BlueCross BlueShield of Western New York Formulary. (List of Covered Drugs)

Transcription

1 BlueCross BlueShield of Western New York 018 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 6 This formulary was updated on 08/16/017. For more recent information or other questions, please contact BlueCross BlueShield of Western New York at or for TTY users (TTY 711), October 1 February 14, 8 a.m. to 8 p.m., 7 days a week and February 15 September 30, 8 a.m. to 8 p.m., Monday Friday, or visit bcbswny.com/medicare. Y0086_PTD63 Accepted

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 BlueCross BlueShield of Western New York. When it refers to plan or our plan, BlueCross BlueShield BlueSaver (HMO), BlueCross BlueShield Senior Blue Select (HMO), BlueCross BlueShield Senior Blue 651 (HMO), BlueCross BlueShield Forever Blue Focus (PPO), BlueCross BlueShield Forever Blue Value (PPO), and BlueCross BlueShield Forever Blue 751 (PPO). This document includes list of the drugs (formulary) for our plan which is current as of 08/16/017. For an updated formulary, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy network, and/or copayments/coinsurance may change on January 1, 019, and from time to time during the year. What is the BlueCross BlueShield of Western New York Formulary? A formulary is list of covered drugs selected by BlueCross BlueShield of Western New York 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. BlueCross BlueShield of Western New York will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a BlueCross BlueShield of Western New York 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 08/16/017. To get updated information about the drugs covered by BlueCross BlueShield of Western New York, please contact us. Our contact information appears on the front and back cover pages. II

3 In the event that our plan has made an error in the printed formulary during the year, we will notify you directly by mail. We will send you a written notification explaining the error and a new formulary page reflecting the correct text and benefit. How do I use the Formulary? There are two ways to find your drug within the formulary: Medical Condition The formulary begins on page. The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category, Antihypertensive Therapy. If you know what your drug is used for, look for the category name in the list that begins on page number. 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 index page number 7. 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? BlueCross BlueShield of Western New York 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: BlueCross BlueShield of Western New York requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from BlueCross BlueShield of Western New York before you fill your prescriptions. If you don t get approval, BlueCross BlueShield of Western New York may not cover the drug. Quantity Limits: For certain drugs, BlueCross BlueShield of Western New York limits the amount of the drug that BlueCross BlueShield of Western New York will cover. For example, BlueCross III

4 BlueShield of Western New York provides 30 tablets per prescription for atorvastatin. This may be in addition to a standard one-month or three-month supply. Step Therapy: In some cases, BlueCross BlueShield of Western New York 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, BlueCross BlueShield of Western New York may not cover B unless you try A first. If A does not work for you, BlueCross BlueShield of Western New York 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. 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 BlueCross BlueShield of Western New York 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 BlueCross BlueShield of Western New York formulary? on IV for information about how to request an exception. What if my drug is not on the Formulary? If your drug is not included in this formulary (list of covered drugs), you should first contact Member Services and ask if your drug is covered. If you learn that BlueCross BlueShield of Western New York does not cover your drug, you have two options: You can ask Member Services for a list of similar drugs that are covered by BlueCross BlueShield of Western New York. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by BlueCross BlueShield of Western New York. You can ask BlueCross BlueShield of Western New York 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 BlueCross BlueShield of Western New York Formulary? You can ask BlueCross BlueShield of Western New York to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make. IV

5 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, BlueCross BlueShield of Western New York limits the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover a greater amount. Generally, BlueCross BlueShield of Western New York will only approve your request for an exception if the alternative drugs included on the plan s formulary, the lower cost-sharing drug or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects. You should contact us to ask us for an initial coverage decision for a formulary, tiering, or utilization restriction exception. When you request a formulary, tiering, or utilization restriction exception you should submit a statement from your prescriber or physician supporting your request. Generally, we must make our decision within 7 hours of getting your prescriber s supporting statement. You can request an expedited (fast) exception if you or your doctor 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. What do I do before I can talk to my doctor about changing my drugs or requesting an exception? As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan. For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary 30-day supply (unless you have a prescription written for fewer when you go to a network pharmacy. After your first 30-day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days. If you are a resident of a long-term care facility, we will allow you to refill your prescription until we have provided you with a 93-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 31day V

6 emergency supply of that drug (unless you have a prescription for fewer while you pursue a formulary exception. If you submit a prescription for a transition eligible drug and it is rejected at Point of Sale, a message will be relayed to the pharmacists to call for additional instructions if you underwent a recent level of care change. After confirming that you had a level of care change, the pharmacist will be instructed to enter a series of override codes to allow you to receive a one-time transition supply of your prescription. At that time, all transition supply procedures will apply including member notifications for transition supply fills. For more information For more detailed information about your BlueCross BlueShield of Western New York prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about BlueCross BlueShield of Western New York, 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 BlueCross BlueShield of Western New York Formulary The formulary that begins on the next page provides coverage information about the drugs covered by BlueCross BlueShield of Western New York. If you have trouble finding your drug in the list, turn to the Index that begins on page 77. The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., WELCHOL) and generic drugs are listed in lower-case italics (e.g., simvasatin). The information in the column tells you if BlueCross BlueShield of Western New York has any special requirements for coverage of your drug. VI

