LEGEND SYMBOL NAME DESCRIPTION. There is a limit on the amount of this drug that is covered per prescription, or within a specific time frame.

Transcription

1 LEGEND TIER NAME 1 Covered SYMBOL NAME DESCRIPTION QL Quantity Limit There is a limit on the amount of this drug that is covered per prescription, or within a specific time frame. PA ST Prior Authorization Step Therapy You (or your physician) are required to get prior authorization before you fill your prescription for this drug. Without prior approval, we may not cover this drug. In some cases, you may be required to first try certain drugs to treat your medical condition before we will cover another drug for that condition. LA Limited Access This prescription drug is limited to certain pharmacies. PA B vs D Prior Authorization- Part B vs. Part D Medicare Part B vs. Part D determination required. 1

2 2018 ALOHACARE ADVANTAGE PLUS FORMULARY (HMO SNP) (List of Covered Drugs) DRUG NAME DRUG TIER REQUIREMENTS/LIMITS ANTI - INFECTIVES ANTIFUNGAL AGENTS ABELCET 100 MG/20 ML VIAL PA B vs D AMBISOME 50 MG VIAL PA B vs D amphotericin b 50 mg vial PA B vs D CANCIDAS (IV 50 MG VIAL, IV 70 MG VIAL) PA B vs D caspofungin acetate 50 mg vial PA B vs D clotrimazole 10 mg troche CRESEMBA (186 MG CAPSULE, 372 MG VIAL) fluconazole (10 mg/ml susp recon, 40 mg/ml susp recon, 50 mg tablet, 100 mg tablet, 150 mg tablet, 200 mg tablet) fluconazole in sodium chloride, isoosmotic (200mg/0.1l piggyback, 200mg/0.1l pggybk btl, 400mg/0.2l pggybk btl, 400mg/0.2l piggyback) flucytosine (250 mg capsule, 500 mg capsule) griseofulvin ultramicrosize (125 mg tablet, 250 mg tablet) griseofulvin, microsize (125 mg/5ml oral susp, 500 mg tablet) itraconazole 100 mg capsule ketoconazole 200 mg tablet MYCAMINE (50 MG VIAL, 100 MG VIAL) NOXAFIL (40 MG/ML SUSPENSION, DR 100 MG TABLET) nystatin (150mm unit powder(ea), 500mm unit powder(ea), 500k unit tablet, /ml oral susp) 2

3 ORAVIG 50 MG BUCCAL TABLET SPORANOX 10 MG/ML SOLUTION terbinafine hcl 250 mg tablet voriconazole (50 mg tablet, 200 mg/5ml susp recon, 200 mg vial, 200 mg tablet) ANTIVIRALS abacavir sulfate (20 mg/ml solution, 300 mg tablet) abacavir sulfate/lamivudine mg tablet abacavir/lamivudine/zidovudine mg tablet acyclovir (200 mg/5ml oral susp, 200 mg capsule, 400 mg tablet, 800 mg tablet) acyclovir sodium 50 mg/ml vial PA B vs D adefovir dipivoxil 10 mg tablet amantadine hcl (50 mg/5 ml solution, 100 mg tablet, 100 mg capsule) APTIVUS (100 MG/ML SOLUTION, 250 MG CAPSULE) atazanavir sulfate (150 mg capsule, 200 mg capsule, 300 mg capsule) ATRIPLA TABLET BARACLUDE 0.05 MG/ML SOLUTION BIKTARVY MG TABLET cidofovir 75 mg/ml vial PA B vs D COMPLERA TABLET CRIXIVAN (200 MG CAPSULE, 400 MG CAPSULE) DESCOVY MG TABLET didanosine (125 mg capsule dr, 200 mg capsule dr, 250 mg capsule dr, 400 mg capsule dr) 3

4 EDURANT 25 MG TABLET efavirenz (50 mg capsule, 200 mg capsule, 600 mg tablet) EMTRIVA (10 MG/ML SOLUTION, 200 MG CAPSULE) entecavir (0.5 mg tablet, 1 mg tablet) EPCLUSA 400 MG-100 MG TABLET EPIVIR HBV 25 MG/5 ML SOLN EVOTAZ 300 MG-150 MG TABLET famciclovir (125 mg tablet, 250 mg tablet, 500 mg tablet) fosamprenavir calcium 700 mg tablet FUZEON 90 MG VIAL ganciclovir sodium 500 mg vial PA B vs D GENVOYA TABLET PA, QL (28 PER 28 DAYS) HARVONI MG TABLET PA, QL (28 PER 28 DAYS) INTELENCE (25 MG TABLET, 100 MG TABLET, 200 MG TABLET) INVIRASE (200 MG CAPSULE, 500 MG TABLET) ISENTRESS (25 MG TABLET CHEW, 100 MG POWDER PACKET, 100 MG TABLET CHEW, 400 MG TABLET) JULUCA MG TABLET KALETRA ( MG TABLET, MG TABLET) lamivudine (10 mg/ml solution, 100 mg tablet, 150 mg tablet, 300 mg tablet) lamivudine/zidovudine mg tablet LEXIVA (50 MG/ML SUSPENSION, 700 MG TABLET) 4

5 lopinavir/ritonavir /5 solution MODERIBA (200 MG TABLET, MG DOSEPACK, MG DOSEPACK) nevirapine (50 mg/5 ml oral susp, 100 mg tab er 24h, 200 mg tablet, 400 mg tab er 24h) NORVIR (80 MG/ML SOLUTION, 100 MG SOFTGEL CAP, 100 MG TABLET) ODEFSEY TABLET oseltamivir phosphate (6 mg/ml susp recon, 30 mg capsule, 45 mg capsule, 75 mg capsule) PREVYMIS (240 MG TABLET, 240 MG/12 ML VIAL, 480 MG TABLET, 480 MG/24 ML VIAL) PREZCOBIX 800 MG-150 MG TABLET PREZISTA (75 MG TABLET, 100 MG/ML SUSPENSION, 150 MG TABLET, 600 MG TABLET, 800 MG TABLET) REBETOL 40 MG/ML SOLUTION RELENZA 5 MG DISKHALER RESCRIPTOR (100 MG TABLET, 200 MG TABLET) RETROVIR 200 MG/20 ML VIAL REYATAZ (50 MG POWDER PACKET, 150 MG CAPSULE, 200 MG CAPSULE, 300 MG CAPSULE) RIBASPHERE (200 MG CAPSULE, 200 MG TABLET, 400 MG TABLET, 600 MG TABLET) RIBASPHERE RIBAPAK ( MG, MG, MG, MG) ribavirin (200 mg capsule, 200 mg tablet) 5

6 rimantadine hcl 100 mg tablet SELZENTRY (20 MG/ML ORAL SOLN, 25 MG TABLET, 75 MG TABLET, 150 MG TABLET, 300 MG TABLET) stavudine (15 mg capsule, 20 mg capsule, 30 mg capsule, 40 mg capsule) STRIBILD TABLET SUSTIVA (50 MG CAPSULE, 200 MG CAPSULE, 600 MG TABLET) SYNAGIS 50 MG/0.5 ML VIAL LA TAMIFLU (6 MG/ML SUSPENSION, 30 MG CAPSULE, 45 MG CAPSULE, 75 MG CAPSULE) tenofovir disoproxil fumarate 300 mg tablet TIVICAY (10 MG TABLET, 25 MG TABLET, 50 MG TABLET) TRIUMEQ TABLET TRUVADA (100 MG-150 MG TABLET, 133 MG-200 MG TABLET, 167 MG-250 MG TABLET, 200 MG-300 MG TABLET) valacyclovir hcl 1000 mg tablet QL (120 PER 30 DAYS) valacyclovir hcl 500 mg tablet QL (60 PER 30 DAYS) valganciclovir hcl (50 mg/ml soln recon, 450 mg tablet) VEMLIDY 25 MG TABLET VIDEX (2 GM SOLN, 4 GM SOLN) VIDEX EC 125 MG CAPSULE VIRACEPT (250 MG TABLET, 625 MG TABLET) VIREAD (150 MG TABLET, 200 MG TABLET, 250 MG TABLET, 300 MG TABLET, POWDER) 6

7 ZEPATIER MG TABLET PA, QL (28 PER 28 DAYS) ZERIT 1 MG/ML SOLUTION ZIAGEN 20 MG/ML SOLUTION zidovudine (10 mg/ml syrup, 100 mg capsule, 300 mg tablet) CEPHALOSPORINS cefaclor (125 mg/5ml susp recon, 250 mg capsule, 250 mg/5ml susp recon, 375 mg/5ml susp recon, 500 mg capsule, 500 mg tab er 12h) cefadroxil (1 g tablet, 250 mg/5ml susp recon, 500 mg/5ml susp recon, 500 mg capsule) cefazolin sodium (1 g vial port, 1 g vial, 10 g vial, 20 g vial, 100 g bulkbaginj, 300g bulkbaginj, 500 mg vial) cefdinir (125 mg/5ml susp recon, 250 mg/5ml susp recon, 300 mg capsule) cefepime hcl (1 g vial, 2 g vial) cefixime (100 mg/5ml susp recon, 200 mg/5ml susp recon) cefotaxime sodium (1 g vial, 2 g vial, 500 mg vial) cefotetan disodium (1 g vial, 2 g vial) cefoxitin sodium (1 g vial, 2 g vial, 10 g vial) cefpodoxime proxetil (50 mg/5 ml susp recon, 100 mg tablet, 100 mg/5ml susp recon, 200 mg tablet) cefprozil (125 mg/5ml susp recon, 250 mg tablet, 250 mg/5ml susp recon, 500 mg tablet) ceftazidime (1 g vial, 2 g vial, 6 g vial) ceftriaxone sodium (1 g vial, 1 g vial port, 2 g vial port, 2 g vial, 10 g vial, 100 g bulkbaginj, 250 mg vial, 500 mg vial) 7

