Drug Benefit List 2012

28:00 CENTRAL NERVOUS SYSTEM AGENTS

28:08.04 NONSTEROIDAL ANTI- INFLAMMATORY AGENTS

ACETYLSALICYLIC ACID

80mg Chewable Tablet

02321750 ASA SOR

02009013 ASAPHEN PMS

02280167 ASATAB ODN

02250675 EURO-ASA EUR

02269139 JAMP-ASA JMP

02202352 RIVASA RIV

ST 80mg Delayed Release Tablet

02283905 ACETYLSALICYLIC ACID JMP

02321769 ASA EC SOR

02238545 ASAPHEN EC PMS

02311496 PRO-ASA 80MG EC TAB PRO

02311518 PRO-ASA 80MG TAB PRO

ST 81mg Delayed Release Tablet

02242281 ENTROPHEN EC PED

02283700 PRAXIS ASA EC PMS

ST 162mg Delayed Release Tablet

02247550 ASAPHEN EC PMS

ST 325mg Delayed Release Tablet

02010526 ASA VTH

02352427 ASATAB EC ODN

02150417 ASPIRIN BCD

02050161 ENTROPHEN WAM

00010332 ENTROPHEN-5 WAM

02284529 PMS-ASA EC PMS

02285371 PMS-ASA EC PMS

ST 650mg Delayed Release Tablet

00794244 ASA WSB

02352435 ASATAB EC ODN

02284537 PMS-ASA EC PMS

ST 81mg Enteric Coated Tablet

02243101 ASA PMS

02244993 ASA PMS

02237726 ASPIRIN BCD

02243801 EQUATE DAILY LOW-DOSE PMS

ST 325mg Enteric Coated Tablet

00510696 APO-ASEN ECT APX

00216666 NOVASEN TEV

ST 650mg Enteric Coated Tablet

00472476 ASA APX

02046261 ASA FRS

00010340 ENTROPHEN 10 FRS

01905392 ENTROPHEN-10 FRS

00229296 NOVASEN TEV

150mg Suppository

00785547 PMS-ASA PMS

650mg Suppository

00582867 ASA JNO

ST 80mg Tablet

02150352 ASPIRIN BCD

02202360 RIVASA RIV

ST 325mg Tablet

00472468 APO-ASA APX

00036145 ASA PED

00230324 ASA TEV

00530336 ASA VTH *

02150328 ASPIRIN BCD

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

02239941 CELEBREX PFI

200mg Capsule

02239942 CELEBREX PFI

DICLOFENAC SODIUM

25mg Delayed Release Tablet

02302616 PMS-DICLOFENAC PMS

50mg Delayed Release Tablet

02302624 PMS-DICLOFENAC PMS

25mg Enteric Coated Tablet

00839175 APO-DICLO APX

02231662 DOM-DICLOFENAC DPC

00886017 NU-DICLO NXP

02231502 PMS-DICLOFENAC PMS

02261952 SANDOZ-DICLOFENAC SDZ

00808539 TEVA-DICLOFENAC TEV

50mg Enteric Coated Tablet

00839183 APO-DICLO APX

02352397 DICLOFENAC EC SAN

00870978 DICLOFENAC-50 PDL

02231663 DOM-DICLOFENAC DPC

00886025 NU-DICLO NXP

02231503 PMS-DICLOFENAC PMS

02261960 SANDOZ-DICLOFENAC SDZ

00808547 TEVA-DICLOFENAC TEV

00514012 VOLTAREN NVR

50mg Suppository

02231506 PMS-DICLOFENAC PMS

02261928 SANDOZ-DICLOFENAC SDZ

00632724 VOLTAREN NVR

100mg Suppository

02231508 PMS-DICLOFENAC PMS

02261936 SANDOZ-DICLOFENAC SDZ

00632732 VOLTAREN NVR

75mg Sustained Release Tablet

02352400 DICLOFENAC SR SAN

02224119 DICLOFENAC-SR PDL

02231664 DOM-DICLOFENAC SR DPC

02228203 NU-DICLO SR NXP

02231504 PMS-DICLOFENAC SR PMS

02261901 SANDOZ-DICLOFENAC SR SDZ

02158582 TEVA-DICLOFENAC SR TEV

00782459 VOLTAREN SR NVR

100mg Sustained Release Tablet

02091194 APO-DICLO SR APX

02224127 DICLOFENAC-SR PDL

02228211 NU-DICLO SR NXP

02231505 PMS-DICLOFENAC SR PMS

02261944 SANDOZ-DICLOFENAC SR SDZ

02048698 TEVA-DICLOFENAC SR TEV

00590827 VOLTAREN SR NVR

DICLOFENAC SODIUM, MISOPROSTOL

50mg & 200mcg Tablet

01917056 ARTHROTEC PFI

75mg & 200mcg Tablet

02229837 ARTHROTEC PFI

DIFLUNISAL

250mg Tablet

02039486 APO-DIFLUNISAL APX

02048493 TEVA-DIFLUNISAL TEV

500mg Tablet

02039494 APO-DIFLUNISAL APX

02058413 NU-DIFLUNISAL NXP

FLURBIPROFEN

50mg Tablet

01912046 APO-FLURBIPROFEN APX

02100509 NOVO-FLURPROFEN TEV

02020661 NU-FLURBIPROFEN NXP

100mg Tablet

01912038 APO-FLURBIPROFEN APX

02100517 NOVO-FLURPROFEN TEV

02020688 NU-FLURBIPROFEN NXP

IBUPROFEN

200mg Capsule

02241769 ADVIL LIQUI-GEL WRI

02281384 IBUPROFEN APX

400mg Capsule

02248231 ADVIL LIQUI-GEL WAY

02310880 IBUPROFEN APX

100mg Chewable Tablet

02242522 ADVIL PEDIATRIC WRI

02238626 CHILDREN'S MOTRIN MCL

20mg/mL Oral Liquid

02232297 CHILDREN'S A DVIL WRI

02242365 CHILDREN'S MOTRIN JNO

100mg Tablet

02240527 MOTRIN JUNIOR STRENGTH MCL

200mg Tablet

01933558 ADVIL WRI

00441643 APO-IBUPROFEN APX

02257912 IBUPROFEN PMT

02272849 IBUPROFEN VTH

02186934 MOTRIN MCL

300mg Tablet

00441651 APO-IBUPROFEN APX

02020696 NU-IBUPROFEN NXP

400mg Tablet

00506052 APO-IBUPROFEN APX

00636533 IBUPROFEN PDL

02317338 JAMP IBUPROFEN JMP

02020718 NU-IBUPROFEN NXP

00836133 PMS-IBUPROFEN PMS

600mg Tablet

00585114 APO-IBUPROFEN APX

00658804 IBUPROFEN PDL

00629359 NOVO-PROFEN TEV

02020726 NU-IBUPROFEN NXP

INDOMETHACIN

25mg Capsule

00611158 APO-INDOMETHACIN APX

00337420 NOVO-METHACIN TEV

00865850 NU-INDO NXP

00646261 PRO-INDO PDL

50mg Capsule

00611166 APO-INDOMETHACIN APX

00337439 NOVO-METHACIN TEV

00865869 NU-INDO NXP

00646288 PRO-INDO PDL

50mg Suppository

02231799 SANDOZ INDOMETHACIN SDZ

100mg Suppository

01934139 RATIO-INDOMETHACIN RPH

02231800 SANDOZ INDOMETHACIN SDZ

KETOPROFEN

50mg Capsule

00790427 KETOPROFEN AAP

02044633 NU-KETOPROFEN NXP

02150808 PMS-KETOPROFEN PMS

50mg Enteric Coated Tablet

00790435 KETOPROFEN-E AAP

02150816 PMS-KETOPROFEN PMS

100mg Enteric Coated Tablet

00842664 KETOPROFEN-E AAP

02150824 PMS-KETOPROFEN PMS

100mg Suppository

02015951 PMS-KETOPROFEN PMS

200mg Sustained Release Tablet

02172577 KETOPROFEN SR AAP

MEFENAMIC ACID

250mg Capsule

02237826 DOM-MEFENAMIC ACID DPC

02229452 MEFENAMIC AAP

02229569 NU-MEFENAMIC NXP

MELOXICAM

7.5mg Tablet

02248973 APO-MELOXICAM APX

02250012 CO MELOXICAM COB

02248605 DOM-MELOXICAM DPC

02324326 MELOXICAM PDL

02353148 MELOXICAM SAN

02242785 MOBICOX BOE

02255987 MYLAN-MELOXICAM MYL

02258315 NOVO-MELOXICAM TEV

02248607 PHL-MELOXICAM PHH

02248267 PMS-MELOXICAM PMS

02247889 RATIO-MELOXICAM RPH

15mg Tablet

02248974 APO-MELOXICAM APX

02250020 CO MELOXICAM COB

02248606 DOM-MELOXICAM DPC

02353156 MELOXICAM SAN

02242786 MOBICOX BOE

02255995 MYLAN-MELOXICAM MYL

02258323 NOVO-MELOXICAM TEV

02248608 PHL-MELOXICAM PHH

02248268 PMS-MELOXICAM PMS

02248031 RATIO-MELOXICAM RPH

NAPROXEN

250mg Enteric Coated Tablet

02246699 APO-NAPROXEN EC APX

02162792 NAPROSYN E HLR

02350785 NAPROXEN EC SAN

02243312 NOVO-NAPROX TEV

375mg Enteric Coated Tablet

02246700 APO-NAPROXEN EC APX

02162415 NAPROSYN E HLR

02350793 NAPROXEN EC SAN

02243313 NOVO-NAPROX TEV

02294702 PMS-NAPROXEN EC PMS

02310945 PRO-NAPROXEN EC PDL

500mg Enteric Coated Tablet

02246701 APO-NAPROXEN EC APX

02241024 MYLAN-NAPROXEN EC MYL

02162423 NAPROSYN E HLR

02243314 NOVO-NAPROX TEV

02294710 PMS-NAPROXEN EC PMS

02310953 PRO-NAPROXEN EC PDL

25mg/mL Suspension

02162431 NAPROSYN HLR

750mg Sustained Release Tablet

02162466 NAPROSYN SR HLR

125mg Tablet

00522678 APO-NAPROXEN APX

00865621 NU-NAPROX NXP

NAPROXEN

250mg Tablet

00522651 APO-NAPROXEN APX

00590762 NAPROXEN PDL

02350750 NAPROXEN SAN

00565350 NOVO-NAPROX TEV

00865648 NU-NAPROX NXP

02240786 RIVA-NAPROXEN RIV

375mg Tablet

00600806 APO-NAPROXEN APX

02243432 MYLAN-NAPROXEN MYL

00655686 NAPROXEN PDL

02350769 NAPROXEN SAN

00627097 NOVO-NAPROX TEV

00865656 NU-NAPROX NXP

02240787 RIVA-NAPROXEN RIV

500mg Tablet

00592277 APO-NAPROXEN APX

00618721 NAPROXEN PDL

02350777 NAPROXEN SAN

00589861 NOVO-NAPROX TEV

00865664 NU-NAPROX NXP

02240788 RIVA-NAPROXEN RIV

NAPROXEN SODIUM

275mg Tablet

02162725 ANAPROX HLR

00784354 APO-NAPRO NA APX

00887056 NAPROXEN NA PDL

02351013 NAPROXEN SODIUM SAN

00778389 NOVO-NAPROX SODIUM TEV

550mg Tablet

02162717 ANAPROX DS HLR

01940309 APO-NAPRO NA DS APX

02153386 NAPROXEN-NA DF PDL

02026600 NOVO-NAPROX SODIUM DS TEV

02240828 RIVA-NAPROXEN SODIUM RIV

PIROXICAM

10mg Capsule

00642886 APO-PIROXICAM APX

00865761 NU-PIROX NXP

00836249 PMS-PIROXICAM PMS

20mg Capsule

00642894 APO-PIROXICAM APX

02239536 DOM-PIROXICAM DPC

00865788 NU-PIROX NXP

00836230 PMS-PIROXICAM PMS

10mg Suppository

02154420 PMS-PIROXICAM PMS

20mg Suppository

02154463 PMS-PIROXICAM PMS

10mg Tablet

00695718 NOVO-PIROCAM TEV

20mg Tablet

00695696 NOVO-PIROCAM TEV

SULINDAC

150mg Tablet

00778354 APO-SULIN APX

00745588 NOVO-SUNDAC TEV

02042576 NU-SULINDAC NXP

200mg Tablet

00778362 APO-SULIN APX

00745596 NOVO-SUNDAC TEV

02042584 NU-SULINDAC NXP

TIAPROFENIC ACID

200mg Tablet

02179679 NOVO-TIAPROFENIC TEV

02230827 PMS-TIAPROFENIC PMS

300mg Tablet

02136120 APO-TIAPROFENIC APX

02231060 DOM-TIAPROFENIC DPC

02179687 NOVO-TIAPROFENIC TEV

02146886 NU-TIAPROFENIC NXP

28:08.08 OPIATE AGONISTS

ACETAMINOPHEN, CAFFEINE CITRATE, CODEINE PHOSPHATE

300mg & 15mg & 15mg Tablet

00706515 PMS-ACET 2 PMS

00653241 RATIO-LENOLTEC NO.2 RPH

02163934 TYLENOL WITH CODEINE JNO

300mg & 15mg & 30mg Tablet

00653276 RATIO-LENOLTEC NO.3 RPH

02163926 TYLENOL WITH CODEINE JNO

300mg & 30mg & 15mg Tablet

02232388 EXDOL-15 PED

300mg & 30mg & 30mg Tablet

02232389 EXDOL-30 PED

325mg & 30mg & 15mg Tablet

00293504 ATASOL-15 HOR

325mg & 30mg & 30mg Tablet

00293512 ATASOL-30 HOR

ACETAMINOPHEN, CODEINE PHOSPHATE

32mg & 1.6mg/mL Elixir

00816027 PMS-ACETAMINOPHEN WITH CODEINE PMS

02163942 TYLENOL WITH CODEINE JNO

300mg & 30mg Tablet

01999648 ACET CODEINE 30 PMS

02232658 PROCET-30 PDL

00608882 RATIO-EMTEC-30 RPH

00789828 TRIATEC-30 TRI

300mg & 60mg Tablet

00621463 LENOLTEC NO.4 RPH

02163918 TYLENOL WITH CODEINE JNO

