2019 CDPHP® Commercial Clinical Formulary- 2/media/Files/pharmacy/Formulary-2.pdf · ATTENZIONE:...

2019 CDPHP Commercial Formulary 2

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2019 CDPHP Commercial Clinical Formulary- 2

(Effective 1-1-2019)

NON-DISCRIMINATION/MULTI-LANGUAGE INTERPRETER SERVICES: APPLIES TO MEMBERS/ENROLLEES ONLY

Discrimination is Against the Law Capital District Physicians Health Plan, Inc. (CDPHP) complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. CDPHP does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.

CDPHP: Provides free aids and services to people with disabilities to communicate effectively with us, such as:

o Qualified sign language interpreterso Written information in other formats (large print, audio, accessible electronic formats,

other formats) Provides free language services to people whose primary language is not English, such as:

o Qualified interpreterso Information written in other languages

If you need these services, contact the CDPHP Civil Rights Coordinator.

If you believe that CDPHP has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: CDPHP Civil Rights Coordinator, 500 Patroon Creek Blvd., Albany, NY 12206, 1-844-391-4803 (TTY/TDD: 711), Fax (518) 641-3401. You can file a grievance by mail, fax, or electronically at https://www.cdphp.com/customer-support/email-cdphp. If you need help filing a grievance, the CDPHP Civil Rights Coordinator is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201, 1-800-868-1019 (TDD 1-800-537-7697).


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Multi-language Interpreter Services

ATTENTION: If you speak a non-English language, language assistance services, free of charge, are available to you. Call the number on your member ID card (TTY: 711).

ATENCIN: Si habla otro idioma que no es el ingls, tiene a su disposicin servicios gratuitos de asistencia lingstica. Llame al nmero que figura en su tarjeta de identificacin de miembro (TTY: 711).

ID 711

: , . ID (: 711).

ATANSYON: Si ou pale yon lang ki pa Angle, wap jwenn svis asistans lang gratis disponib pou ou. Rele nimewo ki sou kat ID manm ou a (TTY: 711).

: . ID (TTY: 711).

ATTENZIONE: Se non parla inglese n una lingua anglofona, sono disponibili servizi gratuiti di assistenza linguistica. Chiami il numero presente sulla scheda ID dei membri (TTY: 711).

. , : ) TTY:711( ID

, (TTY: 711(

UWAGA: Jeeli mwisz po polsku, moesz skorzysta z bezpatnej pomocy jzykowej. Zadzwo pod numer na Twojej czonkowskiej karcie ID (TTY: 711).

. : )TTY :711 .(

ATTENTION : Si vous parlez franais, des services d'aide linguistique vous sont proposs gratuitement. Appelez au numro indiqu sur votre carte de membre (ATS : 711).

: )TTY: 711 (

ATENSYON: Kung nagsasalita kayo ng wikang iba sa Ingles, magagamit niyo ang mga serbisyo sa tulong sa wika nang walang bayad. Tawagan ang numero sa inyong card miyembro ID (TTY: 711).

: , . (TTY: 711).

VINI RE: Nse flisni nj gjuh jo-anglisht, shrbime falas t ndihms s gjuhs jan n dispozicion pr ju. Telefonojini numrit n kartn tuaj t ID t antarit (TTY: 711).


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CDPHP Commercial Formulary 2

INTRODUCTION CDPHP (Capital District Physicians' Health Plan, Inc. and CDPHP Universal Benefits, Inc.) is pleased to provide the CDPHP Commercial Formulary 2 as a useful reference and informational tool to assist practitioners in selecting clinically appropriate and cost-effective drug therapies.

The information contained in this CDPHP Commercial Formulary 2 and its appendices is provided by CDPHP, solely for the convenience of medical practitioners. CDPHP does not warrant or assure accuracy of such information. This CDPHP Commercial Formulary 2 is not intended to be a substitute for the knowledge, expertise, skill, and judgment of the medical practitioner in his/her choice of prescription drugs. All the information in the CDPHP Commercial Formulary 2 is provided as a reference for drug therapy selection. Specific drug selection for an individual patient rests solely with the prescriber. The document is subject to state-specific regulations and rules, including, but not limited to, those regarding generic substitution, controlled substance schedules, preference for brands and mandatory generics whenever applicable.

CDPHP assumes no responsibility for the actions or omissions of any medical practitioner based upon reliance, in whole or in part, on the information contained herein. The medical practitioner should consult the drug manufacturer's product literature or standard references for more detailed information.

National guidelines can be found on the National Guideline Clearinghouse site at http://www.guideline.gov.

Please note, the information found in the CDPHP Commercial Formulary 2 does not apply to any of the CDPHP Medicare or Medicaid products that offer prescription drug benefits. For information on these plans, please visit the Medicare or Medicaid Information section on http://www.cdphp.com.

PREFACE The CDPHP Commercial Formulary 2 represents CDPHP's prescription drug formulary and is organized by sections. The first section includes a list of CDPHP drugs requiring prior authorization. Thereafter, each section is divided by therapeutic drug class primarily defined by mechanism of action. Products are listed alphabetically within each tier. This is a comprehensive list, only dosage forms and strengths of the drug cited are included in the CDPHP Commercial Formulary 2. Generics should be considered the first line of prescribing.

The CDPHP formulary is a closed formulary. In a closed formulary, drugs are either covered or excluded (not covered). Excluded products are only available by medical exception. Coverage of any agent listed in the formulary is subject to the member's contract. Quantity limits, prior authorization, dose optimization, and/or step therapy requirements may apply. Non self-administered Injectables are generally covered under the medical benefit. Injectables that are listed in the CDPHP Commercial Formulary 2 are covered under the prescription drug coverage section of the member contract. In addition, over-the-counter (OTC) products, with the exception of insulin and diabetes monitoring products, are usually not covered. Enteral nutrition products which have been authorized for coverage will have a tier 3 cost share unless otherwise specified in the member contract.

Drugs represented in the CDPHP Commercial Formulary 2 may have varying cost to the member. Tier 1 medications are available at the lowest cost, and tier 3 medications and medications not on the list will cost the most.


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The tiered format places drugs into tiers in the following manner: Tier 1: Generic prescription drugs which offer the most cost-effective alternative to available brand-name prescription

drug products. It may also include those brand-name prescription drug products determined by the Plan's Pharmacy and Therapeutics (P&T) Committee to be included in quality initiative programs.

Tier 2: Preferred brand-name prescription drug products which offer overall clinical and/or financial value. Selected generic prescription drug products may also be included in this tier if they are not as cost effective as a tier 1 generic drug.

Tier 3: All other covered brand-name or generic prescription drugs which do not offer significant clinical and/or cost advantages over a tier 1 or a tier 2 drug.

Due to Federal and New York State mandates, certain drug classes will have no member cost share or a reduced member cost share than what is stated in this document. Examples of these drug classes include, but are not limited to, diabetic drugs, oral contraceptives and oral oncology drugs.

Please note that all new drugs will be excluded from the formulary and require prior authorization until reviewed by the CDPHP P&T Committee.

PHARMACY AND THERAPEUTICS (P&T) COMMITTEE The CDPHP P&T Committee includes a cross-section of practicing network physicians and pharmacists whose primary role on the committee is to ensure that the most clinically appropriate and cost-effective drugs will be available for CDPHP members. The P&T Committee is responsible for reviewing new drugs, reviewing and revising pharmacy policies, reviewing patient profiles and drug utilization review quarterly reports, and reviewing clinical initiatives/programs for all lines of business. The members of the P&T Committee are bound by a confidentiality and conflict of interest agreement, which is renewed annually.

The actions of the CDPHP P&T Committee are communicated after each committee meeting by posting final decisions on the CDPHP Web page Formulary Updates section of Rx Corner on the Providers tab of http://www.cdphp.com.

PRODUCT SELECTION CRITERIA All new drugs will be excluded from the formulary and require prior authorization review until reviewed by the P&T Committee. CDPHP P&T Committee will consider inclusion to the formulary based on CVS Caremark's recommendations.

When a new drug is considered for formulary inclusion, it will be reviewed relative to similar drugs currently on formulary. In addition, the entire CDPHP formulary is reviewed on an annual basis.

Quantity limitations, prior authorizations, dose optimization, and/or step therapy may also apply to formulary drugs. Excluded drugs are not covered unless medical exception procedures have been followed and a medical exception is approved. Please note that certain drugs are additionally excluded in member contracts (e.g., cosmetic agents).

GENERIC SUBSTITUTION Generic substitution is a pharmacy action whereby a generic version is dispensed rather than a prescribed brand-name product. Drugs Listed on the formulary in lower case indicate generic drug and listings in upper case indicate Brand drug.

One way to reduce out-of-pocket cost is by requesting a generic drug. Generic drugs are usually priced lower than their brand-name equivalents. Research shows that members can save an average of 30-80% when they fill their prescriptions with a generic drug instead of a brand-name drug.


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Prescription generic drugs undergo a strict U.S. Food and Drug Administration (FDA) approval process. Here are just some of the FDA standards and practices that generic manufacturers must follow:

A generic medicine must be bioequivalent (performs in the same manner) to its brand-name counterpart. A generic medicine must pass the FDA's review for both active and inactive ingredients. The manufacturer facility of the generic medicine must pass FDA inspection. The generic medicine must have the same active ingredients and be available in the same strength and dosage

form as its brand-name counterpart. The label of the generic medicine must include the same information found on the packaging of its brand-name

counterpart. Finally, the FDA continues to monitor the generic drug for quality control after it has been approved (http://www.fda.gov).

The FDA is very strict in their review of a generic medicine before it goes to market. In most cases, the average person would not be able to tell the difference between a generic and a brand-name drug, other than the size, color, or shape. U.S. trademark laws require that generics look different from their brand-name equivalents.

SPECIALTY DRUGS (SP) Specialty pharmaceuticals are used in the management of complex chronic or genetic conditions and certain catastrophic diseases. They are often injectable medications, but they may also include oral agents. CDPHP has chosen CVS Caremark Specialty Pharmacy Services to dispense certain high-cost injectables and biotech drugs for its members. Eligible members will need to register and will receive a 30-day supply of medications and additional supplies needed to administer the medications.

Getting started with CVS Caremark Specialty Pharmacy Services is easy. There are three different options for contacting them: by phone toll-free at 1-800-237-2767; by fax toll-free at 1-800-323-2445; or online at http://www.caremark.com. CVS Caremark provides side-effect counseling, condition-specific materials, refill reminder calls, and access to health care professionals for emergency consultation 24 hours a day, seven days a week. CVS Caremark also provides Patient Resource Centers online at http://www.caremark.com. CDPHP members can access the latest news, helpful tips, interactive tools, drug information, safety alerts, support groups, links to communities, as well as other useful resources. For a complete list of specialty medications, visit Providers tab/Rx Corner/Specialty Pharmacy at http://www.cdphp.com. Drugs that are available to be filled through CVS Caremark Specialty Pharmacy services are noted within this booklet by the "SP" symbol, and drugs which are required to be filled through CVS Caremark Specialty Pharmacy are noted by the symbol "SPC." CVS Caremark Specialty Pharmacy can be contacted by calling toll-free at 1-800-237-2767.

PRIOR AUTHORIZATION (PA) CDPHP requires prior authorization for certain drugs before they will be approved for coverage. Coverage will be approved when specific approval criteria for that drug is met, according to CDPHP policies.

The list of drugs that require prior authorization is subject to change from time to time and may not be all-inclusive. Drugs that require prior authorization are noted within this booklet by the "PA" symbol.

Prior authorization can be requested through the CDPHP Pharmacy Department by faxing the request to (518) 641-3208.


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PRESCRIPTION QUANTITY MANAGEMENT CDPHP, working closely with the P&T Committee members, has chosen to limit the quantity of certain drugs that CDPHP may cover for a member. Quantity limits are in place for quality and/or clinical considerations. The list of drugs that have quantity limits is subject to change from time to time and may not be all-inclusive. Drugs that have quantity limits are noted within this booklet by the "QL" symbol.

DOSE OPTIMIZATION Dose optimization is a program to support appropriate and cost-effective drug therapy by recommending a higher once-daily dose of a product when members are taking multiple-daily doses of a lower strength. For example, a member may be taking two 20 mg tablets of a drug per day when only one 40 mg tablet could be used. If a practitioner determines that multiple daily doses are medically necessary, please submit the CDPHP Medical Exception Form by fax to (518) 641-3208 for consideration.

STEP THERAPY (ST) The Step Therapy (ST) program is another form of prior authorization. The step therapy program uses a standard protocol to determine if members qualify for a drug that otherwise would not be covered. Using the standard protocol, certain drugs are not covered unless members have tried one or more "prerequisite therapy" medication(s) first.

Drugs that require step therapy are noted within this booklet by the "ST" symbol. The list of drugs that require step therapy is subject to change from time to time and may not be all-inclusive.

If it is medically necessary for a member to use a step therapy medication as initial therapy without trying a "prerequisite therapy" drug, the practitioner can request coverage of the step therapy medication by submitting the CDPHP Medical Exception Form by fax to (518) 641-3208 for consideration.


MEDICAL EXCEPTION PROCESS The CDPHP P&T Committee developed the Medical Exception policy so that practitioners may request an excluded drug for a specific patient when medically necessary. The Medical Exception process is coordinated through CDPHP's Pharmacy Department. Requests are processed in the order received. Medical exceptions can be requested through the CDPHP Pharmacy Department by faxing the request to (518) 641-3208. In addition, a member may initiate a medical exception request by calling the telephone number to CVS Caremark printed on their CDPHP identification card or by utilizing the "Medical Exception Request" option found under Prescription Forms & Lists on the Forms and Tools section on the members tab of CDPHP's website, www.cdphp.com. A response will be sent to both the medical practitioner and member as soon as possible.

