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

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1 Value Plan Express Scripts Medicare (PDP) 2017 Formulary (List of Covered s) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN Formulary File Submission ID: 17067, V18 This formulary was updated on 10/19/2017. For more recent information or other questions, please contact Express Scripts Medicare (PDP) Customer Service at ; New York State residents: or, for TTY users, , 24 hours a day, 7 days a week, or visit ATTENTION: If you speak a language other than English, language assistance services, free of charge, are available to you. Call ; New York residents: (TTY: ). ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al ; para residentes de New York: (TTY: ). This information is available in braille, large print and other formats for people with disabilities. Please contact Customer Service if you need plan information in another format. Y0046_F00SNV7A Accepted F00SNV7BW4

2 Note to existing members: This formulary has changed since last year. Please review this document to make sure that it still contains the drugs you take. When this drug list (formulary) refers to we, us, or our, it means Medco Containment Life Insurance Company and Medco Containment Insurance Company of New York (for members located in New York State only). When it refers to plan or our plan, it means Express Scripts Medicare. This document includes a list of the drugs (formulary) for our plan, which is current as of October 19, 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, 2018, and from time to time during the year. What is the Express Scripts Medicare Formulary? A formulary is a list of covered drugs selected by Express Scripts Medicare in consultation with a team of healthcare providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. Express Scripts Medicare will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at an Express Scripts Medicare network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage. Can the Formulary (drug list) change? Generally, if you are taking a drug on our 2017 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2017 coverage year except when a new, less expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released. Other types of formulary changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug. It will remain available at the same cost-sharing for those members taking it for the remainder of the coverage year. We feel it is important that you have continued access for the remainder of the coverage year to the formulary drugs that were available when you chose our plan, except for cases in which you can save additional money or we cannot ensure your safety. If we remove drugs from our formulary, or add prior authorization, quantity limits and/or step therapy restrictions on a drug, or move a drug to a higher cost-sharing tier, we must notify affected members of the change at least 60 days before the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 60-day supply of the drug. If the Food and Administration deems a drug on our formulary to be unsafe or the drug s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug. The enclosed formulary is current as of October 19, To get updated information about the drugs covered by Express Scripts Medicare, please contact us. Our contact information appears on the front and back cover pages. If there are additional changes made to the formulary that affect you and are not mentioned above, you will be notified in writing of these changes within a reasonable period of time from when the changes are made. i

3 How do I use the Formulary? There are two ways to find your drug within the formulary: Medical Condition The formulary begins on page 1. The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category Cardiovascular, Hypertension/Lipids. If you know what your drug is used for, look for the category name in the list that begins on page 1. Then look under the category name for your drug. Alphabetical Listing If you are not sure what category to look under, you should look for your drug in the Index that begins on page 66. The Index provides an alphabetical list of all of the drugs included in this document. Both brand-name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the Index and find the name of your drug in the first column of the list. What are generic drugs? Express Scripts Medicare covers both brand-name drugs and generic drugs. A generic drug is approved by the FDA as having the same active ingredient as the brand-name drug. Generally, generic drugs cost less than brand-name drugs. Are there any restrictions on my coverage? Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include: Prior Authorization: Express Scripts Medicare requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from Express Scripts Medicare before you fill your prescriptions. If you don t get approval, Express Scripts Medicare may not cover the drug. Quantity Limits: For certain drugs, Express Scripts Medicare limits the amount of the drug that Express Scripts Medicare will cover. For example, Express Scripts Medicare provides two inhalers (17 grams) for a 1-month supply per prescription for PROAIR HFA. This may be in addition to a standard 1-month or 3-month supply. Step Therapy: In some cases, Express Scripts Medicare requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if A and B both treat your medical condition, Express Scripts Medicare may not cover B unless you try A first. If A does not work for you, Express Scripts Medicare will then cover B. You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 1. You can also get more information about the restrictions applied to specific covered drugs by visiting our website. We have posted online documents that explain our prior authorization and step therapy restrictions. You may also ask us to send you a copy. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. ii

4 You can ask Express Scripts Medicare to make an exception to these restrictions or limits or for a list of other, similar drugs that may treat your health condition. See the section How do I request an exception to the Express Scripts Medicare Formulary? on page iii for information about how to request an exception. What if my drug is not on the Formulary? If your drug is not included in this formulary (list of covered drugs), you should first contact Customer Service and ask if your drug is covered. If you learn that Express Scripts Medicare does not cover your drug, you have two options: You can ask Customer Service for a list of similar drugs that are covered by Express Scripts Medicare. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by Express Scripts Medicare. You can ask Express Scripts Medicare to make an exception and cover your drug. See below for information about how to request an exception. How do I request an exception to the Express Scripts Medicare Formulary? You can ask Express Scripts Medicare to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make. You can ask us to cover a drug even if it is not on our formulary. If approved, this drug will be covered at a pre-determined cost-sharing level, and you would not be able to ask us to provide the drug at a lower cost-sharing level. You can ask us to cover a formulary drug at a lower cost-sharing level if this drug is not on the specialty tier. If approved, this would lower the amount you must pay for your drug. You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, Express Scripts Medicare limits the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover a greater amount. Generally, Express Scripts Medicare will only approve your request for an exception if the alternative drugs included on the plan s formulary, the lower cost-sharing drug or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects. You should contact us to ask us for an initial coverage decision for a formulary, tiering or utilization restriction exception. When you request a formulary, tiering or utilization restriction exception, you should submit a statement from your prescriber or physician supporting your request. Generally, we must make our decision within 72 hours of getting your prescriber s supporting statement. You can request an expedited (fast) exception if you or your doctor believes that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get a supporting statement from your doctor or other prescriber. iii

5 What do I do before I can talk to my doctor about changing my drugs or requesting an exception? As a new or continuing member in our plan, you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan. For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary 30-day supply (unless you have a prescription written for fewer when you go to a network pharmacy. After your first 30-day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days. If you are a resident of a long-term care facility, we will allow you to refill your prescription until we have provided you with a 91- to 98-day transition supply, consistent with dispensing increment (unless you have a prescription written for fewer. We will cover more than one refill of these drugs for the first 90 days you are a member of our plan. If you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 31-day emergency supply of that drug (unless you have a prescription for fewer while you pursue a formulary exception. Other times when we will cover a temporary 30-day transition supply (or less, if you have a prescription written for fewer include: When you leave a long-term care facility When you are discharged from a hospital When you leave a skilled nursing facility When you cancel hospice care When you are discharged from a psychiatric hospital with a medication regimen that is highly individualized If you are entering a long-term care facility, we will cover a 31-day transition supply. The plan will send you a letter within 3 business days of your filling a temporary transition supply, notifying you that this was a temporary supply and explaining your options. For more information For more detailed information about your Express Scripts Medicare prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about Express Scripts Medicare, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. If you have general questions about Medicare prescription drug coverage, please call Medicare at MEDICARE ( ), 24 hours a day, 7 days a week. TTY users should call Or, visit iv