7 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 *: Diabetic test strips are not covered under Medicare Part D. The test strips listed in this document are those that may be covered under Medicare Part B if your Plan includes Part B coverage. +: We provide additional coverage of this prescription drug in the coverage gap for Senior Blue 651 (HMO) and Forever Blue 751 (PPO). Please refer to 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. If it is determined that coverage for this drug falls under Medicare Part B, your cost will not be the tier co-pay in this drug list. Please refer to Chapter 4 of your evidence of coverage for the cost of Part B drugs or contact customer service. 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

8 Name ANTI - INFECTIVES ANTIFUNGAL AGENTS ABELCET 5 B/D PA; MO AMBISOME 5 B/D PA; MO amphotericin b 4 B/D PA; MO CANCIDAS 5 B/D PA; MO clotrimazole mucous membrane CRESEMBA INTRAVENOUS CRESEMBA ORAL fluconazole fluconazole in nacl (iso-osm) intravenous piggyback 00 mg/100 ml fluconazole in nacl (iso-osm) intravenous piggyback 400 mg/00 ml 5 flucytosine griseofulvin microsize griseofulvin ultramicrosize itraconazole ketoconazole oral MYCAMINE NOXAFIL ORAL nystatin oral suspension nystatin oral tablet Name ORAVIG 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 4 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

9 Name CRIXIVAN ORAL CAPSULE 00 MG, 400 MG DESCOVY didanosine oral capsule,delayed release(dr/ec) 15 mg didanosine oral capsule,delayed release(dr/ec) 00 mg, 50 mg, 400 mg EDURANT EMTRIVA entecavir EPCLUSA (8 per 8 EPIVIR HBV ORAL SOLUTION EVOTAZ famciclovir FUZEON SUBCUTANEOUS RECON SOLN ganciclovir sodium B/D PA; MO GENVOYA HARVONI (8 per 8 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 TABLET MG KALETRA ORAL TABLET MG lamivudine lamivudinezidovudine LEXIVA ORAL SUSPENSION LEXIVA ORAL TABLET lopinavir-ritonavir moderiba moderiba dose pack oral tablets,dose pack 400 mg (7)- 400 mg (7) moderiba dose pack oral tablets,dose pack 600 mg (7)- 600 mg (7) nevirapine NORVIR ODEFSEY 3

10 Name oseltamivir PREZCOBIX PREZISTA ORAL SUSPENSION PREZISTA ORAL TABLET 150 MG, 75 MG PREZISTA ORAL TABLET 600 MG, 800 MG REBETOL ORAL SOLUTION RELENZA DISKHALER RESCRIPTOR RETROVIR INTRAVENOUS REYATAZ ORAL CAPSULE 150 MG, 00 MG, 300 MG REYATAZ ORAL POWDER IN PACKET ribasphere oral capsule ribasphere oral tablet 00 mg, 400 mg ribasphere oral tablet 600 mg ribasphere ribapak oral tablets,dose pack 00 mg (7)- 400 mg (7) Name 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 TRUVADA 4 rimantadine SELZENTRY ORAL TABLET stavudine oral capsule STRIBILD SUSTIVA ORAL CAPSULE 00 MG SUSTIVA ORAL CAPSULE 50 MG SUSTIVA ORAL TABLET SYNAGIS INTRAMUSCULA R SOLUTION 50 MG/0.5 ML TAMIFLU ORAL SUSPENSION FOR RECONSTITUTIO N TIVICAY ORAL TABLET 10 MG TIVICAY ORAL TABLET 5 MG, 50 MG ; LA TRIUMEQ

11 Name valacyclovir PA; MO; QL (30 per 30 valganciclovir VEMLIDY VIDEX GRAM PEDIATRIC VIRACEPT ORAL TABLET VIREAD ZEPATIER (8 per 8 ZERIT ORAL RECON SOLN ZIAGEN ORAL SOLUTION 4 MO 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 Name 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 cefoxitin intravenous recon soln 1 gram, gram cefoxitin intravenous recon soln 10 gram 5 cefpodoxime cefprozil ceftazidime injection recon soln 1 gram, gram ceftazidime injection recon soln 6 gram ceftriaxone injection recon soln 10 gram ceftriaxone injection recon soln 50 mg, 500 mg ceftriaxone intravenous

