GEMCare Medicare Plus (HMO) & Physicians Choice Medicare Plus (HMO) 2015 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN HPMS Approved Formulary File Submission ID, Version Number: 15463 v19 This formulary was updated on October 27, 2015. For more recent information or other questions, please contact us at the following numbers 24 hours a day, seven days a week: GEMCare Medicare Plus HMO members call Member Services Department at toll free 877-697- Physicians Choice Medicare Plus HMO San Luis Obispo and Santa Barbara Counties members call Member Services Department at toll-free 877-744-2668 TTY/TDD users should call 1-866-706-4757, or visit www.gemcarehealthplan.com. This information is available for free in other languages. Please call our Member Services Department number listed on the front and back cover pages. H5609_14_434A CMS Accepted 11152014 GEMCare Medicare Plus and Physicians Choice Medicare Plus are offered by GEMCare Health Plan, an HMO plan with a Medicare contract. Enrollment in GEMCare Medicare Plus and Physicians Choice Medicare Plus depends on contract renewal.
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 GEMCare Health Plan. When it refers to plan or our plan, it means GEMCare Medicare Plus or Physicians Choice Medicare Plus. This document includes a list of the drugs (formulary) for our plan which is current as of October 27, 2015. 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/coninsurance may change on January 1, 2016, and from time to time during the year. What is the GEMCare Medicare Plus or Physicians Choice Medicare Plus Formulary? A formulary is a list of covered drugs selected by GEMCare Medicare Plus or Physicians Choice Medicare Plus in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. GEMCare Medicare Plus or Physicians Choice Medicare Plus will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a GEMCare Medicare Plus or Physicians Choice Medicare Plus 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 2015 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2015 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 can ensure your safety. 2
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 Drug 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 27, 2015. To get updated information about the drugs covered by GEMCare Medicare Plus or Physicians Choice Medicare Plus, please contact us. Our contact information appears on the front and back cover pages. In the event of nonmaintenance changes to the formulary throughout the plan year, we may make changes via errata sheets mailed to you. Additionally, you may visit our website for a link to the errata sheet. How do I use the Formulary? There are two ways to find your drug within the formulary: Medical Condition The formulary begins on page 9. 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 AGENTS. If you know what your drug is used for, look for the category name in the list that begins on page 9. 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 166. 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? GEMCare Medicare Plus or Physicians Choice Medicare Plus 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. 3
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: GEMCare Medicare Plus or Physicians Choice Medicare Plus requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from GEMCare Medicare Plus or Physicians Choice Medicare Plus before you fill your prescriptions. If you don t get approval, GEMCare Medicare Plus or Physicians Choice Medicare Plus may not cover the drug. Quantity Limits: For certain drugs, GEMCare Medicare Plus or Physicians Choice Medicare Plus limits the amount of the drug that GEMCare Medicare Plus or Physicians Choice Medicare Plus will cover. For example, GEMCare Medicare Plus or Physicians Choice Medicare Plus provides thirty tablets per prescription for meloxicam. This may be in addition to a standard one-month or three-month supply. Step Therapy: In some cases, GEMCare Medicare Plus or Physicians Choice Medicare Plus requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, GEMCare Medicare Plus or Physicians Choice Medicare Plus may not cover Drug B unless you try Drug A first. If Drug A does not work for you, GEMCare Medicare Plus or Physicians Choice Medicare Plus will then cover Drug B. You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 9. You can also get more information about the restrictions applied to specific covered drugs by visiting our Web site. We have posted on line 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. You can ask GEMCare Medicare Plus or Physicians Choice Medicare Plus 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 GEMCare Medicare Plus or Physicians Choice Medicare Plus formulary? on page 5 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 Member Services and ask if your drug is covered. 4
If you learn that GEMCare Medicare Plus or Physicians Choice Medicare Plus does not cover your drug, you have two options: You can ask Member Services for a list of similar drugs that are covered by GEMCare Medicare Plus or Physicians Choice Medicare Plus. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by GEMCare Medicare Plus or Physicians Choice Medicare Plus. You can ask GEMCare Medicare Plus or Physicians Choice Medicare Plus 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 GEMCare Medicare Plus or Physicians Choice Medicare Plus Formulary? You can ask GEMCare Medicare Plus or Physicians Choice Medicare Plus 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, GEMCare Medicare Plus or Physicians Choice Medicare Plus 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, GEMCare Medicare Plus or Physicians Choice Medicare Plus 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 5