EDITOR Your comments and suggestions regarding the CDPHP Commercial Formulary 2 are encouraged. Your input is vital to this formulary's continued success. All responses will be reviewed and considered. Please send your comments to:

CDPHP Pharmacy Department 500 Patroon Creek Boulevard Albany, NY 12206-1057 Email: [email protected] www.cdphp.com

NOTICE The information contained in this document is proprietary. The information may not be copied in whole or in part without the written permission of Capital District Physicians' Health Plan, Inc., Capital Physicians' Healthcare Network, Inc., and CDPHP Universal Benefits, Inc. (collectively known as CDPHP). 2013. All rights reserved.

The drug names listed here are the registered and/or unregistered trademarks of third-party pharmaceutical companies unrelated to and unaffiliated with CDPHP. These trademarked brand names are included here for informational purposes only and are not intended to imply or suggest any affiliation between CDPHP and such third party pharmaceutical companies.

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Drug Name Drug Tier Requirements/LimitsANALGESICS

COX-II INHIBITORScelecoxib cap 50 mg 2 QL (60 caps / 30 days)celecoxib cap 100 mg 2 QL (60 caps / 30 days)celecoxib cap 200 mg 2 QL (60 caps / 30 days)celecoxib cap 400 mg 2 QL (60 caps / 30 days)

GOUTallopurinol tab 100 mg 1allopurinol tab 300 mg 1colchicine cap 0.6 mg 2colchicine tab 0.6 mg 2colchicine w/ probenecid tab 0.5-500 mg 1probenecid tab 500 mg 1ULORIC TAB 40MG 3ULORIC TAB 80MG 3

NON-OPIOID ANALGESICSbutalbital-acetaminophen-caffeine cap 50-300-40 mg

1

butalbital-acetaminophen-caffeine tab 50-325-40 mg

1

butalbital-aspirin-caffeine cap 50-325-40 mg

1

NSAIDSdiclofenac potassium tab 50 mg 1diclofenac sodium tab delayed release 25 mg

1

diclofenac sodium tab delayed release 50 mg

1

diclofenac sodium tab delayed release 75 mg

1

diclofenac sodium tab er 24hr 100 mg 1diflunisal tab 500 mg 1etodolac cap 200 mg 1etodolac cap 300 mg 1etodolac tab 400 mg 1etodolac tab 500 mg 1fenoprofen calcium tab 600 mg 2flurbiprofen tab 50 mg 1flurbiprofen tab 100 mg 1ibu tab 400mg 1ibu tab 600mg 1ibu tab 800mg 1ibuprofen susp 100 mg/5ml 1 OTC

1

ibuprofen tab 400 mg 1ibuprofen tab 600 mg 1ibuprofen tab 800 mg 1indomethacin cap 25 mg 1indomethacin cap 50 mg 1indomethacin cap er 75 mg 1ketoprofen cap 50 mg 1ketoprofen cap 75 mg 1ketoprofen cap er 24hr 200 mg 1ketorolac tromethamine tab 10 mg 1 QL (20 tabs / 30 days)meclofenamate sodium cap 50 mg 1meclofenamate sodium cap 100 mg 1mefenamic acid cap 250 mg 2meloxicam tab 7.5 mg 1meloxicam tab 15 mg 1nabumetone tab 500 mg 1nabumetone tab 750 mg 1naproxen dr tab 375mg 1naproxen dr tab 500mg 1naproxen sodium tab 275 mg 1naproxen sodium tab 550 mg 1naproxen susp 125 mg/5ml 1naproxen tab 250 mg 1naproxen tab 375 mg 1naproxen tab 500 mg 1oxaprozin tab 600 mg 1piroxicam cap 10 mg 1piroxicam cap 20 mg 1sulindac tab 150 mg 1sulindac tab 200 mg 1tolmetin sodium cap 400 mg 1tolmetin sodium tab 200 mg 1tolmetin sodium tab 600 mg 1

NSAIDS, COMBINATIONSdiclofenac w/ misoprostol tab delayed release 50-0.2 mg

3

diclofenac w/ misoprostol tab delayed release 75-0.2 mg

3

NSAIDS, TOPICALdiclofenac sodium gel 1% 2 QL (1000 gm / 30 days)

OPIOID ANALGESICSacetaminophen w/ codeine soln 120-12 mg/5ml

1 QL (3750 mL / 30 days)

acetaminophen w/ codeine tab 300-15 mg 1 QL (300 tabs / 30 days)2

acetaminophen w/ codeine tab 300-30 mg 1 QL (300 tabs / 30 days)acetaminophen w/ codeine tab 300-60 mg 1 QL (300 tabs / 30 days)buprenorphine td patch weekly 5 mcg/hr 3 QL (4 ea / 30 days)buprenorphine td patch weekly 10 mcg/hr 3 QL (4 ea / 30 days)buprenorphine td patch weekly 15 mcg/hr 3 QL (4 ea / 30 days)buprenorphine td patch weekly 20 mcg/hr 3 QL (4 ea / 30 days)butalbital-acetaminophen-caff w/ cod cap 50-325-40-30 mg

1 QL (90 / 30 days)

butorphanol tartrate nasal soln 10 mg/ml 1 QL (5mL / 30 days)BUTRANS DIS 5MCG/HR 3 QL (4 patches / 30

days)BUTRANS DIS 7.5/HR 3 QL (4 patches / 30

days)BUTRANS DIS 10MCG/HR 3 QL (4 patches / 30



days)codeine sulfate tab 30 mg 3EMBEDA CAP 30-1.2MG 3 QL (60 caps / 30 days),

PAendocet tab 5-325mg 1 QL (300 tabs / 30 days)endocet tab 7.5-325 1 QL (300 tabs / 30 days)endocet tab 10-325mg 1 QL (240 tabs / 30 days)fentanyl citrate lozenge on a handle 200 mcg

1 QL (120 lpop / 30 days), PA

fentanyl citrate lozenge on a handle 400 mcg










fentanyl td patch 72hr 12 mcg/hr 1 QL (10 patches / 30 days), PA




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hydrocodone-acetaminophen soln 7.5-325 mg/15ml

1 QL (4500mL / 30 days)

hydrocodone-acetaminophen tab 5-325 mg1 QL (300 tabs / 30 days)hydrocodone-acetaminophen tab 7.5-325 mg

1 QL (300 tabs / 30 days)

hydrocodone-acetaminophen tab 10-325 mg


hydrocodone-ibuprofen tab 7.5-200 mg 1 QL (180 tabs / 30 days)hydromorphone hcl liqd 1 mg/ml 1 QL (180 mL / 30 days)hydromorphone hcl tab 2 mg 1 QL (180 tabs / 30 days)hydromorphone hcl tab 4 mg 1 QL (180 tabs / 30 days)hydromorphone hcl tab 8 mg 1 QL (120 tabs / 30 days),

PAhydromorphone hcl tab er 24hr deter 8 mg 3 QL (60 tabs / 30 days),

PAhydromorphone hcl tab er 24hr deter 12 mg

3 QL (60 tabs / 30 days), PA

hydromorphone hcl tab er 24hr deter 16 mg


hydromorphone hcl tab er 24hr deter 32 mg


methadone hcl tab 5 mg 1 QL (90 tabs / 30 days), PA

methadone hcl tab 10 mg 1 QL (90 tabs / 30 days), PA

methadose tab 5mg 1 QL (90 tabs / 30 days), PA

morphine sulfate oral soln 10 mg/5ml 1 QL (900 mL / 30 days)morphine sulfate oral soln 20 mg/5ml 1 QL (900 mL / 30 days)morphine sulfate oral soln 100 mg/5ml (20 mg/ml)

1 QL (180 mL / 30 days)

morphine sulfate suppos 5 mg 1 QL (180 suppositories / 30 days)



morphine sulfate tab 15 mg 1 QL (180 tabs / 30 days)morphine sulfate tab 30 mg 1 QL (180 tabs / 30 days)morphine sulfate tab er 15 mg 1 QL (90 tabs / 30 days),

PAmorphine sulfate tab er 30 mg 1 QL (90 tabs / 30 days),

PA

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morphine sulfate tab er 60 mg 1 QL (60 ea / 30 days), PA

morphine sulfate tab er 100 mg 1 QL (60 ea / 30 days), PA

morphine sulfate tab er 200 mg 1 QL (60 tabs / 30 days), PA

nalbuphine hcl inj 10 mg/ml 1 PAnalbuphine hcl inj 20 mg/ml 1 PANUCYNTA ER TAB 50MG 3 QL (60 ea / 30 days),

PA, STNUCYNTA ER TAB 100MG 3 QL (60 ea / 30 days),

PA, STNUCYNTA ER TAB 150MG 3 QL (60 tabs / 30 days),



PA, STNUCYNTA TAB 50MG 2 PANUCYNTA TAB 75MG 2 PANUCYNTA TAB 100MG 2 PAoxycodone hcl cap 5 mg 1 QL (180 caps / 30 days)oxycodone hcl soln 5 mg/5ml 1 QL (900 mL / 30 days)oxycodone hcl tab 5 mg 1 QL (240 tabs / 30 days)oxycodone hcl tab 10 mg 1 QL (240 tabs / 30 days)oxycodone hcl tab 15 mg 1 QL (120 tabs / 30 days)oxycodone hcl tab 20 mg 1 QL (120 tabs / 30 days)oxycodone hcl tab 30 mg 1 QL (60 tabs / 30 days)oxycodone hcl tab er 12hr deter 10 mg 3 QL (90 tabs / 30 days),

PAoxycodone hcl tab er 12hr deter 15 mg 3 QL (90 tabs/ 30 days),

PAoxycodone hcl tab er 12hr deter 20 mg 3 QL (90 tabs / 30 days),



PAoxycodone w/ acetaminophen tab 2.5-325 mg


oxycodone w/ acetaminophen tab 5-325 mg


oxycodone w/ acetaminophen tab 7.5-325 mg


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oxycodone w/ acetaminophen tab 10-325 mg


oxycodone-aspirin tab 4.8355-325 mg 1 QL (360 tabs / 30 days)oxycodone-ibuprofen tab 5-400 mg 1 QL (270 tabs / 30 days)oxymorphone hcl tab 5 mg 1 QL (120 tabs / 30 days),

PAoxymorphone hcl tab 10 mg 1 QL (120 tabs / 30 days),

PAoxymorphone hcl tab er 12hr 5 mg 3 QL (60 tabs / 30 days),

PAoxymorphone hcl tab er 12hr 7.5 mg 3 QL (60 tabs / 30 days),






PAroxicet tab 5-325mg 1 QL (300 tabs / 30 days)tramadol hcl tab 50 mg 1 QL (240 tabs / 30 days)tramadol hcl tab er 24hr 100 mg 2 QL (30 tabs / 30 days)tramadol hcl tab er 24hr 200 mg 2 QL (30 tabs / 30 days)tramadol hcl tab er 24hr 300 mg 2 QL (30 tabs / 30 days)tramadol-acetaminophen tab 37.5-325 mg 1 QL (240 tabs / 30 days)

ANTI-INFECTIVESAMINOGLYCOSIDES

neomycin sulfate tab 500 mg 1paromomycin sulfate cap 250 mg 3 PAstreptomycin sulfate for inj 1 gm 2 PA

ANTIBACTERIALS, CEPHALOSPORINS, First Generationcefadroxil cap 500 mg 1cefadroxil for susp 250 mg/5ml 1cefadroxil for susp 500 mg/5ml 1cefadroxil tab 1 gm 1cephalexin cap 250 mg 1cephalexin cap 500 mg 1cephalexin for susp 125 mg/5ml 1cephalexin for susp 250 mg/5ml 1cephalexin tab 250 mg 1cephalexin tab 500 mg 1KEFLEX CAP 750MG 2

6

ANTIBACTERIALS, CEPHALOSPORINS, Fourth Generationcefepime hcl for inj 1 gm 2 PAcefepime hcl for inj 2 gm 2 PA

ANTIBACTERIALS, CEPHALOSPORINS, Second Generationcefaclor cap 250 mg 1cefaclor cap 500 mg 1CEFACLOR ER TAB 500MG 2cefaclor for susp 125 mg/5ml 1cefaclor for susp 250 mg/5ml 1cefaclor for susp 375 mg/5ml 1cefprozil for susp 125 mg/5ml 1cefprozil for susp 250 mg/5ml 1cefprozil tab 250 mg 1cefprozil tab 500 mg 1CEFTIN SUS 250/5ML 3cefuroxime axetil tab 250 mg 1cefuroxime axetil tab 500 mg 1

ANTIBACTERIALS, CEPHALOSPORINS, Third Generationcefdinir cap 300 mg 1cefdinir for susp 125 mg/5ml 1cefdinir for susp 250 mg/5ml 1cefditoren pivoxil tab 200 mg (base equivalent)

3

cefditoren pivoxil tab 400 mg (base equivalent)

3

cefixime for susp 100 mg/5ml 2cefixime for susp 200 mg/5ml 2cefpodoxime proxetil for susp 50 mg/5ml 1cefpodoxime proxetil for susp 100 mg/5ml 1cefpodoxime proxetil tab 100 mg 1cefpodoxime proxetil tab 200 mg 1ceftazidime for inj 1 gm 2 PAceftazidime for inj 2 gm 2 PAceftazidime for inj 6 gm 2 PAceftibuten cap 400 mg 3ceftriaxone sodium for inj 1 gm 2 PAceftriaxone sodium for inj 2 gm 2 PAceftriaxone sodium for inj 10 gm 2 PAceftriaxone sodium for inj 250 mg 2 PAceftriaxone sodium for inj 500 mg 2 PAceftriaxone sodium for iv soln 1 gm 2 PAceftriaxone sodium for iv soln 2 gm 2 PASUPRAX CAP 400MG 2SUPRAX CHW 100MG 2