12 Name 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 SUPRAX ORAL CAPSULE SUPRAX ORAL SUSPENSION FOR RECONSTITUTIO N 500 MG/5 ML SUPRAX ORAL TABLET,CHEWAB LE 4 MO 4 4 MO TEFLARO ERYTHROMYCINS / OTHER MACROLIDES azithromycin clarithromycin e.e.s. 400 oral tablet ery-tab oral tablet,delayed release (dr/ec) 50 mg, 333 mg ERY-TAB ORAL TABLET,DELAYE D RELEASE (DR/EC) 500 MG Name erythrocin (as stearate) oral tablet 50 mg ERYTHROCIN INTRAVENOUS RECON SOLN 500 MG erythromycin ethylsuccinate oral suspension for reconstitution erythromycin ethylsuccinate oral tablet erythromycin oral capsule,delayed release(dr/ec) erythromycin oral tablet MISCELLANEOUS ANTIINFECTIVES ALBENZA ALINIA ORAL SUSPENSION FOR RECONSTITUTIO N ALINIA ORAL TABLET amikacin injection solution 500 mg/ ml atovaquone atovaquoneproguanil aztreonam injection recon soln 1 gram baciim 6

13 Name bacitracin intramuscular BETHKIS 5 B/D PA; MO; QL (4 per 8 BILTRICIDE CAPASTAT 4 CAYSTON ; LA; QL (84 per 8 chloramphenicol sod succinate chloroquine phosphate clindamycin hcl clindamycin in 5 % dextrose clindamycin pediatric clindamycin phosphate injection clindamycin phosphate intravenous solution 600 mg/4 ml COARTEM colistin (colistimethate na) dapsone daptomycin DARAPRIM 5 PA; MO EMVERM ethambutol Name 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 7 hydroxychloroquine imipenem-cilastatin INVANZ INJECTION isoniazid injection 4 MO 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

14 Name neomycin paromomycin 4 MO PASER PENTAM 4 MO polymyxin b sulfate PRIFTIN PRIMAQUINE pyrazinamide quinine sulfate rifabutin 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 ; QL (9 per 30 ; QL (60 Name amoxicillin oral capsule amoxicillin oral suspension for reconstitution amoxicillin oral tablet amoxicillin oral tablet,chewable 15 mg, 50 mg amoxicillin-pot clavulanate 8 ampicillin 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

15 Name 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 oxacillin injection recon soln gram 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 5 3 penicillin g sodium penicillin v potassium Name 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 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 4 MO sulfamethoxazoletrimethoprim TETRACYCLINES 9

16 Name demeclocycline 4 MO doxy-100 doxycycline hyclate oral capsule doxycycline hyclate oral tablet 100 mg, 0 mg doxycycline hyclate oral tablet,delayed release (dr/ec) doxycycline monohydrate oral capsule doxycycline monohydrate oral suspension for reconstitution doxycycline monohydrate oral tablet minocycline oral capsule minocycline oral tablet minocycline oral tablet extended release 4 hr morgidox oral capsule 50 mg 4 MO 4 MO tetracycline VIBRAMYCIN ORAL SYRUP URINARY TRACT AGENTS methenamine hippurate nitrofurantoin Name nitrofurantoin macrocrystal nitrofurantoin monohyd/m-cryst 10 PRIMSOL 4 MO trimethoprim VANCOMYCIN vancomycin intravenous recon soln 1,000 mg, 10 gram, 500 mg vancomycin oral capsule ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS ADJUNCTIVE AGENTS dexrazoxane hcl intravenous recon soln 50 mg ELITEK KEPIVANCE leucovorin calcium injection recon soln 100 mg, 350 mg leucovorin calcium oral levoleucovorin intravenous solution 5 mesna MESNEX ORAL 5 XGEVA 5 B/D PA; MO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS ABRAXANE 5 B/D PA; MO

17 Name 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 B/D PA; MO 5 PA; MO (60 per 30 5 PA; MO ALECENSA (40 per 30 ALIMTA INTRAVENOUS RECON SOLN 500 MG 5 B/D PA; MO ALUNBRIG (180 per 30 anastrozole ARRANON 5 B/D PA AVASTIN 5 B/D PA; MO azacitidine 5 B/D PA; MO azathioprine B/D PA; MO azathioprine sodium B/D PA BAVENCIO 5 B/D PA; MO; LA BELEODAQ 5 B/D PA; MO bexarotene bicalutamide BICNU 5 B/D PA; MO Name bleomycin injection recon soln 30 unit BOSULIF ORAL TABLET 100 MG BOSULIF ORAL TABLET 500 MG B/D PA; MO 5 PA; MO (30 per 30 busulfan 5 B/D PA BUSULFEX 5 B/D PA 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 B/D PA; MO 3 B/D PA; MO cisplatin B/D PA; MO cladribine 5 B/D PA; MO clofarabine 5 B/D PA CLOLAR 5 B/D PA COMETRIQ 5 PA; MO COSMEGEN 5 B/D PA; MO COTELLIC 5 PA; MO; LA; QL (63 per 8 CYCLOPHOSPHA MIDE ORAL CAPSULE cyclosporine intravenous cyclosporine modified 3 B/D PA; MO B/D PA B/D PA; MO 11

