Workforce Safety & Insurance Revised Document Date: 07/21/2015 1600 E Century Ave Ste 1 PO Box 5585 Bismarck, ND 58506-5585 701.328.3800 1.800.777.5033 www.workforcesafety.com 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. 59 Antipsychotics Description Brand Name B/G Cost Status 5907 Benzisoxazoles Iloperidone Tab 1mg Fanapt B N/F Iloperidone Tab 2mg Fanapt B N/F Iloperidone Tab 4mg Fanapt B N/F Iloperidone Tab 6mg Fanapt B N/F Iloperidone Tab 8mg Fanapt B N/F
Iloperidone Tab 10mg Fanapt B N/F Iloperidone Tab 12mg Fanapt B N/F Iloperidone Tab Pk Fanapt Titration Pack B N/F 1mg x 2; 2mg x 2; 4mg x 2; 6mg x 2 Paliperidone Tab Ext Rel 1.5mg Invega B N/F Paliperidone Tab Ext Rel 3mg Invega B N/F Paliperidone Tab Ext Rel 6mg Invega B N/F Paliperidone Tab Ext Rel 9mg Invega B N/F Risperidone Oral Soln 1mg/ml Risperdal G PA Quantity Limits: 2.00 per day Risperidone Tab 0.25mg Risperdal G PA Quantity Limits: 2.00 per day Risperidone Tab 0.5mg Risperdal G PA Quantity Limits: 2.00 per day Risperidone Tab 1mg Risperdal G PA Quantity Limits: 2.00 per day Risperidone Tab 2mg Risperdal G PA Quantity Limits: 2.00 per day Risperidone Tab 3mg Risperdal G PA Quantity Limits: 2.00 per day Risperidone Tab 4mg Risperdal G PA Quantity Limits: 2.00 per day Risperidone Tab Oral Disintegrating 0.25mg G PA Quantity Limits: 2.00 per day Risperidone Tab Oral Disintegrating 0.5mg Risperdal M-Tab G PA Quantity Limits: 2.00 per day Risperidone Tab Oral Disintegrating 1mg Risperdal M-Tab G PA Quantity Limits: 2.00 per day Risperidone Tab Oral Disintegrating 2mg Risperdal M-Tab G PA Quantity Limits: 2.00 per day Risperidone Tab Oral Disintegrating 3mg Risperdal M-Tab G PA Quantity Limits: 2.00 per day Risperidone Tab Oral Disintegrating 4mg Risperdal M-Tab G PA 5910 Phenylbutylpiperadine Derivatives Haloperidol Oral Soln 2mg/ml G PA Haloperidol Tab 0.5mg G PA Haloperidol Tab 1mg G PA Haloperidol Tab 2mg G PA Haloperidol Tab 5mg G PA Haloperidol Tab 10mg G PA Haloperidol Tab 20mg G PA Pimozide Tab 1mg Orap B N/F Pimozide Tab 2mg Orap B N/F 5915 Dibenzapines Asenapine Tab SL 2.5mg Saphris B N/F Asenapine Tab SL 5mg Saphris B N/F 2
Asenapine Tab SL 10mg Saphris B N/F Clozapine Susp 50mg/ml Versacloz B PA Clozapine Tab 25mg Clozaril G PA Clozapine Tab 50mg G PA Clozapine Tab 100mg Clozaril G PA Clozapine Tab 200mg G PA Clozapine Tab Oral Disintegrating 12.5mg Fazaclo G N/F Clozapine Tab Oral Disintegrating 25mg Fazaclo G N/F Clozapine Tab Oral Disintegrating 100mg Fazaclo G N/F Clozapine Tab Oral Disintegrating 150mg Fazaclo G N/F Clozapine Tab Oral Disintegrating 200mg Fazaclo G N/F Loxapine Cap 5mg G N/F Loxapine Cap 10mg G N/F Loxapine Cap 25mg G N/F Loxapine Cap 50mg G N/F Loxapine Powder for Inh 10mg Adasuve B N/F Quantity Limits: 2.00 per day Olanzapine Tab 2.5mg Zyprexa G PA Quantity Limits: 2.00 per day Olanzapine Tab 5mg Zyprexa G PA Quantity Limits: 2.00 per day Olanzapine Tab 7.5mg Zyprexa G PA Quantity Limits: 2.00 per day Olanzapine Tab 10mg Zyprexa G PA Quantity Limits: 2.00 per day Olanzapine Tab 15mg Zyprexa G PA