6 Express Scripts Medicare s Formulary The formulary that begins on page 1 provides coverage information about the drugs covered by Express Scripts Medicare. If you have trouble finding your drug in the list, turn to the Index that begins on page 66. The first column of the chart lists the drug name. Brand-name drugs are capitalized (e.g., NEXIUM ) and generic drugs are listed in lowercase italics (e.g., omeprazole). The information in the column tells you if Express Scripts Medicare has any special requirements for coverage of your drug. B/D PA: Part B or Part D Prior Authorization. This drug may be covered under Medicare Part B or Part D depending upon the circumstances. Information may need to be submitted describing the use and setting of the drug to make the determination. LA: Limited Availability. This prescription may be available only at certain pharmacies. For more information, consult your Pharmacy Directory or call Customer Service at (New York State residents: ), 24 hours a day, 7 days a week. TTY users should call MO: Mail-Order. This prescription drug is available through our home delivery pharmacy service, as well as through our retail network pharmacies. Consider using mail order for your long-term medications (the ones you take regularly, such as high blood pressure medications). Retail network pharmacies may be more appropriate for short-term prescriptions (such as antibiotics). PA: Prior Authorization. The plan requires you or your doctor to get prior authorization for certain drugs. This means that you will need to get approval before you fill your prescription. If you don t get approval, we may not cover the drug. QL: Quantity Limit. For certain drugs, the plan limits the amount of the drug that we will cover. ST: Step Therapy. In some cases, the plan requires you to first try a certain drug to treat your medical condition before we will cover another drug for that condition. For example, if A and B both treat your medical condition, we may not cover B unless you try A first. If A does not work for you, we will then cover B. Your costs The amount you pay for a covered drug will depend on: Your coverage stage. Express Scripts Medicare has different stages of coverage. In each stage, the amount you pay for a drug may change. The drug tier for your drug. Each covered drug is in one of five drug tiers. Each tier may have a different copayment or coinsurance amount. The s chart on the following page explains what types of drugs are included in each tier and shows how costs may change with each tier. The Evidence of Coverage has more information about the plan s coverage stages and lists the copayment and coinsurance amounts for each tier. v

7 If you qualify for Extra Help If you qualify for Extra Help for your prescription drugs, your copayments and coinsurance may be lower. Please refer to the Evidence of Coverage Rider for People Who Get Extra Help Paying for Prescription s (LIS Rider) to find out what your costs are or you may contact Customer Service for more information. s 1: Preferred Generic s 2: Generic s 3: Preferred Brand s 4: Non-Preferred s 5: Specialty s Description This tier includes commonly prescribed generic drugs and may include other low-cost drugs. Use 1 drugs for the lowest copayments. This tier includes generic drugs and may include other low-cost drugs. Use 2 drugs to keep your copayments low. This tier includes preferred brand-name drugs as well as some generic drugs. s in this tier will generally have lower copayments than non-preferred drugs. This tier includes non-preferred brand-name drugs as well as some generic drugs. Many drugs in 4 have lower-cost alternatives in s 1, 2, and 3. Ask your doctor if switching to a lower-cost generic or preferred brand drug may be right for you. s in this tier are limited to up to a 31-day supply. This tier includes very high-cost brand-name and generic drugs. To learn more about medications in this tier, you may contact a pharmacist at the numbers listed on the front and back covers of this document. s in this tier are limited to up to a 31-day supply. Key The abbreviations listed below may appear on the following pages in the column that tells you if there are any special requirements for coverage of your drug. You can find information on what the symbols and abbreviations on these tables mean by going to page v. B/D PA: Part B or Part D Prior Authorization LA: Limited Availability MO: Mail-Order PA: Prior Authorization QL: Quantity Limit ST: Step Therapy vi

8 Name ANTI - INFECTIVES ANTIFUNGAL AGENTS ABELCET 5 B/D PA; MO AMBISOME 5 B/D PA; MO amphotericin b 4 B/D PA; MO CANCIDAS 5 B/D PA; MO clotrimazole mucous membrane CRESEMBA INTRAVENOUS CRESEMBA ORAL fluconazole in nacl (iso-osm) intravenous piggyback 200 mg/100 ml fluconazole in nacl (iso-osm) intravenous piggyback 400 mg/200 ml fluconazole oral suspension for reconstitution fluconazole oral 5 4 flucytosine griseofulvin microsize griseofulvin ultramicrosize itraconazole ketoconazole oral MYCAMINE INTRAVENOUS RECON SOLN 100 MG Name MYCAMINE INTRAVENOUS RECON SOLN 50 MG NOXAFIL ORAL nystatin oral suspension nystatin oral SPORANOX ORAL SOLUTION terbinafine hcl oral voriconazole intravenous voriconazole oral suspension for reconstitution voriconazole oral ANTIVIRALS abacavir oral abacavir-lamivudine abacavirlamivudinezidovudine acyclovir oral capsule acyclovir oral suspension 200 mg/5 ml acyclovir oral acyclovir sodium intravenous solution 4 B/D PA; MO adefovir amantadine hcl oral capsule amantadine hcl oral solution 1

9 Name amantadine hcl oral APTIVUS ORAL CAPSULE APTIVUS ORAL SOLUTION ATRIPLA BARACLUDE ORAL SOLUTION 5 cidofovir 4 B/D PA; MO COMPLERA CRIXIVAN ORAL CAPSULE 200 MG, 400 MG DESCOVY didanosine oral capsule,delayed release(dr/ec) 125 mg didanosine oral capsule,delayed release(dr/ec) 200 mg, 250 mg, 400 mg 3 EDURANT EMTRIVA entecavir EPCLUSA (28 per 28 EPIVIR HBV ORAL SOLUTION EPZICOM EVOTAZ famciclovir FUZEON SUBCUTANEOUS RECON SOLN Name ganciclovir sodium 4 B/D PA; MO GENVOYA HARVONI (168 per 168 INTELENCE ORAL TABLET 100 MG, 200 MG INTELENCE ORAL TABLET 25 MG INVIRASE ISENTRESS HD ISENTRESS ORAL POWDER IN PACKET ISENTRESS ORAL TABLET ISENTRESS ORAL TABLET,CHEWAB LE 100 MG ISENTRESS ORAL TABLET,CHEWAB LE 25 MG KALETRA ORAL SOLUTION KALETRA ORAL TABLET MG KALETRA ORAL TABLET MG lamivudine oral solution lamivudine oral 100 mg lamivudine oral 150 mg, 300 mg 2

10 Name lamivudinezidovudine LEXIVA ORAL SUSPENSION LEXIVA ORAL TABLET lopinavir-ritonavir moderiba moderiba dose pack oral s,dose pack 200 mg (7)- 400 mg (7), 600 mg (7)- 400 mg (7) moderiba dose pack oral s,dose pack 400 mg (7)- 400 mg (7), 600 mg (7)- 600 mg (7) nevirapine oral suspension nevirapine oral nevirapine oral extended release 24 hr NORVIR ORAL CAPSULE NORVIR ORAL SOLUTION NORVIR ORAL TABLET 3 ODEFSEY oseltamivir PREZCOBIX PREZISTA ORAL SUSPENSION Name 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, 200 MG, 300 MG REYATAZ ORAL POWDER IN PACKET ribavirin oral capsule ribavirin oral 200 mg rimantadine SELZENTRY ORAL TABLET SOVALDI (168 per 168 stavudine oral capsule STRIBILD SUSTIVA ORAL CAPSULE 200 MG SUSTIVA ORAL CAPSULE 50 MG SUSTIVA ORAL TABLET 3