18 Name cyclosporine oral capsule 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 B/D PA; MO DARZALEX 5 B/D PA; MO; LA daunorubicin intravenous solution B/D PA decitabine 5 B/D PA; MO 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 5 B/D PA; MO B/D PA; MO 5 B/D PA; MO DROXIA EMCYT EMPLICITI 5 B/D PA; MO epirubicin intravenous solution 00 mg/100 ml ERBITUX INTRAVENOUS SOLUTION 100 MG/50 ML B/D PA; MO 5 B/D PA; MO Name ERIVEDGE (30 per 30 ERWINAZE 5 B/D PA; MO ETOPOPHOS 4 B/D PA; MO etoposide intravenous B/D PA; MO exemestane FARESTON FARYDAK ORAL CAPSULE 10 MG FARYDAK ORAL CAPSULE 15 MG, 0 MG (1 per 1 (6 per 1 FASLODEX 5 B/D PA; MO FIRMAGON KIT W DILUENT SYRINGE SUBCUTANEOUS RECON SOLN 10 MG FIRMAGON KIT W DILUENT SYRINGE SUBCUTANEOUS RECON SOLN 80 MG fludarabine intravenous recon soln fluorouracil intravenous solution.5 gram/50 ml 5 B/D PA; MO 3 B/D PA; MO B/D PA; MO B/D PA; MO flutamide 1

19 Name FOLOTYN INTRAVENOUS SOLUTION 40 MG/ ML (0 MG/ML) gemcitabine intravenous recon soln 1 gram 5 B/D PA; MO B/D PA; MO gengraf B/D PA; MO GILOTRIF ORAL TABLET 0 MG GILOTRIF ORAL TABLET 30 MG GILOTRIF ORAL TABLET 40 MG (60 per 30 (40 per 30 (30 per 30 GLEOSTINE HALAVEN 5 B/D PA; MO HERCEPTIN INTRAVENOUS RECON SOLN 440 MG 5 B/D PA; MO HEXALEN hydroxyurea IBRANCE (1 per 8 ICLUSIG ORAL TABLET 15 MG ICLUSIG ORAL TABLET 45 MG 5 PA; QL (90 (30 per 30 idarubicin B/D PA ifosfamide intravenous recon soln 1 gram B/D PA; MO Name imatinib oral tablet 100 mg imatinib oral tablet 400 mg 5 PA; MO (60 per 30 IMBRUVICA (10 per 30 IMFINZI 5 B/D PA; MO; 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 B/D PA; MO ISTODAX 5 B/D PA; MO JAKAFI ORAL TABLET 10 MG, 15 MG, 0 MG, 5 MG JAKAFI ORAL TABLET 5 MG 5 PA; MO (60 per 30 JEVTANA 5 B/D PA; MO KADCYLA INTRAVENOUS RECON SOLN 100 MG 5 PA; MO KEYTRUDA 5 PA; MO KISQALI 5 PA; MO KISQALI FEMARA CO-PACK 5 PA; MO 13

20 Name KYPROLIS 5 B/D PA; MO LARTRUVO 5 B/D PA; MO; LA LENVIMA 5 PA; MO letrozole LEUKERAN leuprolide subcutaneous kit B/D PA; MO LONSURF 5 PA; MO LUPRON DEPOT 5 PA; MO LUPRON DEPOT (NTH) LUPRON DEPOT (4 MONTH) LUPRON DEPOT (6 MONTH) LUPRON DEPOT- PED INTRAMUSCULA R KIT 11.5 MG, 15 MG 5 PA; MO 5 PA; MO 5 PA; MO 5 PA; MO LYNPARZA 5 PA; MO LYSODREN MATULANE megestrol oral suspension 400 mg/10 ml (40 mg/ml), 65 mg/5 ml 4 PA; MO megestrol oral tablet 4 PA; MO MEKINIST ORAL TABLET 0.5 MG MEKINIST ORAL TABLET MG (10 per 30 (30 per 30 melphalan hcl 5 B/D PA Name 14 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 B/D PA; MO 5 B/D PA; MO mitoxantrone B/D PA; MO MUSTARGEN 4 B/D PA; MO mycophenolate mofetil hcl mycophenolate mofetil oral capsule mycophenolate mofetil oral suspension for reconstitution mycophenolate mofetil oral tablet mycophenolate sodium B/D PA B/D PA; MO 5 B/D PA; MO B/D PA; MO B/D PA; MO NEXAVAR 5 PA; MO; LA; QL (10 per 30 nilutamide NINLARO ORAL CAPSULE.3 MG NINLARO ORAL CAPSULE 3 MG (6 per 8 (4 per 8

