cy2010 pdf 10059-24 · title: cy2010 pdf 10059-24.xls author: ï¿½ï¿½lidbnbj created date:...

ANTIFUNGAL AGENTS page 3ANTIVIRALS 3CEPHALOSPORINS 6ERYTHROMYCINS AND OTHER MACROLIDES 8MISCELLANEOUS ANTIINFECTIVES 8PENICILLINS 10QUINOLONES 12SULFA'S AND RELATED AGENTS 12TETRACYCLINES 13URINARY TRACT AGENTS 14VANCOMYCIN 14

ADJUNCTIVE AGENTS 14ANTINEOPLASTIC AND IMMUNOSUPPRESSANT DRUGS 14

ANTICONVULSANTS 18ANTIPARKINSONISM AGENTS 21MIGRAINE AND CLUSTER HEADACHE THERAPY 22MISCELLANEOUS NEUROLOGICAL THERAPY 23MUSCLE RELAXANTS AND ANTISPASMODIC THERAPY 24NARCOTIC ANALGESICS 25NON-NARCOTIC ANALGESICS 29PROPOXYPHENE 31PSYCHOTHERAPEUTIC DRUGS 31

ANTIARRHYTHMIC AGENTS 40ANTIHYPERTENSIVE THERAPY 41CARDIAC GLYCOSIDES 51COAGULATION THERAPY 51LIPID/CHOLESTEROL LOWERING AGENTS 53MISCELLANEOUS CARDIOVASCULAR AGENTS 55NITRATES 55

ANTIPSORIATIC / ANTISEBORRHEIC 56BURN THERAPY 56MISCELLANEOUS DERMATOLOGICALS 56THERAPY FOR ACNE 57TOPICAL ANESTHETICS 58TOPICAL ANTIBACTERIALS 58TOPICAL ANTIFUNGALS 58TOPICAL ANTIVIRALS 59TOPICAL CORTICOSTEROIDS 59TOPICAL ENZYMES 62TOPICAL SCABICIDES / PEDICULICIDES 62

IRRIGATING SOLUTIONS 62MISCELLANEOUS AGENTS 62SMOKING DETERRENTS 64

MISCELLANEOUS AGENTS 64MISCELLANEOUS OTIC PREPARATIONS 64OTIC STEROID / ANTIBIOTIC 64

ADRENAL HORMONES 64ANTITHYROID AGENTS 66DIABETES THERAPY 66MISCELLANEOUS HORMONES 69THYROID HORMONES 70

EAR - NOSE AND THROAT

MEDICATIONS

ENDOCRINE/DIABETES

2010 Medicare Part-D Formulary

Table of Contents

AUTONOMIC AND CNS DRUGS -

NEUROLOGY AND PSYCH

CARDIOVASCULAR -

HYPERTENSION AND LIPIDS

DERMATOLOGICALS/TOPICAL

THERAPY

DIAGNOSTICS AND

MISCELLANEOUS AGENTS

Formulary ID: 00010059 Version: 24

ANTI - INFECTIVES

ANTINEOPLASTIC AND

IMMUNOSUPPRESSANT DRUGS

ANTIDIARRHEALS AND ANTISPASMODICS 71MISCELLANEOUS GASTROINTESTINAL AGENTS 72ULCER THERAPY 74

BIOTECHNOLOGY DRUGS 75VACCINES AND MISCELLANEOUS IMMUNOLOGICALS 77

GOUT THERAPY 78OSTEOPOROSIS THERAPY 78OTHER RHEUMATOLOGICALS 79

ESTROGENS AND PROGESTINS 79MISCELLANEOUS OB/GYN 81ORAL CONTRACEPTIVES AND RELATED AGENTS 82OXYTOCICS 83

ANTIBIOTICS 83ANTIVIRALS 84BETA-BLOCKERS 84CHOLINESTERASE INHIBITOR MIOTICS 84CYCLOPLEGIC MYDRIATICS 84DIRECT ACTING MIOTICS 84MISCELLANEOUS OPHTHALMOLOGICS 84NON-STEROIDAL ANTI-INFLAMMATORY AGENTS 85ORAL DRUGS FOR GLAUCOMA 85OTHER GLAUCOMA DRUGS 85STEROID-ANTIBIOTIC COMBINATIONS 85STEROIDS 86STEROID-SULFONAMIDE COMBINATIONS 86SULFONAMIDES 86SYMPATHOMIMETICS 86VASOCONSTRICTOR DECONGESTANTS 86

ANTIHISTAMINE AND ANTIALLERGENIC AGENTS 87COUGH AND COLD THERAPY 88PULMONARY AGENTS 88

ANTICHOLINERGICS AND ANTISPASMODICS 90BENIGN PROSTATIC HYPERPLASIA(BPH) THERAPY 90CHOLINERGIC STIMULANTS 91MISCELLANEOUS UROLOGICALS 91

ELECTROLYTES 91MISCELLANEOUS NUTRITION PRODUCTS 92MISCELLANEOUS VITAMINS - HEMATINICS AND ELECTROLYTES 92VITAMINS AND HEMATINICS 94

GASTROENTEROLOGY

IMMUNOLOGY - VACCINES AND

BIOTECHNOLOGYMUSCULOSKELETAL AND

RHEUMATOLOGY

OBSTETRICS AND

GYNECOLOGY

KeyGeneric- drug covered at generic copay

OPHTHALMOLOGY

RESPIRATORY - ALLERGY -

COUGH AND COLD

UROLOGICALS

VITAMINS - HEMATINICS AND

ELECTROLYTES

QL Days- The number of days within the quantity limit time period

QL- Quantity Limit Restriction Applies: Limits the amount of drug that a beneficiary may receive in a certain period.

QL Amount- Total number of dosage units a beneficiary may receive within the given time period

Preferred Brand- drug covered at preferred brand copayNon-preferred Brand- drug covered at non-preferred copay

Specialty- drug covered at specialty copay / coinsurance

PA- Prior Authorization Required: Coverage of this drug is subject to review by the plan and is based on Pharmacy

policy.

PA BvD- Prior Authorization Required: This drug may be covered under Medicare part B or D depending upon the

circumstance. Information may need to be submitted describing the use and setting of the drug to make thedetermination.

Highmark Medicare Part-D Formulary 2010

ANTI - INFECTIVES ANTIFUNGAL AGENTS

Drug NameDosage

FormStrength Tier Level PA QL

QL

AmountQL Days

ABELCET SUSP 5MG/ML SpecialtyAMBISOME SUSR 50MG Non-preferred BrandAMPHOTEC SUSR 50MG Non-preferred BrandAMPHOTERICIN B SOLR 50MG GenericANCOBON CAPS 250MG Preferred BrandANCOBON CAPS 500MG Preferred BrandCANCIDAS SOLR 50MG Non-preferred BrandCANCIDAS SOLR 70MG Non-preferred BrandCLOTRIMAZOLE TROC 10MG GenericDIFLUCAN SUSR 10MG/ML Non-preferred BrandDIFLUCAN SUSR 40MG/ML Non-preferred BrandDIFLUCAN TABS 100MG Non-preferred BrandDIFLUCAN TABS 150MG Non-preferred BrandDIFLUCAN TABS 200MG Non-preferred BrandDIFLUCAN TABS 50MG Non-preferred BrandDIFLUCAN IN NACL SOLN 200MG/100ML; 0.9%Non-preferred BrandERAXIS SOLR 100MG Preferred BrandFLUCONAZOLE SUSR 10MG/ML GenericFLUCONAZOLE SUSR 40MG/ML GenericFLUCONAZOLE TABS 100MG GenericFLUCONAZOLE TABS 150MG GenericFLUCONAZOLE TABS 200MG GenericFLUCONAZOLE TABS 50MG GenericFLUCONAZOLE IN DEXTROSE SOLN 0; 400MG/200MLGenericGRIFULVIN V TABS 500MG Preferred BrandGRISEOFULVIN MICROSIZE SUSP 125MG/5ML GenericGRIS-PEG TABS 125MG Non-preferred BrandGRIS-PEG TABS 250MG Non-preferred BrandITRACONAZOLE CAPS 100MG GenericKETOCONAZOLE TABS 200MG GenericLAMISIL TABS 250MG Non-preferred Brand QL 90 180LAMISIL PACK 125MG Non-preferred Brand QL 90 180LAMISIL PACK 187.5MG Non-preferred Brand QL 90 180

MYCAMINE SOLR 100MG Non-preferred BrandMYCAMINE SOLR 50MG Non-preferred BrandNOXAFIL SUSP 40MG/ML Non-preferred BrandNYSTATIN SUSP 100000UNIT/ML GenericNYSTATIN TABS 500000UNIT GenericSPORANOX CAPS 100MG Non-preferred BrandSPORANOX SOLN 10MG/ML Preferred BrandSPORANOX PULSEPAK CAPS 100MG Non-preferred BrandTERBINAFINE HCL TABS 250MG Generic QL 90 180VFEND SUSR 40MG/ML SpecialtyVFEND TABS 200MG SpecialtyVFEND TABS 50MG SpecialtyVFEND IV SOLR 200MG SpecialtyANTI - INFECTIVES ANTIVIRALS

Drug NameDosage


QL

AmountQL Days

ACYCLOVIR CAPS 200MG GenericACYCLOVIR SUSP 200MG/5ML GenericACYCLOVIR TABS 400MG GenericACYCLOVIR TABS 800MG GenericACYCLOVIR SODIUM SOLR 500MG GenericAMANTADINE HCL CAPS 100MG Generic

3 of 94 Formulary ID: 00010059, Version: 24 Effective: 08/01/10


AMANTADINE HCL TABS 100MG GenericAPTIVUS CAPS 250MG SpecialtyAPTIVUS SOLN 100 MG/ML Specialty

ATRIPLA TABS 600MG; 200MG; 300MGSpecialtyBARACLUDE SOLN 0.05MG/ML Preferred BrandBARACLUDE TABS 0.5MG SpecialtyBARACLUDE TABS 1MG SpecialtyCOMBIVIR TABS 150MG; 300MG Preferred BrandCOPEGUS TABS 200MG SpecialtyCRIXIVAN CAPS 100MG Preferred BrandCRIXIVAN CAPS 200MG Preferred BrandCRIXIVAN CAPS 333MG Preferred BrandCRIXIVAN CAPS 400MG Preferred BrandCYTOVENE SOLR 500MG Preferred BrandDIDANOSINE CPDR 200MG GenericDIDANOSINE CPDR 250MG GenericDIDANOSINE CPDR 400MG GenericDIDANOSINE CPDR 125MG GenericEMTRIVA CAPS 200MG Preferred BrandEMTRIVA SOLN 10MG/ML Preferred BrandEPIVIR SOLN 10MG/ML Preferred BrandEPIVIR TABS 150MG Preferred BrandEPIVIR TABS 300MG Preferred BrandEPIVIR HBV SOLN 5MG/ML Preferred BrandEPIVIR HBV TABS 100MG Preferred BrandEPZICOM TABS 600MG; 300MG Preferred BrandFAMCICLOVIR TABS 125MG GenericFAMCICLOVIR TABS 250MG GenericFAMCICLOVIR TABS 500MG GenericFAMVIR TABS 125MG Non-preferred BrandFAMVIR TABS 250MG Non-preferred BrandFAMVIR TABS 500MG Non-preferred BrandFLUMADINE TABS 100MG Non-preferred BrandFOSCARNET SODIUM SOLN 24MG/ML GenericFOSCAVIR SOLN 24MG/ML Non-preferred BrandFUZEON KIT 90MG Specialty

GANCICLOVIR CAPS 250MG GenericGANCICLOVIR CAPS 500MG GenericHEPSERA TABS 10MG Preferred BrandINTELENCE TABS 100MG SpecialtyINVIRASE CAPS 200MG SpecialtyINVIRASE TABS 500MG SpecialtyISENTRESS TABS 400MG SpecialtyKALETRA SOLN 400MG/5ML; 100MG/5MLSpecialtyKALETRA TABS 100MG; 25MG SpecialtyKALETRA TABS 200MG; 50MG SpecialtyLEXIVA SUSP 50MG/ML Preferred BrandLEXIVA TABS 700MG Preferred BrandNORVIR CAPS 100MG Preferred BrandNORVIR TABS 100MG Preferred BrandNORVIR SOLN 80MG/ML Preferred BrandPREZISTA TABS 400MG SpecialtyPREZISTA TABS 600MG SpecialtyPREZISTA TABS 75MG Preferred BrandREBETOL CAPS 200MG SpecialtyREBETOL SOLN 40MG/ML SpecialtyRELENZA DISKHALER AEPB 5MG/BLISTER Preferred BrandRESCRIPTOR TABS 100MG Preferred Brand



RESCRIPTOR TABS 200MG Preferred BrandRETROVIR CAPS 100MG Non-preferred BrandRETROVIR SYRP 50MG/5ML Non-preferred BrandRETROVIR TABS 300MG Non-preferred BrandRETROVIR IV INFUSION SOLN 10MG/ML Preferred BrandREYATAZ CAPS 100MG Preferred BrandREYATAZ CAPS 150MG Preferred BrandREYATAZ CAPS 200MG Preferred BrandREYATAZ CAPS 300MG Preferred BrandRIBAPAK MISC 0 SpecialtyRIBAPAK TABS 600MG SpecialtyRIBAPAK TABS 400MG SpecialtyRIBASPHERE CAPS 200MG SpecialtyRIBASPHERE TABS 200MG GenericRIBASPHERE TABS 400MG SpecialtyRIBASPHERE TABS 600MG SpecialtyRIBAVIRIN CAPS 200MG SpecialtyRIBAVIRIN TABS 200MG GenericRIBAVIRIN TABS 400MG SpecialtyRIBAVIRIN TABS 600MG SpecialtyRIMANTADINE HCL TABS 100MG GenericSELZENTRY TABS 150MG SpecialtySELZENTRY TABS 300MG SpecialtySTAVUDINE CAPS 15MG GenericSTAVUDINE CAPS 20MG GenericSTAVUDINE CAPS 30MG GenericSTAVUDINE CAPS 40MG GenericSTAVUDINE SOLR 1 MG/ML GenericSUSTIVA CAPS 200MG Preferred BrandSUSTIVA CAPS 50MG Preferred BrandSUSTIVA TABS 600MG Preferred BrandTAMIFLU CAPS 30MG Preferred BrandTAMIFLU CAPS 45MG Preferred BrandTAMIFLU CAPS 75MG Preferred BrandTAMIFLU SUSR 12MG/ML Preferred BrandTRIZIVIR TABS 300MG; 150MG; 300MGPreferred Brand

TRUVADA TABS 200MG; 300MG SpecialtyTYZEKA TABS 600MG Non-preferred BrandVALCYTE TABS 450MG SpecialtyVALTREX TABS 1GM Preferred BrandVALTREX TABS 500MG Preferred BrandVIDEX EC CPDR 125MG Preferred BrandVIDEX EC CPDR 200MG Non-preferred BrandVIDEX EC CPDR 250MG Non-preferred BrandVIDEX EC CPDR 400MG Non-preferred BrandVIDEX PEDIATRIC SOLR 2GM Preferred BrandVIRACEPT POWD 50MG/GM Preferred BrandVIRACEPT TABS 250MG SpecialtyVIRACEPT TABS 625MG SpecialtyVIRAMUNE SUSP 50MG/5ML Preferred BrandVIRAMUNE TABS 200MG Preferred BrandVIRAZOLE SOLR 6GM Preferred BrandVIREAD TABS 300MG Preferred BrandVISTIDE SOLN 75MG/ML Non-preferred BrandZERIT CAPS 15MG Non-preferred BrandZERIT CAPS 20MG Non-preferred BrandZERIT CAPS 30MG Non-preferred BrandZERIT CAPS 40MG Non-preferred Brand



ZERIT SOLR 1MG/ML Non-preferred BrandZIAGEN SOLN 20MG/ML Preferred BrandZIAGEN TABS 300MG Preferred BrandZIDOVUDINE CAPS 100MG GenericZIDOVUDINE SYRP 50MG/5ML GenericZIDOVUDINE TABS 300MG GenericZOVIRAX CAPS 200MG Non-preferred BrandZOVIRAX SUSP 200MG/5ML Non-preferred BrandZOVIRAX TABS 400MG Non-preferred BrandZOVIRAX TABS 800MG Non-preferred BrandANTI - INFECTIVES CEPHALOSPORINS