11 Name SYNAGIS INTRAMUSCULA R SOLUTION 50 MG/0.5 ML ; LA TAMIFLU TIVICAY ORAL TABLET 10 MG TIVICAY ORAL TABLET 25 MG, 50 MG TRIUMEQ TRUVADA valacyclovir ; QL (31 VALCYTE ORAL RECON SOLN valganciclovir oral recon soln valganciclovir oral VEMLIDY VIDEX 2 GRAM PEDIATRIC VIRACEPT ORAL TABLET VIREAD ZERIT ORAL RECON SOLN ZIAGEN ORAL SOLUTION zidovudine oral capsule zidovudine oral syrup zidovudine oral CEPHALOSPORINS Name cefaclor oral capsule 250 mg cefaclor oral capsule 500 mg cefadroxil oral capsule cefadroxil oral suspension for reconstitution 250 mg/5 ml, 500 mg/5 ml cefadroxil oral cefazolin injection recon soln 1 gram, 500 mg cefazolin injection recon soln 10 gram cefdinir oral capsule cefdinir oral suspension for reconstitution 4 cefepime cefixime cefotaxime injection recon soln 1 gram, 2 gram, 500 mg cefoxitin intravenous recon soln 1 gram cefoxitin intravenous recon soln 10 gram cefoxitin intravenous recon soln 2 gram 2 2 cefpodoxime ceftazidime injection recon soln 1 gram, 2 gram ceftazidime injection recon soln 6 gram 4 4

12 Name ceftriaxone injection recon soln 10 gram ceftriaxone injection recon soln 250 mg, 500 mg ceftriaxone intravenous cefuroxime axetil oral cefuroxime sodium injection recon soln 750 mg cefuroxime sodium intravenous recon soln 1.5 gram cefuroxime sodium intravenous recon soln 7.5 gram cephalexin oral capsule 250 mg, 500 mg cephalexin oral suspension for reconstitution cephalexin oral SUPRAX ORAL CAPSULE SUPRAX ORAL SUSPENSION FOR RECONSTITUTIO N 500 MG/5 ML 4 2 TEFLARO ERYTHROMYCINS / OTHER MACROLIDES azithromycin intravenous azithromycin oral packet 4 Name azithromycin oral suspension for reconstitution azithromycin oral 250 mg, 250 mg (6 pack) azithromycin oral 500 mg, 500 mg (3 pack), 600 mg clarithromycin oral suspension for reconstitution 125 mg/5 ml clarithromycin oral suspension for reconstitution 250 mg/5 ml clarithromycin oral clarithromycin oral extended release 24 hr e.e.s. 400 oral erythrocin (as stearate) oral 250 mg ERYTHROCIN INTRAVENOUS RECON SOLN 500 MG erythromycin ethylsuccinate oral suspension for reconstitution erythromycin ethylsuccinate oral erythromycin oral capsule,delayed release(dr/ec) 5

13 Name erythromycin oral MISCELLANEOUS ANTIINFECTIVES ALBENZA ALINIA amikacin injection solution 500 mg/2 ml atovaquone atovaquoneproguanil oral mg atovaquoneproguanil oral mg AZACTAM IN DEXTROSE (ISO- OSM) aztreonam injection recon soln 1 gram 4 BILTRICIDE CAPASTAT 4 CAYSTON ; LA; QL (84 per 28 chloramphenicol sod succinate chloroquine phosphate oral 250 mg chloroquine phosphate oral 500 mg 2 clindamycin hcl Name clindamycin in 5 % dextrose intravenous piggyback 300 mg/50 ml, 600 mg/50 ml clindamycin in 5 % dextrose intravenous piggyback 900 mg/50 ml clindamycin pediatric clindamycin phosphate injection clindamycin phosphate intravenous solution 600 mg/4 ml COARTEM colistin (colistimethate na) 6 2 CUBICIN DAPSONE daptomycin DARAPRIM 3 PA; MO EMVERM ethambutol oral 100 mg ethambutol oral 400 mg gentamicin in nacl (iso-osm) intravenous piggyback 100 mg/100 ml gentamicin in nacl (iso-osm) intravenous piggyback 60 mg/50 ml, 80 mg/100 ml 2

14 Name gentamicin in nacl (iso-osm) intravenous piggyback 80 mg/50 ml gentamicin injection solution 40 mg/ml gentamicin sulfate (pf) intravenous solution 100 mg/10 ml hydroxychloroquine imipenem-cilastatin isoniazid oral solution isoniazid oral ivermectin linezolid intravenous 3 linezolid oral mefloquine meropenem metronidazole in nacl (iso-os) metronidazole oral NEBUPENT 3 B/D PA; MO; QL (1 per 28 neomycin paromomycin PASER PENTAM PRIFTIN PRIMAQUINE pyrazinamide quinine sulfate Name rifabutin rifampin intravenous rifampin oral SIRTURO ; LA STREPTOMYCIN SYNERCID 5 tinidazole tobramycin in % nacl tobramycin sulfate injection solution 10 mg/ml tobramycin sulfate injection solution 40 mg/ml 5 B/D PA; MO; QL (280 per 28 TRECATOR TYGACIL XIFAXAN ORAL TABLET 200 MG XIFAXAN ORAL TABLET 550 MG PENICILLINS amoxicillin oral capsule amoxicillin oral suspension for reconstitution amoxicillin oral amoxicillin oral,chewable 125 mg, 250 mg ; QL (9 per 30 ; QL (62 7

15 Name amoxicillin-pot clavulanate oral suspension for reconstitution mg/5 ml, mg/5 ml amoxicillin-pot clavulanate oral suspension for reconstitution mg/5 ml, mg/5 ml amoxicillin-pot clavulanate oral amoxicillin-pot clavulanate oral extended release 12 hr amoxicillin-pot clavulanate oral,chewable ampicillin oral capsule ampicillin sodium injection recon soln 1 gram, 10 gram ampicillin sodium injection recon soln 125 mg ampicillin-sulbactam injection recon soln 1.5 gram, 3 gram ampicillin-sulbactam injection recon soln 15 gram 2 Name AUGMENTIN ORAL SUSPENSION FOR RECONSTITUTIO N MG/5 ML dicloxacillin nafcillin injection recon soln 1 gram nafcillin injection recon soln 10 gram penicillin g potassium injection recon soln 5 million unit penicillin g procaine intramuscular syringe 1.2 million unit/2 ml penicillin g sodium penicillin v potassium piperacillintazobactam intravenous recon soln gram piperacillintazobactam intravenous recon soln 4.5 gram, 40.5 gram ZOSYN IN DEXTROSE (ISO- OSM) INTRAVENOUS PIGGYBACK 2.25 GRAM/50 ML 3 8

