2018 Ohana Community Care Services (CCS) Comprehensive Preferred Drug List (List of Covered Drugs)

Transcription

1 2018 Ohana Community Care Services (CCS) Comprehensive referred Drug List (List of Covered Drugs) Ohana Health lan 00 lease read: This document contains information about the drugs we cover in this plan. lease note that the Ohana Community Care Services (CCS) referred Drug List is updated quarterly. roviders, please visit our website at to view updates to the preferred drug list. Members, please visit our website at to view updates to the preferred drug list. Last updated (10/01/2018)

2 Vaccines: Vaccines are covered under the Vaccines for Children program for members through 18 years of age. Coverage beyond the age of 18 is evaluated through the A process. This plan has a limit of 248 dosage units, unless otherwise specified through a quantity limit. Drug Name reference Details Coverage Details *Adhd/Anti-Narcolepsy/Anti- Obesity/Anorexiants* *Adhd Agent - Selective Alpha Adrenergic Agonists*** clonidine hcl er oral tablet extended release 12 hour 0.1 guanfacine hcl er oral tablet extended release 24 hour 1, 2, 3, 4 *Adhd Agent - Selective Norepinephrine Reuptake Inhibitor*** atomoxetine hcl oral capsule 10, 100, 18, 25, 40, 60, 80 *Amphetamine Mixtures*** amphetamine-dextroamphet er oral capsule extended release 24 hour 10, 15, 20, 25, 30, 5 amphetamine-dextroamphetamine oral tablet 10, 12.5, 15, 5, 7.5 amphetamine-dextroamphetamine oral tablet 20 amphetamine-dextroamphetamine oral tablet 30 *Amphetamines*** dextroamphetamine sulfate er oral capsule extended release 24 hour 10, 15, 5 dextroamphetamine sulfate oral tablet 10, 5 methamphetamine hcl oral tablet 5 VYVANSE ORAL CASULE 10 MG, 20 MG, 30 MG, 40 MG, 50 MG, 60 MG, 70 MG ZENZEDI ORAL TABLET 15 MG, 2.5 MG, 20 MG, 30 MG, 7.5 MG QL (62 EA per 31 days); AL QL (93 EA per 31 days) QL (62 EA per 31 days) AL =referred, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= Generic drugs 1

3 Drug Name reference Details Coverage Details *Stimulants - Misc.*** ATENSIO XR ORAL CASULE EXTENDED RELEASE 24 HOUR 10 MG, 15 MG, 20 MG, 30 MG, 40 MG, 50 MG, 60 MG DAYTRANA TRANSDERMAL ATCH 10 MG/9HR, 15 MG/9HR, 20 MG/9HR, 30 MG/9HR dexmethylphenidate hcl er oral capsule extended release 24 hour 10, 15, 20, 30, 40, 5 dexmethylphenidate hcl oral tablet 10, 2.5, 5 FOCALIN XR ORAL CASULE EXTENDED RELEASE 24 HOUR 20 MG, 25 MG, 35 MG METADATE ER ORAL TABLET EXTENDED RELEASE 20 MG methylphenidate hcl er (cd) oral capsule extended release 10, 20, 30, 40, 50, 60 methylphenidate hcl er (la) oral capsule extended release 24 hour 20, 30, 40, 60 methylphenidate hcl er oral tablet extended release 10, 20 methylphenidate hcl er oral tablet extended release 18, 27, 36 methylphenidate hcl er oral tablet extended release 24 hour 18, 27, 36 methylphenidate hcl er oral tablet extended release 24 hour 54 methylphenidate hcl er oral tablet extended release 54 methylphenidate hcl oral solution 10 /5ml, 5 /5ml AL QL (31 EA per 31 days); AL QL (62 EA per 31 days); AL AL QL (93 EA per 31 days); AL QL (62 EA per 31 days); AL QL (62 EA per 31 days); AL QL (31 EA per 31 days); AL QL (31 EA per 31 days); AL AL methylphenidate hcl oral tablet 10, 5 AL methylphenidate hcl oral tablet 20 methylphenidate hcl oral tablet chewable 10, 2.5, 5 QL (93 EA per 31 days); AL AL =referred, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= Generic drugs 2

