIMAXIN IV INTRAVENOUS RECON SOLN 500 pyrazinamide QUALAQUIN quinine sulfate rifabutin RIFADIN ORAL CAPSULE 150 RIFAMATE rifampin RIFATER SIRTURO ; LA SIVEXTRO INTRAVENOUS SIVEXTRO ORAL STREPTOMYCIN STROMECTOL SYNERCID 4 TIGECYCLINE 4 TINDAMAX ORAL TABLET tinidazole TOBI 4 B/D PA; MO; QL (280 per 28 TOBI PODHALER INHALATION CAPSULE, W/INHALATION DEVICE ; QL (224 per 28 Name tobramycin in % nacl tobramycin sulfate injection solution 4 B/D PA; MO; QL (280 per 28 TRECATOR TYGACIL VABOMERE 4 XIFAXAN ORAL TABLET 200 XIFAXAN ORAL TABLET 550 ZYVOX INTRAVENOUS PARENTERAL SOLUTION 600 /300 ML ; QL (9 per 30 ; QL (60 ZYVOX ORAL PENICILLINS amoxicillin oral capsule amoxicillin oral suspension for reconstitution amoxicillin oral tablet amoxicillin oral tablet,chewable 125 mg, 250 mg amoxicillin-pot clavulanate ampicillin oral capsule 500 mg 11

13 Name ampicillin sodium injection recon soln 1 gram, 10 gram, 125 mg ampicillin-sulbactam injection recon soln 1.5 gram, 3 gram ampicillin-sulbactam injection recon soln 15 gram AUGMENTIN ORAL SUSPENSION FOR RECONSTITUTIO N /5 ML 1 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 2 gram/50 ml oxacillin injection recon soln 10 gram oxacillin injection recon soln 2 gram 1 4 Name PENICILLIN G POT IN DEXTROSE INTRAVENOUS PIGGYBACK 2 MILLION UNIT/50 ML PENICILLIN G POT IN DEXTROSE INTRAVENOUS PIGGYBACK 3 MILLION UNIT/50 ML penicillin g potassium injection recon soln 20 million unit penicillin g procaine intramuscular syringe 1.2 million unit/2 ml 12 2 penicillin g sodium penicillin v potassium piperacillintazobactam intravenous recon soln 2.25 gram, gram, 4.5 gram, 40.5 gram UNASYN INJECTION RECON SOLN 15 GRAM UNASYN INJECTION RECON SOLN 3 GRAM 3

14 Name ZOSYN IN DEXTROSE (ISO- OSM) INTRAVENOUS PIGGYBACK 2.25 GRAM/50 ML ZOSYN IN DEXTROSE (ISO- OSM) INTRAVENOUS PIGGYBACK GRAM/50 ML ZOSYN INTRAVENOUS RECON SOLN 40.5 GRAM QUINOLONES 3 AVELOX AVELOX IN NACL (ISO-OSMOTIC) BAXDELA INTRAVENOUS BAXDELA ORAL CIPRO IN D5W INTRAVENOUS PIGGYBACK 400 /200 ML CIPRO ORAL SUSPENSION,MIC ROCAPSULE RECON CIPRO ORAL TABLET 250, 500 ciprofloxacin 1 ciprofloxacin (mixture) 4 3 Name ciprofloxacin hcl oral ciprofloxacin in 5 % dextrose intravenous piggyback 200 mg/100 ml ciprofloxacin lactate intravenous solution 400 mg/40 ml LEVAQUIN ORAL TABLET levofloxacin in d5w intravenous piggyback 500 mg/100 ml, 750 mg/150 ml levofloxacin intravenous 13 1 levofloxacin oral moxifloxacin oral MOXIFLOXACIN- SOD.ACE,SUL- WATER ofloxacin oral tablet 300 mg ofloxacin oral tablet 400 mg 3 1 SULFA'S / RELATED AGENTS BACTRIM BACTRIM DS sulfadiazine sulfamethoxazoletrimethoprim TETRACYCLINES

15 Name demeclocycline DORYX MPC 3 ST; MO DORYX ORAL TABLET,DELAYE D RELEASE (DR/EC) 200, 50 3 ST; MO doxy-100 doxycycline hyclate oral capsule doxycycline hyclate oral tablet doxycycline hyclate oral tablet,delayed release (dr/ec) doxycycline monohydrate oral capsule doxycycline monohydrate oral suspension for reconstitution doxycycline monohydrate oral tablet MINOCIN ORAL CAPSULE 100, 50 minocycline oral capsule minocycline oral tablet minocycline oral tablet extended release 24 hr 135 mg, 45 mg, 90 mg 3 ST; MO Name morgidox oral capsule 50 mg ORACEA 3 ST; MO SOLODYN ORAL TABLET EXTENDED RELEASE 24 HR 105, 115, 55, 65, 80 4 ST; MO TARGADOX 3 ST; MO tetracycline VIBRAMYCIN ORAL CAPSULE 100 VIBRAMYCIN ORAL SUSPENSION FOR RECONSTITUTIO N VIBRAMYCIN ORAL SYRUP 3 ST; MO XIMINO 3 ST; MO URINARY TRACT AGENTS FURADANTIN 3 HIPREX MACROBID MACRODANTIN methenamine hippurate MONUROL nitrofurantoin nitrofurantoin macrocrystal 14

16 Name nitrofurantoin monohyd/m-cryst trimethoprim VANCOMYCIN VANCOCIN vancomycin intravenous recon soln 1,000 mg, 10 gram, 500 mg vancomycin oral capsule ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS ADJUNCTIVE AGENTS dexrazoxane hcl intravenous recon soln 250 mg ELITEK FUSILEV KEPIVANCE leucovorin calcium injection recon soln 100 mg, 350 mg leucovorin calcium oral levoleucovorin intravenous solution 4 mesna MESNEX INTRAVENOUS 4 MESNEX ORAL XGEVA 4 B/D PA; MO Name ZINECARD (AS HCL) INTRAVENOUS RECON SOLN 250 ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS ABRAXANE 4 B/D PA; MO adriamycin intravenous solution 20 mg/10 ml adrucil intravenous solution 500 mg/10 ml AFINITOR DISPERZ AFINITOR ORAL TABLET 10 AFINITOR ORAL TABLET 2.5, 5, B/D PA 1 B/D PA; MO 4 PA; MO (60 per 30 4 PA; MO ALECENSA (240 per 30 ALIMTA INTRAVENOUS RECON SOLN B/D PA; MO ALIQOPA 4 B/D PA; MO; LA ALKERAN INTRAVENOUS ALUNBRIG ORAL TABLET B/D PA (30 per 30 15

17 Name ALUNBRIG ORAL TABLET 30 ALUNBRIG ORAL TABLET 90 ALUNBRIG ORAL TABLETS,DOSE PACK (180 per 30 (60 per 30 (30 per 30 anastrozole ARIMIDEX AROMASIN ARRANON 4 B/D PA ASTAGRAF XL 3 B/D PA; MO AVASTIN 4 B/D PA; MO azacitidine 4 B/D PA; MO AZASAN 3 B/D PA; MO azathioprine 1 B/D PA; MO azathioprine sodium 1 B/D PA BAVENCIO 4 B/D PA; MO; LA BELEODAQ 4 B/D PA; MO bexarotene bicalutamide BICNU 4 B/D PA; MO bleomycin injection recon soln 30 unit 1 B/D PA; MO BORTEZOMIB 4 B/D PA; MO BOSULIF ORAL TABLET 100 BOSULIF ORAL TABLET 400, PA; MO (30 per 30 Name busulfan 4 B/D PA BUSULFEX 4 B/D PA CABOMETYX 4 PA; MO; LA CALQUENCE 4 PA; MO; LA; QL (60 per 30 CAMPTOSAR INTRAVENOUS SOLUTION 100 /5 ML CAPRELSA ORAL TABLET 100 CAPRELSA ORAL TABLET 300 carboplatin intravenous solution 3 B/D PA; MO 4 PA; MO; LA; QL (90 per 30 4 PA; MO; LA; QL (30 per 30 1 B/D PA; MO CASODEX CELLCEPT INTRAVENOUS CELLCEPT ORAL CAPSULE CELLCEPT ORAL SUSPENSION FOR RECONSTITUTIO N CELLCEPT ORAL TABLET 2 B/D PA; MO 3 B/D PA; MO 4 B/D PA; MO 4 B/D PA; MO cisplatin 1 B/D PA; MO cladribine 4 B/D PA; MO clofarabine 4 B/D PA CLOLAR 4 B/D PA COMETRIQ 4 PA; MO 16

