Formulary - Cloudfront.net

Transcription

Effective October 1, 2016
18 Quantity Limits
23 Index
Multi-tiered Prescription Drug Formulary Listing
Drug name
Criteria Tier
Abbreviations apap acetaminophen
caps capsules
ER extended release
lot lotion
neb nebulizer
ODT dissolving
Drug name
Suggested preferred
alternatives
oint ointment
pkt packet
prod product
pwd powder
SL under the tongue
soln solution
supp suppositories
susp suspension
syr syringe
tabs tablets
( sub-lingual )
1.5.1
Penicillins
amoxicillin
amoxicillin/potassium clavulanate
ampicillin
dicloxacillin
penicillin V
Amoxicillin ER
SP
Bicillin CR/Bicillin LA
Moxatag
1.2
1.6
1
1
1
1
1
2
2
amoxicillin
Tetracyclines
No kits or combination packages are covered; see individual products for coverage
information.
demeclocycline
1
doxycycline
1
doxycycline hyclate/
PA
3
monohydrate/ER/DR
minocycline
1
minocycline ER
PA
3 minocycline
tetracycline
1
Acticlate
PA
3 doxycycline
Avidoxy
PA
3 doxycycline
Doryx
PA
3 doxycycline
Doryx MPC
PA
3 doxycycline
Doxycycline IR/DR
PA
3 doxycycline
Minocin 75 mg
3 minocycline
Morgidox caps
PA
3 doxycycline
Oracea
PA
3 doxycycline
Solodyn ER
PA
3 minocycline
Targadox
PA
3 doxycycline
Adoxa, Acticlate, Doryx, Monodox, Morgidox, Oracea, Solodyn ER, Targadox,
doxycycline hyclate/ monohydrate/ER. Minocycline ER: Trial and failure/intolerance
to a total of 2 generic, immediate-release products must be documented, one
minocycline and one doxycycline product. Trial of each should be a minimum of 1
month. Medical records documenting the trial and failure/intolerance to each of the
generic products must accompany the prior authorization request.
1.3
cefaclor, cefaclor ER
cefadroxil
cefdinir
cefditoren pivoxil
cefixime susp
cefpodoxime tabs
cefprozil
ceftibuten
cefuroxime sodium
cephalexin
Suprax tabs
1.4.1
1.8.1
1
1
1
1
1
1
1
1
1
1
Zepatier
1.8.2
PA = Prior authorization required
1
1
1
1
1
2
generic antibiotic
1
SP
1
1
1
1
1
1
1
1
1
1
1
2
PA,QL,SP
PA, QL, SP
PA,QL,SP
PA,QL,SP
QL
SP
SP
SP
PA,QL,SP
QL
PA,QL,SP
3
3 Zovirax topical
3 Harvoni
2
2
3
3 ribavirin
3 ribavirin
3 ribavirin
2
3
3
2
PA, ST,
SP, QL
PA, ST, SP
3 Harvoni
3 Harvoni
HIV/AIDS Therapy
All oral antiretroviral medications and protease inhibitors without a generic
equivalent are available at tier 2 copay. Those medications with a generic equivalent
available are subject to mandatory substitution.
Fuzeon
3
3 cefpodoxime, cefdinir
1.9
Erythromycins and Other Macrolides
azithromycin
azithromycin 1 gm pwd pkts
azithromycin susp
clarithromycin
clarithromycin ER
erythromycin
PCE
QL
1
Miscellaneous Antivirals
acyclovir
adefovir dipivoxil
amantadine
entecavir
famciclovir
ganciclovir
lamivudine/HBV
ribavirin
rimantadine
valacyclovir
valganciclovir
Cytovene
Daklinza
Denavir topical
Epclusa
Harvoni
Olysio
Relenza
Ribapak dosepack
Ribatab tabs/dosepak
Ribasphere
Sovaldi
Tamiflu
Technivie
Tyzeka
Viekira Pak/Viekira XR
Cephalosporins
3 ciprofloxacin,levofloxacin
Urinary Tract Agents
methenamine
nitrofurantoin
nitrofurantoin macrocrystals
nitrofurantoin susp
trimethoprim
Monurol
QL
Urogesic Blue
3 amoxicillin
1
1
1
1
1
Sulfa and Related Agents
sulfamethoxazole/trimethoprim
1.7
Suggested preferred
alternatives
Fluoroquinolones
ciprofloxacin tabs/susp
ciprofloxacin ER
levofloxacin tabs/oral soln
moxifloxacin
ofloxacin
Factive
QL
Chapter 1: Anti-Infectives
1.1
Criteria Tier
Antifungal Agents
clotrimazole troche
1
fluconazole
1
flucytosine
1
griseofulvin microsize
1
griseofulvin ultramicrosize
1
itraconazole
1
nystatin tabs/susp
1
terbinafine tab
1
ST = Step therapy If criteria not met, PA required
1
1
1
1
1
1
3 erythromycin
QL = Quantity limits If exceeded, PA required
1
SP = Specialty pharmacy
Drug name
Criteria Tier
voriconazole tab/susp
Cresemba
Noxafil
Onmel
Oravig
Sporanox oral soln
1.11.1
Ketek
Sivextro
Xifaxan
TOBI/TOBI Podhaler
3
3
3 itraconazole
3 clotrimazole troche
3
SP, QL
QL
1
1
1
1
1
3
3 TOBI, tobramycin
3 84 doses/28 days per each 60 days
3 metronidazole, oral vancomycin
caps/soln
3 azithromycin, clarithromycin
3
3 ciprofloxacin
2
tobramycin neb soln
SP, QL
SP, QL
PA, QL
QL
PA, QL
SP, QL
1
1
1
1
QL
3
3
Antimalarials
atovaquone-proguanil
chloroquine
hydroxychloroquine
quinine SO4
Coartem
1.11.4
PA
PA
PA, QL
PA, QL
1
1
1
1
QL
3
Antimycobacterials
rifabutin
1
Chapter 2: Antineoplastic and immunosuppressant drugs
2.1.2
Antimetabolites
capecitabine
Purixan susp
2.1.6
SP
1
3
Miscellaneous Antineoplastic Drugs
anagrelide
anastrozole
azathioprine 50 mg
bexarotene
bicalutamide
cyclophosphamide tabs
cyclosporine
exemestane
flutamide
gengraf
hydroxyurea
imatinib
leflunomide
letrozole
leuprolide 1 mg
megestrol
mercaptopurine
SP
QL
PA, SP
PA, SP
Criteria Tier
methotrexate
mycophenolate mofetil
mycophenolate sodium
nilutamide
octreotide
SP
sirolimus
tacrolimus
tamoxifen citrate
temozolomide
SP
tretinoin
PA, QL, SP
Alecensa
PA,QL,SP
Afinitor
Astagraf XL
PA,QL,SP
Bosulif
PA, QL, SP
Cabometyx
PA,QL,SP
Caprelsa (vandetanib)
PA,QL,SP
Cometriq
PA, QL, SP
Cotellic
Cyclosporine 50 mg softgel
Cyclophosphamide caps
Envarsus XR
QL
PA,QL,SP
Erivedge 150 mg
PA,QL,SP
Farydak
Gilotrif
PA, SP
SP
Gleostine
Hycamtin
SP
PA,QL,SP
Ibrance
Iclusig
PA,QL,SP
Imbruvica
PA,QL,SP
PA,QL,SP
Inlyta
Iressa
SP
PA,QL,SP
Jakafi
PA,QL,SP
Lenvima
PA,QL,SP
Lonsurf
PA,QL,SP
Lynparza
PA,QL,SP
Mekinist
Mesnex
Neoral
Nexavar
SP
Ninlaro
PA, SP
PA,QL,SP
Odomzo
Oforta
SP
Pomalyst
PA,QL,SP
Revlimid
PA,QL,SP
Sandimmune
PA,QL,SP
Signifor
Sprycel
PA, SP
PA,QL,SP
Stivarga
PA,QL,SP
Sutent
PA,QL,SP
Tafinlar
PA,QL,SP
Tagrisso
Tarceva
SP
Tasigna
PA, SP
Thalomid
SP
Tykerb
PA, SP
Venclexta
PA, SP, QL
for starter
PA,QL,SP
Votrient
PA,QL,SP
Xalkori
PA,QL,SP
Xtandi
PA,QL,SP
Zelboraf
Zolinza
PA
Zortress
QL
PA,QL,SP
Zydelig
Antiparasitics
atovaquone
ivermectin
metronidazole
tinidazole
Emverm
Impavido
1.11.3
1
Miscellaneous Anti-Infectives
clindamycin HCl
dapsone
linezolid
tobramycin neb soln
vancomycin caps
Alinia
Bethkis
Cayston
Dificid
1.11.2
Drug name
Suggested preferred
alternatives
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
Suggested preferred
alternatives
1
1
1
1
1
1
1
1
1
1
3
3
3 tacrolimus
3
3
2
3
3
2
3
3
2
3
3
3
3
3
3
3
3
2
2
3
3
3
3
2
2
3
3
3
3
3
2
2
3
3
3
3
3
3
2
3
2
3
3
2
3
3
3
3
3
3
2
Drug name
Criteria Tier
Zykaydia
Zytiga
PA,QL,SP
PA,QL,SP
2.2.1
Drug name
Suggested preferred
alternatives
3
3
Magnacet
Maxidone
Reprexain
Vicoprofen
Xartemis XR
Xolox
Zolvit
Adjunctive Agents
Vistogard
PA,QL,SP
3
Chapter 3: Autonomic and CNS Drugs; Neurology and Psychiatry
3.1.1
Narcotics
buprenorphine tabs
fentanyl oral
transmucosal
fentanyl patches
12, 25, 50, 75, 100
hydromorphone
hydromorphone ER
(Exalgo equivalent)
meperidine HCl
morphine SO4/ER
morphine SO4 ER
20, 30, 50, 60, 80, 100 mg
(Kadian equivalent)
morphine SO4 ER
30, 45, 60, 75, 90, 120 mg
(Avinza equivalent)
oxycodone
Oxymorphone IR
oxymorphone ER
roxicet
Abstral SL tabs
Alcet
Belbuca
Butrans Patches
Codeine SO4 Soln
Embeda
Fentanyl patches
37.5, 62.5, 87.5 mcg
Fentora buccal tabs
Hysingla ER
Kadian ER, 10, 40, 70,
130, 150, 200 mg
Lazanda nasal spray
MSIR
Nucynta/Nucynta ER
Onsolis
Opana ER
PA, QL
PA
1
1
QL
1
ST, QL
1
1
QL
1
1
1
QL
1
Oxaydo
Oxycontin
Oxycodone ER
Oxy IR
Roxicodone
Subsys
Xtampza XR
Zohydro ER
PA
QL
QL
3.1.2
ST
3.3.1
Oxycontin, oxycodone, morphine
SO4/ER
Oxycontin, oxycodone, morphine
SO4/ER
1
1
1
1
PA, QL
PA, QL
QL
3 fentanyl transmucosal
3 oxycodone/apap
3
3 fentanyl patch, tramadol, NSAID
2
generics
3 morphine SO4 ER
3 generic fentanyl patches
PA
PA, QL
QL
3 fentanyl oral transmucosal
3 generics
3 morphine SO4 ER, Oxycontin
PA
QL, PA
PA, QL
3 fentanyl oral transmucosal
2
3
3
3 morphine SO4 ER, oxycodone ER/SA,
generics
3 oxycodone IR
PA,QL,SP
ST
PA, QL
QL
PA, QL
mefenamic acid
meloxicam
nabumetone
naproxen/ER
piroxicam
sulindac
Cambia pwd pac
ST, QL
Duexis
ST, QL
Fenortho
ST
Fenoprofen 200 and 400 ST
mg
Flector patches
QL
Nalfon
ST
Naproxen CR
ST
Pennsaid 2% soln
QL
Prevacid NapraPac
Sprix nasal spray
QL, ST
Tivorbex
ST, QL
Vimovo
QL, PA
Vivlodex
ST, QL
Zorvolex
ST
1
1
1
1
1
1
3.3.3
3
3
3
3
3
3
3
oxycodone/apap
hydrocodone/apap
hydrocodone/apap
hydrocodone/ibuprofen
oxycodone/apap
oxycodone/apap
hydrocodone/apap
3
3
3
3
diclofenac, generic NSAID
Ibuprofen + famotidine
Generic NSAID
generic NSAID
3
3
3
3
3
3
3
3
3
3
Voltaren Gel
generic NSAID
generic NSAID
diclofenac drops,Voltaren gel
generic NSAID + generic ppi
generic NSAID
generic NSAID
generic NSAID+generic ppi
generic NSAID
Salicylates
3 Relagesic, OTC prods
3 generic
Miscellaneous Analgesics
butorphanol nasal spray QL
1
pentazocine/naloxone
1
tramadol HCL
1
tramadol/apap
1
tramadol ER
QL
1
tramadol ER
QL
1
(Ryzolt equivalent) tabs
tramadol ER tabs
QL
1
(Ultram ER equivalent)
Conzip ER
QL
3 tramadol, tramadol ER tabs
Dologesic
2
LAGesic
1
Rhinoflex
3
Rybix ODT
3 tramadol
Tramadol 150 mg caps QL
3 tramadol, tramadol ER tabs
Zflex
3
2
3 generics
Combination Narcotic/Analgesics
acetaminophen /codeine
apap/caffeine/dihydrocodeine
buprenorphine/
PA, QL
naloxone SL tabs
hydrocodone/apap
hydrocodone/ibuprofen
oxycodone/acetaminophen
oxycodone/aspirin
oxycodone/ibuprofen
Endocet
Allzital
1
1
1
1
1
1
1
1
1
1
choline and magnesium trisalicylate 1
diflunisal
1
salsalate
1
Duraxin
Zorprin
Oxycontin
oxycodone immediate release
oxycodone immediate release
fentanyl oral transmucosal
Suggested preferred
alternatives
NSAIDs/COX II Inhibitors
celecoxib
QL
diclofenac
diclofenac topical drops
diclofenac topical gel 1% QL
diclofenac-misoprostol
etodolac
ibuprofen
indomethacin/SR
ketorolac
QL
ketoprofen
3.3.2
2
3
3
3
3
Criteria Tier
1
1
1
1
1
1
1
1
1
3 butabarbital/apap
3
Drug name
Criteria Tier
Drug name
Suggested preferred
alternatives
3.3.4 Narcotic Antagonists
Narcan Nasal Spray
3.4.1
Sumavel Dosepro
Treximet
Zembrace
Zomig nasal spray
QL
QL
QL
1
1
1
1
1
QL
QL
1
1
1
1
QL
QL
1
1
QL
1
QL
3 sumatriptan injection
2
3
3
3 sumatriptan nasal spray
2
sumatriptan, rizatriptan, zolmitriptan,
naratriptan
2
2
QL
QL
QL
QL
QL
QL
3.7
Antiparkinsonism Agents
benztropine
bromocriptine mesylate
carbidopa
carbidopa/levodopa
carbidopa/levodopa/entacapone
entacapone
pramipexole
pramipexole ER
ropinirole/ropinirole ER
selegiline HCl
tolcapone
trihexyphenidyl
Azilect
Apokyn
SP
PA,QL,SP
Duopa
Neupro
QL
Rytary
3.6
mephobarbital
oxcarbazepine
phenobarbital
phenytoin
phenytoin sodium extended
primidone
tiagabine
topiramate/sprinkle
valproic acid
zonisamide
Aptiom
Banzel tabs/susp
Briviact
Diastat/Diastat Acudial QL
Equetro
Fycompa
Gabitril 12, 16 mg
Gralise
PA, QL
Horizant ER
PA, QL
Lyrica caps/oral soln
ST
Onfi
Oxtellar XR
Phenytek
Qudexy XR
Sabril
SP
Spritam
Stavzor
Topiramate ER
Vimpat
3
Headache Therapy
alagesic oral soln
almotriptan
butalbital compound
butalbital/apap
dihydroergotamine
nasal spray
frovatriptan
isometh/caffeine/apap
naratriptan
rizatriptan/
rizatriptan ODT
sumatriptan nasal spray
sumatriptan tabs
and injections
zolmitriptan/
zolmitriptan ODT
Alsuma injection
Midrin
Migralam
Migraten
Onzetra Xsail
Relpax
3.5
QL
1
1
1
1
1
1
1
1
1
1
1
1
3
2
3
3 ropinirole, ropinirole ER
3
3.8.1
1
1
1
1
1
1
1
3.8.2
1
1
1
3
2
3
2
3 carbamazapine, carbamazepine ER
3
2
3
3
3
3
3
3
3
gabapentin
gabapentin, pramipexole
gabapentin
oxcarbazepine
topiramate
2
3
3 valproic acid
3 topiramate
3
1
1
1
1
1
1
1
3
3
3
2
3 memantine+donepezil
2
2
3
1
1
1
1
1
1
1
1
1
3
3 chlorzoxazone
2
Myasthenia Gravis
pyridostigmine/ER
3.9.1
1
1
1
1
1
1
1
1
1
1
Muscle Relaxants and Antispasmotic Agents
baclofen
carisoprodol
chlorzoxazone
cyclobenzaprine/cyclo-benzaprine ER
dantrolene
metaxalone
methocarbamol
orphenadrine
tizanidine
Durabac
Lorzone
Relagesic
1
1
Suggested preferred
alternatives
Miscellaneous Neurological Therapy
donepezil/donepezil ODT
galantamine
galantamine ER
memantine/memantine QL
dosepak
(dosepk)
rivastigmine
rivastigmine patches
QL
tetrabenazine
PA, SP
PA,QL,SP
Ampyra
PA,QL,SP
Aubagio
PA,QL,SP
Keveyis
Namenda XR
QL
Namzaric
QL
PA,QL,SP
Gilenya
PA,QL,SP
Tecfidera
SP, QL
Zinbryta
Anticonvulsants
carbamazepine/XR
carbamazepine ER
caps/tabs
clonazepam/clonazepam wafers
diazepam rectal gel
QL
divalproex/ER/sprinkles
ethosuximide
felbamate
Gabapentin caps/tabs/oral soln
lamotrigine/lamotrigine ODT/
lamotrigine ER
lamotrigine starter kit
QL
levetiracetam
levetiracetam ER
Criteria Tier
1
Hypnotic Agents
4
Drug name
estazolam
eszopiclone
flurazepam
temazepam
triazolam
zaleplon
zolpidem
zolpidem ER
zolpidem sublingual
Belsomra
Edluar
Hetlioz
Rozerem
Silenor
Zolpimist
3.9.2.1
Criteria Tier
QL
QL
QL
QL
QL, ST
QL, ST
PA,QL,SP
QL
QL, ST
QL, ST
3.9.2.4
3
3
3
3
3
3
zaleplon, zolpidem/ER, eszopiclone
Rozerem
1
1
1
1
1
1
1
1
1
(formerly Brintellix)
Viibryd
QL, ST
3 generics
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
3
3 risperidone, quetiapine, olanzapine
starter pack
1
1
1
1
1
1
1
1
3.9.4
3
3
3
3
3
3
3
Trazodone/generic SSRI
generic SSRI/SNRI
2
1
1
1
3 selegiline tabs
2
3
3
3
3
QL
PA, QL
QL
clozapine
risperidone, quetiapine, olanzapine
2
3 clozapine
3 risperidone, quetiapine, olanzapine
PA
Miscellaneous Psychotherapeutic Agents
amphetamine salt combo
amphetamine salt combo ER
armodafinil
QL
dexmethylphenidate
dexmethylphenidate ER
5, 10, 15, 20, 30, 40 mg
dextroamphetamine
disulfiram
guanfacine ER
methylphenidate, tabs, oral soln,
chewable tabs
methylphenidate CD
QL
(Metadate CD
equivalent)
methylphenidate ER
(Ritalin LA equivalent)
methylphenidate ER
(Concerta equivalent)
modafinil
QL
Adderall 7.5,12.5,
ST
and 15 mg
Adderall XR
ST
Addyi
PA, QL
Adzenys XR-ODT
ST, QL
SSRI, bupropion SR/XL
generic SSRI/SNRI
generic SSRI/SNRI
bupropion SR/XL
Suggested preferred
alternatives
Miscellaneous Antipsychotics
Fazaclo ODT
Latuda
Rexulti
Saphris
Seroquel XR
Versacloz
Vraylar
Selective Serotonin Reuptake Inhibitors
citalopram
escitalopram
fluoxetine
fluoxetine DR 90-mg cap
fluvoxamine maleate
fluvoxamine ER
paroxetine
paroxetine CR
sertraline
Brisdelle
QL, ST
Pexeva
Trintellix
QL, ST
Criteria Tier
aripiprazole/aripiprazole
ODT
clozapine/clozapine ODT
fluphenazine
haloperidol
loxapine
molindone
olanzapine/olanzapine ODT
olanzapine/fluoxetine
paliperidone ER
perphenazine
pimozide
quetiapine
risperidone
risperidone ODT
thioridazine
trifluoperazine
ziprasidone
Clozapine ODT, 150, 200 mg
QL for
Fanapt
MAO Inhibitors
phenelzine
selegiline
tranylcypromine sulfate
Emsam
QL
Marplan
Drug name
3.9.3.3
Miscellaneous Antidepressants
bupropion HCl, bupropion SR
buproprion XL
QL
duloxetine
mirtazapine
nefazodone
trazodone HCl
venlafaxine
venlafaxine ER
Aplenzin
QL
Desvenlafaxine
QL, ST
Fetzima
ST
Forfivo XL
QL
Nuplazid
PA, QL
Oleptro ER
QL
Pristiq
QL, ST
Savella
QL
3.9.2.3
1
1
1
1
1
1
1
1
1
Tricyclics
amitriptyline
clomipramine
doxepin
imipramine
imipramine PM
trimipramine
desipramine
nortriptyline
protriptyline
3.9.2.2
Suggested preferred
alternatives
1
1
1
1
1
1
1
1
1
1
1
1
1
3 methylphenidate/ER, amphetamine
combinations
3 amphetamine salt combo ER
3
combinations
Aptensio XR
ST
combinations
Campral
3
Daytrana
ST, QL
combinations
Desoxyn
ST
3 methamphetamine
Dexedrine tab
3 dextroamphetamine
Dyanavel XR
ST
1
1
1
1
1
1
1
1
1
3 generics
3 paroxetine or generics
3 generics
5
Drug name
Criteria Tier
Evekeo
Focalin XR 25, 35 mg
Kapvay ER
Nuedexta 20-10 mg
Procentra oral soln
ST
QL
PA, QL
ST
Quillichew ER
ST
Quillivant XR
ST
3
3
3
3
3
3.9.5
Drug name
Criteria Tier
combinations
dextroamphetamine
dexmethylphneidate ER
methylphenidate, Strattera
clopidogrel 75 mg
clopidogrel 300 mg
dipyridamole
ticlopidine HCl
Brilinta
Durlaza
Effient
Zontivity
QL
methylphenidate/ER, amphetamine
combinations
combinations
combinations
3 methylphenidate ER
Ritalin LA 10 mg, 60 mg ST
Strattera
QL
Vyvanse
ST
Xyrem
Zenzedi
Suggested preferred
alternatives
4.4.3
combinations
3
3 dextroamphetamine
4.4.5
1
1
1
1
1
1
1
4.4.6
4.5.1
3
Antiarrhythmics
disopyramide phosphate
dofetilide
procainamide HCl
quinidine
flecainide
propafenone
propafenone SR
amiodarone
sotalol/sotalol AF
Multaq
Sotylize liquid
4.2
4.3
1
1
1
1
1
1
1
1
1
3 amiodarone
3 sotalol tabs
Cardiac Glycosides
digoxin
Lanoxin 62.5, 187.5 mcg
1
4.4.2
3
Anticoagulants
1
1
2
3
2
2
3
2
Antiplatelet Drugs
aspirin/dipyridamole
cilostazol
2
3
Heparin
Hemostatics
1
1
1
1
1
1
1
1
1
1
1
1
1
torsemide
triamterene /HCTZ
Dyrenium
1
1
2
Beta Blockers
amlodipine
2
2
Thiazide and Related Diuretics
4.5.3.2
1
1
2
1
1
Miscellaneous Coagulation Agents
atenolol
betaxolol
bisoprolol fumarate
carvedilol
labetalol
metoprolol succinate ER
metoprolol tartrate
nadolol
pindolol
propranolol
propranolol ER
timolol
Bystolic
Cartrol
Coreg CR
QL
Hemangeol
Innopran XL
Levatol
3
Nitrates
jantoven
warfarin sodium
Eliquis
Iprivask
PA, SP
Mephyton
Pradaxa
QL
Savaysa
QL
Xarelto/Xarelto dosepack
3 clopidogrel, Effient
3
amiloride
amiloride /HCTZ
bumetanide
chlorothiazide
ethacrynic acid
furosemide
hydrochlorothiazide
indapamide
metolazone
eplerenone
spironolactone
spironolactone/HCTZ
4.5.2
isosorbide
1
nitroglycerin tabs, caps, oint, patches 1
nitroglycerin spray
QL
1
Nitromist
QL
4.4.1
QL
QL
QL
pentoxifylline
Chapter 4: Cardiovascular, Hypertension and Lipids
4.1
Not covered; in-hospital use only
1
1
All factor prods
SP
aminocaproic acid, 500-mg tabs
tranexamic acid, 650 mg QL
Aminocaproic Acid, 1000-mg tabs
Promacta
QL, SP
Anxiolytics
alprazolam
alprazolam ER
alprazolam ODT
buspirone HCl
diazepam
lorazepam
oxazepam
Midazolam
1
Although these medications may be obtained through a retail pharmacy, they are
considered specialty medications and the specialty copay will be charged.
