open/closed - Capital BlueCross

Transcription

FORMULARY
(OPEN/CLOSED)
2016
Health care benefit programs issued or administered by Capital BlueCross and/or its subsidiaries, Capital Advantage Insurance
Company,® Capital Advantage Assurance Company® and Keystone Health Plan® Central. Independent licensees of the
BlueCross BlueShield Association. Communications issued by Capital BlueCross in its capacity as administrator of programs
and provider relations for all companies.
C34-835 (11/15)
Capital BlueCross Formulary 2016
Effective July 1, 2016
THE FORMULARY ................................................................................................................................................................................................... 4
HOW TO USE THE FORMULARY........................................................................................................................................................................... 4
GENERIC DRUG SUBSTITUTION .......................................................................................................................................................................... 5
NON-PRESCRIPTION MEDICATION (OTC) POLICY* ........................................................................................................................................... 6
COMPOUND DRUG POLICY ................................................................................................................................................................................... 6
BENEFIT EXCLUSIONS / LIMITATIONS* ............................................................................................................................................................... 6
PRIOR AUTHORIZATION PROGRAM .................................................................................................................................................................... 6
QUANTITY LIMITATIONS........................................................................................................................................................................................ 7
MAINTENANCE DRUGS ......................................................................................................................................................................................... 7
INJECTABLE MEDICATION POLICY ..................................................................................................................................................................... 7
SPECIALTY MEDICATION PROVIDER: OUTPATIENT PRESCRIPTION DRUG BENEFIT................................................................................. 7
SPECIALTY DRUGS ................................................................................................................................................................................................ 8
LEGEND ................................................................................................................................................................................................................. 10
NOTICE................................................................................................................................................................................................................... 10
ANALGESICS......................................................................................................................................................................................................... 11
NSAIDs-M..................................................................................................................................................................................................... 11
NSAIDs, COMBINATIONS-M....................................................................................................................................................................... 11
NSAIDs, TOPICAL-M ................................................................................................................................................................................... 11
COX-2 INHIBITORS-M ................................................................................................................................................................................. 12
GOUT-M ....................................................................................................................................................................................................... 12
OPIOID ANALGESICS ................................................................................................................................................................................. 12
NON-OPIOID ANALGESICS ........................................................................................................................................................................ 14
ANTI-INFECTIVES ................................................................................................................................................................................................. 14
ANTIBACTERIALS ....................................................................................................................................................................................... 14
ANTIFUNGALS ............................................................................................................................................................................................ 16
ANTIMALARIALS ......................................................................................................................................................................................... 17
ANTIRETROVIRAL AGENTS-M .................................................................................................................................................................. 17
ANTITUBERCULAR AGENTS ..................................................................................................................................................................... 18
ANTIVIRALS................................................................................................................................................................................................. 18
MISCELLANEOUS ....................................................................................................................................................................................... 19
ANTINEOPLASTIC AGENTS ................................................................................................................................................................................ 20
ALKYLATING AGENTS ............................................................................................................................................................................... 20
ANTIMETABOLITES .................................................................................................................................................................................... 20
CYTOPROTECTIVE AGENTS..................................................................................................................................................................... 20
HORMONAL ANTINEOPLASTIC AGENTS ................................................................................................................................................. 20
IMMUNOMODULATORS ............................................................................................................................................................................. 21
KINASE INHIBITORS ................................................................................................................................................................................... 21
TOPOISOMERASE INHIBITORS ................................................................................................................................................................ 22
MISCELLANEOUS ....................................................................................................................................................................................... 22
CARDIOVASCULAR .............................................................................................................................................................................................. 22
ACE INHIBITORS-M .................................................................................................................................................................................... 22
ACE INHIBITOR/CALCIUM CHANNEL BLOCKER COMBINATIONS-M .................................................................................................... 23
ACE INHIBITOR/DIURETIC COMBINATIONS-M * ..................................................................................................................................... 23
ADRENOLYTICS, CENTRAL-M .................................................................................................................................................................. 23
ALDOSTERONE RECEPTOR ANTAGONISTS-M ...................................................................................................................................... 23
ALPHA BLOCKERS-M ................................................................................................................................................................................. 23
ANGIOTENSIN II RECEPTOR ANTAGONISTS/DIURETIC COMBINATIONS-M ...................................................................................... 24
ANGIOTENSIN II RECEPTOR ANTAGONIST/CALCIUM CHANNEL BLOCKER COMBINATIONS-M ..................................................... 24
ANGIOTENSIN II RECEPTOR ANTAGONIST/CALCIUM CHANNEL BLOCKER/DIURETIC COMBINATIONS-M ................................... 25
ANTIARRHYTHMICS-M ............................................................................................................................................................................... 25
ANTILIPEMICS-M ........................................................................................................................................................................................ 25
BETA-BLOCKERS-M ................................................................................................................................................................................... 27
BETA-BLOCKER/DIURETIC COMBINATIONS-M ...................................................................................................................................... 27
CALCIUM CHANNEL BLOCKERS-M .......................................................................................................................................................... 27
CALCIUM CHANNEL BLOCKER/ANTILIPEMIC COMBINATIONS-M ........................................................................................................ 28
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DIGITALIS GLYCOSIDES-M ....................................................................................................................................................................... 28
DIRECT RENIN INHIBITORS/DIURETIC COMBINATIONS-M ................................................................................................................... 28
DIURETICS-M .............................................................................................................................................................................................. 28
NEPRILYSIN INHIBITOR/ANGIOTENSIN II RECEPTOR ANTAGONIST COMBINATIONS-M ................................................................. 29
NITRATES-M................................................................................................................................................................................................ 29
NITRATE/VASODILATOR COMBINATIONS-M .......................................................................................................................................... 29
PULMONARY ARTERIAL HYPERTENSION-M .......................................................................................................................................... 29
MISCELLANEOUS-M ................................................................................................................................................................................... 30
CENTRAL NERVOUS SYSTEM ............................................................................................................................................................................ 30
ANTIANXIETY .............................................................................................................................................................................................. 30
ANTICONVULSANTS-M .............................................................................................................................................................................. 30
ANTIDEMENTIA-M ...................................................................................................................................................................................... 32
ANTIDEPRESSANTS-M .............................................................................................................................................................................. 33
ANTIPARKINSONIAN AGENTS-M .............................................................................................................................................................. 35
ANTIPSYCHOTICS-M .................................................................................................................................................................................. 35
ATTENTION DEFICIT HYPERACTIVITY DISORDER ................................................................................................................................ 36
FIBROMYALGIA-M ...................................................................................................................................................................................... 37
HUNTINGTON'S DISEASE AGENTS-M ...................................................................................................................................................... 37
HYPNOTICS................................................................................................................................................................................................. 37
MIGRAINE .................................................................................................................................................................................................... 38
MOOD STABILIZERS-M .............................................................................................................................................................................. 39
MULTIPLE SCLEROSIS AGENTS-M .......................................................................................................................................................... 39
MUSCULOSKELETAL THERAPY AGENTS ............................................................................................................................................... 39
NARCOLEPSY ............................................................................................................................................................................................. 40
PSYCHOTHERAPEUTIC-MISCELLANEOUS ............................................................................................................................................. 40
RESTLESS LEGS SYNDROME .................................................................................................................................................................. 40
ENDOCRINE AND METABOLIC ........................................................................................................................................................................... 41
ANDROGENS .............................................................................................................................................................................................. 41
ANTIDIABETICS-M ...................................................................................................................................................................................... 41
ANTIOBESITY .............................................................................................................................................................................................. 45
CALCIUM RECEPTOR ANTAGONISTS-M ................................................................................................................................................. 45
CALCIUM REGULATORS-M ....................................................................................................................................................................... 45
CONTRACEPTIVES .................................................................................................................................................................................... 46
ENDOMETRIOSIS ....................................................................................................................................................................................... 49
ESTROGENS-M ........................................................................................................................................................................................... 49
ESTROGEN/PROGESTINS-M .................................................................................................................................................................... 50
ESTROGEN/SELECTIVE ESTROGEN RECEPTOR MODULATOR COMBINATIONS-M ......................................................................... 50
FERTILITY REGULATORS .......................................................................................................................................................................... 50
GLUCOCORTICOIDS .................................................................................................................................................................................. 51
GLUCOSE ELEVATING AGENTS ............................................................................................................................................................... 51
HUMAN GROWTH HORMONES ................................................................................................................................................................. 51
HYPERPARATHYROID TREATMENT, VITAMIN D ANALOGS-M ............................................................................................................. 51
INSULIN-LIKE GROWTH FACTOR ............................................................................................................................................................. 52
PHENYLKETONURIA TREATMENT AGENTS ........................................................................................................................................... 52
PHOSPHATE BINDER AGENTS-M............................................................................................................................................................. 52
PROGESTINS-M .......................................................................................................................................................................................... 52
SELECTIVE ESTROGEN RECEPTOR MODULATORS-M......................................................................................................................... 52
THYROID AGENTS-M ................................................................................................................................................................................. 52
VASOPRESSINS ......................................................................................................................................................................................... 53
MISCELLANEOUS ....................................................................................................................................................................................... 53
GASTROINTESTINAL ........................................................................................................................................................................................... 53
ANTIDIARRHEALS ...................................................................................................................................................................................... 53
ANTIEMETICS ............................................................................................................................................................................................. 53
ANTISPASMODICS ..................................................................................................................................................................................... 54
CHOLELITHOLYTICS-M .............................................................................................................................................................................. 54
H2 RECEPTOR ANTAGONISTS-M * ........................................................................................................................................................... 54
INFLAMMATORY BOWEL DISEASE .......................................................................................................................................................... 54
IRRITABLE BOWEL SYNDROME-M ........................................................................................................................................................... 55
LAXATIVES .................................................................................................................................................................................................. 55
OPIOID-INDUCED CONSTIPATION ........................................................................................................................................................... 55
PANCREATIC ENZYMES-M ........................................................................................................................................................................ 55
PROSTAGLANDINS-M ................................................................................................................................................................................ 55
PROTON PUMP INHIBITORS-M * .............................................................................................................................................................. 55
STEROIDS, RECTAL ................................................................................................................................................................................... 56
ULCER THERAPY COMBINATIONS .......................................................................................................................................................... 56
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MISCELLANEOUS-M ................................................................................................................................................................................... 56
GENITOURINARY .................................................................................................................................................................................................. 56
BENIGN PROSTATIC HYPERPLASIA-M .................................................................................................................................................... 56
ERECTILE DYSFUNCTION ......................................................................................................................................................................... 57
URINARY ANTISPASMODICS-M ................................................................................................................................................................ 57
MISCELLANEOUS ....................................................................................................................................................................................... 58
HEMATOLOGIC ..................................................................................................................................................................................................... 58
ANTICOAGULANTS .................................................................................................................................................................................... 58
ANTIHEMOPHILIC AGENTS ....................................................................................................................................................................... 58
HEMATOPOIETIC GROWTH FACTORS .................................................................................................................................................... 59
HEMOSTATICS............................................................................................................................................................................................ 59
HEREDITARY ANGIOEDEMA AGENTS ..................................................................................................................................................... 59
IDIOPATHIC THROMBOCYTOPENIC PURPURA AGENTS-M.................................................................................................................. 60
IRON CHELATING AGENTS ....................................................................................................................................................................... 60
PLATELET AGGREGATION INHIBITORS-M .............................................................................................................................................. 60
PLATELET SYNTHESIS INHIBITORS-M .................................................................................................................................................... 60
STEM CELL MOBILIZERS ........................................................................................................................................................................... 60
MISCELLANEOUS-M ................................................................................................................................................................................... 60
IMMUNOLOGIC AGENTS...................................................................................................................................................................................... 60
BIOLOGIC DISEASE-MODIFYING AGENTS .............................................................................................................................................. 60
DISEASE-MODIFYING ANTIRHEUMATIC DRUGS (DMARDs)-M ............................................................................................................. 61
IMMUNE GLOBULINS ................................................................................................................................................................................. 61
IMMUNOMODULATORS-M ......................................................................................................................................................................... 61
IMMUNOSUPPRESSANTS-M ..................................................................................................................................................................... 61
NUTRITIONAL/SUPPLEMENTS............................................................................................................................................................................ 62
ELECTROLYTES ......................................................................................................................................................................................... 62
VITAMINS AND MINERALS ........................................................................................................................................................................ 62
RESPIRATORY ...................................................................................................................................................................................................... 63
ANAPHYLAXIS TREATMENT AGENTS ..................................................................................................................................................... 63
ANTICHOLINERGICS-M .............................................................................................................................................................................. 63
ANTICHOLINERGIC/BETA AGONIST COMBINATIONS-M ....................................................................................................................... 63
ANTIHISTAMINES, LOW SEDATING.......................................................................................................................................................... 63
ANTIHISTAMINES, NONSEDATING-M....................................................................................................................................................... 63
ANTIHISTAMINES, SEDATING ................................................................................................................................................................... 64
ANTIHISTAMINE/DECONGESTANT COMBINATIONS .............................................................................................................................. 64
ANTITUSSIVES............................................................................................................................................................................................ 64
ANTITUSSIVE COMBINATIONS ................................................................................................................................................................. 64
BETA AGONISTS-M .................................................................................................................................................................................... 64
CYSTIC FIBROSIS ...................................................................................................................................................................................... 65
LEUKOTRIENE MODIFIERS-M ................................................................................................................................................................... 65
MAST CELL STABILIZERS-M ..................................................................................................................................................................... 65
NASAL ANTIHISTAMINES .......................................................................................................................................................................... 65
NASAL ANTIHISTAMINE/STEROID COMBINATIONS ............................................................................................................................... 65
NASAL STEROIDS-M .................................................................................................................................................................................. 65
PHOSPHODIESTERASE-4 INHIBITORS .................................................................................................................................................... 66
PULMONARY FIBROSIS AGENTS ............................................................................................................................................................. 66
STEROID/BETA AGONIST COMBINATIONS-M ......................................................................................................................................... 66
STEROID INHALANTS-M ............................................................................................................................................................................ 66
XANTHINES-M ............................................................................................................................................................................................. 67
TOPICAL ................................................................................................................................................................................................................ 67
DERMATOLOGY.......................................................................................................................................................................................... 67
MOUTH/THROAT/DENTAL AGENTS ......................................................................................................................................................... 71
OPHTHALMIC .............................................................................................................................................................................................. 72
OTIC ............................................................................................................................................................................................................. 74
WEBSITES ............................................................................................................................................................................................................. 75
INDEX ..................................................................................................................................................................................................................... 77
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THE FORMULARY
Capital BlueCross (Capital) has created the Formulary to give members access to quality, affordable
medications and to provide physicians with a reference list of preferred medications for cost-effective
prescribing. The Formulary represents the cornerstone of drug therapy quality assurance and cost
containment efforts.
The Capital Formulary was developed and is maintained by the Capital BlueCross Pharmacy and
Therapeutics (P&T) Committee. This committee, composed of practicing physicians from various medical
specialties, practicing pharmacists, and other health care providers, reviews medications in all therapeutic
categories based on safety and effectiveness and designates the most effective agent(s) in each class.
Formulary development and maintenance is a dynamic process. The P&T Committee will regularly review
new and existing medications to ensure the Formulary remains responsive to the needs of our members and
providers.
A provider may request a reconsideration of tier status for a medication on the Capital Formulary by
completing a Formulary Status Reconsiderations Form or by writing a letter indicating the significant
advantages of the specific drug product and mailing it to the address below:
Pharmacy Services
Capital BlueCross P&T Committee
P.O. Box 773735
Harrisburg, PA 17177-3735
The P&T Committee will review drug-specific requests and communicate the results of the review to the
requesting provider. Patient-specific requests need to follow the Professional Provider dispute and appeal
process.
HOW TO USE THE FORMULARY
The Formulary lists the most commonly prescribed medications by therapeutic class. Medications listed in
bold lower case print are generic medications, and medications listed in all UPPER CASE PRINT are
brand-name medications. For each drug listed, it is indicated whether that drug falls in the Generic Preferred
category, Generic Non-Preferred category, Brand Preferred category or Brand Non-Preferred category.
These categories are defined as follows:

Generic Preferred (GP) and Generic Non-Preferred (GNP): Drugs that contain the same active
ingredient(s) as their corresponding brand-name drug and have been approved by the U.S. Food
and Drug Administration (FDA) for therapeutic equivalency to their brand-name product. Please
note that not all strengths and formulations of generic drugs have the same tier status.

Brand Preferred (BP): Drugs that have been reviewed by the Capital BlueCross Pharmacy &
Therapeutics Committee and found to have therapeutic advantage or overall value over nonpreferred brands, factoring safety, efficacy, and cost.

Brand Non-Preferred (BNP): Drugs that have been reviewed by the Capital BlueCross Pharmacy
& Therapeutics Committee and found not to have significant therapeutic advantage or overall value
over alternative generics, preferred brands or over-the-counter medications.
To help maximize the pharmacy benefit, preferred formulary alternatives, where applicable, are provided. Please note
that the information provided is not intended to substitute for the physician's independent medical judgment based on
the member's specific needs. The information contained in this document is current at the time of printing, is not all
encompassing and is subject to change.
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The Formulary serves as a reference guide suitable for various formulary systems, ranging from an open
incentive four-tier formulary to a closed formulary.

The open formulary provides access to all covered products, whether they are designated generic
preferred (tier 1), generic non-preferred (tier 2), brand preferred (tier 3), or brand non-preferred
(tier 4). Under this formulary system, members are encouraged to use generic or preferred brand
drugs which typically carry a lower copayment/coinsurance than non-preferred brand drugs.
(Please note that all plans do not include a two-tier generic benefit with a different
copayment/coinsurance for each generic tier. For plans that do not have a two-tier generic benefit,
the generic copayment/coinsurance will be applied to both generic preferred and generic nonpreferred drugs. Please also note that for specialty medications, the specialty generic cost share,
when applicable, will apply to both generic preferred and generic non-preferred specialty
medications.)

The closed formulary provides access to only products that are on the formulary (generic preferred,
generic non-preferred and brand preferred drugs)*. Under this formulary, non-formulary drugs
(brand non-preferred drugs) are not covered unless approved via a Non-Formulary Consideration
Process. The provider or member may initiate a request that coverage be granted when medically
necessary. The Non-Formulary Consideration Process may require the trial and failure of two (2)
formulary alternatives (if two are available) prior to approval of the non-formulary medication.
Approvals will be member- and drug-specific. Each unique non-formulary drug exception must be
reviewed and approved separately.
*Select brand non-preferred drugs may be covered due to Affordable Care Act mandates under
Health Care Reform.
As determined by the member’s benefit plan, the member may share more of the cost for brand-name drugs,
especially those designated as non-preferred brands. Despite being listed in the formulary, please note that
some drugs are excluded by benefit design and therefore are not covered (see Benefit Exclusions/Limitations
below). Newly-released brand-name drugs are not covered until the P&T Committee reviews the
medication’s safety and efficacy profile. Brand-name drugs that have an available generic equivalent,
deemed suitable for substitution by the P&T Committee, are placed in the non-preferred brand category.
The Formulary applies only to prescription medications dispensed in outpatient pharmacies. The Formulary
does not apply to inpatient medications or to medications obtained from and/or administered by a physician
or a home health agency.
While Capital BlueCross strives to provide prompt notice of changes and updates, the Formulary, as well as
the pharmacy clinical programs (such as prior authorization, quantity level limits, etc.), are subject to change.
Please visit our website at www.capbluecross.com for current information. If preferred, contact our
pharmacy benefit manager via phone at the number listed below.
CVS Caremark®
1-800-585-5794 (for provider and member inquires)
On behalf of Capital BlueCross, CVS Caremark assists in the administration of our prescription drug
program. CVS Caremark is an independent pharmacy benefit manager.
GENERIC DRUG SUBSTITUTION
Generic drug substitution is encouraged if the FDA has determined the generic drug is bioequivalent to the
brand-name product. Depending on the member's prescription drug benefit plan, one of the following generic
substitution policies will be applied. The member's financial responsibility for a brand-name medication when
a generic equivalent is available will vary depending on the member's generic substitution program.

For members with mandatory generic substitution, if the physician indicates "Dispense As Written"
(DAW) or if a member requests a brand-name product when a generic is available, the member is
responsible for the cost difference between the brand-name medication and its generic cost
(ancillary charge) in addition to the member's applicable brand copayment/coinsurance, up to the
original cost of the brand-name medication.
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
For members with restricted generic substitution, if a member requests a brand-name product
when a generic is available, the member is responsible for the cost difference between the brandname medication and its generic cost (ancillary charge) in addition to the member's applicable
brand copayment/coinsurance, up to the original cost of the brand-name medication. If the
physician indicates DAW, then the member pays the applicable copayment/coinsurance for the
brand product and is not required to pay the ancillary charge.

For members with voluntary generic substitution, the member will pay only the applicable
copayment/coinsurance for the brand product.
Capital encourages generic substitution, when possible and appropriate, to help reduce the member's out-ofpocket expense, plus help contain the overall cost of the prescription drug benefit.
NON-PRESCRIPTION MEDICATION (OTC) POLICY*
Select Over-The-Counter (OTC) products may be covered as determined by Capital BlueCross or if
mandated by the Patient Protection and Affordable Care Act (PPACA).
If a prescription drug has an available OTC equivalent, the prescription drug will not be covered. Physicians
and pharmacists should guide and refer members to the OTC equivalent product, when appropriate.
*As mandated by PPACA, select Over-The-Counter medications may be covered at $0 cost share for
members with individual coverage or members of a non-grandfathered group health plan. Please consult
your employer for questions relating to grandfathered status.
COMPOUND DRUG POLICY
Prescribed compound drug products are considered Brand Non-Preferred (BNP) and require prior
authorization.
BENEFIT EXCLUSIONS / LIMITATIONS*
Depending on the member's pharmacy benefit plan, some medications listed may not be covered for
individual members based on benefit design purchased by the member or employer group. Examples of
contractual exclusions include, but are not limited to:

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

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


Appetite suppressants (weight loss)
Infertility medications
Drugs used for cosmetic purposes (wrinkles, hair loss, etc.)
Erectile dysfunction medications
Smoking cessation products
Contraceptives
Non self-administered injectable drugs
Allergy serums
Experimental and investigational (including off-label use) use
Some types of vitamins (non-prenatal)
Products with OTC equivalents
Some members' employer groups may choose to purchase additional coverage for these drug classes, while
other employer groups may choose to exclude these drug classes from their Capital BlueCross health benefit
plan.
*As mandated by PPACA, select medications in these drug classes may be covered at $0 cost share for
members with individual coverage or members of a non-grandfathered group health plan. Please consult
your employer for questions relating to grandfathered status.
PRIOR AUTHORIZATION PROGRAM
Most pharmacy benefit plans include the prior authorization program. Prior authorization helps encourage
appropriate and cost-effective use of certain drugs by allowing coverage only after clinical criteria are met. All
clinical criteria are regularly reviewed and approved by the P&T Committee.
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Drugs requiring prior authorization are subject to change. Please always visit our website
(www.capbluecross.com) for the most up-to-date information on drugs requiring prior authorization.
Drugs requiring prior authorization are designated in the Formulary by “PAR” (Prior Authorization Required)
after the drug name. These drugs require prior authorization before members can obtain them as a covered
benefit. For some drugs, part of the criteria may be automated (Enhanced Prior Authorization or EPA) to
encourage first-line agents before second-line agents are utilized. If automated criteria are not met, then prior
authorization is required by the physician (or representative) or pharmacist by calling / faxing the request with
supporting clinical information to the pharmacy benefit manager at:
CVS Caremark Prior Authorization Department
Telephone: 1-800-294-5979
Fax: 1-888-836-0730
QUANTITY LIMITATIONS
Some drug products may be subject to quantity limitations based on FDA-recommended doses or adopted
clinical guidelines. These drugs are designated in the Formulary by “QLL” (Quantity Level Limits) after the
drug name. The purpose of these maximum quantity limits is to ensure the proper billing of products and
encourage the use of therapeutically indicated drug regimens. Quantity limitations are subject to change.