18 Name COSMEGEN 4 B/D PA; MO COTELLIC 4 PA; MO; LA; QL (63 per 28 CYCLOPHOSPHA MIDE ORAL CAPSULE cyclosporine intravenous cyclosporine modified cyclosporine oral capsule 2 B/D PA; MO 1 B/D PA 1 B/D PA; MO 1 B/D PA; MO CYRAMZA 4 B/D PA; MO cytarabine 1 B/D PA; MO cytarabine (pf) injection solution 2 gram/20 ml (100 mg/ml) dacarbazine intravenous recon soln 200 mg 1 B/D PA; MO 1 B/D PA; MO DACOGEN 4 B/D PA; MO dactinomycin 1 B/D PA DARZALEX 4 B/D PA; MO; LA daunorubicin intravenous solution 1 B/D PA decitabine 4 B/D PA; MO docetaxel intravenous solution 160 mg/16 ml (10 mg/ml) 4 B/D PA Name docetaxel intravenous solution 80 mg/4 ml (20 mg/ml) 4 B/D PA; MO DOXIL 4 B/D PA; MO doxorubicin intravenous solution 50 mg/25 ml doxorubicin, pegliposomal 1 B/D PA; MO 4 B/D PA; MO DROXIA ELIGARD 3 PA; MO ELIGARD (3 MONTH) ELIGARD (4 MONTH) ELIGARD (6 MONTH) ELLENCE INTRAVENOUS SOLUTION 200 /100 ML 3 PA; MO 3 PA; MO 3 PA; MO 3 B/D PA; MO EMCYT EMPLICITI 4 B/D PA; MO ENVARSUS XR 3 B/D PA; MO epirubicin intravenous solution 200 mg/100 ml ERBITUX INTRAVENOUS SOLUTION 100 /50 ML 1 B/D PA; MO 4 B/D PA; MO ERIVEDGE (30 per 30 17

19 Name ERWINAZE 4 B/D PA; MO ETOPOPHOS 3 B/D PA; MO etoposide intravenous 1 B/D PA; MO exemestane FARESTON FARYDAK ORAL CAPSULE 10 FARYDAK ORAL CAPSULE 15, 20 (12 per 21 (6 per 21 FASLODEX 4 B/D PA; MO FEMARA FIRMAGON KIT W DILUENT SYRINGE SUBCUTANEOUS RECON SOLN 120 FIRMAGON KIT W DILUENT SYRINGE SUBCUTANEOUS RECON SOLN 80 fludarabine intravenous recon soln fluorouracil intravenous solution 5 gram/100 ml 4 B/D PA; MO 2 B/D PA; MO 1 B/D PA; MO 1 B/D PA; MO flutamide Name FOLOTYN INTRAVENOUS SOLUTION 40 /2 ML (20 /ML) gemcitabine intravenous recon soln 1 gram GEMZAR INTRAVENOUS RECON SOLN 1 GRAM 4 B/D PA; MO 1 B/D PA; MO 3 B/D PA; MO gengraf 1 B/D PA; MO GILOTRIF ORAL TABLET 20 GILOTRIF ORAL TABLET 30 GILOTRIF ORAL TABLET 40 GLEEVEC ORAL TABLET 100 GLEEVEC ORAL TABLET 400 (60 per 30 (40 per 30 (30 per 30 4 PA; MO (60 per 30 GLEOSTINE HALAVEN 4 B/D PA; MO HERCEPTIN 4 B/D PA; MO HEXALEN HYCAMTIN INTRAVENOUS 4 B/D PA; MO HYDREA hydroxyurea 18

20 Name IBRANCE (21 per 28 ICLUSIG ORAL TABLET 15 ICLUSIG ORAL TABLET 45 4 PA; QL (90 (30 per 30 IDAMYCIN PFS 3 B/D PA; MO idarubicin 1 B/D PA IDHIFA ORAL TABLET 100 IDHIFA ORAL TABLET 50 IFEX INTRAVENOUS RECON SOLN 1 GRAM ifosfamide intravenous recon soln 1 gram imatinib oral tablet 100 mg imatinib oral tablet 400 mg IMBRUVICA ORAL CAPSULE PA; MO; LA; QL (30 per 30 4 PA; MO; LA; QL (60 per 30 3 B/D PA; MO 1 B/D PA; MO 4 PA; MO (60 per 30 (120 per 30 IMFINZI 4 B/D PA; MO; LA IMURAN 3 B/D PA; MO INLYTA ORAL TABLET 1 4 PA; MO Name INLYTA ORAL TABLET 5 (120 per 30 IRESSA (30 per 30 irinotecan intravenous solution 100 mg/5 ml 1 B/D PA; MO ISTODAX 4 B/D PA; MO JAKAFI ORAL TABLET 10, 15, 20, 5 JAKAFI ORAL TABLET 25 4 PA; MO (60 per 30 JEVTANA 4 B/D PA; MO KADCYLA 4 PA; MO KEYTRUDA 4 PA; MO KISQALI 4 PA; MO KISQALI FEMARA CO-PACK 4 PA; MO KYPROLIS 4 B/D PA; MO LARTRUVO 4 B/D PA; MO; LA LENVIMA 4 PA; MO letrozole LEUKERAN leuprolide subcutaneous kit LONSURF 4 PA; MO LUPRON DEPOT 4 PA; MO LUPRON DEPOT (NTH) 4 PA; MO 19

21 Name LUPRON DEPOT (NTH) LUPRON DEPOT (6 MONTH) LUPRON DEPOT- PED (NTH) INTRAMUSCULA R SYRINGE KIT 30 LUPRON DEPOT- PED INTRAMUSCULA R KIT 11.25, 15 4 PA; MO 4 PA; MO 4 PA; MO 4 PA; MO LYNPARZA 4 PA; MO LYSODREN MATULANE MEGACE ES 4 PA; MO megestrol oral suspension 400 mg/10 ml (40 mg/ml), 625 mg/5 ml 1 PA; MO megestrol oral tablet 1 PA; MO MEKINIST ORAL TABLET 0.5 MEKINIST ORAL TABLET 2 (120 per 30 (30 per 30 melphalan hcl 4 B/D PA mercaptopurine methotrexate sodium 1 B/D PA; MO methotrexate sodium (pf) injection recon soln 1 B/D PA Name methotrexate sodium (pf) injection solution mitomycin intravenous recon soln 20 mg, 5 mg mitomycin intravenous recon soln 40 mg 1 B/D PA; MO 1 B/D PA; MO 4 B/D PA; MO mitoxantrone 1 B/D PA; MO MUSTARGEN 3 B/D PA; MO mycophenolate mofetil hcl mycophenolate mofetil oral capsule mycophenolate mofetil oral suspension for reconstitution mycophenolate mofetil oral tablet mycophenolate sodium 1 B/D PA 1 B/D PA; MO 4 B/D PA; MO 1 B/D PA; MO 1 B/D PA; MO MYFORTIC 3 B/D PA; MO MYLOTARG 4 B/D PA; MO; LA NEORAL 3 B/D PA; MO NERLYNX ; LA NEXAVAR 4 PA; MO; LA; QL (120 per 30 NILANDRON nilutamide NINLARO ORAL CAPSULE 2.3 (6 per 28 20