enoxaparin
1
fondaparinux
1
Fragmin
3
2
PA, SP
Suggested preferred
alternatives
1
1
1
1
1
1
1
1
1
1
1
1
3 atenolol, metoprolol
2
3 Ages 2 yr and under
2
Calcium Channel Blockers/Dihydropyridines
1
6
Drug name
Criteria Tier
cartia XT
diltiazem, diltiazem ER,
diltiazem SR, diltiazem SA
felodipine
isradipine
nicardipine HCl
nifedipine, nifedipine ER
nimodipine
nisoldipine
verapamil HCl/verapamil SR
verapamil ER PM
Cardene SR
Cardizem LA
Nymalize
Verelan
Verelan PM
4.5.4
2
3 nimodipine
3 verapamil, felodipine
3 verapamil ER PM
3 lisinopril tabs
1
1
1
QL
Byvalson
Dutoprol
Lexxel
Prestalia
Teczem
Tribenzor
QL
Vecamyl
PA,QL,SP
4.5.9
1
SP
SP
PA,QL,SP 1
3 isosorbide dinitrate + hydralazine
3
3
3
Other Hypertensive Combinations
amlodipine/benazepril
amlodipine/valsartan
amlodipine/valsartan/HCTZ
atenolol/chlorthalidone
benazepril HCT
bisoprolol fumarate/HCTZ
captopril/HCTZ
enalapril maleate/HCTZ
fosinopri/HCTZ
1
1
1
1
1
1
1
1
1
1
1
1
QL, ST
QL, ST
Benicar HCT
Edarbyclor
ST
QL, ST
Edarbi
QL, ST
Tekamlo
Tekturna
Tekturna HCT
QL, ST
QL,ST
QL, ST
3
3 losartan, eprosartan, irbesartan,
valsartan, candesartan
3 losartan/irbesartan/HCTZ valsartan/HCTZ
3 losartan/HCTZ, irbesartan /HCTZ
losartan + chlorthalidone
3 losartan, eprosartan, irbesartan,
valsartan, candesartan
3
3
3
Lipid/Cholesterol-Lowering Agent
4 preferred medications (simvastatin, pravastatin, lovastatin, atorvastatin, fluvastatin
caps, Crestor) must be used within 180 days for a non-preferred medication
(Altoprev, Lescol XL, Livalo) to process.
atorvastatin
1
atorvastatin/amlodipine
1
cholestyramine/light
1
colestipol tabs
1
fenofibrate
1
fluvastatin
1
fluvastatin ER
1
gemfibrozil
1
lovastatin
1
omega-3 acid ethyl esters
1
pravastatin
1
rosuvastatin
1
simvastatin
1
Advicor
QL
2
Altoprev
QL, ST
3 lovastatin
Colestid pwd
2
colestipol tabs
Fenofibrate 50, 120, 150 mg
3 fenofibrate
Fenofibric acid
3 fenofibrate
3
3
1
1
SP, PA
SP
PA, QL, SP
3 Exforge, valsartan + amlodipine,
losartan + amlodipine
3
3 Metoprolol + HCTZ
3 benazepril/amlodipine
3
3 diltiazem + enalapril, irbesartan /HCTZ
3 losartan+amlodipine, valsartan/
HCTZ + amlodipine
3
Angiotensin II Receptor Blockers and Renin Inhibitors
candesartan
candesartan/HCTZ
eprosartan
eprosartan/HCTZ
irbesartan
irbesartan/HCTZ
losartan
losartan/HCTZ
telmisartan
telmisartan/HCTZ
valsartan
valsartan/HCTZ
Amturnide
Benicar
4.6
Vasodilators
Suggested preferred
alternatives
1
1
1
1
1
1
1
1
QL, ST
3 doxazosin mesylate
1
1
1
1
1
Agents for Pheochromocytoma
epoprostenol
epoprostenol diluent
sildenafil 20 mg PAH
BiDil
hydralazine
minoxidil
Orenitram ER
Remodulin
Uptravi
4.5.8
3 felodipine, nicardipine, nifedipine
1
1
1
1
1
1
1
1
1
1
phenoxybenzamine
4.5.7
1
1
1
1
1
1
1
1
PA
Criteria Tier
lisinopril /HCTZ
metoprolol /HCTZ
moexipril/HCTZ
Nadolol/bendroflumethiazide
propranolol/HCTZ
quinapril/HCTZ
telmisartan/amlodipine
trandolopril/verapamil
Azor
QL, ST
Adrenergic Antagonists and Related Drugs
doxazosin mesylate
prazosin HCl
terazosin
Cardura XL
clonidine
clonidine weekly patch
guanabenz acetate
guanfacine
methyldopa
4.5.5
1
1
ACE Inhibitors
benazepril
captopril
enalapril maleate
fosinopril
lisinopril
moexipril
perindopril
quinapril
ramipril
trandolapril
Qbrelis
4.5.5
Drug name
Suggested preferred
alternatives
1
1
1
1
1
1
1
1
1
7
Drug name
Fenoglide
Fibricor
Juxtapid
Kynamro
Lipofen
Liptruzet
Livalo
Lofibra
Niaspan
Praluent
Repatha
Simcor
Triglide
Vascepa
Vytorin
Welchol tabs/pkts
Zetia
4.7
Criteria Tier
3
3
3
3
3
3
3
PA,QL,SP
PA,QL,SP
Suggested preferred
alternatives
Drug name
fenofibrate
fenofibrate
Desonate
desonide
desoximetasone
fluocinolone
hydrocortisone
Verdeso foam
fenofibrate
Atorvastatin + Zeita
simvastatin, pravastatin, lovastatin,
atorvastatin, fluvastatin cap, Crestor
3 fenofibrate
QL
QL, ST
5.2
PA,QL,SP
PA,QL,SP
QL
3
3
2
3 fenofibrate
3 omega-3 acid ethyl esters
3
QL
QL
5.3
QL
Miscellaneous Cardiovascular Agents
midodrine
Corlanor
Entresto
Ranexa
1
QL
PA, QL
QL
3
3
3
Chapter 5: Dermatologicals, topical therapy
5.1
Topical Corticosteroids
All brand-name topical corticosteroids without a generic equivalent will be available
at a tier 3 copay.
5.1.1
Topical Corticosteroids, Very High Potency
clobetasol propionate
diflorasone diacetate
halobetasol propionate
Temovate
Ultravate lotion
5.1.2
5.1.3
3 generics
3 generics
1
1
1
3
3
3
3
3
generics
generics
generics
generics
generics
Topical Corticosteroids, Medium Potency
flurandrenolide
hydrocortisone butyrate
triamcinolone acetonide
Cloderm
Cordran
Dermatop E oint
Elocon
fluticasone
Locoid
Luxiq
mometasone
Pandel
prednicarbate
5.1.4
1
1
1
Topical corticosteroids, High Potency
amcinonide
betamethasone
fluocinonide
Clocortolone Pivalate cream
Diprolene, Diprolene AF
Halog, Halog E
Sernivo
Topicort/Topicort LP/
Topicort spray
1
1
1
3
3
3
3
generics
generics
prednicarbate cream, generics
generics
1
3 generics, HC butyrate cream
3 generics
1
3 generics
1
Topical Corticosteroids, Low Potency
hydrocortisone /aloe
alclometasone
3 generics
1
1
1
1
3 desonide cream/oint/lot, generics
QL
1
1
1
1
1
1
3 hydropramox gel
Therapy for Acne
adapalene cream, gel
amnesteen
benzoyl peroxide,
various formulations
benzoyl peroxide pads
bpo 4, 8% gel
bpo 3, 6, 9%, foaming cloths
claravis
clindamycin phosphate
clindamycin/benzoyl peroxide
clindamycin/tretinoin
erythromycin
erythromycin/benzoyl peroxide
metronidazole cream/gel/lot
myorisan
oscion cleanser/pads
prascion cleanser
sodium sulfacetamide medicated
pads/cleanser/cream/lot
sotret
sulfacetamide/sulfur topical prod
sulfacleanse susp
sulfatol gel
tretinoin, tretinoin micro
zenatane
Absorbica
Acanya Gel
ST
Aczone
Adapalene Lot
Apop
Avar/Avar LS/Avar-E LS
Avita
.
Azelex
Benzefoam /Benzefoam Ultra
BPS gel
Benzoyl Peroxide 2.5% wash
Brevoxyl acne wash
Clindareach
Delos cleanser/lot
Differin lot and 0.3% gel
Epiduo/Epiduo Forte
Finacea
Garimide
Inova Easy Pads
Metrogel
Mirvaso
Neobenz Micro
Neuac
Noritate
Nuox gel
2
2
Suggested preferred
alternatives
Topical Anesthetics
lidocaine HCI
lidocaine patches
lidocaine/prilocaine
lidocaine/tetracaine
Novacort gel
2
Criteria Tier
1
1
1
NO MAIL ORDER
1
1
1
1
1
1
1
1
1
1
1
1
1
1
NO MAIL ORDER
NO MAIL ORDER
1
1
1
1
1
1
NO MAIL ORDER
3
3
3
3
3
3
3
3
3
3
3
NO MAIL ORDER
NO MAIL ORDER
tretinoin
Plexion, Prascion
tretinoin
tretinoin
benzoyl peroxide
benzoyl peroxide
benzoyl peroxide
2
benzoyl peroxide creamy wash
3 clindamycin
3 benzoyl peroxide, OTC
2
generics (adapalene) for 0.1% gel/cream
2
3 metronidazole cream, tretinoin
3 sulfacetamide/sulfur, OTC
3 benzoyl peroxide, OTC
2
metronidazole gel
3
3 benzoyl peroxide
3 clindamycin/benzoyl peroxide
2
3 benzoyl peroxide/sulfacetamide
8
Drug name
Criteria Tier
Suggested preferred
alternatives
Drug name
hydrocortisone acetate gel 2%
benzoyl peroxide pad/oscion prods
shampoo
Akurza cream/lot
Durasal
Salex 6% shampoo
Salicylic 6% cream/lot
Salvax 6% foam
Virasal
Nuzon gel
Onexton
Pacnex LP/HP cleansing pads
Plexion cleansing cloths
Retin-A 0.08% micro pump
Rosac
Rosula
Rosula clarifying wash
Rosula NS
SE Benzoyl Peroxide 7% wash
Sodium Sulfamide/Sulfur gel
Soolantra
Sumadan wash
Sumaxin
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Synalar
Tazorac
Tretin-X
Triaz
Vanoxide HC
Veltin gel
Zencia wash
Zoderm
3
3
3
3
3
3 clindamycin and/or tretinoin
3 sulfacetamide/sulfur
3 benzoyl peroxide
5.4
ST
1
1
1
1
1
3
3
3 mupirocin cream/oint
3
3
5.11
1
1
1
1
1
1
3
3
3
3
3
3
3
3
3
econazole cream
ketoconazole, nystatin
ketoconazole, nystatin
ciclopirox
ciclopirox
econazole cream
naftifine cream
5.12
1
3 Zovirax + hydrocortisone
2
1
Keratolytics
salicylic acid 26% liquid
salicylic acid ER film
salicylic acid 6% foam/cream/lot/
1
1
1
1
1
1
1
1
1
1
3 calcipotriene
3
3 Enbrel, Humira
2
3 calcipotriene/betamethasone
3 Seb-Prev cream/gel
3 Seb-Prev 10% prods
3 pramoxine/HC
1
3
3 calcipotriene oint/soln
3 Enbrel, Humira
3 OTC selenium sulfide
3
3
Topical Scabicides/Pediculicides
QL
1
1
1
2
2
QL
3
2
QL
QL
malathion
3
3
Miscellaneous Dermatologicals
allanderm-T oint
aluminum acetate soln
cem-urea 45%
doxepin cream
imiquimod 5% cream
pruclair cream
prutect topical emulsion
pruvel cream
re-urea lot/gel/emulsion
sodium hyaluronate lot
tacrolimus oint
PA
Urea: different strengths/prods
Alevicyn
Aluvea cream
Atopiclair cream
Atrapro Dermal spray/hydrogel
Aquaphilic /Triamcin
Bionect
Carac cream
ketoconazole
Re Sa 6% cream/lot
salicylic acid 26% liquid
OTC salicylic acid shampoo
Re Sa 6% cream/lot
salicylic acid foam 6%
salicylic acid
Antipsoriatic/Antiseborrheic
malathion lot
permethrin 5% cream
spinosad 0.9% susp
Eurax 10% cream/lot
Lindane 1% lot/shampoo
Lycelle removal kit
Ovide lot
Sklice 0.5% lot
Ulesfia lot
Burn Therapy
silver sulfadiazine
5.9
sulfacetamide/sulfur
OTC acne cleansing prod,
sulfacleanse susp
generics
Dovonex, tretinoin
tretinoin
benzoyl peroxide pad, oscion prod
Suggested preferred
alternatives
3
3
3
3
3
3
acitretin
calcipotriene oint/soln/cream
calcipotriene/betamethasone
drithocreme HP
hydrocort-pramox gel
re-sa 6% cream/lot
selenium sulfide
Calcitrene
Calcitriol oint
PA,QL,SP
Cosentyx
Dovonex
Enstilar foam
Ovace cream/gel
Ovace Plus
cream/wash/foam
Pramosone/Pramosone E
Seb-Prev cream/gel/wash
Sodium Sulfacetamide cleanser
Sorilux
Taltz
PA,SP,QL
Tersi foam
Vectical oint
QL
Zithranol shampoo
Topical Antivirals
acyclovir oint
Xerese cream
Zovirax cream
5.7
5.10
Topical Antifungals
ciclopirox
clotrimazole/betamethasone
econazole cream
ketoconazole cream/shampoo
naftifine cream
oxiconazole cream
Ecoza
Ertaczo
Exelderm
Jublia
QL
Kerydin
QL
Luzu
Naftin Gel
Vusion
Xolegel
5.6
Prascion
Sodium sulfacetamide medicated pads
benzoyl peroxide or OTC
Topical Antibacterials
gentamicin
hydro-iodoquinol 2-1
hydrocortisone/iodoquin
ol/aloe
mafenide pwd pkts
mupirocin cream/oint
Alcortin-A
Aloquin
Altabax
Neo-Synalar
Silvrstat dressing gel
5.5
tretinoin
Criteria Tier
1
1
1
1
1
1
1
1
1
1
1
1
3
3 urea
3 pruclair cream
3
3 generics
3
2
9
Drug name
Criteria Tier
Carb-o-philic
Condylox
Elidel
PA
Fluorouracil cream/soln
HPR Plus
HPR emollient foam/plus emollient
Hydro 35/40 foam
Hylase wound gel
Hylira lot
Kerafoam
Keratol HC 1%
Kerol AD emulsion
Kerol Redi-Cloths
Latrix XM emulsion
MimyX cream
Neosalus
Picato gel
QL
Podofilox
Radigel Acemannan hydrogel
Regranex gel
QL
Solaraze
Sonafine topical
Tolak 4%
Tropazone lot
Umecta 40% nail film/mousse
Umecta PD
Urealac
Uramaxin cream/foam/lot/
applicator
Uramaxin GT Kit/Uramaxin GT
pre-filled applicator
Valchlor
PA, SP
Venelex
Veregen
Xclair
Zyclara
Drug name
Suggested preferred
alternatives
3
Aquoral spray
Caphosol
Gelx oral gel
Mugard oral
wound rinse
Mucotrol gel wafer
Numoisyn liquid
Numoisyn lozenges
Orafate
Oralone paste
Prothelial
Salicept susp
2
3 generic topical corticosteroid
1
1
1
3 urea lot, cream, gel
3
3 sod hyaluronate lot
3
1
3
3 urea oint/lot
3 urea
3 Biafine RE
3
3
1
3
7.1
2
1
3 urea
3 urea
6.4
1
1
7.4.1
2
3
3 antipyrine/benzocaine
3
1
1
1
1
1
2
1
3 thyroid, levoxyl, levothroid, levothyroxine
2
3 levoxyl, levothroid, levothyroxine
1
1
1
1
1
1
1
1
2
3 methylprednisolone
3 prednisone
1
Androgens
danazol
methyltestosterone
oxandrolone
testosterone gel packs
(Androgel pkt equiv)
testosterone gel pump
Anadrol-50
Androderm
Androgel pump
Axiron
Fortesta
Natesto
Striant
Testim
3 Ciprodex
1
1
1
1
1
1
1
1
Adrenal Hormones
cortisone
dexamethasone
hydrocortisone
methylprednisolone
prednisolone
prednisolone sodium
phosphate ODT
prednisone
zema-pak 6- and 10-day
Acthar H.P. gel
PA, SP
Medrol 2, 8, 32 mg
Rayos
PA,QL
Veripred 20
Miscellaneous Agents
cevimeline
chlorhexidine rinse
olopatadine nasal
pilocarpine tabs
triamcinolone dental paste
SP
Thyroid Hormones
7.3
1
1
1
1
1
1
1
2
QL, SP
levoxyl
levothroid
levothyroxine sodium
liothyronine sodium
np thyroid
thyroid
unithroid
westhroid
Armour Thyroid
Nature-Throid, 16, 32, 65, 130
Nature-Throid 97.5, 260 mg
Thyrolar
Tirosint
Westhroid-P
WP Thyroid
3 fluorouracil
3
3 fluorouracil
3
3 urea 40%
3 ciprofloxacin, ofloxacin
3 generics
3
3 OTC saliva substitutes
3
3
3 triamcinolone dental paste
3
Antithyroid Agents
7.2
Miscellaneous Otic Preparations
acetic acid, acetic acid HC
antipyrine/benzocaine
borofair otic
ciprofloxacin otic
fluocinolone otic
ofloxacin otic
neomycin/polymyxin/HC
Aurax otic
Cetraxal otic
Halog, Halog E
Ciprodex otic
Cipro HC otic
Domeboro otic
Myoxin otic susp
Otic Care otic soln
Otozin ear drops
Pinnacaine otic drops
TriOxin otic
3
3
QL, SP
methimazole
propylthiouracil (PTU)
Chapter 6: Ear, Nose and Throat Medications
6.2
Suggested preferred
alternatives
Chapter 7: Endocrine/Diabetes
2
3
3
3 Aldara, Condylox
3
3 imiquimod
Criteria Tier
PA
QL
QL
PA
QL
QL
QL
ST, QL
ST, QL
ST, QL
1
1
1
1
1
2
2
2
2
3
3
3
3
Androgel
Androgel, Axiron, testosterone
10
Drug name
Criteria Tier
Testosterone gel
Vogelxo
ST, QL
ST, QL
7.4.2
Drug name
Suggested preferred
alternatives
3 Androgel, Axiron, testosterone
3 Androgel, Axiron, testosterone
glimepiride
glipizide/glipizide ER
glyburide
metformin HCl, metformin ER
metformin ER (Glumetza equiv)PA
metformin/glipizide
metformin/glyburide
miglitol
nateglinide
pioglitazone
pioglitazone/glimepiride
pioglitazone/metformin
repaglinide
repaglinide/metformin
Cycloset
Glyxambi
ST, QL
Actoplus Met XR
QL
Avandamet
Avandaryl
Avandia
Symlin
PA
Bydureon vials/pens
QL
Byetta
QL
Farxiga
ST, QL
Invokamet
ST, QL
Invokana
ST, QL
Janumet/Janumet XR
QL
Januvia
QL
Jardiance
ST, QL
Jentadueto
QL
Jentadueto XR
QL
Kazano and
ST, QL
alogliptin/metformin
Nesina and alogliptin
ST, QL
Onglyza
ST, QL
Oseni and
ST, QL
alogliptin/pioglitazone
Kombiglyze XR
ST, QL
Synjardy
ST, QL
Tanzeum
ST, QL
Tradjenta
QL
Trulicity
ST, QL
Victoza
QL
Xigduo XR
ST, QL
Ovulatory Stimulants
Injectable drugs for infertility are not covered by many benefit plans. You must
have a injectable fertility prescription rider in your BCNEPA Contract/Policy for any
injectable fertility medication to be covered. A Fertility Drug Discount Progm is
available through Freedom Fertility Pharmacy, a leading provider of specialty
pharmacy services. The Freedom Advantage progm provides a discount for those
that don’t have coverage for fertility drugs and FertilityAssist providing free
medication for qualified patients. For more information, visit www.freedomfertility.com
or call 1.800.660.4283.
