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

Transcription

1 2015 Ohana Community Care Services (CCS) Comprehensive referred Drug List (List of Covered Drugs) Ohana Health lan 00 lease read: This document contains information about the drugs we cover in this plan. lease note that the Ohana Community Care Services (CCS) referred Drug List is updated quarterly. roviders, please visit our website at to view updates to the preferred drug list. Members, please visit our website at to view updates to the preferred drug list. Last updated (7/01/2015)

2 This plan has a limit of 248 dosage units, unless otherwise specified through a quantity limit. Drug Name reference Details Coverage Details *Adhd/Anti-Narcolepsy/Anti-Obesity/Anorexia nts* *Amphetamines**-*Amphetamine Mixtures*** amphetamine-dextroamphet er oral capsule extended release 24 hour 10, 15, 20, 25, 30, 5 amphetamine-dextroamphetamine oral tablet 10, 12.5, 15, 20, 30, 5, 7.5 *Amphetamines**-*Amphetamines*** dextroamphetamine sulfate er oral capsule extended release 24 hour 10, 15, 5 dextroamphetamine sulfate oral tablet 10, 5 methamphetamine hcl oral tablet 5 ROCENTRA ORAL SOLUTION 5 MG/5ML VYVANSE ORAL CASULE 10 MG, 20 MG, 30 MG, 40 MG, 50 MG, 60 MG, 70 MG ZENZEDI ORAL TABLET 15 MG, 2.5 MG, 20 MG, 30 MG, 7.5 MG *Attention-Deficit/Hyperactivity Disorder (Adhd) Agents**-*Adhd Agent - Selective Alpha Adrenergic Agonists*** clonidine hcl er oral tablet extended release 12 hr* 0.1 guanfacine hcl er oral tablet extended release 24 hr* 1, 2, 3, 4 *Attention-Deficit/Hyperactivity Disorder (Adhd) Agents**-*Adhd Agent - Selective Norepinephrine Reuptake Inhibitor*** STRATTERA ORAL CASULE 10 MG, 100 MG, 18 MG, 25 MG, 40 MG, 60 MG, 80 MG =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/rx, UERCASE= Brand name drugs/ 1

3 Drug Name reference Details Coverage Details *Stimulants - Misc.**-*Stimulants - Misc.*** ATENSIO XR ORAL CASULE EXTENDED RELEASE 24 HOUR 10 MG, 15 MG, 20 MG, 30 MG, 40 MG, 50 MG, 60 MG DAYTRANA TRANSDERMAL ATCH 10 MG/9HR, 15 MG/9HR, 20 MG/9HR, 30 MG/9HR dexmethylphenidate hcl er oral capsule extended release 24 hour 10, 15, 30, 40, 5 dexmethylphenidate hcl oral tablet 10, 2.5, 5 FOCALIN XR ORAL CASULE EXTENDED RELEASE 24 HOUR 20 MG, 25 MG, 35 MG METADATE ER ORAL TABLET EXTENDEDRELEASE* 20 MG METHYLIN ORAL TABLET CHEWABLE 10 MG, 2.5 MG, 5 MG methylphenidate hcl er (cd) oral capsule extended release* 10, 20, 30, 40, 50, 60 methylphenidate hcl er (la) oral capsule extended release 24 hour 20, 30, 40 methylphenidate hcl er oral tablet extendedrelease* 10, 18, 20, 27, 36, 54 methylphenidate hcl oral solution 10 /5ml, 5 /5ml methylphenidate hcl oral tablet 10, 20, 5 QUILLIVANT XR ORAL SUSENSION RECONSTITUTED 25 MG/5ML RITALIN LA ORAL CASULE EXTENDED RELEASE 24 HOUR 10 MG, 60 MG =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/rx, UERCASE= Brand name drugs/ 2