22 Name NINLARO ORAL CAPSULE 3 NINLARO ORAL CAPSULE 4 (4 per 28 (3 per 28 NIPENT 4 B/D PA; MO NULOJIX 4 B/D PA; MO octreotide acetate injection solution 1,000 mcg/ml, 500 mcg/ml octreotide acetate injection solution 100 mcg/ml, 200 mcg/ml, 50 mcg/ml ODOMZO 4 PA; MO; LA; QL (30 per 30 OPDIVO INTRAVENOUS SOLUTION 100 /10 ML, 40 /4 ML oxaliplatin intravenous recon soln 100 mg oxaliplatin intravenous solution 100 mg/20 ml 4 PA; MO 1 B/D PA; MO 1 B/D PA; MO paclitaxel 1 B/D PA; MO PERJETA 4 B/D PA; MO POMALYST ; LA PROGRAF INTRAVENOUS PROGRAF ORAL CAPSULE 0.5, 1 2 B/D PA; MO 3 B/D PA; MO Name PROGRAF ORAL CAPSULE 5 4 B/D PA; MO PURIXAN RAPAMUNE ORAL SOLUTION RAPAMUNE ORAL TABLET 0.5 RAPAMUNE ORAL TABLET 1, 2 4 B/D PA; MO 3 B/D PA; MO 4 B/D PA; MO REVLIMID 4 PA; MO; LA RITUXAN 4 PA; MO RUBRACA ORAL TABLET 200 RUBRACA ORAL TABLET PA; MO; LA; QL (180 per 30 4 PA; MO; LA; QL (120 per 30 RYDAPT 4 PA; MO SANDIMMUNE INTRAVENOUS SANDIMMUNE ORAL CAPSULE SANDIMMUNE ORAL SOLUTION SANDOSTATIN INJECTION SOLUTION 100 MCG/ML SANDOSTATIN INJECTION SOLUTION 50 MCG/ML, 500 MCG/ML 3 B/D PA; MO 3 B/D PA; MO 2 B/D PA; MO 21

23 Name SANDOSTATIN LAR DEPOT INTRAMUSCULA R SUSPENSION,EXT ENDED REL RECON SIGNIFOR SIGNIFOR LAR SIMULECT INTRAVENOUS RECON SOLN 20 sirolimus oral tablet 0.5 mg, 1 mg sirolimus oral tablet 2 mg 2 B/D PA; MO 1 B/D PA; MO 4 B/D PA; MO SOLTAMOX SOMATULINE DEPOT SPRYCEL ORAL TABLET 100, 20, 50, 80 SPRYCEL ORAL TABLET 140 SPRYCEL ORAL TABLET 70 4 PA; MO (30 per 30 (60 per 30 STIVARGA (84 per 28 SUTENT ORAL CAPSULE PA; MO Name SUTENT ORAL CAPSULE 25, 37.5 SUTENT ORAL CAPSULE 50 SYLVANT INTRAVENOUS RECON SOLN 100 (60 per 30 (30 per 30 4 B/D PA; MO SYNRIBO 4 B/D PA; MO TABLOID tacrolimus oral 1 B/D PA; MO TAFINLAR ORAL CAPSULE 50 TAFINLAR ORAL CAPSULE 75 TAGRISSO ORAL TABLET 40 TAGRISSO ORAL TABLET 80 (180 per 30 (120 per 30 4 PA; MO; LA; QL (60 per 30 4 PA; MO; LA; QL (30 per 30 tamoxifen TARCEVA ORAL TABLET 100, 25 TARCEVA ORAL TABLET PA; MO (30 per 30 TARGRETIN TASIGNA ORAL CAPSULE PA; MO 22

24 Name TASIGNA ORAL CAPSULE 200 TAXOTERE INTRAVENOUS SOLUTION 80 /4 ML (20 /ML) (112 per 28 4 B/D PA; MO TECENTRIQ 4 B/D PA; MO; LA THALOMID 4 PA; MO thiotepa 4 B/D PA; MO toposar 1 B/D PA; MO topotecan intravenous recon soln 4 B/D PA TORISEL 4 B/D PA; MO TREANDA INTRAVENOUS RECON SOLN TRELSTAR INTRAMUSCULA R SUSPENSION FOR RECONSTITUTIO N 11.25, 3.75 TRELSTAR INTRAMUSCULA R SYRINGE tretinoin (chemotherapy) 4 B/D PA; MO 4 B/D PA; MO 4 B/D PA; MO TREXALL 3 B/D PA; MO TRISENOX 4 B/D PA; MO Name TYKERB 4 PA; MO; LA; QL (180 per 30 VECTIBIX INTRAVENOUS SOLUTION 100 /5 ML (20 /ML) 4 B/D PA; MO VELCADE 4 B/D PA; MO VENCLEXTA ORAL TABLET 10, 50 VENCLEXTA ORAL TABLET 100 VENCLEXTA STARTING PACK VERZENIO ORAL TABLET 100 VERZENIO ORAL TABLET 150 VERZENIO ORAL TABLET 200 VERZENIO ORAL TABLET 50 2 PA; MO; LA 4 PA; MO; LA 4 PA; MO; LA; QL (42 per PA; MO; LA; QL (120 per 30 4 PA; MO; LA; QL (80 per 30 4 PA; MO; LA; QL (60 per 30 4 PA; MO; LA; QL (240 per 30 VIDAZA 4 B/D PA; MO vinblastine intravenous solution vincasar pfs intravenous solution 1 mg/ml 1 B/D PA; MO 1 B/D PA 23

25 Name vincristine intravenous solution 1 mg/ml vinorelbine intravenous solution 50 mg/5 ml 1 B/D PA; MO 1 B/D PA; MO VOTRIENT (120 per 30 VYXEOS 4 B/D PA; MO XALKORI ORAL CAPSULE 200 XALKORI ORAL CAPSULE PA; MO (60 per 30 XATMEP 4 B/D PA; MO XERMELO 4 PA; MO; LA; QL (90 per 30 XTANDI (120 per 30 YERVOY INTRAVENOUS SOLUTION 50 /10 ML (5 /ML) 4 B/D PA; MO YONDELIS 4 B/D PA; MO ZALTRAP INTRAVENOUS SOLUTION 100 /4 ML (25 /ML) 4 B/D PA; MO ZANOSAR 3 B/D PA; MO Name ZEJULA 4 PA; MO; LA; QL (90 per 30 ZELBORAF (240 per 30 ZOLINZA ZORTRESS 4 B/D PA; MO ZYDELIG (90 per 30 ZYKADIA (150 per 30 ZYTIGA ORAL TABLET 250 (120 per 30 AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH ANTICONVULSANTS APTIOM ORAL TABLET 200, 400, 800 APTIOM ORAL TABLET 600 BANZEL ORAL SUSPENSION BANZEL ORAL TABLET 200 BANZEL ORAL TABLET 400 BRIVIACT INTRAVENOUS BRIVIACT ORAL 3 24

26 Name carbamazepine oral capsule, er multiphase 12 hr carbamazepine oral suspension 100 mg/5 ml carbamazepine oral tablet carbamazepine oral tablet extended release 12 hr carbamazepine oral tablet,chewable CARBATROL CELONTIN ORAL CAPSULE 300 CEREBYX INJECTION SOLUTION 500 PE/10 ML clonazepam 1 PA; MO DEPACON DEPAKENE DEPAKOTE DEPAKOTE ER DEPAKOTE SPRINKLES 3 DIASTAT DIASTAT ACUDIAL DILANTIN 30 DILANTIN EXTENDED 100 Name DILANTIN INFATABS 50 DILANTIN /5 ML divalproex oral capsule, delayed rel sprinkle divalproex oral tablet extended release 24 hr divalproex oral tablet,delayed release (dr/ec) epitol EQUETRO ethosuximide felbamate oral suspension felbamate oral tablet FELBATOL fosphenytoin injection solution 100 mg pe/2 ml FYCOMPA ORAL SUSPENSION FYCOMPA ORAL TABLET gabapentin oral capsule 100 mg gabapentin oral capsule 300 mg gabapentin oral capsule 400 mg gabapentin oral solution 250 mg/5 ml ; QL (1080 ; QL (360 ; QL (270 ; QL (