Please check your provider manual or the on-line formulary at our website (www.capbluecross.com) for the
most up-to-date information on drugs that are part of this program. If a quantity of medication exceeding the
limit is required, the physician (or representative) or pharmacist should call / fax the request with supporting
clinical information to the pharmacy benefit manager at:
CVS Caremark Prior Authorization Department
Telephone: 1-800-294-5979
Fax: 1-888-836-0730
MAINTENANCE DRUGS
Maintenance drugs are prescriptions commonly used to treat conditions that are considered chronic or longterm. These conditions usually require regular, daily use of medicines. Examples of maintenance drugs are
those used to treat high blood pressure, heart disease and diabetes.
INJECTABLE MEDICATION POLICY
Self-administered pharmacy injectable medications are usually covered under the Capital BlueCross
prescription drug benefit. Injectable medications that are not routinely self-administered are not covered
under the prescription drug benefit, but may be covered under the member’s medical benefit. Procurement of
select medical injectable medications may be available from ACRO Pharmaceuticals (by calling
1-800-906-7798 or faxing 1-877-381-3806), Capital BlueCross’ specialty medical injectable provider, which
will assist with distribution and billing of these medications.
On behalf of Capital BlueCross, ACRO Pharmaceutical Services LLC assists in the administration of
physician-administered specialty medications. ACRO Pharmaceutical Services is an independent company.
SPECIALTY MEDICATION PROVIDER: OUTPATIENT PRESCRIPTION DRUG BENEFIT
Specialty oral medications and self-administered injectable medications are available through Accredo®
under the Capital BlueCross outpatient prescription drug benefit. Members or providers can call
1-877-595-3707 or fax 1-888-773-7386 to receive more information on starting service. The following
medications are available through Accredo. (This list is current as of the printing of this formulary but is
subject to change.)
On behalf of Capital BlueCross, Accredo Health Group, Inc. assists in the delivery of specialty medications
directly to our Members. Accredo Health Group, Inc. is an independent company.
Note: Bolded products on the Specialty Drugs list below are available exclusively from Accredo.
Products denoted with an asterisk (*) on the Specialty Drugs list below may also be obtained at
network pharmacies.
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Specialty Drugs
ACTEMRA* PAR, QLL
ACTHAR HP* PAR
ACTIMMUNE*
ADCIRCA* PAR
ADEMPAS* PAR
ADVATE*
AFINITOR*
ALECENSA* PAR
ALPHANATE*
ALPHANINE SD*
ALPROLIX*
AMPYRA* PAR, QLL
APOKYN*
ARANESP PAR
ARCALYST*
AUBAGIO* PAR
AVONEX
BARACLUDE*
BEBULIN*
BEBULIN VH*
BENEFIX*
BERINERT*
BETASERON
BETHKIS*
BEXAROTENE
BOSULIF* PAR
BRAVELLE
CAPECITABINE
CAPRELSA*
CARBAGLU*
CERDELGA* PAR
CETROTIDE
CHOLBAM* PAR
CHORIONIC GONADOTROPIN*
CIMZIA* PAR, QLL
COAGADEX*
COMETRIQ* PAR
COPAXONE
COPEGUS
CORIFACT*
COSENTYX* PAR
COTELLIC* PAR
CYSTADANE*
CYSTAGON* PAR
CYSTARAN*
DAKLINZA* PAR
EGRIFTA* PAR
ELIGARD*
ELOCTATE*
ENBREL PAR, QLL
ENTECAVIR*
EPOGEN PAR
ERIVEDGE* PAR
ESBRIET* PAR
EXJADE* PAR
EXTAVIA* EPA
FARYDAK* PAR
FEIBA NF*
FEIBA VH*
FERRIPROX* PAR
FIRAZYR*
FIRMAGON*
FOLLISTIM AQ
FORTEO PAR
FUZEON
GANIRELIX
GATTEX* PAR
GENOTROPIN PAR
GILENYA*
GILOTRIF* PAR
GLATIRAMER
GLEEVEC*
GONAL-F
GONAL-RFF
GRANIX*
HARVONI PAR
HETLIOZ PAR
HELIXATE FS*
HEMOFIL M*
HIZENTRA*
HUMATE-P
HUMATROPE PAR
HUMIRA PAR, QLL
HYCAMTIN*
HYQVIA*
IBRANCE* PAR
ICLUSIG* PAR
IDELVION*
IMATINIB MESYLATE*
IMBRUVICA* PAR
INCRELEX PAR
INLYTA* PAR
INTRON A
IRESSA*
IXINITY*
JADENU* PAR
JAKAFI* PAR
JUXTAPID* PAR
KALYDECO* PAR
KINERET PAR, QLL
KOATE-DVI*
KOGENATE FS*
KORLYM* PAR
KUVAN*
KYNAMRO PAR
LENVIMA* PAR
LETAIRIS* PAR
LEUKINE
LEUPROLIDE ACETATE
LONSURF* PAR
LUPANETA*
LUPRON DEPOT
LYNPARZA* PAR
MATULANE*
8
MEKINIST* PAR
MENOPUR*
MIRCERA*
MODERIBA*
MONOCLATE-P*
MONONINE*
MOZOBIL* PAR
MYALEPT* PAR
NATPARA* PAR
NEULASTA
NEUPOGEN
NEXAVAR
NINLARO* PAR
NORDITROPIN PAR
NORTHERA* PAR
NOVAREL
NOVOEIGHT*
NOVOSEVEN RT*
NUTROPIN AQ PAR
NUWIQ*
OCTREOTIDE*
ODOMZO* PAR
OFEV PAR
OLYSIO* PAR
OMNITROPE* PAR
OPSUMIT* PAR
ORENCIA 125 mg/mL* PAR, QLL
ORENITRAM PAR
ORFADIN*
ORKAMBI* PAR
OTEZLA PAR
OTREXUP*
OVIDREL
PEGASYS
PEGINTRON EPA
PEGINTRON REDIPEN EPA
PLEGRIDY*
POMALYST* PAR
PRALUENT* PAR
PREGNYL
PROCRIT PAR
PROCYSBI* PAR
PROFILNINE SD*
PROMACTA*
PULMOZYME*
RASUVO*
RAVICTI*
REBETOL
REBIF EPA
RECOMBINATE*
REMODULIN*
REPATHA* PAR
REPRONEX
REVATIO* PAR
REVLIMID
RIBAPAK*
RIBASPHERE*
RIBAVIRIN
RIXUBIS*
SABRIL*
SAIZEN PAR
SAMSCA
SANDOSTATIN*
SANDOSTATIN LAR*
SENSIPAR*
SEROSTIM PAR
SIGNIFOR* PAR
SILDENAFIL* PAR
SIMPONI* PAR, QLL
SOMATULINE* PAR
SOMAVERT*
SOVALDI* PAR
SPRYCEL
STELARA* PAR, QLL
STIVARGA* PAR
STRENSIQ* PAR
SUTENT
SYLATRON* PAR
SYNAREL*
TAFINLAR* PAR
TAGRISSO* PAR
TALTZ* PAR
TARCEVA PAR
TARGRETIN
TASIGNA
TECFIDERA
TECHNIVIE* PAR
TEMODAR
TEMOZOLOMIDE
TETRABENAZINE* PAR
THALOMID
TIKOSYN*
TOBI*
TOBRAMYCIN INHALATION SOLN*
TRACLEER* PAR
TRETTEN*
TYKERB
TYVASO* PAR
UPTRAVI* PAR
VALCHLOR*
VELTASSA* PAR
VENTAVIS* PAR
VIEKIRA PAK* PAR
VOTRIENT*
WILATE*
XALKORI*
XELJANZ* PAR
XELJANZ XR* PAR
XELODA
XENAZINE* PAR
XTANDI* PAR
XURIDEN* PAR
XYNTHA*
ZARXIO*
ZELBORAF*
ZEPATIER PAR
ZOLINZA
ZOMACTON* PAR
9
ZORBTIVE PAR
ZYDELIG* PAR
ZYKADIA PAR
ZYTIGA* PAR
LEGEND
AL
BNP
BP
EPA
GP and GNP
M
OTC
PAR
PHC
QLL
SRx
boldface
delayed-rel
ext-rel
Age Limitations apply.
Brand Non-Preferred: Drugs that have been reviewed by the Capital BlueCross
Pharmacy & Therapeutics Committee and found not to have significant therapeutic
advantage or overall value over alternative generics, preferred brands or over-thecounter medications.
Brand Preferred: Drugs that have been reviewed by the Capital BlueCross
Pharmacy & Therapeutics Committee and found to have therapeutic advantage or
overall value over non-preferred brands, factoring safety, efficacy, and cost.
Enhanced Prior Authorization applies.
Generic Preferred and Generic Non-Preferred: Drugs that contain the same active
ingredient(s) as their corresponding brand-name drug and have been approved by
the Food and Drug Administration (FDA) for therapeutic equivalency to their brandname product.
Maintenance Drugs: ‘M’ located after the drug class name indicates the drugs in the
class are generally considered maintenance drugs.
Over-The-Counter medication.
Prior Authorization Required.
Preventive Health Care: Drugs that have been reviewed by the Capital BlueCross
Pharmacy & Therapeutics Committee and are mandated by the Patient Protection
and Affordable Care Act (PPACA) to have $0 cost share for members with individual
coverage or members of a group health plan that is not "grandfathered" under
PPACA. Please consult your employer for questions relating to grandfathered status.
Quantity Level Limits apply.
Specialty Drug available from Accredo.
Indicates generic; boldface may not apply to every strength or dosage form under
the listed generic name.
Delayed-release (also known as enteric-coated), refer to the reference brand listed
for clarification.
Extended-release (also known as sustained-release), refer to the reference brand
listed for clarification.
NOTICE
The information provided is intended to establish a guideline to help promote Formulary compliance, but it is
in no way to be considered all encompassing. The Formulary is also in no way meant to interfere with the
physician's independent medical judgment based on specific needs of the patient. The information contained
herein is current at the time of printing and may be subject to change. Members should refer to their
Certificate of Coverage for specific terms, conditions, exclusions and limitations relating to coverage.
The information contained in this document is proprietary. The information may not be copied in whole or in
part without written permission. ©2016. All rights reserved.
This document contains references to brand-name prescription drugs that are trademarks or registered
trademarks of pharmaceutical manufacturers.
Capital BlueCross and CVS Caremark do not operate the websites/organizations listed below, nor are they
responsible for the availability or reliability of the websites' content. These listings do not imply or constitute
an endorsement, sponsorship or recommendation by Capital BlueCross or CVS Caremark.
10
ANALGESICS
Practice guidelines of pain management are available at:
http://www.asahq.org
NSAIDs-M
ibuprofen
meloxicam tabs
naproxen EC tabs 375 mg
naproxen sodium tabs 275 mg
naproxen tabs
sulindac tabs 150 mg
diclofenac potassium
diclofenac sodium delayed-rel
diflunisal
etodolac
indomethacin
ketoprofen
meloxicam susp
nabumetone
naproxen EC tabs 500 mg
naproxen sodium ext-rel
naproxen sodium tabs 550 mg
naproxen susp
oxaprozin
piroxicam
sulindac tabs 200 mg
ZORVOLEX
MOBIC
NAPRELAN
ZIPSOR
PAR
PAR
PAR
GP
GP
GP
GP
GP
GP
GNP
GNP
GNP
GNP
GNP
GNP
GNP
GNP
GNP
GNP
GNP
GNP
GNP
GNP
GNP
BP
BNP
BNP
BNP
PREFERRED ALTERNATIVES
MOBIC: meloxicam
NAPRELAN: naproxen sodium ext-rel
ZIPSOR: diclofenac potassium, diclofenac sodium, ibuprofen, naproxen, naproxen EC, naproxen sodium
NSAIDs, COMBINATIONS-M
PAR
PAR
DUEXIS
VIMOVO
BNP
BNP
DUEXIS: diclofenac potassium, diclofenac sodium, ibuprofen, naproxen, naproxen EC, naproxen sodium
VIMOVO: diclofenac potassium, diclofenac sodium, ibuprofen, naproxen, naproxen EC, naproxen sodium
NSAIDs, TOPICAL-M
EPA
PAR
diclofenac sodium soln
FLECTOR
PENNSAID
GNP
BNP
BNP
GP = Generic Preferred GNP = Generic Non-Preferred BP = Brand Preferred BNP = Brand Non-Preferred
AL = Age Limitations apply EPA = Enhanced Prior Authorization applies M = Maintenance Drugs OTC = Over-The-Counter medication
PAR = Prior Authorization Required PHC = Preventive Health Care QLL = Quantity Level Limits apply SRx = Specialty Drug available from Accredo
11
PAR
REXAPHENAC
BNP
FLECTOR: meloxicam, naproxen
PENNSAID: diclofenac sodium soln
REXAPHENAC: diclofenac sodium soln
COX-2 INHIBITORS-M
EPA
EPA
celecoxib
CELEBREX
GNP
BNP
CELEBREX: celecoxib
GOUT-M
allopurinol
colchicine
probenecid
COLCRYS
ULORIC
EPA
GP
GNP
GNP
BNP
BNP
COLCRYS: colchicine
ULORIC: allopurinol
OPIOID ANALGESICS
Practice Guidelines for Cancer Pain Management (includes WHO analgesic ladder) are available at:
http://www.nccn.org
Opioid guidelines in the management of chronic non-malignant pain are available at:
http://www.asipp.org/Guidelines.htm
QLL
QLL
QLL
QLL
QLL
QLL
QLL
EPA, QLL
QLL
QLL
QLL
QLL
QLL
codeine sulfate tabs 15 mg
codeine/acetaminophen soln
codeine/acetaminophen tabs 300/15 mg, 300/30 mg
hydrocodone/acetaminophen tabs 5/325 mg
hydromorphone tabs 2 mg
meperidine tabs 50 mg
morphine sulfate soln 20 mg/5 mL
tramadol
butorphanol nasal spray
codeine/acetaminophen tabs 300/60 mg
fentanyl patches
fentanyl transmucosal lozenges
hydrocodone/acetaminophen caps
hydrocodone/acetaminophen soln 7.5/325 mg/15 mL
hydrocodone/acetaminophen tabs 2.5/325 mg, 5/300 mg,
7.5/300 mg, 7.5/325 mg, 10/300 mg, 10/325 mg
hydrocodone/ibuprofen
hydromorphone ext-rel
hydromorphone soln, supp
GP
GP
GP
GP
GP
GP
GP
GP
GNP
GNP
GNP
GNP
GNP
GNP
GNP
GNP
GNP
GNP
12
QLL
QLL
QLL
QLL
QLL
QLL
QLL
EPA, QLL
EPA, QLL
QLL
QLL
EPA, QLL
QLL
EPA, QLL
QLL
QLL
QLL
QLL
QLL
QLL
EPA, QLL
QLL
QLL
QLL
QLL
QLL
hydromorphone tabs 4 mg, 8 mg
meperidine soln
meperidine tabs 100 mg
morphine sulfate ext-rel
morphine sulfate soln 20 mg/mL, 10 mg/5 mL
morphine sulfate tabs
oxycodone
oxycodone/acetaminophen tabs
oxycodone/aspirin
oxycodone/ibuprofen
oxymorphone
tramadol ext-rel
tramadol/acetaminophen
ABSTRAL
ACTIQ
BUTRANS
DURAGESIC
FENTORA
KADIAN
LAZANDA
MS CONTIN
NUCYNTA
NUCYNTA ER
OPANA
OPANA ER
OXYCONTIN
SUBSYS
ULTRACET
ULTRAM
ULTRAM ER
XARTEMIS XR
ZOHYDRO ER
GNP
GNP
GNP
GNP
GNP
GNP
GNP
GNP
GNP
GNP
GNP
GNP
GNP
BNP
BNP
BNP
BNP
BNP
BNP
BNP
BNP
BNP
BNP
BNP
BNP
BNP
BNP
BNP
BNP
BNP
BNP
BNP
ACTIQ: fentanyl transmucosal lozenges
DURAGESIC: fentanyl patches
FENTORA: fentanyl transmucosal lozenges
KADIAN: morphine sulfate ext-rel
LAZANDA: fentanyl transmucosal lozenges
MS CONTIN: morphine sulfate ext-rel
NUCYNTA: oxycodone
NUCYNTA ER: morphine sulfate ext-rel
OPANA: morphine sulfate ext-rel, oxymorphone
OPANA ER: morphine sulfate ext-rel
OXYCONTIN: oxycodone, morphine sulfate ext-rel
SUBSYS: fentanyl transmucosal lozenges
ULTRACET: tramadol/acetaminophen
ULTRAM: tramadol
ULTRAM ER: tramadol ext-rel
13
XARTEMIS XR: oxycodone, oxycodone/acetaminophen
ZOHYDRO ER: morphine sulfate ext-rel
NON-OPIOID ANALGESICS
butalbital/acetaminophen/caffeine caps, tabs
butalbital/aspirin/caffeine caps, tabs
GNP
GNP
ANTI-INFECTIVES
Hepatitis: CDC recommendations on the treatment of hepatitis are available at:
http://www.cdc.gov/hepatitis/Resources/
Guidelines for the management of chronic hepatitis by the American Association for the Study of Liver Disease are available at:
http://www.aasld.org
HIV/AIDS: Guidelines for the treatment of HIV patients by the U.S. Department of Health and Human Services are available at:
http://www.aidsinfo.nih.gov
Infective Endocarditis: American Heart Association recommendations for the prevention of bacterial endocarditis are available at:
http://www.myamericanheart.org
Influenza: Recommendations of the Advisory Committee on Immunization Practices are available at:
http://www.cdc.gov/ncidod/diseases/flu/fluvirus.htm
International Travel: CDC recommendations for international travel are available at:
http://www.cdc.gov/travel
Sexually Transmitted Diseases: CDC Sexually Transmitted Diseases Guidelines are available at:
http://www.cdc.gov/std/treatment/default.htm
Respiratory Tract Infection/Antibiotic Use/Community Acquired Pneumonia/Other: Principles of appropriate antibiotic use
for treatment of nonspecific upper respiratory tract infection in adults are available at:
http://www.cdc.gov/flu/
Practice guidelines and statements developed and endorsed by the Infectious Diseases Society of America are available at:
http://www.idsociety.org
ANTIBACTERIALS
Aminoglycosides
neomycin sulfate tabs
GP
cephalexin caps 250 mg, 500 mg
cefadroxil
cephalexin susp
cephalexin tabs 250 mg
GP
GNP
GNP
GNP
cefaclor
cefprozil
cefuroxime axetil tabs
CEFTIN
GNP
GNP
GNP
BNP
Cephalosporins
First Generation
Second Generation
CEFTIN: cefuroxime
14
Third Generation
cefdinir
cefditoren
cefixime susp 100 mg/5 mL, 200 mg/5 mL
cefpodoxime
ceftibuten
CEDAX
SPECTRACEF
SUPRAX
GNP
GNP
GNP
GNP
GNP
BNP
BNP
BNP
CEDAX: ceftibuten
SPECTRACEF: cefditoren
SUPRAX susp 100 mg/5 mL, 200 mg/5 mL: cefixime susp 100 mg/5 mL, 200 mg/5 mL
Erythromycins/Macrolides
azithromycin tabs 250 mg
azithromycin susp
azithromycin tabs 500 mg, 600 mg
clarithromycin
clarithromycin ext-rel
erythromycin
erythromycin ethylsuccinate
BIAXIN
DIFICID
ZITHROMAX
ZMAX
GP
GNP
GNP
GNP
GNP
GNP
GNP
BNP
BNP
BNP
BNP
BIAXIN: clarithromycin
DIFICID: vancomycin
ZITHROMAX: azithromycin
ZMAX: azithromycin
Fluoroquinolones
ciprofloxacin
levofloxacin
ciprofloxacin ext-rel
moxifloxacin
ofloxacin
AVELOX
AVELOX ABC PACK
FACTIVE
LEVAQUIN
GP
GP
GNP
GNP
GNP
BNP
BNP
BNP
BNP
AVELOX: moxifloxacin
FACTIVE: ciprofloxacin, levofloxacin, moxifloxacin, ofloxacin
LEVAQUIN: levofloxacin
15
Penicillins
amoxicillin caps, susp, tabs
amoxicillin chewable tabs
ampicillin caps 250 mg
penicillin VK
amoxicillin ext-rel
amoxicillin/clavulanate
amoxicillin/clavulanate ext-rel
ampicillin caps 500 mg
ampicillin susp
MOXATAG
GP
GP
GP
GP
GNP
GNP
GNP
GNP
GNP
BNP
MOXATAG: amoxicillin ext-rel
Sulfonamides
sulfamethoxazole/trimethoprim tabs
sulfamethoxazole/trimethoprim susp
GP
GNP
tetracycline caps 250 mg
doxycycline hyclate caps 50 mg, 100 mg
doxycycline hyclate tabs 20 mg, 100 mg
doxycycline monohydrate
minocycline
minocycline ext-rel
tetracycline caps 500 mg
ADOXA
AVIDOXY
DORYX
SOLODYN
GP
GNP
GNP
GNP
GNP
GNP
GNP
BNP
BNP
BNP
BNP
Tetracyclines
ADOXA: doxycycline monohydrate
AVIDOXY: doxycycline monohydrate
DORYX: doxycycline hyclate
SOLODYN: minocycline ext-rel
ANTIFUNGALS
PAR
PAR
fluconazole tabs 50 mg, 150 mg
clotrimazole troches
fluconazole susp
fluconazole tabs 100 mg, 200 mg
griseofulvin ultramicrosize
itraconazole
nystatin
terbinafine
voriconazole
CRESEMBA
GP
GNP
GNP
GNP
GNP
GNP
GNP
GNP
GNP
BNP
16
DIFLUCAN
LAMISIL
SPORANOX
VFEND
PAR
BNP
BNP
BNP
BNP
CRESEMBA: voriconazole
DIFLUCAN: fluconazole
LAMISIL: terbinafine
SPORANOX: itraconazole
VFEND: voriconazole
ANTIMALARIALS
atovaquone/proguanil
mefloquine
COARTEM
GNP
GNP
BNP
ANTIRETROVIRAL AGENTS-M
Brand-name products with FDA-approved generic equivalents are Non-Preferred.
Antiretroviral Combinations-M
abacavir/lamivudine/zidovudine
lamivudine/zidovudine
ATRIPLA
COMPLERA
EPZICOM
ODEFSEY
STRIBILD
TRUVADA
EVOTAZ
PREZCOBIX
TRIUMEQ
TRIZIVIR
GNP
GNP
BP
BP
BP
BP
BP
BP
BNP
BNP
BNP
BNP
Chemokine Receptor Antagonists-M
SELZENTRY
BP
Fusion Inhibitors-M
SRx
FUZEON
BP
ISENTRESS
TIVICAY
BP
BNP
Integrase Inhibitors-M
Non-nucleoside Reverse Transcriptase Inhibitors-M
nevirapine
nevirapine ext-rel
EDURANT
INTELENCE
RESCRIPTOR
SUSTIVA
GNP
GNP
BP
BP
BP
BP
17
VIRAMUNE XR
BNP
Nucleoside Reverse Transcriptase Inhibitors-M
abacavir tabs
didanosine delayed-rel
lamivudine
stavudine
zidovudine
EMTRIVA
VIDEX soln
ZIAGEN soln 20 mg/mL
GNP
GNP
GNP
GNP
GNP
BP
BP
BP
Nucleotide Reverse Transcriptase Inhibitors-M
VIREAD
BP
Protease Inhibitors-M
APTIVUS
CRIXIVAN
INVIRASE
KALETRA
LEXIVA
NORVIR
PREZISTA
REYATAZ
VIRACEPT
BP
BP
BP
BP
BP
BP
BP
BP
BP
isoniazid tabs 300 mg
ethambutol
isoniazid syrup
isoniazid tabs 100 mg
rifampin
SIRTURO
GP
GNP
GNP
GNP
GNP
BNP
valganciclovir
VALCYTE
GNP
BNP
ANTITUBERCULAR AGENTS
PAR
ANTIVIRALS
Cytomegalovirus Agents
VALCYTE: valganciclovir
Hepatitis Agents
Hepatitis B
SRx
SRx
entecavir
lamivudine
BARACLUDE
EPIVIR-HBV
GNP
GNP
BNP
BNP
18
TYZEKA
BNP
BARACLUDE: entecavir
EPIVIR-HBV: lamivudine
TYZEKA: lamivudine
Hepatitis C
SRx
SRx
SRx
SRx
PAR, SRx
PAR, SRx
SRx
SRx
Moderiba tabs
Ribapak
Ribasphere
ribavirin
HARVONI
SOVALDI
COPEGUS
REBETOL
GNP
GNP
GNP
GNP
BP
BP
BNP
BNP
COPEGUS: ribavirin
Herpes Agents
acyclovir caps 200 mg
acyclovir tabs 400 mg, 800 mg
famciclovir
valacyclovir
DENAVIR
FAMVIR
VALTREX
GP
GNP
GNP
GNP
BNP
BNP
BNP
FAMVIR: famciclovir
VALTREX: valacyclovir
Influenza Agents
QLL
QLL
TAMIFLU
RELENZA
BP
BNP
RELENZA: TAMIFLU
MISCELLANEOUS
clindamycin caps 150 mg, 300 mg
metronidazole tabs 250 mg, 500 mg
trimethoprim
ivermectin
linezolid
nitrofurantoin ext-rel
nitrofurantoin macrocrystals
vancomycin
SIVEXTRO
MACROBID
GP
GP
GP
GNP
GNP
GNP
GNP
GNP
BP
BNP
19
VANCOCIN
XIFAXAN 550 mg
ZYVOX
BNP
BNP
BNP
MACROBID: nitrofurantoin ext-rel
VANCOCIN: vancomycin
ZYVOX: linezolid
ANTINEOPLASTIC AGENTS
Clinical practice guidelines in oncology are available at:
http://www.asco.org
http://www.nccn.org
ALKYLATING AGENTS
SRx
SRx
SRx
ANTIMETABOLITES
SRx
SRx
temozolomide
VALCHLOR
TEMODAR
GNP
BP
BNP
capecitabine
mercaptopurine
XELODA
GNP
GNP
BNP
leucovorin 5 mg
leucovorin 10 mg, 15 mg, 25 mg
GP
GNP
CYTOPROTECTIVE AGENTS
HORMONAL ANTINEOPLASTIC AGENTS
Antiandrogens
bicalutamide
PAR, SRx
XTANDI
PAR, SRx
ZYTIGA
CASODEX
GNP
BP
BP
BNP
Antiestrogens
PAR*, PHC
GNP
tamoxifen
*PAR is needed for coverage under PHC. Limited to women age 35 years and older with no previous history of
breast cancer, ductal carcinoma in situ (CIS) or lobular carcinoma in situ.
