Preferred Drug List (PDL)

Transcription

Preferred
Drug List (PDL)
New Jersey
Effective Date: 10/1/16
© 2016 United Healthcare Services, Inc. All rights reserved.
Listing of Preferred Drugs
INTRODUCTION
PREFACE
UnitedHealthcare Community Plan is pleased to provide
this Listing of Preferred Drugs to be used when
prescribing for patients covered by the pharmacy benefit
plan offered by UnitedHealthcare Community Plan. The
drugs listed in this Listing of Preferred Drugs are intended
to provide sufficient options to treat patients who require
treatment with a drug from that pharmacologic or
therapeutic class. The drugs listed in the UnitedHealthcare
Community Plan Listing of Preferred Drugs have been
reviewed and approved by the Pharmacy and Therapeutics
Committee. The drugs have been selected to provide the
most clinically appropriate and cost-effective medications
for patients who have their drug benefit administered
through UnitedHealthcare Community Plan. It is also
recognized there may be occasions where an unlisted drug
is desired for proper medical management of a specific
patient. In those infrequent instances, the unlisted
medication may be requested through the prior
authorization process.
UnitedHealthcare Community Plan assumes no
responsibility for the actions or omissions of any medical
provider based upon reliance, in whole or in part, on the
information contained herein. The medical provider should
consult the drug manufacturer’s product literature or
standard references for more detailed information.
National guidelines can be found on the Web sites listed in
the Web site section or go to the National Guideline
Clearinghouse site at http://www.guideline.gov.
The UnitedHealthcare Community Plan Listing of
Preferred Drugs is organized by sections. Each section
includes therapeutic groups identified by either a drug class
or disease state.
Products are listed by generic name. Brand names are
included as a reference to assist in product recognition.
Unless exceptions are noted, generally all applicable
dosage forms and strengths of the drug cited are included in
the Listing of Preferred Drugs. Generics should be
considered the first line of prescribing.
The drugs represented have been reviewed by the
Pharmacy and Therapeutics (P&T) Committee and are
approved for inclusion. The Listing of Preferred Drugs is
reflective of current medical practice as of the date of
review.
Preferred Drugs covers selected over-the-counter (OTC)
products. You are encouraged to prescribe OTC
medications when clinically appropriate.
This edition incorporates drugs added to the Listing of
Preferred Drugs since the last edition as well as numerous
revisions to the prescribing information based on changes
in pharmacotherapy. Comments and suggestions from
practicing physicians have also been incorporated to ensure
that the UnitedHealthcare Community Plan Listing of
Preferred Drugs is reflective of current medical practice.
PHARMACY AND THERAPEUTICS (P&T)
COMMITTEE
The P&T Committee includes physicians and pharmacists
who are not employees or agents of UnitedHealthcare
Community Plan or its affiliates. They must adhere to the
Ethics Policy standards of the P&T Committee.
UnitedHealthcare Community Plan medical directors and
pharmacists also participate in the P&T Committee. The
P&T Committee meets quarterly to discuss a variety of
issues. Those issues pertaining to pharmaceutical selection
and pharmacy program management are communicated
quarterly. This newsletter is distributed to all participating
physicians who have received the preferred drug listing.
Preferred drug listing decisions are also communicated
quarterly on the UnitedHealthcare Community Plan internet
site.
NOTICE
The information contained in this Listing of Preferred
Drugs and its appendices is provided by UnitedHealthcare
Community Plan, solely for the convenience of medical
providers. UnitedHealthcare Community Plan does not
warrant or assure accuracy of such information nor is it
intended to be comprehensive in nature.
This Listing of Preferred Drugs is not intended to be a
substitute for the knowledge, expertise, skill and judgment
of the medical provider in their choice of prescription
drugs.
UHC1004a {Released 2/25/11}
i
OUTPATIENT PRESCRIPTION DRUG
BENEFIT-COVERED MEDICATIONS
Extended-release and delayed-release products
require their own entry.
Medically necessary outpatient prescription drugs are
covered when prescribed by a provider licensed to
prescribe federal legend drugs or medicines. Some items
are covered only with prior authorization. Eligibility for
Outpatient Prescription Drug Benefits and copays are based
on the individual member’s benefit plan.
diltiazem sustained release CARDIZEM SR
Dosage forms covered will be consistent with the
category and use where listed.
Neomycin/polymixin B/ Cortisporin
Hydrocortisone
PRODUCT SELECTION CRITERIA
The P&T Committee considers clinical information on
new-to-market drugs that are typically included in an
outpatient pharmacy benefit. The evaluation includes all or
part of the following:
• Safety
• Efficacy
• Comparison studies
• Approved indications
• Adverse effects
• Contraindications/Warnings/Precautions
• Pharmacokinetics
• Patient administration/compliance considerations
• Medical outcome and pharmacoeconomic
studies
As listed in the OTIC section, this is limited to the otic
solution and suspension. From this entry the ophthalmic
solution and ointment, and the topical cream cannot be
assumed to be on the list unless there are entries for these
products in the OPHTHALMIC and DERMATOLOGY
sections of the Listing of Preferred Drugs.
When a strength or dosage form is specified, only the
specified strength and dosage form is on the Listing of
Preferred Drugs. Other strengths/dosage forms of the
reference product are not
cefixime (400mg tabs only)
GENERIC SUBSTITUTION
When a new drug is considered for inclusion, it will be
reviewed relative to similar drugs currently included in the
UnitedHealthcare Community Plan Listing of Preferred
Drugs. This review process may result in deletion of
drug(s) in a particular therapeutic class in an effort to
continually promote the most clinically useful and costeffective agents.
Preferred Drugs requires generic substitution on the
majority of products when a generic equivalent is available.
Generic substitution is a pharmacy action whereby a
generic equivalent is dispensed rather than the brand name
product. The PDL indicates generic availability in the
“Covered Drug” column.
All the information in the Listing of Preferred Drugs is
provided as a reference for drug therapy selection. Specific
drug selection for an individual patient rests solely with the
prescriber.
If a brand name drug is medically necessary, please submit
a prior authorization request.
The UnitedHealthcare Community Plan MAC list sets a
ceiling price for the reimbursement of certain multisource
prescription drugs. This price will typically cover the
acquisition of most generics but not branded versions of the
same drug. The products selected for inclusion on the
MAC list are commonly prescribed and dispensed and have
usually gone through the FDA’s review and approval
process.
An important consideration for generic substitution is the
knowledge that all approvals of generic drugs by the FDA
since 1984, and many generic approvals prior to 1984, have
a showing of bioequivalence between the generic versions
and the reference brand product. To gain FDA approval:
LISTING OF PREFERRED DRUGS PRODUCT
DESCRIPTIONS
To assist in understanding which specific strengths and
dosage forms are covered on the Listing of Preferred
Drugs, examples are noted below. The general principles
shown in the examples can then usually be extended to
other entries in the book. Any exceptions are noted in the
drug list. There may also be a statement associated with a
drug list that gives additional information about which
specific products or dosage forms are covered.
Products covered include all strengths associated
with the dosage form of the cited brand name
product.
carvedilol
SUPRAX
1. The generic drug must contain the same active
ingredient(s), be the same strength and the same dosage
form as the brand name product.
Coreg
All strengths of Coreg would be covered by this listing.
2. The FDA has given the generic an “A” rating compared
to the branded product indicating bioequivalence, and
UHC1004a
ii
• Agents used to promote fertility
• Agents used for erectile dysfunction
• Agents used for cosmetic hair growth
• Drugs from manufacturers that do not participate
in the FFS Medicaid Drug Rebate Program
• Diagnostic products
• Medical supplies and DME except as listed:
syringes, needles, lancets, alcohol swabs, spacers,
preferred diabetes test strips, peak flow meters
(Astech, Assess, Peak Air brands, max two per
year), vaporizer (limit of 1 per 3 years), humidifier
(limit of 1 per 3 years)
• Mirena
has determined the generic is therapeutically equivalent
to the reference brand. The ratings of generic drugs are
available by referring to the FDA reference, Approved
Drug Products with Therapeutic Equivalence
Evaluations (Orange Book).
When the above two criteria are met, a generic can be
substituted with the full expectation that the substituted
product will produce the same clinical effect and safety
profile as the prescribed product. Drug products that have a
narrow therapeutic index (NTI) can also be guided by these
principles. It is not necessary for the health care provider to
approach any one therapeutic class of drug products (e.g.,
NTI drugs) differently from any other class, when there has
been a determination of therapeutic equivalence by the
FDA for the drug products under consideration. Also,
additional clinical tests or examinations by the physician
are not needed when a therapeutically equivalent generic
drug product is substituted for the brand name product.
DAYS SUPPLY DISPENSING LIMITATIONS
UnitedHealthcare Community Plan members may receive
up to a one month supply of a specific medication per
prescription order or prescription refill. A medication may
be reordered or refilled when eighty-five percent (85%) of
the medication has been utilized. If a claim is submitted
before 85% of the medication has been used, based on the
original day supply submitted on the claim, the claim will
reject with a "refill too soon" message.
There are now many brand name products that are
repackaged or distributed under a generic label. The generic
label version should always be considered therapeutically
equivalent and substitutable for the source branded product.
MANDATORY GENERIC SUBSTITUTION
Preferred Drugs requires mandatory generic substitution on
the vast majority of products when a generic equivalent is
available; however, brand name drugs may be covered in
certain situations by requesting a prior authorization. The
Drugs prior authorization (PA) list does not include
branded items where a generic equivalent is covered.
DRUG EFFICACY STUDY IMPLEMENTATION
(DESI) DRUGS
Drugs first marketed between 1938 and 1962 were
approved as safe but required no showing of effectiveness
for FDA approval. Beginning in 1962, all new drugs were
required to be both safe and effective before they could be
marketed. This legislation also applied retroactively to all
drugs approved as safe from 1938-1962. The DESI
program was established by the FDA to review the
effectiveness of these pre-1962 drugs for their labeled
indications, and a determination of “fully effective” was
made for most of these products and they remain in the
marketplace. A few DESI products remain classified as
“less than fully effective” while awaiting final
administrative disposition. Also, classified as DESI are
many products listed as identical, similar, or related to
actual DESI products. UnitedHealthcare Community
Plan’s Listing of Preferred Drugs does not cover DESI
“less than fully effective” drug products.
PRIOR AUTHORIZATION OF NON-LISTING OF
PREFERRED DRUGS MEDICATIONS
The drugs in the UnitedHealthcare Community Plan Listing
of Preferred Drugs have been selected to provide the most
clinically appropriate and cost-effective medications for
patients who have their drug benefit administered through
UnitedHealthcare Community Plan. It is also recognized
that there may be occasions where an unlisted drug is
desired for the proper medical management of a specific
patient. In those infrequent instances, the prior
authorization process reviews requests for unlisted
medications the physician may consider medically
necessary for patient management.
Requests for these exceptions should be either made in
writing by the physician and faxed or called into:
PLAN EXCLUSIONS
The following drug categories are excluded from coverage
under the outpatient pharmacy benefit and are not part of
the UnitedHealthcare Community Plan Listing of Preferred
Drugs.
UnitedHealthcare Community Plan
Pharmacy Services Department
Fax 866-940-7328
Phone 800-310-6826
• DESI drugs
• Anti-obesity agents
• Experimental / research drugs
• Cosmetic drugs
• Immunization agents
• Nutritional / diet supplements
• Blood and blood plasma products
UHC1004a
A prior authorization request form is available in the
UnitedHealthcare Community Plan provider manual and
should be used for all prior authorization requests if
possible. Appropriate documentation must be provided to
iii
support the medical necessity of the non-preferred drug
request. The UnitedHealthcare Community Plan Pharmacy
Department will respond to all requests in accordance with
state requirements.
Physicians are requested to adhere to this Listing of
Preferred Drugs when prescribing for patients covered by
their pharmacy benefit plan offered by UnitedHealthcare
Community Plan. If a pharmacist receives a prescription
for a non-preferred drug, the pharmacist should contact the
prescribing physician and request that the prescription be
changed to a medication included in this Listing of
Preferred Drugs. If a preferred alternative is not
appropriate the physician should then be instructed to
contact the Plan for a prior authorization.
Controlled Substances
You may fill any FOUR medications from the following
classes in a 30-day period:
• opiate analgesics
• select muscle relaxants
Additional fills will require prior authorization.
Medications in these classes may also be subject to
individual quantity limits.
Additions to the QL program drug list will be made from
time to time and providers notified accordingly. As always,
we recognize that a number of patient-specific variables
must be taken into consideration when drug therapy is
prescribed and therefore overrides will be available through
the medical exception (prior authorization) process. Please
contact the UnitedHealthcare Community Plan Pharmacy
Prior Notification Service at 800-310-6826 with questions.
Please contact the UnitedHealthcare Community Plan
Pharmacy Services Department at 800-310-6826 with
questions concerning the prior authorization process.
Specialty Pharmaceutical Management Program
UnitedHealthcare Community Plan is continuously looking
for ways to provide high quality cost effective care for Plan
members. The Specialty Pharmaceutical Management
Program helps UnitedHealthcare Community Plan to
achieve these goals. Injectable medications that are part of
this program require plan authorization and are not
available through the retail pharmacy network.
To obtain authorization, the provider must submit the
appropriate Prior Authorization form to the
UnitedHealthcare Community Plan Pharmacy Department
via fax at
866-940-7328.
The UnitedHealthcare Community Plan Pharmacy
Department will review and respond to all requests in
accordance with state requirements, and if authorized for
payment, UnitedHealthcare Community Plan will
coordinate the delivery of the product to the member or
provider.
Drugs that are part of this program and are on the Listing of
Preferred Drugs are identified in this booklet by the
designation "SP".
Prior Authorization request forms can be requested by
calling the UnitedHealthcare Community Plan Pharmacy
Department at 800-310-6826.
NON-PREFERRED DRUGS 5-DAY TEMPORARY
SUPPLY OVERRIDES
To ensure the use of PDL drugs, all non- PDL drugs should
be discussed with the prescribing physician. If you cannot
speak to the physician immediately, and there is an
immediate need for the medication, the claim processing
system will accept an override to permit a one-time
dispensing of a 5-day supply of the newly prescribed
non-PDL drug. The pharmacy should submit a claim for a
5 day supply, with a PA Type of 8 and Prior Authorization
number of “00000000120”. Please note that non-preferred
drugs are available for a 5-day supply, however availability
is subject to the benefit design. For assistance, pharmacies
may call 800-310-6826.
The pharmacy should contact the physician to discuss a
non-preferred drug or if a prior authorization request is
warranted. If the prescribing physician feels a drug is
medically necessary, the physician may fax a request for
prior authorization to UnitedHealthcare Community Plan at
800-310-6826.
QUANTITY LIMITATIONS (QL)
Prescriptions for monthly quantities greater than the
indicated limit require a prior authorization request.
Quantity limits based on Efficient Medication Dosing
The Efficient Medication Dosing Program is designed to
consolidate medication dosage to the most efficient daily
quantity to increase adherence to therapy and also promote
the efficient use of health care dollars.
The limits for the program are established based on FDA
approval for dosing and the availability of the total daily
dose in the least amount of tablets or capsules daily.
Quantity Limits in the prescription claims processing
system will limit the dispensing to consolidate dosing. The
pharmacy claims processing system will prompt the
pharmacist to request a new prescription order from the
physician.
UHC1004a
iv
STEP THERAPY (ST)
The following preferred drugs are routinely covered only
after a sufficient trial of an indicated first-line agent has
been adequately tried and failed. These medications may
also be requested through the Prior authorization process.
While lower cost preferred alternatives may be appropriate
in many instances, other non-preferred alternatives are
available with prior authorization (PA).
STEP Drug
First-Line Agent(s)
(Tanzeum,
Victoza)
metformin
Lantus vials
trial of Toujeo Solostar
midodrine
Trial of fludrocortisone
Optivar
14 day trial of ketotifen within previous
90 days required first.
Amerge
Trial at a minimum dose of 50mg of
sumatriptan tablets.
oxymorphone ER 30-day trial of both Fentanyl patch and
(non-crush
morphine sulfate ER at least 200mg per
resistant)
day
Aricept 23mg
90 day trial of Aricept 10mg daily
Ranexa
Breo Ellipta
1) 30 day trial of one inhaled
corticosteroid (e.g. Arnuity Ellipta,
Asmanex) OR 2) 60 day trial of a longacting beta2- agonist (e.g. Arcapta,
Striverdi) OR 60 day trial of an orally
inhaled anticholinergic agent (e.g. Incruse
Ellipta, Atrovent, Combivent, Anoro
Ellipta).