7

SUPRAX CHW 200MG 2tazicef inj 1gm 3 PAtazicef inj 2gm 3 PA

ANTIBACTERIALS, ERYTHROMYCINS/MACROLIDESazithromycin for susp 100 mg/5ml 1azithromycin for susp 200 mg/5ml 1azithromycin powd pack for susp 1 gm 1azithromycin tab 250 mg 1azithromycin tab 500 mg 1azithromycin tab 600 mg 1clarithromycin for susp 125 mg/5ml 1clarithromycin for susp 250 mg/5ml 1clarithromycin tab 250 mg 1clarithromycin tab 500 mg 1clarithromycin tab er 24hr 500 mg 1DIFICID TAB 200MG 3 STe.e.s. 400 tab 400mg 1ery-tab tab 250mg ec 3ery-tab tab 333mg ec 3ery-tab tab 500mg ec 3ERYPED SUS 400/5ML 3erythrocin tab 250mg 1erythromycin ethylsuccinate for susp 200 mg/5ml

3

erythromycin ethylsuccinate tab 400 mg 1erythromycin tab 500 mg 1erythromycin w/ delayed release particles cap 250 mg

1

ANTIBACTERIALS, FLUOROQUINOLONESciprofloxacin for oral susp 250 mg/5ml (5%) (5 gm/100ml)

2

ciprofloxacin for oral susp 500 mg/5ml (10%) (10 gm/100ml)

2

ciprofloxacin hcl tab 100 mg (base equiv) 1ciprofloxacin hcl tab 250 mg (base equiv) 1ciprofloxacin hcl tab 500 mg (base equiv) 1ciprofloxacin hcl tab 750 mg (base equiv) 1ciprofloxacin-ciprofloxacin hcl tab er 24hr 500 mg (base eq)

1

ciprofloxacin-ciprofloxacin hcl tab er 24hr 1000 mg(base eq)

1

FACTIVE TAB 320MG 3levofloxacin oral soln 25 mg/ml 1levofloxacin tab 250 mg 1levofloxacin tab 500 mg 1

8

levofloxacin tab 750 mg 1moxifloxacin hcl tab 400 mg (base equiv) 2

ANTIBACTERIALS, KETOLIDESKETEK TAB 300MG 3 PAKETEK TAB 400MG 3 PA

ANTIBACTERIALS, PENICILLINSamoxicillin & k clavulanate chew tab 200-28.5 mg

1

amoxicillin & k clavulanate chew tab 400-57 mg

1

amoxicillin & k clavulanate for susp 200-28.5 mg/5ml

1


1

amoxicillin & k clavulanate for susp 400-57 mg/5ml

1


1

amoxicillin & k clavulanate tab 250-125 mg1amoxicillin & k clavulanate tab 500-125 mg1amoxicillin & k clavulanate tab 875-125 mg1amoxicillin & k clavulanate tab er 12hr 1000-62.5 mg

1

amoxicillin (trihydrate) cap 250 mg 1amoxicillin (trihydrate) cap 500 mg 1amoxicillin (trihydrate) chew tab 125 mg 1amoxicillin (trihydrate) chew tab 250 mg 1amoxicillin (trihydrate) for susp 125 mg/5ml

1

amoxicillin (trihydrate) for susp 200 mg/5ml

1


1


1

amoxicillin (trihydrate) tab 500 mg 1amoxicillin (trihydrate) tab 875 mg 1ampicillin cap 250 mg 1ampicillin cap 500 mg 1ampicillin for susp 125 mg/5ml 1ampicillin for susp 250 mg/5ml 1AUGMENTIN SUS 125/5ML 2dicloxacillin sodium cap 250 mg 1dicloxacillin sodium cap 500 mg 1penicillin v potassium for soln 125 mg/5ml 1

9

penicillin v potassium for soln 250 mg/5ml 1penicillin v potassium tab 250 mg 1penicillin v potassium tab 500 mg 1

ANTIBACTERIALS, SULFONAMIDESSULFADIAZINE TAB 500MG 3sulfamethoxazole-trimethoprim susp 200-40 mg/5ml

1

sulfamethoxazole-trimethoprim tab 400-80 mg

1

sulfamethoxazole-trimethoprim tab 800-160 mg

1

ANTIBACTERIALS, TETRACYCLINESdemeclocycline hcl tab 150 mg 1demeclocycline hcl tab 300 mg 1doxycycline monohydrate cap 50 mg 1doxycycline monohydrate cap 75 mg 3 STdoxycycline monohydrate cap 100 mg 1doxycycline monohydrate cap 150 mg 3 STminocycline hcl cap 50 mg 1minocycline hcl cap 75 mg 1minocycline hcl cap 100 mg 1tetracycline hcl cap 250 mg 3tetracycline hcl cap 500 mg 3

ANTIFUNGALSABELCET INJ 5MG/ML 2 PAAMPHOTEC INJ 50MG 3 PAAMPHOTEC INJ 100MG 3 PAamphotericin b for inj 50 mg 2 PAcaspofungin acetate for iv soln 50 mg 3 PAcaspofungin acetate for iv soln 70 mg 3 PAclotrimazole troche 10 mg 1CRESEMBA CAP 186 MG 3 PA, STERAXIS INJ 50MG 3 PAERAXIS INJ 100MG 3 PAfluconazole for susp 10 mg/ml 1fluconazole for susp 40 mg/ml 1fluconazole tab 50 mg 1fluconazole tab 100 mg 1fluconazole tab 150 mg 1fluconazole tab 200 mg 1flucytosine cap 250 mg 3 PAgriseofulvin microsize susp 125 mg/5ml 1griseofulvin microsize tab 500 mg 3griseofulvin ultramicrosize tab 125 mg 3

10

griseofulvin ultramicrosize tab 250 mg 3itraconazole cap 100 mg 2itraconazole oral soln 10 mg/ml 3ketoconazole tab 200 mg 1NOXAFIL SUS 40MG/ML 3NOXAFIL TAB 100MG 3nystatin oral powder 1nystatin susp 100000 unit/ml 1nystatin tab 500000 unit 1terbinafine hcl tab 250 mg 1voriconazole tab 50 mg 3voriconazole tab 200 mg 3

ANTIMALARIALSatovaquone-proguanil hcl tab 62.5-25 mg 2atovaquone-proguanil hcl tab 250-100 mg 2chloroquine phosphate tab 250 mg 1chloroquine phosphate tab 500 mg 1COARTEM TAB 20-120MG 3mefloquine hcl tab 250 mg 1PRIMAQUINE TAB 26.3MG 3quinine sulfate cap 324 mg 3

ANTIRETROVIRALS, ANTIRETROVIRAL ADJUVANTSTYBOST TAB 150MG 2 SP

ANTIRETROVIRALS, ANTIRETROVIRAL COMBINATIONSabacavir sulfate-lamivudine tab 600-300 mg

2

abacavir sulfate-lamivudine-zidovudine tab 300-150-300 mg

2 SP

ATRIPLA TAB 2 SPBIKTARVY TAB 2 SPCIMDUO TAB 300-300 2 SPCOMPLERA TAB 2 SPDESCOVY TAB 200/25 2EVOTAZ TAB 300-150 2 SPGENVOYA TAB 2JULUCA TAB 50-25MG 2lamivudine-zidovudine tab 150-300 mg 2 SPODEFSEY TAB 2PREZCOBIX TAB 800-150 2 SPSTRIBILD TAB 2 SPSYMFI LO TAB 2 SPSYMFI TAB 2 SPTRIUMEQ TAB 2 SPTRUVADA TAB 100-150 2

11

TRUVADA TAB 133-200 2TRUVADA TAB 167-250 2TRUVADA TAB 200-300 2 SP

ANTIRETROVIRALS, CHEMOKINE RECEPTOR ANTAGONISTSSELZENTRY SOL 20MG/ML 2SELZENTRY TAB 25MG 2SELZENTRY TAB 75MG 2SELZENTRY TAB 150MG 2SELZENTRY TAB 300MG 2

ANTIRETROVIRALS, FUSION INHIBITORSFUZEON INJ 90MG 3 SPC

ANTIRETROVIRALS, INTEGRASE INHIBITORSISENTRESS CHW 25MG 2 SPISENTRESS CHW 100MG 2 SPISENTRESS HD TAB 600MG 2ISENTRESS POW 100MG 2 SPISENTRESS TAB 400MG 2 SPTIVICAY TAB 10MG 2TIVICAY TAB 25MG 2TIVICAY TAB 50MG 2VITEKTA TAB 85MG 2VITEKTA TAB 150MG 2

ANTIRETROVIRALS, NON-NUCLEOSIDE REVERSE TRANSCRIPTASE INHIBITORS

EDURANT TAB 25MG 2 SPefavirenz cap 50 mg 2efavirenz cap 200 mg 2efavirenz tab 600 mg 2INTELENCE TAB 25MG 2 SPINTELENCE TAB 100MG 2 SPINTELENCE TAB 200MG 2 SPnevirapine susp 50 mg/5ml 2 SPnevirapine tab 200 mg 1 SPnevirapine tab er 24hr 400 mg 2RESCRIPTOR TAB 100 MG 2 SPRESCRIPTOR TAB 200MG 2 SP

ANTIRETROVIRALS, NUCLEOSIDE REVERSE TRANSCRIPTASE INHIBITORS

abacavir sulfate soln 20 mg/ml (base equiv)

2

abacavir sulfate tab 300 mg (base equiv) 2 SPdidanosine delayed release capsule 200 mg1 SPdidanosine delayed release capsule 250 mg1 SPdidanosine delayed release capsule 400 mg1 SP12

EMTRIVA CAP 200MG 2 SPEMTRIVA SOL 10MG/ML 2 SPlamivudine oral soln 10 mg/ml 2 SPlamivudine tab 150 mg 2 SPlamivudine tab 300 mg 2 SPstavudine cap 15 mg 1 SPstavudine cap 20 mg 1 SPstavudine cap 30 mg 1 SPstavudine cap 40 mg 1 SPVIDEX EC CAP 125MG 2 SPVIDEX SOL 2GM 2 SPVIDEX SOL 4GM 2 SPzidovudine cap 100 mg 1 SPzidovudine syrup 10 mg/ml 1 SPzidovudine tab 300 mg 1 SP

ANTIRETROVIRALS, NUCLEOTIDE REVERSE TRANSCRIPTASE INHIBITORS

tenofovir disoproxil fumarate tab 300 mg 2VIREAD POW 40MG/GM 2 SPVIREAD TAB 150MG 2 SPVIREAD TAB 200MG 2 SPVIREAD TAB 250MG 2 SP

ANTIRETROVIRALS, PROTEASE INHIBITORSAPTIVUS CAP 250MG 2 SPAPTIVUS SOL 2 SPatazanavir sulfate cap 150 mg (base equiv)2atazanavir sulfate cap 200 mg (base equiv)2atazanavir sulfate cap 300 mg (base equiv)2CRIXIVAN CAP 200MG 2 SPCRIXIVAN CAP 400MG 2 SPfosamprenavir calcium tab 700 mg (base equiv)

2

INVIRASE CAP 200MG 2 SPINVIRASE TAB 500MG 2 SPKALETRA TAB 100-25MG 2 SPKALETRA TAB 200-50MG 2 SPLEXIVA SUS 50MG/ML 2 SPlopinavir-ritonavir soln 400-100 mg/5ml (80-20 mg/ml)

2 SP

NORVIR CAP 100MG 2 SPNORVIR SOL 80MG/ML 2 SPPREZISTA TAB 75MG 2 SPPREZISTA TAB 150MG 2 SPPREZISTA TAB 600MG 2 SP

13

PREZISTA TAB 800MG 2 SPREYATAZ POW 50MG 2 SPritonavir tab 100 mg 2 SPVIRACEPT TAB 250MG 2 SPVIRACEPT TAB 625MG 2 SP

ANTITUBERCULAR AGENTScycloserine cap 250 mg 1ethambutol hcl tab 100 mg 1ethambutol hcl tab 400 mg 1isoniazid syrup 50 mg/5ml 1isoniazid tab 100 mg 1isoniazid tab 300 mg 1PASER GRA 4GM 3PRIFTIN TAB 150MG 2pyrazinamide tab 500 mg 1RIFAMATE CAP 3rifampin cap 150 mg 1rifampin cap 300 mg 1RIFATER TAB 2SIRTURO TAB 100MG 3 PATRECATOR TAB 250MG 3

ANTIVIRALS, CYTOMEGALOVIRUS AGENTSPREVYMIS TAB 240MG 3 PAPREVYMIS TAB 480MG 3 PAvalganciclovir hcl tab 450 mg (base equivalent)

3 PA

ANTIVIRALS, HEPATITIS AGENTS, Hepatitis Badefovir dipivoxil tab 10 mg 3 PA; SPBARACLUDE SOL .05MG/ML 2 SPentecavir tab 0.5 mg 2entecavir tab 1 mg 2EPIVIR HBV SOL 5MG/ML 2 SPlamivudine tab 100 mg (hbv) 2 SPTYZEKA TAB 600MG 3 PA; SP