Aromatase Inhibitors
anastrozole
letrozole
ARIMIDEX
FEMARA
GNP
GNP
BNP
BNP
FEMARA: letrozole
Gonadotropin Releasing Hormone (GnRH) Antagonists
SRx
FIRMAGON
BNP
20
Luteinizing Hormone-releasing Hormone (LHRH) Agonists
SRx
leuprolide acetate
SRx
ELIGARD
SRx
LUPRON DEPOT
GNP
BP
BP
Progestins
megestrol acetate tabs 20 mg
megestrol acetate tabs 40 mg
GP
GNP
IMMUNOMODULATORS
SRx
SRx
PAR, SRx
REVLIMID
THALOMID
POMALYST
BP
BP
BNP
KINASE INHIBITORS
SRx
SRx
PAR, SRx
SRx
PAR, SRx
PAR, SRx
PAR, SRx
PAR, SRx
PAR, SRx
PAR, SRx
PAR, SRx
SRx
PAR, SRx
PAR, SRx
PAR, SRx
SRx
SRx
PAR, SRx
SRx
PAR, SRx
PAR, SRx
PAR, SRx
SRx
SRx
SRx
SRx
SRx
PAR, SRx
PAR, SRx
SRx
PAR, SRx
imatinib mesylate
AFINITOR
ALECENSA
CAPRELSA
COMETRIQ
COTELLIC
GILOTRIF
IBRANCE
ICLUSIG
IMBRUVICA
INLYTA
IRESSA
JAKAFI
LENVIMA
MEKINIST
NEXAVAR
SPRYCEL
STIVARGA
SUTENT
TAFINLAR
TAGRISSO
TARCEVA
TASIGNA
TYKERB
VOTRIENT
XALKORI
ZELBORAF
ZYKADIA
BOSULIF
GLEEVEC
ZYDELIG
GNP
BP
BP
BP
BP
BP
BP
BP
BP
BP
BP
BP
BP
BP
BP
BP
BP
BP
BP
BP
BP
BP
BP
BP
BP
BP
BP
BP
BNP
BNP
BNP
21
TOPOISOMERASE INHIBITORS
SRx
HYCAMTIN caps
BP
MISCELLANEOUS
SRx
PAR, SRx
PAR, SRx
PAR, SRx
SRx
PAR, SRx
PAR, SRx
SRx
SRx
PAR, SRx
SRx
GNP
BP
BP
BP
BP
BP
BP
BP
BP
BNP
BNP
bexarotene
ERIVEDGE
LONSURF
LYNPARZA
MATULANE
NINLARO
ODOMZO
TARGRETIN gel
ZOLINZA
FARYDAK
TARGRETIN caps
CARDIOVASCULAR
The Eighth Report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure
is available at:
http://jama.jamanetwork.com/article.aspx?articleid=1791497
Guidelines for the evaluation and management of cardiovascular diseases in adults are available at:
http://www.acc.org
http://www.heartfailureguideline.org
ACE INHIBITORS-M
Guidelines for the use of ACE inhibitors are available at:
http://professional.diabetes.org
http://www.acc.org
PAR
PAR
PAR
benazepril
enalapril
fosinopril
lisinopril
quinapril
ramipril
captopril
moexipril
perindopril
trandolapril
ACCUPRIL
ACEON
ALTACE
GP
GP
GP
GP
GP
GP
GNP
GNP
GNP
GNP
BNP
BNP
BNP
22
PAR
MAVIK
BNP
ACCUPRIL: quinapril
ACEON: perindopril
ALTACE: ramipril
MAVIK: trandolapril
ACE INHIBITOR/CALCIUM CHANNEL BLOCKER COMBINATIONS-M
amlodipine/benazepril
trandolapril/verapamil ext-rel
PAR
LOTREL
PAR
PRESTALIA
PAR
TARKA
GNP
GNP
BNP
BNP
BNP
LOTREL: amlodipine/benazepril
PRESTALIA: amlodipine/benazepril, trandolapril/verapamil ext-rel
TARKA: trandolapril/verapamil ext-rel
ACE INHIBITOR/DIURETIC COMBINATIONS-M *
enalapril/hydrochlorothiazide
lisinopril/hydrochlorothiazide
benazepril/hydrochlorothiazide
captopril/hydrochlorothiazide
fosinopril/hydrochlorothiazide
moexipril/hydrochlorothiazide
quinapril/hydrochlorothiazide
GP
GP
GNP
GNP
GNP
GNP
GNP
* Brand Non-preferred ACE Inhibitor/Diuretic Combinations will require prior authorization.
ADRENOLYTICS, CENTRAL-M
clonidine
guanfacine tabs 1 mg
clonidine transdermal
guanfacine tabs 2 mg
CATAPRES-TTS
ALDOSTERONE RECEPTOR ANTAGONISTS-M
spironolactone tabs 25 mg
eplerenone
spironolactone tabs 50 mg, 100 mg
INSPRA
GP
GP
GNP
GNP
BNP
GP
GNP
GNP
BNP
INSPRA: eplerenone
ALPHA BLOCKERS-M
Guidelines for the use of alpha blockers in various patient populations are available at:
prazosin 1 mg
GP
23
terazosin
doxazosin
prazosin 2 mg, 5 mg
GP
GNP
GNP
ANGIOTENSIN II RECEPTOR ANTAGONISTS/DIURETIC COMBINATIONS-M
Guidelines for the use of angiotensin II receptor antagonists in various patient populations are available at:
PAR
PAR
PAR
PAR
PAR
PAR
PAR
PAR
PAR
PAR
PAR
candesartan
candesartan/hydrochlorothiazide
eprosartan
irbesartan
irbesartan/hydrochlorothiazide
losartan
losartan/hydrochlorothiazide
telmisartan
telmisartan/hydrochlorothiazide
valsartan
valsartan/hydrochlorothiazide
BENICAR
BENICAR HCT
ATACAND
ATACAND HCT
AVALIDE
AVAPRO
COZAAR
DIOVAN
DIOVAN HCT
EDARBI
HYZAAR
MICARDIS
MICARDIS HCT
GNP
GNP
GNP
GNP
GNP
GNP
GNP
GNP
GNP
GNP
GNP
BP
BP
BNP
BNP
BNP
BNP
BNP
BNP
BNP
BNP
BNP
BNP
BNP
ATACAND: candesartan
ATACAND HCT: candesartan/hctz
AVALIDE: irbesartan/hctz
AVAPRO: irbesartan
COZAAR: losartan
DIOVAN: valsartan
DIOVAN HCT: valsartan/hctz
HYZAAR: losartan/hctz
MICARDIS: telmisartan
MICARDIS HCT: telmisartan/hctz
ANGIOTENSIN II RECEPTOR ANTAGONIST/CALCIUM CHANNEL BLOCKER COMBINATIONS-M
amlodipine/valsartan
GNP
telmisartan/amlodipine
GNP
AZOR
BP
24
PAR
EXFORGE
BNP
EXFORGE: amlodipine/valsartan
ANGIOTENSIN II RECEPTOR ANTAGONIST/CALCIUM CHANNEL BLOCKER/DIURETIC COMBINATIONS-M
amlodipine/valsartan/hydrochlorothiazide
GNP
TRIBENZOR
BP
PAR
EXFORGE HCT
BNP
EXFORGE HCT: amlodipine/valsartan/hydrochlorothiazide
ANTIARRHYTHMICS-M
Guidelines for the use of antiarrhythmics and cardiac glycosides in various patient populations are available at:
http://www.acc.org
amiodarone tabs 200 mg
sotalol tabs 80 mg, 160 mg
amiodarone tabs 100 mg, 400 mg
flecainide
propafenone
quinidine gluconate
quinidine sulfate tabs
sotalol tabs 120 mg, 240 mg
TIKOSYN
SRx
GP
GP
GNP
GNP
GNP
GNP
GNP
GNP
BP
ANTILIPEMICS-M
The 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults
is available at:
http://circ.ahajournals.org/content/early/2013/11/11/01.cir.0000437738.63853.7a
Bile Acid Resins-M
cholestyramine
colestipol
WELCHOL
Cholesterol Absorption Inhibitors-M
ZETIA
GNP
GNP
BP
BP
Fibrates-M
fenofibrate
fenofibric acid delayed-rel
gemfibrozil
ANTARA
LOFIBRA
TRICOR
TRILIPIX
GNP
GNP
GNP
BNP
BNP
BNP
BNP
ANTARA: fenofibrate
LOFIBRA: fenofibrate
25
TRICOR: fenofibrate
TRILIPIX: fenofibric acid delayed-rel
HMG-CoA Reductase Inhibitors/Combinations-M
QLL
lovastatin
EPA*, QLL
simvastatin
QLL
atorvastatin
QLL
fluvastatin
QLL
fluvastatin ext-rel
QLL
pravastatin
QLL
rosuvastatin
EPA**, QLL
VYTORIN
PAR, QLL
ALTOPREV
PAR, QLL
CRESTOR
PAR, QLL
LESCOL XL
PAR, QLL
LIPITOR
PAR, QLL
LIVALO
PAR, QLL
MEVACOR
PAR, QLL
PRAVACHOL
PAR, QLL
ZOCOR
GP
GP
GNP
GNP
GNP
GNP
GNP
BP
BNP
BNP
BNP
BNP
BNP
BNP
BNP
BNP
*EPA only applies to simvastatin 80 mg
**EPA only applies to VYTORIN 10 mg-80 mg
ALTOPREV: atorvastatin, fluvastatin, fluvastatin ext-rel, lovastatin, rosuvastatin, simvastatin
LESCOL XL: fluvastatin ext-rel
LIPITOR: atorvastatin
LIVALO: atorvastatin, fluvastatin, fluvastatin ext-rel, lovastatin, rosuvastatin, simvastatin
MEVACOR: lovastatin
PRAVACHOL: pravastatin
ZOCOR: simvastatin
Niacins-M
niacin ext-rel
NIASPAN
GNP
BNP
NIASPAN: niacin ext-rel
Omega-3 Fatty Acids-M
omega-3 acid ethyl esters
LOVAZA
VASCEPA
GNP
BNP
BNP
LOVAZA: omega-3 acid ethyl esters
VASCEPA: omega-3 acid ethyl esters
PCSK9 Inhibitors-M
PAR, SRx
PAR, SRx
PRALUENT
REPATHA
BP
BP
26
Miscellaneous-M
PAR, SRx
PAR, SRx
JUXTAPID
KYNAMRO
BP
BNP
BETA-BLOCKERS-M
Guidelines for the use of beta-blockers and beta-blocker combinations in various patient populations are available at:
http://www.acc.org
atenolol
carvedilol
metoprolol tartrate
propranolol tabs 10 mg, 20 mg, 40 mg, 80 mg
bisoprolol
labetalol
metoprolol succinate ext-rel
nadolol
propranolol ext-rel
propranolol soln
propranolol tabs 60 mg
BYSTOLIC
COREG
COREG CR
INDERAL LA
TOPROL-XL
GP
GP
GP
GP
GNP
GNP
GNP
GNP
GNP
GNP
GNP
BP
BNP
BNP
BNP
BNP
COREG: carvedilol
COREG CR: carvedilol
INDERAL LA: propranolol ext-rel
TOPROL-XL: metoprolol succinate ext-rel
BETA-BLOCKER/DIURETIC COMBINATIONS-M
Guidelines for the use of beta-blockers and diuretic combinations in various patient populations are available at:
http://www.acc.org
atenolol/chlorthalidone
bisoprolol/hydrochlorothiazide
DUTOPROL
CALCIUM CHANNEL BLOCKERS-M
Dihydropyridines-M
amlodipine
felodipine ext-rel
isradipine
nicardipine
nifedipine
nifedipine ext-rel
nisoldipine ext-rel
NORVASC
GP
GP
BP
GP
GNP
GNP
GNP
GNP
GNP
GNP
BNP
27
SULAR
BNP
NORVASC: amlodipine
SULAR: nisoldipine ext-rel
Nondihydropyridines-M
diltiazem 30 mg, 60 mg, 120 mg
verapamil
diltiazem 90 mg
diltiazem ext-rel
Matzim LA
verapamil ext-rel
CARDIZEM
CARDIZEM CD
CARDIZEM LA
VERELAN PM
PAR
PAR
PAR
PAR
GP
GP
GNP
GNP
GNP
GNP
BNP
BNP
BNP
BNP
CARDIZEM: diltiazem ext-rel
CARDIZEM CD: diltiazem ext-rel
CARDIZEM LA: diltiazem ext-rel
VERELAN PM: verapamil ext-rel
CALCIUM CHANNEL BLOCKER/ANTILIPEMIC COMBINATIONS-M
amlodipine/atorvastatin
CADUET
GNP
BNP
CADUET: amlodipine/atorvastatin
DIGITALIS GLYCOSIDES-M
digoxin
LANOXIN
DIRECT RENIN INHIBITORS/DIURETIC COMBINATIONS-M
TEKTURNA
TEKTURNA HCT
GNP
BNP
BP
BP
DIURETICS-M
Loop Diuretics-M
furosemide
torsemide tabs 5 mg, 10 mg
bumetanide
torsemide tabs 20 mg, 100 mg
DEMADEX
LASIX
GP
GP
GNP
GNP
BNP
BNP
DEMADEX: torsemide
LASIX: furosemide
28
Potassium-sparing Diuretics-M
amiloride
Thiazides and Thiazide-like Diuretics-M
hydrochlorothiazide caps
hydrochlorothiazide tabs 25 mg, 50 mg
indapamide
metolazone tabs 10 mg
chlorthalidone
hydrochlorothiazide tabs 12.5 mg
metolazone tabs 2.5 mg, 5 mg
GNP
GP
GP
GP
GP
GNP
GNP
GNP
Diuretic Combinations-M
amiloride/hydrochlorothiazide
triamterene/hydrochlorothiazide
spironolactone/hydrochlorothiazide
NEPRILYSIN INHIBITOR/ANGIOTENSIN II RECEPTOR ANTAGONIST COMBINATIONS-M
PAR
ENTRESTO
GP
GP
GNP
BP
NITRATES-M
Oral-M
isosorbide mononitrate
isosorbide mononitrate ext-rel tabs 30 mg
isosorbide dinitrate
isosorbide mononitrate ext-rel tabs 60 mg, 120 mg
nitroglycerin tabs
GP
GP
GNP
GNP
GNP
nitroglycerin lingual spray
NITROSTAT
GNP
BP
Sublingual/Translingual-M
NITRATE/VASODILATOR COMBINATIONS-M
BIDIL
BNP
BIDIL: isosorbide dinitrate + hydralazine
PULMONARY ARTERIAL HYPERTENSION-M
Endothelin Receptor Antagonists-M
PAR, SRx
LETAIRIS
PAR, SRx
OPSUMIT
PAR, SRx
TRACLEER
BNP
BNP
BNP
LETAIRIS: sildenafil, ADCIRCA
OPSUMIT: sildenafil, ADCIRCA
TRACLEER: sildenafil, ADCIRCA
Phosphodiesterase Inhibitors-M
PAR, SRx
sildenafil tabs 20 mg
PAR, SRx
ADCIRCA
GNP
BP
29
PAR, SRx
PAR, SRx
REVATIO susp
REVATIO tabs
BP
BNP
REVATIO tabs: sildenafil tabs
Prostacyclin Receptor Agonists-M
PAR, SRx
UPTRAVI
BNP
Prostaglandin Vasodilators-M
PAR, SRx
SRx
PAR, SRx
PAR, SRx
BNP
BNP
BNP
BNP
ORENITRAM
REMODULIN
TYVASO
VENTAVIS
Soluble Guanylate Cyclase Stimulators-M
PAR, SRx
ADEMPAS
BP
MISCELLANEOUS-M
PAR
PAR
hydralazine tabs 10 mg
methyldopa tabs 250 mg
hydralazine tabs 25 mg, 50 mg, 100 mg
methyldopa tabs 500 mg
RANEXA
CORLANOR
GP
GP
GNP
GNP
BP
BNP
CENTRAL NERVOUS SYSTEM
Practice guidelines for psychiatric disorders are available at:
http://www.psych.org
ANTIANXIETY
Benzodiazepines
alprazolam
clonazepam tabs
diazepam
lorazepam tabs
alprazolam ext-rel
alprazolam orally disintegrating tabs
clonazepam orally disintegrating tabs
lorazepam oral concentrate
GP
GP
GP
GP
GNP
GNP
GNP
GNP
buspirone tabs 5 mg, 10 mg, 15 mg
buspirone tabs 7.5 mg, 30 mg
fluvoxamine
GP
GNP
GNP
Miscellaneous
ANTICONVULSANTS-M
Practice guidelines for the treatment of epilepsy are available at:
http://www.aan.com
carbamazepine chews, tabs
GP
30
PAR
divalproex sodium delayed-rel tabs 125 mg
gabapentin caps 100 mg
lamotrigine tabs 25 mg, 100 mg, 150 mg, 200 mg
phenobarbital tabs 30 mg, 60 mg
topiramate tabs 25 mg
carbamazepine ext-rel
carbamazepine susp
diazepam rectal gel
divalproex sodium delayed-rel tabs 250 mg, 500 mg
divalproex sodium ext-rel
gabapentin caps 300 mg, 400 mg
gabapentin tabs, soln
lamotrigine ext-rel
lamotrigine orally disintegrating tabs
lamotrigine tabs 50 mg
levetiracetam
levetiracetam ext-rel
oxcarbazepine
phenobarbital elixir
phenobarbital tabs
15 mg, 16.2 mg, 32.4 mg, 64.8 mg, 97.2 mg, 100 mg
phenytoin
phenytoin sodium
phenytoin sodium extended
primidone
tiagabine
topiramate sprinkle caps
topiramate tabs 50 mg, 100 mg, 200 mg
valproic acid
zonisamide
APTIOM
BANZEL
CARBATROL
DEPAKOTE
DEPAKOTE ER
DILANTIN
DILANTIN INFATABS
FYCOMPA
KEPPRA
KEPPRA XR
LAMICTAL
LAMICTAL ODT
LAMICTAL XR
NEURONTIN
PHENYTEK
POTIGA
GP
GP
GP
GP
GP
GNP
GNP
GNP
GNP
GNP
GNP
GNP
GNP
GNP
GNP
GNP
GNP
GNP
GNP
GNP
GNP
GNP
GNP
GNP
GNP
GNP
GNP
GNP
GNP
BNP
BNP
BNP
BNP
BNP
BNP
BNP
BNP
BNP
BNP
BNP
BNP
BNP
BNP
BNP
BNP
31
SRx
SABRIL
STAVZOR
TEGRETOL-XR
TOPAMAX
TRILEPTAL
VIMPAT
ZONEGRAN
BNP
BNP
BNP
BNP
BNP
BNP
BNP
BANZEL: gabapentin, lamotrigine, levetiracetam
CARBATROL: carbamazepine ext-rel
DEPAKOTE: divalproex sodium delayed-rel
DEPAKOTE ER: divalproex sodium ext-rel
KEPPRA: levetiracetam
KEPPRA XR: levetiracetam ext-rel
LAMICTAL: lamotrigine
LAMICTAL ODT: lamotrigine orally disintegrating tabs
LAMICTAL XR: lamotrigine ext-rel
NEURONTIN: gabapentin
POTIGA: gabapentin, lamotrigine, levetiracetam
STAVZOR: valproic acid
TEGRETOL-XR: carbamazepine ext-rel
TOPAMAX: topiramate
TRILEPTAL: oxcarbazepine
VIMPAT: gabapentin, lamotrigine, levetiracetam
ZONEGRAN: zonisamide
ANTIDEMENTIA-M
Practice guidelines for the management of dementia are available at:
http://www.aan.com
EPA
EPA
EPA
EPA
donepezil
donepezil orally disintegrating tabs
galantamine
galantamine ext-rel
memantine
rivastigmine
NAMENDA XR
ARICEPT
EXELON
NAMENDA
RAZADYNE
RAZADYNE ER
GNP
GNP
GNP
GNP
GNP
GNP
BP
BNP
BNP
BNP
BNP
BNP
ARICEPT: donepezil
EXELON: rivastigmine
NAMENDA: memantine
RAZADYNE: galantamine
RAZADYNE ER: galantamine ext-rel
32
ANTIDEPRESSANTS-M
Although these agents are primarily indicated for depression, some of these are also approved for other indications, including
bipolar disorder, obsessive-compulsive disorder, panic disorder and premenstrual dysphoric disorder.