Trial of one drug from the following
classes: beta blockers, calcium channel
blockers, long acting nitrates
Renvela
8 week trial of calcium acetate
calcipotriene
cream & oint
0.005%
Trial of two topical corticosteroids
calcitriol
3mcg/gm
Trial of two topical corticosteroids
Ditropan XL
30 day trial of oxybutynin immediate
release. Step Therapy only applies to
members less than 65 years of age.
SGLT-2
At least a 90 day trial of 1500mg/day of
Inhibitors
metformin
(Jardiance,
Invokana,
Invokamet, Synjardy)
tacrolimus 0.03%Trial of two different topical
corticosteroids. Step therapy only applies
to members 12 years of age and older.
tacrolimus 0.1% Minimum age of 16. Trial of two
different topical corticosteroids.
DPP4 Inhibitors At least a 90 day trial of 1500mg/day of
(Tradjenta,
metformin.
Jentadueto,
Onglyza, Kombiglyze)
Dulera
tolterodine
trospium
1) 30 day trial of one inhaled
corticosteroid (e.g. Arnuity Ellipta,
Asmanex) OR 2) 60 day trial of a longacting beta2- agonist (e.g. Arcapta,
Striverdi) OR 60 day trial of an orally
inhaled anticholinergic agent (e.g. Incruse
Ellipta, Atrovent, Combivent, Anoro
Ellipta).
TZD’s
At least a 90 day trial of 1500mg/day of
(ActosPlusMet, metformin
ActoPlusMet XR, Duetact)
Elidel
Trial of two different topical
corticosteroids. Step therapy only applies
to members 12 years of age and older.
Xopenex Respules 30 day trial of Albuterol .083% or .5%
respules.
fenofibrate
Fill of a statin or 90 days of gemfibrozil
within the previous 180 days.
Uloric
8 week trial of up to 600mg of
allopurinol required first.
Vancocin
One fill of metronidazole tabs or caps
Zohydro ER
GLP-1 Agonists At least a 90 day trial of 1500mg/day of
UHC1004a
v
30-day trial of both Fentanyl patch and
morphine sulfate ER at least 200mg per
day
LISTING OF PREFERRED DRUGS SUGGESTIONS
Providers who wish to propose Listing of Preferred Drugs
suggestions should forward the information to the
UnitedHealthcare Community Plan Director of Pharmacy
Services by either mail or fax.
NOTICE
The information contained in this document is proprietary
information. The information may not be copied in whole
or in part without the written permission of
UnitedHealthcare Community Plan. All rights reserved.
1001 Brinton Road
Pittsburgh, PA 15221
Fax 866-940-7328
Phone 800-310-6826
Email [email protected]
The drug names listed here are the registered and/or
unregistered trademarks of third-party pharmaceutical
companies unrelated to and unaffiliated with
UnitedHealthcare Community Plan. These trademarked
brand names are included here for informational purposes
only and are not intended to imply or suggest any
affiliation between UnitedHealthcare Community Plan and
such third-party pharmaceutical companies.
Providers should furnish adequate documentation, such as
clinical studies from the medical literature, in order for the
request to be considered for Listing of Preferred Drugs
addition. This literature should include information
documenting clinical necessity as well as therapeutic
advantages over current Listing of Preferred Drugs
products. Suggestions received by UnitedHealthcare
Community Plan will be reviewed by the Pharmacy and
Therapeutics Committee at the subsequent P&T Committee
meeting.
If viewing this Listing of Preferred Drugs via the Internet,
please be advised that the Listing of Preferred Drugs is
updated periodically and changes may appear prior to their
effective date to allow for notification.
Mental health agents, specific anticonvulsants,
antiretroviral agents, nicotine replacement products,
and substance abuse deterrents are carved out of the
UnitedHealthcare Community Plan drug benefit and
are paid by the Department of Health and Mental
Hygiene (DHMH) Maryland Pharmacy Program. Refer
to the Maryland Medicaid Mental Health Preferred
Drug List for a complete listing
https://dhmh.maryland.gov/pap/Pages/paphome.aspx
EDITOR
Your comments and suggestions regarding the
Drugs are encouraged. Your input is vital to this Listing of
Preferred Drugs’ continued success. All responses will be
reviewed and considered. Please send your comments to:
1001 Brinton Road
Pittsburgh, PA 15221
Fax 866-940-7328
LEGEND
#
Only the dosage forms/strengths of the brand
name products noted are on the Listing of
Preferred Drugs
OTC
over-the-counter
delayed-rel delayed-release (also known as enteric coated)
EC
enteric-coated
ext-rel
extended-release (also known as sustainedrelease)
PA
Prior Authorization required
QL
Quantity Limits apply
ST
Step Therapy, see pages V-VI for details
SP
Specialty Pharmaceuticals, see pages IV-V for
details
UHC1004a
vi
Table of Contents
Antineoplastics & Immunosuppressants . . . 4
Antineoplastic Agents . . . . . . . . . . . . . . . . . . . . . . 4
Hormonal Antineoplastic Agents . . . . . . . . . . . . . 5
Immunomodulators . . . . . . . . . . . . . . . . . . . . . . . . 5
Immunosuppressants . . . . . . . . . . . . . . . . . . . . . . 6
Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Dermatology . . . . . . . . . . . . . . . . . . . . . . . . . 16
Acne Vulgaris . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Bacterial Infections . . . . . . . . . . . . . . . . . . . . . . . 16
Corticosteroids . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Fungal Infections . . . . . . . . . . . . . . . . . . . . . . . . . 17
Psoriasis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Rosacea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Scabies and Pediculosis . . . . . . . . . . . . . . . . . . 18
Viral Infections . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Blood Modifiers - Anticoagulants . . . . . . . . . 7
Anticoagulants . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Blood Cell Formation . . . . . . . . . . . . . . . . . . . . . . . 7
Platelet Inhibitors . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Ear, Nose & Throat . . . . . . . . . . . . . . . . . . . . 19
Ear . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Nose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Throat and Mouth . . . . . . . . . . . . . . . . . . . . . . . . 21
Cardiovascular Agents . . . . . . . . . . . . . . . . . 8
Ace Inhibitors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Ace Inhibitor/Diuretic Combinations . . . . . . . . . . 8
Adrenolytics, Central . . . . . . . . . . . . . . . . . . . . . . . 8
Alpha Blockers . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Angiotensin II Receptor Blockers (Antagonists) . 8
Angiotensin II Receptor Blocker Combinations . 8
Antiarrhythmics and Cardiac Glycosides . . . . . . 8
Beta Blockers and Beta Blocker/
Diuretic Combinations . . . . . . . . . . . . . . . . . . . . . . 9
Calcium Channel Blockers . . . . . . . . . . . . . . . . . . 9
Diuretics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Lipid Lowering Agents . . . . . . . . . . . . . . . . . . . . 10
Nitrates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Potassium-Removing Agents . . . . . . . . . . . . . . 11
Pulmonary Arterial Hypertension . . . . . . . . . . . 11
Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Endocrinology . . . . . . . . . . . . . . . . . . . . . . . 21
Adrenal Corticosteroids . . . . . . . . . . . . . . . . . . . 21
Androgens . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Diabetes Mellitus . . . . . . . . . . . . . . . . . . . . . . . . . 21
Growth Stimulating Agents . . . . . . . . . . . . . . . . 23
Osteoporosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Thyroid Disease . . . . . . . . . . . . . . . . . . . . . . . . . 23
Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Gastrointestinal . . . . . . . . . . . . . . . . . . . . . . 23
Diarrhea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Emesis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Gastroesophageal Reflux Disease (Gerd)/
Peptic Ulcers . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
Gastrointestinal Spasm . . . . . . . . . . . . . . . . . . . 24
Inflammatory Bowel Disease . . . . . . . . . . . . . . . 25
Laxatives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
Pancreatic Enzymes . . . . . . . . . . . . . . . . . . . . . . 25
Probiotic Supplementation . . . . . . . . . . . . . . . . 25
Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
Central Nervous System . . . . . . . . . . . . . . . 11
Alzheimer’s Disease . . . . . . . . . . . . . . . . . . . . . . 11
Analgesics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Migraine Acute Therapy . . . . . . . . . . . . . . . . . . . 13
Migraine Prophylactic Therapy . . . . . . . . . . . . . 14
Multiple Sclerosis . . . . . . . . . . . . . . . . . . . . . . . . 14
Myasthenia Gravis . . . . . . . . . . . . . . . . . . . . . . . 14
Parkinson’s Disease . . . . . . . . . . . . . . . . . . . . . . 14
Seizures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Infectious Diseases . . . . . . . . . . . . . . . . . . . 26
Anthelmintics . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
Antibacterials . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
Antifungals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
Antivirals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
2
Urological . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
Symptomatic Benign Prostatic Hypertrophy . . 49
Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
Cytomegalovirus Treatment . . . . . . . . . . . . . . . . 28
Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
Musculoskeletal . . . . . . . . . . . . . . . . . . . . . . 30
Arthritis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
Gout . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
Skeletal Muscle Relaxants . . . . . . . . . . . . . . . . . 31
Vitamins and Minerals . . . . . . . . . . . . . . . . . 50
Potassium . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . 54
Anaphylaxis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
Cystic Fibrosis . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
Hereditary Angioedema . . . . . . . . . . . . . . . . . . . 54
Hyperphosphatemia . . . . . . . . . . . . . . . . . . . . . . 54
Immune Thrombocytopenic Purpura . . . . . . . . 54
Medical Devices . . . . . . . . . . . . . . . . . . . . . . . . . 54
Metabolic Modifiers . . . . . . . . . . . . . . . . . . . . . . 54
Vaccine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
OB-GYN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
Contraceptives . . . . . . . . . . . . . . . . . . . . . . . . . . 32
Endometriosis . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
Hormone Therapy/Menopause . . . . . . . . . . . . 33
Vaginal Infections . . . . . . . . . . . . . . . . . . . . . . . . 33
Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
Ophthalmic . . . . . . . . . . . . . . . . . . . . . . . . . . 34
Allergy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
Anti-Inflammatories . . . . . . . . . . . . . . . . . . . . . . . 34
Glaucoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
Infections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
OTC MEDICATIONS . . . . . . . . . . . . . . . . . . . 57
Acne . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
Antifungals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
Atopic Dermatitis . . . . . . . . . . . . . . . . . . . . . . . . . 57
Cough/Cold Allergy . . . . . . . . . . . . . . . . . . . . . . 57
Diabetes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
Earwax Removal Products . . . . . . . . . . . . . . . . 58
Family Planning . . . . . . . . . . . . . . . . . . . . . . . . . . 58
First Aid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
Gastrointestinal . . . . . . . . . . . . . . . . . . . . . . . . . . 58
Lice Products . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
Motion Sickness . . . . . . . . . . . . . . . . . . . . . . . . . 59
Ophthalmics . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
Smoking Cessation Products . . . . . . . . . . . . . . 59
Vitamins/Minerals . . . . . . . . . . . . . . . . . . . . . . . . 60
Warts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60
Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . 60
Psychiatric . . . . . . . . . . . . . . . . . . . . . . . . . . 36
Alcohol Deterrents* . . . . . . . . . . . . . . . . . . . . . . 36
Anxiety* . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
Attention Deficit Hyperactivity Disorder (ADHD)* Diagnosis Required . . . . . . . . . . . . . . . . . . . . . . 37
Bipolar Disorder* . . . . . . . . . . . . . . . . . . . . . . . . 37
Depression* . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
Insomnia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
Medications Coverable for Participating
Behavioral Health Prescribers± . . . . . . . . . . . . 38
Narcotic Antagonists* . . . . . . . . . . . . . . . . . . . . 42
Psychoses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
Smoking Cessation* . . . . . . . . . . . . . . . . . . . . . 42
Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
Index of covered drugs . . . . . . . . . . . . . . . . 61
Respiratory Drugs . . . . . . . . . . . . . . . . . . . . 43
Antitussives, Decongestants, Expectorants and
Combinations . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
Asthma/COPD . . . . . . . . . . . . . . . . . . . . . . . . . . 48
3
Generic Drug Name
Brand Drug Name
Covered
Drug
Requirements & Limits
Antineoplastics & Immunosuppressants
Antineoplastic Agents
Alkylating Agents
altretamine
busulfan
chlorambucil
cyclophosphamide
estramustine
phosphate sodium
lomustine
melphalan
temozolomide
HEXALEN
MYLERAN
LEUKERAN
CYTOXAN
GLEOSTINE
ALKERAN
TEMODAR
brand
brand
generic
capecitabine
mercaptopurine
thioguanine
trifluridine/tipiracil
XELODA
PURINETHOL
TABLOID
LONSURF
generic
generic
brand
brand
QL
PA, SP
panobinostat
vorinostat
FARYDAK
ZOLINZA
brand
brand
PA, SP
PA, SP
afatinib
alectinib
axitinib
bosutinib
cabozantinib
ceritinib
cobimetinib
crizotinib
dabrafenib
dasatinib
erlotinib
GILOTRIF
ALECENSA
INLYTA
BOSULIF
COMETRIQ
ZYKADIA
COTELLIC
XALKORI
TAFINLAR
SPRYCEL
TARCEVA
AFINITOR
AFINITOR DISPERZ
IRESSA
IMBRUVICA
ZYDELIG
GLEEVEC
TYKERB
LENVIMA
TASIGNA
brand
brand
brand
brand
brand
brand
brand
brand
brand
brand
brand
PA, SP
PA, SP
PA, SP