ANTIVIRALS, HEPATITIS AGENTS, Hepatitis CMAVYRET TAB 100-40MG 3 PA; SPCOLYSIO CAP 150MG 3 PA; (MNPA); SPCREBETOL SOL 40MG/ML 3 PA; SPCRIBAPAK TAB 600/DAY 3 PA; SPCribasphere cap 200mg 3 PA; SPCribasphere tab 200mg 3 PA; SPCribasphere tab 400mg 3 PA; SPCribavirin cap 200 mg 3 PA; SPCribavirin tab 200 mg 3 PA; SPC

14

ribavirin tab 600 mg 3 PA; SPCANTIVIRALS, HERPES AGENTS

acyclovir cap 200 mg 1acyclovir susp 200 mg/5ml 1acyclovir tab 400 mg 1acyclovir tab 800 mg 1famciclovir tab 125 mg 1famciclovir tab 250 mg 1famciclovir tab 500 mg 1valacyclovir hcl tab 1 gm 1valacyclovir hcl tab 500 mg 1

ANTIVIRALS, INFLUENZA AGENTSoseltamivir phosphate cap 30 mg (base equiv)

2 QL (28 caps / 180 days)

oseltamivir phosphate cap 45 mg (base equiv)


oseltamivir phosphate cap 75 mg (base equiv)


oseltamivir phosphate for susp 6 mg/ml (base equiv)

2 QL (180 mL / 180 days)

RELENZA MIS DISKHALE 2 QL (2 inhalers / 180 days)

rimantadine hydrochloride tab 100 mg 1TAMIFLU CAP 30MG 2 QL (28 caps / 180

days); Excluded for New Starts

TAMIFLU CAP 45MG 2 QL (14 caps / 180 days); Excluded for New Starts

TAMIFLU CAP 75MG 2 QL (14 caps / 180 days); Excluded for New Starts

MISCELLANEOUSalbendazole tab 200 mg 3ALINIA SUS 100/5ML 2ALINIA TAB 500MG 2atovaquone susp 750 mg/5ml 3 PAaztreonam for inj 1 gm 3 PAaztreonam for inj 2 gm 3 PAclindamycin hcl cap 75 mg 1clindamycin hcl cap 150 mg 1clindamycin hcl cap 300 mg 1clindamycin palmitate hcl for soln 75 mg/5ml (base equiv)

1

dapsone tab 25 mg 115

dapsone tab 100 mg 1daptomycin for iv soln 500 mg 3 PADARAPRIM TAB 25MG 3 PAivermectin tab 3 mg 3linezolid for susp 100 mg/5ml 2linezolid tab 600 mg 2methenamine hippurate tab 1 gm 1metronidazole cap 375 mg 1metronidazole tab 250 mg 1metronidazole tab 500 mg 1MONUROL PAK GRANULES 3NEBUPENT INH 300MG 3nitrofurantoin macrocrystalline cap 25 mg 2nitrofurantoin macrocrystalline cap 50 mg 1nitrofurantoin macrocrystalline cap 100 mg 1nitrofurantoin monohydrate macrocrystalline cap 100 mg

1

praziquantel tab 600 mg 3PRIMSOL SOL 50MG/5ML 3rifabutin cap 150 mg 3tinidazole tab 250 mg 2tinidazole tab 500 mg 2trimethoprim tab 100 mg 1vancomycin hcl cap 125 mg (base equivalent)

3

vancomycin hcl cap 250 mg (base equivalent)

3

XIFAXAN TAB 200MG 3 QL (126 tabs / 30 days)XIFAXAN TAB 550MG 3

ANTINEOPLASTIC AGENTSALKYLATING AGENTS

CEENU CAP 10MG 2CEENU CAP 40MG 2CEENU CAP 100MG 2cyclophosphamide cap 25 mg 2cyclophosphamide cap 50 mg 2EMCYT CAP 140MG 2GLIADEL WAF 7.7MG 2HEXALEN CAP 50MG 2LEUKERAN TAB 2MG 2melphalan tab 2 mg 2MYLERAN TAB 2MG 2temozolomide cap 5 mg 3 PA; SPCtemozolomide cap 20 mg 3 PA; SPCtemozolomide cap 100 mg 3 PA; SPC16

temozolomide cap 140 mg 3 PA; SPCtemozolomide cap 180 mg 3 PA; SPCtemozolomide cap 250 mg 3 PA; SPCVALCHLOR GEL 0.016% 3 PAZANOSAR INJ 1GM 3 PA

ANTIBIOTICSmitoxantrone hcl inj conc 20 mg/10ml (2 mg/ml)

3 PA

mitoxantrone hcl inj conc 25 mg/12.5ml (2 mg/ml)

3 PA

mitoxantrone hcl inj conc 30 mg/15ml (2 mg/ml)

3 PA

ANTIMETABOLITEScapecitabine tab 150 mg 3 PA; SPCcapecitabine tab 500 mg 3 PA; SPCDEPOCYT INJ 50MG/5ML 3mercaptopurine tab 50 mg 1methotrexate sodium tab 2.5 mg (base equiv)

1

PURIXAN SUS 20MG/ML 2 SPCTABLOID TAB 40MG 3

HORMONAL ANTINEOPLASTICS, ANTIANDROGENSbicalutamide tab 50 mg 1flutamide cap 125 mg 1nilutamide tab 150 mg 2 Excluded for new startsXTANDI CAP 40MG 3 PA; Excluded for New

Starts; SPCZYTIGA TAB 250MG 2 PA; SPCZYTIGA TAB 500MG 2 PA; SPC

HORMONAL ANTINEOPLASTICS, ANTIESTROGENSFARESTON TAB 60MG 2tamoxifen citrate tab 10 mg (base equivalent)

1 ACA

tamoxifen citrate tab 20 mg (base equivalent)

1 ACA

HORMONAL ANTINEOPLASTICS, AROMATASE INHIBITORSanastrozole tab 1 mg 1exemestane tab 25 mg 2letrozole tab 2.5 mg 1

HORMONAL ANTINEOPLASTICS, GONADOTROPIN RELEASING HORMONE ANTAGONISTS

FIRMAGON INJ 80MG 3 PA; SPCFIRMAGON INJ 120MG 3 PA; SPC

17

HORMONAL ANTINEOPLASTICS, LUTEINIZING HORMONE-RELEASING HORMONE (LHRH) AGONISTS

leuprolide acetate inj kit 5 mg/ml 3 SPCLUPRON DEPOT INJ 3.75MG 3 SPCLUPRON DEPOT INJ 11.25MG 3 SPCLUPRON DEPOT INJ 22.5MG 3 SPCLUPRON DEPOT INJ 30MG 3 SPCLUPRON DEPOT INJ 45MG 3 SPC

HORMONAL ANTINEOPLASTICS, PROGESTINSmegestrol acetate tab 20 mg 1megestrol acetate tab 40 mg 1

IMMUNOMODULATORSPOMALYST CAP 1MG 3 PA; (MNPA), SPCREVLIMID CAP 2.5MG 3 PA; SPCREVLIMID CAP 5MG 3 PA; SPCREVLIMID CAP 10MG 3 PA; SPCREVLIMID CAP 15MG 3 PA; SPCREVLIMID CAP 25MG 3 PA; SPCTHALOMID CAP 50MG 3 PA; SPCTHALOMID CAP 100MG 3 PA; SPCTHALOMID CAP 150MG 3 PA; SPCTHALOMID CAP 200MG 3 PA; SPC

KINASE INHIBITORSAFINITOR DIS TAB 2MG 3 PA; SPCAFINITOR DIS TAB 3MG 3 PA; SPCAFINITOR DIS TAB 5MG 3 PA; SPCAFINITOR TAB 2.5MG 3 PA; SPCAFINITOR TAB 5MG 3 PA; SPCAFINITOR TAB 7.5MG 3 PA; SPCAFINITOR TAB 10MG 3 PA; SPCALECENSA CAP 150MG 3 PA; SPCBOSULIF TAB 100MG 3 PA; SPCBOSULIF TAB 400MG 3 PA; SPCBOSULIF TAB 500MG 3 PA; SPCCABOMETYX TAB 20MG 3 PA; SPCCABOMETYX TAB 40MG 3 PA; SPCCABOMETYX TAB 60MG 3 PA; SPCCAPRELSA TAB 100MG 3 PACAPRELSA TAB 300MG 3 PACOMETRIQ KIT 60MG 3 PA; SPCOMETRIQ KIT 100MG 3 PA; SPCOMETRIQ KIT 140MG 3 PA; SPCOTELLIC TAB 20MG 3 PA; SPCGILOTRIF TAB 20MG 3 PA

18

GILOTRIF TAB 30MG 3 PAGILOTRIF TAB 40MG 3 PAIBRANCE CAP 75MG 2 PA; SPCIBRANCE CAP 100MG 2 PA; SPCIBRANCE CAP 125MG 2 PA; SPCICLUSIG TAB 15MG 3 PA; SPICLUSIG TAB 45MG 3 PA; SPimatinib mesylate tab 100 mg (base equivalent)

3 PA; SPC

imatinib mesylate tab 400 mg (base equivalent)

3 PA; SPC

IMBRUVICA CAP 70MG 3 PA; SPIMBRUVICA CAP 140MG 3 PAIMBRUVICA TAB 140MG 3 PA; SPIMBRUVICA TAB 280MG 3 PA; SPIMBRUVICA TAB 420MG 3 PA; SPIMBRUVICA TAB 560MG 3 PA; SPINLYTA TAB 1MG 3 PA; SPCINLYTA TAB 5MG 3 PA; SPCJAKAFI TAB 5MG 3 QL (60 tabs / 30 days),

PA; SPCJAKAFI TAB 10MG 3 QL (60 tabs / 30 days),




PA; SPCKISQALI 200 PAK FEMARA 2 PA; SPCKISQALI 400 PAK FEMARA 2 PA; SPCKISQALI 600 PAK FEMARA 2 PA; SPCKISQALI TAB 200DOSE 2 PA; SPCKISQALI TAB 400DOSE 2 PA; SPCKISQALI TAB 600DOSE 2 PA; SPCLENVIMA CAP 4MG 3 PA; SPCLENVIMA CAP 8 MG 3 PA; SPCLENVIMA CAP 10 MG 3 PALENVIMA CAP 10 MG 3 PA; SPCLENVIMA CAP 12MG 3 PA; SPCLENVIMA CAP 14 MG 3 PALENVIMA CAP 14 MG 3 PA; SPCLENVIMA CAP 18 MG 3 PA; SPCLENVIMA CAP 20 MG 3 PALENVIMA CAP 20 MG 3 PA; SPC

19

LENVIMA CAP 24 MG 3 PALENVIMA CAP 24 MG 3 PA; SPCMEKINIST TAB 0.5MG 3 PA; SPCMEKINIST TAB 2MG 3 PA; SPCNEXAVAR TAB 200MG 3 PA; SPCRYDAPT CAP 25MG 3 PA; SPCSPRYCEL TAB 20MG 3 PA; SPCSPRYCEL TAB 50MG 3 PA; SPCSPRYCEL TAB 70MG 3 PA; SPCSPRYCEL TAB 80MG 3 PA; SPCSPRYCEL TAB 100MG 3 PA; SPCSPRYCEL TAB 140MG 3 PA; SPCSTIVARGA TAB 40MG 3 PA; SPCSUTENT CAP 12.5MG 3 PA; SPCSUTENT CAP 25MG 3 PA; SPCSUTENT CAP 37.5MG 3 PA; SPCSUTENT CAP 50MG 3 PA; SPCTAFINLAR CAP 50MG 3 PA; SPCTAFINLAR CAP 75MG 3 PA; SPCTAGRISSO TAB 40MG 3 PA; SPCTAGRISSO TAB 80MG 3 PA; SPCTARCEVA TAB 25MG 3 PA; SPCTARCEVA TAB 100MG 3 PA; SPCTARCEVA TAB 150MG 3 PA; SPCTASIGNA CAP 50MG 3 PA; SPCTASIGNA CAP 150MG 3 PA; SPCTASIGNA CAP 200MG 3 PA; SPCtemsirolimus soln for iv infusion 25 mg/ml 3 PATYKERB TAB 250MG 3 PA; SPCVANDETANIB TAB 100MG 3 PAVANDETANIB TAB 300MG 3 PAVERZENIO TAB 50MG 3 PA; SPCVERZENIO TAB 100MG 3 PA; SPCVERZENIO TAB 150MG 3 PA; SPCVERZENIO TAB 200MG 3 PA; SPCVOTRIENT TAB 200MG 3 PA; SPCXALKORI CAP 200MG 3 PA; SPCXALKORI CAP 250MG 3 PA; SPCZELBORAF TAB 240MG 3 PA; SPCZYDELIG TAB 100MG 3 PAZYDELIG TAB 150MG 3 PAZYKADIA CAP 150MG 3 PA; SPC

MISCELLANEOUSbexarotene cap 75 mg 3 PA; SPCDROXIA CAP 200MG 220

DROXIA CAP 300MG 2DROXIA CAP 400MG 2ERIVEDGE CAP 150MG 3 PA; SPChydroxyurea cap 500 mg 1leucovorin calcium tab 5 mg 1leucovorin calcium tab 10 mg 1leucovorin calcium tab 15 mg 1leucovorin calcium tab 25 mg 1LONSURF TAB 15-6.14 3 PA; SPCLONSURF TAB 20-8.19 3 PA; SPCLYSODREN TAB 500MG 2MATULANE CAP 50MG 2MESNEX TAB 400MG 2NINLARO CAP 2.3MG 3 PA; SPCNINLARO CAP 3MG 3 PA; SPCNINLARO CAP 4MG 3 PA; SPCODOMZO CAP 200MG 3 PA; SPCRITUXAN INJ 100MG 3 PA, STRUBRACA TAB 200MG 3 PA; SPCRUBRACA TAB 250MG 3 PA; SPCRUBRACA TAB 300MG 3 PA; SPCTHERACYS INJ 3TICE BCG INJ 3tretinoin cap 10 mg 1VENCLEXTA TAB 10MG 3 PAVENCLEXTA TAB 50MG 3 PAVENCLEXTA TAB 100MG 3 PAVENCLEXTA TAB START PK 3 PAZEJULA CAP 100MG 3 PA; SPZOLINZA CAP 100MG 3 PA; SPC