Guidelines for the evaluation and management of bipolar and depressive disorders are available at:
Selective Serotonin Reuptake Inhibitors (SSRIs)-M
QLL
citalopram tabs
QLL
fluoxetine caps 10 mg, 20 mg
QLL
fluoxetine tabs 10 mg
QLL
paroxetine
QLL
sertraline tabs
QLL
citalopram soln
QLL
escitalopram
QLL
fluoxetine caps 40 mg
QLL
fluoxetine delayed-rel
QLL
fluoxetine soln
QLL
fluoxetine tabs 20 mg
QLL
paroxetine HCl ext-rel
QLL
sertraline oral concentrate
PAR, QLL
BRINTELLIX
PAR, QLL
CELEXA
PAR, QLL
LEXAPRO
PAR, QLL
PAXIL
PAR, QLL
PAXIL CR
PAR, QLL
PEXEVA
PAR, QLL
PROZAC
PAR, QLL
PROZAC WEEKLY
PAR
SARAFEM
PAR
VIIBRYD
PAR, QLL
ZOLOFT
GP
GP
GP
GP
GP
GNP
GNP
GNP
GNP
GNP
GNP
GNP
GNP
BNP
BNP
BNP
BNP
BNP
BNP
BNP
BNP
BNP
BNP
BNP
CELEXA: citalopram
LEXAPRO: escitalopram
PAXIL: paroxetine
PAXIL CR: paroxetine ext-rel
PEXEVA: paroxetine
PROZAC: fluoxetine
PROZAC WEEKLY: fluoxetine delayed-rel
VIIBRYD: citalopram, escitalopram, fluoxetine, paroxetine
ZOLOFT: sertraline
Serotonin Norepinephrine Reuptake Inhibitors (SNRIs)-M
duloxetine delayed-rel
QLL
Irenka
venlafaxine
QLL
venlafaxine ext-rel
PAR
CYMBALTA
PAR, QLL
DESVENLAFAXINE ER
GNP
GNP
GNP
GNP
BNP
BNP
33
PAR, QLL
PAR, QLL
PAR, QLL
PAR, QLL
EFFEXOR XR
FETZIMA
KHEDEZLA
PRISTIQ
BNP
BNP
BNP
BNP
CYMBALTA: duloxetine delayed-rel
DESVENLAFAXINE ER: duloxetine delayed-rel, Irenka, venlafaxine, venlafaxine ext-rel
EFFEXOR XR: venlafaxine ext-rel
FETZIMA: duloxetine delayed-rel, Irenka, venlafaxine, venlafaxine ext-rel
KHEDEZLA: duloxetine delayed-rel, Irenka, venlafaxine, venlafaxine ext-rel
PRISTIQ: duloxetine delayed-rel, Irenka, venlafaxine, venlafaxine ext-rel
Tricyclic Antidepressants (TCAs)-M
amitriptyline 10 mg, 25 mg, 50 mg, 75 mg, 150 mg
doxepin caps 10 mg
doxepin oral concentrate
imipramine HCl tabs 10 mg
nortriptyline caps
amitriptyline 100 mg
desipramine
doxepin caps 25 mg, 50 mg, 75 mg, 100 mg, 150 mg
imipramine HCl tabs 25 mg, 50 mg
imipramine pamoate
nortriptyline soln
protriptyline
GP
GP
GP
GP
GP
GNP
GNP
GNP
GNP
GNP
GNP
GNP
Miscellaneous Agents-M
PAR
PAR
PAR
PAR
PAR
PAR
mirtazapine tabs 15 mg
trazodone tabs 50 mg, 100 mg, 150 mg
bupropion
bupropion ext-rel
mirtazapine orally disintegrating tabs
mirtazapine tabs 7.5 mg, 30 mg, 45 mg
nefazodone
trazodone tabs 300 mg
APLENZIN
EMSAM
OLEPTRO
WELLBUTRIN
WELLBUTRIN SR
WELLBUTRIN XL
GP
GP
GNP
GNP
GNP
GNP
GNP
GNP
BNP
BNP
BNP
BNP
BNP
BNP
APLENZIN: bupropion ext-rel
EMSAM: citalopram, paroxetine
OLEPTRO: trazodone
WELLBUTRIN: bupropion
WELLBUTRIN SR: bupropion ext-rel
WELLBUTRIN XL: bupropion ext-rel
34
ANTIPARKINSONIAN AGENTS-M
Practice guidelines for the diagnosis and treatment of Parkinson's disease are available at:
http://www.aan.com
benztropine
amantadine
bromocriptine
carbidopa/levodopa
carbidopa/levodopa orally disintegrating tabs
carbidopa/levodopa/entacapone
entacapone
pramipexole
pramipexole ext-rel
ropinirole
ropinirole ext-rel
APOKYN
NEUPRO
COMTAN
MIRAPEX
MIRAPEX ER
REQUIP
REQUIP XL
STALEVO
SRx
EPA
GP
GNP
GNP
GNP
GNP
GNP
GNP
GNP
GNP
GNP
GNP
BP
BP
BNP
BNP
BNP
BNP
BNP
BNP
COMTAN: entacapone
MIRAPEX: pramipexole
MIRAPEX ER: pramipexole ext-rel
REQUIP: ropinirole
REQUIP XL: ropinirole ext-rel
STALEVO: carbidopa/levodopa/entacapone
ANTIPSYCHOTICS-M
Atypicals-M
QLL
QLL
QLL
QLL
PAR
PAR
PAR
PAR, QLL
risperidone tabs 1 mg
aripiprazole
clozapine
olanzapine
olanzapine orally disintegrating tabs
olanzapine/fluoxetine
paliperidone ext-rel
quetiapine
risperidone orally disintegrating tabs
risperidone tabs 0.25 mg, 0.5 mg, 2 mg, 3 mg, 4 mg
ziprasidone
ABILIFY
FANAPT
GEODON
INVEGA
GP
GNP
GNP
GNP
GNP
GNP
GNP
GNP
GNP
GNP
GNP
BNP
BNP
BNP
BNP
35
PAR
PAR
PAR
PAR
PAR
PAR
PAR, QLL
PAR
PAR
PAR, QLL
PAR, QLL
LATUDA
REXULTI
RISPERDAL
RISPERDAL M-TABS
SAPHRIS
SEROQUEL
SEROQUEL XR
SYMBYAX
VRAYLAR
ZYPREXA
ZYPREXA ZYDIS
BNP
BNP
BNP
BNP
BNP
BNP
BNP
BNP
BNP
BNP
BNP
ABILIFY: aripiprazole
FANAPT: aripiprazole, olanzapine, paliperidone ext-rel, quetiapine, risperidone, ziprasidone
GEODON: ziprasidone
INVEGA: paliperidone ext-rel
LATUDA: aripiprazole, olanzapine, paliperidone ext-rel, quetiapine, risperidone, ziprasidone
REXULTI: aripiprazole, olanzapine, paliperidone ext-rel, quetiapine, risperidone, ziprasidone
RISPERDAL: risperidone
RISPERDAL M-TABS: risperidone orally disintegrating tabs
SAPHRIS: aripiprazole, olanzapine, paliperidone ext-rel, quetiapine, risperidone, ziprasidone
SEROQUEL: quetiapine
SEROQUEL XR: quetiapine
SYMBYAX: olanzapine/fluoxetine
VRAYLAR: aripiprazole, olanzapine, paliperidone ext-rel, quetiapine, risperidone, ziprasidone
ZYPREXA: olanzapine
ZYPREXA ZYDIS: olanzapine orally disintegrating tabs
Miscellaneous-M
haloperidol oral concentrate
thioridazine tabs 50 mg
haloperidol tabs
thioridazine tabs 10 mg, 25 mg, 100 mg
GP
GP
GNP
GNP
ATTENTION DEFICIT HYPERACTIVITY DISORDER
Guidelines for the evaluation and management of attention deficit disorder are available at:
http://www.aacap.org
http://www.aap.org
PAR
amphetamine/dextroamphetamine mixed salts
amphetamine/dextroamphetamine mixed salts ext-rel
clonidine ext-rel
dexmethylphenidate
dexmethylphenidate ext-rel
dextroamphetamine
guanfacine ext-rel
methylphenidate
methylphenidate ext-rel
VYVANSE
ADDERALL
GNP
GNP
GNP
GNP
GNP
GNP
GNP
GNP
GNP
BP
BNP
36
PAR
PAR
ADDERALL XR
CONCERTA
DAYTRANA
DYANAVEL XR
FOCALIN
FOCALIN XR
INTUNIV
KAPVAY
METADATE CD
METHYLIN
PROCENTRA
RITALIN LA
STRATTERA
PAR
PAR
PAR
PAR
PAR
PAR
PAR
PAR
PAR
BNP
BNP
BNP
BNP
BNP
BNP
BNP
BNP
BNP
BNP
BNP
BNP
BNP
ADDERALL: amphetamine/dextroamphetamine mixed salts
ADDERALL XR: amphetamine/dextroamphetamine mixed salts ext-rel
CONCERTA: methylphenidate ext-rel
DAYTRANA: methylphenidate ext-rel
DYANAVEL XR: amphetamine/dextroamphetamine mixed salts ext-rel
FOCALIN: dexmethylphenidate
FOCALIN XR: dexmethylphenidate ext-rel
INTUNIV: guanfacine ext-rel
KAPVAY: clonidine ext-rel
METADATE CD: methylphenidate ext-rel
METHYLIN: methylphenidate
PROCENTRA: dextroamphetamine
RITALIN LA: methylphenidate ext-rel
STRATTERA: amphetamine/dextroamphetamine mixed salts,
amphetamine/dextroamphetamine mixed salts ext-rel, dexmethylphenidate, dexmethylphenidate ext-rel,
dextroamphetamine, methylphenidate, methylphenidate ext-rel
FIBROMYALGIA-M
EPA
EPA
LYRICA
SAVELLA
HUNTINGTON'S DISEASE AGENTS-M
PAR, SRx
tetrabenazine
PAR, SRx
XENAZINE
BP
BP
GNP
BNP
XENAZINE: tetrabenazine
HYPNOTICS
Practice parameters for the treatment of sleep disorders and clinical guidelines for the evaluation and management of chronic
insomnia in adults are available at:
http://www.aasmnet.org
Benzodiazepines
flurazepam caps 30 mg
temazepam caps 15 mg, 30 mg
flurazepam caps 15 mg
temazepam caps 7.5 mg, 22.5 mg
GP
GP
GNP
GNP
37
Nonbenzodiazepines
QLL
QLL
QLL
QLL
QLL
EPA, QLL
EPA, QLL
PAR
EPA, QLL
PAR, SRx
EPA, QLL
EPA, QLL
EPA, QLL
EPA, QLL
triazolam
GNP
zolpidem
eszopiclone
zaleplon
zolpidem ext-rel
zolpidem sublingual
ROZEREM
AMBIEN
AMBIEN CR
BELSOMRA
EDLUAR
HETLIOZ
INTERMEZZO
LUNESTA
SONATA
ZOLPIMIST
GP
GNP
GNP
GNP
GNP
BP
BNP
BNP
BNP
BNP
BNP
BNP
BNP
BNP
BNP
AMBIEN: zolpidem
AMBIEN CR: zolpidem ext-rel
BELSOMRA: eszopiclone, zaleplon, zolpidem, zolpidem ext-rel, zolpidem sublingual, ROZEREM
EDLUAR: zolpidem, zolpidem sublingual
INTERMEZZO: zolpidem sublingual
LUNESTA: eszopiclone
SONATA: zaleplon
ZOLPIMIST: zolpidem, zolpidem sublingual
MIGRAINE
Guidelines for prevention and management of migraine headaches are available at:
http://www.aan.com
Selective Serotonin Agonists
QLL
QLL
QLL
QLL
QLL
QLL
QLL
QLL
EPA, QLL
EPA, QLL
EPA, QLL
EPA, QLL
EPA, QLL
EPA, QLL
EPA, QLL
EPA, QLL
almotriptan
frovatriptan
naratriptan
rizatriptan
rizatriptan orally disintegrating tabs
sumatriptan
zolmitriptan
zolmitriptan orally disintegrating tabs
AMERGE
AXERT
FROVA
IMITREX
MAXALT
MAXALT-MLT
RELPAX
SUMAVEL DOSEPRO
GNP
GNP
GNP
GNP
GNP
GNP
GNP
GNP
BNP
BNP
BNP
BNP
BNP
BNP
BNP
BNP
38
EPA, QLL
EPA, QLL
ZOMIG
ZOMIG-ZMT
BNP
BNP
AMERGE: naratriptan
AXERT: almotriptan
FROVA: frovatriptan
IMITREX: sumatriptan
MAXALT: rizatriptan
MAXALT-MLT: rizatriptan orally disintegrating tabs
RELPAX: almotriptan, frovatriptan, naratriptan, rizatriptan, sumatriptan, zolmitriptan
ZOMIG: zolmitriptan
ZOMIG-ZMT: zolmitriptan orally disintegrating tabs
Selective Serotonin Agonist/Nonsteroidal Anti-inflammatory Drug (NSAID) Combinations
EPA, QLL
TREXIMET
BNP
TREXIMET: sumatriptan + naproxen
MOOD STABILIZERS-M
lithium carbonate caps, tabs
lithium carbonate ext-rel caps 300 mg
LITHIUM SOLN
GP
GNP
BP
MULTIPLE SCLEROSIS AGENTS-M
Practice guidelines for multiple sclerosis are available at:
http://www.aan.com
SRx
PAR, QLL, SRx
SRx
SRx
SRx
SRx
SRx
PAR, SRx
SRx
EPA, SRx
EPA, SRx
glatiramer
AMPYRA
AVONEX
BETASERON
COPAXONE 40 mg
GILENYA
TECFIDERA
AUBAGIO
COPAXONE 20 mg
EXTAVIA
REBIF
GNP
BP
BP
BP
BP
BP
BP
BNP
BNP
BNP
BNP
AUBAGIO: glatiramer, AVONEX, BETASERON, COPAXONE 40 mg, GILENYA, TECFIDERA
COPAXONE 20 mg: glatiramer
EXTAVIA: glatiramer, AVONEX, BETASERON, COPAXONE 40 mg, GILENYA, TECFIDERA
REBIF: glatiramer, AVONEX, BETASERON, COPAXONE 40 mg, GILENYA, TECFIDERA
MUSCULOSKELETAL THERAPY AGENTS
carisoprodol tabs 350 mg
cyclobenzaprine tabs 5 mg, 10 mg
methocarbamol
baclofen tabs
carisoprodol tabs 250 mg
GP
GP
GP
GNP
GNP
39
PAR
NARCOLEPSY
PAR
PAR
PAR
PAR
chlorzoxazone
cyclobenzaprine tabs 7.5 mg
metaxalone
orphenadrine ext-rel
tizanidine
AMRIX
SKELAXIN
GNP
GNP
GNP
GNP
GNP
BNP
BNP
armodafinil
modafinil
NUVIGIL
PROVIGIL
GNP
GNP
BNP
BNP
NUVIGIL: armodafinil
PROVIGIL: modafinil
PSYCHOTHERAPEUTIC-MISCELLANEOUS
Opioid Antagonists
NARCAN NASAL SPRAY
EVZIO
BP
BNP
EVZIO: NARCAN NASAL SPRAY
Partial Opioid Agonist/Opioid Antagonist Combinations
QLL
buprenorphine/naloxone sublingual tabs
QLL
SUBOXONE FILM
GNP
BP
Smoking Deterrents
Treating Tobacco Use and Dependence: 2008 Update-Clinical Practice Guideline is available at:
http://www.ahrq.gov/professionals/clinicians-providers/guidelines-recommendations/tobacco/index.html
PHC, QLL*
PHC, QLL*
PHC, QLL*
PHC, QLL*
PHC, QLL*
PHC, QLL*
PHC, QLL*
bupropion ext-rel
nicotine polacrilex gum
nicotine polacrilex lozenge
nicotine transdermal
CHANTIX
NICOTROL INHALER
NICOTROL NS
GNP
GNP
GNP
GNP
BP
BP
BP
*QLL Limited to a 180 day treatment regimen.
RESTLESS LEGS SYNDROME
HORIZANT
BNP
40
ENDOCRINE AND METABOLIC
ANDROGENS
Clinical practice guidelines for the treatment of hypogonadism are available at:
http://www.aace.com
testosterone cypionate
testosterone enanthate
testosterone gel
testosterone gel pump 1%
ANDRODERM
ANDROGEL 1% (50 mg), 1.62%
AXIRON
ANDROGEL 1% (25 mg)
ANDROGEL PUMP 1%
FORTESTA
TESTIM
VOGELXO
GNP
GNP
GNP
GNP
BP
BP
BP
BNP
BNP
BNP
BNP
BNP
ANDROGEL 1% (25 mg): testosterone gel
ANDROGEL PUMP 1%: testosterone gel pump 1%
FORTESTA: testosterone gel
TESTIM: testosterone gel
VOGELXO: testosterone gel
ANTIDIABETICS-M
Guidelines of treatment and management of diabetes are available at:
Alpha-glucosidase Inhibitors-M
acarbose
miglitol
GLYSET
PRECOSE
GNP
GNP
BNP
BNP
GLYSET: miglitol
PRECOSE: acarbose
Amylin Analogs-M
EPA
SYMLINPEN
BP
metformin
metformin ext-rel tabs 500 mg
metformin ext-rel tabs
metformin ext-rel tabs 750 mg
FORTAMET
GLUCOPHAGE XR
GLUMETZA
GP
GP
GNP
GNP
BNP
BNP
BNP
Biguanides-M
*
PAR
PAR
PAR
41
PAR
RIOMET
BNP
* refers to generic for GLUMETZA
FORTAMET: metformin ext-rel
GLUCOPHAGE XR: metformin ext-rel
GLUMETZA: metformin ext-rel
RIOMET: metformin
Biguanide/Sulfonylurea Combinations-M
glyburide/metformin tabs 1.25/250 mg
glipizide/metformin
glyburide/metformin tabs 2.5/500 mg, 5/500 mg
GLUCOVANCE
METAGLIP
GP
GNP
GNP
BNP
BNP
GLUCOVANCE: glyburide/metformin
METAGLIP: glipizide/metformin
Dipeptidyl Peptidase-4 (DPP-4) Inhibitors/Combinations-M
alogliptin
alogliptin/metformin
alogliptin/pioglitazone
JANUMET
JANUMET XR
JANUVIA
JENTADUETO
TRADJENTA
PAR
KAZANO
PAR
KOMBIGLYZE XR
PAR
NESINA
PAR
ONGLYZA
PAR
OSENI
GNP
GNP
GNP
BP
BP
BP
BP
BP
BNP
BNP
BNP
BNP
BNP
KAZANO: alogliptin/metformin
KOMBIGLYZE XR: alogliptin, alogliptin/metformin, alogliptin/pioglitazone, JANUMET, JANUMET XR, JANUVIA,
JENTADUETO, TRADJENTA
NESINA: alogliptin
ONGLYZA: alogliptin, alogliptin/metformin, alogliptin/pioglitazone JANUMET, JANUMET XR, JANUVIA,
JENTADUETO, TRADJENTA
OSENI: alogliptin/pioglitazone
Incretin Mimetic Agents-M
PAR
PAR
TRULICITY
VICTOZA
BYDUREON
BYETTA
BP
BP
BNP
BNP
42
PAR
TANZEUM
BNP
BYDUREON: TRULICITY, VICTOZA
BYETTA: TRULICITY, VICTOZA
TANZEUM: TRULICITY, VICTOZA
Insulins-M
LANTUS
LEVEMIR
NOVOLIN 70/30
NOVOLIN N
NOVOLIN R
NOVOLOG
NOVOLOG MIX 70/30
TOUJEO
AFREZZA
APIDRA
HUMALOG
HUMALOG MIX
HUMULIN 70/30
HUMULIN N
HUMULIN R
RELION products
TRESIBA
PAR
PAR
PAR
PAR
PAR
PAR
PAR
PAR
BP
BP
BP
BP
BP
BP
BP
BP
BNP
BNP
BNP
BNP
BNP
BNP
BNP
BNP
BNP
AFREZZA: NOVOLOG
APIDRA: NOVOLOG
HUMALOG: NOVOLOG
HUMULIN: NOVOLIN
RELION products: NOVOLIN
TRESIBA: LANTUS, LEVEMIR, TOUJEO
Insulin Sensitizers-M
pioglitazone
ACTOS
GNP
BNP
ACTOS: pioglitazone
Insulin Sensitizer/Biguanide Combinations-M
pioglitazone/metformin
ACTOPLUS MET XR
ACTOPLUS MET
GNP
BP
BNP
ACTOPLUS MET: pioglitazone/metformin
43
Insulin Sensitizer/Sulfonylurea Combinations-M
pioglitazone/glimepiride
DUETACT
GNP
BNP
DUETACT: pioglitazone/glimepiride
Meglitinides-M
nateglinide
repaglinide
PRANDIN
STARLIX
GNP
GNP
BNP
BNP
PRANDIN: repaglinide
STARLIX: nateglinide
Meglitinide/Biguanide Combinations-M
repaglinide/metformin
GNP
Sodium-Glucose Co-transporter 2 (SGLT2) Inhibitors-M
FARXIGA
JARDIANCE
PAR
INVOKANA
BP
BP
BNP
INVOKANA: FARXIGA, JARDIANCE
Sodium-Glucose Co-transporter 2 (SGLT2) Inhibitor/Biguanide Combinations-M
XIGDUO XR
PAR
INVOKAMET
BP
BNP
INVOKAMET: XIGDUO XR
Sulfonylureas-M
glimepiride
glipizide
glipizide ext-rel tabs 2.5 mg, 5 mg
glyburide micronized
glyburide tabs 1.25 mg, 2.5 mg
glipizide ext-rel tabs 10 mg
glyburide tabs 5 mg
AMARYL
GP
GP
GP
GP
GP
GNP
GNP
BNP
AMARYL: glimepiride
Supplies-M
NOVOFINE 30, 32 AUTOCOVER
ONETOUCH
SOFT TOUCH
BP
BP
BP
44
SOFTCLIX
ACCU-CHEK
ASCENSIA
BREEZE
CONTOUR
FAST TAKE
FREESTYLE
PRECISION PCX
PRECISION PCX PLUS
PRECISION Q-I-D
PRECISION SOF-TACT
PRECISION XTRA
SURESTEP
PAR
PAR
PAR
PAR
PAR
PAR
PAR
PAR
PAR
PAR
PAR
PAR
BP
BNP
BNP
BNP
BNP
BNP
BNP
BNP
BNP
BNP
BNP
BNP
BNP
ACCU-CHEK: ONETOUCH
ASCENSIA: ONETOUCH
BREEZE: ONETOUCH
CONTOUR: ONETOUCH
FAST TAKE: ONETOUCH
FREESTYLE: ONETOUCH
PRECISION: ONETOUCH
SURESTEP: ONETOUCH
ANTIOBESITY
Guidelines of treatment and management of obesity are available at:
http://www.aace.com
http://www.nhlbi.nih.gov/health-pro/guidelines/in-develop/obesity-evidence-review
Injectable
PAR
SAXENDA
BNP
Oral
PAR
PAR
PAR
PAR
BELVIQ
CONTRAVE
QSYMIA
XENICAL
BNP
BNP
BNP
BNP
XENICAL: ALLI OTC*
* OTC ALLI is not covered under the prescription drug benefit.
CALCIUM RECEPTOR ANTAGONISTS-M
SRx
SENSIPAR
BP
CALCIUM REGULATORS-M
Guidelines of treatment and management of osteoporosis are available at:
http://www.aace.com
http://www.nof.org
Bisphosphonates-M
QLL
alendronate tabs 5 mg, 35 mg, 70 mg
GP
45
QLL
QLL
QLL
EPA, QLL
EPA, QLL
EPA, QLL
EPA, QLL
EPA, QLL
alendronate soln
alendronate tabs 40 mg
ibandronate tabs
risedronate
risedronate delayed-rel
FOSAMAX PLUS D
ACTONEL
ATELVIA
BONIVA tabs
FOSAMAX
GNP
GNP
GNP
GNP
GNP
BP
BNP
BNP
BNP
BNP
ACTONEL: risedronate
ATELVIA: risedronate delayed-rel
BONIVA: ibandronate
FOSAMAX: alendronate
Calcitonins-M
calcitonin-salmon
MIACALCIN
GNP
BNP
MIACALCIN: calcitonin-salmon
Parathyroid Hormones-M
PAR, SRx
PAR, SRx
FORTEO
NATPARA
BP
BNP
Aviane
Gianvi
Junel Fe
Lessina
Lomedia 24 Fe
Lutera
Microgestin 1/20
Microgestin Fe 1/20
LOESTRIN 1/20
LOESTRIN FE 1/20
YAZ
GNP
GNP
GNP
GNP
GNP
GNP
GNP
GNP
BNP
BNP
BNP
CONTRACEPTIVES
EE = ethinyl estradiol
ME = mestranol
Monophasic-M
20 mcg Estrogen-M
PHC
PHC
PHC
PHC
PHC
PHC
PHC
PHC
LOESTRIN: Microgestin
LOESTRIN FE: Junel Fe, Microgestin Fe
YAZ: Gianvi
46
30 mcg Estrogen-M
PHC
PHC
PHC
PHC
PHC
PHC
PHC
PHC
Apri
Cryselle
Junel Fe
Levora
Low-Ogestrel
Microgestin 1.5/30
Microgestin Fe 1.5/30
Ocella
DESOGEN
LOESTRIN 1.5/30
LOESTRIN FE 1.5/30
YASMIN
GNP
GNP
GNP
GNP
GNP
GNP
GNP
GNP
BNP
BNP
BNP
BNP
DESOGEN: Apri
LOESTRIN: Microgestin
LOESTRIN FE: Junel Fe, Microgestin Fe
YASMIN: Ocella
35 mcg Estrogen-M
PHC
PHC
PHC
PHC
PHC
PHC
PHC
PHC
PHC
Kelnor 1/35
Mononessa
Necon 0.5/35
Necon 1/35
Nortrel 0.5/35
Nortrel 1/35
Previfem
Sprintec
Zovia 1/35e
ORTHO-CYCLEN
ORTHO-NOVUM 1/35
GNP
GNP
GNP
GNP
GNP
GNP
GNP
GNP
GNP
BNP
BNP
ORTHO-CYCLEN: Previfem, Sprintec
ORTHO-NOVUM: Nortrel
50 mcg Estrogen-M
PHC
Biphasic-M
PHC
Necon 1/50
GNP
Kariva
MIRCETTE
GNP
BNP
MIRCETTE: Kariva
Triphasic-M
PHC
PHC
PHC
Aranelle
Enpresse
Necon 7/7/7
GNP
GNP
GNP
47
PHC
PHC
PHC
PHC
PHC
PHC
PHC
Nortrel 7/7/7
Tri-Lo Sprintec
Trinessa
Tri-Previfem
Tri-Sprintec
Trivora
Velivet
ESTROSTEP FE
CYCLESSA
ORTHO TRI-CYCLEN
ORTHO TRI-CYCLEN LO
ORTHO-NOVUM 7/7/7
TRI-NORINYL
GNP
GNP
GNP
GNP
GNP
GNP
GNP
BP
BNP
BNP
BNP
BNP
BNP
CYCLESSA: Velivet
ORTHO TRI-CYCLEN: Trinessa, Tri-Previfem, Tri-Sprintec
ORTHO TRI-CYCLEN LO: Tri-Lo Sprintec
ORTHO-NOVUM 7/7/7: Necon 7/7/7, Nortrel 7/7/7
TRI-NORINYL: Aranelle
Four Phase-M
PHC
Extended Cycle-M
PHC
PHC
PHC
PHC
PHC
PHC
PHC
PHC
NATAZIA
BNP
Amethia
Amethia Lo
Camrese
Camrese Lo
Introvale
Jolessa
levonorgestrel/EE 0.1/20 and EE 10
Quasense
LOSEASONIQUE
SEASONIQUE
GNP
GNP
GNP
GNP
GNP
GNP
GNP
GNP
BNP
BNP
LOSEASONIQUE: Amethia Lo, Camrese Lo, levonorgestrel/EE 0.1/20 and EE 10
SEASONIQUE: Amethia, Camrese
Progestin Only-M
PHC
PHC
PHC
Camila
Errin
Jolivette
GNP
GNP
GNP
Emergency Contraception
PHC
PHC
PHC
levonorgestrel
Next Choice One Dose
ELLA
GNP
GNP
BNP
48
Injectable-M
PHC, *
*
medroxyprogesterone acetate 150 mg/mL
DEPO-PROVERA
GNP
BNP
* Copays at retail pharmacy may vary due to package size.