8 cefuroxime axetil (250 mg tablet, 500 mg tablet) cefuroxime sodium (1.5 g vial, 7.5 g vial, 750 mg vial) cephalexin (125 mg/5ml susp recon, 250 mg/5ml susp recon, 250 mg capsule, 250 mg tablet, 500 mg tablet, 500 mg capsule, 750 mg capsule) SUPRAX (100 MG TABLET CHEWABLE, 200 MG TABLET CHEWABLE, 400 MG CAPSULE, 500 MG/5 ML SUSPENSION) TEFLARO (400 MG VIAL, 600 MG VIAL) ERYTHROMYCINS / OTHER MACROLIDES azithromycin (1 g packet, 100 mg/5ml susp recon, 200 mg/5ml susp recon, 250 mg tablet, 500 mg tablet, 500 mg vial port, 500 mg vial, 600 mg tablet) clarithromycin (125 mg/5ml susp recon, 250 mg tablet, 250 mg/5ml susp recon, 500 mg tab er 24h, 500 mg tablet) E.E.S. 400 FILMTAB ERY-TAB (DR 250 MG TABLET, DR 333 MG TABLET, DR 500 MG TABLET) ERYTHROCIN 250 MG FILMTAB ERYTHROCIN LACTOBIONATE (500 MG VIAL, 500 MG ADDVNT VL) erythromycin base (250 mg tablet, 250 mg capsule dr, 500 mg tablet) erythromycin ethylsuccinate (200 mg/5ml susp recon, 400 mg tablet) MISCELLANEOUS ANTIINFECTIVES ALBENZA 200 MG TABLET 8

9 ALINIA (100 MG/5 ML SUSPENSION, 500 MG TABLET) amikacin sulfate 500 mg/2ml vial atovaquone 750 mg/5ml oral susp atovaquone/proguanil hcl (atovaquone/proguanil mg tablet, atovaquone/proguanil mg tablet) aztreonam 1 g vial BACIIM 50,000 UNIT VIAL bacitracin unit vial BETHKIS 300 MG/4 ML AMPULE PA B vs D, QL (224 PER 28 DAYS) BILTRICIDE 600 MG TABLET CAPASTAT SULFATE 1 GM VIAL CAYSTON 75 MG INHAL SOLUTION chloramphenicol sod succinate 1 g vial chloroquine phosphate (250 mg tablet, 500 mg tablet) clindamycin hcl (75 mg capsule, 150 mg capsule, 300 mg capsule) clindamycin palmitate hcl 75 mg/5 ml soln recon clindamycin phosphate (150 mg/ml vial, 600 mg/4ml vial port) clindamycin phosphate/dextrose 5 % in water (phosphate/d5w 900mg/50ml piggyback, phosphate/d5w 600mg/50ml piggyback, phosphate/d5w 300mg/50ml piggyback) COARTEM TABLETS colistin (colistimethate na) 150 mg vial dapsone (25 mg tablet, 100 mg tablet) LA, QL (84 PER 28 DAYS) 9

10 daptomycin 500 mg vial DARAPRIM 25 MG TABLET PA EMVERM 100 MG TABLET CHEW ethambutol hcl (100 mg tablet, 400 mg tablet) gentamicin sulfate 40 mg/ml vial gentamicin sulfate in sodium chloride, iso-osmotic (60 mg/50ml piggyback, 80mg/100ml piggyback, 80 mg/50ml piggyback, 100mg/0.1l piggyback) gentamicin sulfate/pf (sulfate/pf 60 mg/6 ml vial port, sulfate/pf 100mg/10ml vial port) hydroxychloroquine sulfate 200 mg tablet imipenem/cilastatin sodium (imipenem/cilastatin 250 mg vial, imipenem/cilastatin 500 mg vial) INVANZ 1 GM VIAL isoniazid (50 mg/5 ml solution, 100 mg tablet, 100 mg/ml vial, 300 mg tablet) ivermectin 3 mg tablet lincomycin hcl 300 mg/ml vial linezolid (100 mg/5ml susp recon, 600 mg tablet, 600mg/300 piggyback) mefloquine hcl 250 mg tablet meropenem (1 g vial, 500 mg vial) metronidazole (250 mg tablet, 375 mg capsule, 500 mg tablet) metronidazole/sodium chloride 500mg/0.1l piggyback NEBUPENT 300 MG INHAL POWDER neomycin sulfate 500 mg tablet PA B vs D, QL (1 PER 28 DAYS) 10

11 paromomycin sulfate 250 mg capsule PASER GRANULES 4 GM PACKET PENTAM 300 VIAL polymyxin b sulfate 500k unit vial PRIFTIN 150 MG TABLET primaquine phosphate 26.3 mg tablet pyrazinamide 500 mg tablet quinine sulfate 324 mg capsule rifabutin 150 mg capsule rifampin (150 mg capsule, 300 mg capsule, 600 mg vial) SIRTURO 100 MG TABLET LA SIVEXTRO 200 MG VIAL streptomycin sulfate 1 g vial SYNERCID 500 MG VIAL tinidazole (250 mg tablet, 500 mg tablet) TOBI PODHALER 28 MG INHALE CAP tobramycin in 0.225% sod chlor 300 mg/5ml ampul-neb tobramycin sulfate (1.2 g vial, 10 mg/ml vial, 40 mg/ml vial) TRECATOR 250 MG TABLET TYGACIL 50 MG VIAL QL (224 PER 28 DAYS) PA B vs D, QL (280 PER 28 DAYS) XIFAXAN 200 MG TABLET QL (9 PER 30 DAYS) XIFAXAN 550 MG TABLET QL (60 PER 30 DAYS) 11

12 PENICILLINS amoxicillin (125 mg/5ml susp recon, 125 mg tab chew, 200 mg/5ml susp recon, 250 mg capsule, 250 mg/5ml susp recon, 250 mg tab chew, 400 mg/5ml susp recon, 500 mg tablet, 500 mg capsule, 875 mg tablet) amoxicillin/potassium clavulanate (amoxicillin/potassium /5 susp recon, amoxicillin/potassium mg tab chew, amoxicillin/potassium mg tablet, amoxicillin/potassium /5 susp recon, amoxicillin/potassium mg/5 susp recon, amoxicillin/potassium mg tab chew, amoxicillin/potassium mg tablet, amoxicillin/potassium /5 susp recon, amoxicillin/potassium mg tablet, amoxicillin/potassium tab er 12h) ampicillin sodium (1 g vial port, 1 g vial, 10 g vial, 125 mg vial) ampicillin sodium/sulbactam sodium (sodium/sulbactam 1.5 g vial, sodium/sulbactam 1.5 g vial port, sodium/sulbactam 3 g vial, sodium/sulbactam 3 g vial port, sodium/sulbactam 15 g vial) ampicillin trihydrate (125 mg/5ml susp recon, 250 mg/5ml susp recon, 250 mg capsule, 500 mg capsule) AUGMENTIN MG/5 ML BICILLIN C-R (1.2 MILLION UNIT, SYRINGE) BICILLIN L-A (600,000 UNIT/ML, 1,200,000 UNITS, 2,400,000 UNITS) dicloxacillin sodium (250 mg capsule, 500 mg capsule) nafcillin sodium (1 g vial port, 1 g vial, 10 g vial) 12

13 oxacillin sodium (2 g vial port, 2 g vial, 10 g vial) oxacillin sodium in iso-osmotic dextrose ( dextrose(iso-osm) 1 g/50 ml froz.piggy, dextrose(iso-osm) 2 g/50 ml froz.piggy) penicillin g potassium (g 5mm vial, g 20mm vial) penicillin g potassium/dextrosewater (pen g pot/dextrose-water 2mm/50ml froz.piggy, pen g pot/dextrose-water 3mm/50ml froz.piggy) penicillin g procaine 1.2mm/2 ml syringe penicillin g sodium 5mm unit vial penicillin v potassium (125 mg/5ml soln recon, 250 mg tablet, 250 mg/5ml soln recon, 500 mg tablet) piperacillin sodium/tazobactam sodium (sodium/tazobactam 2.25 g vial port, sodium/tazobactam 2.25 g vial, sodium/tazobactam g vial, sodium/tazobactam g vial port, sodium/tazobactam 4.5 g vial, sodium/tazobactam 4.5 g vial port, sodium/tazobactam 40.5 g vial) QUINOLONES BAXDELA 300 MG VIAL ciprofloxacin (250 mg/5ml sus mc rec, 500 mg/5ml sus mc rec) ciprofloxacin hcl (100 mg tablet, 250 mg tablet, 500 mg tablet, 750 mg tablet) ciprofloxacin in 5 % dextrose 200mg/0.1l piggyback ciprofloxacin lactate 400mg/40ml vial ciprofloxacin/ciprofloxacin hcl (ciprofloxacin/ciprofloxa 500 mg tbmp 24hr, ciprofloxacin/ciprofloxa 1000 mg tbmp 24hr) 13

14 levofloxacin (25 mg/ml vial, 250mg/10ml solution, 250 mg tablet, 500mg/20ml solution, 500 mg tablet, 750 mg tablet) levofloxacin/dextrose 5 % in water ( 5 % 500mg/0.1l piggyback, 5 % 750mg/.15l piggyback) moxifloxacin hcl 400 mg tablet ofloxacin (300 mg tablet, 400 mg tablet) SULFA'S / RELATED AGENTS sulfadiazine 500 mg tablet sulfamethoxazole/trimethoprim (sulfamethoxazole/trimethoprim 80-16mg/ml vial, sulfamethoxazole/trimethoprim mg/5 oral susp, sulfamethoxazole/trimethoprim 400mg-80mg tablet, sulfamethoxazole/trimethoprim /20 oral susp, sulfamethoxazole/trimethoprim mg tablet) TETRACYCLINES demeclocycline hcl (150 mg tablet, 300 mg tablet) DOXY 100 VIAL doxycycline hyclate (20 mg tablet, 50 mg tablet dr, 50 mg capsule, 75 mg tablet dr, 75 mg tablet, 100 mg tablet, 100 mg tablet dr, 100 mg capsule, 150 mg tablet dr, 150 mg tablet, 200 mg tablet dr) doxycycline monohydrate (25 mg/5 ml susp recon, 50 mg tablet, 50 mg capsule, 75 mg capsule, 75 mg tablet, 100 mg capsule, 100 mg tablet, 150 mg capsule, 150 mg tablet) 14