PA, SP
PA, SP
PA, SP
PA, SP
PA, SP
PA, SP
PA, SP
PA, SP
brand
PA, SP
brand
brand
brand
generic
brand
brand
brand
PA, SP
PA, SP
PA, SP
PA, QL, SP
PA, SP
PA, SP
PA, SP
Antimetabolites
EMCYT
brand
Histone Deacetylase Inhibitors
Kinase Inhibitor
everolimus
gefitinib
ibrutinib
idelalisib
imatinib mesylate
lapatinib ditosylate
lenvatinib
nilotinib
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
ST = Step Therapy
brand
brand
brand
generic
SP = Specialty Pharmacy
^
Only available through
manual PA process
4
PA, SP
SP
*Available without PA for participating
Behavioral Health Prescribers
±Available without PA for participating
Behavioral Health Prescribers,
otherwise PA required
Covered
Drug
brand
brand
brand
brand
brand
brand
brand
brand
brand
brand
Generic Drug Name
Brand Drug Name
palbociclib
pazopanib
ponatinib
regorafenib
ruxolitinib
sorafenib
sunitinib
trametinib
vandetanib
vemurafenib
IBRANCE
VOTRIENT
ICLUSIG
STIVARGA
JAKAFI
NEXAVAR
SUTENT
MEKINIST
CAPRELSA
ZELBORAF
ixazomib
NINLARO
brand
PA, SP
abiraterone
ZYTIGA
brand
PA, SP
bicalutamide
flutamide
CASODEX
EULEXIN
generic
generic
tamoxifen
toremifene
NOLVADEX
FARESTON
generic
brand
anastrozole
exemestane
letrozole
ARIMIDEX
AROMASIN
FEMARA
generic
generic
generic
leuprolide
LUPRON
LUPRON DEPOT
generic
PA, SP
leuprolide
LUPRON DEPOT 6-MONTH
brand
PA, SP
Proteasome Inhibitors
Hormonal Antineoplastic Agents
Androgen Biosynthesis Inhibitors
Antiandrogens
Antiestrogens
Aromatase Inhibitors
Gonadotropin Releasing Hormone Analog
Progestin
PA, SP
PA, SP
PA, SP
PA, SP
PA, SP
PA, SP
PA, SP
PA, SP
PA, SP
PA, SP
LUPRON DEPOT-PED
megestrol acetate
MEGACE
interferon alfa-2b
peginterferon alfa-2b
INTRON A
SYLATRON
brand
brand
PA, SP
PA, SP
lenalidomide
pomalidomide
thalidomide
REVLIMID
POMALYST
THALOMID
brand
brand
brand
PA, SP
PA, SP
PA, QL
Immunomodulators
Interferons
Miscellaneous
QL = Quantity Limit
ST = Step Therapy
generic
^
manual PA process
5
Brand Drug Name
Covered
Drug
azathioprine
mycophenolate mofetil
mycophenolate sodium
IMURAN
CELLCEPT
MYFORTIC
generic
generic
generic
cyclosporine
SANDIMMUNE
NEORAL
generic
Generic Drug Name
Immunosuppressants
Antimetabolites
Calcineurin Inhibitors
cyclosporine, modified
tacrolimus
Rapamycin Derivative
GENGRAF
HECORIA
PROGRAF
generic
caps, QL
generic
sirolimus
sirolimus
RAPAMUNE
RAPAMUNE
generic
brand
everolimus
ZORTRESS
brand
alitretinoin 1% gel
bexarotene caps and
topical gel
cysteamine bitartrate
etoposide
hydroxyurea
hydroxyurea
mesna
mitotane
octreotide
olaparib
pasireotide
procarbazine
sonidegib
topotecan
tretinoin
vismodegib
PANRETIN
brand
PA
TARGRETIN
brand
PA
Miscellaneous
Miscellaneous
CYSTAGON
VEPESID
DROXIA
HYDREA
MESNEX
LYSODREN
SANDOSTATIN
LYNPARZA
SIGNIFOR
MATULANE
ODOMZO
HYCAMTIN
VESANOID
ERIVEDGE
QL = Quantity Limit
ST = Step Therapy
brand
generic
brand
generic
brand
brand
generic
brand
brand
brand
brand
brand
generic
brand
^
manual PA process
6
tabs
soln
tabs
PA, SP
PA, SP
PA, SP
PA, SP
caps
PA, SP
Generic Drug Name
Brand Drug Name
Covered
Drug
Blood Modifiers - Anticoagulants
Anticoagulants
apixaban
edoxaban
ELIQUIS
SAVAYSA
brand
brand
enoxaparin
LOVENOX
generic
heparin
rivaroxaban
warfarin
HEPARIN
XARELTO
COUMADIN
generic
brand
generic
darbepoetin alfa
ARANESP
EPOGEN
Blood Cell Formation
epoetin alfa
filgrastim
oprelvekin
plerixafor
pegfilgrastim
sargramostim
Platelet Inhibitors
anagrelide
aspirin
cilostazol
clopidogrel
dipyridamole
Miscellaneous
aminocaproic acid
deferasirox
pentoxifylline
extended-release
PROCRIT
ZARXIO
NEUMEGA
MOZOBIL
NEULASTA
LEUKINE
AGRYLIN
BAYER
ECOTRIN
PLETAL
PLAVIX
PERSANTINE
AMICAR
EXJADE
JADENU
TRENTAL
QL = Quantity Limit
ST = Step Therapy
PA, QL, SP,
SP and PA only applies for
quantities greater than
14 days
brand
PA, SP
brand
PA, SP
brand
brand
brand
brand
brand
PA, SP
PA, SP
PA, SP
PA, SP
PA, SP
generic
generic
OTC
generic
generic
generic
QL
brand
500 mg tab & syrup only
brand
PA, SP
generic
^
manual PA process
7
Brand Drug Name
Covered
Drug
benazepril
captopril
enalapril
LOTENSIN
CAPOTEN
VASOTEC
generic
generic
generic
enalapril oral soln
EPANED
fosinopril
lisinopril
quinapril
MONOPRIL
ZESTRIL
ACCUPRIL
generic
generic
generic
LOTENSIN HCT
generic
CAPOZIDE
generic
VASERETIC
generic
MONOPRIL-HCT
generic
QL
ZESTORETIC
generic
QL
ACCURETIC
generic
QL
clonidine
guanfacine
CATAPRES
TENEX
generic
generic
tablets
doxazosin
prazosin
terazosin
CARDURA
MINIPRESS
HYTRIN
generic
generic
generic
losartan
COZAAR
generic
QL
losartan/HCTZ
HYZAAR
generic
QL
amiodarone tabs
digoxin
disopyramide
disopyramide
extended-release
dofetilide
flecainide
CORDARONE
LANOXIN
NORPACE
generic
generic
generic
200 mg and 400 mg
NORPACE CR
brand
Generic Drug Name
Cardiovascular Agents
Ace Inhibitors
Ace Inhibitor/Diuretic Combinations
benazepril/
hydrochlorothiazide
captopril/
hydrochlorothiazide
enalapril/
hydrochlorothiazide
fosinopril/
hydrochlorothiazide
lisinopril/
hydrochlorothiazide
quinapril/
hydrochlorothiazide
Adrenolytics, Central
Alpha Blockers
Angiotensin II Receptor Blockers (Antagonists)
Angiotensin II Receptor Blocker Combinations
Antiarrhythmics and Cardiac Glycosides
TIKOSYN
TAMBOCOR
QL = Quantity Limit
ST = Step Therapy
brand
Members ≥ 8 years of age will
require prior authorization
QL
QL
QL
generic
generic
^
manual PA process
8
Covered
Drug
generic
generic
Generic Drug Name
Brand Drug Name
mexiletine
propafenone
quinidine gluconate extended-release
quinidine sulfate
quinidine sulfate
extended-release
MEXITIL
RYTHMOL
QUINIDINE GLUCONATE
EXT-REL
QUINIDINE SULFATE
QUINIDINE SULFATE
EXT-REL
acebutalol
atenolol
atenolol/chlorthalidone
bisoprolol
bisoprolol/
hydrochlorothiazide
carvedilol
labetalol
metoprolol
metoprolol succinate
pindolol
propranolol
propranolol/HCTZ
sotalol
timolol maleate
SECTRAL
TENORMIN
TENORETIC
ZEBETA
generic
generic
generic
generic
ZIAC
generic
COREG
TRANDATE
LOPRESSOR
TOPROL XL
PINDOLOL
INDERAL
INDERIDE
BETAPACE
generic
generic
generic
generic
generic
generic
generic
generic
generic
amlodipine
felodipine
extended-release
nicardipine
nifedipine
nifedipine
extended-release
nimodipine
nimodipine oral soln
NORVASC
generic
QL
PLENDIL
generic
QL
CARDENE
PROCARDIA
ADALAT CC
generic
generic
diltiazem
diltiazem
extended-release
diltiazem
extended-release
diltiazem
sustained-release
CARDIZEM
generic
CARDIZEM CD
generic
QL
generic
QL
generic
QL
IR only
generic
generic
generic
Beta Blockers and Beta Blocker/Diuretic Combinations
Calcium Channel Blockers
Dihydropyridines
Nondihydropyridines
PROCARDIA XL
NIMOTOP
NYMALIZE
DILACOR XR
TIAZAC
CARDIZEM SR
QL = Quantity Limit
ST = Step Therapy
QL
50 mg and 100 mg only
IR only
tablets
generic
QL
generic
brand
QL
^
manual PA process
9
Generic Drug Name
Brand Drug Name
verapamil
verapamil
extended-release
CALAN
Covered
Drug
generic
CALAN SR
generic
amiloride
amiloride/
hydrochlorothiazide
bumetanide
chlorothiazide
MIDAMOR
generic
MODURETIC
generic
BUMEX
DIURIL
DIURIL ORAL
SUSPENSION
CHLORTHALIDONE
LASIX
HYDROCHLOROTHIAZIDE
MICROZIDE
LOZOL
ZAROXOLYN
ALDACTONE
generic
generic
ALDACTAZIDE
generic
DEMADEX
DYAZIDE
generic
Diuretics
chlorothiazide
chlorthalidone
furosemide
hydrochlorothiazide
hydrochlorothiazide
indapamide
metolazone
spironolactone
spironolactone/
hydrochlorothiazide
torsemide
triamterene/
hydrochlorothiazide
Lipid Lowering Agents
Bile Acid Resin
cholestyramine
Fibrates
MAXZIDE
QUESTRAN
QUESTRAN-LIGHT
brand
generic
generic
generic
generic
generic
generic
generic
generic
LOFIBRA
LOPID
generic
generic
atorvastatin
lovastatin
simvastatin
LIPITOR
MEVACOR
ZOCOR
generic
generic
generic
niacin
niacin extended-release
NIACOR
NIASPAN
generic
generic
alirocumab
ezetimibe
PRALUENT
ZETIA
Niacins
Miscellaneous
QL = Quantity Limit
ST = Step Therapy
QL
QL
soln, tabs
12.5 mg caps
generic
fenofibrate
gemfibrozil
HMG-CoA Reductase Inhibitors and Combinations
brand
brand
^
manual PA process
10
Only the bulk products are
covered (cans). Individual
packets are not covered.
ST
QL
QL
PA, QL, SP
PA
Generic Drug Name
Nitrates
Oral
Brand Drug Name
Covered
Drug
isosorbide dinitrate
extended-release
isosorbide mononitrate
extended-release
ISORDIL
ISOSORBIDE
DINITRATE ER
ISMO
generic
IMDUR
generic
nitroglycerin
nitroglycerin
ISORDIL S.L.
NITROLINGUAL
NITROSTAT
generic
generic
brand
Sublingual
Transdermal
nitroglycerin
nitroglycerin
NITREK
NITRO-DUR
NITRO-BID
Potassium-Removing Agents
generic
generic
generic
transdermal, QL
generic
oint
generic
susp (susp only)
PA, SP
PA, SP
PA, SP
PA, SP
PA
sodium polysterene
sulfonate
KAYEXALATE
ambrisentan
bosentan
macitentan
riociguat
sildenafil
LETAIRIS
TRACLEER
OPSUMIT
ADEMPAS
REVATIO
brand
brand
brand
brand
generic
guanabenz
hydralazine
methyldopa
methyldopa/HCTZ
midodrine
minoxidil
ranolazine
WYTENSIN
APRESOLINE
ALDOMET
ALDORIL
PROAMATINE
LONITEN
RANEXA
generic
generic
generic
generic
generic
generic
brand
Pulmonary Arterial Hypertension
Miscellaneous
ST
ST
Central Nervous System
Alzheimer’s Disease
donepezil
ARICEPT
generic
donepezil
ARICEPT
generic
QL = Quantity Limit
ST = Step Therapy
^
manual PA process
11
5 mg and 10 mg, QL,
Members <18 years of age
will require prior authorization.
23 mg, ST, Members <18
years of age will require prior
authorization.
Generic Drug Name
Brand Drug Name
Covered
Drug
galantamine
RAZADYNE
generic
memantine
NAMENDA
generic
rivastigmine
EXELON
generic
Analgesics
Barbiturate Non-Narcotic Analgesics
butalbital/acetaminophen PHRENILIN
butalbital/acetaminophen SEDAPAP
ESGIC
butalbital/acetaminophen/
FIORICET
caffeine
ZEBUTAL
butalbital/aspirin/caffeine FIORINAL
Non-Narcotic Analgesics
QL, Members <18 years
of age will require prior
authorization.
authorization.
authorization.
generic
generic
QL
QL
generic
QL
generic
QL
acetaminophen
aspirin/acetaminophen/
caffeine
tramadol
TYLENOL
generic
OTC
EXCEDRIN MIGRAINE
generic
OTC
ULTRAM
generic
QL
etodolac
LODINE
generic
ibuprofen
ADVIL
generic
ibuprofen
MOTRIN
generic
IR Only
tabs, chew tabs
and susp, OTC
tabs, chew tabs
and susp
NSAIDS
INDOCIN
ORUDIS
TORADOL
MOBIC
RELAFEN
NAPROSYN
ENTERIC COATEDnaproxen delayed release
NAPROSYN
oxaprozin
DAYPRO
piroxicam
FELDENE
sulindac
CLINORIL
indomethacin
ketoprofen
ketorolac tromethamine
meloxicam
nabumetone
naproxen
Opioids - Narcotic Analgesics
butalbital/apap/caff/cod
butalbital/asa/caff/cod
FIORICET W/CODEINE
FIORINAL W/CODEINE
QL = Quantity Limit
ST = Step Therapy
generic
generic
generic
generic
generic
generic
IR only
QL
QL
generic
generic
generic
generic
generic
generic
^
manual PA process
12
QL, 50-325-40-30 mg
QL
Generic Drug Name
Brand Drug Name
butorphanol
codeine/acetaminophen
codeine sulfate
fentanyl transdermal
STADOL
TYLENOL W/CODEINE
DURAGESIC
LORCET
Covered
Drug
generic
generic
generic
generic
nasal spray, QL
QL
QL
QL
LORTAB
hydrocodone/
acetaminophen
LORTAB ELIXIR
generic
QL
VICODIN ES
ZOHYDRO ER
DILAUDID
DEMEROL
DOLOPHINE
MSIR
RMS
brand
generic
generic
generic
generic
generic
ST
QL
QL
QL
QL
QL
MS CONTIN
generic
QL
OXYFAST
ROXICODONE
generic
generic
soln, QL
QL
PERCOCET
generic
5/325, QL
PERCODAN
OXYMORPHONE ER
generic
generic
QL
QL, ST, non-crush resistant
dihydroergotamine
dihydroergotamine
ergotamine/caffeine
ergotamine tartrate/
caffeine
D.H.E. 45
MIGRANAL
CAFERGOT
MIGERGOT
SUPPOSITORIES
generic
generic
generic
inj, QL
brand
QL
naratriptan
rizatriptan
sumatriptan
AMERGE
MAXALT/MAXALT MLT
IMITREX
IMITREX
4 MG AND 6 MG INJ
generic
generic
generic
ST
QL
QL
generic
4 mg and 6 mg inj
NORCO
VICODIN
hydrocodone ER
hydromorphone
meperidine
methadone
morphine
morphine
morphine
extended-release
oxycodone
oxycodone
oxycodone/
acetaminophen
oxycodone/aspirin
oxymorphone ER
Migraine Acute Therapy
Ergotamine Derivatives
Selective Serotonin Agonists
sumatriptan
QL = Quantity Limit
ST = Step Therapy
^
manual PA process
13
Generic Drug Name
Brand Drug Name
Migraine Prophylactic Therapy
Covered
Drug
amitriptyline
ELAVIL
generic
divalproex sodium
cap sprinkle
DEPAKOTE SPRINKLE
generic
require prior authorization.
DEPAKOTE
generic
Minimum age 2
INDERAL
CALAN
generic
generic
IR only
brand
brand
brand
brand
brand
brand
PA, QL, SP
PA, QL, SP
PA, QL, SP
PA, QL, SP
PA, QL, SP
PA, QL, SP
tabs
syrup
divalproex sodium
delayed-release
propranolol
verapamil
Multiple Sclerosis
dimethyl fumarate
fingolimod
glatiramer acetate
interferon beta-1a
interferon beta-1a
teriflunomide
TECFIDERA
GILENYA
COPAXONE
AVONEX/AVONEX PEN
REBIF
AUBAGIO
pyridostigmine
pyridostigmine
pyridostigmine
extended-release
MESTINON
MESTINON
generic
brand
MESTINON TIMESPAN
generic
amantadine
benztropine
carbidopa/levodopa
carbidopa/levodopa
extended-release
entacapone
pramipexole
ropinirole
selegiline
tolcapone
trihexyphenidyl
SYMMETREL
COGENTIN
SINEMET
generic
generic
generic
SINEMET CR
generic
COMTAN
MIRAPEX
REQUIP
ELDEPRYL
TASMAR
ARTANE
generic
generic
generic
generic
generic
generic
carbamazepine
carbamazepine
extended-release
clobazam
clonazepam
diazepam
divalproex sodium
cap sprinkle
TEGRETOL
CARBATROL
generic
Myasthenia Gravis
Parkinson’s Disease
Seizures
TEGRETOL-XR
ONFI
KLONOPIN
DIASTAT ACUDIAL
DEPAKOTE SPRINKLE
QL = Quantity Limit
ST = Step Therapy
except tabs
tabs
generic
brand
generic
generic
generic
^
manual PA process
14
tablets
tabs
rectal gel, QL
Brand Drug Name
Covered
Drug
DEPAKOTE
generic
Minimum age 2
ZARONTIN
POTIGA
FELBATOL
generic
brand
generic
Age Limits Apply
felbamate oral susp
FELBATOL ORAL SUSP
generic
gabapentin
lacosamide
lamotrigine
NEURONTIN
VIMPAT
LAMICTAL
generic
brand
generic
lamotrigine chew
dispersable tab
LAMICTAL CD CHEW TAB
generic
lamotrigine starter kit
LAMICTAL STARTER KIT
levetiracetam
KEPPRA
methsuximide
CELONTIN
brand
oxcarbazepine
TRILEPTAL
generic
phenobarbital
phenytoin
phenytoin sodium
extended
pregabalin
pregabalin
primidone
rufinamide
PHENOBARBITAL
DILANTIN INFATABS
DILANTIN
generic
generic
tiagabine
GABITRIL
generic
tiagabine
GABITRIL
brand
topiramate
TOPAMAX
generic
topiramate sprinkle caps
TOPAMAX SPRINKLE
generic
valproic acid
vigabatrin oral solution
zonisamide
DEPAKENE
SABRIL SOLUTION
ZONEGRAN
generic
brand
generic
tetrabenazine
XENAZINE
Generic Drug Name
divalproex sodium
delayed-release
ethosuximide
exogabine
felbamate
Miscellaneous
PHENYTEK
LYRICA
LYRICA SOLUTION
MYSOLINE
BANZEL
QL = Quantity Limit
ST = Step Therapy
brand
generic
caps and tabs only
Age Limits Apply
QL*
require prior authorization*.