21 Name NINLARO ORAL CAPSULE 4 MG (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 5 PA; MO B/D PA; MO paclitaxel B/D PA; MO PERJETA 5 B/D PA; MO POMALYST ; LA PROGRAF INTRAVENOUS 3 B/D PA; MO PURIXAN RAPAMUNE ORAL SOLUTION 5 B/D PA; MO REVLIMID 5 PA; MO; LA RITUXAN 5 PA; MO RUBRACA ORAL TABLET 00 MG RUBRACA ORAL TABLET 300 MG 5 PA; MO; LA; QL (180 per 30 5 PA; MO; LA; QL (10 per 30 Name 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 SPRYCEL ORAL TABLET 70 MG 5 PA; MO (30 per 30 (60 per 30 STIVARGA (84 per 8 SUTENT ORAL CAPSULE 1.5 MG 5 PA; MO 15

22 Name SUTENT ORAL CAPSULE 5 MG, 37.5 MG SUTENT ORAL CAPSULE 50 MG SYLVANT INTRAVENOUS RECON SOLN 100 MG (60 per 30 (30 per 30 5 B/D PA; MO SYNRIBO 5 B/D PA; MO 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 TARCEVA ORAL TABLET 150 MG TARGRETIN TOPICAL TASIGNA ORAL CAPSULE 150 MG 5 PA; MO (30 per 30 5 PA; MO Name TASIGNA ORAL CAPSULE 00 MG (11 per 8 TECENTRIQ 5 B/D PA; MO; LA THALOMID 5 PA; MO thiotepa 5 B/D PA; MO toposar B/D PA; MO topotecan intravenous recon soln 5 B/D PA TORISEL 5 B/D PA; MO TREANDA INTRAVENOUS RECON SOLN 100 MG TRELSTAR INTRAMUSCULA R SYRINGE tretinoin (chemotherapy) 5 B/D PA; MO 5 B/D PA; MO TRISENOX 5 B/D PA; MO 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 5 B/D PA; MO VENCLEXTA ORAL TABLET 10 MG, 50 MG VENCLEXTA ORAL TABLET 100 MG 3 PA; MO; LA 5 PA; MO; LA 16

23 Name 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; QL (4 per 180 B/D PA; MO B/D PA B/D PA; MO B/D PA; MO VOTRIENT (10 per 30 XALKORI ORAL CAPSULE 00 MG XALKORI ORAL CAPSULE 50 MG 5 PA; MO (60 per 30 XERMELO 5 PA; MO; LA; QL (90 per 30 XTANDI (10 per 30 YERVOY INTRAVENOUS SOLUTION 50 MG/10 ML (5 MG/ML) 5 B/D PA; MO YONDELIS 5 B/D PA; MO ZALTRAP INTRAVENOUS SOLUTION 100 MG/4 ML (5 MG/ML) 5 B/D PA; MO Name ZANOSAR 4 B/D PA; MO 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 BRIVIACT INTRAVENOUS 4 MO BRIVIACT ORAL 17 4

24 Name 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 clonazepam PA; MO DIASTAT 4 MO DIASTAT ACUDIAL 4 MO 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 fosphenytoin injection solution 100 mg pe/ ml Name FYCOMPA ORAL SUSPENSION FYCOMPA ORAL TABLET gabapentin oral capsule 100 mg gabapentin oral capsule 300 mg gabapentin oral capsule 400 mg gabapentin oral solution 50 mg/5 ml gabapentin oral tablet 600 mg gabapentin oral tablet 800 mg GABITRIL ORAL TABLET 1 MG, 16 MG GRALISE 30-DAY STARTER PACK GRALISE ORAL TABLET EXTENDED RELEASE 4 HR 300 MG GRALISE ORAL TABLET EXTENDED RELEASE 4 HR 600 MG lamotrigine oral tablet lamotrigine oral tablet extended release 4hr 18 1 MO; QL (1080 ; + 1 MO; QL (360 ; + 1 MO; QL (70 ; + ; QL (160 1 MO; QL (180 ; + 1 MO; QL (135 ; + 3 PA; MO; QL (78 per PA; MO; QL (30 per 30 3 PA; MO; QL (90 per 30 4 MO