15 minocycline hcl (45 mg tab er 24h, 50 mg capsule, 50 mg tablet, 65 mg tab er 24h, 75 mg tablet, 75 mg capsule, 90 mg tab er 24h, 100 mg capsule, 100 mg tablet, 115mg tab er 24h, 135 mg tab er 24h) MORGIDOX 50 MG CAPSULE tetracycline hcl (250 mg capsule, 500 mg capsule) VIBRAMYCIN 50 MG/5 ML SYRUP URINARY TRACT AGENTS methenamine hippurate 1 g tablet nitrofurantoin 25 mg/5 ml oral susp nitrofurantoin macrocrystal (25 mg capsule, 50 mg capsule, 100 mg capsule) nitrofurantoin monohyd/m-cryst 100 mg capsule PRIMSOL 50 MG/5 ML ORAL SOLN trimethoprim 100 mg tablet VANCOMYCIN vancomycin hcl (1 g vial, 1 g vial port, 10 g vial, 125 mg capsule, 250 mg capsule, 500 mg vial port, 500 mg vial) ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS ADJUNCTIVE AGENTS dexrazoxane hcl 250 mg vial ELITEK (1.5 MG VIAL, 7.5 MG VIAL) KEPIVANCE 6.25 MG VIAL leucovorin calcium (5 mg tablet, 10 mg tablet, 15 mg tablet, 25 mg tablet, 50 mg vial, 100 mg vial, 200 mg vial, 350 mg vial, 500 mg vial) 15

16 levoleucovorin calcium 10 mg/ml vial mesna 100 mg/ml vial MESNEX 400 MG TABLET XGEVA 120 MG/1.7 ML VIAL PA B vs D ABRAXANE 100 MG VIAL PA B vs D ADRIAMYCIN 20 MG/10 ML VIAL PA B vs D ADRUCIL 500 MG/10 ML VIAL PA B vs D AFINITOR (2.5 MG TABLET, 5 MG TABLET, 7.5 MG TABLET) PA - FOR NEW STARTS ONLY AFINITOR 10 MG TABLET PA - FOR NEW STARTS ONLY, QL (60 PER 30 DAYS) AFINITOR DISPERZ (2 MG TABLET, 3 MG TABLET, 5 MG TABLET) PA - FOR NEW STARTS ONLY ALECENSA 150 MG CAPSULE PA - FOR NEW STARTS ONLY, QL (240 PER 30 DAYS) ALIMTA 500 MG VIAL PA B vs D ALIQOPA 60 MG VIAL PA B vs D, LA ALUNBRIG (90 MG-180 MG TAB PACK, 180 MG TABLET) PA - FOR NEW STARTS ONLY, QL (30 PER 30 OVER TIME) ALUNBRIG 30 MG TABLET PA - FOR NEW STARTS ONLY, QL (180 PER 30 DAYS) ALUNBRIG 90 MG TABLET PA - FOR NEW STARTS ONLY, QL (60 PER 30 DAYS) anastrozole 1 mg tablet ARRANON 250 MG/50 ML VIAL PA B vs D AVASTIN (100 MG/4 ML VIAL, 400 MG/16 ML VIAL) PA B vs D azacitidine 100 mg vial PA B vs D azathioprine 50 mg tablet PA B vs D azathioprine sodium 100 mg vial PA B vs D BAVENCIO 200 MG/10 ML VIAL PA B vs D, LA BELEODAQ 500 MG VIAL PA B vs D bexarotene 75 mg capsule 16

17 bicalutamide 50 mg tablet BICNU 100 MG VIAL PA B vs D bleomycin sulfate 30 unit vial PA B vs D BOSULIF (400 MG TABLET, 500 MG TABLET) PA - FOR NEW STARTS ONLY, QL (30 PER 30 DAYS) BOSULIF 100 MG TABLET PA - FOR NEW STARTS ONLY busulfan 60 mg/10ml vial PA B vs D BUSULFEX 60 MG/10 ML VIAL PA B vs D CABOMETYX (20 MG TABLET, 40 MG TABLET, 60 MG TABLET) PA - FOR NEW STARTS ONLY, LA CALQUENCE 100 MG CAPSULE PA - FOR NEW STARTS ONLY, LA, QL (60 PER 30 DAYS) CAPRELSA 100 MG TABLET PA - FOR NEW STARTS ONLY, LA, QL (90 PER 30 DAYS) CAPRELSA 300 MG TABLET PA - FOR NEW STARTS ONLY, LA, QL (30 PER 30 DAYS) carboplatin (10 mg/ml vial, 150 mg vial) PA B vs D CELLCEPT 500 MG VIAL PA B vs D cisplatin 1 mg/ml vial PA B vs D cladribine 10 mg/10ml vial PA B vs D clofarabine 20 mg/20ml vial PA B vs D CLOLAR 20 MG/20 ML VIAL PA B vs D COMETRIQ (60 MG PACK, 100 MG PK, 140 MG PK) COSMEGEN 0.5 MG VIAL PA B vs D PA - FOR NEW STARTS ONLY COTELLIC 20 MG TABLET PA - FOR NEW STARTS ONLY, LA, QL (63 PER 28 DAYS) cyclophosphamide (25 mg capsule, 50 mg capsule) cyclosporine (25 mg capsule, 100 mg capsule, 250 mg/5ml ampul) cyclosporine, modified (25 mg capsule, 50 mg capsule, 100 mg capsule, 100 mg/ml solution) PA B vs D PA B vs D PA B vs D 17

18 CYRAMZA (100 MG/10 ML VIAL, 500 MG/50 ML VIAL) PA B vs D cytarabine 20 mg/ml vial PA B vs D cytarabine/pf (cytarabine/pf 2 g/20 ml vial, cytarabine/pf 20 mg/ml vial) PA B vs D dacarbazine 200 mg vial PA B vs D dactinomycin 0.5 mg vial PA B vs D DARZALEX (100 MG/5 ML VIAL, 400 MG/20 ML VIAL) daunorubicin hcl (5 mg/ml vial, 20 mg vial) PA B vs D, LA PA B vs D decitabine 50 mg vial PA B vs D docetaxel (20 mg/2 ml vial, 20mg/ml(1) vial, 80 mg/4 ml vial, 80 mg/8 ml vial, 140 mg/7ml vial, 160 mg/8ml vial, 160mg/16ml vial, 200mg/20ml vial) PA B vs D doxorubicin hcl 50 mg/25ml vial PA B vs D doxorubicin hcl peg-liposomal 2 mg/ml vial DROXIA (200 MG CAPSULE, 300 MG CAPSULE, 400 MG CAPSULE) EMCYT 140 MG CAPSULE EMPLICITI (300 MG VIAL, 400 MG VIAL) PA B vs D PA B vs D epirubicin hcl 200mg/0.1l vial PA B vs D ERBITUX 100 MG/50 ML VIAL PA B vs D ERIVEDGE 150 MG CAPSULE PA - FOR NEW STARTS ONLY, QL (30 PER 30 DAYS) ERLEADA 60 MG TABLET PA - FOR NEW STARTS ONLY ERWINAZE 10,000 UNITS VIAL PA B vs D ETOPOPHOS 100 MG VIAL PA B vs D etoposide 20 mg/ml vial PA B vs D exemestane 25 mg tablet FARESTON 60 MG TABLET 18

19 FARYDAK (15 MG CAPSULE, 20 MG CAPSULE) PA - FOR NEW STARTS ONLY, QL (6 PER 21 DAYS) FARYDAK 10 MG CAPSULE PA - FOR NEW STARTS ONLY, QL (12 PER 21 DAYS) FASLODEX 250 MG/5 ML SYRINGE FIRMAGON (2 X 120 MG KIT, 80 MG KIT) PA B vs D PA B vs D fludarabine phosphate 50 mg vial PA B vs D fluorouracil (1 g/20 ml vial, 2.5 g/50ml vial, 5 g/100 ml vial, 500mg/10ml vial) flutamide 125 mg capsule PA B vs D FOLOTYN 40 MG/2 ML VIAL PA B vs D gemcitabine hcl 1 g vial PA B vs D GENGRAF (25 MG CAPSULE, 50 MG CAPSULE, 100 MG/ML SOLUTION, 100 MG CAPSULE) PA B vs D GILOTRIF 20 MG TABLET PA - FOR NEW STARTS ONLY, QL (60 PER 30 DAYS) GILOTRIF 30 MG TABLET PA - FOR NEW STARTS ONLY, QL (40 PER 30 DAYS) GILOTRIF 40 MG TABLET PA - FOR NEW STARTS ONLY, QL (30 PER 30 DAYS) GLEOSTINE (5 MG CAPSULE, 10 MG CAPSULE, 40 MG CAPSULE, 100 MG CAPSULE) HALAVEN 1 MG/2 ML VIAL PA B vs D HERCEPTIN (150 MG VIAL, 440 MG VIAL) HEXALEN 50 MG CAPSULE hydroxyurea 500 mg capsule IBRANCE (75 MG CAPSULE, 100 MG CAPSULE, 125 MG CAPSULE) PA B vs D PA - FOR NEW STARTS ONLY, QL (21 PER 28 DAYS) ICLUSIG 15 MG TABLET PA - FOR NEW STARTS ONLY, QL (90 PER 30 DAYS) ICLUSIG 45 MG TABLET PA - FOR NEW STARTS ONLY, QL (30 PER 30 DAYS) 19