DEPO-PROVERA: medroxyprogesterone acetate
Transdermal-M
PHC
Xulane
GNP
Vaginal-M
PHC
NUVARING
BP
Miscellaneous
OTC, PHC
OTC, PHC
GYNOL II GEL 3%
VCF VAGINAL CONTRACEPTIVE FOAM
BP
BNP
ENDOMETRIOSIS
SRx
SRx
SYNAREL
LUPANETA
BP
BNP
ESTROGENS-M
Guidelines of treatment and management of hormone therapy and menopause are available at:
http://www.menopause.org
https://www.aace.com/files/menopause.pdf
Oral-M
estradiol
estropipate 0.75 mg, 3 mg
estropipate 1.5 mg
PREMARIN
MENEST
GP
GP
GNP
BP
BNP
MENEST: estradiol, PREMARIN
Transdermal-M
estradiol
ALORA
CLIMARA
ESTROGEL
MENOSTAR
VIVELLE-DOT
GNP
BNP
BNP
BNP
BNP
BNP
ALORA: estradiol patch
CLIMARA: estradiol patch
ESTROGEL: estradiol patch
MENOSTAR: estradiol, PREMARIN
VIVELLE-DOT: estradiol patch
49
Vaginal-M
ESTRING
PREMARIN crm
VAGIFEM
BP
BP
BP
estradiol/norethindrone
Jinteli
norethindrone/ethinyl estradiol 0.5 mg/2.5 mcg
PREMPHASE
PREMPRO
ACTIVELLA
FEMHRT 0.5 mg/2.5 mcg
PREFEST
GNP
GNP
GNP
BP
BP
BNP
BNP
BNP
ESTROGEN/PROGESTINS-M
Oral-M
ACTIVELLA: estradiol/norethindrone
FEMHRT 0.5 mg/2.5 mcg: norethindrone/ethinyl estradiol 0.5 mg/2.5 mcg
PREFEST: PREMPRO, PREMPHASE
Transdermal-M
CLIMARA PRO
COMBIPATCH
BP
BP
ESTROGEN/SELECTIVE ESTROGEN RECEPTOR MODULATOR COMBINATIONS-M
DUAVEE
BNP
FERTILITY REGULATORS
GNRH/LHRH Antagonists
SRx
SRx
BP
BP
CETROTIDE
GANIRELIX
Ovulation Stimulants, Gonadotropins
SRx
chorionic gonadotropin - Novarel
SRx
chorionic gonadotropin - Pregnyl
SRx
BRAVELLE
SRx
FOLLISTIM AQ
SRx
GONAL-F
SRx
GONAL-F RFF
SRx
MENOPUR
SRx
OVIDREL
SRx
REPRONEX
GNP
GNP
BP
BP
BNP
BNP
BNP
BNP
BNP
GONAL-F: BRAVELLE, FOLLISTIM AQ
GONAL-F RFF: BRAVELLE, FOLLISTIM AQ
REPRONEX: BRAVELLE, FOLLISTIM AQ
Ovulation Stimulants, Synthetic
clomiphene
GNP
50
GLUCOCORTICOIDS
dexamethasone tabs
0.5 mg, 0.75 mg, 1 mg, 1.5 mg, 4 mg, 6 mg
prednisolone
prednisolone sodium phosphate soln 15 mg/5 mL
prednisone dose pack 5 mg
prednisone tabs
dexamethasone tabs 2 mg
fludrocortisone
hydrocortisone
methylprednisolone
prednisolone sodium phosphate soln 5 mg/5 mL, 25 mg/5 mL
prednisone dose pack 10 mg
prednisone soln
GLUCOSE ELEVATING AGENTS
GLUCAGEN
GLUCAGON
GP
GP
GP
GP
GP
GNP
GNP
GNP
GNP
GNP
GNP
GNP
BP
BP
HUMAN GROWTH HORMONES
Guidelines for use of growth hormone are available at:
http://www.aace.com/publications/guidelines
PAR, SRx
PAR, SRx
PAR, SRx
PAR, SRx
PAR, SRx
PAR, SRx
PAR, SRx
PAR, SRx
PAR, SRx
NORDITROPIN
SEROSTIM
GENOTROPIN
HUMATROPE
NUTROPIN AQ
OMNITROPE
SAIZEN
ZOMACTON
ZORBTIVE
BP
BP
BNP
BNP
BNP
BNP
BNP
BNP
BNP
GENOTROPIN: NORDITROPIN
HUMATROPE: NORDITROPIN
NUTROPIN AQ: NORDITROPIN
OMNITROPE: NORDITROPIN
SAIZEN: NORDITROPIN
ZOMACTON: NORDITROPIN
HYPERPARATHYROID TREATMENT, VITAMIN D ANALOGS-M
calcitriol
doxercalciferol
paricalcitol
HECTOROL
GNP
GNP
GNP
BNP
HECTOROL: doxercalciferol
51
INSULIN-LIKE GROWTH FACTOR
PAR, SRx
INCRELEX
BP
PHENYLKETONURIA TREATMENT AGENTS
SRx
KUVAN
BP
PHOSPHATE BINDER AGENTS-M
calcium acetate
RENAGEL
RENVELA
FOSRENOL
PHOSLO
GNP
BP
BP
BNP
BNP
FOSRENOL: RENAGEL
PHOSLO: calcium acetate
PROGESTINS-M
Oral-M
medroxyprogesterone acetate
megestrol acetate susp
norethindrone acetate
progesterone, micronized
PROMETRIUM
GP
GNP
GNP
GNP
BNP
PROMETRIUM: progesterone, micronized
SELECTIVE ESTROGEN RECEPTOR MODULATORS-M
PAR*, PHC
raloxifene
EVISTA
OSPHENA
GNP
BNP
BNP
*PAR is needed for coverage under PHC. Limited to women age 35 years and older with no previous history of breast
cancer, ductal carcinoma in situ (CIS) or lobular carcinoma in situ.
EVISTA: raloxifene
THYROID AGENTS-M
Antithyroid Agents-M
methimazole tabs 5 mg
methimazole tabs 10 mg
propylthiouracil
GP
GNP
GNP
levothyroxine sodium 25 mcg, 50 mcg, 75 mcg, 88 mcg,
100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg
thyroid tabs
levothyroxine sodium 175 mcg, 200 mcg, 300 mcg
Levoxyl
liothyronine
GP
Thyroid Supplements-M
GP
GNP
GNP
GNP
52
CYTOMEL
SYNTHROID
BNP
BNP
CYTOMEL: liothyronine
SYNTHROID: levothyroxine
VASOPRESSINS
desmopressin
STIMATE
DDAVP
GNP
BP
BNP
DDAVP: desmopressin
MISCELLANEOUS
SRx
PAR, SRx
PAR, SRx
PAR, SRx
PAR, SRx
SRx
SRx
PAR, SRx
PAR, SRx
SRx
PAR, SRx
PAR, SRx
PAR, SRx
SRx
SRx
SRx
octreotide
CYSTAGON
EGRIFTA
KORLYM
MYALEPT
ORFADIN
SANDOSTATIN LAR
SIGNIFOR
SOMATULINE
SOMAVERT
STRENSIQ
ACTHAR HP
PROCYSBI
RAVICTI
SAMSCA
SANDOSTATIN
GNP
BP
BP
BP
BP
BP
BP
BP
BP
BP
BP
BNP
BNP
BNP
BNP
BNP
GASTROINTESTINAL
Guidelines for the treatment and management of various gastrointestinal diseases/conditions are available at:
http://gi.org
http://www.gastro.org
ANTIDIARRHEALS
EPA
diphenoxylate/atropine
FULYZAQ
GNP
BNP
metoclopramide
ondansetron orally disintegrating tabs 4 mg
granisetron
ondansetron orally disintegrating tabs 8 mg
ondansetron tabs, soln
prochlorperazine
trimethobenzamide
GP
GP
GNP
GNP
GNP
GNP
GNP
ANTIEMETICS
QLL
QLL
QLL
QLL
53
QLL
EPA, QLL
QLL
QLL
QLL
EPA, QLL
QLL
QLL
EMEND
AKYNZEO
ANZEMET
CESAMET
SANCUSO
VARUBI
ZOFRAN
ZUPLENZ
BP
BNP
BNP
BNP
BNP
BNP
BNP
BNP
AKYNZEO: granisetron, ondansetron
ANZEMET: granisetron, ondansetron
CESAMET: granisetron, ondansetron
SANCUSO: granisetron, ondansetron
VARUBI: granisetron, ondansetron
ZOFRAN: ondansetron
ANTISPASMODICS
dicyclomine caps, tabs
dicyclomine soln
hyoscyamine sulfate
GP
GNP
GNP
ursodiol
URSO
URSO FORTE
GNP
BNP
BNP
CHOLELITHOLYTICS-M
URSO: ursodiol
URSO FORTE: ursodiol
H2 RECEPTOR ANTAGONISTS-M *
cimetidine 300 mg, 400 mg, 800 mg
famotidine 40 mg
ranitidine tabs 300 mg
nizatidine
ranitidine caps, syrup
GP
GP
GP
GNP
GNP
* If a prescription drug has an available OTC equivalent, the prescription drug will not be covered.
INFLAMMATORY BOWEL DISEASE
Oral Agents-M
balsalazide
budesonide delayed-rel caps
sulfasalazine
ASACOL HD
DELZICOL
LIALDA
PENTASA
APRISO
COLAZAL
GNP
GNP
GNP
BP
BP
BP
BP
BNP
BNP
54
DIPENTUM
BNP
APRISO: DELZICOL, PENTASA
COLAZAL: balsalazide
DIPENTUM: sulfasalazine, DELZICOL, PENTASA
Rectal Agents
CANASA
IRRITABLE BOWEL SYNDROME-M
Irritable Bowel Syndrome with Constipation-M
LINZESS
PAR
AMITIZA
BP
BP
BNP
AMITIZA: LINZESS
Irritable Bowel Syndrome with Diarrhea-M
PAR
VIBERZI
BNP
LAXATIVES
peg 3350/electrolytes
lactulose
GOLYTELY
KRISTALOSE
GP
GNP
BNP
BNP
GOLYTELY: peg 3350/electrolytes
KRISTALOSE: lactulose
OPIOID-INDUCED CONSTIPATION
MOVANTIK
PAR
RELISTOR
BP
BNP
RELISTOR: MOVANTIK
PANCREATIC ENZYMES-M
CREON
BP
misoprostol
GNP
PROTON PUMP INHIBITORS-M *
QLL
omeprazole delayed-rel caps 20 mg
QLL
esomeprazole delayed-rel
QLL
lansoprazole delayed-rel
QLL
omeprazole delayed-rel caps 10 mg, 40 mg
QLL
omeprazole/sodium bicarbonate
QLL
pantoprazole delayed-rel
QLL
rabeprazole delayed-rel
QLL
DEXILANT
GP
GNP
GNP
GNP
GNP
GNP
GNP
BP
PROSTAGLANDINS-M
55
PAR, QLL
PAR, QLL
PAR, QLL
PAR, QLL
PAR, QLL
PAR, QLL
PRILOSEC susp
ACIPHEX
NEXIUM
PREVACID
PRILOSEC
PROTONIX
ZEGERID
BP
BNP
BNP
BNP
BNP
BNP
BNP
* If a prescription drug has an available OTC equivalent, the prescription drug will not be covered.
ACIPHEX: rabeprazole
NEXIUM: esomeprazole
PREVACID: lansoprazole
PRILOSEC: omeprazole
PROTONIX: pantoprazole
ZEGERID: omeprazole/sodium bicarbonate
STEROIDS, RECTAL
hydrocortisone rectal crm
ULCER THERAPY COMBINATIONS
lansoprazole + amoxicillin + clarithromycin
PREVPAC
GNP
GNP
BNP
PREVPAC: lansoprazole + amoxicillin + clarithromycin
MISCELLANEOUS-M
PAR, SRx
SRx
PAR, SRx
cromolyn sodium oral concentrate
sucralfate
CHOLBAM
CARBAGLU
GATTEX
GNP
GNP
BP
BNP
BNP
GENITOURINARY
BENIGN PROSTATIC HYPERPLASIA-M
Guidelines for the management of BPH are available at:
http://www.auanet.org/guidelines
alfuzosin ext-rel
dutasteride
dutasteride/tamsulosin
finasteride
tamsulosin
AVODART
FLOMAX
JALYN
PROSCAR
RAPAFLO
GNP
GNP
GNP
GNP
GNP
BNP
BNP
BNP
BNP
BNP
56
UROXATRAL
BNP
AVODART: dutasteride
FLOMAX: tamsulosin
JALYN: dutasteride/tamsulosin
PROSCAR: finasteride
RAPAFLO: doxazosin, terazosin
UROXATRAL: alfuzosin ext-rel
ERECTILE DYSFUNCTION
Guidelines for the management of erectile dysfunction are available at:
http://www.auanet.org/guidelines
Alprostadil Agents
QLL
QLL
QLL
CAVERJECT
EDEX
MUSE
BNP
BNP
BNP
CAVERJECT: LEVITRA
EDEX: LEVITRA
MUSE: LEVITRA
Phosphodiesterase Inhibitors
QLL
PAR
QLL
QLL
QLL
LEVITRA
CIALIS 2.5 mg, 5 mg
CIALIS 10 mg, 20 mg
STAXYN
VIAGRA
BP
BNP
BNP
BNP
BNP
CIALIS: LEVITRA
STAXYN: LEVITRA
VIAGRA: LEVITRA
URINARY ANTISPASMODICS-M
oxybutynin syrup
darifenacin ext-rel
oxybutynin ext-rel
oxybutynin tabs
tolterodine
tolterodine ext-rel
trospium
trospium ext-rel
GELNIQUE
VESICARE
PAR
DETROL
PAR
DETROL LA
PAR
DITROPAN XL
PAR
ENABLEX
PAR
MYRBETRIQ
GP
GNP
GNP
GNP
GNP
GNP
GNP
GNP
BP
BP
BNP
BNP
BNP
BNP
BNP
57
PAR
TOVIAZ
BNP
DETROL: tolterodine
DETROL LA: tolterodine ext-rel
DITROPAN XL: oxybutynin ext-rel
ENABLEX: darifenacin ext-rel
MYRBETRIQ: darifenacin ext-rel, oxybutynin ext-rel, tolterodine, tolterodine ext-rel, trospium, trospium ext-rel
TOVIAZ: darifenacin ext-rel, oxybutynin ext-rel, tolterodine, tolterodine ext-rel, trospium, trospium ext-rel
MISCELLANEOUS
phenazopyridine
ELMIRON
GP
BP
HEMATOLOGIC
Guidelines of treatment and management of hemophilia are available at:
http://www.hemophilia.org
ANTICOAGULANTS
CHEST guidelines are available at:
http://www.chestnet.org/Guidelines-and-Resources/Guidelines-and-Consensus-Statements/Antithrombotic-Guidelines9th-Ed
Injectable
enoxaparin
FRAGMIN
LOVENOX
GNP
BP
BNP
warfarin
ELIQUIS
XARELTO
COUMADIN
PRADAXA
SAVAYSA
GP
BP
BP
BNP
BNP
BNP
Oral-M
COUMADIN: warfarin
PRADAXA: warfarin, ELIQUIS, XARELTO
SAVAYSA: warfarin, ELIQUIS, XARELTO
Synthetic Heparinoid-like Agents
fondaparinux
ARIXTRA
GNP
BNP
ARIXTRA: fondaparinux
ANTIHEMOPHILIC AGENTS
SRx
SRx
SRx
SRx
ADVATE
ALPHANATE
ALPHANINE SD
BEBULIN VH
BP
BP
BP
BP
58
SRx
SRx
SRx
SRx
SRx
SRx
SRx
SRx
SRx
SRx
SRx
SRx
SRx
SRx
SRx
SRx
SRx
SRx
SRx
BENEFIX
FEIBA NF
FEIBA VH
HELIXATE FS
HEMOFIL M
HUMATE-P
KOATE-DVI
KOGENATE FS
MONOCLATE-P
MONONINE
NOVOSEVEN RT
PROFILNINE SD
RECOMBINATE
WILATE
CORIFACT
IXINITY
NOVOEIGHT
NUWIQ
XYNTHA
BP
BP
BP
BP
BP
BP
BP
BP
BP
BP
BP
BP
BP
BP
BNP
BNP
BNP
BNP
BNP
HEMATOPOIETIC GROWTH FACTORS
Guidelines for the management of neutropenia are available at:
http://www.asco.org
Guidelines for the management of anemia associated with chronic kidney disease are available at:
http://www.kidney.org/professionals/kdoqi/guidelines_commentaries.cfm#guidelines
PAR, SRx
SRx
SRx
SRx
SRx
PAR, SRx
PAR, SRx
PAR, SRx
SRx
ARANESP
GRANIX
LEUKINE
NEULASTA
NEUPOGEN
PROCRIT
EPOGEN
MIRCERA
ZARXIO
BP
BP
BP
BP
BP
BP
BNP
BNP
BNP
EPOGEN: PROCRIT
MIRCERA: PROCRIT
HEMOSTATICS
tranexamic acid
LYSTEDA
GNP
BNP
LYSTEDA: tranexamic acid
HEREDITARY ANGIOEDEMA AGENTS
SRx
BERINERT
BP
59
SRx
FIRAZYR
BP
IDIOPATHIC THROMBOCYTOPENIC PURPURA AGENTS-M
SRx
PROMACTA
BP
IRON CHELATING AGENTS
PAR, SRx
PAR, SRx
BP
BNP
EXJADE
FERRIPROX
PLATELET AGGREGATION INHIBITORS-M
AL, OTC, PHC, QLL, *
aspirin 81 mg, 162 mg, 325 mg
aspirin chew tabs
aspirin delayed-rel 81 mg, 162 mg, 325 mg
clopidogrel
dipyridamole
dipyridamole ext-rel/aspirin
EFFIENT
AGGRENOX
PLAVIX
ZONTIVITY
GNP
GNP
GNP
GNP
GNP
GNP
BP
BNP
BNP
BNP
* Limited to one dose per day (≤325 mg) for men ages 45 to 79 and women ages 55 to 79.
AGGRENOX: dipyridamole ext-rel/aspirin
PLAVIX: clopidogrel
PLATELET SYNTHESIS INHIBITORS-M
anagrelide
GNP
STEM CELL MOBILIZERS
PAR, SRx
MOZOBIL
BP
cilostazol
pentoxifylline ext-rel
CYSTADANE
JADENU
GNP
GNP
BNP
BNP
MISCELLANEOUS-M
SRx
PAR, SRx
IMMUNOLOGIC AGENTS
Guidelines for the management of rheumatic diseases are available at:
http://www.rheumatology.org
BIOLOGIC DISEASE-MODIFYING AGENTS
PAR, QLL, SRx
ENBREL
PAR, QLL, SRx
HUMIRA
PAR, QLL, SRx
ACTEMRA 162 mg/0.9 mL
PAR, QLL, SRx
CIMZIA
PAR, QLL, SRx
KINERET
PAR, QLL, SRx
ORENCIA 125 mg/mL
BP
BP
BNP
BNP
BNP
BNP
60
PAR, QLL, SRx
SIMPONI
BNP
ACTEMRA 162 mg/0.9 mL: ENBREL, HUMIRA
CIMZIA: ENBREL, HUMIRA
ORENCIA 125 mg/mL: ENBREL, HUMIRA
KINERET: ENBREL, HUMIRA
SIMPONI: ENBREL, HUMIRA
DISEASE-MODIFYING ANTIRHEUMATIC DRUGS (DMARDs)-M
hydroxychloroquine
methotrexate oral
SRx
OTREXUP
PAR, SRx
XELJANZ
PAR, SRx
XELJANZ XR
GNP
GNP
BNP
BNP
BNP
XELJANZ: ENBREL, HUMIRA
XELJANZ XR: ENBREL, HUMIRA
IMMUNE GLOBULINS
SRx
SRx
HIZENTRA
HYQVIA
BNP
BNP
IMMUNOMODULATORS-M
CDC recommendations on the treatment of hepatitis are available at:
http://www.cdc.gov/hepatitis/Resources/
Guidelines for the management of hepatitis are available at:
Interferons-M
SRx
SRx
SRx
EPA, SRx
EPA, SRx
PAR, SRx
ACTIMMUNE
INTRON A
PEGASYS
PEGINTRON
PEGINTRON REDIPEN
SYLATRON
BP
BP
BP
BNP
BNP
BNP
PEGINTRON: PEGASYS
PEGINTRON REDIPEN: PEGASYS
Miscellaneous-M
SRx
PAR, SRx
ARCALYST
OTEZLA
BP
BNP
OTEZLA: ENBREL, HUMIRA
IMMUNOSUPPRESSANTS-M
Antimetabolites-M
azathioprine
mycophenolate mofetil
GNP
GNP
61
mycophenolate sodium delayed-rel
CELLCEPT
GNP
BNP
CELLCEPT: mycophenolate
Calcineurin Inhibitors-M
cyclosporine
cyclosporine, modified
tacrolimus
GNP
GNP
GNP
sirolimus
ZORTRESS
GNP
BP
Rapamycin Derivatives-M
NUTRITIONAL/SUPPLEMENTS
ELECTROLYTES
Potassium-M
potassium chloride effervescent tabs 25 mEq
potassium chloride oral liq 10%, 20%
Potassium-Removing Agents
PAR, SRx
VELTASSA
VITAMINS AND MINERALS
Folic Acid Agents-M
folic acid tabs 0.4 mg, 0.8 mg
folic acid tabs 1 mg
GP
GNP
BNP
GP
GP
* Limited to one dose per day (0.4 mg to 0.8 mg) for women through age 55.