clomiphene
1
7.4.3
calcitriol
desmopressin tabs/nasal soln
cabergoline
QL
doxercalciferol
paricalcitol
Cerdelga
PA, SP
Cerezyme
PA, SP
DDAVP
SP
Elaprase
PA, SP
Elelyso
PA, SP
Fabrazyme
PA, SP
PA,QL,SP
Korlym
Kuvan
PA, SP
Lumizyme
PA, SP
PA,QL,SP
Myalept
Myozyme
PA, SP
Naglazyme
PA, SP
PA,QL,SP
Natpara
PA,QL,SP
Samsca
Sensipar
SP
Stimate
SP
Somavert
PA, SP
Strensiq
PA, SP, QL
Synarel
PA, SP
Vimizim
PA, SP
Vpriv
PA, SP
Zavesca
PA, SP
7.4.4
7.5.1
1
1
1
1
1
3
2
2
3
3
2
3
2
3
3
3
2
3
3
2
2
2
3
2
3
3 Cerezyme
2
Gonadotropin and Related Agents
Cetrotide
Ganirelix
Novarel
Pregnyl
PA, SP
PA, SP
PA, SP
PA, SP
3 (injectable fertility med)
3 (injectable fertility med)
1
(injectable fertility med)
2
(injectable fertility med)
Afrezza
Apidra
Humalog, Humalog Mix
Humulin
Lantus
Lantus Solostar
Levemir
Levemir Flex Pen/Flex Touch
Novolin
Novolog
Relion
Toujeo Solostar
Tresiba Flextouch
7.5.2
Glucagon
1
1
1
1
3 metformin, metformin ER
1
1
1
1
1
1
1
1
1
3 metformin, sulfonylurea
3
2
3
3
3
3
2
2
3 Invokana
2
2
2
2
3 Invokana
2
2
3 Janumet, Janumet XR, Jentadueto
3 Januvia, Tradjenta
3 Januvia, Tradjenta
3 Januvia or Tradjenta + pioglitazone
3 Janumet, Janumet XR, Jentadueto
3 Invokamet
3 Byetta, Bydureon, Victoza
2
3 Byetta, Bydureon, Victoza
2
3 Invokamet
QL
3
Insulin Syringes/Misc. Durable Medical Equipment
Asthma Pack III
2
AsTech
2
Asthma Mentor
2
EasiVent chamber
2
Easy Touch syrs
3
I-port
QL
3
Minimed reservoirs
PA
2
Opti chamber
2
Paradigm infusion sets PA
2
Paradigm silhouette sets PA
2
Polyfin infusion sets,
PA
2
extension sets, QR infusion sets
Quick-release teflon
PA
2
cannula
Silhouette infusion sets PA
2
Sof-Set infusion sets
PA
2
Sof-Set mini infusion sets PA
2
3 formulary insulins
3 Humalog, Novolog
2
2
2
2
2
2
2
2
3 Humulin, Novolin
3 Lantus, Levemir
3 Lantus, Levemir
Non-Insulin Hypoglycemic Agents
acarbose
Suggested preferred
alternatives
7.5.3 Glucose Elevating Agents
7.5.4
Insulin Therapy
Criteria Tier
1
11
Drug name
Criteria Tier
Drug name
Suggested preferred
alternatives
Sure-T infusion sets
2
All insulin pumps and insulin pump supplies require prior authorization.
All Bayer and Abbott meters listed may be obtained for free by taking a prescription
to any participating pharmacy. This is a partial listing of available blood glucose
meters. Any meter other than the Bayer and Abbott prods that are listed are
considered non-preferred and must be obtained through your DME benefits.
Products relating to meters other than Bayer and Abbott (i.e. control solutions, etc),
are tier 3.
Roche Meters: Accu-Chek Active,
Compact Plus, Aviva Plus, Nano
Smartview Meter and any other
Roche meter
Bayer Meters: Contour Next EZ,
Contour USB, Contour Next,
Contour Next USB, Breeze-2 .
For Medtronic pump users: Contour
Next EZ Link
Continuous glucose monitoring
system
DexCom G4 Platinum
Abbott Meters:
FreeStyle Freedom Lite
FreeStyle Lite, FreeStyle InsuLinX,
FreeStyle Neo
Guardian RT starter kit
monitoring sensors
(Medtronic, DexCom)
Enlite sensors (Medtronic) PA, QL
FreeStyle InsuLinX
QL
test strips (Abbott)
Free Style Lite test strips QL
(Abbott)
FreeStyle Neo test strips QL
LifeScan test strips/
PA,QL
supplies: One Touch Ultra and
Select, SureStep, One Touch Verio and
any other LifeScan strips/supplies
Monoject
Novofine 30, 32
Novofine Autocover
Precision Sure Dose
Precision Xtra
QL
Prodigy No Coding
PA, QL
test strips
Prodigy pen needles/mini pen
needles/short pen needles/syrs
G4 Platinum sensors
PA, QL
(for DexCom system)
Soft Touch lancets
Sure-T lancets
Unistrip-1
PA, QL
Other brands
PA, QL
Refer to DME benefits through DME providers;
Covered alternatives: Bayer and Abbott
products (see listing for covered products)
Free Monitor Progm Take your Rx to any
participating pharmacy.
See MiniMed Paradigm Real-Time, Guardian RT
or DexCom
Refer to DME; prior authorization is required for
the transmitter/receiver as well as the sensors.
(Sensors go through pharmacy benefit). Covered
alternatives: Bayer and Abbott prods (see listing
for covered products)
Free Monitor Progm Take your Rx to any
participating pharmacy or call 1.866.224.8892
for home delivery
Refer to DME; prior authorization is required
for the transmitter as well as the sensors.
(Sensor go through pharmacy benefit). Covered
alternatives: Bayer products, Abbott products
Life Scan Meters: One Touch ultra
mini, Ultra 2 , Ultra Smart, Ultra
Link, One Touch Verio IQ Meter,
One Touch Verio Sync and any
other Life Scan Monitors
Refer to DME benefits through DME providers;
Prodigy pocket meter
Covered alternatives: Bayer and Abbott
MiniMed Paradigm Real-Time
products (see listing for covered products)
Prodigy Autocode talking meter
Prodigy voice meter
Sidekick blood glucose monitor
Solus V2
Unistrip-1
V-Go Insulin delivery system
Tier 3, PA, QL of 30/30
Bayer and Abbott test strips and meters listed are preferred and first step in step
therapy; all others are non-preferred and require prior authorization. If authorization
is obtained, any test strip and supplies other than Bayer or Abbott products are subject
to tier 3 copay. All blood glucose test strips are restricted to a quantity of 150/month. A
prior authorization must be submitted for consideration for a larger quantity.
Accu-Chek Active
PA,QL
3 Abbott/Bayer test strips
test strips
Accu-Chek Aviva
PA,QL
Plus/Connect test strips
Accu-Chek Compack Plus PA,QL
test strips
Accu-Chek Safe-T-Pro lancets
2
Accu-Chek Smartview
PA,QL
test strips
Accu-Chek Softclix
2
Accu-Chek SoftTouch
2
B-D prods
2
Contour test strips
QL
2
(Bayer)
Contour Next test strips QL
(Bayer)
Breeze-2 test strips
QL
(Bayer)
Continuous glucose
PA, QL
2
Suggested preferred
alternatives
3
2
2
2
2
2
2
2
2
3
3
2
2
Chapter 8: Gastroenterology
8.1.1
H2 Antagonists
cimetidine
famotidine
nizatidine
ranitidine
8.1.2
1
1
1
1
Prostaglandins
misoprostol
8.1.3
8.1.4
1
Other Ulcer Therapy
sucralfate
Omeclamox-Pak
Prevpac
Pylera
1
QL
QL
3
3
3
Proton Pump Inhibitors
Use of 4 of our first-line meds—omeprazole, pantoprazole, rabeprazole,
lansoprazole, omeprazole/bicarbonate, Dexilant—must be noted within past
180 days for Prevacid Solutabs, esomeprazole, Nexium, Zegerid pkts or Aciphex
Sprinkles to be covered. Children ages 13 and under exempt from step therapy.
esomeprazole 20, 40 mg QL, ST
lansoprazole
omeprazole
omeprazole/
ST
bicarbonate caps
pantoprazole
rabeprazole
Aciphex sprinkles
QL, ST
Dexilant
QL
Nexium susp/pkt
Prevacid solutabs
Prilosec granules
Zegerid pkts
QL, ST
ST
QL, ST
QL, ST
8.2.1
2
Criteria Tier
pantoprazole, omeprazole,
3 rabeprazole, Dexilant
2
2
pantoprazole, omeprazole,
rabeprazole, Dexilant
1
1
3 pantoprazole, omeprazole,
rabeprazole, Dexilant
3 pantoprazole, omeprazole,
rabeprazole
3
3
3 omeprazole
3 pantoprazole, omeprazole, Dexilant
Antidiarrheals
paregoric
diphenoxylate/atropine
3
1
1
1
12
Drug name
Criteria Tier
Fulyzaq
ST, QL
8.2.2
1
2
3 hyoscyamine sulfate ER
1
1
Rectiv 0.4% gel
Relistor tabs/injection
Rowasa kit
Sfrowasa
Uceris
Viberzi
Visicol
Zelnorm
1
1
1
1
2
3 generic antispasmodic
2
3 hyoscyamine, dispas
2
8.3.4
3 hyoscyamine, dispas
3 Creon, Pancreaze, Zenpep
2
1
1
1
1
1
females only
1
1
1
1
8.3.5
3 lidocaine-HC 3 1% cream
3 Delzicol, sulfasalazine, balsalazide
2
2
Lidocaine 3%/HC 2.5% gel
2
9.1.1
3 OTC hydrocortisone + lidocaine oint,
AnaMantlle HC
3 pramoxine/HC
3 Analpram HC
3 pramoxine/HC
3 OTC hydrocortisone + lidocaine oint,
AnaMantle HC
3
3
2
mesalamine kit
2
3 budesonide
3
3 peg 3350/electrolytes, Moviprep
3
QL
PA, QL
QL
PA
QL
QL
1
1
1
1
1
1
3
QL
QL, ST
PA, QL
2
3
3
3
3
3
PA
QL, ST
ondansetron, granisetron
ondansetron, granisetron
prochlorperazine, trimethobenzamide
ondansetron ODT
1
2
QL
3 peg 3350/electrolytes/Moviprep
Erythroid Stimulants
Aranesp
Epogen
Procrit
9.1.2
SP
SP
SP
9.1.3
2
3
3 Delzicol, Asacol HD, Lialda
3
3 Procrit
2
SP
SP
PA,QL,SP
PA, SP
PA, SP
2
2
PA, SP
PA,QL,SP
QL, SP
QL, SP
ST, QL, SP
QL, SP
SP
PA,QL,SP
PA, QL,
SP, ST
2
2
3 Granix
Granix
3
Interferons
Actimmune
Avonex
Betaseron
Copaxone
Extavia
Infergen
Intron A
Pegasys
Peg-Intron: only after
special consideration
1
2
Myeloid Stimulants
Granix
Leukine
Neulasta
Neupogen
Zarxio
3 ursodiol
3 Enbrel, Humira
3
2
(reformulation of Asacol)
3
2
2
Chapter 9: Immunology, Vaccines and Biotechnology
3
2
3
PA, QL,SP
Bowel Evacuants
gavilyte soln
Moviprep (8.3.5)
Prepopik pwd pkt
Suprep Bowel prep kit
TriLyte
1
1
1
1
Suggested preferred
alternatives
Antivertigo and Antiemetic Agents
dronabinol
granisetron
ondansetron
prochlorperazine
promethazine supp
trimethobenzamide HCl
Diclegis
Emend caps/susp
Anzemet
Sancuso Patch
Transderm-Scop
Varubi
Zuplenz
Miscellaneous Gastrointestinal Agents
alosetron
balsalazide
budesonide Ec
hc-pramoxine
hydrocortisone 2.5%
cream
lidocaine-HC 3 1% cream
mesalamine kit
metoclopramide HCl/ODT
peg 3350 and electrolytes,
peg 3350/electrolytes/flavor packs
pramoxine/hydrocortisone
sulfasalazine
ursodiol
z-pram cream
Amitiza
QL
Analpram HC cream/lot
AnaMantle HC Forte cream
Apriso
ST
Asacol HD
AnaMantle HC
Azulfidine En-Tab
Canasa
Chenodal tabs
PA, SP
Cimzia
PA, QL,
SP, ST
CoLyte
Cystadane
SP
Delzicol
Dipentum
ST
PA,QL,SP
Gattex
Giazo
ST
Halflytely
Kristalose
Lactulose
Lialda
Linzess
QL
Mesalamine 800 mg
ST
Movantik
QL
Criteria Tier
Pertzye
Pramcort cream
Pramosone cream/ lot/oint
Procort cream
Rectagel HC gel
Digestive Enzymes
dicyclomine
dispas
glycopyrolate tabs
methscopalamine bromide
Creon
Gastrinex NF
IB-Stat
QL
Mar-Spas
Pancreaze
Pro-Hyo
Ultresa
Viokace
Zenpep DR
8.3.3
Osmoprep
Ocaliva
Pentasa
Peranex HC
Combination Anticholinergics
antispasmodic elixir
belladonna/phenobarb
8.3.2
3
Antispasmodics
hyoscyamine
Cuvposa soln
Symax Duotab
8.2.3
Drug name
Suggested preferred
alternatives
3 Betaseron, Rebif, Copaxone
2
2
2
2
2
3 Pegasys
13
Drug name
Plegridy
Rebif all dosage forms
Sylatron
9.1.4
Criteria Tier
PA, QL,
SP, ST
QL, SP
PA,QL,SP
Suggested preferred
alternatives
9.1.5
2
Xeljanz/Xeljanz XR
PA, QL,
SP, ST
10.4
3
Suggested preferred
alternatives
3 Enbrel. Humira, Orencia
PA,QL,SP
PA,QL,SP
PA,QL,SP
PA,QL,SP
PA,QL,SP
3
3 Norditropin
3 Norditropin
2
3 Norditropin
PA,QL,SP
PA,QL,SP
PA,QL,SP
PA,QL,SP
PA,QL,SP
3
3
3
3
3
Osteoporosis Therapy
alendronate
ibandronate
raloxifene
risedronate
risedronate, dr
Actonel with Calcium
Binosto
Fortical
Forteo
Fosamax plus D
Norditropin
Norditropin
Norditropin
Norditropin
Norditropin
QL
QL
1
1
1
1
1
QL
QL
3 alendronate, ibandronate, risedronate
3 alendronate, ibandronate, risedronate
alendronate, ibandronate, risedronate
1
PA, SP
QL
2
3 alendronate or ibandronate with OTC
vitamin D
3 alendronate, ibandronate
3
Miacalcin
Osphena
Chapter 11: Obstetric and gynocology
Interleukins
PA,QL,SP
PA,QL,SP
QL, SP
Arcalyst
Ilaris
Neumega
Criteria Tier
Growth Hormones
Egrifta
Genotropin
Humatrope
Norditropin
Nutropin, Nutropin AQ,
Nutropin Depot
Omnitrope
Protropin
Saizen
Serostim
Zomacton
Drug name
3
3 1 dose/8 weeks; subject to 2 copays
11.1.1
Monophasic/Biphasic/Triphasic Agents
Gammagard
PA, SP
Gammaked
PA, SP
Gamunex-C
PA, SP
Hizentra 20%
PA, SP
3 SC through pharmacy benefit
IV through medical benefit
Both require PA
Both require PA
Both require PA
3
Hyqvia
PA, SP
3
Grastek
3
Oralair
PA, QL
PA,QL,SP
Please refer to the Women’s Health Care Reform Contraceptive Listing in the Index of
this formulary. This lists all generic contraceptives that are available at zero-cost
share for those groups currently covered under HCR. For those members not
currently covered under health care reform, a tier 1 copay will apply to the generic
contraceptives.The brand contraceptives /emergency contraceptives listed below as
well as any others are subject to a tier 3 copay for those with or without HCR; they
are not covered under HCR zero-cost share. All contraceptives are subject to quantity
limits of one cycle per month.