4 Drug Name reference Details Coverage Details *Analgesics - Opioid* *Opioid Agonists**-*Opioid Agonists*** METHADONE HCL INTENSOL ORAL CONCENTRATE 10 MG/ML methadone hcl oral concentrate 10 /ml A methadone hcl oral solution 10 /5ml, 5 /5ml methadone hcl oral tablet 10, 5 A methadone hcl oral tablet soluble 40 A METHADOSE ORAL CONCENTRATE 10 MG/ML METHADOSE ORAL TABLET SOLUBLE 40 MG *Opioid artial Agonists**-*Opioid artial Agonists*** buprenorphine hcl sublingual tablet sublingual 2, 8 zubsolv sublingual tablet sublingual , ZUBSOLV SUBLINGUAL TABLET SUBLINGUAL MG *Antianxiety Agents* *Antianxiety Agents - Misc.**-*Antianxiety Agents - Misc.*** buspirone hcl oral tablet 10, 15, 30, 5, 7.5 hydroxyzine hcl intramuscular* solution 25 /ml, 50 /ml hydroxyzine hcl oral solution 10 /5ml hydroxyzine hcl oral tablet 10, 25, 50 hydroxyzine pamoate oral capsule 100, 25, 50 meprobamate oral tablet 200, 400 *Benzodiazepines**-*Benzodiazepines*** alprazolam er oral tablet extended release 24 hr* 0.5, 1, 2, 3 ALRAZOLAM INTENSOL ORAL CONCENTRATE 1 MG/ML =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/rx, UERCASE= Brand name drugs/ A A A A A A A 3

5 Drug Name reference Details Coverage Details alprazolam oral tablet 0.25, 0.5, 1, 2 alprazolam oral tablet dispersible 0.25, 0.5, 1, 2 alprazolam xr oral tablet extended release 24 hr* 0.5, 1, 2, 3 chlordiazepoxide hcl oral capsule 10, 25, 5 clorazepate dipotassium oral tablet 15, 3.75, 7.5 diazepam injection solution 5 /ml DIAZEAM INTENSOL ORAL CONCENTRATE 5 MG/ML diazepam intramuscular* device 10 /2ml diazepam oral solution 1 /ml diazepam oral tablet 10, 2, 5 lorazepam injection solution 2 /ml, 4 /ml LORAZEAM INTENSOL ORAL CONCENTRATE 2 MG/ML lorazepam oral concentrate 2 /ml lorazepam oral tablet 0.5, 1, 2 oxazepam oral capsule 10, 15, 30 *Anticonvulsants* *Anticonvulsants - Benzodiazepines**-*Anticonvulsants - Benzodiazepines*** clonazepam oral tablet 0.5, 1, 2 clonazepam oral tablet dispersible 0.125, 0.25, 0.5, 1, 2 *Anticonvulsants - Misc.**-*Anticonvulsants - Misc.*** carbamazepine er oral capsule extended release 12 hour 100, 200, 300 carbamazepine er oral tablet extended release 12 hr* 200, 400 carbamazepine oral suspension 100 /5ml carbamazepine oral tablet 200 carbamazepine oral tablet chewable 100 =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/rx, UERCASE= Brand name drugs/ 4

6 Drug Name reference Details Coverage Details gabapentin oral capsule 100, 300, 400 gabapentin oral solution 250 /5ml gabapentin oral tablet 600, 800 LAMICTAL ODT ORAL KIT 25 & 50 & 100 MG, 25 (21)-50 (7) MG, 50 (42)-100(14) MG LAMICTAL STARTER ORAL KIT 25 (35) MG, 25 (42)-100 (7) MG, 25 (84)-100(14) MG LAMICTAL XR ORAL KIT 25 & 50 & 100 MG, 25 (21)-50 (7) MG, 50 & 100 & 200 MG lamotrigine er oral tablet extended release 24 hr* 100, 200, 25, 250, 300, 50 lamotrigine oral tablet 100, 150, 200, 25 lamotrigine oral tablet chewable 25, 5 lamotrigine oral tablet dispersible 100, 200, 25, 50 levetiracetam er oral tablet extended release 24 hr* 500, 750 levetiracetam intravenous* solution 500 /5ml levetiracetam oral solution 100 /ml levetiracetam oral tablet 1000, 250, 500, 750 oxcarbazepine oral suspension 300 /5ml oxcarbazepine oral tablet 150, 300, 600 OXTELLAR XR ORAL TABLET EXTENDED RELEASE 24 HR* 150 MG, 300 MG, 600 MG QUDEXY XR ORAL 100 MG, 150 MG, 200 MG, 25 MG, 50 MG TEGRETOL-XR ORAL TABLET EXTENDED RELEASE 12 HR* 100 MG TOIRAMATE ER ORAL 100 MG, 150 MG, 200 MG, 25 MG, 50 MG topiramate oral capsule sprinkle 15, 25 topiramate oral tablet 100, 200, 25, 50 =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/rx, UERCASE= Brand name drugs/ 5

