medicaid formulary - Gateway Health Plan

Transcription

2013
MEDICAID
FORMULARY
INTRODUCTION
The Gateway Health Plan® formulary is a list of FDA-approved covered medications reviewed and
approved by our Pharmacy and Therapeutics (P&T) Committee and the Department of Public
Welfare (DPW). The P&T Committee is comprised of actively participating network physicians
and pharmacists who select products on the basis of their safety, efficacy, quality and cost to the
plan.
Physicians are requested to prescribe medications included in the formulary whenever medically
appropriate. All drugs in the formulary are not necessarily covered by each patient’s prescription
drug coverage. Providers can contact Provider/Pharmacy Services with any questions related to a
member’s prescription coverage limitations.
The drug formulary is divided into major therapeutic categories (chapters) for easy use. Products
that are approved for more than one therapeutic indication may be included in more than one
chapter. Drugs are listed by generic names; brand names are specified for reference. The notes
column in the formulary book will tell you which drugs may have any additional requirements or
limits on them.
The P&T Committee meets on a quarterly basis to review and revise the formulary. All providers
(both participating pharmacies and physicians) are provided access to the Gateway Health Plan®
formulary and are periodically notified of formulary updates.
Providers may request the addition of a medication to the formulary. Requests must include the
drug name, rationale for inclusion on the formulary, role in therapy and formulary medications that
may be replaced by the addition. The committee will review requests. All requests should be
forwarded in writing to:
Gateway Health Plan®-P&T Committee
Pharmacy Department
US Steel Tower
Floor 41
600 Grant Street
Pittsburgh, PA 15219
The formulary is accessible online at www.gatewayhealthplan.com. It may be searched by drug
name or drug class. Future updates to our formulary will be available, both by provider
publication and online. Additional hard copies of the formulary may be printed directly from our
formulary website, or requested as follows:
• Physician Practices: 1-800-392-1145
• Pharmacy Network Providers: 1-800-528-6738
Questions about the formulary and its use can be directed to:
Pharmacy Services Department…….1-800-528-6738
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PHARMACY CO-PAYMENTS
Co-payments will apply to Gateway members 18 years of age and older. These co-payments do
not apply to any member who is pregnant or in a nursing home. Please note, members cannot be
denied a service if they are unable to pay their co-pay.
Members may fall into two medical assistance categories, Medical Assistance (MA) and General
Assistance (GA). Practitioners can verify a member’s medical assistance benefit category through
the Department of Public Welfare PROMISe TM Eligibility Verification System (EVS).
For Medical Assistance (MA) members 18 years of age and older, the benefit structure for
prescription drugs is as follows:
• $1.00 for formulary generic prescription drugs
• $3.00 for formulary brand prescription drugs
• Copays will apply to any approved prior authorization for a non-formulary drug
• Medications within the following specified therapeutic categories will be excluded from the
copay requirements for MA recipients only, which will be noted at the point of sale
transaction:
o Antipsychotics
o Family Planning
o Antidiabetic Agents, including Insulin
o Antineoplastic Agents
o Antiparkinson Agents
o Antiglaucoma Agents
o Antihypertensive Agents
o Anticonvulsants
o HIV/AIDS medications
o Cardiovascular preparations (Antiarrhythmics, Antianginals, Anticoagulants, Lipid
Lowering Agents)
For General Assistance (GA) members 18 years of age and older, the benefit structure for
prescription drugs is as follows:
• $1.00 for formulary generic prescription drugs
• $3.00 for formulary brand prescription drugs
• Copays will apply to any approved prior authorization for a non-formulary drug
• There are NO COPAY exceptions for GA members
SIX PRESCRIPTION BENEFIT LIMIT
Members can get up to 6 prescriptions each month. This rule does not apply if:
• Member is under 21 years of age; or
• Member is pregnant; or
• Member lives in a nursing home or an intermediate care facility
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In some instances, Gateway can approve more than 6 prescriptions. This is called a benefit limit
exception. Gateway can grant a benefit limit exception if:
• Member has a serious chronic illness or health condition and without the additional service, the
life of the member would be in danger; or
• Member has a serious chronic illness or health condition and without the additional service, the
member’s health would get much worse; or
• Member would need more expensive services if the exception is not granted; or
• It would be against federal law for Gateway Health Plan® to deny the exception
Some exceptions can happen at the pharmacy. A benefit limit exception can be made at the
pharmacy if the member has a prescription for one of the drugs listed below:
Drugs to treat:
• Abnormal or irregular heartbeat
• Angina
• Asthma or COPD (chronic obstructive pulmonary disease)
• Bipolar disease
• Cancer
• Cholesterol (statins)
• Depression
• Diabetes
• Enzyme deficiencies
• Glaucoma
• Hemophilia
• Hepatitis
• High blood pressure
• HIV/AIDS
• Immune deficiency
• Infection
• Multiple sclerosis
• Nausea and vomiting
• Opiate dependency
• Parkinson’s disease
• Pulmonary hypertension
• Serious mental illness
• Thyroid disorders
Drugs to prevent:
• Blood clots
• Pregnancy
• Seizures
Drugs to:
• Reduce stomach acid
• Replace potassium
• Stop migraine headaches
• Suppress the immune system
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If the prescription is not approved at the pharmacy, the doctor or provider who prescribed the
drug can ask Gateway for an exception. To ask for a benefit limit exception, the doctor or provider
who prescribed the drug should complete a Pharmacy Benefit Limit Exception Request Form
found on page 16 and fax it back to the Pharmacy Department at 1-888-245-2049. The doctor or
provider may also call the pharmacy prior notification service and the give our staff person:
• Member name, address, date of birth, and Gateway Health Plan® ID number
• Provider name, address, telephone and fax number, medical license number and National
Provider Identifier number.
• Information about the drug being prescribed, member’s diagnosis and why the exception is
needed.
Once Gateway has the needed information, we will respond to the request within 24 to 72 hours.
The member and doctor will get a written notice of the decision.
If the member needs the drug right away, his/her pharmacist may give up to a 5 day emergency
supply to the member.
If a request for an exception is denied, the member and prescribing doctor will get a written notice
of the decision. The written notice will explain how to appeal. The written notice will explain how
and when to ask for a Fair Hearing with the Department of Public Welfare or file a complaint or
grievance with Gateway Health Plan® if the request for a benefit limit exception is denied. If the
member needs help filing an appeal they can call Gateway Health Plan® Member Services at
1-800-392-1147, TTY/TDD: 711.
FORMULARY MEDICATION COVERAGE
•
Approved Medications
Only FDA-approved medications are eligible for coverage.
•
Investigational/Experimental Drug Use
Drugs prescribed for investigational or experimental purposes are not eligible for
reimbursement.
•
Formulary Drugs
Formulary drugs are those reviewed and recommended for inclusion by Gateway’s P&T
Committee. These drugs are selected based upon their safety, efficacy, quality and cost.
Physicians and pharmacists should use formulary drugs when they believe it medically
appropriate to do so.
•
Nonformulary Drugs
A non-formulary drug is one that has not been recommended for inclusion by Gateway’s P&T
Committee on the basis of safety, efficacy, quality and cost. Physicians are requested to
comply with the drug formulary when prescribing medications for participants when medically
appropriate. A physician may request a non-formulary medication only if medical necessity or
failure of formulary alternatives are documented by the physician on the Gateway Health Plan®
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Request for Nonformulary Drug Coverage Form. When presented a prescription for a nonformulary drug, a pharmacist should attempt to contact the prescribing physician in
order to suggest formulary alternatives. If the physician is unavailable, the pharmacist should
contact Gateway Health Plan® at 1-800-528-6738 to help secure a formulary alternative. The
pharmacist may dispense up to a 5 day supply after hours, weekends and holidays.
•
Generic Substitution
When there is a generic version of a brand name drug available, Gateway requires the generic
drug be given. Generic drugs are subject to specific reimbursement levels, such as Maximum
Allowable Cost (MAC) price reimbursements. Drugs that are available in generic form will
appear in bold in the formulary book. The bold font indicates that the generic drug product is
on the formulary but the branded product is not. Requests for “Brand Necessary” medications
will be considered a nonformulary medication request and will require authorization. The
Gateway Health Plan® Request for Nonformualry Drug Coverage Form must be submitted
with sufficient documentation to substantiate medical necessity of the Brand Name
medication. Physicians are encouraged to prescribe generic medications whenever clinically
appropriate.
•
Prior Authorization
Prior Authorization (prior approval) is necessary for coverage of certain medications. In these
cases, clinical criteria, based on current medical information and approved by Gateway’s P&T
Committee and the Department of Public Welfare, must be met or additional information
must be provided before coverage is approved. To avoid interruptions in therapy for ongoing
medication, Gateway Health Plan® will provide a 15-day supply of the medication to the
member. Prior authorizations are processed by calling Gateway Health Plan® at
1-800-528-6738 or physicians may complete a drug specific prior authorization form by
accessing the website at www.gatewayhealthplan.com. Physicians should fax the completed
prior authorization form to 1-888-245-2049 for processing. All requests for prior authorization
will receive a response within 24 hours. Drugs that are available in generic form will appear in
bold in the formulary book. The bold font indicates that the generic drug product requires a
prior authorization.
Brand Name
Abilfy**
Aricept
Avonex
Compound
Copaxone
Elidel
Enbrel
Exelon
Geodon*
Gleevec
Humira
Incivek
Latuda*
Generic Name
aripiprazole
donepezil
interferon beta- 1a
compound
glatiramer acetate
pimecrolimus
etanercept
rivastigmine
ziprasidone
imatinib
adalimumab
telaprevir
lurasidone
Brand Name
Pegasys
Peg-Intron
Procrit
Pulmozyne
Razadyne
Remicade
Risperdal*
Saphris*
Seroquel*
Suboxone Film
Subutex
Synagis
Synvisc and Synvisc One
Generic Name
peginterferon alfa-2a
peginterferon alfa-2b
epoetin alfa
dornase alfa
galantamine
infliximab
risperidone
asenapine
quetiapine
buprenorphine/naloxone
buprenorphine
palivizumab
hylan G-F 20
5
Lupron
Neupogen
Norditropin
leuprolide
filgrastim
somatropin
Victrelis
Voltaren Gel
Zyprexa*
boceprevir
diclofenac sodium
olanzapine
*The following atypical antipsychotics require prior authorization in certain situations:
1.) All strengths for children less than 18 years of age
2.) Low dose strengths for adults aged 18 to 60 for the following atypical only:
a. Seroquel 25mg, 50mg, and 100mg
** Abilify requires a prior authorization for all ages
•
Once Daily Medications
Some medications are indicated to be taken as a once daily dose rather than several times
throughout the day. In these situations, Gateway Health Plan® will cover only the larger dose
for 30 days. For example, your physician writes you a prescription to take a 5mg tablet twice a
day. If a 10mg tablet exists in that medication, Gateway Health Plan® will cover this strength
rather than two of the 5mg tablets. Should there be a medical explanation as to why you would
need to take a lesser dose twice a day, your physician may call Gateway Health Plan® at
1-800-528-6738 to request a medical exception.
•
Quantity Limits
For certain drugs, Gateway Health Plan® has established quantity limits (limits on the amount
of drug you can have filled) that the FDA has approved as safe and effective. Prescriptions in
excess of the covered monthly quantity would require a medical exception request from the
prescribing physician. For example, Gateway provides coverage for 9 tablets of sumatriptan
(generic Imitrex) 100mg every 30 days. Medications with quantity limits are denoted by QL in
the formulary booklet. Below is a list of quantity limits based on FDA recommended dosing.
Brand Name
Abilify
Accuneb
Actonel 5mg, 30mg
Actonel Once-a-Week 35mg
Actonel Once-a-Month 150mg
Actonel with Calcium
Actos
ActoPlus Met
Adderall
Adderall XR 5mg, 10mg, 15mg
Adderall XR 20mg, 25mg, 30mg
Advair HFA/Advair Diskus
Altace 1.25 mg, 2.5 mg, 5 mg
Alupent
Amaryl 1 mg, 2 mg
Generic Name
aripiprazole
albuterol inhalation solution
risedronate
risedronate
risedronate
risedronate plus calcium
pioglitazone
pioglitazone/metformin
amphetamine salt combination
amphetamine salt combination extended
release
amphetamine salt combination extended
release
fluticasone propionate/salmeterol
ramipril
metaproterenol
glimepiride
Quantity Limit
30 tablets per month
120 vials or 360 mL per month
4 tablets per month
1 tablet per month
1 package (28 tablets) per 28 days
30 capsules per month
1 inhaler or diskus per month
6
Brand Name
Ambien
Arava
Aricept
Arixtra
Asmanex
Aspirin with codeine
Atrovent HFA
Atrovent Inhalation Solution
Atrovent Nasal Spray 0.06%
Atrovent Nasal Spray 0.03%
Avandamet
Avandaryl 4/1mg, 4/4mg
Avandaryl 4/2mg
Avandia
Avelox
Avonex
Biaxin, Biaxin XL
Calan SR
Cardizem CD/SR
Cardura
Celexa
Cipro
Codeine phosphate injection
Codeine sulfate tablets
Codeine sulfate solution
Combivent
Concerta 18mg, 27mg, 54mg
Concerta 36mg
Copaxone
Cozaar
Cymbalta 20mg, 30mg
Cymbalta 60mg
Demerol tablets
Demerol solution
Dexedrine 5mg
Dexedrine 10mg
Dexedrine 15mg
Diflucan 150mg
Dilaudid tablets
Dilaudid solution
Ditropan XL
Duetact
Generic Name
zolpidem
leflunomide
donepezil
fondaparinux
mometasone furoate
Aspirin with codeine
ipratropium bromide inhaler
ipratropium bromide inhalation solution
ipratropium bromide nasal spray
ipratropium bromide nasal spray
rosiglitazone/metformin
rosiglitazone/glimepiride
rosiglitazone
moxifloxacin
interferon beta-1a
clarithromycin
verapamil
verapamil
doxazosin
citalopram
ciprofloxacin
Codeine phosphate injection
Codeine sulfate tablets
Codeine sulfate solution
ipratropium bromide/albuterol
methylphenidate extended release
glatiramer acetate
losartan
duloxetine
duloxetine
meperidine
Meperidine
d-amphetamine sulfate
fluconazole
hydromorphone
hydromorphone
oxybutynin extended release
pioglitazone/glimepiride
Quantity Limit
10 syringes per month
1 inhaler per month
2 inhalers per month
2 bottles per month (30mL total)
1 bottle per month (30mL)
1 package (4 vials) per month
28 tablets per 30 days
28 tablets per 30 days
1000 mL per month
1 package of 30 vials per month
1000 mL per month
2 tablets per month
1000 mL per month
7
Brand Name
Dulera
Duragesic
Effexor XR 150 mg
Effexor XR 37.5mg, 75 mg
Enbrel 25mg
Enbrel 50mg
Exelon
Flomax
Flonase
Flovent HFA
Floxin 200mg
Floxin 300mg
Floxin 400mg
Focalin
Focalin XR
Forteo
Fosamax 5mg, 10mg
Fosamax Weekly 35mg, 70mg
Fragmin
Geodon
Glucotrol XL
Humira
Hycodan solution
Hytrin
Hyzaar
Imitrex 25mg, 50mg
Imitrex 100mg
Imitrex Injection
Imitrex Nasal Spray
Intal
Intuniv
Isentress
Janumet
Januvia
Lamisil
Latuda
Letairis
Lexapro
Lipitor
Lortab solution
Lotensin, Lotensin HCT
Lovenox
Generic Name
mometasone/formeterol
fentanyl transdermal patches
venlafaxine extended release
venlafaxine extended release
etanercept
etanercept
rivastigmine
tamsulosin
fluticasone propionate nasal spray
fluticasone propionate inhaler
ofloxacin
ofloxacin
ofloxacin
dexmethylphenidate
dexmethylphenidate
teriparatide
alendronate
alendronate
dalteparin
ziprasidone
glipizide xl
adalimumab
hydrocodone/homatropine
terazosin
losartan/hydrochlorothiazide
sumatriptan
sumatriptan
sumatriptan
sumatriptan
cromolyn sodium inhalation solution
guanfacine
raltegravir potassium
sitagliptin/metformin
sitagliptin
terbinafine
lurasidone
ambrisentan
Escitalopram
atorvastatin
hydrocodone/acetaminophen
benzapril, benzapril/hydrochlorothiazide
enoxaparin sodium
Quantity Limit
1 inhaler per month
10 patches per month
8 vials per month
4 vials per month
2 nasal spray devices per month
1 prefilled pen per month
4 tablets per month
1000 mL per month
9 tablets per month
2 boxes (4 injections) per month
1 box (6 spray units) per month
90 tablets per year
2700 ml per month
8
Brand Name
Lupron Depot
Luvox 25 mg, 50 mg
Maxair Autohaler
Maxalt, Maxalt MLT
Metadate CD
Methadone
Ms Contin tablets
MS IR tablets
MS IR solution
Migranal
Monopril
Nasacort AQ
Neurontin 100, 300, 400, 600mg
Neurontin 800mg
Norvasc
Opana IR
Opana ER
Oxycodone solution
Paxil
Percocet tablets
Percodan tablets
Phenergan with Codeine solution
Phenergan VC with Codeine
solution
Plan B
Plendil
Pravachol
Premarin
Prevacid
Prinivil, Prinizide
Procardia XL
Protonix
Prozac
Pulmicort Respules 0.25, 0.5mg
Pulmicort Respules 1mg
Pulmozyme
Razadyne
Relenza
Remeron
Risperdal
Risperdal Consta
Ritalin 5mg, 10mg
Generic Name
leuprolide acetate
fluvoxamine maleate
pirbuterol acetate
rizatriptan
methadone
morphine sulfate controlled release
morphine sulfate immediate-release
Morphine sulfate immediate-release
dihydroergotamine mesylate
fosinopril
triamcinolone
gabapentin
gabapentin
amlodipine
oxymorphone
oxymorphone
oxycodone solution
paroxetine
oxycodone/acetaminophen
oxycodone/aspirin
promethazine/codeine
Promethazine/codeine/phenylephrine
solution
levonorgestrel
felodipine
pravastatin
estrogens, conjugated
lansoprazole
lisinopril, lisinopril/hydrochlorothiazide
nifedipine
pantoprazole
fluoxetine
budesonide
budesonide
dornase alfa
galantamine
zanamivir
mirtazapine
risperidone
risperidone
methylphenidate
Quantity Limit
1 kit per month
1 inhaler per month
1000 mL per month
4 ampules per month
2 nasal spray devices per month
180 tablets or capsules per month
1000 mL per month
1000 mL per month
1000 mL per month
2 tablets per month
20 blisters per 6 months
2 injections per month
9
Brand Name
Ritalin 20mg
Ritalin SR
Roxicet solution
Roxicodone
Saphris
Serevent Diskus
Seroquel
Seroquel XR
Singulair
Sonata
Spiriva Handihaler
Strattera
Suboxone Film
Subutex
Symbicort
Synagis 50mg, 100mg
Synvisc
Tamiflu
Tiazac
Tylenol with codeine elixir
Tylenol with codeine tablets
Ultracet
Ultram
Vasotec
Ventolin HFA
Vesicare
Vicodin
Vicodin ES
Vicoprofen
Vyvanse
Zithromax 250mg
Zithromax 500mg
Zocor
Zoloft
Zofran, Zofran ODT 4mg, 8mg
Zofran, Zofran ODT 24mg
Zyprexa
•
Generic Name
methylphenidate
oxycodone/acetaminophen
oxycodone immediate release
asenapine
salmeterol
quetiapine
quetiapine
montelukast
zaleplon
tiotropium
atomoxetine
buprenorphine/naloxone
buprenorphine
budesonide/formoterol
palivizumab
Hylan G-F 20
oseltamivir
diltiazem
codeine/acetaminophen
Codeine/acetaminophen
tramadol/acetaminophen
tramadol
enalapril
albuterol inhaler
solifenacin
hydrocodone/ibuprofen
lisdexamfetamine
azithromycin
azithromycin
simvastatin
sertraline
ondansetron
ondansetron
olanzapine
Quantity Limit
120 tablet per month
1000 mL per month
1 inhaler per month
30 capsules (1 handihaler) per month
60 film strips per month
1 inhaler per month
1 vial per month
3 syringes per 20 days
10 capsules per 6 months
2700 mL per month
6 tablets per month
4 tablets per month
2 tablets per month
Step Therapy
In some cases, Gateway Health Plan® requires you to first try certain drugs to treat your
medical condition before covering another drug for that condition. For example, if Drug A
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and Drug B both treat your medical condition, Gateway may not cover Drug B unless you try
Drug A first. If Drug A does not work for you, Gateway will then cover Drug B.