Drug NameDosage


QL

AmountQL Days

CEDAX CAPS 400MG Non-preferred BrandCEDAX SUSR 90MG/5ML Non-preferred BrandCEFACLOR CAPS 250MG GenericCEFACLOR CAPS 500MG GenericCEFACLOR SUSR 125MG/5ML GenericCEFACLOR SUSR 250MG/5ML GenericCEFACLOR SUSR 375MG/5ML GenericCEFACLOR ER TB12 500MG GenericCEFADROXIL CAPS 500MG GenericCEFADROXIL SUSR 250MG/5ML GenericCEFADROXIL SUSR 500MG/5ML GenericCEFADROXIL TABS 1GM GenericCEFAZOLIN SODIUM SOLR 1GM GenericCEFAZOLIN SODIUM SOLN 1GM; 5% GenericCEFAZOLIN SODIUM SOLR 20GM Non-preferred BrandCEFAZOLIN SODIUM SOLN 500MG; 5% Non-preferred BrandCEFAZOLIN SODIUM SOLR 500MG GenericCEFDINIR CAPS 300MG GenericCEFDINIR SUSR 125MG/5ML GenericCEFDINIR SUSR 250MG/5ML GenericCEFEPIME SOLR 1GM GenericCEFEPIME SOLR 2GM GenericCEFIZOX IN DEXTROSE 5% SOLN 1GM/50ML; 5% Non-preferred Brand

CEFIZOX IN DEXTROSE 5% SOLN 2GM/50ML; 5% Non-preferred BrandCEFOTAXIME SODIUM SOLR 10GM GenericCEFOTAXIME SODIUM SOLR 1GM GenericCEFOTAXIME SODIUM SOLR 2GM GenericCEFOTAXIME SODIUM SOLR 500MG GenericCEFOTETAN SOLR 10GM Non-preferred BrandCEFOTETAN SOLR 1GM Non-preferred BrandCEFOTETAN SOLR 2GM Non-preferred BrandCEFOXITIN SODIUM SOLR 10GM GenericCEFOXITIN SODIUM SOLR 1GM GenericCEFOXITIN SODIUM SOLR 2GM GenericCEFOXITIN SODIUM SOLR 2GM; 2.2% GenericCEFOXITIN SODIUM SOLR 1GM; 4% GenericCEFPODOXIME PROXETIL SUSR 100MG/5ML GenericCEFPODOXIME PROXETIL SUSR 50MG/5ML GenericCEFPODOXIME PROXETIL TABS 100MG GenericCEFPODOXIME PROXETIL TABS 200MG GenericCEFPROZIL SUSR 125MG/5ML GenericCEFPROZIL SUSR 250MG/5ML GenericCEFPROZIL TABS 250MG GenericCEFPROZIL TABS 500MG GenericCEFTAZIDIME SOLR 1GM Generic



CEFTAZIDIME SOLR 2GM GenericCEFTAZIDIME SOLR 6GM GenericCEFTIN SUSR 125MG/5ML Non-preferred BrandCEFTIN SUSR 250MG/5ML Non-preferred BrandCEFTIN TABS 250MG Non-preferred BrandCEFTIN TABS 500MG Non-preferred BrandCEFTRIAXONE SODIUM SOLR 10GM GenericCEFTRIAXONE SODIUM SOLR 250MG GenericCEFTRIAXONE SODIUM SOLR 500MG GenericCEFTRIAXONE/DEXTROSE SOLR 1GM; 3.74% Preferred BrandCEFTRIAXONE/DEXTROSE SOLR 2GM; 2.22% Preferred BrandCEFUROXIME AXETIL SUSR 125MG/5ML GenericCEFUROXIME AXETIL SUSR 250MG/5ML GenericCEFUROXIME AXETIL TABS 250MG GenericCEFUROXIME AXETIL TABS 500MG GenericCEFUROXIME SODIUM SOLR 1.5GM GenericCEFUROXIME SODIUM SOLR 7.5GM GenericCEFUROXIME SODIUM SOLR 750MG GenericCEFUROXIME/DEXTROSE SOLR 1.5GM; 2.9% Non-preferred BrandCEFUROXIME/DEXTROSE SOLR 750MG; 4.1% Non-preferred BrandCEPHALEXIN CAPS 250MG GenericCEPHALEXIN CAPS 500MG GenericCEPHALEXIN SUSR 125MG/5ML GenericCEPHALEXIN SUSR 250MG/5ML GenericCEPHALEXIN TABS 250MG GenericCEPHALEXIN TABS 500MG GenericCLAFORAN SOLR 10GM Non-preferred BrandCLAFORAN SOLR 1GM Non-preferred BrandCLAFORAN SOLR 2GM Non-preferred BrandCLAFORAN SOLR 500MG Non-preferred BrandCLAFORAN/D5W SOLN 1GM/50ML; 5% Non-preferred BrandCLAFORAN/D5W SOLN 2GM/50ML; 5% Non-preferred BrandFORTAZ SOLR 1GM Non-preferred BrandFORTAZ SOLN 1GM/50ML; 5% Non-preferred BrandFORTAZ SOLN 2GM/50ML; 5% Non-preferred BrandFORTAZ SOLR 2GM Non-preferred Brand

FORTAZ SOLR 6GM Non-preferred BrandKEFLEX CAPS 250MG Non-preferred BrandKEFLEX CAPS 500MG Non-preferred BrandKEFLEX CAPS 750MG Non-preferred BrandMAXIPIME SOLR 1GM Non-preferred BrandMAXIPIME SOLR 2GM Preferred BrandOMNICEF CAPS 300MG Non-preferred BrandOMNICEF SUSR 125MG/5ML Non-preferred BrandOMNICEF SUSR 250MG/5ML Non-preferred BrandRANICLOR CHEW 250MG Non-preferred BrandRANICLOR CHEW 375MG Non-preferred BrandROCEPHIN SOLR 1GM Non-preferred BrandROCEPHIN IN ISO-OSMOTIC DEXTROSESOLN 20MG/ML; 0 Non-preferred BrandROCEPHIN IN ISO-OSMOTIC DEXTROSESOLN 40MG/ML; 0 Non-preferred BrandSPECTRACEF TABS 200MG Non-preferred BrandSPECTRACEF TABS 400MG Non-preferred BrandSUPRAX SUSR 100MG/5ML Preferred BrandSUPRAX SUSR 200MG/5ML Preferred BrandSUPRAX TABS 400MG Preferred BrandTAZICEF SOLR 1GM Non-preferred BrandTAZICEF SOLR 2GM Non-preferred BrandTAZICEF SOLR 6GM Non-preferred Brand



VANTIN TABS 200MG Non-preferred BrandZINACEF SOLR 1.5GM Preferred BrandZINACEF SOLR 7.5GM Non-preferred BrandZINACEF SOLR 750MG Non-preferred BrandZINACEF IN ISO-OSMOTIC DEXTROSE SOLN 750MG; 0 Preferred BrandZINACEF IN ISO-OSMOTIC DILUENT SOLN 1.5GM; 0 Non-preferred BrandANTI - INFECTIVES ERYTHROMYCINS AND OTHER MACROLIDES

Drug NameDosage


QL

AmountQL Days

AZITHROMYCIN SOLR 500MG GenericAZITHROMYCIN SUSR 100MG/5ML GenericAZITHROMYCIN SUSR 200MG/5ML GenericAZITHROMYCIN TABS 250MG GenericAZITHROMYCIN TABS 500MG GenericAZITHROMYCIN TABS 600MG GenericBIAXIN SUSR 125MG/5ML Non-preferred BrandBIAXIN SUSR 250MG/5ML Non-preferred BrandBIAXIN TABS 250MG Non-preferred BrandBIAXIN TABS 500MG Non-preferred BrandBIAXIN XL TB24 500MG Non-preferred BrandBIAXIN XL PAC TB24 500MG Non-preferred BrandCLARITHROMYCIN SUSR 125MG/5ML GenericCLARITHROMYCIN SUSR 250MG/5ML GenericCLARITHROMYCIN TABS 250MG GenericCLARITHROMYCIN TABS 500MG GenericCLARITHROMYCIN ER TB24 500MG GenericE.E.S. 400 TABS 400MG GenericE.E.S. GRANULES SUSR 200MG/5ML Non-preferred BrandERYPED 200 SUSR 200MG/5ML Non-preferred BrandERYPED 400 SUSR 400MG/5ML Preferred BrandERY-TAB TBEC 250MG GenericERY-TAB TBEC 333MG GenericERY-TAB TBEC 500MG Preferred BrandERYTHROCIN LACTOBIONATE SOLR 500MG Preferred BrandERYTHROCIN STEARATE TABS 250MG GenericERYTHROCIN STEARATE TABS 500MG Generic

ERYTHROMYCIN /SULFISOXAZOLE SUSR 200MG/5ML; 600MG/5MLGenericERYTHROMYCIN BASE TABS 250MG Preferred BrandERYTHROMYCIN BASE TABS 500MG Preferred BrandPCE TBEC 333MG Non-preferred BrandPCE TBEC 500MG Non-preferred BrandZITHROMAX SOLR 500MG Non-preferred BrandZITHROMAX SUSR 100MG/5ML Non-preferred BrandZITHROMAX SUSR 200MG/5ML Non-preferred BrandZITHROMAX TABS 250MG Non-preferred BrandZITHROMAX TABS 500MG Non-preferred BrandZITHROMAX TABS 600MG Non-preferred BrandZITHROMAX TRI-PAK TABS 500MG Non-preferred BrandZITHROMAX Z-PAK TABS 250MG Non-preferred BrandZMAX SUSR 2GM Non-preferred BrandANTI - INFECTIVES MISCELLANEOUS ANTIINFECTIVES

Drug NameDosage


QL

AmountQL Days

ALBENZA TABS 200MG Non-preferred BrandALINIA SUSR 100MG/5ML Non-preferred BrandALINIA TABS 500MG Non-preferred BrandAMIKACIN SULFATE SOLN 50MG/ML GenericAMIKACIN SULFATE SOLN 250MG/ML Generic



AMIKIN SOLN 50MG/ML Non-preferred BrandAMIKIN SOLN 250MG/ML GenericARALEN TABS 500MG Non-preferred BrandAZACTAM SOLR 2GM Preferred BrandAZACTAM IN DEXTROSE SOLN 1GM; 0 Preferred BrandAZACTAM IN DEXTROSE SOLN 2GM; 0 Preferred BrandBACIIM SOLR 50000UNIT GenericBACITRACIN SOLR 50000UNIT GenericBILTRICIDE TABS 600MG Preferred BrandCAPASTAT SULFATE SOLR 1GM Non-preferred BrandCHLORAMPHENICOL SODIUM SUCCINATESOLR 1GM Non-preferred BrandCHLOROQUINE PHOSPHATE TABS 250MG GenericCHLOROQUINE PHOSPHATE TABS 500MG GenericCLEOCIN CAPS 150MG Non-preferred BrandCLEOCIN CAPS 300MG Non-preferred BrandCLEOCIN CAPS 75MG Preferred BrandCLEOCIN GALAXY SOLN 300MG/50ML; 5%Non-preferred BrandCLEOCIN GALAXY SOLN 600MG/50ML; 5%Non-preferred BrandCLEOCIN GALAXY SOLN 900MG/50ML; 5%Non-preferred BrandCLEOCIN PEDIATRIC GRANULES SOLR 75MG/5ML Preferred BrandCLEOCIN PHOSPHATE SOLN 150MG/ML Non-preferred BrandCLINDAMYCIN HCL CAPS 150MG GenericCLINDAMYCIN HCL CAPS 300MG GenericCLINDAMYCIN PHOSPHATE ADD-VANTAGESOLN 150MG/ML GenericCOLISTIMETHATE SODIUM SOLR 150MG GenericCOLY-MYCIN M SOLR 150MG SpecialtyCUBICIN SOLR 500MG SpecialtyDAPSONE TABS 100MG Preferred BrandDAPSONE TABS 25MG Preferred BrandDARAPRIM TABS 25MG Preferred BrandETHAMBUTOL HCL TABS 100MG GenericETHAMBUTOL HCL TABS 400MG GenericFANSIDAR TABS 25MG; 500MG Preferred BrandFLAGYL CAPS 375MG Non-preferred BrandFLAGYL TABS 250MG Non-preferred BrandFLAGYL TABS 500MG Non-preferred Brand

FLAGYL ER TB24 750MG Non-preferred BrandGENTAMICIN SULFATE SOLN 10MG/ML Preferred BrandGENTAMICIN SULFATE SOLN 40MG/ML GenericGENTAMICIN SULFATE/0.9% SODIUM CHLORIDESOLN 0.9MG/ML; 0.9% Non-preferred BrandGENTAMICIN SULFATE/0.9% SODIUM CHLORIDESOLN 1.4MG/ML; 0.9% Non-preferred BrandGENTAMICIN SULFATE/0.9% SODIUM CHLORIDESOLN 1MG/ML; 0.9% GenericGENTAMICIN SULFATE/0.9% SODIUM CHLORIDESOLN 1.6MG/ML; 0.9% GenericGENTAMICIN SULFATE/SODIUM CHLORIDESOLN 1.2MG/ML; 0.9% GenericHYDROXYCHLOROQUINE SULFATE TABS 200MG GenericINVANZ SOLR 1GM Non-preferred BrandISONARIF CAPS 150MG; 300MG GenericISONIAZID SOLN 100MG/ML GenericISONIAZID SYRP 50MG/5ML Preferred BrandISONIAZID TABS 100MG GenericISONIAZID TABS 300MG GenericISOTONIC GENTAMICIN SOLN 0.6MG/ML; 0.9% GenericISOTONIC GENTAMICIN SOLN 0.8MG/ML; 0.9% GenericKANAMYCIN SULFATE SOLN 333MG/ML GenericKETEK TABS 300MG Preferred BrandKETEK TABS 400MG Preferred BrandLARIAM TABS 250MG Non-preferred BrandLINCOCIN SOLN 300MG/ML Non-preferred Brand



MALARONE TABS 250MG; 100MG Preferred BrandMALARONE TABS 62.5MG; 25MG Preferred BrandMEBENDAZOLE CHEW 100MG GenericMEFLOQUINE HCL TABS 250MG GenericMEPRON SUSP 750MG/5ML SpecialtyMERREM SOLR 500MG Preferred BrandMETRONIDAZOLE CAPS 375MG GenericMETRONIDAZOLE TABS 250MG GenericMETRONIDAZOLE TABS 500MG GenericMETRONIDAZOLE IN NACL 0.79% SOLN 5MG/ML; 0.79% GenericMYAMBUTOL TABS 100MG Non-preferred BrandMYAMBUTOL TABS 400MG Non-preferred BrandMYCOBUTIN CAPS 150MG Preferred BrandNEO-FRADIN SOLN 25MG/ML Preferred BrandNEOMYCIN SULFATE TABS 500MG GenericNEUTREXIN SOLR 25MG Non-preferred BrandPAROMOMYCIN SULFATE CAPS 250MG GenericPASER PACK 4GM Non-preferred BrandPENTAM 300 SOLR 300MG Non-preferred BrandPLAQUENIL TABS 200MG Non-preferred BrandPOLYMYXIN B SULFATE SOLR 500000UNIT GenericPRIFTIN TABS 150MG Preferred BrandPRIMAQUINE PHOSPHATE TABS 26.3MG Preferred BrandPRIMAXIN I.M. SOLR 500MG; 500MG Non-preferred BrandPRIMAXIN IV SOLR 250MG; 250MG Non-preferred BrandPRIMAXIN IV SOLR 500MG; 500MG Non-preferred BrandPYRAZINAMIDE TABS 500MG GenericQUALAQUIN CAPS 324MG Non-preferred BrandRIFADIN CAPS 150MG Non-preferred BrandRIFADIN CAPS 300MG Non-preferred BrandRIFADIN SOLR 600MG Non-preferred BrandRIFAMATE CAPS 150MG; 300MG Non-preferred BrandRIFAMPIN CAPS 150MG GenericRIFAMPIN CAPS 300MG GenericRIFAMPIN SOLR 600MG GenericRIFATER TABS 50MG; 300MG; 120MGNon-preferred Brand

SEROMYCIN CAPS 250MG Preferred BrandSTREPTOMYCIN SULFATE SOLR 1GM Preferred BrandSTROMECTOL TABS 3MG Non-preferred BrandSYNERCID SOLR 350MG; 150MG Non-preferred BrandTINDAMAX TABS 250MG Non-preferred BrandTINDAMAX TABS 500MG Non-preferred BrandTOBI NEBU 300MG/5ML Non-preferred Brand PA- BvDTOBRAMYCIN SULFATE SOLN 10MG/ML GenericTOBRAMYCIN SULFATE SOLN 80MG/2ML GenericTOBRAMYCIN SULFATE/SODIUM CHLORIDESOLN 0.9%; 0.8MG/ML Non-preferred BrandTOBRAMYCIN SULFATE/SODIUM CHLORIDESOLN 0.9%; 1.2MG/ML Non-preferred BrandTRECATOR TABS 250MG Non-preferred BrandTYGACIL SOLR 50MG SpecialtyVIBATIV SOLN 15MG/ML Non-preferred Brand PA- BvDXIFAXAN TABS 200MG Non-preferred BrandZYVOX SOLN 2MG/ML SpecialtyZYVOX SUSR 100MG/5ML SpecialtyZYVOX TABS 600MG SpecialtyANTI - INFECTIVES PENICILLINS