decision within 72 hours of getting your prescriber s supporting statement. You can request an expedited (fast) exception if you or your doctor believe 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. 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 days) 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-day transition supply, consistent with dispensing increment, (unless you have a prescription written for fewer days). We will cover more than one refill of these drugs for the first 90 days if 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 days) while you pursue a formulary exception. Exceptions are available for members who have experienced a change in the level of care they are receiving which requires them to transition from one facility or treatment center to another. Examples of situations in which members would be eligible for the one-time temporary fill exception when they are outside of the three month effective date into the Part D program are as follows: i. If a beneficiary was discharged from the hospital and was provided a discharge list of medications based upon the formulary of the hospital. ii. Members who end their skilled nursing facility Medicare Part A stay (where payments include all pharmacy charges) and who need to revert back to their Part D plan formulary 6
iii. Members who give up Hospice Status to revert back to standard Medicare Part A and B benefits iv. Members who are discharged from Chronic Psychiatric Hospitals with medication regimens that are highly individualized. All of these situations would warrant a temporary one-time fill exception regardless of if the member is in their first ninety (90) days of program enrollment. For more information For more detailed information about your GEMCare Medicare Plus or Physicians Choice Medicare Plus prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about GEMCare Medicare Plus or Physicians Choice Medicare Plus, 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 1-800-MEDICARE (1-800-633-4227) 24 hours a day/7 days a week. TTY users should call 1-877-486-2048. Or, visit http://www.medicare.gov. GEMCare Medicare Plus or Physicians Choice Medicare Plus Formulary The formulary that begins on page 9 provides coverage information about the drugs covered by GEMCare Medicare Plus or Physicians Choice Medicare Plus. If you have trouble finding your drug in the list, turn to the Index that begins on page 166. The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., HUMIRA) and generic drugs are listed in lower-case italics (e.g., lisinopril). The information in the Requirements/Limits column tells you if GEMCare Medicare Plus or Physicians Choice Medicare Plus has any special requirements for coverage of your drug. Tier Level Tier Name 1 Preferred Generic 2 Non-Preferred Generic 3 Preferred Brand 4 Non-Preferred Brand 5 Specialty 7
Prescription Drugs Your Costs Prescription drug deductible $0 Initial coverage stage One month supply* Three month supply** Tier 1 $5 $15 Tier 2 $15 $45 Tier 3 $45 $135 Tier 4 $90 $270 Tier 5 33% 33% Coverage gap stage (after prescription costs reach There is a 55% discount for most brand name drugs and 21% for generics. $2,960) Catastrophic coverage stage (after you have paid $4,700 out-of-pocket) The greater of $2.65 for generics, $6.60 for brand-name, or 5%. *30 day supply of covered drugs obtained at a network pharmacy with standard retail cost-sharing or an out-of-network pharmacy; 31-day supply of covered drugs obtained at a network long-term care pharmacy. **90-day supply of covered drugs obtained at a network pharmacy with standard retail cost-sharing or a network mail order pharmacy. 8
ANALGESICS Analgesics alagesic lq sol 1 apap/codeinesol120-12/5 1 Quantity limitation 4500 per 30 days apap/codeinetab300-15mg 1 Quantity limitation 400 per 30 days apap/codeinetab300-30mg 1 Quantity limitation 400 per 30 days apap/codeinetab300-60mg 1 Quantity limitation 400 per 30 days ascomp/cod cap30mg 2 Quantity limitation 120 per 30 days but/apap/cafcap 1 but/apap/cafcapcodeine 1 Quantity limitation 360 per 30 days but/apap/caftab 1 but/asa/caffcap 1 butal/apap tab50-325mg 1 endocet tab10-325mg 2 Quantity limitation 240 per 30 days endocet tab5-325mg 2 Quantity limitation 240 per 30 days endocet tab7.5-325 2 Quantity limitation 240 per 30 days hycet sol7.5-325 2 hydroco/apapsol7.5-325 2 Quantity limitation 3600 per 30 days Quantity limitation 3600 per 30 days hydroco/apaptab10-300mg 2 Quantity limitation 240 per 30 days hydroco/apaptab10-325mg 2 Quantity limitation 240 per 30 days hydroco/apaptab5-300mg 2 Quantity limitation 240 per 30 days hydroco/apaptab5-325mg 2 Quantity limitation 240 per 30 days hydroco/apaptab7.5-300 2 Quantity limitation 240 per 30 days hydroco/apaptab7.5-325 2 Quantity limitation 240 per 30 days hydrocod/ibutab7.5-200 2 Quantity limitation 120 per 30 days oxycod/apap tab10-325mg 2 Quantity limitation 240 per 30 days oxycod/apap tab2.5-325 2 Quantity limitation 240 per 30 days oxycod/apap tab5-325mg 2 Quantity limitation 240 per 30 days oxycod/apap tab7.5-325 2 Quantity limitation 240 per 30 days oxycod/asa tab 2 Quantity limitation 120 per 30 days oxycod/ibu tab5-400mg 2 Quantity limitation 120 per 30 days tramadl/apaptab37.5-325 2 Quantity limitation 240 per 30 days vicodin tab5-300mg 2 Quantity limitation 240 per 30 days vicodin es tab7.5-300 2 Quantity limitation 240 per 30 days vicodin hp tab10-300mg 2 Quantity limitation 240 per 30 days xodol tab10-300mg 2 Quantity limitation 240 per 30 days xodol tab5-300mg 2 Quantity limitation 240 per 30 days xodol tab7.5-300 2 Quantity limitation 240 per 30 days 9