Brand Name
ActoPlus Met
Actos
Avandamet
Avandaryl
Avandia
Duetact
Janumet
Januvia
Restasis
Generic Name
pioglitazone/metformin
pioglitazone
rosiglitazone/metformin
rosiglitazone
pioglitazone/glimepiride
sitagliptan-metformin
sitagliptan phosphate
cyclosporine ophthalmic suspension
•
Specialty Pharmacy Information
Some medications, including injectable medications, listed in the formulary booklet are
available through a specialty pharmacy network. These medications are denoted as SPN in the
formulary drug listing.
•
Compounded Prescriptions
Compounded prescriptions are considered formulary drugs provided they contain at least one
listed formulary drug in the final product. A claim for a compounded prescription should be
submitted with all NDCs used in the compound. The compound cost will automatically
calculate based upon coverage of the submitted ingredients. Payment will only be made for
FDA approved drugs and drugs not excluded from payment by Medical Assistance. A
compounded medication may require prior authorization to determine medical necessity. Prior
authorizations are processed by calling Gateway Health Plan® at 1-800-528-6738, or physicians
may complete a prior authorization form specifically for compounded prescriptions by
accessing the website at www.gatewayhealthplan.com. Physicians should fax the completed
prior authorization form to 1-888-245-2049 for processing. All requests for prior
authorization will receive a response within 24 hours.
•
Over-the-counter (OTC) Medications
Gateway Health Plan® does provide coverage for a number of OTC medications written as a
prescription. Please refer to the Gateway Health Plan® OTC Formulary referenced on page 17
for a specific listing of covered categories.
•
Drug Efficacy Study Implementation (DESI) Drug
A DESI drug is one that was approved by the FDA solely on the basis of their safety prior to
1962. Subsequent to 1962, Congress required drugs to be shown to be effective as well. As a
result, the FDA initiated a DESI to evaluate the effectiveness of medications previously
approved based on safety alone. DESI drugs may continue to be marketed until proceedings
evaluating efficacy have been concluded, at which point continued marketing would only be
permitted if a New Drug Application is submitted for those drugs. Gateway Health Plan®
excludes all DESI drugs as defined by the FDA.
•
Non-rebated Manufacturers
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Gateway Health Plan®, by direction of DPW, excludes coverage for any drug marketed by a
drug company who does not participate in the Medicaid Drug Rebate Program.
•
Medications Covered by Other Insurers (Coordination of Benefits and
Third Party Liability)
As an agent of the Commonwealth of Pennsylvania Medical Assistance Program, Gateway
Health Plan® is always the payer of last resort in the event that a member receives a medication
that is covered by another payer source. The claim must be billed to the primary insurance,
and subsequently billed on-line or submitted on a Universal Claim Form (UCF) to Gateway
Health Plan® for any outstanding balance.
•
Non-covered Drugs
Non-covered drugs include the following categories:
• Drugs and other items prescribed for obesity or appetite control
• Over the counter drugs in the form of troches, lozenges, throat tablets, cough drops,
chewing gum, mouthwashes and similar items
• Drugs and devices not approved by the FDA or whose use is not approved by the FDA
• Placebos
• Prescription and over the counter soaps, cleansing agents, dentifrices, mouthwashes,
douche solutions, diluents, ear wax removal agents, deodorants, liniments, antiseptics,
irrigants, emollients and other personal care items
• Prescription and over the counter food supplements and substitutes
• Durable Medical Equipment (DME) items
• Items prescribed or ordered by a physician who has been barred or suspended from
participating in the Medical Assistance Program
• Fertility promoting agents
• Drugs for the treatment of erectile dysfunction
• Agents prescribed for cosmetic purposes or approved by the FDA for cosmetic purposes
only
REQUEST FOR NONFORMULARY DRUG COVERAGE
If changing to a formulary medication is not medically advisable for a patient, a physician must
initiate a Request for Nonformulary Drug Coverage by faxing the request form on page 15 to
1-888-245-2049 during normal business hours, or call 1-800-392-1147 during off-hours and
weekends, with all of the information requested on the form.
All requests for exception will receive a response within 24 hours. In the event a decision has not
been made in 24 hours, Gateway Health Plan® will authorize a temporary supply of the
nonformulary medication. For new therapies, up to a 5 day supply may be dispensed and for
ongoing therapies, a 15-day supply of the nonformulary medication must be dispensed, pending
the final determination of the request.
Gateway Health Plan® members have the right to appeal any decision regarding prescription drug
coverage.
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PROVIDER NUMBER
When processing a prescription claim for a Gateway Health Plan® member, a valid NPI number is
required.
DAYS SUPPLY DISPENSING LIMITATIONS
Gateway Health Plan® members may receive up to a 34-day supply of a pharmaceutical product
per prescription order or refill. A 34-day supply shall be interpreted to mean consecutive 34-day
supply, i.e., if a physician prescribes a medication b.i.d. (two times a day), a 34-day supply
corresponds to a quantity of 68.
The prescriber is urged to prescribe in amounts that adhere to FDA guidelines and accepted
standards of care. The dispensing pharmacist must accurately compute the days supply.
VACATION SUPPLIES
All requests for an early refill or a quantity in excess of a 34 day supply due to upcoming travel
must be made by the prescribing physician. The physician must include the following in a request
for a vacation supply of maintenance medication: your destination, your departure and return
dates, any travel documentation including flight reservations or hotel confirmations, the dose,
strength, frequency, and quantity of the medications that are being requested.
Medications being requested that have abuse potential will be reviewed on a case by case basis with
the prescribing physician and Gateway Clinical Pharmacist and/or Medical Director. If approved
upon review of information submitted, a vacation supply of no more than one month will be
allowed. Gateway Health Plan® will only allow one vacation supply per year through this process.
In addition, a Gateway Health Plan® member can get their medications filled anywhere in the
United States at a participating network pharmacy.
RECIPIENT RESTRICTION PROGRAM
Gateway’s Recipient Restriction Program is a program to detect and deter member misutilization
and/or fraud/abuse. This program restricts members to one PCP and/or one Participating
Pharmacy of the member’s choice for a period of five years. Gateway Health Plan® contacts the
member’s physician and pharmacy of choice to ask if they would be willing to accept a restricted
member. Our program interfaces with the DPW (Department of Public Welfare) centralized
Recipient Restriction program. This enables DPW to continue the restrictions for a five-year
period across the Pennsylvania Medical Assistance Program. Once a member is identified for this
program through referrals from participating pharmacies or physicians or generated utilization
reports, a complete review of pharmacy and medial claims data is performed. Upon completion of
the review, if misutilization, fraud and/or abuse can be documented and has met the DPW
approved restriction criteria, the member is recommended for restriction to a PCP and/or
Participating Pharmacy. Upon approval from Gateway’s Recipient Restriction Committee and the
Department of Public Welfare, the member is then restricted or “locked-in” to one PCP and/or
one Participating Pharmacy. Please note: the restriction is not enforced in the case of an
emergency. Please contact Gateway Health Plan® for assistance if this situation occurs. If you
13
suspect member misutilization and/or fraud and/or abuse please contact our Pharmacy Services
Department at 1-800-528-6738 or our Special Investigations Unit at 1-800-685-5235.
APPEALS AND COMPLAINTS
Gateway Health Plan® providers and members have the right to appeal any denial made by the
plan. Details regarding appeals, complaints, and grievances may be found in the Member
Handbook or the Provider Manual. To request a Member Handbook, call Member Services at:
1-800-392-1147. To request a Provider Manual, call Provider Relations at: 1-800-392-1145. Both
manuals are available online at www.gatewayhealthplan.com.
ELECTRONIC PRESCRIBING
Gateway Health Plan® is able to accept and administer the transmittal of electronic prescriptions
and is highly interested in expanding the use of electronic prescribing across all network physicians
and pharmacies. Physicians who use electronic prescribing will have access to a number of
electronic prescribing features though Gateway’s connectivity with Surescripts including the ability
to see:
 Plan formularies
 Member eligibility data
 Plan gender edits
 Plan quantity limits
 Drugs that require prior authorization or part of specific step therapies
Gateway feels that the most significant advantage of electronic prescribing is its propensity to
reduce medication errors, increase compliance, and improve the overall care to patients.
Electronic prescribing will also enhance physician efficiency in handling prescriptions for initial
coverage and refills, thus saving administrative time and effort.
PHARMACY BENEFIT INQUIRIES
Providers having questions regarding a member’s pharmacy benefit, please call
1-800-528-6738. If you are a member with a question regarding your pharmacy benefit, please call
Pharmacy Member Services at 1-800-392-1147 (TTY/TDD users: 711).
14
NON-FORMULARY DRUG EXCEPTION FORM
The DRUG SPECIFIC PRIOR AUTHORIZATION and STEP THERAPY FORMS are available on the website at
www.gatewayhealthplan.com. If you need to speak to a Pharmacy Services Representative, call 1-800-528-6738.
FAX COMPLETED FORM TO: (888) 245- 2049
SECTION A - MEMBER INFORMATION
Last name:
Date of Birth:
First name:
Allergies:
Member ID:
Type of reaction(s):
SECTION B - PHARMACY INFORMATION
Pharmacy Phone Number:
Pharmacy Name:
SECTION C - CLINICAL INFORMATION
Dosage and Frequency: Quantity:
Length of therapy:
Drug Name Requested:
Diagnosis for which drug is being requested:
FORMULARY ALTERNATIVES THAT HAVE BEEN USED BY THE PATIENT
You must be able to document the therapeutic failure or contraindication to formulary products for a request to
be approved.
Drug Name/ Strength
Dates Tried:
Reason therapy failed or discontinued
Is member currently or recently hospitalized?
Date of Discharge: Reason for Hospitalization:
Yes □
No □
Additional Clinical or Supporting Information: Please include current office notes, lab data, and other
supporting medical literature.
Prescriber Name (printed):
SECTION D - PRESCRIBER INFORMATION
Prescriber Specialty:
NPI Number:
Office Phone:
Office Fax:
Prescriber Signature:
Date:
If the request is denied, the prescriber can change the prescription to an appropriate formulary alternative or with written
member consent file an appeal with Gateway. The Drug Formulary is available on the website at www.gatewayhealthplan.com.
Revised 8/2011
MAY PHOTOCOPY FOR OFFICE USE
15
PHARMACY BENEFIT LIMIT EXCEPTION REQUEST FORM
Please complete and fax all requested information below including any progress notes, laboratory test results,
or chart documentation as applicable to Gateway Health Plan® Pharmacy Services.
FAX: (888) 245-2049
If needed, you may call to speak to a Pharmacy Services Representative.
PHONE: (800) 528-6738 Monday through Friday 8:30am to 4:30pm
PROVIDER INFORMATION
Requesting Physician:
Physician Specialty:
Office Address:
NPI:
Office Contact:
Office Phone:
Office Fax:
MEMBER INFORMATION
Patient Name:
Gateway ID:
DOB:
MEDICAL INFORMATION
Diagnosis:_________________________________________________________________________
MEDICATION(S) REQUIRING EXCEPTION TO THE BENEFIT LIMIT
Drug Name
Strength
Frequency
Duration/Refills
BENEFIT LIMIT REVIEW CRITERIA
1. Patient has a serious chronic systemic illness or other serious health condition and denial of the exception
will jeopardize the life of the member.
Yes
No If yes, please explain and provide supporting documentation from the medical record.
2. Patient has a serious chronic systemic illness or other serious health condition and denial of the exception
will result in the rapid, serious deterioration of the health of the member.
Yes
3. Patient would require more expensive services if the exception is not granted.
Yes
4. Granting the exception is necessary in order to comply with Federal law.
Yes
SUPPORTING INFORMATION (Attach additional documentation as needed.)
Is this a prescription for a drug that requires prior authorization?
□ Yes* □ No *If yes, submit the documentation to support a request for prior authorization of the drug.
I attest that the information provided and statements made herein are true, accurate and complete, to the
best of my knowledge, and I understand that any falsification, omission, or concealment of material fact
may subject me to civil and criminal liability.
Prescribing Physician Signature
Date
16
GATEWAY HEALTH PLAN® OTC FORMULARY
(FOR COVERAGE, DRUGS MUST BE WRITTEN AS A PRESCRIPTION)
Drugs are listed alphabetically by category. Specific OTC drugs are listed as examples and are not
inclusive of all covered products.