Beyaz 28
QL
3
Generess FE
QL
3
Layolis FE
QL
3
Lo Minastrin 24 Fe
QL
3 Any FDA-approved generic or
Minastrin 24 Fe
QL
3 preferred contraceptive
Natazia
QL
3
Ovcon 50
QL
3
Safyral
QL
3
3
11.2
Ragwitek
PA, QL
3
methylergonovine
9.2
2
Vaccines and Miscellaneous Immunologicals
Oxytocics
Chapter 10: Musculoskeletal and Rheumatology
11.3.1
10.2
medroxyprogesterone acetate
norethindrone acetate
progesterone caps
Crinone
Depo-SubQ Provera
QL
Endometrin supp
First-Progesterone vaginal supp
Makena
PA, SP,QL
Progesterone in oil
PA, SP
Progesterone pwd
Prochieve
Gout Therapy
allopurinol
probenecid
Colchicine
Colcrys
Mitigare
Uloric
Zurampic
10.3.2
1
1
3 Colcrys
2
QL
PA
3
3 allopurinol
3 allopurinol
Miscellaneous Rheumatological Agents
Actemra infusion, Orencia infusion, Remicade, Simponi Aria and Stelara are covered
under the medical benefit. They require step therapy and prior authorization.
Actemra subcutaneous PA,QL,SP
3 Enbrel, Humira, Orencia
PA,QL,SP
Cimzia
PA,QL,SP
Enbrel
2
PA,QL,SP
Humira
2
PA,QL,SP
Kineret
PA,QL,SP
2
Enbrel, Humira
Orencia 125-mg
syr/clickjet
3 Enbrel, Humira
Otezla/Otezla dose pack PA,QL,ST
PA
3 methotrexate tabs/injection
Otrexup
PA
3 methotrexate tabs/injection
Rosuvo
PA, QL,
Simponi
SP, ST
11.3.2
Progestins
1
1
1
2
2
3 Crinone, Prochieve
3 Crinone, Prochieve
2
1
3
2
Estrogens
estradiol tabs
estradiol patches
Alora
QL
estropipate
Cenestin
Climara
QL
Delestrogen
Divigel
Elestrin Subject to 3 copays, home
delivery or retail
Enjuvia
1
1
1
3
1
3
3
3
3
3
Premarin
estradiol patches
Premarin
estradiol patches
estradiol patches
3 Premarin
14
Drug name
Criteria Tier
Estraderm
Estriol
QL
2
12.4
2
2
2
1
1
1
1
12.5
2
3 Activella, Premphase, Prempro
3
2
2
QL
12.6
12.7
3 Cleocin vaginal gel
1
SP, QL
Mirena
SP, QL
Skyla
12.1
Beta Blockers
carteolol
levobunolol HCl
timolol maleate,
timolol maleate XE
betaxolol
Betoptic S
QL
QL
QL
1
1
1
QL
QL
1
1
1
1
1
1
1
1
2
3
3
3
3
ketorolac
bromfenac
bromfenac
bromfenac
bromfenac
1
1
1
1
1
1
1
1
2
3
3
3 ofloxacin, ciprofloxacin, levofloxacin
3 ofloxacin, ciprofloxacin, levofloxacin
Sulfonamides
1
Steroids
fluorometholone
prednisolone acetate
Alrex
Durezol
FML Forte
Lotemax
Pred Mild
Vexol
Chapter 12: Ophthalmology
3 latanoprost/ bimatoprost
Antibiotics
sulfacetamide sodium
12.11
1
1
1
1
Non-Steroidal Anti-Inflammatory Agents
3 OTC Prods
3 OTC Prods, teraconazole
3 OTC Prods, teraconazole
12.10
3 dorzolamide/timolol
3 latanoprost
Cycloplegic Mydriatics
ciprofloxin 0.3%
erythromycin
gatifloxacin
gentamicin
levofloxacin 0.5%
ofloxacin opth soln
polymyxin B/trimethoprim
tobramycin sulfate
Azasite
Besivance
Ciloxan ophthalmic oint
Moxeza
Vigamox
3 Must have contraceptive benefit;
will be delivered from the specialty
pharmacy to your physician for insertion
Must have contraceptive benefit;
2
Zero copay under HCR benefits.
3 Must have contraceptive benefit;
2
Oral Drugs for Glaucoma
12.9
1
1
SP, QL
QL
QL
QL
QL
ST, QL
3 metronidazole
1
Diaphragms and Other Non-Oral Contraceptives
Lileta
3 betaxolol, timolol
QL
QL
QL
bromfenac 0.09%
ketorolac 0.4%
ketorolac 0.5%
Acuvail
Ilevro
Nevanac
Prolensa
Voltaren
2
1
1
1
1
2
atropine
cyclopentolate
1
1
1
QL
QL
QL
2
QL
QL
QL
QL
acetazolamide
methazolamide
Suggested preferred
alternatives
Other Glaucoma Drugs
bimatoprost
bromfenac 0.09%
latanoprost
travoprost
Lumigan
Travatan-Z
Zioptan
Vaginal Antifungals
nystatin
terconazole cream/supp
3, 7
Gynazole 1
Terazol 3 supp
Zazole Vaginal supp
11.4.5
estradiol
Premarin
estradiol patch
estradiol patch
Vaginal Cleansers/Anti-Infectives
amino acid vaginal cream
clindamycin vaginal cream
metronidazole vaginal cream
Cleocin vaginal cream
Clindesse
Fem pH
Nuvessa
Vandazole
11.4.3
3 estradiol
Estrogen Combinations
covaryx
covaryx HS
estradiol/norethindrone
jinteli
Angeliq
Climara Pro
QL
Combipatch
Duavee
Prefest
Premphase
Prempro
11.4.2
2
3
3
3
3
Criteria Tier
Istalol
metipranolol
pilocarpine HCl
dorzolamide HCl
dorzolamide HCl/timolol
Azopt
Betimol
Combigan
Cosopt PF
Rescula
Any compound containing estriol will
not be covered
3 estradiol patches
3 Premarin
Estrogel
QL
Estring Subject to 3 copays, home
delivery or retail
Evamist
QL
Femring Subject to 3 copays, home
delivery or retail
Femtrace
Menest
Menostar
Minivelle
QL
Ortho-Est
Premarin
Vagifem
11.3.3
Drug name
Suggested preferred
alternatives
1
1
3 Alocril
3 prednisolone acetate
2
3
2
2
2
15
Drug name
Criteria Tier
Drug name
Suggested preferred
alternatives
Criteria Tier
Obredon
Polytussin AC
Tussionex
Tuzistra XR
12.12
Steroid-Antibiotic Combinations
neomycin/bacitracin/polymyxin/
hydrocortisone
neomycin/polymyxin/
dexamethasone
tobramycin/dexamethasone
Pred-G
Tobradex oint
Zylet
12.14
1
13.3.3
2
3
1
1
2
3 brimonidine, Alphagan-P
13.3.3
2
3
3
3
3
3 azelastine
3 azelastine
3 azelastine
QL
PA,QL,SP
QL
2
QL
3 Restasis
13.3.4
Antivirals
trifluridine
Zirgan
2
Chapter 31: Respiratory, Allergy and Cough and Cold
13.1.1
Antihistamines
cyproheptadine
desloratadine
hydroxyzine
levocetirizine
levocetirizine oral soln
1
1
1
1
Covered
only age
12 yrs
promethazine HCl
Aldex chewables
1
13.3.5
1
3 Allegra OTC, loratadine OTC
cetirizine OTC
3 Allegra OTC, loratadine OTC
cetirizine OTC
Karbinal ER
13.2.1
Allegra OTC, loratadine OTC
cetirizine OTC, desloratadine tabs
Allegra OTC, loratadine OTC
cetirizine OTC
Antitussive Combinations
benzonatate
guaifenesin /codeine
hydrocodone/cpm/pseudoephedrine
phenylephrine/chlorpheniraminedrops
promethazine /codeine
promethazine /DM
Flowtuss
Hycofenix
Ninjacof XG
1
1
1
1
1
1
3 Generic antitussive
3 Allegra-D OTC, other OTC prods
1
1
3
2
2
2
Beta Agonists
QL
QL
QL
QL
QL, ST
QL
QL
QL, ST
QL
QL
QL
1
1
1
3 Foradil
2
2
3 Ventolin HFA, ProAir HFA
2
2
2
3 Foradil, Serevent
2
2
QL
Inhaled Corticosteroids
budesonide neb
Aerospan
Alvesco
Arnuity Ellipta
Asmanex HFA
Asmanex Twisthaler
Flovent Diskus
Flovent HFA
Pulmicort Flexhaler
Qvar
1
1
Xanthines
albuterol/ER tabs
albuterol inhalant soln
levalbuterol
Arcapta Neohaler
Brovana
Foradil
Maxair-Autohaler
Perforomist
ProAir HFA/Respiclick
Proventil HFA
Serevent Diskus
Striverdi Respimat
Ventolin HFA
Volmax
Xopenex HFA
1
1
1
1
Generic antitussive
Generic antitussive
Generic antitussive
Generic antitussive
Decongestant/Antihistamines
dyphylline
Theophylline ER
Difil-G/Forte
Theo-Dur
Uni-Dur
Uniphyl
2
Miscellaneous Ophthalmologics
azelastine
cromolyn sodium
epinastine
olopatadine
Alocril
Alomide
Bepreve
Cystaran
Emadine
Lastacaft
Pataday
Pazeo
Restasis
Xiidra
12.16
QL
QL
QL
3
3
3
3
pseudoephedrine HCL/chlor-mal
Clarinex D 12 hr
QL
Rynatan
Semprex-D
1
Sympathomimetics
apraclonidine
brimonidine tartrate
Alphagan P 0.1%
Iopidine 1%
12.15
13.2.3
1
Suggested preferred
alternatives
1
QL, ST
QL, ST
QL
QL
QL
QL
QL
QL
QL, ST
3 Flovent, Pulmicort, Asmanex
3
2
2
2
2
2
Intranasal Steroids
budesonide
flunisolide
fluticasone
ipratropium
mometasone
triamcinolone
Beconase AQ
QL
QL
QL
QL
QL
QL
QL, ST
Children’s Qnasl
QL, ST
Omnaris
QL, ST
Qnasl
QL, ST
Veramyst
QL, ST
Zetonna
QL, ST
1
1
1
1
1
1
3 flunisolide, fluticasone, budesonide
Nasonex
Nasonex
Nasonex, triamcinolone
16
Drug name
13.3.6
Criteria Tier
Drug name
Suggested preferred
alternatives
tolterodine
tolterodine ER
trospium Cl
trospium Cl ER
Gelnique
Myrbetriq
Oxytrol
Miscellaneous Pulmonary Agents
acetylcysteine
cromolyn sodium
epinephrine auto-inject
ipratropium
Ipratropium/albuterol
montelukast
sildenafil (PAH)
zafirlukast
Adcirca
Adempas
Adrenaclick
Advair Diskus,
Advair HFA
Anoro Ellipta
Atrovent HFA
Auvi-Q
Bevespi Aerosphere
Breo Ellipta
Cinryze
Combivent Respimat
Daliresp
Dulera
EpiPen/EpiPen Jr
Esbriet
Firazyr
Hyper-Sal
Incruse Ellipta
Kalydeco
Letairis
Letairis
Mucomyst
Nebusal
Ofev
Opsumit
Orkambi
Pulmozyme
Revatio oral susp
Ruconest
Seebri neohaler
Spiriva/Respimat
Stiolto Respimat
Symbicort
Tracleer
Tudorza
Tyvaso
Utibron Neohaler
Ventavis
Zyflo
1
1
QL
QL
QL
QL
PA,QL,SP
3 EpiPen, EpiPen Jr, Auvi-Q
1
1
1
1
1
QL
QL
QL
QL
QL
PA, SP
QL
QL, PA
QL
QL
PA,QL,SP
PA, SP
2
2
2
3
3 EpiPen, EpiPen Jr, Auvi-Q
3
2
3
2
3
2
2
3
3
3
3
2
2
2
2
2
14.2
2
2
3 oxybutynin ER, trospium, Vesicare,
Gelnique, trospium ER, tolterodine ER
3 oxybutynin ER, trospium, Vesicare,
trospium ER, tolterodine ER
2
Urinary Anesthetics
2
3 sildenafil tabs
3
3
1
Miscellaneous Urologicals
1
1
1
1
1
QL
QL
QL
3
3
3
2
QL
QL
3
3
3 re-methylphen
3
3
3
QL
QL
1
3 phosenamine
3
QL
Benign Prostatic Hyperplasia (BPH) Therapy
alfuzosin
dutasteride
dutasteride/tamsulosin
finasteride
Rapaflo
tamsulosin
3
3 Letairis
3
QL
1
1
1
1
3 tamsulosin, alfuzosin
1
Chapter 15: Vitamins, Hematinics and Electrolytes
15.1
Vitamins and Hematinics
Most prenatal vitamins are available at a tier 1 or tier 2 copay.
folic acid 1 mg
1
Bright Beginnings bar
preferred prenatal vitamin
Eligen B12
3 OTC B12 tabs
Floriva
3
Nascobal Nasal spray
3 OTC B12 tabs
Poly Vi Flor Film Strips
3 Generic chewable tabs
Prefera-OB
2
Prenate Elite
Quflora
3
Texavite
3
Tricare Prenatal w/DHA
2
3
2
3
2
3
3
2
3 montelukast
1
Anticholinergics and antispasmodics
darifenacin
flavoxate
oxybutynin chloride
oxybutynin chloride ER
QL
14.5
Cholinergic stimulants
bethanechol
Vesicare
phosenamine
potassium citrate ER
re methylphen
uro-L
uro-MP
Caverject
Cialis
Edex
Elmiron
Levitra
Muse
Prosed DS
Renacidin
Staxyn
Stendra
Uritact-EC
Uta cap
Viagra
Chapter 14: Urologicals
14.1
QL
14.4
2
PA,QL,SP
PA,QL,SP
PA,QL,SP
SP
PA, SP
PA,QL,SP
QL
QL
QL
QL
PA, SP,
QL, ST
QL
PA,QL,SP
QL
PA, SP
QL, ST
QL
QL
phenazopyridine HCl
2
Suggested preferred
alternatives
1
1
1
1
Toviaz
14.3
PA,QL,SP
PA,QL,SP
QL
QL
QL
PA,QL,SP
PA,QL,SP
PA,QL,SP
Criteria Tier
15.3.1
Potassium
K-tab 8 mEq
potassium chloride/SA
Effer-K
1
1
1
1
1
1
2
17
Drug name
15.3.2
Criteria Tier
Drug name
Suggested preferred
alternatives
Vashe wound therapy
Other electrolytes
calcium acetate
Phoslyra
1
16.8
3 calcium acetate
Cetylev
15.4.1
Miscellaneous Nutrition Products
Arginaid
Prekunil
Criteria Tier
Suggested preferred
alternatives
3
Antidotes
3
In addition to the prescription medications listed in this
formulary, a number of specific medications which are
administered by your physician are covered under the medical
portion of your policy.
3
Note: Only for patients diagnosed with
phenylketonuria; no copay
Chapter 16: Diagnostics and miscellaneous agents
16.1
etidronate disodium
risedronate 30 mg
sevelamer carbonate
sodium phenylbutyrate
Aralast
Carbaglu
Ferriprox
Formaldehyde
Fosrenol
Glassia
Increlex
Jadenu
Neutrasal
Orfadin
Prolastin
Ravicti
Renagel
Renvela susp
Skelid
Veltassa
Velphoro
Xuriden
Zemaira
16.2
1
1
1
1
SP
PA,QL,SP
PA,SP
2
2
3
1
3 sevelamer carbonate, Renagel
SP
PA, SP
PA, SP
2
PA, SP
SP, ST
SP
2
2
3
3
3
Aralast, Glassia
3
2
2
3
3
3
3
PA, SP
PA, SP
SP
2
Aralast, Glassia
Smoking Deterrents
All generic and single source brand smoking cessation prods are available at zero
copay under Health Care Reform benefits. You must present a prescription from
your physician at the pharmacy to obtain these prods.
bupropion SR
No copay—HCR benefit
nicotine patches (generic)
nicotine gum (generic)
nicotine lozenges (generic)
Chantix
Nicotrol
Nicotrol NS
16.3
Anorexiants
Weight loss medications are not covered by many benefit plans. You must have a
weight loss prescription rider in your BCNPEA Policy/Contract for any weight loss
medication to be covered. In addition, even with a weight loss rider in place, most
plans require prior authorization.