20 idarubicin hcl 1 mg/ml vial PA B vs D IDHIFA 100 MG TABLET PA - FOR NEW STARTS ONLY, LA, QL (30 PER 30 DAYS) IDHIFA 50 MG TABLET PA - FOR NEW STARTS ONLY, LA, QL (60 PER 30 DAYS) ifosfamide 1 g vial PA B vs D imatinib mesylate 100 mg tablet PA - FOR NEW STARTS ONLY imatinib mesylate 400 mg tablet PA - FOR NEW STARTS ONLY, QL (60 PER 30 DAYS) IMBRUVICA 140 MG CAPSULE PA - FOR NEW STARTS ONLY, QL (120 PER 30 DAYS) IMFINZI (120 MG/2.4 ML VIAL, 500 MG/10 ML VIAL) PA B vs D, LA INLYTA 1 MG TABLET PA - FOR NEW STARTS ONLY INLYTA 5 MG TABLET PA - FOR NEW STARTS ONLY, QL (120 PER 30 DAYS) IRESSA 250 MG TABLET PA - FOR NEW STARTS ONLY, QL (30 PER 30 DAYS) irinotecan hcl 100 mg/5ml vial PA B vs D ISTODAX (10 MG KIT, 10 MG VIAL) JAKAFI (5 MG TABLET, 10 MG TABLET, 15 MG TABLET, 20 MG TABLET) PA B vs D PA - FOR NEW STARTS ONLY JAKAFI 25 MG TABLET PA - FOR NEW STARTS ONLY, QL (60 PER 30 DAYS) JEVTANA (60 MG/1.5 ML KIT, 60 MG/1.5 ML VIAL) KADCYLA (100 MG VIAL, 160 MG VIAL) KEYTRUDA (50 MG VIAL, 100 MG/4 ML VIAL) KISQALI (200 MG DAILY, 400 MG DAILY, 600 MG DAILY) KISQALI FEMARA CO-PACK (200 MG, 400 MG, 600 MG) KYPROLIS (30 MG VIAL, 60 MG VIAL) PA B vs D PA - FOR NEW STARTS ONLY PA - FOR NEW STARTS ONLY PA - FOR NEW STARTS ONLY PA - FOR NEW STARTS ONLY PA B vs D 20

21 LARTRUVO (190 MG/19 ML VIAL, 500 MG/50 ML VIAL) LENVIMA (8 MG DAILY, 10 MG DAILY, 14 MG DAILY, 18 MG DAILY, 20 MG DAILY, 24 MG DAILY) letrozole 2.5 mg tablet LEUKERAN 2 MG TABLET leuprolide acetate (1 mg/0.2ml vial, 1 mg/0.2ml kit) LONSURF (15 MG-6.14 MG TABLET, 20 MG-8.19 MG TABLET) LUPRON DEPOT (DEPOT 3.75 MG KIT, DEPOT-4 MONTH KIT, DEPOT 7.5 MG KIT, DEPOT MG 3MO KIT, DEPOT 22.5 MG 3MO KIT, DEPOT 45 MG 6MO KIT) LUPRON DEPOT (LUPANETA) (DEPO 11.25MG (LUPANETA), DEPOT 3.75MG (LUPANETA)) LUPRON DEPOT-PED (7.5 MG KIT, MG KIT, MG 3MO, 15 MG KIT, 30 MG 3MO KIT) LYNPARZA (50 MG CAPSULE, 100 MG TABLET, 150 MG TABLET) LYSODREN 500 MG TABLET MATULANE 50 MG CAPSULE megestrol acetate (20 mg tablet, 40 mg tablet) megestrol acetate (400mg/10ml oral susp, 625mg/5ml oral susp) PA B vs D, LA PA - FOR NEW STARTS ONLY PA - FOR NEW STARTS ONLY PA - FOR NEW STARTS ONLY PA - FOR NEW STARTS ONLY PA - FOR NEW STARTS ONLY PA - FOR NEW STARTS ONLY PA - FOR NEW STARTS ONLY MEKINIST 0.5 MG TABLET PA - FOR NEW STARTS ONLY, QL (120 PER 30 DAYS) MEKINIST 2 MG TABLET PA - FOR NEW STARTS ONLY, QL (30 PER 30 DAYS) melphalan hcl 50 mg vial PA B vs D mercaptopurine 50 mg tablet methotrexate sodium (2.5 mg tablet, 25 mg/ml vial) PA PA B vs D 21

22 methotrexate sodium/pf (sodium/pf 1 g vial, sodium/pf 25 mg/ml vial) mitomycin (5 mg vial, 20 mg vial, 40 mg vial) PA B vs D PA B vs D mitoxantrone hcl 2 mg/ml vial PA B vs D MUSTARGEN 10 MG VIAL PA B vs D mycophenolate mofetil (200 mg/ml susp recon, 250 mg capsule, 500 mg tablet) mycophenolate mofetil hcl 500 mg vial mycophenolate sodium (180 mg tablet dr, 360 mg tablet dr) PA B vs D PA B vs D PA B vs D MYLOTARG 4.5 MG VIAL PA B vs D, LA NERLYNX 40 MG TABLET LA NEXAVAR 200 MG TABLET PA - FOR NEW STARTS ONLY, LA, QL (120 PER 30 DAYS) nilutamide 150 mg tablet NINLARO 2.3 MG CAPSULE PA - FOR NEW STARTS ONLY, QL (6 PER 28 DAYS) NINLARO 3 MG CAPSULE PA - FOR NEW STARTS ONLY, QL (4 PER 28 DAYS) NINLARO 4 MG CAPSULE PA - FOR NEW STARTS ONLY, QL (3 PER 28 DAYS) NULOJIX 250 MG VIAL PA B vs D octreotide acetate (50 mcg/ml ampul, 50 mcg/ml vial, 100 mcg/ml vial, 100 mcg/ml ampul, 200 mcg/ml vial, 500 mcg/ml vial, 500 mcg/ml ampul, 1000mcg/ml vial) ODOMZO 200 MG CAPSULE PA - FOR NEW STARTS ONLY, LA, QL (30 PER 30 DAYS) OPDIVO (40 MG/4 ML VIAL, 100 MG/10 ML VIAL) oxaliplatin (100mg/20ml vial, 100 mg vial) PA - FOR NEW STARTS ONLY PA B vs D paclitaxel 6 mg/ml vial PA B vs D 22

23 PERJETA 420 MG/14 ML VIAL PA B vs D POMALYST (1 MG CAPSULE, 2 MG CAPSULE, 3 MG CAPSULE, 4 MG CAPSULE) PROGRAF 5 MG/ML AMPULE PA B vs D PURIXAN 20 MG/ML ORAL SUSP RAPAMUNE 1 MG/ML ORAL SOLN REVLIMID (2.5 MG CAPSULE, 5 MG CAPSULE, 10 MG CAPSULE, 15 MG CAPSULE, 20 MG CAPSULE, 25 MG CAPSULE) LA PA B vs D PA - FOR NEW STARTS ONLY, LA RITUXAN 10 MG/ML VIAL PA - FOR NEW STARTS ONLY RUBRACA 200 MG TABLET PA - FOR NEW STARTS ONLY, LA, QL (180 PER 30 DAYS) RUBRACA 300 MG TABLET PA - FOR NEW STARTS ONLY, LA, QL (120 PER 30 DAYS) RYDAPT 25 MG CAPSULE PA - FOR NEW STARTS ONLY SANDIMMUNE 100 MG/ML SOLN PA B vs D SANDOSTATIN LAR DEPOT (10 MG KT, 10 MG VL, 20 MG KT, 20 MG VL, 30 MG KT, 30 MG VL) SIGNIFOR (0.3 MG/ML, 0.6 MG/ML, 0.9 MG/ML) SIMULECT 20 MG VIAL PA B vs D sirolimus (0.5 mg tablet, 1 mg tablet, 2 mg tablet) SOLTAMOX 10 MG/5 ML SOLN SOMATULINE DEPOT (60 MG/0.2 ML, 90 MG/0.3 ML, 120 MG/0.5 ML) SPRYCEL (20 MG TABLET, 50 MG TABLET, 80 MG TABLET, 100 MG TABLET) PA B vs D PA - FOR NEW STARTS ONLY SPRYCEL 140 MG TABLET PA - FOR NEW STARTS ONLY, QL (30 PER 30 DAYS) SPRYCEL 70 MG TABLET PA - FOR NEW STARTS ONLY, QL (60 PER 30 DAYS) 23

24 STIVARGA 40 MG TABLET PA - FOR NEW STARTS ONLY, QL (84 PER 28 DAYS) SUTENT (25 MG CAPSULE, 37.5 MG CAPSULE) PA - FOR NEW STARTS ONLY, QL (60 PER 30 DAYS) SUTENT 12.5 MG CAPSULE PA - FOR NEW STARTS ONLY SUTENT 50 MG CAPSULE PA - FOR NEW STARTS ONLY, QL (30 PER 30 DAYS) SYLVANT 100 MG VIAL PA B vs D SYNRIBO 3.5 MG/ML VIAL PA B vs D TABLOID 40 MG TABLET tacrolimus (0.5 mg capsule, 1 mg capsule, 5 mg capsule) PA B vs D TAFINLAR 50 MG CAPSULE PA - FOR NEW STARTS ONLY, QL (180 PER 30 DAYS) TAFINLAR 75 MG CAPSULE PA - FOR NEW STARTS ONLY, QL (120 PER 30 DAYS) TAGRISSO 40 MG TABLET PA - FOR NEW STARTS ONLY, LA, QL (60 PER 30 DAYS) TAGRISSO 80 MG TABLET PA - FOR NEW STARTS ONLY, LA, QL (30 PER 30 DAYS) tamoxifen citrate (10 mg tablet, 20 mg tablet) TARCEVA (25 MG TABLET, 100 MG TABLET) PA - FOR NEW STARTS ONLY TARCEVA 150 MG TABLET PA - FOR NEW STARTS ONLY, QL (30 PER 30 DAYS) TARGRETIN 1% GEL TASIGNA 150 MG CAPSULE PA - FOR NEW STARTS ONLY TASIGNA 200 MG CAPSULE PA - FOR NEW STARTS ONLY, QL (112 PER 28 DAYS) TECENTRIQ 1,200 MG/20 ML VIAL PA B vs D, LA THALOMID (50 MG CAPSULE, 100 MG CAPSULE, 150 MG CAPSULE, 200 MG CAPSULE) thiotepa 15 mg vial PA B vs D TOPOSAR (100 MG/5 ML VIAL, 500 MG/25 ML VIAL, 1,000 MG/50 ML VIAL) PA - FOR NEW STARTS ONLY PA B vs D 24