Drug NameDosage


QL

AmountQL Days

AMOCLAN SUSP 200-28.5/5 Generic



AMOCLAN SUSP 400-57MG/5 Generic

AMOXICILLIN CAPS 250MG GenericAMOXICILLIN CAPS 500MG GenericAMOXICILLIN CHEW 125MG GenericAMOXICILLIN CHEW 200MG GenericAMOXICILLIN CHEW 250MG GenericAMOXICILLIN CHEW 400MG GenericAMOXICILLIN SUSR 125MG/5ML GenericAMOXICILLIN SUSR 200MG/5ML GenericAMOXICILLIN SUSR 250MG/5ML GenericAMOXICILLIN SUSR 400MG/5ML GenericAMOXICILLIN TABS 500MG GenericAMOXICILLIN TABS 875MG GenericAMOXICILLIN/CLAVULANATE POTASSIUMCHEW 200MG; 28.5MG GenericAMOXICILLIN/CLAVULANATE POTASSIUMCHEW 400MG; 57MG GenericAMOXICILLIN/CLAVULANATE POTASSIUMSUSR 200MG/5ML; 28.5MG/5MLGenericAMOXICILLIN/CLAVULANATE POTASSIUMSUSR 400MG/5ML; 57MG/5MLGenericAMOXICILLIN/CLAVULANATE POTASSIUMSUSR 600MG/5ML; 42.9MG/5MLGenericAMOXICILLIN/CLAVULANATE POTASSIUMTABS 250MG; 125MG GenericAMOXICILLIN/CLAVULANATE POTASSIUMTABS 500MG; 125MG GenericAMOXICILLIN/CLAVULANATE POTASSIUMSUSR 250MG/5ML; 62.5MG/5MLGenericAMOXICILLIN/POTASSIUM CLAVULANATETABS 875MG; 125MG GenericAMOXIL CAPS 500MG GenericAMOXIL SUSR 250MG/5ML GenericAMOXIL SUSR 400MG/5ML Non-preferred BrandAMPICILLIN CAPS 250MG GenericAMPICILLIN CAPS 500MG GenericAMPICILLIN SUSR 125MG/5ML GenericAMPICILLIN SUSR 250MG/5ML GenericAMPICILLIN SODIUM SOLR 10GM GenericAMPICILLIN SODIUM SOLR 125MG Preferred BrandAMPICILLIN SODIUM SOLR 1GM GenericAMPICILLIN-SULBACTAM SOLR 10GM; 5GM GenericAMPICILLIN-SULBACTAM SOLR 2GM; 1GM GenericAUGMENTIN CHEW 250MG; 62.5MG Preferred BrandAUGMENTIN SUSR 125MG/5ML; 31.25MG/5MLPreferred Brand

AUGMENTIN SUSR 250MG/5ML; 62.5MG/5MLPreferred BrandAUGMENTIN SUSR 400MG/5ML; 57MG/5MLNon-preferred BrandAUGMENTIN TABS 250MG; 125MG Non-preferred BrandAUGMENTIN TABS 500MG; 125MG Non-preferred BrandAUGMENTIN TABS 875MG; 125MG Non-preferred BrandAUGMENTIN ES-600 SUSR 600MG/5ML; 42.9MG/5MLNon-preferred BrandAUGMENTIN XR TB12 1000MG; 62.5MGNon-preferred BrandBACTOCILL IN DEXTROSE SOLN 0; 1GM/50ML Non-preferred BrandBACTOCILL IN DEXTROSE SOLN 0; 2GM/50ML Non-preferred BrandBICILLIN C-R SUSP 300000UNIT/ML; 300000UNIT/MLPreferred BrandBICILLIN C-R SUSP 900000UNIT/ML; 300000UNIT/MLPreferred BrandBICILLIN L-A SUSP 1200000UNIT/2MLPreferred BrandBICILLIN L-A SUSP 2400000UNIT/4MLPreferred BrandBICILLIN L-A SUSP 600000UNIT/ML Preferred BrandDICLOXACILLIN SODIUM CAPS 250MG GenericDICLOXACILLIN SODIUM CAPS 500MG GenericMOXATAG TB24 775MG Non-preferred BrandNAFCILLIN SODIUM SOLR 10GM GenericNAFCILLIN SODIUM SOLR 1GM GenericNALLPEN/DEXTROSE SOLN 0; 1GM/50ML Preferred BrandNALLPEN/DEXTROSE SOLN 0; 2GM/50ML Preferred BrandOXACILLIN SODIUM SOLR 10GM Non-preferred Brand



OXACILLIN SODIUM SOLR 1GM Non-preferred BrandPENICILLIN G POTASSIUM SOLR 20MU GenericPENICILLIN G POTASSIUM SOLR 5MU GenericPENICILLIN G POTASSIUM IN ISO-OSMOTIC DEXTROSESOLN 0; 40000UNIT/MLNon-preferred BrandPENICILLIN G POTASSIUM IN ISO-OSMOTIC DEXTROSESOLN 0; 60000UNIT/MLNon-preferred BrandPENICILLIN G PROCAINE SUSP 600000UNIT/ML Preferred BrandPENICILLIN G SODIUM SOLR 5000000UNIT Non-preferred BrandPENICILLIN V POTASSIUM SOLR 125MG/5ML GenericPENICILLIN V POTASSIUM SOLR 250MG/5ML GenericPENICILLIN V POTASSIUM TABS 250MG GenericPENICILLIN V POTASSIUM TABS 500MG GenericPFIZERPEN-G SOLR 20MU GenericPFIZERPEN-G SOLR 5MU GenericPIPERACILLIN SODIUM SOLR 3GM Non-preferred BrandPIPERACILLIN SODIUM SOLR 40GM Non-preferred BrandTIMENTIN SOLR 0.1GM; 3GM Non-preferred BrandTRIMOX CAPS 500MG GenericUNASYN SOLR 2GM; 1GM Non-preferred BrandUNASYN BULK PACK SOLR 10GM; 5GM Non-preferred BrandVEETIDS SOLR 125MG/5ML GenericVEETIDS TABS 250MG GenericVEETIDS TABS 500MG GenericZOSYN SOLR 3GM; 0.375GM Preferred BrandZOSYN SOLN 5%; 2GM/50ML; 0.25GM/50MLPreferred BrandZOSYN SOLN 5%; 3GM/50ML; 0.375GM/50MLPreferred BrandANTI - INFECTIVES QUINOLONES

Drug NameDosage


QL

AmountQL Days

AVELOX SOLN 400MG/250ML; 0.8%Preferred BrandAVELOX TABS 400MG Preferred BrandAVELOX ABC PACK TABS 400MG Preferred BrandCIPRO TABS 250MG Non-preferred BrandCIPRO TABS 500MG Non-preferred BrandCIPRO TABS 750MG Non-preferred BrandCIPRO SUSR 500MG/5ML Preferred BrandCIPRO SUSR 5GM/100ML Preferred Brand

CIPRO I.V.-IN D5W SOLN 200MG; 5% Non-preferred BrandCIPROFLOXACIN SOLN 400MG GenericCIPROFLOXACIN ER TB24 1000MG; 0 GenericCIPROFLOXACIN EXTENDED-RELEASETB24 500MG; 0 GenericCIPROFLOXACIN HCL TABS 100MG GenericCIPROFLOXACIN HCL TABS 250MG GenericCIPROFLOXACIN HCL TABS 500MG GenericCIPROFLOXACIN HCL TABS 750MG GenericFACTIVE TABS 320MG Non-preferred BrandLEVAQUIN SOLN 25MG/ML Non-preferred BrandLEVAQUIN SOLN 25MG/ML Non-preferred BrandLEVAQUIN TABS 250MG Non-preferred BrandLEVAQUIN TABS 500MG Non-preferred BrandLEVAQUIN TABS 750MG Non-preferred BrandLEVAQUIN PREMIX SOLN 5%; 250MG/50MLNon-preferred BrandNOROXIN TABS 400MG Non-preferred BrandOFLOXACIN TABS 200MG GenericOFLOXACIN TABS 300MG GenericOFLOXACIN TABS 400MG GenericPROQUIN XR TB24 500MG Non-preferred BrandANTI - INFECTIVES SULFA'S AND RELATED AGENTS



Drug NameDosage


QL

AmountQL Days

BACTRIM TABS 400MG; 80MG Non-preferred BrandBACTRIM DS TABS 800MG; 160MG Non-preferred BrandGANTRISIN PEDIATRIC SUSP 500MG/5ML Non-preferred BrandSEPTRA TABS 400MG; 80MG Non-preferred BrandSEPTRA DS TABS 800MG; 160MG Non-preferred BrandSULFADIAZINE TABS 500MG GenericSULFAMETHOXAZOLE /TRIMETHOPRIMSOLN 400MG/5ML; 80MG/5MLGenericSULFAMETHOXAZOLE /TRIMETHOPRIMSUSP 200MG/5ML; 40MG/5MLGenericSULFAMETHOXAZOLE /TRIMETHOPRIMTABS 400MG; 80MG GenericSULFAMETHOXAZOLE/TRIMETHOPRIM DSTABS 800MG; 160MG GenericSULFATRIM SUSP 200MG/5ML; 40MG/5MLGenericANTI - INFECTIVES TETRACYCLINES

Drug NameDosage


QL

AmountQL Days

ADOXA TABS 100MG Non-preferred BrandADOXA TABS 50MG Non-preferred BrandADOXA PAK 1/100 TABS 100MG Non-preferred BrandADOXA PAK 1/150 TABS 150MG Non-preferred BrandADOXA PAK 1/75 TABS 75MG Non-preferred BrandADOXA PAK 2/100 TABS 100MG Non-preferred BrandDECLOMYCIN TABS 150MG Non-preferred BrandDECLOMYCIN TABS 300MG SpecialtyDEMECLOCYCLINE HCL TABS 150MG GenericDEMECLOCYCLINE HCL TABS 300MG GenericDORYX TBEC 100MG Non-preferred BrandDORYX TBEC 75MG Non-preferred BrandDORYX TBEC 150MG Non-preferred BrandDOXY-CAPS CAPS 100MG GenericDOXYCYCLINE HYCLATE CAPS 100MG GenericDOXYCYCLINE HYCLATE CAPS 50MG GenericDOXYCYCLINE HYCLATE CPEP 75MG Preferred BrandDOXYCYCLINE HYCLATE SOLR 100MG GenericDOXYCYCLINE HYCLATE TABS 100MG GenericDOXYCYCLINE HYCLATE TABS 20MG Generic

DOXYCYCLINE HYCLATE SOLR 100MG GenericDOXYCYCLINE MONOHYDRATE SUSR 25MG/5ML GenericDOXYCYCLINE MONOHYDRATE TABS 50MG GenericDOXYCYCLINE MONOHYDRATE TABS 75MG GenericDOXYCYCLINE MONOHYDRATE TABS 150MG GenericDYNACIN TABS 100MG Non-preferred BrandDYNACIN TABS 50MG Non-preferred BrandDYNACIN TABS 75MG Non-preferred BrandMINOCIN CAPS 100MG Non-preferred BrandMINOCIN CAPS 50MG Non-preferred BrandMINOCYCLINE HCL CAPS 100MG GenericMINOCYCLINE HCL CAPS 50MG GenericMINOCYCLINE HCL CAPS 75MG GenericMINOCYCLINE HCL TABS 100MG GenericMINOCYCLINE HCL TABS 50MG GenericMINOCYCLINE HCL TABS 75MG GenericMONODOX CAPS 100MG Non-preferred BrandMONODOX CAPS 50MG Non-preferred BrandMONODOX CAPS 75MG Non-preferred BrandMYRAC TABS 100MG GenericMYRAC TABS 50MG GenericMYRAC TABS 75MG Generic



ORACEA CPDR 40MG Non-preferred BrandPERIOSTAT TABS 20MG Non-preferred BrandSOLODYN TB24 135MG Non-preferred BrandSOLODYN TB24 45MG Non-preferred BrandSOLODYN TB24 90MG Non-preferred BrandTETRACYCLINE HCL CAPS 250MG GenericTETRACYCLINE HCL CAPS 500MG GenericVIBRAMYCIN CAPS 100MG Non-preferred BrandVIBRAMYCIN SUSR 25MG/5ML Non-preferred BrandVIBRAMYCIN SYRP 50MG/5ML Preferred BrandVIBRATAB TABS 100MG Non-preferred BrandANTI - INFECTIVES URINARY TRACT AGENTS

Drug NameDosage


QL

AmountQL Days

FURADANTIN SUSP 25MG/5ML Preferred BrandHIPREX TABS 1GM Non-preferred BrandMACROBID CAPS 100MG Non-preferred BrandMACRODANTIN CAPS 100MG Non-preferred BrandMACRODANTIN CAPS 25MG Preferred BrandMACRODANTIN CAPS 50MG Non-preferred BrandMETHENAMINE HIPPURATE TABS 1GM GenericMONUROL PACK 5.631GM Non-preferred BrandNITROFURANTOIN MACROCRYSTALLINECAPS 50MG GenericNITROFURANTOIN MONOHYDRATE CAPS 100MG GenericPRIMSOL SOLN 50MG/5ML Non-preferred BrandTRIMETHOPRIM TABS 100MG GenericUREX TABS 1GM Non-preferred BrandANTI - INFECTIVES VANCOMYCIN

Drug NameDosage


QL

AmountQL Days

VANCOCIN HCL CAPS 125MG SpecialtyVANCOCIN HCL CAPS 250MG SpecialtyVANCOMYCIN HCL SOLR 1000MG GenericVANCOMYCIN HCL SOLR 10GM Preferred BrandVANCOMYCIN HCL ISO-OSMOTIC DEXTROSESOLN 0; 1GM/200ML Non-preferred BrandANTINEOPLASTIC AND

IMMUNOSUPPRESSANT DRUGSADJUNCTIVE AGENTS

Drug NameDosage


QL

AmountQL Days

AMIFOSTINE SOLR 500MG GenericDEXRAZOXANE SOLR 500MG GenericELITEK SOLR 1.5MG SpecialtyETHYOL SOLR 500MG Non-preferred BrandFUSILEV SOLR 50MG Non-preferred BrandLEUCOVORIN CALCIUM SOLR 100MG GenericLEUCOVORIN CALCIUM SOLR 350MG GenericLEUCOVORIN CALCIUM TABS 10MG Preferred BrandLEUCOVORIN CALCIUM TABS 15MG Preferred BrandLEUCOVORIN CALCIUM TABS 25MG GenericLEUCOVORIN CALCIUM TABS 5MG GenericMESNA SOLN 100MG/ML GenericMESNEX SOLN 100MG/ML SpecialtyMESNEX TABS 400MG SpecialtyZINECARD SOLR 500MG Non-preferred BrandANTINEOPLASTIC AND

IMMUNOSUPPRESSANT DRUGSANTINEOPLASTIC AND IMMUNOSUPPRESSANT DRUGS

Drug NameDosage


QL

AmountQL Days



ABRAXANE SUSR 100MG Non-preferred BrandADRIAMYCIN SOLN 2MG/ML GenericAFINITOR TABLET 10MG Specialty PAAFINITOR TABLET 5MG Specialty PAALKERAN SOLR 50MG Non-preferred BrandARIMIDEX TABS 1MG Preferred BrandAROMASIN TABS 25MG Non-preferred BrandARRANON SOLN 5MG/ML Non-preferred BrandARZERRA SOLN 10MG/ml Specialty PA- BvDAZASAN TABS 100MG Non-preferred Brand PA- BvDAZASAN TABS 75MG Non-preferred Brand PA- BvDAZATHIOPRINE TABS 50MG Generic PA- BvDAZATHIOPRINE SODIUM SOLR 100MG Generic PA- BvDBICALUTAMIDE TABS 50 MG Generic

BICNU SOLR 100MG Non-preferred BrandBLEOMYCIN SULFATE SOLR 30UNIT GenericBUSULFEX SOLN 6MG/ML Non-preferred BrandCAMPATH SOLN 30MG/ML Non-preferred BrandCAMPTOSAR SOLN 20MG/ML Non-preferred BrandCARBOPLATIN SOLN 150MG/15ML GenericCASODEX TABS 50MG Non-preferred BrandCEENU CAPS 100MG Preferred BrandCEENU CAPS 10MG Preferred BrandCEENU CAPS 40MG Preferred BrandCELLCEPT CAPS 250MG Preferred Brand PA- BvDCELLCEPT SUSR 200MG/ML Preferred Brand PA- BvDCELLCEPT TABS 500MG Preferred Brand PA- BvDCELLCEPT INTRAVENOUS SOLR 500MG Non-preferred Brand PA- BvDCERUBIDINE SOLR 20MG Non-preferred BrandCISPLATIN SOLN 100MG/100ML GenericCLADRIBINE SOLN 1MG/ML GenericCOSMEGEN SOLR 0.5MG Non-preferred BrandCYCLOPHOSPHAMIDE TABS 25MG GenericCYCLOPHOSPHAMIDE TABS 50MG GenericCYCLOPHOSPHAMIDE SOLR 1GM GenericCYCLOPHOSPHAMIDE SOLR 500MG Generic