benzphetamine
PA
1
diethylpropion
PA
1
phendimetrazine
PA
1
phentermine
PA
1
Belviq
PA
3
Contrave
PA
3
Qsymia
PA
3
Saxenda
PA
3
Suprenza
PA
3
Xenical
PA
3
16.6
Irrgating Solutions
18
Quantity Limits:
Drug prod
Maximum quantity
per 30-day supply
Drug prod
Maximum quantity
per 30-day supply
Abstral SL
Aciphex
Actemra
Actonel with Calcium
Actoplus Met XR
120 tabs of one strength
30 pkts of one strength
4 syrs
28 tabs (1 pkt)
60 tabs of 15/1,000 OR
30 tabs of 30/1,000
60 tabs
30 tablets
Quantity will be determined at the
time of auth approval
30 tablets
2 twinpacks (4 syr)
60 tabs
240 capsules
30 tabs
6 tablets
30 tabs
8 patches
60 caps
60 tabs
30 tabs
30 patches of one strength
150 gm (2 x 75-gm pumps)
1 tab
4 vials
30 tablets of one strength
28 tabs of one strength (28-tab bottle)
2 units
4 vials/pens for 28 days
2 pump bottles
30 tabs
15 vials
56 doses (224 ml) every 60 days
4 doses
60 tabs
30 tabs
Max dose of 16 mg/day
Quantity will be determined at time
of auth approval
Max dose of 24 mg/6 mg per day
of auth approval
2 units
4 patches of one strength
4 doses
1 prefilled pen
30 tablets
10 tabs
9 pkts
30 tabs of 300 mg/ 60 tabs of 100 mg
30 tabs of either
Caverject
Impulse: 2 kits of 2 doses each
Injection: 6 doses (1 carton)
84 doses/28 days per each 60 days
60 caps (age: 18 yrs and under)
30 caps
60 caps
30 caps
3 vials
Adcirca 20 mg
Addyi 100 mg
Adempas
Adzenys XR-ODT, all strengths
Adrenaclick
Advicor
Afinitor
Alecensa 150 mg
alfuzosin
almotriptan 6.25, 12.5 mg
Altoprev
Alora
Amitiza
Ampyra ER
Amturnide
Androderm
Androgel
Anzemet
Aplenzin
Arcalyst
armodafinil 50, 150, 200, 250 mg
Aubagio
Auvi-Q
Avonex
Axiron soln
Baraclude
Belsomra 5, 10, 15, 20 mg
Betaseron
Bethkis 300 mg/4 ml
Binosto 70 mg
Bosulif 100, 500 mg
Brilinta 60,90 mg
Brisdelle 7.5 mg
buprenorphine tabs all strengths
buprenorphine/naloxone tabs
all strengths
butorphanol nasal spray
Butrans patches all strengths
Bydureon 2 mg
Byetta
Byvalson
cabergoline 0.5 mg
Cabometyx 20, 40, 60 mg
Cambia 50 mg pwd pks
Caprelsa (vandetanib)
Cardura XL 4, 8 mg tabs
Cayston
celecoxib 50 mg
celecoxib 100 mg
celecoxib 200 mg
celecoxib 400 mg
Chorionic gonadotropin
5,000, 10,000 units, generic
Cialis all strengths
Cimzia 200 mg
Cimzia starter kit
Climara patches
Climara Pro patches
Coartem
codeine
Cometriq
Continuous glucose sensors
Contraceptives
Conzip ER
Copaxone 20 mg
Copaxone 40 mg
Cordran patch
Cordran tape
Corlanor 5, 7.5 mg
Cosentyx syr/pens
Cotellic 20 mg
Cystaran Opth
Daliresp 500 mcg
Daklinza 30, 60, 90 mg
Daytrana 10, 15, 20, 30 mg
Desvenalafaxine ER 50 and 100 mg
DexCom G4 sensors
Diastat/Diastat Acudial/diazepam
rectal gel
diclofenac gel 1%
Dificid 200 mg
dihydroergotamine nasal spray
4 mg/ml
Duexis 800-26.6 mg
Duopa
Durlaza
Edarbi 40, 80 mg tabs
Edarbyclor
Edex
Edluar 5, 10 mg
Effient 5, 10 mg
Egrifta 1 mg, 2 mg vials
Eliquis 2.5, 5 mg
Embeda all strengths
Emend
Emend
Emend Suspension
Emsam 6, 9, 12 mg patches
19
4 tabs
6 vials for the first month only;
then 2 vials per month
1 starter kit to initiate therapy
4 patches
4 patches
24 tabs
Daily doses greater than 480 mg
require prior authorization
1 daily dose unit (dose is determined
at time of auth)
Sof-sensor 10 sensors/30 days
Enlite sensors 5 sensors/30 days
1 cycle per month
30 syrs
12 syrs
24 patches (2 boxes)
2 rolls
60 tabs
63 tabs/28 days
4 bottles
30 tabs
30 patches of any strength
4 sensors
1 box of 2 rectal delivery systems each
5x100 gm tubes
20 tabs
8 units
90 tabs
28 cassettes
30 capsules
4 vials OR kits
30 tabs of any strength
36 tabs the first fill, 30 tabs thereafter
30 vials of one strength
60 tabs
60 tabs
125 mg2, 80 mg4
2 of the tri-fold pack
6 packets
30 patches of any strength
Quantity Limits:
Drug prod
Maximum quantity
per 30-day supply
Drug prod
Maximum quantity
per 30-day supply
Emverm 100 mg
Enbrel
12 tablets
25 mg8 syrs, 50 mg4 syrs;
greater requires prior authorization
60 tablets
30 tablets
Quantity to be determined at time of
auth approval
Hetlioz 20 mg
Horizant ER 300, 600 mg
hydrocodone
30 caps
30 tabs
Quantity limit varies depending on
the diagnosis for which prior
authorization was approved
14 bottles (30 ml)
1 tab
21 caps
of auth approval
1 vial every 60 days
90/120 caps (diagnosis determined)
12 nasal spray devices
Entresto 49/51 mg and 97/103 mg
Envarsus XR, all strengths
Epclusa
Epi E-Z Pen/EZ Pen Jr epinephrine
auto-inject
Epipen
EpiPen Jr
Erivedge 150 mg caps
Esclim
esomeprazole 20, 40 mg
Estraderm
Estrasorb
Estrogel
Evamist
exemestane 25 mg
Extavia
Factive 320 mg
Fanapt starter pack
Farxiga 5, 10 mg
Farydak 10, 15, 20 mg
hydromorphone ER (Exalgo equiv)
Hysingla ER
Humira
2 units
IB Oral Spray
ibandronate 150 mg
Ibrance 75, 100, 125 mg
Iclusig 15, 45 mg
2 units
2 units
28 caps/28 days
8 patches
30 caps
8 patches
1 carton of 56 pouches
One 50-gm pump
1 metered-dose pump
30 tabs
15 vials
7 tabs
1 pack
auth approval
fentanyl patches 12, 25, 50, 75, 100 10 patches
Fentanyl patches 37.5, 62.5, 87.5
10 patches
Ferriprox
auth approval
Fibricor
30 tabs
Flector Patches
30 patches
Forfivo XL 450 mg
30 tabs
Fortesta Gel Pump, 60 gm
1 unit
Fosamax Plus D 70 mg/2,800 IU
4 tabs
frovatriptan 2.5 mg
9 tabs
Fulyzaq 125 mg
60 tabs
Gattex
30 doses
Gelnique 10%
30 sachets
Gelnique 3%
1 gel pump
Gilenya 0.5 mg
28 caps/28 days
Gleostine 10, 40, 100 mg
auth approval
Golytely
1 pkt
Glyxambi 10/5, 25/5
30 tabs
Glucagon
2 vials
Glucose meter
1 meter every 390 days
Glucose meter strips
150 strips
Glucose sensors, continuous
10 sensors
Gralise
30 of the 300 mg tabs,
90 of the 600 mg tabs, 1 starter kit
granisetron
10 tabs
Grastek
30 tabs
Growth hormone (all)
auth approval
Gynazole 1
1 package
Harvoni
28 tabs (length of therapy
determined at time of approval)
Hepsera
30 tabs
Ilaris 180-mg vials
Imbruvica 140 mg
Imitrex/sumatriptan 5, 20 mg
nasal spray
Imitrex/sumatriptan/Alsumta syr
(injection) 4, 6 mg
Infergen 9, 15 mcg
I-port
Invokamet
Invokana 100, 300 mg
Jakafi 5, 10, 15, 20, 25 mg
Janumet
Januvia 25, 50 , 100 mg
Jardiance 10, 25 mg
Jentadueto all strengths
Jentadueto XR 2.5-1000
Jentadueto XR 5-1000
Jublia
Juxtapid all strengths
Kadian ER
10, 40, 70, 130, 150, 200 mg
Kalydeco 150 mg
Kalydeco 50-, 75-mg pkts
Kapvay ER
Kazano and alogliptin/metformin all
strengths
Kerydin
Ketek 300, 400 mg
ketorolac
Keveyis
Kineret
Kombiglyze XR 2.5/1,000
Kombiglyze XR 5/500, 5/1,000
Korlym 300 mg
Kynamro
lamotrigine starter pack
Latuda 20, 40, 80, 120 mg
Lazanda, all strengths
Lenvima 8,10, 14, 18, 20, 24 mg
20
4 syrs/vials
12 vials OR syrs
1 box (10 systems)
60 tabs
30 tabs
of auth approval
60 tabs
30 tabs
60 tablets
30 tablets
1 bottle
of auth approval
30 caps of one strength
60 tabs
60 pkts of one strength
60 tabs of any strength/1 dose pack
60 tabs
1 bottle
20 tabs
Maximum daily dosage of 40 mg and
limited to a five-day supply within a
90-day period
auth approval
auth approval
60 tabs
30 tabs
auth approval
4 doses
1 pack of each strength
30 tabs of any one strength
90 doses
Quantity Limits:
Drug prod
Letairis 5, 10 mg
Levitra
Linzess 145, 290 mg
Liptruzet all strengths
Livalo 1, 2, 4 mg
Lonsurf tablets
Lynparza 50 mg
Lyrica caps
Lyrica oral soln
Makena 250 mg/ml, 1 ml vial
memantine dose pack
methylphenidate CD all strengths
Migranal 1 mg/ml
Minivelle patch all strengths
modafinil 100, 200 mg
Monurol
Morphine SO4 ER
(Kadian equivalent)
20, 30, 50, 60, 80, 100 mg
Movantik 12.5, 25 mg
Moviprep
MuGard Oral Rinse
Muse
Myalept
Maximum quantity
per 30-day supply
Drug prod
Maximum quantity
per 30-day supply
auth approval
30 tabs
4 tabs
30 tabs
auth approval
480 caps
Max of 600 mg/day
2x 473 ml
4x 1 ml
1 pack
8 ampules
8 patches
30 tabs of the 100 mg OR
60 tabs of the 200 mg
1 sachet
30 caps
Oravig 50 mg
Orencia 125 mg syr or Clickjet
Orkambi
Oseni and alogliptin/pioglitazone- all
strengths
Osphena 60 mg
Otezla 10, 20, 30 mg
Otezla starter pack, 14 day/ 28 day
oxycodone (short acting)
14 buccal tabs
4 doses
120 tablets
30 tabs
Oxycodone ER
Oxycontin
(all strengths except 80 mg)
Oxycontin 80 mg
Oxytrol patches all strengths
PEG-Intron all strengths
Pegasys 180 mcg
Peak Flow meters
Pennsaid 2% soln
Pexeva 10, 40 mg
Pexeva 20, 30 mg
Picato gel 0.015%, 0.05%
Plan B
Pomalyst 1, 2, 3, 4 mg
30 tabs
60 tabs
1 starter pack
120 of the 80 mg OR
90 of all other strengths
120 of the 80 mg OR
90 of all other strengths
120 tabs
8 patches
4 units
4 syrs OR one convenience pack
Maximum of 2 per year
2x 112 gm bottle
30 tabs
60 tabs
1 pkg of one strength
1 unit
auth approval
Pradaxa 75, 110, 150 mg
Praluent 75 mg, 150 mg
2 doses of one strength
Pregnyl
3 vials
Prepopik pwd pkt
1 unit
Prevacid solutabs 15, 30 mg
30 solutabs
Prevpak patient pack
1 pack (14-package size)
Pristiq 50, 100 mg
Profasi
3 vials
Promacta 12.5, 25, 50 mg
30 tabs of one or more strengths
Pulmicort Respules 0.25, 0.5 mg/2ml 70 ampules
Qsymia all strengths
30 caps
Ragwitek
30 tabs
Ranexa 500 mg
60 tabs
Rayos 1, 2, 5 mg
30 of the 5 mg OR 60 of 1, 2 mg tabs
Rebif all dosage forms
12 units per 28 days
Rectiv 0.4% Gel
30 gm
Regranex 0.01% gel 15 gm
15 gm/30 days, 45 gm/365 days
Relenza
20 blisters (max of 2x 365 days)
Relistor all strengths
2 kits (14 vials) OR 15 vials
Relpax 20 mg
12 tabs
Relpax 40 mg
6 tabs
Repatha syringes
auth approval
Repatha Pushtronex
1 unit
Requip Starter Kit
1 kit (home delivery or retail)
Revlimid all strengths
auth approval
Rexulti 0.25, 0.5, 1,2,3,4 mg
rivastigmine patches, all strengths 4 patches
rizatriptan/rizatriptan ODT 5, 10 mg 12 tabs
Rozerem 8 mg
30 tabs
Samsca 30, 60 mg
10 tabs
1 bottle
6x 8-oz bottles
4 urethral supp
of auth approval
Myrbetriq 25, 50 mg
Namenda XR
30 caps OR one titration pack
Namzaric all strengths
naratriptan 1, 2.5 mg
Narcan Nasal Spray
4 doses
Natesto
3 pumps
Natpara
auth approval
Nesina and alogliptin all strengths
30 tabs
Nebupent
1 container (inhaler)
Neulasta
2 syrs
Neumega
21 vials
Neupro all strengths
30 patches
Nexium pkts
30 pkts
next choice
1 unit
Nitromist/nitroglycerin spray
1 unit (only 4.1, 4.9 gm size covered)
Nuedexta 20-10 mg
60 caps
Nuplazid 17 mg
60 tablets
Ocaliva 5,10 mg tabs
30 tablets of one strength
Odomzo 200 mg capsules
30 capsules
Oleptro ER 150, 300 mg tabs
60 of the 150 mg tabs OR
30 of the 300 mg tabs
Olysio 150 mg
30 caps
Omeclamox-Pack
1 pack
Omnaris Nasal
2 units
Onglyza 2.5, 5 mg
Onmel 200 mg
28 tabs
Onsolis 200, 400, 600, 800, 1200 mcg 90 soluble films of one strength
Onzetra Xsail
1 pkt with 8 doses
Opsumit 10 mg
30 tabs
Oralair
30 tabs (also titrating dose for children)
21
Quantity Limits:
Drug prod
Maximum quantity
per 30-day supply
Drug prod
Maximum quantity
per 30-day supply
Sancuso patch 3.1 mg
Saphris 2.5, 5, 10 mg
Savaysa 15, 30, 60 mg
Savella 12.5, 25, 50, 100 mg
Saxenda
Sidekick monitor
Signifor amps
Sklice 0.5% Lot
sildenafil 20 mg (for PAH)
Silenor 3, 6 mg
Simponi 50 mg
Sivextro 200 mg
1 patch
5 pens
3 units
60 doses
1 tube (4 oz)
90 tabs
One 0.5 ml syr
6 tabs
Uptravi dose--pack
Uptravi 200, 400, 600, 800, 1000,
1200,1400, 1600 mcg tabs
V-go Insulin delivery device
Valturna all strengths
Vascepa 1 gm
Vecamyl
Sovaldi 400 mg
28 tabs (length of therapy
Maximum of 2 per year
2x 120 ml bottles
30 caps
5 bottles ( 1 pkg)
4 ODT tabs
4 tabs
120 tabs
60 caps
Qty determined at time of auth
approval
Qty determined at time of auth approval
4 injections
auth approval
Quantity based on weight
60 tablets
30 tablets
Qty determined at time of auth
approval
10 caps (max of 2x/365 days)
3 bottles (max of 2x/365 days)
4 doses
1 starter pack OR 60 of the 240 mg caps
1 carton containing 28 days supply
30 tabs
30 tabs
1 tube of the 20 gm size
1 box of 3 suppositories
One 45-gm tube
30 of the 25 mg OR
60 of the 50 mg OR
2x 75-gm bottles
56 ampules every 60 days OR
Podhaler, box of 4 weekly packs/
60 days
30 tabs
30 tabs/caps of one strength
30 tabs
9 tabs
30 tabs
6 bottles
1 starter dose-pack
Quantity to be determined at the
30 units
30 tabs
120 caps
1 starting pack
30 tabs
4 tabs (males over 18)
28 day supply (length of therapy
1 package
2 or 3 pens (determined by PA)
360 caps, length of therapy
determined by auth
20 packets
30 tablets
120 tabs
Spacers for Inhalation
spinosad 0.9% topical susp
Spiriva
Sprix nasal spray
Staxyn
Stendra
Stivarga 40 mg
Strattera (up to 100 mg daily)
Strensiq 18, 28, 40, 80 mg
Subsys all strengths
Sumavel dosepro
Sutent all strengths
Sylatron
Synjardy, all strengths
Tagrisso 40, 80 mg
Taltz syringes/pens
Tamiflu 75 mg
Tamiflu for oral susp 6 mg/ml
Tanzeum Pen Injectors
Tecfidera
Technivie
Tekamlo
Tekturna all strengths
Tekturna HCT all strengths
terconazole 3 cream 0.8%
Terazol 3 supp
terconazole 7 cream 0.4%
Testosterone gel
TOBI/TOBI Podhaler/
tobramycin neb soln
Tradjenta 5 mg
tramadol ER
tranexamic acid 650 mg
Treximet
Tribenzor
Uceris 9 mg ER tabs
Ulesfia lot
Uloric 40, 80 mg
Venclexta starting pack
Vesicare
Viagra
Viekira Pak/Viekira XR
Viibryd
Viibryd Starter pack
Victoza
Victrelis 200 mg
Viekira/Viekira XR
Vimovo
Vistogard 10 gm
Vivlodex 5 mg, 10 mg
Votrient 200 mg
Vogelxo gel
Vytorin
Xalkori
Xartemis XR
Xeljanz 5 mg
Xeljanz XR 11 mg
Xiidra Eye Drops
Xtampza XR 9, 13.5, 18, 27, 36 mg
Xtandi 40 mg
zaleplon 5 mg
zaleplon 10 mg