25 topotecan hcl 4 mg vial PA B vs D TORISEL 25 MG KIT PA B vs D TREANDA (25 MG VIAL, 100 MG VIAL) TRELSTAR (3.75 MG SYRINGE, 3.75 MG VIAL, MG SYRINGE, MG VIAL, 22.5 MG VIAL, 22.5 MG SYRINGE) tretinoin 10 mg capsule TRISENOX (10 MG/10 ML AMPULE, 12 MG/6 ML VIAL) PA B vs D PA B vs D PA B vs D TYKERB 250 MG TABLET PA - FOR NEW STARTS ONLY, LA, QL (180 PER 30 DAYS) VECTIBIX 100 MG/5 ML VIAL PA B vs D VELCADE 3.5 MG VIAL PA B vs D VENCLEXTA (10 MG TABLET, 50 MG TABLET, 100 MG TABLET) PA - FOR NEW STARTS ONLY, LA VENCLEXTA STARTING PACK PA - FOR NEW STARTS ONLY, LA, QL (42 PER 180 DAYS) VERZENIO 100 MG TABLET PA - FOR NEW STARTS ONLY, LA, QL (120 PER 30 DAYS) VERZENIO 150 MG TABLET PA - FOR NEW STARTS ONLY, LA, QL (80 PER 30 DAYS) VERZENIO 200 MG TABLET PA - FOR NEW STARTS ONLY, LA, QL (60 PER 30 DAYS) VERZENIO 50 MG TABLET PA - FOR NEW STARTS ONLY, LA, QL (240 PER 30 DAYS) vinblastine sulfate 1 mg/ml vial PA B vs D VINCASAR PFS 1 MG/ML VIAL PA B vs D vincristine sulfate 1 mg/ml vial PA B vs D vinorelbine tartrate 50 mg/5 ml vial PA B vs D VOTRIENT 200 MG TABLET PA - FOR NEW STARTS ONLY, QL (120 PER 30 DAYS) VYXEOS 44 MG-100 MG VIAL PA B vs D XALKORI 200 MG CAPSULE PA - FOR NEW STARTS ONLY XALKORI 250 MG CAPSULE PA - FOR NEW STARTS ONLY, QL (60 PER 30 DAYS) 25

26 XATMEP 2.5 MG/ML ORAL SOLUTION PA B vs D XERMELO 250 MG TABLET PA, LA, QL (90 PER 30 DAYS) XTANDI 40 MG CAPSULE PA - FOR NEW STARTS ONLY, QL (120 PER 30 DAYS) YERVOY 50 MG/10 ML VIAL PA B vs D YONDELIS 1 MG VIAL PA B vs D ZALTRAP 100 MG/4 ML VIAL PA B vs D ZANOSAR 1 GM POWDER VIAL PA B vs D ZEJULA 100 MG CAPSULE PA - FOR NEW STARTS ONLY, LA, QL (90 PER 30 DAYS) ZELBORAF 240 MG TABLET PA - FOR NEW STARTS ONLY, QL (240 PER 30 DAYS) ZOLINZA 100 MG CAPSULE ZORTRESS (0.25 MG TABLET, 0.5 MG TABLET, 0.75 MG TABLET) ZYDELIG (100 MG TABLET, 150 MG TABLET) PA B vs D PA - FOR NEW STARTS ONLY, QL (90 PER 30 DAYS) ZYKADIA 150 MG CAPSULE PA - FOR NEW STARTS ONLY, QL (150 PER 30 DAYS) ZYTIGA 250 MG TABLET PA - FOR NEW STARTS ONLY, QL (120 PER 30 DAYS) AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH ANTICONVULSANTS APTIOM (200 MG TABLET, 400 MG TABLET, 600 MG TABLET, 800 MG TABLET) BANZEL (40 MG/ML SUSPENSION, 200 MG TABLET, 400 MG TABLET) BRIVIACT (10 MG TABLET, 10 MG/ML ORAL SOLN, 25 MG TABLET, 50 MG TABLET, 50 MG/5 ML VIAL, 75 MG TABLET, 100 MG TABLET) 26

27 carbamazepine (100 mg tab er 12h, 100 mg/5ml oral susp, 100 mg cpmp 12hr, 100 mg tab chew, 200 mg tab er 12h, 200 mg tablet, 200 mg cpmp 12hr, 300 mg cpmp 12hr, 400 mg tab er 12h) CELONTIN 300 MG KAPSEAL clonazepam (0.125 mg tab rapdis, 0.25 mg tab rapdis, 0.5 mg tab rapdis, 0.5 mg tablet, 1 mg tab rapdis, 1 mg tablet, 2 mg tab rapdis, 2 mg tablet) DIASTAT 2.5 MG PEDI SYSTEM DIASTAT ACUDIAL ( MG KT, MG) DILANTIN 30 MG CAPSULE divalproex sodium (125 mg tablet dr, 125 mg cap dr spr, 250 mg tablet dr, 250 mg tab er 24h, 500 mg tab er 24h, 500 mg tablet dr) EPITOL 200 MG TABLET ethosuximide (250 mg/5ml solution, 250 mg capsule) felbamate (400 mg tablet, 600 mg/5ml oral susp, 600 mg tablet) fosphenytoin sodium 100mg pe/2 vial FYCOMPA (0.5 MG/ML ORAL SUSP, 2 MG TABLET, 4 MG TABLET, 6 MG TABLET, 8 MG TABLET, 10 MG TABLET, 12 MG TABLET) gabapentin (250 mg/5ml solution, 300 mg/6ml solution) PA - FOR NEW STARTS ONLY QL (2160 PER 30 DAYS) gabapentin 100 mg capsule QL (1080 PER 30 DAYS) gabapentin 300 mg capsule QL (360 PER 30 DAYS) gabapentin 400 mg capsule QL (270 PER 30 DAYS) gabapentin 600 mg tablet QL (180 PER 30 DAYS) gabapentin 800 mg tablet QL (135 PER 30 DAYS) 27

28 GABITRIL (12 MG TABLET, 16 MG TABLET) GRALISE 30-DAY STARTER PACK PA, QL (78 PER 180 DAYS) GRALISE ER 300 MG TABLET PA, QL (30 PER 30 DAYS) GRALISE ER 600 MG TABLET PA, QL (90 PER 30 DAYS) lamotrigine (5 mg tb chw dsp, 25 mg tab rapdis, 25 mg tb chw dsp, 25 mg tab er 24, 25 mg tablet, 50 mg tab rapdis, 50 mg tab er 24, 100 mg tablet, 100 mg tab rapdis, 100 mg tab er 24, 150 mg tablet, 200 mg tab er 24, 200 mg tablet, 200 mg tab rapdis, 250 mg tab er 24, 300 mg tab er 24) levetiracetam (100 mg/ml solution, 250 mg tablet, 500 mg tab er 24h, 500 mg tablet, 500 mg/5ml vial, 500 mg/5ml solution, 750 mg tablet, 750 mg tab er 24h, 1000 mg tablet) levetiracetam in sodium chloride, iso-osmotic ((iso-os) 500mg/0.1l piggyback, (iso-os) 1000mg/100 piggyback, (iso-os) 1500mg/100 piggyback) LYRICA 100 MG CAPSULE PA - FOR NEW STARTS ONLY, QL (180 PER 30 DAYS) LYRICA 150 MG CAPSULE PA - FOR NEW STARTS ONLY, QL (120 PER 30 DAYS) LYRICA 20 MG/ML ORAL SOLUTION PA - FOR NEW STARTS ONLY, QL (900 PER 30 DAYS) LYRICA 200 MG CAPSULE PA - FOR NEW STARTS ONLY, QL (90 PER 30 DAYS) LYRICA 225 MG CAPSULE PA - FOR NEW STARTS ONLY, QL (81 PER 30 DAYS) LYRICA 25 MG CAPSULE PA - FOR NEW STARTS ONLY, QL (720 PER 30 DAYS) LYRICA 300 MG CAPSULE PA - FOR NEW STARTS ONLY, QL (60 PER 30 DAYS) LYRICA 50 MG CAPSULE PA - FOR NEW STARTS ONLY, QL (360 PER 30 DAYS) 28

29 LYRICA 75 MG CAPSULE PA - FOR NEW STARTS ONLY, QL (240 PER 30 DAYS) ONFI (2.5 MG/ML SUSPENSION, 10 MG TABLET, 20 MG TABLET) oxcarbazepine (150 mg tablet, 300 mg/5ml oral susp, 300 mg tablet, 600 mg tablet) PEGANONE 250 MG TABLET phenobarbital (15 mg tablet, 16.2 mg tablet, 20 mg/5 ml elixir, 30 mg tablet, 32.4 mg tablet, 60 mg tablet, 64.8 mg tablet, 97.2mg tablet, 100 mg tablet) phenytoin (50 mg tab chew, 100 mg/4ml oral susp, 125 mg/5ml oral susp) phenytoin sodium (50 mg/ml ampul, 50 mg/ml vial) phenytoin sodium extended (100 mg capsule, 200 mg capsule, 300 mg capsule) primidone (50 mg tablet, 250 mg tablet) ROWEEPRA (500 MG TABLET, 750 MG TABLET, 1,000 MG TABLET) SABRIL (500 MG POWDER PACKET, 500 MG TABLET) SPRITAM (250 MG TABLET, 500 MG TABLET, 750 MG TABLET, 1,000 MG TABLET) tiagabine hcl (2 mg tablet, 4 mg tablet) topiramate (15 mg cap sprink, 25 mg cap sprink, 25 mg tablet, 50 mg tablet, 100 mg tablet, 200 mg tablet) valproic acid (as sodium salt) (valproate sodium) (salt) 250 mg/5ml solution, salt) 500 mg/5ml vial, salt) 500mg/10ml solution) PA - FOR NEW STARTS ONLY PA - FOR NEW STARTS ONLY LA PA - FOR NEW STARTS ONLY 29