7 Drug Name reference Details Coverage Details TROKENDI XR ORAL CASULE EXTENDED RELEASE 24 HOUR 100 MG, 200 MG, 25 MG, 50 MG *Gaba Modulators**-*Gaba Modulators*** GABITRIL ORAL TABLET 12 MG, 16 MG tiagabine hcl oral tablet 2, 4 *Valproic Acid**-*Valproic Acid*** divalproex sodium er oral tablet extended release 24 hr* 250, 500 divalproex sodium oral capsule sprinkle 125 divalproex sodium oral tablet delayed release 125, 250, 500 STAVZOR ORAL CASULE DELAYED RELEASE 125 MG, 250 MG, 500 MG valproate sodium intravenous* solution 100 /ml valproic acid oral capsule 250 valproic acid oral solution 250 /5ml valproic acid oral syrup 250 /5ml *Antidepressants* *Alpha-2 Receptor Antagonists (Tetracyclics)**-*Alpha-2 Receptor Antagonists (Tetracyclics)*** mirtazapine oral tablet 15, 30, 45, 7.5 mirtazapine oral tablet dispersible 15, 30, 45 *Antidepressants - Misc.**-*Antidepressants - Misc.*** ALENZIN ORAL TABLET EXTENDED RELEASE 24 HR* 174 MG ALENZIN ORAL TABLET EXTENDED RELEASE 24 HR* 348 MG, 522 MG bupropion hcl er (sr) oral tablet extended release 12 hr* 100, 150, 200 bupropion hcl er (xl) oral tablet extended release 24 hr* 150, 300 bupropion hcl oral tablet 100, 75 DL antidepressants.) =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/rx, UERCASE= Brand name drugs/ 6

8 Drug Name reference Details Coverage Details FORFIVO XL ORAL TABLET EXTENDED RELEASE 24 HR* 450 MG maprotiline hcl oral tablet 25, 50, 75 *Monoamine Oxidase Inhibitors (Maois)**-*Monoamine Oxidase Inhibitors (Maois)*** EMSAM TRANSDERMAL ATCH 24 HR 12 MG/24HR, 6 MG/24HR, 9 MG/24HR MARLAN ORAL TABLET 10 MG phenelzine sulfate oral tablet 15 tranylcypromine sulfate oral tablet 10 *Selective Serotonin Reuptake Inhibitors (Ssris)**-*Selective Serotonin Reuptake Inhibitors (Ssris)*** citalopram hydrobromide oral solution 10 /5ml citalopram hydrobromide oral tablet 10, 20, 40 escitalopram oxalate oral solution 5 /5ml escitalopram oxalate oral tablet 10, 20, 5 fluoxetine hcl oral capsule 10, 20, 40 fluoxetine hcl oral capsule delayed release 90 fluoxetine hcl oral solution 20 /5ml fluoxetine hcl oral tablet 10, 20, 60 fluvoxamine maleate er oral capsule extended release 24 hour 100, 150 fluvoxamine maleate oral tablet 100, 25, 50 paroxetine hcl er oral tablet extended release 24 hr* 12.5, 25, 37.5 paroxetine hcl oral tablet 10, 20, 30, 40 AXIL ORAL SUSENSION 10 MG/5ML EXEVA ORAL TABLET 10 MG, 20 MG, 30 MG, 40 MG DL antidepressants.) DL antidepressants.) DL antidepressants.) DL antidepressants.) DL antidepressants.) =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/rx, UERCASE= Brand name drugs/ 7