MITOTIC INHIBITORSetoposide cap 50 mg 1

TOPOISOMERASE INHIBITORSHYCAMTIN CAP 0.25MG 3 PA; SPCHYCAMTIN CAP 1MG 3 PA; SPC

CARDIOVASCULARACE INHIBITOR/CALCIUM CHANNEL BLOCKER COMBINATIONS

amlodipine besylate-benazepril hcl cap 2.5-10 mg

1 PD

amlodipine besylate-benazepril hcl cap 5-10 mg

1 PD


1 PD

21


1 PD


1 PD


1 PD

ACE INHIBITOR/DIURETIC COMBINATIONSbenazepril & hydrochlorothiazide tab 5-6.25 mg

1 PD

benazepril & hydrochlorothiazide tab 10-12.5 mg

1 PD

benazepril & hydrochlorothiazide tab 20-12.5 mg

1 PD

benazepril & hydrochlorothiazide tab 20-25 mg

1 PD

captopril & hydrochlorothiazide tab 25-15 mg

1 PD


1 PD


1 PD


1 PD

enalapril maleate & hydrochlorothiazide tab 5-12.5 mg

1 PD

enalapril maleate & hydrochlorothiazide tab 10-25 mg

1 PD

fosinopril sodium & hydrochlorothiazide tab 10-12.5 mg

1 PD

fosinopril sodium & hydrochlorothiazide tab 20-12.5 mg

1 PD

lisinopril & hydrochlorothiazide tab 10-12.5 mg

1 PD

lisinopril & hydrochlorothiazide tab 20-12.5 mg

1 PD

lisinopril & hydrochlorothiazide tab 20-25 mg

1 PD

moexipril-hydrochlorothiazide tab 15-12.5 mg

1 PD

moexipril-hydrochlorothiazide tab 15-25 mg

1 PD

quinapril-hydrochlorothiazide tab 10-12.5 mg

1 PD

quinapril-hydrochlorothiazide tab 20-12.5 mg

1 PD

22

quinapril-hydrochlorothiazide tab 20-25 mg1 PDACE INHIBITORS

benazepril hcl tab 5 mg 1 PDbenazepril hcl tab 10 mg 1 PDbenazepril hcl tab 20 mg 1 PDbenazepril hcl tab 40 mg 1 PDcaptopril tab 12.5 mg 1 PDcaptopril tab 25 mg 1 PDcaptopril tab 50 mg 1 PDcaptopril tab 100 mg 1 PDenalapril maleate tab 2.5 mg 1 PDenalapril maleate tab 5 mg 1 PDenalapril maleate tab 10 mg 1 PDenalapril maleate tab 20 mg 1 PDfosinopril sodium tab 10 mg 1 PDfosinopril sodium tab 20 mg 1 PDfosinopril sodium tab 40 mg 1 PDlisinopril tab 2.5 mg 1 PD; subject to dose

optimizationlisinopril tab 5 mg 1 PD; subject to dose

optimizationlisinopril tab 10 mg 1 PD; subject to dose

optimizationlisinopril tab 20 mg 1 PDlisinopril tab 30 mg 1 PDlisinopril tab 40 mg 1 PDmoexipril hcl tab 7.5 mg 1 PDmoexipril hcl tab 15 mg 1 PDperindopril erbumine tab 2 mg 1 PDperindopril erbumine tab 4 mg 1 PDperindopril erbumine tab 8 mg 1 PDquinapril hcl tab 5 mg 1 PDquinapril hcl tab 10 mg 1 PDquinapril hcl tab 20 mg 1 PDquinapril hcl tab 40 mg 1 PDramipril cap 1.25 mg 1 PDramipril cap 2.5 mg 1 PDramipril cap 5 mg 1 PDramipril cap 10 mg 1 PDtrandolapril tab 1 mg 1 PDtrandolapril tab 2 mg 1 PDtrandolapril tab 4 mg 1 PD

ADRENOLYTICS, CENTRALclonidine hcl tab 0.1 mg 1 PDclonidine hcl tab 0.2 mg 1 PD23

clonidine hcl tab 0.3 mg 1 PDclonidine td patch weekly 0.1 mg/24hr 1 PDclonidine td patch weekly 0.2 mg/24hr 1 PDclonidine td patch weekly 0.3 mg/24hr 1 PDguanfacine hcl tab 1 mg 1 PDguanfacine hcl tab 2 mg 1 PDmethyldopa tab 250 mg 1 PDmethyldopa tab 500 mg 1 PD

ALDOSTERONE RECEPTOR ANTAGONISTSCAROSPIR SUS 25MG/5ML 2 PDeplerenone tab 25 mg 1eplerenone tab 50 mg 1spironolactone tab 25 mg 1 PDspironolactone tab 50 mg 1 PDspironolactone tab 100 mg 1 PD

ALPHA BLOCKERSdoxazosin mesylate tab 1 mg 1doxazosin mesylate tab 2 mg 1doxazosin mesylate tab 4 mg 1doxazosin mesylate tab 8 mg 1prazosin hcl cap 1 mg 1prazosin hcl cap 2 mg 1prazosin hcl cap 5 mg 1terazosin hcl cap 1 mg (base equivalent) 1terazosin hcl cap 2 mg (base equivalent) 1terazosin hcl cap 5 mg (base equivalent) 1terazosin hcl cap 10 mg (base equivalent) 1

ANGIOTENSIN II RECEPTOR ANTAGONIST/CALCIUM CHANNEL BLOCKER COMBINATIONS

amlodipine besylate-valsartan tab 5-160 mg

2 PD


2 PD


2 PD


2 PD

ANGIOTENSIN II RECEPTOR ANTAGONIST/CALCIUM CHANNEL BLOCKER/DIURETIC COMBINATIONS

amlodipine-valsartan-hydrochlorothiazide tab 5-160-12.5 mg

2 PD

amlodipine-valsartan-hydrochlorothiazide tab 5-160-25 mg

2 PD

24

amlodipine-valsartan-hydrochlorothiazide tab 10-160-12.5 mg

2 PD


2 PD


2 PD

ANGIOTENSIN II RECEPTOR ANTAGONIST/DIURETIC COMBINATIONS

irbesartan-hydrochlorothiazide tab 150-12.5 mg

1 PD

irbesartan-hydrochlorothiazide tab 300-12.5 mg

1 PD

losartan potassium & hydrochlorothiazide tab 50-12.5 mg

1 PD

losartan potassium & hydrochlorothiazide tab 100-12.5 mg

1 PD

losartan potassium & hydrochlorothiazide tab 100-25 mg

1 PD

valsartan-hydrochlorothiazide tab 80-12.5 mg

1 PD


1 PD

valsartan-hydrochlorothiazide tab 160-25 mg

1 PD


1 PD

valsartan-hydrochlorothiazide tab 320-25 mg

1 PD

ANGIOTENSIN II RECEPTOR ANTAGONISTScandesartan cilexetil tab 4 mg 2 PDcandesartan cilexetil tab 8 mg 2 PDcandesartan cilexetil tab 16 mg 2 PDcandesartan cilexetil tab 32 mg 2 PDEDARBI TAB 40MG 3 ST; PDEDARBI TAB 80MG 3 ST; PDeprosartan mesylate tab 600 mg 3 ST; PDirbesartan tab 75 mg 1 PD; subject to dose

optimizationirbesartan tab 150 mg 1 PDirbesartan tab 300 mg 1 PDlosartan potassium tab 25 mg 1 PDlosartan potassium tab 50 mg 1 PDlosartan potassium tab 100 mg 1 PDolmesartan medoxomil tab 5 mg 2 ST; PDolmesartan medoxomil tab 20 mg 2 ST; PD

25

olmesartan medoxomil tab 40 mg 2 ST; PDtelmisartan tab 20 mg 3 PD; subject to dose

optimizationtelmisartan tab 40 mg 3 PDtelmisartan tab 80 mg 3 PDvalsartan tab 40 mg 3 PDvalsartan tab 80 mg 3 PDvalsartan tab 160 mg 3 PDvalsartan tab 320 mg 3 PD

ANTIARRHYTHMICSamiodarone hcl tab 200 mg 1amiodarone hcl tab 400 mg 1disopyramide phosphate cap 100 mg 1disopyramide phosphate cap 150 mg 1dofetilide cap 125 mcg (0.125 mg) 3 SPdofetilide cap 250 mcg (0.25 mg) 3 SPdofetilide cap 500 mcg (0.5 mg) 3 SPflecainide acetate tab 50 mg 1flecainide acetate tab 100 mg 1flecainide acetate tab 150 mg 1mexiletine hcl cap 150 mg 1mexiletine hcl cap 200 mg 1mexiletine hcl cap 250 mg 1MULTAQ TAB 400MG 3 PA; PDNORPACE CAP 100MG CR 3NORPACE CAP 150MG CR 3PACERONE TAB 100MG 2pacerone tab 200mg 1procainamide hcl inj 100 mg/ml 1 PAPROCAINAMIDE HCL INJ 500 MG/ML 3 PApropafenone hcl cap er 12hr 225 mg 2propafenone hcl cap er 12hr 325 mg 2propafenone hcl cap er 12hr 425 mg 2propafenone hcl tab 150 mg 1propafenone hcl tab 225 mg 1propafenone hcl tab 300 mg 1quinidine gluconate tab er 324 mg 1quinidine sulfate tab er 300 mg 1sorine tab 80mg 1 PDsorine tab 120mg 1 PDsorine tab 160mg 1 PDsorine tab 240mg 1 PDsotalol af tab 80mg 1 PDsotalol af tab 120mg 1 PDsotalol af tab 160mg 1 PD26

sotalol hcl tab 80 mg 1 PDsotalol hcl tab 120 mg 1 PDsotalol hcl tab 160 mg 1 PDsotalol hcl tab 240 mg 1 PD

ANTILIPEMICS, BILE ACID RESINScholestyramine light powder 4 gm/dose 1 PDcholestyramine light powder packets 4 gm 1 PDcholestyramine powder 4 gm/dose 1 PDcholestyramine powder packets 4 gm 1 PDcolesevelam hcl packet for susp 3.75 gm 3 PDcolesevelam hcl tab 625 mg 3 PDcolestipol hcl granule packets 5 gm 1 PDcolestipol hcl granules 5 gm 1 PDcolestipol hcl tab 1 gm 1 PDprevalite pow 4gm 1 PD

ANTILIPEMICS, CHOLESTEROL ABSORPTION INHIBITORSezetimibe tab 10 mg 3 PD

ANTILIPEMICS, FIBRATESfenofibrate micronized cap 67 mg 1 PDfenofibrate micronized cap 134 mg 1 PDfenofibrate micronized cap 200 mg 1 PDfenofibrate tab 48 mg 2 PDfenofibrate tab 54 mg 1 PDfenofibrate tab 145 mg 2 PDfenofibrate tab 160 mg 1 PDgemfibrozil tab 600 mg 1 PD

ANTILIPEMICS, HMG-COA REDUCTASE INHIBITORS/COMBINATIONS

atorvastatin calcium tab 10 mg (base equivalent)

1 PD, ACA; subject to dose optimization


1 PD, ACA; subject to dose optimization


1 PD; subject to dose optimization


1 PD

ezetimibe-simvastatin tab 10-10 mg 3 PDezetimibe-simvastatin tab 10-20 mg 3 PDezetimibe-simvastatin tab 10-40 mg 3 PDezetimibe-simvastatin tab 10-80 mg 3 PDfluvastatin sodium cap 20 mg 3 PD, ACA; subject to

dose optimizationfluvastatin sodium cap 40 mg 3 PD, ACALIVALO TAB 4MG 3 ST; PD

27

lovastatin tab 10 mg 1 PD, ACAlovastatin tab 20 mg 1 PD, ACAlovastatin tab 40 mg 1 PD, ACApravastatin sodium tab 10 mg 1 PD, ACA; subject to

dose optimizationpravastatin sodium tab 20 mg 1 PD, ACA; subject to

dose optimizationpravastatin sodium tab 40 mg 1 PD, ACApravastatin sodium tab 80 mg 1 PD, ACArosuvastatin calcium tab 5 mg 2 PD, ACA; subject to

dose optimizationrosuvastatin calcium tab 10 mg 2 PD, ACA; subject to

dose optimizationrosuvastatin calcium tab 20 mg 2 PD; subject to dose

optimizationrosuvastatin calcium tab 40 mg 2 PDsimvastatin tab 5 mg 1 PD, ACA; subject to

dose optimizationsimvastatin tab 10 mg 1 PD, ACA; subject to

dose optimizationsimvastatin tab 20 mg 1 PD, ACA; subject to

dose optimizationsimvastatin tab 40 mg 1 PD, ACAsimvastatin tab 80 mg 1 PD

ANTILIPEMICS, MICROSOMAL TRIGLYCERIDE TRANSFER PROTEIN INHIBITORS

JUXTAPID CAP 10MG 3 PA; (MNPA), PDANTILIPEMICS, NIACINS

niacin tab er 500 mg (antihyperlipidemic) 2 PDniacin tab er 750 mg (antihyperlipidemic) 2 PDniacin tab er 1000 mg (antihyperlipidemic) 2 PD

