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:

1. have failed to achieve adequate response with 2 other listed NSAIDs, or
2. have experienced an adverse event attributable to 2 other listed NSAIDs, or
3. have a history of a serious gastrointestinal complication such as bleeding or perforation.

For patients with rheumatoid arthritis who:

1. have failed to achieve adequate response with 2 other listed NSAIDs, or
2. have experienced an adverse event attributable to 2 other listed NSAIDs, or
3. 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:

1. chronic pain and palliative care patients as an alternative to products containing codeine in combination with acetaminophen or ASA with or without caffeine, or
2. 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:

1. failed an adequate trial with TWO alternative agents (such as a tricyclic antidepressant or anticonvulsant) due to intolerance or lack of response or
2. 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:

1. intolerance or lack of response to an adequate trial of another antipsychotic agent or
2. 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