Drug Benefit List 2010
28:00 CENTRAL NERVOUS SYSTEM AGENTS
28:08.04 NONSTEROIDAL ANTI-INFLAMMATORY AGENTS
ACETYLSALICYLIC ACID
- 80mg Chewable Tablet
- 2009013 ASAPHEN PMS
- 2269139 JAMP-ASA JMP
- 2202352 RIVASA RIV
- 80mg Delayed Release Tablet
- 2283905 ACETYLSALICYLIC ACID JMP
- 2238545 ASAPHEN EC PMS
- 162mg Delayed Release Tablet
- 2247550 ASAPHEN EC PMS
- 325mg Delayed Release Tablet
- 2284529 PMS-ASA EC PMS
- 650mg Delayed Release Tablet
- 2284537 PMS-ASA EC PMS
- 81mg Enteric Coated Tablet
- 2243101 ASA PMS
- 2244993 ASA PMS
- 2237726 ASPIRIN BCD
- 2242281 ENTROPHEN EC PED
- 2283700 PRAXIS ASA EC PMS
- 325mg Enteric Coated Tablet
- 510696 APO-ASEN ECT APX
- 2010526 ASA VTH
- 2150417 ASPIRIN BCD
- 2050161 ENTROPHEN WAM
- 10332 ENTROPHEN-5 WAM
- 216666 NOVASEN NOP
- 2285371 PMS-ASA EC PMS
- 650mg Enteric Coated Tablet
- 472476 ASA APX
- 794244 ASA WSB
- 2046261 ASA FRS
- 1905392 ENTROPHEN-10 FRS
- 229296 NOVASEN NOP
- 150mg Suppository
- 785547 PMS-ASA PMS
- 650mg Suppository
- 582867 ASA JNO
- 80mg Tablet
- 2150352 ASPIRIN BCD
- 2250675 EURO-ASA EUR
- 2311496 PRO-ASA 80MG EC TAB PRO
- 2311518 PRO-ASA 80MG TAB PRO
- 2202360 RIVASA RIV
- 2321750 ZYM-ASA ZYM
- 2321769 ZYM-ASA EC ZYM
ACETYLSALICYLIC ACID
- 325mg Tablet
- 472468 APO-ASA APX
- 36145 ASA PED
- 230324 ASA NOP
- 530336 ASA * VTH
- 2150328 ASPIRIN BCD
- 650mg Tablet
- 10340 ENTROPHEN 10 FRS
CELECOXIB
Limited use benefit (prior approval required).
For patients with osteoarthritis who have failed therapy with acetaminophen and who:
- have failed to achieve adequate response with 2 other listed NSAIDs, or
- have experienced an adverse event attributable to 2 other listed NSAIDs, or
- have a history of a serious gastrointestinal complication such as bleeding or perforation.
For patients with rheumatoid arthritis who:
- have failed to achieve adequate response with 2 other listed NSAIDs, or
- have experienced an adverse event attributable to 2 other listed NSAIDs, or
- have a history of a serious gastrointestinal complication such as bleeding or perforation.
- 100mg Capsule
- 2239941 CELEBREX PFI
- 200mg Capsule
- 2239942 CELEBREX PFI
DICLOFENAC SODIUM
- 25mg Delayed Release Tablet
- 2302616 PMS-DICLOFENAC 25MG DR PMS
- 50mg Delayed Release Tablet
- 2302624 PMS-DICLOFENAC 50MG DR PMS
- 25mg Enteric Coated Tablet
- 839175 APO-DICLO APX
- 870951 DICLOFENAC-25 PDL
- 2231662 DOM-DICLOFENAC DPC
- 808539 NOVO-DIFENAC NOP
- 886017 NU-DICLO NXP
- 2231502 PMS-DICLOFENAC PMS
- 2261952 SANDOZ-DICLOFENAC SDZ
- 50mg Enteric Coated Tablet
- 839183 APO-DICLO APX
- 870978 DICLOFENAC-50 PDL
- 2231663 DOM-DICLOFENAC DPC
- 808547 NOVO-DIFENAC NOP
- 886025 NU-DICLO NXP
- 2231503 PMS-DICLOFENAC PMS
- 2261960 SANDOZ-DICLOFENAC SDZ
- 514012 VOLTAREN NVR
DICLOFENAC SODIUM
- 50mg Suppository
- 2231506 PMS-DICLOFENAC PMS
- 2241224 SANDOZ DICLOFENAC SDZ
- 2261928 SANDOZ-DICLOFENAC SDZ
- 632724 VOLTAREN NVR
- 100mg Suppository
- 2231508 PMS-DICLOFENAC PMS
- 2241225 SANDOZ DICLOFENAC SDZ
- 2261936 SANDOZ-DICLOFENAC SDZ
- 632732 VOLTAREN NVR
- 75mg Sustained Release Tablet
- 2224119 DICLOFENAC-SR PDL
- 2231664 DOM-DICLOFENAC SR DPC
- 2158582 NOVO-DIFENAC SR NOP
- 2228203 NU-DICLO SR NXP
- 2231504 PMS-DICLOFENAC SR PMS
- 2261901 SANDOZ-DICLOFENAC SR SDZ
- 782459 VOLTAREN SR NVR
- 100mg Sustained Release Tablet
- 2091194 APO-DICLO SR APX
- 2224127 DICLOFENAC-SR PDL
- 2231665 DOM-DICLOFENAC SR DPC
- 2048698 NOVO-DIFENAC SR NOP
- 2228211 NU-DICLO SR NXP
- 2231505 PMS-DICLOFENAC SR PMS
- 2261944 SANDOZ-DICLOFENAC SR SDZ
- 590827 VOLTAREN SR NVR
DICLOFENAC SODIUM, MISOPROSTOL
- 50mg & 200mcg Tablet
- 1917056 ARTHROTEC PFI
- 75mg & 200mcg Tablet
- 2229837 ARTHROTEC PFI
DIFLUNISAL
- 250mg Tablet
- 2039486 APO-DIFLUNISAL APX
- 2048493 NOVO-DIFLUNISAL NOP
- 500mg Tablet
- 2039494 APO-DIFLUNISAL APX
- 2058413 NU-DIFLUNISAL NXP
FLURBIPROFEN
- 50mg Tablet
- 647942 ANSAID PFI
- 1912046 APO-FLURBIPROFEN APX
- 1947729 FLURBIPROFEN PRO
- 2100509 NOVO-FLURPROFEN NOP
- 2020661 NU-FLURBIPROFEN NXP
- 100mg Tablet
- 600792 ANSAID PFI
- 1912038 APO-FLURBIPROFEN APX
- 1947737 FLURBIPROFEN PRO
- 2100517 NOVO-FLURPROFEN NOP
- 2020688 NU-FLURBIPROFEN NXP
IBUPROFEN
- 200mg Capsule
- 2241769 ADVIL LIQUI-GEL WRI
- 2281384 IBUPROFEN APX
- 400mg Capsule
- 2248231 ADVIL LIQUI-GEL WAY
- 2310880 IBUPROFEN APX
- 100mg Chewable Tablet
- 2246403 ADVIL JUNIOR STRENGTH WRI
- 40mg/mL Drop
- 2242522 ADVIL PEDIATRIC WRI
- 2238626 CHILDREN'S MOTRIN MCL
- 20mg/mL Oral Liquid
- 2232297 CHILDREN'S ADVIL WRI
- 2242365 CHILDREN'S MOTRIN JNO
- 100mg Tablet
- 2240527 MOTRIN JUNIOR STRENGTH MCL
- 200mg Tablet
- 1933558 ADVIL WRI
- 441643 APO-IBUPROFEN APX
- 636517 IBUPROFEN PDL
- 2238004 IBUPROFEN VTH
- 2257912 IBUPROFEN PMT
- 2272849 IBUPROFEN VTH
- 2186934 MOTRIN MCL
- 300mg Tablet
- 441651 APO-IBUPROFEN APX
- 636525 IBUPROFEN PDL
- 2020696 NU-IBUPROFEN NXP
- 400mg Tablet
- 506052 APO-IBUPROFEN APX
- 636533 IBUPROFEN PDL
- 2317338 JAMP IBUPROFEN JMP
- 2020718 NU-IBUPROFEN NXP
- 836133 PMS-IBUPROFEN PMS
- 600mg Tablet
- 585114 APO-IBUPROFEN APX
- 658804 IBUPROFEN PDL
- 629359 NOVO-PROFEN NOP
- 2020726 NU-IBUPROFEN NXP
INDOMETHACIN
- 25mg Capsule
- 611158 APO-INDOMETHACIN APX
- 337420 NOVO-METHACIN NOP
- 865850 NU-INDO NXP
- 646261 PRO-INDO PDL
- 50mg Capsule
- 611166 APO-INDOMETHACIN APX
- 337439 NOVO-METHACIN NOP
- 865869 NU-INDO NXP
- 646288 PRO-INDO PDL
- 50mg Suppository
- 2231799 SANDOZ INDOMETHACIN SDZ
INDOMETHACIN
- 100mg Suppository
- 1934139 RATIO-INDOMETHACIN RPH
- 2231800 SANDOZ INDOMETHACIN SDZ
KETOPROFEN
- 50mg Capsule
- 790427 APO-KETO APX
- 2044633 NU-KETOPROFEN NXP
- 2150808 PMS-KETOPROFEN PMS
- 50mg Enteric Coated Tablet
- 790435 APO KETO-E APX
- 2150816 PMS-KETOPROFEN PMS
- 100mg Enteric Coated Tablet
- 842664 APO-KETO-E APX
- 2150824 PMS-KETOPROFEN PMS
- 50mg Suppository
- 2148773 PMS-KETOPROFEN PMS
- 100mg Suppository
- 2015951 PMS-KETOPROFEN PMS
- 200mg Sustained Release Tablet
- 2172577 APO-KETO SR APX
- 2210487 KETOPROFEN-SR PDL
MEFENAMIC ACID
- 250mg Capsule
- 2229452 APO-MEFENAMIC APX
- 2237826 DOM-MEFENAMIC ACID DPC
- 2230408 MEFENAMIC PDL
- 2229569 NU-MEFENAMIC NXP
MELOXICAM
- 7.5mg Tablet
- 2248973 APO-MELOXICAM APX
- 2250012 CO MELOXICAM COB
- 2248605 DOM-MELOXICAM DPC
- 2255987 GEN-MELOXICAM GEN
- 2242785 MOBICOX BOE
- 2258315 NOVO-MELOXICAM NOP
- 2248607 PHL-MELOXICAM PHH
- 2248267 PMS-MELOXICAM PMS
- 2247889 RATIO-MELOXICAM RPH
- 15mg Tablet
- 2248974 APO-MELOXICAM APX
- 2250020 CO MELOXICAM COB
- 2248606 DOM-MELOXICAM DPC
- 2255995 GEN-MELOXICAM GEN
- 2242786 MOBICOX BOE
- 2258323 NOVO-MELOXICAM NOP
- 2248608 PHL-MELOXICAM PHH
- 2248268 PMS-MELOXICAM PMS
- 2248031 RATIO-MELOXICAM RPH
NAPROXEN
- 250mg Enteric Coated Tablet
- 2246699 APO-NAPROXEN EC APX
- 2162792 NAPROSYN E HLR
- 2243312 NOVO-NAPROX NOP
- 375mg Enteric Coated Tablet
- 2246700 APO-NAPROXEN EC APX
- 2162415 NAPROSYN E HLR
- 2243313 NOVO-NAPROX NOP
- 2294702 PMS-NAPROXEN EC PMS
- 500mg Enteric Coated Tablet
- 2246701 APO-NAPROXEN EC APX
- 2241024 GEN-NAPROXEN EC GEN
- 2162423 NAPROSYN E HLR
- 2243314 NOVO-NAPROX NOP
- 2294710 PMS-NAPROXEN EC PMS
- 2310953 PRO-NAPROXEN EC PDL
- 25mg/mL Suspension
- 2162431 NAPROSYN HLR
- 750mg Sustained Release Tablet
- 2162466 NAPROSYN SR HLR
- 125mg Tablet
- 522678 APO-NAPROXEN APX
- 590754 NAPROXEN PDL
- 865621 NU-NAPROX NXP
- 250mg Tablet
- 522651 APO-NAPROXEN APX
- 590762 NAPROXEN PDL
- 565350 NOVO-NAPROX NOP
- 865648 NU-NAPROX NXP
- 2240786 RIVA-NAPROXEN RIV
- 375mg Tablet
- 600806 APO-NAPROXEN APX
- 2243432 GEN-NAPROXEN GEN
- 655686 NAPROXEN PDL
- 627097 NOVO-NAPROX NOP
- 865656 NU-NAPROX NXP
- 2240787 RIVA-NAPROXEN RIV
- 500mg Tablet
- 592277 APO-NAPROXEN APX
- 618721 NAPROXEN PDL
- 589861 NOVO-NAPROX NOP
- 865664 NU-NAPROX NXP
- 2240788 RIVA-NAPROXEN RIV
NAPROXEN SODIUM
- 275mg Tablet
- 2162725 ANAPROX HLR
- 784354 APO-NAPRO NA APX
- 887056 NAPROXEN NA PDL
- 778389 NOVO-NAPROX SODIUM NOP
NAPROXEN SODIUM
- 550mg Tablet
- 2162717 ANAPROX DS HLR
- 1940309 APO-NAPRO NA DS APX
- 2153386 NAPROXEN-NA DF PDL
- 2026600 NOVO-NAPROX SODIUM DS NOP
- 2240828 RIVA-NAPROXEN SODIUM RIV
PIROXICAM
- 10mg Capsule
- 642886 APO-PIROXICAM APX
- 2171813 GEN-PIROXICAM GEN
- 865761 NU-PIROX NXP
- 658839 PIROXICAM PDL
- 836249 PMS-PIROXICAM PMS
- 20mg Capsule
- 642894 APO-PIROXICAM APX
- 2239536 DOM-PIROXICAM DPC
- 2171821 GEN-PIROXICAM GEN
- 865788 NU-PIROX NXP
- 658820 PIROXICAM PDL
- 836230 PMS-PIROXICAM PMS
- 10mg Suppository
- 2154420 PMS-PIROXICAM PMS
- 20mg Suppository
- 2154463 PMS-PIROXICAM PMS
- 10mg Tablet
- 695718 NOVO-PIROCAM NOP
- 20mg Tablet
- 695696 NOVO-PIROCAM NOP
SULINDAC
- 150mg Tablet
- 778354 APO-SULIN APX
- 745588 NOVO-SUNDAC NOP
- 2042576 NU-SULINDAC NXP
- 808628 SULINDAC PDL
- 200mg Tablet
- 778362 APO-SULIN APX
- 745596 NOVO-SUNDAC NOP
- 2042584 NU-SULINDAC NXP
- 2239164 PENTA-SULINDAC PEN
- 808636 SULINDAC PDL
TIAPROFENIC ACID
- 200mg Tablet
- 2179679 NOVO-TIAPROFENIC NOP
- 2231249 PENTA-TIAPROFENIC PEN
- 2230827 PMS-TIAPROFENIC PMS
- 300mg Tablet
- 2136120 APO-TIAPROFENIC APX
- 2231060 DOM-TIAPROFENIC DPC
- 2179687 NOVO-TIAPROFENIC NOP
- 2146886 NU-TIAPROFENIC NXP
- 2231250 PENTA-TIAPROFENIC PEN
- 2145014 TIAPROFENIC PDL
28:08.08 OPIATE AGONISTS
ACETAMINOPHEN, CAFFEINE CITRATE, CODEINE PHOSPHATE
- 300mg & 15mg & 15mg Tablet
- 706515 PMS-ACET 2 PMS
- 653241 RATIO-LENOLTEC NO.2 RPH
- 2163934 TYLENOL WITH CODEINE NO.2 JNO
- 300mg & 15mg & 30mg Tablet
- 653276 RATIO-LENOLTEC NO.3 RPH
- 2163926 TYLENOL WITH CODEINE NO.3 JNO
- 300mg & 30mg & 15mg Tablet
- 293504 ATASOL-15 HOR
- 2232388 EXDOL-15 PED
- 300mg & 30mg & 30mg Tablet
- 293512 ATASOL-30 HOR
- 2232389 EXDOL-30 PED
ACETAMINOPHEN, CODEINE PHOSPHATE
- 32mg & 1.6mg/mL Elixir
- 816027 PMS-ACETAMINOPHEN WITH CODEINE PMS
- 2163942 TYLENOL WITH CODEINE JNO
- 300mg & 30mg Tablet
- 1999648 ACET CODEINE 30 PMS
- 2232658 PROCET-30 PDL
- 608882 RATIO-EMTEC-30 RPH
- 789828 TRIATEC-30 TRI
- 300mg & 60mg Tablet
- 621463 LENOLTEC NO.4 RPH
- 2163918 TYLENOL WITH CODEINE NO.4 JNO
ACETAMINOPHEN, OXYCODONE HCL
- 325mg & 2.5mg Tablet
- 1916491 PERCOCET DEMI BMS
- 325mg & 5mg Tablet
- 2324628 APO-OXYCODONE/ACET APX
- 1916548 ENDOCET EDM
- 2307898 NOVO-OXYCODONE ACET NOP
- 1916475 PERCOCET BMS
- 2245758 PMS-OXYCODONE ACETAMINOPHEN PMS
- 2327171 PRO-OXYCOD ACET PDL
- 608165 RATIO-OXYCOCET RPH
- 2242468 RIVACOCET RIV
ACETYLSALICYLIC ACID, CAFFEINE CITRATE, CODEINE PHOSPHATE
- 375mg & 30mg & 15mg Tablet
- 2234510 282 PED
- 375mg & 30mg & 30mg Tablet
- 2238645 292 PED
ACETYLSALICYLIC ACID, OXYCODONE HCL
- 325mg & 5mg Tablet
- 1916572 PERCODAN BMS
- 608157 RATIO-OXYCODAN RPH
CODEINE MONOHYDRATE, CODEINE SULFATE TRIHYDRATE
Limited use benefit (prior approval required).