ANTILIPEMICS, OMEGA-3 FATTY ACIDSomega-3-acid ethyl esters cap 1 gm 3 PD

ANTILIPEMICS, PCSK9 INHIBITORSREPATHA INJ 140MG/ML 2 PA; SPCREPATHA PUSH INJ 420/3.5 2 PA; SPCREPATHA SURE INJ 140MG/ML 2 PA; SPC

BETA-BLOCKER/DIURETIC COMBINATIONSatenolol & chlorthalidone tab 50-25 mg 1 PDatenolol & chlorthalidone tab 100-25 mg 1 PDbisoprolol & hydrochlorothiazide tab 2.5-6.25 mg

1 PD

bisoprolol & hydrochlorothiazide tab 5-6.25 mg

1 PD

28

bisoprolol & hydrochlorothiazide tab 10-6.25 mg

1 PD

metoprolol & hydrochlorothiazide tab 50-25 mg

1 PD


1 PD


1 PD

nadolol & bendroflumethiazide tab 40-5 mg1 PDnadolol & bendroflumethiazide tab 80-5 mg1 PDpropranolol & hydrochlorothiazide tab 40-25 mg

1 PD

propranolol & hydrochlorothiazide tab 80-25 mg

1 PD

BETA-BLOCKERSacebutolol hcl cap 200 mg 1 PDacebutolol hcl cap 400 mg 1 PDatenolol tab 25 mg 1 PDatenolol tab 50 mg 1 PDatenolol tab 100 mg 1 PDbetaxolol hcl tab 10 mg 1 PDbetaxolol hcl tab 20 mg 1 PDbisoprolol fumarate tab 5 mg 1 PDbisoprolol fumarate tab 10 mg 1 PDBYSTOLIC TAB 2.5MG 2 PDBYSTOLIC TAB 5MG 2 PDBYSTOLIC TAB 10MG 2 PDBYSTOLIC TAB 20MG 2 PDcarvedilol tab 3.125 mg 1 PDcarvedilol tab 6.25 mg 1 PDcarvedilol tab 12.5 mg 1 PDcarvedilol tab 25 mg 1 PDlabetalol hcl tab 100 mg 1 PDlabetalol hcl tab 200 mg 1 PDlabetalol hcl tab 300 mg 1 PDmetoprolol succinate tab er 24hr 25 mg (tartrate equiv)

1 PD

metoprolol succinate tab er 24hr 50 mg (tartrate equiv)

1 PD


1 PD


1 PD

metoprolol tartrate tab 25 mg 1 PDmetoprolol tartrate tab 50 mg 1 PD

29

metoprolol tartrate tab 100 mg 1 PDnadolol tab 20 mg 1 PDnadolol tab 40 mg 1 PDnadolol tab 80 mg 1 PDpindolol tab 5 mg 1 PDpindolol tab 10 mg 1 PDpropranolol hcl cap er 24hr 60 mg 1 PDpropranolol hcl cap er 24hr 80 mg 1 PDpropranolol hcl cap er 24hr 120 mg 1 PDpropranolol hcl cap er 24hr 160 mg 1 PDpropranolol hcl oral soln 20 mg/5ml 1 PDpropranolol hcl oral soln 40 mg/5ml 1 PDpropranolol hcl tab 10 mg 1 PDpropranolol hcl tab 20 mg 1 PDpropranolol hcl tab 40 mg 1 PDpropranolol hcl tab 60 mg 1 PDpropranolol hcl tab 80 mg 1 PDtimolol maleate tab 5 mg 1 PDtimolol maleate tab 10 mg 1 PDtimolol maleate tab 20 mg 1 PD

CALCIUM CHANNEL BLOCKERS, DIHYDROPYRIDINESafeditab tab 30mg cr 1 PDafeditab tab 60mg cr 1 PDamlodipine besylate tab 2.5 mg (base equivalent)


amlodipine besylate tab 5 mg (base equivalent)


amlodipine besylate tab 10 mg (base equivalent)

1 PD

felodipine tab er 24hr 2.5 mg 1 PDfelodipine tab er 24hr 5 mg 1 PDfelodipine tab er 24hr 10 mg 1 PDisradipine cap 2.5 mg 1 PDisradipine cap 5 mg 1 PDnicardipine hcl cap 20 mg 1 PDnicardipine hcl cap 30 mg 1 PDnifediac cc tab 30mg er 1 PDnifediac cc tab 60mg er 1 PDnifedical xl tab 30mg 1 PDnifedical xl tab 60mg 1 PDnifedipine tab er 24hr 30 mg 1 PDnifedipine tab er 24hr 60 mg 1 PDnifedipine tab er 24hr 90 mg 1 PDnifedipine tab er 24hr osmotic release 30 mg

1 PD

30

nifedipine tab er 24hr osmotic release 60 mg

1 PD

nifedipine tab er 24hr osmotic release 90 mg

1 PD

nimodipine cap 30 mg 1nisoldipine tab er 24hr 8.5 mg 1 PDnisoldipine tab er 24hr 17 mg 1 PDnisoldipine tab er 24hr 20 mg 1 PD; subject to dose

optimizationnisoldipine tab er 24hr 25.5 mg 1 PDnisoldipine tab er 24hr 30 mg 1 PDnisoldipine tab er 24hr 34 mg 1 PDnisoldipine tab er 24hr 40 mg 1 PD

CALCIUM CHANNEL BLOCKERS, NON-DIHYDROPYRIDINESCARDIZEM LA TAB 120MG 2 PDcartia xt cap 120/24hr 1 PDcartia xt cap 180/24hr 1 PDcartia xt cap 240/24hr 1 PDcartia xt cap 300/24hr 1 PDdilt-cd cap 120mg 1 PDdilt-cd cap 180mg 1 PDdilt-cd cap 240mg 1 PDdilt-cd cap 300mg 1 PDdiltiazem hcl cap er 24hr 120 mg 1 PDdiltiazem hcl cap er 24hr 180 mg 1 PDdiltiazem hcl cap er 24hr 240 mg 1 PDdiltiazem hcl coated beads cap er 24hr 120 mg

1 PD

diltiazem hcl coated beads cap er 24hr 180 mg

1 PD


1 PD


1 PD


1 PD

diltiazem hcl extended release beads cap er 24hr 120 mg

1 PD


1 PD


1 PD


1 PD

31


1 PD


1 PD

diltiazem hcl tab 30 mg 1 PDdiltiazem hcl tab 60 mg 1 PDdiltiazem hcl tab 90 mg 1 PDdiltiazem hcl tab 120 mg 1 PDdiltzac cap 120mg/24 1 PDdiltzac cap 180mg/24 1 PDdiltzac cap 240mg/24 1 PDdiltzac cap 300mg/24 1 PDdiltzac cap 360mg/24 1 PDmatzim la tab 180mg/24 1 PDmatzim la tab 240mg/24 1 PDmatzim la tab 300mg/24 1 PDmatzim la tab 360mg/24 1 PDmatzim la tab 420mg/24 1 PDtaztia xt cap 120mg/24 1 PDtaztia xt cap 180mg/24 1 PDtaztia xt cap 240mg/24 1 PDtaztia xt cap 300mg/24 1 PDtaztia xt cap 360mg/24 1 PDverapamil hcl cap er 24hr 100 mg 1 PDverapamil hcl cap er 24hr 120 mg 1 PDverapamil hcl cap er 24hr 180 mg 1 PDverapamil hcl cap er 24hr 200 mg 1 PDverapamil hcl cap er 24hr 240 mg 1 PDverapamil hcl cap er 24hr 300 mg 1 PDverapamil hcl cap er 24hr 360 mg 1 PDverapamil hcl tab 40 mg 1 PDverapamil hcl tab 80 mg 1 PDverapamil hcl tab 120 mg 1 PDverapamil hcl tab er 120 mg 1 PDverapamil hcl tab er 180 mg 1 PDverapamil hcl tab er 240 mg 1 PD

DIGITALIS GLYCOSIDESdigox tab 0.25mg 1digox tab 0.125mg 1digoxin oral soln 0.05 mg/ml 1digoxin tab 125 mcg (0.125 mg) 1digoxin tab 250 mcg (0.25 mg) 1LANOXIN TAB 0.0625MG 3LANOXIN TAB 0.1875MG 3

DIRECT RENIN INHIBITORS/DIURETIC COMBINATIONS32

TEKTURNA TAB 150MG 3 ST; PDTEKTURNA TAB 300MG 3 ST; PD

DIURETICS, CARBONIC ANHYDRASE INHIBITORSacetazolamide sodium for inj 500 mg 2 PAmethazolamide tab 25 mg 1methazolamide tab 50 mg 1

DIURETICS, DIURETIC COMBINATIONSamiloride & hydrochlorothiazide tab 5-50 mg

1 PD

spironolactone & hydrochlorothiazide tab 25-25 mg

1 PD

triamterene & hydrochlorothiazide cap 37.5-25 mg

1 PD

triamterene & hydrochlorothiazide cap 50-25 mg

1 PD

triamterene & hydrochlorothiazide tab 37.5-25 mg

1 PD

triamterene & hydrochlorothiazide tab 75-50 mg

1 PD

DIURETICS, LOOP DIURETICSbumetanide tab 0.5 mg 1 PDbumetanide tab 1 mg 1 PDbumetanide tab 2 mg 1 PDethacrynic acid tab 25 mg 3furosemide oral soln 10 mg/ml 1 PDfurosemide tab 20 mg 1 PDfurosemide tab 40 mg 1 PDfurosemide tab 80 mg 1 PDtorsemide tab 5 mg 1torsemide tab 10 mg 1torsemide tab 20 mg 1torsemide tab 100 mg 1

DIURETICS, POTASSIUM-SPARING DIURETICSamiloride hcl tab 5 mg 1DYRENIUM CAP 50MG 3DYRENIUM CAP 100MG 3

DIURETICS, THIAZIDES AND THIAZIDE-LIKE DIURETICSchlorothiazide tab 250 mg 1 PDchlorothiazide tab 500 mg 1 PDchlorthalidone tab 25 mg 1 PDchlorthalidone tab 50 mg 1 PDDIURIL SUS 250/5ML 3 PDhydrochlorothiazide cap 12.5 mg 1 PDhydrochlorothiazide tab 12.5 mg 1 PD

33

hydrochlorothiazide tab 25 mg 1 PDhydrochlorothiazide tab 50 mg 1 PDindapamide tab 1.25 mg 1 PDindapamide tab 2.5 mg 1 PDmethyclothiazide tab 5 mg 2 ST; PDmetolazone tab 2.5 mg 1metolazone tab 5 mg 1metolazone tab 10 mg 1

HEART FAILUREENTRESTO TAB 24-26MG 3ENTRESTO TAB 49-51MG 3ENTRESTO TAB 97-103MG 3

MISCELLANEOUShydralazine hcl tab 10 mg 1 PDhydralazine hcl tab 25 mg 1 PDhydralazine hcl tab 50 mg 1 PDhydralazine hcl tab 100 mg 1 PDminoxidil tab 2.5 mg 1 PDminoxidil tab 10 mg 1 PDphenoxybenzamine hcl cap 10 mg 3RANEXA TAB 500MG 2 STRANEXA TAB 1000MG 2 ST

NITRATES, ORALisosorbide dinitrate tab 5 mg 1 PDisosorbide dinitrate tab 10 mg 1 PDisosorbide dinitrate tab 20 mg 1 PDisosorbide dinitrate tab 30 mg 1 PDisosorbide dinitrate tab er 40 mg 1 PDisosorbide mononitrate tab 10 mg 1 PDisosorbide mononitrate tab 20 mg 1 PDisosorbide mononitrate tab er 24hr 30 mg 1 PDisosorbide mononitrate tab er 24hr 60 mg 1 PDisosorbide mononitrate tab er 24hr 120 mg 1 PD

NITRATES, SUBLINGUAL/TRANSLINGUALnitroglycerin sl tab 0.3 mg 2nitroglycerin sl tab 0.4 mg 2nitroglycerin sl tab 0.6 mg 2

NITRATES, TRANSDERMALminitran dis 0.2mg/hr 1minitran dis 0.4mg/hr 1minitran dis 0.6mg/hr 1NITRO-DUR DIS 0.3MG/HR 2 PDNITRO-DUR DIS 0.8MG/HR 2 PDnitroglycerin td patch 24hr 0.1 mg/hr 134

nitroglycerin td patch 24hr 0.1 mg/hr 1 PDnitroglycerin td patch 24hr 0.2 mg/hr 1 PDnitroglycerin td patch 24hr 0.4 mg/hr 1 PDnitroglycerin td patch 24hr 0.6 mg/hr 1 PD

PULMONARY ARTERIAL HYPERTENSION, ENDOTHELIN RECEPTOR ANTAGONISTS

LETAIRIS TAB 5MG 3 PA; SPCLETAIRIS TAB 10MG 3 PA; SPCOPSUMIT TAB 10MG 3 PA; SPCTRACLEER TAB 32MG 3 PA; SPCTRACLEER TAB 62.5MG 3 PA; SPCTRACLEER TAB 125MG 3 PA; SPC

PULMONARY ARTERIAL HYPERTENSION, PHOSPHODIESTERASE INHIBITORS

REVATIO SUS 10MG/ML 3 PA; SPCsildenafil citrate iv soln 10 mg/12.5ml (base equivalent)