9 Drug Name reference Details Coverage Details sertraline hcl oral concentrate 20 /ml sertraline hcl oral tablet 100, 25, 50 *Serotonin Modulators**-*Serotonin Modulators*** BRINTELLIX ORAL TABLET 10 MG, 20 MG, 5 MG nefazodone hcl oral tablet 100, 150, 200, 250, 50 OLETRO ORAL TABLET EXTENDED RELEASE 24 HR* 150 MG, 300 MG trazodone hcl oral tablet 100, 150, 300, 50 VIIBRYD ORAL KIT 10 & 20 & 40 MG VIIBRYD ORAL TABLET 10 MG, 20 MG, 40 MG *Serotonin-Norepinephrine Reuptake Inhibitors (Snris)**-*Serotonin-Norepinephrine Reuptake Inhibitors (Snris)*** desvenlafaxine er oral tablet extended release 24 hr* 100, 50 duloxetine hcl oral capsule delayed release particles 20, 30, 60 FETZIMA ORAL CASULE EXTENDED RELEASE 24 HOUR 120 MG, 20 MG, 40 MG, 80 MG FETZIMA TITRATION ORAL 20 & 40 MG KHEDEZLA ORAL TABLET EXTENDED RELEASE 24 HR* 100 MG, 50 MG RISTIQ ORAL TABLET EXTENDED RELEASE 24 HR* 100 MG, 25 MG, 50 MG venlafaxine hcl er oral capsule extended release 24 hour 150, 37.5, 75 venlafaxine hcl er oral tablet extended release 24 hr* 150, 225, 37.5, 75 venlafaxine hcl oral tablet 100, 25, 37.5, 50, 75 DL antidepressants.) DL antidepressants.) DL antidepressants.) DL antidepressants.) DL antidepressants.) DL antidepressants.) DL antidepressants.) DL antidepressants.) =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/rx, UERCASE= Brand name drugs/ 8

10 Drug Name reference Details Coverage Details *Tricyclic Agents**-*Tricyclic Agents*** amitriptyline hcl oral tablet 10, 100, 150, 25, 50, 75 amoxapine oral tablet 100, 150, 25, 50 clomipramine hcl oral capsule 25, 50, 75 desipramine hcl oral tablet 10, 100, 150, 25, 50, 75 doxepin hcl oral capsule 10, 100, 150, 25, 50, 75 doxepin hcl oral concentrate 10 /ml imipramine hcl oral tablet 10, 25, 50 imipramine pamoate oral capsule 100, 125, 150, 75 nortriptyline hcl oral capsule 10, 25, 50, 75 protriptyline hcl oral tablet 10, 5 SURMONTIL ORAL CASULE 100 MG, 25 MG, 50 MG *Antihistamines* *Antihistamines - Ethanolamines**-*Antihistamines - Ethanolamines*** aler-dryl oral tablet 50 OTC diphenhydramine hcl injection solution 50 /ml diphenhydramine hcl oral capsule 25, 50 OTC diphenhydramine hcl oral elixir 12.5 /5ml OTC diphenhydramine hcl oral tablet 25 OTC *Antihypertensives* *Antiadrenergic Antihypertensives**-*Antiadrenergics - Centrally Acting*** clonidine hcl oral tablet 0.1, 0.2, 0.3 guanfacine hcl oral tablet 1, 2 DL antidepressants.) =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/rx, UERCASE= Brand name drugs/ 9