QL, Maximum age of 9
for solution
QL, Maximum age of 9
for suspension
generic
brand
brand
generic
brand
brand
^
manual PA process
15
PA
oral solution, PA
tablets only, QL
Age Limits Apply,
2mg & 4mg
Age Limits Apply,
12mg & 16mg
QL
QL, Members ≥ 8 years of age
PA, SP
QL
PA, SP
Brand Drug Name
Covered
Drug
isotretinoin
ACCUTANE
generic
PA
azelaic acid
benzoyl peroxide
clindamycin
clindamycin
clindamycin
erythromycin
erythromycin
FINACEA
BENZAC AC
CLEOCIN T
CLEOCIN T
CLEOCIN T
ERYGEL
T-STAT
NEUTROGENA OIL FREE
ACNE WASH
SULFACET-R
PLEXION
ATRALIN
brand
generic
generic
generic
generic
generic
generic
gel
gel
lotion
soln
gel 2%
soln
generic
liquid 2%, OTC
generic
generic
lotion
AVITA
generic
Generic Drug Name
Dermatology
Acne Vulgaris
Oral
Topical
salicylic acid
sulfacetamide/sulfur
sulfacetamide/sulfur
tretinoin
Bacterial Infections
RETIN-A
bacitracin
gentamicin
mupirocin
neomycin/polymyxin B/
bacitracin
silver sulfadiazine
BACITRACIN
GENTAK
BACTROBAN
generic
generic
generic
ointment, 22 gram tube only
NEOSPORIN
generic
OTC
SILVADENE
generic
alclometasone
ACLOVATE
DERMA-SMOOTHE
OIL/FS
SYNALAR
CORTIZONE
HYTONE
HYTONE
CORTIZONE-10 INTENSIVE
HEALING
generic
0.05% crm/oint
generic
oil 0.01%
generic
generic
generic
generic
soln/crm 0.01%
crm, oint, lot OTC
crm 0.5%, 1%, & 2.5%
lotion 1% & 2.5%
generic
crm 0.5% & 1%, OTC
BETA-VAL
generic
crm/oint/lotion 0.1%
Corticosteroids
Low Potency
fluocinolone acetonide
hydrocortisone
hydrocortisone
hydrocortisone
hydrocortisone/aloe
Medium Potency
betamethasone val
QL = Quantity Limit
ST = Step Therapy
^
manual PA process
16
OTC
Generic Drug Name
flurandrenolide
fluticasone propionate
hydrocortisone butyrate
hydrocortisone valerate
mometasone furoate
prednicarbate
triamcinolone acetonide
High Potency
betamethasone
augmented dip
betamethasone
augmented dip
betamethasone
dipropionate
fluocinonide
fluocinonide emulsified
base
Very High Potency
betamethasone dip
augmented
betamethasone dip
augmented
clobetasol propionate
halobetasol
Fungal Infections
ciclopirox
clotrimazole
clotrimazole
clotrimazole with
betamethasone
ketoconazole
miconazole
miconazole
miconazole
nystatin
terbinafine
tolnaftate
Covered
Drug
generic
oil 0.01%
generic
brand
generic
generic
generic
generic
generic
generic
generic
crm, oint 0.025%
tape
crm 0.05%, oint 0.005%
crm/oint/soln 0.1%
crm 0.2%
crm/oint/soln 0.1%
crm 0.1%
crm/lot/oint 0.025%
crm/oint/lotion 0.1%
DIPROLENE
generic
lotion 0.05%
DIPROLENE AF
generic
crm 0.05%
generic
crm/lotion/oint 0.05%
LIDEX
generic
crm/oint/gel/soln 0.05%
LIDEX E
generic
crm 0.05%
KENALOG
generic
crm 0.5%
DIPROLENE
generic
gel 0.05%
DIPROLENE
generic
oint 0.05%
TEMOVATE
ULTRAVATE
generic
generic
soln 0.05%
cream
PENLAC SOLUTION 8%
LOTRIMIN AF
MYCELEX
generic
generic
generic
OTC
LOTRISONE
generic
NIZORAL
DESENEX
MICATIN
MONISTAT-DERM
MYCOSTATIN
LAMISIL AT
TINACTIN
generic
generic
generic
generic
generic
generic
generic
Brand Drug Name
DERMA-SMOOTHE
OIL/FS
SYNALAR
CORDRAN
CUTIVATE
LOCOID
WESTCORT
ELOCON
DERMATOP
KENALOG
KENALOG
QL = Quantity Limit
ST = Step Therapy
^
manual PA process
17
2% OTC
OTC
OTC
OTC
Brand Drug Name
Covered
Drug
acitretin
calcipotriene
calcipotriene
calcitriol
methoxsalen
salicylic acid
SORIATANE
DOVONEX
DOVONEX
VECTICAL
OXSORALEN-ULTRA
SCALPICIN
generic
generic
generic
generic
generic
generic
oral caps, PA
crm/oint, ST
soln
ST
brimonidine
MIRVASO
METROCREAM
brand
PA
metronidazole
METROGEL
Generic Drug Name
Psoriasis
Rosacea
liquid 3%
generic
METROLOTION
Scabies and Pediculosis
crotamiton
malathion
permethrin
permethrin
pyrethrins/piperonyl but
Viral Infections
podofilox
salicylic acid 17%/
collodion
EURAX
OVIDE
ELIMITE
NIX CREME RINSE
RID SHAMPOO/
BUTOXIDE SHAMPOO
brand
generic
generic
generic
5%, QL
1%, OTC
generic
4% OTC
CONDYLOX SOL
generic
sol
DUOFILM
generic
OTC
brand
soln/cream, OTC
Miscellaneous
aluminum acetate
aluminum chloride
hexahydrate
ammonium lactate
ammonium lactate
becaplermin gel
calamine
collagenase
fluorouracil
fluorouracil
fluorouracil
hexachlorophene
hydrocortisone
imiquimod 5% cream
HYPERCARE 20%
generic
LAC-HYDRIN
LACTINOL
REGRANEX
generic
generic
brand
brand
brand
generic
generic
brand
brand
SANTYL
CARAC
EFUDEX
FLUOROPLEX
PHISOHEX
PROCTOSOL HC
CREAM 2.5%
PROCTOZONE
CREAM-HC 2.5%
ANUSOL HC 2.5%
ALDARA
QL = Quantity Limit
ST = Step Therapy
crm 12%, lotion 5% & 12%
lotion 10%
PA
lotion/ointment, OTC
QL
0.5% cream
1% cream
generic
generic
^
manual PA process
18
PA
Covered
Drug
generic
generic
generic
generic
generic
brand
Generic Drug Name
Brand Drug Name
ketoconazole
lidocaine
lidocaine
lidocaine
lidocaine/prilocaine
nitroglycerin
NIZORAL SHAMPOO
LIDAMANTEL
LMX-4
XYLOCAINE
EMLA
RECTIV
pimecrolimus
ELIDEL
brand
selenium sulfide
SELSUN
generic
tacrolimus
PROTOPIC 0.03%
generic
tacrolimus
PROTOPIC 0.1%
generic
urea 40%
UREA
generic
shampoo 2%
3% cream
4% cream (15 gm tubes), QL
jelly 2%
2.5% cream
0.4% rectal ointment, PA
cream QL, ST, Step therapy is
not required for members ages
2-11; not covered for members
less than 2 years of age
lotion 2.5%
ointment 0.03% ST, Step
therapy is not required for
members ages 2-11; not
covered for members less
than 2 years of age
ointment 0.1%, ST
(minimum age 16)
lotion
VOSOL OTIC
generic
otic
DOMEBORO OTIC
generic
VOSOL HC OTIC
generic
BENZOTIC
DEBROX
generic
generic
6.5%, OTC
CIPRODEX
brand
PA
CORTISPORIN OTIC
generic
otic
FLOXIN OTIC
generic
Ear, Nose & Throat
Ear
acetic acid
acetic acid/
aluminum acetate
acetic acid/
hydrocortisone
benzocaine/antipyrine
carbamide peroxide
ciprofloxacin/
dexamethasone
hydrocortisone
ofloxacin
Nose
Antihistamines - First Generation, Sedating
chlorpheniramine maleate
chlorpheniramine
extended-release
clemastine
cyproheptadine
diphenhydramine
CHLOR-TRIMETON
SYRUP
CHLOR-TRIMETON
ALLERGY
CLEMASTINE
CYPROHEPTADINE
QL = Quantity Limit
ST = Step Therapy
generic
2 mg/5 ml, OTC
generic
12 mg, OTC
generic
generic
generic
^
manual PA process
19
Generic Drug Name
Brand Drug Name
diphenhydramine
hydroxyzine HCL
hydroxyzine pamoate
BENADRYL
ATARAX
VISTARIL
Covered
Drug
generic
generic
generic
cetirizine
ZYRTEC
generic
cetirizine chew tab
ZYRTEC CHEWABLE TABLET
generic
Antihistamines - Second Generation, Nonsedating
levocetirizine
loratadine
XYZAL
ALAVERT
CLARITIN
OTC
*
*
generic
OTC
OTC, Members ≥ 8 years
authorization.
tabs
generic
OTC
Antihistamines - Others Antihistamine/Decongestant Combinations
azelastine
ASTELIN
generic
TRIOTANN
generic
ACTIFED
generic
Antihistamine/Decongestant Combinations - First Generation
chlorpheniramine/
phenylephrine/
pyrilamine
chlorpheniramine/
pseudoephedrine
spray
OTC
Antihistamine/Decongestant Combinations - Second Generation
cetirizine hydrochloride/
pseudoephedrine
hydrochloride
12 hours
extended-release
ZYRTEC-D
loratadine/
pseudoephedrine
extended-release
ALAVERT ALRG
TAB/SINUS
Nasal Steroids
generic
5 mg-120 mg tablet
generic
OTC
ALAVERT-D
ALLERGY/CONG
FLONASE
NASACORT ALLERGY
triamcinolone nasal spray
24 HOUR
fluticasone
Miscellaneous Nasal Decongestants
generic
brand
OTC
oxymetazoline
AFRIN
NEO-SYNEPHRINE
generic
OTC
phenylephrine
DIMEATAPP DRO
DECONGES
generic
OTC
NASALCROM
ATROVENT NASAL SPRAY
generic
generic
OTC
QL
Miscellaneous Nasal
cromolyn sodium
ipratropium nasal
QL = Quantity Limit
ST = Step Therapy
^
manual PA process
20
Generic Drug Name
Brand Drug Name
saline nasal spray 0.65%
OCEAN NASAL SPRAY
Covered
Drug
generic
chlorhexidine gluconate
lidocaine viscous
pilocarpine
triamcinolone
PERIDEX
XYLOCAINE
SALAGEN
KENALOG IN ORABASE
generic
generic
generic
generic
paste
DECADRON
FLORINEF
CORTEF
MEDROL
MEDROL
generic
generic
generic
generic
generic
brand
4mg, 8mg, 16mg, 32mg
2mg
generic
syrup
Throat and Mouth
OTC
Endocrinology
Adrenal Corticosteroids
cortisone acetate
dexamethasone
fludrocortisone
hydrocortisone
methylprednisolone
methylprednisolone
prednisolone
prednisolone
prednisolone sodium
phosphate
prednisone
Androgens
PRELONE
ORAPRED
PEDIAPRED
DELTASONE
generic
generic
testosterone cypionate
DEPO-TESTOSTERONE
generic
testosterone enanthate
DELATESTRYL
generic
testosterone gel
topical tube, packet,
and pump bottle
Vials only. Disposable
syringes not covered.
TESTOSTERONE 1% TOPICAL GEL
generic
PA
glucagon, human
recombinant
GLUCAGON
brand
QL
NOVOLOG
brand
QL, vials
NOVOLOG MIX 70/30
brand
QL, vials
LANTUS
brand
QL, ST, vials
TOUJEO SOLOSTAR
brand
NOVOLIN R
RELION R
HUMULIN N
NOVOLIN N
brand
brand
brand
brand
Diabetes Mellitus
Glucose Elevating Agents
Insulins
insulin aspart
insulin aspart
protamine 70%/
insulin aspart 30%
insulin glargine
insulin glargine
300 unit/ml
insulin human
insulin human
insulin isophane
insulin isophane human
QL = Quantity Limit
ST = Step Therapy
^
manual PA process
21
OTC, QL, vials
OTC, QL, vials
OTC, QL, vials
OTC, QL, vials
Generic Drug Name
Brand Drug Name
70%/regular 30%
70%/regular 30%
insulin isophane/regular
insulin lisopro pro/lispro
insulin lisopro prot/lispro
insulin lispro
insulin regular
RELION N
Covered
Drug
brand
brand
OTC, QL, vials
RELION 70/30
brand
OTC, QL, vials
HUMULIN 70/30
HUMALOG MIX 50/50
HUMALOG MIX 75/25
HUMALOG
HUMULIN R
brand
brand
brand
brand
brand
OTC, QL, vials
QL, vials
QL, vials
QL, vials
OTC, QL, vials
ONE TOUCH SYSTEMS (ULTRA 2, ULTRAMINI,
VERIO, VERIO FLEX, VERIO IQ, VERIO SYNC)
brand
ONE TOUCH TEST STRIPS (ULTRA, VERIO)
brand
acarbose
canagliflozin
canagliflozin/metformin
chlorpropamide
empagliflozin
empagliflozin/metformin
glimepiride
glipizide
glipizide extended-release
glyburide
glyburide, micronized
linagliptin
linagliptin/metformin
metformin
metformin ER
metformin/glyburide
nateglinide
pioglitazone
pioglitazone/glimepiride
pioglitazone/metformin
pioglitazone/metformin ER
repaglinide
saxagliptin
saxagliptin/metformin
tolazamide
OTC, QL, vials
NOVOLIN 70/30
Monitoring - Strips and Kits/Diabetic Supplies
Oral Agents
PRECOSE
INVOKANA
INVOKAMET
DIABINESE
JARDIANCE
SYNJARDY
AMARYL
GLUCOTROL
GLUCOTROL XL
MICRONASE
GLYNASE
TRADJENTA
JENTADUETO
GLUCOPHAGE
GLUCOPHAGE ER
GLUCOVANCE
STARLIX
ACTOS
DUETACT
ACTOPLUSMET
ACTOPLUS MET XR
PRANDIN
ONGLYZA
KOMBIGLYZE
TOLINASE
QL = Quantity Limit
ST = Step Therapy
generic
brand
brand
generic
brand
brand
generic
generic
generic
generic
generic
brand
brand
generic
generic
generic
generic
generic
generic
generic
brand
generic
brand
brand
generic
^
manual PA process
22
QL for insulin dependent or
pregnant members: allow
testing up to 6 times per day
QL for non-insulin
dependent members: allow
once daily testing
ST
ST
ST
ST
ST
ST
QL
ST
QL, ST
ST
ST
ST
Covered
Drug
generic
Generic Drug Name
Brand Drug Name
tolbutamide
TOLBUTAMIDE
albiglutide
liraglutide
pramlintide
TANZEUM
VICTOZA
SYMLIN
brand
brand
brand
ST
ST
PA
mecasermin
somatropin
INCRELEX
NUTROPIN AQ NUSPIN
brand
brand
PA, SP
PA, SP
alendronate
calcitonin-salmon
calcitonin-salmon
etidronate
raloxifene
teriparatide inj
FOSAMAX
MIACALCIN
FORTICAL
DIDRONEL
EVISTA
FORTEO
generic
generic
brand
generic
generic
brand
QL
nasal spray, QL
nasal spray, QL
levothyroxine
levothyroxine
liothyronine
liotrix
methimazole
propylthiouracil
LEVOXYL
SYNTHROID
CYTOMEL
THYROLAR
TAPAZOLE
PROPYLTHIOURACIL
generic
generic
generic
brand
generic
generic
asfotase alfa
cabergoline
cholic acid
desmopressin
methylergonovine
mifepristone
pegvisomant
sapropterin
STRENSIQ
DOSTINEX
CHOLBAM
DDAVP
METHERGINE
KORLYM
SOMAVERT
KUVAN
KUVAN POWDER FOR
SOLUTION
VISTOGARD
brand
generic
brand
generic
generic
brand
brand
brand
PA, SP
brand
PA, SP
brand
SP
diphenoxylate/atropine
loperamide
loperamide
LOMOTIL
IMODIUM A-D
LOPERAMIDE
generic
generic
generic
OTC
aprepitant
EMEND
dronabinol
MARINOL
Miscellaneous Antidiabetic Agents
Growth Stimulating Agents
Osteoporosis
Thyroid Disease
Miscellaneous
sapropterin powder
uridine
PA, SP
PA, SP
QL
PA, SP
PA, SP
PA, SP
Gastrointestinal
Diarrhea
Emesis
QL = Quantity Limit
ST = Step Therapy
brand
generic
^
manual PA process
23
QL applies to 40 mg, 80 mg
and 80-125 mg
PA
Generic Drug Name
Brand Drug Name
meclizine
metoclopramide
ANTIVERT
REGLAN
ZOFRAN
ondansetron
prochlorperazine
promethazine
trimethobenzamide
Covered
Drug
generic
generic
generic
QL
generic
generic
generic
*
300 mg caps
brand
OTC
MAALOX
generic
OTC
MYLANTA
generic
OTC
TAGAMET
NEXIUM 24HR OTC
generic
brand
ZOFRAN ODT
COMPAZINE
PHENERGAN
TIGAN
Gastroesophageal Reflux Disease (Gerd)/Peptic Ulcers
alginic acid/sodium
bicarbonate
alumina/magnesia
alumina/magnesia/
simethicone
cimetidine
esomeprazole
esomeprazole granules
famotidine
NEXIUM DELAYED
RELEASE PACKET
PEPCID
PEPCID AC
brand
generic
PA
Members ≥ 2 years
authorization.