3 PA; SPC

sildenafil citrate tab 20 mg 3 QL (30 tabs / 30 days), PA; SPC

tadalafil tab 20 mg (pah) 3 PA; SPCPULMONARY ARTERIAL HYPERTENSION, PROSTAGLANDIN VASODILATORS

epoprostenol sodium for inj 0.5 mg 3 PA; SPCepoprostenol sodium for inj 1.5 mg 3 PA; SPCREMODULIN INJ 1MG/ML 3 PA; SPCREMODULIN INJ 2.5MG/ML 3 PA; SPCREMODULIN INJ 5MG/ML 3 PA; SPCREMODULIN INJ 10MG/ML 3 PA; SPCTYVASO START SOL 0.6MG/ML 3 PA; SPC

PULMONARY ARTERIAL HYPERTENSION, SOLUBLE GUANYLATE CYCLASE STIMULATORS

ADEMPAS TAB 0.5MG 3 PA; SPCADEMPAS TAB 1.5MG 3 PA; SPCADEMPAS TAB 1MG 3 PA; SPCADEMPAS TAB 2.5MG 3 PA; SPCADEMPAS TAB 2MG 3 PA; SPC

VASOPRESSORSmidodrine hcl tab 2.5 mg 1midodrine hcl tab 5 mg 1midodrine hcl tab 10 mg 1

CENTRAL NERVOUS SYSTEMANTIANXIETY, BENZODIAZEPINES

alprazolam tab 0.5 mg 1 QL (90 tabs / 30 days)35

alprazolam tab 0.25 mg 1 QL (90 tabs / 30 days)alprazolam tab 1 mg 1 QL (90 tabs / 30 days)alprazolam tab 2 mg 1 QL (60 tabs / 30 days)alprazolam tab er 24hr 0.5 mg 2 QL (60 tabs / 30 days)alprazolam tab er 24hr 1 mg 2 QL (60 tabs / 30 days)alprazolam tab er 24hr 2 mg 2 QL (60 tabs / 30 days)alprazolam tab er 24hr 3 mg 2 QL (60 tabs / 30 days)clonazepam tab 0.5 mg 1 PDclonazepam tab 1 mg 1 PDclonazepam tab 2 mg 1 PDclorazepate dipotassium tab 3.75 mg 1 QL (120 tabs / 30 days)clorazepate dipotassium tab 7.5 mg 1 QL (120 tabs / 30 days)clorazepate dipotassium tab 15 mg 1 QL (120 tabs / 30 days)diazepam oral soln 1 mg/ml 1 QL (1200 mL / 30 days)diazepam tab 2 mg 1 QL (120 tabs / 30 days)diazepam tab 5 mg 1 QL (120 tabs / 30 days)diazepam tab 10 mg 1 QL (120 tabs / 30 days)lorazepam tab 0.5 mg 1 QL (150 tabs / 30 days)lorazepam tab 1 mg 1 QL (150 tabs / 30 days)lorazepam tab 2 mg 1 QL (150 tabs / 30 days)oxazepam cap 10 mg 1 QL (120 caps / 30 days)oxazepam cap 15 mg 1 QL (120 caps / 30 days)oxazepam cap 30 mg 1 QL (120 caps / 30 days)

ANTIANXIETY, MISCELLANEOUSbuspirone hcl tab 5 mg 1buspirone hcl tab 7.5 mg 1buspirone hcl tab 10 mg 1buspirone hcl tab 15 mg 1buspirone hcl tab 30 mg 1clomipramine hcl cap 25 mg 1clomipramine hcl cap 50 mg 1clomipramine hcl cap 75 mg 1fluvoxamine maleate tab 25 mg 1fluvoxamine maleate tab 50 mg 1fluvoxamine maleate tab 100 mg 1meprobamate tab 200 mg 2meprobamate tab 400 mg 2

ANTICONVULSANTSAPTIOM TAB 200MG 3 PA; PDBANZEL SUS 40MG/ML 3 PA; PDBANZEL TAB 200MG 3 PA; PDBANZEL TAB 400MG 3 PA; PDcarbamazepine cap er 12hr 300 mg 1 PD; generic of Carbatrolcarbamazepine chew tab 100 mg 1 PD

36

carbamazepine susp 100 mg/5ml 1 PDcarbamazepine tab 200 mg 1 PDcarbamazepine tab er 12hr 100 mg 1 PDcarbamazepine tab er 12hr 200 mg 1 PD, generic of Tegretol

XRcarbamazepine tab er 12hr 400 mg 1 PD, generic of Tegretol

XRCELONTIN CAP 300MG 3 PDclobazam tab 10 mg 3 PA; MNPAclobazam tab 20 mg 3 PA; MNPAdiazepam rectal gel delivery system 2.5 mg

2

diazepam rectal gel delivery system 10 mg 2diazepam rectal gel delivery system 20 mg 2divalproex sodium cap delayed release sprinkle 125 mg

1 PD

divalproex sodium tab delayed release 125 mg

1 PD


1 PD


1 PD

divalproex sodium tab er 24 hr 250 mg 1 PDdivalproex sodium tab er 24 hr 500 mg 1 PDepitol tab 200mg 1 PDethosuximide cap 250 mg 1 PDethosuximide soln 250 mg/5ml 1 PDfelbamate tab 400 mg 3 PDfelbamate tab 600 mg 3 PDFYCOMPA TAB 10MG 3 PA; PDgabapentin cap 100 mg 1gabapentin cap 300 mg 1gabapentin cap 400 mg 1gabapentin tab 600 mg 1gabapentin tab 800 mg 1lamotrigine orally disintegrating tab 25 mg 2 PDlamotrigine orally disintegrating tab 100 mg

2 PD

lamotrigine orally disintegrating tab 200 mg

2 PD

lamotrigine tab 25 mg 1 PDlamotrigine tab 100 mg 1 PDlamotrigine tab 150 mg 1 PDlamotrigine tab 200 mg 1 PDlamotrigine tab chewable dispersible 5 mg 1 PD

37

lamotrigine tab chewable dispersible 25 mg1 PDlamotrigine tab er 24hr 25 mg 3 PDlamotrigine tab er 24hr 50 mg 3 PDlamotrigine tab er 24hr 100 mg 3 PDlamotrigine tab er 24hr 200 mg 3 PDlamotrigine tab er 24hr 250 mg 3 PDlamotrigine tab er 24hr 300 mg 3 PDlevetiracetam oral soln 100 mg/ml 1 PDlevetiracetam tab 250 mg 1 PDlevetiracetam tab 500 mg 1 PDlevetiracetam tab 750 mg 1 PDlevetiracetam tab 1000 mg 1 PDlevetiracetam tab er 24hr 500 mg 1 PDlevetiracetam tab er 24hr 750 mg 1 PDoxcarbazepine susp 300 mg/5ml (60 mg/ml)

1 PD

oxcarbazepine tab 150 mg 1 PDoxcarbazepine tab 300 mg 1 PDoxcarbazepine tab 600 mg 1 PDPEGANONE TAB 250MG 3 PA; PDphenobarbital tab 15 mg 1 PDphenobarbital tab 16.2 mg 1 PDphenobarbital tab 30 mg 1 PDphenobarbital tab 32.4 mg 1 PDphenobarbital tab 60 mg 1 PDphenobarbital tab 64.8 mg 1 PDphenobarbital tab 97.2 mg 1 PDphenobarbital tab 100 mg 1 PDphenytoin chew tab 50 mg 2 PDphenytoin sodium extended cap 100 mg 1 PDphenytoin susp 125 mg/5ml 1 PDPOTIGA TAB 50MG 3 PA; PDPOTIGA TAB 200MG 3 PA; PDPOTIGA TAB 300MG 3 PA; PDPOTIGA TAB 400MG 3 PA; PDprimidone tab 50 mg 1 PDprimidone tab 250 mg 1 PDSABRIL TAB 500MG 3 PA; SPC; PDtiagabine hcl tab 2 mg 2 PDtiagabine hcl tab 4 mg 2 PDtiagabine hcl tab 12 mg 2 PDtiagabine hcl tab 16 mg 2 PDtopiragen tab 25mg 1 PDtopiragen tab 50mg 1 PDtopiragen tab 100mg 1 PD38

topiragen tab 200mg 1 PDtopiramate sprinkle cap 15 mg 1 PDtopiramate sprinkle cap 25 mg 1 PDtopiramate tab 25 mg 1 PDtopiramate tab 50 mg 1 PDtopiramate tab 100 mg 1 PDtopiramate tab 200 mg 1 PDvalproate sodium oral soln 250 mg/5ml (base equiv)

1 PD

valproic acid cap 250 mg 1 PDvigabatrin powd pack 500 mg 3 PA; SPC; PDVIMPAT SOL 10MG/ML 2 PA; PDVIMPAT TAB 50MG 2 PA; PDVIMPAT TAB 100MG 2 PA; PDVIMPAT TAB 150MG 2 PA; PDVIMPAT TAB 200MG 2 PA; PDzonisamide cap 25 mg 1 PDzonisamide cap 50 mg 1 PDzonisamide cap 100 mg 1 PD

ANTIDEMENTIAdonepezil hydrochloride tab 5 mg 1donepezil hydrochloride tab 10 mg 1galantamine hydrobromide cap er 24hr 8 mg

1

galantamine hydrobromide cap er 24hr 16 mg

1

galantamine hydrobromide cap er 24hr 24 mg

1

galantamine hydrobromide oral soln 4 mg/ml

1

galantamine hydrobromide tab 4 mg 1galantamine hydrobromide tab 8 mg 1galantamine hydrobromide tab 12 mg 1memantine hcl cap er 24hr 7 mg 2memantine hcl cap er 24hr 14 mg 2memantine hcl cap er 24hr 21 mg 2memantine hcl cap er 24hr 28 mg 2memantine hcl oral solution 2 mg/ml 2memantine hcl tab 5 mg 2memantine hcl tab 5 mg (28) & 10 mg (21) titration pak

2

memantine hcl tab 10 mg 2NAMENDA XR CAP TITRATIO 2rivastigmine tartrate cap 1.5 mg (base equivalent)

1

39

rivastigmine tartrate cap 3 mg (base equivalent)

1

rivastigmine tartrate cap 4.5 mg (base equivalent)

1

rivastigmine tartrate cap 6 mg (base equivalent)

1

ANTIDEPRESSANTS, MISCELLANEOUSbudeprion tab 100mg sr 1budeprion tab 150mg sr 1budeprion xl tab 150mg 1budeprion xl tab 300mg 1bupropion hcl tab 75 mg 1bupropion hcl tab 100 mg 1bupropion hcl tab er 12hr 100 mg 1bupropion hcl tab er 12hr 150 mg 1bupropion hcl tab er 12hr 200 mg 1bupropion hcl tab er 24hr 150 mg 1bupropion hcl tab er 24hr 300 mg 1maprotiline hcl tab 25 mg 1maprotiline hcl tab 50 mg 1maprotiline hcl tab 75 mg 1mirtazapine orally disintegrating tab 15 mg 1mirtazapine orally disintegrating tab 30 mg 1mirtazapine orally disintegrating tab 45 mg 1mirtazapine tab 7.5 mg 1mirtazapine tab 15 mg 1mirtazapine tab 30 mg 1mirtazapine tab 45 mg 1nefazodone hcl tab 100 mg 1nefazodone hcl tab 200 mg 1nefazodone hcl tab 250 mg 1trazodone hcl tab 50 mg 1trazodone hcl tab 100 mg 1trazodone hcl tab 150 mg 1trazodone hcl tab 300 mg 1

ANTIDEPRESSANTS, MONOAMINE OXIDASE INHIBITORS (MAOIs)EMSAM DIS 6MG/24HR 3EMSAM DIS 9MG/24HR 3EMSAM DIS 12MG/24H 3MARPLAN TAB 10MG 3phenelzine sulfate tab 15 mg 2tranylcypromine sulfate tab 10 mg 1

ANTIDEPRESSANTS, SELECTIVE SEROTONIN REUPTAKE INHIBITORS (SSRIs)

40

citalopram hydrobromide oral soln 10 mg/5ml

1

citalopram hydrobromide tab 10 mg (base equiv)

1


1


1

escitalopram oxalate soln 5 mg/5ml (base equiv)

1

escitalopram oxalate tab 5 mg (base equiv)

1


1


1

fluoxetine hcl cap 10 mg 1fluoxetine hcl cap 20 mg 1fluoxetine hcl cap 40 mg 1fluoxetine hcl solution 20 mg/5ml 1fluoxetine hcl tab 10 mg 2fluoxetine hcl tab 20 mg 2fluoxetine hcl tab 60 mg 2paroxetine hcl tab 10 mg 1paroxetine hcl tab 20 mg 1paroxetine hcl tab 30 mg 1paroxetine hcl tab 40 mg 1paroxetine hcl tab er 24hr 37.5 mg 3 excluded for new startssertraline hcl oral concentrate for solution 20 mg/ml

1

sertraline hcl tab 25 mg 1sertraline hcl tab 50 mg 1sertraline hcl tab 100 mg 1TRINTELLIX TAB 10MG 3 PA, STVIIBRYD TAB 10MG 3 STVIIBRYD TAB 20MG 3 STVIIBRYD TAB 40MG 3 ST

ANTIDEPRESSANTS, SEROTONIN NOREPINEPHRINE REUPTAKE INHIBITORS (SNRIs)

desvenlafaxine succinate tab er 24hr 25 mg (base equiv)

2


2


2

41

duloxetine hcl enteric coated pellets cap 20 mg (base eq)

2


2


2

FETZIMA CAP 120MG 3 PAvenlafaxine hcl cap er 24hr 37.5 mg (base equivalent)

1

venlafaxine hcl cap er 24hr 75 mg (base equivalent)

1

venlafaxine hcl cap er 24hr 150 mg (base equivalent)