For treatment of:
- chronic pain and palliative care patients as an alternative to products containing codeine in combination with acetaminophen or ASA with or without caffeine, or
- chronic pain and palliative care patients as an alternative to regular release codeine tablets when large doses are required.
- 50mg Long Acting Tablet
- 2230302 CODEINE CONTIN CR PFR
- 100mg Long Acting Tablet
- 2163748 CODEINE CONTIN CR PFR
- 150mg Long Acting Tablet
- 2163780 CODEINE CONTIN CR PFR
- 200mg Long Acting Tablet
- 2163799 CODEINE CONTIN CR PFR
CODEINE PHOSPHATE
- 30mg/mL Injection
- 544884 CODEINE * SDZ
- 497282 CODEINE PHOSPHATE * ABB
- 60mg/mL Injection
- 497290 CODEINE PHOSPHATE * ABB
- 2mg/mL Liquid
- 380571 LINCTUS CODEINE ATL
- 5mg/mL Syrup
- 50024 CODEINE PHOSPHATE ATL
- 779474 RATIO-CODEINE RPH
- 15mg Tablet
- 779458 CODEINE RPH
- 2009889 CODEINE RIV
- 2243978 PMS-CODEINE PMS
- 593435 RATIO-CODEINE RPH
- 30mg Tablet
- 2009757 CODEINE RIV
- 593451 CODEINE PHOSPHATE RPH
- 2243979 PMS-CODEINE PMS
FENTANYL
Limited use benefit (prior approval required).
For the management of chronic pain in patients who are unresponsive or intolerant to at least one long-acting oral sustained released product, such as morphine, hydromorphone and oxycodone, despite appropriate dose titration and adjunctive therapy including laxatives and antiemetics.
- 12mcg/h Transdermal Patch
- 2341379 PMS-FENTANYL MTX PMS
- 2330105 RAN-FENTANYL MATRIX PATCH 12 RBY
- 2311925 RATIO-FENTANYL RPH
- 2327112 SANDOZ FENTANYL SDZ
FENTANYL
Limited use benefit (prior approval required).
For the management of chronic pain in patients who are unresponsive or intolerant to at least one long-acting oral sustained released product, such as morphine, hydromorphone and oxycodone, despite appropriate dose titration and adjunctive therapy including laxatives and antiemetics.
- 25mcg/h Transdermal Patch
- 2275813 DURAGESIC MAT JNO
- 2314630 NOVO-FENTANYL NOP
- 2341387 PMS-FENTANYL MTX PMS
- 2249391 RAN-FENTANYL RBY
- 2330113 RAN-FENTANYL MATRIX RBY
- 2282941 RATIO-FENTANYL RPH
- 2327120 SANDOZ FENTANYL SDZ
- 50mcg/h Transdermal Patch
- 2275821 DURAGESIC MAT JNO
- 2314649 NOVO-FENTANYL NOP
- 2341395 PMS-FENTANYL MTX PMS
- 2249413 RAN-FENTANYL RBY
- 2330121 RAN-FENTANYL MATRIX RBY
- 2282968 RATIO-FENTANYL RPH
- 2327147 SANDOZ FENTANYL SDZ
- 75mcg/h Transdermal Patch
- 2275848 DURAGESIC MAT JNO
- 2314657 NOVO-FENTANYL NOP
- 2341409 PMS-FENTANYL MTX PMS
- 2249421 RAN-FENTANYL RBY
- 2330148 RAN-FENTANYL MATRIX RBY
- 2282976 RATIO-FENTANYL RPH
- 2327155 SANDOZ FENTANYL SDZ
- 100mcg/h Transdermal Patch
- 2275856 DURAGESIC MAT JNO
- 2314665 NOVO-FENTANYL NOP
- 2341417 PMS-FENTANYL MTX PMS
- 2249448 RAN-FENTANYL RBY
- 2330156 RAN-FENTANYL MATRIX RBY
- 2282984 RATIO-FENTANYL RPH
- 2327163 SANDOZ FENTANYL TRANSDERMAL SYSTEM SDZ
HYDROMORPHONE HCL
Limited use benefit. Prior approval required for controlled release capsules only. Regular release dosage forms are full benefits and do not require prior approval.
For treatment of moderate to severe chronic pain when other opioids such as morphine have been ineffective in controlling pain or in patients experiencing intolerable side.
- 3mg Controlled Release Capsule
- 2125323 HYDROMORPH CONTIN PFR
- 6mg Controlled Release Capsule
- 2125331 HYDROMORPH CONTIN PFR
- 12mg Controlled Release Capsule
- 2125366 HYDROMORPH CONTIN PFR
- 18mg Controlled Release Capsule
- 2243562 HYDROMORPH CONTIN PFR
HYDROMORPHONE HCL
Limited use benefit. Prior approval required for controlled release capsules only. Regular release dosage forms are full benefits and do not require prior approval.
For treatment of moderate to severe chronic pain when other opioids such as morphine have been ineffective in controlling pain or in patients experiencing intolerable side.
- 24mg Controlled Release Capsule
- 2125382 HYDROMORPH CONTIN PFR
- 30mg Controlled Release Capsule
- 2125390 HYDROMORPH CONTIN PFR
- 2mg/mL Injection
- 627100 DILAUDID ABB
- 2145901 HYDROMORPHONE SDZ
- 10mg/mL Injection
- 622133 DILAUDID HP ABB
- 2145928 HYDROMORPHONE HP 10 SDZ
- 20mg/mL Injection
- 2146118 DILAUDID HP PLUS ABB
- 2145936 HYDROMORPHONE HP 20 SDZ
- 50mg/mL Injection
- 2145863 DILAUDID XP ABB
- 2146126 HYDROMORPHONE HP 50 SDZ
- 99003163 HYDROMORPHONE HP 50 SDZ
- 1mg/mL Oral Liquid
- 786535 DILAUDID ABB
- 1916386 PMS-HYDROMORPHONE PMS
- 3mg Suppository
- 125105 DILAUDID ABB
- 1916394 PMS-HYDROMORPHONE PMS
- 1mg Tablet
- 705438 DILAUDID ABB
- 2192101 PHL-HYDROMORPHONE PHH
- 885444 PMS-HYDROMORPHONE PMS
- 2mg Tablet
- 125083 DILAUDID ABB
- 2249928 PHL-HYDROMORPHONE PHH
- 885436 PMS-HYDROMORPHONE PMS
- 4mg Tablet
- 125121 DILAUDID ABB
- 2249936 PHL-HYDROMORPHONE PHH
- 885401 PMS-HYDROMORPHONE PMS
- 8mg Tablet
- 786543 DILAUDID ABB
- 2192144 PHL-HYDROMORPHONE PHH
- 885428 PMS-HYDROMORPHONE PMS
MEPERIDINE HCL
Limited use benefit (prior approval not required).
Limited to 2 weeks supply for acute pain. Coverage will be limited to 60 tablets per one month period.
- 25mg/mL Injection
- 497444 PETHIDINE * ABB
MEPERIDINE HCL
Limited use benefit (prior approval not required).
Limited to 2 weeks supply for acute pain. Coverage will be limited to 60 tablets per one month period.
- 50mg/mL Injection
- 2242003 DEMEROL ABB
- 725765 MEPERIDINE SDZ
- 497452 PETHIDINE ABB
- 75mg/mL Injection
- 2242004 DEMEROL ABB
- 725757 MEPERIDINE SDZ
- 497460 PETHIDINE * ABB
- 100mg/mL Injection
- 2242005 DEMEROL ABB
- 725749 MEPERIDINE SDZ
- 497479 PETHIDINE ABB
- 50mg Tablet
- 2138018 DEMEROL SAC
MORPHINE HCL
- 30mg Sustained Release Tablet
- 776181 M.O.S. SR VAE
- 60mg Sustained Release Tablet
- 776203 M.O.S. SR VAE
- 1mg/mL Syrup
- 614491 DOLORAL 1 ATL
- 607762 RATIO-MORPHINE RPH
- 5mg/mL Syrup
- 614505 DOLORAL 5 ATL
- 607770 RATIO-MORPHINE RPH
- 10mg/mL Syrup
- 632503 M.O.S. 10 VAE
- 690783 RATIO-MORPHINE RPH
- 20mg/mL Syrup
- 690791 RATIO-MORPHINE RPH
- 50mg/mL Syrup
- 690236 M.O.S. 50 VAE
- 10mg Tablet
- 690198 M.O.S. 10 VAE
- 20mg Tablet
- 690201 M.O.S. 20 VAE
- 40mg Tablet
- 690228 M.O.S. 40 VAE
- 60mg Tablet
- 690244 M.O.S. 60 VAE
MORPHINE SULFATE
- 20mg/mL Drop
- 621935 STATEX PMS
- 50mg/mL Drop
- 705799 STATEX PMS
- 0.5mg/mL Injection
- 2021056 MORPHINE LP SDZ
- 1949047 MORPHINE SULFATE ABB
MORPHINE SULFATE
- 1mg/mL Injection
- 2021048 MORPHINE LP * SDZ
- 1949055 MORPHINE SULFATE ABB
- 1980696 MORPHINE SULFATE SDZ
- 2mg/mL Injection
- 850314 MORPHINE SULFATE ABB
- 1964437 MORPHINE SULFATE SDZ
- 2242484 MORPHINE SULFATE SDZ
- 5mg/mL Injection
- 1964429 MORPHINE SULFATE SDZ
- 10mg/mL Injection
- 392588 MORPHINE SULFATE SDZ
- 850322 MORPHINE SULFATE ABB
- 15mg/mL Injection
- 392561 MORPHINE SULFATE SDZ
- 25mg/mL Injection
- 676411 MORPHINE HP 25 SDZ
- 50mg/mL Injection
- 617288 MORPHINE HP 50 SDZ
- 2137267 MORPHINE SULFATE HOS
- 5mg Suppository
- 632228 STATEX PMS
- 10mg Suppository
- 632201 STATEX PMS
- 20mg Suppository
- 596965 STATEX PMS
- 10mg Sustained Release Capsule
- 2242163 KADIAN MAY
- 2019930 M-ESLON SAC
- 15mg Sustained Release Capsule
- 2177749 M-ESLON SAC
- 20mg Sustained Release Capsule
- 2184435 KADIAN SR MAY
- 30mg Sustained Release Capsule
- 2019949 M-ESLON SR SAC
- 50mg Sustained Release Capsule
- 2184443 KADIAN SR MAY
- 60mg Sustained Release Capsule
- 2019957 M-ESLON SR SAC
- 100mg Sustained Release Capsule
- 2184451 KADIAN SR MAY
- 2019965 M-ESLON SR SAC
- 200mg Sustained Release Capsule
- 2177757 M-ESLON SR SAC
- 15mg Sustained Release Tablet
- 2015439 MS CONTIN SR PFR
- 2302764 NOVO-MORPHINE SR NOP
- 2245284 PMS-MORPHINE SULFATE PMS
- 2244790 RATIO-MORPHINE SULFATE SR RPH
MORPHINE SULFATE
- 30mg Sustained Release Tablet
- 2014297 MS CONTIN SR PFR
- 2302772 NOVO-MORPHINE SR NOP
- 2245285 PMS-MORPHINE SULFATE PMS
- 2244791 RATIO-MORPHINE SULFATE SR RPH
- 60mg Sustained Release Tablet
- 2014300 MS CONTIN SR PFR
- 2302780 NOVO-MORPHINE SR NOP
- 2245286 PMS-MORPHINE SULFATE PMS
- 2244792 RATIO-MORPHINE SULFATE SR RPH
- 100mg Sustained Release Tablet
- 2014319 MS CONTIN SR PFR
- 2302799 NOVO-MORPHINE SR NOP
- 2245287 PMS-MORPHINE SR PMS
- 200mg Sustained Release Tablet
- 2014327 MS CONTIN SR PFR
- 2302802 NOVO-MORPHINE SR NOP
- 2245288 PMS-MORPHINE SR PMS
- 1mg/mL Syrup
- 591467 STATEX PMS
- 5mg/mL Syrup
- 591475 STATEX PMS
- 10mg/mL Syrup
- 647217 STATEX PMS
- 5mg Tablet
- 2009773 M.O.S. SULFATE VAE
- 2014203 MS IR PFR
- 594652 STATEX PMS
- 10mg Tablet
- 2009765 M.O.S. SULFATE VAE
- 2014211 MS IR PFR
- 594644 STATEX PMS
- 20mg Tablet
- 2014238 MS IR PFR
- 25mg Tablet
- 2009749 M.O.S. SULFATE VAE
- 594636 STATEX PMS
- 30mg Tablet
- 2014254 MS IR PFR
- 50mg Tablet
- 2009706 M.O.S. SULFATE VAE
- 675962 STATEX PMS
OXYCODONE HCL
Limited use benefit. Prior approval required for controlled release tablets only. Regular release dosage forms are full benefits and do not require prior approval.
For treatment of moderate to severe chronic pain when other opioids such as morphine have been ineffective in controlling pain or in patients experiencing intolerable side.