CYCLOSPORINE CAPS 100MG Generic PA- BvDCYCLOSPORINE CAPS 25MG Generic PA- BvDCYCLOSPORINE SOLN 50MG/ML Generic PA- BvDCYCLOSPORINE MODIFIED CAPS 50MG Preferred Brand PA- BvDCYCLOSPORINE MODIFIED SOLN 100MG/ML Generic PA- BvDCYCLOSPORINE MODIFIED CAPS 100MG Generic PA- BvDCYTARABINE SOLR 500MG GenericCYTARABINE AQUEOUS SOLN 100MG/ML Non-preferred BrandCYTARABINE AQUEOUS SOLN 20MG/ML GenericCYTOXAN SOLR 2GM Non-preferred BrandDACARBAZINE SOLR 200MG GenericDACOGEN SOLR 50MG Non-preferred BrandDAUNORUBICIN HCL INJ 5MG/ML Non-preferred BrandDAUNOXOME INJ 2MG/ML Non-preferred BrandDOXIL INJ 2MG/ML Non-preferred BrandDOXORUBICIN HCL SOLR 50MG GenericDROXIA CAPS 200MG Non-preferred BrandDROXIA CAPS 300MG Non-preferred BrandDROXIA CAPS 400MG Non-preferred BrandELIGARD KIT 22.5MG Non-preferred BrandELIGARD KIT 30MG Non-preferred BrandELIGARD KIT 45MG Non-preferred Brand



ELIGARD KIT 7.5MG Non-preferred BrandELLENCE SOLN 2MG/ML Non-preferred BrandELOXATIN SOLN 100MG/20ML Non-preferred BrandELSPAR SOLR 10000UNIT Non-preferred BrandEMCYT CAPS 140MG Preferred BrandEPIRUBICIN HCL SOLN 50MG/25ML GenericETOPOPHOS SOLR 100MG Non-preferred BrandETOPOSIDE SOLN 20MG/ML GenericFARESTON TABS 60MG Preferred BrandFASLODEX SOLN 125MG/2.5ML SpecialtyFASLODEX SOLN 250MG/5ML SpecialtyFEMARA TABS 2.5MG Preferred BrandFIRMAGON SOLR 80MG Non-preferred BrandFIRMAGON SOLR 120MG SpecialtyFLUDARA SOLR 50MG Non-preferred BrandFLUDARABINE PHOSPHATE SOLN 50MG/2ML Non-preferred BrandFLUOROURACIL SOLN 500MG/10ML GenericFLUTAMIDE CAPS 125MG GenericGEMZAR SOLR 1GM Non-preferred BrandGENGRAF CAPS 100MG Generic PA- BvDGENGRAF CAPS 25MG Generic PA- BvDGENGRAF SOLN 100MG/ML Generic PA- BvDGLEEVEC TABS 100MG Specialty PAGLEEVEC TABS 400MG Specialty PAHEXALEN CAPS 50MG Preferred BrandHYCAMTIN SOLR 4MG Non-preferred BrandHYDREA CAPS 500MG Non-preferred BrandHYDROXYUREA CAPS 500MG GenericIDAMYCIN PFS SOLN 1MG/ML Non-preferred BrandIDARUBICIN HCL SOLN 10MG/10ML GenericIFEX SOLR 1GM Non-preferred BrandIFOSFAMIDE SOLR 1GM Non-preferred BrandIFOSFAMIDE/MESNA KIT 3000MG; 1000MGNon-preferred BrandIFOSFAMIDE/MESNA KIT 1GM; 1GM GenericIMURAN TABS 50MG Non-preferred Brand PA- BvDIRESSA TABS 250MG Specialty PA

IRINOTECAN SOLN 100MG/5ML GenericISTODAX SOLN 5MG/ML Specialty PA- BvDLEUKERAN TABS 2MG Preferred BrandLEUPROLIDE ACETATE KIT 1MG/0.2ML GenericLEUSTATIN SOLN 1MG/ML Non-preferred BrandLUPRON 2 WEEK SUPPLY KIT 5MG/ML SpecialtyLUPRON DEPOT KIT 11.25MG Preferred BrandLUPRON DEPOT KIT 3.75MG Preferred BrandLUPRON DEPOT KIT 22.5MG SpecialtyLUPRON DEPOT KIT 30MG SpecialtyLUPRON DEPOT KIT 7.5MG SpecialtyLUPRON DEPOT-PED KIT 11.25MG SpecialtyLUPRON DEPOT-PED KIT 15MG SpecialtyLYSODREN TABS 500MG Preferred BrandMATULANE CAPS 50MG SpecialtyMEGACE ES SUSP 625MG/5ML Non-preferred Brand PA- BvDMEGACE ORAL SUSP 40MG/ML Non-preferred Brand PA- BvDMEGESTROL ACETATE SUSP 40MG/ML Generic PA- BvDMEGESTROL ACETATE TABS 20MG GenericMEGESTROL ACETATE TABS 40MG GenericMERCAPTOPURINE TABS 50MG GenericMETHOTREXATE TABS 2.5MG Generic PA- BvD



METHOTREXATE SODIUM SOLR 1GM Non-preferred Brand PA- BvDMETHOTREXATE SODIUM SOLN 25MG/ML Generic PA- BvDMITOMYCIN SOLR 20MG GenericMITOXANTRONE HCL CONC 2MG/ML GenericMUSTARGEN SOLR 10MG Non-preferred BrandMYCOPHENOLATE MOFETIL 250 MG Generic PA- BvDMYCOPHENOLATE MOFETIL 500 MG Generic PA- BvDMYFORTIC TBEC 180MG Preferred Brand PA- BvDMYFORTIC TBEC 360MG Preferred Brand PA- BvDMYLOTARG SOLR 5MG Non-preferred BrandNAVELBINE SOLN 50MG/5ML Non-preferred BrandNEORAL CAPS 100MG Preferred Brand PA- BvDNEORAL CAPS 25MG Preferred Brand PA- BvDNEORAL SOLN 100MG/ML Preferred Brand PA- BvDNEXAVAR TABS 200MG Specialty PANILANDRON TABS 150MG Preferred BrandNIPENT SOLR 10MG Non-preferred BrandNOVANTRONE CONC 2MG/ML SpecialtyOCTREOTIDE ACETATE SOLN 1000MCG/ML SpecialtyOCTREOTIDE ACETATE SOLN 100MCG/ML SpecialtyOCTREOTIDE ACETATE SOLN 200MCG/ML SpecialtyOCTREOTIDE ACETATE SOLN 500MCG/ML SpecialtyOCTREOTIDE ACETATE SOLN 50MCG/ML GenericONCASPAR SOLN 750UNIT/ML Non-preferred BrandONTAK SOLN 150MCG/ML Non-preferred BrandONXOL CONC 30MG/5ML GenericORTHOCLONE OKT3 INJ 1MG/ML Non-preferred BrandPACLITAXEL CONC 100MG/16.7ML GenericPENTOSTATIN SOLR 10MG GenericPHOTOFRIN SOLR 75MG Non-preferred BrandPLATINOL AQ SOLN 1MG/ML Non-preferred BrandPROGRAF CAPS 0.5MG Preferred Brand PA- BvDPROGRAF CAPS 1MG Preferred Brand PA- BvDPROGRAF CAPS 5MG Specialty PA- BvDPROGRAF SOLN 5MG/ML Preferred Brand PA- BvDPURINETHOL TABS 50MG Non-preferred Brand

RAPAMUNE SOLN 1MG/ML Preferred Brand PA- BvDRAPAMUNE TABS 1MG Preferred Brand PA- BvDRAPAMUNE TABS 2MG Preferred Brand PA- BvDREVLIMID CAPS 10MG Specialty PAREVLIMID CAPS 15MG Specialty PAREVLIMID CAPS 25MG Specialty PAREVLIMID CAPS 5MG Specialty PARHEUMATREX TABS 2.5MG Preferred Brand PA- BvDRITUXAN CONC 10MG/ML Specialty PA- BvDSANDIMMUNE CAPS 100MG Preferred Brand PA- BvDSANDIMMUNE CAPS 25MG Preferred Brand PA- BvDSANDIMMUNE SOLN 50MG/ML Preferred Brand PA- BvDSANDIMMUNE SOLN 100MG/ML Preferred Brand PA- BvDSANDOSTATIN SOLN 1000MCG/ML SpecialtySANDOSTATIN SOLN 100MCG/ML SpecialtySANDOSTATIN SOLN 200MCG/ML SpecialtySANDOSTATIN SOLN 500MCG/ML SpecialtySANDOSTATIN SOLN 50MCG/ML SpecialtySANDOSTATIN LAR DEPOT KIT 10MG SpecialtySANDOSTATIN LAR DEPOT KIT 20MG SpecialtySANDOSTATIN LAR DEPOT KIT 30MG SpecialtySIMULECT SOLR 20MG Non-preferred Brand PA- BvD



SOMATULINE DEPOT SOLN 120MG/0.5ML SpecialtySOMATULINE DEPOT SOLN 90MG/0.3ML SpecialtySPRYCEL TABS 20MG Specialty PASPRYCEL TABS 50MG Specialty PASPRYCEL TABS 70MG Specialty PASPRYCEL TAB 100MG Specialty PASUTENT CAPS 12.5MG Specialty PASUTENT CAPS 25MG Specialty PASUTENT CAPS 50MG Specialty PATABLOID TABS 40MG Preferred BrandTAMOXIFEN CITRATE TABS 10MG GenericTAMOXIFEN CITRATE TABS 20MG GenericTARCEVA TABS 100MG Specialty PATARCEVA TABS 150MG Specialty PATARCEVA TABS 25MG Specialty PATARGRETIN CAPS 75MG SpecialtyTARGRETIN GEL 1% SpecialtyTASIGNA CAPS 200MG Specialty PATAXOTERE CONC 80MG/2ML Non-preferred BrandTHIOTEPA SOLR 15MG GenericTOPOSAR SOLN 20MG/ML GenericTREANDA SOLR 100MG Non-preferred Brand PA- BvDTRELSTAR DEPOT SUSR 3.75MG Non-preferred BrandTRELSTAR LA SUSR 11.25MG Non-preferred BrandTREXALL TABS 10MG Preferred Brand PA- BvDTREXALL TABS 15MG Preferred Brand PA- BvDTREXALL TABS 5MG Preferred Brand PA- BvDTREXALL TABS 7.5MG Preferred Brand PA- BvDTRISENOX SOLN 10MG/10ML Non-preferred BrandTYKERB TABS 250MG Specialty PAVECTIBIX SOLN 200MG/10ML Non-preferred BrandVELCADE SOLR 3.5MG Specialty PA- BvDVESANOID CAPS 10MG SpecialtyVIDAZA SUSR 100MG SpecialtyVINBLASTINE SULFATE SOLR 10MG GenericVINCASAR PFS SOLN 1MG/ML Generic

VINCRISTINE SULFATE SOLN 1MG/ML GenericVINORELBINE TARTRATE SOLN 10MG/ML GenericVOTRIENT TABLET 200 MG Specialty PAZANOSAR SOLR 1GM Non-preferred BrandZENAPAX CONC 25MG/5ML Non-preferred Brand PA- BvDZOLINZA CAPS 100MG Specialty PAAUTONOMIC AND CNS DRUGS -

NEUROLOGY AND PSYCHANTICONVULSANTS

Drug NameDosage


QL

AmountQL Days

BANZEL TABS 200MG Non-preferred BrandBANZEL TABS 400MG Non-preferred BrandCARBAMAZEPINE CHEW 100MG GenericCARBAMAZEPINE SUSP 100MG/5ML GenericCARBAMAZEPINE TABS 200MG GenericCARBAMAZEPINE ER TB12 200 MG GenericCARBAMAZEPINE ER TB12 400 MG GenericCARBATROL CP12 100MG Non-preferred BrandCARBATROL CP12 200MG Non-preferred BrandCARBATROL CP12 300MG Non-preferred BrandCELONTIN CAPS 300MG Preferred BrandCEREBYX SOLN 500MG PE/10MLNon-preferred Brand



DEPACON SOLN 100MG/ML Non-preferred BrandDEPAKENE CAPS 250MG Non-preferred BrandDEPAKENE SYRP 250MG/5ML Non-preferred BrandDEPAKOTE TBEC 125MG Non-preferred BrandDEPAKOTE TBEC 250MG Non-preferred BrandDEPAKOTE TBEC 500MG Non-preferred BrandDEPAKOTE ER TB24 250MG Non-preferred BrandDEPAKOTE ER TB24 500MG Non-preferred BrandDEPAKOTE SPRINKLES CPSP 125MG Non-preferred BrandDILANTIN CAPS 100MG Non-preferred BrandDILANTIN CAPS 30MG Preferred BrandDILANTIN SUSP 125MG/5ML Non-preferred BrandDILANTIN INFATABS CHEW 50MG Preferred BrandDIVALPROEX SODIUM CPSP 125MG GenericDIVALPROEX SODIUM TBEC 125MG GenericDIVALPROEX SODIUM TBEC 250MG GenericDIVALPROEX SODIUM TB24 250MG GenericDIVALPROEX SODIUM TBEC 500MG GenericDIVALPROEX SODIUM TB24 500MG GenericEPITOL TABS 200MG GenericEQUETRO CP12 100MG Non-preferred BrandEQUETRO CP12 200MG Non-preferred BrandEQUETRO CP12 300MG Non-preferred BrandETHOSUXIMIDE CAPS 250MG GenericETHOSUXIMIDE SOLN 250MG/5ML GenericFELBATOL SUSP 600MG/5ML Preferred BrandFELBATOL TABS 400MG Preferred BrandFELBATOL TABS 600MG Preferred BrandFOSPHENYTOIN SODIUM SOLN 100MG PE/2ML GenericGABAPENTIN CAPS 100MG GenericGABAPENTIN CAPS 300MG GenericGABAPENTIN CAPS 400MG GenericGABAPENTIN TABS 600MG GenericGABAPENTIN TABS 800MG GenericGABITRIL TABS 12MG Preferred BrandGABITRIL TABS 16MG Preferred Brand

GABITRIL TABS 2MG Preferred BrandGABITRIL TABS 4MG Preferred BrandKEPPRA SOLN 500MG/5ML Non-preferred BrandKEPPRA SOLN 100MG/ML Preferred BrandKEPPRA TABS 1000MG Non-preferred BrandKEPPRA TABS 250MG Non-preferred BrandKEPPRA TABS 500MG Non-preferred BrandKEPPRA TABS 750MG Non-preferred BrandKEPPRA XR TB24 500MG Non-preferred BrandKEPPRA XR TB24 750MG Non-preferred BrandLAMICTAL TABS 100MG Non-preferred BrandLAMICTAL TABS 150MG Non-preferred BrandLAMICTAL TABS 200MG Non-preferred BrandLAMICTAL TABS 25MG Non-preferred BrandLAMICTAL CHEWABLE DISPERSIBLE TBDP 25MG Non-preferred BrandLAMICTAL CHEWABLE DISPERSIBLE TBDP 5MG Non-preferred BrandLAMICTAL ODT TBDP 100MG Non-preferred BrandLAMICTAL ODT TBDP 200MG Non-preferred BrandLAMICTAL ODT TBDP 25MG Non-preferred BrandLAMICTAL ODT TBDP 50MG Non-preferred BrandLAMICTAL STARTER/NOT TAKING CARBAMAZEPINEKIT 0 Non-preferred BrandLAMICTAL STARTER/TAKING CARBAMAZEPINE/NOT TAKING VALPROATEKIT 0 Non-preferred Brand