11 Drug Name reference Details Coverage Details *Antiparkinson Agents* *Antiparkinson Anticholinergics**-*Antiparkinson Anticholinergics*** benztropine mesylate injection solution 1 /ml benztropine mesylate oral tablet 0.5, 1, 2 trihexyphenidyl hcl oral elixir 0.4 /ml trihexyphenidyl hcl oral tablet 2, 5 *Antiparkinson Dopaminergics**-*Antiparkinson Dopaminergics*** amantadine hcl oral capsule 100 amantadine hcl oral syrup 50 /5ml amantadine hcl oral tablet 100 *Antipsychotics/Antimanic Agents* *Antimanic Agents**-*Antimanic Agents*** lithium carbonate er oral tablet extendedrelease* 300, 450 lithium carbonate oral capsule 150, 300, 600 lithium carbonate oral tablet 300 *Antipsychotics - Misc.**-*Antipsychotics - Misc.*** EQUETRO ORAL CASULE EXTENDED RELEASE 12 HOUR 100 MG, 200 MG, 300 MG GEODON INTRAMUSCULAR* SOLUTION RECONSTITUTED 20 MG LATUDA ORAL TABLET 120 MG, 20 MG, 40 MG, 60 MG, 80 MG ziprasidone hcl oral capsule 20, 40, 60, 80 *Benzisoxazoles**-*Benzisoxazoles*** FANAT ORAL TABLET 1 MG, 10 MG, 12 MG, 2 MG, 4 MG, 6 MG, 8 MG FANAT TITRATION ACK ORAL TABLET 1 & 2 & 4 & 6 MG =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/rx, UERCASE= Brand name drugs/ 10

12 Drug Name reference Details Coverage Details INVEGA ORAL TABLET EXTENDED RELEASE 24 HR* 1.5 MG, 3 MG, 6 MG, 9 MG INVEGA SUSTENNA INTRAMUSCULAR* SUSENSION 117 MG/0.75ML, 156 MG/ML, 234 MG/1.5ML, 39 MG/0.25ML, 78 MG/0.5ML RISERDAL CONSTA INTRAMUSCULAR* SUSENSION RECONSTITUTED 12.5 MG, 25 MG, 37.5 MG, 50 MG risperidone oral solution 1 /ml risperidone oral tablet 0.25, 0.5, 1, 2, 3, 4 risperidone oral tablet dispersible 0.25, 0.5, 1, 2, 3, 4 *Butyrophenones**-*Butyrophenones*** haloperidol decanoate intramuscular* solution 100 /ml, 50 /ml haloperidol lactate injection solution 5 /ml haloperidol lactate oral concentrate 2 /ml haloperidol oral tablet 0.5, 1, 10, 2, 20, 5 *Dibenzapines**-*Dibenzodiazepines*** clozapine oral tablet 100, 200, 25, 50 clozapine oral tablet dispersible 100, 12.5, 25 FAZACLO ORAL TABLET DISERSIBLE 150 MG, 200 MG VERSACLOZ ORAL SUSENSION 50 MG/ML *Dibenzapines**-*Dibenzo-Oxepino yrroles*** SAHRIS SUBLINGUAL TABLET SUBLINGUAL 10 MG, 2.5 MG, 5 MG *Dibenzapines**-*Dibenzothiazepines*** quetiapine fumarate oral tablet 100, 200, 25, 300, 400, 50 =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/rx, UERCASE= Brand name drugs/ 11

13 Drug Name reference Details Coverage Details SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR* 150 MG, 200 MG, 300 MG, 400 MG, 50 MG *Dibenzapines**-*Dibenzoxazepines*** ADASUVE INHALATION AEROSOL OWDER, BREATH ACTIVATED 10 MG loxapine succinate oral capsule 10, 25, 5, 50 *Dibenzapines**-*Thienbenzodiazepines*** olanzapine intramuscular* solution reconstituted 10 olanzapine oral tablet 10, 15, 2.5, 20, 5, 7.5 olanzapine oral tablet dispersible 10, 15, 20, 5 ZYREXA RELREVV INTRAMUSCULAR* SUSENSION RECONSTITUTED 210 MG, 300 MG, 405 MG *henothiazines**-*henothiazines*** chlorpromazine hcl injection solution 25 /ml chlorpromazine hcl oral tablet 10, 100, 200, 25, 50 fluphenazine decanoate injection solution 25 /ml fluphenazine hcl injection solution 2.5 /ml fluphenazine hcl oral concentrate 5 /ml fluphenazine hcl oral elixir 2.5 /5ml fluphenazine hcl oral tablet 1, 10, 2.5, 5 perphenazine oral tablet 16, 2, 4, 8 prochlorperazine edisylate injection solution 5 /ml prochlorperazine maleate oral tablet 10, 5 prochlorperazine suppository 25 thioridazine hcl oral tablet 10, 100, 25, 50 =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/rx, UERCASE= Brand name drugs/ 12