27 Name gabapentin oral tablet 600 mg gabapentin oral tablet 800 mg GABITRIL ORAL TABLET 12, 16 GABITRIL ORAL TABLET 2, 4 GRALISE 30-DAY STARTER PACK GRALISE ORAL TABLET EXTENDED RELEASE 24 HR 300 GRALISE ORAL TABLET EXTENDED RELEASE 24 HR 600 ; QL (180 ; QL (135 2 PA; MO; QL (78 per PA; MO; QL (30 per 30 2 PA; MO; QL (90 per 30 KEPPRA ORAL KEPPRA XR KLONOPIN 3 PA; MO LAMICTAL ODT LAMICTAL ORAL TABLET LAMICTAL ORAL TABLET, CHEWABLE DISPERSIBLE 25, 5 Name LAMICTAL STARTER (BLUE) KIT LAMICTAL STARTER (GREEN) KIT LAMICTAL STARTER (ORANGE) KIT LAMICTAL XR LAMICTAL XR STARTER (BLUE) LAMICTAL XR STARTER (GREEN) LAMICTAL XR STARTER (ORANGE) lamotrigine oral tablet lamotrigine oral tablet extended release 24hr 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 26 1

28 Name levetiracetam intravenous levetiracetam oral solution 100 mg/ml levetiracetam oral tablet levetiracetam oral tablet extended release 24 hr LYRICA CR ORAL TABLET EXTENDED RELEASE 24 HR 165 LYRICA CR ORAL TABLET EXTENDED RELEASE 24 HR 330 LYRICA CR ORAL TABLET EXTENDED RELEASE 24 HR 82.5 LYRICA ORAL CAPSULE 100 LYRICA ORAL CAPSULE 150 LYRICA ORAL CAPSULE 200 LYRICA ORAL CAPSULE PA; MO; QL (120 per 30 3 PA; MO; QL (60 per 30 3 PA; MO; QL (240 per 30 2 PA; MO; QL (180 per 30 2 PA; MO; QL (120 per 30 2 PA; MO; QL (90 per 30 2 PA; MO; QL (81 per 30 Name LYRICA ORAL CAPSULE 25 LYRICA ORAL CAPSULE 300 LYRICA ORAL CAPSULE 50 LYRICA ORAL CAPSULE 75 LYRICA ORAL SOLUTION 2 PA; MO; QL (720 per 30 2 PA; MO; QL (60 per 30 2 PA; MO; QL (360 per 30 2 PA; MO; QL (240 per 30 2 PA; MO; QL (900 per 30 MYSOLINE NEURONTIN ORAL CAPSULE 100 NEURONTIN ORAL CAPSULE 300 NEURONTIN ORAL CAPSULE 400 NEURONTIN ORAL SOLUTION NEURONTIN ORAL TABLET 600 NEURONTIN ORAL TABLET 800 ONFI ORAL SUSPENSION 3 PA; MO; QL (1080 per 30 3 PA; MO; QL (360 per 30 3 PA; MO; QL (270 per 30 3 PA; MO; QL (2160 per 30 3 PA; MO; QL (180 per 30 3 PA; MO; QL (135 per 30 2 PA; MO 27

29 Name ONFI ORAL TABLET 10, 20 2 PA; MO oxcarbazepine OXTELLAR XR PEGANONE phenobarbital 1 PA; MO PHENYTEK phenytoin oral suspension 125 mg/5 ml phenytoin oral tablet,chewable phenytoin sodium extended phenytoin sodium intravenous solution primidone QUDEXY XR 3 PA; MO roweepra oral tablet 1,000 mg, 500 mg, 750 mg roweepra oral tablet 500 mg, 750 mg SABRIL ; LA SPRITAM TEGRETOL ORAL SUSPENSION TEGRETOL ORAL TABLET 1 TEGRETOL XR tiagabine TOPAMAX 3 PA; MO Name topiramate oral capsule, sprinkle TOPIRAMATE ORAL CAPSULE,SPRINK LE,ER 24HR topiramate oral tablet 1 PA; MO 3 PA; MO 1 PA; MO TRILEPTAL TROKENDI XR ORAL CAPSULE,EXTEN DED RELEASE 24HR 100, 25, 50 TROKENDI XR ORAL CAPSULE,EXTEN DED RELEASE 24HR PA; MO 4 PA; MO valproate sodium valproic acid valproic acid (as sodium salt) oral solution 250 mg/5 ml vigabatrin ; LA VIMPAT INTRAVENOUS VIMPAT ORAL SOLUTION VIMPAT ORAL TABLET 2 ZARONTIN ZONEGRAN ORAL CAPSULE 100, 25 3 PA; MO 28

30 Name zonisamide 1 PA; MO ANTIPARKINSONISM AGENTS APOKYN ; LA AZILECT benztropine injection benztropine oral 1 PA; MO bromocriptine carbidopa carbidopa-levodopa carbidopa-levodopaentacapone COGENTIN COMTAN DUOPA 3 B/D PA; MO ELDEPRYL 3 entacapone GOCOVRI ORAL CAPSULE,EXTEN DED RELEASE 24HR 137 GOCOVRI ORAL CAPSULE,EXTEN DED RELEASE 24HR 68.5 (60 per 30 (30 per 30 LODOSYN MIRAPEX MIRAPEX ER NEUPRO PARLODEL pramipexole rasagiline Name REQUIP REQUIP XL ropinirole RYTARY selegiline hcl SINEMET SINEMET CR STALEVO 100 STALEVO 125 STALEVO 150 STALEVO 200 STALEVO 50 STALEVO 75 TASMAR ORAL TABLET 100 tolcapone ZELAPAR MIGRAINE / CLUSTER HEADACHE THERAPY almotriptan malate oral tablet 12.5 mg almotriptan malate oral tablet 6.25 mg ; QL (24 per 28 ; QL (18 per 28 AMERGE ; QL (18 per 28 AXERT ORAL TABLET 12.5 AXERT ORAL TABLET 6.25 ; QL (24 per 28 ; QL (18 per 28 CAFERGOT dihydroergotamine injection 29

31 Name dihydroergotamine nasal ; QL (8 per 28 eletriptan hbr ; QL (18 per 28 ergotamine-caffeine FROVA ; QL (27 per 28 frovatriptan ; QL (27 per 28 IMITREX NASAL SPRAY,NON- AEROSOL 20 /ACTUATION IMITREX NASAL SPRAY,NON- AEROSOL 5 /ACTUATION ; QL (18 per 28 ; QL (36 per 28 IMITREX ORAL ; QL (18 per 28 IMITREX STATDOSE KIT REFILL SUBCUTANEOUS CARTRIDGE 6 /0.5 ML IMITREX STATDOSE PEN SUBCUTANEOUS PEN INJECTOR 4 /0.5 ML IMITREX SUBCUTANEOUS MAXALT ORAL TABLET 10 MAXALT ORAL TABLET 5 ; QL (8 per 28 ; QL (8 per 28 ; QL (8 per 28 ; QL (36 per 28 3 QL (36 per 28 Name MAXALT-MLT ; QL (36 per 28 migergot MIGRANAL ; QL (8 per 28 naratriptan ; QL (18 per 28 ONZETRA XSAIL ; QL (32 per 28 RELPAX ; QL (18 per 28 rizatriptan ; QL (36 per 28 sumatriptan nasal spray,non-aerosol 20 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 SUMAVEL DOSEPRO ; QL (18 per 28 ; QL (36 per 28 ; QL (18 per 28 ; QL (8 per 28 ; QL (8 per 28 ; QL (8 per 28 ; QL (9 per 28 30