Nonsteroidal Anti-Inflammatory Drugs celecoxib cap100mg 2 Quantity limitation 60 per 30 days celecoxib cap200mg 2 Quantity limitation 60 per 30 days celecoxib cap400mg 2 Quantity limitation 60 per 30 days celecoxib cap50mg 2 Quantity limitation 60 per 30 days diclofen pottab50mg 1 diclofenac tab100mg er 2 diclofenac tab25mg dr 1 diclofenac tab50mg dr 1 diclofenac tab75mg dr 1 diflunisal tab500mg 2 etodolac cap200mg 2 etodolac cap300mg 2 etodolac tab400mg 2 etodolac tab500mg 2 fenoprofen tab600mg 2 FLECTOR DIS1.3% 4 flurbiprofentab100mg 2 flurbiprofentab50mg 2 ibuprofen sus100/5ml 1 ibuprofen tab400mg 1 ibuprofen tab600mg 1 ibuprofen tab800mg 1 This prescription drug is part of the free first fill program and will be provided at zero cost share when you select this medication over the brand name version of selected medications. This prescription drug is part of the free first fill program and will be provided at zero cost share when you select this medication over the brand name version of selected medications. This prescription drug is part of the free first fill program and will be provided at zero cost share when you select this medication over the brand name version of selected medications. This prescription drug is part of the free first fill program and will be provided at zero cost share when you select this medication over the 10
brand name version of selected medications. INDOCIN SUS25MG/5ML 4 indomethacincap25mg 2 indomethacincap50mg 2 indomethacincap75mg er 2 ketoprofen cap200mg er 2 ketoprofen cap50mg 2 ketoprofen cap75mg 2 ketorolac inj15mg/ml 2 ketorolac inj30mg/ml 2 meclofen sodcap100mg 2 meclofen sodcap50mg 2 meloxicam tab15mg 1 meloxicam tab7.5mg 1 nabumetone tab500mg 2 nabumetone tab750mg 2 naproxen sus125/5ml 1 naproxen tab250mg 1 naproxen tab375mg 1 naproxen tab500mg 1 Quantity limitation 30 per 30 days; This prescription drug is part of the free first fill program and will be provided at zero cost share when you select this medication over the brand name version of selected medications. Quantity limitation 30 per 30 days; This prescription drug is part of the free first fill program and will be provided at zero cost share when you select this medication over the brand name version of selected medications. 11
naproxen dr tab375mg 1 naproxen dr tab500mg 1 naproxen sodtab275mg 1 naproxen sodtab550mg 1 piroxicam cap10mg 1 piroxicam cap20mg 1 sulindac tab150mg 2 sulindac tab200mg 2 tolmetin sodcap400mg 2 tolmetin sodtab600mg 2 Opioid Analgesics, Long-Acting fentanyl dis100mcg/h 2 Quantity limitation 30 per 30 days; fentanyl dis12mcg/hr 2 Quantity limitation 30 per 30 days; fentanyl dis25mcg/hr 2 Quantity limitation 30 per 30 days; fentanyl dis50mcg/hr 2 Quantity limitation 30 per 30 days; fentanyl dis75mcg/hr 2 Quantity limitation 30 per 30 days; fentanyl dis37.5mcg/hr 2 Quantity limitation 30 per 30 days; fentanyl dis62.5mcg/hr 2 Quantity limitation 30 per 30 days; 12
fentanyl dis87.5mcg/hr 2 Quantity limitation 30 per 30 days; levorphanol tab2mg 2 Quantity limitation 120 per 30 days METHADONE INJ10MG/ML 4 Quantity limitation 120 per 30 days; This drug may be covered under Medicare Part B or D depending upon the circumstances. Information may need to be submitted describing the use and setting of drug to make the methadone sol10mg/5ml 2 Quantity limitation 600 per 30 days methadone sol5mg/5ml 2 Quantity limitation 1200 per 30 days methadone tab10mg 1 Quantity limitation 120 per 30 days methadone tab5mg 1 Quantity limitation 120 per 30 days morphine sulcap100mg er 2 Quantity limitation 60 per 30 days morphine sulcap10mg er 2 Quantity limitation 60 per 30 days morphine sulcap120mg er 2 Quantity limitation 60 per 30 days morphine sulcap20mg er 2 Quantity limitation 60 per 30 days morphine sulcap30mg er 2 Quantity limitation 60 per 30 days morphine sulcap45mg er 2 Quantity limitation 60 per 30 days morphine sulcap50mg er 2 Quantity limitation 60 per 30 days morphine sulcap60mg er 2 Quantity limitation 60 per 30 days morphine sulcap75mg er 2 Quantity limitation 60 per 30 days morphine sulcap80mg er 2 Quantity limitation 60 per 30 days morphine sulcap90mg er 2 Quantity limitation 60 per 30 days morphine sultab100mg er 2 Quantity limitation 120 per 30 days morphine sultab15mg er 2 Quantity limitation 120 per 30 days morphine sultab200mg er 2 Quantity limitation 120 per 30 days morphine sultab30mg er 2 Quantity limitation 120 per 30 days morphine sultab60mg er 2 Quantity limitation 120 per 30 days OXYCONTIN TAB10MG CR 4 Quantity limitation 90 per 30 days OXYCONTIN TAB15MG CR 4 Quantity limitation 60 per 30 days OXYCONTIN TAB20MG CR 4 Quantity limitation 120 per 30 days OXYCONTIN TAB30MG CR 4 Quantity limitation 60 per 30 days OXYCONTIN TAB40MG CR 4 Quantity limitation 120 per 30 days OXYCONTIN TAB60MG CR 4 Quantity limitation 120 per 30 days OXYCONTIN TAB80MG CR 4 Quantity limitation 120 per 30 days Opioid Analgesics, Short-Acting 13