Analgesics
Obstetrics & Gynecology
Acetaminophen
Acetaminophen combinations
Aspirin
Aspirin combinations
Nonsteroidal anti-inflammatory agents
Salicylates
Dermatologicals/Topical Therapy
Acne (benzoyl peroxide)
Anesthetics (benzocaine, dibucaine, lidocaine,
cyclomethycaine, pramoxine, tetracaine)
Antibacterials (bacitracin, neomycin, triple
antibiotic preparation, povidone-iodine)
Anti-inflammatory agents (hydrocortisone 1%)
Dermatological baths (colloidal oatmeal)
Fungicides (clotrimazole, miconazole, tolnaftate,
terbinafine, undecylenic acid, salicyclic acid,
triacetin)
Tar preparations (not including soaps and
cleansing agents)
Wet dressings (aluminum acetate)
Scabicides/pediculicides (permethrin, RID)
Contraceptives (condoms, contraceptive jellies)
Contraceptive devices
Pregnancy Test Kits
Vaginal fungicides
Ophthalmic Preparations
Ocular lubricants (polyvinyl alcohol or cellulose
derivatives)
Antihistamine (Alaway, Zaditor)
Decongestants (Naphcon, Visine)
Phenylephrine 0.12%
Sodium chloride
Respiratory, Allergy, Cough & Cold
Antihistamines (diphenhydramine, loratadine,
cetirizine)
Bronchodilators
Cough and cold products (for MA recipients under
21 years of age; prior authorization required for
children less than 4 years of age)
Nasal preparations (naphazoline, xylometazoline,
oxymetazoline, phenylephrine, saline)
Saline for inhalation
Endocrine/Diabetes
Insulin
Insulin needles and syringes
Diagnostic devices
Diabetic supplies (FreeStyle Lite, FreeStyle
InsuLinx, and Precision Xtra) products, lancets,
strips, alcohol swabs)
Smoking Cessation Products
Nicotine replacement
Vitamins, Hematinics & Electrolytes
Gastroenterology
Antacids
Antidiarrheals (kaolin-pectin combinations,
loperamide)
Antiflatulents (simethicone)
Antinauseants (cyclizine, meclizine,
dimenhydrinate)
Laxatives and stool softeners (Miralax, Milk of
Magnesia, bisacodyl, docusate)
Histamine-2 receptor antagonists
Vitamins
Prenatal vitamins
Calcium salts
Iron products (not including long-acting products)
Nicotinic acid
Oral electrolyte mixtures
Medical Supplies
®
Please check with Gateway Health Plan for
coverage
17
®
Gateway Health Plan Pennsylvania Medicaid Formulary
Generic Name
ANTI-INFECTIVE
AMINOGLYCOSIDES
Brand Name
Notes
Gentamicin Sulfate Inj
Gentamicin Sulfate
SPN
Neomycin Sulfate
Tobramycin Sulfate Inj
Tobramycin/0.25 Normal Saline
Neomycin Sulfate
Tobramycin Sulfate
Tobi
SPN
SPN
ANTI-INFECTIVE, MISC
Albendazole
Clindamycin HCl
Clindamycin Palmitate
Albenza
Cleocin HCl
Cleocin Palmitate
Clindamycin Phosphate Inj
Dapsone
Imipenem/Cilastatin sodium Inj
Iodoquinol
Mebendazole
Meropenem
Cleocin Phosphate
Dapsone
Primaxin
Yodoxin
Vermox
Merrem
SPN
Palivizumab
Paromomycin Sulfate
Praziquantel
Vancomycin HCl
Synagis
Humatin
Biltricide
Vancocin HCl
QL PA SPN
Vancomycin HCl Inj
Vancocin HCl
SPN
SPN
SPN
ANTI-MYCOBACTERIUM AGENTS
Ethambutol HCl
Isoniazid
Myambutol
Isoniazid
Pyrazinamide
Rifabutin
Pyrazinamide
Mycobutin
ANTIFUNGAL AGENTS
Amphotericin B Inj
Clotrimazole Troche
Fungizone IV
Mycelex Troche
SPN
Fluconazole
Fluconazole Inj
Flucytosine
Diflucan
Diflucan
Ancobon
QL
SPN
Griseofulvin Ultramicrosize
Griseofulvin,Microsize
Ketoconazole
Gris PEG
Grifulvin V
Nizoral
Nystatin
Terbinafine HCl
Mycostatin
Lamisil
QL
ANTIMALARIAL DRUGS
Atovaquone/Proguanil HCl
Chloroquine Phosphate
Hydroxychloroquine Sulfate
Mefloquine HCl
Primaquine Phosphate
Pyrimethamine
Malarone
Aralen Phosphate
Plaquenil
Lariam
Primaquine
Daraprim
ANTIPROTOZOAL
Atovaquone
Mepron
Metronidazole
Pentamidine Isethionate
Flagyl
Nebupent
ANTIVIRALS, GENERAL
Bold - Generic Covered (Brand is nonformulary)
PA - Prior Authorization Required
GA - Generic Available (Brand is also on formulary)
QL - Quantity Limit Applies
SPN - Speciality Pharmacy Network
ST - Step Therapy Protocol
Page 18
®
Generic Name
Brand Name
Acyclovir
Amantadine HCl
Zovirax
Symmetrel
Famciclovir
Ganciclovir Sodium
Valacyclovir HCl
Valganciclovir Hydrochloride
Famvir
Cytovene
Valtrex
Valcyte
Notes
ANTIVIRALS, HIV/AIDS
Integrase Inhibitor
Raltegravir Potassium
Isentress
QL
NON-NUCLEOSIDE, RTI
Delavirdine Mesylate
Efavirenz
Etravirine
Rescriptor
Sustiva
Intelence
Nevirapine
Nevirapine
Rilpivirine
Viramune XR
Viramune
Edurant
NUCLEOSIDE ALG, RTI COMB
Abacavir Sulfate/Lamivudine
Epzicom
Zidovudine/Lamivudine
Zidovudine/Lamivudine/Abacavir
Combivir
Trizivir
NUCLEOSIDE ANALOG, RTI
Abacavir Sulfate
Didanosine
Ziagen
Videx EC
Didanosine solution
Emtricitabine
Lamivudine
Videx
Emtriva
Epivir
Stavudine
Zidovudine
Zerit
Retrovir
NUCLEOSIDE, NUCLEOTIDE, NNRTI COMB
Efavirenz/Emtricitabine/Tenofovir
Atripla
Emtricitabine/Rilpivirine/Tenofovir
Complera
NUCLEOSIDE-NUCLEOTIDE ANALOG
Emtricitabine/Tenofovir
Truvada
NUCLEOTIDE ANALOG, RTI
Tenofovir Disoproxil Fumarate
Viread
PROTEASE INHIBITOR COMB
Ritonavir/Lopinavir
Kaletra
PROTEASE INHIBITORS
Atazanavir Sulfate
Darunavir ethanolate
Reyataz
Prezista
Fosamprenavir Calcium
Indinavir Sulfate
Nelfinavir Mesylate
Ritonavir
Saquinavir
Saquinavir Mesylate
Tipranavir
Lexiva
Crixivan
Viracept
Norvir
Fortovase
Invirase
Aptivus
CEPHALOSPORINS
1ST GENERATION
Page 19
®
Generic Name
Brand Name
Cefadroxil Hydrate
Cefazolin Sodium Inj
Duricef
Ancef
Cephalexin Monohydrate
Keflex
Notes
SPN
2nd GENERATION
Cefaclor
Cefotetan Disodium Inj
Cefoxitin Sodium Inj
Cefprozil
Cefuroxime Axetil
Ceclor
Cefotan
Mefoxin
Cefzil
Ceftin
Cefuroxime Sodium Inj
Zinacef
SPN
Omnicef
Vantin
Fortaz
Tazicef
Rocephin
SPN
SPN
SPN
Maxipime
SPN
Boceprevir
Victrelis
PA
Telaprevir
Lamivudine
Peginterferon Alfa-2A
Incivek
Epivir HBV
Pegasys
PA
Peginterferon Alfa-2B
Ribavirin
Ribavirin
PEG-Intron
RibaPak
Rebetol
PA SPN
SPN
Azithromycin
Clarithromycin
Clarithromycin
Zithromax
Biaxin
Biaxin XL
QL
QL
QL
Ery E-Succ/Sulfisoxazole
Erythromycin Base
Erythromycin Base
Pediazole
E-Mycin
Ery-Tab
Erythromycin Base
Erythromycin Estolate
Erythromycin Ethylsuccinate
Erythromycin Stearate
Eryc
E.E.S.
Eryped
Erythrocin Stearate
SPN
SPN
3RD GENERATION
Cefdinir
Cefpodoxime
Ceftazidime Pentahydrate Inj
Ceftriaxone Sodium Inj
4TH GENERATION
Cefepime HCl Inj
HEPATITIS B&C
PA SPN
MACROLIDES/KETOLIDES
NEURAMINIDASE INHIBITORS
Oseltamivir phosphate
Zanamivir
Tamiflu
Relenza
QL
QL
PENICILLINS
Amox Tr/Potassium Clavulanate
Augmentin
Augmentin ES
Amoxicillin Trihydrate
Ampicillin Sodium Inj
Ampicillin Sodium/Sulbactam Na Inj
Augmentin XR
Amoxil
Ampicillin
Unasyn
SPN
SPN
Page 20
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Generic Name
Brand Name
Notes
Ampicillin Trihydrate
Dicloxacillin Sodium
Principen
Dynapen
Nafcillin Sodium Inj
Oxacillin Sodium Inj
Penicillin V Potassium
Piperacillin Na/Tazobactam Na Inj
Piperacillin Sodium Inj
Nafcillin
Oxacillin
Pen-Vee K
Veetids
Zosyn
Piperacillin
SPN
SPN
Ticarcillin/K Clavulanate Inj
Timentin
SPN
levofloxacin
Ciprofloxacin HCl
Ciprofloxacin Lactate Inj
Moxifloxacin HCl
Moxifloxacin HCl Inj
Levaquin
Cipro
Cipro I.V.
Avelox
Avelox I.V.
QL
SPN
QL
SPN
Ofloxacin
Floxin
QL
SPN
SPN
QUINOLONES
SULFONAMIDES
Sulfadiazine
Sulfadiazine
Sulfamethoxazole/Trimethoprim
Sulfamethoxazole/Trimethoprim Inj
Sulfisoxazole
Bactrim DS
Bactrim IV
Sulfisoxazole
SPN
TETRACYCLINES
Demeclocycline
Declomycin
Doxycycline Hyclate
Minocycline HCl
Vibramycin
Dynacin
Tetracycline HCl
Achromycin V
TUBERCULOSIS
Cycloserine
Rifampin
Rifapentine
Seromycin
Rifadin
Priftin
URINARY TRACT AGENTS
Nitrofurantoin Macrocrystal
Nitrofurantoin/Nitrofuran Mac
Trimethoprim
Macrodantin
Macrobid
Proloprim
Page 21
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Generic Name
CANCER/IMMUNOSUPPRESSION
CANCER CHEMOTHERAPY
ALKYLATING AGENTS
Brand Name
Altretamine
Hexalen
Busulfan
Busulfan
Chlorambucil
Cyclophosphamide
Hydroxyurea
Lomustine
Busulfex
Myleran
Leukeran
Cytoxan
Hydrea
CeeNu
Melphalan HCl
Temozolomide
Alkeran
Temodar
Notes
SPN
ANTIANDROGENIC AGENTS
Bicalutamide
Flutamide
Nilutamide
Casodex
Eulexin
Nilandron
ANTIMETABOLITES
Mercaptopurine
Purinethol
Methotrexate Sodium
Thioguanine
Methotrexate
Thioguanine
MISC
Anastrozole
Arimidex
Bevacizumab
Etoposide
Imatinib Mesylate
Avastin
VePesid
Gleevec
Letrozole
Leucovorin Calcium
Leuprolide acetate
Femara
Leucovorin Calcium
Lupron Depot
Leuprolide acetate
Megestrol Acetate
Lupron
Megace
Mitotane
Procarbazine HCl
Tamoxifen Citrate
Lysodren
Matulane
Nolvadex
Toremifene Citrate
Tretinoin
Fareston
Vesanoid
SPN
PA SPN
SPN
QL PA SPN
QL PA SPN
HEMATOLOGY
HEMATINICS
Epoetin Alfa
Procrit
PA SPN
Neupogen
PA SPN
Azathioprine Sodium
Cyclosporine
Cyclosporine, Modified
Mycophenolate Mofetil
Imuran
Sandimmune
Neoral
CellCept
GA
GA
Sirolimus
Tacrolimus Anhydrous
Rapamune
Prograf
LEUKOCYTE (WBC) STIM
Filgrastim
IMMUNOSUPPRESSIVES
Page 22
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Generic Name
CARDIOVASCULAR
ANTIARRHYTHMICS
Brand Name
Dronedarone
Multaq
Amiodarone HCl
Amiodarone HCl Inj
Disopyramide Phosphate
Dofetilide
Flecainide Acetate
Cordarone
Amiodarone
Norpace
Norpace CR
Tikosyn
Tambocor
Mexiletine HCl
Procainamide HCl
Propafenone HCl
Quinidine Gluconate
Quinidine Sulfate
Mexitil
Pronestyl
Rythmol
Quinidine Gluconate
Quinidex
Notes
SPN
ANTIHYPERTENSIVES
ACE INHIBITORS
Benazepril HCl
Lotensin
QL
Benazepril/Hydrochlorothiazide
Captopril
Lotensin HCT
Capoten
QL
Captopril/Hydrochlorothiazide
Enalapril Maleate
Enalapril/Hydrochlorothiazide
Capozide
Vasotec
Vaseretic
Fosinopril
Fosinopril/Hydrochlorothiazide
Monopril
Monopril HCT
QL
Lisinopril
Lisinopril/Hydrochlorothiazide
Quinapril HCl/HCTZ/Mag Carb
Prinivil
Prinzide
Accuretic
QL
QL
Quinapril HCl/Mag Carb
Ramipril
Accupril
Altace
QL
QL
ALPHA BLOCKERS
Doxazosin Mesylate
Phenoxybenzamine HCl
Cardura
Dibenzyline
Prazosin HCl
Terazosin HCl
Minipress
Hytrin
QL
QL
ALPHA/BETA BLOCKERS
Carvedilol
Coreg
Labetalol HCl
Normodyne
ARBs
Losartan potassium
Losartan/Hydrochlorothiazide
Cozaar
Hyzaar
QL
QL
BETA-BLOCKERS
Acebutolol HCl
Atenolol
Atenolol/Chlorthalidone
Bisoprolol Fumarate
Bisoprolol Fumarate/HCTz
Metoprolol Succinate
Sectral
Tenormin
Tenoretic
Zebeta
Ziac
Toprol XL
Metoprolol Tartrate
Metoprolol Tartrate/HCTz
Lopressor
Lopressor HCT
Page 23
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Generic Name
Brand Name
Nadolol
Pindolol
Corgard
Pindolol
Propranolol HCl
Propranolol HCl LA
Propranolol HCl/HCTz
Sotalol HCl
Sotalol HCl
Timolol Maleate
Inderal
Inderal LA
Inderide
Betapace AF
Betapace
Blocadren
Notes
CALCIUM CHANNEL BLOCKERS
Amlodipine Besylate
Diltiazem HCl
Diltiazem HCl Inj
Diltiazem HCl SA
Diltiazem HCl SR 12
Diltiazem HCl SR 24
Norvasc
Cardizem
Diltiazem HCl
Tiazac
Cardizem SR
Cardizem CD
QL
Felodipine
Nifedipine
Nimodipine
Verapamil HCl
Plendil
Procardia XL
Nimotop
Calan
QL
QL
Verapamil HCl SR
Calan SR
QL
SPN
QL
QL
QL
DIURETICS
Amiloride HCl
Amiloride HCl/HCTZ
Bumetanide
Midamor
Moduretic
Bumex
Bumetanide Inj
Chlorothiazide
Chlorthalidone
Bumex
Diuril
Chlorthalidone
Ethacrynic Acid
Furosemide
Furosemide Inj
Edecrin
Lasix
Lasix
Hydrochlorothiazide
Indapamide
Hydrochlorothiazide
Lozol
Methyclothiazide
Metolazone
Spironolactone
Spironolactone/HCTZ
Torsemide
Triamterene
Triamterene/HCTZ
Enduron
Zaroxolyn
Aldactone
Aldactazide
Demadex
Dyrenium
Dyazide
Triamterene/HCTZ
Maxzide
SPN
SPN
MISC
Clonidine HCl
Clonidine HCl Transdermal
Clonidine/Chlorthalidone
Guanfacine HCl
Methyldopa
Methyldopa/Hydrochlorothiazide
Catapres
Catapres TTS
Clorpres
Tenex
Aldomet
Aldoril
Metyrosine
Reserpine
Demser
Reserpine
Page 24
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Generic Name
OTHER HYPERTENSIVE COMBO
Amlodipine Besylate/Benazepril
Brand Name
Notes
Lotrel
VASODILATORS
Hydralazine HCl
Hydralazine HCl/HCTz
Apresoline
Hydra-Zide
Minoxidil
Loniten
CIRCULATION/COAGULATION
Rivaroxaban
Xarelto
ANTICOAGULANTS
Warfarin Sodium
Coumadin
GA
Amicar
GA
ANTIFIBRINOLYTICS
Aminocaprioic Acid
ANTIPLATELETS
Anagrelide HCl
Aspirin/Dipyridamole
Cilostazol
Clopidogrel Bisulfate
Dipyridamole
Agrylin
Aggrenox
Pletal
Plavix
Persantine
Ticlopidine HCl
Ticlid
HEPARINS
Dalteparin Sodium,Porcine
Enoxaparin Sodium
Fragmin
Lovenox
QL
QL
Fondaparinux
Heparin Sodium,Beef
Heparin Sodium,Porcine
Arixtra
Heparin Sodium,Beef
QL
Heparin Sodium,Porcine IV
Heparin Sodium
Porcine
SPN
SPN
MISC
Pentoxifylline
Trental
DIGITALIS GLYCOSIDES
Digoxin
Lanoxin
GA
LIPID MANAGEMENT
BILE ACID SEQUESTRANTS
Cholestyramine/Aspartame
Cholestyramine/Sucrose
Colestipol HCl
Questran Light
Questran
Colestid
FIBRATES
Fenofibrate
Fenofibrate (Micronized)
Gemfibrozil
Lofibra
Lofibra
Lopid
NICOTINIC ACID
Niacin
Niaspan
STATINS
Atorvastatin