ACETAMINOPHEN, OXYCODONE HCL

325mg & 2.5mg Tablet

01916491 PERCOCET DEMI BMS

325mg & 5mg Tablet

02324628 APO-OXYCODONE/ACET APX

01916548 ENDOCET EDM

02361361 OXYCODONE/ACET SAN

01916475 PERCOCET BMS

02327171 PRO-OXYCOD ACET PDL

00608165 RATIO-OXYCOCET RPH

02242468 RIVACOCET RIV

02307898 SANDOZ OXYCODONE ACET SDZ

ACETYLSALICYLIC ACID, CAFFEINE CITRATE, CODEINE PHOSPHATE

375mg & 30mg & 15mg Tablet

02234510 282 PED

375mg & 30mg & 30mg Tablet

02238645 292 PED

ACETYLSALICYLIC ACID, OXYCODONE HCL

325mg & 5mg Tablet

00608157 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

02230302 CODEINE CONTIN CR PFR

100mg Long Acting Tablet

02163748 CODEINE CONTIN CR PFR

150mg Long Acting Tablet

02163780 CODEINE CONTIN CR PFR

200mg Long Acting Tablet

02163799 CODEINE CONTIN CR PFR

CODEINE PHOSPHATE

30mg/mL Injection

00544884 CODEINE SDZ *

00497282 CODEINE PHOSPHATE ABB *

60mg/mL Injection

00497290 CODEINE PHOSPHATE ABB *

2mg/mL Liquid

00380571 LINCTUS CODEINE ATL

5mg/mL Syrup

00050024 CODEINE PHOSPHATE ATL

00779474 RATIO-CODEINE RPH

15mg Tablet

00779458 CODEINE RPH

02009889 CODEINE RIV

00593435 RATIO-CODEINE RPH

30mg Tablet

02009757 CODEINE RIV

00593451 CODEINE PHOSPHATE RPH

02243979 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

02341379 PMS-FENTANYL MTX PMS

02330105 RAN-FENTANYL MATRIX RBY

02311925 RATIO-FENTANYL RPH

02327112 SANDOZ FENTANYL SDZ

25mcg/h Transdermal Patch

02275813 DURAGESIC MAT JNO

02314630 NOVO-FENTANYL TEV

02341387 PMS-FENTANYL MTX PMS

02330113 RAN-FENTANYL MATRIX RBY

02282941 RATIO-FENTANYL RPH

02327120 SANDOZ FENTANYL SDZ

50mcg/h Transdermal Patch

02275821 DURAGESIC MAT JNO

02314649 NOVO-FENTANYL TEV

02341395 PMS-FENTANYL MTX PMS

02330121 RAN-FENTANYL MATRIX RBY

02282968 RATIO-FENTANYL RPH

02327147 SANDOZ FENTANYL SDZ

75mcg/h Transdermal Patch

02275848 DURAGESIC MAT JNO

02314657 NOVO-FENTANYL TEV

02341409 PMS-FENTANYL MTX PMS

02330148 RAN-FENTANYL MATRIX RBY

02282976 RATIO-FENTANYL RPH

02327155 SANDOZ FENTANYL SDZ

100mcg/h Transdermal Patch

02275856 DURAGESIC MAT JNO

02314665 NOVO-FENTANYL TEV

02341417 PMS-FENTANYL MTX PMS

02330156 RAN-FENTANYL MATRIX RBY

02282984 RATIO-FENTANYL RPH

02327163 SANDOZ FENTANYL SDZ

HYDROMORPHONE

2mg/mL Injection

00627100 DILAUDID PFR

02145901 HYDROMORPHONE SDZ

10mg/mL Injection

00622133 DILAUDID HP PFR

02145928 HYDROMORPHONE HP 10 SDZ

20mg/mL Injection

02145936 HYDROMORPHONE HP 20 SDZ

50mg/mL Injection

02146126 HYDROMORPHONE HP 50 SDZ

99003163 HYDROMORPHONE HP 50 SDZ

1mg/mL Oral Liquid

00786535 DILAUDID PFR

01916386 PMS-HYDROMORPHONE PMS

3mg Suppository

01916394 PMS-HYDROMORPHONE PMS

1mg Tablet

00705438 DILAUDID PFR

02192101 HYDROMORPHONE SOR

00885444 PMS-HYDROMORPHONE PMS

02319403 TEVA-HYDROMORPHONE TEV

2mg Tablet

00125083 DILAUDID PFR

02249928 HYDROMORPHONE SOR

00885436 PMS-HYDROMORPHONE PMS

02319411 TEVA-HYDROMORPHONE TEV

4mg Tablet

00125121 DILAUDID PFR

02249936 HYDROMORPHONE SOR

00885401 PMS-HYDROMORPHONE PMS

02319438 TEVA-HYDROMORPHONE TEV

8mg Tablet

00786543 DILAUDID PFR

02192144 HYDROMORPHONE SOR

00885428 PMS-HYDROMORPHONE PMS

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

02125323 HYDROMORPH CONTIN PFR

4.5mg Controlled Release Capsule

02359502 HYDROMORPH CONTIN PFR

6mg Controlled Release Capsule

02125331 HYDROMORPH CONTIN PFR

9mg Controlled Release Capsule

02359510 HYDROMORPH CONTIN PFR

12mg Controlled Release Capsule

02125366 HYDROMORPH CONTIN PFR

18mg Controlled Release Capsule

02243562 HYDROMORPH CONTIN PFR

24mg Controlled Release Capsule

02125382 HYDROMORPH CONTIN PFR

30mg Controlled Release Capsule

02125390 HYDROMORPH CONTIN PFR

MEPERIDINE

25mg/mL Injection

00497444 MEPERIDINE ABB *

50mg/mL Injection

02242003 DEMEROL ABB

00497452 MEPERIDINE ABB

00725765 MEPERIDINE SDZ

75mg/mL Injection

02242004 DEMEROL ABB

00497460 MEPERIDINE ABB *

00725757 MEPERIDINE SDZ

100mg/mL Injection

02242005 DEMEROL ABB

00725749 MEPERIDINE SDZ

00497479 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 Tablet

02138018 DEMEROL SAC

METHADONE

Powder

00908835 METHADONE

METHADONE HCL

limited use benefit (prior approval required) with the following criteria:

Prescriber is registered with Health Canada and is eligible to prescribe methadone for the management of pain. AND For the management of moderate to severe cancer pain or chronic non-cancer pain, as an alternative to other opioids. OR, For the management of pain for palliative care patients. Pharmacists may only dispense a maximum supply of 30 days at one time.

Methadone pseudo DINs listed for the treatment of pain should not be used for methadone maintenance therapy. Methadone for the treatment of opioid dependency is an open benefit covered under the NIHB Program (Methadone maintenance therapy pseudo DIN 908835). For information regarding the adjudication rules of methadone for the treatment of opioid dependency, please refer to the NIHB Provider Guide for Pharmacy Benefits.

1mg/mL Oral Liquid

02247694 METADOL PAL

10mg/mL Oral Liquid

02241377 METADOL PAL

Powder

09991180 METHADONE POWDER (PAIN)

1mg Tablet

02247698 METADOL PAL

5mg Tablet

02247699 METADOL PAL

10mg Tablet

02247700 METADOL PAL

25mg Tablet

02247701 METADOL PAL

MORPHINE HCL

30mg Sustained Release Tablet

00776181 M.O.S. SR VAE

60mg Sustained Release Tablet

00776203 M.O.S. SR VAE

1mg/mL Syrup

00614491 DOLORAL 1 ATL

00607762 RATIO-MORPHINE RPH

5mg/mL Syrup

00614505 DOLORAL 5 ATL

00607770 RATIO-MORPHINE RPH

10mg/mL Syrup

00632503 M.O.S. 10 VAE

00690783 RATIO-MORPHINE RPH

20mg/mL Syrup

00690791 RATIO-MORPHINE RPH

50mg/mL Syrup

00690236 M.O.S. 50 VAE

10mg Tablet

00690198 M.O.S. 10 VAE

20mg Tablet

00690201 M.O.S. 20 VAE

40mg Tablet

00690228 M.O.S. 40 VAE

60mg Tablet

00690244 M.O.S. 60 VAE

MORPHINE SULFATE

20mg/mL Drop

00621935 STATEX PMS

50mg/mL Drop

00705799 STATEX PMS

0.5mg/mL Injection

02021056 MORPHINE LP SDZ

01949047 MORPHINE SULFATE ABB

1mg/mL Injection

02021048 MORPHINE LP SDZ *

01949055 MORPHINE SULFATE ABB

01980696 MORPHINE SULFATE SDZ

2mg/mL Injection

00850314 MORPHINE SULFATE ABB

01964437 MORPHINE SULFATE SDZ

02242484 MORPHINE SULFATE SDZ

5mg/mL Injection

01964429 MORPHINE SULFATE SDZ

10mg/mL Injection

00392588 MORPHINE SULFATE SDZ

00850322 MORPHINE SULFATE ABB

15mg/mL Injection

00392561 MORPHINE SULFATE SDZ

25mg/mL Injection

00676411 MORPHINE HP 25 SDZ

50mg/mL Injection

00617288 MORPHINE HP 50 SDZ

02137267 MORPHINE SULFATE HOS

5mg Suppository

00632228 STATEX PMS

10mg Suppository

00632201 STATEX PMS

20mg Suppository

00596965 STATEX PMS

10mg Sustained Release Capsule

02242163 KADIAN MAY

02019930 M-ESLON SAC

15mg Sustained Release Capsule

02177749 M-ESLON SAC

20mg Sustained Release Capsule

02184435 KADIAN MAY

30mg Sustained Release Capsule

02019949 M-ESLON SAC

50mg Sustained Release Capsule

02184443 KADIAN MAY

60mg Sustained Release Capsule

02019957 M-ESLON SAC

100mg Sustained Release Capsule

02184451 KADIAN MAY

02019965 M-ESLON SAC

200mg Sustained Release Capsule

02177757 M-ESLON SAC

15mg Sustained Release Tablet

02350815 MORPHINE SR SAN

02015439 MS CONTIN SR PFR

02302764 NOVO-MORPHINE SR TEV

30mg Sustained Release Tablet

02350890 MORPHINE SR SAN

02014297 MS CONTIN SR PFR

02302772 NOVO-MORPHINE SR TEV

60mg Sustained Release Tablet

02350912 MORPHINE SR SAN

02014300 MS CONTIN SR PFR

02302780 NOVO-MORPHINE SR TEV

02245286 PMS-MORPHINE SULFATE PMS

100mg Sustained Release Tablet

02350920 MORPHINE SR SAN

02014319 MS CONTIN SR PFR

02302799 NOVO-MORPHINE SR TEV

200mg Sustained Release Tablet

02350947 MORPHINE SR SAN

02014327 MS CONTIN SR PFR

02302802 NOVO-MORPHINE SR TEV

02245288 PMS-MORPHINE SR PMS

1mg/mL Syrup

00591467 STATEX PMS

5mg/mL Syrup

00591475 STATEX PMS

10mg/mL Syrup

00647217 STATEX PMS

5mg Tablet

02009773 M.O.S. SULFATE VAE

02014203 MS IR PFR

00594652 STATEX PMS

10mg Tablet

02009765 M.O.S. SULFATE VAE

02014211 MS IR PFR

00594644 STATEX PMS

20mg Tablet

02014238 MS IR PFR

25mg Tablet

02009749 M.O.S. SULFATE VAE

00594636 STATEX PMS

30mg Tablet

02014254 MS IR PFR

50mg Tablet

02009706 M.O.S. SULFATE VAE

00675962 STATEX PMS

OXYCODONE HCL

10mg Suppository

00392480 SUPEUDOL SDZ

20mg Suppository

00392472 SUPEUDOL SDZ

5mg Tablet

02325950 OXYCODONE PDL

02231934 OXY-IR PFR

02319977 PMS-OXYCODONE PMS

00789739 SUPEUDOL SDZ

10mg Tablet

02240131 OXY-IR PFR

02319985 PMS-OXYCODONE PMS

00443948 SUPEUDOL SDZ

20mg Tablet

02240132 OXY-IR PFR

02319993 PMS-OXYCODONE PMS

02262983 SUPEUDOL SDZ

28:08.12 OPIATE PARTIAL AGONISTS

BUPRENORPHINE HCL/NALOXONE HCL

Limited use benefit (prior approval required).

For the treatment of opioid dependence in patients who have a contraindication to methadone due to:

• Evidence of (or high risk for) QT interval prolongation; and
• Prescribed by a physician with experience in substitution treatment in Opioid drug dependence or completion of an accredited Suboxone Education Program.