LAMICTAL STARTER/TAKING VALPROATEKIT 25MG Non-preferred BrandLAMICTAL XR TB24 100 MG Non-preferred BrandLAMICTAL XR TB24 200 MG Non-preferred BrandLAMICTAL XR TB24 25 MG Non-preferred BrandLAMICTAL XR TB24 50 MG Non-preferred BrandLAMOTRIGINE TABS 100MG GenericLAMOTRIGINE TABS 150MG GenericLAMOTRIGINE TABS 200MG GenericLAMOTRIGINE TABS 25MG GenericLAMOTRIGINE TBDP 25MG GenericLAMOTRIGINE TBDP 5MG GenericLEVETIRACETAM SOLN 100MG/ML GenericLEVETIRACETAM TABS 1000MG GenericLEVETIRACETAM TABS 250MG GenericLEVETIRACETAM TABS 500MG GenericLEVETIRACETAM TABS 750MG GenericLYRICA CAPS 100MG Non-preferred Brand PALYRICA CAPS 150MG Non-preferred Brand PALYRICA CAPS 200MG Non-preferred Brand PALYRICA CAPS 225MG Non-preferred Brand PALYRICA CAPS 25MG Non-preferred Brand PALYRICA CAPS 300MG Non-preferred Brand PALYRICA CAPS 50MG Non-preferred Brand PALYRICA CAPS 75MG Non-preferred Brand PAMYSOLINE TABS 250MG Non-preferred BrandMYSOLINE TABS 50MG Non-preferred BrandNEURONTIN CAPS 100MG Non-preferred BrandNEURONTIN CAPS 300MG Non-preferred BrandNEURONTIN CAPS 400MG Non-preferred BrandNEURONTIN SOLN 250MG/5ML Preferred BrandNEURONTIN TABS 600MG Non-preferred BrandNEURONTIN TABS 800MG Non-preferred BrandOXCARBAZEPINE TABS 150MG GenericOXCARBAZEPINE TABS 300MG GenericOXCARBAZEPINE TABS 600MG GenericPEGANONE TABS 250MG Preferred Brand

PHENYTEK CAPS 200MG Preferred BrandPHENYTEK CAPS 300MG Preferred BrandPHENYTOIN SUSP 125MG/5ML GenericPHENYTOIN SODIUM SOLN 50MG/ML Preferred BrandPHENYTOIN SODIUM EXTENDED CAPS 100MG GenericPRIMIDONE TABS 250MG GenericPRIMIDONE TABS 50MG GenericSABRIL SOL 50MG/ML Specialty

SABRIL TABLET 50MG/ML Specialty

STAVZOR CPDR 125MG Non-preferred BrandSTAVZOR CPDR 250MG Non-preferred BrandSTAVZOR CPDR 500MG Non-preferred BrandTEGRETOL CHEW 100MG Non-preferred BrandTEGRETOL SUSP 100MG/5ML Non-preferred BrandTEGRETOL TABS 200MG Preferred BrandTEGRETOL-XR TB12 100MG Preferred BrandTEGRETOL-XR TB12 200MG Non-preferred BrandTEGRETOL-XR TB12 400MG Non-preferred BrandTOPAMAX TABS 100MG Non-preferred BrandTOPAMAX TABS 200MG Non-preferred BrandTOPAMAX TABS 25MG Non-preferred BrandTOPAMAX TABS 50MG Non-preferred Brand



TOPAMAX SPRINKLE CPSP 15MG Non-preferred BrandTOPAMAX SPRINKLE CPSP 25MG Non-preferred BrandTOPIRAMATE TABLET 100MG GenericTOPIRAMATE CAPS 15MG GenericTOPIRAMATE TABLET 200MG GenericTOPIRAMATE CAPS 25MG GenericTOPIRAMATE TABLET 25MG GenericTOPIRAMATE TABLET 50MG GenericTRILEPTAL SUSP 300MG/5ML Non-preferred BrandTRILEPTAL TABS 150MG Non-preferred BrandTRILEPTAL TABS 300MG Non-preferred BrandTRILEPTAL TABS 600MG Non-preferred BrandVALPROATE SODIUM SOLN 100MG/ML GenericVALPROIC ACID CAPS 250MG GenericVALPROIC ACID SYRP 250MG/5ML GenericVIMPAT TABS 100MG Non-preferred BrandVIMPAT TABS 150MG Non-preferred BrandVIMPAT TABS 200MG Non-preferred BrandVIMPAT TABS 50MG Non-preferred BrandVIMPAT 200 MG/20MLSOLN Non-preferred BrandZARONTIN CAPS 250MG Non-preferred BrandZARONTIN SOLN 250MG/5ML Non-preferred BrandZONEGRAN CAPS 100MG Non-preferred BrandZONEGRAN CAPS 25MG Non-preferred BrandZONISAMIDE CAPS 100MG GenericZONISAMIDE CAPS 25MG GenericZONISAMIDE CAPS 50MG GenericAUTONOMIC AND CNS DRUGS -

NEUROLOGY AND PSYCHANTIPARKINSONISM AGENTS

Drug NameDosage


QL

AmountQL Days

APOKYN SOLN 10MG/ML SpecialtyATAMET TABS 25MG; 250MG Non-preferred BrandAZILECT TABS 0.5MG Non-preferred BrandAZILECT TABS 1MG Non-preferred BrandBENZTROPINE MESYLATE TABS 0.5MG Generic

BENZTROPINE MESYLATE TABS 1MG GenericBENZTROPINE MESYLATE TABS 2MG GenericBENZTROPINE MESYLATE SOLN 1MG/ML Non-preferred BrandBROMOCRIPTINE MESYLATE CAPS 5MG GenericBROMOCRIPTINE MESYLATE TABS 2.5MG GenericCARBIDOPA/LEVODOPA TABS 10MG; 100MG GenericCARBIDOPA/LEVODOPA TABS 25MG; 100MG GenericCARBIDOPA/LEVODOPA TABS 25MG; 250MG GenericCARBIDOPA/LEVODOPA CR TBCR 25MG; 100MG GenericCARBIDOPA/LEVODOPA ODT TBDP 10MG; 100MG GenericCARBIDOPA/LEVODOPA ODT TBDP 25MG; 100MG GenericCARBIDOPA/LEVODOPA ODT TBDP 25MG; 250MG GenericCARBIDOPA/LEVODOPA SR TBCR 50MG; 200MG GenericCOGENTIN SOLN 1MG/ML Non-preferred BrandCOMTAN TABS 200MG Non-preferred BrandELDEPRYL CAPS 5MG Non-preferred BrandLODOSYN TABS 25MG Non-preferred BrandMIRAPEX TABS 0.125MG Preferred BrandMIRAPEX TABS 0.25MG Preferred BrandMIRAPEX TABS 0.5MG Preferred BrandMIRAPEX TABS 0.75MG Preferred BrandMIRAPEX TABS 1.5MG Preferred Brand



MIRAPEX TABS 1MG Preferred BrandMIRAPEX ER TABS 0.375 MG Non-preferred BrandMIRAPEX ER TABS 0.75 MG Non-preferred BrandMIRAPEX ER TABS 1.5 MG Non-preferred BrandMIRAPEX ER TABS 3.0 MG Non-preferred BrandMIRAPEX ER TABS 4.5 MG Non-preferred BrandPARCOPA TBDP 10MG; 100MG Non-preferred BrandPARCOPA TBDP 25MG; 100MG Non-preferred BrandPARCOPA TBDP 25MG; 250MG Non-preferred BrandPARLODEL CAPS 5MG Non-preferred BrandPARLODEL TABS 2.5MG Non-preferred BrandREQUIP TABS 0.25MG Non-preferred BrandREQUIP TABS 0.5MG Non-preferred BrandREQUIP TABS 1MG Non-preferred BrandREQUIP TABS 2MG Non-preferred BrandREQUIP TABS 3MG Non-preferred BrandREQUIP TABS 4MG Non-preferred BrandREQUIP TABS 5MG Non-preferred BrandREQUIP XL TB24 12MG Non-preferred BrandREQUIP XL TB24 2MG Non-preferred BrandREQUIP XL TB24 4MG Non-preferred BrandREQUIP XL TB24 8MG Non-preferred BrandREQUIP XL TB24 6 MG Non-preferred BrandROPINIROLE HCL TABS 0.25MG GenericROPINIROLE HCL TABS 0.5MG GenericROPINIROLE HCL TABS 1MG GenericROPINIROLE HCL TABS 2MG GenericROPINIROLE HCL TABS 3MG GenericROPINIROLE HCL TABS 4MG GenericROPINIROLE HCL TABS 5MG GenericSELEGILINE HCL CAPS 5MG GenericSELEGILINE HCL TABS 5MG GenericSINEMET TABS 10MG; 100MG Non-preferred BrandSINEMET TABS 25MG; 100MG Non-preferred BrandSINEMET TABS 25MG; 250MG Non-preferred BrandSINEMET CR TBCR 25MG; 100MG Non-preferred Brand

SINEMET CR TBCR 50MG; 200MG Non-preferred BrandSTALEVO 100 TABS 25MG; 200MG; 100MGNon-preferred BrandSTALEVO 125 TABS 31.25MG; 200MG; 125MGNon-preferred BrandSTALEVO 150 TABS 37.5MG; 200MG; 150MGNon-preferred BrandSTALEVO 200 TABS 50MG; 200MG; 200MGNon-preferred BrandSTALEVO 50 TABS 12.5MG; 200MG; 50MGNon-preferred BrandSTALEVO 75 TABS 18.75MG; 200MG; 75MGNon-preferred BrandTASMAR TABS 100MG Non-preferred BrandTASMAR TABS 200MG Non-preferred BrandTRIHEXYPHENIDYL HCL ELIX 0.4MG/ML GenericTRIHEXYPHENIDYL HCL TABS 2MG GenericTRIHEXYPHENIDYL HCL TABS 5MG GenericZELAPAR TBDP 1.25MG Non-preferred BrandAUTONOMIC AND CNS DRUGS -

NEUROLOGY AND PSYCHMIGRAINE AND CLUSTER HEADACHE THERAPY

Drug NameDosage


QL

AmountQL Days

AMERGE TABS 1MG Preferred Brand QL 8 25AMERGE TABS 2.5MG Preferred Brand QL 8 25AXERT TABS 12.5MG Preferred Brand QL 8 25AXERT TABS 6.25MG Preferred Brand QL 8 25CAFERGOT TABS 100MG; 1MG Preferred Brand



D.H.E. 45 SOLN 1MG/ML SpecialtyDIHYDROERGOTAMINE MESYLATE SOLN 1MG/ML GenericERGOMAR SUBL 2MG Preferred BrandERGOTAMINE TARTRATE/CAFFEINE TABS 100MG; 1MG GenericFROVA TABS 2.5MG Non-preferred Brand QL 12 25IMITREX SOLN 6MG/0.5ML Preferred Brand QL 9 25IMITREX SOLN 20MG/ACT Preferred Brand QL 9 25IMITREX SOLN 5MG/ACT Preferred Brand QL 9 25IMITREX TABS 100MG Non-preferred Brand QL 9 25IMITREX TABS 25MG Non-preferred Brand QL 9 25IMITREX TABS 50MG Non-preferred Brand QL 9 25IMITREX STATDOSE REFILL KIT 4MG/0.5ML Non-preferred Brand QL 12 25IMITREX STATDOSE REFILL KIT 6MG/0.5ML Non-preferred Brand QL 12 25MAXALT TABS 10MG Preferred Brand QL 12 25MAXALT TABS 5MG Preferred Brand QL 12 25MAXALT-MLT TBDP 10MG Preferred Brand QL 12 25MAXALT-MLT TBDP 5MG Preferred Brand QL 12 25MIGERGOT SUPP 100MG; 2MG GenericMIGRANAL SOLN 4MG/ML Preferred Brand QL 8 25RELPAX TABS 20MG Preferred Brand QL 6 25RELPAX TABS 40MG Preferred Brand QL 6 25SUMATRIPTAN SUCCINATE VIAL (SDV,MDV OR ADDITIVE) (ML)4MG/0.5ML Generic QL 12 25SUMATRIPTAN SUCCINATE SOLN 6MG/0.5ML Generic QL 9 25SUMATRIPTAN SUCCINATE TABS 100MG Generic QL 9 25SUMATRIPTAN SUCCINATE TABS 25MG Generic QL 9 25SUMATRIPTAN SUCCINATE TABS 50MG Generic QL 9 25SUMAVEL DOSEPRO PREFILL12MG/ML Non-preferred Brand QL 12 25

TREXIMET TABS 500MG; 85MG Non-preferred Brand QL 9 25ZOMIG SOLN 5MG Preferred Brand QL 8 25ZOMIG TABS 2.5MG Preferred Brand QL 8 25ZOMIG TABS 5MG Preferred Brand QL 8 25ZOMIG ZMT TBDP 2.5MG Preferred Brand QL 8 25ZOMIG ZMT TBDP 5MG Preferred Brand QL 8 25AUTONOMIC AND CNS DRUGS -

NEUROLOGY AND PSYCHMISCELLANEOUS NEUROLOGICAL THERAPY

Drug NameDosage


QL

AmountQL Days

AMPYRA TABS 10MG Specialty PAARICEPT TABS 10MG Preferred BrandARICEPT TABS 5MG Preferred BrandARICEPT ODT TBDP 10MG Preferred BrandARICEPT ODT TBDP 5MG Preferred BrandCOGNEX CAPS 10MG Non-preferred BrandCOGNEX CAPS 20MG Non-preferred BrandCOGNEX CAPS 30MG Non-preferred BrandCOGNEX CAPS 40MG Non-preferred BrandCOPAXONE KIT 20MG/ML SpecialtyEXELON CAPS 1.5MG Preferred BrandEXELON CAPS 3MG Preferred BrandEXELON CAPS 4.5MG Preferred BrandEXELON CAPS 6MG Preferred BrandEXELON PT24 4.6MG/24HR Preferred BrandEXELON PT24 9.5MG/24HR Preferred BrandEXELON SOLN 2MG/ML Preferred BrandEXTAVIA INJECTION0.25MG/ML Specialty

GALANTAMINE HYDROBROMIDE CP24 16MG GenericGALANTAMINE HYDROBROMIDE CP24 24MG GenericGALANTAMINE HYDROBROMIDE CP24 8MG Generic



GALANTAMINE HYDROBROMIDE TABS 12MG GenericGALANTAMINE HYDROBROMIDE TABS 4MG GenericGALANTAMINE HYDROBROMIDE TABS 8MG GenericGALANTAMINE HYDROBROMIDE SOLN 4MG/ML GenericMYTELASE TABS 10MG Non-preferred BrandNAMENDA SOLN 10MG/5ML Preferred BrandNAMENDA TABS 10MG Preferred BrandNAMENDA TABS 5MG Preferred BrandNAMENDA TITRATION PAK TABS 0 Preferred BrandRAZADYNE SOLN 4MG/ML Non-preferred BrandRAZADYNE TABS 12MG Non-preferred BrandRAZADYNE TABS 4MG Non-preferred BrandRAZADYNE TABS 8MG Non-preferred BrandRAZADYNE ER CP24 16MG Non-preferred BrandRAZADYNE ER CP24 24MG Non-preferred BrandRAZADYNE ER CP24 8MG Non-preferred BrandXENAZINE TABS 12.5MG Specialty PAXENAZINE TABS 25MG Specialty PAAUTONOMIC AND CNS DRUGS -

NEUROLOGY AND PSYCHMUSCLE RELAXANTS AND ANTISPASMODIC THERAPY

Drug NameDosage


QL

AmountQL Days

BACLOFEN TABS 10MG GenericBACLOFEN TABS 20MG GenericCARISOPRODOL TABS 350MG GenericCARISOPRODOL /ASPIRIN /CODEINE TABS 325MG; 200MG; 16MGGenericCARISOPRODOL/ASPIRIN TABS 325MG; 200MG GenericCHLORZOXAZONE TABS 250MG GenericCHLORZOXAZONE TABS 500MG GenericCYCLOBENZAPRINE HCL TABS 10MG GenericCYCLOBENZAPRINE HCL TABS 5MG GenericDANTRIUM CAPS 100MG Non-preferred BrandDANTRIUM CAPS 25MG Non-preferred BrandDANTRIUM CAPS 50MG Non-preferred BrandDANTROLENE SODIUM CAPS 100MG GenericDANTROLENE SODIUM CAPS 25MG Generic

DANTROLENE SODIUM CAPS 50MG GenericFEXMID TABS 7.5MG Non-preferred BrandFLEXERIL TABS 10MG Non-preferred BrandFLEXERIL TABS 5MG Non-preferred BrandMEPROBAMATE TABS 200MG GenericMEPROBAMATE TABS 400MG GenericMESTINON SYRP 60MG/5ML Preferred BrandMESTINON TABS 60MG Non-preferred BrandMESTINON TIMESPAN TBCR 180MG Preferred BrandMETHOCARBAMOL TABS 500MG GenericMETHOCARBAMOL TABS 750MG GenericNORFLEX SOLN 30MG/ML Non-preferred BrandORPHENADRINE /ASA /CAFFEINE TABS 385MG; 30MG; 25MGGenericORPHENADRINE CITRATE SOLN 30MG/ML GenericORPHENADRINE CITRATE ER TB12 100MG GenericORPHENADRINE COMPOUND DS TABS 770MG; 60MG; 50MGGenericPARAFON FORTE DSC TABS 500MG Non-preferred BrandPYRIDOSTIGMINE BROMIDE TABS 60MG GenericREGONOL SOLN 5MG/ML GenericROBAXIN SOLN 100MG/ML Non-preferred BrandROBAXIN TABS 500MG Non-preferred BrandROBAXIN-750 TABS 750MG Non-preferred Brand