32 Name TREXIMET ORAL TABLET TREXIMET ORAL TABLET ZEMBRACE SYMTOUCH ; QL (9 per 28 ; QL (18 per 28 ; QL (8 per 28 zolmitriptan ; QL (18 per 28 ZOMIG ; QL (18 per 28 ZOMIG ZMT ; QL (18 per 28 MISCELLANEOUS NEUROLOGICAL THERAPY AMPYRA 4 PA; MO; LA ARICEPT AUBAGIO 4 PA; MO AUSTEDO ORAL TABLET 12, 9 AUSTEDO ORAL TABLET 6 COPAXONE SUBCUTANEOUS SYRINGE 20 /ML COPAXONE SUBCUTANEOUS SYRINGE 40 /ML donepezil oral tablet 10 mg, 5 mg 4 PA; MO; LA; QL (120 per 30 4 PA; MO; LA; QL (60 per 30 (30 per 30 (12 per 28 Name donepezil oral tablet 23 mg donepezil oral tablet,disintegrating EXELON TRANSDERMAL EXONDYS 51 4 PA; MO galantamine GILENYA 4 PA; MO glatiramer subcutaneous syringe 20 mg/ml glatiramer subcutaneous syringe 40 mg/ml glatopa subcutaneous syringe 20 mg/ml HORIZANT ORAL TABLET EXTENDED RELEASE 300 HORIZANT ORAL TABLET EXTENDED RELEASE 600 INGREZZA ORAL CAPSULE 40 INGREZZA ORAL CAPSULE 80 4 PA; QL (30 (12 per 28 (30 per 30 3 PA; MO; QL (30 per 30 3 PA; MO; QL (60 per 30 4 PA; MO; LA; QL (60 per 30 4 PA; MO; LA; QL (30 per 30 KEVEYIS 4 PA; MO memantine oral solution 1 PA; MO 31

33 Name memantine oral tablet MEMANTINE ORAL TABLETS,DOSE PACK NAMENDA ORAL TABLET NAMENDA TITRATION PAK 1 PA; MO 3 PA; MO 3 PA; MO 3 PA; MO NAMENDA XR 2 PA; MO NAMZARIC 2 PA; MO NUEDEXTA RADICAVA RAZADYNE ER RAZADYNE ORAL TABLET rivastigmine rivastigmine tartrate TECFIDERA 4 PA; MO; LA tetrabenazine oral tablet 12.5 mg tetrabenazine oral tablet 25 mg (240 per 30 (120 per 30 TYSABRI 4 PA; MO; LA XENAZINE ORAL TABLET 12.5 XENAZINE ORAL TABLET 25 4 PA; MO; LA; QL (240 per 30 4 PA; MO; LA; QL (120 per 30 Name ZINBRYTA 4 PA; MO; LA; QL (1 per 28 MUSCLE RELAXANTS / ANTISPASMODIC THERAPY baclofen cyclobenzaprine oral tablet DANTRIUM ORAL CAPSULE 25, 50 3 PA; MO dantrolene FEXMID 3 PA; MO GABLOFEN INTRATHECAL SOLUTION 40,000 MCG/20ML (2,000 MCG/ML) LIORESAL INTRATHECAL SOLUTION 2,000 MCG/ML, 500 MCG/ML 4 B/D PA; MO 2 B/D PA; MO MESTINON ORAL MESTINON TIMESPAN pyridostigmine bromide tizanidine ZANAFLEX NARCOTIC ANALGESICS ABSTRAL (120 per 30 32

34 Name acetaminophencodeine oral solution mg/5 ml acetaminophencodeine oral tablet mg, mg acetaminophencodeine oral tablet mg ; QL (4500 ; QL (360 ; QL (180 ACTIQ (120 per 30 ARYMO ER 3 PA; MO; QL (120 per 30 BELBUCA 3 PA; MO; QL (60 per 30 BUPRENEX ; QL (266 buprenorphine hcl injection solution buprenorphine hcl injection syringe buprenorphine hcl sublingual BUPRENORPHINE TRANSDERMAL PATCH WEEKLY 10 MCG/HOUR, 15 MCG/HOUR, 20 MCG/HOUR, 5 MCG/HOUR ; QL (266 1 QL (266 per 30 3 PA; MO; QL (4 per 28 BUTRANS 2 PA; MO; QL (4 per 28 Name codeine sulfate oral tablet DILAUDID ORAL LIQUID DILAUDID ORAL TABLET DOLOPHINE ORAL TABLET 10 DOLOPHINE ORAL TABLET 5 DURAGESIC TRANSDERMAL PATCH 72 HOUR 100 MCG/HR, 75 MCG/HR DURAGESIC TRANSDERMAL PATCH 72 HOUR 12 MCG/HR, 25 MCG/HR, 50 MCG/HR duramorph (pf) injection solution 0.5 mg/ml duramorph (pf) injection solution 1 mg/ml EMBEDA ORAL CAPSULE,ORAL ONLY,EXT.REL PELL 100-4, , ; QL (180 ; QL (2400 ; QL (180 3 PA; MO; QL (120 per 30 3 PA; MO; QL (240 per 30 (10 per 30 3 PA; MO; QL (10 per 30 ; QL ( QL (2000 per 30 (90 per 30 33

35 Name EMBEDA ORAL CAPSULE,ORAL ONLY,EXT.REL PELL , , 50-2 endocet oral tablet mg, mg, mg EXALGO ER ORAL TABLET EXTENDED RELEASE 24 HR 12, 8 EXALGO ER ORAL TABLET EXTENDED RELEASE 24 HR 16, 32 3 PA; MO; QL (90 per 30 ; QL (360 3 PA; MO; QL (60 per 30 (60 per 30 fentanyl citrate (120 per 30 fentanyl transdermal patch 72 hour 100 mcg/hr, 12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr FENTANYL TRANSDERMAL PATCH 72 HOUR 37.5 MCG/HOUR, 62.5 MCG/HOUR FENTANYL TRANSDERMAL PATCH 72 HOUR 87.5 MCG/HOUR 1 PA; MO; QL (10 per 30 3 PA; MO; QL (10 per 30 (10 per 30 FENTORA (120 per 30 Name HYCET 3 QL (5550 per 30 hydrocodoneacetaminophen oral solution mg/15 ml hydrocodoneacetaminophen oral tablet mg, mg, mg hydrocodoneacetaminophen oral tablet mg, mg, mg, mg hydrocodoneibuprofen oral tablet mg, mg, mg ; QL (5550 ; QL (390 ; QL (360 ; QL (50 hydromorphone (pf) ; QL (240 hydromorphone injection syringe 2 mg/ml hydromorphone oral liquid hydromorphone oral tablet hydromorphone oral tablet extended release 24 hr 12 mg, 8 mg hydromorphone oral tablet extended release 24 hr 16 mg, 32 mg 1 QL (1200 per 30 ; QL (2400 ; QL (180 1 PA; MO; QL (60 per 30 (60 per 30 34