8mg & 2mg Sublingual Tablet

02295709 SUBOXONE RBP

09991204 SUBOXONE MAINTENANCE RBP

PENTAZOCINE HCL

50mg Tablet

02137984 TALWIN SAC

PENTAZOCINE LACTATE

30mg/mL Injection

02241976 TALWIN ABB

28:08.92 MISCELLANEOUS ANALGESICS AND ANTIPYRETICS

ACETAMINOPHEN

ST 80mg Chewable Tablet

01905856 ACETAMINOPHEN TRI

02015676 ACETAMINOPHEN TAN

02017458 ACETAMINOPHEN RIV

02129957 ACETAMINOPHEN VTH

02263815 PEDIAPHEN CHEWABLE EUR

ST 160mg Chewable Tablet

02017431 ACETAMINOPHEN RIV

02230934 ACETAMINOPHEN TAN

02231011 FEVERHALT PED

02263823 PEDIAPHEN CHEWABLE EUR

80mg/mL Drop

01904140 ACETAMINOPHEN TAN

01905864 ACETAMINOPHEN TRI

00631353 ATASOL HOR

02230787 FEVERHALT PED

02263793 PEDIAPHEN EUR

02027801 PEDIATRIX RPH

00887587 PMS-ACETAMINOPHEN PMS

00875988 TEMPRA MJO

02046059 TYLENOL MCL

16mg/mL Liquid

01905848 ACETAMINOPHEN TRI

02263807 PEDIAPHEN EUR

00792713 PMS-ACETAMINOPHEN PMS

00884553 TEMPRA MJO

32mg/mL Liquid

01901389 ACETAMINOPHEN JMP

01958836 ACETAMINOPHEN TRI

02263831 PEDIAPHEN EUR

02027798 PEDIATRIX RPH

00792691 PMS-ACETAMINOPHEN PMS

00875996 TEMPRA DOUBLE STRENGTH MJO

02046040 TYLENOL MCL

80mg/mL Oral Liquid

02237390 ACETAMINOPHEN PER

120mg Suppository

01919385 ABENOL PED

02230434 ACET 120 PMS

02046660 PMS-ACETAMINOPHEN PMS

160mg Suppository

02230435 ACET PMS

325mg Suppository

01919393 ABENOL PED

02230436 ACET 325 PMS

02046687 PMS-ACETAMINOPHEN PMS

650mg Suppository

01919407 ABENOL PED

02230437 ACET 650 PMS

02046695 PMS-ACETAMINOPHEN PMS

ST 80mg Tablet

02238295 CHILDREN'S TYLENOL SOFT CHEWS JNO

ST 160mg Tablet

02142805 ACETAMINOPHEN WTR

02241361 TYLENOL JUNIOR STRENGTH JNO

ST 325mg Tablet

00374148 ACETAMINOPHEN WAM

00382752 ACETAMINOPHEN PRO

00589241 ACETAMINOPHEN PMS

00605751 ACETAMINOPHEN VTH *

00743542 ACETAMINOPHEN PMT

00789801 ACETAMINOPHEN TRI

01938088 ACETAMINOPHEN JMP

02022214 ACETAMINOPHEN RIV

00544981 APO-ACETAMINOPHEN APX

02229873 APO-ACETAMINOPHEN APX

00293482 ATASOL HOR

00389218 NOVO-GESIC TEV

00891177 PMS-ACETAMINOPHEN PMS *

00559393 TYLENOL MCL

00723894 TYLENOL MCL

ST 500mg Tablet

00386626 ACETAMINOPHEN PDL

00549703 ACETAMINOPHEN PMT

00567663 ACETAMINOPHEN PED

00589233 ACETAMINOPHEN PMS

00605778 ACETAMINOPHEN VTH

00789798 ACETAMINOPHEN TRI

01939122 ACETAMINOPHEN JMP

02022222 ACETAMINOPHEN RIV

02252813 ACETAMINOPHEN PMT

02255251 ACETAMINOPHEN PMT

00545007 APO-ACETAMINOPHEN APX

02229977 APO-ACETAMINOPHEN APX

00013668 ATASOL FORTE HOR

00482323 NOVO-GESIC TEV

00892505 PMS-ACETAMINOPHEN PMS

01962353 TANTAPHEN TAN

00863270 TYLENOL MCL

00559407 TYLENOL EXTRA STRENGTH MCL

00723908 TYLENOL EXTRA STRENGTH MCL

FLOCTAFENINE

200mg Tablet

02244680 FLOCTAFENINE AAP

400mg Tablet

02244681 FLOCTAFENINE AAP

28:12.04 ANTICONVULSANTS - BARBITURATES

PHENOBARBITAL

5mg/mL Liquid

00645575 PHENOBARB PED

15mg Tablet

00178799 PHENOBARB PED

30mg Tablet

00178802 PHENOBARB PED

60mg Tablet

00178810 PHENOBARB PED

100mg Tablet

00178829 PHENOBARB PED

PRIMIDONE

125mg Tablet

00399310 PRIMIDONE AAP

250mg Tablet

00396761 PRIMIDONE AAP

28:12.08 ANTICONVULSANTS - BENZODIAZEPINES

CLONAZEPAM

0.25mg Tablet

02179660 PMS-CLONAZEPAM PMS

0.5mg Tablet

02177889 APO-CLONAZEPAM APX

02230366 CLONAPAM VAE

02270641 CO CLONAZEPAM COB

02130998 DOM-CLONAZEPAM DPC

02224100 DOM-CLONAZEPAM-R DPC

02230950 MYLAN-CLONAZEPAM MYL

02173344 NU-CLONAZEPAM NXP

02145227 PHL-CLONAZEPAM PHH

02236948 PHL-CLONAZEPAM-R 0.5MG PHH

02048701 PMS-CLONAZEPAM PMS

02207818 PMS-CLONAZEPAM R PMS

02311593 PRO-CLONAZEPAM PDL

02242077 RIVA-CLONAZEPAM RIV

00382825 RIVOTRIL HLR

02233960 SANDOZ-CLONAZEPAM SDZ

02239024 TEVA-CLONAZEPAM TEV

02345676 ZYM-CLONAZEPAM ZYM

1mg Tablet

02230368 CLONAPAM VAE

02270668 CO CLONAZEPAM COB

02145235 PHL-CLONAZEPAM PHH

02048728 PMS-CLONAZEPAM PMS

02311607 PRO-CLONAZEPAM PDL

02233982 SANDOZ-CLONAZEPAM SDZ

02303329 ZYM-CLONAZEPAM ZYM

2mg Tablet

02177897 APO-CLONAZEPAM APX

02230369 CLONAPAM VAE

02270676 CO CLONAZEPAM COB

02131013 DOM-CLONAZEPAM DPC

02230951 GEN-CLONAZEPAM MYL

02173352 NU-CLONAZEPAM NXP

02145243 PHL-CLONAZEPAM PHH

02048736 PMS-CLONAZEPAM PMS

02311615 PRO-CLONAZEPAM PDL

02242078 RIVA-CLONAZEPAM RIV

00382841 RIVOTRIL HLR

02233985 SANDOZ-CLONAZEPAM SDZ

02239025 TEVA-CLONAZEPAM TEV

02303337 ZYM-CLONAZEPAM ZYM

28:12.12 ANTICONVULSANTS - HYDANTOINS

PHENYTOIN

30mg Capsule

00022772 DILANTIN PFI

PHENYTOIN

100mg Capsule

00022780 DILANTIN PFI

50mg Chewable Tablet

00023698 DILANTIN INFATABS PFI

6mg/mL Suspension

00023442 DILANTIN 30 PFI

25mg/mL Suspension

00023450 DILANTIN 125 PFI

02250896 TARO-PHENYTOIN TAR

28:12.20 ANTICONVULSANTS- SUCCINIMIDES

ETHOSUXIMIDE

250mg Capsule

00022799 ZARONTIN ERF

50mg/mL Syrup

00023485 ZARONTIN ERF

METHSUXIMIDE

300mg Capsule

00022802 CELONTIN ERF

28:12.92 MISCELLANEOUS ANTICONVULSANTS

CARBAMAZEPINE

100mg Chewable Tablet

02231542 PMS-CARBAMAZEPINE PMS

02261855 SANDOZ-CARBAMAZEPINE SDZ

02244403 TARO-CARBAMAZEPINE TAR

00369810 TEGRETOL NVR

200mg Chewable Tablet

02231540 PMS-CARBAMAZEPINE PMS

02261863 SANDOZ-CARBAMAZEPINE SDZ

02244404 TARO-CARBAMAZEPINE TAR

00665088 TEGRETOL NVR

200mg Extended Release Tablet

02261839 SANDOZ-CARBAMAZEPINE SDZ

400mg Extended Release Tablet

02261847 SANDOZ-CARBAMAZEPINE SDZ

20mg/mL Suspension

02194333 TEGRETOL NVR

200mg Sustained Release Tablet

02238222 DOM-CARBAMAZEPINE CR DPC

02241882 MYLAN-CARBAMAZEPINE CR MYL

02231543 PMS-CARBAMAZEPINE CR PMS

02237907 TARO-CARBAMAZEPINE CR TAR

00773611 TEGRETOL CR NVR

400mg Sustained Release Tablet

02238223 DOM-CARBAMAZEPINE CR DPC

02241883 MYLAN-CARBAMAZEPINE CR MYL

02231544 PMS-CARBAMAZEPINE CR PMS

02237908 TARO-CARBAMAZEPINE CR TAR

00755583 TEGRETOL CR NVR

200mg Tablet

00402699 APO-CARBAMAZEPINE APX

00578460 CARBAMAZEPINE PDL

02042568 NU-CARBAMAZEPINE NXP

00010405 TEGRETOL NVR

00782718 TEVA-CARBAMAZ TEV

DIVALPROEX SODIUM

125mg Enteric Coated Tablet

02239698 APO-DIVALPROEX APX

00596418 EPIVAL ABB

02239517 NU-DIVALPROEX NXP

02244138 PMS-DIVALPROEX PMS

02239701 TEVA-DIVALPROEX TEV

250mg Enteric Coated Tablet

02239699 APO-DIVALPROEX APX

02240342 DIVALPROEX PDL

00596426 EPIVAL ABB

02239518 NU-DIVALPROEX NXP

02244139 PMS-DIVALPROEX PMS

02239702 TEVA-DIVALPROEX TEV

500mg Enteric Coated Tablet

02239700 APO-DIVALPROEX APX

02240343 DIVALPROEX PDL

00596434 EPIVAL ABB

02239519 NU-DIVALPROEX NXP

02244140 PMS-DIVALPROEX PMS

02239703 TEVA-DIVALPROEX TEV

GABAPENTIN

100mg Capsule

02244304 APO-GABAPENTIN APX

02256142 CO GABAPENTIN COB

02243743 DOM-GABAPENTIN DPC

02246314 GABAPENTIN MEL

02304775 GABAPENTIN SOR

02353245 GABAPENTIN SAN

02248259 MYLAN-GABAPENTIN MYL

02084260 NEURONTIN PFI

02244513 NOVO-GABAPENTIN TEV

02243446 PMS-GABAPENTIN PMS

02310449 PRO-GABAPENTIN PDL

02319055 RAN-GABAPENTIN RBY

02251167 RIVA-GABAPENTIN RIV

300mg Capsule

02244305 APO-GABAPENTIN APX

02256150 CO GABAPENTIN COB

02243744 DOM-GABAPENTIN DPC

02246315 GABAPENTIN MEL

02304783 GABAPENTIN SOR

02353253 GABAPENTIN SAN

02248260 MYLAN-GABAPENTIN MYL

02084279 NEURONTIN PFI

02244514 NOVO-GABAPENTIN TEV

02243447 PMS-GABAPENTIN PMS

02310457 PRO-GABAPENTIN PDL

02319063 RAN-GABAPENTIN RBY

02251175 RIVA-GABAPENTIN RIV

400mg Capsule

02244306 APO-GABAPENTIN APX

02256169 CO GABAPENTIN COB

02243745 DOM-GABAPENTIN DPC

02246316 GABAPENTIN MEL

02304791 GABAPENTIN SOR

02353261 GABAPENTIN SAN

02248261 MYLAN-GABAPENTIN MYL

02084287 NEURONTIN PFI

02244515 NOVO-GABAPENTIN TEV

02243448 PMS-GABAPENTIN PMS

02310465 PRO-GABAPENTIN PDL

02319071 RAN-GABAPENTIN RBY

02260905 RATIO-GABAPENTIN RPH

02251183 RIVA-GABAPENTIN RIV

600mg Tablet

02293358 APO-GABAPENTIN APX

02285843 GD-GABAPENTIN PFI

02239717 NEURONTIN PFI

02248457 NOVO-GABAPENTIN TEV

02255898 PMS-GABAPENTIN PMS

02310473 PRO-GABAPENTIN PDL

02259796 RIVA-GABAPENTIN RIV

800mg Tablet

02293366 APO-GABAPENTIN APX

02239718 NEURONTIN PFI

02247346 NOVO-GABAPENTIN TEV

02255901 PMS-GABAPENTIN PMS

02310481 PRO-GABAPENTIN PDL

02259818 RIVA-GABAPENTIN RIV

LAMOTRIGINE

2mg Chewable Tablet

02243803 LAMICTAL GSK

5mg Chewable Tablet

02240115 LAMICTAL GSK

25mg Tablet

02245208 APO-LAMOTRIGINE APX

02142082 LAMICTAL GSK

02302969 LAMOTRIGINE PDL

02343010 LAMOTRIGINE SAN

02265494 MYLAN-LAMOTRIGINE MYL

02248232 NOVO-LAMOTRIGINE TEV

02246897 PMS-LAMOTRIGINE PMS

02243352 RATIO-LAMOTRIGINE RPH

100mg Tablet

02245209 APO-LAMOTRIGINE APX

02142104 LAMICTAL GSK

02302985 LAMOTRIGINE PDL

02343029 LAMOTRIGINE SAN

02265508 MYLAN-LAMOTRIGINE MYL

02248233 NOVO-LAMOTRIGINE TEV

02246898 PMS-LAMOTRIGINE PMS

02243353 RATIO-LAMOTRIGINE RPH

150mg Tablet

02245210 APO-LAMOTRIGINE APX

02142112 LAMICTAL GSK

02302993 LAMOTRIGINE PDL

02343037 LAMOTRIGINE SAN

02265516 MYLAN-LAMOTRIGINE MYL

02248234 NOVO-LAMOTRIGINE TEV

02246899 PMS-LAMOTRIGINE PMS

02246963 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 two anti-epileptic medications used either as monotherapy or in combination. This product must be prescribed by a Neurologist.