SKELAXIN TABS 800MG Non-preferred BrandSOMA TABS 250MG Non-preferred BrandSOMA TABS 350MG Non-preferred BrandTIZANIDINE HCL TABS 2MG GenericTIZANIDINE HCL TABS 4MG GenericZANAFLEX CAPS 2MG Non-preferred BrandZANAFLEX CAPS 4MG Non-preferred BrandZANAFLEX CAPS 6MG Non-preferred BrandZANAFLEX TABS 4MG Non-preferred BrandAUTONOMIC AND CNS DRUGS -

NEUROLOGY AND PSYCHNARCOTIC ANALGESICS

Drug NameDosage


QL

AmountQL Days

ACETAMINOPHEN/CODEINE SOLN 120MG/5ML; 12MG/5MLGenericACETAMINOPHEN/CODEINE TABS 300MG; 15MG GenericACETAMINOPHEN/CODEINE #3 TABS 300MG; 30MG GenericACETAMINOPHEN/CODEINE #4 TABS 300MG; 60MG GenericACTIQ LPOP 1200MCG Specialty PA QL 120 25ACTIQ LPOP 1600MCG Specialty PA QL 120 25ACTIQ LPOP 200MCG Specialty PA QL 120 25ACTIQ LPOP 400MCG Specialty PA QL 120 25ACTIQ LPOP 600MCG Specialty PA QL 120 25ACTIQ LPOP 800MCG Specialty PA QL 120 25ASCOMP/CODEINE CAPS 325MG; 50MG; 40MG; 30MGGenericASTRAMORPH SOLN 0.5MG/ML Non-preferred BrandASTRAMORPH SOLN 1MG/ML Non-preferred BrandAVINZA CP24 45MG Non-preferred BrandAVINZA CP24 75MG Non-preferred BrandAVINZA CP24 120MG Non-preferred BrandAVINZA CP24 30MG Non-preferred BrandAVINZA CP24 60MG Non-preferred BrandAVINZA CP24 90MG Non-preferred BrandBUPRENEX SOLN 0.3MG/ML Non-preferred BrandBUPRENORPHINE HCL SOLN 0.3MG/ML GenericBUTALBITAL /APAP /CAFFEINE /CODEINECAPS 325MG; 50MG; 40MG; 30MGGenericCAPITAL/CODEINE SUSP 120MG/5ML; 12MG/5MLPreferred Brand

CODEINE SULFATE TABS 15 MG GenericCODEINE SULFATE TABS 30 MG GenericCODEINE SULFATE TABS 60 MG GenericCO-GESIC TABS 500MG; 5MG Non-preferred BrandCOMBUNOX TABS 400MG; 5MG Non-preferred BrandDEMEROL SOLN 100MG/ML Non-preferred BrandDEMEROL SOLN 25MG/ML Non-preferred BrandDEMEROL SOLN 50MG/ML Non-preferred BrandDEMEROL SOLN 75MG/ML Non-preferred BrandDEMEROL TABS 100MG Non-preferred BrandDEMEROL TABS 50MG Non-preferred BrandDILAUDID TABS 2MG Non-preferred BrandDILAUDID TABS 4MG Non-preferred BrandDILAUDID TABS 8MG Non-preferred BrandDILAUDID SOLN 1 MG/ML Non-preferred BrandDILAUDID SOLN 2 MG/ML Non-preferred BrandDILAUDID SOLN 4 MG/ML Non-preferred BrandDILAUDID-5 LIQD 1MG/ML Preferred BrandDILAUDID-HP SOLN 10MG/ML Non-preferred BrandDOLOPHINE TABS 10MG Non-preferred BrandDOLOPHINE HCL TABS 5MG Non-preferred BrandDURAGESIC PT72 100MCG/HR Non-preferred Brand



DURAGESIC PT72 12.5MCG/HR Non-preferred BrandDURAGESIC PT72 25MCG/HR Non-preferred BrandDURAGESIC PT72 50MCG/HR Non-preferred BrandDURAGESIC PT72 75MCG/HR Non-preferred BrandDURAMORPH SOLN 0.5MG/ML GenericDURAMORPH SOLN 1MG/ML GenericEMBEDA CAPS 20/0.8 Non-preferred Brand QL 60 25

EMBEDA CAPS 30/1.2 Non-preferred Brand QL 60 25

EMBEDA CAPS 50/2 Non-preferred Brand QL 60 25

ENDOCET TABS 325MG; 10MG GenericENDOCET TABS 650MG; 10MG GenericENDOCET TABS 325MG; 7.5MG GenericENDOCET TABS 500MG; 7.5MG GenericENDOCET TABS 325MG; 5MG GenericENDODAN TABS 325MG; 4.5MG; 0.38MGGenericFENTANYL PT72 100MCG/HR GenericFENTANYL PT72 12.5MCG/HR GenericFENTANYL PT72 25MCG/HR GenericFENTANYL PT72 50MCG/HR GenericFENTANYL PT72 75MCG/HR GenericFENTANYL CITRATE SOLN 0.05MG/ML GenericFENTANYL CITRATE ORAL TRANSMUCOSALLPOP 1200MCG Specialty PA QL 120 25FENTANYL CITRATE ORAL TRANSMUCOSALLPOP 1600MCG Specialty PA QL 120 25FENTANYL CITRATE ORAL TRANSMUCOSALLPOP 200MCG Specialty PA QL 120 25FENTANYL CITRATE ORAL TRANSMUCOSALLPOP 400MCG Specialty PA QL 120 25FENTANYL CITRATE ORAL TRANSMUCOSALLPOP 600MCG Specialty PA QL 120 25FENTANYL CITRATE ORAL TRANSMUCOSALLPOP 800MCG Specialty PA QL 120 25FENTORA TABS 100MCG Specialty PA QL 120 25FENTORA TABS 200MCG Specialty PA QL 120 25FENTORA TABS 300MCG Specialty PA QL 120 25FENTORA TABS 400MCG Specialty PA QL 120 25FENTORA TABS 600MCG Specialty PA QL 120 25FENTORA TABS 800MCG Specialty PA QL 120 25FIORICET /CODEINE CAPS 325MG; 50MG; 40MG; 30MGNon-preferred BrandFIORINAL/CODEINE #3 CAPS 325MG; 50MG; 40MG; 30MGNon-preferred BrandHYCET SOLN 325MG/15ML; 7.5MG/15MLNon-preferred Brand

HYDROCODONE /ACETAMINOPHEN TABS 325MG; 10MG GenericHYDROCODONE /ACETAMINOPHEN TABS 500MG; 10MG GenericHYDROCODONE /ACETAMINOPHEN TABS 650MG; 10MG GenericHYDROCODONE /ACETAMINOPHEN TABS 660MG; 10MG GenericHYDROCODONE /ACETAMINOPHEN TABS 325MG; 5MG GenericHYDROCODONE /ACETAMINOPHEN TABS 500MG; 5MG GenericHYDROCODONE /ACETAMINOPHEN TABS 325MG; 7.5MG GenericHYDROCODONE /ACETAMINOPHEN TABS 500MG; 7.5MG GenericHYDROCODONE /ACETAMINOPHEN TABS 650MG; 7.5MG GenericHYDROCODONE /ACETAMINOPHEN TABS 750MG; 7.5MG GenericHYDROCODONE /ACETAMINOPHEN SOLN 500MG/15ML; 7.5MG/15MLGenericHYDROCODONE /ACETAMINOPHEN SOLN 325MG/15ML; 10MG/15MLGenericHYDROCODONE /ACETAMINOPHEN-HSTABS 500MG; 2.5MG GenericHYDROCODONE /IBUPROFEN TABS 7.5MG; 200MG GenericHYDROCODONE BITARTRATE/ACETAMINOPHENTABS 750MG; 10MG GenericHYDROMORPHONE HCL SOLN 10MG/ML GenericHYDROMORPHONE HCL TABS 2MG GenericHYDROMORPHONE HCL TABS 4MG GenericHYDROMORPHONE HCL TABS 8MG GenericINFUMORPH 200 SOLN 10MG/ML Non-preferred BrandINFUMORPH 500 SOLN 25MG/ML Non-preferred BrandKADIAN CP24 100MG Non-preferred Brand



KADIAN CP24 30MG Non-preferred BrandKADIAN CP24 60MG Non-preferred BrandKADIAN CP24 10MG Non-preferred BrandKADIAN CP24 200MG Non-preferred BrandKADIAN CP24 20MG Non-preferred BrandKADIAN CP24 50MG Non-preferred BrandKADIAN CP24 80MG Non-preferred BrandLEVO DROMORAN SOLN 2MG/ML Non-preferred BrandLEVORPHANOL TARTRATE TABS 2MG GenericLORCET 10/650 TABS 650MG; 10MG Non-preferred BrandLORCET PLUS TABS 650MG; 7.5MG Non-preferred BrandLORTAB ELIX 500MG/15ML; 7.5MG/15MLNon-preferred BrandLORTAB 10 TABS 500MG; 10MG Non-preferred BrandLORTAB 5 TABS 500MG; 5MG Non-preferred BrandLORTAB 7.5 TABS 500MG; 7.5MG Non-preferred BrandMAGNACET TABS 400MG; 10MG Non-preferred BrandMAGNACET TABS 400MG; 2.5MG Non-preferred BrandMAGNACET TABS 400MG; 5MG Non-preferred BrandMAGNACET TABS 400MG; 7.5MG Non-preferred BrandMARGESIC-H CAPS 500MG; 5MG GenericMAXIDONE TABS 750MG; 10MG Non-preferred BrandMEPERIDINE HCL SOLN 100MG/ML GenericMEPERIDINE HCL SOLN 10MG/ML GenericMEPERIDINE HCL SOLN 25MG/ML GenericMEPERIDINE HCL SOLN 50MG/ML GenericMEPERIDINE HCL SOLN 75MG/ML Non-preferred BrandMEPERIDINE HCL SOLN 50MG/5ML GenericMEPERIDINE HCL TABS 100MG GenericMEPERIDINE HCL TABS 50MG GenericMETHADONE HCL CONC 10MG/ML GenericMETHADONE HCL SOLN 10MG/ML GenericMETHADONE HCL SOLN 10MG/5ML Preferred BrandMETHADONE HCL SOLN 5MG/5ML Preferred BrandMETHADONE HCL TABS 10MG GenericMETHADONE HCL TABS 5MG GenericMETHADOSE TABS 10MG Generic

METHADOSE TABS 5MG GenericMORPHINE SULFATE SOLN 10MG/5ML GenericMORPHINE SULFATE SOLN 20MG/5ML GenericMORPHINE SULFATE SOLN 0.5MG/ML GenericMORPHINE SULFATE SOLN 1MG/ML GenericMORPHINE SULFATE SOLN 5MG/ML GenericMORPHINE SULFATE TABS 15MG GenericMORPHINE SULFATE TABS 30MG GenericMORPHINE SULFATE ER TB12 100MG GenericMORPHINE SULFATE ER TB12 15MG GenericMORPHINE SULFATE ER TB12 200MG GenericMORPHINE SULFATE ER TB12 30MG GenericMORPHINE SULFATE ER TB12 60MG GenericMS CONTIN TB12 100MG Non-preferred BrandMS CONTIN TB12 15MG Non-preferred BrandMS CONTIN TB12 200MG Non-preferred BrandMS CONTIN TB12 30MG Non-preferred BrandMS CONTIN TB12 60MG Non-preferred BrandNORCO TABS 325MG; 10MG Non-preferred BrandNORCO TABS 325MG; 5MG Non-preferred BrandNORCO TABS 325MG; 7.5MG Non-preferred BrandONSOLIS FILM 1200 MCG Specialty PA QL 120 25



ONSOLIS FILM 200 MCG Specialty PA QL 120 25ONSOLIS FILM 400 MCG Specialty PA QL 120 25ONSOLIS FILM 600 MCG Specialty PA QL 120 25ONSOLIS FILM 800 MCG Specialty PA QL 120 25OPANA TABS 10MG Non-preferred BrandOPANA TABS 5MG Non-preferred BrandOPANA ER TB12 15MG Non-preferred Brand QL 120 25OPANA ER TB12 30MG Non-preferred Brand QL 120 25OPANA ER TB12 7.5MG Non-preferred Brand QL 120 25OPANA ER TB12 10MG Non-preferred Brand QL 120 25OPANA ER TB12 20MG Non-preferred Brand QL 120 25OPANA ER TB12 40MG Non-preferred Brand QL 120 25OPANA ER TB12 5MG Non-preferred Brand QL 120 25ORAMORPH SR TB12 100MG GenericORAMORPH SR TB12 15MG GenericORAMORPH SR TB12 30MG GenericORAMORPH SR TB12 60MG GenericOXYCODONE /ACETAMINOPHEN TABS 650MG; 10MG GenericOXYCODONE /ACETAMINOPHEN CAPS 500MG; 5MG GenericOXYCODONE /ACETAMINOPHEN TABS 325MG; 5MG GenericOXYCODONE /APAP TABS 500MG; 7.5MG GenericOXYCODONE /ASPIRIN TABS 325MG; 4.5MG; 0.38MGGenericOXYCODONE /IBUPROFEN TABS 400MG; 5MG GenericOXYCODONE HCL TABS 15MG GenericOXYCODONE HCL TABS 30MG GenericOXYCODONE HCL TABS 5MG GenericOXYCODONE HCL ER TB12 10MG Generic QL 120 25OXYCODONE HCL ER TB12 20MG Generic QL 120 25OXYCODONE HCL ER TB12 40MG Generic QL 120 25OXYCODONE HCL ER TB12 80MG Generic QL 120 25OXYCODONE/ACETAMINOPHEN 325 MG,2.5 MGTABS GenericOXYCODONE-APAP TABS 325MG; 7.5MG GenericOXYCODONE-APAP TABS 325MG; 10MG GenericOXYCONTIN TB12 10MG Preferred Brand QL 120 25OXYCONTIN TB12 15MG Preferred Brand QL 120 25OXYCONTIN TB12 20MG Preferred Brand QL 120 25

OXYCONTIN TB12 30MG Preferred Brand QL 120 25OXYCONTIN TB12 40MG Preferred Brand QL 120 25OXYCONTIN TB12 60MG Preferred Brand QL 120 25OXYCONTIN TB12 80MG Preferred Brand QL 120 25PANLOR DC CAPS 356.4MG; 30MG; 16MGNon-preferred BrandPANLOR SS TABS 712.8MG; 60MG; 32MGNon-preferred BrandPERCOCET TABS 325MG; 10MG Non-preferred BrandPERCOCET TABS 650MG; 10MG Non-preferred BrandPERCOCET TABS 325MG; 2.5MG Non-preferred BrandPERCOCET TABS 325MG; 5MG Non-preferred BrandPERCOCET TABS 325MG; 7.5MG Non-preferred BrandPERCOCET TABS 500MG; 7.5MG Non-preferred BrandPERCODAN TABS 325MG; 4.5MG; 0.38MGNon-preferred BrandREPREXAIN TABS 10MG; 200MG GenericREPREXAIN TABS 2.5MG; 200MG Non-preferred BrandREPREXAIN TABS 5MG; 200MG Non-preferred BrandROXICET SOLN 325MG/5ML; 5MG/5MLPreferred BrandROXICET TABS 325MG; 5MG GenericROXICET TABS 500MG; 5MG Preferred BrandROXICODONE TABS 15MG Non-preferred BrandROXICODONE TABS 30MG Non-preferred BrandSTAGESIC CAPS 500MG; 5MG Generic



SUBUTEX SUBL 2MG Preferred Brand QL 15 90SUBUTEX SUBL 8MG Preferred Brand QL 15 90SYNALGOS-DC CAPS 356.4MG; 30MG; 16MGNon-preferred BrandTREZIX CAPS 356.4MG; 30MG; 16MGGenericTYLENOL/CODEINE #3 TABS 300MG; 30MG Non-preferred BrandTYLENOL/CODEINE #4 TABS 300MG; 60MG Non-preferred BrandTYLOX CAPS 500MG; 5MG Non-preferred BrandVANACET TABS 500MG; 5MG Non-preferred BrandVICODIN TABS 500MG; 5MG Non-preferred BrandVICODIN ES TABS 750MG; 7.5MG Non-preferred BrandVICODIN HP TABS 660MG; 10MG Non-preferred BrandVICOPROFEN TABS 7.5MG; 200MG Non-preferred BrandXODOL TABS 300MG; 10MG Non-preferred BrandXODOL TABS 300MG; 5MG Non-preferred BrandXODOL TABS 300MG; 7.5MG Non-preferred BrandZERLOR TABS 712.8MG; 60MG; 32MGGenericZYDONE TABS 400MG; 10MG Non-preferred BrandZYDONE TABS 400MG; 5MG Non-preferred BrandZYDONE TABS 400MG; 7.5MG Non-preferred BrandAUTONOMIC AND CNS DRUGS -