butorphanol sol10mg/ml 2 Quantity limitation 10 per 30 days duramorph inj0.5mg/ml 2 duramorph inj1mg/ml 2 fentanyl ot loz1200mcg 2 Quantity limitation 120 per 30 days; This medication requires prior fentanyl ot loz1600mcg 2 Quantity limitation 120 per 30 days; This medication requires prior fentanyl ot loz200mcg 2 Quantity limitation 120 per 30 days; This medication requires prior fentanyl ot loz400mcg 2 Quantity limitation 120 per 30 days; This medication requires prior fentanyl ot loz600mcg 2 Quantity limitation 120 per 30 days; This medication requires prior fentanyl ot loz800mcg 2 Quantity limitation 120 per 30 days; This medication requires prior 14
hydromorphontab2mg 2 Quantity limitation 120 per 30 days hydromorphontab4mg 2 Quantity limitation 120 per 30 days hydromorphontab8mg 2 Quantity limitation 120 per 30 days morphine sultab15mg 2 Quantity limitation 120 per 30 days morphine sultab30mg 2 Quantity limitation 120 per 30 days nalbuphine inj10mg/ml 2 Quantity limitation 120 per 30 days; This drug may be covered under Medicare Part B or D depending upon the circumstances. Information may need to be submitted describing the use and setting of drug to nalbuphine inj20mg/ml 2 make the Quantity limitation 120 per 30 days; This drug may be covered under Medicare Part B or D depending upon the circumstances. Information may need to be submitted describing the use and setting of drug to make the oxycodone cap5mg 2 Quantity limitation 120 per 30 days oxycodone con100/5ml 2 Quantity limitation 120 per 30 days oxycodone tab10mg 2 Quantity limitation 120 per 30 days oxycodone tab15mg 2 Quantity limitation 120 per 30 days oxycodone tab20mg 2 Quantity limitation 120 per 30 days oxycodone tab30mg 2 Quantity limitation 120 per 30 days oxycodone tab5mg 2 Quantity limitation 120 per 30 days tramadol hcltab50mg 1 Quantity limitation 240 per 30 days ANESTHETICS Local Anesthetics lido/prilocncre2.5-2.5% 2 lidocaine inj0.5% 2 lidocaine inj1% 2 15
lidocaine oin5% 1 lidocaine pad5% 2 Quantity limitation 90 per 30 days; lidocaine sol2% visc 1 lidocaine sol4% 1 ANTI-ADDICTION/SUBSTANCE ABUSE TREATMENT AGENTS Alcohol Deterrents/Anti-craving acampro cal tab333mg 2 disulfiram tab250mg 2 disulfiram tab500mg 2 VIVITROL INJ380MG 5 Opioid Dependence Treatments bupren/naloxsub2-0.5mg 2 Quantity limitation 90 per 30 days bupren/naloxsub8-2mg 2 Quantity limitation 90 per 30 days buprenorphininj0.3mg/ml 2 buprenorphinsub2mg 2 Quantity limitation 120 per 30 days buprenorphinsub8mg 2 Quantity limitation 120 per 30 days BUTRANS DIS10MCG/HR 4 Quantity limitation 4 per 28 days BUTRANS DIS15MCG/HR 4 Quantity limitation 4 per 28 days BUTRANS DIS20MCG/HR 4 Quantity limitation 4 per 28 days BUTRANS DIS5MCG/HR 4 Quantity limitation 4 per 28 days SUBOXONE MIS12-3MG 4 Quantity limitation 90 per 30 days SUBOXONE MIS2-0.5MG 4 Quantity limitation 90 per 30 days SUBOXONE MIS4-1MG 4 Quantity limitation 90 per 30 days SUBOXONE MIS8-2MG 4 Quantity limitation 90 per 30 days Opioid Reversal Agents naloxone inj1mg/ml 2 naltrexone tab50mg 2 Smoking Cessation Agents buproban tab150mg 2 Quantity limitation 90 per 30 days bupropion tab100mg 2 Quantity limitation 120 per 30 days bupropion tab100mg sr 2 Quantity limitation 60 per 30 days bupropion tab150mg sr 2 Quantity limitation 90 per 30 days bupropion tab200mg sr 2 Quantity limitation 30 per 30 days 16
bupropion tab75mg 2 Quantity limitation 180 per 30 days bupropn hcl tab150mg xl 2 bupropn hcl tab300mg xl 2 Quantity limitation 60 per 30 days; CHANTIX PAK0.5& 1MG 4 CHANTIX TAB0.5MG 4 Quantity limitation 60 per 30 days; CHANTIX TAB1MG 4 Quantity limitation 60 per 30 days; FORFIVO XL TAB450MG 4 Quantity limitation 30 per 30 days NICOTROL NS SPR10MG/ML 3 Quantity limitation 40 per 30 days ANTIBACTERIALS Aminoglycosides gentak oin0.3% op 1 gentam/nacl inj0.9mg/ml 2 gentam/nacl inj1.4mg/ml 2 gentam/nacl inj100mg 2 gentam/nacl inj60mg 2 gentam/nacl inj80mg 2 gentam/nacl inj80mg 2 gentamicin cre0.1% 1 gentamicin inj10mg/ml 2 GENTAMICIN OIN0.1% 1 17
gentamicin sol0.3% op 1 neomycin tab500mg 2 paromomycin cap250mg 2 streptomycininj1gm 2 tobramycin inj10mg/ml 2 tobramycin inj80mg/2ml 2 tobramycin neb300/5ml 5 tobramycin sol0.3% op 2 Antibacterials colistimeth inj150mg 2 neo/poly gu sol40/ml ir 2 SYNERCID INJ500MG 5 18
Antibacterials, Other acetic acid sol2% otic 2 baciim inj50000unt 2 bacitracin oinop 2 chloramphen inj1gm 2 CLEOCIN SUP100MG 4 clindamycin cap150mg 2 clindamycin cap300mg 2 clindamycin cap75mg 2 clindamycin cre2% vag 2 clindamycin gel1% 2 clindamycin inj150mg/ml 2 clindamycin lot1% 2 clindamycin pad1% 2 clindamycin sol1% 2 clindamycin sol75mg/5ml 2 CUBICIN SOL500MG 4 linezolid inj2mg/ml 5 19
mafenide acepak5% 2 methenam hiptab1gm 2 metron/nacl inj500mg 2 metronidazolcre0.75% 2 metronidazolgel0.75% 2 metronidazolgel0.75%vag 2 metronidazollot0.75% 2 metronidazoltab250mg 2 metronidazoltab500mg 2 MONUROL PAKGRANULES 4 mupirocin cre2% 2 mupirocin oin2% 2 nitrofur maccap50mg 2 nitrofurantncap100mg 2 nitrofurantnsus25mg/5ml 2 SULFAMYLON CRE85MG/GM 4 trimethoprimtab100mg 2 TYGACIL INJ50MG 4 vancomycin cap125mg 2 vancomycin cap250mg 2 vancomycin inj1000mg 2 vancomycin inj10gm 2 vancomycin inj500mg 2 ZYVOX SUS100MG/5M 5 ZYVOX TAB600MG 5 Quantity limitation 56 per 28 days; 20