ST 250mg Tablet

02285924 APO-LEVETIRACETAM APX

02274183 CO LEVETIRACETAM COB

02247027 KEPPRA UCB

02353342 LEVETIRACETAM SAN

02296101 PMS-LEVETIRACETAM PMS

ST 500mg Tablet

02285932 APO-LEVETIRACETAM APX

02274191 CO LEVETIRACETAM COB

02247028 KEPPRA UCB

02353350 LEVETIRACETAM SAN

02296128 PMS-LEVETIRACETAM PMS

02311380 PRO-LEVETIRACETAM PDL

ST 750mg Tablet

02285940 APO-LEVETIRACETAM APX

02274205 CO LEVETIRACETAM COB

02247029 KEPPRA UCB

02353369 LEVETIRACETAM SAN

02296136 PMS-LEVETIRACETAM PMS

02311399 PRO-LEVETIRACETAM PDL

TOPIRAMATE

15mg Sprinkle Capsule

02239907 TOPAMAX SPRINKLE JNO

25mg Sprinkle Capsule

02239908 TOPAMAX SPRINKLE JNO

25mg Tablet

02351307 ACCEL-TOPIRAMATE ACP

02279614 APO-TOPIRAMATE APX

02287765 CO TOPIRAMATE COB

02271141 DOM-TOPIRAMATE DPC *

02315645 MINT-TOPIRAMATE MIN

02263351 MYLAN-TOPIRAMATE MYL

02248860 NOVO-TOPIRAMATE TEV

02271184 PHL-TOPIRAMATE PHH

02262991 PMS-TOPIRAMATE PMS

02313650 PRO-TOPIRAMATE PDL

02260050 SANDOZ-TOPIRAMATE SDZ

02230893 TOPAMAX JNO

02356856 TOPIRAMATE SAN

02325136 ZYM-TOPIRAMATE ZYM

28:12.92 MISCELLANEOUS ANTICONVULSANTS

TOPIRAMATE

50mg Tablet

02312085 PMS-TOPIRAMATE PMS

100mg Tablet

02351315 ACCEL-TOPIRAMATE ACP

02279630 APO-TOPIRAMATE APX

02287773 CO TOPIRAMATE COB

02271168 DOM-TOPIRAMATE DPC *

02315653 MINT-TOPIRAMATE MIN

02263378 MYLAN-TOPIRAMATE MYL

02248861 NOVO-TOPIRAMATE TEV

02271192 PHL-TOPIRAMATE PHH

02263009 PMS-TOPIRAMATE PMS

02313669 PRO-TOPIRAMATE PDL

02260069 SANDOZ-TOPIRAMATE SDZ

02230894 TOPAMAX JNO

02356864 TOPIRAMATE SAN

02325144 ZYM-TOPIRAMATE ZYM

200mg Tablet

02351323 ACCEL-TOPIRAMATE ACP

02279649 APO-TOPIRAMATE APX

02287781 CO TOPIRAMATE COB

02271176 DOM-TOPIRAMATE DPC *

02315661 MINT-TOPIRAMATE MIN

02263386 MYLAN-TOPIRAMATE MYL

02248862 NOVO-TOPIRAMATE TEV

02271206 PHL-TOPIRAMATE PHH

02263017 PMS-TOPIRAMATE PMS

02313677 PRO-TOPIRAMATE PDL

02267837 SANDOZ-TOPIRAMATE SDZ

02230896 TOPAMAX JNO

02356872 TOPIRAMATE SAN

02325152 ZYM-TOPIRAMATE ZYM

VALPROATE, SODIUM

50mg/mL Syrup

02238370 APO-VALPROIC APX

00443832 DEPAKENE ABB

02238817 DOM-VALPROIC ACID DPC

02236807 PMS-VALPROIC ACID PMS

02140063 RATIO-VALPROIC RPH

VALPROIC ACID

250mg Capsule

02238048 APO-VALPROIC APX

00443840 DEPAKENE ABB

02231030 DOM-VALPROIC ACID DPC

02184648 MYLAN-VALPROIC MYL

02100630 NOVO-VALPROIC TEV

02237830 NU-VALPROIC NXP

02230768 PMS-VALPROIC ACID PMS

02239714 SANDOZ-VALPROIC SDZ

02238546 VALPROIC PDL

500mg Enteric Coated Capsule

02231031 DOM-VALPROIC ACID DPC

02218321 NOVO-VALPROIC TEV

02260662 PHL-VALPROIC ACID PHH

02229628 PMS-VALPROIC ACID PMS

VIGABATRIN

500mg Powder

02068036 SABRIL OVA

500mg Tablet

02065819 SABRIL OVA

28:16.04 ANTIDEPRESSANTS

AMITRIPTYLINE HCL

10mg Tablet

00370991 AMITRIPTYLINE PRO

02248131 DOM-AMITRIPTYLINE DPC

00335053 ELAVIL AAP

02247302 PMS-AMITRIPTYLINE PMS

25mg Tablet

00371009 AMITRIPTYLINE PRO

02248132 DOM-AMITRIPTYLINE DPC

00335061 ELAVIL AAP

02247303 PMS-AMITRIPTYLINE PMS

50mg Tablet

00456349 AMITRIPTYLINE PDL

02248133 DOM-AMITRIPTYLINE DPC

00335088 ELAVIL AAP

00271152 LEVATE VAE

02247304 PMS-AMITRIPTYLINE PMS

75mg Tablet

00754129 ELAVIL AAP

00405612 LEVATE VAE

BUPROPION HCL (WELLBUTRIN)

Limited use benefit with quantity and frequency limits (prior approval is not required).

Coverage of Wellbutrin XL and Bupropion SR is limited to 300 mg per day. (Note: this product will not be approved for coverage for smoking cessation).