Prenatal Vitamins
Prenatabs FA
Prenatal Plus
DUET DHA
PRENATE ELITE
GP
GP
BNP
BNP
DUET DHA: generics
PRENATE ELITE: generics
Miscellaneous
AL, OTC, PHC, *
AL, OTC, PHC, QLL, **
cyanocobalamin inj 1000 mcg/mL
ergocalciferol caps
cholecalciferol (vitamin D3) caps, tabs 400 IU
ferrous sulfate drops 15 mg/mL
ferrous sulfate elixir 220 mg/5 mL
Wee Care susp 15 mg/1.25 mL
MEPHYTON
FERROUS SULFATE syp 300 mg/5 mL
GP
GP
GNP
GNP
GNP
GNP
BP
BNP
62
MYKIDZ IRON susp 15 mg/1.5 mL
BNP
* Limited to 400 IU caps, tabs for members age 65 years and older.
** Limited to children through age one.
RESPIRATORY
Guidelines to the management, prevention, or treatment of COPD and asthma are available at:
http://www.aaaai.org
http://www.ginasthma.com
http://www.goldcopd.com
http://www.nhlbi.nih.gov
The Allergy Report and guidelines for allergy-related conditions are available at:
ANAPHYLAXIS TREATMENT AGENTS
epinephrine
EPIPEN
EPIPEN JR.
GNP
BP
BP
ANTICHOLINERGICS-M
ipratropium nasal spray
ipratropium soln
ATROVENT HFA
SPIRIVA
INCRUSE ELLIPTA
TUDORZA
GNP
GNP
BP
BP
BNP
BNP
ANTICHOLINERGIC/BETA AGONIST COMBINATIONS-M
Short Acting-M
ipratropium/albuterol
COMBIVENT RESPIMAT
GNP
BP
PAR
PAR
Long Acting-M
ANORO ELLIPTA
ANTIHISTAMINES, LOW SEDATING
levocetirizine
XYZAL
BP
GNP
BNP
XYZAL: OTC cetirizine*, OTC fexofenadine*, OTC loratadine*, levocetirizine
* OTC cetirizine, OTC fexofenadine and OTC loratadine are not covered under the prescription drug benefit.
ANTIHISTAMINES, NONSEDATING-M
desloratadine
CLARINEX
GNP
BNP
CLARINEX: OTC cetirizine*, OTC fexofenadine*, OTC loratadine*, desloratadine
* OTC cetirizine, OTC fexofenadine and OTC loratadine are not covered under the prescription drug benefit.
63
ANTIHISTAMINES, SEDATING
hydroxyzine HCl syrup
hydroxyzine pamoate caps 25 mg, 50 mg
hydroxyzine HCl tabs
hydroxyzine pamoate caps 100 mg
ANTIHISTAMINE/DECONGESTANT COMBINATIONS
promethazine/phenylephrine
CLARINEX-D
GP
GP
GNP
GNP
GNP
BNP
CLARINEX-D: OTC cetirizine*+decongestant*, OTC fexofenadine*+decongestant*, OTC loratadine*+decongestant*
* OTC cetirizine, OTC fexofenadine, OTC loratadine and OTC decongestants are not covered under the prescription
drug benefit.
ANTITUSSIVES
Clinical practice guidelines are available at:
http://journal.publications.chestnet.org/article.aspx?articleID=1084267
benzonatate caps 100 mg
benzonatate caps 200 mg
GP
GNP
codeine/guaifenesin liquid
codeine/promethazine
codeine/brompheniramine/pseudoephedrine
codeine/promethazine/phenylephrine
hydrocodone/chlorpheniramine ext-rel
TUSSIONEX
GP
GP
GNP
GNP
GNP
BNP
dextromethorphan/promethazine
GP
albuterol soln
levalbuterol
PROAIR HFA
VENTOLIN HFA
PROVENTIL HFA
XOPENEX
XOPENEX HFA
GNP
GNP
BP
BP
BNP
BNP
BNP
ANTITUSSIVE COMBINATIONS
Opioid
Non-opioid
BETA AGONISTS-M
Inhalants-M
Short Acting-M
PROVENTIL HFA: PROAIR HFA, VENTOLIN HFA
XOPENEX: levalbuterol
XOPENEX HFA: PROAIR HFA, VENTOLIN HFA
64
Long Acting-M
Hand-held Active Inhalation-M
SEREVENT
ARCAPTA NEOHALER
BP
BNP
albuterol sulfate syrup
albuterol tabs
GP
GNP
tobramycin inhalation soln
KALYDECO
ORKAMBI
PULMOZYME
BETHKIS
TOBI
GNP
BP
BP
BP
BNP
BNP
montelukast
zafirlukast
ACCOLATE
SINGULAIR
ZYFLO CR
GNP
GNP
BNP
BNP
BNP
Oral Agents-M
CYSTIC FIBROSIS
SRx
PAR, SRx
PAR, SRx
SRx
SRx
SRx
LEUKOTRIENE MODIFIERS-M
ACCOLATE: zafirlukast
SINGULAIR: montelukast
MAST CELL STABILIZERS-M
cromolyn soln
GNP
azelastine
olopatadine
ASTEPRO
PATANASE
GNP
GNP
BNP
BNP
NASAL ANTIHISTAMINES
ASTEPRO: azelastine
PATANASE: olopatadine
NASAL ANTIHISTAMINE/STEROID COMBINATIONS
EPA
DYMISTA
BNP
DYMISTA: azelastine
NASAL STEROIDS-M
PAR
PAR
flunisolide spray
mometasone spray
BECONASE AQ
NASONEX
GNP
GNP
BNP
BNP
65
PAR
PAR
PAR, QLL
PAR
OMNARIS
QNASL
VERAMYST
ZETONNA
BNP
BNP
BNP
BNP
BECONASE AQ: OTC FLONASE ALLERGY RELIEF*, OTC NASACORT ALLERGY 24HR*,
OTC RHINOCORT ALLERGY*, flunisolide, mometasone
NASONEX: OTC FLONASE ALLERGY RELIEF*, OTC NASACORT ALLERGY 24HR*,
OTC RHINOCORT ALLERGY*, mometasone
OMNARIS: OTC FLONASE ALLERGY RELIEF*, OTC NASACORT ALLERGY 24HR*, OTC RHINOCORT ALLERGY*,
flunisolide, mometasone
QNASL: OTC FLONASE ALLERGY RELIEF*, OTC NASACORT ALLERGY 24HR*, OTC RHINOCORT ALLERGY*,
VERAMYST: OTC FLONASE ALLERGY RELIEF*, OTC NASACORT ALLERGY 24HR*,
OTC RHINOCORT ALLERGY*, flunisolide, mometasone
ZETONNA: OTC FLONASE ALLERGY RELIEF*, OTC NASACORT ALLERGY 24HR*, OTC RHINOCORT ALLERGY*,
* OTC FLONASE ALLERGY RELIEF, OTC NASACORT ALLERGY 24HR and OTC RHINOCORT ALLERGY are not
covered under the prescription drug benefit.
PHOSPHODIESTERASE-4 INHIBITORS
DALIRESP
BNP
PULMONARY FIBROSIS AGENTS
PAR, SRx
ESBRIET
PAR, SRx
OFEV
BP
BP
STEROID/BETA AGONIST COMBINATIONS-M
QLL
ADVAIR DISKUS
QLL
ADVAIR HFA
QLL
BREO ELLIPTA
QLL
DULERA
PAR, QLL
SYMBICORT
BP
BP
BP
BP
BNP
STEROID INHALANTS-M
QLL
QLL
QLL
QLL
QLL
QLL
QLL
budesonide inhalation susp
ASMANEX
FLOVENT
ALVESCO
ARNUITY ELLIPTA
PULMICORT FLEXHALER
PULMICORT RESPULES
QVAR
GNP
BP
BP
BNP
BNP
BNP
BNP
BNP
ALVESCO: ASMANEX, FLOVENT
ARNUITY ELLIPTA: ASMANEX, FLOVENT
PULMICORT FLEXHALER: ASMANEX, FLOVENT
PULMICORT RESPULES: budesonide inhalation susp
QVAR: ASMANEX, FLOVENT
66
XANTHINES-M
theophylline ext-rel 12hr tabs 100 mg
theophylline
GP
GNP
TOPICAL
DERMATOLOGY
Acne
Guidelines for the care and treatment of acne vulgaris are available at:
http://www.aad.org/education-and-quality-care/clinical-guidelines
Topical
adapalene
Avita
clindamycin
clindamycin/benzoyl peroxide
erythromycin
erythromycin/benzoyl peroxide
sulfacetamide sodium
tretinoin
tretinoin gel microsphere
TAZORAC
ACANYA
ACZONE
ATRALIN
AZELEX
BENZACLIN
DIFFERIN
DUAC
EPIDUO
KLARON
RETIN-A MICRO
TRETIN-X
PAR*
PAR*
PAR*
PAR*
EPA
PAR*
PAR*
PAR*
GNP
GNP
GNP
GNP
GNP
GNP
GNP
GNP
GNP
BP
BNP
BNP
BNP
BNP
BNP
BNP
BNP
BNP
BNP
BNP
BNP
*PAR required for members age 25 and older.
ACANYA: clindamycin/benzoyl peroxide
ACZONE: clindamycin, erythromycin
ATRALIN: tretinoin
AZELEX: tretinoin
BENZACLIN: clindamycin/benzoyl peroxide
DIFFERIN: adapalene
DUAC: clindamycin/benzoyl peroxide
EPIDUO: adapalene
KLARON: sulfacetamide sodium
RETIN-A MICRO: tretinoin, tretinoin gel microsphere
TRETIN-X: tretinoin
Actinic Keratosis
fluorouracil crm, soln
GNP
67
CARAC
BNP
CARAC: fluorouracil crm
Antibiotics
mupirocin oint
gentamicin crm
gentamicin oint
mupirocin crm
silver sulfadiazine
ALTABAX
BACTROBAN
CENTANY
GP
GNP
GNP
GNP
GNP
BNP
BNP
BNP
ALTABAX: mupirocin
BACTROBAN: mupirocin
CENTANY: mupirocin
Antifungals
ciclopirox
econazole
ketoconazole
naftifine
nystatin
oxiconazole
ERTACZO
EXELDERM
LOPROX
LUZU
MENTAX
NAFTIN
OXISTAT
PENLAC
GNP
GNP
GNP
GNP
GNP
GNP
BNP
BNP
BNP
BNP
BNP
BNP
BNP
BNP
EXELDERM: ketoconazole, econazole, oxiconazole
ERTACZO: ketoconazole, econazole, oxiconazole
LOPROX: ciclopirox
LUZU: ketoconazole, econazole, oxiconazole
MENTAX: ketoconazole, econazole, oxiconazole
NAFTIN: naftifine
OXISTAT: oxiconazole
PENLAC: ciclopirox
Antifungal/Corticosteroid Combinations
clotrimazole/betamethasone
nystatin/triamcinolone
GNP
GNP
68
Antipsoriatics
Guidelines of care for the management and treatment of psoriasis with topical therapies are available at:
http://www.aad.org
Injectable
PAR, SRx
PAR, QLL, SRx
COSENTYX
STELARA
BNP
BNP
COSENTYX: ENBREL, HUMIRA
STELARA: ENBREL, HUMIRA
Oral
acitretin
methoxsalen oral
GNP
GNP
calcipotriene
calcipotriene/betamethasone diproprionate oint
calcitriol oint
DOVONEX
TACLONEX
VECTICAL
GNP
GNP
GNP
BNP
BNP
BNP
Topical
DOVONEX: calcipotriene
TACLONEX: calcipotriene/betamethasone dipropionate oint
VECTICAL: calcitriol oint
Antiseborrheics
selenium sulfide lotion, shampoo 2.5%
GP
hydrocortisone crm, oint 2.5%
alclometasone crm, oint 0.05%
desonide crm, lotion, oint 0.05%
fluocinolone acetonide oil 0.01%
PRAMOSONE
GP
GNP
GNP
GNP
BP
triamcinolone acetonide crm, oint 0.1%, 0.025%
clocortolone crm 0.1%
desoximetasone crm, oint 0.05%
fluticasone propionate crm, lotion 0.05%, oint 0.005%
hydrocortisone butyrate crm, oint, soln 0.1%
hydrocortisone valerate crm, oint 0.2%
mometasone crm, lotion, oint 0.1%
triamcinolone acetonide crm, oint 0.5%
triamcinolone acetonide lotion
GP
GNP
GNP
GNP
GNP
GNP
GNP
GNP
GNP
Corticosteroids
Low Potency
Medium Potency
69
LOCOID
BNP
LOCOID: hydrocortisone butyrate
High Potency
betamethasone dipropionate augmented crm, lotion 0.05%
betamethasone dipropionate crm, lotion, oint 0.05%
desoximetasone crm, oint 0.25%, gel 0.05%
diflorasone diacetate crm 0.05%
fluocinonide crm, gel, oint, soln 0.05%
triamcinolone acetonide crm 0.5%
GNP
GNP
GNP
GNP
GNP
GNP
betamethasone dipropionate augmented gel, oint 0.05%
clobetasol propionate crm, foam, gel, lotion, oint, shampoo,
soln, spray 0.05%
diflorasone diacetate oint 0.05%
GNP
GNP
Very High Potency
GNP
Immunomodulators
Guidelines for the treatment of atopic dermatitis are available at:
http://www.aad.org/education/clinical-guidelines
tacrolimus
ELIDEL
PROTOPIC
GNP
BP
BNP
PROTOPIC: tacrolimus
Local Analgesics
lidocaine patch
LIDODERM
GNP
BNP
LIDODERM: lidocaine patch
Local Anesthetics
lidocaine gel, soln
lidocaine crm, lotion
lidocaine/prilocaine
SYNERA
GP
GNP
GNP
BNP
EMLA: lidocaine/prilocaine
SYNERA: lidocaine/prilocaine
Rosacea
doxycycline monohydrate
metronidazole crm, gel, lotion
FINACEA
SOOLANTRA
GNP
GNP
BP
BP
70
PAR
PAR
PAR
METROCREAM
METROGEL
NORITATE
ORACEA
BNP
BNP
BNP
BNP
METROCREAM: metronidazole crm, gel, lotion
METROGEL: metronidazole crm, gel, lotion
NORITATE: metronidazole crm, gel, lotion
ORACEA: doxycycline monohydrate
Scabicides and Pediculicides
malathion
permethrin
spinosad
NATROBA
Miscellaneous Skin and Mucous Membrane
aluminum chloride soln 20%
acyclovir oint
imiquimod
podofilox
CONDYLOX gel
ALDARA
CONDYLOX soln
PRUMYX
SALKERA
ZOVIRAX crm
ZOVIRAX oint
GNP
GNP
GNP
BNP
GP
GNP
GNP
GNP
BP
BNP
BNP
BNP
BNP
BNP
BNP
ALDARA: imiquimod
CONDYLOX soln: podofilox
SALKERA: salicylic acid
ZOVIRAX oint: acyclovir oint
MOUTH/THROAT/DENTAL AGENTS
Anesthetics - Topical Oral
lidocaine viscous
GP
Miscellaneous
AL, PHC, QLL, *
AL, PHC, QLL, *
AL, PHC, QLL, *
AL, PHC, QLL, *
AL, PHC, QLL, *
chlorhexidine gluconate
sodium fluoride 1 mg (2.2 mg) tabs
sodium fluoride chew tabs
sodium fluoride paste 1.1%
sodium fluoride/potassium nitrate paste 1.1-5%
sodium fluoride 0.5 mg (1.1 mg) tabs
sodium fluoride soln 0.125 mg/drop F
(from 0.275 mg/drop NaF)
sodium fluoride soln 0.25 mg/drop F (from 0.55 mg/drop NaF),
0.5 mg/mL F (from 1.1 mg/mL NaF)
GP
GP
GP
GP
GP
GNP
GNP
GNP
71
PREVIDENT
BNP
* Limited to children through age 18. Over-the-counter products are excluded even with a prescription.
PREVIDENT: sodium fluoride
OPHTHALMIC
Preferred Practice Pattern Guidelines for the treatment of various ophthalmic conditions are available at:
http://one.aao.org
Antiallergics
cromolyn sodium
azelastine
epinastine
olopatadine
EMADINE
ALOCRIL
ALOMIDE
ELESTAT
LASTACAFT
PATANOL
GP
GNP
GNP
GNP
BP
BNP
BNP
BNP
BNP
BNP
ALOCRIL: cromolyn
ALOMIDE: cromolyn
ELESTAT: OTC ZADITOR*, epinastine
PATANOL: OTC ZADITOR*, olopatadine
* OTC ZADITOR is not covered under the prescription drug benefit.
Anti-infectives
ciprofloxacin
erythromycin
gentamicin soln
ofloxacin
polymyxin B/trimethoprim
tobramycin
gentamicin oint
levofloxacin
sulfacetamide oint 10%
sulfacetamide soln 10%
BESIVANCE
CILOXAN
VIGAMOX
GP
GP
GP
GP
GP
GP
GNP
GNP
GNP
GNP
BNP
BNP
BNP
BESIVANCE: ciprofloxacin, ofloxacin
CILOXAN: ciprofloxacin
VIGAMOX: ciprofloxacin, ofloxacin
72
Anti-infective/Anti-inflammatory Combinations
neomycin/polymyxin B/dexamethasone
tobramycin/dexamethasone susp 0.3%/0.1%
TOBRADEX oint
TOBRADEX susp
ZYLET
GNP
GNP
BP
BNP
BNP
TOBRADEX susp: tobramycin/dexamethasone susp
Anti-inflammatories
Nonsteroidal
bromfenac sodium
diclofenac sodium
fluorometholone 0.1% susp
ketorolac
ACULAR
ACULAR LS
ACUVAIL
GNP
GNP
GNP
GNP
BNP
BNP
BNP
ACUVAIL: ketorolac
Steroidal
prednisolone acetate
ALREX
LOTEMAX
FML FORTE
VEXOL
GNP
BP
BP
BNP
BNP
FML FORTE: ALREX, LOTEMAX
VEXOL: ALREX, LOTEMAX
Beta-blockers-M
Nonselective-M
timolol maleate soln
levobunolol soln
timolol maleate gel
BETIMOL
GP
GNP
GNP
BNP
BETIMOL: timolol
Carbonic Anhydrase Inhibitors-M
Topical-M
dorzolamide
AZOPT
TRUSOPT
GNP
BP
BNP
TRUSOPT: dorzolamide
73
Carbonic Anhydrase Inhibitor/Beta-blocker Combinations-M
dorzolamide/timolol
COSOPT
GNP
BNP
COSOPT: dorzolamide/timolol
Immunomodulators-M
RESTASIS
BNP
pilocarpine
GNP
bimatoprost
latanoprost
travoprost
LUMIGAN
TRAVATAN Z
XALATAN
ZIOPTAN
GNP
GNP
GNP
BP
BP
BNP
BNP
Parasympathomimetics-M
Prostaglandins-M
XALATAN: latanoprost
ZIOPTAN: bimatoprost, latanoprost, travoprost, LUMIGAN, TRAVATAN Z
Sympathomimetics-M
brimonidine 0.2%
brimonidine 0.15%
ALPHAGAN P
GP
GNP
BP
OTIC
Clinical practice guidelines for the treatment of otitis media are available at:
http://www.aap.org
Anti-infectives
ofloxacin otic
Anti-infective/Anti-inflammatory Combinations
acetic acid/hydrocortisone
CIPRODEX
CIPRO HC OTIC
GNP
GNP
BP
BNP
CIPRO HC OTIC: CIPRODEX
Miscellaneous
fluocinolone acetonide oil
GNP
74
WEBSITES
Agency for Healthcare Research and Quality
http://www.ahrq.gov
Alzheimer's Association
http://www.alz.org
American Academy of Allergy, Asthma and
Immunology
American Academy of Child & Adolescent Psychiatry
http://www.aacap.org
American Academy of Dermatology
http://www.aad.org
American Academy of Neurology
http://www.aan.com
American Academy of Ophthalmology
http://www.aao.org
American Academy of Pediatrics
http://www.aap.org
American Association for the Study of Liver Disease
American Association of Clinical Endocrinologists
http://www.aace.com
American Association of Diabetes Educators
http://www.diabeteseducator.org
American Cancer Society
http://www.cancer.org
American College of Allergy, Asthma and Immunology
http://www.acaai.org
American College of Cardiology
http://www.acc.org
American College of Chest Physicians
http://www.chestnet.org
American Congress of Obstetricians and
Gynecologists
http://www.acog.org
American Diabetes Association
http://www.diabetes.org
American Gastroenterological Association
http://www.gastro.org
American Headache Society Committee for Headache
Education
http://www.achenet.org
American Heart Association
American Lung Association
http://www.lung.org
American Medical Association
http://www.ama-assn.org
American Psychiatric Association
American Society of Anesthesiologists
American Society of Clinical Oncology
http://www.asco.org
American Society of Interventional Pain Physicians
http://www.asipp.org
American Urological Association
http://www.auanet.org
Centers for Disease Control and Prevention
http://www.cdc.gov
Guideline topics: AIDS
http://www.cdc.gov/hiv/default.html
American College of Gastroenterology
http://gi.org
Guideline topics: Sexually Transmitted Diseases
http://www.cdc.gov/std/treatment/default.htm
American College of Physicians
http://www.acponline.org
CVS Caremark
http://www.caremark.com
American College of Rheumatology
http://www.rheumatology.org
The Food and Drug Administration
http://www.fda.gov
75
Global Initiative for Asthma
http://www.ginasthma.com
National Foundation for Infectious Diseases
http://www.nfid.org
Infectious Diseases Society of America
http://www.idsociety.org
National Guideline Clearinghouse
http://www.guideline.gov
Institute for Safe Medication Practices
http://www.ismp.org
National Heart, Lung and Blood Institute
http://www.nhlbi.nih.gov
Johns Hopkins AIDS Service
http://www.thebody.com/content/art12096.html
National Institutes of Health
http://www.nih.gov
Juvenile Diabetes Research Foundation International
http://jdrf.org
National Kidney Foundation
http://www.kidney.org
MedWatch
http://www.fda.gov/Safety/MedWatch/default.htm
National Osteoporosis Foundation
http://www.nof.org
National Agricultural Library
http://www.nal.usda.gov
North American Menopause Society
http://www.menopause.org
National Cancer Institute
http://www.cancer.gov/cancertopics