36 Name HYSINGLA ER ORAL TABLET,ORAL ONLY,EXT.REL.24 HR 100, 120, 80 HYSINGLA ER ORAL TABLET,ORAL ONLY,EXT.REL.24 HR 20, 30, 40, 60 IBUDONE ORAL TABLET (60 per 30 3 PA; MO; QL (60 per 30 ; QL (50 ibuprofen-oxycodone ; QL (28 KADIAN ORAL CAPSULE,EXTEN D.RELEASE PELLETS 10, 100, 20, 30, 40, 50, 60, 80 KADIAN ORAL CAPSULE,EXTEN D.RELEASE PELLETS 200 LAZANDA NASAL SPRAY,NON- AEROSOL 100 MCG/SPRAY LAZANDA NASAL SPRAY,NON- AEROSOL 300 MCG/SPRAY 3 PA; MO; QL (90 per 30 (90 per 30 (45 per 30 4 PA; QL (23 Name LAZANDA NASAL SPRAY,NON- AEROSOL 400 MCG/SPRAY (30 per 30 levorphanol tartrate ; QL (120 lorcet (hydrocodone) ; QL (360 lorcet hd ; QL (360 lorcet plus oral tablet mg 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 injection syringe 5 mg/ml MORPHINE INTRAVENOUS SYRINGE 10 /ML ; QL (360 1 QL (150 per 30 1 PA; MO; QL (600 per 30 1 PA; MO; QL (1200 per 30 1 PA; MO; QL (120 per 30 1 PA; MO; QL (240 per 30 ; QL (900 1 QL (400 per 30 3 QL (200 per 30 35

37 Name morphine intravenous syringe 2 mg/ml morphine intravenous syringe 4 mg/ml MORPHINE INTRAVENOUS SYRINGE 8 /ML morphine oral capsule, er multiphase 24 hr morphine oral capsule,extend.relea se pellets morphine oral solution 1 QL (1000 per 30 1 QL (500 per 30 3 QL (250 per 30 1 PA; MO; QL (60 per 30 1 PA; MO; QL (90 per 30 ; QL (900 morphine oral tablet ; QL (180 morphine oral tablet extended release 100 mg morphine oral tablet extended release 15 mg, 200 mg, 30 mg, 60 mg MS CONTIN ORAL TABLET EXTENDED RELEASE 100, 200, 60 MS CONTIN ORAL TABLET EXTENDED RELEASE 15, 30 1 PA; MO; QL (60 per 30 1 PA; MO; QL (120 per 30 (120 per 30 3 PA; MO; QL (120 per 30 Name NORCO ; QL (360 OPANA ORAL TABLET 10 OPANA ORAL TABLET 5 ; QL (360 ; QL (180 OXAYDO ; QL (360 oxycodone oral capsule oxycodone oral concentrate oxycodone oral solution oxycodone oral tablet 10 mg, 15 mg, 20 mg, 30 mg oxycodone oral tablet 5 mg OXYCODONE ORAL TABLET,ORAL ONLY,EXT.REL.12 HR 10, 20, 40 OXYCODONE ORAL TABLET,ORAL ONLY,EXT.REL.12 HR 15, 30, 60 OXYCODONE ORAL TABLET,ORAL ONLY,EXT.REL.12 HR 80 ; QL (360 ; QL (180 ; QL (1200 ; QL (180 ; QL (360 3 PA; MO; QL (90 per 30 3 PA; QL (90 (60 per 30 36

38 Name oxycodoneacetaminophen oral solution oxycodoneacetaminophen oral tablet mg, mg, mg, mg 1 QL (1860 per 30 ; QL (360 oxycodone-aspirin ; QL (360 OXYCONTIN ORAL TABLET,ORAL ONLY,EXT.REL.12 HR 10, 15, 20, 30, 40, 60 OXYCONTIN ORAL TABLET,ORAL ONLY,EXT.REL.12 HR 80 oxymorphone oral tablet 10 mg oxymorphone oral tablet 5 mg oxymorphone oral tablet extended release 12 hr PERCOCET ORAL TABLET , , 5-325, PA; MO; QL (90 per 30 (60 per 30 ; QL (360 ; QL (180 1 PA; MO; QL (90 per 30 ; QL (360 PRIMLEV ; QL (390 Name ROXICODONE ORAL TABLET 15, 30 ROXICODONE ORAL TABLET 5 ; QL (180 3 QL (360 per 30 SUBSYS (120 per 30 SYNALGOS-DC ; QL (300 TREZIX ORAL CAPSULE TYLENOL- CODEINE #3 TYLENOL- CODEINE #4 ; QL (300 ; QL (360 ; QL (180 vicodin ; QL (390 vicodin es ; QL (390 vicodin hp ; QL (390 XTAMPZA ER 3 PA; MO; QL (90 per 30 ZOHYDRO ER ORAL CAPSULE, ORAL ONLY, ER 12HR 3 PA; MO; QL (90 per 30 NON-NARCOTIC ANALGESICS ANAPROX DS 3 ST; MO ARTHROTEC 50 3 ST; MO ARTHROTEC 75 3 ST; MO 37

39 Name BUNAVAIL BUCCAL FILM BUNAVAIL BUCCAL FILM , buprenorphinenaloxone sublingual tablet mg buprenorphinenaloxone sublingual tablet 8-2 mg butorphanol tartrate injection solution 1 mg/ml butorphanol tartrate injection solution 2 mg/ml butorphanol tartrate nasal ; QL (30 ; QL (60 ; QL (360 ; QL (90 ; QL (857 ; QL (428 ; QL (10 per 28 CAMBIA 3 ST; MO; QL (9 CELEBREX celecoxib CONZIP 3 PA; MO; QL (30 per 30 DAYPRO 3 ST; MO diclofenac potassium diclofenac sodium oral diclofenac sodium topical drops diclofenac sodium topical gel 1 % ; QL (300 per 28 ; QL (1000 per 28 Name diclofenacmisoprostol diflunisal DUEXIS 3 ST; MO EC-NAPROSYN 3 ST; MO etodolac EVZIO ; QL (0.8 FELDENE 3 ST; MO FENOPROFEN ORAL CAPSULE 400 fenoprofen oral tablet 3 ST; MO FLECTOR 3 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 24 hr 200 mg LODINE ORAL TABLET 3 ST meclofenamate mefenamic acid meloxicam oral tablet 15 mg 38

40 Name meloxicam oral tablet 7.5 mg MOBIC ORAL TABLET 15 MOBIC ORAL TABLET 7.5 ; QL (30 3 ST; MO 3 ST; MO; QL (30 per 30 nabumetone nalbuphine injection solution 10 mg/ml nalbuphine injection solution 20 mg/ml naloxone injection solution naloxone injection syringe 1 mg/ml ; QL (200 ; QL (100 naltrexone NAPRELAN CR 3 ST; MO NAPROSYN ORAL TABLET 500 naproxen oral suspension 3 ST; MO naproxen oral tablet naproxen oral tablet,delayed release (dr/ec) naproxen sodium oral tablet 275 mg, 550 mg naproxen sodium oral tablet, er multiphase 24 hr Name NARCAN NASAL SPRAY,NON- AEROSOL 4 /ACTUATION ; QL (2 per 28 NUCYNTA ER 3 PA; MO; QL (60 per 30 NUCYNTA ORAL TABLET 100 NUCYNTA ORAL TABLET 50 NUCYNTA ORAL TABLET 75 ; QL (181 ; QL (362 ; QL (242 oxaprozin PENNSAID TOPICAL SOLUTION IN METERED-DOSE PUMP 4 ST; MO; QL (224 per 28 piroxicam profeno 1 SPRIX 3 ST SUBOXONE SUBLINGUAL FILM 12-3 SUBOXONE SUBLINGUAL FILM SUBOXONE SUBLINGUAL FILM 4-1, 8-2 ; QL (60 ; QL (360 ; QL (90 sulindac TIVORBEX 3 ST; MO; QL (90 per 30 39