Beta-lactam, Cephalosporins cefaclor cap250mg 2 cefaclor cap500mg 2 cefaclor er tab500mg 2 cefadroxil cap500mg 2 cefadroxil sus250/5ml 2 cefadroxil sus500/5ml 2 cefadroxil tab1gm 2 cefazolin inj10gm 2 cefazolin inj1gm 2 cefazolin inj1gm/50ml 2 cefazolin inj500mg 2 cefdinir cap300mg 2 cefdinir sus125/5ml 2 cefdinir sus250/5ml 2 cefepime inj1gm 2 21
CEFEPIME INJ1GM 2 cefepime inj2gm 2 CEFEPIME INJ2GM 2 cefixime sus100/5ml 2 cefixime sus200/5ml 2 cefoxitin inj10gm 2 cefoxitin inj1gm 2 cefoxitin inj2gm 2 cefoxitin inj2gm 2 22
cefpodo proxsus100/5ml 2 cefpodo proxsus50mg/5ml 2 cefpodoxime tab100mg 2 cefpodoxime tab200mg 2 cefprozil sus125/5ml 2 cefprozil sus250/5ml 2 cefprozil tab250mg 2 cefprozil tab500mg 2 ceftriaxone inj10gm 2 ceftriaxone inj1gm 2 ceftriaxone inj250mg 2 ceftriaxone inj2gm 2 ceftriaxone inj500mg 2 cefuroxime inj1.5gm 2 23
cefuroxime inj7.5gm 2 cefuroxime inj750mg 2 cefuroxime tab250mg 2 cefuroxime tab500mg 2 cephalexin cap250mg 1 cephalexin cap500mg 1 cephalexin sus125/5ml 1 cephalexin sus250/5ml 1 cephalexin tab250mg 1 cephalexin tab500mg 1 SUPRAX CAP400MG 4 suprax chw100mg 2 suprax chw200mg 2 SUPRAX SUS100/5ML 4 SUPRAX SUS200/5ML 4 SUPRAX SUS500/5ML 4 SUPRAX TAB400MG 4 TEFLARO INJ400MG 4 TEFLARO INJ600MG 4 24
Beta-lactam, Other AZACTAM/DEX INJ1GM 3 AZACTAM/DEX INJ2GM 5 aztreonam inj1gm 2 imipenem/cilinj250mg 2 imipenem/cilinj500mg 2 INVANZ INJ1GM 4 meropenem inj500mg 2 Beta-lactam, Penicillins amox/k clav chw200mg 2 amox/k clav chw400mg 2 amox/k clav sus200/5ml 2 amox/k clav sus250/5ml 2 amox/k clav sus400/5ml 2 amox/k clav sus600/5ml 2 amox/k clav tab250mg 2 amox/k clav tab500mg 2 25
amox/k clav tab875mg 2 amoxicillin cap250mg 1 amoxicillin cap500mg 1 amoxicillin chw125mg 1 amoxicillin chw250mg 1 amoxicillin sus125/5ml 1 amoxicillin sus200/5ml 1 amoxicillin sus250/5ml 1 amoxicillin sus400/5ml 1 amoxicillin tab500mg 1 amoxicillin tab875mg 1 amox-pot clataber 2 ampicillin cap250mg 1 ampicillin cap500mg 1 ampicillin inj10gm 2 ampicillin inj125mg 2 ampicillin inj1gm 2 ampicillin sus125/5ml 1 ampicillin sus250/5ml 1 amp-sulbactainj1.5gm 2 amp-sulbactainj15gm 2 26
amp-sulbactainj3gm 2 BICILLIN C-RINJ1200000 4 BICILLIN C-RINJ900/300 4 BICILLIN L-AINJ1200000 4 BICILLIN L-AINJ2400000 4 BICILLIN L-AINJ600000 4 dicloxacill cap250mg 2 dicloxacill cap500mg 2 nafcillin inj10gm 5 nafcillin inj1gm 2 pen g proc inj600000 2 pen g sod inj5000000 2 27
PENICILL GK/INJDEX 2MU 4 PENICILL GK/INJDEX 3MU 4 penicilln gkinj5mu 2 penicilln vksol125/5ml 1 penicilln vksol250/5ml 1 penicilln vktab250mg 1 penicilln vktab500mg 1 piper/tazobainj3-0.375g 2 piper/tazobainj4-0.5gm 2 ZOSYN SOL2-0.25GM 4 ZOSYN SOL3-0.375G 4 Macrolides azithromycininj500mg 2 28
azithromycinsus100/5ml 2 Quantity limitation 30 per 5 days azithromycinsus200/5ml 2 Quantity limitation 90 per 5 days azithromycintab250mg 2 Quantity limitation 6 per 5 days azithromycintab500mg 2 Quantity limitation 6 per 5 days azithromycintab600mg 2 Quantity limitation 6 per 5 days clarithromycsus125/5ml 2 clarithromycsus250/5ml 2 clarithromyctab250mg 2 Quantity limitation 28 per 14 days clarithromyctab500mg 2 Quantity limitation 28 per 14 days clarithromyctab500mg er 2 Quantity limitation 28 per 14 days ery pad2% 1 ery-tab tab250mg ec 1 ery-tab tab333mg ec 1 ery-tab tab500mg ec 1 ERYTHROCIN INJ500MG 4 erythrocin tab250mg 1 ERYTHROM ETHTAB400MG 1 erythromycingel2% 1 erythromycinoinop 1 erythromycinsol2% 1 erythromycintab250mg bs 1 erythromycintab500mg bs 1 ZMAX SUS2GM 4 Quantity limitation 60 per 30 days Quinolones AVELOX INJ 4 CILOXAN OIN0.3% OP 4 ciprofloxacninj200mg 2 29
ciprofloxacninj400mg 2 ciprofloxacnsol0.3% op 1 ciprofloxacntab1000mg 1 ciprofloxacntab100mg 1 ciprofloxacntab250mg 1 ciprofloxacntab500mg 1 ciprofloxacntab500mg er 1 ciprofloxacntab750mg 1 levofloxacininj25mg/ml 2 levofloxacinsol0.5% 2 levofloxacinsol25mg/ml 2 levofloxacintab250mg 2 Quantity limitation 14 per 14 days levofloxacintab500mg 2 Quantity limitation 14 per 14 days levofloxacintab750mg 2 Quantity limitation 14 per 14 days ofloxacin dro0.3% op 1 ofloxacin dro0.3%otic 1 ofloxacin tab200mg 2 ofloxacin tab300mg 2 ofloxacin tab400mg 2 VIGAMOX DRO0.5% 4 Sulfonamides silver sulfacre1% 2 smz/tmp ds tab800-160 1 smz-tmp inj400-80/5 2 30
smz-tmp sus200-40/5 1 smz-tmp tab400-80mg 1 sod sulfacetsol10% op 2 ssd cre1% 2 sulfacet sodoin10% op 2 sulfacetamidsus10% 2 sulfadiazinetab500mg 2 Tetracyclines demeclocycl tab150mg 2 demeclocycl tab300mg 2 doxycyc monotab150mg 2 doxycyc monotab50mg 2 doxycyc monotab75mg 2 doxycycl hyccap100mg 2 doxycycl hyccap50mg 2 doxycycl hyctab100mg 2 doxycycl hyctab100mg dr 2 doxycycl hyctab150mg dr 2 doxycycl hyctab75mg dr 2 doxycycline cap75mg 2 minocycline cap100mg 1 minocycline cap50mg 1 minocycline cap75mg 1 minocycline tab100mg 1 minocycline tab50mg 1 minocycline tab75mg 1 ANTICONVULSANTS Anticonvulsants, Other APTIOM TAB200MG 4 Quantity limitation 180 per 30 days APTIOM TAB400MG 4 Quantity limitation 90 per 30 days APTIOM TAB600MG 4 Quantity limitation 60 per 30 days APTIOM TAB800MG 4 Quantity limitation 45 per 30 days LEVETIRACETAINJ10MG/ML 4 LEVETIRACETAINJ15MG/ML 4 LEVETIRACETAINJ5MG/ML 4 levetiracetasol100mg/ml 2 levetiracetatab1000mg 2 levetiracetatab250mg 2 levetiracetatab500mg 2 levetiracetatab500mg er 2 Quantity limitation 180 per 30 days 31