NEUROLOGY AND PSYCHNON-NARCOTIC ANALGESICS

Drug NameDosage


QL

AmountQL Days

ACETAMINOPHEN/CAFFEINE/DIHYDROCODEINE BITARTRATETABS 712.8MG; 60MG; 32MGGenericANAPROX TABS 275MG Non-preferred BrandANAPROX DS TABS 550MG Non-preferred BrandARTHROTEC 50 TABS 50MG; 200MCG Non-preferred BrandARTHROTEC 75 TABS 75MG; 200MCG Non-preferred BrandBUTORPHANOL TARTRATE SOLN 1MG/ML GenericBUTORPHANOL TARTRATE SOLN 2MG/ML GenericBUTORPHANOL TARTRATE SOLN 10MG/ML GenericCATAFLAM TABS 50MG Non-preferred BrandCELEBREX CAPS 100MG Preferred BrandCELEBREX CAPS 200MG Preferred BrandCELEBREX CAPS 400MG Preferred BrandCELEBREX CAPS 50MG Preferred Brand

CLINORIL TABS 200MG Non-preferred BrandDAYPRO TABS 600MG Non-preferred BrandDEPADE TABS 50MG GenericDICLOFENAC POTASSIUM TABS 50MG GenericDICLOFENAC SODIUM TBEC 75MG GenericDICLOFENAC SODIUM EC TBEC 25MG GenericDICLOFENAC SODIUM EC TBEC 50MG GenericDICLOFENAC SODIUM XR TB24 100MG GenericDIFLUNISAL TABS 500MG GenericEC-NAPROSYN TBEC 375MG Non-preferred BrandEC-NAPROSYN TBEC 500MG Non-preferred BrandEQUAGESIC TABS 325MG; 200MG Non-preferred BrandETODOLAC CAPS 200MG GenericETODOLAC CAPS 300MG GenericETODOLAC TABS 400MG GenericETODOLAC TABS 500MG GenericETODOLAC ER TB24 400MG GenericETODOLAC ER TB24 500MG GenericETODOLAC ER TB24 600MG GenericFELDENE CAPS 10MG Non-preferred BrandFELDENE CAPS 20MG Non-preferred BrandFENOPROFEN CALCIUM TABS 600MG Generic



FLECTOR PTCH 1.3% Non-preferred BrandFLURBIPROFEN TABS 100MG GenericFLURBIPROFEN TABS 50MG GenericIBU TABS 600MG GenericIBUPROFEN SUSP 100MG/5ML GenericIBUPROFEN TABS 400MG GenericIBUPROFEN TABS 800MG GenericINDOCIN SUSP 25MG/5ML Preferred BrandINDOCIN SR CPCR 75MG Non-preferred BrandINDOMETHACIN CAPS 25MG GenericINDOMETHACIN CAPS 50MG GenericINDOMETHACIN ER CPCR 75MG GenericKETOPROFEN CAPS 50MG GenericKETOPROFEN CAPS 75MG GenericKETOPROFEN ER CP24 200MG GenericKETOROLAC TROMETHAMINE SOLN 15MG/ML GenericKETOROLAC TROMETHAMINE SOLN 30MG/ML GenericKETOROLAC TROMETHAMINE TABS 10MG GenericMECLOFENAMATE SODIUM CAPS 100MG GenericMECLOFENAMATE SODIUM CAPS 50MG GenericMELOXICAM SUSP 7.5MG/5ML GenericMELOXICAM TABS 15MG GenericMELOXICAM TABS 7.5MG GenericMOBIC SUSP 7.5MG/5ML Non-preferred BrandMOBIC TABS 15MG Non-preferred BrandMOBIC TABS 7.5MG Non-preferred BrandNABUMETONE TABS 500MG GenericNABUMETONE TABS 750MG GenericNALBUPHINE HCL SOLN 10MG/ML GenericNALBUPHINE HCL SOLN 20MG/ML GenericNALFON CAPS 200MG Non-preferred BrandNALOXONE HCL SOLN 0.4MG/ML GenericNALOXONE HCL SOLN 1MG/ML GenericNALTREXONE HCL TABS 50MG GenericNAPRELAN TB24 375MG Non-preferred BrandNAPRELAN TB24 500MG Non-preferred Brand

NAPROSYN SUSP 125MG/5ML Non-preferred BrandNAPROSYN TABS 250MG Non-preferred BrandNAPROSYN TABS 375MG Non-preferred BrandNAPROSYN TABS 500MG Non-preferred BrandNAPROXEN SUSP 125MG/5ML GenericNAPROXEN TABS 375MG GenericNAPROXEN DR TBEC 375MG GenericNAPROXEN DR TBEC 500MG GenericNAPROXEN SODIUM TABS 275MG GenericNAPROXEN SODIUM TABS 550MG GenericNUCYNTA TABS 100 MG Non-preferred BrandNUCYNTA TABS 50 MG Non-preferred BrandNUCYNTA TABS 75 MG Non-preferred BrandOXAPROZIN TABS 600MG GenericPENTAZOCINE /ACETAMINOPHEN TABS 650MG; 25MG GenericPENTAZOCINE/NALOXONE HCL TABS 0.5MG; 50MG GenericPIROXICAM CAPS 10MG GenericPIROXICAM CAPS 20MG GenericPONSTEL CAPS 250MG Non-preferred BrandREVIA TABS 50MG Non-preferred BrandRYZOLT TABLET, MULTIPHASIC RELEASE 24HR100MG Non-preferred Brand

RYZOLT TABLET, MULTIPHASIC RELEASE 24HR200MG Non-preferred Brand



RYZOLT TABLET, MULTIPHASIC RELEASE 24HR300MG Non-preferred Brand

STADOL SOLN 2MG/ML Non-preferred BrandSUBOXONE SUBL 2MG; 0.5MG Preferred Brand QL 90 30SUBOXONE SUBL 8MG; 2MG Preferred Brand QL 90 30SULINDAC TABS 150MG GenericSULINDAC TABS 200MG GenericTALACEN TABS 650MG; 25MG Non-preferred BrandTALWIN SOLN 30MG/ML Non-preferred BrandTALWIN NX TABS 0.5MG; 50MG Non-preferred BrandTOLMETIN SODIUM CAPS 400MG GenericTOLMETIN SODIUM TABS 200MG GenericTOLMETIN SODIUM TABS 600MG GenericTRAMADOL HCL TABS 50MG GenericTRAMADOL HYDROCHLORIDE/ACETAMINOPHENTABS 325MG; 37.5MG GenericULTRACET TABS 325MG; 37.5MG Non-preferred BrandULTRAM TABS 50MG Non-preferred BrandULTRAM ER TB24 100MG Non-preferred BrandULTRAM ER TB24 200MG Non-preferred BrandULTRAM ER TB24 300MG Non-preferred BrandVOLTAREN GEL 1% Non-preferred BrandVOLTAREN TBEC 75MG Non-preferred BrandVOLTAREN-XR TB24 100MG Non-preferred BrandZIPSOR CAPS 25 MG Non-preferred BrandAUTONOMIC AND CNS DRUGS -

NEUROLOGY AND PSYCHPROPOXYPHENE

Drug NameDosage


QL

AmountQL Days

BALACET 325 TABS 325MG; 100MG GenericDARVOCET A500 TABS 500MG; 100MG Non-preferred BrandDARVOCET-N 100 TABS 650MG; 100MG Non-preferred BrandDARVOCET-N 50 TABS 325MG; 50MG Non-preferred BrandDARVON CAPS 65MG Non-preferred BrandDARVON-N TABS 100MG Non-preferred BrandPROPOXYPHENE /ACETAMINOPHEN TABS 650MG; 65MG GenericPROPOXYPHENE HCL CAPS 65MG GenericPROPOXYPHENE-N /ACETAMINOPHEN TABS 500MG; 100MG Generic

PROPOXYPHENE-N /ACETAMINOPHEN TABS 650MG; 100MG GenericPROPOXYPHENE-N /ACETAMINOPHEN TABS 325MG; 50MG GenericAUTONOMIC AND CNS DRUGS -

NEUROLOGY AND PSYCHPSYCHOTHERAPEUTIC DRUGS

Drug NameDosage


QL

AmountQL Days

ABILIFY SOLN 9.75MG/1.3ML Non-preferred BrandABILIFY SOLN 1MG/ML Non-preferred BrandABILIFY TABS 10MG Non-preferred BrandABILIFY TABS 15MG Non-preferred BrandABILIFY TABS 20MG Non-preferred BrandABILIFY TABS 2MG Non-preferred BrandABILIFY TABS 30MG Non-preferred BrandABILIFY TABS 5MG Non-preferred BrandABILIFY DISCMELT TBDP 10MG Non-preferred BrandABILIFY DISCMELT TBDP 15MG Non-preferred BrandADDERALL TABS 2.5MG; 2.5MG; 2.5MG; 2.5MGNon-preferred BrandADDERALL TABS 3.125MG; 3.125MG; 3.125MG; 3.125MGNon-preferred BrandADDERALL TABS 3.75MG; 3.75MG; 3.75MG; 3.75MGNon-preferred BrandADDERALL TABS 5MG; 5MG; 5MG; 5MGNon-preferred BrandADDERALL TABS 7.5MG; 7.5MG; 7.5MG; 7.5MGNon-preferred BrandADDERALL TABS 1.25MG; 1.25MG; 1.25MG; 1.25MGNon-preferred Brand



ADDERALL TABS 1.875MG; 1.875MG; 1.875MG; 1.875MGNon-preferred BrandADDERALL XR CP24 2.5MG; 2.5MG; 2.5MG; 2.5MGNon-preferred BrandADDERALL XR CP24 3.75MG; 3.75MG; 3.75MG; 3.75MGNon-preferred BrandADDERALL XR CP24 5MG; 5MG; 5MG; 5MGNon-preferred BrandADDERALL XR CP24 6.25MG; 6.25MG; 6.25MG; 6.25MGNon-preferred BrandADDERALL XR CP24 7.5MG; 7.5MG; 7.5MG; 7.5MGNon-preferred BrandADDERALL XR CP24 1.25MG; 1.25MG; 1.25MG; 1.25MGNon-preferred BrandAMBIEN TABS 10MG Non-preferred BrandAMBIEN TABS 5MG Non-preferred BrandAMBIEN CR TBCR 12.5MG Non-preferred BrandAMBIEN CR TBCR 6.25MG Non-preferred BrandAMITRIPTYLINE HCL TABS 100MG GenericAMITRIPTYLINE HCL TABS 10MG GenericAMITRIPTYLINE HCL TABS 150MG GenericAMITRIPTYLINE HCL TABS 25MG GenericAMITRIPTYLINE HCL TABS 50MG GenericAMITRIPTYLINE HCL TABS 75MG GenericAMOXAPINE TABS 100MG GenericAMOXAPINE TABS 150MG GenericAMOXAPINE TABS 25MG GenericAMOXAPINE TABS 50MG GenericAMPHETAMINE SALT COMBO TABS 2.5MG; 2.5MG; 2.5MG; 2.5MGGenericAMPHETAMINE SALT COMBO TABS 3.125MG; 3.125MG; 3.125MG; 3.125MGGenericAMPHETAMINE SALT COMBO TABS 3.75MG; 3.75MG; 3.75MG; 3.75MGGenericAMPHETAMINE SALT COMBO TABS 5MG; 5MG; 5MG; 5MGGenericAMPHETAMINE SALT COMBO TABS 7.5MG; 7.5MG; 7.5MG; 7.5MGGenericAMPHETAMINE SALT COMBO TABS 1.25MG; 1.25MG; 1.25MG; 1.25MGGenericAMPHETAMINE SALT COMBO TABS 1.875MG; 1.875MG; 1.875MG; 1.875MGGenericANAFRANIL CAPS 25MG Non-preferred BrandANAFRANIL CAPS 50MG Non-preferred BrandANAFRANIL CAPS 75MG Non-preferred BrandAPLENZIN TABS 174 MG Non-preferred BrandAPLENZIN TB24 348MG Non-preferred BrandAPLENZIN TB24 522MG Non-preferred BrandBUDEPRION SR TB12 100MG GenericBUDEPRION SR TB12 150MG Generic

BUDEPRION XL TB24 300MG GenericBUDEPRION XL TB24 150MG GenericBUPROBAN TABLET 150 MG Generic

BUPROPION HCL TABS 100MG GenericBUPROPION HCL TABS 75MG GenericBUPROPION HCL SR TB12 100MG GenericBUPROPION HCL SR TB12 150MG GenericBUPROPION HCL SR TB12 200MG GenericBUSPAR TABS 10MG Non-preferred BrandBUSPAR TABS 15MG Non-preferred BrandBUSPAR TABS 30MG Non-preferred BrandBUSPAR TABS 5MG Non-preferred BrandBUSPIRONE HCL TABS 10MG GenericBUSPIRONE HCL TABS 15MG GenericBUSPIRONE HCL TABS 30MG GenericBUSPIRONE HCL TABS 5MG GenericBUSPIRONE HCL TABS 7.5MG GenericCELEXA SOLN 10MG/5ML Non-preferred BrandCELEXA TABS 10MG Non-preferred BrandCELEXA TABS 20MG Non-preferred BrandCELEXA TABS 40MG Non-preferred BrandCHLORDIAZEPOXIDE /AMITRIPTYLINE TABS 25MG; 10MG Generic



CHLORDIAZEPOXIDE /AMITRIPTYLINE TABS 12.5MG; 5MG GenericCHLORPROMAZINE HCL SOLN 25MG/ML GenericCHLORPROMAZINE HCL TABS 100MG GenericCHLORPROMAZINE HCL TABS 10MG GenericCHLORPROMAZINE HCL TABS 200MG GenericCHLORPROMAZINE HCL TABS 25MG GenericCHLORPROMAZINE HCL TABS 50MG GenericCITALOPRAM HYDROBROMIDE SOLN 10MG/5ML GenericCITALOPRAM HYDROBROMIDE TABS 10MG GenericCITALOPRAM HYDROBROMIDE TABS 20MG GenericCITALOPRAM HYDROBROMIDE TABS 40MG GenericCLOMIPRAMINE HCL CAPS 25MG GenericCLOMIPRAMINE HCL CAPS 50MG GenericCLOMIPRAMINE HCL CAPS 75MG GenericCLOZAPINE TABS 100MG GenericCLOZAPINE TABS 200MG Preferred BrandCLOZAPINE TABS 25MG GenericCLOZAPINE TABS 50MG GenericCLOZARIL TABS 100MG Preferred BrandCLOZARIL TABS 25MG Preferred BrandCONCERTA TBCR 18MG Preferred BrandCONCERTA TBCR 27MG Preferred BrandCONCERTA TBCR 36MG Preferred BrandCONCERTA TBCR 54MG Preferred BrandCYMBALTA CPEP 20MG Non-preferred Brand PACYMBALTA CPEP 30MG Non-preferred Brand PACYMBALTA CPEP 60MG Non-preferred Brand PADAYTRANA PTCH 10MG/9HR Non-preferred BrandDAYTRANA PTCH 15MG/9HR Non-preferred BrandDAYTRANA PTCH 20MG/9HR Non-preferred BrandDAYTRANA PTCH 30MG/9HR Non-preferred BrandDESIPRAMINE HCL TABS 100MG GenericDESIPRAMINE HCL TABS 10MG GenericDESIPRAMINE HCL TABS 150MG GenericDESIPRAMINE HCL TABS 25MG GenericDESIPRAMINE HCL TABS 50MG Generic

DESIPRAMINE HCL TABS 75MG GenericDESOXYN TABS 5MG Non-preferred BrandDEXEDRINE CP24 10MG Non-preferred BrandDEXEDRINE CP24 15MG Non-preferred BrandDEXEDRINE CP24 5MG Non-preferred BrandDEXMETHYLPHENIDATE HCL TABS 10MG GenericDEXMETHYLPHENIDATE HCL TABS 2.5MG GenericDEXMETHYLPHENIDATE HCL TABS 5MG GenericDEXTROAMPHETAMINE SULFATE TABS 10MG GenericDEXTROAMPHETAMINE SULFATE TABS 5MG GenericDEXTROAMPHETAMINE SULFATE ER CP24 10MG GenericDEXTROAMPHETAMINE SULFATE ER CP24 15MG GenericDEXTROAMPHETAMINE SULFATE ER CP24 5MG GenericDOXEPIN HCL CAPS 100MG GenericDOXEPIN HCL CAPS 10MG GenericDOXEPIN HCL CAPS 150MG GenericDOXEPIN HCL CAPS 25MG GenericDOXEPIN HCL CAPS 50MG GenericDOXEPIN HCL CAPS 75MG GenericDOXEPIN HCL CONC 10MG/ML GenericEDLUAR SUBL 10 MG Non-preferred BrandEDLUAR SUBL 5 MG Non-preferred Brand