100mg Sustained Release Tablet

02331616 BUPROPION SR PDL

02325373 PMS-BUPROPION SR PMS

02285657 RATIO-BUPROPION RPH

02275074 SANDOZ-BUPROPION SR SDZ

150mg Sustained Release Tablet

02325357 BUPROPION SR PDL

02313421 PMS-BUPROPION SR PMS

02285665 RATIO-BUPROPION RPH

02275082 SANDOZ-BUPROPION SR SDZ

02237825 WELLBUTRIN SR VAE

02275090 WELLBUTRIN XL VAE

300mg Sustained Release Tablet

02275104 WELLBUTRIN XL VAE

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

02238441 ZYBAN VAE

CITALOPRAM

10MG Tablet

02355248 ACCEL-CITALOPRAM ACP

02301822 CITALOPRAM MEL

02325047 CITALOPRAM PDL

02371871 MAR-CITALOPRAM MAR

02370077 MINT-CITALOPRAM MIN

02273543 PHL-CITALOPRAM PHH

02270609 PMS-CITALOPRAM PMS

02303256 RIVA-CITALOPRAM RIV

02312336 TEVA-CITALOPRAM TEV

20mg Tablet

02355256 ACCEL-CITALOPRAM ACP

02246056 APO-CITALOPRAM APX

02239607 CELEXA LUD

02257513 CITALOPRAM PDL

02301830 CITALOPRAM MEL

02306239 CITALOPRAM ODN

02353660 CITALOPRAM SAN

02248050 CO CITALOPRAM COB

02248942 DOM-CITALOPRAM DPC

02313405 JAMP-CITALOPRAM JMP

02371898 MAR-CITALOPRAM MAR

02304686 MINT-CITALOPRAM MIN

02246594 MYLAN-CITALOPRAM MYL

02248996 NU-CITALOPRAM NXP

02248944 PHL-CITALOPRAM PHH

02248010 PMS-CITALOPRAM PMS

02285622 RAN-CITALO RBY

02252112 RATIO-CITALOPRAM RPH

02249278 RIVA-CITALOPRAM RIV

02303264 RIVA-CITALOPRAM RIV

02248170 SANDOZ-CITALOPRAM SDZ

02293218 TEVA-CITALOPRAM TEV

30mg Tablet

02296152 CTP 30 ORY

40mg Tablet

02355264 ACCEL-CITALOPRAM ACP

02246057 APO-CITALOPRAM APX

02239608 CELEXA LUD

02257521 CITALOPRAM PDL

02301849 CITALOPRAM MEL

02306247 CITALOPRAM ODN

02353679 CITALOPRAM SAN

02248051 CO CITALOPRAM COB

02248943 DOM-CITALOPRAM DPC

02313413 JAMP-CITALOPRAM JMP

02371901 MAR-CITALOPRAM MAR

02304694 MINT-CITALOPRAM MIN

02246595 MYLAN-CITALOPRAM MYL

02248997 NU-CITALOPRAM NXP

02248945 PHL-CITALOPRAM PHH

02248011 PMS-CITALOPRAM PMS

02285630 RAN-CITALO RBY

02252120 RATIO-CITALOPRAM RPH

02249286 RIVA-CITALOPRAM RIV

02303272 RIVA-CITALOPRAM RIV

02248171 SANDOZ-CITALOPRAM SDZ

02293226 TEVA-CITALOPRAM TEV

CLOMIPRAMINE HCL

10mg Tablet

00330566 ANAFRANIL ORY

02040786 APO-CLOMIPRAMINE APX

02244816 CO CLOMIPRAMINE COB

02230256 TEVA-CLOPAMINE TEV

25mg Tablet

00324019 ANAFRANIL ORY

02040778 APO-CLOMIPRAMINE APX

02244817 CO CLOMIPRAMINE COB

02130165 TEVA-CLOPAMINE TEV

50mg Tablet

00402591 ANAFRANIL ORY

02040751 APO-CLOMIPRAMINE APX

02244818 CO CLOMIPRAMINE COB

02130173 TEVA-CLOPAMINE TEV

DESIPRAMINE HCL

10mg Tablet

02216248 APO-DESIPRAMINE APX

02211939 NU-DESIPRAMINE NXP

02223341 TEVA-DESIPRAMINE TEV

25mg Tablet

02216256 APO-DESIPRAMINE APX

02130092 DOM-DESIPRAMINE DPC

02211947 NU-DESIPRAMINE NXP

02223325 TEVA-DESIPRAMINE TEV

50mg Tablet

02216264 APO-DESIPRAMINE APX

02130106 DOM-DESIPRAMINE DPC

02211955 NU-DESIPRAMINE NXP

01946277 PMS-DESIPRAMINE PMS

02223333 TEVA-DESIPRAMINE TEV

75mg Tablet

02216272 APO-DESIPRAMINE APX

02211963 NU-DESIPRAMINE NXP

01946242 PMS-DESIPRAMINE PMS

02223368 TEVA-DESIPRAMINE TEV

100mg Tablet

02216280 APO-DESIPRAMINE APX

02211971 NU-DESIPRAMINE NXP

DOXEPIN HCL

10mg Capsule

02049996 APO-DOXEPIN APX

00024325 SINEQUAN ERF

25mg Capsule

02050005 APO-DOXEPIN APX

01913425 NOVO-DOXEPIN TEV

00024333 SINEQUAN ERF

50mg Capsule

02050013 APO-DOXEPIN APX

01913433 NOVO-DOXEPIN TEV

00024341 SINEQUAN ERF

75mg Capsule

02050021 APO-DOXEPIN APX

01913441 NOVO-DOXEPIN TEV

00400750 SINEQUAN ERF

100mg Capsule

02050048 APO-DOXEPIN APX

01913468 NOVO-DOXEPIN TEV

00326925 SINEQUAN ERF

150mg Capsule

01913476 NOVO-DOXEPIN TEV

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

02301482 CYMBALTA LIL

60mg Sustained Release Capsule

02301490 CYMBALTA LIL

28:16.04 ANTIDEPRESSANTS

FLUOXETINE HCL

10mg Capsule

02216353 APO-FLUOXETINE APX

02242177 CO-FLUOXETINE SCN

02177617 DOM-FLUOXETINE DPC

02286068 FLUOXETINE SAN

02237813 MYLAN-FLUOXETINE MYL

02216582 NOVO-FLUOXETINE TEV

02192756 NU-FLUOXETINE NXP

02223481 PHL-FLUOXETINE PHH

02177579 PMS-FLUOXETINE PMS

02314991 PRO-FLUOXETINE PDL

02018985 PROZAC LIL

02241371 RATIO-FLUOXETINE RPH

02242123 RIVA-FLUOXETINE RIV

02243486 SANDOZ-FLUOXETINE SDZ

02302659 ZYM-FLUOXETINE ZYM

20mg Capsule

02216361 APO-FLUOXETINE APX

02242178 CO-FLUOXETINE SCN

02177625 DOM-FLUOXETINE DPC

02286076 FLUOXETINE SAN

02237814 MYLAN-FLUOXETINE MYL

02216590 NOVO-FLUOXETINE TEV

02192764 NU-FLUOXETINE NXP

02223503 PHL-FLUOXETINE PHH

02177587 PMS-FLUOXETINE PMS

02315009 PRO-FLUOXETINE PDL

00636622 PROZAC LIL

02241374 RATIO-FLUOXETINE RPH

02242124 RIVA-FLUOXETINE RIV

02243487 SANDOZ-FLUOXETINE SDZ

02302667 ZYM-FLUOXETINE ZYM

4mg/mL Liquid

02231328 APO-FLUOXETINE APX

FLUVOXAMINE MALEATE

50mg Tablet

02231329 APO-FLUVOXAMINE APX

02255529 CO FLUVOXAMINE COB

02241347 DOM-FLUVOXAMINE DPC

02236753 FLUVOXAMINE PDL

01919342 LUVOX ABB

02239953 NOVO-FLUVOXAMINE TEV

02231192 NU-FLUVOXAMINE NXP

02240682 PMS-FLUVOXAMINE PMS

02218453 RATIO-FLUVOXAMINE RPH

02303345 RIVA-FLUVOX RIV

02247054 SANDOZ-FLUVOXAMINE SDZ

100mg Tablet

02231330 APO-FLUVOXAMINE APX

02255537 CO FLUVOXAMINE COB

02241348 DOM-FLUVOXAMINE DPC

02236754 FLUVOXAMINE PDL

01919369 LUVOX ABB

02239954 NOVO-FLUVOXAMINE TEV

02231193 NU-FLUVOXAMINE NXP

02240683 PMS-FLUVOXAMINE PMS

02218461 RATIO-FLUVOXAMINE RPH

02303361 RIVA-FLUVOX RIV

02247055 SANDOZ-FLUVOXAMINE SDZ

IMIPRAMINE HCL

10mg Tablet

00360201 IMIPRAMINE AAP

00021504 NOVO-PRAMINE TEV

25mg Tablet

00312797 IMIPRAMINE AAP

50mg Tablet

00326852 IMIPRAMINE AAP

00021520 NOVO-PRAMINE TEV

75mg Tablet

00644579 IMIPRAMINE AAP

MAPROTILINE HCL

25mg Tablet

02158612 NOVO-MAPROTILINE TEV

50mg Tablet

02158620 NOVO-MAPROTILINE TEV

75mg Tablet

02158639 NOVO-MAPROTILINE TEV

MIRTAZAPINE

15mg Orally Disintegrating Tablet

02299801 AURO-MIRTAZAPINE OD AUR

02279894 NOVO-MIRTAZAPINE OD TEV

02248542 REMERON RD FRS

30mg Orally Disintegrating Tablet

02299828 AURO-MIRTAZAPINE OD AUR

02279908 NOVO-MIRTAZAPINE OD TEV

02248543 REMERON RD FRS

45mg Orally Disintegrating Tablet

02299836 AURO-MIRTAZAPINE OD AUR

02279916 NOVO-MIRTAZAPINE OD TEV

02248544 REMERON RD FRS

15mg Tablet

02286610 APO-MIRTAZAPINE APX

02281732 MIRTAZAPINE MEL

02256096 MYLAN-MIRTAZAPINE MYL

02273942 PMS-MIRTAZAPINE PMS

02312778 PRO-MIRTAZAPINE PDL

02250594 SANDOZ-MIRTAZAPINE SDZ

02325179 ZYM-MIRTAZAPINE ZYM

30mg Tablet

02286629 APO-MIRTAZAPINE APX

02274361 CO MIRTAZAPINE COB

02252287 DOM-MIRTAZAPINE DPC

02252279 MIRTAZAPINE MEL

02370689 MIRTAZAPINE SAN

02256118 MYLAN-MIRTAZAPINE MYL

02259354 NOVO-MIRTAZAPINE TEV

02248762 PMS-MIRTAZAPINE PMS

02312786 PRO-MIRTAZAPINE PDL

02270927 RATIO-MIRTAZAPINE RPH

02243910 REMERON FRS

02265265 RIVA-MIRTAZAPINE RIV

02250608 SANDOZ-MIRTAZAPINE SDZ

02325187 ZYM-MIRTAZAPINE ZYM

45mg Tablet

02286637 APO-MIRTAZAPINE APX

02256126 MYLAN-MIRTAZAPINE MYL

MOCLOBEMIDE

100mg Tablet

02232148 APO-MOCLOBEMIDE APX

02239746 NOVO-MOCLOBEMIDE TEV

02237111 NU-MOCLOBEMIDE NXP

150mg Tablet

02232150 APO-MOCLOBEMIDE APX

00899356 MANERIX MAB

02239747 NOVO-MOCLOBEMIDE TEV

02237112 NU-MOCLOBEMIDE NXP

02243218 PMS-MOCLOBEMIDE PMS

300mg Tablet

02240456 APO-MOCLOBEMIDE APX

02166747 MANERIX MAB

02239748 NOVO-MOCLOBEMIDE TEV

02243219 PMS-MOCLOBEMIDE PMS

NORTRIPTYLINE HCL

10mg Capsule

02223511 APO-NORTRIPTYLINE APX

00015229 AVENTYL PHH

02178729 DOM-NORTRIPTYLINE DPC

02231781 NOVO-NORTRIPTYLINE TEV

02223139 NU-NORTRIPTYLINE NXP

02177692 PMS-NORTRIPTYLINE PMS

25mg Capsule

02223538 APO-NORTRIPTYLINE APX

00015237 AVENTYL PHH

02178737 DOM-NORTRIPTYLINE DPC

02231782 NOVO-NORTRIPTYLINE TEV

02223147 NU-NORTRIPTYLINE NXP

02177706 PMS-NORTRIPTYLINE PMS

PAROXETINE HCL

10mg Tablet

02240907 APO-PAROXETINE APX

02262746 CO PAROXETINE COB

02248447 DOM-PAROXETINE DPC

02248012 MYLAN-PAROXETINE MYL

02248556 NOVO-PAROXETINE TEV

02248719 NU-PAROXETINE NXP

02248450 PAROXETINE MEL

02248913 PAROXETINE PDL

02282844 PAROXETINE SAN

02302012 PAROXETINE SOR

02027887 PAXIL GSK

02247750 PMS-PAROXETINE PMS

02247810 RATIO-PAROXETINE RPH

02248559 RIVA-PAROXETINE RIV

02269422 SANDOZ-PAROXETINE SDZ

20mg Tablet

02240908 APO-PAROXETINE APX

02262754 CO PAROXETINE COB

02248448 DOM-PAROXETINE DPC

02248013 MYLAN-PAROXETINE MYL

02248557 NOVO-PAROXETINE TEV

02248720 NU-PAROXETINE NXP

02248451 PAROXETINE MEL

02248914 PAROXETINE PDL

02282852 PAROXETINE SAN

02302020 PAROXETINE SOR

01940481 PAXIL GSK

02247751 PMS-PAROXETINE PMS

02247811 RATIO-PAROXETINE RPH

02248560 RIVA-PAROXETINE RIV

02254751 SANDOZ-PAROXETINE SDZ

02269430 SANDOZ-PAROXETINE SDZ

30mg Tablet

02240909 APO-PAROXETINE APX

02262762 CO PAROXETINE COB

02248449 DOM-PAROXETINE DPC

02248014 MYLAN-PAROXETINE MYL

02248558 NOVO-PAROXETINE TEV

02248721 NU-PAROXETINE NXP

02248452 PAROXETINE MEL

02248915 PAROXETINE PDL

02282860 PAROXETINE SAN

02302039 PAROXETINE SOR

01940473 PAXIL GSK

02247752 PMS-PAROXETINE PMS

02247812 RATIO-PAROXETINE RPH