Lovastatin
Lipitor
Mevacor
QL ST
Pravastatin
Simvastatin
Pravachol
Zocor
QL
QL
Page 25
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Generic Name
Brand Name
Notes
MISC
ranolazine
Ranexa
NITRATES
LONG ACTING
Isosorbide Dinitrate
Isosorbide Dinitrate SR
Isosorbide Mononitrate
Nitroglycerin Oint
Nitroglycerin SA
Isordil
Dilatrate-SR
Imdur
Nitrol
Nitro-Bid
Nitroglycerin Transdermal
RAPID ACTING
Nitroglycerin
Nitroglycerin Spray
Nitrostat
Nitrolingual
GA
Page 26
®
Generic Name
CENTRAL NERVOUS SYSTEM
ADHD/NARCOLEPSY
guanfacine
Brand Name
Notes
Intuniv
QL
Amphet Asp/Amphet/D-Amphet XR
D-Amphetamine Sulfate
Adderall XR
Dexedrine
QL
QL
Dexmethylphenidate HCl XR
lisdexamfetamine
Methylphenidate HCl Mphase
Methylphenidate HCl Sa
Methylphenidate HCl SR
Methylphenidate Tab Sa Osm
Focalin XR
Vyvanse
Metadate CD
Metadate ER
Ritalin SR
Concerta
QL
QL
QL
QL
QL
QL
Strattera
QL
Amphet Asp/Amphet/D-Amphet
Dexmethylphenidate HCl
Methamphetamine HCl
Methylphenidate HCl
Adderall
Focalin
Desoxyn
Ritalin
QL
QL
QL
QL
methylphenidate solution
Methylin
QL
LONG ACTING STIMULANTS
MISC
Atomoxetine
SHORT ACTING STIMULANTS
ANTICONVULSANTS
Carbamazepine
Tegretol XR
Carbamazepine
Clonazepam
Diazepam
Tegretol
Klonopin
Diastat
Divalproex Sodium
Divalproex Sodium
Ethosuximide
Depakote
Depakote ER
Zarontin
Felbamate
Gabapentin
Lamotrigine
Felbatol
Neurontin
Lamictal
Levetiracetam
Mephobarbital
Oxcarbazepine
Phenobarbital
Phenytoin
Keppra
Mebaral
Trileptal
Phenobarbital
Dilantin
Primidone
Tiagabine HCl
Topiramate
Valproate Sodium
Mysoline
Gabitril
Topamax
Depakene
Zonisamide
Zonegran
QL
GA
GA
GA
ANTIDEPRESSANTS
MAO INHIBITORS
Phenelzine Sulfate
Tranylcypromine Sulfate
Nardil
Parnate
MISC
Mirtazapine
Remeron
QL
Page 27
®
Generic Name
Brand Name
Notes
NDRIs
Bupropion HCl
Bupropion HCl SR
Wellbutrin
Wellbutrin SR
SARIs
Nefazodone HCl
Nefazodone
Trazodone HCl
Desyrel
SNRIs
Desvenlafaxine
Duloxetine HCl
Venlafaxine HCl
Venlafaxine HCl XR
Pristiq
Cymbalta
Effexor
Effexor XR
QL
QL
Viibryd
QL
Citalopram Hydrobromide
Escitalopram Oxalate
Celexa
Lexapro
QL
QL
Fluoxetine HCl
Fluvoxamine Maleate
Paroxetine HCl
Sertraline HCl
Prozac
Luvox
Paxil
Zoloft
QL
QL
QL
QL
QL
SSRI & 5HT1A Partial Agonists
Vilazodone
SSRIs
TRICYCLICS
Amitriptyline HCl
Elavil
Amoxapine
Clomipramine HCl
Amoxapine
Anafranil
Desipramine HCl
Doxepin HCl
Imipramine HCl
Norpramin
Sinequan
Tofranil
Maprotiline HCl
Nortriptyline HCl
Protriptyline HCl
Maprotiline HCl
Pamelor
Vivactil
Trimipramine Maleate
Surmontil
ANTIPSYCHOTICS
ATYPICAL
Aripiprazole
Asenapine
Clozapine
Abilify
Saphris
Clozaril
QL PA
QL PA
Lurasidone
Olanzapine
Quetiapine Fumarate
Quetiapine fumarate
Risperidone
Risperidone Microspheres
Ziprasidone HCl
Latuda
Zyprexa
Seroquel
Seroquel XR
Risperdal
Risperdal Consta
Geodon
QL
QL
QL
QL
QL
QL
QL
Droperidol
Haloperidol
SPN
PA
PA
PA
PA
PA
PA
BUTYROPHENONES
Droperidol Inj
Haloperidol
MISC
Loxapine Succinate
Pimozide
Loxitane
Orap
Page 28
®
Generic Name
Thiothixene
Brand Name
Notes
Navane
PHENOTHIAZINES
Chlorpromazine HCl
Fluphenazine Decanoate
Thorazine
Prolixin Decanoate
Fluphenazine HCl
Perphenazine
Thioridazine HCl
Trifluoperazine HCl
Prolixin
Perphenazine
Mellaril
Stelazine
ANXIOLYTIC
Alprazolam
Buspirone HCl
Chlordiazepoxide HCl
Clorazepate Dipotassium
Xanax
Buspar
Librium
Tranxene
Diazepam
Lorazepam
Oxazepam
Valium
Ativan
Serax
CHOLINESTERASE INHIBITORS
ALZHEIMERS DRUGS
Donepezil HCl
galantamine HBr
Aricept
Razadyne
QL PA
QL PA
Rivastigmine Tartrate
Exelon
QL PA
MYASTHENIA GRAVIS
Neostigmine Bromide
Pyridostigmine Bromide
Prostigmin
Mestinon
MANIA THERAPY
Lithium Carbonate
Lithium Carbonate Tab Sa
Eskalith
Eskalith CR
Lithobid
GA
Lithium Citrate
Lithium Citrate
GA
Copaxone
Avonex
QL PA SPN
QL PA SPN
MULTIPLE SCLEROSIS
Glatiramer Acetate
Interferon Beta-1A
PARASYMPATHETIC AGENTS
Cevimeline HCl
Pilocarpine HCl
Evoxac
Salagen
PARKINSON'S DISEASE DRUGS
Amantadine HCl
Symmetrel
Benztropine Mesylate
Carbidopa/Levodopa
Carbidopa/Levodopa
Entacapone
Pramipexole Di-HCl
Cogentin
Sinemet CR
Sinemet
Comtan
Mirapex
Ropinirole HCl
Selegiline HCl
Trihexyphenidyl HCl
Requip
Eldepryl
Trihexyphenidyl HCl
SEDATIVE-HYPNOTICS
Chloral Hydrate
Chloral Hydrate
Page 29
®
Generic Name
Brand Name
Temazepam
Triazolam
Restoril
Halcion
Zaleplon
Zolpidem
Sonata
Ambien
Notes
QL
QL
Page 30
®
Generic Name
DERMATOLOGY
ACNE
SYSTEMIC
Isotretinoin
Brand Name
Accutane
TOPICAL
Adapalene
Differin
Sulfacetamide Sodium
Tretinoin
Klaron
Retin-A
PSORIASIS
Acitretin
Calcipotriene cream
Calcipotriene soln.
Soriatane
Dovonex
Dovonex
ROSACEA
Metronidazole
Metronidazole
Metronidazole
Metrogel
Metrolotion
Metrocream
SEBORRHEA
Selenium Sulfide
Selsun Rx
Sebizon
TOPICAL ANTIBACTERIAL
Clindamycin Phosphate
Cleocin T
Erythromycin Base/Benz Per
Erythromycin Base/Ethanol
Benzamycin
A/T/S
Emgel
Gentamicin Sulfate
Erycette
Erygel
Gentamicin Sulfate
Mupirocin
Mupirocin oint
Silver Sulfadiazine
Bactroban Nasal
Bactroban
Silvadene
Sulfacetamide Sodium/Sulfur
Sulfacet-R
TOPICAL ANTIFUNGALS
Clotrimazole Cream
Clotrimazole/Betamet Diprop
Ketoconazole
Nystatin
Nystatin/Triamcin
Lotrimin AF
Lotrisone
Ketoconazole
Mycostatin
Mycolog II
TOPICAL ANTINEOPLASTIC
Fluorouracil
Efudex
TOPICAL CORTICOSTEROID
HIGH POTENCY
Betamethasone Diprop/Prp Gly Crm
Betamethasone Dipropionate Crm
Betamethasone Dipropionate Lot
Diprolene AF 0.05%
Diprosone 0.05%
Alphatrex 0.05%
Betamethasone Dipropionate Oint
Betamethasone Dipropropionate Gel
Betamethasone Valerate Oint
Desoximetasone Crm, Oint
Maxivate 0.05%
Diprolene 0.05%
Betatrex 0.1%
Topicort 0.25%
Page 31
Notes
®
Generic Name
Brand Name
Desoximetasone Gel
Fluocinonide Crm, Gel, Oint, Sol
Topicort 0.05%
Lidex
Fluocinonide/Emollient Cream
Triamcinolone Acetonide Cream
Triamcinolone Acetonide Ointment
Lidex-E 0.05%
Aristocort 0.5%
Aristocort HP 0.5%
Notes
LOW POTENCY
Desonide Cream, Oint, Lot
Fluocinolone Acetonide Cream, Soln
Fluocinolone Acetonide Oil
Desowen 0.05%
Synalar 0.01%
Derma-Smoothe/FS
Hydrocortisone Cream, Oint, Lot
Hytone 2.5%
MEDIUM POTENCY
Betamethasone Valerate 0.1% Crm, Lot
Desoximetasone Cream
Fluocinolone Acetonide Cream, Oint
Flurandrenolide Medicated Tape
Hydrocortisone Valerate Crm, Oint
Mometasone Furoate Crm, Oint
Betatrex 0.1%
Topicort LP 0.05%
Synalar 0.025%
Cordran (4Mcg/Sq Cm)
Westcort 0.2%
Elocon
Mometasone Furoate Lotion
Elocon
Triamcinolone Acetonide Aerosol Spray
Triamcinolone Acetonide Crm, Lot, Oint
Kenalog 0.1%
Kenalog 0.025%
Kenalog 0.1%
VERY HIGH POTENCY
Betamet Diprop/Prop Gly Oint
Diprolene 0.05%
Clobetasol Propionate Crm, Gel, Oint, Soln
Temovate 0.05%
TOPICAL IMMUNOSUPPRESSIVE
Imiquimod
Aldara
Pimecrolimus
Elidel
PA
TOPICAL LOCAL ANESTHETICS
Lidocaine 2% Jelly
Lidocaine 3% Cream
Xylocaine 2% Jelly
Lidamantle 3%
TOPICAL MISC
Aluminum Chloride
Drysol
Crotamiton
Lindane
Malathion
Eurax
Lindane
Ovide
Methoxsalen
Methoxsalen, Rapid
Permethrin
Podofilox
Oxsoralen
Oxsoralen Ultra
Elimite
Condylox
Page 32
®
Generic Name
Brand Name
Notes
ENDOCRINE
CONTRACEPTIVES
BI-PHASIC
Norethindrone-Ethinyl Estrad
Ortho-Novum 10/11
EMERGENCY
Levonorgestrel
Plan B
QL
EXTENDED CYCLE
Levonorgestrel/ethinyl estradiol
Jolessa
Introvale
INJECTABLE
Medroxyprogesterone Acet
Depo-Provera
INTRAVAGINAL
Etonogestrel/ethinyl estradiol
NuvaRing
MONO-PHASIC
Desog-Et Estra/Ethin Estra
Desogestrel-Ethinyl Estradiol
Ethynodiol D-Ethinyl Estradiol
Mircette
Ortho-Cept
Demulen
Levonorgestrel-Eth Estra
Noreth A-Et Estra/Fe Fumarate
Alesse
Estrostep Fe
Loestrin Fe
Modicon
Ortho-Novum
Norethindrone-Mestranol
Norgestrel-Ethinyl Estradiol
Ortho-Novum 1/50
Lo/Ovral
Ovral
PROGESTIN ONLY
Norethindrone
Ortho Micronor
Norgestrel
Ovrette
TRI-PHASIC
Norgestimate-Ethinyl Estradiol
Triphasil
Ortho Tri-Cyclen
Ortho-Cyclen
Ortho Tri-Cyclen Lo
CORTICOSTEROIDS, INJECTABLE
Methylprednisolone Sodium Succinate
Solu-Medrol
SPN
CORTICOSTEROIDS, ORAL
Betamethasone Syrup
Cortisone Acetate
Dexamethasone
Hydrocortisone
Methylprednisolone
Prednisolone
Prednisolone Sod Phosphate
Prednisone
Celestone Syrup
Cortisone Acetate
Decadron
Cortef
Medrol
Prelone
Orapred
Deltasone
Triamcinolone
Aristocort
DIABETES, INSULIN
Insulin glulisine
Insulin Aspart
Apidra/Apidra SoloSTAR
Novolog (vial, cartridge, pen)
Page 33
®
Generic Name
Brand Name
Insulin detemir
Insulin Glargine,Hum.Rec.Anlog
Levemir (vial, pen)
Lantus (vial, cartridge)
Insulin
Insulin
Insulin
Insulin
Insulin
Insulin
Lantus Solostar (pen)
Humulin (vial, pen)
Novolin (vial)
Humalog (vial, cartridge, pen)
Humalog Mix 75/25 (vial, pen)
Glargine,Hum.Rec.Anog
Human Rec
Human Rec
Lispro,Human Rec.Anlog
Npl/Insulin Lispro
Npl/Insulin Lispro
Insuln Asp Prt/Insulin Aspart
Notes
Novolog Mix 70/30 (vial, pen)
DIABETES, ORAL
Sitagliptin/Simvastatin
Juvisync
ALPHA-GLUCOSIDASE INHIBITORS
Acarbose
Miglitol
Precose
Glyset
BIGUANIDES
Metformin extended-release
Metformin HCl
Glucophage XR
Glucophage
DPP-4 Inhibitors
Sitagliptin phos / metformin
Sitagliptin Phosphate
Janumet
Januvia
QL ST
QL ST
MEGLITINIDES
Repaglinide
Prandin
SULFONYLUREAS
Glimepiride
Amaryl
QL
Glipizide
Glipizide XL
Glipizide/Metformin
Glucotrol
Glucotrol XL
Metaglip
QL
Glyburide
Glyburide
Glyburide, Micronized
Diabeta
Micronase
Glynase
Glyburide/Metformin HCl
Glucovance
TZDs
Pioglitazone / Metformin
Pioglitazone HCl
Pioglitazone/Glimepiride
ACTOplus met
Actos
Duetact
QL ST
QL ST
QL ST
Rosiglitazone Maleate
Rosiglitazone/Glimepiride
Rosiglitazone/Metformin HCl
Avandia
Avandaryl
Avandamet
QL ST
QL ST
QL ST
ENDOCRINE MISC
Bromocriptine Mesylate
Danazol
Desmopressin Acetate
Fludrocortisone Acetate
Glucagon,Human Recombinant
Parlodel
Danocrine
DDAVP Tablets
DDAVP Nasal Spray
DDAVP Nasal Solution
Florinef Acetate
Glucagon Emergency Kit
Methylergonovine Maleate
Nafarelin Acetate
Methergine
Synarel
Page 34
®
Generic Name
GROWTH HORMONE RELATED
Somatropin
Brand Name
Norditropin
Notes
PA SPN
HORMONE THERAPY
ANDROGENS
Fluoxymesterone
Methyltestosterone
Methyltestosterone
Androxy
Android
Methitest
Testosterone
Testosterone Cypionate
Testosterone Enanthate
Androderm
Depo-Testosterone
Delatestryl
ESTROGENIC AGENTS
Estradiol
Estradiol
Estradiol
Climara
Estraderm
Vivelle
Estradiol
Estradiol/Noreth Ac
Estrogen,Con/M-Progest Acet
Vivelle-DOT
Combipatch
Premphase
Prempro
Estrogens,Conjugated
Estrogens,Esterified
Estropipate
Premarin
Menest
Ogen
Ethinyl Estradiol/Noreth Ac
Femhrt
QL
MISC
Norethindrone Acetate
Provera
Aygestin
Norlutate
OSTEOPOROSIS
Alendronate Sodium
Calcitonin,Salmon,Synthetic
Fosamax
Miacalcin Nasal Spray
QL
Etidronate Disodium
Raloxifene HCl
Risedronate Sodium
Didronel
Evista
Actonel
QL
Risedronate Sodium
Teriparatide
Forteo
QL
QL SPN
Levothyroxine Sodium
Levothroid
GA
Liothyronine Sodium
Liotrix
Methimazole
Propylthiouracil
Thyroid
Synthroid
Cytomel
Thyrolar
Tapazole
Propylthiouracil
Armour Thyroid
GA
THYROID RELATED
GA
Page 35
®
Generic Name
GASTROINTESTINAL
ANTIDIARRHEALS
Brand Name
Diphenoxylate HCl/Atrop Sulf
Lomotil
Paregoric
Paregoric
Notes
ANTINAUSEANTS
Droperidol Inj
Meclizine HCl
Ondansetron HCl
Prochlorperazine Maleate
Prochlorperazine Maleate, Supp
Droperidol
Antivert
Zofran
Compazine
Compazine Suppository
Promethazine HCl
Promethazine HCl
Scopolamine Hydrobromide
Phenergan Suppository
Phenergan
Transderm-Scop
SPN
QL
ANTISPASMODICS
Dicyclomine HCl
Bentyl
GASTROINTESTINAL MISC
Metoclopramide HCl
Octreotide Acetate
Reglan
Sandostatin
Octreotide Acetate
Ursodiol
Sandostatin LAR
URSO
Ursodiol
Actigall
SPN
SPN
INFLAMMATORY BOWEL
Balsalazide Disodium
HC Acetate/Pramoxine HCl
Hydrocortisone
Colazal
Proctofoam-HC
Proctocream-HC
Hydrocortisone Acetate
Hydrocortisone Acetate cream
Infliximab
Cortifoam
Proctocort
Remicade
Mesalamine
Mesalamine
Rowasa
Asacol
Mesalamine
Sulfasalazine
Pentasa
Azulfidine
PA SPN
LAXATIVES/CATHARTICS
Lactulose
Sod Chloride/NaHCo3/Kcl/Peg'S
Lactulose
Nulytely
Sod Sulf/Sod/NaHCo3/Kcl/Peg'S
Colyte
PANCREATIC ENZYMES
Amylase/Lipase/Protease
Creon
ULCER THERAPY
H2 RECEPTOR ANTAGONIST
Cimetidine
Cimetidine HCl Inj
Famotidine
Tagamet
Tagamet
Pepcid
Famotidine Inj
Ranitidine HCl
Pepcid
Zantac
SPN
SPN
MISC
Lansoprazole/Amox Tr/Clarith
Sucralfate
Tetracyc HCl/Bis Ss/Metronid
Prevpac
Carafate
Helidac
Page 36
®
Generic Name
Brand Name
Notes
PPI
Lansoprazole
omeprazole
Pantoprazole
Prevacid
Prilosec
Protonix
QL
QL
QL
PROSTAGLANDINS
Misoprostol
Cytotec
Page 37
®
Generic Name
MISCELLANEOUS
AMYOTROPHIC LATERAL SCLEROSIS AGENTS
Riluzole
Brand Name
Notes
Rilutek
ANAPHYLAXIS THERAPY AGENTS
Epinephrine
Epinephrine
Epipen
Epipen Jr.