- 5mg Controlled Release Tablet
- 2258129 OXYCONTIN PFR
OXYCODONE HCL
Limited use benefit. Prior approval required for controlled release tablets only. Regular release dosage forms are full benefits and do not require prior approval.
For treatment of moderate to severe chronic pain when other opioids such as morphine have been ineffective in controlling pain or in patients experiencing intolerable side.
- 10mg Controlled Release Tablet
- 2202441 OXYCONTIN PFR
- 15mg Controlled Release Tablet
- 2323192 OXYCONTIN PFR
- 20mg Controlled Release Tablet
- 2202468 OXYCONTIN PFR
- 30mg Controlled Release Tablet
- 2323206 OXYCONTIN PFR
- 40mg Controlled Release Tablet
- 2202476 OXYCONTIN PFR
- 60mg Controlled Release Tablet
- 2323214 OXYCONTIN PFR
- 80mg Controlled Release Tablet
- 2202484 OXYCONTIN PFR
- 10mg Suppository
- 392480 SUPEUDOL SDZ
- 20mg Suppository
- 392472 SUPEUDOL SDZ
- 5mg Tablet
- 2231934 OXY-IR PFR
- 2319977 PMS-OXYCODONE PMS
- 789739 SUPEUDOL SDZ
- 10mg Tablet
- 2240131 OXY-IR PFR
- 2319985 PMS-OXYCODONE PMS
- 443948 SUPEUDOL SDZ
- 20mg Tablet
- 2240132 OXY-IR PFR
- 2319993 PMS-OXYCODONE PMS
- 2262983 SUPEUDOL SDZ
28:08.12 OPIATE PARTIAL AGONISTS
PENTAZOCINE HCL
- 50mg Tablet
- 2137984 TALWIN SAC
PENTAZOCINE LACTATE
- 30mg/mL Injection
- 2241976 TALWIN ABB
28:08.92 MISCELLANEOUS ANALGESICS AND ANTIPYRETICS
ACETAMINOPHEN
- 80mg Chewable Tablet
- 2129957 ACETAMIN CHILD WTR
- 1905856 ACETAMINOPHEN TRI
- 2017458 ACETAMINOPHEN RIV
- 2015676 CHILDREN'S ACETAMINOPHEN TAN
- 2263815 PEDIAPHEN CHEWABLE EUR
- 160mg Chewable Tablet
- 2017431 ACETAMINOPHEN RIV
- 2231011 FEVERHALT PED
- 2263823 PEDIAPHEN CHEWABLE EUR
- 2230934 TANTAPHEN GRAPE TAN
- 876038 TEMPRA CHILDREN MJO
- 80mg/mL Drop
- 1904140 ACETAMINOPHEN TAN
- 1905864 ACETAMINOPHEN TRI
- 631353 ATASOL HOR
- 2230787 FEVERHALT PED
- 2263793 PEDIAPHEN EUR
- 2027801 PEDIATRIX RPH
- 887587 PMS-ACETAMINOPHEN PMS
- 875988 TEMPRA MJO
- 2046059 TYLENOL GRAPE MCL
- 16mg/mL Liquid
- 1905848 ACETAMINOPHEN TRI
- 2263807 PEDIAPHEN EUR
- 792713 PMS-ACETAMINOPHEN PMS
- 884553 TEMPRA MJO
- 32mg/mL Liquid
- 1901389 ACETAMINOPHEN JMP
- 1958836 ACETAMINOPHEN TRI
- 2263831 PEDIAPHEN EUR
- 2027798 PEDIATRIX RPH
- 792691 PMS-ACETAMINOPHEN PMS
- 875996 TEMPRA DOUBLE STRENGTH MJO
- 2046040 TYLENOL MCL
- 120mg Suppository
- 1919385 ABENOL PED
- 2230434 ACET 120 PMS
- 2046660 PMS-ACETAMINOPHEN PMS
- 160mg Suppository
- 2230435 ACET PMS
- 325mg Suppository
- 1919393 ABENOL PED
- 2230436 ACET 325 PMS
- 2046687 PMS-ACETAMINOPHEN PMS
- 650mg Suppository
- 1919407 ABENOL PED
- 2230437 ACET 650 PMS
- 2046695 PMS-ACETAMINOPHEN PMS
ACETAMINOPHEN
- 80mg Tablet
- 2238295 CHILDREN'S TYLENOL SOFT CHEWS JNO
- 160mg Tablet
- 2142805 ACETAMINOPHEN WTR
- 2021420 CEPHANOL RIV
- 2241361 TYLENOL JUNIOR STRENGTH JNO
- 325mg Tablet
- 374148 ACETAMINOPHEN WAM
- 382752 ACETAMINOPHEN PRO
- 589241 ACETAMINOPHEN PMS
- 605751 ACETAMINOPHEN * VTH
- 743542 ACETAMINOPHEN PMT
- 789801 ACETAMINOPHEN TRI
- 1938088 ACETAMINOPHEN JMP
- 2022214 ACETAMINOPHEN RIV
- 544981 APO-ACETAMINOPHEN APX
- 2229873 APO-ACETAMINOPHEN APX
- 293482 ATASOL HOR
- 389218 NOVO-GESIC NOP
- 891177 PMS-ACETAMINOPHEN * PMS
- 559393 TYLENOL MCL
- 723894 TYLENOL MCL
- 500mg Tablet
- 386626 ACETAMINOPHEN PDL
- 549703 ACETAMINOPHEN PMT
- 567663 ACETAMINOPHEN PED
- 589233 ACETAMINOPHEN PMS
- 605778 ACETAMINOPHEN VTH
- 789798 ACETAMINOPHEN TRI
- 1939122 ACETAMINOPHEN JMP
- 2022222 ACETAMINOPHEN RIV
- 2252813 ACETAMINOPHEN PMT
- 2255251 ACETAMINOPHEN PMT
- 545007 APO-ACETAMINOPHEN APX
- 2229977 APO-ACETAMINOPHEN APX
- 13668 ATASOL FORTE HOR
- 482323 NOVO-GESIC NOP
- 892505 PMS-ACETAMINOPHEN PMS
- 1962353 TANTAPHEN TAN
- 863270 TYLENOL MCL
- 559407 TYLENOL EXTRA STRENGTH MCL
- 723908 TYLENOL EXTRA STRENGTH MCL
FLOCTAFENINE
- 200mg Tablet
- 2244680 APO-FLOCTAFENINE APX
- 400mg Tablet
- 2244681 APO-FLOCTAFENINE APX
28:12.04 ANTICONVULSANTS - BARBITURATES
PHENOBARBITAL
- 5mg/mL Liquid
- 645575 PMS-PHENOBARBITAL PMS
PHENOBARBITAL
- 15mg Tablet
- 178799 PHENOBARBITAL PMS
- 30mg Tablet
- 178802 PHENOBARBITAL PMS
- 60mg Tablet
- 178810 PHENOBARBITAL PMS
- 100mg Tablet
- 178829 PHENOBARBITAL PMS
PRIMIDONE
- 125mg Tablet
- 399310 APO-PRIMIDONE APX
- 250mg Tablet
- 396761 APO-PRIMIDONE APX
28:12.08 ANTICONVULSANTS - BENZODIAZEPINES
CLONAZEPAM
- 0.25MG Tablet
- 2236947 PHL-CLONAZEPAM 0.25MG PMI
- 2179660 PMS-CLONAZEPAM PMS
- 0.5mg Tablet
- 2177889 APO-CLONAZEPAM APX
- 2230366 CLONAPAM VAE
- 2220598 CLONAZEPAM PDL
- 2270641 CO CLONAZEPAM COB
- 2130998 DOM-CLONAZEPAM DPC
- 2224100 DOM-CLONAZEPAM-R DPC
- 2230950 GEN-CLONAZEPAM GEN
- 2237277 MED-CLONAZEPAM MEC
- 2239024 NOVO-CLONAZEPAM NOP
- 2173344 NU-CLONAZEPAM NXP
- 2145227 PHL-CLONAZEPAM PHH
- 2236948 PHL-CLONAZEPAM-R 0.5MG PMI
- 2048701 PMS-CLONAZEPAM PMS
- 2207818 PMS-CLONAZEPAM R PMS
- 2311593 PRO-CLONAZEPAM PDL
- 2103656 RATIO-CLONAZEPAM RPH
- 2242077 RIVA-CLONAZEPAM RIV
- 382825 RIVOTRIL HLR
- 2233960 SANDOZ-CLONAZEPAM SDZ
- 2303310 ZYM-CLONAZEPAM ZYM
- 2345676 ZYM-CLONAZEPAM ZYM
- 1mg Tablet
- 2230368 CLONAPAM VAE
- 2270668 CO CLONAZEPAM COB
- 2145235 PHL-CLONAZEPAM PHH
- 2048728 PMS-CLONAZEPAM PMS
- 2311607 PRO-CLONAZEPAM PDL
- 2233982 SANDOZ-CLONAZEPAM SDZ
- 2303329 ZYM-CLONAZEPAM ZYM
CLONAZEPAM
- 2mg Tablet
- 2177897 APO-CLONAZEPAM APX
- 2230369 CLONAPAM VAE
- 2220601 CLONAZEPAM PDL
- 2270676 CO CLONAZEPAM COB
- 2131013 DOM-CLONAZEPAM DPC
- 2230951 GEN-CLONAZEPAM GEN
- 2237278 MED-CLONAZEPAM MEC
- 2239025 NOVO-CLONAZEPAM NOP
- 2173352 NU-CLONAZEPAM NXP
- 2145243 PHL-CLONAZEPAM PHH
- 2048736 PMS-CLONAZEPAM PMS
- 2311615 PRO-CLONAZEPAM PDL
- 2103737 RATIO-CLONAZEPAM RPH
- 2242078 RIVA-CLONAZEPAM RIV
- 382841 RIVOTRIL HLR
- 2233985 SANDOZ-CLONAZEPAM SDZ
- 2303337 ZYM-CLONAZEPAM ZYM
28:12.12 ANTICONVULSANTS - HYDANTOINS
PHENYTOIN
- 30mg Capsule
- 22772 DILANTIN PFI
- 100mg Capsule
- 22780 DILANTIN PFI
- 50mg Chewable Tablet
- 23698 DILANTIN INFATABS PFI
- 6mg/mL Suspension
- 23442 DILANTIN 30 PFI
- 25mg/mL Suspension
- 23450 DILANTIN 125 PFI
- 2250896 TARO-PHENYTOIN TAR
28:12.20 ANTICONVULSANTS- SUCCINIMIDES
ETHOSUXIMIDE
- 250mg Capsule
- 22799 ZARONTIN ERF
- 50mg/mL Syrup
- 23485 ZARONTIN ERF
METHSUXIMIDE
- 300mg Capsule
- 22802 CELONTIN ERF
28:12.92 MISCELLANEOUS ANTICONVULSANTS
CARBAMAZEPINE
- 100mg Chewable Tablet
- 2231542 PMS-CARBAMAZEPINE PMS
- 2261855 SANDOZ-CARBAMAZEPINE SDZ
- 2244403 TARO-CARBAMAZEPINE TAR
- 369810 TEGRETOL NVR
CARBAMAZEPINE
- 200mg Chewable Tablet
- 2231540 PMS-CARBAMAZEPINE PMS
- 2261863 SANDOZ-CARBAMAZEPINE SDZ
- 2244404 TARO-CARBAMAZEPINE TAR
- 665088 TEGRETOL NVR
- 200mg Extended Release Tablet
- 2261839 SANDOZ-CARBAMAZEPINE SDZ
- 400mg Extended Release Tablet
- 2261847 SANDOZ-CARBAMAZEPINE SDZ
- 20mg/mL Suspension
- 2194333 TEGRETOL NVR
- 200mg Sustained Release Tablet
- 2238222 DOM-CARBAMAZEPINE CR DPC
- 2241882 GEN-CARBAMAZEPINE CR GEN
- 2231543 PMS-CARBAMAZEPINE SRT PMS
- 2237907 TARO-CARBAMAZEPINE CR TAR
- 773611 TEGRETOL CR NVR
- 400mg Sustained Release Tablet
- 2238223 DOM-CARBAMAZEPINE CR DPC
- 2241883 GEN-CARBAMAZEPINE CR GEN
- 2231544 PMS-CARBAMAZEPINE SRT PMS
- 2237908 TARO-CARBAMAZEPINE CR TAR
- 755583 TEGRETOL CR NVR
- 200mg Tablet
- 402699 APO-CARBAMAZEPINE APX
- 578460 CARBAMAZEPINE PDL
- 782718 NOVO-CARBAMAZ NOP
- 2042568 NU-CARBAMAZEPINE NXP
- 10405 TEGRETOL NVR
DIVALPROEX SODIUM
- 125mg Delayed Release Tablet
- 2265133 GEN-DIVALPROEX GEN
- 250mg Delayed Release Tablet
- 2265141 GEN-DIVALPROEX GEN
- 500mg Delayed Release Tablet
- 2265168 GEN-DIVALPROEX GEN
- 125mg Enteric Coated Tablet
- 2239698 APO-DIVALPROEX APX
- 596418 EPIVAL ABB
- 2239701 NOVO-DIVALPROEX NOP
- 2239517 NU-DIVALPROEX NXP
- 2244138 PMS-DIVALPROEX PMS
- 250mg Enteric Coated Tablet
- 2239699 APO-DIVALPROEX APX
- 596426 EPIVAL ABB
- 2239702 NOVO-DIVALPROEX NOP
- 2239518 NU-DIVALPROEX NXP
- 2244139 PMS-DIVALPROEX PMS
DIVALPROEX SODIUM
- 500mg Enteric Coated Tablet
- 2239700 APO-DIVALPROEX APX
- 2240343 DIVALPROEX EC PDL
- 596434 EPIVAL ABB
- 2239703 NOVO-DIVALPROEX NOP
- 2239519 NU-DIVALPROEX NXP
- 2244140 PMS-DIVALPROEX PMS
GABAPENTIN
- 100mg Capsule
- 2244304 APO-GABAPENTIN APX
- 2256142 CO GABAPENTIN COB
- 2243743 DOM-GABAPENTIN DPC
- 2248259 GEN-GABAPENTIN GEN
- 2084260 NEURONTIN PFI
- 2244513 NOVO-GABAPENTIN NOP
- 2246314 PHL-GABAPENTIN PMI
- 2243446 PMS-GABAPENTIN PMS
- 2310449 PRO-GABAPENTIN PDL
- 2319055 RAN-GABAPENTIN RBY
- 2260883 RATIO-GABAPENTIN RPH
- 2251167 RIVA-GABAPENTIN RIV
- 2304775 ZYM-GABAPENTIN ZYM
- 300mg Capsule
- 2244305 APO-GABAPENTIN APX
- 2256150 CO GABAPENTIN COB
- 2243744 DOM-GABAPENTIN DPC
- 2249375 GABAPENTIN PRE
- 2273853 GABAPENTIN GEN
- 2248260 GEN-GABAPENTIN GEN
- 2084279 NEURONTIN PFI
- 2244514 NOVO-GABAPENTIN NOP
- 2246315 PHL-GABAPENTIN PMI
- 2243447 PMS-GABAPENTIN PMS
- 2310457 PRO-GABAPENTIN PDL
- 2319063 RAN-GABAPENTIN RBY
- 2260891 RATIO-GABAPENTIN RPH
- 2251175 RIVA-GABAPENTIN RIV
- 2304783 ZYM-GABAPENTIN ZYM
- 400mg Capsule
- 2244306 APO-GABAPENTIN APX
- 2256169 CO GABAPENTIN COB
- 2243745 DOM-GABAPENTIN DPC
- 2249383 GABAPENTIN PRE
- 2248261 GEN-GABAPENTIN GEN
- 2084287 NEURONTIN PFI
- 2244515 NOVO-GABAPENTIN NOP
- 2246316 PHL-GABAPENTIN PMI
- 2243448 PMS-GABAPENTIN PMS
- 2310465 PRO-GABAPENTIN PDL
- 2319071 RAN-GABAPENTIN RBY
- 2260905 RATIO-GABAPENTIN RPH
- 2251183 RIVA-GABAPENTIN RIV
- 2304791 ZYM-GABAPENTIN ZYM
GABAPENTIN
- 600mg Tablet
- 2293358 APO-GABAPENTIN APX
- 2239717 NEURONTIN PFI
- 2248457 NOVO-GABAPENTIN NOP
- 2255898 PMS-GABAPENTIN PMS
- 2310473 PRO-GABAPENTIN PDL
- 2260913 RATIO-GABAPENTIN RPH
- 2259796 RIVA-GABAPENTIN RIV
- 800mg Tablet
- 2293366 APO-GABAPENTIN APX
- 2239718 NEURONTIN PFI
- 2247346 NOVO-GABAPENTIN NOP
- 2255901 PMS-GABAPENTIN PMS
- 2310481 PRO-GABAPENTIN PDL
- 2260921 RATIO-GABAPENTIN RPH
- 2259818 RIVA-GABAPENTIN RIV
LAMOTRIGINE
- 2mg Chewable Tablet
- 2243803 LAMICTAL GSK
- 5mg Chewable Tablet
- 2240115 LAMICTAL GSK
- 25mg Tablet
- 2245208 APO-LAMOTRIGINE APX
- 2265494 GEN-LAMOTRIGINE GEN
- 2142082 LAMICTAL GSK
- 2302969 LAMOTRIGINE PDL
- 2248232 NOVO-LAMOTRIGINE NOP
- 2246897 PMS-LAMOTRIGINE PMS
- 2243352 RATIO-LAMOTRIGINE RPH
- 100mg Tablet
- 2245209 APO-LAMOTRIGINE APX
- 2265508 GEN-LAMOTRIGINE GEN
- 2142104 LAMICTAL GSK
- 2302985 LAMOTRIGINE PDL
- 2248233 NOVO-LAMOTRIGINE NOP
- 2246898 PMS-LAMOTRIGINE PMS
- 2243353 RATIO-LAMOTRIGINE RPH
- 150mg Tablet
- 2245210 APO-LAMOTRIGINE APX
- 2265516 GEN-LAMOTRIGINE GEN
- 2142112 LAMICTAL GSK
- 2302993 LAMOTRIGINE PDL
- 2248234 NOVO-LAMOTRIGINE NOP
- 2246899 PMS-LAMOTRIGINE PMS
- 2246963 RATIO-LAMOTRIGINE RPH
LEVETIRACETAM
Limited use benefit (prior approval required).