levetiracetatab750mg 2 levetiracetatab750mg er 2 Quantity limitation 120 per 30 days levetiracetminj500/5ml 2 POTIGA TAB200MG 4 Quantity limitation 180 per 30 days POTIGA TAB300MG 4 Quantity limitation 120 per 30 days POTIGA TAB400MG 4 Quantity limitation 90 per 30 days POTIGA TAB50MG 4 Quantity limitation 720 per 30 days Calcium Channel Modifying Agents CELONTIN CAP300MG 4 ethosuximidecap250mg 2 ethosuximidesol250/5ml 2 LYRICA CAP100MG 4 LYRICA CAP150MG 4 LYRICA CAP200MG 4 LYRICA CAP225MG 4 LYRICA CAP25MG 4 LYRICA CAP300MG 4 LYRICA CAP50MG 4 LYRICA CAP75MG 4 LYRICA SOL20MG/ML 4 zonisamide cap100mg 1 zonisamide cap25mg 1 zonisamide cap50mg 1 Gamma-aminobutyric Acid (GABA) Augmenting Agents clonazep odttab0.125mg 2 clonazep odttab0.25mg 2 clonazep odttab0.5mg 2 clonazep odttab1mg 2 clonazep odttab2mg 2 clonazepam tab0.5mg 2 clonazepam tab1mg 2 clonazepam tab2mg 2 cloraz dipottab15mg 2 Quantity limitation 90 per 30 days cloraz dipottab3.75mg 2 Quantity limitation 90 per 30 days cloraz dipottab7.5mg 2 Quantity limitation 90 per 30 days DIASTAT ACDLGEL12.5-20 4 Quantity limitation 40 per 30 days DIASTAT ACDLGEL5-10MG 4 Quantity limitation 30 per 30 days DIASTAT PED GEL2.5M GEL 4 Quantity limitation 30 per 30 days diazepam con5mg/ml 2 Quantity limitation 240 per 30 days DIAZEPAM GEL10MG 4 Quantity limitation 30 per 30 days DIAZEPAM GEL2.5MG 4 Quantity limitation 30 per 30 days DIAZEPAM GEL20MG 4 Quantity limitation 40 per 30 days diazepam sol1mg/ml 2 Quantity limitation 1200 per 30 days 32
diazepam tab10mg 2 Quantity limitation 180 per 30 days diazepam tab2mg 2 Quantity limitation 90 per 30 days diazepam tab5mg 2 Quantity limitation 240 per 30 days divalproex cap125mg 2 divalproex tab125mg dr 2 divalproex tab250mg dr 2 divalproex tab250mg er 2 divalproex tab500mg dr 2 divalproex tab500mg er 2 FYCOMPA TAB10MG 4 Quantity limitation 30 per 30 days FYCOMPA TAB12MG 4 Quantity limitation 30 per 30 days FYCOMPA TAB2MG 4 Quantity limitation 120 per 30 days FYCOMPA TAB4MG 4 Quantity limitation 90 per 30 days FYCOMPA TAB6MG 4 Quantity limitation 60 per 30 days FYCOMPA TAB8MG 4 Quantity limitation 30 per 30 days gabapentin cap100mg 2 Quantity limitation 360 per 30 days gabapentin cap300mg 2 Quantity limitation 360 per 30 days gabapentin cap400mg 2 Quantity limitation 270 per 30 days gabapentin sol250/5ml 2 gabapentin tab600mg 2 Quantity limitation 180 per 30 days gabapentin tab800mg 2 Quantity limitation 120 per 30 days GABITRIL TAB12MG 4 GABITRIL TAB16MG 4 lorazepam con2mg/ml 1 lorazepam tab0.5mg 1 lorazepam tab1mg 1 lorazepam tab2mg 1 ONFI SUS2.5MG/ML 4 ONFI TAB10MG 4 Quantity limitation 60 per 30 days ONFI TAB20MG 4 Quantity limitation 60 per 30 days phenobarb elx20mg/5ml 2 Quantity limitation 1500 per 30 days PHENOBARB TAB100MG 2 PHENOBARB TAB15MG 2 phenobarb tab16.2mg 2 Quantity limitation 360 per 30 days PHENOBARB TAB30MG 2 Quantity limitation 195 per 30 days phenobarb tab32.4mg 2 Quantity limitation 180 per 30 days PHENOBARB TAB60MG 2 PHENOBARB TAB64.8MG 2 Quantity limitation 90 per 30 days PHENOBARB TAB97.2MG 2 Quantity limitation 60 per 30 days primidone tab250mg 2 primidone tab50mg 2 SABRIL POW500MG 5 Quantity limitation 180 per 30 days; This prescription may be 33
available only at certain pharmacies. For more information please call 1-800-546-5677 24 hours a day- seven days a week. TTY/TDD users should call 1-866- 706-4757. SABRIL TAB500MG 5 tiagabine tab2mg 2 tiagabine tab4mg 2 valproate inj100mg/ml 2 valproic acdcap250mg 2 valproic acdsyp250/5ml 2 Glutamate Reducing Agents felbamate sus600/5ml 2 felbamate tab400mg 2 felbamate tab600mg 2 lamotrigine chw25mg 2 lamotrigine chw5mg 2 lamotrigine tab100mg 2 lamotrigine tab100mg er 2 lamotrigine tab150mg 2 lamotrigine tab200mg 2 lamotrigine tab200mg er 2 lamotrigine tab250mg er 2 lamotrigine tab25mg 2 lamotrigine tab25mg er 2 lamotrigine tab300mg er 2 lamotrigine tab50mg er 2 lamotrigine tabodt 25mg 2 lamotrigine tabodt 50mg 2 lamotrigine tabodt 100mg 2 lamotrigine tabodt 200mg 2 topiramate cap15mg 2 topiramate cap25mg 2 topiramate tab100mg 2 topiramate tab200mg 2 topiramate tab25mg 2 Quantity limitation 180 per 30 days; This prescription may be available only at certain pharmacies. For more information please call 1-800-546-5677 24 hours a day- seven days a week. TTY/TDD users should call 1-866- 706-4757. 34
topiramate tab50mg 2 TROKENDI XR CAP100MG 4 TROKENDI XR CAP200MG 4 TROKENDI XR CAP25MG 4 TROKENDI XR CAP50MG 4 Sodium Channel Agents BANZEL SUS40MG/ML 4 Quantity limitation 2400 per 30 days BANZEL TAB200MG 4 Quantity limitation 240 per 30 days BANZEL TAB400MG 5 Quantity limitation 240 per 30 days carbamazepincap100mg er 1 carbamazepincap200mg er 1 carbamazepincap300mg er 1 carbamazepinchw100mg 1 carbamazepinsus100/5ml 1 carbamazepintab200mg 1 carbamazepintab200mg er 1 carbamazepintab400mg er 1 epitol tab200mg 2 fosphenytoininj100/2ml 2 oxcarbazepinsus300mg/5m 2 oxcarbazepintab150mg 2 oxcarbazepintab300mg 2 oxcarbazepintab600mg 2 OXTELLAR XR TAB150MG 4 Quantity limitation 480 per 30 days OXTELLAR XR TAB300MG 4 Quantity limitation 240 per 30 days OXTELLAR XR TAB600MG 4 Quantity limitation 120 per 30 days PEGANONE TAB250MG 4 phenytoin chw50mg 1 phenytoin inj50mg/ml 2 phenytoin sus125/5ml 1 phenytoin excap100mg 1 35