30 valproic acid 250 mg capsule vigabatrin 500 mg powd pack LA VIMPAT (10 MG/ML SOLUTION, 50 MG TABLET, 100 MG TABLET, 150 MG TABLET, 200 MG/20 ML VIAL, 200 MG TABLET) zonisamide (25 mg capsule, 50 mg capsule, 100 mg capsule) PA - FOR NEW STARTS ONLY ANTIPARKINSONISM AGENTS APOKYN 30 MG/3 ML CARTRIDGE benztropine mesylate (0.5 mg tablet, 1 mg tablet, 2 mg tablet) benztropine mesylate (2 mg/2 ml vial, 2 mg/2 ml ampul) bromocriptine mesylate (2.5 mg tablet, 5 mg capsule) carbidopa 25 mg tablet carbidopa/levodopa (carbidopa/levodopa 10mg-100mg tab rapdis, carbidopa/levodopa 10mg-100mg tablet, carbidopa/levodopa 25mg-100mg tablet, carbidopa/levodopa 25mg- 100mg tablet er, carbidopa/levodopa 25mg-100mg tab rapdis, carbidopa/levodopa 25mg-250mg tab rapdis, carbidopa/levodopa 25mg-250mg tablet, carbidopa/levodopa 50mg- 200mg tablet er) carbidopa/levodopa/entacapone (carbidopa/levodopa/entacapone mg tablet, carbidopa/levodopa/entacapone mg tablet, carbidopa/levodopa/entacapone tablet, carbidopa/levodopa/entacapone tablet, carbidopa/levodopa/entacapone mg tablet, carbidopa/levodopa/entacapone tablet) LA PA 30

31 entacapone 200 mg tablet NEUPRO (1 MG/24 HR PATCH, 2 MG/24 HR PATCH, 3 MG/24 HR PATCH, 4 MG/24 HR PATCH, 6 MG/24 HR PATCH, 8 MG/24 HR PATCH) pramipexole di-hcl (0.125 mg tablet, 0.25 mg tablet, mg tab er 24h, 0.5 mg tablet, 0.75 mg tab er 24h, 0.75 mg tablet, 1 mg tablet, 1.5 mg tablet, 1.5 mg tab er 24h, 2.25 mg tab er 24h, 3 mg tab er 24h, 3.75 mg tab er 24h, 4.5 mg tab er 24h) rasagiline mesylate (0.5 mg tablet, 1 mg tablet) ropinirole hcl (0.25 mg tablet, 0.5 mg tablet, 1 mg tablet, 2 mg tablet, 2 mg tab er 24h, 3 mg tablet, 4 mg tablet, 4 mg tab er 24h, 5 mg tablet, 6 mg tab er 24h, 8 mg tab er 24h, 12 mg tab er 24h) selegiline hcl (5 mg capsule, 5 mg tablet) tolcapone 100 mg tablet MIGRAINE / CLUSTER HEADACHE THERAPY almotriptan malate 12.5 mg tablet QL (24 PER 28 DAYS) almotriptan malate 6.25 mg tablet QL (18 PER 28 DAYS) dihydroergotamine mesylate 0.5mg/spry spray/pump dihydroergotamine mesylate 1 mg/ml ampul eletriptan hydrobromide (20 mg tablet, 40 mg tablet) ergotamine tartrate/caffeine 1 mg- 100mg tablet QL (8 PER 28 DAYS) QL (18 PER 28 DAYS) frovatriptan succinate 2.5 mg tablet QL (27 PER 28 DAYS) MIGERGOT SUPPOSITORY naratriptan hcl (1 mg tablet, 2.5 mg tablet) QL (18 PER 28 DAYS) 31

32 rizatriptan benzoate (5 mg tab rapdis, 5 mg tablet, 10 mg tab rapdis, 10 mg tablet) QL (36 PER 28 DAYS) sumatriptan 20 mg spray QL (18 PER 28 DAYS) sumatriptan 5 mg spray QL (36 PER 28 DAYS) sumatriptan succ/naproxen sod 85mg-500mg tablet sumatriptan succinate (25 mg tablet, 50 mg tablet, 100 mg tablet) sumatriptan succinate (4 mg/0.5ml cartridge, 4 mg/0.5ml pen injctr, 6 mg/0.5ml syringe, 6 mg/0.5ml cartridge, 6 mg/0.5ml pen injctr, 6 mg/0.5ml vial) zolmitriptan (2.5 mg tablet, 2.5 mg tab rapdis, 5 mg tablet, 5 mg tab rapdis) QL (18 PER 28 DAYS) QL (8 PER 28 DAYS) QL (18 PER 28 DAYS) MISCELLANEOUS NEUROLOGICAL THERAPY AMPYRA ER 10 MG TABLET PA, LA AUBAGIO (7 MG TABLET, 14 MG TABLET) COPAXONE 40 MG/ML SYRINGE PA, QL (12 PER 28 DAYS) donepezil hcl (5 mg tablet, 5 mg tab rapdis, 10 mg tablet, 10 mg tab rapdis, 23 mg tablet) galantamine hbr (4 mg/ml solution, 4 mg tablet, 8 mg cap24h pel, 8 mg tablet, 12 mg tablet, 16 mg cap24h pel, 24 mg cap24h pel) GILENYA 0.5 MG CAPSULE PA glatiramer acetate 20 mg/ml syringe PA, QL (30 PER 30 DAYS) glatiramer acetate 40 mg/ml syringe PA, QL (12 PER 28 DAYS) GLATOPA 20 MG/ML SYRINGE PA, QL (30 PER 30 DAYS) memantine hcl (2 mg/ml solution, 5 mg tablet, 7 mg cap spr 24, 10 mg tablet, 14 mg cap spr 24, 21 mg cap spr 24, 28 mg cap spr 24) NAMENDA XR (7 MG CAPSULE, 14 MG CAPSULE, 21 MG CAPSULE, 28 MG CAPSULE, TITRATION PACK) PA PA PA 32

33 NAMZARIC (7 MG-10 MG CAPSULE, 14 MG-10 MG CAPSULE, 21 MG-10 MG CAPSULE, 28 MG-10 MG CAPSULE, TITRATION PACK) PA NUEDEXTA MG CAPSULE RADICAVA 30 MG/100 ML BAG rivastigmine (4.6mg/24hr patch td24, 9.5mg/24hr patch td24, 13.3mg/24h patch td24) rivastigmine tartrate (1.5 mg capsule, 3 mg capsule, 4.5 mg capsule, 6 mg capsule) TECFIDERA (DR 120 MG CAPSULE, DR 240 MG CAPSULE, STARTER PACK) PA, LA tetrabenazine 12.5 mg tablet PA, QL (240 PER 30 DAYS) tetrabenazine 25 mg tablet PA, QL (120 PER 30 DAYS) TYSABRI 300 MG/15 ML VIAL PA, LA MUSCLE RELAXANTS / ANTISPASMODIC THERAPY baclofen (10 mg tablet, 20 mg tablet) cyclobenzaprine hcl (5 mg tablet, 7.5 mg tablet, 10 mg tablet) dantrolene sodium (25 mg capsule, 50 mg capsule, 100 mg capsule) LIORESAL INTRATHECAL (0.05 MG/1 ML AMP, 10 MG/5 ML K, 10 MG/20 ML K, 40 MG/20 ML K) MESTINON 60 MG/5 ML SYRUP pyridostigmine bromide (60 mg tablet, 180 mg tablet er) tizanidine hcl (2 mg tablet, 2 mg capsule, 4 mg capsule, 4 mg tablet, 6 mg capsule) PA PA B vs D NARCOTIC ANALGESICS acetaminophen with codeine 300mg-60mg tablet QL (180 PER 30 DAYS) 33

34 acetaminophen with codeine phosphate (120-12mg/5 solution, 300mg/12.5 solution) acetaminophen with codeine phosphate (300mg-15mg tablet, 300mg-30mg tablet) buprenorphine hcl (0.3 mg/ml vial, 0.3 mg/ml syringe) buprenorphine hcl (2 mg tab subl, 8 mg tab subl) BUTRANS (5 MCG/HR PATCH, 7.5 MCG/HR PATCH, 10 MCG/HR PATCH, 15 MCG/HR PATCH, 20 MCG/HR PATCH) codeine sulfate (30 mg tablet, 60 mg tablet) DURAMORPH 10 MG/10 ML AMPUL DURAMORPH 5 MG/10 ML AMPUL ENDOCET (5-325 TABLET, MG TABLET, MG TABLET) fentanyl (12 mcg/hr patch td72, 25 mcg/hr patch td72, 50mcg/hr patch td72, 75mcg/hr patch td72, 100 mcg/hr patch td72) fentanyl citrate (200 mcg lozenge hd, 400 mcg lozenge hd, 600 mcg lozenge hd, 800 mcg lozenge hd, 1200 mcg lozenge hd, 1600 mcg lozenge hd) hydrocodone bitartrate/acetaminophen (hydrocodone/acetaminophen /5 solution, hydrocodone/acetaminophen 5-217mg/10 solution, hydrocodone/acetaminophen /15 solution) QL (4500 PER 30 DAYS) QL (360 PER 30 DAYS) QL (266 PER 30 DAYS) PA, QL (4 PER 28 DAYS) QL (180 PER 30 DAYS) QL (2000 PER 30 DAYS) QL (4000 PER 30 DAYS) QL (360 PER 30 DAYS) PA, QL (10 PER 30 DAYS) PA, QL (120 PER 30 DAYS) QL (5550 PER 30 DAYS) 34