OTC Pepcid AC 10 mg
and 20 mg also covered/
encouraged with written
prescription.
lansoprazole
PREVACID
generic
lansoprazole
delayed-release
PREVACID SOLUTAB
generic
orally disintegrating tabs,
Members ≥ 2 years
authorization. QL
PRILOSEC
generic
Capsules only, QL
PROTONIX
ZANTAC
ZANTAC
CARAFATE
generic
generic
generic
generic
CARAFATE SUSPENSION
generic
BENTYL
ROBINUL
LEVSIN
generic
generic
generic
omeprazole
delayed-release
pantoprazole
ranitidine
ranitidine syrup
sucralfate
sulcralfate
Gastrointestinal Spasm
dicyclomine
glycopyrrolate
hyoscyamine sulfate
QL = Quantity Limit
ST = Step Therapy
^
manual PA process
24
150 mg tabs
suspension, Members 10
years of age up to 65 years
authorization.
tablets only
Generic Drug Name
Brand Drug Name
Covered
Drug
hyoscyamine sulfate
extended-release
LEVSINEX
generic
Inflammatory Bowel Disease
balsalazide
budesonide
hydrocortisone
COLAZAL
ENTOCORT EC
COLOCORT
APRISO
mesalamine
extended-release
DELZICOL
mesalamine
extended-release
mesalamine
mesalamine supp
olsalazine sodium
sulfasalazine
sulfasalazine
delayed-release
LIALDA
generic
generic
generic
PA
enema
brand
PENTASA
ASACOL HD
generic
ROWASA
CANASA
DIPENTUM
AZULFIDINE
generic
brand
brand
generic
AZULFIDINE EN-TABS
generic
enema only
Laxatives
casanthranol-docusate
sodium
docusate calcium plus
docusate potasssium
docusate sodium
glycerin
lactulose
peg 3350/electrolytes
peg 3350/sodium
bicarbonate/sodium
chloride
peg 3350/sodium
bicarbonate/sodium
chloride/potassium
chloride
polyethylene glycol 3350
sennosides
Pancreatic Enzymes
pancrelipase
generic
OTC
COLACE
GLYCERIN SUPPOSITORY
ENULOSE
COLYTE
generic
generic
generic
generic
generic
generic
OTC
OTC
OTC
suppository, OTC
TRILYTE
generic
NULYTELY
generic
MIRALAX
SENOKOT
generic
generic
CREON
CREON 3000 UNIT
ZENPEP
brand
ACIDOPHILUS XTRA
brand
Probiotic Supplementation
acidophilus
QL = Quantity Limit
ST = Step Therapy
^
manual PA process
25
8.6 mg tab, OTC
OTC
Generic Drug Name
Brand Drug Name
acidophilus
ACIDOPHILUS
ACIDOPHILUS/BIFIDUS
WAFER
ACIDOPHILUS/CITRUS
PECTIN
ACIDOPHILUS/PECTIN
FLORANEX
PROBIOTIC FORMULA
acidophilus/bifidus
acidophilus/citrus pectin
acidophilus/pectin
lactobacillus
probiotic product
Miscellaneous
atropine sulfate
misoprostol
naloxegol
teduglutide
ursodiol
Covered
Drug
brand
caps and tabs, OTC
generic
OTC
generic
tabs, OTC
generic
generic
brand
caps, OTC
chewable tabs, OTC
caps, OTC
SAL-TROPINE
CYTOTEC
MOVANTIK
GATTEX
ACTIGALL
URSO
URSO FORTE
brand
generic
brand
brand
PA
PA, SP
ALBENZA
STROMECTOL
BILTRICIDE
brand
brand
brand
generic
Infectious Diseases
Anthelmintics
albendazole
ivermectin
praziquantel
Antibacterials
Antituberculosis Agents
aminosalicyclic acid
cycloserine
ethambutol
ethionamide
isoniazid
pyrazinamide
rifabutin
rifampin
rifapentine
PASER
SEROMYCIN
MYAMBUTOL
TRECATOR
ISONIAZID
PYRAZINAMIDE
MYCOBUTIN
RIFADIN
PRIFTIN
Cephalosporins - First Generation
PA
brand
generic
generic
brand
generic
generic
generic
generic
brand
cefadroxil
cephalexin
DURICEF
KEFLEX
generic
generic
tabs are not covered
cefaclor
cefprozil
cefuroxime axetil
CECLOR
CEFZIL
CEFTIN
generic
generic
generic
tabs
Cephalosporins - Second Generation
QL = Quantity Limit
ST = Step Therapy
^
manual PA process
26
Generic Drug Name
Brand Drug Name
cefuroxime axetil
CEFTIN
Covered
Drug
brand
cefdinir
cefixime
OMNICEF
SUPRAX
generic
brand
400 mg caps only, QL
ciprofloxacin
levofloxacin
ofloxacin
CIPRO
LEVAQUIN
FLOXIN
generic
generic
generic
tablets only
tabs
azithromycin
clarithromycin
clarithromycin ER
erythromycin
delayed-release
erythromycin
delayed-release
erythromycin
ethylsuccinate
erythromycin stearate
erythromycin/sulfisoxazole
ZITHROMAX
BIAXIN
BIAXIN XL
generic
generic
generic
ERYC
generic
Cephalosporins - Third Generation
Fluoroquinolones
Macrolides
Penicillins
amoxicillin
amoxicillin
amoxicillin/clavulanate
ampicillin
dicloxacillin
penicillin VK
Sulfonamides
sulfamethoxazole/
trimethoprim, DS
Tetracyclines
ERY-TAB
generic
ERYTHROCIN
PEDIAZOLE
generic
generic
BACTRIM
BACTRIM DS
minocycline
DOXYCYCLINE
MONOHYDRATE
MINOCIN
vancomycin HCl
clotrimazole
fluconazole
griseofulvin microsize
griseofulvin ultramicrosize
itraconazole
doxycycline monohydrate
Miscellaneous
Antifungals
suspension
QL
brand
E.E.S.
AMOXICILLIN CAPSULES
AND CHEWABLES
AMOXIL SUSP
AUGMENTIN
PRINCIPEN
DICLOXACILLIN
VEETIDS
generic
generic
generic
generic
generic
generic
Except 500 mg and 875 mg
film-coated tabs.
suspension
generic
generic
generic
capsules, except 75 mg
VANCOCIN HCL
generic
cap, ST
MYCELEX
DIFLUCAN
GRIFULVIN V
GRIS-PEG
SPORANOX
generic
generic
generic
generic
generic
troches
QL
QL = Quantity Limit
ST = Step Therapy
^
manual PA process
27
caps, PA, QL
Generic Drug Name
Brand Drug Name
itraconazole
ketoconazole
nystatin
terbinafine
voriconazole
SPORANOX
NIZORAL
MYCOSTATIN
LAMISIL
VFEND
Covered
Drug
brand
generic
generic
generic
generic
ganciclovir
valganciclovir
CYTOVENE
VALCYTE
generic
generic
tabs only
enfuvirtide
FUZEON KIT
brand
SP
adefovir
HEPSERA
generic
elbasvir/grazoprevir
ZEPATIER
brand
entecavir
interferon alfa-2b
lamivudine
peginterferon alfa-2a
peginterferon alfa-2a
BARACLUDE
INTRON A
EPIVIR HBV
PEGASYS
PEGASYS PROCLICK
brand
brand
brand
brand
brand
ribavirin
REBETOL/COPEGUS
generic
sofosbuvir
SOVALDI
brand
sofosbuvir/velpatasvir
EPCLUSA
brand
acyclovir
valacyclovir
ZOVIRAX
VALTREX
generic
generic
caps, tabs, suspension
amantadine
oseltamivir
rimantadine
zanamivir
SYMMETREL
TAMIFLU
FLUMADINE
RELENZA
generic
brand
generic
brand
except tabs
QL
delavirdine
efavirenz
nevirapine
nevirapine ER
rilpivirine
RESCRIPTOR
SUSTIVA
VIRAMUNE
VIRAMUNE XR
EDURANT
brand
brand
generic
brand
brand
abacavir
abacavir/lamivudine
ZIAGEN
EPZICOM
generic
brand
Antivirals
Cytomegalovirus Treatment
Entry/Fusion Inhibitors
Hepatitis Treatment
Herpes Treatment
Influenza Treatment
soln, PA, SP
QL
PA
PA, SP, preferred for
Genotypes 1 & 4
PA, SP
PA, SP
PA, SP
200 mg caps and tabs only,
PA, SP
Genotype 2
Genotypes 2, 3, 5, & 6
Non-Nucleoside Reverse Transcriptase Inhibitors - Diagnosis Required
QL
Nucleoside Analogues Nucleoside Reverse - Transcriptase Inhibitors/and Combinations
-Diagnosis Required
QL = Quantity Limit
ST = Step Therapy
^
manual PA process
28
Generic Drug Name
abacavir/lamivudine/
zidovudine
didanosine
didanosine
delayed-release
emtricitabine
emtricitabine/rilpivirine/
tenofovir
lamivudine
lamivudine/zidovudine
stavudine
zidovudine
Brand Drug Name
Covered
Drug
TRIZIVIR
generic
VIDEX
brand
VIDEX EC
generic
EMTRIVA
brand
COMPLERA
brand
EPIVIR
COMBIVIR
ZERIT
RETROVIR
generic
generic
generic
generic
Nucleoside/Nucleotide Reverse - Transcriptase Inhibitor Combination - Diagnosis Required
cobicistat/elvitegravir/ emSTRIBILD
tricitabine/tenofovir
efavirenz/emtricitabine/
ATRIPLA
tenofovir
emtricitabine/tenofovir
TRUVADA
brand
PA^
brand
brand
Nucleotide Analogues Nucleotide Reverse Transcriptase Inhibitor - Diagnosis Required
tenofovir
VIREAD
brand
atazanavir
REYATAZ
REYATAZ POWDER
PACKET
PREZISTA
LEXIVA
CRIXIVAN
KALETRA
VIRACEPT
NORVIR
INVIRASE
APTIVUS
brand
Protease Inhibitors - Diagnosis Required
atazanavir
darunavir
fosamprenavir
indinavir
lopinavir/ritonavir
nelfinavir
ritonavir
saquinavir mesylate
tipranavir
Miscellaneous
elvitegravir/cobicistat/
emtricitabine/tenofovir GENVOYA
alafenamide fumarate
brand
brand
brand
brand
brand
brand
brand
brand
brand
require prior authorization
brand
Diagnosis Required
TRIUMEQ
brand
Diagnosis Required
MEPRON
SIRTURO
ARALEN
CLEOCIN
generic
brand
generic
generic
PA
Miscellaneous
abacavir/dolutegravir/
lamivudine
atovaquone
bedaquiline
chloroquine phosphate
clindamycin
QL = Quantity Limit
ST = Step Therapy
^
manual PA process
29
150 mg and 300 mg only
Covered
Drug
brand
brand
brand
brand
brand
generic
generic
brand
generic
generic
brand
Generic Drug Name
Brand Drug Name
cobicistat
dapsone
darunavir/cobicistat
dolutegravir
etravirine
hydroxychloroquine
linezolid
maraviroc
mefloquine
metronidazole
neomycin sulfate
TYBOST
DAPSONE
PREZCOBIX
TIVICAY
INTELENCE
PLAQUENIL
ZYVOX
SELZENTRY
LARIAM
FLAGYL
nitazoxanide suspension
ALINIA SUSPENSION
brand
nitazoxanide tablet
nitrofurantoin
extended-release
nitrofurantoin
macrocrystals
ALINIA
brand
nitrofurantoin susp
palivizumab
paromomycin
povidone-iodine
primaquine
pyrimethamine
raltegravir
MACROBID
generic
MACRODANTIN
generic
FURADANTIN SUSP
25 MG/5 ML
SYNAGIS
HUMATIN
DARAPRIM
ISENTRESS
generic
brand
generic
generic
generic
brand
brand
raltegravir
ISENTRESS CHEWABLE
brand
raltegravir susp
ISENTRESS SUSP
brand
trimethoprim
TRIMETHOPRIM
generic
Diagnosis Required
Diagnosis Required
Diagnosis Required
Diagnosis Required
PA
Diagnosis Required
tabs only
PA
PA
OTC
PA
Diagnosis Required
chewable tablet,
Diagnosis Required
Members ≥ 2 years
of age will require
prior authorization.