EFFEXOR TABS 100MG Non-preferred BrandEFFEXOR TABS 25MG Non-preferred BrandEFFEXOR TABS 37.5MG Non-preferred BrandEFFEXOR TABS 50MG Non-preferred BrandEFFEXOR XR CP24 150MG Non-preferred BrandEFFEXOR XR CP24 37.5MG Non-preferred BrandEFFEXOR XR CP24 75MG Non-preferred BrandEMSAM PT24 12MG/24HR Non-preferred BrandEMSAM PT24 6MG/24HR Non-preferred BrandEMSAM PT24 9MG/24HR Non-preferred BrandERGOLOID MESYLATES TABS 1MG GenericFANAPT TABS 1 MG Non-preferred BrandFANAPT TABS 10 MG Non-preferred BrandFANAPT TABS 12MG Non-preferred BrandFANAPT TABS 2 MG Non-preferred BrandFANAPT TABS 4MG Non-preferred BrandFANAPT TABS 6 MG Non-preferred BrandFANAPT TABS 8 MG Non-preferred BrandFANAPT TABS 1MG/2MG/4MG/6MGNon-preferred BrandFAZACLO TBDP 100MG Preferred BrandFAZACLO TBDP 12.5MG Preferred BrandFAZACLO TBDP 25MG Preferred BrandFLUOXETINE HCL CAPS 10MG GenericFLUOXETINE HCL CAPS 20MG GenericFLUOXETINE HCL CAPS 40MG GenericFLUOXETINE HCL SOLN 20MG/5ML GenericFLUOXETINE HCL TABS 10MG GenericFLUOXETINE HCL TABS 20MG GenericFLUPHENAZINE DECANOATE SOLN 25MG/ML GenericFLUPHENAZINE HCL CONC 5MG/ML GenericFLUPHENAZINE HCL ELIX 2.5MG/5ML GenericFLUPHENAZINE HCL SOLN 2.5MG/ML GenericFLUPHENAZINE HCL TABS 10MG GenericFLUPHENAZINE HCL TABS 1MG GenericFLUPHENAZINE HCL TABS 2.5MG GenericFLUPHENAZINE HCL TABS 5MG Generic

FLUVOXAMINE MALEATE TABS 100MG GenericFLUVOXAMINE MALEATE TABS 25MG GenericFLUVOXAMINE MALEATE TABS 50MG GenericFOCALIN TABS 10MG Non-preferred BrandFOCALIN TABS 2.5MG Non-preferred BrandFOCALIN TABS 5MG Non-preferred BrandFOCALIN XR CP24 10MG Non-preferred BrandFOCALIN XR CP24 15MG Non-preferred BrandFOCALIN XR CP24 20MG Non-preferred BrandFOCALIN XR CP24 5MG Non-preferred BrandGEODON CAPS 20MG Preferred BrandGEODON CAPS 40MG Preferred BrandGEODON CAPS 60MG Preferred BrandGEODON CAPS 80MG Preferred BrandGEODON SOLR 20MG Preferred BrandGUANIDINE HCL TABS 125MG Non-preferred BrandHALDOL SOLN 5MG/ML Non-preferred BrandHALDOL DECANOATE-100 SOLN 100MG/ML Preferred BrandHALDOL DECANOATE-50 SOLN 50MG/ML Preferred BrandHALOPERIDOL CONC 2MG/ML GenericHALOPERIDOL TABS 0.5MG GenericHALOPERIDOL TABS 10MG Generic



HALOPERIDOL TABS 1MG GenericHALOPERIDOL TABS 20MG GenericHALOPERIDOL TABS 2MG GenericHALOPERIDOL TABS 5MG GenericHALOPERIDOL DECANOATE SOLN 100MG/ML GenericHALOPERIDOL DECANOATE SOLN 50MG/ML GenericHALOPERIDOL LACTATE SOLN 5MG/ML GenericIMIPRAMINE HCL TABS 10MG GenericIMIPRAMINE HCL TABS 25MG GenericIMIPRAMINE HCL TABS 50MG GenericIMIPRAMINE PAMOATE CAPS 100MG GenericIMIPRAMINE PAMOATE CAPS 125MG GenericIMIPRAMINE PAMOATE CAPS 150MG GenericIMIPRAMINE PAMOATE CAPS 75MG GenericINVEGA TB24 3MG Non-preferred BrandINVEGA TB24 6MG Non-preferred BrandINVEGA TB24 9MG Non-preferred BrandINVEGA SUSTENNA INJ 0.5 ML Non-preferred BrandINVEGA SUSTENNA INJ 0.25 ML Non-preferred BrandINVEGA SUSTENNA INJ 0.75 ML Non-preferred BrandINVEGA SUSTENNA INJ 1.0 ML Non-preferred BrandINVEGA SUSTENNA INJ 1.5 ML Non-preferred BrandLEXAPRO SOLN 5MG/5ML Preferred BrandLEXAPRO TABS 10MG Preferred BrandLEXAPRO TABS 20MG Preferred BrandLEXAPRO TABS 5MG Preferred BrandLIMBITROL TABS 12.5MG; 5MG Non-preferred BrandLIQUADD SOLN 5MG/5ML Non-preferred BrandLITHIUM CARBONATE CAPS 150MG GenericLITHIUM CARBONATE CAPS 300MG GenericLITHIUM CARBONATE CAPS 600MG Preferred BrandLITHIUM CARBONATE TABS 300MG GenericLITHIUM CARBONATE ER TBCR 300MG GenericLITHIUM CARBONATE ER TBCR 450MG GenericLITHIUM CITRATE SYRP 8MEQ/5ML GenericLITHOBID TBCR 300MG Non-preferred Brand

LOXAPINE SUCCINATE CAPS 10MG GenericLOXAPINE SUCCINATE CAPS 25MG GenericLOXAPINE SUCCINATE CAPS 50MG GenericLOXAPINE SUCCINATE CAPS 5MG GenericLOXITANE CAPS 10MG Non-preferred BrandLOXITANE CAPS 25MG Non-preferred BrandLOXITANE CAPS 50MG Non-preferred BrandLOXITANE CAPS 5MG Non-preferred BrandLUNESTA TABS 1MG Non-preferred BrandLUNESTA TABS 2MG Non-preferred BrandLUNESTA TABS 3MG Non-preferred BrandLUVOX CR CP24 100MG Non-preferred BrandLUVOX CR CP24 150MG Non-preferred BrandMAPROTILINE HCL TABS 25MG GenericMAPROTILINE HCL TABS 50MG GenericMAPROTILINE HCL TABS 75MG GenericMARPLAN TABS 10MG Preferred BrandMETADATE CD CPCR 10MG Preferred BrandMETADATE CD CPCR 20MG Preferred BrandMETADATE CD CPCR 30MG Preferred BrandMETADATE CD CPCR 40MG Preferred BrandMETADATE CD CPCR 50MG Preferred Brand



METADATE CD CPCR 60MG Preferred BrandMETADATE ER TBCR 20MG GenericMETHAMPHETAMINE HCl TAB 5 MG GenericMETHYLIN CHEW 10MG Non-preferred BrandMETHYLIN CHEW 2.5MG Non-preferred BrandMETHYLIN CHEW 5MG Non-preferred BrandMETHYLIN SOLN 10MG/5ML Non-preferred BrandMETHYLIN SOLN 5MG/5ML Non-preferred BrandMETHYLIN TABS 10MG GenericMETHYLIN TABS 20MG GenericMETHYLIN TABS 5MG GenericMETHYLIN ER TBCR 10MG GenericMETHYLIN ER TBCR 20MG GenericMETHYLPHENIDATE HCL TABS 10MG GenericMETHYLPHENIDATE HCL TABS 20MG GenericMETHYLPHENIDATE HCL TABS 5MG GenericMETHYLPHENIDATE HCL ER TBCR 20MG GenericMIRTAZAPINE TABS 15MG GenericMIRTAZAPINE TBDP 15MG GenericMIRTAZAPINE TABS 30MG GenericMIRTAZAPINE TABS 45MG GenericMIRTAZAPINE TABS 7.5MG GenericMIRTAZAPINE ODT TBDP 30MG GenericMIRTAZAPINE ODT TBDP 45MG GenericMOBAN TABS 10MG Preferred BrandMOBAN TABS 25MG Preferred BrandMOBAN TABS 50MG Preferred BrandMOBAN TABS 5MG Preferred BrandNARDIL TABS 15MG Preferred BrandNAVANE CAPS 10MG Non-preferred BrandNAVANE CAPS 20MG Preferred BrandNAVANE CAPS 2MG Non-preferred BrandNAVANE CAPS 5MG Non-preferred BrandNEFAZODONE HCL TABS 100MG GenericNEFAZODONE HCL TABS 150MG GenericNEFAZODONE HCL TABS 200MG Generic

NEFAZODONE HCL TABS 250MG GenericNEFAZODONE HCL TABS 50MG GenericNORPRAMIN TABS 100MG Non-preferred BrandNORPRAMIN TABS 10MG Non-preferred BrandNORPRAMIN TABS 150MG Non-preferred BrandNORPRAMIN TABS 25MG Non-preferred BrandNORPRAMIN TABS 50MG Non-preferred BrandNORPRAMIN TABS 75MG Non-preferred BrandNORTRIPTYLINE HCL CAPS 10MG GenericNORTRIPTYLINE HCL CAPS 25MG GenericNORTRIPTYLINE HCL CAPS 50MG GenericNORTRIPTYLINE HCL CAPS 75MG GenericNORTRIPTYLINE HCL SOLN 10MG/5ML GenericNUVIGIL TABLET 150 MG Non-preferred Brand PANUVIGIL TABLET 250 MG Non-preferred Brand PANUVIGIL TABLET 50 MG Non-preferred Brand PAORAP TABS 1MG Preferred BrandORAP TABS 2MG Preferred BrandPAMELOR CAPS 10MG Non-preferred BrandPAMELOR CAPS 25MG Non-preferred BrandPAMELOR CAPS 50MG Non-preferred BrandPAMELOR CAPS 75MG Non-preferred Brand



PAMELOR SOLN 10MG/5ML Non-preferred BrandPARNATE TABS 10MG Non-preferred BrandPAROXETINE HCL SUSP 10MG/5ML GenericPAROXETINE HCL TABS 10MG GenericPAROXETINE HCL TABS 20MG GenericPAROXETINE HCL TABS 30MG GenericPAROXETINE HCL TABS 40MG GenericPAROXETINE HCL ER TB24 12.5MG GenericPAROXETINE HCL ER TB24 25MG GenericPAXIL SUSP 10MG/5ML Non-preferred BrandPAXIL TABS 10MG Non-preferred BrandPAXIL TABS 20MG Non-preferred BrandPAXIL TABS 30MG Non-preferred BrandPAXIL TABS 40MG Non-preferred BrandPAXIL CR TB24 12.5MG Non-preferred BrandPAXIL CR TB24 25MG Non-preferred BrandPAXIL CR TB24 37.5MG Non-preferred BrandPERPHENAZINE TABS 16MG GenericPERPHENAZINE TABS 2MG GenericPERPHENAZINE TABS 4MG GenericPERPHENAZINE TABS 8MG GenericPERPHENAZINE /AMITRIPTYLINE TABS 10MG; 2MG GenericPERPHENAZINE /AMITRIPTYLINE TABS 25MG; 2MG GenericPERPHENAZINE /AMITRIPTYLINE TABS 10MG; 4MG GenericPERPHENAZINE /AMITRIPTYLINE TABS 25MG; 4MG GenericPERPHENAZINE /AMITRIPTYLINE TABS 50MG; 4MG GenericPEXEVA TABS 10MG Non-preferred BrandPEXEVA TABS 20MG Non-preferred BrandPEXEVA TABS 30MG Non-preferred BrandPEXEVA TABS 40MG Non-preferred BrandPRISTIQ TB24 100MG Non-preferred BrandPRISTIQ TB24 50MG Non-preferred BrandPROTRIPTYLINE HCL TABS 10MG GenericPROTRIPTYLINE HCL TABS 5MG GenericPROVIGIL TABS 100MG Preferred Brand PAPROVIGIL TABS 200MG Preferred Brand PA

PROZAC CAPS 10MG Non-preferred BrandPROZAC CAPS 20MG Non-preferred BrandPROZAC CAPS 40MG Non-preferred BrandPROZAC SOLN 20MG/5ML Non-preferred BrandPROZAC TABS 10MG Non-preferred BrandPROZAC WEEKLY CPDR 90MG Non-preferred BrandRAPIFLUX TABS 20MG Non-preferred BrandREMERON TABS 15MG Non-preferred BrandREMERON TABS 30MG Non-preferred BrandREMERON TABS 45MG Non-preferred BrandREMERON SOLTAB TBDP 15MG Non-preferred BrandREMERON SOLTAB TBDP 30MG Non-preferred BrandREMERON SOLTAB TBDP 45MG Non-preferred BrandRISPERDAL SOLN 1MG/ML Non-preferred BrandRISPERDAL TABS 0.25MG Non-preferred BrandRISPERDAL TABS 0.5MG Non-preferred BrandRISPERDAL TABS 1MG Non-preferred BrandRISPERDAL TABS 2MG Non-preferred BrandRISPERDAL TABS 3MG Non-preferred BrandRISPERDAL TABS 4MG Non-preferred BrandRISPERDAL CONSTA SUSR 12.5MG Preferred BrandRISPERDAL CONSTA SUSR 25MG Preferred Brand



RISPERDAL CONSTA SUSR 37.5MG Preferred BrandRISPERDAL CONSTA SUSR 50MG SpecialtyRISPERDAL M-TAB TBDP 0.5MG Non-preferred BrandRISPERDAL M-TAB TBDP 1MG Preferred BrandRISPERDAL M-TAB TBDP 2MG Non-preferred BrandRISPERDAL M-TAB TBDP 3MG Non-preferred BrandRISPERDAL M-TAB TBDP 4MG Non-preferred BrandRISPERIDONE SOLN 1MG/ML GenericRISPERIDONE TABS 0.25MG GenericRISPERIDONE TABS 0.5MG GenericRISPERIDONE TABS 1MG GenericRISPERIDONE TABS 2MG GenericRISPERIDONE TABS 3MG GenericRISPERIDONE TABS 4MG GenericRISPERIDONE ODT TBDP 0.25 MG GenericRISPERIDONE ODT TBDP 3 MG GenericRISPERIDONE ODT TBDP 4 MG GenericRISPERIDONE ODT TBDP 0.50MG GenericRISPERIDONE ODT TBDP 2MG GenericRITALIN TABS 10MG Non-preferred BrandRITALIN TABS 20MG Non-preferred BrandRITALIN TABS 5MG Non-preferred BrandRITALIN LA CP24 10MG Non-preferred BrandRITALIN LA CP24 20MG Non-preferred BrandRITALIN LA CP24 30MG Non-preferred BrandRITALIN LA CP24 40MG Non-preferred BrandRITALIN SR TBCR 20MG Non-preferred BrandROZEREM TABS 8MG Preferred BrandSAPHRIS SL TAB 5 MG Non-preferred BrandSAPHRIS SL TAB 10 MG Non-preferred BrandSARAFEM TABS 10MG Non-preferred BrandSARAFEM TABS 20MG Non-preferred BrandSAVELLA TABS 100MG Non-preferred Brand PASAVELLA TABS 12.5MG Non-preferred Brand PASAVELLA PACK 12.5MG,25MG, 50MGNon-preferred Brand PASAVELLA TABS 25MG Non-preferred Brand PA

SAVELLA TABS 50MG Non-preferred Brand PASELFEMRA CAPS 10MG GenericSELFEMRA CAPS 20MG GenericSEROQUEL TABS 100MG Preferred BrandSEROQUEL TABS 200MG Preferred BrandSEROQUEL TABS 25MG Preferred BrandSEROQUEL TABS 300MG Preferred BrandSEROQUEL TABS 400MG Preferred BrandSEROQUEL TABS 50MG Preferred BrandSEROQUEL XR TB24

cy2010 pdf 10059-24 · title: cy2010 pdf 10059-24.xls author: ï¿½ï¿½lidbnbj created date:...

Documents