4 Drug Name reference Details Coverage Details QUILLIVANT XR ORAL SUSENSION RECONSTITUTED 25 MG/5ML RITALIN LA ORAL CASULE EXTENDED RELEASE 24 HOUR 10 MG *Analgesics - Opioid* *Opioid artial Agonists*** buprenorphine hcl sublingual tablet sublingual 2, 8 zubsolv sublingual tablet sublingual , ZUBSOLV SUBLINGUAL TABLET SUBLINGUAL MG, MG, MG *Antianxiety Agents* *Antianxiety Agents - Misc.*** buspirone hcl oral tablet 10, 15, 30, 5, 7.5 hydroxyzine hcl intramuscular solution 25 /ml, 50 /ml hydroxyzine hcl oral solution 10 /5ml hydroxyzine hcl oral syrup 10 /5ml hydroxyzine hcl oral tablet 10, 25, 50 hydroxyzine pamoate oral capsule 100, 25, 50 meprobamate oral tablet 200, 400 *Benzodiazepines*** alprazolam er oral tablet extended release 24 hour 0.5, 1, 2, 3 ALRAZOLAM INTENSOL ORAL CONCENTRATE 1 MG/ML alprazolam oral tablet 0.25, 0.5, 1, 2 alprazolam oral tablet dispersible 0.25, 0.5, 1, 2 alprazolam xr oral tablet extended release 24 hour 0.5, 1, 2, 3 chlordiazepoxide hcl oral capsule 10, 25, 5 AL A A A =referred, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= Generic drugs 3

5 Drug Name reference Details Coverage Details clorazepate dipotassium oral tablet 15, 3.75, 7.5 DIAZEAM INTENSOL ORAL CONCENTRATE 5 MG/ML diazepam oral solution 1 /ml diazepam oral tablet 10, 2, 5 lorazepam injection solution 2 /ml, 4 /ml LORAZEAM INTENSOL ORAL CONCENTRATE 2 MG/ML lorazepam oral concentrate 2 /ml lorazepam oral tablet 0.5, 1, 2 oxazepam oral capsule 10, 15, 30 *Anticonvulsants* *Anticonvulsants - Benzodiazepines*** clonazepam oral tablet 0.5, 1, 2 clonazepam oral tablet dispersible 0.125, 0.25, 0.5, 1, 2 *Anticonvulsants - Misc.*** carbamazepine er oral capsule extended release 12 hour 100, 200, 300 carbamazepine er oral tablet extended release 12 hour 200, 400 carbamazepine oral suspension 100 /5ml carbamazepine oral tablet 200 carbamazepine oral tablet chewable 100 gabapentin oral capsule 100, 300, 400 gabapentin oral solution 250 /5ml gabapentin oral tablet 600, 800 LAMICTAL ODT ORAL KIT 25 & 50 & 100 MG, 25 (21)-50 (7) MG, 50 (42)-100(14) MG LAMICTAL XR ORAL KIT 25 & 50 & 100 MG, 25 (21)-50 (7) MG, 50 & 100 & 200 MG lamotrigine er oral tablet extended release 24 hour 100, 200, 25, 250, 300, 50 lamotrigine oral tablet 100, 150, 200, 25 lamotrigine oral tablet chewable 25, 5 AL (Min 13 Years) AL (Min 13 Years) =referred, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= Generic drugs 4