Zegerid
Zelboraf 240 mg
Zembrace 4 mg syr
Zetia
Zinbryta 150 mg syringes
Zohydro ER
zolmitriptan/zolmitriptan ODT
2.5, 5 mg tabs
zolpidem 5, 10 mg
zolpidem ER 6.25, 12.5 mg
zolpidem sublingual, 1.75, 3.5 mg
Zolpimist
Zomig nasal spray
Zortress 0.25, 0.5, 0.75 mg
Zuplenz film strips
Zydelig 100, 150 mg
Zykaydia 150 mg
Zytiga 250 mg
22
30 tubes OR
30 pkts OR 2x 75-gm gel pumps
30 tabs
120 tabs
60 tabs
30 tabs
1 pkt of 60
90 capsules
120 caps
30 caps
60 caps
30 packs
240 tabs
2 pkts of 4 syringes
30 tabs
4 syringes
60 tabs
6 tabs
30 tabs
30 tabs
30 tabs
7.7 ml (1 bottle)
6 bottles
60 tabs
10 strips
150 caps
120 tabs
Inhaler/Ophthalmic Quantity Limits:
Drug prod
Strength per dose
Package size
Maximum 30-day Maximum 90-day
supply (retail)
supply (home delivery)
Advair Diskus
Advair Diskus
Aerospan
Alvesco
Alupent (metaproterenol)
Anoro Ellipta (umeclidinium/vilanterol)
Arcapta Neohaler /caps (indacaterol maleate)
Arnuity Ellipta
Asmanex (mometasone)
Asmanex HFA (mometasone)
azelastine Nasal Spray (astelin equiv)
azelastine Nasal Spray (astepro equiv)
Atrovent HFA
Beconase AQ
Bevespi Aerosphere
Breo Ellipta
Breo Ellipta
Brovana
Children’s Qnasl
Combivent Respimat
Dulera
DuoNeb
Flonase AQ
flunisolide
Foradil Aerolizer/Caps
Foradil Aerolizer/Caps
Incruse Ellipta
Intal Inhaler
Intal Inhaler
ipratropium nasal inhaler 0.06%
ipratropium nasal inhaler 0.03%
Maxair Autohaler
mometasone nasal
Pazeo ophthmalic
Perforomist
ProAir HFA
Proventil HFA
Pulmicort Turbuhaler
budesonide Respules
Qnasal nasal spray `
Qvar
Rhinocort AQ
Seebri Neohaler
Serevent Diskus
Serevent Diskus
Spiriva Respimat
Stiolto Respimat
Striverdi Respimat
Symbicort
100/50, 250/50, 500/50
100/50, 250/50, 500/50
80 mcg
80 mcg and 160 mcg
0.65 mg
62.5 mcg/vilanterol 25 mcg
75 mcg
100 mcg, 200 mcg
220 mcg
100 mcg, 200 mcg
137 mcg
0.15%
14 mcg
42 mcg
9/4.8 mcg
100 mcg/25 mcg
200 mcg/25 mcg
15 mcg
40 mcg
20/120 mcg
100 mcg/5 mcg, 200 mcg/5 mcg
2.5-0.5/3 ml
50 mcg
25 mcg
12 mcg
12 mcg
62.5 mcg
800 mcg
800 mcg
42 mcg
21 mcg
200 mcg
50 mcg
0.7%
20 mcg
90 mcg
90 mcg
200 mcg
0.25, 0.5 mg, 1 mg
80 mcg
40 mcg and 80 mcg
32 mcg
15.6 mcg
50 mcg
50 mcg
1.25 mcg and 2.5 mcg
2.5 mcg/2.5 mcg
2.5 mcg
80/4.5, 160/4.5
28 blisters
60 blisters
8.9 gm (120 doses)
6.1 gm
14 gm
1 units (30 doses)
30 caps
30 doses
30, 60, 120 doses
13 gm (120 doses)
30 ml
30 ml
12.9 gm
25 gm
120 doses
60 doses
60 doses
60 doses
60 doses (1 unit)
4 gm
13 gm
3 ml
16 gm
25 ml
18
60
30 doses (1 unit)
8.1 gm
14.2 gm
15 ml
30 ml
14 gm
17 gm
4 ml
60 dose box
8.5 gm
6.7 gm
200-dose
30-dose box
8.7 gm
7.3 gm
8.6 gm
60 inhalations
28/box
60/box
60 doses
60 inhalations
60 inhalations
60 inhalations
1
2
2
2
3
1
1
1
2
1
2 bottles
2 bottles
2
2
1 canister
1 unit
1 unit
1x 60
1 unit
3
2
210
2
3
4
2
1
2
2
3
2
1
2
1
1
2
2
2
2
1
3
3
1
1
2
1
1
1
2
Symbicort
Tilade
Tudorza Pressair 400 mcg
Utibron Neohaler
Ventolin HFA
80/4.5, 160/4.5
1.75 mg
400 mcg
27.5/15.6 mcg
90 mcg
120 inhalations
16.2 gm
60 inhalations
60 inhalations
18 gm
2
3
1
1
2
Inhalers
23
0
6
6
6
9
3
3
3
6
3
6 bottles
6 bottles
6
6
3 canisters
2 units
2 units
3x 60
3 units
9
6
630
6
9
0
6
3
6
6
9
6
3
6
3
3
6
6
6
6
3
9
9
3
0
6
3
3
3
6 of the 120-inhalations
(60-inhalation canister
not covered by mail)
6
9
3
3
6
Inhaler/Ophthalmic Quantity Limits:
Drug prod
Strength per dose
Package size
Maximum 30-day Maximum 90-day
supply (retail)
supply (home delivery)
Veramyst Nasal Spray
Xopenex HFA inhaler
Zetonna nasalsSpray
27.5 mcg
45 mcg
37 mcg
10 gm
15 gm
6.1
2
2
1
24
6
6
3
Index
A
Abilify, see aripiprazole
Absorbica, 5.3
Abstral SL, 3.1.1
Acanya, 5.3
acarbose, 7.5.2
Accu-Chek, 7.5.4
Accu-Chek Active, 7.5.4
Accu-Chek Aviva Plus/Connect,
7.5.4
Accu-Chek Compact Plus, 7.5.4
Accu-Chek Safe-T-Pro, 7.5.4
Accu-Chek Smartview, 7.5.4
Accu-Chek Softclix, 7.5.4
Accu-Chek SoftTouch, 7.5.4
acetaminophen/codeine, 3.1.2
Acetazolamide, 12.5
acetic acid, acetic acid HC, 6.2
acetylcysteine, 13.3.6
Aciphex, 8.1.4 and see
rabeprazole
Aclovate, see alclometasone
Actemra, 10.3.2
Acthar H.P., 7.3
Acticlate, 1.2
Actimmune, 9.1.3
actinin, 5.11
acitretin, 5.10
Actonel, see risedronate
Actonel with Calcium, 10.4
Actoplus Met XR, 7.5.2
Acuvail , 12.7
acyclovir, 5.6
Aczone, 5.3
adapalene, 5.3
Adapalene, 5.3
Adcirca, 13.3.6
Adderall, 3.9.4
Adderall XR, 3.9.4
Addyi, 3.9.4
adefovir dipovoxil, 1.8.1
Adempas, 13.3.6
Adrenaclick, 13.3.6
Advair Diskus, Advair HFA, 13.3.6
Advicor, 4.6
Adzenys XR-ODT, 3.9.4
Aerospan, 13.3.4
Afrezza, 7.5.1
Afinitor, 2.1.6
Aggrenox, see
aspirin/dipyridamole
Akurza, 5.9
alagesic, 3.4.1
albuterol, 13.3.3
albuterol/ER tabs, 13.3.3
Alcet, 3.1.1
Alclometasone, 5.1.4
Alcortin-A, 5.4
Aldex Chewables, 13.1.1
Alecensa, 2.1.6
alendronate, 10.4
Alevicyn, 5.12
Alfuzosin , 14.5
Alinia, 1.11.1
All factor prods, 4.4.5
allanderm-T, 5.12
allopurinol, 10.2
Allzital, 3.1.2
almotriptan, 3.4.1
Alocril, 12.15
alogliptin, 7.5.2
alogliptin/metformin, 7.5.2
alogliptin/pioglitazone, 7.5.2
Alomide, 12.15
Alora, 11.3.2
alosetron, 8.3.3
alprazolam, 3.9.5
alprazolam ER, 3.9.5
alprazolam ODT, 3.9.5
Alrex, 12.11
Alsuma, 3.4.1
Altabax, 5.4
Altoprev, 4.6
aluminum acetate, 5.12
Aluvea, 5.12
Alvesco, 13.3.4
Amcinonide, 5.1.2
amiloride, 4.5.1
amiloride /HCTZ, 4.5.1
amino acid vaginal cream, 11.4.2
Aminocaproic Acid, 4.4.5
aminocaproic acid, 4.4.5
amiodarone, 4.1
Amitiza, 8.3.3
amitriptyline, 3.9.2.1
amlodipine, 4.5.3.2
amlodipine/benazepril, 4.5.8
amlodipine/valsartan, 4.5.8
amlodipine/valsartan/HCTZ,
4.5.8
amnesteem, 5.3
amoxicillin, 1.1
Amoxicillin ER, 1.1
amoxicillin/potassium
clavulanate, 1.1
amphetamine salt combo, 3.9.4
amphetamine salt combo ER,
3.9.4
ampicillin, 1.1
Ampyra, 3.7
Amturnide, 4.5.9
Anadrol-50, 7.4.1
anagrelide, 2.1.6
Analpram HC, 8.3.3
AnaMantle HC, 8.3.3
AnaMantle HC Forte Cream,
8.3.3
anastrozole, 2.1.6
Androderm, 7.4.1
Androgel, 7.4.1
Androgel packets, see
testosterone
Angeliq, 11.3.3
Anoro Ellipta, 13.3.6
antipyrine/benzocaine, 6.2
antispasmodic elixir, 8.2.3
Anzemet, 8.3.4
apap/caffeine/dihydrocodeine,
3.1.2
Apidra, 7.5.1
Aplenzin, 3.9.2.2
Apokyn, 3.5
Apop, 5.3
Apriso, 8.3.3
Aptensio XR. 3.9.4
Aptiom, 3.6
Aquaphilic/Triamcin , 5.12
Aquoral, 6.4
Aptensio XR, 3.9.4
Aralast, 16.1
Aranesp, 9.1.1
Arcalyst, 9.1.5
Arcapta, 13.3.3
Arginaid, 15.4.1
Aricept, see donepezil
aripiprazole/aripiprazole odt,
3.9.3.3
armodafinil, 3.9.4
Armour Thyroid, 7.2
Arnuity Ellipta, 13.3.4
Asacol HD, 8.3.3
Asmalpred Plus, 7.3
Asmanex/HFA, 13.3.4
aspirin/dipyridamole, 4.4.2
Astagraf XL, 2.1.6
AsTech, 7.5.4
Astepro, see azelastine nasal
Asthma Mentor, 7.5.4
Asthma Pack III, 7.5.4
Atelvia, see risedronate, dr
atenolol, 4.5.2
atenolol/chlorthalidone, 4.5.8
Atopiclair, 5.12
atorvastatin, 4.6
atorvastatin/amlodipine, 4.6
atovaquone, 1.11.2
atovaquone-proguanil, 1.11.3
Atrapro, 5.12
atropine, 12.6
Atrovent HFA, 13.3.6
Atrovent, 13.3.6
Aubagio, 3.7
Aurax, 6.2
Auvi-Q, 13.3.6
Avandamet, 7.5.2
Avandaryl, 7.5.2
Avandia, 7.5.2
Avar/Avar LS, 5.3
Avar-E LS, 5.3
Avelox, Avelox ABC, see
moxifloxacin
Avidoxy, 1.2
Avinza, see morphine SO4 ER
Avita, 5.3
Avodart, see dutasteride
Avonex, 9.1.3
Axert, see almotriptan
Axiron, 7.4.1
Azasite, 12.9
azathioprine, 2.1.6
azelastine, 12.15
azelastine, 6.4
Azelex, 5.3
Azilect, 3.5
azithromycin, 1.4.1
Azmacort , 13.3.4
Azopt, 12.4
Azor, 4.5.8
Azulfidine En-Tab, 8.3.3
B
baclofen, 3.8.1
balsalazide, 8.3.3
Banzel, 3.6
B-D prods, 7.5.4
Beconase AQ, 13.3.5
belladonna/phenobarb, 8.2.3
Belsomra, 3.9.1
Belviq, 16.3
benazepril, 4.5.4
benazepril HCT, 4.5.8
bendroflumethiazide, 4.5.8
Benicar, 4.5.9
Benicar HCT, 4.5.8
25
Benzaclin, see
Benzefoam Ultra, 5.3
Benzefoam, 5.3
benzonatate, 13.2.1
benzoyl peroxide, 5.3
benzphetamine, 16.3
benztropine, 3.5
Bepreve, 12.15
Besivance, 12.9
betamethasone, 1.9
Betamethasone, 5.1.2
Betaseron, 9.1.3
betaxolol, 4.5.2
Betaxolol, 12.1
bethanechol, 14.1
Bethkis, 1.11.1
Betimol, 12.1
Betoptic S, 12.1
Bevespi, 13.3.6
bexarotene, 2.1.6
Beyaz 28, 11.1.1
bicalutamide, 2.1.6
bicarbonate, 8.1.4
Bicillin CR/Bicillin LA, 1.1
BiDil, 4.5.7
bimatoprost, 12.4
Binosto, 10.4
bisoprolol fumarate, 4.5.2
bisoprolol fumarate /HCTZ, 4.5.8
borofair otic, 6.2
Bosulif, 2.1.6
BP wash, 5.3
Benzoyl, 5.3
Bevespi, 13.3.6
BPS gel, 5.3
Breeze-2 (Bayer), 7.5.4
Breo Ellipta, 13.3.6
Brevoxyl, 5.3
Bright Beginnings Bar, 15.1
Brilinta, 4.4.2
brimonidine tartrate , 12.14
Brintellix, see Trintellix
Bionect, 5.12
Brisdelle, 3.9.2.4
Briviact, 3.6
bromfenac, 12.7
bromocriptine mesylate, 3.5
Briviact, 3.6
Brovana, 13.3.3
budesonide ec, 8.3.3
budesonide nasal, 13.3.5
budesonide neb, 13.3.4
bumetanide, 4.5.1
buprenorphine tabs, 3.1.1
buprenorphine/naloxone, 3.1.2
bupropion HCl, SR, XL, 3.9.2.2
bupropion SR, 16.2
buspirone HCl, 3.9.5
butalbital compound, 3.4.1
butalbital/apap, 3.4.1
butorphanol, 3.3.3
Butrans, 3.1.1
Bydureon, 7.5.2
Byetta, 7.5.2
Bystolic, 4.5.2
Byvalson, 4.5.8
C
Cabergoline, 7.4.3
Cabometyx, 2.1.6
Index
calcipotriene/betamethasone,
5.10
calcipotriene oint/soln/cream,
5.1
Calcitrene, 5.1
calcitriol, 7.4.3
Calcitriol, 5.1
calcium acetate , 15.3.2
Cambia, 3.3.1
Campral, 3.9.4
Canasa, 8.3.3
candesartan, 4.5.9
candesartan/HCTZ, 4.5.9
capecitabine, 2.1.2
Caphosol, 6.4
Caprelsa (vandetanib), 2.1.6
captopril, 4.5.4
captopril /HCTZ, 4.5.8
Carac, 5.12
Carbaglu, 16.1
carbamazepine ER, 3.6
carbamazepine/XR, 3.6
carbidopa/levodopa, 3.5
Carb-o-philic, 5.12
Cardene SR, 4.5.3.2
Cardizem LA, 4.5.3.2
Cardura XL, 4.5.5
carisoprodol, 3.8.1
carteolol HCl, 12.1
cartia XT, 4.5.3.2
Cartrol, 4.5.2
carvedilol, 4.5.2
Catapres-TTS, see clonidine
Caverject, 14.4
Cayston, 1.11.1
Cedax, see ceftibuten
cefaclor/cefaclor ER, 1.3
cefadroxil, 1.3
cefditoren pivoxil, 1.3
cefixime, 1.3
ceftibuten, 1.3
Celebrex, see celecoxib
celecoxib, 3.3.1
Cellcept, see mycophenolate
mofetil
cem-urea, 5.12
Cenestin, 11.3.2
Cerdelga, 7.4.3
Cerezyme, 7.4.3
Cetraxal, 6.2
Cetrotide, 7.4.4
Cetylev, 16.8
cevimeline, 6.4
Chantix, 16.2
Chenodal, 8.3.3
Children’s Qnasl, 13.3.5
chlorhexidine rinse, 6.4
chloroquine, 1.11.3
chlorothiazide, 4.5.1
chlorpheniramine drops, 13.2.1
chlorzoxazone, 3.8.1
Cholbam, 8.3.1
cholestyramine/light, 4.6
choline and magnesium
trisalicylate, 3.3.2
Cialis, 14.4
ciclopirox, 5.5
cilostazol, 4.4.2
Ciloxan, 12.9
cimetidine, 8.1.1
Cimzia, 8.3.3
Cinryze, 13.3.6
Cipro HC, 6.2
Cipro Susp, see ciprofloxacin
Cipro XR, see ciprofloxacin ER
Ciprodex, 6.2
ciprofloxacin, 1.5.1
ciprofloxacin ER, 1.5.1
ciprofloxacin, 6.2
ciprofloxin, 12.9
citalopram, 3.9.2.4
claravis, 5.3
Clarinex D, 13.2.3
clarithromycin, 1.4.1
clarithromycin ER, 1.4.1
Cleocin, 11.4.2
Climara , 11.3.2
Climara Pro, 11.3.3
clindamycin HCl, 1.11.1
clindamycin phosphate, 5.3
clindamycin vag cream, 11.4.2
clindamycin/benzoyl peroxide,
5.3
clindamycin/tretinoin, 5.3
Clindareach, 5.3
Clindesse, 11.4.2
clobetasol propionate , 5.1.1
Clocortolone Pivalate, 5.1.3
Cloderm, 5.1.3
clomiphene, 7.4.2
clomipramine, 3.9.2.1
clonazepam, 3.6
clonidine, 4.5.5
clonidine patch, 4.5.5
clopidogrel, 4.4.2
clopidogrel, 4.4.2
clotrimazole troche, 1.9
clotrimazole/betamethasone,
5.5
clozapine/clozapine ODT, 3.9.3.3
Coartem, 1.11.3
Codeine SO4, 3.1.1
Colchicine, 10.2
Colcrys, 10.2
Colestid, 4.6
colestipol, 4.6
CoLyte, 8.3.3
Combigan, 12.4
Combipatch, 11.3.3
Combivent Respimat, 13.3.6
Cometriq, 2.1.6
Compazine, see prochlorperazine
Condylox, 5.12
sensors, 7.5.4
system, 7.5.4
Contour test strips, 7.5.4
Contour Next test strips, 7.5.4
Contrave, 16.3
Conzip ER, 3.3.3
Copaxone, 9.1.3
Cordran, 5.1.3
Coreg CR, 4.5.2
Corlanor, 4.7
cortisone, 7.3
Cosentyx, 5.10
Cosopt PF, 12.4
Cotellic, 2.1.6
covaryx, 11.3.3
covaryx HS, 11.3.3
Creon, 8.3.2
Cresemba, 1.9
Crestor, see rosuvastatin
Crinone, 11.3.1
cromolyn sodium, 13.3.6
cromolyn sodium, 12.15
Cuvposa, 8.2.2
cyclobenzaprine/
cyclo-benzaprine ER, 3.8.1
cyclopentolate, 12.6
cyclophosphamide, 2.1.6
Cyclophosphamide, 2.1.6
Cycloset, 7.5.2
cyclosporine, 2.1.6
Cyclosporine, 2.1.6
Cymbalta, see duloxetine
cyproheptadine, 13.1.1
Cystadane, 8.3.3
Cystaran, 12.15
D
Daklinza, 1.8.1
Daliresp, 13.3.6
danazol, 7.4.1
dantrolene, 3.8.1
dapsone, 1.11.1
darifenacin, 14.2
Daytrana, 3.9.4
DDAVP, 7.4.3
Delestrogen, 11.3.2
Delos, 5.3
Delzicol, 8.3.3
demeclocycline, 1.2
Depo-SubQ Provera, 11.3.1
Dermatop E, 5.1.3
desipramine, 3.9.2.1
desloratadine, 13.1.1
desmopressin, 7.4.3
Desonate, 5.1.4
Desonide, 5.1.4
Desoximetasone, 5.1.4
Desoxyn, 3.9.4
Desvenlafaxine, 3.9.2.2
Detrol LA, see tolterodine ER
dexamethasone, 7.3
dexamethasone, 12.11
DexCom SEVEN Plus/G4
Platinum, 7.5.4
Dexedrine, 3.9.4
Dexilant (formerly Kapidex),
8.1.4
dexmethylphenidate, 3.9.4
dexmethylphenidate ER, 3.9.4
dextroamphetamine, 3.9.4
Diastat/Diastat Acudial, 3.6
diazepam, 3.9.5
diazepam rectal gel, 3.6
Dibenzyline, see
phenoxybenzamine
Diclegis, 8.3.4
diclofenac, 3.3.1
diclofenac gel 1%, 3.3.1.1
diclofenac-misoprostol, 3.3.1
dicloxacillin, 1.1
dicyclomine, 8.3.2
Didronel, see etidronate
diethylpropion, 16.3
Differin, 5.3
Differin, see adapalene
Dificid, 1.11.1
Difil-G/Forte, 13.3.1
diflorasone diacetate , 5.1.1
diflunisal, 3.3.2
26
digoxin, 4.2
dihydroergotamine, 3.4.1
diltiazem, diltiazem ER, diltiazem
SR, diltiazem SA, 4.5.3.2
Diovan, see valsartan
Dipentum, 8.3.3
Diphenoxylate/atropine, 8.2.1