For the use in combination with other anti-epileptic medication(s) in the treatment of partial seizures in patients who are refractory to adequate trials of three anti-epileptic medications used either as monotherapy or in combination.
This product must be prescribed by a Neurologist.
- 250mg Tablet
- 2285924 APO-LEVETIRACETAM APX
- 2274183 CO LEVETIRACETAM COB
- 2247027 KEPPRA UCB
- 2296101 PMS-LEVETIRACETAM PMS
- 500mg Tablet
- 2285932 APO-LEVETIRACETAM APX
- 2274191 CO LEVETIRACETAM COB
- 2247028 KEPPRA UCB
- 2296128 PMS-LEVETIRACETAM PMS
- 750mg Tablet
- 2285940 APO-LEVETIRACETAM APX
- 2274205 CO LEVETIRACETAM COB
- 2247029 KEPPRA UCB
- 2296136 PMS-LEVETIRACETAM PMS
TOPIRAMATE
- 15mg Sprinkle Capsule
- 2239907 TOPAMAX SPRINKLE JNO
- 25mg Sprinkle Capsule
- 2239908 TOPAMAX SPRINKLE JNO
- 25mg Tablet
- 2279614 APO-TOPIRAMATE APX
- 2287765 CO TOPIRAMATE COB
- 2271141 DOM-TOPIRAMATE * DPC
- 2263351 GEN-TOPIRAMATE GEN
- 2315645 MINT-TOPIRAMATE MIN
- 2248860 NOVO-TOPIRAMATE NOP
- 2271184 PHL-TOPIRAMATE PMI
- 2262991 PMS-TOPIRAMATE PMS
- 2313650 PRO-TOPIRAMATE PDL
- 2256827 RATIO-TOPIRAMATE RPH
- 2260050 SANDOZ-TOPIRAMATE SDZ
- 2230893 TOPAMAX JNO
- 2325136 ZYM-TOPIRAMATE ZYM
- 50mg Tablet
- 2312085 PMS-TOPIRAMATE PMS
TOPIRAMATE
- 100mg Tablet
- 2279630 APO-TOPIRAMATE APX
- 2287773 CO TOPIRAMATE COB
- 2271168 DOM-TOPIRAMATE * DPC
- 2263378 GEN-TOPIRAMATE GEN
- 2315653 MINT-TOPIRAMATE MIN
- 2248861 NOVO-TOPIRAMATE NOP
- 2271192 PHL-TOPIRAMATE PMI
- 2263009 PMS-TOPIRAMATE PMS
- 2313669 PRO-TOPIRAMATE PDL
- 2256835 RATIO-TOPIRAMATE RPH
- 2260069 SANDOZ-TOPIRAMATE SDZ
- 2230894 TOPAMAX JNO
- 2325144 ZYM-TOPIRAMATE ZYM
- 200mg Tablet
- 2279649 APO-TOPIRAMATE APX
- 2287781 CO TOPIRAMATE COB
- 2271176 DOM-TOPIRAMATE * DPC
- 2263386 GEN-TOPIRAMATE GEN
- 2315661 MINT-TOPIRAMATE MIN
- 2248862 NOVO-TOPIRAMATE NOP
- 2313677 PDL-TOPIRAMATE PDL
- 2271206 PHL-TOPIRAMATE PMI
- 2263017 PMS-TOPIRAMATE PMS
- 2256843 RATIO-TOPIRAMATE RPH
- 2267837 SANDOZ-TOPIRAMATE SDZ
- 2230896 TOPAMAX JNO
- 2325152 ZYM-TOPIRAMATE ZYM
VALPROATE, SODIUM
- 50mg/mL Syrup
- 2238370 APO-VALPROIC APX
- 443832 DEPAKENE ABB
- 2238817 DOM-VALPROIC ACID DPC
- 2236807 PMS-VALPROIC ACID PMS
- 2140063 RATIO-VALPROIC RPH
VALPROIC ACID
- 250mg Capsule
- 2238048 APO-VALPROIC APX
- 443840 DEPAKENE ABB
- 2231030 DOM-VALPROIC ACID DPC
- 2184648 GEN-VALPROIC GEN
- 2230663 MED-VALPROIC ACID MEC
- 2100630 NOVO-VALPROIC NOP
- 2237830 NU-VALPROIC NXP
- 2238546 PDL-VALPROIC PDL
- 2231248 PENTA-VALPROIC PEN
- 2230768 PMS-VALPROIC ACID PMS
- 2140047 RATIO-VALPROIC ACID RPH
- 2239714 SANDOZ-VALPROIC SDZ
VALPROIC ACID
- 500mg Enteric Coated Capsule
- 2231031 DOM-VALPROIC ACID DPC
- 2218321 NOVO-VALPROIC NOP
- 2260662 PHL-VALPROIC ACID PHH
- 2229628 PMS-VALPROIC ACID PMS
- 2140055 RATIO-VALPROIC ACID RPH
- 2239713 SANDOZ-VALPROIC SDZ
VIGABATRIN
- 500mg Powder
- 2068036 SABRIL OVA
- 500mg Tablet
- 2065819 SABRIL OVA
28:16.04 ANTIDEPRESSANTS
AMITRIPTYLINE HCL
- 10mg Tablet
- 370991 AMITRIPTYLINE PRO
- 335053 APO-AMITRIPTYLINE APX
- 2248131 DOM-AMITRIPTYLINE DPC
- 37400 NOVO-TRIPTYN NOP
- 2247302 PMS-AMITRIPTYLINE PMS
- 25mg Tablet
- 371009 AMITRIPTYLINE PRO
- 335061 APO-AMITRIPTYLINE APX
- 2248132 DOM-AMITRIPTYLINE DPC
- 37419 NOVO-TRIPTYN NOP
- 2247303 PMS-AMITRIPTYLINE PMS
- 50mg Tablet
- 456349 AMITRIPTYLINE PDL
- 335088 APO-AMITRIPTYLINE APX
- 2248133 DOM-AMITRIPTYLINE DPC
- 271152 LEVATE ICN
- 37427 NOVO-TRIPTYN NOP
- 2247304 PMS-AMITRIPTYLINE PMS
- 75mg Tablet
- 754129 APO-AMITRIPTYLINE APX
- 354295 ELAVIL FRS
- 405612 LEVATE VAE
BUPROPION HCL
- 100mg Sustained Release Tablet
- 2325373 RATIO-BUPROPION SR PMS
BUPROPION HCL (WELLBUTRIN)
Limited use benefit (prior approval required).
For treatment of depression in patients unresponsive to or intolerant of other listed antidepressants. (Note: this product will not be approved for coverage for smoking cessation).
- 100mg Sustained Release Tablet
- 2285657 RATIO-BUPROPION RPH
- 2275074 SANDOZ-BUPROPION SR SDZ
BUPROPION HCL (WELLBUTRIN)
Limited use benefit (prior approval required).
For treatment of depression in patients unresponsive to or intolerant of other listed antidepressants. (Note: this product will not be approved for coverage for smoking cessation).
- 150mg Sustained Release Tablet
- 2313421 PMS-BUPROPION SR PMS
- 2285665 RATIO-BUPROPION RPH
- 2275082 SANDOZ-BUPROPION SR SDZ
- 2237825 WELLBUTRIN SR BPC
- 2275090 WELLBUTRIN XL BOV
- 300mg Sustained Release Tablet
- 2275104 WELLBUTRIN XL BOV
BUPROPION HCL (ZYBAN)
Limited use benefit with quantity and frequency limits (prior approval is not required).
For smoking cessation:
Coverage is limited to 180 tablets during a one-year period. The year starts on the date the first prescription is filled. Once this quantity has been reached, the client is eligible again for coverage for bupropion HCl when one year has elapsed from the day the initial prescription was filled.
- 150mg Sustained Release Tablet
- 2238441 ZYBAN SR BPC
CITALOPRAM
- 10mg Tablet
- 2312336 NOVO-CITALOPRAM NOP
- 2273543 PHI-CITALOPRAM PMI
- 2270609 PMS-CITALOPRAM PMS
- 2303256 RIVA-CITALOPRAM RIV
- 2301822 ZYM-CITALOPRAM ZYM
- 20mg Tablet
- 2246056 APO-CITALOPRAM APX
- 2239607 CELEXA LUD
- 2257513 CITALOPRAM-20 PDL
- 2248050 CO CITALOPRAM COB
- 2248942 DOM-CITALOPRAM DPC
- 2246594 GEN-CITALOPRAM GEN
- 2313405 JAMP-CITALOPRAM JMP
- 2304686 MINT-CITALOPRAM MIN
- 2293218 NOVO-CITALOPRAM NOP
- 2248996 NU-CITALOPRAM NXP
- 2248944 PHL-CITALOPRAM PHH
- 2248010 PMS-CITALOPRAM PMS
- 2249227 PREM-CITALOPRAM PRE
- 2285622 RAN-CITALO RBY
- 2268000 RAN-CITALOPRAM RBY
- 2252112 RATIO-CITALOPRAM RPH
- 2249278 RIVA-CITALOPRAM RIV
- 2303264 RIVA-CITALOPRAM RIV
- 2248170 SANDOZ-CITALOPRAM SDZ
- 2301830 ZYM-CITALOPRAM ZYM
- 30mg Tablet
- 2296152 CTP ORY
CITALOPRAM
- 40mg Tablet
- 2246057 APO-CITALOPRAM APX
- 2239608 CELEXA LUD
- 2257521 CITALOPRAM PDL
- 2248051 CO CITALOPRAM COB
- 2248943 DOM-CITALOPRAM DPC
- 2246595 GEN-CITALOPRAM GEN
- 2313413 JAMP-CITALOPRAM JMP
- 2304694 MINT-CITALOPRAM MIN
- 2293226 NOVO-CITALOPRAM NOP
- 2248997 NU-CITALOPRAM NXP
- 2248945 PHL-CITALOPRAM PHH
- 2248011 PMS-CITALOPRAM PMS
- 2249235 PREM-CITALOPRAM PRE
- 2285630 RAN-CITALO RBY
- 2268019 RAN-CITALOPRAM RBY
- 2252120 RATIO-CITALOPRAM RPH
- 2249286 RIVA-CITALOPRAM RIV
- 2303272 RIVA-CITALOPRAM RIV
- 2248171 SANDOZ-CITALOPRAM SDZ
- 2301849 ZYM-CITALOPRAM ZYM
CLOMIPRAMINE HCL
- 10mg Tablet
- 330566 ANAFRANIL ORY
- 2040786 APO-CLOMIPRAMINE APX
- 2130122 CLOMIPRAMINE PDL
- 2244816 CO CLOMIPRAMINE COB
- 2188996 MED-CLOMIPRAMINE MEC
- 2230256 NOVO-CLOPAMINE NOP
- 25mg Tablet
- 324019 ANAFRANIL ORY
- 2040778 APO-CLOMIPRAMINE APX
- 2130130 CLOMIPRAMINE PDL
- 2244817 CO CLOMIPRAMINE COB
- 2189003 MED-CLOMIPRAMINE MEC
- 2130165 NOVO-CLOPAMINE NOP
- 50mg Tablet
- 402591 ANAFRANIL ORY
- 2040751 APO-CLOMIPRAMINE APX
- 2130149 CLOMIPRAMINE PDL
- 2244818 CO CLOMIPRAMINE COB
- 2189011 MED-CLOMIPRAMINE MEC
- 2130173 NOVO-CLOPAMINE NOP
DESIPRAMINE HCL
- 10mg Tablet
- 2216248 APO-DESIPRAMINE APX
- 2222981 DESIPRAMINE PDL
- 2223341 NOVO-DESIPRAMINE NOP
- 2211939 NU-DESIPRAMINE NXP
DESIPRAMINE HCL
- 25mg Tablet
- 2216256 APO-DESIPRAMINE APX
- 2223007 DESIPRAMINE PDL
- 2130092 DOM-DESIPRAMINE DPC
- 2223325 NOVO-DESIPRAMINE NOP
- 2211947 NU-DESIPRAMINE NXP
- 50mg Tablet
- 2216264 APO-DESIPRAMINE APX
- 2223015 DESIPRAMINE PDL
- 2130106 DOM-DESIPRAMINE DPC
- 2223333 NOVO-DESIPRAMINE NOP
- 2211955 NU-DESIPRAMINE NXP
- 1946277 PMS-DESIPRAMINE PMS
- 75mg Tablet
- 2216272 APO-DESIPRAMINE APX
- 2223023 DESIPRAMINE PDL
- 2223368 NOVO-DESIPRAMINE NOP
- 2211963 NU-DESIPRAMINE NXP
- 1946242 PMS-DESIPRAMINE PMS
- 100mg Tablet
- 2216280 APO-DESIPRAMINE APX
- 2223031 DESIPRAMINE PDL
- 2211971 NU-DESIPRAMINE NXP
DOXEPIN HCL
- 10mg Capsule
- 2049996 APO-DOXEPIN APX
- 24325 SINEQUAN ERF
- 25mg Capsule
- 2050005 APO-DOXEPIN APX
- 1913425 NOVO-DOXEPIN NOP
- 24333 SINEQUAN ERF
- 50mg Capsule
- 2050013 APO-DOXEPIN APX
- 1913433 NOVO-DOXEPIN NOP
- 24341 SINEQUAN ERF
- 75mg Capsule
- 2050021 APO-DOXEPIN APX
- 1913441 NOVO-DOXEPIN NOP
- 400750 SINEQUAN ERF
- 100mg Capsule
- 2050048 APO-DOXEPIN APX
- 1913468 NOVO-DOXEPIN NOP
- 326925 SINEQUAN ERF
- 150mg Capsule
- 1913476 NOVO-DOXEPIN NOP
- 10mg Tablet
- 2150727 DOXEPINE PDL
- 25mg Tablet
- 2150735 DOXEPINE PDL
- 50mg Tablet
- 2150743 DOXEPINE PDL
DOXEPIN HCL
- 75mg Tablet
- 2150751 DOXEPINE PDL
- 100mg Tablet
- 2150778 DOXEPINE PDL
- 150mg Tablet
- 2150786 DOXEPINE PDL
DULOXETINE HCL
Limited use benefit (prior approval required).
