Pharmacy Benefit Management (PBM) Program FORMULARY/PRODUCT RESTRICTIONS
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1 Workforce Safety & Insurance Revised Document Date: 07/23/ E Century Ave Ste 1 PO Box 5585 Bismarck, ND Pharmacy Benefit Management (PBM) Program FORMULARY/PRODUCT RESTRICTIONS Key: B G Available as brand name only Available as a generic equivalent $ Average cost < $50 per prescription $$ Average cost $50 to $99 per prescription $$$ Average cost $100 to $249 per prescription $$$$ Average cost $250 to $499 per prescription $$$$$ Average cost > $499 per prescription F N/F PA Formulary: Indicates that the product is available without prior authorization. Non-Formulary: Indicates that the product is not available. An alternative F (Formulary) or PA (Prior Authorization) agent must be selected. Prior Authorization: Indicates that the product require prior approval by WSI before being dispensed to the injured worker. 61 ADHD/Anti-Narcolepsy/ Anti-Obesity/Anorexiants Description Brand Name B/G Cost Status 6110 Amphetamines Quantity Limits: 2.00 per day Amphetamine Salts Cap Ext Rel 5mg Adderall XR G PA Quantity Limits: 2.00 per day Amphetamine Salts Cap Ext Rel 10mg Adderall XR G PA Quantity Limits: 2.00 per day Amphetamine Salts Cap Ext Rel 15mg Adderall XR G PA Quantity Limits: 2.00 per day Amphetamine Salts Cap Ext Rel 20mg Adderall XR G PA
2 Quantity Limits: 2.00 per day Amphetamine Salts Cap Ext Rel 25mg Adderall XR G PA Quantity Limits: 2.00 per day Amphetamine Salts Cap Ext Rel 30mg Adderall XR G PA Amphetamine Salts Tab 5mg Adderall G PA Amphetamine Salts Tab 7.5mg Adderall G PA Amphetamine Salts Tab 10mg Adderall G PA Amphetamine Salts Tab 12.5mg Adderall G PA Amphetamine Salts Tab 15mg Adderall G PA Amphetamine Salts Tab 20mg Adderall G PA Amphetamine Salts Tab 30mg Adderall G PA Dextroamphetamine Cap Ext Rel 5mg Dexedrine G PA Dextroamphetamine Cap Ext Rel 10mg Dexedrine G PA Dextroamphetamine Cap Ext Rel 15mg Dexedrine G PA Dextroamphetamine Soln 5mg/5ml ProCentra G PA Dextroamphetamine Tab 2.5mg Zenzedi B N/F Dextroamphetamine Tab 5mg Dexedrine, Zenzedi G PA Dextroamphetamine Tab 7.5mg Zenzedi B N/F Dextroamphetamine Tab 10mg Dexedrine, Zenzedi G PA Dextroamphetamine Tab 15mg Zenzedi B N/F Dextroamphetamine Tab 20mg Zenzedi B N/F Dextroamphetamine Tab 30mg Zenzedi B N/F Lisdexamfetamine Cap 10mg Vyvanse B PA Lisdexamfetamine Cap 20mg Vyvanse B PA Lisdexamfetamine Cap 30mg Vyvanse B PA Lisdexamfetamine Cap 40mg Vyvanse B PA Lisdexamfetamine Cap 50mg Vyvanse B PA Lisdexamfetamine Cap 60mg Vyvanse B PA Lisdexamfetamine Cap 70mg Vyvanse B PA Methamphetamine Tab 5mg Desoxyn G N/F 6120 Anorexiants Benzphetamine Tab 25mg Regimex B N/F Benzphetamine Tab 50mg Didrex G PA Diethylpropion Tab 25mg Radtue G PA Diethylpropion Tab Ext Rel 75mg G PA 2
3 Lorcaserin Tab 10mg Belviq B PA Phendimetrazine Cap Ext Rel 105mg Bontril Slow-Release, G PA Melfiat-105 Unicelles Phendimetrazine Tab 35mg Bontril PDM G PA Phentermine Cap 15mg G PA Phentermine Cap 18.75mg G PA Phentermine Cap 30mg G PA Phentermine Cap 37.5mg Adipex-P G PA Phentermine Tab 8mg G PA Phentermine Tab 37.5mg Adipex-P G PA Phentermine Tab Oral Dis 15mg Suprenza B N/F Phentermine Tab Oral Dis 30mg Suprenza B N/F Phentermine Tab Oral Dis 37.5mg Suprenza B N/F Anorexiant Combinations 3.75mg-23mg 7.5mg-46mg 11.25mg-69mg 15mg-92mg 6125 Anorexiants - Miscellaneous Fat Absorption Decreasing Agents Orlistat Cap 60mg Alli B PA Orlistat Cap 120mg Xenical B PA 6130 Analeptics Caffeine Oral Soln 20mg/ml Cafcit G N/F Caffeine Tab 200mg NoDoz, Vivarin G N/F 6135 Attention-Deficit/Hyperactivity Disorder (ADHD) Agents Atomoxetine Cap 10mg Strattera B PA Atomoxetine Cap 18mg Strattera B PA Atomoxetine Cap 25mg Strattera B PA Atomoxetine Cap 40mg Strattera B PA 3