Quantity Limits: 2.00 per day Olanzapine Tab 20mg Zyprexa G PA Quantity Limits: 2.00 per day Olanzapine Tab Oral Disintegrating 5mg Zyprexa Zydis G PA Quantity Limits: 2.00 per day Olanzapine Tab Oral Disintegrating 10mg Zyprexa Zydis G PA Quantity Limits: 2.00 per day Olanzapine Tab Oral Disintegrating 15mg Zyprexa Zydis G PA Quantity Limits: 2.00 per day Olanzapine Tab Oral Disintegrating 20mg Zyprexa Zydis G PA Quetiapine Tab 25mg Seroquel G PA Quetiapine Tab 50mg Seroquel G PA Quetiapine Tab 100mg Seroquel G PA Quetiapine Tab 200mg Seroquel G PA Quetiapine Tab 300mg Seroquel G PA Quetiapine Tab 400mg Seroquel G PA Quantity Limits: 2.00 per day Quetiapine Tab Ext Rel 50mg Seroquel XR B PA 3
Quantity Limits: 2.00 per day Quetiapine Tab Ext Rel 150mg Seroquel XR B PA Quantity Limits: 2.00 per day Quetiapine Tab Ext Rel 200mg Seroquel XR B PA Quantity Limits: 2.00 per day Quetiapine Tab Ext Rel 300mg Seroquel XR B PA Quantity Limits: 2.00 per day Quetiapine Tab Ext Rel 400mg Seroquel XR B PA 5920 Phenothiazines Chlorpromazine Tab 10mg G PA Chlorpromazine Tab 25mg G PA Chlorpromazine Tab 50mg G PA Chlorpromazine Tab 100mg G PA Chlorpromazine Tab 200mg G PA Fluphenazine Elixir 2.5mg/5ml G N/F Fluphenazine Soln 5mg/ml G N/F Fluphenazine Tab 1mg G N/F Fluphenazine Tab 2.5mg G N/F Fluphenazine Tab 5mg G N/F Fluphenazine Tab 10mg G N/F Perphenazine Tab 2mg G PA Perphenazine Tab 4mg G PA Perphenazine Tab 8mg G PA Perphenazine Tab 16mg G PA Prochlorperazine Supp 25mg Compazine, Compro G F Prochlorperazine Tab 5mg Compazine G F Prochlorperazine Tab 10mg Compazine G F Thioridazine Tab 10mg G N/F Thioridazine Tab 25mg G N/F Thioridazine Tab 50mg G N/F Thioridazine Tab 100mg G N/F Trifluoperazine Tab 1mg G N/F Trifluoperazine Tab 2mg G N/F Trifluoperazine Tab 5mg G N/F Trifluoperazine Tab 10mg G N/F 5925 Quinolinone Derivatives Aripiprazole Tab 2mg Abilify G PA 4
Aripiprazole Tab 5mg Abilify G PA Aripiprazole Tab 10mg Abilify G PA Aripiprazole Tab 15mg Abilify G PA Aripiprazole Tab 20mg Abilify G PA Aripiprazole Tab 30mg Abilify G PA 5930 Thioxanthene Derivatives Thiothixene Cap 1mg G N/F Thiothixene Cap 2mg G N/F Thiothixene Cap 5mg G N/F Thiothixene Cap 10mg G N/F 5940 Antipsychotics - Miscellaneous Carbamazepine Cap Sus Rel 100mg Equetro B PA Carbamazepine Cap Sus Rel 200mg Equetro B PA Carbamazepine Cap Sus Rel 300mg Equetro B PA Lurasidone Tab 20mg Latuda B N/F Lurasidone Tab 40mg Latuda B N/F Lurasidone Tab 60mg Latuda B N/F Lurasidone Tab 80mg Latuda B N/F Lurasidone Tab 120mg Latuda B N/F Quantity Limits: 2.00 per day Ziprasidone Cap 20mg Geodon G PA Quantity Limits: 2.00 per day Ziprasidone Cap 40mg Geodon G PA Quantity Limits: 2.00 per day Ziprasidone Cap 60mg Geodon G PA Quantity Limits: 2.00 per day Ziprasidone Cap 80mg Geodon G PA 5950 Antimanic Agents Lithium Carbonate Cap 150mg G PA Lithium Carbonate Cap 300mg G PA Lithium Carbonate Cap 600mg G PA Lithium Carbonate Tab 300mg G PA Lithium Carbonate Tab Ext Rel 300mg Lithobid G PA Lithium Carbonate Tab Ext Rel 450mg G N/F Lithium Citrate Syrup 8mEq/5ml G PA 5