41 Name tolmetin oral capsule tolmetin oral tablet 600 mg TRAMADOL ORAL CAPSULE,ER BIPHASE 24 HR TRAMADOL ORAL CAPSULE,ER BIPHASE 24 HR , PA; MO; QL (30 per 30 3 PA; MO; QL (30 per 30 tramadol oral tablet ; QL (240 tramadol oral tablet extended release 24 hr 100 mg, 200 mg tramadol oral tablet, er multiphase 24 hr tramadolacetaminophen 1 PA; MO; QL (30 per 30 1 PA; MO; QL (30 per 30 ; QL (240 ULTRACET ; QL (240 ULTRAM ; QL (240 VIMOVO 3 ST; MO VIVITROL VIVLODEX ORAL CAPSULE 10 VIVLODEX ORAL CAPSULE 5 3 ST; MO 3 ST; MO; QL (30 per 30 Name VOLTAREN TOPICAL GEL 1 % ; QL (1000 per 28 ZIPSOR 3 ST; MO ZORVOLEX 3 ST; MO ZUBSOLV SUBLINGUAL TABLET , , , , ZUBSOLV SUBLINGUAL TABLET ; QL (30 ; QL (60 PSYCHOTHERAPEUTIC DRUGS ABILIFY MAINTENA ABILIFY ORAL TABLET 10 ABILIFY ORAL TABLET 15, 20 ABILIFY ORAL TABLET 2 ABILIFY ORAL TABLET 30 ABILIFY ORAL TABLET 5 ADDERALL ORAL TABLET 20, 5, 7.5 ; QL (90 ; QL (60 ; QL (450 ; QL (30 ; QL (180 ADDERALL XR ADZENYS XR- ODT 40

42 Name AMBIEN 3 ST; MO; QL (30 per 30 AMBIEN CR 3 ST; MO; QL (30 per 30 amitriptyline 1 PA; MO amoxapine ANAFRANIL 3 PA; MO APLENZIN ORAL TABLET EXTENDED RELEASE 24 HR 174 APLENZIN ORAL TABLET EXTENDED RELEASE 24 HR 348 APLENZIN ORAL TABLET EXTENDED RELEASE 24 HR 522 ; QL (90 ; QL (60 ; QL (30 APTENSIO XR aripiprazole oral solution aripiprazole oral tablet 10 mg aripiprazole oral tablet 15 mg aripiprazole oral tablet 2 mg aripiprazole oral tablet 20 mg ; QL (90 ; QL (60 ; QL (450 ; QL (60 Name aripiprazole oral tablet 30 mg aripiprazole oral tablet 5 mg aripiprazole oral tablet,disintegrating 10 mg aripiprazole oral tablet,disintegrating 15 mg ; QL (30 ; QL (180 ; QL (90 ; QL (60 ARISTADA armodafinil 3 PA; MO ATIVAN ORAL 3 PA; MO atomoxetine BELSOMRA 3 ST; MO; QL (30 per 30 BRISDELLE ; QL (30 bupropion hcl oral tablet bupropion hcl oral tablet extended release 12 hr 100 mg bupropion hcl oral tablet extended release 12 hr 150 mg bupropion hcl oral tablet extended release 12 hr 200 mg bupropion hcl oral tablet extended release 24 hr 150 mg bupropion hcl oral tablet extended release 24 hr 300 mg ; QL (120 ; QL (90 ; QL (60 ; QL (90 ; QL (60 41

43 Name buspirone CELEXA ORAL TABLET 10 CELEXA ORAL TABLET 20 CELEXA ORAL TABLET 40 ; QL (120 ; QL (60 ; QL (30 chlorpromazine citalopram oral solution citalopram oral tablet 10 mg citalopram oral tablet 20 mg citalopram oral tablet 40 mg ; QL (120 ; QL (60 ; QL (30 clomipramine 3 PA; MO clonidine hcl oral tablet extended release 12 hr clorazepate dipotassium 1 PA; MO clozapine oral tablet clozapine oral tablet,disintegrating 100 mg, 12.5 mg, 25 mg CLOZAPINE ORAL TABLET,DISINTE GRATING 150, 200 CLOZARIL CONCERTA 1 3 Name CYMBALTA ORAL CAPSULE,DELAY ED RELEASE(DR/EC) 20 CYMBALTA ORAL CAPSULE,DELAY ED RELEASE(DR/EC) 30 CYMBALTA ORAL CAPSULE,DELAY ED RELEASE(DR/EC) 60 ; QL (180 ; QL (120 ; QL (60 DAYTRANA desipramine DESOXYN 3 PA; MO DESVENLAFAXIN E ORAL TABLET EXTENDED RELEASE 24 HR 100 DESVENLAFAXIN E ORAL TABLET EXTENDED RELEASE 24 HR 50 desvenlafaxine succinate oral tablet extended release 24 hr 100 mg ; QL (120 ; QL (240 ; QL (120 42

44 Name desvenlafaxine succinate oral tablet extended release 24 hr 25 mg desvenlafaxine succinate oral tablet extended release 24 hr 50 mg DEXEDRINE SPANSULE ; QL (480 ; QL (240 dexmethylphenidate dextroamphetamine oral capsule, extended release dextroamphetamine oral tablet dextroamphetamineamphetamine diazepam intensol 1 PA; MO diazepam oral solution 5 mg/5 ml (1 mg/ml) 1 PA; MO diazepam oral tablet 1 PA; MO doxepin oral 3 PA; MO duloxetine oral capsule,delayed release(dr/ec) 20 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 (120 ; QL (90 ; QL (60 Name EFFEXOR XR ORAL CAPSULE,EXTEN DED RELEASE 24HR 150 EFFEXOR XR ORAL CAPSULE,EXTEN DED RELEASE 24HR 37.5 EFFEXOR XR ORAL CAPSULE,EXTEN DED RELEASE 24HR 75 ; QL (60 ; QL (180 ; QL (90 EMSAM ergoloid escitalopram oxalate oral solution escitalopram oxalate oral tablet 10 mg escitalopram oxalate oral tablet 20 mg escitalopram oxalate oral tablet 5 mg ; QL (60 ; QL (30 ; QL (120 eszopiclone 3 ST; MO; QL (30 per 30 FANAPT ORAL TABLET 1 FANAPT ORAL TABLET 10, 8 FANAPT ORAL TABLET 12 ; QL (720 ; QL (90 ; QL (60 43

45 Name FANAPT ORAL TABLET 2 FANAPT ORAL TABLET 4 FANAPT ORAL TABLET 6 FANAPT ORAL TABLETS,DOSE PACK FAZACLO ORAL TABLET,DISINTE GRATING 100 FAZACLO ORAL TABLET,DISINTE GRATING 12.5, 150, 200, 25 FETZIMA ORAL CAPSULE,EXT REL 24HR DOSE PACK FETZIMA ORAL CAPSULE,EXTEN DED RELEASE 24 HR 120 FETZIMA ORAL CAPSULE,EXTEN DED RELEASE 24 HR 20 FETZIMA ORAL CAPSULE,EXTEN DED RELEASE 24 HR 40 FETZIMA ORAL CAPSULE,EXTEN DED RELEASE 24 HR 80 ; QL (360 ; QL (180 ; QL (120 ; QL (8 per ; QL (28 per 28 ; QL (30 ; QL (180 ; QL (90 ; QL (45 Name fluoxetine oral capsule 10 mg fluoxetine oral capsule 20 mg fluoxetine oral capsule 40 mg fluoxetine oral capsule,delayed release(dr/ec) fluoxetine oral solution fluoxetine oral tablet 10 mg fluoxetine oral tablet 20 mg, 60 mg fluphenazine decanoate ; QL (240 ; QL (60 ; QL (4 per 28 ; QL (240 fluphenazine hcl fluvoxamine oral capsule,extended release 24hr 100 mg fluvoxamine oral capsule,extended release 24hr 150 mg fluvoxamine oral tablet 100 mg fluvoxamine oral tablet 25 mg fluvoxamine oral tablet 50 mg ; QL (90 ; QL (60 ; QL (90 ; QL (360 ; QL (180 FOCALIN FOCALIN XR FORFIVO XL ; QL (30 44