1

venlafaxine hcl tab 25 mg 1venlafaxine hcl tab 37.5 mg 1venlafaxine hcl tab 50 mg 1venlafaxine hcl tab 75 mg 1venlafaxine hcl tab 100 mg 1

ANTIDEPRESSANTS, TRICYCLIC ANTIDEPRESSANTS (TCAs)amitriptyline hcl tab 10 mg 1amitriptyline hcl tab 25 mg 1amitriptyline hcl tab 50 mg 1amitriptyline hcl tab 75 mg 1amitriptyline hcl tab 100 mg 1amitriptyline hcl tab 150 mg 1amoxapine tab 25 mg 3amoxapine tab 50 mg 3amoxapine tab 100 mg 3amoxapine tab 150 mg 3desipramine hcl tab 10 mg 1desipramine hcl tab 25 mg 1desipramine hcl tab 50 mg 1desipramine hcl tab 75 mg 1desipramine hcl tab 100 mg 1desipramine hcl tab 150 mg 1doxepin hcl cap 10 mg 1doxepin hcl cap 25 mg 1doxepin hcl cap 50 mg 1doxepin hcl cap 75 mg 1doxepin hcl cap 100 mg 1doxepin hcl cap 150 mg 1doxepin hcl conc 10 mg/ml 1imipramine hcl tab 10 mg 1imipramine hcl tab 25 mg 1imipramine hcl tab 50 mg 1

42

nortriptyline hcl cap 10 mg 1nortriptyline hcl cap 25 mg 1nortriptyline hcl cap 50 mg 1nortriptyline hcl cap 75 mg 1nortriptyline hcl soln 10 mg/5ml 1protriptyline hcl tab 5 mg 1protriptyline hcl tab 10 mg 1trimipramine maleate cap 25 mg 3trimipramine maleate cap 50 mg 3trimipramine maleate cap 100 mg 3

ANTIPARKINSONIAN AGENTSamantadine hcl cap 100 mg 1amantadine hcl syrup 50 mg/5ml 1amantadine hcl tab 100 mg 1APOKYN INJ 10MG/ML 3 PAbenztropine mesylate tab 0.5 mg 1benztropine mesylate tab 1 mg 1benztropine mesylate tab 2 mg 1bromocriptine mesylate cap 5 mg (base equivalent)

1

bromocriptine mesylate tab 2.5 mg (base equivalent)

1

carbidopa & levodopa tab 10-100 mg 1carbidopa & levodopa tab 25-100 mg 1carbidopa & levodopa tab 25-250 mg 1carbidopa & levodopa tab er 25-100 mg 1carbidopa & levodopa tab er 50-200 mg 1carbidopa tab 25 mg 3carbidopa-levodopa-entacapone tabs 12.5-50-200 mg

2

carbidopa-levodopa-entacapone tabs 18.75-75-200 mg

2

carbidopa-levodopa-entacapone tabs 25-100-200 mg

2


2


2

carbidopa-levodopa-entacapone tabs 50-200-200 mg

2

DUOPA SUS 4.63-20 3entacapone tab 200 mg 2pramipexole dihydrochloride tab 0.5 mg 1pramipexole dihydrochloride tab 0.25 mg 1pramipexole dihydrochloride tab 0.75 mg 1

43

pramipexole dihydrochloride tab 0.125 mg 1pramipexole dihydrochloride tab 1 mg 1pramipexole dihydrochloride tab 1.5 mg 1pramipexole dihydrochloride tab er 24hr 0.75 mg

3

pramipexole dihydrochloride tab er 24hr 0.375 mg

3


3


3

pramipexole dihydrochloride tab er 24hr 3 mg

3


3


3

rasagiline mesylate tab 0.5 mg (base equiv)

2

rasagiline mesylate tab 1 mg (base equiv) 2ropinirole hydrochloride tab 0.5 mg 1ropinirole hydrochloride tab 0.25 mg 1ropinirole hydrochloride tab 1 mg 1ropinirole hydrochloride tab 2 mg 1ropinirole hydrochloride tab 3 mg 1ropinirole hydrochloride tab 4 mg 1ropinirole hydrochloride tab 5 mg 1selegiline hcl cap 5 mg 1selegiline hcl tab 5 mg 1tolcapone tab 100 mg 3 PAtrihexyphenidyl hcl elixir 0.4 mg/ml 1trihexyphenidyl hcl tab 2 mg 1trihexyphenidyl hcl tab 5 mg 1

ANTIPSYCHOTICS, ATYPICALSABILIFY SOL 1MG/ML 3 QL (150 mL / 30 days),

PAaripiprazole oral solution 1 mg/ml 3 QL (150mL / 30 days),

PAaripiprazole tab 2 mg 2 QL (30 tabs / 30 days)aripiprazole tab 5 mg 2 QL (30 tabs / 30 days)aripiprazole tab 10 mg 2 QL (30 tabs / 30 days)aripiprazole tab 15 mg 2 QL (30 tabs / 30 days)aripiprazole tab 20 mg 2 QL (30 tabs / 30 days)aripiprazole tab 30 mg 2 QL (30 tabs / 30 days)clozapine tab 25 mg 1

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clozapine tab 50 mg 1clozapine tab 100 mg 1clozapine tab 200 mg 1FANAPT PAK 3 PAFANAPT TAB 1MG 3 QL (60 tabs / 30 days),

PAFANAPT TAB 2MG 3 QL (60 tabs / 30 days),






PALATUDA TAB 20MG 3 QL (30 tabs / 30 days),




PAolanzapine tab 2.5 mg 1 QL (90 tabs / 30 days);

PA under 13 yoaolanzapine tab 5 mg 1 QL (90 tabs / 30 days);

PA under 13 yoaolanzapine tab 7.5 mg 1 QL (90 tabs / 30 days);




PA under 13 yoapaliperidone tab er 24hr 1.5 mg 3 QL (30 tabs / 30 days),

PApaliperidone tab er 24hr 3 mg 3 QL (30 tabs / 30 days),



PA45

quetiapine fumarate tab 25 mg 1 QL (120 tabs / 30 days); PA under 10 yoa






quetiapine fumarate tab er 24hr 50 mg 2 QL (60 tabs / 30 days), PA; PA ages < 10





REXULTI TAB 0.5MG 3 QL (30 tabs / 30 days), PA

REXULTI TAB 0.25MG 3 QL (30 tabs / 30 days), PA

REXULTI TAB 1MG 3 QL (30 tabs / 30 days), PA




risperidone orally disintegrating tab 0.5 mg1 QL (90 tabs / 30 days)risperidone orally disintegrating tab 0.25 mg


risperidone orally disintegrating tab 1 mg 1 QL (90 tabs / 30 days)risperidone orally disintegrating tab 2 mg 1 QL (90 tabs / 30 days)risperidone orally disintegrating tab 3 mg 1 QL (90 tabs / 30 days)risperidone orally disintegrating tab 4 mg 1 QL (90 tabs / 30 days)risperidone soln 1 mg/ml 1risperidone tab 0.5 mg 1 QL (90 tabs / 30 days)risperidone tab 0.25 mg 1 QL (90 tabs / 30 days)risperidone tab 1 mg 1 QL (90 tabs / 30 days)

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risperidone tab 2 mg 1 QL (90 tabs / 30 days)risperidone tab 3 mg 1 QL (90 tabs / 30 days)risperidone tab 4 mg 1 QL (90 tabs / 30 days)SAPHRIS SUB 2.5MG 3 QL (60 tabs / 30 days),

PASAPHRIS SUB 5MG 3 QL (60 tabs / 30 days),

PASAPHRIS SUB 10MG 3 QL (60 tabs / 30 days),

PAVRAYLAR CAP 1.5-3MG 3 QL (30 caps / 30 days),

PAVRAYLAR CAP 1.5MG 3 QL (30 caps / 30 days),

PAVRAYLAR CAP 3MG 3 QL (30 caps / 30 days),

PAVRAYLAR CAP 4.5MG 3 QL (30 caps / 30 days),

PAVRAYLAR CAP 6MG 3 QL (30 caps / 30 days),

PAziprasidone hcl cap 20 mg 2 QL (60 caps / 30 days);

PA under 18 yoaziprasidone hcl cap 40 mg 2 QL (60 caps / 30 days);



PA under 18 yoaANTIPSYCHOTICS, MISCELLANEOUS

chlorpromazine hcl tab 10 mg 1chlorpromazine hcl tab 25 mg 1chlorpromazine hcl tab 50 mg 1chlorpromazine hcl tab 100 mg 1chlorpromazine hcl tab 200 mg 1fluphenazine hcl elixir 2.5 mg/5ml 1fluphenazine hcl oral conc 5 mg/ml 1fluphenazine hcl tab 1 mg 1fluphenazine hcl tab 2.5 mg 1fluphenazine hcl tab 5 mg 1fluphenazine hcl tab 10 mg 1haloperidol lactate oral conc 2 mg/ml 1haloperidol tab 0.5 mg 1haloperidol tab 1 mg 1haloperidol tab 2 mg 1haloperidol tab 5 mg 1haloperidol tab 10 mg 1

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haloperidol tab 20 mg 1loxapine succinate cap 5 mg 1loxapine succinate cap 10 mg 1loxapine succinate cap 25 mg 1loxapine succinate cap 50 mg 1perphenazine tab 2 mg 1perphenazine tab 4 mg 1perphenazine tab 8 mg 1perphenazine tab 16 mg 1pimozide tab 1 mg 3 PApimozide tab 2 mg 3 PAthioridazine hcl tab 10 mg 1thioridazine hcl tab 25 mg 1thioridazine hcl tab 50 mg 1thioridazine hcl tab 100 mg 1thiothixene cap 1 mg 1thiothixene cap 2 mg 1thiothixene cap 5 mg 1thiothixene cap 10 mg 1trifluoperazine hcl tab 1 mg (base equivalent)

1

trifluoperazine hcl tab 2 mg (base equivalent)

1


1


1

ATTENTION DEFICIT HYPERACTIVITY DISORDERamphetamine-dextroamphetamine cap er 24hr 5 mg


amphetamine-dextroamphetamine cap er 24hr 10 mg










amphetamine-dextroamphetamine tab 5 mg


amphetamine-dextroamphetamine tab 7.5 mg


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amphetamine-dextroamphetamine tab 12.5 mg








atomoxetine hcl cap 10 mg (base equiv) 2 QL (30 caps / 30 days)atomoxetine hcl cap 18 mg (base equiv) 2 QL (30 caps / 30 days)atomoxetine hcl cap 25 mg (base equiv) 2 QL (30 caps / 30 days)atomoxetine hcl cap 40 mg (base equiv) 2 QL (30 caps / 30 days)atomoxetine hcl cap 60 mg (base equiv) 2 QL (30 caps / 30 days)atomoxetine hcl cap 80 mg (base equiv) 2 QL (30 caps / 30 days)atomoxetine hcl cap 100 mg (base equiv) 2 QL (30 caps / 30 days)clonidine hcl tab er 12hr 0.1 mg 1DAYTRANA DIS 10MG/9HR 2 QL (30 patches / 30

days)DAYTRANA DIS 15MG/9HR 2 QL (30 patches / 30



days)dexmethylphenidate hcl cap er 24 hr 5 mg 2 QL (30 caps / 30 days)dexmethylphenidate hcl cap er 24 hr 10 mg


dexmethylphenidate hcl cap er 24 hr 15 mg












dexmethylphenidate hcl tab 2.5 mg 1 QL (90 tabs / 30 days)dexmethylphenidate hcl tab 5 mg 1 QL (90 tabs / 30 days)dexmethylphenidate hcl tab 10 mg 1 QL (90 tabs / 30 days)

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dextroamphetamine sulfate cap er 24hr 5 mg






dextroamphetamine sulfate tab 5 mg 1 QL (120 tabs / 30 days)dextroamphetamine sulfate tab 10 mg 1 QL (120 tabs / 30 days)guanfacine hcl tab er 24hr 1 mg (base equiv)

2

guanfacine hcl tab er 24hr 2 mg (base equiv)

2


2


2

metadate tab 20mg er 1methamphetamine hcl tab 5 mg 3methylin tab 5mg 1 QL (90 tabs / 30 days)methylin tab 10mg 1 QL (90 tabs / 30 days)methylin tab 10mg er 1methylin tab 20mg 1 QL (90 tabs / 30 days)methylin tab 20mg er 1methylphenidate hcl cap er 10 mg (cd) 1 QL (60 caps / 30 days);

generic for Metadate CDmethylphenidate hcl cap er 20 mg (cd) 1 QL (60 caps / 30 days);

generic for Metadate CDmethylphenidate hcl cap er 24hr 20 mg (la)

1 QL (60 caps / 30 days); generic for Ritalin LA

methylphenidate hcl cap er 24hr 30 mg (la)


methylphenidate hcl cap er 24hr 40 mg (la)


methylphenidate hcl cap er 30 mg (cd) 1 QL (60 caps / 30 days); generic for Metadate CD




methylphenidate hcl soln 5 mg/5ml 2 QL (1800 mL / 30 days)methylphenidate hcl soln 10 mg/5ml 2methylphenidate hcl tab 5 mg 1 QL (90 tabs / 30 days)methylphenidate hcl tab 10 mg 1 QL (90 tabs / 30 days)

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methylphenidate hcl tab 20 mg 1 QL (90 tabs / 30 days)methylphenidate hcl tab er 10 mg 1methylphenidate hcl tab er 20 mg 1methylphenidate hcl tab er osmotic release (osm) 18 mg

1 QL (

2019 CDPHP® Commercial Clinical Formulary- 2/media/Files/pharmacy/Formulary-2.pdf · ATTENZIONE:...

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