ANTI-ALCOHOLIC PREPARATIONS
Disulfiram
Antabuse
Naltrexone HCl
Revia
METALLIC POISON,AGENTS TO TREAT
Penicillamine
Succimer
Cuprimine
Chemet
SMOKING DETERRENTS
Bupropion HCl
Zyban
SUBSTANCE ABUSE AGENTS
Buprenorphine
Buprenorphine/Naloxone
Subutex
Suboxone Film
QL PA
QL PA
Page 38
®
Generic Name
OPHTHALMICS
ANTI-GLAUCOMA
CARBONIC ANHYDRASE INHIBITORS
Brand Name
Acetazolamide
Diamox
Methazolamide
Neptazane
MIOTICS/OTHER INTRAOC
Apraclonidine HCl
Betaxolol HCl
Betaxolol HCl
Brimonidine Tartrate
Carbachol
Iopidine
Betoptic S
Betoptic
Alphagan P 0.1%
Alphagan P 0.15%
Isopto Carbachol
Carteolol HCl
Dorzolamide HCl
Echothiophate Iodide
Latanoprost
Levobunolol HCl
Ocupress
Trusopt
Phospholine Iodide
Xalatan
Betagan
Pilocarpine HCl
Pilocarpine HCl Gel
Pilocar
Pilopine HS
Timolol Maleate
Timolol Maleate
Timolol Maleate/Dorzolam HCl
Timoptic
Timoptic-XE
Cosopt
Travoprost
Travatan Z
MYDRIATICS
Atropine Sulfate
Cyclopentolate HCl
Isopto Atropine
Cyclogyl
Dipivefrin HCl
Homatropine Hbr
Homatropine Hbr
Propine
Isopto Homatropine 5%
Tropicamide
Mydriacyl
EYE ALLERGIES
ANTIHISTAMINES
Olopatadine HCl
Pataday
DECONGESTANTS
Phenylephrine HCl
Neo-Synephrine
MAST CELL STABILIZERS
Cromolyn Sodium
Crolom
Lodoxamide Tromethamine
Alomide
EYE ANTI-INFECTIVE
moxifloxacin
Vigamox
AMINOGLYCOSIDES
Gentamicin Sulfate
Garamycin
Neomy Sulf/Bacitra/Polymyxin B
Tobramycin Sulfate
Neosporin
Tobrex
ANTIBIOTIC-CORTICOID COMBO
Na Sulfacetm/Prednis Sp
Na Sulfacetm/Prednisol Ac
Vasocidin
Blephamide
Blephamide S.O.P.
Page 39
Notes
®
Generic Name
Brand Name
Neo/Polymyx B Sulf/Dexameth
Neomy Sulf/Polymyx B Sulf/HC
Maxitrol
Cortisporin
Neomycin Sulfate/Dex Na Ph
Tobramycin Sulfate/Dexameth
NeoDecadron
TobraDex (drops)
TobraDex (oint)
Notes
ANTIBIOTICS
Bacitracin
Bacitracin/Polymyxin B Sulfate
Chloramphenicol
Bacitracin
Polysporin
Chloroptic
Ciprofloxacin HCl
Erythromycin Base
Gentamicin Sulfate
Ofloxacin
Polymyxin B Sulfate/Tmp
Ciloxan
Erythromycin
Garamycin
Ocuflox
Polytrim
Bleph-10
ANTIVIRALS
Trifluridine
Viroptic
EYE ANTI-INFLAMMATORY
NSAID
Diclofenac Sodium
Flurbiprofen Sodium
Voltaren
Ocufen
Ketorolac Tromethamine
Acular
Acular LS
STEROID
Dexamethasone
Dexamethasone Sod Phosphate
Maxidex
Decadron
Fluorometholone
Prednisolone Acetate
FML Forte
Pred Forte
Pred Mild
Rimexolone
Inflamase Forte
Vexol
EYE MISC
Cyclosporine
Hypromellose
Restasis
Lacrisert
ST
Page 40
®
Generic Name
Brand Name
ORAL CARE
DENTAL AIDS AND PREPARATIONS
Chlorhexidine Gluconate
Peridex
Doxycycline Hyclate
Triamcinolone Acetonide Dental Paste
Periostat
Kenalog In Orabase
Page 41
Notes
®
Generic Name
Brand Name
OTIC
EAR ANTI-INF/ANTI-INFLAM
Ciprofloxacin HCl/Dexameth
Ciprodex
Cortisporin
EAR ANTI-INFECTIVE
Acetic Acid
Acetic Acid/Aluminum Acetate
Acetic Acid/Hydrocortisone
Ofloxacin
Vosol
Domeboro
Vosol HC
Floxin Otic
EAR MISC
Antipyrine/Benzocaine/Glycerin
Antipyrine W/Benzocaine
Page 42
Notes
®
Generic Name
PAIN/INFLAMMATION
ANTI-GOUT
Allopurinol
Brand Name
Notes
Zyloprim
ANTI-INFLAMMATORY
Diclofenac Sodium
Voltaren Gel
QL PA
TRADITIONAL NSAID
Diclofenac Sodium
Etodolac
Flurbiprofen
Ibuprofen
Indomethacin
Indomethacin SR
Voltaren
Lodine
Ansaid
Motrin
Indocin
Indocin SR
Ketoprofen
Meloxicam
Nabumetone
Naproxen
Naproxen Sodium
Orudis
Mobic
Relafen
Naprosyn
Anaprox
Naproxen Sodium
Piroxicam
Anaprox DS
Feldene
Sulindac
Clinoril
ANTIARTHRITICS MISC
Hylan G-F 20
Synvisc/Synvisc One
QL PA SPN
ANTIMIGRAINE
ERGOT ALKALOIDS & DERIVATIVES
Dihydroergotamine Mesylate
D.H.E.45
Ergotamine Tartrate
Ergotamine Tartrate/Caffeine
Migranal
Ergomar
Cafergot
QL
Rizatriptan Benzoate
Maxalt
QL
Sumatriptan
Maxalt Mlt
Imitrex
QL
QL
Duragesic
Methadone
MS Contin
Opana ER
QL
QL
SEROTONIN 5-HT4 RECEPTOR ANTAGONISTS
NARCOTIC ANALGESICS
EXT. REL. NARC. ANALG.
Fentanyl
Methadone
Morphine Sulfate
Oxymorphone extended release
QL
IMM. REL. NARC. ANALG.
Codeine Phos
Codeine Phos/Acetaminophen
Codeine Phos/Aspirin
Codeine Phosphate
Tylenol W/Codeine
Aspirin W/Codeine
Codeine Sulf
Hydrocodone Bit/Acetaminophen
Hydrocodone/Ibuprofen
Hydromorphone HCl
Codeine Sulfate
Vicodin
Vicoprofen
Dilaudid
Meperidine HCl
Morphine Sulfate
Demerol
MSIR
Page 43
®
Generic Name
Brand Name
Morphine Sulfate
Oxycodone HCl
RMS-Suppository
Roxicodone
Oxycodone HCl/Acetaminophen
Oxycodone/Aspirin
Oxymorphone
Tramadol HCl
Tramadol/Acetaminophen
Percocet
Percodan
Opana
Ultram
Ultracet
Notes
QL
QL
NON-NARCOTIC ANALGESICS
NON-SALICYLATE
Acetaminophen/Butalbital
Phrenilin
Phrenilin Forte
Acetaminophen/Caffeine/Butalb
Fioricet
SALICYLATE
Aspirin/Caffeine/Butalbital
Chol Sal/Magnesium Salicylate
Diflunisal
Salsalate
Fiorinal
Trilisate
Dolobid
Disalcid
RHEUMATOID ARTHRITIS
ANTI-ARTHRITIC, FOLATE ANTAG
Methotrexate Sodium
Methotrexate
Methotrexate Sodium
Rheumatrex
GOLD SALTS
Auranofin
Gold Sodium Thiomalate
Ridaura
Myochrysine
MISC
Infliximab
Remicade
PA SPN
Leflunomide
Arava
QL
Humira
Enbrel
QL PA SPN
QL PA SPN
Baclofen
Carisoprodol
Chlorzoxazone
Cyclobenzaprine HCl
Dantrolene Sodium
Lioresal
Soma
Parafon Forte DSC
Flexeril
Dantrium
SPN
Methocarbamol
Orphenadrine citrate
Tizanidine (tablets)
Robaxin
Norflex
Zanaflex
TNF
Adalimumab
Etanercept
SKELETAL MUSCLE RELAXANTS
Page 44
®
Generic Name
Brand Name
Notes
RESPIRATORY
COUGH/COLD/ALLERGY
ANTIHISTAMINES
Clemastine Fumarate
Tavist
Cyproheptadine HCl
Dexchlorpheniramine Maleate
Diphenhydramine HCl Inj
Fexofenadine
Hydroxyzine HCl
Hydroxyzine Pamoate
Cyproheptadine HCl
Benadryl
Allegra
Atarax
Vistaril
Promethazine HCl
Phenergan
SPN
ANTITUSSIVES, NARCOTIC
Codeine/Promethazine HCl
Guaifenesin/Codeine Phos
Hydrocodone Bit/Homatropine
P-Ephed HCl/Hydrocodone Bit
Phenylephrine HCl/Cod/Prometh
Phenergan W/Codeine
Guaifenesin W/Codeine
Hycodan
Histussin D Oral Solution
Phenergan VC W/Codeine
Phenylephrine/Hydrocodone/Cp
Histussin HC
ANTITUSSIVES, NON-NARCOTIC
Benzonatate
Tessalon
Dm Hb/P-Ephed HCl/BPM
Dm Hb/P-Ephed HCl/Carbinox
DM Hb/Prometh HCl
Bromfed DM
Rondec-DM
Promethazine DM
Guaifenesin/Dm Hb
Phenylephrine HCl/Prometh HCl
Guaifenesin DM
Promethazine VC
DECONGESTANT/ ANTIHISTAMINE
P-Ephed HCl/Brompheniramin
Bromfed
Bromfed-PD
P-Ephed HCl/Carbinox Mal
Rondec
Rondec-TR
Pseudoephedrine HCl/Acrivas
Pseudoephedrine HCl/Chlor-Mal
Semprex-D
Deconamine Syrup
Deconamine SR
EXPECTORANT COMBINATIONS
Guaifenesin/P-Ephed HCl
Entex PSE
INHALED NASAL AGENTS
Anticholinergic
Ipratropium bromide
Atrovent Nasal Spray
QL
NASAL ANTIHISTAMINE
Azelastine HCl
Azelastine HCl
Astepro
Astelin
NASAL STEROID
Fluticasone Propionate
Triamcinolone acetonide
Flonase
Nasacort AQ
QL
QL
Albuterol Sulfate
Albuterol Sulfate
Accuneb
Ventolin HFA
QL
QL
Albuterol Sulfate
Albuterol Sulfate Inh Soln
QL
INHALED RESPIRATORY AGENTS
BETA-ADRENERGIC AGENTS
Page 45
®
Generic Name
Brand Name
Albuterol Sulfate
Albuterol Sulfate/Ipratropium
Vospire ER
Combivent
Isoetharine Solution
Metaproterenol Sulfate
Pirbuterol Acetate
Salmeterol Xinafoate
Terbutaline Sulfate
Alupent
Maxair Autohaler
Serevent Diskus
Brethine
Notes
QL
QL
QL
QL
BETA-ADRENERGICS AND GLUCOCORTICOID AGENTS
Budesonide/Formoterol Fumarate
Symbicort
QL
Fluticasone/Salmeterol
Mometasone/Formoterol
Advair Diskus
Advair HFA
Dulera
QL
QL
QL
Atrovent HFA
Atrovent Inhalant Solution
Spiriva
QL
QL
QL
Pulmicort Respules
Flovent HFA/Diskus
Asmanex
QL
QL
QL
Intal
QL
Montelukast Sodium
Singulair
QL
Zafirlukast
Accolate
QL
Mucomyst
Pulmozyme
QL PA SPN
Letairis
QL SPN
GENERAL BRONCHODILATOR AGENTS
Ipratropium Bromide
Ipratropium Bromide
Tiotropium Bromide
GLUCOCORTICOIDS
Budesonide
Mometasone
MAST CELL STABILIZERS
Cromolyn Sodium
LEUKOTRIENE ANTAGONISTS
MUCOLYTICS
Acetylcysteine
Dornase Alfa
PULMONARY ANTI-HTN
Ambrisentan
XANTHINES
Aminophylline
Aminophylline
Aminophylline Inj
Theophylline Anhydrous
Aminophylline
Quibron-T SR
Uniphyl
SPN
Theophylline/D5W Inj
Theophylline
SPN
Page 46
®
Generic Name
Brand Name
Notes
UROLOGY
ANTISPASMODIC/ ANTI-INCONTINENCE
Oxybutynin Chloride extended release
Ditropan XL
Bethanechol Chloride
Flavoxate HCl
Urecholine
Urispas
Oxybutynin Chloride
Solifenacin
Ditropan
Vesicare
QL
QL
BPH MEDS
Alfuzosin HCl
Doxazosin Mesylate
Dutasteride
Finasteride
Uroxatral
Cardura
Avodart
Proscar
Tamsulosin
Terazosin HCl
Flomax
Hytrin
QL
QL
QL
URICOSURIC AGENTS
Probenecid
Probenecid
URINARY PH MODIFIERS
Mag Carb/Citric Acid/G-Lactone
Potassium Citrate
Renacidin
Urocit-K
URINARY TRACT ANALGESIC AGENTS
Pentosan Polysulfate Sodium
Elmiron
Phenazopyridine HCl
Pyridium
Page 47
®
Generic Name
Brand Name
VAGINAL
VAGINAL ANTIBIOTICS
Cleocin (cream)
Metronidazole
Cleocin (supp)
Metrogel-Vaginal
VAGINAL ANTIFUNGALS
Butoconazole Nitrate
Nystatin
Terconazole
Gynazole-1
Nystatin
Terazol
VAGINAL ESTROGEN
Estradiol
Estring
Premarin
VAGINAL MISC
Acetic Ac/Ricinoleic/Oxyquinol
Acidic Vaginal
VAGINAL SULFONAMIDES
Sulfanilamide
Sulfathiaz/Sulfacet/Sulfabenz
AVC
Triple Sulfa
Page 48
Notes
®
Generic Name
VITAMIN/ELECTROLYTE
ELECTROLYTE DEPLETERS
Brand Name
Calcium Acetate
Phoslo
Sevelamer
Sevelamer carbonate
Sodium Polystyrene Sulfonate
Renagel
Renvela
Kayexalate
Notes