6 Drug Name reference Details Coverage Details lamotrigine oral tablet dispersible 100, 200, 25, 50 lamotrigine starter kit-blue oral kit 25 (35) lamotrigine starter kit-green oral kit 25 (84)- 100(14) lamotrigine starter kit-orange oral kit 25 (42)- 100 (7) levetiracetam er oral tablet extended release 24 hour 500, 750 levetiracetam intravenous solution 500 /5ml levetiracetam oral solution 100 /ml levetiracetam oral tablet 1000, 250, 500, 750 oxcarbazepine oral suspension 300 /5ml oxcarbazepine oral tablet 150, 300, 600 OXTELLAR XR ORAL TABLET EXTENDED RELEASE 24 HOUR 150 MG, 300 MG, 600 MG QUDEXY XR ORAL CASULE ER 24 HOUR SRINKLE 100 MG, 150 MG, 200 MG, 25 MG, 50 MG SRITAM ORAL TABLET DISINTEGRATING SOLUBLE 1000 MG, 250 MG, 500 MG, 750 MG TEGRETOL-XR ORAL TABLET EXTENDED RELEASE 12 HOUR 100 MG TOIRAMATE ER ORAL CASULE ER 24 HOUR SRINKLE 100 MG, 150 MG, 200 MG, 25 MG, 50 MG topiramate oral capsule sprinkle 15, 25 topiramate oral tablet 100, 200, 25, 50 TROKENDI XR ORAL CASULE EXTENDED RELEASE 24 HOUR 100 MG, 200 MG, 25 MG, 50 MG *Gaba Modulators*** GABITRIL ORAL TABLET 12 MG, 16 MG tiagabine hcl oral tablet 2, 4 =referred, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= Generic drugs 5

7 Drug Name reference Details Coverage Details *Valproic Acid*** divalproex sodium er oral tablet extended release 24 hour 250, 500 divalproex sodium oral capsule delayed release sprinkle 125 divalproex sodium oral tablet delayed release 125, 250, 500 valproate sodium intravenous solution 100 /ml valproic acid oral capsule 250 valproic acid oral solution 250 /5ml valproic acid oral syrup 250 /5ml *Antidepressants* *Alpha-2 Receptor Antagonists (Tetracyclics)*** mirtazapine oral tablet 15, 30, 45, 7.5 mirtazapine oral tablet dispersible 15, 30, 45 *Antidepressants - Misc.*** ALENZIN ORAL TABLET EXTENDED RELEASE 24 HOUR 174 MG, 348 MG, 522 MG bupropion hcl er (sr) oral tablet extended release 12 hour 100, 150, 200 bupropion hcl er (xl) oral tablet extended release 24 hour 150, 300 bupropion hcl oral tablet 100, 75 FORFIVO XL ORAL TABLET EXTENDED RELEASE 24 HOUR 450 MG maprotiline hcl oral tablet 25, 50, 75 *Modified Cyclics*** nefazodone hcl oral tablet 100, 150, 200, 250, 50 OLETRO ORAL TABLET EXTENDED RELEASE 24 HOUR 150 MG, 300 MG trazodone hcl oral tablet 100, 150, 300, 50 TRINTELLIX ORAL TABLET 10 MG, 20 MG, 5 MG ST; Must fail 2 generic DL ST; Must fail 2 generic DL ST; Must fail 2 generic DL ST; Must fail 2 generic DL =referred, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= Generic drugs 6

8 Drug Name reference Details Coverage Details VIIBRYD ORAL KIT 10 & 20 & 40 MG VIIBRYD ORAL TABLET 10 MG, 20 MG, 40 MG VIIBRYD STARTER ACK ORAL KIT 10 & 20 MG *Monoamine Oxidase Inhibitors (Maois)*** EMSAM TRANSDERMAL ATCH 24 HOUR 12 MG/24HR, 6 MG/24HR, 9 MG/24HR MARLAN ORAL TABLET 10 MG phenelzine sulfate oral tablet 15 tranylcypromine sulfate oral tablet 10 *Selective Serotonin Reuptake Inhibitors (Ssris)*** citalopram hydrobromide oral solution 10 /5ml citalopram hydrobromide oral tablet 10, 20, 40 escitalopram oxalate oral solution 5 /5ml escitalopram oxalate oral tablet 10, 20, 5 fluoxetine hcl oral capsule 10, 20, 40 fluoxetine hcl oral capsule delayed release 90 fluoxetine hcl oral solution 20 /5ml fluoxetine hcl oral tablet 10, 20, 60 fluvoxamine maleate er oral capsule extended release 24 hour 100, 150 fluvoxamine maleate oral tablet 100, 25, 50 paroxetine hcl er oral tablet extended release 24 hour 12.5, 25, 37.5 paroxetine hcl oral tablet 10, 20, 30, 40 AXIL ORAL SUSENSION 10 MG/5ML EXEVA ORAL TABLET 10 MG, 20 MG, 30 MG, 40 MG ST; Must fail 2 generic DL ST; Must fail 2 generic DL ST; Must fail 2 generic DL ST; Must fail 2 generic DL ST; Must fail 2 generic DL ST; Must fail 2 generic DL ST; Must fail 2 generic DL =referred, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= Generic drugs 7