16 Name ZOSYN IN DEXTROSE (ISO- OSM) INTRAVENOUS PIGGYBACK GRAM/50 ML QUINOLONES ciprofloxacin 2 ciprofloxacin hcl oral ciprofloxacin in 5 % dextrose intravenous piggyback 200 mg/100 ml ciprofloxacin lactate intravenous solution 400 mg/40 ml levofloxacin in d5w intravenous piggyback 500 mg/100 ml levofloxacin in d5w intravenous piggyback 750 mg/150 ml levofloxacin intravenous levofloxacin oral solution levofloxacin oral 2 moxifloxacin oral ofloxacin oral 300 mg ofloxacin oral 400 mg 4 SULFA'S / RELATED AGENTS sulfadiazine Name sulfamethoxazoletrimethoprim intravenous sulfamethoxazoletrimethoprim oral TETRACYCLINES demeclocycline doxy-100 doxycycline hyclate oral capsule doxycycline hyclate oral 100 mg, 20 mg doxycycline hyclate oral,delayed release (dr/ec) doxycycline monohydrate oral capsule 100 mg, 50 mg, 75 mg doxycycline monohydrate oral suspension for reconstitution doxycycline monohydrate oral minocycline oral capsule minocycline oral minocycline oral extended release 24 hr morgidox oral capsule 50 mg URINARY TRACT AGENTS 2 9

17 Name methenamine hippurate nitrofurantoin nitrofurantoin macrocrystal oral capsule 100 mg, 25 mg nitrofurantoin macrocrystal oral capsule 50 mg nitrofurantoin monohyd/m-cryst PRIMSOL trimethoprim VANCOMYCIN vancomycin intravenous recon soln 1,000 mg vancomycin intravenous recon soln 10 gram, 500 mg vancomycin oral capsule VIBATIV INTRAVENOUS RECON SOLN 750 MG ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS ADJUNCTIVE AGENTS FUSILEV KEPIVANCE leucovorin calcium injection recon soln 100 mg, 350 mg 5 Name leucovorin calcium oral levoleucovorin intravenous recon soln 50 mg levoleucovorin intravenous solution mesna MESNEX ORAL XGEVA 3 3 ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS ABRAXANE adriamycin intravenous solution 20 mg/10 ml adrucil intravenous solution 500 mg/10 ml AFINITOR DISPERZ AFINITOR ORAL TABLET 10 MG AFINITOR ORAL TABLET 2.5 MG, 5 MG, 7.5 MG 3 4 B/D PA; MO 5 PA; MO (62 per 31 5 PA; MO ALECENSA 3 PA; MO; QL (248 per 31 ALIMTA INTRAVENOUS RECON SOLN 500 MG ALUNBRIG 4 PA; MO; LA; QL (186 per 31 anastrozole 10

18 Name ARRANON 3 AVASTIN azacitidine azathioprine 2 B/D PA; MO azathioprine sodium 3 B/D PA BAVENCIO ; LA BELEODAQ bexarotene bicalutamide BICNU bleomycin injection recon soln 30 unit BOSULIF ORAL TABLET 100 MG BOSULIF ORAL TABLET 500 MG busulfan 5 BUSULFEX 4 4 B/D PA; MO 3 PA; MO 3 PA; MO; QL (31 per 31 CABOMETYX 4 PA; MO; LA CAPRELSA ORAL TABLET 100 MG CAPRELSA ORAL TABLET 300 MG carboplatin intravenous solution CELLCEPT INTRAVENOUS 5 PA; MO; LA; QL (93 per 31 5 PA; MO; LA; QL (31 per 31 3 B/D PA; MO cisplatin cladribine 4 B/D PA; MO clofarabine 3 CLOLAR 4 COMETRIQ 5 PA; MO Name COTELLIC 4 PA; MO; LA; QL (63 per 28 CYCLOPHOSPHA MIDE ORAL CAPSULE cyclosporine intravenous cyclosporine modified cyclosporine oral capsule 3 B/D PA; MO 4 B/D PA 3 B/D PA; MO 3 B/D PA; MO CYRAMZA 5 B/D PA; MO cytarabine 2 B/D PA; MO cytarabine (pf) injection solution 2 gram/20 ml (100 mg/ml) dacarbazine intravenous recon soln 200 mg 2 B/D PA; MO DARZALEX ; LA daunorubicin intravenous solution decitabine docetaxel intravenous solution 80 mg/4 ml (20 mg/ml), 80 mg/8 ml (10 mg/ml) doxorubicin intravenous solution 50 mg/25 ml doxorubicin, pegliposomal 11 2 DROXIA

19 Name ELLENCE INTRAVENOUS SOLUTION 200 MG/100 ML EMCYT EMPLICITI 4 B/D PA; MO epirubicin intravenous solution 200 mg/100 ml ERBITUX INTRAVENOUS SOLUTION 100 MG/50 ML ERIVEDGE (31 per 31 ERWINAZE ETOPOPHOS etoposide intravenous exemestane FARESTON FARYDAK ORAL CAPSULE 10 MG FARYDAK ORAL CAPSULE 15 MG, 20 MG (12 per 21 FASLODEX FIRMAGON KIT W DILUENT SYRINGE fludarabine intravenous recon soln fluorouracil intravenous solution 2.5 gram/50 ml (6 per 21 2 B/D PA; MO Name flutamide FOLOTYN INTRAVENOUS SOLUTION 40 MG/2 ML (20 MG/ML) gemcitabine intravenous recon soln 1 gram gengraf oral capsule 100 mg, 25 mg gengraf oral capsule 50 mg 4 B/D PA; MO 3 B/D PA; MO gengraf oral solution 4 B/D PA; MO GILOTRIF ORAL TABLET 20 MG GILOTRIF ORAL TABLET 30 MG GILOTRIF ORAL TABLET 40 MG (62 per 31 (42 per 31 (31 per 31 GLEOSTINE HALAVEN HERCEPTIN INTRAVENOUS RECON SOLN 440 MG HEXALEN hydroxyurea IBRANCE (21 per 28 ICLUSIG ORAL TABLET 15 MG 5 PA; QL (93 12