FLUORIDE PREPARATIONS
Sodium Fluoride
Luride
FOLIC ACID PREPARATIONS
Folic Acid
Folvite
IODINE CONTAINING AGENTS
Potassium Iodide
SSKI
IRON REPLACEMENT
Iron Dextran Complex
InFeD
SPN
METABOLIC DEFICIENCY AGENTS
Levocarnitine
Carnitor
PEDIATRIC VITAMIN PREPARATIONS
Fluoride Ion/Iron/Vit A,C&D
Fluoride Ion/Multivitamins
Tri-Vi-Flor W/Iron
Poly-Vi-Flor
Fluoride Ion/Multivits W-Fe
Fluoride Ion/Vit A,C&D
Poly-Vi-Flor W/Iron
Tri-Vi-Flor
POTASSIUM REPLACEMENT
Pot Chloride/Pot Bicarb/Cit Ac
Potassium Bicarbonate/Cit Ac
K-Lyte/Cl
K-Lyte
Potassium Chloride
Potassium Chloride
Potassium Chloride
K-Dur
K-Lor
K-Tab
Potassium Chloride
Potassium Chloride
Potassium Chloride
Kaon-Cl 10
Kay Ciel
Klor-Con
Potassium Chloride
Potassium Chloride
Micro-K
Micro-K 8
PRENATAL VITAMIN PREPARATIONS
PN w-CA64/Iron/Cb & Gl/FA/DSS/DH
PNV22/Iron Cbn & Gluc/FA/DSS/DHA
PNV67/Sod Iron EDTA & PS/FA/OM3
Prenatal Vit/Fe Fumarate/Fa/Se
Prenatal Vit/Iron,Carb/Doss/Fa
Citranatal 90 DHA
Citranatal DHA
Citranatal Assure
Duet DHA Complete
Materna
Prenate Advance
Prenatal Vit/Iron,Carb/Doss/Fa/LM-Folate
Prenate Elite
VITAMIN B PREPARATIONS
Folic Acid/Vit. B Complex with C
Nephrocaps
VITAMIN B12 PREPARATIONS
Cyanocobalamin
Nascobal
VITAMIN D PREPARATIONS
Calcitriol
Rocaltrol
Page 49
Pennsylvania Medicaid Formulary Class Index
ANTI-INFECTIVE
AMINOGLYCOSIDES
ANTI-INFECTIVE, MISC
ANTI-MYCOBACTERIUM AGENTS
ANTIFUNGAL AGENTS
ANTIMALARIAL DRUGS
ANTIPROTOZOAL
ANTIVIRALS, GENERAL
ANTIVIRALS, HIV/AIDS
CEPHALOSPORINS
HEPATITIS B&C
MACROLIDES/KETOLIDES
NEURAMINIDASE INHIBITORS
PENICILLINS
QUINOLONES
SULFONAMIDES
TETRACYCLINES
TUBERCULOSIS
URINARY TRACT AGENTS
CANCER/IMMUNOSUPPRESSION
CANCER CHEMOTHERAPY
HEMATOLOGY
IMMUNOSUPPRESSIVES
CARDIOVASCULAR
ANTIARRHYTHMICS
ANTIHYPERTENSIVES
CIRCULATION/COAGULATION
DIGITALIS GLYCOSIDES
LIPID MANAGEMENT
MISC
NITRATES
CENTRAL NERVOUS SYSTEM
ADHD/NARCOLEPSY
ANTICONVULSANTS
ANTIDEPRESSANTS
ANTIPSYCHOTICS
ANXIOLYTIC
CHOLINESTERASE INHIBITORS
MANIA THERAPY
MULTIPLE SCLEROSIS
PARASYMPATHETIC AGENTS
PARKINSON'S DISEASE DRUGS
SEDATIVE-HYPNOTICS
DERMATOLOGY
ACNE
PSORIASIS
ROSACEA
SEBORRHEA
TOPICAL ANTIBACTERIAL
TOPICAL ANTIFUNGALS
TOPICAL ANTINEOPLASTIC
TOPICAL CORTICOSTEROID
TOPICAL IMMUNOSUPPRESSIVE
18
18
18
18
18
18
18
18
19
19
20
20
20
20
21
21
21
21
21
22
22
22
22
23
23
23
25
25
25
26
26
27
27
27
27
28
29
29
29
29
29
29
29
31
31
31
31
31
31
31
31
31
32
Page 50
TOPICAL LOCAL ANESTHETICS
TOPICAL MISC
ENDOCRINE
CONTRACEPTIVES
CORTICOSTEROIDS, INJECTABLE
CORTICOSTEROIDS, ORAL
DIABETES, INSULIN
DIABETES, ORAL
ENDOCRINE MISC
GROWTH HORMONE RELATED
HORMONE THERAPY
OSTEOPOROSIS
THYROID RELATED
GASTROINTESTINAL
ANTIDIARRHEALS
ANTINAUSEANTS
ANTISPASMODICS
GASTROINTESTINAL MISC
INFLAMMATORY BOWEL
LAXATIVES/CATHARTICS
PANCREATIC ENZYMES
ULCER THERAPY
MISCELLANEOUS
AMYOTROPHIC LATERAL SCLEROSIS AGENTS
ANAPHYLAXIS THERAPY AGENTS
ANTI-ALCOHOLIC PREPARATIONS
METALLIC POISON,AGENTS TO TREAT
SMOKING DETERRENTS
SUBSTANCE ABUSE AGENTS
OPHTHALMICS
ANTI-GLAUCOMA
EYE ALLERGIES
EYE ANTI-INFECTIVE
EYE ANTI-INFLAMMATORY
EYE MISC
ORAL CARE
DENTAL AIDS AND PREPARATIONS
OTIC
EAR ANTI-INF/ANTI-INFLAM
EAR ANTI-INFECTIVE
EAR MISC
PAIN/INFLAMMATION
ANTI-GOUT
ANTI-INFLAMMATORY
ANTIARTHRITICS MISC
ANTIMIGRAINE
NARCOTIC ANALGESICS
NON-NARCOTIC ANALGESICS
RHEUMATOID ARTHRITIS
SKELETAL MUSCLE RELAXANTS
RESPIRATORY
COUGH/COLD/ALLERGY
INHALED NASAL AGENTS
32
32
33
33
33
33
33
34
34
35
35
35
35
36
36
36
36
36
36
36
36
36
38
38
38
38
38
38
38
39
39
39
39
40
40
41
41
42
42
42
42
43
43
43
43
43
43
44
44
44
45
45
45
Page 51
INHALED RESPIRATORY AGENTS
LEUKOTRIENE ANTAGONISTS
MUCOLYTICS
PULMONARY ANTI-HTN
XANTHINES
UROLOGY
BPH MEDS
URICOSURIC AGENTS
URINARY PH MODIFIERS
URINARY TRACT ANALGESIC AGENTS
VAGINAL
VAGINAL ANTIBIOTICS
VAGINAL ANTIFUNGALS
VAGINAL ESTROGEN
VAGINAL MISC
VAGINAL SULFONAMIDES
VITAMIN/ELECTROLYTE
ELECTROLYTE DEPLETERS
FLUORIDE PREPARATIONS
FOLIC ACID PREPARATIONS
IODINE CONTAINING AGENTS
IRON REPLACEMENT
METABOLIC DEFICIENCY AGENTS
PEDIATRIC VITAMIN PREPARATIONS
POTASSIUM REPLACEMENT
PRENATAL VITAMIN PREPARATIONS
VITAMIN B PREPARATIONS
VITAMIN B12 PREPARATIONS
VITAMIN D PREPARATIONS
45
46
46
46
46
47
47
47
47
47
47
48
48
48
48
48
48
49
49
49
49
49
49
49
49
49
49
49
49
49
Page 52
Pennsylvania Medicaid Formulary Index
A/T/S
31
Amiloride HCl
24
Atovaquone/Proguanil HCl
18
Abacavir Sulfate
19
Amiloride HCl/HCTZ
24
Atripla
19
Abacavir Sulfate/Lamivudine
19
Aminocaprioic Acid
25
Atropine Sulfate
39
Abilify
28
Aminophylline
46
Atrovent HFA
46
Acarbose
34
Aminophylline Inj
46
Atrovent Inhalant Solution
46
Accolate
46
Amiodarone
23
Atrovent Nasal Spray
45
Accuneb
45
Amiodarone HCl
23
Augmentin
20
Accupril
23
Amiodarone HCl Inj
23
Augmentin ES
20
Accuretic
23
Amitriptyline HCl
28
Augmentin XR
20
Accutane
31
Amlodipine Besylate
24
Auranofin
44
Acebutolol HCl
23
Amlodipine Besylate/Benazepril
25
Avandamet
34
44
20
Avandaryl
34
Acetaminophen/Caffeine/Butalb
44
Amoxapine
28
Avandia
34
Acetazolamide
39
Amoxicillin Trihydrate
20
Avastin
22
Acetic Ac/Ricinoleic/Oxyquinol
48
Amoxil
20
AVC
48
Acetic Acid
42
Amphet Asp/Amphet/D-Amphet
27
Avelox
21
Acetic Acid/Aluminum Acetate
42
Amphet Asp/Amphet/D-Amphet XR
27
Avelox I.V.
21
Acetic Acid/Hydrocortisone
42
Amphotericin B Inj
18
Avodart
47
Acetylcysteine
46
Ampicillin
20
Avonex
29
Achromycin V
21
Ampicillin Sodium Inj
20
Aygestin
35
Acidic Vaginal
48
Ampicillin Sodium/Sulbactam Na Inj
20
Azathioprine Sodium
22
Acitretin
31
Ampicillin Trihydrate
21
Azelastine HCl
45
Actigall
36
Amylase/Lipase/Protease
36
Azithromycin
20
Actonel
35
Anafranil
28
Azulfidine
36
35
Anagrelide HCl
25
Bacitracin
40
ACTOplus met
34
Anaprox
43
Bacitracin/Polymyxin B Sulfate
40
Actos
34
Anaprox DS
43
Baclofen
44
Acular
40
Anastrozole
22
Bactrim DS
21
Acular LS
40
Ancef
20
Bactrim IV
21
Acyclovir
19
Ancobon
18
Bactroban
31
Adalimumab
44
Androderm
35
Bactroban Nasal
31
Adapalene
31
Android
35
Balsalazide Disodium
36
Adderall
27
Androxy
35
Benadryl
45
Adderall XR
27
Ansaid
43
Benazepril HCl
23
Advair Diskus
46
Antabuse
38
Benazepril/Hydrochlorothiazide
23
Advair HFA
46
Antipyrine W/Benzocaine
42
Bentyl
36
Aggrenox
25
Antipyrine/Benzocaine/Glycerin
42
Benzamycin
31
Agrylin
25
Antivert
36
Benzonatate
45
Albendazole
18
Apidra/Apidra SoloSTAR
33
Benztropine Mesylate
29
Albenza
18
Apraclonidine HCl
39
Betagan
39
Albuterol Sulfate
45,46
Apresoline
25
Betamet Diprop/Prop Gly Oint
32
Albuterol Sulfate Inh Soln
45
Aptivus
19
Betamethasone Diprop/Prp Gly Crm
31
Albuterol Sulfate/Ipratropium
46
Aralen Phosphate
18
Betamethasone Dipropionate Crm
31
Aldactazide
24
Arava
44
Betamethasone Dipropionate Lot
31
Aldactone
24
Aricept
29
Betamethasone Dipropionate Oint
31
Aldara
32
Arimidex
22
Betamethasone Dipropropionate Gel
31
Aldomet
24
Aripiprazole
28
Betamethasone Syrup
33
Aldoril
24
Aristocort
33
Betamethasone Valerate 0.1% Crm, Lot
32
Alendronate Sodium
35
Aristocort 0.5%
32
Betamethasone Valerate Oint
31
Alesse
33
Aristocort HP 0.5%
32
Betapace
24
Alfuzosin HCl
47
Arixtra
25
Betapace AF
24
Alkeran
22
Armour Thyroid
35
Betatrex 0.1%
31,32
Allegra
45
Asacol
36
Betaxolol HCl
39
Allopurinol
43
Asenapine
28
Bethanechol Chloride
47
Alomide
39
Asmanex
46
Betoptic
39
Alphagan P 0.1%
39
Aspirin W/Codeine
43
Betoptic S
39
Alphagan P 0.15%
39
Aspirin/Caffeine/Butalbital
44
Bevacizumab
22
Alphatrex 0.05%
31
Aspirin/Dipyridamole
25
Biaxin
20
Alprazolam
29
Astelin
45
Biaxin XL
20
Altace
23
Astepro
45
Bicalutamide
22
Altretamine
22
Atarax
45
Biltricide
18
Aluminum Chloride
32
Atazanavir Sulfate
19
Bisoprolol Fumarate
23
Alupent
46
Atenolol
23
Bisoprolol Fumarate/HCTz
23
Amantadine HCl
19,29
Atenolol/Chlorthalidone
23
Bleph-10
40
Amaryl
34
Ativan
29
Blephamide
39
Ambien
30
Atomoxetine
27
Blephamide S.O.P.
39
Ambrisentan
46
Atorvastatin
25
Blocadren
24
Amicar
25
Atovaquone
18
Boceprevir
20
Page 53
Brethine
46
Cephalexin Monohydrate
20
Colestid
25
39
Cevimeline HCl
29
Colestipol HCl
25
Bromfed
45
Chemet
38
Colyte
36
Bromfed DM
45
Chloral Hydrate
29
Combipatch
35
Bromfed-PD
45
Chlorambucil
22
Combivent
46
Bromocriptine Mesylate
34
Chloramphenicol
40
Combivir
19
Budesonide
46
Chlordiazepoxide HCl
29
Compazine
36
Budesonide/Formoterol Fumarate
46
Chlorhexidine Gluconate
41
Compazine Suppository
36
Bumetanide
24
Chloroptic
40
Complera
19
Bumetanide Inj
24
Chloroquine Phosphate
18
Comtan
29
Bumex
24
Chlorothiazide
24
Concerta
27
Buprenorphine
38
Chlorpromazine HCl
29
Condylox
32
Buprenorphine/Naloxone
38
Chlorthalidone
24
Copaxone
29
Bupropion HCl
28,38
Chlorzoxazone
44
Cordarone
23
Bupropion HCl SR
28
Chol Sal/Magnesium Salicylate
44
Cordran (4Mcg/Sq Cm)
32
Buspar
29
Cholestyramine/Aspartame
25
Coreg
23
Buspirone HCl
29
Cholestyramine/Sucrose
25
Corgard
24
Busulfan
22
Cilostazol
25
Cortef
33
Busulfex
22
Ciloxan
40
Cortifoam
36
Butoconazole Nitrate
48
Cimetidine
36
Cortisone Acetate
33
Cafergot
43
Cimetidine HCl Inj
36
Cortisporin
40,42
Calan
24
Cipro
21
Cosopt
39
Calan SR
24
Cipro I.V.
21
Coumadin
25
Calcipotriene cream
31
Ciprodex
42
Cozaar
23
Calcipotriene soln.