02248561 RIVA-PAROXETINE RIV

02254778 SANDOZ-PAROXETINE SDZ

02269449 SANDOZ-PAROXETINE SDZ

40mg Tablet

02293749 PMS-PAROXETINE PMS

PHENELZINE SULFATE

15mg Tablet

00476552 NARDIL PFI

SERTRALINE

25mg Capsule

02238280 APO-SERTRALINE APX

02287390 CO SERTRALINE COB

02245748 DOM-SERTRALINE DPC

02242519 MYLAN-SERTRALINE MYL

02240485 NOVO-SERTRALINE TEV

02247047 NU-SERTRALINE NXP

02245824 PHL-SERTRALINE PHH

02244838 PMS-SERTRALINE PMS

02248496 RIVA-SERTRALINE RIV

02245159 SANDOZ-SERTRALINE SDZ

02303779 SERTRALINE MEL

02353520 SERTRALINE SAN

02241302 SERTRALINE-25 PDL

02132702 ZOLOFT PFI

50mg Capsule

02238281 APO-SERTRALINE APX

02287404 CO SERTRALINE COB

02245749 DOM-SERTRALINE DPC

02242520 MYLAN-SERTRALINE MYL

02240484 NOVO-SERTRALINE TEV

02247048 NU-SERTRALINE NXP

02245825 PHL-SERTRALINE PHH

02244839 PMS-SERTRALINE PMS

02248497 RIVA-SERTRALINE RIV

02245160 SANDOZ-SERTRALINE SDZ

02303809 SERTRALINE MEL

02353539 SERTRALINE SAN

02241303 SERTRALINE-50 PDL

01962817 ZOLOFT PFI

100mg Capsule

02238282 APO-SERTRALINE APX

02287412 CO SERTRALINE COB

02245750 DOM-SERTRALINE DPC

02242521 MYLAN-SERTRALINE MYL

02240481 NOVO-SERTRALINE TEV

02247050 NU-SERTRALINE NXP

02245826 PHL-SERTRALINE PHH

02244840 PMS-SERTRALINE PMS

02248498 RIVA-SERTRALINE RIV

02245161 SANDOZ-SERTRALINE SDZ

02303817 SERTRALINE MEL

02353547 SERTRALINE SAN

02241304 SERTRALINE-100 PDL

01962779 ZOLOFT PFI

TRANYLCYPROMINE SULFATE

10mg Tablet

01919598 PARNATE GSK

TRAZODONE HCL

50mg Tablet

02147637 APO-TRAZODONE APX

02128950 DOM-TRAZODONE DPC

02231683 MYLAN-TRAZODONE MYL

02144263 NOVO-TRAZODONE TEV

02165384 NU-TRAZODONE NXP

02236941 PHL-TRAZODONE PHH

01937227 PMS-TRAZODONE PMS

02164353 TRAZODONE PDL

02348772 TRAZODONE SAN

02230284 TRAZOREL VAE

75mg Tablet

02237339 PMS-TRAZODONE PMS

100mg Tablet

02147645 APO-TRAZODONE APX

02128969 DOM-TRAZODONE DPC

02231684 MYLAN-TRAZODONE MYL

02144271 NOVO-TRAZODONE TEV

02165392 NU-TRAZODONE NXP

02236942 PHL-TRAZODONE PHH

01937235 PMS-TRAZODONE PMS

02164361 TRAZODONE PDL

02348780 TRAZODONE SAN

02230285 TRAZOREL VAE

150mg Tablet

02147653 APO-TRAZODONE D APX

02144298 NOVO-TRAZODONE TEV

02165406 NU-TRAZODONE D NXP

02164388 TRAZODONE PDL

02348799 TRAZODONE SAN

TRIMIPRAMINE MALEATE

75mg Capsule

02070987 TRIMIPRAMINE AAP

12.5mg Tablet

02020599 NU-TRIMIPRAMINE NXP

00740799 TRIMIPRAMINE AAP

25mg Tablet

01940430 NOVO-TRIPRAMINE TEV

02020602 NU-TRIMIPRAMINE NXP

00740802 TRIMIPRAMINE AAP

50mg Tablet

01940449 NOVO-TRIPRAMINE TEV

02020610 NU-TRIMIPRAMINE NXP

00740810 TRIMIPRAMINE AAP

100mg Tablet

01940457 NOVO-TRIPRAMINE TEV

02020629 NU-TRIMIPRAMINE NXP

00740829 TRIMIPRAMINE AAP

VENLAFAXINE HCL

37.5mg Sustained Release Capsule

02331683 APO-VENLAFAXINE XR APX

02304317 CO VENLAFAXINE XR COB

02237279 EFFEXOR XR WAY

02310279 MYLAN-VENLAFAXINE XR MYL

02275023 NOVO-VENLAFAXINE XR TEV

02278545 PMS-VENLAFAXINE XR PMS

02273969 RATIO-VENLAFAXINE XR RPH

02307774 RIVA-VENLAFAXINE XR RIV

02310317 SANDOZ VENLAFAXINE XR SDZ

02339242 VENLAFAXINE XR PDL

02354713 VENLAFAXINE XR SAN

75mg Sustained Release Capsule

02331691 APO-VENLAFAXINE XR APX

02304325 CO VENLAFAXINE XR COB

02237280 EFFEXOR XR WAY

02310287 MYLAN-VENLAFAXINE XR MYL

02275031 NOVO-VENLAFAXINE XR TEV

02278553 PMS-VENLAFAXINE XR PMS

02273977 RATIO-VENLAFAXINE SR RPH

02307782 RIVA-VENLAFAXINE XR RIV

02310325 SANDOZ VENLAFAXINE XR SDZ

02339250 VENLAFAXINE XR PDL

02354721 VENLAFAXINE XR SAN

150mg Sustained Release Capsule

02331705 APO-VENLAFAXINE XR APX

02304333 CO VENLAFAXINE XR COB

02237282 EFFEXOR XR WAY

02310295 MYLAN-VENLAFAXINE XR MYL

02275058 NOVO-VENLAFAXINE XR TEV

02278561 PMS-VENLAFAXINE XR PMS

02273985 RATIO-VENLAFAXINE XR RPH

02307790 RIVA-VENLAFAXINE XR RIV

02310333 SANDOZ VENLAFAXINE XR SDZ

02339269 VENLAFAXINE XR PDL

02354748 VENLAFAXINE XR SAN

28:16.08 ANTIPSYCHOTIC AGENTS

ARIPIPRAZOLE

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

2mg Tablet

02322374 ABILIFY BMS

5mg Tablet

02322382 ABILIFY BMS

10mg Tablet

02322390 ABILIFY BMS

15mg Tablet

02322404 ABILIFY BMS

20mg Tablet

02322412 ABILIFY BMS

30mg Tablet

02322455 ABILIFY BMS

CHLORPROMAZINE

25mg/mL Injection

00743518 CHLORPROMAZINE HCL SDZ

25mg Tablet

00232823 TEVA-CHLORPROMAZINE TEV

50mg Tablet

00232807 TEVA-CHLORPROMAZINE TEV

100mg Tablet

00232831 TEVA-CHLORPROMAZINE TEV

CLOZAPINE

25mg Tablet

02248034 APO-CLOZAPINE APX

00894737 CLOZARIL NVR

02247243 GEN-CLOZAPINE MYL

50mg Tablet

02305003 GEN-CLOZAPINE MYL

100mg Tablet

02248035 APO-CLOZAPINE APX

00894745 CLOZARIL NVR

02247244 GEN-CLOZAPINE MYL

200mg Tablet

02305011 GEN-CLOZAPINE MYL

FLUPENTHIXOL DECANOATE

20mg/mL Injection

02156032 FLUANXOL DEPOT LUD

100mg/mL Injection

02156040 FLUANXOL DEPOT LUD

FLUPENTHIXOL DIHYDROCHLORIDE

0.5mg Tablet

02156008 FLUANXOL LUD

3mg Tablet

02156016 FLUANXOL LUD

FLUPHENAZINE DECANOATE

25mg/mL Injection

02239636 FLUPHENAZINE OMEGA OMG

02091275 PMS-FLUPHENAZINE PMS

100mg/mL Injection

02242570 FLUPHENAZINE OMEGA OMG

00755575 MODECATE BMS

02241928 PMS-FLUPHENAZINE PMS

FLUPHENAZINE HCL

1mg Tablet

00405345 APO-FLUPHENAZINE APX

2mg Tablet

00410632 APO-FLUPHENAZINE APX

5mg Tablet

00405361 APO-FLUPHENAZINE APX

HALOPERIDOL

5mg/mL Injection

00808652 HALOPERIDOL SDZ

2mg/mL Solution

00759503 PMS-HALOPERIDOL PMS

0.5mg Tablet

00396796 APO-HALOPERIDOL APX

00363685 NOVO-PERIDOL TEV

1mg Tablet

00396818 APO-HALOPERIDOL APX

00363677 NOVO-PERIDOL TEV

2mg Tablet

00396826 APO-HALOPERIDOL APX

00363669 NOVO-PERIDOL TEV

5mg Tablet

00396834 APO-HALOPERIDOL APX

00363650 NOVO-PERIDOL TEV

10mg Tablet

00463698 APO-HALOPERIDOL APX

00713449 NOVO-PERIDOL TEV

20mg Tablet

00768820 NOVO-PERIDOL TEV

HALOPERIDOL DECANOATE

50mg/mL Injection

02130297 HALOPERIDOL LA SDZ

02230707 PMS-HALOPERIDOL LA PMS

100mg/mL Injection

02130300 HALOPERIDOL LA SDZ

02239640 HALOPERIDOL LA OMG

02230708 PMS-HALOPERIDOL LA PMS

LOXAPINE HCL

25mg/mL Oral Liquid

02239101 XYLAC MMT

LOXAPINE SUCCINATE

2.5mg Tablet

02242868 XYLAC MMT

5mg Tablet

02239918 DOM-LOXAPINE DPC

02237534 NU-LOXAPINE NXP

02236943 PHL-LOXAPINE PHH

02230837 XYLAC MMT

10mg Tablet

02239919 DOM-LOXAPINE DPC

02237535 NU-LOXAPINE NXP

02236944 PHL-LOXAPINE PHH

02230838 XYLAC MMT

25mg Tablet

02239920 DOM-LOXAPINE DPC

02237536 NU-LOXAPINE NXP

02236945 PHL-LOXAPINE PHH

02230839 XYLAC MMT

50mg Tablet

02239921 DOM-LOXAPINE DPC

02237537 NU-LOXAPINE NXP

02236946 PHL-LOXAPINE PHH

02230840 XYLAC MMT

METHOTRIMEPRAZINE

2mg Tablet

02238403 APO-METHOPRAZINE APX

5mg Tablet

02238404 APO-METHOPRAZINE APX

02232903 PMS-METHOTRIMEPRAZINE PMS

25mg Tablet

02238405 APO-METHOPRAZINE APX

01964925 NOVO-MEPRAZINE TEV

50mg Tablet

02238406 APO-METHOPRAZINE APX

OLANZAPINE

5mg Orally Disintegrating Tablet

02360616 APO-OLANZAPINE ODT APX

02327562 CO OLANZAPINE ODT COB

02321343 NOVO-OLANZAPINE ODT TEV

02338645 OLANZAPINE ODT PDL

02352974 OLANZAPINE ODT SAN

02303191 PMS-OLANZAPINE ODT PMS

02327775 SANDOZ OLANZAPINE ODT SDZ

02243086 ZYPREXA ZYDIS LIL

10mg Orally Disintegrating Tablet

02360624 APO-OLANZAPINE ODT APX

02327570 CO OLANZAPINE ODT COB

02321351 NOVO-OLANZAPINE ODT TEV

02338653 OLANZAPINE ODT PDL

02352982 OLANZAPINE ODT SAN

02303205 PMS-OLANZAPINE ODT PMS

02327783 SANDOZ OLANZAPINE ODT SDZ

02243087 ZYPREXA ZYDIS LIL

15mg Orally Disintegrating Tablet

02360632 APO-OLANZAPINE ODT APX

02327589 CO OLANZAPINE ODT COB

02321378 NOVO-OLANZAPINE ODT TEV

02338661 OLANZAPINE ODT PDL

02352990 OLANZAPINE ODT SAN

02303213 PMS-OLANZAPINE ODT PMS

02327791 SANDOZ OLANZAPINE ODT SDZ

02243088 ZYPREXA ZYDIS LIL

2.5mg Tablet

02281791 APO-OLANZAPINE APX

02325659 CO OLANZAPINE COB

02337878 MYLAN-OLANZAPINE MYL

02276712 NOVO-OLANZAPINE TEV

02311968 OLANZAPINE PDL

02372819 OLANZAPINE SAN

02303116 PMS-OLANZAPINE PMS

02337126 RIVA-OLANZAPINE RIV

02310341 SANDOZ-OLANZAPINE PDL

02229250 ZYPREXA LIL

5mg Tablet

02281805 APO-OLANZAPINE APX

02325667 CO OLANZAPINE COB

02337886 MYLAN-OLANZAPINE MYL

02276720 NOVO-OLANZAPINE TEV

02311976 OLANZAPINE PDL

02372827 OLANZAPINE SAN

02303159 PMS-OLANZAPINE PMS

02337134 RIVA-OLANZAPINE RIV

02310368 SANDOZ-OLANZAPINE PDL

02229269 ZYPREXA LIL

7.5mg Tablet

02281813 APO-OLANZAPINE APX

02325675 CO OLANZAPINE COB

02337894 MYLAN-OLANZAPINE MYL

02276739 NOVO-OLANZAPINE TEV

02311984 OLANZAPINE PDL

02372835 OLANZAPINE SAN

02303167 PMS-OLANZAPINE PMS

02337142 RIVA-OLANZAPINE RIV

02310376 SANDOZ-OLANZAPINE PDL

02229277 ZYPREXA LIL

10mg Tablet

02281821 APO-OLANZAPINE APX

02325683 CO OLANZAPINE COB

02337908 MYLAN-OLANZAPINE MYL

02276747 NOVO-OLANZAPINE TEV

02311992 OLANZAPINE PDL

02372843 OLANZAPINE SAN

02303175 PMS-OLANZAPINE PMS

02337150 RIVA-OLANZAPINE RIV

02310384 SANDOZ-OLANZAPINE PDL

02229285 ZYPREXA LIL

15mg Tablet

02281848 APO-OLANZAPINE APX

02325691 CO OLANZAPINE COB

02337916 MYLAN-OLANZAPINE MYL