9 Drug Name reference Details Coverage Details sertraline hcl oral concentrate 20 /ml sertraline hcl oral tablet 100, 25, 50 *Serotonin-Norepinephrine Reuptake Inhibitors (Snris)*** desvenlafaxine er oral tablet extended release 24 hour 100, 50 desvenlafaxine fumarate er oral tablet extended release 24 hour 50 desvenlafaxine succinate er oral tablet extended release 24 hour 100, 25, 50 duloxetine hcl oral capsule delayed release particles 20, 30, 40, 60 FETZIMA ORAL CASULE EXTENDED RELEASE 24 HOUR 120 MG, 20 MG, 40 MG, 80 MG FETZIMA TITRATION ORAL CASULE ER 24 HOUR THERAY ACK 20 & 40 MG IRENKA ORAL CASULE DELAYED RELEASE ARTICLES 40 MG venlafaxine hcl er oral capsule extended release 24 hour 150, 37.5, 75 venlafaxine hcl er oral tablet extended release 24 hour 150, 225, 37.5, 75 venlafaxine hcl oral tablet 100, 25, 37.5, 50, 75 *Tricyclic Agents*** amitriptyline hcl oral tablet 10, 100, 150, 25, 50, 75 amoxapine oral tablet 100, 150, 25, 50 clomipramine hcl oral capsule 25, 50, 75 desipramine hcl oral tablet 10, 100, 150, 25, 50, 75 doxepin hcl oral capsule 10, 100, 150, 25, 50, 75 doxepin hcl oral concentrate 10 /ml imipramine hcl oral tablet 10, 25, 50 ST; Must fail 2 generic DL ST; Must fail 2 generic DL ST; Must fail 2 generic DL ST; Must fail 2 generic DL =referred, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= Generic drugs 8

10 Drug Name reference Details Coverage Details imipramine pamoate oral capsule 100, 125, 150, 75 nortriptyline hcl oral capsule 10, 25, 50, 75 nortriptyline hcl oral solution 10 /5ml protriptyline hcl oral tablet 10, 5 SURMONTIL ORAL CASULE 25 MG, 50 MG trimipramine maleate oral capsule 100, 25, 50 *Antihistamines* *Antihistamines - Ethanolamines*** aler-dryl oral tablet 50 diphenhydramine hcl injection solution 50 /ml diphenhydramine hcl oral capsule 25, 50 diphenhydramine hcl oral elixir 12.5 /5ml diphenhydramine hcl oral tablet 25 *Antihypertensives* *Antiadrenergics - Centrally Acting*** clonidine hcl oral tablet 0.1, 0.2, 0.3 guanfacine hcl oral tablet 1, 2 *Antiparkinson Agents* *Antiparkinson Anticholinergics*** benztropine mesylate oral tablet 0.5, 1, 2 trihexyphenidyl hcl oral elixir 0.4 /ml trihexyphenidyl hcl oral tablet 2, 5 *Antiparkinson Dopaminergics*** amantadine hcl oral capsule 100 amantadine hcl oral syrup 50 /5ml amantadine hcl oral tablet 100 *Antipsychotics/Antimanic Agents* *Antimanic Agents*** lithium carbonate er oral tablet extended release 300, 450 lithium carbonate oral capsule 150, 300, 600 ST; Must fail 2 generic DL =referred, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= Generic drugs 9