Diagnosis Required
tabs only
Musculoskeletal
Arthritis
Disease Modifying Anti-Rheumatic Drugs
adalimumab
anakinra
auranofin
azathioprine
HUMIRA
KINERET
RIDAURA
IMURAN
brand
brand
brand
generic
PA, SP
PA, SP
Only available through manual PA process
^
QL = Quantity Limit
ST = Step Therapy
^
manual PA process
30
DEPEN TITRATABLE
AZULFIDINE
Covered
Drug
brand
brand
generic
generic
generic
brand
generic
AZULFIDINE EN-TABS
generic
Generic Drug Name
Brand Drug Name
certolizumab pegol
etanercept
hydroxychloroquine
leflunomide
methotrexate
penicillamine
sulfasalazine
sulfasalazine
delayed-release
CIMZIA
ENBREL
PLAQUENIL
ARAVA
acetaminophen
TYLENOL
BAYER
NSAIDs and Other Analgesics
aspirin
capsaicin
celecoxib
ECOTRIN
etodolac
CELEBREX
VOLTAREN 1% TOPICAL
GEL
LODINE
ibuprofen
ADVIL
diclofenac 1% gel
MOTRIN
INDOCIN
ORUDIS
MOBIC
NAPROSYN
ENTERIC COATEDnaproxen delayed release
NAPROSYN
oxaprozin
DAYPRO
piroxicam
FELDENE
sulindac
CLINORIL
Gout
generic
OTC
brand
generic
OTC
PA, QL
generic
PA
generic
IR only
tabs, chew tabs
and susp, OTC
tabs, chew tabs and susp
generic
generic
generic
generic
generic
generic
generic
generic
generic
brand
brand
generic
chlorzoxazone
cyclobenzaprine
methocarbamol
orphenadrine
extended-release
PARAFON FORTE DSC
FLEXERIL
ROBAXIN
generic
generic
generic
NORFLEX
generic
baclofen
BACLOFEN
generic
QL = Quantity Limit
ST = Step Therapy
IR only
QL
generic
ZYLOPRIM
MITIGARE
ULORIC
PROBENECID
Spasticity
PA, SP
OTC
allopurinol
colchicine
febuxostat
probenecid
Skeletal Muscle Relaxants
Muscle Spasm
PA, SP
PA, SP
generic
generic
ibuprofen
indomethacin
ketoprofen
meloxicam
naproxen
^
manual PA process
31
ST
Generic Drug Name
Brand Drug Name
dantrolene
diazepam
tizanidine
DANTRIUM
VALIUM
ZANAFLEX
Covered
Drug
generic
generic
generic
desogestrel/EE
norethindrone/EE
MIRCETTE
ORTHO-NOVUM 10/11
generic
generic
QL
QL
levonorgestrel
levonorgestrel
PLAN B
PLAN B ONE STEP
generic
generic
QL
1.5 mg tab
levonorgestrel/EE
SEASONALE
generic
QL
medroxyprogesterone
acetate
DEPO-PROVERA
generic
QL
QL
tabs only, QL
OB-GYN
Contraceptives
Biphasic
Emergency Contraception
Extended Cycle
Injectable
Intravaginal
etonogestrel/EE
NUVARING
ORTHO COIL
brand
ring, QL
ortho diaphragm
ORTHO FLAT
brand
QL
generic
generic
0.1/20, QL
1/20, QL
generic
1/20, QL
ORTHO FLEX
Monophasic - 20 mcg Estrogen
levonorgestrel/EE
ALESSE
norethindrone acetate/EE LOESTRIN 1/20
norethindrone acetate/EE/
LOESTRIN FE 1/20
iron
desogestrel/EE
levonorgestrel/EE
norethindrone acetate/EE
norethindrone acetate/EE/
iron
norgestrel/EE
ORTHO-CEPT
NORDETTE
LOESTRIN 1.5/30
generic
generic
generic
0.15/30, QL
0.15/30, QL
1.5/30, QL
LOESTRIN FE 1.5/30
generic
1.5/30, QL
LO/OVRAL
generic
0.3/30, QL
ethynodiol diacetate/EE
norethindrone/EE
norethindrone/EE
norethindrone/EE
norgestimate/EE
ZOVIA 1/35
BALZIVA
MODICON
ORTHO-NOVUM 1/35
ORTHO-CYCLEN
generic
generic
generic
generic
generic
1/35, QL
0.4/35, QL
0.5/35, QL
1/35, QL
0.25/35, QL
ethynodiol diacetate/EE
ZOVIA 1/50
generic
1/50, QL
QL = Quantity Limit
ST = Step Therapy
^
manual PA process
32
Generic Drug Name
Brand Drug Name
norethindrone/EE
norethindrone/ME
norgestrel/EE
OVCON 50
ORTHO-NOVUM 1/50
OVRAL
Covered
Drug
generic
generic
generic
norethindrone
norgestrel
ORTHO MICRONOR
OVRETTE
generic
generic
norelgestromin/EE
ORTHO EVRA
generic
desogestrel/EE
levonorgestrel/EE
norethindrone
acetate/EE/iron
norethindrone/EE
norethindrone/EE
norgestimate/EE
CYCLESSA
TRIVORA
generic
generic
QL
QL
ESTROSTEP FE
generic
QL
ORTHO-NOVUM 7/7/7
TRI-NORINYL
ORTHO TRI-CYCLEN
generic
generic
generic
QL
QL
QL
danazol
DANOCRINE
generic
Gender edits apply: for female
patients only.
Progestin
Transdermal
Triphasic
Endometriosis
Hormone Therapy/Menopause
Estrogens - Intravaginal
estradiol
estrogens, conjugated
ESTRACE CRM
PREMARIN
estradiol
estrogens, conjugated
estrogens, conjugated,
synthetic A
synthetic B
estropipate
ESTRACE
PREMARIN
generic
brand
CENESTIN
brand
ENJUVIA
brand
OGEN
generic
estradiol
CLIMARA
generic
Estrogens - Oral
Estrogens - Transdermal
Estrogen/Progestin
estrogens, conjugated/me- PREMPHASE
droxyprogesterone
PREMPRO
brand
brand
1/50, QL
1/50, QL
0.5/50, QL
crm
QL
brand
Progestins
medroxyprogesterone
acetate
norethindrone acetate
Vaginal Infections
PROVERA
generic
AYGESTIN
generic
QL = Quantity Limit
ST = Step Therapy
^
manual PA process
33
Brand Drug Name
Covered
Drug
fluconazole
metronidazole
DIFLUCAN
FLAGYL
generic
generic
QL
tabs
clotrimazole
clindamycin
GYNE-LOTRIMIN
CLEOCIN
METROGEL-VAGINAL
generic
generic
OTC
crm
Generic Drug Name
Oral
Vaginal
metronidazole
miconazole
miconazole
terconazole
Miscellaneous
conjugated estrogen/
bazedoxifene
methylergonovine
tranexamic acid
METROGEL 1%
MONISTAT
MONISTAT 3
TERAZOL 3/7
DUAVEE
generic
generic
generic
generic
OTC
crm
brand
METHERGINE
LYSTEDA
generic
generic
OPTIVAR
CROLOM
ALAWAY OTC
generic
generic
brand
brand
PA
Ophthalmic
Allergy
azelastine
cromolyn sodium
ketotifen
naphazoline/antazoline
naphazoline/glycerin
naphazoline HCL
naphazoline/zinc sulfate
tetrahydrozoline/
zinc sulfate
CLEAR EYES REDNESS
RELIEF
VASOCLEAR
VASOCLEAR A
VISINE-AC
ST
QL
generic
generic
generic
soln 0.02%
generic
Anti-Inflammatories
Anti-Infective/Anti-Inflammatory Combinations
gentamicin/prednisolone
acetate
dexamethasone
hydrocortisone
sulfacetamide/pred phos
tobramycin/
dexamethasone
PRED-G
brand
MAXITROL
generic
CORTISPORIN
generic
VASOCIDIN
generic
TOBRADEX
generic
QL = Quantity Limit
ST = Step Therapy
^
manual PA process
34
10%/0.25%
Brand Drug Name
Covered
Drug
VOLTAREN
OCUFEN
ACULAR/ACULAR LS
generic
generic
generic
DEXASOL
generic
soln 0.1%
FML
FML FORTE
FML LIQUIFILM
PRED FORTE
PRED MILD
INFLAMASE FORTE
VEXOL
brand
brand
generic
generic
brand
generic
brand
oint 0.1%
susp 0.25%
susp 0.1%
1%
0.12%
1%
carteolol
levobunolol
metipranolol
timolol
timolol maleate
BETAGAN
OPTIPRANOLOL
TIMOPTIC XE
TIMOPTIC
generic
generic
generic
generic
generic
dorzolamide
TRUSOPT
generic
dorzolamide/
timolol maleate
COSOPT
generic
ecothiophate
PHOSPHOLINE IODINE
brand
atropine
cyclopentolate
homatropine
scopolamine
ISOPTO ATROPINE
CYCLOGYL
ISOPTO HOMATROPINE
ISOPTO HYOSCINE
generic
generic
generic
brand
acetazolamide
acetazolamide
extended-release
methazolamide
ACETAZOLAMIDE
generic
DIAMOX SEQUELS
generic
NEPTAZANE
generic
latanoprost
XALATAN
generic
pilocarpine
pilocarpine
ISOPTO CARPINE
PILOPINE HS GEL
generic
brand
Generic Drug Name
Nonsteroidal
diclofenac sodium
flurbiprofen
ketorolac
Steroidal
dexamethasone sodium
phosphate
fluorometholone
fluorometholone
fluorometholone
prednisolone acetate
prednisolone acetate
prednisolone phosphate
rimexolone
Glaucoma
Beta-Blockers
Carbonic Anhydrase Inhibitors
ophthalmic solution
0.3% ophthalmic solution
gel forming solution
Carbonic Anhydrase Inhibitor/Beta-Blocker Combination
Cholinesterase Inhibitor
Mydriatics
Oral
Prostaglandins
Topical - Parasympathomimetics
QL = Quantity Limit
ST = Step Therapy
^
manual PA process
35
QL
Generic Drug Name
Covered
Drug
ALPHAGAN P
ALPHAGAN P
ALPHAGAN
brand
generic
generic
0.1%
0.15%
0.2%
CILOXAN
ERYTHROMYCIN
ZYMAR
GENTAK
generic
generic
generic
brand
generic
NEOSPORIN
generic
OCUFLOX
POLYSPORIN
POLYTRIM
BLEPH-10
generic
generic
generic
generic
Brand Drug Name
Topical - Sympathomimetics
brimonidine
brimonidine
brimonidine
Infections
Bacterial
bacitracin
ciprofloxacin
erythromycin
gatifloxin
gentamicin
gramicidin
ofloxacin
polymyxin B/bacitracin
polymyxin B/trimethoprim
sulfacetamide
sulfacetamide/
phenylephrine
tobramycin
Viral
trifluridine
Miscellaneous
cysteamine 0.44%
ophthalmic solution
sodium chloride
hypertonic
VASOSULF
PA
oint/soln
brand
TOBREX
generic
VIROPTIC
generic
CYSTARAN
brand
PA, SP
MURO 128
generic
soln 5%
acamprosate
disulfiram
naltrexone
CAMPRAL
ANTABUSE
REVIA
brand
generic
generic
alprazolam
chlordiazepoxide
clonazepam
clorazepate
diazepam
lorazepam
XANAX
LIBRIUM
KLONOPIN
TRANXENE
VALIUM
ATIVAN
generic
generic
generic
generic
generic
generic
Psychiatric
Alcohol Deterrents*
Anxiety*
Benzodiazepines
QL = Quantity Limit
ST = Step Therapy
^
manual PA process
36
QL, IR only
not wafers
QL
QL
Generic Drug Name
Brand Drug Name
oxazepam
SERAX
Covered
Drug
generic
buspirone
fluvoxamine
BUSPAR
LUVOX
generic
generic
ADDERALL
generic
Age Limits Apply, QL
ADDERALL XR
(BRAND ADDERALL XR
IS PREFERRED)
brand
atomoxetine
STRATTERA
brand
dextroamphetamine
guanfacine ER
lisdexamfetamine
DEXTROSTAT
INTUNIV
VYVANSE
brand
generic
brand
methylphenidate
RITALIN
generic
methylphenidate
extended-release
CONCERTA
generic
methylphenidate
extended-release
RITALIN-SR
generic
DEPAKOTE SPRINKLE
generic
DEPAKOTE
generic
Minimum age 2
LITHIUM CARBONATE
ESKALITH CR
generic
Miscellaeous
QL
Attention Deficit Hyperactivity Disorder (ADHD)* - Diagnosis Required
amphetamine/
dextroamphetamine
mixed salts
amphetamine/
dextroamphetamine
mixed salts
extended-release
Bipolar Disorder*
divalproex sodium
cap sprinkle
divalproex sodium
delayed-release
lithium carbonate
lithium carbonate
extended-release
Age Limits Apply,
Diagnoisis Required
Age Limits Apply,
tabs only, QL
METADATE ER
RITALIN LA
LITHOBID
Depression*
Monoamine Oxidase Inhibitor (MAOI)
generic
tranylcypromine
PARNATE
generic
citalopram
escitalopram
CELEXA
LEXAPRO
generic
generic
fluoxetine
PROZAC
generic
paroxetine
sertraline
PAXIL
ZOLOFT
generic
generic
Selective Serotonin Reuptake Inhibitor (SSRIs)
QL = Quantity Limit
ST = Step Therapy
^
manual PA process
37
QL
tablets, QL
10 mg and 20 mg caps and
20 mg soln only
tablets
QL
Generic Drug Name
Brand Drug Name
Serotonin Norepinephrine Reuptake Inhibitors (SNRIs)
Covered
Drug
duloxetine
venlafaxine
venlafaxine XR
CYMBALTA
EFFEXOR
EFFEXOR XR
generic
generic
generic
QL
QL
QL
amitriptyline
amoxapine
desipramine
doxepin
imipramine HCL
nortriptyline
ELAVIL
generic
generic
generic
generic
generic
generic
tablets
Tricyclic Antidepressants (TCAs)
NORPRAMIN
SINEQUAN
TOFRANIL
PAMELOR
Tricyclic Antidepressant/Phenothiazine Combination
amitriptyline/perphenazine TRIAVIL
Miscellaneous Agents
tablets
generic
bupropion
bupropion
extended-release
bupropion
extended-release
maprotiline
mirtazapine
trazodone
WELLBUTRIN
generic
WELLBUTRIN SR
generic
QL
WELLBUTRIN XL
generic
150 mg and 300 mg
LUDIOMIL
REMERON
DESYREL
generic
generic
generic
tabs (not soltabs)
50, 100, & 150 mg only
flurazepam
temazepam
triazolam
DALMANE
RESTORIL
HALCION
generic
generic
generic
QL
15 mg and 30 mg only, QL
QL
chloral hydrate
diphenhydramine
zaleplon
zolpidem
CHLORAL HYDRATE
NYTOL QUICK CAPS
SONATA
AMBIEN
generic
generic
generic
generic
OTC
QL
QL
alprazolam ODT
alprazolam tab SR 24HR
amphetamine sulfate
amphetamine susp extended release
amphetamine tab extended release dispersible
aripiprazole lauroxil IM ER
susp
NIRAVAM
XANAX XR
EVEKEO
generic
generic
brand
Age Limits Apply
aripiprazole ODT
Insomnia
Benzodiazepines
Non-Benzodiazepines
Medications Coverable for Participating Behavioral Health Prescribers±
DYANAVEL XR
brand
ADZENYS XR-ODT
brand
ARISTADA
brand
ABILIFY DISCMELT
brand
QL = Quantity Limit
ST = Step Therapy
^
manual PA process
38
Age Limits Apply,
Diagnosis Required
Generic Drug Name
Brand Drug Name
Covered
Drug
aripiprazole oral solution
ABILIFY SOLUTION
brand
Age Limits Apply,
Diagnosis Required
SAPHRIS
brand
Diagnosis Required
REXULTI
brand
QL
SUBOXONE
brand
QL, 4 & 12mg
SUBOXONE
generic
QL
ZUBSOLV
brand
QL
BUNAVAIL
brand
QL
FORFIVO XL
brand
asenapine maleate
sublingual
brexpiprazole
buprenorphine hcl-naloxone hcl SL film
buprenorphine hcl-naloxone hcl SL tab
buprenorphine hcl-naloxone hcl SL
buprenorphine-naloxone
buccal film
bupropion HCL tab SR
24HR
bupropion hcl (smoking
deterrent) tab SR 12hr
bupropion hydrobromide
carbamazepine
(antipsychotic) cap
SR 12HR
cariprazine
chlordiazepoxideamitriptyline
clomipramine
clonazepam ODT
clonidine HCL tab
SR 12HR
ZYBAN
generic
APLENZIN
brand
EQUETRO
brand
VRAYLAR
brand
LIMBITROL DS
generic
ANAFRANIL
KLONOPIN WAFER
generic
generic
KAPVAY
generic
clozapine
CLOZARIL
generic
clozapine ODT
clozapine susp
FAZACLO
VERSACLOZ
DESVENLAFAXINE
FUMARATE TAB SR
24HR
generic
brand
PRISTIQ
generic
KHEDEZLA
generic
dexmethylphenidate
FOCALIN
generic
dexmethylphenidate HCL
cap SR 24 HR
FOCALIN XR
generic
desvenlafaxine fumarate
tab SR 24HR
desvenlafaxine succinate
tab SR 24HR