For the treatment of neuropathic pain in patients with diabetes who have:
- failed an adequate trial with TWO alternative agents (such as a tricyclic antidepressant or anticonvulsant) due to intolerance or lack of response or
- a contraindication to alternative agents
The dose of duloxetine will be limited to a maximum of 60 mg daily.
Note that NIHB has adopted a Common Drug Review CEDAC recommendation that Cymbalta NOT be added to public drug plan formularies for the treatment of major depressive disorder.
- 30mg Sustained Release Capsule
- 2301482 CYMBALTA LIL
- 60mg Sustained Release Capsule
- 2301490 CYMBALTA LIL
FLUOXETINE HCL
- 10mg Capsule
- 2216353 APO-FLUOXETINE APX
- 2242177 CO-FLUOXETINE SCN
- 2177617 DOM-FLUOXETINE DPC
- 2220121 FLUOXETINE PDL
- 2237813 GEN-FLUOXETINE GEN
- 2216582 NOVO-FLUOXETINE NOP
- 2192756 NU-FLUOXETINE NXP
- 2223481 PHL-FLUOXETINE PHH
- 2177579 PMS-FLUOXETINE PMS
- 2314991 PRO-FLUOXETINE PDL
- 2018985 PROZAC LIL
- 2241371 RATIO-FLUOXETINE RPH
- 2242123 RIVA-FLUOXETINE RIV
- 2243486 SANDOZ-FLUOXETINE SDZ
- 2302659 ZYM-FLUOXETINE ZYM
FLUOXETINE HCL
- 20mg Capsule
- 2216361 APO-FLUOXETINE APX
- 2242178 CO-FLUOXETINE SCN
- 2177625 DOM-FLUOXETINE DPC
- 2220148 FLUOXETINE PDL
- 2237814 GEN-FLUOXETINE GEN
- 2216590 NOVO-FLUOXETINE NOP
- 2192764 NU-FLUOXETINE NXP
- 2223503 PHL-FLUOXETINE PHH
- 2177587 PMS-FLUOXETINE PMS
- 2315009 PRO-FLUOXETINE PDL
- 636622 PROZAC LIL
- 2241374 RATIO-FLUOXETINE RPH
- 2242124 RIVA-FLUOXETINE RIV
- 2243487 SANDOZ-FLUOXETINE SDZ
- 2302667 ZYM-FLUOXETINE ZYM
- 40mg Capsule
- 2245283 FXT ORY
- 4mg/mL Liquid
- 2231328 APO-FLUOXETINE APX
- 2177595 PMS-FLUOXETINE PMS
FLUVOXAMINE MALEATE
- 50mg Tablet
- 2231329 APO-FLUVOXAMINE APX
- 2255529 CO FLUVOXAMINE COB
- 2241347 DOM-FLUVOXAMINE DPC
- 2236753 FLUVOXAMINE PDL
- 1919342 LUVOX SPH
- 2239953 NOVO-FLUVOXAMINE NOP
- 2231192 NU-FLUVOXAMINE NXP
- 2240682 PMS-FLUVOXAMINE PMS
- 2218453 RATIO-FLUVOXAMINE RPH
- 2303345 RIVA-FLUVOX RIV
- 2247054 SANDOZ-FLUVOXAMINE SDZ
- 100mg Tablet
- 2231330 APO-FLUVOXAMINE APX
- 2255537 CO FLUVOXAMINE COB
- 2241348 DOM-FLUVOXAMINE DPC
- 2236754 FLUVOXAMINE PDL
- 1919369 LUVOX SPH
- 2239954 NOVO-FLUVOXAMINE NOP
- 2231193 NU-FLUVOXAMINE NXP
- 2240683 PMS-FLUVOXAMINE PMS
- 2218461 RATIO-FLUVOXAMINE RPH
- 2303361 RIVA-FLUVOX RIV
- 2247055 SANDOZ-FLUVOXAMINE SDZ
IMIPRAMINE HCL
- 10mg Tablet
- 360201 APO-IMIPRAMINE APX
- 371017 IMIPRAMINE PRO
- 21504 NOVO-PRAMINE NOP
IMIPRAMINE HCL
- 25mg Tablet
- 312797 APO-IMIPRAMINE APX
- 371025 IMIPRAMINE PRO
- 50mg Tablet
- 326852 APO-IMIPRAMINE APX
- 456357 IMIPRAMINE PDL
- 21520 NOVO-PRAMINE NOP
- 75mg Tablet
- 644579 APO-IMIPRAMINE APX
MAPROTILINE HCL
- 25mg Tablet
- 2158612 NOVO-MAPROTILINE NOP
- 50mg Tablet
- 2158620 NOVO-MAPROTILINE NOP
- 75mg Tablet
- 2158639 NOVO-MAPROTILINE NOP
MIRTAZAPINE
- 15mg Orally Disintegrating Tablet
- 2279894 NOVO-MIRTAZAPINE OD NOP
- 2248542 REMERON RD ORG
- 30mg Orally Disintegrating Tablet
- 2279908 NOVO-MIRTAZAPINE OD NOP
- 2248543 REMERON RD ORG
- 45mg Orally Disintegrating Tablet
- 2279916 NOVO-MIRTAZAPINE OD NOP
- 2248544 REMERON RD ORG
- 15mg Tablet
- 2286610 APO-MIRTAZAPINE APX
- 2256096 GEN-MIRTAZAPINE GEN
- 2281732 MIRTAZAPINE MEL
- 2273942 PMS-MIRTAZAPINE PMS
- 2312778 PRO-MIRTAZAPINE PDL
- 2250594 RHOXAL-MIRTAZAPINE RHO
- 30mg Tablet
- 2286629 APO-MIRTAZAPINE APX
- 2274361 CO MIRTAZAPINE COB
- 2252287 DOM-MIRTAZAPINE DPC
- 2256118 GEN-MIRTAZAPINE GEN
- 2259354 NOVO-MIRTAZAPINE NOP
- 2252279 PHL-MIRTAZAPINE PHH
- 2248762 PMS-MIRTAZAPINE PMS
- 2312786 PRO-MIRTAZAPINE PDL
- 2270927 RATIO-MIRTAZAPINE RPH
- 2243910 REMERON ORG
- 2265265 RIVA-MIRTAZAPINE RIV
- 2250608 SANDOZ-MIRTAZAPINE SDZ
- 2325179 ZYM-MIRTAZAPINE ZYM
- 2325187 ZYM-MIRTAZAPINE ZYM
- 45mg Tablet
- 2286637 APO-MIRTAZAPINE APX
- 2256126 GEN-MIRTAZAPINE GEN
MOCLOBEMIDE
- 100mg Tablet
- 2232148 APO-MOCLOBEMIDE APX
- 2236928 MOCLOBEMIDE PDL
- 2239746 NOVO-MOCLOBEMIDE NOP
- 2237111 NU-MOCLOBEMIDE NXP
- 150mg Tablet
- 2232150 APO-MOCLOBEMIDE APX
- 899356 MANERIX HLR
- 2239747 NOVO-MOCLOBEMIDE NOP
- 2237112 NU-MOCLOBEMIDE NXP
- 2243218 PMS-MOCLOBEMIDE PMS
- 300mg Tablet
- 2240456 APO-MOCLOBEMIDE APX
- 2166747 MANERIX HLR
- 2239748 NOVO-MOCLOBEMIDE NOP
- 2243219 PMS-MOCLOBEMIDE PMS
NORTRIPTYLINE HCL
- 10mg Capsule
- 2223511 APO-NORTRIPTYLINE APX
- 15229 AVENTYL PHH
- 2178729 DOM-NORTRIPTYLINE DPC
- 2231686 GEN-NORTRIPTYLINE GEN
- 2231781 NOVO-NORTRIPTYLINE NOP
- 2223139 NU-NORTRIPTYLINE NXP
- 2177692 PMS-NORTRIPTYLINE PMS
- 2240789 RATIO-NORTRIPTYLINE RPH
- 25mg Capsule
- 2223538 APO-NORTRIPTYLINE APX
- 15237 AVENTYL PHH
- 2178737 DOM-NORTRIPTYLINE DPC
- 2231782 NOVO-NORTRIPTYLINE NOP
- 2223147 NU-NORTRIPTYLINE NXP
- 2177706 PMS-NORTRIPTYLINE PMS
PAROXETINE HCL
- 10mg Tablet
- 2240907 APO-PAROXETINE APX
- 2262746 CO PAROXETINE COB
- 2248447 DOM-PAROXETINE DPC
- 2248012 GEN-PAROXETINE GEN
- 2248556 NOVO-PAROXETINE NOP
- 2248719 NU-PAROXETINE NXP
- 2248913 PAROXETINE PDL
- 2027887 PAXIL GSK
- 2248450 PHL-PAROXETINE PHH
- 2247750 PMS-PAROXETINE PMS
- 2247810 RATIO-PAROXETINE RPH
- 2254743 RHOXAL-PAROXETINE RHO
- 2248559 RIVA-PAROXETINE RIV
- 2269422 SANDOZ-PAROXETINE SDZ
- 2302012 ZYM-PAROXETINE ZYM
PAROXETINE HCL
- 20mg Tablet
- 2240908 APO-PAROXETINE APX
- 2262754 CO PAROXETINE COB
- 2248448 DOM-PAROXETINE DPC
- 2248013 GEN-PAROXETINE GEN
- 2248557 NOVO-PAROXETINE NOP
- 2248720 NU-PAROXETINE NXP
- 2248914 PAROXETINE PDL
- 1940481 PAXIL GSK
- 2248451 PHL-PAROXETINE PHH
- 2247751 PMS-PAROXETINE PMS
- 2247811 RATIO-PAROXETINE RPH
- 2248560 RIVA-PAROXETINE RIV
- 2254751 SANDOZ-PAROXETINE SDZ
- 2269430 SANDOZ-PAROXETINE SDZ
- 2302020 ZYM-PAROXETINE ZYM
- 30mg Tablet
- 2240909 APO-PAROXETINE APX
- 2262762 CO PAROXETINE COB
- 2248449 DOM-PAROXETINE DPC
- 2248014 GEN-PAROXETINE GEN
- 2248558 NOVO-PAROXETINE NOP
- 2248721 NU-PAROXETINE NXP
- 2248915 PAROXETINE PDL
- 1940473 PAXIL GSK
- 2248452 PHL-PAROXETINE PHH
- 2247752 PMS-PAROXETINE PMS
- 2251361 PREM-PAROXETINE PRE
- 2247812 RATIO-PAROXETINE RPH
- 2248561 RIVA-PAROXETINE RIV
- 2254778 SANDOZ-PAROXETINE SDZ
- 2269449 SANDOZ-PAROXETINE SDZ
- 2302039 ZYM-PAROXETINE ZYM
- 40mg Tablet
- 2293749 PMS-PAROXETINE PMS
PHENELZINE SULFATE
- 15mg Tablet
- 476552 NARDIL PFI
SERTRALINE
- 25mg Capsule
- 2238280 APO-SERTRALINE APX
- 2287390 CO SERTRALINE COB
- 2245748 DOM-SERTRALINE DPC
- 2242519 GEN-SERTRALINE GEN
- 9857435 GEN-SERTRALINE (ONT) GEN
- 2240485 NOVO-SERTRALINE NOP
- 2247047 NU-SERTRALINE NXP
- 2245824 PHL-SERTRALINE PHH
- 2244838 PMS-SERTRALINE PMS
- 2245787 RATIO-SERTRALINE RPH
- 9857460 RHOXAL-SERTRALINE (ONT) RHO
- 2248496 RIVA-SERTRALINE RIV
- 2245159 SANDOZ-SERTRALINE SDZ
- 2241302 SERTRALINE-25 PDL
- 2132702 ZOLOFT PFI
- 2303779 ZYM-SERTRALINE ZYM
- 50mg Capsule
- 2238281 APO-SERTRALINE APX
- 2287404 CO SERTRALINE COB
- 2245749 DOM-SERTRALINE DPC
- 2242520 GEN-SERTRALINE GEN
- 9857443 GEN-SERTRALINE (ONT) GEN
- 2240484 NOVO-SERTRALINE NOP
- 2247048 NU-SERTRALINE NXP
- 2245825 PHL-SERTRALINE PHH
- 2244839 PMS-SERTRALINE PMS
- 2245788 RATIO-SERTRALINE RPH
- 9857478 RHOXAL-SERTRALINE (ONT) RHO
- 2248497 RIVA-SERTRALINE RIV
- 2245160 SANDOZ-SERTRALINE SDZ
- 2241303 SERTRALINE-50 PDL
- 1962817 ZOLOFT PFI
- 2303809 ZYM-SERTRALINE ZYM
- 100mg Capsule
- 2238282 APO-SERTRALINE APX
- 2287412 CO SERTRALINE COB
- 2245750 DOM-SERTRALINE DPC
- 2242521 GEN-SERTRALINE GEN
- 9857451 GEN-SERTRALINE (ONT) GEN
- 2240481 NOVO-SERTRALINE NOP
- 2247050 NU-SERTRALINE NXP
- 2245826 PHL-SERTRALINE PHH
- 2244840 PMS-SERTRALINE PMS
- 2245789 RATIO-SERTRALINE RPH
- 9857486 RHOXAL-SERTRALINE (ONT) RHO
- 2248498 RIVA-SERTRALINE RIV
- 2245161 SANDOZ-SERTRALINE SDZ
- 2241304 SERTRALINE-100 PDL
- 1962779 ZOLOFT PFI
- 2303817 ZYM-SERTRALINE ZYM
TRANYLCYPROMINE SULFATE
- 10mg Tablet
- 1919598 PARNATE GSK
TRAZODONE HCL
- 50mg Tablet
- 2147637 APO-TRAZODONE APX
- 579351 DESYREL BMS
- 2128950 DOM-TRAZODONE DPC
- 2231683 GEN-TRAZODONE GEN
- 2144263 NOVO-TRAZODONE NOP
- 2165384 NU-TRAZODONE NXP
- 2232543 PENTA-TRAZODONE PEN
- 2236941 PHL-TRAZODONE PHH
- 1937227 PMS-TRAZODONE PMS
- 2053187 RATIO-TRAZODONE RPH
- 2277344 RATIO-TRAZODONE RPH
- 2164353 TRAZODONE PDL
- 2230284 TRAZOREL VAE
- 75mg Tablet
- 2237339 PMS-TRAZODONE PMS
- 100mg Tablet
- 2147645 APO-TRAZODONE APX
- 579378 DESYREL BMS
- 2128969 DOM-TRAZODONE DPC
- 2231684 GEN-TRAZODONE GEN
- 2144271 NOVO-TRAZODONE NOP
- 2165392 NU-TRAZODONE NXP
- 2232544 PENTA-TRAZODONE PEN
- 2236942 PHL-TRAZODONE PHH
- 1937235 PMS-TRAZODONE PMS
- 2053195 RATIO-TRAZODONE RPH