11 Drug Name reference Details Coverage Details lithium carbonate oral tablet 300 *Antipsychotics - Misc.*** EQUETRO ORAL CASULE EXTENDED RELEASE 12 HOUR 100 MG, 200 MG, 300 MG GEODON INTRAMUSCULAR SOLUTION RECONSTITUTED 20 MG LATUDA ORAL TABLET 120 MG, 20 MG, 40 MG, 60 MG, 80 MG NULAZID ORAL TABLET 17 MG VRAYLAR ORAL CASULE 1.5 MG, 3 MG, 4.5 MG, 6 MG VRAYLAR ORAL CASULE THERAY ACK 1.5 & 3 MG ziprasidone hcl oral capsule 20, 40, 60, 80 *Benzisoxazoles*** FANAT ORAL TABLET 1 MG, 10 MG, 12 MG, 2 MG, 4 MG, 6 MG, 8 MG FANAT TITRATION ACK ORAL TABLET 1 & 2 & 4 & 6 MG INVEGA SUSTENNA INTRAMUSCULAR SUSENSION 117 MG/0.75ML, 156 MG/ML, 234 MG/1.5ML, 39 MG/0.25ML, 78 MG/0.5ML INVEGA TRINZA INTRAMUSCULAR SUSENSION 273 MG/0.875ML, 410 MG/1.315ML, 546 MG/1.75ML, 819 MG/2.625ML paliperidone er oral tablet extended release 24 hour 1.5, 3, 6, 9 RISERDAL CONSTA INTRAMUSCULAR SUSENSION RECONSTITUTED 12.5 MG, 25 MG, 37.5 MG, 50 MG risperidone oral solution 1 /ml risperidone oral tablet 0.25, 0.5, 1, 2, 3, 4 risperidone oral tablet dispersible 0.25, 0.5, 1, 2, 3, 4 =referred, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= Generic drugs 10

12 Drug Name reference Details Coverage Details *Butyrophenones*** haloperidol decanoate intramuscular solution 100 /ml, 50 /ml haloperidol lactate injection solution 5 /ml haloperidol lactate oral concentrate 2 /ml haloperidol oral tablet 0.5, 1, 10, 2, 20, 5 *Dibenzodiazepines*** clozapine oral tablet 100, 200, 25, 50 clozapine oral tablet dispersible 100, 12.5, 150, 200, 25 VERSACLOZ ORAL SUSENSION 50 MG/ML *Dibenzo-Oxepino yrroles*** SAHRIS SUBLINGUAL TABLET SUBLINGUAL 10 MG, 2.5 MG, 5 MG *Dibenzothiazepines*** quetiapine fumarate er oral tablet extended release 24 hour 150, 200, 300, 50 quetiapine fumarate er oral tablet extended release 24 hour 400 quetiapine fumarate oral tablet 100, 200, 25, 300, 400, 50 *Dibenzoxazepines*** ADASUVE INHALATION AEROSOL OWDER BREATH ACTIVATED 10 MG loxapine succinate oral capsule 10, 25, 5, 50 *henothiazines*** chlorpromazine hcl injection solution 25 /ml chlorpromazine hcl oral tablet 10, 100, 200, 25, 50 fluphenazine decanoate injection solution 25 /ml fluphenazine hcl injection solution 2.5 /ml fluphenazine hcl oral concentrate 5 /ml fluphenazine hcl oral elixir 2.5 /5ml =referred, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= Generic drugs 11