desvenlafaxine tab SR
24HR
QL = Quantity Limit
ST = Step Therapy
Age Limits Apply,
Diagnosis Required
200 mg, Age Limits Apply,
Diagnosis Required
Diagnosis Required
Diagnosis Required
generic
^
manual PA process
39
Age Limits Apply,
Diagnosis Required
Age Limits Apply,
Diagnosis Required
Generic Drug Name
Brand Drug Name
dextroamphetamine
ZENZEDI
dextroamphetamine
sulfate oral solution
diazepam concentrate
solution
divalproex sodium SR
24hr
duloxetine
escitalopram 10mg &
methylfolate-B12-B6-D
thpk
escitalopram oxalate soln
fluoxetine capsule
fluoxetine HCL (PMDD)
tabs
fluoxetine HCL cap
delayed-release 90 mg
fluoxetine tablet
fluvoxamine maleate cap
SR 24HR
haloperidol lactate oral
conc
iloperidone
imipramine pamoate
isocarboxazid
lamotrigine ODT
lamotrigine SR 24hr
levomilnacipran
lorazepam concentrate
solution
loxapine aerosol powder
breath activated
lurasidone
meprobamate tablet
methamphetamine
methylphenidate
chew tabs
methylphenidate
extended-release
Covered
Drug
brand
PROCENTRA
generic
DIAZEPAM INTENSOL
generic
DEPAKOTE ER
generic
IRENKA
generic
PRAMLYTE
LEXAPRO ORAL
SOLUTION
PROZAC
SARAFEM
Age Limits Apply,
Diagnosis Required
Age Limits Apply,
Diagnosis Required
QL
brand
generic
oral solution
generic
40mg
brand
PROZAC WEEKLY
generic
FLUOXETINE
generic
LUVOX CR
generic
HALDOL CONCENTRATE
generic
QL
FANAPT
TOFRANIL-PM
MARPLAN
LAMICTAL ODT
LAMICTAL XR
FETZIMA
brand
generic
brand
generic
generic
brand
Diagnosis Required
LORAZEPAM INTENSOL
generic
ADASUVE
brand
LATUDA
EQUANIL
brand
generic
DESOXYN
generic
METHYLIN
generic
APTENSIO XR
QL = Quantity Limit
ST = Step Therapy
brand
^
manual PA process
40
Diagnosis Required
Age Limits Apply,
Diagnosis Required
Age Limits Apply,
Diagnosis Required
Age Limits Apply,
Diagnosis Required
Generic Drug Name
Brand Drug Name
methylphenidate
extended-release
QUILLIVANT XR
suspension
methylphenidate HCL
METADATE CD
cap CR
methylphenidate hcl chew
QUILLICHEW ER
tab extended release
Covered
Drug
brand
Age Limits Apply,
Diagnosis Required
generic
Age Limits Apply,
Diagnosis Required
brand
Age Limits Apply,
Diagnosis Required
methylphenidate patch
DAYTRANA
mirtazapine ODT
molindone
naloxone hcl solution autoinjector
nefazodone
nicotine inhaler system
nicotine nasal spray
nicotine TD patch
24 HR kit
olanzapine-fluoxetine
olanzapine INJ
REMERON SOLTAB
MOBAN
SERZONE
NICOTROL INHALER
NICOTROL NS
NICOTINE TD PATCH
24 HR KIT
SYMBYAX
ZYPREXA
generic
brand
brand
olanzapine ODT
ZYPREXA ZYDIS
generic
olanzapine pamoate for
extended-release
IM sus
Age Limits Apply,
Diagnosis Required
ZYPREXA RELPREVV
brand
Diagnosis Required
generic
Age Limits Apply,
Diagnosis Required
EVZIO
brand
generic
brand
brand
paliperidone tab SR 24HR INVEGA
generic
generic
PAXIL
risperidone ODT
RISPERDAL M-TAB
generic
selegiline td patch
trazodone
trimipramine
EMSAM
DESYREL
SURMONTIL
brand
generic
brand
brand
PAXIL CR
generic
PEXEVA
NARDIL
NUPLAZID
VIVACTIL
brand
generic
brand
generic
SEROQUEL XR
QL
QL
brand
paroxetine HCL oral susp
paroxetine HCL tab SR
24HR
paroxetine mesylate tab
phenelzine
pimavanserin
protriptyline
quetiapine fumarate tab
SR 24HR
QL = Quantity Limit
ST = Step Therapy
QL
brand
^
manual PA process
41
Age Limits Apply,
Diagnosis Required
Age Limits Apply,
Diagnosis Required
300mg
Generic Drug Name
valproic acid cap
delayed-release
venlafaxine HCL tab
SR 24HR
vilazodone
vortioxetine
Narcotic Antagonists*
Brand Drug Name
STAVZOR
VENLAFAXINE HCL TAB SR
24HR
VIIBRYD
TRINTELLIX
buprenorphine
SUBUTEX
buprenorphine/naloxone
SUBOXONE
naloxone
naloxone
naltrexone
NALOXONE INJ
NARCAN NASAL SPRAY
REVIA
Psychoses
Atypicals* - Diagnosis Required
Covered
Drug
brand
generic
brand
brand
generic
brand
generic
brand
generic
PA, QL*
2 mg and 8 mg film only,
PA, QL*
QL
aripiprazole
ABILIFY TABLETS
aripiprazole ER injection
ABILIFY MAINTENA
clozapine
CLOZARIL
generic
olanzapine
ZYPREXA
generic
paliperidone
paliperidone
quetiapine
INVEGA SUSTENNA
INVEGA TRINZA
SEROQUEL
brand
brand
generic
risperidone
RISPERDAL
generic
risperidone
RISPERDAL CONSTA
risperidone oral soln
RISPERDAL SOLUTION
generic
ziprasidone
GEODON
generic
Age Limit Applies, tablets,
PA, QL, Certain daily doses
require half tablet dosing:
5 mg once daily – must be
dosed as 10 mg tablet, ½
tab once daily 10 mg once
daily – must be dosed as 20
mg tablet, ½ tab once daily
15 mg once daily – must be
dosed as 30 mg tablet, ½ tab
once daily
Age Limit Applies, PA, QL
Age Limit Applies, 25mg,
50mg & 100mg only
Age Limit Applies,
tablets, QL
Age Limit Applies, QL
Age Limit Applies, QL,
(Not M-Tabs)
QL, Members ≥ 8 years of age
nicotine
nicotine polacrilex gum
NICODERM CQ
NICORETTE OTC
generic
generic
patches, QL
QL
Smoking Cessation*
QL = Quantity Limit
ST = Step Therapy
generic
brand
brand
^
manual PA process
42
Generic Drug Name
Brand Drug Name
nicotine polacrilex lozenge COMMITT OTC
varenicline
CHANTIX
Miscellaneous
Covered
Drug
generic
brand
QL
QL
chlorpromazine
dextromethorphan/
quinidine
fluphenazine
fluphenazine decanoate
THORAZINE
generic
Diagnosis Required
NUEDEXTA
brand
PA
PROLIXIN
PROLIXIN DECANOATE
generic
generic
haloperidol
HALDOL
generic
haloperidol decanoate
loxapine
perphenazine
pimozide
thioridazine
thiothixene
trifluoperazine
HALDOL DECANOATE
LOXITANE
TRILAFON
ORAP
MELLARIL
NAVANE
STELAZINE
generic
generic
generic
generic
generic
generic
generic
Diagnosis Required
Diagnosis Required
Diagnosis Required,
tablets only
Diagnosis Required
Diagnosis Required
Diagnosis Required
Diagnosis Required
Diagnosis Required
Diagnosis Required
Respiratory Drugs
Antitussives, Decongestants, Expectorants and Combinations
benzonatate
brompheniramine &
phenylephrine
brompheniramine/
pseudoephedrine
brompheniramine/
pseudoephedrine
brompheniramine/
pseudoephedrine
brompheniramine/
pseudoephedrine/
dextromethorphan
brompheniramine/
pseudoephedrine/
dextromethorphan
TESSALON
DIMETAPP CLD ELX/
ALLERGY
ACCUHIST DROPS
RESPERAL-DM
BROMFENEX PD CAP
DIMETAPP ELX
CLD/ALLE
generic
generic
generic
liquid
generic
UNI-HIST DRO
CARDEC SYP
RONDEC SYRUP
generic
syrup
ACCUHIST PDX DROPS
generic
liquid
BROMALINE DM
generic
elixir
QL = Quantity Limit
ST = Step Therapy
^
manual PA process
43
Generic Drug Name
Covered
Drug
generic
syrup
HISTACOL DM
generic
syrup
RYNATUSS
generic
RONDEC DROPS
generic
liquid
generic
syrup
TUSSI-12 S
generic
susp
TANAFED
generic
susp
TRIOTANN PEDIATRIC
SUSP
generic
susp
Brand Drug Name
BROMFED DM
brompheniramine/
pseudoephedrine/
dextromethorphan
brompheniramine/
pseudoephedrine/
dextromethorphan/
guaifenesin
carbetapentane/
chlorpheniramine/
ephedrine/
phenylephrine
carbinoxamine/
pseudoephedrine
chlorphen-PEmethscopolamine
chlorphen tan/
carbetapentane tan
chlorphen tan/
pseudoeph tan
chlorphen tan/pyrilamine
tan/PE tan
chlorpheniramine/
dextromethorphan
DALLERGY DM
CARBOFED
NEO DM
ANAPLEX DM
DURADRYL
QV-ALLERGY
R-TANNAMINE
ROBITUSSIN PED LIQ
CGH/COLD
ROBITUSSIN LIQ
CGH/CLD
generic
DIMETAPP SYP CGH/CLD
CORICIDIN TAB
CGH/CLD
chlorpheniramine maleate ED A-HIST TABLETS AND
phenylephrine HCL
LIQUID
RONDEC DROPS
chlorpheniramine/
phenylephrine
CARDEC DRO
RONDEC SYRUP
chlorpheniramine/
phenylephrine
CARDEC SYP
chlorpheniramine tan/
RYNATAN PEDIATRIC SUSP
phenylephrine tan
QL = Quantity Limit
ST = Step Therapy
generic
generic
liquid
generic
syrup
generic
susp
^
manual PA process
44
Generic Drug Name
Brand Drug Name
chlorpheniramine/
pseudoephedrine
codeine/
chlorpheniramine/
pseudoephedrine
HISTEX
codeine/guaifenesin
GG/CODEINE
CPM/PSE
DIHISTINE DH
PHENYLHIST LIQ DH
Covered
Drug
generic
generic
GUIATUSS AC
generic
QL
M-CLEAR WC
codeine/guaifenesin/pseuGUIATUSS DAC
doephedrine
PROMETHAZINE
codeine/promethazine
W/CODEINE
codeine/promethazine/
PROMETHAZINE VC
phenylephrine
W/CODEINE
dextromethorphan/
brompheniramine/
BROMETANE DX
pseudoephedrine
dextromethorphan/
carbinoxamine/
CARDEC-DM
pseudoephedrine
dextromethorphanDURATUSS DM ELX
guaifenesin
GG/DM CR
dextromethorphan/
guaifenesin
dextromethorphanguaifenesin
dextromethorphan hbr
dextromethorphan
polistirex
extended-release
dextromethorphan/
promethazine
guaifenesin
guaifenesin
guaifenesin
extended-release
MUCINEX DM
ROBITUSSIN DM
TUSSIN DM
ROBITUSSIN LIQ CGH/
CONG
ROBITUSSIN SYP MAX-ST
ROBITUSSIN PED SYP
DELSYM
PHENERGAN DM
PROMETHAZINE SYP DM
ROBITUSSIN
ROBITUSSIN SYP
CHST CNG
MUCINEX
QL = Quantity Limit
ST = Step Therapy
generic
generic
QL
generic
QL
generic
generic
drops
generic
soln 25-225 mg/5 ml
generic
OTC
generic
liq 10-200 mg/ 5 ml
generic
syrup
brand
OTC
generic
generic
OTC
generic
syrup 100 mg/5 ml
generic
OTC
^
manual PA process
45
Generic Drug Name
Brand Drug Name
guaifenesin/
pseudoephedrine
guaifenesin/
pseudoephedrine/
dextromethorphan
guaifenesin/
pseudoephedrine
extended-release
ROBITUSSIN PE
guaifenesin/
pseudoephedrine
extended-release
hydrocodone/
chlorpheniramine/
phenylephrine
hydrocodone/guaifenesin
hydrocodone/homatropine
loratadine &
pseudoephedrine SR
24hr
phenyleph/bromphen/
dextromethorphan/
guaifenesin
phenylephrine/
brompheniramine/
dextromethorphan
phenylephrine/
chlorpheniramine
phenylephrine/
chlorpheniramine/
dextromethorphan
phenylephrine/
chlorpheniramine/
dextromethorphan
PSE/GG
Covered
Drug
generic
syrup, OTC
ROBITUSSIN CF
generic
GUAIFED
generic
GUAIFEN PSE
MUCINEX D
generic
OTC
GG/PSE CR
HISTUSSIN HC
VITUSSIN
HYDROCODO/GG SYP
HYCODAN
HYDROMET SYP
HYDROCODONE/
TAB HOMATROP
generic
generic
generic
ALLERGY/CONG TAB RELIEF
generic
ALLANHIST SYP PDX
generic
generic
tab 10-240 mg
OTC
QUAL-TUSSIN SYP DC
generic
ATUSS DR
generic
syrup
DE-CHLOR DM
generic
syrup
QL = Quantity Limit
ST = Step Therapy
^
manual PA process
46
Generic Drug Name
phenylephrine/
chlorpheniramine/
dextromethorphan
phenylephrine/
chlorpheniramine/
dextromethorphan
phenylephrine/
chlorpheniramine/
dihydrocodeine
phenylephrine/
dextromethorphan
phenylephrine/
dextromethorphan/
guaifenesin
phenylephrine/ephed/
CPM
w/carbetapentane
phenylephrine/guaifenesin
phenylephrine/
hydrocodone/
guaifenesin
phenylephrine/
pyrilamine/
dextromethorphan
phenylephrine/
pyrilamine
w/hydrocodone
phenylephrine tan/
pyrilamine tan/
carbeta tan
promethazine &
phenylephrine
pseudoephedrine/
acetaminophen/
dextromethorphan
Brand Drug Name
Covered
Drug
generic
syrup
generic
liquid
RONDEC DM
STATUSS DM SYP
CARDEC DM SYP
MINUTUSS DR SYP
RONDEC DM DROPS
CARDEC DM DRO
ROBITUSSIN LIQ
CGH/ALRG
DIHYDRO-PE SYP
generic
DIMETAPP DRO
DCON/CGH
generic
ROBITUSSIN LIQ
CGH/CLD
generic
RYNATUSS PEDIATRIC
SUSP
generic
ROBITUSSIN LIQ
HD/CHST
generic
QUAL-TUSSIN SYP DC
generic
CODAL-DM
generic
CODIMAL DH
generic
syrup
TUSSI 12D S
generic
susp
PROMETH VC SYP
6.25-5/5
generic
syrup 6.25-5 mg/ 5 mg
MAPAP COLD TAB
generic
QL = Quantity Limit
ST = Step Therapy
^
manual PA process
47
susp
Generic Drug Name
pseudoephedrine/
chlorpheniramine/
dextromethorphan
pseudoephedrine/
dextromethorphan/
guaifenesin
pseudoephedrine/
iburprofen
pseudoephedrine tan/
dexchlorphen tan/
DM tan
pyrilamine tan/
phenyleph tan
tripolidine/
pseudoephedrine
Asthma/COPD
Inhalers - Beta Agonists
Brand Drug Name
PEDIACARE LIQ
MULTI-SY
ROBITUSSIN LIQ PED
NGHT
MULTI SYMPTOM TAB
COLD RLF
CHILD IBUPRO
SUS COLD
IBUOROFEN TAB
COLD/SIN
TANAFED DMX
SUSPENSION
Covered
Drug
generic
generic
generic
generic
susp
generic
susp
TRI-FED X
RYNA-12 S
TRIPROL/PSE SYP
APHEDRID TAB
generic
albuterol sulfate
indacaterol
olodaterol
VENTOLIN HFA
ARCAPTA NEOHALER
STRIVERDI RESPIMAT
brand
brand
brand
QL
fluticasone furoate
mometasone
mometasone inhalation
ARNUITY ELLIPTA
ASMANEX TWISTHALER
ASMANEX HFA
brand
brand
brand
QL
QL
QL
fluticasone/vilanterol
mometasone/formoterol
BREO ELLIPTA
DULERA
brand
brand
ST
ST
cromolyn
ipratropium/albuterol
ipratropium HFA
nedocromil
omalizumab
umeclidinium inhalation
umeclidinium/vilanterol
INTAL
COMBIVENT
COMBIVENT RESPIMAT
ATROVENT HFA
TILADE
XOLAIR
INCRUSE ELLIPTA
ANORO ELLIPTA
brand
brand
brand
brand
brand
brand
brand
brand
QL
QL
inhaler
Inhalers - Corticosteroids
Inhalers -Corticosteroid/Beta Agonist Combinations
Inhalers - Others
Inhalers for Nebulization
QL = Quantity Limit
ST = Step Therapy
^
manual PA process
48
PA, SP
Generic Drug Name
Brand Drug Name
Covered
Drug
0.63 mg/3 ml and 1.25 mg /3
ml, Covered for members less
than 8 years of age. Members
≥ 8 years of age will require
prior authorization.