02276755 NOVO-OLANZAPINE TEV

02312018 OLANZAPINE PDL

02372851 OLANZAPINE SAN

02303183 PMS-OLANZAPINE PMS

02337169 RIVA-OLANZAPINE RIV

02310392 SANDOZ-OLANZAPINE PDL

02238850 ZYPREXA LIL

PERICYAZINE

5mg Capsule

01926780 NEULEPTIL ERF

10mg Capsule

01926772 NEULEPTIL ERF

20mg Capsule

01926764 NEULEPTIL ERF

10mg/mL Drop

01926756 NEULEPTIL ERF

PERPHENAZINE

3.2mg/mL Liquid

00751898 PMS-PERPHENAZINE PMS

2mg Tablet

00335134 APO-PERPHENAZINE APX

4mg Tablet

00335126 APO-PERPHENAZINE APX

8mg Tablet

00335118 APO-PERPHENAZINE APX

16mg Tablet

00335096 APO-PERPHENAZINE APX

PIMOZIDE

2mg Tablet

02245432 APO-PIMOZIDE APX

00313815 ORAP PHH

4mg Tablet

02245433 APO-PIMOZIDE APX

00313823 ORAP PHH

PIPOTIAZINE PALMITATE

25mg/mL Injection

01926667 PIPORTIL L4 SAC

PROCHLORPERAZINE

5mg/mL Injection

00789747 PROCHLORPERAZINE SDZ

10mg Suppository

00753688 PMS-PROCHLORPERAZINE PMS

00789720 PROCHLORPERAZINE SDZ

5mg Tablet

00886440 APO-PROCHLORAZINE APX

01964399 NU-PROCHLOR NXP

00753661 PMS-PROCHLORPERAZINE PMS

10mg Tablet

00886432 APO-PROCHLORAZINE APX

01964402 NU-PROCHLOR NXP

00753637 PMS-PROCHLORPERAZINE PMS

QUETIAPINE FUMARATE

25mg Tablet

02313901 APO-QUETIAPINE APX

02316080 CO QUETIAPINE COB

02298996 DOM-QUETIAPINE DPC

02330415 JAMP-QUETIAPINE JMP

02307804 MYLAN-QUETIAPINE MYL

02284235 NOVO-QUETIAPINE TEV

02299054 PHL-QUETIAPINE PHH

02296551 PMS-QUETIAPINE PMS

02317346 PRO-QUETIAPINE PDL

02317893 QUETIAPINE MEL

02353164 QUETIAPINE SAN

02311704 RATIO-QUETIAPINE RPH

02316692 RIVA-QUETIAPINE RIV

02313995 SANDOZ-QUETIAPINE SDZ

02236951 SEROQUEL AZC

50mg Tablet

02361892 PMS-QUETIAPINE VTH

100mg Tablet

02313928 APO-QUETIAPINE APX

02316099 CO QUETIAPINE COB

02299003 DOM-QUETIAPINE DPC

02330423 JAMP-QUETIAPINE JMP

02307812 MYLAN-QUETIAPINE MYL

02284243 NOVO-QUETIAPINE TEV

02299062 PHL-QUETIAPINE PHH

02296578 PMS-QUETIAPINE PMS

02317354 PRO-QUETIAPINE PDL

02317907 QUETIAPINE MEL

02353172 QUETIAPINE SAN

02311712 RATIO-QUETIAPINE RPH

02316706 RIVA-QUETIAPINE RIV

02314002 SANDOZ-QUETIAPINE SDZ

02236952 SEROQUEL AZC

150mg Tablet

02284251 NOVO-QUETIAPINE TEV

200mg Tablet

02313936 APO-QUETIAPINE APX

02316110 CO QUETIAPINE COB

02299038 DOM-QUETIAPINE DPC

02330458 JAMP-QUETIAPINE JMP

02307839 MYLAN-QUETIAPINE MYL

02284278 NOVO-QUETIAPINE TEV

02299089 PHL-QUETIAPINE PHH

02296594 PMS-QUETIAPINE PMS

02317362 PRO-QUETIAPINE PDL

02317923 QUETIAPINE MEL

02353199 QUETIAPINE SAN

02311747 RATIO-QUETIAPINE RPH

02316722 RIVA-QUETIAPINE RIV

02314010 SANDOZ-QUETIAPINE SDZ

02236953 SEROQUEL AZC

300mg Tablet

02313944 APO-QUETIAPINE APX

02316129 CO QUETIAPINE COB

02299046 DOM-QUETIAPINE DPC

02330466 JAMP-QUETIAPINE JMP

02307847 MYLAN-QUETIAPINE MYL

02284286 NOVO-QUETIAPINE TEV

02299097 PHL-QUETIAPINE PHH

02296608 PMS-QUETIAPINE PMS

02317370 PRO-QUETIAPINE PDL

02317931 QUETIAPINE MEL

02353202 QUETIAPINE SAN

02316730 RIVA-QUETIAPINE RIV

02314029 SANDOZ-QUETIAPINE SDZ

02244107 SEROQUEL AZC

RISPERIDONE

0.5mg Orally Disintegrating Tablet

02247704 RISPERDAL-M JNO

1mg Orally Disintegrating Tablet

02291789 PMS-RISPERIDONE ODT PMS

02247705 RISPERDAL-M JNO

2mg Orally Disintegrating Tablet

02291797 PMS-RISPERIDONE ODT PMS

02247706 RISPERDAL-M JNO

3mg Orally Disintegrating Tablet

02268086 RISPERDAL-M JNO

4mg Orally Disintegrating Tablet

02268094 RISPERDAL-M JNO

1mg/mL Solution

02280396 APO-RISPERIDONE APX

02279266 PMS-RISPERIDONE PMS

02236950 RISPERDAL JNO

0.25mg Tablet

02371766 MAR-RISPERIDONE MAR

0.25mg Tablet

02282119 APO-RISPERIDONE APX

02282585 CO RISPERIDONE COB

02359790 MINT-RISPERIDONE MIN

02282240 MYLAN-RISPERIDONE MYL

02282690 NOVO-RISPERIDONE TEV

02258439 PHL-RISPERIDONE PHH

02252007 PMS-RISPERIDONE PMS

02312700 PRO-RISPERIDONE PDL

02280906 RAN-RISPERIDONE RBY

02264757 RATIO-RISPERIDONE RPH

02328305 RBX-RISPERIDONE RBY

02240551 RISPERDAL JNO

02303485 RISPERIDONE MEL

02356880 RISPERIDONE SAN

02283565 RIVA-RISPERIDONE RIV

02303655 SANDOZ RISPERIDONE SDZ

0.5mg Tablet

02282127 APO-RISPERIDONE APX

02282593 CO RISPERIDONE COB

02278448 DOM-RISPERIDONE DPC

02371774 MAR-RISPERIDONE MAR

02359804 MINT-RISPERIDONE MIN

02282259 MYLAN-RISPERIDONE MYL

02264188 NOVO-RISPERIDONE TEV

02258447 PHL-RISPERIDONE PHH

02252015 PMS-RISPERIDONE PMS

02312719 PRO-RISPERIDONE PDL

02280914 RAN-RISPERIDONE RBY

02264765 RATIO-RISPERIDONE RPH

02328313 RBX-RISPERIDONE RBY

02240552 RISPERDAL JNO

02303493 RISPERIDONE MEL

02356899 RISPERIDONE SAN

02283573 RIVA-RISPERIDONE RIV

02303663 SANDOZ RISPERIDONE SDZ

1mg Tablet

02282135 APO-RISPERIDONE APX

02282607 CO RISPERIDONE COB

02278456 DOM-RISPERIDONE DPC

02371782 MAR-RISPERIDONE MAR

02359812 MINT-RISPERIDONE MIN

02282267 MYLAN-RISPERIDONE MYL

02264196 NOVO-RISPERIDONE TEV

02258455 PHL-RISPERIDONE PHH

02252023 PMS-RISPERIDONE PMS

02312727 PRO-RISPERIDONE PDL

02280922 RAN-RISPERIDONE RBY

02264773 RATIO-RISPERIDONE RPH

02328321 RBX-RISPERIDONE RBY

02025280 RISPERDAL JNO

02303507 RISPERIDONE MEL

02356902 RISPERIDONE SAN

02283581 RIVA-RISPERIDONE RIV

02279800 SANDOZ-RISPERIDONE SDZ

2mg Tablet

02282143 APO-RISPERIDONE APX

02282615 CO RISPERIDONE COB

02278464 DOM-RISPERIDONE DPC

02371790 MAR-RISPERIDONE MAR

02359820 MINT-RISPERIDONE MIN

02282275 MYLAN-RISPERIDONE MYL

02264218 NOVO-RISPERIDONE TEV

02258463 PHL-RISPERIDONE PHH

02252031 PMS-RISPERIDONE PMS

02312735 PRO-RISPERIDONE PDL

02280930 RAN-RISPERIDONE RBY

02264781 RATIO-RISPERIDONE RPH

02328348 RBX-RISPERIDONE RBY

02025299 RISPERDAL JNO

02303515 RISPERIDONE MEL

02356910 RISPERIDONE SAN

02283603 RIVA-RISPERIDONE RIV

02279819 SANDOZ-RISPERIDONE SDZ

3mg Tablet

02282151 APO-RISPERIDONE APX

02282623 CO RISPERIDONE COB

02278472 DOM-RISPERIDONE DPC

02371804 MAR-RISPERIDONE MAR

02359839 MINT-RISPERIDONE MIN

02282283 MYLAN-RISPERIDONE MYL

02264226 NOVO-RISPERIDONE TEV

02258471 PHL-RISPERIDONE PHH

02252058 PMS-RISPERIDONE PMS

02312743 PRO-RISPERIDONE PDL

02280949 RAN-RISPERIDONE RBY

02264803 RATIO-RISPERIDONE RPH

02328364 RBX-RISPERIDONE RBY

02025302 RISPERDAL JNO

02303523 RISPERIDONE MEL

02356929 RISPERIDONE SAN

02283611 RIVA-RISPERIDONE RIV

02279827 SANDOZ-RISPERIDONE SDZ

4mg Tablet

02282178 APO-RISPERIDONE APX

02282631 CO RISPERIDONE COB

02371812 MAR-RISPERIDONE MAR

02359847 MINT-RISPERIDONE MIN

02282291 MYLAN-RISPERIDONE MYL

02264234 NOVO-RISPERIDONE TEV

02258498 PHL-RISPERIDONE PHH

02252066 PMS-RISPERIDONE PMS

02312751 PRO-RISPERIDONE PDL

02280957 RAN-RISPERIDONE RBY

02264811 RATIO-RISPERIDONE RPH

02328372 RBX-RISPERIDONE RBY

02025310 RISPERDAL JNO

02303531 RISPERIDONE MEL

02356937 RISPERIDONE SAN

02283638 RIVA-RISPERIDONE RIV

02279835 SANDOZ-RISPERIDONE SDZ

THIOPROPERAZINE MESYLATE

10mg Tablet

01927639 MAJEPTIL ERF

THIOTHIXENE

2mg Capsule

00024430 NAVANE ERF

5mg Capsule

00024449 NAVANE ERF

10mg Capsule

00024457 NAVANE ERF

TRIFLUOPERAZINE HCL

10mg/mL Liquid

00751871 PMS-TRIFLUOPERAZINE PMS

1mg Tablet

00345539 TRIFLUOPERAZINE AAP

2mg Tablet

00312754 TRIFLUOPERAZINE AAP

5mg Tablet

00312746 TRIFLUOPERAZINE AAP

10mg Tablet

00326836 TRIFLUOPERAZINE AAP

20mg Tablet

00595942 TRIFLUOPERAZINE AAP

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

02298597 ZELDOX PFI

40MG Capsule

02298600 ZELDOX PFI

60mg Capsule

02298619 ZELDOX PFI

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

80mg Capsule

02298627 ZELDOX PFI

28:20.04 AMPHETAMINES

DEXTROAMPHETAMINE SULFATE

10mg Sustained Release Capsule

01924559 DEXEDRINE SPANSULE GSK

15mg Sustained Release Capsule

01924567 DEXEDRINE SPANSULE GSK

5mg Tablet

01924516 DEXEDRINE GSK

28:20.92 MISC ANOREXIGENIC AGENTS & RESPIRATORY & CEREBRAL STIMULANT

METHYLPHENIDATE

20mg Sustained Release Tablet

02266687 APO-METHYLPHENIDATE SR APX

00632775 RITALIN SR NVR

02320312 SANDOZ-METHYLPHENIDATE SR SDZ

5mg Tablet

02273950 APO-METHYLPHENIDATE APX

02326221 METHYLPHENIDATE PDL

02234749 PMS-METHYLPHENIDATE PMS

10mg Tablet

02249324 APO-METHYLPHENIDATE APX

02326248 METHYLPHENIDATE PDL

00584991 PMS-METHYLPHENIDATE PMS

00005606 RITALIN NVR

20mg Tablet

02249332 APO-METHYLPHENIDATE APX

02326256 METHYLPHENIDATE PDL

00585009 PMS-METHYLPHENIDATE PMS

00005614 RITALIN NVR

METHYLPHENIDATE HCL

The limited use benefit (prior approval required) criteria for Concerta^® (and generics) are:

• For the treatment of patients aged 6 to 18 with Attention Deficit Hyperactivity Disorder (ADHD) who demonstrate significant and problematic disruptive behaviour or who have problems with inattention that interferes with learning AND
• For whom the medication is prescribed by, or in consultation with, a specialist in pediatric psychiatry, pediatrics, or a general practitioner with expertise in ADHD, AND
• For whom sustained release methylphenidate (i.e., Ritalin^® SR) or sustained release dextroamphetamine (i.e., Dexedrine Spansules) has not adequately controlled the symptoms of the disorder.