13 Drug Name reference Details Coverage Details fluphenazine hcl oral tablet 1, 10, 2.5, 5 perphenazine oral tablet 16, 2, 4, 8 prochlorperazine edisylate injection solution 5 /ml prochlorperazine maleate oral tablet 10, 5 prochlorperazine rectal suppository 25 thioridazine hcl oral tablet 10, 100, 25, 50 trifluoperazine hcl oral tablet 1, 10, 2, 5 *Quinolinone Derivatives*** ABILIFY INTRAMUSCULAR SOLUTION 9.75 MG/1.3ML ABILIFY MAINTENA INTRAMUSCULAR REFILLED SYRINGE 300 MG, 400 MG ABILIFY MAINTENA INTRAMUSCULAR SUSENSION RECONSTITUTED 300 MG, 400 MG ABILIFY MAINTENA INTRAMUSCULAR SUSENSION RECONSTITUTED ER 300 MG, 400 MG aripiprazole oral solution 1 /ml aripiprazole oral tablet 10, 15, 2, 20, 30, 5 aripiprazole oral tablet dispersible 10, 15 ARISTADA INTRAMUSCULAR REFILLED SYRINGE 1064 MG/3.9ML, 441 MG/1.6ML, 662 MG/2.4ML, 882 MG/3.2ML REXULTI ORAL TABLET 0.25 MG, 0.5 MG, 1 MG, 2 MG, 3 MG, 4 MG *Thienbenzodiazepines*** olanzapine intramuscular solution reconstituted 10 olanzapine oral tablet 10, 15, 2.5, 20, 5, 7.5 ; AL (Min 18 Years) =referred, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= Generic drugs 12

14 Drug Name reference Details Coverage Details olanzapine oral tablet dispersible 10, 15, 20, 5 ZYREXA RELREVV INTRAMUSCULAR SUSENSION RECONSTITUTED 210 MG, 300 MG, 405 MG *Thioxanthenes*** thiothixene oral capsule 1, 10, 2, 5 *Beta Blockers* *Beta Blockers Non-Selective*** propranolol hcl er oral capsule extended release 24 hour 120, 160, 60, 80 propranolol hcl intravenous solution 1 /ml propranolol hcl oral solution 20 /5ml, 40 /5ml propranolol hcl oral tablet 10, 20, 40, 60, 80 *Multivitamins* *B-Complex Vitamins*** b complex oral capsule vitamin-b complex oral tablet *B-Complex W/ C*** vitamin b complex-c oral capsule *sychotherapeutic And Neurological Agents - Misc.* *Alcohol Deterrents*** acamprosate calcium oral tablet delayed release 333 disulfiram oral tablet 500 *Benzodiazepines & Tricyclic Agents*** chlordiazepoxide-amitriptyline oral tablet 10-25, *henothiazines & Tricyclic Agents*** perphenazine-amitriptyline oral tablet 2-10, 2-25, 4-10, 4-25, 4-50 *sychotherapeutic And Neurological Agents - Misc.*** QL (186 EA per 31 days) pimozide oral tablet 1, 2 AL (Min 12 Years) =referred, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= Generic drugs 13

15 Drug Name reference Details Coverage Details *Thienbenzodiazepines & Ssris*** olanzapine-fluoxetine hcl oral capsule 12-25, 12-50, 3-25, 6-25, 6-50 *Vitamins* *Vitamin B-1*** thiamine hcl injection solution 100 /ml vitamin b-1 oral tablet 100 =referred, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= Generic drugs 14