35 hydrocodone bitartrate/acetaminophen (hydrocodone/acetaminophen mg tablet, hydrocodone/acetaminophen 5 mg- 325mg tablet, hydrocodone/acetaminophen mg tablet, hydrocodone/acetaminophen 10mg-325mg tablet) hydrocodone bitartrate/acetaminophen (hydrocodone/acetaminophen 5 mg-300mg tablet, hydrocodone/acetaminophen mg tablet, hydrocodone/acetaminophen 10mg-300mg tablet) hydrocodone/ibuprofen (hydrocodone/ibuprofen 5mg- 200mg tablet, hydrocodone/ibuprofen mg tablet, hydrocodone/ibuprofen 10mg-200mg tablet) hydromorphone hcl (2 mg tablet, 4 mg tablet, 8 mg tablet) hydromorphone hcl (2 mg/ml syringe, 2mg/ml(1) syringe) hydromorphone hcl (8 mg tab er 24h, 12 mg tab er 24h, 16 mg tab er 24h, 32 mg tab er 24h) QL (360 PER 30 DAYS) QL (390 PER 30 DAYS) QL (50 PER 30 DAYS) QL (180 PER 30 DAYS) QL (1200 PER 30 DAYS) PA, QL (60 PER 30 DAYS) hydromorphone hcl 1 mg/ml liquid QL (2400 PER 30 DAYS) hydromorphone hcl/pf (hcl/pf 10 mg/ml vial, hcl/pf 10 mg/ml ampul) ibuprofen/oxycodone hcl 400mg- 5mg tablet QL (240 PER 30 DAYS) QL (28 PER 30 DAYS) levorphanol tartrate 2 mg tablet QL (120 PER 30 DAYS) LORCET MG TABLET QL (360 PER 30 DAYS) LORCET HD MG TABLET QL (360 PER 30 DAYS) LORCET PLUS MG TABLET LORTAB (5-325 MG TABLET, MG TABLET, MG TABLET) QL (360 PER 30 DAYS) QL (360 PER 30 DAYS) 35

36 methadone hcl (10 mg/ml vial, 10 mg/ml syringe) QL (150 PER 30 DAYS) methadone hcl 10 mg tablet PA, QL (120 PER 30 DAYS) methadone hcl 10 mg/5 ml solution PA, QL (600 PER 30 DAYS) methadone hcl 5 mg tablet PA, QL (240 PER 30 DAYS) methadone hcl 5 mg/5 ml solution PA, QL (1200 PER 30 DAYS) morphine sulfate (10 mg cap er pel, 20 mg cap er pel, 30 mg cap er pel, 50 mg cap er pel, 60 mg cap er pel, 80 mg cap er pel, 100 mg cap er pel) morphine sulfate (10 mg/5 ml solution, 20 mg/5 ml solution, 100 mg/5ml solution) morphine sulfate (15 mg tablet er, 30 mg tablet er, 60 mg tablet er, 200 mg tablet er) morphine sulfate (15 mg tablet, 30 mg tablet) morphine sulfate (30 mg cpmp 24hr, 45 mg cpmp 24hr, 60 mg cpmp 24hr, 75 mg cpmp 24hr, 90 mg cpmp 24hr, 100 mg tablet er, 120 mg cpmp 24hr) PA, QL (90 PER 30 DAYS) QL (900 PER 30 DAYS) PA, QL (120 PER 30 DAYS) QL (180 PER 30 DAYS) PA, QL (60 PER 30 DAYS) morphine sulfate 2 mg/ml syringe QL (1000 PER 30 DAYS) morphine sulfate 4 mg/ml syringe QL (500 PER 30 DAYS) morphine sulfate 5 mg/ml syringe QL (400 PER 30 DAYS) oxycodone hcl (10 mg tablet, 15 mg tablet, 20 mg/ml oral conc, 20 mg tablet, 30 mg tablet) oxycodone hcl (5 mg capsule, 5 mg tablet) QL (180 PER 30 DAYS) QL (360 PER 30 DAYS) oxycodone hcl 5 mg/5 ml solution QL (1200 PER 30 DAYS) oxycodone hcl/acetaminophen (hcl/acetaminophen mg tablet, hcl/acetaminophen 5 mg- 325mg tablet, hcl/acetaminophen mg tablet, hcl/acetaminophen 10mg-325mg tablet) QL (360 PER 30 DAYS) 36

37 oxycodone hcl/acetaminophen 5-325/5 ml solution oxycodone hcl/aspirin tablet OXYCONTIN (10 MG TABLET, 15 MG TABLET, 20 MG TABLET, 30 MG TABLET, 40 MG TABLET, 60 MG TABLET) QL (1860 PER 30 DAYS) QL (360 PER 30 DAYS) PA, QL (90 PER 30 DAYS) OXYCONTIN 80 MG TABLET PA, QL (60 PER 30 DAYS) oxymorphone hcl (5 mg tab er 12h, 7.5 mg tab er 12h, 10 mg tab er 12h, 15 mg tab er 12h, 20 mg tab er 12h, 30 mg tab er 12h, 40 mg tab er 12h) PA, QL (90 PER 30 DAYS) oxymorphone hcl 10 mg tablet QL (360 PER 30 DAYS) oxymorphone hcl 5 mg tablet QL (180 PER 30 DAYS) VICODIN MG TABLET QL (390 PER 30 DAYS) VICODIN ES MG TABLET QL (390 PER 30 DAYS) VICODIN HP MG TABLET QL (390 PER 30 DAYS) ZAMICET MG/15 ML SOLN QL (5550 PER 30 DAYS) NON-NARCOTIC ANALGESICS buprenorphine hcl/naloxone hcl 2 mg-0.5mg tab subl buprenorphine hcl/naloxone hcl 8 mg-2 mg tab subl QL (360 PER 30 DAYS) QL (90 PER 30 DAYS) butorphanol tartrate 1 mg/ml vial QL (857 PER 30 DAYS) butorphanol tartrate 10 mg/ml spray QL (10 PER 28 DAYS) butorphanol tartrate 2 mg/ml vial QL (428 PER 30 DAYS) celecoxib (50 mg capsule, 100 mg capsule, 200 mg capsule, 400 mg capsule) diclofenac potassium 50 mg tablet diclofenac sodium (25 mg tablet dr, 50 mg tablet dr, 75 mg tablet dr, 100 mg tab er 24h) diclofenac sodium 1 % gel (gram) QL (1000 PER 28 DAYS) 37

38 diclofenac sodium 1.5 % drops QL (300 PER 28 DAYS) diclofenac sodium/misoprostol (sodium/misoprostol 50 tab ir dr, sodium/misoprostol 75 tab ir dr) diflunisal 500 mg tablet etodolac (200 mg capsule, 300 mg capsule, 400 mg tab er 24h, 400 mg tablet, 500 mg tab er 24h, 500 mg tablet, 600 mg tab er 24h) fenoprofen calcium 600 mg tablet FLECTOR 1.3% PATCH PA, QL (60 PER 30 DAYS) flurbiprofen (50 mg tablet, 100 mg tablet) IBU (400 MG TABLET, 600 MG TABLET, 800 MG TABLET) ibuprofen (100 mg/5ml oral susp, 400 mg tablet, 600 mg tablet, 800 mg tablet) ketoprofen (50 mg capsule, 75 mg capsule, 200 mg cap24h pel) meclofenamate sodium (50 mg capsule, 100 mg capsule) mefenamic acid 250 mg capsule meloxicam 15 mg tablet meloxicam 7.5 mg tablet QL (30 PER 30 DAYS) nabumetone (500 mg tablet, 750 mg tablet) nalbuphine hcl (10 mg/ml ampul, 10 mg/ml vial) nalbuphine hcl (20 mg/ml ampul, 20 mg/ml vial) naloxone hcl (0.4 mg/ml vial, 0.4 mg/ml syringe, 1 mg/ml syringe) naltrexone hcl 50 mg tablet naproxen (125 mg/5ml oral susp, 250 mg tablet, 375 mg tablet dr, 375 mg tablet, 500 mg tablet, 500 mg tablet dr) QL (200 PER 30 DAYS) QL (100 PER 30 DAYS) 38

39 naproxen sodium (275 mg tablet, 375 mg tbmp 24hr, 500 mg tbmp 24hr, 550 mg tablet) NARCAN 4 MG NASAL SPRAY QL (2 PER 28 DAYS) oxaprozin 600 mg tablet piroxicam (10 mg capsule, 20 mg capsule) PROFENO 600 MG TABLET SUBOXONE (4 MG-1 MG FILM, 8 MG-2 MG FILM) QL (90 PER 30 DAYS) SUBOXONE 12 MG-3 MG SL FILM QL (60 PER 30 DAYS) SUBOXONE 2 MG-0.5 MG SL FILM sulindac (150 mg tablet, 200 mg tablet) tolmetin sodium (400 mg capsule, 600 mg tablet) tramadol hcl (100 mg tab er 24h, 100 mg tbmp 24hr, 200 mg tab er 24h, 200 mg tbmp 24hr, 300 mg tbmp 24hr, 300 mg tab er 24h) QL (360 PER 30 DAYS) PA, QL (30 PER 30 DAYS) tramadol hcl 50 mg tablet QL (240 PER 30 DAYS) tramadol hcl/acetaminophen mg tablet QL (240 PER 30 DAYS) VOLTAREN 1% GEL QL (1000 PER 28 DAYS) ZUBSOLV ( MG TABLET, MG TABLET, MG TABLET, MG TABLET) QL (30 PER 30 DAYS) ZUBSOLV MG TABLET SL QL (60 PER 30 DAYS) PSYCHOTHERAPEUTIC DRUGS ABILIFY MAINTENA (ER 300 MG VL, ER 300 MG SYR, ER 400 MG SYR) amitriptyline hcl (10 mg tablet, 25 mg tablet, 50 mg tablet, 75 mg tablet, 100 mg tablet, 150 mg tablet) amoxapine (25 mg tablet, 50 mg tablet, 100 mg tablet, 150 mg tablet) PA - FOR NEW STARTS ONLY 39