25 Name lamotrigine oral tablet, chewable dispersible lamotrigine oral tablet,disintegrating levetiracetam in nacl (iso-os) intravenous piggyback 1,000 mg/100 ml, 1,500 mg/100 ml levetiracetam in nacl (iso-os) intravenous piggyback 500 mg/100 ml levetiracetam intravenous levetiracetam oral solution 100 mg/ml levetiracetam oral tablet levetiracetam oral tablet extended release 4 hr LYRICA ORAL CAPSULE 100 MG LYRICA ORAL CAPSULE 150 MG LYRICA ORAL CAPSULE 00 MG LYRICA ORAL CAPSULE 5 MG LYRICA ORAL CAPSULE 5 MG 4 MO 3 PA; MO; QL (180 per 30 3 PA; MO; QL (10 per 30 3 PA; MO; QL (90 per 30 3 PA; MO; QL (81 per 30 3 PA; MO; QL (70 per 30 Name LYRICA ORAL CAPSULE 300 MG LYRICA ORAL CAPSULE 50 MG LYRICA ORAL CAPSULE 75 MG LYRICA ORAL SOLUTION ONFI ORAL SUSPENSION ONFI ORAL TABLET 10 MG, 0 MG 3 PA; MO; QL (60 per 30 3 PA; MO; QL (360 per 30 3 PA; MO; QL (40 per 30 3 PA; MO; QL (900 per 30 3 PA; MO 3 PA; MO oxcarbazepine PEGANONE phenobarbital PA; MO phenytoin oral suspension 15 mg/5 ml phenytoin oral tablet,chewable phenytoin sodium extended phenytoin sodium intravenous solution primidone roweepra oral tablet 1,000 mg, 750 mg roweepra oral tablet 500 mg SABRIL ; LA SPRITAM 4 MO 19

26 Name tiagabine 4 MO 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 benztropine injection benztropine oral PA; MO bromocriptine 4 MO carbidopa carbidopa-levodopa carbidopa-levodopaentacapone 4 MO entacapone NEUPRO pramipexole rasagiline ropinirole selegiline hcl tolcapone Name 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 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 ; QL (18 per 8 ; QL (36 per 8 ; QL (18 per 8 ; QL (8 per 8 ; QL (8 per 8 0

27 Name sumatriptan succinate subcutaneous solution sumatriptan succinate subcutaneous syringe 6 mg/0.5 ml ; QL (8 per 8 ; QL (8 per 8 zolmitriptan ; QL (18 per 8 MISCELLANEOUS NEUROLOGICAL THERAPY AMPYRA 5 PA; MO; LA AUBAGIO 5 PA; MO COPAXONE SUBCUTANEOUS SYRINGE 40 MG/ML donepezil oral tablet 10 mg, 5 mg donepezil oral tablet 3 mg donepezil oral tablet,disintegrating (1 per 8 4 MO 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 Name rivastigmine rivastigmine tartrate TECFIDERA 5 PA; MO; LA tetrabenazine oral tablet 1.5 mg tetrabenazine oral tablet 5 mg (40 per 30 (10 per 30 TYSABRI 5 PA; MO; LA MUSCLE RELAXANTS / ANTISPASMODIC THERAPY baclofen cyclobenzaprine oral tablet 4 PA; MO dantrolene LIORESAL INTRATHECAL SOLUTION,000 MCG/ML, 500 MCG/ML LIORESAL INTRATHECAL SOLUTION 50 MCG/ML MESTINON ORAL SYRUP pyridostigmine bromide 3 B/D PA; MO 3 B/D PA tizanidine NARCOTIC ANALGESICS acetaminophencodeine oral solution 10-1 mg/5 ml PA; MO; QL (4500 per 30 1

28 Name 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 PA; MO; QL (360 per 30 PA; MO; QL (180 per 30 ; QL (66 QL (66 per 30 ; QL (100 ; QL (5 BUTRANS 3 PA; MO; QL (4 per 8 codeine sulfate oral tablet duramorph (pf) injection solution 0.5 mg/ml duramorph (pf) injection solution 1 mg/ml endocet oral tablet mg, 5-35 mg, mg PA; MO; QL (180 per 30 ; QL (4000 QL (000 per 30 PA; MO; QL (360 per 30 fentanyl citrate (10 per 30 fentanyl transdermal patch 7 hour 100 mcg/hr, 1 mcg/hr, 5 mcg/hr, 50 mcg/hr, 75 mcg/hr PA; MO; QL (10 per 30 Name 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 PA; MO; QL (5550 per 30 PA; MO; QL (360 per 30 PA; MO; QL (50 per 30 hydromorphone (pf) ; QL (40 hydromorphone injection syringe mg/ml 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, 3 mg QL (100 per 30 PA; MO; QL (400 per 30 PA; MO; QL (180 per 30 PA; MO; QL (60 per 30 (60 per 30 ibuprofen-oxycodone PA; MO; QL (8 per 30 levorphanol tartrate PA; MO; QL (10 per 30