Diprolene, Diprolene AF, 5.1.2
dipyridamole, 4.4.2
disopyramide phosphate, 4.1
dispas, 8.3.2
disulfiram, 3.9.4
divalproex/ER/sprinkes, 3.6
Divigel, 11.3.2
dofetilide, 4.1
Dologesic, 3.3.3
Domeboro otic, 6.2
donepezil/donepezil ODT, 3.7
Doryx, 1.2
Doryx MPC, 1.2
dorzolamide HCl, 12.4
dorzolamide HCl/timolol, 12.4
Dovonex, 5.1
doxazosin mesylate, 4.5.5
doxepin, 3.9.2.1
doxepin cream 5.12
doxercalciferol, 7.4.3
doxycycline, 1.2
doxycycline hyclate/
monohydrate/ER/DR, 1.2
Doxycycline IR/ER, 1.2
drithocreme HP, 5.1
dronabinol, 8.3.4
Duavee, 11.3.3
Duexis, 3.3.1
Dulera, 13.3.6
duloxetine, 3.9.2.2
Duoneb, see ipratropium/
albuterol
Duopa, 3.5
dutateride, 14.5
Durabac, 3.8.1
Durasal, 5.9
Duraxin, 3.3.2
Durezol, 12.11
Durlaza, 4.4.2+
dutasteride/tamsulosin, 14.5
Dutoprol, 4.5.8
Dyanavel XR, 3.9.4
dyphylline, 13.3.1
Dyrenium, 4.5.1
E
EasiVent chamber, 7.5.4
Easy Touch syrs, 7.5.4
econazole, 5.5
Ecoza, 5.5
Edarbi, 4.5.9
Edarbyclor, 4.5.9
Edecrin , see ethacrynic acid
Edex, 14.4
Edluar, 3.9.1
Effer-K, 15.3.1
Effient, 4.4.2
Egrifta, 9.1.4
Elaprase, 7.4.3
Elelyso, 10.4
Elestrin, 11.3.2
Elidel, 5.12
Eligen B12, 15.1
Eliquis, 4.4.1
Index
Elmiron, 14.4
Elocon, 5.1.3
Emadine, 12.15
Embeda, 3.1.1
Emend, 8.3.4
Emsam, 3.9.2.3
Emverm, 1.11.2
Enablex, see darifenacin
enalapril maleate, 4.5.4
enalapril maleate /HCTZ, 4.5.8
Enbrel , 10.3.2
Endocet, 3.1.2
Endometrin, 11.3.1
Enjuvia, 11.3.2
enoxaparin, 4.4.3
Enstilar, 5.10
entacapone, 3.5
entacapone, 3.5
entecavir, 1.8.1
Entresto, 4.7
Envarsus XR, 2.1.6
Epclusa, 1.8.1
Epiduo/Epiduo Forte, 5.3
Epinastine, 12.15
epinephrine, 13.3.6
EpiPen/EpiPen Jr, 13.3.6
Epivir-HBV, see lamivudine
eplerenone, 4.5.1
Epogen, 9.1.1
epoprostenol, 4.5.7
eprosartan, 4.5.9
eprosartan/HCTZ, 4.5.9
Equetro, 3.6
Erivedge, 2.1.6
Ertaczo, 5.5
Erythromycin , 12.9
Erythromycin , 1.4.1
erythromycin , 5.3
erythromycin/benzoyl peroxide,
5.3
Esbriet, 13.3.6
escitalopram, 3.9.2.4
esomeprazole, 8.1.4
estazolam, 3.9.1
Estraderm, 11.3.2
estradiol, 11.3.2
estradiol/norethindrone, 11.3.3
Estrasorb, 11.3.2
Estring, 11.3.2
Estriol, 11.3.2
Estrogel, 11.3.2
estropipate, 11.3.2
eszopiclone, 3.9.1
ethacrynic acid, 4.5.1
ethosuximide, 3.6
etidronate, 16.1
etodolac, 3.3.1
Eurax, 5.11
Evamist, 11.3.2
Evekeo, 3.9.4
Evista, see raloxifene
Exalgo ER, see hydromorphone
ER
Exelderm, 5.5
Exelon, see rivastigmine
exemestane, 2.1.6
Exforge, see amlodipine/
valsartan
Exforge HCT, see amlodipine/
valsartan/HCTZ
Extavia, 9.1.3
Fragmin, 4.4.3
Free Style, 7.5.4 & 7.5.5
Frova, see frovatriptan
frovatriptan, 3.4.1
Fulyzaq, 8.2.1
furosemide, 4.5.1
Fuzeon, 1.8.2
Fycompa, 3.6
F
Fabrazyme, 7.4.3
Factive, 1.5.1
famotidine, 8.1.1
Fanapt, 3.9.3.3
Farxiga, 7.5.2
Farydak, 2.1.6
Fazaclo ODT, 3.9.3.3
felbamate, 3.6
felodipine, 4.5.3.2
Fem pH, 11.4.2
Femring, 11.3.2
Femtrace , 11.3.2
fenofibrate, 4.6
Fenofibrate, 4.6
Fenofibric Acid, 4.6
Fenoglide, 4.6
Fenoprofen, 3.3.1.1
Fenortho, 3.3.1.1
fentanyl oral transmucosal, 3.1.1
fentanyl, 3.1.1
Fentanyl, 3.1.1
Fentora buccal tabs, 3.1.1
Ferriprox, 16.1
Fetzima, 3.9.2.2
Fibricor, 4.6
Finacea, 5.3
finasteride , 14.5
Firazyr, 13.3.6
flavoxate, 14.2
flecainide, 4.1
Flector, 3.3.1
Floriva, 15.1
Flo-Pred, 7.3
Flovent Diskus, 13.3.4
Flovent HFA , 13.3.4
Flowtuss, 13.2.1
fluconazole, 1.9
flucytosine, 1.9
flunisolide, 13.3.5
fluocinolone, 5.1.4
fluocinolone, 6.2
fluocinonide, 5.1.2
fluorometholone, 12.11
Fluorouracil, 5.12
fluoxetine, 3.9.2.4
fluoxetine, 3.9.2.4
fluphenazine, 3.9.3.3
flurandrenolide, 5.1.3
flurazepam, 3.9.1
flutamide, 2.1.6
fluticasone, 13.3.5
fluticasone, 5.1.3
fluvastatin, 4.6
fluvastatin ER, 4.6
fluvoxamine ER, 3.9.2.4
fluvoxamine maleate, 3.9.2.4
FML Forte, 12.11
Focalin XR, 3.9.4, also see
dexmethylphenidate ER
fondaparinux, 4.4.3
Foradil, 13.3.3
Forfivo XL, 3.9.2.2
Formaldehyde, 16.1
Forteo, 10.4
Fortesta, 7.4.1
Fortical, 10.4
Fosamax plus D, 10.4
fosinopri/HCTZ, 4.5.8
fosinopril, 4.5.4
Fosrenol, 16.1
G
gabapentin, 3.6
Gabitril, 3.6
galantamine, 3.7
galantamine ER, 3.7
Gammagard, 9.2
Gammaked, 9.2
Gamunex-C, 9.2
Ganirelix, 7.4.4
Garimide, 5.3
Gastrinex NF, 8.3.2
gatifloxacin, 12.9
Gattex, 8.3.3
gavilyte, 8.3.5
Gelnique, 14.2
Gelx, 6.4
gemfibrozil, 4.6
Generess FE, 11.1.1
gengraf, 2.1.5
Genotropin, 9.1.4
gentamicin, 5.4
gentamicin, 12.9
Giazo, 8.3.3
Gilotrif, 2.1.6
Gilenya, 3.7
Glassia , 16.1
Gleevec, see imatinib
Gleostine, 2.1.6
glimepiride, 7.5.2
glipizide/glipizide ER, 7.5.2
Glucagon, 7.5.3
Glumetza, see metformin ER
(glumetza equiv)
glyburide, 7.5.2
glycopyrolate, 8.3.2
Glyset, see miglitol
Glyxambi, 7.5.2
Gralise, 3.6
granisetron, 8.3.4
Granix, 9.1.2
Grastek, 9.2
griseofulvin, 1.9
guaifenesin /codeine, 13.2.1
guanabenz acetate, 4.5.5
guanfacine, 4.5.5
guanfacine ER, 3.9.4
Guardian RT, 7.5.4
Gynazole 1, 11.4.3
H
Halflytely, 8.3.3
halobetasol propionate , 5.1.1
Halog, Halog E, 5.1.2
haloperidol, 3.9.3.3
HC, 8.3.3
hcl/chlor-mal, 13.2.3
hc-pramoxine, 8.3.3
Hectorol, see doxercalciferol
Hemangeol, 4.5.2
Hepsera, see adefovir dipivoxil
Hetlioz, 3.9.1
Hizentra, 9.2
27
Horizant ER, 3.6
HPR, HPR Plus, 5.12
Humalog, Humalog Mix, 7.5.1
Humatrope, 9.1.4
Humira, 10.3.2
Humulin, 7.5.1
Hycamtin, 2.1.6
Hycofenix, 13.2.1
Hydralazine, 4.5.7
Hydro, 5.12
hydrochlorothiazide, 4.5.1
hydrocodone/apap, 3.1.2
hydrocodone/cpm/
pseudoephedrine, 13.2.1
hydrocodone/ibuprofen, 3.1.2
hydrocortisone, 7.3
hydrocortisone rectal, 8.3.3
hydrocortisone, 5.1.4
hydrocortisone/aloe , 5.1.4
hydrocortisone butyrate, 5.1.3
hydrocort-pramox, 5.1
hydro-iodoquinol 2-1, 5.4
hydrocortisone/iodoquinol/aloe,
5.4
hydromorphone, 3.1.1
hydromorphone ER, 3.1.1
hydroxychloroquine, 1.11.3
hydroxyurea, 2.1.6
hydroxyzine, 13.1.1
Hylase, 5.12
Hylira, 5.12
Hyoscyamine, 8.2.2
Hyper-Sal, 13.3.6
Hyqvia, 9.2
Hysingla ER, 3.1.1
I
ibandronate, 10.4
Ibrance, 2.1.1
IB-Stat, 8.3.2
ibuprofen, 3.3.1
Iclusig, 2.1.6
Ilaris, 9.1.5
Ilevro, 12.7
imatinib, 2.1.6
Imbruvica, 2.1.6
imipramine, 3.9.2.1
Imipramine PM, 3.9.2.1
imiquimod, 5.12
Impavido, 1.11.2
Increlex, 16.1
Incruse Ellipta, 13.3.6
indapamide, 4.5.1
Inderal LA, see propranolol LA
indomethacin/SR, 3.3.1
Infergen, 9.1.3
Inlyta, 2.1.6
Innopran XL, 4.5.2
Inova Easy Pads, 5.3
Intermezzo, see zolpidem
sublingual
Intron A, 9.1.3
Intuniv ER, see guanfacine ER
Invega, see paliperidone ER
Invokamet, 7.5.2
Invokana, 7.5.2
Iopidine, 12.14
I-port, 7.5.4
ipratropium, 13.3.5
Index
ipratropium, 13.3.6
Ipratropium/albuterol, 13.3.6
Iprivask, 4.4.1
irbesartan, 4.5.9
irbesartan /HCTZ, 4.5.9
Iressa, 2.1.6
isometh/caffeine/apap, 3.4.1
isosorbide, 4.3
isradipine, 4.5.3.2
Istalol, 12.1
itraconazole, 1.9
ivermectin, 1.11.2
J
Jadenu, 16.1
Jakafi, 2.1.6
Jalyn, see dutasteride/tamsulosin
jantoven, 4.4.1
Janumet/Janumet XR, 7.5.2
Januvia, 7.5.2
Jardiance, 7.5.2
Jentadueto, 7.5.2
Jentadueto XR, 7.5.2
jinteli, 11.3.3
Jublia, 5.5
Juxtapid, 4.6
K
K-tabs 8 mEq, 15.3.1
Kadian ER, 3.1.1
Kalydeco, 13.3.6
Kapvay ER, 3.9.4
Karbinal ER, 13.1.1
Kazano, 7.5.2
Kerafoam, 5.12
Keralac, see urea
Keratol HC, 5.12
Kerol AD, 5.12
Kerol Redi-Cloths, 5.12
Kerydin, 5.5
Ketek, 1.11.1
ketoconazole tab, 1.9
ketoconazole cream/shampoo,
5.5
ketoprofen, 3.3.1
ketorolac, 3.3.1
ketorolac, 12.7
Keveyis, 3.7
Kineret, 10.3.2
Kombiglyze XR, 7.5.2
Korlym, 7.4.3
Kristalose, 8.3.3
Kuvan, 7.4.3
Kynamro, 4.6
L
labetalol, 4.5.2
Lactulose, 8.3.3
LAGesic, 3.3.3
Lamictal ODT, see lamotrigine
ODT
lamuvidine/HBV, 1.8.1
lamotrigine/lamotrigine
ODT/lamotrigine ER, 3.6
Lanoxin, 4.2 and see digoxin
lansoprazole, 8.1.4
lansoprazole ODT, 8.1.4
Lantus, 7.5.1
Lantus Solostar, 7.5.1
Lastacaft, 12.15
latanoprost, 12.4
Latrix XM, 5.12
Latuda, 3.9.3.3
Layolis FE, 11.1.1
Lazanda, 3.1.1
leflunomide, 2.1.6
Lenvima, 2.1.6
Lescol XL, see fluvastatin ER
Letairis, 13.3.6
letrozole, 2.1.6
Leukine, 9.1.2
leuprolide, 2.1.6
levalbuterol, 13.3.3
Levatol, 4.5.2
Levemir, 7.5.1
Levemir Flex Pen/Flex Touch,
7.5.1
levetiracetam, 3.6
levetiracetam ER, 3.6
Levitra, 14.4
levobunolol HCl , 12.1
levocetirizine, 13.1.1
levocetirizine, 13.1.1
levofloxacin 0.5%, 12.9
levofloxacin, 1.5.1
levothroid, 7.2
levothyroxine sodium, 7.2
levoxyl, 7.2
Lexxel, 4.5.8
Lialda, 8.3.3
lidocaine, 5.2
Lidocaine 3%/, 8.3.3
lidocaine HCI, 5.2
lidocaine-HC, 8.3.3
lidocaine-prilocaine, 5.2
lidocaine-tetracaine, 5.2
Lidoderm, see lidocaine patches
LifeScan, 7.5.4
Lileta, 11.4.5
Lindane, 5.11
linezolid, 1.11.1
Linzess, 8.3.3
liothyronine sodium, 7.2
Lipofen, 4.6
Liptruzet, 4.6
lisinopril, 4.5.4
lisinopril /HCTZ, 4.5.8
Livalo, 4.6
Locoid, 5.1.3 and see
hydrocortisone butyrate
lodocortisone, 5.3
Lodosyn, see carbidopa
Lofibra, 4.6
Lonsurf, 2.1.6
lorazepam, 3.9.5
Lorzone, 3.8.1
losartan, 4.5.9
losartan/HCTZ, 4.5.9
Lotemax, 12.11
Lotronex, see alosetron
lovastatin, 4.6
Lovaza, see omega-3 acid ethyl
esters
loxapine, 3.9.3.3
Lumigan, 12.4
Lumizyme, 7.4.3
Lunesta, see eszopiclone
Luxiq, 5.1.3
Luzu, 5.5
Lycelle, 5.11
Lynparza, 2.1.6
Lyrica, 3.6
M
mafenide, 5.4
Magnacet, 3.1.2
Makena, 11.3.1
malathion, 5.11
Marplan, 3.9.2.3
Mar-Spas, 8.3.2
Maxair, 13.3.3
Maxidone, 3.1.2
Medrol, 7.3
medroxyprogesterone acetate,
11.3.1
mefenamic acid, 3.3.1
Megace ES, see megestrol
megestrol , 2.1.6
Mekinist, 2.1.6
meloxicam, 3.3.1
memantine, 3.7
Menest, 11.3.2
Menostar, 11.3.2
meperidine HCl, 3.1.1
mephobarbital, 3.6
Mephyton, 4.4.1
Mepron, see atovaquone
mercaptopurine, 2.1.6
Meridia, 16.3
mesalamine, 8.3.3
Mesalamine, 8.3.3
Mesnex, 2.1.6
Mestinon, see pyridostigmine
metaxalone, 3.8.1
metformin ER, 7.5.2
metformin ER (Glumetza equiva),
7.5.2
metformin HCl, 7.5.2
metformin/glipizide, 7.5.2
methazolamide, 12.5
methenamine, 1.7
methimazole, 7.1
methocarbamol, 3.8.1
methotrexate, 2.1.6
methscopalamine Br, 8.3.2
methyldopa, 4.5.5
methylergonovine, 11.2
Methylin, see methylphenidate
methylphenidate, 3.9.4
methylphenidate CD, 3.9.4
methylphenidate ER, 3.9.4
methylphenidate ER, 3.9.4
methylprednisolone, 7.3
methyltestosterone, 7.4.1
Metipranolol, 12.1
metoclopramide HCl/ODT, 8.3.3
metolazone, 4.5.1
metoprolol succinate ER, 4.5.2
metoprolol tartrate, 4.5.2
metoprolol/HCTZ, 4.5.8
Metozolv ODT , see
metoclopramide ODT
Metrogel, 5.3
metronidazole, 1.11.2
metronidazole, 5.3
metronidazole vaginal cream,
11.4.2
Miacalcin, 10.4
Micardis, see telmisartan
Micardis HCT, see
telmisartan/HCTZ
Midazolam, 3.9.5
midodrine, 4.7
28
Midrin, 3.4.1
miglitol, 7.5.2
Migralam, 3.4.1
Migraten, 3.4.1
MimyX, 5.12
Minastrin 24 FE, 11.1.1
MiniMed Paradigm Real-Time,
7.5.4
Minimed, 7.5.4
Minivelle, 11.3.2
Minocin, 1.2
minocycline , 1.2
minocycline ER, 1.2
minoxidil, 4.5.7
Mirapex ER, see pramipexole ER
Mirena, 11.4.5
mirtazapine, 3.9.2.2
Mirvaso, 5.3
misoprostol, 8.1.2
Mitigare, 10.2
modafinil, 3.9.4
moexipril, 4.5.4
moexipril /HCTZ, 4.5.8
molindone, 3.9.3.3
mometasone, 5.1.3
mometasone nasal, 13.3.5
Monoject, 7.5.4
montelukast, 13.3.6
Monurol, 1.7
Morgidox, 1.2
morphine SO4 ER, 3.1.1
Movantik, 8.3.3
Moviprep, 8.3.5
Moxatag, 1.1
Moxeza, 12.9
moxifloxacin, 1.5.1
MSIR, 3.1.1
Mucomyst, 13.3.6
Mucotrol, 6.4
Mugard, 6.4
Multaq, 4.1
mupirocin, 5.4
Muse, 14.4
Myalept, 7.4.3
Mycobutin, see rifabutin
mycophenolate mofetil, 2.1.6
mycophenolate sodium, 2.1.6
Myfortic, see mycophenolate
sodium
myorisan, 5.3
Myoxin, 6.2
Myozyme, 7.4.3
Myrebetriq, 14.2
N
nabumetone, 3.3.1
nadolol, 4.5.2
nadolol, 4.5.8
naftifine cream, 5.5
Naftin gel, 5.5
Naglazyme, 7.4.3
Nalfon, 3.3.1
Namenda, see memantine
Namenda XR, 3.7
Namzaric, 3.7
Naprelan, 3.3.1
Naprelan CR, see naproxen ER
naproxen/ER, 3.3.1
naratriptan, 3.4.1
Narcan nasal. 3.3.4
Nascobal, 15.1
Index
Nasonex, see mometasone nasal
Natazia, 11.1.1
nateglinide, 7.5.2
Natesto, 7.4.1
Natpara, 7.4.3
Nature-Throid, 7.2
Nebusal, 13.3.6
Neevo/Neevo DHA, 15.1
nefazodone, 3.9.2.2
Neobenz Micro, 5.3
Neobenz Micro SD, 5.3
neomycin/bacitracin/, 12.12
neomycin/polymyxin/
examethasone, 12.12
neomycin/polymyxin/HC, 6.2
Neoral, 2.1.6
Neosalus, 5.12
Neo-Synalar, 5.4
Neptazane, see methazolamide
Nesina, 7.5.2
Neulasta, 9.1.2
Neumega, 9.1.5
Neupogen, 9.1.2
Neupro, 3.5
Neutrasal, 16.1
Nevanac , 12.7
Nexavar, 2.1.6
Nexium susp/pkt, 8.1.4
Nexium caps, see esomeprazole
Niaspan, 4.6
nicardipine HCl, 4.5.3.2
nifedipine, nifedipine ER, 4.5.3.2
Nilandron, see nilutamide
nilutamide, 2.1.6
nimodipine, 4.5.3.2
Ninjacof-XG, 13.2.1
nisoldipine, 4.5.3.2
nitrofurantoin, 1.7
nitroglycerin, 4.3
Nitromist, 4.3
nizatidine, 8.1.1
Norditropin, 9.1.4
norethindrone acetate, 11.3.1
Noritate, 5.3
nortriptyline, 3.9.2.1
Novacort, 5.2
Novarel, 7.4.4
Novofine, 7.5.4
Novolin, 7.5.1
Novolog, 7.5.1
Noxafil, 1.9
np thyroid, 7.2
Nucynta/Nucynta ER, 3.1.1
Nuedexta, 3.9.4
Numoisyn, 6.4
Nuox gel, 5.3
Nuplazid, 3.9.2.2
Nutropin, Nutropin AQ, Nutropin
Depot, 9.1.4
Nuvessa, 11.4.2
Nuvigil, see armodafinil
Nuzon gel, 5.3
Nymalize, 4.5.3.2
nystatin troche/susp, 1.9
nystatin, 11.4.3
nystatin/triamcinolone, 5.5
O
Obredon, 13.2.1
Ocaliva, 8.3.3
octreotide, 2.1.6
Odomzo, 2.1.6
Ofev, 13.3.6
ofloxacin, 1.5.1
ofloxacin opth soln, 12.9
ofloxacin otic, 6.2
Oforta, 2.1.6
olanzapine/fluoxetine, 3.9.3.3
olanzapine/olanzapine ODT,
3.9.3.3
Oleptro ER, 3.9.2.2
olopatadine, 6.4
olopatadine eye, 12.15
Olysio, 1.8.1
Omeclamox-Pak8.1.3
omega-3, 4.6
omeprazole, 8.1.4
Omnaris, 13.3.5
Omnitrope, 9.1.4
ondansetron, 8.3.4
One Touch, 7.5.4
Onexton, 5.3
Onfi, 3.6