- 2277352 RATIO-TRAZODONE RPH
- 2164361 TRAZODONE PDL
- 2230285 TRAZOREL VAE
- 150mg Tablet
- 2147653 APO-TRAZODONE D APX
- 702277 DESYREL DIVIDOSE BMS
- 2231685 GEN-TRAZODONE GEN
- 2144298 NOVO-TRAZODONE NOP
- 2165406 NU-TRAZODONE D NXP
- 2053209 RATIO-TRAZODONE RPH
- 2277360 RATIO-TRAZODONE RPH
- 2164388 TRAZODONE PDL
TRIMIPRAMINE MALEATE
- 75mg Capsule
- 2070987 APO-TRIMIP APX
- 2147599 TRIMIPRAMINE PDL
- 12.5mg Tablet
- 740799 APO-TRIMIPRAMINE APX
- 2020599 NU-TRIMIPRAMINE NXP
- 761702 TRIMIPRAMINE PRO
TRIMIPRAMINE MALEATE
- 25mg Tablet
- 740802 APO-TRIMIPRAMINE APX
- 1940430 NOVO-TRIPRAMINE NOP
- 2020602 NU-TRIMIPRAMINE NXP
- 761710 TRIMIPRAMINE PDL
- 50mg Tablet
- 740810 APO-TRIMIPRAMINE APX
- 1940449 NOVO-TRIPRAMINE NOP
- 2020610 NU-TRIMIPRAMINE NXP
- 761729 TRIMIPRAMINE PDL
- 100mg Tablet
- 740829 APO-TRIMIPRAMINE APX
- 1940457 NOVO-TRIPRAMINE NOP
- 2020629 NU-TRIMIPRAMINE NXP
- 761737 TRIMIPRAMINE PDL
VENLAFAXINE HCL
- 37.5mg Sustained Release Capsule
- 2331683 APO-VENLAFAXINE XR APX
- 2304317 CO VENLAFAXINE XR COB
- 2237279 EFFEXOR XR WAY
- 2310279 GEN-VENLAFAXINE XR GEN
- 2275023 NOVO-VENLAFAXINE XR NOP
- 2278545 PMS-VENLAFAXINE XR PMS
- 2273969 RATIO-VENLAFAXINE XR RPH
- 2307774 RIVA-VENLAFAXINE XR RIV
- 2310317 SANDOZ VENLAFAXINE XR SDZ
- 75mg Sustained Release Capsule
- 2331691 APO-VENLAFAXINE XR APX
- 2304325 CO VENLAFAXINE XR COB
- 2237280 EFFEXOR XR WAY
- 2310287 GEN-VENLAFAXINE XR GEN
- 2275031 NOVO-VENLAFAXINE XR NOP
- 2278553 PMS-VENLAFAXINE XR PMS
- 2273977 RATIO-VENLAFAXINE SR RPH
- 2307782 RIVA-VENLAFAXINE XR RIV
- 2310325 SANDOZ VENLAFAXINE XR SDZ
- 150mg Sustained Release Capsule
- 2331705 APO-VENLAFAXINE XR APX
- 2304333 CO VENLAFAXINE XR COB
- 2237282 EFFEXOR XR WAY
- 2310295 GEN-VENLAFAXINE XR GEN
- 2275058 NOVO-VENLAFAXINE XR NOP
- 2278561 PMS-VENLAFAXINE XR PMS
- 2273985 RATIO-VENLAFAXINE XR RPH
- 2307790 RIVA-VENLAFAXINE XR RIV
- 2310333 SANDOZ VENLAFAXINE XR SDZ
28:16.08 ANTIPSYCHOTIC AGENTS
CHLORPROMAZINE
- 25mg/mL Injection
- 743518 CHLORPROMAZINE HCL SDZ
CHLORPROMAZINE
- 25mg Tablet
- 232823 NOVO-CHLORPROMAZINE NOP
- 50mg Tablet
- 232807 NOVO-CHLORPROMAZINE NOP
- 100mg Tablet
- 232831 NOVO-CHLORPROMAZINE NOP
CLOZAPINE
- 25mg Tablet
- 2248034 APO-CLOZAPINE APX
- 894737 CLOZARIL NVR
- 2247243 GEN-CLOZAPINE GEN
- 50mg Tablet
- 2305003 GEN-CLOZAPINE GEN
- 100mg Tablet
- 2248035 APO-CLOZAPINE APX
- 894745 CLOZARIL NVR
- 2247244 GEN-CLOZAPINE GEN
- 200mg Tablet
- 2305011 GEN-CLOZAPINE GEN
FLUPENTHIXOL DECANOATE
- 20mg/mL Injection
- 2156032 FLUANXOL DEPOT LUD
- 100mg/mL Injection
- 2156040 FLUANXOL DEPOT LUD
FLUPENTHIXOL DIHYDROCHLORIDE
- 0.5mg Tablet
- 2156008 FLUANXOL LUD
- 3mg Tablet
- 2156016 FLUANXOL LUD
FLUPHENAZINE DECANOATE
- 25mg/mL Injection
- 2239636 FLUPHENAZINE OMEGA OMG
- 2091275 PMS-FLUPHENAZINE PMS
- 100mg/mL Injection
- 2242570 FLUPHENAZINE OMEGA OMG
- 755575 MODECATE BMS
- 2241928 PMS-FLUPHENAZINE PMS
FLUPHENAZINE HCL
- 0.5mg/mL Elixir
- 893420 PMS-FLUPHENAZINE PMS
- 1mg Tablet
- 405345 APO-FLUPHENAZINE APX
- 563846 FLUPHENAZINE PDL
- 2mg Tablet
- 410632 APO-FLUPHENAZINE APX
- 563838 FLUPHENAZINE PDL
- 5mg Tablet
- 405361 APO-FLUPHENAZINE APX
HALOPERIDOL
- 5mg/mL Injection
- 808652 HALOPERIDOL SDZ
- 2mg/mL Solution
- 759503 PMS-HALOPERIDOL PMS
- 0.5mg Tablet
- 396796 APO-HALOPERIDOL APX
- 587796 HALOPERIDOL PDL
- 363685 NOVO-PERIDOL NOP
- 1mg Tablet
- 396818 APO-HALOPERIDOL APX
- 587788 HALOPERIDOL PDL
- 363677 NOVO-PERIDOL NOP
- 2mg Tablet
- 396826 APO-HALOPERIDOL APX
- 761745 HALOPERIDOL PDL
- 363669 NOVO-PERIDOL NOP
- 5mg Tablet
- 396834 APO-HALOPERIDOL APX
- 761753 HALOPERIDOL PDL
- 363650 NOVO-PERIDOL NOP
- 10mg Tablet
- 463698 APO-HALOPERIDOL APX
- 761761 HALOPERIDOL PDL
- 713449 NOVO-PERIDOL NOP
- 20mg Tablet
- 768820 NOVO-PERIDOL NOP
HALOPERIDOL DECANOATE
- 50mg/mL Injection
- 2130297 HALOPERIDOL LA SDZ
- 2230707 PMS-HALOPERIDOL LA PMS
- 100mg/mL Injection
- 2130300 HALOPERIDOL LA SDZ
- 2239640 HALOPERIDOL LA OMG
- 2230708 PMS-HALOPERIDOL LA PMS
LOXAPINE HCL
- 25mg/mL Oral Liquid
- 2239101 PMS-LOXAPINE PMS
LOXAPINE SUCCINATE
- 2.5mg Tablet
- 2242868 PMS-LOXAPINE PMS
- 5mg Tablet
- 2239918 DOM-LOXAPINE DPC
- 2237534 NU-LOXAPINE NXP
- 2238196 PDL-LOXAPINE PDL
- 2236943 PHL-LOXAPINE PHH
- 2230837 PMS-LOXAPINE PMS
LOXAPINE SUCCINATE
- 10mg Tablet
- 2239919 DOM-LOXAPINE DPC
- 2237535 NU-LOXAPINE NXP
- 2238197 PDL-LOXAPINE PDL
- 2236944 PHL-LOXAPINE PHH
- 2230838 PMS-LOXAPINE PMS
- 25mg Tablet
- 2239920 DOM-LOXAPINE DPC
- 2237536 NU-LOXAPINE NXP
- 2236945 PDL-LOXAPINE PHH
- 2238198 PDL-LOXAPINE PDL
- 2230839 PMS-LOXAPINE PMS
- 50mg Tablet
- 2239921 DOM-LOXAPINE DPC
- 2237537 NU-LOXAPINE NXP
- 2236946 PDL-LOXAPINE PHH
- 2238199 PDL-LOXAPINE PDL
- 2230840 PMS-LOXAPINE PMS
METHOTRIMEPRAZINE
- 2mg Tablet
- 2238403 APO-METHOPRAZINE APX
- 2239632 METHOTRIMEPRAZINE PDL
- 5mg Tablet
- 2238404 APO-METHOPRAZINE APX
- 2239633 METHOTRIMEPRAZINE PDL
- 2232903 PMS-METHOTRIMEPRAZINE PMS
- 25mg Tablet
- 2238405 APO-METHOPRAZINE APX
- 2239634 METHOTRIMEPRAZINE PDL
- 1964925 NOVO-MEPRAZINE NOP
- 50mg Tablet
- 2238406 APO-METHOPRAZINE APX
- 2239635 METHOTRIMEPRAZINE PDL
OLANZAPINE
- 5mg Orally Disintegrating Tablet
- 2327562 CO OLANZAPINE ODT CBT
- 2321343 NOVO-OLANZAPINE ODT NOP
- 2303191 PMS-OLANZAPINE ODT PMS
- 2327775 SANDOZ OLANZAPINE ODT SDZ
- 2243086 ZYPREXA ZYDIS LIL
- 10mg Orally Disintegrating Tablet
- 2327570 CO OLANZAPINE ODT CBT
- 2321351 NOVO-OLANZAPINE ODT NOP
- 2303205 PMS-OLANZAPINE ODT PMS
- 2327783 SANDOZ OLANZAPINE ODT SDZ
- 2243087 ZYPREXA ZYDIS LIL
OLANZAPINE
- 15mg Orally Disintegrating Tablet
- 2281848 APO-OLANZAPINE APX
- 2327589 CO OLANZAPINE ODT CBT
- 2321378 NOVO-OLANZAPINE ODT NOP
- 2303213 PMS-OLANZAPINE ODT PMS
- 2327791 SANDOZ OLANZAPINE ODT SDZ
- 2243088 ZYPREXA ZYDIS LIL
- 2.5mg Tablet
- 2281791 APO-OLANZAPINE APX
- 2325659 CO OLANZAPINE CBT
- 2276712 NOVO-OLANZAPINE NOP
- 2303116 PMS-OLANZAPINE PMS
- 2229250 ZYPREXA LIL
- 5mg Tablet
- 2281805 APO-OLANZAPINE APX
- 2325667 CO OLANZAPINE CBT
- 2276720 NOVO-OLANZAPINE NOP
- 2303159 PMS-OLANZAPINE PMS
- 2229269 ZYPREXA LIL
- 7.5mg Tablet
- 2281813 APO-OLANZAPINE APX
- 2325675 CO OLANZAPINE CBT
- 2276739 NOVO-OLANZAPINE NOP
- 2303167 PMS-OLANZAPINE PMS
- 2229277 ZYPREXA LIL
- 10mg Tablet
- 2281821 APO-OLANZAPINE APX
- 2325683 CO OLANZAPINE CBT
- 2276747 NOVO-OLANZAPINE NOP
- 2303175 PMS-OLANZAPINE PMS
- 2229285 ZYPREXA LIL
- 15mg Tablet
- 2325691 CO OLANZAPINE CBT
- 2276755 NOVO-OLANZAPINE NOP
- 2303183 PMS-OLANZAPINE PMS
- 2238850 ZYPREXA LIL
- 20mg Tablet
- 2325713 CO OLANZAPINE CBT
PERICYAZINE
- 5mg Capsule
- 1926780 NEULEPTIL ERF
- 10mg Capsule
- 1926772 NEULEPTIL ERF
- 20mg Capsule
- 1926764 NEULEPTIL ERF
- 10mg/mL Drop
- 1926756 NEULEPTIL ERF
PERPHENAZINE
- 3.2mg/mL Liquid
- 751898 PMS-PERPHENAZINE PMS
PERPHENAZINE
- 2mg Tablet
- 335134 APO-PERPHENAZINE APX
- 563757 PERPHENAZINE PDL
- 4mg Tablet
- 335126 APO-PERPHENAZINE APX
- 563749 PERPHENAZINE PDL
- 8mg Tablet
- 335118 APO-PERPHENAZINE APX
- 563730 PERPHENAZINE PDL
- 16mg Tablet
- 335096 APO-PERPHENAZINE APX
- 563722 PERPHENAZINE PDL
PIMOZIDE
- 2mg Tablet
- 2245432 APO-PIMOZIDE APX
- 313815 ORAP PHH
- 4mg Tablet
- 2245433 APO-PIMOZIDE APX
- 313823 ORAP PHH
PIPOTIAZINE PALMITATE
- 25mg/mL Injection
- 1926667 PIPORTIL L4 SAC
- 50mg/mL Injection
- 894672 PIPORTIL L4 * RHO
PROCHLORPERAZINE
- 5mg/mL Injection
- 789747 PROCHLORPERAZINE SDZ
- 10mg Suppository
- 753688 PMS-PROCHLORPERAZINE PMS
- 789720 PROCHLORPERAZINE SDZ
- 5mg Tablet
- 886440 APO-PROCHLORAZINE APX
- 1964399 NU-PROCHLOR NXP
- 753661 PMS-PROCHLORPERAZINE PMS
- 10mg Tablet
- 886432 APO-PROCHLORAZINE APX
- 1964402 NU-PROCHLOR NXP
- 753637 PMS-PROCHLORPERAZINE PMS
QUETIAPINE FUMARATE
- 25mg Tablet
- 2313901 APO-QUETIAPINE APX
- 2316080 CO QUETIAPINE COB
- 2307804 GEN-QUETIAPINE GEN
- 2330415 JAMP-QUETIAPINE JMP
- 2284235 NOVO-QUETIAPINE NOP
- 2299054 PHL-QUETIAPINE PMI
- 2296551 PMS-QUETIAPINE PMS
- 2317346 PRO-QUETIAPINE PDL
- 2311704 RATIO-QUETIAPINE RPH
- 2316692 RIVA-QUETIAPINE RIV
- 2313995 SANDOZ-QUETIAPINE SDZ
- 2236951 SEROQUEL AZC
- 2317893 ZYM-QUETIAPINE ZYM
- 100mg Tablet
- 2313928 APO-QUETIAPINE APX
- 2316099 CO QUETIAPINE COB
- 2307812 GEN-QUETIAPINE GEN
- 2330423 JAMP-QUETIAPINE JMP
- 2284243 NOVO-QUETIAPINE NOP
- 2299062 PHL-QUETIAPINE PMI
- 2296578 PMS-QUETIAPINE PMS
- 2317354 PRO-QUETIAPINE PDL
- 2311712 RATIO-QUETIAPINE RPH
- 2316706 RIVA-QUETIAPINE RIV
- 2314002 SANDOZ-QUETIAPINE SDZ
- 2236952 SEROQUEL AZC
- 2317907 ZYM-QUETIAPINE ZYM
- 150mg Tablet