20 Name ICLUSIG ORAL TABLET 45 MG idarubicin 4 IDHIFA ORAL TABLET 100 MG IDHIFA ORAL TABLET 50 MG ifosfamide intravenous recon soln 1 gram imatinib oral 100 mg imatinib oral 400 mg (31 per 31 5 PA; MO; LA; QL (31 per 31 5 PA; MO; LA; QL (62 per 31 5 PA; MO (62 per 31 IMBRUVICA (124 per 31 IMFINZI ; LA INLYTA ORAL TABLET 1 MG INLYTA ORAL TABLET 5 MG 5 PA; MO (124 per 31 IRESSA 4 PA; MO; QL (31 per 31 irinotecan intravenous solution 100 mg/5 ml ISTODAX JAKAFI ORAL TABLET 10 MG, 15 MG, 20 MG, 5 MG 5 PA; MO Name JAKAFI ORAL TABLET 25 MG (62 per 31 JEVTANA KADCYLA INTRAVENOUS RECON SOLN 100 MG 5 PA; MO KEYTRUDA KISQALI 4 PA; MO KISQALI FEMARA CO-PACK 4 PA; MO KYPROLIS LARTRUVO ; LA LENVIMA 5 PA; MO letrozole LEUKERAN leuprolide subcutaneous kit LONSURF 5 PA; MO LUPRON DEPOT 5 PA; MO LUPRON DEPOT (NTH) LUPRON DEPOT (NTH) LUPRON DEPOT (6 MONTH) LUPRON DEPOT- PED INTRAMUSCULA R KIT MG, 15 MG 5 PA; MO 5 PA; MO 5 PA; MO 5 PA; MO LYNPARZA 5 PA; MO LYSODREN MATULANE 13

21 Name megestrol oral suspension 400 mg/10 ml (40 mg/ml), 625 mg/5 ml 2 PA; MO megestrol oral 2 PA; MO MEKINIST ORAL TABLET 0.5 MG MEKINIST ORAL TABLET 2 MG melphalan hcl 3 (124 per 31 (31 per 31 mercaptopurine methotrexate sodium 2 B/D PA; MO methotrexate sodium (pf) injection recon soln methotrexate sodium (pf) injection solution 3 B/D PA 2 B/D PA; MO mitomycin mitoxantrone MUSTARGEN mycophenolate mofetil hcl mycophenolate mofetil oral capsule mycophenolate mofetil oral suspension for reconstitution mycophenolate mofetil oral mycophenolate sodium oral,delayed release (dr/ec) 180 mg 3 B/D PA 2 B/D PA; MO 3 B/D PA; MO 2 B/D PA; MO 2 B/D PA; MO Name mycophenolate sodium oral,delayed release (dr/ec) 360 mg 3 B/D PA; MO NERLYNX 5 PA; MO; LA NEXAVAR 5 PA; MO; LA; QL (120 per 30 NILANDRON nilutamide NINLARO ORAL CAPSULE 2.3 MG NINLARO ORAL CAPSULE 3 MG NINLARO ORAL CAPSULE 4 MG NIPENT (6 per 28 (4 per 28 (3 per 28 NULOJIX 5 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 5 PA; MO; LA; QL (31 per 31 OPDIVO INTRAVENOUS SOLUTION 40 MG/4 ML oxaliplatin intravenous solution 100 mg/20 ml paclitaxel 14

22 Name PERJETA POMALYST PROGRAF INTRAVENOUS 3 B/D PA; MO PURIXAN RAPAMUNE ORAL SOLUTION 5 B/D PA; MO REVLIMID 5 PA; MO; LA RITUXAN 5 PA; MO RUBRACA ORAL TABLET 200 MG RUBRACA ORAL TABLET 300 MG 5 PA; MO; LA; QL (186 per 31 5 PA; MO; LA; QL (124 per 31 RYDAPT 5 PA; MO SIGNIFOR SIMULECT INTRAVENOUS RECON SOLN 20 MG sirolimus oral 0.5 mg sirolimus oral 1 mg, 2 mg 3 B/D PA; MO 2 B/D PA; MO 3 B/D PA; MO SOLTAMOX SOMATULINE DEPOT SPRYCEL ORAL TABLET 100 MG, 20 MG, 50 MG, 80 MG SPRYCEL ORAL TABLET 140 MG SPRYCEL ORAL TABLET 70 MG 5 PA; MO (31 per 31 (62 per 31 Name STIVARGA (84 per 28 SUTENT ORAL CAPSULE 12.5 MG SUTENT ORAL CAPSULE 25 MG, 37.5 MG SUTENT ORAL CAPSULE 50 MG SYLVANT INTRAVENOUS RECON SOLN 100 MG 5 PA; MO (62 per 31 (31 per 31 SYNRIBO TABLOID tacrolimus oral 3 B/D PA; MO TAFINLAR ORAL CAPSULE 50 MG TAFINLAR ORAL CAPSULE 75 MG TAGRISSO ORAL TABLET 40 MG TAGRISSO ORAL TABLET 80 MG (186 per 31 (124 per 31 5 PA; MO; LA; QL (62 per 31 5 PA; MO; LA; QL (31 per 31 tamoxifen TARCEVA ORAL TABLET 100 MG, 25 MG TARCEVA ORAL TABLET 150 MG TARGRETIN TOPICAL 5 PA; MO (31 per 31 15

23 Name TASIGNA ORAL CAPSULE 150 MG TASIGNA ORAL CAPSULE 200 MG 5 PA; MO (112 per 28 TECENTRIQ ; LA THALOMID 5 PA; MO thiotepa toposar topotecan intravenous recon soln TORISEL TREANDA INTRAVENOUS RECON SOLN 100 MG 4 TRELSTAR tretinoin (chemotherapy) TRISENOX TYKERB 5 PA; MO; LA; QL (186 per 31 VECTIBIX INTRAVENOUS SOLUTION 100 MG/5 ML (20 MG/ML) 5 B/D PA; MO VELCADE VENCLEXTA 4 PA; MO; LA VENCLEXTA STARTING PACK vinblastine intravenous solution 4 PA; MO; LA; QL (42 per 28 2 B/D PA; MO Name vincasar pfs intravenous solution 1 mg/ml vincristine intravenous solution 1 mg/ml vinorelbine intravenous solution 50 mg/5 ml 2 B/D PA 2 B/D PA; MO VOTRIENT (124 per 31 VYXEOS 5 B/D PA; MO XALKORI ORAL CAPSULE 200 MG XALKORI ORAL CAPSULE 250 MG 5 PA; MO (62 per 31 XATMEP 4 B/D PA; MO XERMELO 5 PA; MO; LA; QL (93 per 31 XTANDI 4 PA; MO; QL (124 per 31 YERVOY INTRAVENOUS SOLUTION 50 MG/10 ML (5 MG/ML) YONDELIS ZALTRAP INTRAVENOUS SOLUTION 100 MG/4 ML (25 MG/ML) ZANOSAR 16

24 Name ZEJULA 5 PA; MO; LA; QL (93 per 31 ZELBORAF 4 PA; MO; QL (248 per 31 ZOLINZA ZORTRESS 5 B/D PA; MO ZYDELIG (93 per 31 ZYKADIA (155 per 31 ZYTIGA ORAL TABLET 250 MG ZYTIGA ORAL TABLET 500 MG (124 per 31 (62 per 31 AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH ANTICONVULSANTS APTIOM ORAL TABLET 200 MG, 400 MG, 800 MG APTIOM ORAL TABLET 600 MG BANZEL ORAL SUSPENSION BANZEL ORAL TABLET 200 MG BANZEL ORAL TABLET 400 MG BRIVIACT INTRAVENOUS BRIVIACT ORAL 4 Name carbamazepine oral capsule, er multiphase 12 hr carbamazepine oral suspension 100 mg/5 ml carbamazepine oral carbamazepine oral extended release 12 hr carbamazepine oral,chewable CELONTIN ORAL CAPSULE 300 MG clonazepam oral clonazepam oral,disintegrating 2 PA; MO 3 PA; MO DIASTAT DIASTAT ACUDIAL diazepam rectal kit 2.5 mg, mg DILANTIN 30 MG divalproex oral capsule, delayed rel sprinkle divalproex oral extended release 24 hr divalproex oral,delayed release (dr/ec) epitol ethosuximide felbamate 17