40 aripiprazole (10 mg tab rapdis, 10 mg tablet) aripiprazole (15 mg tab rapdis, 15 mg tablet, 20 mg tablet) aripiprazole 1 mg/ml solution QL (90 PER 30 DAYS) QL (60 PER 30 DAYS) aripiprazole 2 mg tablet QL (450 PER 30 DAYS) aripiprazole 30 mg tablet QL (30 PER 30 DAYS) aripiprazole 5 mg tablet QL (180 PER 30 DAYS) ARISTADA (ER 441 MG/1.6 ML SYRN, ER 662 MG/2.4 ML SYRN, ER 882 MG/3.2 ML SYRN, ER 1064 MG/3.9 ML SYR) armodafinil (50 mg tablet, 150 mg tablet, 200 mg tablet, 250 mg tablet) atomoxetine hcl (10 mg capsule, 18 mg capsule, 25 mg capsule, 40 mg capsule, 60 mg capsule, 80 mg capsule, 100 mg capsule) bupropion hcl (150 mg tab er 24h, 150 mg tab er 12h) bupropion hcl (200 mg tab er 12h, 300 mg tab er 24h) bupropion hcl (75 mg tablet, 100 mg tablet) PA QL (90 PER 30 DAYS) QL (60 PER 30 DAYS) bupropion hcl 100 mg tab er 12h QL (120 PER 30 DAYS) buspirone hcl (5 mg tablet, 7.5 mg tablet, 10 mg tablet, 15 mg tablet, 30 mg tablet) chlorpromazine hcl (10 mg tablet, 25 mg/ml ampul, 25 mg tablet, 50 mg tablet, 100 mg tablet, 200 mg tablet) citalopram hydrobromide 10 mg tablet citalopram hydrobromide 10 mg/5 ml solution citalopram hydrobromide 20 mg tablet QL (120 PER 30 DAYS) QL (60 PER 30 DAYS) 40

41 citalopram hydrobromide 40 mg tablet clomipramine hcl (25 mg capsule, 50 mg capsule, 75 mg capsule) clonidine hcl 0.1 mg tab er 12h clorazepate dipotassium (3.75 mg tablet, 7.5 mg tablet, 15 mg tablet) clozapine (12.5 mg tab rapdis, 25 mg tab rapdis, 25 mg tablet, 50 mg tablet, 100 mg tab rapdis, 100 mg tablet, 200 mg tablet) desipramine hcl (10 mg tablet, 25 mg tablet, 50 mg tablet, 75 mg tablet, 100 mg tablet, 150 mg tablet) desvenlafaxine succinate 100 mg tab er 24h desvenlafaxine succinate 25 mg tab er 24h desvenlafaxine succinate 50 mg tab er 24h dexmethylphenidate hcl (2.5 mg tablet, 5 mg tablet, 5 mg cpbp 50-50, 10 mg tablet, 10 mg cpbp 50-50, 15 mg cpbp 50-50, 20 mg cpbp 50-50, 25 mg cpbp 50-50, 30 mg cpbp 50-50, 35 mg cpbp 50-50, 40 mg cpbp 50-50) QL (30 PER 30 DAYS) PA - FOR NEW STARTS ONLY PA - FOR NEW STARTS ONLY QL (120 PER 30 DAYS) QL (480 PER 30 DAYS) QL (240 PER 30 DAYS) 41

42 dextroamphetamine sulfsaccharate/amphetamine sulfaspartate (dextroamphetamine/amphetamine 5 mg tablet, dextroamphetamine/amphetamine 5 mg cap er 24h, dextroamphetamine/amphetamine 7.5 mg tablet, dextroamphetamine/amphetamine 10 mg cap er 24h, dextroamphetamine/amphetamine 10 mg tablet, dextroamphetamine/amphetamine 12.5 mg tablet, dextroamphetamine/amphetamine 15 mg cap er 24h, dextroamphetamine/amphetamine 15 mg tablet, dextroamphetamine/amphetamine 20 mg cap er 24h, dextroamphetamine/amphetamine 20 mg tablet, dextroamphetamine/amphetamine 25 mg cap er 24h, dextroamphetamine/amphetamine 30 mg cap er 24h, dextroamphetamine/amphetamine 30 mg tablet) dextroamphetamine sulfate (5 mg capsule er, 5 mg tablet, 10 mg capsule er, 10 mg tablet, 15 mg capsule er) diazepam (2 mg tablet, 5 mg tablet, 5 mg/5 ml solution, 5 mg/ml oral conc, 10 mg tablet) doxepin hcl (10 mg/ml oral conc, 10 mg capsule, 25 mg capsule, 50 mg capsule, 75 mg capsule, 100 mg capsule, 150 mg capsule) PA - FOR NEW STARTS ONLY PA - FOR NEW STARTS ONLY duloxetine hcl 20 mg capsule dr QL (180 PER 30 DAYS) duloxetine hcl 30 mg capsule dr QL (120 PER 30 DAYS) duloxetine hcl 40 mg capsule dr QL (90 PER 30 DAYS) duloxetine hcl 60 mg capsule dr QL (60 PER 30 DAYS) EMSAM (6 MG/24 PATCH, 9 MG/24 PATCH, 12 MG/24 PATCH) 42

43 ergoloid mesylates 1 mg tablet escitalopram oxalate 10 mg tablet QL (60 PER 30 DAYS) escitalopram oxalate 20 mg tablet QL (30 PER 30 DAYS) escitalopram oxalate 5 mg tablet QL (120 PER 30 DAYS) escitalopram oxalate 5 mg/5 ml solution eszopiclone (1 mg tablet, 2 mg tablet, 3 mg tablet) FANAPT (8 MG TABLET, 10 MG TABLET) ST, QL (30 PER 30 DAYS) QL (90 PER 30 DAYS) FANAPT 1 MG TABLET QL (720 PER 30 DAYS) FANAPT 12 MG TABLET QL (60 PER 30 DAYS) FANAPT 2 MG TABLET QL (360 PER 30 DAYS) FANAPT 4 MG TABLET QL (180 PER 30 DAYS) FANAPT 6 MG TABLET QL (120 PER 30 DAYS) FANAPT TITRATION PACK QL (8 PER 28 DAYS) FAZACLO (150 MG ODT, 200 MG ODT) FETZIMA MG TITRATION PAK QL (28 PER 28 DAYS) FETZIMA ER 120 MG CAPSULE QL (30 PER 30 DAYS) FETZIMA ER 20 MG CAPSULE QL (180 PER 30 DAYS) FETZIMA ER 40 MG CAPSULE QL (90 PER 30 DAYS) FETZIMA ER 80 MG CAPSULE QL (45 PER 30 DAYS) fluoxetine hcl (10 mg tablet, 10 mg capsule) fluoxetine hcl (20 mg tablet, 20 mg capsule, 20 mg/5 ml solution, 60 mg tablet) QL (240 PER 30 DAYS) fluoxetine hcl 40 mg capsule QL (60 PER 30 DAYS) fluoxetine hcl 90 mg capsule dr QL (4 PER 28 DAYS) fluphenazine decanoate 25 mg/ml vial 43

44 fluphenazine hcl (1 mg tablet, 2.5 mg tablet, 2.5 mg/ml vial, 2.5 mg/5ml elixir, 5 mg tablet, 5 mg/ml oral conc, 10 mg tablet) fluvoxamine maleate (100 mg cap er 24h, 100 mg tablet) fluvoxamine maleate 150 mg cap er 24h QL (90 PER 30 DAYS) QL (60 PER 30 DAYS) fluvoxamine maleate 25 mg tablet QL (360 PER 30 DAYS) fluvoxamine maleate 50 mg tablet QL (180 PER 30 DAYS) FORFIVO XL 450 MG TABLET QL (30 PER 30 DAYS) GEODON 20 MG/ML VIAL guanidine hcl 125 mg tablet haloperidol (0.5 mg tablet, 1 mg tablet, 2 mg tablet, 5 mg tablet, 10 mg tablet, 20 mg tablet) haloperidol decanoate (50 mg/ml ampul, 50 mg/ml vial, 100 mg/ml vial, 100 mg/ml ampul) haloperidol lactate (2 mg/ml oral conc, 5 mg/ml vial, 5 mg/ml ampul, 5 mg/ml syringe) HETLIOZ 20 MG CAPSULE PA, QL (30 PER 30 DAYS) imipramine hcl (10 mg tablet, 25 mg tablet, 50 mg tablet) imipramine pamoate (75 mg capsule, 100 mg capsule, 125 mg capsule, 150 mg capsule) INVEGA SUSTENNA (39 MG/0.25 ML, 78 MG/0.5 ML, 117 MG/0.75 ML, 156 MG/ML SYRG, 234 MG/1.5 ML) INVEGA TRINZA (273 MG/0.875 ML, 410 MG/1.315 ML, 546 MG/1.75 ML, 819 MG/2.625 ML) LATUDA (60 MG TABLET, 80 MG TABLET) PA - FOR NEW STARTS ONLY PA - FOR NEW STARTS ONLY QL (60 PER 30 DAYS) LATUDA 120 MG TABLET QL (30 PER 30 DAYS) LATUDA 20 MG TABLET QL (240 PER 30 DAYS) 44