14 Drug Name reference Details Coverage Details trifluoperazine hcl oral tablet 1, 10, 2, 5 *Quinolinone Derivatives**-*Quinolinone Derivatives*** ABILIFY DISCMELT ORAL TABLET DISERSIBLE 10 MG, 15 MG ABILIFY MAINTENA INTRAMUSCULAR* SUSENSION RECONSTITUTED 300 MG, 400 MG aripiprazole oral tablet 10, 15, 2, 20, 30, 5 *Thioxanthenes**-*Thioxanthenes*** thiothixene oral capsule 1, 10, 2, 5 *Beta Blockers* *Beta Blockers Non-Selective**-*Beta Blockers Non-Selective*** propranolol hcl er oral capsule extended release 24 hour 120, 160, 60, 80 propranolol hcl intravenous* solution 1 /ml propranolol hcl oral solution 20 /5ml, 40 /5ml propranolol hcl oral tablet 10, 20, 40, 60, 80 *Multivitamins* *B-Complex Vitamins**-*B-Complex Vitamins*** b complex oral capsule OTC b complex vitamins injection solution vitamin-b complex oral tablet OTC *B-Complex W/ C**-*B-Complex W/ C*** vitamin b complex-c oral capsule OTC =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/rx, UERCASE= Brand name drugs/ 13

15 Drug Name reference Details Coverage Details *sychotherapeutic And Neurological Agents - Misc.* *Combination sychotherapeutics**-*benzodiazepines & Tricyclic Agents*** chlordiazepoxide-amitriptyline oral tablet 10-25, *Combination sychotherapeutics**-*henothiazines & Tricyclic Agents*** perphenazine-amitriptyline oral tablet 2-10, 2-25, 4-10, 4-25, 4-50 *Combination sychotherapeutics**-*thienbenzodiazepines & Ssris*** olanzapine-fluoxetine hcl oral capsule 12-25, 12-50, 3-25, 6-25, 6-50 *sychotherapeutic And Neurological Agents - Misc.**-*sychotherapeutic And Neurological Agents - Misc.*** ORA ORAL TABLET 1 MG, 2 MG *Vasomotor Symptom Agents**-*Vasomotor Symptom Agents - Ssris*** BRISDELLE ORAL CASULE 7.5 MG *Vitamins* *Water Soluble Vitamins**-*Vitamin B-1*** thiamine hcl injection solution 100 /ml vitamin b-1 oral tablet 100 OTC =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/rx, UERCASE= Brand name drugs/ 14