25 Name fosphenytoin injection solution 100 mg pe/2 ml FYCOMPA ORAL SUSPENSION FYCOMPA ORAL TABLET gabapentin oral capsule gabapentin oral solution 250 mg/5 ml gabapentin oral 600 mg, 800 mg GABITRIL ORAL TABLET 12 MG, 16 MG LAMICTAL STARTER (BLUE) KIT LAMICTAL STARTER (GREEN) KIT LAMICTAL STARTER (ORANGE) KIT lamotrigine oral lamotrigine oral, chewable dispersible lamotrigine oral,disintegrating levetiracetam in nacl (iso-os) intravenous piggyback 1,000 mg/100 ml, 1,500 mg/100 ml 3 Name levetiracetam in nacl (iso-os) intravenous piggyback 500 mg/100 ml levetiracetam intravenous levetiracetam oral solution 100 mg/ml levetiracetam oral LYRICA ONFI ORAL SUSPENSION ONFI ORAL TABLET 10 MG ONFI ORAL TABLET 20 MG oxcarbazepine oral suspension oxcarbazepine oral 3 PA; MO 3 PA; MO 5 PA; MO PEGANONE phenobarbital oral elixir phenobarbital oral phenytoin oral suspension 125 mg/5 ml phenytoin oral,chewable phenytoin sodium extended phenytoin sodium intravenous solution primidone roweepra oral 1,000 mg, 750 mg 18 3

26 Name roweepra oral 500 mg SABRIL ; LA SPRITAM tiagabine topiramate oral capsule, sprinkle topiramate oral 3 PA; MO 1 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 3 zonisamide 3 PA; MO ANTIPARKINSONISM AGENTS APOKYN ; LA AZILECT benztropine injection benztropine oral bromocriptine carbidopa carbidopa-levodopa oral carbidopa-levodopa oral extended release Name carbidopa-levodopa oral,disintegrating carbidopa-levodopaentacapone entacapone NEUPRO pramipexole oral pramipexole oral extended release 24 hr mg, 2.25 mg, 3 mg, 3.75 mg, 4.5 mg pramipexole oral extended release 24 hr 0.75 mg, 1.5 mg ropinirole oral ropinirole oral extended release 24 hr selegiline hcl tolcapone trihexyphenidyl ZELAPAR MIGRAINE / CLUSTER HEADACHE THERAPY dihydroergotamine injection dihydroergotamine nasal ergotamine-caffeine migergot ; QL (8 per 28 naratriptan ; QL (18 per 28 19

27 Name 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 sumatriptan succinate subcutaneous syringe 6 mg/0.5 ml ; 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 (8 per 28 zolmitriptan ; QL (18 per 28 MISCELLANEOUS NEUROLOGICAL THERAPY AMPYRA 5 PA; MO; LA COPAXONE SUBCUTANEOUS SYRINGE 40 MG/ML donepezil oral 10 mg, 5 mg donepezil oral 23 mg (12 per 28 Name donepezil oral,disintegrating galantamine oral capsule,ext rel. pellets 24 hr galantamine oral solution galantamine oral glatopa (30 per 30 memantine oral solution memantine oral MEMANTINE ORAL TABLETS,DOSE PACK NAMENDA TITRATION PAK 3 PA; MO 3 PA; MO 3 PA; MO 3 PA; MO NAMENDA XR 3 PA; MO NAMZARIC 3 PA; MO NUEDEXTA RADICAVA 5 PA; MO rivastigmine rivastigmine tartrate TECFIDERA 5 PA; MO tetrabenazine 5 PA; MO TYSABRI 5 PA; MO; LA MUSCLE RELAXANTS / ANTISPASMODIC THERAPY baclofen cyclobenzaprine oral 20

28 Name dantrolene LIORESAL INTRATHECAL SOLUTION 2,000 MCG/ML LIORESAL INTRATHECAL SOLUTION 500 MCG/ML MESTINON ORAL SYRUP pyridostigmine bromide tizanidine oral capsule 5 B/D PA; MO 3 B/D PA; MO tizanidine oral NARCOTIC ANALGESICS acetaminophencodeine oral solution mg/5 ml acetaminophencodeine oral mg, mg acetaminophencodeine oral mg buprenorphine hcl injection solution buprenorphine hcl injection syringe buprenorphine hcl sublingual ; QL (4650 ; QL (372 ; QL (186 ; QL (276 4 QL (276 per 31 BUTRANS ; QL (4 per 28 codeine sulfate oral ; QL (186 Name duramorph (pf) injection solution 0.5 mg/ml duramorph (pf) injection solution 1 mg/ml endocet oral mg, mg, mg fentanyl citrate buccal lozenge on a handle 1,200 mcg fentanyl citrate buccal lozenge on a handle 1,600 mcg fentanyl citrate buccal lozenge on a handle 200 mcg fentanyl citrate buccal lozenge on a handle 400 mcg fentanyl citrate buccal lozenge on a handle 600 mcg fentanyl citrate buccal lozenge on a handle 800 mcg fentanyl transdermal patch 72 hour 100 mcg/hr fentanyl transdermal patch 72 hour 12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr hydrocodoneacetaminophen oral solution mg/15 ml ; QL (4134 per 30 4 QL (2067 per 30 ; QL (372 3 PA; MO; QL (40 per 31 3 PA; MO; QL (30 per 31 3 PA; MO; QL (124 per 31 3 PA; MO; QL (120 per 31 3 PA; MO; QL (80 per 31 3 PA; MO; QL (60 per 31 ; QL (9 per 30 ; QL (10 per 30 ; QL (