16 Index ABILIFY ABILIFY MAINTENA...12 acamprosate calcium ADASUVE aler-dryl...9 alprazolam...3 alprazolam er... 3 ALRAZOLAM INTENSOL..3 alprazolam xr...3 amantadine hcl...9 amitriptyline hcl...8 amoxapine... 8 amphetamine-dextroamphet er... 1 amphetaminedextroamphetamine...1 ALENZIN... 6 ATENSIO XR... 2 aripiprazole...12 ARISTADA...12 atomoxetine hcl...1 b complex...13 benztropine mesylate... 9 buprenorphine hcl...3 bupropion hcl... 6 bupropion hcl er (sr)...6 bupropion hcl er (xl)...6 buspirone hcl... 3 carbamazepine... 4 carbamazepine er... 4 chlordiazepoxide hcl...3 chlordiazepoxide-amitriptyline. 13 chlorpromazine hcl citalopram hydrobromide... 7 clomipramine hcl...8 clonazepam... 4 clonidine hcl... 9 clonidine hcl er... 1 clorazepate dipotassium... 4 clozapine DAYTRANA... 2 desipramine hcl... 8 desvenlafaxine er...8 desvenlafaxine fumarate er...8 desvenlafaxine succinate er...8 dexmethylphenidate hcl... 2 dexmethylphenidate hcl er... 2 dextroamphetamine sulfate...1 dextroamphetamine sulfate er...1 diazepam...4 DIAZEAM INTENSOL... 4 diphenhydramine hcl...9 disulfiram...13 divalproex sodium... 6 divalproex sodium er... 6 doxepin hcl...8 duloxetine hcl...8 EMSAM... 7 EQUETRO escitalopram oxalate... 7 FANAT FANAT TITRATION ACK FETZIMA... 8 FETZIMA TITRATION...8 fluoxetine hcl... 7 fluphenazine decanoate...11 fluphenazine hcl... 11, 12 fluvoxamine maleate... 7 fluvoxamine maleate er... 7 FOCALIN XR...2 FORFIVO XL... 6 gabapentin... 4 GABITRIL... 5 GEODON...10 guanfacine hcl... 9 guanfacine hcl er... 1 haloperidol haloperidol decanoate...11 haloperidol lactate...11 hydroxyzine hcl...3 hydroxyzine pamoate... 3 imipramine hcl... 8 imipramine pamoate...9 INVEGA SUSTENNA...10 INVEGA TRINZA...10 IRENKA... 8 LAMICTAL ODT... 4 LAMICTAL XR...4 lamotrigine...4, 5 lamotrigine er...4 lamotrigine starter kit-blue...5 lamotrigine starter kit-green...5 lamotrigine starter kit-orange...5 LATUDA...10 levetiracetam...5 levetiracetam er...5 lithium carbonate...9, 10 lithium carbonate er... 9 lorazepam... 4 LORAZEAM INTENSOL...4 loxapine succinate maprotiline hcl... 6 MARLAN... 7 meprobamate... 3 METADATE ER...2 methamphetamine hcl...1 methylphenidate hcl...2 methylphenidate hcl er...2 methylphenidate hcl er (cd)...2 methylphenidate hcl er (la)... 2 mirtazapine...6 nefazodone hcl...6 nortriptyline hcl...9 NULAZID...10 olanzapine... 12, 13 olanzapine-fluoxetine hcl OLETRO...6 oxazepam...4 oxcarbazepine... 5 OXTELLAR XR... 5 paliperidone er...10 paroxetine hcl... 7 paroxetine hcl er... 7 AXIL... 7 perphenazine perphenazine-amitriptyline EXEVA...7 phenelzine sulfate... 7 pimozide...13 prochlorperazine...12 prochlorperazine edisylate prochlorperazine maleate...12 propranolol hcl propranolol hcl er protriptyline hcl...9 QUDEXY XR... 5 quetiapine fumarate...11 quetiapine fumarate er...11 QUILLIVANT XR...3 REXULTI...12 RISERDAL CONSTA =referred, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= Generic drugs 15

17 risperidone RITALIN LA... 3 SAHRIS...11 sertraline hcl... 8 SRITAM...5 SURMONTIL... 9 TEGRETOL-XR... 5 thiamine hcl...14 thioridazine hcl...12 thiothixene tiagabine hcl...5 topiramate... 5 TOIRAMATE ER...5 tranylcypromine sulfate...7 trazodone hcl...6 trifluoperazine hcl trihexyphenidyl hcl...9 trimipramine maleate... 9 TRINTELLIX... 6 TROKENDI XR... 5 valproate sodium... 6 valproic acid...6 venlafaxine hcl... 8 venlafaxine hcl er... 8 VERSACLOZ...11 VIIBRYD... 7 VIIBRYD STARTER ACK...7 vitamin b complex-c vitamin b vitamin-b complex VRAYLAR...10 VYVANSE...1 ZENZEDI...1 ziprasidone hcl...10 zubsolv...3 ZUBSOLV... 3 ZYREXA RELREVV =referred, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= Generic drugs 16