46 Name GEODON INTRAMUSCULA R GEODON ORAL CAPSULE 20 GEODON ORAL CAPSULE 40 GEODON ORAL CAPSULE 60 GEODON ORAL CAPSULE 80 ; QL (240 ; QL (120 ; QL (80 ; QL (60 guanidine HALDOL HALDOL DECANOATE haloperidol haloperidol decanoate haloperidol lactate injection haloperidol lactate oral HETLIOZ (30 per 30 imipramine hcl 3 PA; MO imipramine pamoate 3 PA; MO INVEGA ORAL TABLET EXTENDED RELEASE 24HR 1.5 ; QL (240 Name INVEGA ORAL TABLET EXTENDED RELEASE 24HR 3 INVEGA ORAL TABLET EXTENDED RELEASE 24HR 6 INVEGA ORAL TABLET EXTENDED RELEASE 24HR 9 INVEGA SUSTENNA INTRAMUSCULA R SYRINGE 117 /0.75 ML, 156 /ML, 234 /1.5 ML, 78 /0.5 ML INVEGA SUSTENNA INTRAMUSCULA R SYRINGE 39 /0.25 ML ; QL (120 ; QL (60 ; QL (41 INVEGA TRINZA KAPVAY KHEDEZLA ORAL TABLET EXTENDED RELEASE 24HR 100 ; QL (120 45

47 Name KHEDEZLA ORAL TABLET EXTENDED RELEASE 24HR 50 LATUDA ORAL TABLET 120 LATUDA ORAL TABLET 20 LATUDA ORAL TABLET 40 LATUDA ORAL TABLET 60, 80 LEXAPRO ORAL TABLET 10 LEXAPRO ORAL TABLET 20 LEXAPRO ORAL TABLET 5 ; QL (240 ; QL (30 ; QL (240 ; QL (120 ; QL (60 ; QL (60 ; QL (30 ; QL (120 lithium carbonate lithium citrate oral solution 8 meq/5 ml LITHOBID lorazepam oral 1 PA; MO loxapine succinate LUNESTA 3 ST; MO; QL (30 per 30 maprotiline MARPLAN metadate er methamphetamine 1 PA; MO Name METHYLIN ORAL SOLUTION methylphenidate hcl oral capsule, er biphasic methylphenidate hcl oral capsule,er biphasic mg, 30 mg, 40 mg, 60 mg methylphenidate hcl oral solution methylphenidate hcl oral tablet methylphenidate hcl oral tablet extended release methylphenidate hcl oral tablet extended release 24hr 18 mg, 27 mg, 36 mg, 54 mg methylphenidate hcl oral tablet,chewable mirtazapine oral tablet mirtazapine oral tablet,disintegrating modafinil 1 PA; MO MYDAYIS NARDIL nefazodone NORPRAMIN ORAL TABLET 10, 25 nortriptyline 46

48 Name NUPLAZID NUVIGIL 3 PA; MO olanzapine intramuscular olanzapine oral tablet 10 mg olanzapine oral tablet 15 mg, 20 mg olanzapine oral tablet 2.5 mg olanzapine oral tablet 5 mg olanzapine oral tablet 7.5 mg olanzapine oral tablet,disintegrating 10 mg olanzapine oral tablet,disintegrating 15 mg, 20 mg olanzapine oral tablet,disintegrating 5 mg olanzapinefluoxetine ORAP ORAL TABLET 1 paliperidone oral tablet extended release 24hr 1.5 mg paliperidone oral tablet extended release 24hr 3 mg paliperidone oral tablet extended release 24hr 6 mg ; QL (60 ; QL (30 ; QL (240 ; QL (120 ; QL (81 ; QL (60 ; QL (30 ; QL (120 ; QL (240 ; QL (120 ; QL (60 Name paliperidone oral tablet extended release 24hr 9 mg ; QL (41 PAMELOR PARNATE paroxetine hcl oral tablet 10 mg paroxetine hcl oral tablet 20 mg paroxetine hcl oral tablet 30 mg paroxetine hcl oral tablet 40 mg paroxetine hcl oral tablet extended release 24 hr 12.5 mg paroxetine hcl oral tablet extended release 24 hr 25 mg paroxetine hcl oral tablet extended release 24 hr 37.5 mg paroxetine mesylate(menop.sym ) PAXIL CR ORAL TABLET EXTENDED RELEASE 24 HR 12.5 PAXIL CR ORAL TABLET EXTENDED RELEASE 24 HR 25 ; QL (180 ; QL (90 ; QL (60 ; QL (45 ; QL (180 ; QL (90 ; QL (60 ; QL (30 ; QL (180 ; QL (90 47

49 Name PAXIL CR ORAL TABLET EXTENDED RELEASE 24 HR 37.5 PAXIL ORAL SUSPENSION PAXIL ORAL TABLET 10 PAXIL ORAL TABLET 20 PAXIL ORAL TABLET 30 PAXIL ORAL TABLET 40 ; QL (60 ; QL (180 ; QL (90 ; QL (60 ; QL (45 perphenazine PEXEVA ORAL TABLET 10 PEXEVA ORAL TABLET 20 PEXEVA ORAL TABLET 30 PEXEVA ORAL TABLET 40 ; QL (180 ; QL (90 ; QL (60 ; QL (45 phenelzine pimozide PRISTIQ ORAL TABLET EXTENDED RELEASE 24 HR 100 PRISTIQ ORAL TABLET EXTENDED RELEASE 24 HR 25 ; QL (120 ; QL (480 Name PRISTIQ ORAL TABLET EXTENDED RELEASE 24 HR 50 ; QL (240 procentra protriptyline PROVIGIL 4 PA; MO PROZAC ORAL CAPSULE 10 PROZAC ORAL CAPSULE 20 PROZAC ORAL CAPSULE 40 quetiapine oral tablet 100 mg quetiapine oral tablet 200 mg quetiapine oral tablet 25 mg quetiapine oral tablet 300 mg quetiapine oral tablet 400 mg quetiapine oral tablet 50 mg quetiapine oral tablet extended release 24 hr 150 mg quetiapine oral tablet extended release 24 hr 200 mg quetiapine oral tablet extended release 24 hr 300 mg ; QL (240 ; QL (60 ; QL (240 ; QL (120 ; QL (902 ; QL (81 ; QL (60 ; QL (480 ; QL (160 ; QL (120 ; QL (81 48

50 Name quetiapine oral tablet extended release 24 hr 400 mg quetiapine oral tablet extended release 24 hr 50 mg ; QL (60 ; QL (480 QUILLICHEW ER QUILLIVANT XR REMERON REMERON SOLTAB REXULTI ORAL TABLET 0.25 REXULTI ORAL TABLET 0.5 REXULTI ORAL TABLET 1 REXULTI ORAL TABLET 2 REXULTI ORAL TABLET 3 REXULTI ORAL TABLET 4 RISPERDAL CONSTA INTRAMUSCULA R SYRINGE 12.5 /2 ML, 25 /2 ML RISPERDAL CONSTA INTRAMUSCULA R SYRINGE 37.5 /2 ML, 50 /2 ML ; QL (480 ; QL (240 ; QL (120 ; QL (60 ; QL (40 ; QL (30 Name RISPERDAL M- TAB ORAL TABLET,DISINTE GRATING 0.5 RISPERDAL M- TAB ORAL TABLET,DISINTE GRATING 1 RISPERDAL M- TAB ORAL TABLET,DISINTE GRATING 3 RISPERDAL M- TAB ORAL TABLET,DISINTE GRATING 4 RISPERDAL ORAL SOLUTION RISPERDAL ORAL TABLET 0.25 RISPERDAL ORAL TABLET 0.5 RISPERDAL ORAL TABLET 1 RISPERDAL ORAL TABLET 2 RISPERDAL ORAL TABLET 3 RISPERDAL ORAL TABLET 4 risperidone oral solution risperidone oral tablet 0.25 mg risperidone oral tablet 0.5 mg ; QL (960 ; QL (480 ; QL (161 ; QL (120 ; QL (480 ; QL (1920 ; QL (960 ; QL (480 ; QL (240 ; QL (161 ; QL (120 ; QL (480 ; QL (1920 ; QL (960 49