phenytoin excap200mg 1 phenytoin excap300mg 1 VIMPAT INJ200MG/20 4 Quantity limitation 1200 per 30 VIMPAT SOL10MG/ML 4 days Quantity limitation 1200 per 30 days VIMPAT TAB100MG 4 Quantity limitation 60 per 30 days VIMPAT TAB150MG 4 Quantity limitation 60 per 30 days VIMPAT TAB200MG 4 Quantity limitation 60 per 30 days VIMPAT TAB50MG 4 Quantity limitation 60 per 30 days ANTIDEMENTIA AGENTS Antidementia Agents, Other ergoloid mestab1mg oral 2 Cholinesterase Inhibitors donepezil tab10mg 2 Quantity limitation 30 per 30 days donepezil tab10mg odt 2 Quantity limitation 30 per 30 days donepezil tab5mg 2 Quantity limitation 30 per 30 days donepezil tab5mg odt 2 Quantity limitation 30 per 30 days donepezil tabhcl 23mg 2 Quantity limitation 30 per 30 days EXELON DIS13.3/24 4 EXELON DIS4.6MG/24 4 EXELON DIS9.5MG/24 4 galantamine cap16mg er 2 Quantity limitation 30 per 30 days galantamine cap24mg er 2 Quantity limitation 30 per 30 days galantamine cap8mg er 2 Quantity limitation 30 per 30 days galantamine sol4mg/ml 2 Quantity limitation 180 per 30 days galantamine tab12mg 2 galantamine tab4mg 2 galantamine tab8mg 2 rivastigminecap1.5mg 2 Quantity limitation 60 per 30 days rivastigminecap3mg 2 Quantity limitation 60 per 30 days rivastigminecap4.5mg 2 Quantity limitation 60 per 30 days rivastigminecap6mg 2 Quantity limitation 60 per 30 days N-methyl-D-aspartate (NMDA) Receptor Antagonist NAMENDA SOL10MG/5ML 3 Quantity limitation 360 per 30 days NAMENDA TAB5MG 3 Quantity limitation 60 per 30 days NAMENDA TAB5MG-10MG 3 Quantity limitation 60 per 30 days NAMENDA TAB10MG 3 Quantity limitation 60 per 30 days NAMENDA XR CAP14MG 3 Quantity limitation 30 per 30 days NAMENDA XR CAP21MG 3 Quantity limitation 30 per 30 days NAMENDA XR CAP28MG 3 Quantity limitation 30 per 30 days NAMENDA XR CAP7MG 3 Quantity limitation 30 per 30 days NAMENDA XR CAPTITRATIO 3 Quantity limitation 30 per 30 days 36
ANTIDEPRESSANTS Antidepressants olanza/fluoxcap12-25mg 2 Quantity limitation 30 per 30 days olanza/fluoxcap12-50mg 2 Quantity limitation 30 per 30 days olanza/fluoxcap3-25mg 2 Quantity limitation 30 per 30 days olanza/fluoxcap6-25mg 2 Quantity limitation 30 per 30 days olanza/fluoxcap6-50mg 2 Quantity limitation 30 per 30 days perphen/amittab2-10mg 2 perphen/amittab2-25mg 2 perphen/amittab4-10mg 2 perphen/amittab4-25mg 2 perphen/amittab4-50mg 2 Antidepressants, Other ABILIFY INJ9.75MG 4 ABILIFY SOL1MG/ML 4 Quantity limitation 900 per 30 days ABILIFY TAB10MG 4 Quantity limitation 90 per 30 days ABILIFY TAB15MG 4 Quantity limitation 60 per 30 days ABILIFY TAB20MG 4 Quantity limitation 60 per 30 days ABILIFY TAB2MG 4 Quantity limitation 450 per 30 days ABILIFY TAB30MG 4 Quantity limitation 30 per 30 days ABILIFY TAB5MG 4 Quantity limitation 180 per 30 days ABILIFY DISCTAB10MG 4 Quantity limitation 90 per 30 days ABILIFY DISCTAB15MG 4 Quantity limitation 60 per 30 days ABILIFY MAININJ300MG 5 ABILIFY MAININJ400MG 5 aripiprazoletab10mg 2 Quantity limitation 90 per 30 days aripiprazoletab15mg 2 Quantity limitation 60 per 30 days aripiprazoletab20mg 2 Quantity limitation 60 per 30 days aripiprazoletab2mg 2 Quantity limitation 450 per 30 days aripiprazoletab30mg 2 Quantity limitation 30 per 30 days aripiprazoletab5mg 2 Quantity limitation 180 per 30 days mirtazapine tab15mg 1 Quantity limitation 30 per 30 days mirtazapine tab15mg odt 2 Quantity limitation 30 per 30 days mirtazapine tab30mg 1 Quantity limitation 30 per 30 days mirtazapine tab30mg odt 2 Quantity limitation 30 per 30 days mirtazapine tab45mg 1 Quantity limitation 30 per 30 days mirtazapine tab45mg odt 2 Quantity limitation 30 per 30 days mirtazapine tab7.5mg 1 Quantity limitation 30 per 30 days 37
quetiapine tab100mg 2 Quantity limitation 240 per 30 days quetiapine tab200mg 2 Quantity limitation 120 per 30 days quetiapine tab25mg 2 Quantity limitation 960 per 30 days quetiapine tab300mg 2 Quantity limitation 90 per 30 days quetiapine tab400mg 2 Quantity limitation 60 per 30 days quetiapine tab50mg 2 Quantity limitation 480 per 30 days REXULTI TAB0.25MG 4 Quantity limitation 480 per 30 days REXULTI TAB0. 5MG 4 Quantity limitation 480 per 30 days REXULTI TAB1MG 4 Quantity limitation 120 per 30 days REXULTI TAB2MG 4 Quantity limitation 60 per 30 days REXULTI TAB3MG 4 Quantity limitation 30 per 30 days REXULTI TAB4MG 4 Quantity limitation 30 per 30 days SEROQUEL XR TAB150MG 4 Quantity limitation 30 per 30 days SEROQUEL XR TAB200MG 4 Quantity limitation 30 per 30 days SEROQUEL XR TAB300MG 4 Quantity limitation 60 per 30 days SEROQUEL XR TAB400MG 4 Quantity limitation 60 per 30 days SEROQUEL XR TAB50MG 4 Quantity limitation 60 per 30 days Monoamine Oxidase Inhibitors EMSAM DIS12MG/24H 4 Quantity limitation 30 per 30 days EMSAM DIS6MG/24HR 4 Quantity limitation 30 per 30 days EMSAM DIS9MG/24HR 4 Quantity limitation 30 per 30 days MARPLAN TAB10MG 4 phenelzine tab15mg 2 tranylcypromtab10mg 2 SSRIs/SNRIs (Selective Serotonin Reuptake Inhibitors/Serotonin Norepinephrine Reuptake Inhibitors) BRINTELLIX TAB10MG 4 Quantity limitation 60 per 30 days BRINTELLIX TAB20MG 4 Quantity limitation 30 per 30 days BRINTELLIX TAB5MG 4 Quantity limitation 120 per 30 days citalopram sol10mg/5ml 1 This prescription drug is part of the free first fill program and will be provided at zero cost share when you select this medication over the brand name version of selected medications. citalopram tab10mg 1 Quantity limitation 30 per 30 days; This prescription drug is part of the free first fill program and will be provided at zero cost share when you select this medication over the brand name version of selected medications. citalopram tab20mg 1 Quantity limitation 30 per 30 days; This prescription drug is part of the 38