29 Name hydrocodoneacetaminophen oral mg, mg, mg, mg, mg, mg, mg hydrocodoneibuprofen oral mg, mg hydrocodoneibuprofen oral mg ; QL (372 ; QL (52 ; QL (52 hydromorphone (pf) ; QL (248 hydromorphone injection syringe 2 mg/ml hydromorphone oral liquid hydromorphone oral methadone injection solution methadone oral solution 10 mg/5 ml methadone oral solution 5 mg/5 ml methadone oral 10 mg methadone oral 5 mg morphine concentrate oral solution morphine intravenous syringe 2 mg/ml 4 QL (1240 per 31 ; QL (1550 ; QL (186 4 QL (160 per 31 ; QL (620 ; QL (1240 ; QL (124 ; QL (248 ; QL (310 4 QL (1034 per 31 Name morphine intravenous syringe 4 mg/ml morphine oral capsule, er multiphase 24 hr 120 mg morphine oral capsule, er multiphase 24 hr 30 mg, 45 mg, 60 mg, 75 mg morphine oral capsule, er multiphase 24 hr 90 mg morphine oral capsule,extend.relea se pellets 10 mg, 20 mg, 30 mg, 50 mg, 60 mg morphine oral capsule,extend.relea se pellets 100 mg morphine oral capsule,extend.relea se pellets 80 mg morphine oral solution 4 QL (517 per 31 ; QL (52 ; QL (62 ; QL (62 ; QL (93 ; QL (62 ; QL (78 ; QL (930 morphine oral ; QL (186 morphine oral extended release 100 mg morphine oral extended release 15 mg, 30 mg morphine oral extended release 200 mg ; QL (62 ; QL (124 ; QL (31 22

30 Name morphine oral extended release 60 mg oxycodone oral capsule oxycodone oral concentrate oxycodone oral solution oxycodone oral 10 mg, 15 mg, 20 mg oxycodone oral 30 mg oxycodone oral 5 mg oxycodoneacetaminophen oral mg, mg, mg, mg ; QL (103 ; QL (372 ; QL (186 ; QL (1240 ; QL (186 ; QL (139 ; QL (372 ; QL (372 oxycodone-aspirin ; QL (372 oxymorphone oral extended release 12 hr 10 mg, 15 mg, 20 mg, 5 mg, 7.5 mg oxymorphone oral extended release 12 hr 30 mg oxymorphone oral extended release 12 hr 40 mg ; QL (93 ; QL (70 ; QL (52 zamicet 4 QL (5735 per 31 NON-NARCOTIC ANALGESICS butorphanol tartrate nasal ; QL (5 per 28 Name celecoxib diclofenac potassium diclofenac sodium oral diclofenac sodium topical drops diclofenac sodium topical gel 1 % diflunisal etodolac oral capsule etodolac oral etodolac oral extended release 24 hr fenoprofen oral flurbiprofen ibuprofen oral suspension ibuprofen oral 400 mg, 600 mg, 800 mg ketoprofen oral capsule ketoprofen oral capsule,ext rel. pellets 24 hr 200 mg meclofenamate mefenamic acid meloxicam oral 15 mg meloxicam oral 7.5 mg ; QL (31 nabumetone naloxone injection solution 23

31 Name naloxone injection syringe 1 mg/ml naltrexone naproxen oral suspension naproxen oral naproxen oral,delayed release (dr/ec) naproxen sodium oral 275 mg, 550 mg naproxen sodium oral, er multiphase 24 hr NARCAN NASAL SPRAY,NON- AEROSOL 4 MG/ACTUATION oxaprozin piroxicam SUBOXONE SUBLINGUAL FILM 12-3 MG SUBOXONE SUBLINGUAL FILM MG SUBOXONE SUBLINGUAL FILM 4-1 MG, 8-2 MG ; QL (2 per 28 ; QL (62 ; QL (372 ; QL (93 sulindac tolmetin oral capsule tolmetin oral 600 mg tramadol oral ; QL (248 Name VOLTAREN GEL TOPICAL GEL 1 % PSYCHOTHERAPEUTIC DRUGS ABILIFY MAINTENA amitriptyline 2 PA; MO amoxapine aripiprazole oral 10 mg aripiprazole oral 15 mg aripiprazole oral 2 mg aripiprazole oral 20 mg aripiprazole oral 30 mg aripiprazole oral 5 mg aripiprazole oral,disintegrating 10 mg aripiprazole oral,disintegrating 15 mg ; QL (93 ; QL (62 ; QL (465 ; QL (62 ; QL (31 ; QL (186 ; QL (93 ; QL (62 atomoxetine bupropion hcl oral bupropion hcl oral extended release 12 hr 100 mg bupropion hcl oral extended release 12 hr 150 mg bupropion hcl oral extended release 12 hr 200 mg ; QL (124 ; QL (93 ; QL (62 24

32 Name bupropion hcl oral extended release 24 hr 150 mg bupropion hcl oral extended release 24 hr 300 mg ; QL (93 ; QL (62 buspirone chlorpromazine citalopram oral solution citalopram oral 10 mg citalopram oral 20 mg citalopram oral 40 mg ; QL (124 ; QL (62 ; QL (31 clomipramine 4 PA; MO clorazepate dipotassium 4 PA; MO clozapine oral clozapine oral,disintegrating 100 mg, 12.5 mg, 25 mg desipramine desvenlafaxine succinate oral extended release 24 hr 100 mg desvenlafaxine succinate oral extended release 24 hr 25 mg desvenlafaxine succinate oral extended release 24 hr 50 mg 4 ; QL (124 ; QL (496 ; QL (248 Name dextroamphetamine oral capsule, extended release dextroamphetamine oral dextroamphetamineamphetamine oral capsule,extended release 24hr diazepam intensol 2 PA; MO diazepam oral solution 5 mg/5 ml (1 mg/ml) 2 PA; MO diazepam oral 2 PA; MO doxepin oral 2 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 (186 ; QL (124 ; QL (93 ; QL (62 EMSAM ergoloid escitalopram oxalate oral solution escitalopram oxalate oral 10 mg escitalopram oxalate oral 20 mg escitalopram oxalate oral 5 mg ; QL (62 ; QL (31 ; QL (124 25

33 Name FANAPT ORAL TABLET 1 MG FANAPT ORAL TABLET 10 MG, 8 MG FANAPT ORAL TABLET 12 MG FANAPT ORAL TABLET 2 MG FANAPT ORAL TABLET 4 MG FANAPT ORAL TABLET 6 MG FANAPT ORAL TABLETS,DOSE PACK FAZACLO ORAL TABLET,DISINTE GRATING 150 MG, 200 MG FETZIMA ORAL CAPSULE,EXT REL 24HR DOSE PACK FETZIMA ORAL CAPSULE,EXTEN DED RELEASE 24 HR 120 MG FETZIMA ORAL CAPSULE,EXTEN DED RELEASE 24 HR 20 MG FETZIMA ORAL CAPSULE,EXTEN DED RELEASE 24 HR 40 MG FETZIMA ORAL CAPSULE,EXTEN DED RELEASE 24 HR 80 MG ; QL (744 ; QL (93 ; QL (62 ; QL (372 ; QL (186 ; QL (124 ; QL (8 per 28 4 ; QL (28 per 28 ; QL (31 ; QL (186 ; QL (93 ; QL (47 Name fluoxetine oral capsule 10 mg fluoxetine oral capsule 20 mg fluoxetine oral capsule 40 mg fluoxetine oral solution fluoxetine oral 10 mg fluoxetine oral 20 mg fluphenazine decanoate ; QL (248 ; QL (62 ; QL (248 fluphenazine hcl fluvoxamine oral 100 mg fluvoxamine oral 25 mg fluvoxamine oral 50 mg GEODON INTRAMUSCULA R guanfacine oral extended release 24 hr ; QL (93 ; QL (372 ; QL (186 haloperidol haloperidol decanoate haloperidol lactate HETLIOZ (31 per 31 imipramine hcl 2 PA; MO imipramine pamoate 4 PA; MO 26