- 2284251 NOVO-QUETIAPINE NOP
- 200mg Tablet
- 2313936 APO-QUETIAPINE APX
- 2316110 CO QUETIAPINE COB
- 2307839 GEN-QUETIAPINE GEN
- 2330458 JAMP-QUETIAPINE JMP
- 2284278 NOVO-QUETIAPINE NOP
- 2299089 PHL-QUETIAPINE PMI
- 2296594 PMS-QUETIAPINE PMS
- 2317362 PRO-QUETIAPINE PDL
- 2311747 RATIO-QUETIAPINE RPH
- 2316722 RIVA-QUETIAPINE RIV
- 2314010 SANDOZ-QUETIAPINE SDZ
- 2236953 SEROQUEL AZC
- 2317923 ZYM-QUETIAPINE ZYM
QUETIAPINE FUMARATE
- 300mg Tablet
- 2313944 APO-QUETIAPINE APX
- 2316129 CO QUETIAPINE COB
- 2307847 GEN-QUETIAPINE GEN
- 2330466 JAMP-QUETIAPINE JMP
- 2284286 NOVO-QUETIAPINE NOP
- 2299097 PHL-QUETIAPINE PMI
- 2296608 PMS-QUETIAPINE PMS
- 2317370 PRO-QUETIAPINE PDL
- 2311755 RATIO-QUETIAPINE RPH
- 2316730 RIVA-QUETIAPINE RIV
- 2314029 SANDOZ-QUETIAPINE SDZ
- 2244107 SEROQUEL AZC
- 2317931 ZYM-QUETIAPINE ZYM
RISPERIDONE
- 0.5mg Orally Disintegrating Tablet
- 2247704 RISPERDAL-M JNO
- 1mg Orally Disintegrating Tablet
- 2247705 RISPERDAL-M JNO
- 2mg Orally Disintegrating Tablet
- 2247706 RISPERDAL-M JNO
- 3mg Orally Disintegrating Tablet
- 2268086 RISPERDAL-M JNO
- 4mg Orally Disintegrating Tablet
- 2268094 RISPERDAL-M JNO
- 1mg/mL Solution
- 2280396 APO-RISPERIDONE APX
- 2279266 PMS-RISPERIDONE PMS
- 2236950 RISPERDAL JNO
- 0.25mg Tablet
- 2282119 APO-RISPERIDONE APX
- 2282585 CO RISPERIDONE COB
- 2282240 GEN-RISPERIDONE GEN
- 2282690 NOVO-RISPERIDONE NOP
- 2258439 PHL-RISPERIDONE PMI
- 2252007 PMS-RISPERIDONE PMS
- 2312700 PRO-RISPERIDONE PDL
- 2280906 RAN-RISPERIDONE RBY
- 2264757 RATIO-RISPERIDONE RPH
- 2328305 RBX-RISPERIDONE RBY
- 2240551 RISPERDAL JNO
- 2283565 RIVA-RISPERIDONE RIV
- 2303655 SANDOZ RISPERIDONE SDZ
- 2279509 SANDOZ-RISPERIDONE SDZ
- 2303485 ZYM-RISPERIDONE ZYM
RISPERIDONE
- 0.5mg Tablet
- 2282127 APO-RISPERIDONE APX
- 2282593 CO RISPERIDONE COB
- 2282259 GEN-RISPERIDONE GEN
- 2264188 NOVO-RISPERIDONE NOP
- 2258447 PHL-RISPERIDONE PMI
- 2252015 PMS-RISPERIDONE PMS
- 2312719 PRO-RISPERIDONE PDL
- 2280914 RAN-RISPERIDONE RBY
- 2264765 RATIO-RISPERIDONE RPH
- 2328313 RBX-RISPERIDONE RBY
- 2240552 RISPERDAL JNO
- 2283573 RIVA-RISPERIDONE RIV
- 2303663 SANDOZ RISPERIDONE SDZ
- 2303493 ZYM-RISPERIDONE ZYM
- 1mg Tablet
- 2282135 APO-RISPERIDONE APX
- 2282607 CO RISPERIDONE COB
- 2282267 GEN-RISPERIDONE GEN
- 2264196 NOVO-RISPERIDONE NOP
- 2258455 PHL-RISPERIDONE PMI
- 2252023 PMS-RISPERIDONE PMS
- 2312727 PRO-RISPERIDONE PDL
- 2280922 RAN-RISPERIDONE RBY
- 2264773 RATIO-RISPERIDONE RPH
- 2328321 RBX-RISPERIDONE RBY
- 2025280 RISPERDAL JNO
- 2283581 RIVA-RISPERIDONE RIV
- 2279800 SANDOZ-RISPERIDONE SDZ
- 2303507 ZYM-RISPERIDONE ZYM
- 2mg Tablet
- 2282143 APO-RISPERIDONE APX
- 2282615 CO RISPERIDONE COB
- 2282275 GEN-RISPERIDONE GEN
- 2264218 NOVO-RISPERIDONE NOP
- 2258463 PHL-RISPERIDONE PMI
- 2252031 PMS-RISPERIDONE PMS
- 2312735 PRO-RISPERIDONE PDL
- 2280930 RAN-RISPERIDONE RBY
- 2264781 RATIO-RISPERIDONE RPH
- 2328348 RBX-RISPERIDONE RBY
- 2025299 RISPERDAL JNO
- 2283603 RIVA-RISPERIDONE RIV
- 2279819 SANDOZ-RISPERIDONE SDZ
- 2303515 ZYM-RISPERIDONE ZYM
RISPERIDONE
- 3mg Tablet
- 2282151 APO-RISPERIDONE APX
- 2282623 CO RISPERIDONE COB
- 2282283 GEN-RISPERIDONE GEN
- 2264226 NOVO-RISPERIDONE NOP
- 2258471 PHL-RISPERIDONE PMI
- 2252058 PMS-RISPERIDONE PMS
- 2312743 PRO-RISPERIDONE PDL
- 2280949 RAN-RISPERIDONE RBY
- 2264803 RATIO-RISPERIDONE RPH
- 2328364 RBX-RISPERIDONE RBY
- 2025302 RISPERDAL JNO
- 2283611 RIVA-RISPERIDONE RIV
- 2279827 SANDOZ-RISPERIDONE SDZ
- 2303523 ZYM-RISPERIDONE ZYM
- 4mg Tablet
- 2282178 APO-RISPERIDONE APX
- 2282631 CO RISPERIDONE COB
- 2282291 GEN-RISPERIDONE GEN
- 2264234 NOVO-RISPERIDONE NOP
- 2258498 PHL-RISPERIDONE PMI
- 2252066 PMS-RISPERIDONE PMS
- 2312751 PRO-RISPERIDONE PDL
- 2280957 RAN-RISPERIDONE RBY
- 2264811 RATIO-RISPERIDONE RPH
- 2328372 RBX-RISPERIDONE RBY
- 2025310 RISPERDAL JNO
- 2283638 RIVA-RISPERIDONE RIV
- 2279835 SANDOZ-RISPERIDONE SDZ
- 2303531 ZYM-RISPERIDONE ZYM
THIOPROPERAZINE MESYLATE
- 10mg Tablet
- 1927639 MAJEPTIL ERF
THIOTHIXENE
- 2mg Capsule
- 24430 NAVANE ERF
- 5mg Capsule
- 24449 NAVANE ERF
- 10mg Capsule
- 24457 NAVANE ERF
TRIFLUOPERAZINE HCL
- 10mg/mL Liquid
- 751871 PMS-TRIFLUOPERAZINE PMS
- 1mg Tablet
- 345539 APO-TRIFLUOPERAZINE APX
- 386529 TRIFLUOPERAZINE PRO
- 2mg Tablet
- 312754 APO-TRIFLUOPERAZINE APX
- 386510 TRIFLUOPERAZINE PRO
- 5mg Tablet
- 312746 APO-TRIFLUOPERAZINE APX
- 386502 TRIFLUOPERAZINE PRO
TRIFLUOPERAZINE HCL
- 10mg Tablet
- 326836 APO-TRIFLUOPERAZINE APX
- 389943 TRIFLUOPERAZINE PDL
- 20mg Tablet
- 595942 APO-TRIFLUOPERAZINE APX
ZIPRASIDONE HCL MONOHYDRATE
Limited use benefit (prior approval required).
For the treatment of schizophrenia and schizoaffective disorders in patients who have:
- intolerance or lack of response to an adequate trial of another antipsychotic agent or
- a contraindication to another antipsychotic agent
- 20MG Capsule
- 2298597 ZELDOX PFI
- 40MG Capsule
- 2298600 ZELDOX PFI
- 60mg Capsule
- 2298619 ZELDOX PFI
- 80mg Capsule
- 2298627 ZELDOX PFI
28:20.04 AMPHETAMINES
DEXTROAMPHETAMINE SULFATE
- 10mg Sustained Release Capsule
- 1924559 DEXEDRINE SPANSULE GSK
- 15mg Sustained Release Capsule
- 1924567 DEXEDRINE SPANSULE GSK
- 5mg Tablet
- 1924516 DEXEDRINE GSK
28:20.92 MISC ANOREXIGENIC AGENTS & RESPIRATORY & CEREBRAL STIMULANT
METHYLPHENIDATE HCL
- 20mg Extended Release Tablet
- 2266687 APO-METHYLPHENIDATE APX
- 20mg Sustained Release Tablet
- 632775 RITALIN SR NVR
- 2320312 SANDOZ-METHYLPHENIDATE SR SDZ
- 5mg Tablet
- 2273950 APO-METHYLPHENIDATE APX
- 2234749 PMS-METHYLPHENIDATE PMS
- 10mg Tablet
- 2249324 APO-METHYLPHENIDATE APX
- 584991 PMS-METHYLPHENIDATE PMS
- 5606 RITALIN NVR
- 20mg Tablet
- 2249332 APO-METHYLPHENIDATE APX
- 585009 PMS-METHYLPHENIDATE PMS
- 5614 RITALIN NVR
MODAFINIL
- 100mg Tablet
- 2239665 ALERTEC DPY
- 2285398 APO-MODAFINIL APX
28:24.08 ANXIOLYTICS, SEDATIVES AND HYPNOTICS - BENZODIAZEPINES
ALPRAZOLAM
- 0.25mg Tablet
- 1908189 ALPRAZOLAM PDL
- 865397 APO-ALPRAZ APX
- 2137534 GEN-ALPRAZOLAM GEN
- 2237264 MED-ALPRAZOLAM MEC
- 1913484 NOVO-ALPRAZOL NOP
- 1913239 NU-ALPRAZ NXP
- 548359 XANAX PFI
- 0.5mg Tablet
- 1908170 ALPRAZOLAM PDL
- 865400 APO-ALPRAZ APX
- 2137542 GEN-ALPRAZOLAM GEN
- 2237265 MED-ALPRAZOLAM MEC
- 1913492 NOVO-ALPRAZOL NOP
- 1913247 NU-ALPRAZ NXP
- 548367 XANAX PFI
- 1mg Tablet
- 2248706 ALPRAZOLAM PDL
- 2243611 APO-ALPRAZ APX
- 2229813 GEN-ALPRAZOLAM GEN
- 723770 XANAX PFI
- 2mg Tablet
- 2243612 APO-ALPRAZ APX
- 2229814 GEN-ALPRAZOLAM GEN
- 813958 XANAX TS PFI
BROMAZEPAM
- 1.5mg Tablet
- 2177153 APO-BROMAZEPAM APX
- 2220512 BROMAZEPAM PDL
- 2192705 GEN-BROMAZEPAM GEN
- 2230666 MED-BROMAZEPAM MEC
- 2171856 NU-BROMAZEPAM NXP
- 3mg Tablet
- 2177161 APO-BROMAZEPAM APX
- 2220520 BROMAZEPAM PDL
- 2192713 GEN-BROMAZEPAM GEN
- 518123 LECTOPAM HLR
- 2230667 MED-BROMAZEPAM MEC
- 2230584 NOVO-BROMAZEPAM NOP
- 2171864 NU-BROMAZEPAM NXP
BROMAZEPAM
- 6mg Tablet
- 2177188 APO-BROMAZEPAM APX
- 2220539 BROMAZEPAM PDL
- 2192721 GEN-BROMAZEPAM GEN
- 518131 LECTOPAM HLR
- 2230668 MED-BROMAZEPAM MEC
- 2230585 NOVO-BROMAZEPAM NOP
- 2171872 NU-BROMAZEPAM NXP
CLOBAZAM
- 10mg Tablet
- 2244638 APO-CLOBAZAM APX
- 2248454 CLOBAZAM PDL
- 2247230 DOM-CLOBAZAM DPC
- 2221799 FRISIUM PED
- 2238334 NOVO-CLOBAZAM NOP
- 2244474 PMS-CLOBAZAM PMS
- 2238797 RATIO-CLOBAZAM RPH
DIAZEPAM
- 1mg/mL Oral Solution
- 891797 PMS-DIAZEPAM PMS
- 2mg Tablet
- 405329 APO-DIAZEPAM APX
- 434396 DIAZEPAM PDL
- 2247490 PMS-DIAZEPAM PMS
- 5mg Tablet
- 362158 APO-DIAZEPAM APX
- 313580 DIAZEPAM PRO
- 2247491 PMS-DIAZEPAM PMS
- 13285 VALIUM HLR
- 10mg Tablet
- 405337 APO-DIAZEPAM APX
- 434388 DIAZEPAM PDL
- 2247492 PMS-DIAZEPAM PMS
- 13773 VIVOL AXX
LORAZEPAM
- 0.5mg Tablet
- 655740 APO-LORAZEPAM APX
- 2041413 ATIVAN WAY
- 2041456 ATIVAN SUBLINGUAL WAY
- 2245784 DOM-LORAZEPAM DPC
- 711101 NOVO-LORAZEM NOP
- 865672 NU-LORAZ NXP
- 655643 PRO-LORAZEPAM PDL
- 1mg Tablet
- 655759 APO-LORAZEPAM APX
- 2041421 ATIVAN WAY
- 2041464 ATIVAN SUBLINGUAL WAY
- 2245785 DOM-LORAZEPAM DPC
- 637742 NOVO-LORAZEM NOP
- 865680 NU-LORAZ NXP
- 655651 PRO-LORAZEPAM PDL
LORAZEPAM
- 2mg Tablet
- 655767 APO-LORAZEPAM APX
- 2041448 ATIVAN WAY
- 2041472 ATIVAN SUBLINGUAL WAY
- 2245786 DOM-LORAZEPAM DPC
- 637750 NOVO-LORAZEM NOP
- 865699 NU-LORAZ NXP
- 655678 PRO-LORAZEPAM PDL
NITRAZEPAM
- 5mg Tablet
- 2245230 APO-NITRAZEPAM APX
- 511528 MOGADON ICN
- 2229654 NITRAZADON VAE
- 2234003 SANDOZ-NITRAZEPAM SDZ
- 10mg Tablet
- 2245231 APO-NITRAZEPAM APX
- 511536 MOGADON ICN
- 2229655 NITRAZADON VAE