31
Ciprofloxacin HCl
21,40
Creon
36
Calcitonin,Salmon,Synthetic
35
Ciprofloxacin HCl/Dexameth
42
Crixivan
19
Calcitriol
49
Ciprofloxacin Lactate Inj
21
Crolom
39
Calcium Acetate
49
Citalopram Hydrobromide
28
Cromolyn Sodium
39,46
Capoten
23
Citranatal 90 DHA
49
Crotamiton
32
Capozide
23
Citranatal Assure
49
Cuprimine
38
Captopril
23
Citranatal DHA
49
Cyanocobalamin
49
Captopril/Hydrochlorothiazide
23
Clarithromycin
20
Cyclobenzaprine HCl
44
Carafate
36
Clemastine Fumarate
45
Cyclogyl
39
Carbachol
39
Cleocin (cream)
48
Cyclopentolate HCl
39
Carbamazepine
27
Cleocin (supp)
48
Cyclophosphamide
22
Carbidopa/Levodopa
29
Cleocin HCl
18
Cycloserine
21
Cardizem
24
Cleocin Palmitate
18
Cyclosporine
22,40
Cardizem CD
24
Cleocin Phosphate
18
Cyclosporine, Modified
22
Cardizem SR
24
Cleocin T
31
Cymbalta
28
Cardura
23,47
Climara
35
Cyproheptadine HCl
45
Carisoprodol
44
Clindamycin HCl
18
Cytomel
35
Carnitor
49
Clindamycin Palmitate
18
Cytotec
37
Carteolol HCl
39
31,48
Cytovene
19
Carvedilol
23
Clindamycin Phosphate Inj
18
Cytoxan
22
Casodex
22
Clinoril
43
D.H.E.45
43
Catapres
24
Clobetasol Propionate Crm, Gel, Oint, Soln
32
Dalteparin Sodium,Porcine
25
Catapres TTS
24
Clomipramine HCl
28
D-Amphetamine Sulfate
27
Ceclor
20
Clonazepam
27
Danazol
34
CeeNu
22
Clonidine HCl
24
Danocrine
34
Cefaclor
20
Clonidine HCl Transdermal
24
Dantrium
44
Cefadroxil Hydrate
20
Clonidine/Chlorthalidone
24
Dantrolene Sodium
44
Cefazolin Sodium Inj
20
Clopidogrel Bisulfate
25
Dapsone
18
Cefdinir
20
Clorazepate Dipotassium
29
Daraprim
18
Cefepime HCl Inj
20
Clorpres
24
Darunavir ethanolate
19
Cefotan
20
Clotrimazole Cream
31
DDAVP Nasal Solution
34
Cefotetan Disodium Inj
20
Clotrimazole Troche
18
DDAVP Nasal Spray
34
Cefoxitin Sodium Inj
20
Clotrimazole/Betamet Diprop
31
DDAVP Tablets
34
Cefpodoxime
20
Clozapine
28
Decadron
33,40
Cefprozil
20
Clozaril
28
Declomycin
21
20
Codeine Phos
43
Deconamine SR
45
Ceftin
20
Codeine Phos/Acetaminophen
43
Deconamine Syrup
45
Ceftriaxone Sodium Inj
20
Codeine Phos/Aspirin
43
Delatestryl
35
Cefuroxime Axetil
20
Codeine Phosphate
43
Delavirdine Mesylate
19
Cefuroxime Sodium Inj
20
Codeine Sulf
43
Deltasone
33
Cefzil
20
Codeine Sulfate
43
Demadex
24
Celestone Syrup
33
Codeine/Promethazine HCl
45
Demeclocycline
21
Celexa
28
Cogentin
29
Demerol
43
CellCept
22
Colazal
36
Demser
24
Page 54
Demulen
33
Domeboro
42
Erythromycin
40
Depakene
27
Donepezil HCl
29
Erythromycin Base
20,40
Depakote
27
Dornase Alfa
46
Erythromycin Base/Benz Per
31
Depakote ER
27
Dorzolamide HCl
39
31
Depo-Provera
33
Dovonex
31
20
Depo-Testosterone
35
Doxazosin Mesylate
23,47
20
Derma-Smoothe/FS
32
Doxepin HCl
28
Erythromycin Stearate
20
Desipramine HCl
28
Doxycycline Hyclate
21,41
Escitalopram Oxalate
28
34
Dronedarone
23
Eskalith
29
Desogestrel-Ethinyl Estradiol
33
Droperidol
28,36
Eskalith CR
29
Desog-Et Estra/Ethin Estra
33
Droperidol Inj
28,36
Estraderm
35
Desonide Cream, Oint, Lot
32
Drysol
32
Estradiol
35,48
Desowen 0.05%
32
Duet DHA Complete
49
Estradiol/Noreth Ac
35
Desoximetasone Cream
32
Duetact
34
Estring
48
Desoximetasone Crm, Oint
31
Dulera
46
35
Desoximetasone Gel
32
Duloxetine HCl
28
35,48
Desoxyn
27
Duragesic
43
Estrogens,Esterified
35
Desvenlafaxine
28
Duricef
20
Estropipate
35
Desyrel
28
Dutasteride
47
Estrostep Fe
33
Dexamethasone
33,40
Dyazide
24
Etanercept
44
Dexamethasone Sod Phosphate
40
Dynacin
21
Ethacrynic Acid
24
45
Dynapen
21
Ethambutol HCl
18
Dexedrine
27
Dyrenium
24
Ethinyl Estradiol/Noreth Ac
35
Dexmethylphenidate HCl
27
E.E.S.
20
Ethosuximide
27
Dexmethylphenidate HCl XR
27
Echothiophate Iodide
39
Ethynodiol D-Ethinyl Estradiol
33
Diabeta
34
Edecrin
24
Etidronate Disodium
35
Diamox
39
Edurant
19
Etodolac
43
Diastat
27
Efavirenz
19
Etonogestrel/ethinyl estradiol
33
Diazepam
27,29
Efavirenz/Emtricitabine/Tenofovir
19
Etoposide
22
Dibenzyline
23
Effexor
28
Etravirine
19
Diclofenac Sodium
40,43
Effexor XR
28
Eulexin
22
Dicloxacillin Sodium
21
Efudex
31
Eurax
32
Dicyclomine HCl
36
Elavil
28
Evista
35
Didanosine
19
Eldepryl
29
Evoxac
29
Didanosine solution
19
Elidel
32
Exelon
29
Didronel
35
Elimite
32
Famciclovir
19
Differin
31
Elmiron
47
Famotidine
36
Diflucan
18
Elocon
32
Famotidine Inj
36
Diflunisal
44
Emgel
31
Famvir
19
Digoxin
25
Emtricitabine
19
Fareston
22
43
Emtricitabine/Rilpivirine/Tenofovir
19
Felbamate
27
Dilantin
27
Emtricitabine/Tenofovir
19
Felbatol
27
Dilatrate-SR
26
Emtriva
19
Feldene
43
Dilaudid
43
E-Mycin
20
Felodipine
24
Diltiazem HCl
24
Enalapril Maleate
23
Femara
22
Diltiazem HCl Inj
24
Enalapril/Hydrochlorothiazide
23
Femhrt
35
Diltiazem HCl SA
24
Enbrel
44
Fenofibrate
25
Diltiazem HCl SR 12
24
Enduron
24
Fenofibrate (Micronized)
25
Diltiazem HCl SR 24
24
Enoxaparin Sodium
25
Fentanyl
43
Diphenhydramine HCl Inj
45
Entacapone
29
Fexofenadine
45
Diphenoxylate HCl/Atrop Sulf
36
Entex PSE
45
Filgrastim
22
Dipivefrin HCl
39
Epinephrine
38
Finasteride
47
Diprolene 0.05%
31,32
Epipen
38
Fioricet
44
Diprolene AF 0.05%
31
Epipen Jr.
38
Fiorinal
44
Diprosone 0.05%
31
Epivir
19
Flagyl
18
Dipyridamole
25
Epivir HBV
20
Flavoxate HCl
47
Disalcid
44
Epoetin Alfa
22
Flecainide Acetate
23
23
Epzicom
19
Flexeril
44
Disulfiram
38
Ergomar
43
Flomax
47
Ditropan
47
Ergotamine Tartrate
43
Flonase
45
Ditropan XL
47
Ergotamine Tartrate/Caffeine
43
Florinef Acetate
34
Diuril
24
Ery E-Succ/Sulfisoxazole
20
Flovent HFA/Diskus
46
Divalproex Sodium
27
Eryc
20
Floxin
21
Dm Hb/P-Ephed HCl/BPM
45
Erycette
31
Floxin Otic
42
Dm Hb/P-Ephed HCl/Carbinox
45
Erygel
31
Fluconazole
18
DM Hb/Prometh HCl
45
Eryped
20
Fluconazole Inj
18
Dofetilide
23
Ery-Tab
20
Flucytosine
18
Dolobid
44
Erythrocin Stearate
20
Fludrocortisone Acetate
34
Page 55
Fluocinolone Acetonide Cream, Oint
32
Grifulvin V
18
Indocin
43
Fluocinolone Acetonide Cream, Soln
32
Gris PEG
18
Indocin SR
43
Fluocinolone Acetonide Oil
32
Griseofulvin Ultramicrosize
18
Indomethacin
43
Fluocinonide Crm, Gel, Oint, Sol
32
Griseofulvin,Microsize
18
Indomethacin SR
43
Fluocinonide/Emollient Cream
32
Guaifenesin DM
45
InFeD
49
Fluoride Ion/Iron/Vit A,C&D
49
Guaifenesin W/Codeine
45
Inflamase Forte
40
Fluoride Ion/Multivitamins
49
Guaifenesin/Codeine Phos
45
Infliximab
36,44
Fluoride Ion/Multivits W-Fe
49
Guaifenesin/Dm Hb
45
Insulin Aspart
33
Fluoride Ion/Vit A,C&D
49
Guaifenesin/P-Ephed HCl
45
Insulin detemir
34
Fluorometholone
40
guanfacine
27
Insulin Glargine,Hum.Rec.Anlog
34
Fluorouracil
31
Guanfacine HCl
24
Insulin Glargine,Hum.Rec.Anog
34
Fluoxetine HCl
28
Gynazole-1
48
Insulin glulisine
33
Fluoxymesterone
35
Halcion
30
Insulin Human Rec
34
Fluphenazine Decanoate
29
Haloperidol
28
Insulin Lispro,Human Rec.Anlog
34
Fluphenazine HCl
29
HC Acetate/Pramoxine HCl
36
Insulin Npl/Insulin Lispro
34
Flurandrenolide Medicated Tape
32
Helidac
36
Insuln Asp Prt/Insulin Aspart
34
Flurbiprofen
43
Heparin Sodium
25
Intal
46
Flurbiprofen Sodium
40
Heparin Sodium,Beef
25
Intelence
19
Flutamide
22
25
Interferon Beta-1A
29
45,46
25
Introvale
33
46
Hexalen
22
Intuniv
27
Fluvoxamine Maleate
28
Histussin D Oral Solution
45
Invirase
19
FML Forte
40
Histussin HC
45
Iodoquinol
18
Focalin
27
Homatropine Hbr
39
Iopidine
39
Focalin XR
27
Humalog (vial, cartridge, pen)
34
Ipratropium bromide
45
Folic Acid
49
34
Ipratropium Bromide
46
Folic Acid/Vit. B Complex with C
49
34
Iron Dextran Complex
49
Folvite
49
Humatin
18
Isentress
19
Fondaparinux
25
Humira
44
46
Fortaz
20
Humulin (vial, pen)
34
Isoniazid
18
Forteo
35
Hycodan
45
Isopto Atropine
39
Fortovase
19
Hydralazine HCl
25
Isopto Carbachol
39
Fosamax
35
Hydralazine HCl/HCTz
25
39
Fosamprenavir Calcium
19
Hydra-Zide
25
39
Fosinopril
23
Hydrea
22
Isordil
26
Fosinopril/Hydrochlorothiazide
23
Hydrochlorothiazide
24
Isosorbide Dinitrate
26
Fragmin
25
Hydrocodone Bit/Acetaminophen
43
Isosorbide Dinitrate SR
26
Fungizone IV
18
Hydrocodone Bit/Homatropine
45
Isosorbide Mononitrate
26
Furosemide
24
Hydrocodone/Ibuprofen
43
Isotretinoin
31
Furosemide Inj
24
Hydrocortisone
33,36
Janumet
34
Gabapentin
27
Hydrocortisone Acetate
36
Januvia
34
Gabitril
27
Hydrocortisone Acetate cream
36
Jolessa
33
galantamine HBr
29
Hydrocortisone Cream, Oint, Lot
32
Juvisync
34
Ganciclovir Sodium
19
Hydrocortisone Valerate Crm, Oint
32
Kaletra
19
Garamycin
39,40
Hydromorphone HCl
43
Kaon-Cl 10
49
Gemfibrozil
25
Hydroxychloroquine Sulfate
18
Kay Ciel
49
Gentamicin Sulfate
18,31,39,40
Hydroxyurea
22
Kayexalate
49
Gentamicin Sulfate Inj
18
Hydroxyzine HCl
45
K-Dur
49
Geodon
28
Hydroxyzine Pamoate
45
Keflex
20
Glatiramer Acetate
29
Hylan G-F 20
43
Kenalog 0.1%
32
Gleevec
22
Hypromellose
40
Kenalog 0.025%
32
Glimepiride
34
Hytone 2.5%
32
Kenalog 0.1%
32
Glipizide
34
Hytrin
23,47
Kenalog In Orabase
41
Glipizide XL
34
Hyzaar
23
Keppra
27
Glipizide/Metformin
34
Ibuprofen
43
Ketoconazole
18,31
Glucagon Emergency Kit
34
Imatinib Mesylate
22
Ketoprofen
43
Glucagon,Human Recombinant
34
Imdur
26
40
Glucophage
34
Imipenem/Cilastatin sodium Inj
18
Klaron
31
Glucophage XR
34
Imipramine HCl
28
Klonopin
27
Glucotrol
34
Imiquimod
32
K-Lor
49
Glucotrol XL
34
Imitrex
43
Klor-Con
49
Glucovance
34
Imuran
22
K-Lyte
49
Glyburide
34
Incivek
20
K-Lyte/Cl
49
Glyburide, Micronized
34
Indapamide
24
K-Tab
49
Glyburide/Metformin HCl
34
Inderal
24
Labetalol HCl
23
Glynase
34
Inderal LA
24
Lacrisert
40
Glyset
34
Inderide
24
Lactulose
36
Gold Sodium Thiomalate
44
Indinavir Sulfate
19
Lamictal
27
Page 56
Lamisil
18
Lovastatin
25
Methylergonovine Maleate
34
Lamivudine
19,20
Lovenox
25
Methylin
27
Lamotrigine
27
Loxapine Succinate
28
Methylphenidate HCl
27
Lanoxin
25
Loxitane
28
Methylphenidate HCl Mphase
27
Lansoprazole
37
Lozol
24
Methylphenidate HCl Sa
27
Lansoprazole/Amox Tr/Clarith
36
Lupron
22
Methylphenidate HCl SR
27
Lantus (vial, cartridge)
34
Lupron Depot
22
methylphenidate solution
27
Lantus Solostar (pen)
34
Lurasidone
28
Methylphenidate Tab Sa Osm
27
Lariam
18
Luride
49
Methylprednisolone
33
Lasix
24
Luvox
28
Methylprednisolone Sodium Succinate
33
Latanoprost
39
Lysodren
22
Methyltestosterone
35
Latuda
28
Macrobid
21
Metoclopramide HCl
36
Leflunomide
44
Macrodantin
21
Metolazone
24
Letairis
46
Mag Carb/Citric Acid/G-Lactone
47
Metoprolol Succinate
23
Letrozole
22
Malarone
18
Metoprolol Tartrate
23
Leucovorin Calcium
22
Malathion
32
Metoprolol Tartrate/HCTz
23
Leukeran
22
Maprotiline HCl
28
Metrocream
31
Leuprolide acetate
22
Materna
49
Metrogel
31
Levaquin
21
Matulane
22
Metrogel-Vaginal
48
Levemir (vial, pen)
34
Maxair Autohaler
46
Metrolotion
31
Levetiracetam
27
Maxalt
43
Metronidazole
18,31,48
Levobunolol HCl
39
Maxalt Mlt
43
Metyrosine
24
Levocarnitine
49
Maxidex
40
Mevacor
25
levofloxacin
21
Maxipime
20
Mexiletine HCl
23
Levonorgestrel
33
Maxitrol
40
Mexitil
23
33
Maxivate 0.05%
31
Miacalcin Nasal Spray
35
33
Maxzide
24
Micro-K
49
Levothroid
35
Mebaral
27
Micro-K 8
49
35
Mebendazole
18
Micronase
34
Lexapro
28
Meclizine HCl
36
Midamor
24
Lexiva
19
Medrol
33
Miglitol
34
Librium
29
33,35
Migranal
43
Lidamantle 3%
32
Mefloquine HCl
18
Minipress
23
Lidex
32
Mefoxin
20
Minocycline HCl
21
Lidex-E 0.05%
32
Megace
22
Minoxidil
25
Lidocaine 2% Jelly
32
Megestrol Acetate
22
Mirapex
29
Lidocaine 3% Cream
32
Mellaril
29
Mircette
33
Lindane
32
Meloxicam
43
Mirtazapine
27
Lioresal
44
Melphalan HCl
22
Misoprostol
37
Liothyronine Sodium
35
Menest
35
Mitotane
22
Liotrix
35
Meperidine HCl
43
Mobic
43
Lipitor
25
Mephobarbital
27
Modicon
33
lisdexamfetamine
27
Mepron
18
Moduretic
24
Lisinopril
23
Mercaptopurine
22
Mometasone
46
Lisinopril/Hydrochlorothiazide
23
Meropenem
18
Mometasone Furoate Crm, Oint
32
Lithium Carbonate
29
Merrem
18
Mometasone Furoate Lotion
32
29
Mesalamine
36
Mometasone/Formoterol
46
Lithium Citrate
29
Mestinon
29