29 Name lorcet (hydrocodone) PA; QL (360 lorcet hd PA; QL (360 lorcet plus oral tablet mg PA; QL (360 lortab PA; QL (360 lortab 5-35 PA; QL (360 lortab PA; QL (360 methadone injection solution methadone oral solution 10 mg/5 ml methadone oral solution 5 mg/5 ml methadone oral tablet 10 mg methadone oral tablet 5 mg morphine concentrate oral solution morphine intravenous syringe mg/ml morphine intravenous syringe 4 mg/ml morphine oral capsule, er multiphase 4 hr QL (150 per 30 PA; MO; QL (600 per 30 PA; MO; QL (100 per 30 PA; MO; QL (10 per 30 PA; MO; QL (40 per 30 PA; MO; QL (900 per 30 QL (1000 per 30 QL (500 per 30 PA; MO; QL (60 per 30 Name morphine oral capsule,extend.relea se pellets morphine oral solution PA; MO; QL (90 per 30 PA; MO; QL (900 per 30 morphine oral tablet PA; MO; QL (180 per 30 morphine oral tablet extended release 100 mg morphine oral tablet extended release 15 mg, 00 mg, 30 mg, 60 mg oxycodone oral capsule oxycodone oral concentrate oxycodone oral solution oxycodone oral tablet 10 mg, 15 mg, 0 mg, 30 mg oxycodone oral tablet 5 mg oxycodoneacetaminophen oral solution oxycodoneacetaminophen oral tablet mg,.5-35 mg, 5-35 mg, mg PA; MO; QL (60 per 30 PA; MO; QL (10 per 30 PA; MO; QL (360 per 30 PA; MO; QL (180 per 30 PA; MO; QL (100 per 30 PA; MO; QL (180 per 30 PA; MO; QL (360 per 30 PA; QL (1860 PA; MO; QL (360 per 30 3

30 Name oxycodone-aspirin PA; MO; QL (360 per 30 OXYCONTIN ORAL TABLET,ORAL ONLY,EXT.REL.1 HR 10 MG, 15 MG, 0 MG, 30 MG, 40 MG, 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 3 PA; MO; QL (90 per 30 (60 per 30 PA; MO; QL (360 per 30 PA; MO; QL (180 per 30 PA; MO; QL (90 per 30 vicodin PA; MO; QL (360 per 30 vicodin es PA; MO; QL (360 per 30 vicodin hp PA; MO; QL (360 per 30 zamicet PA; QL (5550 NON-NARCOTIC ANALGESICS buprenorphinenaloxone sublingual tablet -0.5 mg ; QL (360 Name buprenorphinenaloxone sublingual tablet 8- mg butorphanol tartrate injection solution 1 mg/ml butorphanol tartrate injection solution mg/ml butorphanol tartrate nasal ; QL (90 ; QL (857 ; QL (48 ; QL (10 per 8 celecoxib diclofenac potassium diclofenac sodium oral diclofenac sodium topical drops diclofenac sodium topical gel 1 % diclofenacmisoprostol ; QL (300 per 8 ; QL (1000 per 8 diflunisal etodolac fenoprofen oral tablet FLECTOR 4 PA; MO; QL (60 per 30 flurbiprofen ibuprofen oral suspension ibuprofen oral tablet 400 mg, 600 mg, 800 mg ketoprofen oral capsule 4

31 Name ketoprofen oral capsule,ext rel. pellets 4 hr 00 mg meclofenamate mefenamic acid meloxicam oral tablet 15 mg meloxicam oral tablet 7.5 mg nabumetone nalbuphine injection solution 10 mg/ml nalbuphine injection solution 0 mg/ml naloxone injection solution naloxone injection syringe 1 mg/ml 1 MO; QL (30 ; + ; QL (00 ; QL (100 naltrexone naproxen oral suspension naproxen oral tablet naproxen oral tablet,delayed release (dr/ec) naproxen sodium oral tablet 75 mg, 550 mg naproxen sodium oral tablet, er multiphase 4 hr NARCAN NASAL SPRAY,NON- AEROSOL 4 MG/ACTUATION oxaprozin ; QL ( per 8 Name piroxicam SUBOXONE SUBLINGUAL FILM 1-3 MG SUBOXONE SUBLINGUAL FILM -0.5 MG SUBOXONE SUBLINGUAL FILM 4-1 MG, 8- MG ; 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 VOLTAREN GEL TOPICAL GEL 1 % ZUBSOLV SUBLINGUAL TABLET MG, MG, MG, MG ZUBSOLV SUBLINGUAL TABLET MG PA; MO; QL (30 per 30 PA; MO; QL (30 per 30 ; QL (40 ; QL (1000 per 8 ; QL (30 ; QL (60 PSYCHOTHERAPEUTIC DRUGS 5