- 2234007 SANDOZ-NITRAZEPAM SDZ
OXAZEPAM
- 10mg Tablet
- 402680 APO-OXAZEPAM APX
- 497754 OXAZEPAM PDL
- 568392 ZAPEX RIV
- 15mg Tablet
- 402745 APO-OXAZEPAM APX
- 497762 OXAZEPAM PDL
- 568406 ZAPEX RIV
- 30mg Tablet
- 402737 APO-OXAZEPAM APX
- 497770 OXAZEPAM PDL
- 568414 ZAPEX RIV
TEMAZEPAM
- 15mg Capsule
- 2225964 APO-TEMAZEPAM APX
- 2244814 CO TEMAZEPAM COB
- 2229756 DOM-TEMAZEPAM DPC
- 2231615 GEN-TEMAZEPAM GEN
- 2237294 MED-TEMAZEPAM MEC
- 2230095 NOVO-TEMAZEPAM NOP
- 2223570 NU-TEMAZEPAM NXP
- 2239071 PENTA-TEMAZEPAM PEN
- 2229455 PMS-TEMAZEPAM PMS
- 2243023 RATIO-TEMAZEPAM RPH
- 604453 RESTORIL ORY
- 2229760 TEMAZEPAM PDL
TEMAZEPAM
- 30mg Capsule
- 2225972 APO-TEMAZEPAM APX
- 2244815 CO TEMAZEPAM COB
- 2229758 DOM-TEMAZEPAM DPC
- 2231616 GEN-TEMAZEPAM GEN
- 2237295 MED-TEMAZEPAM MEC
- 2230102 NOVO-TEMAZEPAM NOP
- 2223589 NU-TEMAZEPAM NXP
- 2239072 PENTA-TEMAZEPAM PEN
- 2229456 PMS-TEMAZEPAM PMS
- 2273047 PMS-TEMAZEPAM PMS
- 2243024 RATIO-TEMAZEPAM RPH
- 604461 RESTORIL ORY
- 2229761 TEMAZEPAM PDL
TRIAZOLAM
- 0.125mg Tablet
- 808563 APO-TRIAZO APX
- 1995227 GEN-TRIAZOLAM GEN
- 886084 NU-TRIAZO NXP
- 0.25mg Tablet
- 808571 APO-TRIAZO APX
- 1913506 GEN-TRIAZOLAM GEN
- 886092 NU-TRIAZO NXP
- 860824 TRIAZOLAM PDL
28:24.92 MISCELLANEOUS ANXIOLYTICS, SEDATIVES, AND HYPNOTICS
HYDROXYZINE HCL
- 10mg Capsule
- 739618 HYDROXYZINE PDL
- 738824 NOVO-HYDROXYZIN NOP
- 2241192 RIVA-HYDROXYZIN RIV
- 25mg Capsule
- 739626 HYDROXYZINE PDL
- 738832 NOVO-HYDROXYZIN NOP
- 2241193 RIVA-HYDROXYZIN RIV
- 50mg Capsule
- 739634 HYDROXYZINE PDL
- 738840 NOVO-HYDROXYZIN NOP
- 2241194 RIVA-HYDROXYZIN RIV
- 2mg/mL Syrup
- 24694 ATARAX ERF
- 741817 PMS-HYDROXYZINE PMS
- 10mg Tablet
- 646059 APO-HYDROXYZINE APX
- 25mg Tablet
- 646024 APO-HYDROXYZINE APX
- 50mg Tablet
- 646016 APO-HYDROXYZINE APX
28:28.00 ANTIMANIC AGENTS
LITHIUM CARBONATE
- 150mg Capsule
- 2242837 APO-LITHIUM CARB APX
- 9857532 APO-LITHIUM CARBONATE APX
- 2013231 LITHANE ERF
- 2216132 PMS-LITHIUM CARBONATE PMS
- 300mg Capsule
- 2242838 APO-LITHIUM CARB APX
- 9857540 APO-LITHIUM CARBONATE APX
- 236683 CARBOLITH VAE
- 406775 LITHANE ERF
- 2216140 PMS-LITHIUM CARBONATE PMS
- 600mg Capsule
- 2011239 CARBOLITH VAE
- 2216159 PMS-LITHIUM CARBONATE PMS
LITHIUM CITRATE
- 60mg/mL Syrup
- 2074834 PMS-LITHIUM CITRATE PMS
28:32.28 SELECTIVE SEROTONIN AGONISTS
ALMOTRIPTAN MALATE
- 6.25mg Tablet
- 2248128 AXERT MCL
- 12.5mg Tablet
- 2248129 AXERT MCL
NARATRIPTAN HCL
- 1mg Tablet
- 2237820 AMERGE GSK
- 2314290 NOVO-NARATRIPTAN NOP
- 2.5mg Tablet
- 2237821 AMERGE GSK
- 2314304 NOVO-NARATRIPTAN NOP
- 2322323 SANDOZ NARATRIPTAN SDZ
RIZATRIPTAN
- 5mg Tablet
- 2240520 MAXALT FRS
- 10mg Tablet
- 2240521 MAXALT FRS
- 5mg Wafer
- 2240518 MAXALT RPD FRS
- 10mg Wafer
- 2240519 MAXALT RPD FRS
SUMATRIPTAN HEMISULFATE
- 5mg Nasal Spray
- 2230418 IMITREX GSK
- 20mg Nasal Spray
- 2230420 IMITREX GSK
SUMATRIPTAN SUCCINATE
- 12mg/mL Injection
- 2212188 IMITREX GSK
- 99000598 IMITREX * GSK
- 25mg Tablet
- 2257882 CO SUMATRIPTAN COB
- 2270749 DOM-SUMATRIPTAN DPC
- 2268906 GEN-SUMATRIPTAN GEN
- 2286815 NOVO-SUMATRIPTAN DF NOP
- 2256428 PMS-SUMATRIPTAN PMS
- 50mg Tablet
- 2268388 APO-SUMATRIPTAN APX
- 2257890 CO SUMATRIPTAN COB
- 2270757 DOM-SUMATRIPTAN DPC
- 2268914 GEN-SUMATRIPTAN GEN
- 2212153 IMITREX DF GSK
- 2286823 NOVO-SUMATRIPTAN DF NOP
- 2256436 PMS-SUMATRIPTAN PMS
- 2271583 RATIO-SUMATRIPTAN RPH
- 2263025 SANDOZ-SUMATRIPTAN SDZ
- 100mg Tablet
- 2268396 APO-SUMATRIPTAN APX
- 2257904 CO SUMATRIPTAN COB
- 2270765 DOM-SUMATRIPTAN DPC
- 2268922 GEN-SUMATRIPTAN GEN
- 2212161 IMITREX DF GSK
- 2239367 NOVO-SUMATRIPTAN NOP
- 2286831 NOVO-SUMATRIPTAN DF NOP
- 2256444 PMS-SUMATRIPTAN PMS
- 2271591 RATIO-SUMATRIPTAN RPH
- 2263033 SANDOZ-SUMATRIPTAN SDZ
ZOLMITRIPTAN
- 2.5mg Tablet
- 2238660 ZOMIG AZC
- 2243045 ZOMIG RAPIMELT AZC
28:32.92 MISCELLANEOUS ANTIMIGRANE AGENTS
PIZOTYLINE HYDROGEN MALATE
- 0.5mg Tablet
- 329320 SANDOMIGRAN PED
- 1mg Tablet
- 511552 SANDOMIGRAN DS PED
28:36.08 ANTIPARKINSONIAN AGENTS - ANTICHOLINERGIC AGENTS
BENZTROPINE MESYLATE
- 1mg/mL Injection
- 2238903 BENZTROPINE OMEGA OMG
- 1mg Tablet
- 706531 PMS-BENZTROPINE PMS
BENZTROPINE MESYLATE
- 2mg Tablet
- 426857 APO-BENZTROPINE APX
- 563862 BENZTROPINE PDL
- 587265 PMS-BENZTROPINE PMS
ETHOPROPAZINE HCL
- 50mg Tablet
- 1927744 PARSITAN ERF
PROCYCLIDINE HCL
- 0.5mg/mL Elixir
- 587362 PMS-PROCYCLIDINE PMS
- 2.5mg Tablet
- 649392 PMS-PROCYCLIDINE PMS
- 5mg Tablet
- 587354 PMS-PROCYCLIDINE PMS
TRIHEXYPHENIDYL HCL
- 0.4mg/mL Liquid
- 885398 PMS-TRIHEXYPHENIDYL PMS
- 2mg Tablet
- 545058 APO-TRIHEX APX
- 572802 TRIHEXYPHEN PRO
- 5mg Tablet
- 545074 APO-TRIHEX APX
- 572799 TRIHEXYPHEN PDL
28:36.12 ANTIPARKINSONIAN AGENTS - CATECHOL-O- METHYLTRANSFERASE (COMT) INHIBITORS
ENTACAPONE
- 200mg Tablet
- 2243763 COMTAN NVR
28:36.16 ANTIPARKINSONIAN AGENTS - DOPAMINE PRECURSORS
LEVODOPA, BENZERAZIDE
- 50mg & 12.5mg Capsule
- 522597 PROLOPA HLR
- 100mg & 25mg Capsule
- 386464 PROLOPA HLR
- 200mg & 50mg Capsule
- 386472 PROLOPA HLR
LEVODOPA, CARBIDOPA
- 100mg & 25mg Controlled Release Tablet
- 2272873 APO-LEVOCARB CR APX
- 2028786 SINEMET CR BMS
- 200mg & 50mg Controlled Release Tablet
- 870935 SINEMET CR BMS
- 100mg & 10mg Tablet
- 2195933 APO-LEVOCARB APX
- 2244494 NOVO-LEVOCARBIDOPA NOP
- 2182831 NU-LEVOCARB NXP
- 355658 SINEMET BMS
LEVODOPA, CARBIDOPA
- 100mg & 25mg Tablet
- 2195941 APO-LEVOCARB APX
- 2244495 NOVO-LEVOCARBIDOPA NOP
- 2182823 NU-LEVOCARB NXP
- 2311178 PRO-LEVOCARB PDL
- 513997 SINEMET BMS
- 250mg & 25mg Tablet
- 2195968 APO-LEVOCARB APX
- 2244496 NOVO-LEVOCARBIDOPA NOP
- 2182858 NU-LEVOCARB NXP
- 328219 SINEMET BMS
LEVODOPA, CARBIDOPA,ENTACAPONE
- 50mg & 12.5mg & 200mg Tablet
- 2305933 STALEVO NOV
- 75mg & 18.75mg & 200mg Tablet
- 2337827 STALEVO NOV
- 100mg & 25mg & 200mg Tablet
- 2305941 STALEVO NOV
- 125mg & 31.25mg & 200mg Tablet
- 2337835 STALEVO NOV
- 150mg & 37.5mg & 200mg Tablet
- 2305968 STALEVO NOV
28:36.20 ANTIPARKINSONIAN AGENTS - DOPAMINE RECEPTOR AGONISTS
BROMOCRIPTINE MESYLATE
- 5mg Capsule
- 2230454 APO-BROMOCRIPTINE APX
- 2230719 BROMOCRIPTINE PRO
- 2238637 DOM-BROMOCRIPTINE DPC
- 2236949 PMS-BROMOCRIPTINE PMS
- 2.5mg Tablet
- 2087324 APO-BROMOCRIPTINE APX
- 2153378 BROMOCRIPTINE PRO
- 2238636 DOM-BROMOCRIPTINE DPC
- 2231702 PMS-BROMOCRIPTINE PMS
PRAMIPEXOLE DIHYDROCHLORIDE
- 0.25mg Tablet
- 2292378 APO-PRAMIPEXOLE APX
- 2297302 CO PRAMIPEXOLE CBT
- 2237145 MIRAPEX BOE
- 9857268 MIRAPEX (ONT) * BOE
- 2269309 NOVO-PRAMIPEXOLE NOP
- 2290111 PMS-PRAMIPREXOLE PMS
- 2315262 SANDOZ-PRAMIPEXOLE SDZ
- 0.5mg Tablet
- 2292386 APO-PRAMIPEXOLE APX
- 2297310 CO PRAMIPEXOLE CBT
- 2241594 MIRAPEX BOE
- 2269317 NOVO-PRAMIPEXOLE NOP
- 2290138 PMS-PRAMIPREXOLE PMS
- 2315270 SANDOZ-PRAMIPEXOLE SDZ
PRAMIPEXOLE DIHYDROCHLORIDE
- 1mg Tablet
- 2292394 APO-PRAMIPEXOLE APX
- 2297329 CO PRAMIPEXOLE CBT
- 2237146 MIRAPEX BOE
- 9857269 MIRAPEX (ONT) * BOE
- 2269325 NOVO-PRAMIPEXOLE NOP
- 2290146 PMS-PRAMIPREXOLE PMS
- 2315289 SANDOZ-PRAMIPEXOLE SDZ
- 1.5mg Tablet
- 2292408 APO-PRAMIPEXOLE APX
- 2297337 CO PRAMIPEXOLE CBT
- 2237147 MIRAPEX BOE
- 9857270 MIRAPEX (ONT) * BOE
- 2269333 NOVO-PRAMIPEXOLE NOP
- 2290154 PMS-PRAMIPREXOLE PMS
- 2315297 SANDOZ-PRAMIPEXOLE SDZ
ROPINIROLE HCL
- 0.25mg Tablet
- 2337746 APO-ROPINIROLE APX
- 2316846 CO-ROPINIROLE CBT
- 2326590 PMS-ROPINIROLE PMS
- 2314037 RAN-ROPINIROLE RBY
- 2232565 REQUIP GSK
- 1mg Tablet
- 2337762 APO-ROPINIROLE APX
- 2316854 CO-ROPINIROLE CBT
- 2326612 PMS-ROPINIROLE PMS
- 2314053 RAN-ROPINIROLE RBY
- 2232567 REQUIP GSK
- 2mg Tablet
- 2337770 APO-ROPINIROLE APX
- 2316862 CO-ROPINIROLE CBT
- 2326620 PMS-ROPINIROLE PMS
- 2314061 RAN-ROPINIROLE RBY
- 2232568 REQUIP GSK
- 5mg Tablet
- 2337800 APO-ROPINIROLE APX
- 2316870 CO-ROPINIROLE CBT
- 2326639 PMS-ROPINIROLE PMS
- 2314088 RAN-ROPINIROLE RBY
- 2232569 REQUIP GSK
28:36.32 ANTIPARKINSONIAN AGENTS - MONOAMINE OXIDASE B INHIBITORS
SELEGILINE HCL
- 5mg Tablet
- 2230641 APO-SELEGILINE APX
- 2238340 DOM-SELEGILINE DPC
- 2231036 GEN-SELEGILINE GEN
- 2237289 MED-SELEGILINE MEC
- 2068087 NOVO-SELEGILINE NOP
- 2230717 NU-SELEGILINE NXP
- 2238102 PMS-SELEGILINE PMS
- 2231479 SELEGILINE PDL
28:92.00 MISCELLANEOUS CENTRAL NERVOUS SYSTEM AGENTS
ACAMPROSATE CALCIUM
Limited use benefit (prior approval required).
For patients who have been abstinent from alcohol for at least four days and where available, are currently enrolled in an alcohol addiction treatment program.
- 333mg Sustained Release Tablet
- 2293269 CAMPRAL MYL