34 Name INVEGA SUSTENNA INTRAMUSCULA R SYRINGE 117 MG/0.75 ML, 156 MG/ML, 39 MG/0.25 ML, 78 MG/0.5 ML INVEGA SUSTENNA INTRAMUSCULA R SYRINGE 234 MG/1.5 ML INVEGA TRINZA LATUDA ORAL TABLET 120 MG LATUDA ORAL TABLET 20 MG LATUDA ORAL TABLET 40 MG LATUDA ORAL TABLET 60 MG, 80 MG ; QL (31 ; QL (248 ; QL (124 ; QL (62 lithium carbonate lithium citrate oral solution 8 meq/5 ml lorazepam intensol 3 PA; MO lorazepam oral 2 PA; MO loxapine succinate maprotiline MARPLAN methylphenidate hcl oral capsule, er biphasic methylphenidate hcl oral capsule,er biphasic mg, 40 mg, 60 mg Name methylphenidate hcl oral solution 10 mg/5 ml methylphenidate hcl oral solution 5 mg/5 ml methylphenidate hcl oral mirtazapine oral mirtazapine oral,disintegrating modafinil 3 PA; MO nefazodone nortriptyline NUPLAZID olanzapine intramuscular olanzapine oral 10 mg olanzapine oral 15 mg, 20 mg olanzapine oral 2.5 mg olanzapine oral 5 mg olanzapine oral 7.5 mg olanzapine oral,disintegrating 10 mg olanzapine oral,disintegrating 15 mg, 20 mg olanzapine oral,disintegrating 5 mg ; QL (62 ; QL (31 ; QL (248 ; QL (124 ; QL (83 ; QL (62 ; QL (31 ; QL (124 oxazepam 3 PA; MO 27

35 Name paliperidone oral extended release 24hr 1.5 mg paliperidone oral extended release 24hr 3 mg paliperidone oral extended release 24hr 6 mg paliperidone oral extended release 24hr 9 mg paroxetine hcl oral 10 mg paroxetine hcl oral 20 mg paroxetine hcl oral 30 mg paroxetine hcl oral 40 mg PAXIL ORAL SUSPENSION ; QL (248 ; QL (124 ; QL (62 ; QL (42 ; QL (186 ; QL (93 ; QL (62 ; QL (47 perphenazine phenelzine pimozide PRISTIQ ORAL TABLET EXTENDED RELEASE 24 HR 100 MG PRISTIQ ORAL TABLET EXTENDED RELEASE 24 HR 25 MG ; QL (124 ; QL (496 Name PRISTIQ ORAL TABLET EXTENDED RELEASE 24 HR 50 MG ; QL (248 protriptyline quetiapine oral 100 mg quetiapine oral 200 mg quetiapine oral 25 mg quetiapine oral 300 mg quetiapine oral 400 mg quetiapine oral 50 mg quetiapine oral extended release 24 hr 150 mg quetiapine oral extended release 24 hr 200 mg quetiapine oral extended release 24 hr 300 mg quetiapine oral extended release 24 hr 400 mg quetiapine oral extended release 24 hr 50 mg REXULTI ORAL TABLET 0.25 MG REXULTI ORAL TABLET 0.5 MG REXULTI ORAL TABLET 1 MG ; QL (248 ; QL (124 ; QL (932 ; QL (83 ; QL (62 ; QL (496 ; QL (166 ; QL (124 ; QL (83 ; QL (62 ; QL (496 ; QL (496 ; QL (248 ; QL (124 28

36 Name REXULTI ORAL TABLET 2 MG REXULTI ORAL TABLET 3 MG REXULTI ORAL TABLET 4 MG RISPERDAL CONSTA INTRAMUSCULA R SYRINGE 12.5 MG/2 ML, 25 MG/2 ML RISPERDAL CONSTA INTRAMUSCULA R SYRINGE 37.5 MG/2 ML, 50 MG/2 ML risperidone oral solution risperidone oral 0.25 mg risperidone oral 0.5 mg risperidone oral 1 mg risperidone oral 2 mg risperidone oral 3 mg risperidone oral 4 mg risperidone oral,disintegrating 0.25 mg risperidone oral,disintegrating 0.5 mg ; QL (62 ; QL (42 ; QL (31 ; QL (496 ; QL (1984 ; QL (992 ; QL (496 ; QL (248 ; QL (166 ; QL (124 ; QL (1984 ; QL (992 Name risperidone oral,disintegrating 1 mg risperidone oral,disintegrating 2 mg risperidone oral,disintegrating 3 mg risperidone oral,disintegrating 4 mg RITALIN LA ORAL CAPSULE,ER BIPHASIC MG ; QL (496 ; QL (248 ; QL (166 ; QL (124 ROZEREM ; QL (31 SAPHRIS (BLACK CHERRY) SUBLINGUAL TABLET 10 MG SAPHRIS (BLACK CHERRY) SUBLINGUAL TABLET 2.5 MG SAPHRIS (BLACK CHERRY) SUBLINGUAL TABLET 5 MG SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR 150 MG SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR 200 MG ; QL (62 ; QL (248 ; QL (124 ; QL (166 ; QL (124 29

37 Name SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR 300 MG SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR 400 MG SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR 50 MG sertraline oral concentrate sertraline oral 100 mg sertraline oral 25 mg sertraline oral 50 mg ; QL (83 ; QL (62 ; QL (496 ; QL (62 ; QL (248 ; QL (124 STRATTERA temazepam 3 PA; MO thioridazine thiothixene tranylcypromine trazodone trifluoperazine trimipramine 3 PA; MO TRINTELLIX ORAL TABLET 10 MG TRINTELLIX ORAL TABLET 20 MG ; QL (62 ; QL (31 Name TRINTELLIX ORAL TABLET 5 MG venlafaxine oral capsule,extended release 24hr 150 mg venlafaxine oral capsule,extended release 24hr 37.5 mg venlafaxine oral capsule,extended release 24hr 75 mg venlafaxine oral 100 mg, 75 mg venlafaxine oral 25 mg venlafaxine oral 37.5 mg venlafaxine oral 50 mg VERSACLOZ 5 VIIBRYD ORAL TABLET 10 MG VIIBRYD ORAL TABLET 20 MG VIIBRYD ORAL TABLET 40 MG VIIBRYD ORAL TABLETS,DOSE PACK 10 MG (7)- 20 MG (23) VRAYLAR ORAL CAPSULE 1.5 MG VRAYLAR ORAL CAPSULE 3 MG VRAYLAR ORAL CAPSULE 4.5 MG ; QL (124 ; QL (62 ; QL (186 ; QL (93 ; QL (93 ; QL (279 ; QL (186 ; QL (155 ; QL (124 ; QL (62 ; QL (31 ; QL (30 per 180 ; QL (124 ; QL (62 ; QL (42 30

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