free first fill program and will be provided at zero cost share when you select this medication over the brand name version of selected medications. citalopram tab40mg 1 Quantity limitation 30 per 30 days; This prescription drug is part of the free first fill program and will be provided at zero cost share when you select this medication over the brand name version of selected medications. DESVENLAFAX TAB100MG ER 4 Quantity limitation 120 per 30 days DESVENLAFAX TAB50MG ER 4 Quantity limitation 240 per 30 days duloxetine cap20mg 2 Quantity limitation 180 per 30 days duloxetine cap30mg 2 Quantity limitation 120 per 30 days duloxetine cap40mg 2 Quantity limitation 90 per 30 days duloxetine cap60mg 2 Quantity limitation 60 per 30 days escitalopramsol5mg/5ml 2 Quantity limitation 620 per 30 days escitalopramtab10mg 2 Quantity limitation 60 per 30 days escitalopramtab20mg 2 Quantity limitation 30 per 30 days escitalopramtab5mg 2 Quantity limitation 120 per 30 days FETZIMA CAP120MG 4 Quantity limitation 30 per 30 days FETZIMA CAP20MG 4 Quantity limitation 180 per 30 days FETZIMA CAP40MG 4 Quantity limitation 120 per 30 days FETZIMA CAP80MG 4 Quantity limitation 30 per 30 days FETZIMA CAPTITRATIO 4 Quantity limitation 28 per 28 days fluoxetine cap10mg 1 Quantity limitation 30 per 30 days fluoxetine cap20mg 1 fluoxetine cap40mg 1 Quantity limitation 60 per 30 days fluoxetine sol20mg/5ml 1 fluoxetine tab10mg 1 Quantity limitation 30 per 30 days fluoxetine tab20mg 1 fluvoxamine tab100mg 2 Quantity limitation 90 per 30 days fluvoxamine tab25mg 2 Quantity limitation 360 per 30 days fluvoxamine tab50mg 2 Quantity limitation 180 per 30 days irenka cap40mg 2 Quantity limitation 90 per 30 days KHEDEZLA TAB100MG ER 4 Quantity limitation 120 per 30 days KHEDEZLA TAB50MG ER 4 Quantity limitation 240 per 30 days maprotiline tab25mg 2 maprotiline tab50mg 2 maprotiline tab75mg 2 nefazodone tab100mg 2 nefazodone tab150mg 2 39
nefazodone tab200mg 2 nefazodone tab250mg 2 nefazodone tab50mg 2 paroxetin ertab12.5mg 2 Quantity limitation 150 per 30 days; This prescription drug is part of the free first fill program and will be provided at zero cost share when you select this medication over the brand name version of selected medications. paroxetin ertab37.5mg 2 Quantity limitation 60 per 30 days paroxetine tab10mg 1 Quantity limitation 90 per 30 days; This prescription drug is part of the free first fill program and will be provided at zero cost share when you select this medication over the brand name version of selected medications. paroxetine tab20mg 1 Quantity limitation 60 per 30 days; This prescription drug is part of the free first fill program and will be provided at zero cost share when you select this medication over the brand name version of selected medications. paroxetine tab25mg er 2 Quantity limitation 90 per 30 days; This prescription drug is part of the free first fill program and will be provided at zero cost share when you select this medication over the brand name version of selected medications. paroxetine tab30mg 1 Quantity limitation 60 per 30 days; This prescription drug is part of the free first fill program and will be provided at zero cost share when you select this medication over the brand name version of selected medications. paroxetine tab40mg 1 Quantity limitation 45 per 30 days; This prescription drug is part of the free first fill program and will be provided at zero cost share when you select this medication over the brand name version of selected 40
medications. PAXIL SUS10MG/5ML 4 PRISTIQ TAB100MG 4 Quantity limitation 30 per 30 days PRISTIQ TAB50MG 4 Quantity limitation 240 per 30 days PRISTIQ TAB25MG 4 Quantity limitation 480 per 30 days sertraline con20mg/ml 1 Quantity limitation 300 per 30 days sertraline tab100mg 1 Quantity limitation 60 per 30 days sertraline tab25mg 1 Quantity limitation 240 per 30 days sertraline tab50mg 1 Quantity limitation 120 per 30 days trazodone tab100mg 1 trazodone tab150mg 1 trazodone tab300mg 1 trazodone tab50mg 1 venlafaxine cap150mg er 2 Quantity limitation 60 per 30 days venlafaxine cap37.5mg 2 Quantity limitation 180 per 30 days venlafaxine cap75mg er 2 Quantity limitation 90 per 30 days venlafaxine tab100mg 2 Quantity limitation 90 per 30 days; This prescription drug is part of the free first fill program and will be provided at zero cost share when you select this medication over the brand name version of selected medications. venlafaxine tab150mg er 2 Quantity limitation 60 per 30 days; This prescription drug is part of the free first fill program and will be provided at zero cost share when you select this medication over the brand name version of selected medications. VENLAFAXINE TAB225MG ER 4 Quantity limitation 30 per 30 days venlafaxine tab25mg 2 Quantity limitation 270 per 30 days; This prescription drug is part of the free first fill program and will be provided at zero cost share when you select this medication over the brand name version of selected medications. venlafaxine tab37.5 er 2 Quantity limitation 180 per 30 days; This prescription drug is part of the free first fill program and will be provided at zero cost share when you select this medication over the brand name version of selected medications. 41