Onglyza, 7.5.2
Onmel, 1.9
Onsolis, 3.1.1
Onzetra Xsail, 3.4.1
Opana ER, 3.1.1
Opti Chamber, 7.5.4
Opsumit, 13.3.6
Oracea, 1.2
Orafate, 6.4
Oralair, 9.2
Oralone, 6.4
Orap, see pimozide
Orapred ODT, see prednisolone
sodium phosphate
Oravig, 1.9
Orencia, 10.3.2
Orenitram ER, 4.5.7
Orfadin, 16.1
Orkambi, 13.3.6
orphenadrine, 3.8.1
Ortho-Est, 11.3.3
Ortho-Prefest, 11.3.3
oscion, 5.3
Oseni, 7.5.2
Osmoprep, 8.3.3
Osphena, 10.4
Otezla, 10.3.2
Otic Care, 6.2
Otozin, 6.2
Otrexup, 10.3.2
Ovace, 5.10
Ovace Plus, 5.10
Ovcon 50, 11.1.1
Ovide, 5.11
oxandrolone, 7.4.1
oxaprozin, 3.3.1
Oxaydo, 3.1.1
oxazepam, 3.9.5
oxcarbazepine, 3.6
oxiconazole, 5.5
Oxistat, see oxiconazole
Oxtellar XR, 3.6
Oxy IR, 3.1.1
oxybutynin chloride, 14.2
oxybutynin chloride ER, 14.2
oxycodone, 3.1.1
Oxycodone ER, 3.1.1
oxycodone/acetaminophen,
3.1.2
oxycodone/aspirin, 3.1.2
oxycodone/ibuprofen, 3.1.2
Oxycontin, 3.1.1
oxymorphone IR, 3.1.1
oxymorphone ER, 3.1.1
Oxytrol, 14.2
P
Pacnex LP/HP, 5.3
paliperidone ER, 3.9.3.3
Pancreaze, 8.3.2
Pandel, 5.1.3
pantoprazole, 8.1.4
paricalcitol, 7.4.3
Paradigm, 7.5.4
paregoric, 8.2.1
paroxetine, 3.9.2.4
paroxetine CR, 3.9.2.4
Pataday, 12.15
Patanase, see olopatadine nasal
Patanol, see olopatadine eye
Pazeo, 12.15
PCE, 1.4.1
peg 3350, 8.3.3
Pegasys, 9.1.3
penicillin V, 1.1
Pennsaid 2% soln, 3.3.1
Pennsaid 1.5% soln, see
diclofenac drops
Pentasa, 8.3.3
pentazocine/naloxone, 3.3.3
Pentoxifylline, 4.4.6
Pepcid RPD, 8.1.1
Peranex HC, 8.3.3
Perforomist, 13.3.3
perindopril, 4.5.4
permethrin, 5.11
perphenazine, 3.9.3.3
Pertzye, 8.3.3
Pexeva, 3.9.2.4
phenazopyridine HCl, 14.3
phendimetrazine, 16.3
phenelzine, 3.9.2.3
phenobarbital, 3.6
phenoxybenzamine, 4.5.6
phentermine, 16.3
phenylephrine, 13.2.1
Phenytek, 3.6
phenytoin, 3.6
phenytoin sodium extended, 3.6
phosenamine, 14.4
Phoslyra, 15.3.2
Picato, 5.12
pilocarpine HCl , 12.3
pilocarpine, 6.4
pimozide, 3.9.3.3
pindolol, 4.5.2
Pinnacaine, 6.2
pioglitazone, 7.5.2
pioglitazone/glimepiride, 7.5.2
pioglitazone/metformin, 7.5.2
piroxicam, 3.3.1
Plexion, 5.3
Plexion/SCT/TS, see sodium
Podofilox, 5.12
Polyfin, 7.5.4
Polymyxin B/Trimethoprim, 12.9
polymyxin/hydrocortisone, 12.12
Polytussin AC, 13.2.1
Poly Vi Flor filmstrips, 15.1
Pomalyst, 2.1.6
29
potassium chloride/SA, 15.3.1
potassium citrate ER, 14.4
Pradaxa, 4.4.1
Praluent, 4.6
Pramcort, 8.3.3
pramipexole/ pramipexole ER, 3.5
Pramosone, 8.3.3
Pramosone/Pramosone E, 5.1
pramoxine/hydrocortisone, 8.3.3
Prandimet, see
repaglinide/metformin
Prandin, see repaglinide
prascion, 5.3
pravastatin, 4.6
prazosin HCl, 4.5.5
Precision Sure Dose, 7.5.4
Precision Xtra, 7.5.4
Pred Mild, 12.11
Pred-G, 12.12
Prednicarbate, 5.1.3
prednisolone, 7.3
prednisolone acetate, 12.11
prednisolone sodium phosphate,
7.3
prednisone, 7.3
Prefera-OB, 15.1
Pregnyl, 7.4.4
Prekunil, 15.4.1
Premarin, 11.3.2
Premphase, 11.3.3
Prempro, 11.3.3
Prenate Elite, 15.1
Prepopik, 8.3.5
Prestalia, 4.5.8
Prevacid NapraPac, 3.3.1
Prevpac, 8.1.3
Prilosec, 8.1.4
primidone, 3.6
Pristiq, 3.9.2.2
ProAir HFA/Respiclick, 13.3.3
probenecid, 10.2
procainamide HCl, 4.1
Procentra, 3.9.4
Prochieve, 11.3.1
prochlorperazine, 8.3.4
Procort, 8.3.3
Procrit, 9.1.1
Prodigy, 7.5.4
Prodrin, see isometh/caffeine/
apap
progesterone caps, 11.3.1
Progesterone in oil, 11.3.1
Progesterone pwd, 11.3.1
Pro-Hyo, 8.3.2
Prolastin , 16.1
Prolensa, 12.7
Promacta, 4.4.5
promethazine HCl, 13.1.1
promethazine supp, 8.3.4
promethazine /codeine, 13.2.1
promethazine /DM, 13.2.1
propafenone, 4.1
propafenone SR, 4.1
propoxyphene/apap, 3.3.3
propranolol, 4.5.2
propranolol SA, 4.5.2
propranolol/HCTZ, 4.5.8
propylthiouracil (PTU), 7.1
Prosed DS, 14.4
Prothelial, 6.4
Protopic, see tacrolimus oint
protriptyline, 3.9.2.1
Index
Protropin, 9.1.4
Proventil HFA, 13.3.3
Prozac, 3.9.2.4
pruclair, 5.12
prutect, 5.12
pruvel, 5.12
pseudoephedrine , 13.2.3
Pulmicort Flexhaler , 13.3.4
Pulmicort Respules, see
budesonide neb
Pulmozyme , 13.3.6
Purixan, 2.1.2
Pylera, 8.1.3
pyridostigmine Br, 3.8.2
Q
Qbrelis, 4.5.4
Qnasl, 13.3.5
Qsymia, 16.3
Qudexy XR, 3.6
quetiapine, 3.9.3.3
Quflora, 15.1
Quick Release Teflon Cannula,
7.5.4
Quillichew ER, 3.9.4
Quillivant XR, 3.9.4
quinapril, 4.5.4
quinapril /HCTZ, 4.5.8
quinidine, 4.1
quinine SO4, 1.11.3
Qvar , 13.3.4
R
rabeprazole, 8.1.4
Radigel Acemannan, 5.12
Ragwitek, 9.2
raloxifene, 10.4
ramipril, 4.5.4
Ranexa, 4.7
ranitidine, 8.1.1
Rapaflo, 14.5
Rapamune, see sirolimus
Rasuvo, 10.3.2
Ravicti, 16.1
Rayos, 7.3
re methylphen, 14.4
Rebif, 9.1.3
Rectagel HC Gel, 8.3.3
Rectiv, 8.3.3
Regimex, see benzphetamine
Regranex, 5.12
Relagesic, 3.8.1
Relion, 7.5.1
Relistor, 8.3.3
Relpax, 3.4.1
Remodulin, 4.5.7
Renacidin, 14.4
Renagel, 16.1
Renvela susp, 16.1
Renvela tabs, see sevelamer
carbonate
repaglinide/metformin, 7.5.2
Repatha, 4.6
Reprexain, 3.1.2
re-sa, 5.1
Rescula, 12.4
Restasis, 12.15
Retin A, 5.3
re-urea, 5.12
Revatio, 13.3.6
Revlimid, 2.1.6
Rexulti, 3.9.3.3
Rhinocort Aqua, see budesonide
Rhinoflex, 3.3.3
rifabutin, 1.11.4
risedronate, 10.4
risedronate 30 mg, 16.1
risedronate, dr, 10.4
risperidone, 3.9.3.3
risperidone ODT, 3.9.3.3
Ritalin LA, 3.9.4
rivastigmine, 3.7
rizatriptan/rizatriptan ODT, 3.4.1
ropinirole/ropinirole ER, 3.5
Rosac, 5.3
Rosula, Rosula NS, 5.3
Rosula NS, 5.3
rosuvastatin, 4.6
Rowasa kit, 8.3.3
roxicet, 3.1.1
Roxicodone, 3.1.1
Rozerem, 3.9.1
Ruconest, 13.3.6
Rybix ODT, 3.3.3
Rynatan, 13.2.3
Rytary, 3.5
Simponi, 10.3.2
simvastatin , 4.6
sirolimus, 2.1.6
Sivextro, 1.11.1
Skelid, 16.1
Sklice, 5.11
Skyla IUD, 11.4.5
Sod Sulf/Sulfur Gel, 5.3
sodium hyaluronate, 5.12
sodium phenylbutyrate, 16.1
sodium sulfacetamide cleanser,
5.10
sodium sulfacetamide medicated
pads/lot/cream/cleanser 5.3
Sof-Set, 7.5.4
Soft Touch, 7.5.4
Solaraze, 5.12
Solodyn ER, 1.2
Solus V2, 7.5.4
Soln, 3.7
Somavert, 7.4.3
Sonafine, 5.12
Soolantra, 5.3
Soriatane, see acitretin
Sorilux, 5.1
sotalol/sotalol AF, 4.1
sotret, 5.3
Sotylise, 4.1
Sovaldi, 1.8.1
spinosad, 5.11
Spiriva, 13.3.6
spironolactone, 4.5.1
spironolactone/HCTZ, 4.5.1
Sporanox, 1.9
Spritam, 3.6
Sprix, 3.3.1
Sprycel, 2.1.6
Stavzor, 3.6
Staxyn, 14.4
Stendra, 14.4
Stimate, 7.4.3
Stiolto Respimat, 13.3.6
Stivarga, 2.1.6
Strattera, 3.9.4
Strensiq, 7.4.3
Striant, 7.4.1
Striverdi Respimat, 13.3.3
Suboxone, see buprenorphine/
naloxone
Subsys, 3.1.1
sucralfate, 8.1.3
sulfacetamide sodium, 12.9
sulfacetamide sodium lot/pads,
5.3
sulfacetamide/sulfur, 5.3
sulfacleanse, 5.3
sulfamethoxazole, 1.6
sulfasalazine, 8.3.3
sulfatol, 5.3
sulfisoxazole , 1.6
sulindac, 3.3.1
Sumadan, 5.3
sumatriptan, 3.4.1
Sumavel Dosepro, 3.4.1
Sumaxin, 5.3
Suprax tabs, 1.1,
Suprax susp, see cefixime
Suprenza ODT, 16.3
Suprep, 8.3.5
Sure-T, 7.5.4
Sutent, 2.1.6
Sylatron, 9.1.3
S
Sabril, 3.6
Safyral, 11.1.1
Saizen, 9.1.4
Salex, 5.9
Salicept, 6.4
Salicylic 6%, 5.9
salicylic acid 26%, 5.9
salicylic acid 6%, 5.9
salicylic acid ER film, 5.9
salsalate, 3.3.2
Salvax, 5.9
Samsca, 7.4.3
Sancuso, 8.3.4
Sandimmune, 2.1.6
Sandostatin, see octreotide
Saphris, 3.9.3.3
Sarafem, 3.9.2.4
Savaysa, 4.4.1
Savella, 3.9.2.2
Saxenda, 16.3
SE Benzoyl Peroxide, 5.3
Seb-Prev, 5.1
Seebri Neohaler, 13.3.6
selegiline, 3.9.2.3
selegiline HCl, 3.5
selenium sulfide, 5.1
Semprex-D, 13.2.3
Sensipar, 7.4.3
Serevent Diskus, 13.3.3
Sernivo, 5.1.2
Seroquel XR, 3.9.3.3
Serostim, 9.1.4
sertraline , 3.9.2.4
sevelamer carbonate, 16.1
Seven Plus 7.5.4
Sfrowasa, 8.3.3
Sidekick, 7.5.4
Signifor, 2.1.6
sildenafil 4.5.7
Silenor, 3.9.1
Silhouette, 7.5.4
silver sulfadiazine, 5.7
Silvrstat, 5.4
Simcor, 4.6
30
Symax, 8.2.2
Symbicort, 13.3.6
Symlin, 7.5.2
Synalar, 5.3
Synarel, 7.4.3
Synjardy, 7.5.2
T
Taclonex, see calcipotriene/
betamethasone
tacrolimus, 2.1.6
tacrolimus, 5.12
Tafinlar, 2.1.6
Tagrisso, 2.1.6
Taltz, 5.10
tamoxifen citrate, 2.1.6
Tamsulosin , 14.5
Tanzeum, 7.5.2
Tarceva, 2.1.6
Targadox, 1.2
Targretin, see bexarotene
Tasigna, 2.1.6
Tasmar, see tolcapone
Tazorac, 5.3
Tecfidera, 3.7
Technivie, 1.8.1
Teczem, 4.5.8
Tekamlo, 4.5.9
Tekturna, 4.5.9
Tekturna HCT, 4.5.9
telmisartan, 4.5.9
telmisartan/amlodipine, 4.5.8
telmisartan/HCTZ, 4.5.9
temazepam, 3.9.1
Temodar, see temozolomide
temozolomide, 3.0
Temovate, 5.1.1
Terazol 3, 11.4.3
terazosin, 4.5.5
terbinafine, 1.9
terconazole, 11.4.3
Tersi, 5.1
Testim, 7.4.1
Testosterone, 7.4.1
tetrabenazine, 3.7
tetracycline, 1.2
Teveten HCT, see eprosartan/
HCTZ
Texavite, 15.1
Thalomid, 2.1.6
Theo-Dur, 13.3.1
Theophylline ER, 13.3.1
thioridazine, 3.9.3.3
thyroid, 7.2
Thyrolar, 7.2
tiagabine, 3.6
ticlopidine HCl, 4.4.2
Tikosyn, see dofetilide
timolol, 4.5.2
timolol maleate, 12.1
timolol maleate XE, 12.1
Tinidazole, 1.11.2
Tirosint, 7.2
Tivorbex, 3.3.1.1
tizanidine, 3.8.1
TOBI, 1.11.1
Tobradex, 12.12
tobramycin neb soln, 1.11.1
tobramycin sulfate, 12.9
tobramycin/dexamethasone,
12.12
Index
Tolak, 5.12
tolcapone, 3.5
tolterodine, 14.2
tolterodine ER, 14.2
Topicort/Topicort LP, 5.1.2
topiramate, 3.6
Topiramate ER, 3.6
torsemide, 4.5.1
Toujeo, 7.5.1
Toviaz, 14.2
Tracleer, 13.3.6
Tradjenta, 7.5.2
Tramadol, 3.3.3
tramadol ER, 3.3.3
tramadol HCL, 3.3.3
tramadol/apap, 3.3.3
trandolapril, 4.5.4
trandolopril/verapamil, 4.5.8
tranexamic acid, 4.4.5
Transderm-Scop, 8.3.4
tranylcypromine sulfate, 3.9.2.3
Travatan-Z, 12.4
travoprost, 12.4
trazodone HCl, 3.9.2.2
Tresiba Flextouch, 7.5.1
tretinoin, 2.1.6
tretinoin, tretinoin micro, 5.3
Treximet, 3.4.1
Trezix, see
apap/caffeine/dihydrocodeine
triamcinolone, 13.3.5
triamcinolone acetonide , 5.1.3
triamcinolone, 6.4
triamterene /HCTZ, 4.5.1
Triaz, 5.3
Tricare Prenatal w/DHA, 15.1
Tricor, see fenofibrate
triazolam, 3.9.1
Tribenzor, 4.5.8
trifluoperazine, 3.9.3.3
trifluridine opth, 12.16
Triglide, 4.6
trihexyphenidyl, 3.5
Trilipix, see fenofibrate
TriLyte, 8.3.5
trimethobenzamide HCl, 8.3.4
trimethoprim, 1.6
trimethoprim, 1.7
trimipramine, 3.9.2.1
Trintellix, 3.9.2.4
TriOxin, 6.2
Trulicity, 7.5.2
Tropazone, 5.12
trospium Cl, 14.2
trospium Cl ER, 14.2
Tudorza, 13.3.6
Tussionex, 13.2.1
Tuzistra XR, 13.2.1
Twynsta, see
telmisartan/amlodipine
Tykerb, 2.1.6
Tyvaso , 13.3.6
U
Uceris, 8.3.3
Ulesfia, 5.11
Uloric, 10.2
Ultrasal-ER, see salicylic acid ER
Ultravate lotion, 5.1.1
Ultresa, 8.3.2
Umecta, 5.12
Umecta PD, 5.12
Uni-Dur, 13.3.1
Uniphyl, 13.3.1
Unistrip-1 device, 7.5.4
Unistrip -1 strips, 7.5.5
unithroid, 7.2
Uptravi, 4.5.7
Uramaxin 5.12
Uramaxin GT, 5.12
urea, 5.12
Urealac, 5.12
Urelle, see Uro-L
Uribel, see Uro-MP
Uritact-EC, 14.4
Urocit-K, see potassium citrate
ER
Urogesic Blue, 1.7
Uro-L, 14.4
Uro-MP, 14.4
ursodiol, 8.3.3
Uta cap, 14.4
Utibron Neohaler, 13.3.6
Vimpat, 3.6
Viokace, 8.3.2
Virasal, 5.9
Visicol , 8.3.3
Vistogard, 2.2.1
Vivelle Dot, see estradiol patches
Vogelxo, 7.4.1
Volmax, 13.3.3
Voltaren , 12.7
Voltaren Gel, see diclofenac gel
voriconazole, 1.9
Votrient, 2.1.6
Vpriv, 7.4.3
Vraylar, 3.9.3.3
Vusion, 5.5
Vytorin, 4.6
Vyvanse, 3.9.4
W
warfarin sodium, 4.4.1
Welchol, 4.6
westhroid, 7.2
Westhroid-P, 7.2
WP Thyroid, 7.2
V
Vagifem , 11.3.2
Valchlor, 5.12
Valcyte, see valganciclovir
valganciclovir, 1.8.1
valproic acid, 3.6
valsartan, 4.5.9
valsartan /HCTZ, 4.5.9
vancomycin caps, 1.11.1
Vandazole, 11.4.2
Vanos, see fluocinonide
Vanoxide HC, 5.3
Varubi, 8.3.4
Vascepa, 4.6
Vashe, 16.6
Vecamyl, 4.5.8
Vectical, 5.1
Velphoro, 16.1
Veltin, 5.3
Venclexta, 2.1.6
Venelex, 5.12
venlafaxine, 3.9.2.2
venlafaxine ER, 3.9.2.2
Ventavis, 13.3.6
Ventolin HFA, 13.3.3
Veracloz, 3.9.3.3
Veramyst, 13.3.5
verapamil ER PM, 4.5.3.2
verapamil HCl/, 4.5.3.2
verapamil SR, 4.5.3.2
Verdeso, 5.1.4
Veregen, 5.12
Verelan, 4.5.3.2
Verelan PM, 4.5.3.2
Veripred 20, 7.3
Vesicare, 14.2
Vexol, 12.11
Vfend, see voriconazole
V-Go, 7.5.4
Viagra, 14.4
Viberzi, 8.3.3
Vicoprofen, 3.1.2
Victoza, 7.5.2
Viekira, Viekira XR, 1.8.1
Vigamox, 12.9
Viibryd, 3.9.2.4
Vimizim, 7.4.3
Vimovo, 3.3.1
X
Xalkori, 2.1.6
Xarelto, 4.4.1
Xartemis XR, 3.1.2
Xclair, 5.12
Xeljanz/ Xeljanz XR, 10.3.2
Xeloda, see capecitabine
Xenazine, see tetrabenazine
Xenical, 16.3
Xerese, 5.6
Xifaxan, 1.11.1
Xiidra, 12.15
Xigduo XR, 7.5.2
Xolegel, 5.5
Xolox, 3.1.2
Xopenex HFA, 13.3.3
Xtampza XR, 3.1.1
Xtandi, 2.1.6
Xuriden, 16.1
Xyrem, 3.9.4
Z
zafirlukast, 13.3.6
zaleplon, 3.9.1
Zantac, 8.1.1
Zarxio, 9.1.2
Zavesca, 7.4.3
Zazole, 11.4.3
Zegerid, 8.1.4
Zelboraf, 2.1.6
Zelnorm, 8.3.3
Zemaira , 16.1
zema-pak, 7.3
Zembrace, 3.4.1
Zemplar, see paricalcitol
zenatane, 5.3
Zencia, 5.3
Zenpep DR, 8.3.2
Zenzedi, 3.9.4
Zepatier, 1.8.1
Zetia, 4.6
Zetonna, 13.3.5
Zflex, 3.3.3
Ziana Gel, see
clindamycin/tretinoin
31
Zinbryta, 3.7
Zioptan, 12.4
ziprasidone, 3.9.3.3
Zirgan, 12.16
Zithranol, 5.1
Zmax, see azithromycin
Zoderm, 5.3
Zohydro ER, 3.1.1
Zolinza, 2.1.6
zolmitriptan/zolmitriptan ODT,
3.4.1
zolpidem/ER/sl, 3.9.1
Zolpimist, 3.9.1
Zolvit, 3.1.2
Zonalon, see doxepin cream
Zomacton, 9.1.4
Zomig, 3.4.1
zonisamide, 3.6
Zontivity, 4.4.2
Zorprin, 3.3.2
Zortress, 2.1.6
Zorvolex, 3.3.1.1
Zovirax, 5.6
z-pram, 8.3.3
Zuplenz, 8.3.4
Zurampic, 10.2
Zyclara, 5.12
Zydelig, 2.1.6
Zyflo, 13.3.6
Zykaydia, 2.1.6
Zylet, 12.12
Zymaxid, see gatifloxacin
Zytiga, 2.1.6
Zyvox, see linezolid
06-F0503 6/12
03-B053A 2012.
11/15 .
© Blue Cross of Northeastern Pennsylvania.

Formulary - Cloudfront.net

Transcription

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