Monopril
23
Lithobid
29
Metadate CD
27
Monopril HCT
23
Lo/Ovral
33
Metadate ER
27
Montelukast Sodium
46
Lodine
43
Metaglip
34
Morphine Sulfate
43,44
Lodoxamide Tromethamine
39
Metaproterenol Sulfate
46
Motrin
43
Loestrin Fe
33
Metformin extended-release
34
moxifloxacin
39
Lofibra
25
Metformin HCl
34
Moxifloxacin HCl
21
Lomotil
36
Methadone
43
Moxifloxacin HCl Inj
21
Lomustine
22
Methamphetamine HCl
27
MS Contin
43
Loniten
25
Methazolamide
39
MSIR
43
Lopid
25
Methergine
34
Mucomyst
46
Lopressor
23
Methimazole
35
Multaq
23
Lopressor HCT
23
Methitest
35
Mupirocin
31
Lorazepam
29
Methocarbamol
44
Mupirocin oint
31
Losartan potassium
23
Methotrexate
22,44
Myambutol
18
Losartan/Hydrochlorothiazide
23
Methotrexate Sodium
22,44
Mycelex Troche
18
Lotensin
23
Methoxsalen
32
Mycobutin
18
Lotensin HCT
23
Methoxsalen, Rapid
32
Mycolog II
31
Lotrel
25
Methyclothiazide
24
Mycophenolate Mofetil
22
Lotrimin AF
31
Methyldopa
24
Mycostatin
18,31
Lotrisone
31
Methyldopa/Hydrochlorothiazide
24
Mydriacyl
39
Page 57
Myleran
22
Normodyne
23
Pegasys
20
Myochrysine
44
Norpace
23
Peginterferon Alfa-2A
20
Mysoline
27
Norpace CR
23
Peginterferon Alfa-2B
20
Na Sulfacetm/Prednis Sp
39
Norpramin
28
PEG-Intron
20
39
Nortriptyline HCl
28
Penicillamine
38
Nabumetone
43
Norvasc
24
21
Nadolol
24
Norvir
19
Pentamidine Isethionate
18
Nafarelin Acetate
34
Novolin (vial)
34
Pentasa
36
Nafcillin
21
Novolog (vial, cartridge, pen)
33
Pentosan Polysulfate Sodium
47
Nafcillin Sodium Inj
21
Novolog Mix 70/30 (vial, pen)
34
Pentoxifylline
25
Naltrexone HCl
38
Nulytely
36
Pen-Vee K
21
Naprosyn
43
NuvaRing
33
Pepcid
36
Naproxen
43
Nystatin
18,31,48
45
Naproxen Sodium
43
Nystatin/Triamcin
31
45
Nardil
27
Octreotide Acetate
36
P-Ephed HCl/Hydrocodone Bit
45
Nasacort AQ
45
Ocufen
40
Percocet
44
Nascobal
49
Ocuflox
40
Percodan
44
Navane
29
Ocupress
39
Peridex
41
Nebupent
18
Ofloxacin
21,40,42
Periostat
41
Nefazodone
28
Ogen
35
Permethrin
32
Nefazodone HCl
28
Olanzapine
28
Perphenazine
29
Nelfinavir Mesylate
19
Olopatadine HCl
39
Persantine
25
Neo/Polymyx B Sulf/Dexameth
40
omeprazole
37
Phenazopyridine HCl
47
NeoDecadron
40
Omnicef
20
Phenelzine Sulfate
27
Neomy Sulf/Bacitra/Polymyxin B
39
Ondansetron HCl
36
Phenergan
36,45
40,42
Opana
44
Phenergan Suppository
36
Neomycin Sulfate
18
Opana ER
43
Phenergan VC W/Codeine
45
Neomycin Sulfate/Dex Na Ph
40
Orap
28
Phenergan W/Codeine
45
Neoral
22
Orapred
33
Phenobarbital
27
Neosporin
39
Orphenadrine citrate
44
Phenobarbital
27
Neostigmine Bromide
29
Ortho Micronor
33
Phenoxybenzamine HCl
23
Neo-Synephrine
39
Ortho Tri-Cyclen
33
Phenylephrine HCl
39
Nephrocaps
49
Ortho Tri-Cyclen Lo
33
Phenylephrine HCl/Cod/Prometh
45
Neptazane
39
Ortho-Cept
33
Phenylephrine HCl/Prometh HCl
45
Neupogen
22
Ortho-Cyclen
33
Phenylephrine/Hydrocodone/Cp
45
Neurontin
27
Ortho-Novum
33
Phenytoin
27
Nevirapine
19
Ortho-Novum 1/50
33
Phoslo
49
Niacin
25
Ortho-Novum 10/11
33
Phospholine Iodide
39
Niaspan
25
Orudis
43
Phrenilin
44
Nifedipine
24
Oseltamivir phosphate
20
Phrenilin Forte
44
Nilandron
22
Ovide
32
Pilocar
39
Nilutamide
22
Ovral
33
Pilocarpine HCl
29,39
Nimodipine
24
Ovrette
33
Pilocarpine HCl Gel
39
Nimotop
24
Oxacillin
21
Pilopine HS
39
Nitro-Bid
26
Oxacillin Sodium Inj
21
Pimecrolimus
32
Nitrofurantoin Macrocrystal
21
Oxazepam
29
Pimozide
28
Nitrofurantoin/Nitrofuran Mac
21
Oxcarbazepine
27
Pindolol
24
Nitroglycerin
26
Oxsoralen
32
Pioglitazone / Metformin
34
Nitroglycerin Oint
26
Oxsoralen Ultra
32
Pioglitazone HCl
34
Nitroglycerin SA
26
Oxybutynin Chloride
47
Pioglitazone/Glimepiride
34
Nitroglycerin Spray
26
Oxybutynin Chloride extended release
47
Piperacillin
21
26
Oxycodone HCl
44
Piperacillin Na/Tazobactam Na Inj
21
Nitrol
26
Oxycodone HCl/Acetaminophen
44
Piperacillin Sodium Inj
21
Nitrolingual
26
Oxycodone/Aspirin
44
Pirbuterol Acetate
46
Nitrostat
26
Oxymorphone
44
Piroxicam
43
Nizoral
18
Oxymorphone extended release
43
Plan B
33
Nolvadex
22
Palivizumab
18
Plaquenil
18
Norditropin
35
Pamelor
28
Plavix
25
33
Pantoprazole
37
Plendil
24
Norethindrone
33
Parafon Forte DSC
44
Pletal
25
35
Paregoric
36
PN w-CA64/Iron/Cb & Gl/FA/DSS/DH
49
33
Parlodel
34
49
Norethindrone-Mestranol
33
Parnate
27
49
Norflex
44
Paromomycin Sulfate
18
PNV67/Sod Iron EDTA & PS/FA/OM3
49
33
Paroxetine HCl
28
Podofilox
32
Norgestrel
33
Pataday
39
Polymyxin B Sulfate/Tmp
40
33
Paxil
28
Polysporin
40
Norlutate
35
Pediazole
20
Polytrim
40
Page 58
Poly-Vi-Flor
49
Prostigmin
29
Ritalin
27
Poly-Vi-Flor W/Iron
49
Protonix
37
Ritalin SR
27
Porcine
25
Protriptyline HCl
28
Ritonavir
19
Pot Chloride/Pot Bicarb/Cit Ac
49
Provera
35
Ritonavir/Lopinavir
19
Potassium Bicarbonate/Cit Ac
49
Prozac
28
Rivaroxaban
25
Potassium Chloride
49
Pseudoephedrine HCl/Acrivas
45
Rivastigmine Tartrate
29
Potassium Citrate
47
45
43
Potassium Iodide
49
Pulmicort Respules
46
RMS-Suppository
44
Pramipexole Di-HCl
29
Pulmozyme
46
Robaxin
44
Prandin
34
Purinethol
22
Rocaltrol
49
Pravachol
25
Pyrazinamide
18
Rocephin
20
Pravastatin
25
Pyridium
47
Rondec
45
Praziquantel
18
Pyridostigmine Bromide
29
Rondec-DM
45
Prazosin HCl
23
Pyrimethamine
18
Rondec-TR
45
Precose
34
Questran
25
Ropinirole HCl
29
Pred Forte
40
Questran Light
25
Rosiglitazone Maleate
34
Pred Mild
40
Quetiapine fumarate
28
Rosiglitazone/Glimepiride
34
Prednisolone
33
Quetiapine Fumarate
28
Rosiglitazone/Metformin HCl
34
40
Quibron-T SR
46
Rowasa
36
33,40
Quinapril HCl/HCTZ/Mag Carb
23
Roxicodone
44
Prednisone
33
Quinapril HCl/Mag Carb
23
Rythmol
23
Prelone
33
Quinidex
23
Salagen
29
Premarin
35,48
Quinidine Gluconate
23
Salmeterol Xinafoate
46
Premphase
35
Quinidine Sulfate
23
Salsalate
44
Prempro
35
Raloxifene HCl
35
Sandimmune
22
Prenatal Vit/Fe Fumarate/Fa/Se
49
Raltegravir Potassium
19
Sandostatin
36
Prenatal Vit/Iron,Carb/Doss/Fa
49
Ramipril
23
Sandostatin LAR
36
Prenatal Vit/Iron,Carb/Doss/Fa/LM-Folate
49
Ranexa
26
Saphris
28
Prenate Advance
49
Ranitidine HCl
36
Saquinavir
19
Prenate Elite
49
ranolazine
26
Saquinavir Mesylate
19
Prevacid
37
Rapamune
22
Scopolamine Hydrobromide
36
Prevpac
36
Razadyne
29
Sebizon
31
Prezista
19
Rebetol
20
Sectral
23
Priftin
21
Reglan
36
Selegiline HCl
29
Prilosec
37
Relafen
43
Selenium Sulfide
31
Primaquine
18
Relenza
20
Selsun Rx
31
Primaquine Phosphate
18
Remeron
27
Semprex-D
45
Primaxin
18
Remicade
36,44
Serax
29
Primidone
27
Renacidin
47
Serevent Diskus
46
Principen
21
Renagel
49
Seromycin
21
Prinivil
23
Renvela
49
Seroquel
28
Prinzide
23
Repaglinide
34
Seroquel XR
28
Pristiq
28
Requip
29
Sertraline HCl
28
Probenecid
47
Rescriptor
19
Sevelamer
49
Procainamide HCl
23
Reserpine
24
Sevelamer carbonate
49
Procarbazine HCl
22
Restasis
40
Silvadene
31
Procardia XL
24
Restoril
30
Silver Sulfadiazine
31
Prochlorperazine Maleate
36
Retin-A
31
Simvastatin
25
Prochlorperazine Maleate, Supp
36
Retrovir
19
Sinemet
29
Procrit
22
Revia
38
Sinemet CR
29
Proctocort
36
Reyataz
19
Sinequan
28
Proctocream-HC
36
Rheumatrex
44
Singulair
46
Proctofoam-HC
36
RibaPak
20
Sirolimus
22
Prograf
22
Ribavirin
20
Sitagliptin phos / metformin
34
Prolixin
29
Ridaura
44
Sitagliptin Phosphate
34
Prolixin Decanoate
29
Rifabutin
18
Sitagliptin/Simvastatin
34
Proloprim
21
Rifadin
21
Sod Chloride/NaHCo3/Kcl/Peg'S
36
Promethazine DM
45
Rifampin
21
Sod Sulf/Sod/NaHCo3/Kcl/Peg'S
36
Promethazine HCl
36,45
Rifapentine
21
Sodium Fluoride
49
Promethazine VC
45
Rilpivirine
19
Sodium Polystyrene Sulfonate
49
Pronestyl
23
Rilutek
38
Solifenacin
47
Propafenone HCl
23
Riluzole
38
Solu-Medrol
33
Propine
39
Rimexolone
40
Soma
44
Propranolol HCl
24
Risedronate Sodium
35
Somatropin
35
Propranolol HCl LA
24
Risperdal
28
Sonata
30
Propranolol HCl/HCTz
24
Risperdal Consta
28
Soriatane
31
Propylthiouracil
35
Risperidone
28
Sotalol HCl
24
Proscar
47
Risperidone Microspheres
28
Spiriva
46
Page 59
Spironolactone
24
Thioridazine HCl
29
Tropicamide
39
Spironolactone/HCTZ
24
Thiothixene
29
Trusopt
39
SSKI
49
Thorazine
29
Truvada
19
Stavudine
19
Thyroid
35
Tylenol W/Codeine
43
Stelazine
29
Thyrolar
35
Ultracet
44
Strattera
27
Tiagabine HCl
27
Ultram
44
Suboxone Film
38
Tiazac
24
Unasyn
20
Subutex
38
Ticarcillin/K Clavulanate Inj
21
Uniphyl
46
Succimer
38
Ticlid
25
Urecholine
47
Sucralfate
36
Ticlopidine HCl
25
Urispas
47
31,40
Tikosyn
23
Urocit-K
47
Sulfacetamide Sodium/Sulfur
31
Timentin
21
Uroxatral
47
Sulfacet-R
31
Timolol Maleate
24,39
URSO
36
Sulfadiazine
21
Timolol Maleate/Dorzolam HCl
39
Ursodiol
36
Sulfamethoxazole/Trimethoprim
21
Timoptic
39
Valacyclovir HCl
19
Sulfamethoxazole/Trimethoprim Inj
21
Timoptic-XE
39
Valcyte
19
Sulfanilamide
48
Tiotropium Bromide
46
Valganciclovir Hydrochloride
19
Sulfasalazine
36
Tipranavir
19
Valium
29
Sulfathiaz/Sulfacet/Sulfabenz
48
Tizanidine (tablets)
44
Valproate Sodium
27
Sulfisoxazole
21
Tobi
18
Valtrex
19
Sulindac
43
TobraDex (drops)
40
Vancocin HCl
18
Sumatriptan
43
TobraDex (oint)
40
Vancomycin HCl
18
Surmontil
28
Tobramycin Sulfate
18,39
Vancomycin HCl Inj
18
Sustiva
19
Tobramycin Sulfate Inj
18
Vantin
20
Symbicort
46
40
Vaseretic
23
Symmetrel
19,29
Tobramycin/0.25 Normal Saline
18
Vasocidin
39
Synagis
18
Tobrex
39
Vasotec
23
Synalar 0.01%
32
Tofranil
28
Veetids
21
Synalar 0.025%
32
Topamax
27
Venlafaxine HCl
28
Synarel
34
Topicort 0.05%
32
Venlafaxine HCl XR
28
Synthroid
35
Topicort 0.25%
31
Ventolin HFA
45
Synvisc/Synvisc One
43
Topicort LP 0.05%
32
VePesid
22
Tacrolimus Anhydrous
22
Topiramate
27
Verapamil HCl
24
Tagamet
36
Toprol XL
23
Verapamil HCl SR
24
Tambocor
23
Toremifene Citrate
22
Vermox
18
Tamiflu
20
Torsemide
24
Vesanoid
22
Tamoxifen Citrate
22
Tramadol HCl
44
Vesicare
47
Tamsulosin
47
Tramadol/Acetaminophen
44
Vexol
40
Tapazole
35
Transderm-Scop
36
Vibramycin
21
Tavist
45
Tranxene
29
Vicodin
43
Tazicef
20
Tranylcypromine Sulfate
27
Vicoprofen
43
Tegretol
27
Travatan Z
39
Victrelis
20
Tegretol XR
27
Travoprost
39
Videx
19
Telaprevir
20
Trazodone HCl
28
Videx EC
19
Temazepam
30
Trental
25
Vigamox
39
Temodar
22
Tretinoin
22,31
Viibryd
28
Temovate 0.05%
32
Triamcinolone
33
Vilazodone
28
Temozolomide
22
Triamcinolone acetonide
45
Viracept
19
Tenex
24
Triamcinolone Acetonide Aerosol Spray
32
Viramune
19
Tenofovir Disoproxil Fumarate
19
Triamcinolone Acetonide Cream
32
Viramune XR
19
Tenoretic
23
32
Viread
19
Tenormin
23
Triamcinolone Acetonide Dental Paste
41
Viroptic
40
Terazol
48
Triamcinolone Acetonide Ointment
32
Vistaril
45
Terazosin HCl
23,47
Triamterene
24
Vivactil
28
Terbinafine HCl
18
Triamterene/HCTZ
24
Vivelle
35
Terbutaline Sulfate
46
Triazolam
30
Vivelle-DOT
35
Terconazole
48
Trifluoperazine HCl
29
Voltaren
40,43
Teriparatide
35
Trifluridine
40
Voltaren Gel
43
Tessalon
45
Trihexyphenidyl HCl
29
Vosol
42
Testosterone
35
Trileptal
27
Vosol HC
42
Testosterone Cypionate
35
Trilisate
44
Vospire ER
46
Testosterone Enanthate
35
Trimethoprim
21
Vyvanse
27
Tetracyc HCl/Bis Ss/Metronid
36
Trimipramine Maleate
28
Warfarin Sodium
25
Tetracycline HCl
21
Triphasil
33
Wellbutrin
28
Theophylline
46
Triple Sulfa
48
Wellbutrin SR
28
46
Tri-Vi-Flor
49
Westcort 0.2%
32
Theophylline/D5W Inj
46
Tri-Vi-Flor W/Iron
49
Xalatan
39
Thioguanine
22
Trizivir
19
Xanax
29
Page 60
Xarelto
25
Xylocaine 2% Jelly
32
Yodoxin
18
Zafirlukast
46
Zaleplon
30
Zanaflex
44
Zanamivir
20
Zantac
36
Zarontin
27
Zaroxolyn
24
Zebeta
23
Zerit
19
Ziac
23
Ziagen
19
Zidovudine
19
Zidovudine/Lamivudine
19
Zidovudine/Lamivudine/Abacavir
19
Zinacef
20
Ziprasidone HCl
28
Zithromax
20
Zocor
25
Zofran
36
Zoloft
28
Zolpidem
30
Zonegran
27
Zonisamide
27
Zosyn
21
Zovirax
19
Zyban
38
Zyloprim
43
Zyprexa
28
Page 61
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medicaid formulary - Gateway Health Plan

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