United States Department of Health and Human
Services
http://www.hhs.gov
National Comprehensive Cancer Network
http://www.nccn.org
World Health Organization
http://www.who.int
76
INDEX
A
abacavir tabs, 18
abacavir/lamivudine/zidovudine, 17
ABILIFY, 35
ABSTRAL, 13
ACANYA, 67
acarbose, 41
ACCOLATE, 65
ACCU-CHEK, 45
ACCUPRIL, 22
ACEON, 22
acetic acid/hydrocortisone, 74
ACIPHEX, 56
acitretin, 69
ACTEMRA 162 mg/0.9 mL, 60
ACTHAR HP, 53
ACTIMMUNE, 61
ACTIQ, 13
ACTIVELLA, 50
ACTONEL, 46
ACTOPLUS MET, 43
ACTOPLUS MET XR, 43
ACTOS, 43
ACULAR, 73
ACULAR LS, 73
ACUVAIL, 73
acyclovir caps 200 mg, 19
acyclovir oint, 71
acyclovir tabs 400 mg, 800 mg, 19
ACZONE, 67
adapalene, 67
ADCIRCA, 29
ADDERALL, 36
ADDERALL XR, 37
ADEMPAS, 30
ADOXA, 16
ADVAIR DISKUS, 66
ADVAIR HFA, 66
ADVATE, 58
AFINITOR, 21
AFREZZA, 43
AGGRENOX, 60
AKYNZEO, 54
albuterol soln, 64
albuterol sulfate syrup, 65
albuterol tabs, 65
alclometasone crm, oint 0.05%, 69
ALDARA, 71
ALECENSA, 21
alendronate soln, 46
alendronate tabs 40 mg, 46
alendronate tabs 5 mg, 35 mg, 70 mg, 45
alfuzosin ext-rel, 56
allopurinol, 12
almotriptan, 38
ALOCRIL, 72
alogliptin, 42
alogliptin/metformin, 42
alogliptin/pioglitazone, 42
ALOMIDE, 72
ALORA, 49
ALPHAGAN P, 74
ALPHANATE, 58
ALPHANINE SD, 58
alprazolam, 30
alprazolam ext-rel, 30
alprazolam orally disintegrating tabs, 30
ALREX, 73
ALTABAX, 68
ALTACE, 22
ALTOPREV, 26
aluminum chloride soln 20%, 71
ALVESCO, 66
amantadine, 35
AMARYL, 44
AMBIEN, 38
AMBIEN CR, 38
AMERGE, 38
Amethia, 48
Amethia Lo, 48
amiloride, 29
amiloride/hydrochlorothiazide, 29
amiodarone tabs 100 mg, 400 mg, 25
amiodarone tabs 200 mg, 25
AMITIZA, 55
amitriptyline 10 mg, 25 mg, 50 mg, 75 mg, 150 mg, 34
amitriptyline 100 mg, 34
amlodipine, 27
amlodipine/atorvastatin, 28
amlodipine/benazepril, 23
amlodipine/valsartan, 24
amlodipine/valsartan/hydrochlorothiazide, 25
amoxicillin caps, susp, tabs, 16
amoxicillin chewable tabs, 16
amoxicillin ext-rel, 16
amoxicillin/clavulanate, 16
amoxicillin/clavulanate ext-rel, 16
amphetamine/dextroamphetamine mixed salts, 36
amphetamine/dextroamphetamine mixed salts ext-rel, 36
ampicillin caps 250 mg, 16
ampicillin caps 500 mg, 16
ampicillin susp, 16
AMPYRA, 39
AMRIX, 40
anagrelide, 60
anastrozole, 20
ANDRODERM, 41
ANDROGEL 1% (25 mg), 41
ANDROGEL 1% (50 mg), 1.62%, 41
ANDROGEL PUMP 1%, 41
ANORO ELLIPTA, 63
ANTARA, 25
ANZEMET, 54
APIDRA, 43
APLENZIN, 34
APOKYN, 35
Apri, 47
APRISO, 54
APTIOM, 31
APTIVUS, 18
Aranelle, 47
ARANESP, 59
ARCALYST, 61
ARCAPTA NEOHALER, 65
ARICEPT, 32
77
ARIMIDEX, 20
aripiprazole, 35
ARIXTRA, 58
armodafinil, 40
ARNUITY ELLIPTA, 66
ASACOL HD, 54
ASCENSIA, 45
ASMANEX, 66
aspirin 81 mg, 162 mg, 325 mg, 60
aspirin chew tabs, 60
aspirin delayed-rel 81 mg, 162 mg, 325 mg, 60
ASTEPRO, 65
ATACAND, 24
ATACAND HCT, 24
ATELVIA, 46
atenolol, 27
atenolol/chlorthalidone, 27
atorvastatin, 26
atovaquone/proguanil, 17
ATRALIN, 67
ATRIPLA, 17
ATROVENT HFA, 63
AUBAGIO, 39
AVALIDE, 24
AVAPRO, 24
AVELOX, 15
AVELOX ABC PACK, 15
Aviane, 46
AVIDOXY, 16
Avita, 67
AVODART, 56
AVONEX, 39
AXERT, 38
AXIRON, 41
azathioprine, 61
azelastine, 65, 72
AZELEX, 67
azithromycin susp, 15
azithromycin tabs 250 mg, 15
azithromycin tabs 500 mg, 600 mg, 15
AZOPT, 73
AZOR, 24
B
baclofen tabs, 39
BACTROBAN, 68
balsalazide, 54
BANZEL, 31
BARACLUDE, 18
BEBULIN VH, 58
BECONASE AQ, 65
BELSOMRA, 38
BELVIQ, 45
benazepril, 22
benazepril/hydrochlorothiazide, 23
BENEFIX, 59
BENICAR, 24
BENICAR HCT, 24
BENZACLIN, 67
benzonatate caps 100 mg, 64
benzonatate caps 200 mg, 64
benztropine, 35
BERINERT, 59
BESIVANCE, 72
betamethasone dipropionate
augmented crm, lotion 0.05%, 70
betamethasone dipropionate augmented gel, oint 0.05%, 70
betamethasone dipropionate crm, lotion, oint 0.05%, 70
BETASERON, 39
BETHKIS, 65
BETIMOL, 73
bexarotene, 22
BIAXIN, 15
bicalutamide, 20
BIDIL, 29
bimatoprost, 74
bisoprolol, 27
bisoprolol/hydrochlorothiazide, 27
BONIVA tabs, 46
BOSULIF, 21
BRAVELLE, 50
BREEZE, 45
BREO ELLIPTA, 66
brimonidine 0.15%, 74
brimonidine 0.2%, 74
BRINTELLIX, 33
bromfenac sodium, 73
bromocriptine, 35
budesonide delayed-rel caps, 54
budesonide inhalation susp, 66
bumetanide, 28
buprenorphine/naloxone sublingual tabs, 40
bupropion, 34
bupropion ext-rel, 34, 40
buspirone tabs 5 mg, 10 mg, 15 mg, 30
buspirone tabs 7.5 mg, 30 mg, 30
butalbital/acetaminophen/caffeine caps, tabs, 14
butalbital/aspirin/caffeine caps, tabs, 14
butorphanol nasal spray, 12
BUTRANS, 13
BYDUREON, 42
BYETTA, 42
BYSTOLIC, 27
C
CADUET, 28
calcipotriene, 69
calcipotriene/betamethasone diproprionate oint, 69
calcitonin-salmon, 46
calcitriol, 51
calcitriol oint, 69
calcium acetate, 52
Camila, 48
Camrese, 48
Camrese Lo, 48
CANASA, 55
candesartan, 24
candesartan/hydrochlorothiazide, 24
capecitabine, 20
CAPRELSA, 21
captopril, 22
captopril/hydrochlorothiazide, 23
CARAC, 68
CARBAGLU, 56
carbamazepine chews, tabs, 30
carbamazepine ext-rel, 31
carbamazepine susp, 31
CARBATROL, 31
carbidopa/levodopa, 35
carbidopa/levodopa orally disintegrating tabs, 35
carbidopa/levodopa/entacapone, 35
CARDIZEM, 28
CARDIZEM CD, 28
CARDIZEM LA, 28
carisoprodol tabs 250 mg, 39
carisoprodol tabs 350 mg, 39
carvedilol, 27
CASODEX, 20
CATAPRES-TTS, 23
CAVERJECT, 57
CEDAX, 15
cefaclor, 14
cefadroxil, 14
cefdinir, 15
cefditoren, 15
cefixime susp 100 mg/5 mL, 200 mg/5 mL, 15
cefpodoxime, 15
cefprozil, 14
ceftibuten, 15
CEFTIN, 14
cefuroxime axetil tabs, 14
CELEBREX, 12
celecoxib, 12
CELEXA, 33
CELLCEPT, 62
CENTANY, 68
cephalexin caps 250 mg, 500 mg, 14
cephalexin susp, 14
cephalexin tabs 250 mg, 14
CESAMET, 54
CETROTIDE, 50
CHANTIX, 40
chlorhexidine gluconate, 71
chlorthalidone, 29
chlorzoxazone, 40
CHOLBAM, 56
cholecalciferol (vitamin D3) caps, tabs 400 IU, 62
cholestyramine, 25
chorionic gonadotropin - Novarel, 50
chorionic gonadotropin - Pregnyl, 50
CIALIS 10 mg, 20 mg, 57
CIALIS 2.5 mg, 5 mg, 57
ciclopirox, 68
cilostazol, 60
CILOXAN, 72
cimetidine 300 mg, 400 mg, 800 mg, 54
CIMZIA, 60
CIPRO HC OTIC, 74
CIPRODEX, 74
ciprofloxacin, 15, 72
ciprofloxacin ext-rel, 15
citalopram soln, 33
citalopram tabs, 33
CLARINEX, 63
CLARINEX-D, 64
clarithromycin, 15
clarithromycin ext-rel, 15
CLIMARA, 49
CLIMARA PRO, 50
clindamycin, 67
clindamycin caps 150 mg, 300 mg, 19
clindamycin/benzoyl peroxide, 67
clobetasol propionate crm, foam, gel, lotion, oint,
shampoo, soln, spray 0.05%, 70
clocortolone crm 0.1%, 69
clomiphene, 50
clonazepam orally disintegrating tabs, 30
clonazepam tabs, 30
clonidine, 23
clonidine ext-rel, 36
clonidine transdermal, 23
clopidogrel, 60
clotrimazole troches, 16
clotrimazole/betamethasone, 68
clozapine, 35
COARTEM, 17
codeine sulfate tabs 15 mg, 12
codeine/acetaminophen soln, 12
codeine/acetaminophen tabs 300/15 mg, 300/30 mg, 12
codeine/acetaminophen tabs 300/60 mg, 12
codeine/brompheniramine/pseudoephedrine, 64
codeine/guaifenesin liquid, 64
codeine/promethazine, 64
codeine/promethazine/phenylephrine, 64
COLAZAL, 54
colchicine, 12
COLCRYS, 12
colestipol, 25
COMBIPATCH, 50
COMBIVENT RESPIMAT, 63
COMETRIQ, 21
COMPLERA, 17
COMTAN, 35
CONCERTA, 37
CONDYLOX gel, 71
CONDYLOX soln, 71
CONTOUR, 45
CONTRAVE, 45
COPAXONE 20 mg, 39
COPAXONE 40 mg, 39
COPEGUS, 19
COREG, 27
COREG CR, 27
CORIFACT, 59
CORLANOR, 30
COSENTYX, 69
COSOPT, 74
COTELLIC, 21
COUMADIN, 58
COZAAR, 24
CREON, 55
CRESEMBA, 16
CRESTOR, 26
CRIXIVAN, 18
cromolyn sodium, 72
cromolyn sodium oral concentrate, 56
cromolyn soln, 65
Cryselle, 47
cyanocobalamin inj 1000 mcg/mL, 62
CYCLESSA, 48
cyclobenzaprine tabs 5 mg, 10 mg, 39
cyclobenzaprine tabs 7.5 mg, 40
cyclosporine, 62
cyclosporine, modified, 62
CYMBALTA, 33
CYSTADANE, 60
CYSTAGON, 53
CYTOMEL, 53
D
DALIRESP, 66
darifenacin ext-rel, 57
DAYTRANA, 37
DDAVP, 53
DELZICOL, 54
DEMADEX, 28
DENAVIR, 19
DEPAKOTE, 31
DEPAKOTE ER, 31
DEPO-PROVERA, 49
desipramine, 34
desloratadine, 63
desmopressin, 53
DESOGEN, 47
desonide crm, lotion, oint 0.05%, 69
desoximetasone crm, oint 0.05%, 69
desoximetasone crm, oint 0.25%, gel 0.05%, 70
DESVENLAFAXINE ER, 33
DETROL, 57
DETROL LA, 57
dexamethasone tabs
0.5 mg, 0.75 mg, 1 mg, 1.5 mg, 4 mg, 6 mg, 51
dexamethasone tabs 2 mg, 51
DEXILANT, 55
dexmethylphenidate, 36
dexmethylphenidate ext-rel, 36
dextroamphetamine, 36
dextromethorphan/promethazine, 64
diazepam, 30
diazepam rectal gel, 31
diclofenac potassium, 11
diclofenac sodium, 73
diclofenac sodium delayed-rel, 11
diclofenac sodium soln, 11
dicyclomine caps, tabs, 54
dicyclomine soln, 54
didanosine delayed-rel, 18
DIFFERIN, 67
DIFICID, 15
diflorasone diacetate crm 0.05%, 70
diflorasone diacetate oint 0.05%, 70
DIFLUCAN, 17
diflunisal, 11
digoxin, 28
DILANTIN, 31
DILANTIN INFATABS, 31
diltiazem 30 mg, 60 mg, 120 mg, 28
diltiazem 90 mg, 28
diltiazem ext-rel, 28
DIOVAN, 24
DIOVAN HCT, 24
DIPENTUM, 55
diphenoxylate/atropine, 53
dipyridamole, 60
dipyridamole ext-rel/aspirin, 60
DITROPAN XL, 57
divalproex sodium delayed-rel tabs 125 mg, 31
divalproex sodium delayed-rel tabs 250 mg, 500 mg, 31
divalproex sodium ext-rel, 31
donepezil, 32
donepezil orally disintegrating tabs, 32
DORYX, 16
dorzolamide, 73
dorzolamide/timolol, 74
DOVONEX, 69
doxazosin, 24
doxepin caps 10 mg, 34
doxepin caps 25 mg, 50 mg, 75 mg, 100 mg, 150 mg, 34
doxepin oral concentrate, 34
doxercalciferol, 51
doxycycline hyclate caps 50 mg, 100 mg, 16
doxycycline hyclate tabs 20 mg, 100 mg, 16
doxycycline monohydrate, 16, 70
DUAC, 67
DUAVEE, 50
DUET DHA, 62
DUETACT, 44
DUEXIS, 11
DULERA, 66
duloxetine delayed-rel, 33
DURAGESIC, 13
dutasteride, 56
dutasteride/tamsulosin, 56
DUTOPROL, 27
DYANAVEL XR, 37
DYMISTA, 65
E
econazole, 68
EDARBI, 24
EDEX, 57
EDLUAR, 38
EDURANT, 17
EFFEXOR XR, 34
EFFIENT, 60
EGRIFTA, 53
ELESTAT, 72
ELIDEL, 70
ELIGARD, 21
ELIQUIS, 58
ELLA, 48
ELMIRON, 58
EMADINE, 72
EMEND, 54
EMSAM, 34
EMTRIVA, 18
ENABLEX, 57
enalapril, 22
enalapril/hydrochlorothiazide, 23
ENBREL, 60
enoxaparin, 58
Enpresse, 47
entacapone, 35
entecavir, 18
ENTRESTO, 29
EPIDUO, 67
epinastine, 72
epinephrine, 63
EPIPEN, 63
EPIPEN JR., 63
EPIVIR-HBV, 18
eplerenone, 23
EPOGEN, 59
eprosartan, 24
EPZICOM, 17
ergocalciferol caps, 62
ERIVEDGE, 22
Errin, 48
ERTACZO, 68
erythromycin, 15, 67, 72
erythromycin ethylsuccinate, 15
erythromycin/benzoyl peroxide, 67
ESBRIET, 66
escitalopram, 33
esomeprazole delayed-rel, 55
estradiol, 49
estradiol/norethindrone, 50
ESTRING, 50
ESTROGEL, 49
estropipate 0.75 mg, 3 mg, 49
estropipate 1.5 mg, 49
ESTROSTEP FE, 48
eszopiclone, 38
ethambutol, 18
etodolac, 11
EVISTA, 52
EVOTAZ, 17
EVZIO, 40
EXELDERM, 68
EXELON, 32
EXFORGE, 25
EXFORGE HCT, 25
EXJADE, 60
EXTAVIA, 39
F
FACTIVE, 15
famciclovir, 19
famotidine 40 mg, 54
FAMVIR, 19
FANAPT, 35
FARXIGA, 44
FARYDAK, 22
FAST TAKE, 45
FEIBA NF, 59
FEIBA VH, 59
felodipine ext-rel, 27
FEMARA, 20
FEMHRT 0.5 mg/2.5 mcg, 50
fenofibrate, 25
fenofibric acid delayed-rel, 25
fentanyl patches, 12
fentanyl transmucosal lozenges, 12
FENTORA, 13
FERRIPROX, 60
ferrous sulfate drops 15 mg/mL, 62
ferrous sulfate elixir 220 mg/5 mL, 62
FERROUS SULFATE syp 300 mg/5 mL, 62
FETZIMA, 34
FINACEA, 70
finasteride, 56
FIRAZYR, 60
FIRMAGON, 20
flecainide, 25
FLECTOR, 11
FLOMAX, 56
FLOVENT, 66
fluconazole susp, 16
fluconazole tabs 100 mg, 200 mg, 16
fluconazole tabs 50 mg, 150 mg, 16
fludrocortisone, 51
flunisolide spray, 65
fluocinolone acetonide oil, 74
fluocinolone acetonide oil 0.01%, 69
fluocinonide crm, gel, oint, soln 0.05%, 70
fluorometholone 0.1% susp, 73
fluorouracil crm, soln, 67
fluoxetine caps 10 mg, 20 mg, 33
fluoxetine caps 40 mg, 33
fluoxetine delayed-rel, 33
fluoxetine soln, 33
fluoxetine tabs 10 mg, 33
fluoxetine tabs 20 mg, 33
flurazepam caps 15 mg, 37
flurazepam caps 30 mg, 37
fluticasone propionate crm, lotion 0.05%, oint 0.005%, 69
fluvastatin, 26
fluvastatin ext-rel, 26
fluvoxamine, 30
FML FORTE, 73
FOCALIN, 37
FOCALIN XR, 37
folic acid tabs 0.4 mg, 0.8 mg, 62
folic acid tabs 1 mg, 62
FOLLISTIM AQ, 50
fondaparinux, 58
FORTAMET, 41
FORTEO, 46
FORTESTA, 41
FOSAMAX, 46
FOSAMAX PLUS D, 46
fosinopril, 22
fosinopril/hydrochlorothiazide, 23
FOSRENOL, 52
FRAGMIN, 58
FREESTYLE, 45
FROVA, 38
frovatriptan, 38
FULYZAQ, 53
furosemide, 28
FUZEON, 17
FYCOMPA, 31
G
gabapentin caps 100 mg, 31
gabapentin caps 300 mg, 400 mg, 31
gabapentin tabs, soln, 31
galantamine, 32
galantamine ext-rel, 32
GANIRELIX, 50
GATTEX, 56
GELNIQUE, 57
gemfibrozil, 25
GENOTROPIN, 51
gentamicin crm, 68
gentamicin oint, 68, 72
gentamicin soln, 72
GEODON, 35
Gianvi, 46
GILENYA, 39
GILOTRIF, 21
glatiramer, 39
GLEEVEC, 21
glimepiride, 44
glipizide, 44
glipizide ext-rel tabs 10 mg, 44
glipizide ext-rel tabs 2.5 mg, 5 mg, 44
glipizide/metformin, 42
GLUCAGEN, 51
GLUCAGON, 51
GLUCOPHAGE XR, 41
GLUCOVANCE, 42
GLUMETZA, 41
glyburide micronized, 44
glyburide tabs 1.25 mg, 2.5 mg, 44
glyburide tabs 5 mg, 44
glyburide/metformin tabs 1.25/250 mg, 42
glyburide/metformin tabs 2.5/500 mg, 5/500 mg, 42
GLYSET, 41
GOLYTELY, 55
GONAL-F, 50
GONAL-F RFF, 50
granisetron, 53
GRANIX, 59
griseofulvin ultramicrosize, 16
guanfacine ext-rel, 36
guanfacine tabs 1 mg, 23
guanfacine tabs 2 mg, 23
GYNOL II GEL 3%, 49
H
haloperidol oral concentrate, 36
haloperidol tabs, 36
HARVONI, 19
HECTOROL, 51
HELIXATE FS, 59
HEMOFIL M, 59
HETLIOZ, 38
HIZENTRA, 61
HORIZANT, 40
HUMALOG, 43
HUMALOG MIX, 43
HUMATE-P, 59
HUMATROPE, 51
HUMIRA, 60
HUMULIN 70/30, 43
HUMULIN N, 43
HUMULIN R, 43
HYCAMTIN caps, 22
hydralazine tabs 10 mg, 30
hydralazine tabs 25 mg, 50 mg, 100 mg, 30
hydrochlorothiazide caps, 29
hydrochlorothiazide tabs 12.5 mg, 29
hydrochlorothiazide tabs 25 mg, 50 mg, 29
hydrocodone/acetaminophen caps, 12
hydrocodone/acetaminophen soln 7.5/325 mg/15 mL, 12
hydrocodone/acetaminophen tabs 2.5/325 mg, 5/300 mg,
7.5/300 mg, 7.5/325 mg, 10/300 mg, 10/325 mg, 12
hydrocodone/acetaminophen tabs 5/325 mg, 12
hydrocodone/chlorpheniramine ext-rel, 64
hydrocodone/ibuprofen, 12
hydrocortisone, 51
hydrocortisone butyrate crm, oint, soln 0.1%, 69
hydrocortisone crm, oint 2.5%, 69
hydrocortisone rectal crm, 56
hydrocortisone valerate crm, oint 0.2%, 69
hydromorphone ext-rel, 12
hydromorphone soln, supp, 12
hydromorphone tabs 2 mg, 12
hydromorphone tabs 4 mg, 8 mg, 13
hydroxychloroquine, 61
hydroxyzine HCl syrup, 64
hydroxyzine HCl tabs, 64
hydroxyzine pamoate caps 100 mg, 64
hydroxyzine pamoate caps 25 mg, 50 mg, 64
hyoscyamine sulfate, 54
HYQVIA, 61
HYZAAR, 24
I
ibandronate tabs, 46
IBRANCE, 21
ibuprofen, 11
ICLUSIG, 21
imatinib mesylate, 21
IMBRUVICA, 21
imipramine HCl tabs 10 mg, 34
imipramine HCl tabs 25 mg, 50 mg, 34
imipramine pamoate, 34
imiquimod, 71
IMITREX, 38
INCRELEX, 52
INCRUSE ELLIPTA, 63
indapamide, 29
INDERAL LA, 27
indomethacin, 11
INLYTA, 21
INSPRA, 23
INTELENCE, 17
INTERMEZZO, 38
INTRON A, 61
Introvale, 48
INTUNIV, 37
INVEGA, 35
INVIRASE, 18
INVOKAMET, 44
INVOKANA, 44
ipratropium nasal spray, 63
ipratropium soln, 63
ipratropium/albuterol, 63
irbesartan, 24
irbesartan/hydrochlorothiazide, 24
Irenka, 33
IRESSA, 21
ISENTRESS, 17
isoniazid syrup, 18
isoniazid tabs 100 mg, 18
isoniazid tabs 300 mg, 18
isosorbide dinitrate, 29
isosorbide mononitrate, 29
isosorbide mononitrate ext-rel tabs 30 mg, 29
isosorbide mononitrate ext-rel tabs 60 mg, 120 mg, 29
isradipine, 27
itraconazole, 16
ivermectin, 19
IXINITY, 59
J
JADENU, 60
JAKAFI, 21
JALYN, 56
JANUMET, 42
JANUMET XR, 42
JANUVIA, 42
JARDIANCE, 44
JENTADUETO, 42
Jinteli, 50
Jolessa, 48
Jolivette, 48
Junel Fe, 46, 47
JUXTAPID, 27
K
KADIAN, 13
KALETRA, 18
KALYDECO, 65
KAPVAY, 37
Kariva, 47
KAZANO, 42
Kelnor 1/35, 47
KEPPRA, 31
KEPPRA XR, 31
ketoconazole, 68
ketoprofen, 11
ketorolac, 73
KHEDEZLA, 34
KINERET, 60
KLARON, 67
KOATE-DVI, 59
KOGENATE FS, 59
KOMBIGLYZE XR, 42
KORLYM, 53
KRISTALOSE, 55
KUVAN, 52
KYNAMRO, 27
L
labetalol, 27
lactulose, 55
LAMICTAL, 31
LAMICTAL ODT, 31
LAMICTAL XR, 31
LAMISIL, 17
lamivudine, 18
lamivudine/zidovudine, 17
lamotrigine ext-rel, 31
lamotrigine orally disintegrating tabs, 31