32 Name ABILIFY MAINTENA INTRAMUSCULA R SUSPENSION,EXT ENDED REL RECON 300 MG ABILIFY MAINTENA INTRAMUSCULA R SUSPENSION,EXT ENDED REL SYRING alprazolam oral tablet amitriptyline PA; MO amoxapine aripiprazole oral tablet 10 mg aripiprazole oral tablet 15 mg aripiprazole oral tablet mg aripiprazole oral tablet 0 mg aripiprazole oral tablet 30 mg aripiprazole oral tablet 5 mg aripiprazole oral tablet,disintegrating 10 mg aripiprazole oral tablet,disintegrating 15 mg ; QL (90 ; QL (60 ; QL (450 ; QL (60 ; QL (30 ; QL (180 ; QL (90 ; QL (60 Name ARISTADA INTRAMUSCULA R SUSPENSION,EXT ENDED REL SYRING 1,064 MG/3.9 ML ARISTADA INTRAMUSCULA R SUSPENSION,EXT ENDED REL SYRING 441 MG/1.6 ML, 66 MG/.4 ML, 88 MG/3. ML 6 5 armodafinil 4 PA; MO atomoxetine bupropion hcl oral tablet bupropion hcl oral tablet extended release 1 hr 100 mg bupropion hcl oral tablet extended release 1 hr 150 mg 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 citalopram oral solution

33 Name citalopram oral tablet 10 mg citalopram oral tablet 0 mg citalopram oral tablet 40 mg 1 MO; QL (10 ; + 1 MO; QL (60 ; + 1 MO; QL (30 ; + clomipramine 4 PA; MO clonidine hcl oral tablet extended release 1 hr clorazepate dipotassium 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 ; QL (10 ; QL (480 ; QL (40 dexmethylphenidate dextroamphetamine oral capsule, extended release dextroamphetamine oral tablet dextroamphetamineamphetamine Name diazepam intensol PA; MO diazepam oral solution 5 mg/5 ml (1 mg/ml) PA; MO diazepam oral tablet PA; MO doxepin oral 4 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 4 MO escitalopram oxalate oral solution escitalopram oxalate oral tablet 10 mg escitalopram oxalate oral tablet 0 mg escitalopram oxalate oral tablet 5 mg 1 MO; QL (60 ; + 1 MO; QL (30 ; + 1 MO; QL (10 ; + eszopiclone 4 ST; MO; QL (30 per 30 FANAPT ORAL TABLET 1 MG FANAPT ORAL TABLET 10 MG, 8 MG 4 MO; QL (70 ; QL (90 7

34 Name 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 fluoxetine oral capsule 0 mg ; QL (60 4 MO; QL (360 4 MO; QL (180 ; QL (10 4 MO; QL (8 per 8 4 ; QL (8 per 8 ; QL (30 ; QL (180 ; QL (90 ; QL (45 1 MO; QL (40 ; + Name 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 8 1 MO; 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 4 MO; QL (90 4 MO; QL (60 ; QL (90 ; QL (360 ; QL (180 FORFIVO XL 4 MO; QL (30 GEODON INTRAMUSCULA R 4 MO guanidine haloperidol haloperidol decanoate haloperidol lactate

35 Name HETLIOZ (30 per 30 imipramine hcl 4 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 4 MO 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 Name metadate er methamphetamine PA; MO methylphenidate hcl oral capsule, er biphasic methylphenidate hcl oral capsule,er biphasic 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 4hr methylphenidate hcl oral tablet,chewable mirtazapine oral tablet mirtazapine oral tablet,disintegrating modafinil PA; MO nefazodone nortriptyline NUPLAZID olanzapine intramuscular olanzapine oral tablet 10 mg olanzapine oral tablet 15 mg, 0 mg ; QL (60 ; QL (30 9

36 Name 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 paliperidone oral tablet extended release 4hr 1.5 mg paliperidone oral tablet extended release 4hr 3 mg paliperidone oral tablet extended release 4hr 6 mg paliperidone oral tablet extended release 4hr 9 mg paroxetine hcl oral tablet 10 mg paroxetine hcl oral tablet 0 mg paroxetine hcl oral tablet 30 mg paroxetine hcl oral tablet 40 mg ; QL (40 ; QL (10 ; QL (81 ; QL (60 ; QL (30 ; QL (10 ; QL (40 ; QL (10 ; QL (60 ; QL (41 1 MO; QL (180 ; + 1 MO; QL (90 ; + 1 MO; QL (60 ; + 1 MO; QL (45 ; + Name 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 (180 ; QL (90 ; QL (60 4 MO perphenazine phenelzine pimozide 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 ; QL (40 ; QL (10 ; QL (90 ; QL (81 ; QL (60 ; QL (480 ; QL (160 ; QL (10 30

37 Name 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 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 ; QL (81 ; QL (60 ; QL (480 ; QL (480 ; QL (40 ; QL (10 ; QL (60 ; QL (40 ; QL (30 ; QL (480 1 MO; QL (190 ; + Name 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 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 1 MO; QL (960 ; + 1 MO; QL (480 ; + 1 MO; QL (40 ; + 1 MO; QL (161 ; + 1 MO; QL (10 ; + ; QL (190 ; 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 ; QL (60 ; QL (40 31