18mg Extended Release Tablet

02247732 CONCERTA JNO

02315068 NOVO-METHYLPHENIDATE TEV

27mg Extended Release Tablet

02250241 CONCERTA JNO

02315076 NOVO-METHYLPHENIDATE TEV

36mg Extended Release Tablet

02247733 CONCERTA JNO

02315084 NOVO-METHYLPHENIDATE TEV

54mg Extended Release Tablet

02330377 APO-METHYLPHENIDATE ER APX

02247734 CONCERTA JNO

02315092 NOVO-METHYLPHENIDATE TEV

MODAFINIL

100mg Tablet

02239665 ALERTEC DPY

02285398 MODAFINIL AAP

28:24.08 ANXIOLYTICS, SEDATIVES AND HYPNOTICS - BENZODIAZEPINES

ALPRAZOLAM

0.25mg Tablet

01908189 ALPRAZOLAM PDL

02349191 ALPRAZOLAM SAN

00865397 APO-ALPRAZ APX

02137534 MYLAN-ALPRAZOLAM MYL

01913239 NU-ALPRAZ NXP

01913484 TEVA-ALPRAZOL TEV

00548359 XANAX PFI

0.5mg Tablet

01908170 ALPRAZOLAM PDL

02349205 ALPRAZOLAM SAN

00865400 APO-ALPRAZ APX

02137542 MYLAN-ALPRAZOLAM MYL

01913247 NU-ALPRAZ NXP

01913492 TEVA-ALPRAZOL TEV

00548367 XANAX PFI

1mg Tablet

02248706 ALPRAZOLAM PDL

02243611 APO-ALPRAZ APX

02229813 MYLAN-ALPRAZOLAM MYL

00723770 XANAX PFI

2mg Tablet

02243612 APO-ALPRAZ APX

02229814 MYLAN-ALPRAZOLAM MYL

00813958 XANAX TS PFI

BROMAZEPAM

1.5mg Tablet

02177153 APO-BROMAZEPAM APX

02171856 NU-BROMAZEPAM NXP

3mg Tablet

02177161 APO-BROMAZEPAM APX

02220520 BROMAZEPAM PDL

00518123 LECTOPAM HLR

02171864 NU-BROMAZEPAM NXP

02230584 TEVA-BROMAZEPAM TEV

6mg Tablet

02177188 APO-BROMAZEPAM APX

02220539 BROMAZEPAM PDL

00518131 LECTOPAM HLR

02171872 NU-BROMAZEPAM NXP

02230585 TEVA-BROMAZEPAM TEV

CLOBAZAM

10mg Tablet

02244638 APO-CLOBAZAM APX

02248454 CLOBAZAM PDL

02247230 DOM-CLOBAZAM DPC

02221799 FRISIUM PED

02244474 PMS-CLOBAZAM PMS

02238334 TEVA-CLOBAZAM TEV

DIAZEPAM

1mg/mL Oral Solution

00891797 PMS-DIAZEPAM PMS

2mg Tablet

00405329 APO-DIAZEPAM APX

00434396 DIAZEPAM PDL

02247490 PMS-DIAZEPAM PMS

5mg Tablet

00362158 APO-DIAZEPAM APX

00313580 DIAZEPAM PRO

02247491 PMS-DIAZEPAM PMS

00013285 VALIUM HLR

10mg Tablet

00405337 APO-DIAZEPAM APX

00434388 DIAZEPAM PDL

02247492 PMS-DIAZEPAM PMS

LORAZEPAM

0.5mg Tablet

00655740 APO-LORAZEPAM APX

02041413 ATIVAN WAY

02041456 ATIVAN SUBLINGUAL WAY

02245784 DOM-LORAZEPAM DPC

02351072 LORAZEPAM SAN

00711101 NOVO-LORAZEM TEV

00865672 NU-LORAZ NXP

00655643 PRO-LORAZEPAM PDL

1mg Tablet

00655759 APO-LORAZEPAM APX

02041421 ATIVAN WAY

02041464 ATIVAN SUBLINGUAL WAY

02245785 DOM-LORAZEPAM DPC

02351080 LORAZEPAM SAN

00637742 NOVO-LORAZEM TEV

00865680 NU-LORAZ NXP

00655651 PRO-LORAZEPAM PDL

2mg Tablet

00655767 APO-LORAZEPAM APX

02041448 ATIVAN WAY

02041472 ATIVAN SUBLINGUAL WAY

02245786 DOM-LORAZEPAM DPC

02351099 LORAZEPAM SAN

00637750 NOVO-LORAZEM TEV

00865699 NU-LORAZ NXP

00655678 PRO-LORAZEPAM PDL

NITRAZEPAM

5mg Tablet

02245230 APO-NITRAZEPAM APX

00511528 MOGADON ICN

02229654 NITRAZADON VAE

02234003 SANDOZ-NITRAZEPAM SDZ

10mg Tablet

02245231 APO-NITRAZEPAM APX

00511536 MOGADON VAE

02229655 NITRAZADON VAE

02234007 SANDOZ-NITRAZEPAM SDZ

OXAZEPAM

10mg Tablet

00402680 APO-OXAZEPAM APX

00497754 OXAZEPAM PDL

00568392 RIVA OXAZEPAM RIV

15mg Tablet

00402745 APO-OXAZEPAM APX

00497762 OXAZEPAM PDL

00568406 RIVA OXAZEPAM RIV

30mg Tablet

00402737 APO-OXAZEPAM APX

00497770 OXAZEPAM PDL

00568414 RIVA OXAZEPAM RIV

TEMAZEPAM

15mg Capsule

02225964 APO-TEMAZEPAM APX

02244814 CO TEMAZEPAM COB

02229756 DOM-TEMAZEPAM DPC

02230095 NOVO-TEMAZEPAM TEV

02223570 NU-TEMAZEPAM NXP

02243023 RATIO-TEMAZEPAM RPH

00604453 RESTORIL ORY

02229760 TEMAZEPAM PDL

30mg Capsule

02225972 APO-TEMAZEPAM APX

02244815 CO TEMAZEPAM COB

02229758 DOM-TEMAZEPAM DPC

02230102 NOVO-TEMAZEPAM TEV

02223589 NU-TEMAZEPAM NXP

02243024 RATIO-TEMAZEPAM RPH

00604461 RESTORIL ORY

02229761 TEMAZEPAM PDL

TRIAZOLAM

0.125mg Tablet

00808563 APO-TRIAZO APX

0.25mg Tablet

00808571 APO-TRIAZO APX

28:24.92 MISCELLANEOUS ANXIOLYTICS, SEDATIVES, AND

HYDROXYZINE HCL

10mg Capsule

00646059 APO-HYDROXYZINE APX

00739618 HYDROXYZINE PDL

00738824 NOVO-HYDROXYZIN TEV

02241192 RIVA-HYDROXYZIN RIV

25mg Capsule

00646024 APO-HYDROXYZINE APX

00739626 HYDROXYZINE PDL

00738832 NOVO-HYDROXYZIN TEV

02241193 RIVA-HYDROXYZIN RIV

50mg Capsule

00646016 APO-HYDROXYZINE APX

00739634 HYDROXYZINE PDL

00738840 NOVO-HYDROXYZIN TEV

02241194 RIVA-HYDROXYZIN RIV

2mg/mL Syrup

00024694 ATARAX ERF

00741817 PMS-HYDROXYZINE PMS

28:28.00 ANTIMANIC AGENTS

LITHIUM CARBONATE

150mg Capsule

02242837 APO-LITHIUM CARB APX

09857532 APO-LITHIUM CARBONATE APX

02013231 LITHANE ERF

02216132 PMS-LITHIUM CARBONATE PMS

300mg Capsule

02242838 APO-LITHIUM CARB APX

09857540 APO-LITHIUM CARBONATE APX

00236683 CARBOLITH VAE

00406775 LITHANE ERF

02216140 PMS-LITHIUM CARBONATE PMS

600mg Capsule

02011239 CARBOLITH VAE

02216159 PMS-LITHIUM CARBONATE PMS

LITHIUM CITRATE

60mg/mL Syrup

02074834 PMS-LITHIUM CITRATE PMS

28:32.28 SELECTIVE SEROTONIN AGONISTS

ALMOTRIPTAN MALATE

6.25mg Tablet

02248128 AXERT MCL

12.5mg Tablet

02248129 AXERT MCL

NARATRIPTAN HCL

1mg Tablet

02237820 AMERGE GSK

02314290 NOVO-NARATRIPTAN TEV

2.5mg Tablet

02237821 AMERGE GSK

02314304 NOVO-NARATRIPTAN TEV

02322323 SANDOZ NARATRIPTAN SDZ

RIZATRIPTAN

5mg Tablet

02240520 MAXALT FRS

10mg Tablet

02240521 MAXALT FRS

5mg Wafer

02240518 MAXALT RPD FRS

10mg Wafer

02240519 MAXALT RPD FRS

SUMATRIPTAN HEMISULFATE

5mg Nasal Spray

02230418 IMITREX GSK

20mg Nasal Spray

02230420 IMITREX GSK

SUMATRIPTAN SUCCINATE

6mg/0.5mL Injection

02361698 SUMATRIPTAN SUN SUN

12mg/mL Injection

02212188 IMITREX GSK

99000598 IMITREX GSK *

25mg Tablet

02257882 CO SUMATRIPTAN COB

02270749 DOM-SUMATRIPTAN DPC

02268906 MYLAN-SUMATRIPTAN MYL

02286815 NOVO-SUMATRIPTAN DF TEV

02256428 PMS-SUMATRIPTAN PMS

02286513 SUMATRIPTAN SAN

SUMATRIPTAN SUCCINATE

50mg Tablet

02268388 APO-SUMATRIPTAN APX

02257890 CO SUMATRIPTAN COB

02270757 DOM-SUMATRIPTAN DPC

02212153 IMITREX DF GSK

02268914 MYLAN-SUMATRIPTAN MYL

02286823 NOVO-SUMATRIPTAN DF TEV

02256436 PMS-SUMATRIPTAN PMS

02263025 SANDOZ-SUMATRIPTAN SDZ

02286521 SUMATRIPTAN SAN

02324652 SUMATRIPTAN PDL

100mg Tablet

02268396 APO-SUMATRIPTAN APX

02257904 CO SUMATRIPTAN COB

02270765 DOM-SUMATRIPTAN DPC

02212161 IMITREX DF GSK

02268922 MYLAN-SUMATRIPTAN MYL

02239367 NOVO-SUMATRIPTAN TEV

02286831 NOVO-SUMATRIPTAN DF TEV

02256444 PMS-SUMATRIPTAN PMS

02263033 SANDOZ-SUMATRIPTAN SDZ

02286548 SUMATRIPTAN SAN

02324660 SUMATRIPTAN PDL

ZOLMITRIPTAN

2.5mg Orally Disintegrating Tablet

02324768 PMS-ZOLMITRIPTAN ODT PMS

02362996 SANDOZ ZOLMITRIPTAN ODT SDZ

02342545 TEVA-ZOLMITRIPTAN OD TEV

02243045 ZOMIG RAPIMELT AZC

2.5mg Tablet

02369036 MYLAN ZOLMITRIPTAN MYL

02324229 PMS-ZOLMITRIPTAN PMS

02362988 SANDOZ ZOLMITRIPTAN SDZ

02313960 TEVA-ZOLMITRIPTAN TEV

02238660 ZOMIG AZC

28:32.92 MISCELLANEOUS ANTIMIGRANE AGENTS

FLUNARIZINE HCL

5mg Capsule

02246082 FLUNARIZINE AAP

PIZOTYLINE HYDROGEN MALATE

0.5mg Tablet

00329320 SANDOMIGRAN PED

1mg Tablet

00511552 SANDOMIGRAN DS PED

28:36.08 ANTIPARKINSONIAN AGENTS - ANTICHOLINERGIC AGENTS

BENZTROPINE MESYLATE

1mg/mL Injection

02238903 BENZTROPINE OMEGA OMG

1mg Tablet

00706531 PMS-BENZTROPINE PMS

2mg Tablet

00426857 APO-BENZTROPINE APX

00587265 PMS-BENZTROPINE PMS

ETHOPROPAZINE HCL

50mg Tablet

01927744 PARSITAN ERF

PROCYCLIDINE HCL

0.5mg/mL Elixir

00587362 PMS-PROCYCLIDINE PMS

2.5mg Tablet

00649392 PMS-PROCYCLIDINE PMS

5mg Tablet

00587354 PMS-PROCYCLIDINE PMS

TRIHEXYPHENIDYL HCL

0.4mg/mL Liquid

00885398 PMS-TRIHEXYPHENIDYL PMS

2mg Tablet

00545058 TRIHEXYPHENIDYL AAP

5mg Tablet

00545074 TRIHEXYPHENIDYL AAP

28:36.12 ANTIPARKINSONIAN AGENTS - CATECHOL-O- METHYLTRANSFERASE (COMT) INHIBITORS

ENTACAPONE

ST 200mg Tablet

02243763 COMTAN NVR

28:36.16 ANTIPARKINSONIAN AGENTS - DOPAMINE PRECURSORS

LEVODOPA, BENZERAZIDE

ST 50mg & 12.5mg Capsule

00522597 PROLOPA HLR

ST 100mg & 25mg Capsule

00386464 PROLOPA HLR

ST 200mg & 50mg Capsule

00386472 PROLOPA HLR

LEVODOPA, CARBIDOPA

ST 100mg & 25mg Controlled Release Tablet

02272873 LEVOCARB CR AAP

02028786 SINEMET CR BMS

ST 200mg & 50mg Controlled Release Tablet

00870935 SINEMET CR BMS

ST 100mg & 10mg Tablet

02195933 APO-LEVOCARB APX

02244494 NOVO-LEVOCARBIDOPA TEV

02182831 NU-LEVOCARB NXP

00355658 SINEMET BMS

ST 100mg & 25mg Tablet

02195941 APO-LEVOCARB APX

02244495 NOVO-LEVOCARBIDOPA TEV

02182823 NU-LEVOCARB NXP

02311178 PRO-LEVOCARB PDL

00513997 SINEMET BMS

ST 250mg & 25mg Tablet

02195968 APO-LEVOCARB APX

02244496 NOVO-LEVOCARBIDOPA TEV

02182858 NU-LEVOCARB NXP

00328219 SINEMET BMS

LEVODOPA, CARBIDOPA,ENTACAPONE

ST 50mg & 12.5mg & 200mg Tablet

02305933 STALEVO NVR

ST 75mg & 18.75mg & 200mg Tablet

02337827 STALEVO NVR

ST 100mg & 25mg & 200mg Tablet

02305941 STALEVO NVR

ST 125mg & 31.25mg & 200mg Tablet

02337835 STALEVO NVR

ST 150mg & 37.5mg & 200mg Tablet

02305968 STALEVO NVR

28:36.20 ANTIPARKINSONIAN AGENTS - DOPAMINE RECEPTOR AGONISTS

BROMOCRIPTINE MESYLATE

5mg Capsule

02230454 APO-BROMOCRIPTINE APX

02238637 DOM-BROMOCRIPTINE DPC

02236949 PMS-BROMOCRIPTINE PMS

2.5mg Tablet

02087324 APO-BROMOCRIPTINE APX

02238636 DOM-BROMOCRIPTINE DPC

02231702 PMS-BROMOCRIPTINE PMS

CABERGOLINE

Limited use benefit (prior approval required).

For treatment of hyperprolactinemia in patients who have failed therapy with or are intolerant to bromocriptine.

0.5mg Tablet

02301407 CO CABERGOLINE COB

02242471 DOSTINEX PFI

PRAMIPEXOLE DIHYDROCHLORIDE

ST 0.25mg Tablet

02292378 APO-PRAMIPEXOLE APX

02297302 CO PRAMIPEXOLE COB

02237145 MIRAPEX BOE

09857268 MIRAPEX (ONT) BOE *

02376350 MYLAN-PRAMIPEXOLE MYL

02269309 NOVO-PRAMIPEXOLE TEV

02290111 PMS-PRAMIPREXOLE PMS

02325802 PRAMIPEXOLE PDL

02367602 PRAMIPEXOLE SAN

02315262 SANDOZ-PRAMIPEXOLE SDZ

ST 0.5mg Tablet

02292386 APO-PRAMIPEXOLE APX

02297310 CO PRAMIPEXOLE COB

02241594 MIRAPEX BOE

02376369 MYLAN-PRAMIPEXOLE MYL

02269317 NOVO-PRAMIPEXOLE TEV

02290138 PMS-PRAMIPREXOLE PMS

02325810 PRAMIPEXOLE PDL

02367610 PRAMIPEXOLE SAN

02315270 SANDOZ-PRAMIPEXOLE SDZ

ST 1mg Tablet

02292394 APO-PRAMIPEXOLE APX

02297329 CO PRAMIPEXOLE COB

02237146 MIRAPEX BOE

09857269 MIRAPEX (ONT) BOE *

02376377 MYLAN-PRAMIPEXOLE MYL

02269325 NOVO-PRAMIPEXOLE TEV

02290146 PMS-PRAMIPREXOLE PMS

02325829 PRAMIPEXOLE PDL

02367629 PRAMIPEXOLE SAN

02315289 SANDOZ-PRAMIPEXOLE SDZ

ST 1.5mg Tablet

02292408 APO-PRAMIPEXOLE APX

02297337 CO PRAMIPEXOLE COB

02237147 MIRAPEX BOE

09857270 MIRAPEX (ONT) BOE *

02376385 MYLAN-PRAMIPEXOLE MYL

02269333 NOVO-PRAMIPEXOLE TEV

02290154 PMS-PRAMIPREXOLE PMS

02325837 PRAMIPEXOLE PDL

02367645 PRAMIPEXOLE SAN

02315297 SANDOZ-PRAMIPEXOLE SDZ

ROPINIROLE HCL

ST 0.25mg Tablet

02337746 APO-ROPINIROLE APX

02316846 CO-ROPINIROLE COB

02326590 PMS-ROPINIROLE PMS

02314037 RAN-ROPINIROLE RBY

02232565 REQUIP GSK

02353040 ROPINIROLE SAN

ST 1mg Tablet

02337762 APO-ROPINIROLE APX

02316854 CO-ROPINIROLE COB

02326612 PMS-ROPINIROLE PMS

02314053 RAN-ROPINIROLE RBY

02232567 REQUIP GSK

02353059 ROPINIROLE SAN

ST 2mg Tablet

02337770 APO-ROPINIROLE APX

02316862 CO-ROPINIROLE COB

02326620 PMS-ROPINIROLE PMS

02314061 RAN-ROPINIROLE RBY

02232568 REQUIP GSK

02353067 ROPINIROLE SAN

ST 5mg Tablet

02337800 APO-ROPINIROLE APX

02316870 CO-ROPINIROLE COB

02326639 PMS-ROPINIROLE PMS

02314088 RAN-ROPINIROLE RBY

02232569 REQUIP GSK

02353075 ROPINIROLE SAN

28:36.32 ANTIPARKINSONIAN AGENTS - MONOAMINE OXIDASE B INHIBITORS

SELEGILINE HCL

ST 5mg Tablet

02230641 APO-SELEGILINE APX

02238340 DOM-SELEGILINE DPC

02231036 MYLAN-SELEGILINE MYL

02068087 NOVO-SELEGILINE TEV

02230717 NU-SELEGILINE NXP

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

02293269 CAMPRAL MYL

TETRABENAZINE

25mg Tablet

02199270 NITOMAN VAE