4 Atomoxetine Cap 60mg Strattera B PA Atomoxetine Cap 80mg Strattera B PA Atomoxetine Cap 100mg Strattera B PA Guanfacine Tab Ext Rel 1mg Intuniv G PA Guanfacine Tab Ext Rel 2mg Intuniv G PA Guanfacine Tab Ext Rel 3mg Intuniv G PA Guanfacine Tab Ext Rel 4mg Intuniv G PA 6140 Stimulants Miscellaneous Quantity Limits: 2.00 per day Armodafinil Tab 50mg Nuvigil B PA Quantity Limits: 1.00 per day Armodafinil Tab 150mg Nuvigil B PA Quantity Limits: 1.00 per day Armodafinil Tab 200mg Nuvigil B PA Quantity Limits: 1.00 per day Armodafinil Tab 250mg Nuvigil B PA Dexmethylphenidate Cap Ext Rel 5mg Focalin XR G N/F Dexmethylphenidate Cap Ext Rel 10mg Focalin XR G N/F Dexmethylphenidate Cap Ext Rel 15mg Focalin XR G N/F Dexmethylphenidate Cap Ext Rel 20mg Focalin XR G N/F Dexmethylphenidate Cap Ext Rel 25mg Focalin XR B N/F Dexmethylphenidate Cap Ext Rel 30mg Focalin XR G N/F Dexmethylphenidate Cap Ext Rel 35mg Focalin XR B N/F Dexmethylphenidate Cap Ext Rel 40mg Focalin XR G N/F Dexmethylphenidate Tab 2.5mg Focalin G N/F Dexmethylphenidate Tab 5mg Focalin G N/F Dexmethylphenidate Tab 10mg Focalin G N/F Quantity Limits: 1.00 per day Methylphenidate Cap Con Rel 10mg Metadate CD G PA Quantity Limits: 1.00 per day Methylphenidate Cap Con Rel 20mg Metadate CD G PA Quantity Limits: 1.00 per day Methylphenidate Cap Con Rel 30mg Metadate CD G PA Quantity Limits: 1.00 per day Methylphenidate Cap Con Rel 40mg Metadate CD G PA Quantity Limits: 1.00 per day Methylphenidate Cap Con Rel 50mg Metadate CD G PA Quantity Limits: 1.00 per day Methylphenidate Cap Con Rel 60mg Metadate CD G PA Methylphenidate Cap Ext Rel 10mg Aptensio XR B N/F Methylphenidate Cap Ext Rel 15mg Aptensio XR B N/F Methylphenidate Cap Ext Rel 20mg Aptensio XR B N/F Methylphenidate Cap Ext Rel 30mg Aptensio XR B N/F 4
5 Methylphenidate Cap Ext Rel 40mg Aptensio XR B N/F Methylphenidate Cap Ext Rel 50mg Aptensio XR B N/F Methylphenidate Cap Ext Rel 60mg Aptensio XR B N/F Methylphenidate Cap Sus Rel 10mg Ritalin LA B PA Methylphenidate Cap Sus Rel 20mg Ritalin LA B PA Methylphenidate Cap Sus Rel 30mg Ritalin LA B PA Methylphenidate Cap Sus Rel 40mg Ritalin LA B PA Methylphenidate Cap Sus Rel 60mg Ritalin LA B PA Methylphenidate Oral Soln 5mg/5ml Methylin G PA Methylphenidate Oral Soln 10mg/5ml Methylin G PA 300mg/60ml 600mg/120ml 750mg/150ml 900mg/180ml Methylphenidate Tab 5mg Ritalin G PA Methylphenidate Tab 10mg Ritalin G PA Methylphenidate Tab 20mg Ritalin G PA Methylphenidate Tab Chew 2.5mg Methylin G PA Methylphenidate Tab Chew 5mg Methylin G PA Methylphenidate Tab Chew 10mg Methylin G PA Methylphenidate Tab Ext Rel 10mg G PA Quantity Limits: 1.00 per day Methylphenidate Tab Ext Rel 18mg Concerta G PA Quantity Limits: 1.00 per day Methylphenidate Tab Ext Rel 20mg Metadate ER, Ritalin-SR G PA Quantity Limits: 1.00 per day Methylphenidate Tab Ext Rel 27mg Concerta G PA Quantity Limits: 2.00 per day Methylphenidate Tab Ext Rel 36mg Concerta G PA Quantity Limits: 1.00 per day Methylphenidate Tab Ext Rel 54mg Concerta G PA Methylphenidate Transdermal 10mg/24hrs Daytrana B N/F Methylphenidate Transdermal 15mg/24hrs Daytrana B N/F Methylphenidate Transdermal 20mg/24hrs Daytrana B N/F Methylphenidate Transdermal 30mg/24hrs Daytrana B N/F 5
6 Quantity Limits: 2.00 per day Modafinil Tab 100mg Provigil G PA Quantity Limits: 2.00 per day Modafinil Tab 200mg Provigil G PA 6
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