16 Index ABILIFY DISCMELT ABILIFY MAINTENA ADASUVE aler-dryl... 9 alprazolam... 4 alprazolam er... 3 ALRAZOLAM INTENSOL... 3 alprazolam xr... 4 amantadine hcl amitriptyline hcl... 9 amoxapine... 9 amphetamine-dextroamphet er... 1 amphetamine-dextroamphetamine... 1 ALENZIN... 6 ATENSIO XR... 2 aripiprazole b complex b complex vitamins benztropine mesylate BRINTELLIX... 8 BRISDELLE buprenorphine hcl... 3 bupropion hcl... 6 bupropion hcl er (sr)... 6 bupropion hcl er (xl)... 6 buspirone hcl... 3 carbamazepine... 4 carbamazepine er... 4 chlordiazepoxide hcl... 4 chlordiazepoxide-amitriptyline chlorpromazine hcl citalopram hydrobromide... 7 clomipramine hcl... 9 clonazepam... 4 clonidine hcl... 9 clonidine hcl er... 1 clorazepate dipotassium... 4 clozapine DAYTRANA... 2 desipramine hcl... 9 desvenlafaxine er... 8 dexmethylphenidate hcl... 2 dexmethylphenidate hcl er... 2 dextroamphetamine sulfate... 1 dextroamphetamine sulfate er... 1 diazepam... 4 DIAZEAM INTENSOL... 4 diphenhydramine hcl... 9 divalproex sodium... 6 divalproex sodium er... 6 doxepin hcl... 9 duloxetine hcl... 8 EMSAM... 7 EQUETRO escitalopram oxalate... 7 FANAT FANAT TITRATION ACK FAZACLO FETZIMA... 8 FETZIMA TITRATION... 8 fluoxetine hcl... 7 fluphenazine decanoate fluphenazine hcl fluvoxamine maleate... 7 fluvoxamine maleate er... 7 FOCALIN XR... 2 FORFIVO XL... 7 gabapentin... 5 GABITRIL... 6 GEODON guanfacine hcl... 9 guanfacine hcl er... 1 haloperidol haloperidol decanoate haloperidol lactate hydroxyzine hcl... 3 hydroxyzine pamoate... 3 imipramine hcl... 9 imipramine pamoate... 9 INVEGA INVEGA SUSTENNA KHEDEZLA... 8 LAMICTAL ODT... 5 LAMICTAL STARTER... 5 LAMICTAL XR... 5 lamotrigine... 5 lamotrigine er... 5 LATUDA levetiracetam... 5 levetiracetam er... 5 lithium carbonate lithium carbonate er lorazepam... 4 LORAZEAM INTENSOL... 4 loxapine succinate maprotiline hcl... 7 MARLAN... 7 meprobamate... 3 METADATE ER... 2 methadone hcl... 3 METHADONE HCL INTENSOL... 3 METHADOSE... 3 methamphetamine hcl... 1 METHYLIN... 2 methylphenidate hcl... 2 methylphenidate hcl er... 2 methylphenidate hcl er (cd)... 2 methylphenidate hcl er (la)... 2 mirtazapine... 6 nefazodone hcl... 8 nortriptyline hcl... 9 olanzapine olanzapine-fluoxetine hcl OLETRO... 8 ORA oxazepam... 4 oxcarbazepine... 5 OXTELLAR XR... 5 paroxetine hcl... 7 paroxetine hcl er... 7 AXIL... 7 perphenazine perphenazine-amitriptyline EXEVA... 7 phenelzine sulfate... 7 RISTIQ... 8 ROCENTRA... 1 prochlorperazine prochlorperazine edisylate prochlorperazine maleate propranolol hcl propranolol hcl er protriptyline hcl... 9 QUDEXY XR... 5 quetiapine fumarate QUILLIVANT XR... 2 RISERDAL CONSTA risperidone RITALIN LA... 2 SAHRIS SEROQUEL XR sertraline hcl... 8 STAVZOR... 6 STRATTERA... 1 SURMONTIL... 9 =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/rx, UERCASE= Brand name drugs/ 15

17 TEGRETOL-XR... 5 thiamine hcl thioridazine hcl thiothixene tiagabine hcl... 6 topiramate... 5 TOIRAMATE ER... 5 tranylcypromine sulfate... 7 trazodone hcl... 8 trifluoperazine hcl trihexyphenidyl hcl TROKENDI XR... 6 valproate sodium... 6 valproic acid... 6 venlafaxine hcl... 8 venlafaxine hcl er... 8 VERSACLOZ VIIBRYD... 8 vitamin b complex-c vitamin b vitamin-b complex VYVANSE... 1 ZENZEDI... 1 ziprasidone hcl zubsolv... 3 ZUBSOLV... 3 ZYREXA RELREVV =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/rx, UERCASE= Brand name drugs/ 16