lamotrigine tabs 25 mg, 100 mg, 150 mg, 200 mg, 31
lamotrigine tabs 50 mg, 31
LANOXIN, 28
lansoprazole + amoxicillin + clarithromycin, 56
lansoprazole delayed-rel, 55
LANTUS, 43
LASIX, 28
LASTACAFT, 72
latanoprost, 74
LATUDA, 36
LAZANDA, 13
LENVIMA, 21
LESCOL XL, 26
Lessina, 46
LETAIRIS, 29
letrozole, 20
leucovorin 10 mg, 15 mg, 25 mg, 20
leucovorin 5 mg, 20
LEUKINE, 59
leuprolide acetate, 21
levalbuterol, 64
LEVAQUIN, 15
LEVEMIR, 43
levetiracetam, 31
levetiracetam ext-rel, 31
LEVITRA, 57
levobunolol soln, 73
levocetirizine, 63
levofloxacin, 15, 72
levonorgestrel, 48
levonorgestrel/EE 0.1/20 and EE 10, 48
Levora, 47
levothyroxine sodium 175 mcg, 200 mcg, 300 mcg, 52
levothyroxine sodium 25 mcg, 50 mcg, 75 mcg, 88 mcg,
100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 52
Levoxyl, 52
LEXAPRO, 33
LEXIVA, 18
LIALDA, 54
lidocaine crm, lotion, 70
lidocaine gel, soln, 70
lidocaine patch, 70
lidocaine viscous, 71
lidocaine/prilocaine, 70
LIDODERM, 70
linezolid, 19
LINZESS, 55
liothyronine, 52
LIPITOR, 26
lisinopril, 22
lisinopril/hydrochlorothiazide, 23
lithium carbonate caps, tabs, 39
lithium carbonate ext-rel caps 300 mg, 39
LITHIUM SOLN, 39
LIVALO, 26
LOCOID, 70
LOESTRIN 1.5/30, 47
LOESTRIN 1/20, 46
LOESTRIN FE 1.5/30, 47
LOESTRIN FE 1/20, 46
LOFIBRA, 25
Lomedia 24 Fe, 46
LONSURF, 22
LOPROX, 68
lorazepam oral concentrate, 30
lorazepam tabs, 30
losartan, 24
losartan/hydrochlorothiazide, 24
LOSEASONIQUE, 48
LOTEMAX, 73
LOTREL, 23
lovastatin, 26
LOVAZA, 26
LOVENOX, 58
Low-Ogestrel, 47
LUMIGAN, 74
LUNESTA, 38
LUPANETA, 49
LUPRON DEPOT, 21
Lutera, 46
LUZU, 68
LYNPARZA, 22
LYRICA, 37
LYSTEDA, 59
M
MACROBID, 19
malathion, 71
MATULANE, 22
Matzim LA, 28
MAVIK, 23
MAXALT, 38
MAXALT-MLT, 38
medroxyprogesterone acetate, 52
medroxyprogesterone acetate 150 mg/mL, 49
mefloquine, 17
megestrol acetate susp, 52
megestrol acetate tabs 20 mg, 21
megestrol acetate tabs 40 mg, 21
MEKINIST, 21
meloxicam susp, 11
meloxicam tabs, 11
memantine, 32
MENEST, 49
MENOPUR, 50
MENOSTAR, 49
MENTAX, 68
meperidine soln, 13
meperidine tabs 100 mg, 13
meperidine tabs 50 mg, 12
MEPHYTON, 62
mercaptopurine, 20
METADATE CD, 37
METAGLIP, 42
metaxalone, 40
metformin, 41
metformin ext-rel tabs, 41
metformin ext-rel tabs 500 mg, 41
metformin ext-rel tabs 750 mg, 41
methimazole tabs 10 mg, 52
methimazole tabs 5 mg, 52
methocarbamol, 39
methotrexate oral, 61
methoxsalen oral, 69
methyldopa tabs 250 mg, 30
methyldopa tabs 500 mg, 30
METHYLIN, 37
methylphenidate, 36
methylphenidate ext-rel, 36
methylprednisolone, 51
metoclopramide, 53
metolazone tabs 10 mg, 29
metolazone tabs 2.5 mg, 5 mg, 29
metoprolol succinate ext-rel, 27
metoprolol tartrate, 27
METROCREAM, 71
METROGEL, 71
metronidazole crm, gel, lotion, 70
metronidazole tabs 250 mg, 500 mg, 19
MEVACOR, 26
MIACALCIN, 46
MICARDIS, 24
MICARDIS HCT, 24
Microgestin 1.5/30, 47
Microgestin 1/20, 46
Microgestin Fe 1.5/30, 47
Microgestin Fe 1/20, 46
miglitol, 41
minocycline, 16
minocycline ext-rel, 16
MIRAPEX, 35
MIRAPEX ER, 35
MIRCERA, 59
MIRCETTE, 47
mirtazapine orally disintegrating tabs, 34
mirtazapine tabs 15 mg, 34
mirtazapine tabs 7.5 mg, 30 mg, 45 mg, 34
misoprostol, 55
MOBIC, 11
modafinil, 40
Moderiba tabs, 19
moexipril, 22
moexipril/hydrochlorothiazide, 23
mometasone crm, lotion, oint 0.1%, 69
mometasone spray, 65
MONOCLATE-P, 59
Mononessa, 47
MONONINE, 59
montelukast, 65
morphine sulfate ext-rel, 13
morphine sulfate soln 20 mg/5 mL, 12
morphine sulfate soln 20 mg/mL, 10 mg/5 mL, 13
morphine sulfate tabs, 13
MOVANTIK, 55
MOXATAG, 16
moxifloxacin, 15
MOZOBIL, 60
MS CONTIN, 13
mupirocin crm, 68
mupirocin oint, 68
MUSE, 57
MYALEPT, 53
mycophenolate mofetil, 61
mycophenolate sodium delayed-rel, 62
MYKIDZ IRON susp 15 mg/1.5 mL, 63
MYRBETRIQ, 57
N
nabumetone, 11
nadolol, 27
naftifine, 68
NAFTIN, 68
NAMENDA, 32
NAMENDA XR, 32
NAPRELAN, 11
naproxen EC tabs 375 mg, 11
naproxen EC tabs 500 mg, 11
naproxen sodium ext-rel, 11
naproxen sodium tabs 275 mg, 11
naproxen sodium tabs 550 mg, 11
naproxen susp, 11
naproxen tabs, 11
naratriptan, 38
NARCAN NASAL SPRAY, 40
NASONEX, 65
NATAZIA, 48
nateglinide, 44
NATPARA, 46
NATROBA, 71
Necon 0.5/35, 47
Necon 1/35, 47
Necon 1/50, 47
Necon 7/7/7, 47
nefazodone, 34
neomycin sulfate tabs, 14
neomycin/polymyxin B/dexamethasone, 73
NESINA, 42
NEULASTA, 59
NEUPOGEN, 59
NEUPRO, 35
NEURONTIN, 31
nevirapine, 17
nevirapine ext-rel, 17
NEXAVAR, 21
NEXIUM, 56
Next Choice One Dose, 48
niacin ext-rel, 26
NIASPAN, 26
nicardipine, 27
nicotine polacrilex gum, 40
nicotine polacrilex lozenge, 40
nicotine transdermal, 40
NICOTROL INHALER, 40
NICOTROL NS, 40
nifedipine, 27
nifedipine ext-rel, 27
NINLARO, 22
nisoldipine ext-rel, 27
nitrofurantoin ext-rel, 19
nitrofurantoin macrocrystals, 19
nitroglycerin lingual spray, 29
nitroglycerin tabs, 29
NITROSTAT, 29
nizatidine, 54
NORDITROPIN, 51
norethindrone acetate, 52
norethindrone/ethinyl estradiol 0.5 mg/2.5 mcg, 50
NORITATE, 71
Nortrel 0.5/35, 47
Nortrel 1/35, 47
Nortrel 7/7/7, 48
nortriptyline caps, 34
nortriptyline soln, 34
NORVASC, 27
NORVIR, 18
NOVOEIGHT, 59
NOVOFINE 30, 32 AUTOCOVER, 44
NOVOLIN 70/30, 43
NOVOLIN N, 43
NOVOLIN R, 43
NOVOLOG, 43
NOVOLOG MIX 70/30, 43
NOVOSEVEN RT, 59
NUCYNTA, 13
NUCYNTA ER, 13
NUTROPIN AQ, 51
NUVARING, 49
NUVIGIL, 40
NUWIQ, 59
nystatin, 16, 68
nystatin/triamcinolone, 68
O
Ocella, 47
octreotide, 53
ODEFSEY, 17
ODOMZO, 22
OFEV, 66
ofloxacin, 15, 72
ofloxacin otic, 74
olanzapine, 35
olanzapine orally disintegrating tabs, 35
olanzapine/fluoxetine, 35
OLEPTRO, 34
olopatadine, 65, 72
omega-3 acid ethyl esters, 26
omeprazole delayed-rel caps 10 mg, 40 mg, 55
omeprazole delayed-rel caps 20 mg, 55
omeprazole/sodium bicarbonate, 55
OMNARIS, 66
OMNITROPE, 51
ondansetron orally disintegrating tabs 4 mg, 53
ondansetron orally disintegrating tabs 8 mg, 53
ondansetron tabs, soln, 53
ONETOUCH, 44
ONGLYZA, 42
OPANA, 13
OPANA ER, 13
OPSUMIT, 29
ORACEA, 71
ORENCIA 125 mg/mL, 60
ORENITRAM, 30
ORFADIN, 53
ORKAMBI, 65
orphenadrine ext-rel, 40
ORTHO TRI-CYCLEN, 48
ORTHO TRI-CYCLEN LO, 48
ORTHO-CYCLEN, 47
ORTHO-NOVUM 1/35, 47
ORTHO-NOVUM 7/7/7, 48
OSENI, 42
OSPHENA, 52
OTEZLA, 61
OTREXUP, 61
OVIDREL, 50
oxaprozin, 11
oxcarbazepine, 31
oxiconazole, 68
OXISTAT, 68
oxybutynin ext-rel, 57
oxybutynin syrup, 57
oxybutynin tabs, 57
oxycodone, 13
oxycodone/acetaminophen tabs, 13
oxycodone/aspirin, 13
oxycodone/ibuprofen, 13
OXYCONTIN, 13
oxymorphone, 13
P
paliperidone ext-rel, 35
pantoprazole delayed-rel, 55
paricalcitol, 51
paroxetine, 33
paroxetine HCl ext-rel, 33
PATANASE, 65
PATANOL, 72
PAXIL, 33
PAXIL CR, 33
peg 3350/electrolytes, 55
PEGASYS, 61
PEGINTRON, 61
PEGINTRON REDIPEN, 61
penicillin VK, 16
PENLAC, 68
PENNSAID, 11
PENTASA, 54
pentoxifylline ext-rel, 60
perindopril, 22
permethrin, 71
PEXEVA, 33
phenazopyridine, 58
phenobarbital elixir, 31
phenobarbital tabs
15 mg, 16.2 mg, 32.4 mg, 64.8 mg, 97.2 mg, 100 mg, 31
phenobarbital tabs 30 mg, 60 mg, 31
PHENYTEK, 31
phenytoin, 31
phenytoin sodium, 31
phenytoin sodium extended, 31
PHOSLO, 52
pilocarpine, 74
pioglitazone, 43
pioglitazone/glimepiride, 44
pioglitazone/metformin, 43
piroxicam, 11
PLAVIX, 60
podofilox, 71
polymyxin B/trimethoprim, 72
POMALYST, 21
potassium chloride effervescent tabs 25 mEq, 62
potassium chloride oral liq 10%, 20%, 62
POTIGA, 31
PRADAXA, 58
PRALUENT, 26
pramipexole, 35
pramipexole ext-rel, 35
PRAMOSONE, 69
PRANDIN, 44
PRAVACHOL, 26
pravastatin, 26
prazosin 1 mg, 23
prazosin 2 mg, 5 mg, 24
PRECISION PCX, 45
PRECISION PCX PLUS, 45
PRECISION Q-I-D, 45
PRECISION SOF-TACT, 45
PRECISION XTRA, 45
PRECOSE, 41
prednisolone, 51
prednisolone acetate, 73
prednisolone sodium phosphate soln 15 mg/5 mL, 51
prednisolone sodium phosphate soln
5 mg/5 mL, 25 mg/5 mL, 51
prednisone dose pack 10 mg, 51
prednisone dose pack 5 mg, 51
prednisone soln, 51
prednisone tabs, 51
PREFEST, 50
PREMARIN, 49
PREMARIN crm, 50
PREMPHASE, 50
PREMPRO, 50
Prenatabs FA, 62
Prenatal Plus, 62
PRENATE ELITE, 62
PRESTALIA, 23
PREVACID, 56
PREVIDENT, 72
Previfem, 47
PREVPAC, 56
PREZCOBIX, 17
PREZISTA, 18
PRILOSEC, 56
PRILOSEC susp, 56
primidone, 31
PRISTIQ, 34
PROAIR HFA, 64
probenecid, 12
PROCENTRA, 37
prochlorperazine, 53
PROCRIT, 59
PROCYSBI, 53
PROFILNINE SD, 59
progesterone, micronized, 52
PROMACTA, 60
promethazine/phenylephrine, 64
PROMETRIUM, 52
propafenone, 25
propranolol ext-rel, 27
propranolol soln, 27
propranolol tabs 10 mg, 20 mg, 40 mg, 80 mg, 27
propranolol tabs 60 mg, 27
propylthiouracil, 52
PROSCAR, 56
PROTONIX, 56
PROTOPIC, 70
protriptyline, 34
PROVENTIL HFA, 64
PROVIGIL, 40
PROZAC, 33
PROZAC WEEKLY, 33
PRUMYX, 71
PULMICORT FLEXHALER, 66
PULMICORT RESPULES, 66
PULMOZYME, 65
Q
QNASL, 66
QSYMIA, 45
Quasense, 48
quetiapine, 35
quinapril, 22
quinapril/hydrochlorothiazide, 23
quinidine gluconate, 25
quinidine sulfate tabs, 25
QVAR, 66
R
rabeprazole delayed-rel, 55
raloxifene, 52
ramipril, 22
RANEXA, 30
ranitidine caps, syrup, 54
ranitidine tabs 300 mg, 54
RAPAFLO, 56
RAVICTI, 53
RAZADYNE, 32
RAZADYNE ER, 32
REBETOL, 19
REBIF, 39
RECOMBINATE, 59
RELENZA, 19
RELION products, 43
RELISTOR, 55
RELPAX, 38
REMODULIN, 30
RENAGEL, 52
RENVELA, 52
repaglinide, 44
repaglinide/metformin, 44
REPATHA, 26
REPRONEX, 50
REQUIP, 35
REQUIP XL, 35
RESCRIPTOR, 17
RESTASIS, 74
RETIN-A MICRO, 67
REVATIO susp, 30
REVATIO tabs, 30
REVLIMID, 21
REXAPHENAC, 12
REXULTI, 36
REYATAZ, 18
Ribapak, 19
Ribasphere, 19
ribavirin, 19
rifampin, 18
RIOMET, 42
risedronate, 46
risedronate delayed-rel, 46
RISPERDAL, 36
RISPERDAL M-TABS, 36
risperidone orally disintegrating tabs, 35
risperidone tabs 0.25 mg, 0.5 mg, 2 mg, 3 mg, 4 mg, 35
risperidone tabs 1 mg, 35
RITALIN LA, 37
rivastigmine, 32
rizatriptan, 38
rizatriptan orally disintegrating tabs, 38
ropinirole, 35
ropinirole ext-rel, 35
rosuvastatin, 26
ROZEREM, 38
S
SABRIL, 32
SAIZEN, 51
SALKERA, 71
SAMSCA, 53
SANCUSO, 54
SANDOSTATIN, 53
SANDOSTATIN LAR, 53
SAPHRIS, 36
SARAFEM, 33
SAVAYSA, 58
SAVELLA, 37
SAXENDA, 45
SEASONIQUE, 48
selenium sulfide lotion, shampoo 2.5%, 69
SELZENTRY, 17
SENSIPAR, 45
SEREVENT, 65
SEROQUEL, 36
SEROQUEL XR, 36
SEROSTIM, 51
sertraline oral concentrate, 33
sertraline tabs, 33
SIGNIFOR, 53
sildenafil tabs 20 mg, 29
silver sulfadiazine, 68
SIMPONI, 61
simvastatin, 26
SINGULAIR, 65
sirolimus, 62
SIRTURO, 18
SIVEXTRO, 19
SKELAXIN, 40
sodium fluoride 0.5 mg (1.1 mg) tabs, 71
sodium fluoride 1 mg (2.2 mg) tabs, 71
sodium fluoride chew tabs, 71
sodium fluoride paste 1.1%, 71
(from 0.275 mg/drop NaF), 71
(from 0.55 mg/drop NaF), 0.5 mg/mL F
(from 1.1 mg/mL NaF), 71
sodium fluoride/potassium nitrate paste 1.1-5%, 71
SOFT TOUCH, 44
SOFTCLIX, 45
SOLODYN, 16
SOMATULINE, 53
SOMAVERT, 53
SONATA, 38
SOOLANTRA, 70
sotalol tabs 120 mg, 240 mg, 25
sotalol tabs 80 mg, 160 mg, 25
SOVALDI, 19
SPECTRACEF, 15
spinosad, 71
SPIRIVA, 63
spironolactone tabs 25 mg, 23
spironolactone tabs 50 mg, 100 mg, 23
spironolactone/hydrochlorothiazide, 29
SPORANOX, 17
Sprintec, 47
SPRYCEL, 21
STALEVO, 35
STARLIX, 44
stavudine, 18
STAVZOR, 32
STAXYN, 57
STELARA, 69
STIMATE, 53
STIVARGA, 21
STRATTERA, 37
STRENSIQ, 53
STRIBILD, 17
SUBOXONE FILM, 40
SUBSYS, 13
sucralfate, 56
SULAR, 28
sulfacetamide oint 10%, 72
sulfacetamide sodium, 67
sulfacetamide soln 10%, 72
sulfamethoxazole/trimethoprim susp, 16
sulfamethoxazole/trimethoprim tabs, 16
sulfasalazine, 54
sulindac tabs 150 mg, 11
sulindac tabs 200 mg, 11
sumatriptan, 38
SUMAVEL DOSEPRO, 38
SUPRAX, 15
SURESTEP, 45
SUSTIVA, 17
SUTENT, 21
SYLATRON, 61
SYMBICORT, 66
SYMBYAX, 36
SYMLINPEN, 41
SYNAREL, 49
SYNERA, 70
SYNTHROID, 53
T
TACLONEX, 69
tacrolimus, 62, 70
TAFINLAR, 21
TAGRISSO, 21
TAMIFLU, 19
tamoxifen, 20
tamsulosin, 56
TANZEUM, 43
TARCEVA, 21
TARGRETIN caps, 22
TARGRETIN gel, 22
TARKA, 23
TASIGNA, 21
TAZORAC, 67
TECFIDERA, 39
TEGRETOL-XR, 32
TEKTURNA, 28
TEKTURNA HCT, 28
telmisartan, 24
telmisartan/amlodipine, 24
telmisartan/hydrochlorothiazide, 24
temazepam caps 15 mg, 30 mg, 37
temazepam caps 7.5 mg, 22.5 mg, 37
TEMODAR, 20
temozolomide, 20
terazosin, 24
terbinafine, 16
TESTIM, 41
testosterone cypionate, 41
testosterone enanthate, 41
testosterone gel, 41
testosterone gel pump 1%, 41
tetrabenazine, 37
tetracycline caps 250 mg, 16
tetracycline caps 500 mg, 16
THALOMID, 21
theophylline, 67
theophylline ext-rel 12hr tabs 100 mg, 67
thioridazine tabs 10 mg, 25 mg, 100 mg, 36
thioridazine tabs 50 mg, 36
thyroid tabs, 52
tiagabine, 31
TIKOSYN, 25
timolol maleate gel, 73
timolol maleate soln, 73
TIVICAY, 17
tizanidine, 40
TOBI, 65
TOBRADEX oint, 73
TOBRADEX susp, 73
tobramycin, 72
tobramycin inhalation soln, 65
tobramycin/dexamethasone susp 0.3%/0.1%, 73
tolterodine, 57
tolterodine ext-rel, 57
TOPAMAX, 32
topiramate sprinkle caps, 31
topiramate tabs 25 mg, 31
topiramate tabs 50 mg, 100 mg, 200 mg, 31
TOPROL-XL, 27
torsemide tabs 20 mg, 100 mg, 28
torsemide tabs 5 mg, 10 mg, 28
TOUJEO, 43
TOVIAZ, 58
TRACLEER, 29
TRADJENTA, 42
tramadol, 12
tramadol ext-rel, 13
tramadol/acetaminophen, 13
trandolapril, 22
trandolapril/verapamil ext-rel, 23
tranexamic acid, 59
TRAVATAN Z, 74
travoprost, 74
trazodone tabs 300 mg, 34
trazodone tabs 50 mg, 100 mg, 150 mg, 34
TRESIBA, 43
tretinoin, 67
tretinoin gel microsphere, 67
TRETIN-X, 67
TREXIMET, 39
triamcinolone acetonide crm 0.5%, 70
triamcinolone acetonide crm, oint 0.1%, 0.025%, 69
triamcinolone acetonide crm, oint 0.5%, 69
triamcinolone acetonide lotion, 69
triamterene/hydrochlorothiazide, 29
triazolam, 38
TRIBENZOR, 25
TRICOR, 25
TRILEPTAL, 32
TRILIPIX, 25
Tri-Lo Sprintec, 48
trimethobenzamide, 53
trimethoprim, 19
Trinessa, 48
TRI-NORINYL, 48
Tri-Previfem, 48
Tri-Sprintec, 48
TRIUMEQ, 17
Trivora, 48
TRIZIVIR, 17
trospium, 57
trospium ext-rel, 57
TRULICITY, 42
TRUSOPT, 73
TRUVADA, 17
TUDORZA, 63
TUSSIONEX, 64
TYKERB, 21
TYVASO, 30
TYZEKA, 19
U
ULORIC, 12
ULTRACET, 13
ULTRAM, 13
ULTRAM ER, 13
UPTRAVI, 30
UROXATRAL, 57
URSO, 54
URSO FORTE, 54
ursodiol, 54
V
VAGIFEM, 50
valacyclovir, 19
VALCHLOR, 20
VALCYTE, 18
valganciclovir, 18
valproic acid, 31
valsartan, 24
valsartan/hydrochlorothiazide, 24
VALTREX, 19
VANCOCIN, 20
vancomycin, 19
VARUBI, 54
VASCEPA, 26
VCF VAGINAL CONTRACEPTIVE FOAM, 49
VECTICAL, 69
Velivet, 48
VELTASSA, 62
venlafaxine, 33
venlafaxine ext-rel, 33
VENTAVIS, 30
VENTOLIN HFA, 64
VERAMYST, 66
verapamil, 28
verapamil ext-rel, 28
VERELAN PM, 28
VESICARE, 57
VEXOL, 73
VFEND, 17
VIAGRA, 57
VIBERZI, 55
VICTOZA, 42
VIDEX soln, 18
VIGAMOX, 72
VIIBRYD, 33
VIMOVO, 11
VIMPAT, 32
VIRACEPT, 18
VIRAMUNE XR, 18
VIREAD, 18
VIVELLE-DOT, 49
VOGELXO, 41
voriconazole, 16
VOTRIENT, 21
VRAYLAR, 36
VYTORIN, 26
VYVANSE, 36
W
warfarin, 58
Wee Care susp 15 mg/1.25 mL, 62
WELCHOL, 25
WELLBUTRIN, 34
WELLBUTRIN SR, 34
WELLBUTRIN XL, 34
WILATE, 59
X
XALATAN, 74
XALKORI, 21
XARELTO, 58
XARTEMIS XR, 13
XELJANZ, 61
XELJANZ XR, 61
XELODA, 20
XENAZINE, 37
XENICAL, 45
XIFAXAN 550 mg, 20
XIGDUO XR, 44
XOPENEX, 64
XOPENEX HFA, 64
XTANDI, 20
Xulane, 49
XYNTHA, 59
XYZAL, 63
Y
YASMIN, 47
YAZ, 46
Z
zafirlukast, 65
zaleplon, 38
ZARXIO, 59
ZEGERID, 56
ZELBORAF, 21
ZETIA, 25
ZETONNA, 66
ZIAGEN soln 20 mg/mL, 18
zidovudine, 18
ZIOPTAN, 74
ziprasidone, 35
ZIPSOR, 11
ZITHROMAX, 15
ZMAX, 15
ZOCOR, 26
ZOFRAN, 54
ZOHYDRO ER, 13
ZOLINZA, 22
zolmitriptan, 38
zolmitriptan orally disintegrating tabs, 38
ZOLOFT, 33
zolpidem, 38
zolpidem ext-rel, 38
zolpidem sublingual, 38
ZOLPIMIST, 38
ZOMACTON, 51
ZOMIG, 39
ZOMIG-ZMT, 39
ZONEGRAN, 32
zonisamide, 31
ZONTIVITY, 60
ZORBTIVE, 51
ZORTRESS, 62
ZORVOLEX, 11
Zovia 1/35e, 47
ZOVIRAX crm, 71
ZOVIRAX oint, 71
ZUPLENZ, 54
ZYDELIG, 21
ZYFLO CR, 65
ZYKADIA, 21
ZYLET, 73
ZYPREXA, 36
ZYPREXA ZYDIS, 36
ZYTIGA, 20
ZYVOX, 20
Pharmacy Services
Capital BlueCross P&T Committee
P.O. Box 773735
Harrisburg, PA 17177-3735
2016 Capital BlueCross Formulary

open/closed - Capital BlueCross

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