soln 0.083%, 0.5%
susp, Members ≥ 5 years
authorization. QL
soln, QL
soln, QL
soln
QL, ST
albuterol
ACCUNEB
generic
albuterol
PROVENTIL
generic
budesonide
PULMICORT RESPULES
generic
cromolyn
ipratropium
levalbuterol HCl
INTAL
ATROVENT
DUONEB
XOPENEX RESPULES
generic
generic
generic
generic
metaproterenol
terbutaline
METAPROTERENOL SYRUP generic
BRETHINE
generic
montelukast
SINGULAIR
generic
QL
theophylline
theophylline
extended-release
theophylline
extended-release
theophylline
extended-release
theophylline
extended-release
THEOPHYLLINE
generic
liquid
brand
caps
THEOCHRON
generic
tabs
THEOPHYLLINE EXT-REL
generic
caps (12 hr)
UNIPHYL
generic
tabs
Oral Agents - Beta Agonists
Oral Agents - Leukotriene Modifiers
Oral Agents - Theophylline
THEO-24
Urological
Symptomatic Benign Prostatic Hypertrophy
alfuzosin ER
doxazosin
finasteride
tamsulosin
terazosin
UROXATRAL
CARDURA
PROSCAR
FLOMAX
HYTRIN
generic
generic
generic
generic
generic
bethanechol
URECHOLINE
generic
Miscellaneous
QL = Quantity Limit
ST = Step Therapy
^
manual PA process
49
Generic Drug Name
Brand Drug Name
hyoscyamine,
methenamine,
phenyl salicylate,
UTIRA C
sodium phosphate
monobasic, methylene
blue
HIPREX
methenamine hippurate
UREX
oxybutynin chloride
DITROPAN XL
oxybutynin IR
DITROPAN
potassium citrate
UROCIT-K
propantheline
phenazopyridine
PYRIDIUM
sodium citrate/citric acid BICITRA
tolterodine
DETROL
trospium
SANCTURA
Covered
Drug
brand
generic
generic
generic
generic
generic
generic
generic
generic
generic
QL, ST
ST
ST
Vitamins and Minerals
calcitriol
ROCALTROL
generic
calcitriol oral soln
ROCALTROL SOLUTION
generic
calcium
cholecalciferol
cholecalciferol
cholecalciferol
cholecalciferol
OS-CAL
VITAMIN D TAB 400 UNIT
VITAMIN D CAP 400 UNIT
VITAMIN D CAP
2000 UNIT
D3-50 CAP
BIO-D DRO-MULSION
BIO-D-MULSIO
DRO FORTE
generic
brand
brand
brand
brand
OTC
tab 400 unit, OTC
tab 1000 unit, OTC
tab 2000 unit, OTC
cap 400 unit, OTC
brand
cap 2000 unit, OTC
brand
brand
cyanocobalamin
VITAMIN B-12
generic
electrolyte
PEDIALYTE
generic
cap 50000 unit, OTC
drops 400 unit/0.03 ml, OTC
drops 2000 unit/0.03 ml,
OTC
inj, Coverage for these
medications will be
determined by the member’s
individual benefits.
Please refer to individual
plan documents for coverage
information.
soln, oral, OTC
cholecalciferol
cholecalciferol
cholecalciferol
cholecalciferol
QL = Quantity Limit
ST = Step Therapy
brand
^
manual PA process
50
Generic Drug Name
ergocalciferol (D2)
ferrous bisglycinate/polysaccarides iron
ferrous sulfate
Covered
Drug
DRISDOL
generic
Coverage for these
medications will be
information.
NIFEREX
generic
caps, OTC
FEOSOL
GEL-KAM
generic
OTC
Coverage for these
medications will be
information.
Brand Drug Name
LURIDE
fluoride
LURIDE LOZI-TABS
generic
PREVIDENT
PHOS-FLUR
folic acid
FOLIC ACID
generic
magnesium oxide
MAG-OX
generic
multivitamins/
fluoride/±iron
POLY-VI-FLOR
generic
multivitamins/minerals
CENTRUM
generic
phytonadione
polysaccharide iron
complex
MEPHYTON
brand
NIFEREX
QL = Quantity Limit
ST = Step Therapy
generic
^
manual PA process
51
OTC, Coverage for these
medications will be
information.
Coverage for these
medications will be
information.
medications will be
information.
elixir, OTC
Generic Drug Name
prenat-FE Bis-FE
prot succ-FA-CA
& omega 3
prenat-FE Bis-FE
prot succ-FA-CA
& omega 3
prenat-FE Bis-FE
prot succ-FA-CA
& omega 3
prenat-FE bis-FE
prot succ-FA-CA
& omega DR
prenat w/o A w/fecbn-feglDSS-FA & DHA
prenatal vit w/FE
bisglyc-FE prot
succ-FA
prenatal vit w/FE
bisglycinate
chelate-FA
prenatal vit w/FE
bisglycinate
chelate-FA
prenatal vit w/FE b
isglycinate chelate-FA
prenatal vit w/FE
polysac cmplx-FA
prenatal vit w/ iron
carbonyl-FA
prenatal vitamins
w/folic acid
Brand Drug Name
Covered
Drug
COMPLETE NATALCARE
PAK DHA
brand
TRUST NATALCARE
PAK DHA
brand
PRUET DHA PAK
SETONET PAK
brand
PRUET DHAEC PAK
brand
FOLTABS PAK PLUS DHA
RE OB + DHA PAK
brand
VINATE III
brand
VITAPHIL
brand
GENTEX ADE 28-1 MG
brand
VINATE AZ EX
brand
EDGE OB CHW
brand
ATABEX PRENATAL
brand
PRENATAL VITAMINS W/
FOLIC ACID
CENOGEN OB/ULTRA
MATERNA
generic
QL
brand
tab 32-1 mg
NATALCARE
NESTABSCBF/FA/RX
prenatal vit w/o vit a w/fe
bisglycinate-fa
prenatal w/o A w/ FE
carbonyl-FE
gluc-DSS-FA
NIFEREX-PN FORTE
FOLTABS PRENATAL
TRI RX
QL = Quantity Limit
ST = Step Therapy
brand
^
manual PA process
52
Generic Drug Name
Brand Drug Name
vitamin A
Covered
Drug
generic
vitamin ADC/fluoride/±iron
TRI-VI-FLOR
drops
generic
vitamin B complex/
vitamin C/folic acid
generic
NEPHROCAPS
vitamin B-1
vitamin C
vitamin B-6
vitamins pediatric
generic
generic
generic
TRI-VI-SOL
zinc
Potassium
generic
generic
OTC
Coverage for these
medications will be
information.
Coverage for these
medications will be
information.
OTC
OTC
OTC
members <3 years old,
medications will be
information.
OTC
phosphorus
potassium acid phosphate
potassium bicarbonate/
potassium citrate
effervescent
potassium chloride
potassium chloride
K-PHOS NEUTRAL
K-PHOS ORIGINAL
generic
brand
tabs
K-LYTE
generic
tabs
K-LOR
POTASSIUM CHLORIDE
K-DUR 10
generic
generic
powder
liquid
potassium chloride
extended-release
K-DUR 20
generic
tabs
generic
caps
potassium chloride
extended-release
potassium iodide
KLOR-CON 8
KLOR-CON 10
MICRO-K 10
PIMA
QL = Quantity Limit
ST = Step Therapy
brand
^
manual PA process
53
Generic Drug Name
Brand Drug Name
Covered
Drug
brand
QL
brand
PA, SP
generic
brand
brand
PA, SP
PA, SP
brand
PA, SP
brand
brand
PA, SP
PA, SP
Miscellaneous
Anaphylaxis
epinephrine
EPIPEN
EPIPEN JR.
TWINJECT
Cryopyrin — Associated Periodic Syndromes (CAPS)
canakinumab
ILARIS
acetylcysteine
aztreonam
dornase alfa
MUCOMYST
CAYSTON
PULMOZYME
KALYDECO
Cystic Fibrosis
ivacaftor
lumacaftor/ivacaftor
tobramycin neb soln
KALYDECO GRANULES
ORKAMBI
BETHKIS
C1 Inhibitor, Human
icatibant
BERINERT
FIRAZYR
brand
brand
PA, SP
PA, SP
calcium acetate
cinacalcet
sevelamer
PHOSLO
SENSIPAR
RENVELA
generic
brand
generic
667 mg tablet only
PA
ST
nintedanib
pirfenidone capsule
OFEV
ESBRIET
brand
brand
PA, SP
PA, SP
eltrombopag
PROMACTA
brand
PA, SP
Hereditary Angioedema
Hyperphosphatemia
Idiopathic Pulmonary Fibrosis (IPF)
Immune Thrombocytopenic Purpura
Medical Devices
spacers
Metabolic Modifiers
QL
carglumic acid
glycerol phenylbutyrate
sodium phenylbutyrate
oral powder
CARBAGLU
RAVICTI
BUPHENYL ORAL
POWDER
diphtheria-tetanus tox adsorbed (dt) im
DIP/TET PED INJ
Vaccine
hepatitis a vaccine susp
HAVRIX
VAQTA
hepatitis b vaccine (recom- ENGERIX-B
binant)
RECOMBIVAX HB
QL = Quantity Limit
ST = Step Therapy
brand
brand
PA, SP
PA, SP
generic
PA
brand
QL
brand
QL
brand
QL
^
manual PA process
54
Generic Drug Name
human papillomavirus
(hpv) 9-valent recomb
vac
(hpv) bival (type 16,
18) recmb vac
(hpv) quadrivalent
recombinant vac
influenza virus vaccine
recombinant hemagglutinin (ha)
split
split high-dose pf
split pf
split quadrivalent
tiss-cult subunit
types a&b surface
antigen
measles, mumps & rubella
virus vaccines for inj
meningococcal (a, c, y,
and w-135)
and w-135) conjugate
vaccine
and w-135) oligo conj
vac for inj
pneumococcal 13-valent
conjugate
pneumococcal vaccine
polyvalent
Covered
Drug
GARDASIL 9
brand
QL
CERVARIX
brand
QL
GARDASIL
brand
QL
FLUBLOK
brand
QL
brand
QL
FLUZONE HD PF
brand
QL
AFLURIA PF
brand
QL
brand
QL
FLUCELVAX
brand
QL
FLUVIRIN
brand
QL
M-M-R II
brand
QL
MENOMUNE
brand
QL
MENACTRA
brand
QL
MENVEO
brand
QL
PREVNAR 13
brand
QL
brand
QL
Brand Drug Name
AFLURIA
FLUZONE SPLT
FLUARIX QUAD
FLULAVAL QUAD
FLUZONE QUAD
PNEUMOVAX
PNEUMOVAX 23
QL = Quantity Limit
ST = Step Therapy
^
manual PA process
55
Generic Drug Name
Brand Drug Name
tet tox-diph-acell pertuss
ad
ADACEL
BOOSTRIX
tetanus-diphtheria toxoids TENIVAC
(td)
TET/DIP TOX INJ
tetanus immune globulin
HYPERTET S/D
(human)
typhoid vaccine
VIVOTIF BERNA
varicella virus vac live for
VARIVAX
subcutaneous
zoster vaccine live
ZOSTAVAX
QL = Quantity Limit
ST = Step Therapy
Covered
Drug
brand
QL
brand
QL
brand
QL
brand
capsules
brand
QL
brand
QL, Age Limits Apply
^
manual PA process
56
Generic Drug Name
Brand Drug Name Examples
OTC MEDICATIONS
The following is a list of OTC products on the PDL. Some OTC products are listed on the drug
list. OTC products covered are restricted to generics when available. Brand names are provided
as reference only.
Acne
CLEARASIL
benzoyl peroxide crm, gel, lotion
Antifungals
clotrimazole
MICATIN
miconazole crm, soln
LOTRIMIN AF
tolnaftate
TINACTIN
MONISTAT
vaginal products
GYNE-LOTRIMIN
Atopic Dermatitis
BETACARE CREAM AND LOTION
CETAPHIL CREAM AND LOTION
DERMAPHOR OINTMENT
emollients
E-OINTMENT
GLYCERIN TOPICAL
Cough/Cold Allergy
CHLOR-TRIMETON
BENADRYL
CLARITIN
antihistamines
ALAVERT
ZYRTEC
Antihistamine/Decongestant Combinations
brompheniramine/pseudoephedrine
cetirizine/pseudoephedrine OTC
chlorpheniramine/pseudoephedrine
DIMETAPP
ZYRTEC D
ACTIFED
ALAVERT ALRG TAB/SINUS
loratadine/pseudoephedrine
ALAVERT D
ALLERGY/CONG
QL = Quantity Limit
ST = Step Therapy
^
manual PA process
57
Generic Drug Name
Cough/Cold
ROBITUSSIN
ROBITUSSIN DM
antitussives
Age edit applied. Not covered for members under ROBITUSSIN PE
the age 2.
ROBITUSSIN CF
DELSYM
NEO-SYNEPHRINE
nasal sprays
Diabetes
alcohol swabs
glucose oral tablets
insulin (vials only)
Earwax Removal Products
AFRIN
DIMETAPP DRO DECONGES
CURITY ALCOHOL PADS
HUMULIN
NOVOLIN
carbamide peroxide
DEBROX
condoms
contraceptive foam
contraceptive gel
TROJAN
DELFEN
GYNOL II
Burow’s soln, wet dressings
dermatological baths
hydrocortisone crm, oint
DOMEBORO
COLLOIDAL OATMEAL BATHS
CORTAID
NEOSPORIN
topical antibacterials
MYCITRACIN
Family Planning
First Aid
Gastrointestinal
antacids liquids, chew tabs
antidiarrheals
electrolyte rehydrating soln
famotidine
laxative enemas
QL = Quantity Limit
ST = Step Therapy
BACITRACIN
MYLANTA LIQUID
MAALOX LIQUID
TUMS
IMODIUM A-D
KAOPECTATE
PEDIALYTE
PEPCID AC
FLEET ENEMA
^
manual PA process
58
Generic Drug Name
DULCOLAX
laxatives
psyllium
rectal hydrocortisone crm, suppositories
simethicone
stool softeners
sugar+orthophosphoric acid
FLEET PHOSPHO-SODA
METAMUCIL
PREPARATION H
MYLICON
COLACE
EMETROL
permethrin
piperonyl butoxide gel, liquid shampoo
NIX
PIPERONYL BUTOXIDE
dimenhydrinate
meclizine
DRAMAMINE
BONINE
allergic conjunctivitis
artificial tears
ALAWAY
HYPOTEARS
VISINE
decongestants
MURINE
Lice Products
Motion Sickness
Ophthalmics
NAPHCON A
Pain
acetaminophen tabs, liquid,
drops, suppositories
TYLENOL
BAYER
aspirin tabs, EC. tabs
ECOTRIN
aspirin with buffers tabs
ibuprofen tabs, chew tabs and susp
Smoking Cessation Products
nicotine
ADVIL
MOTRIN IB
COMMIT LOZENGES (QUANTITY LIMIT)
NICODERM CQ (QUANTITY LIMIT)
NICOTINE GUM (QUANTITY LIMIT)
QL = Quantity Limit
ST = Step Therapy
^
manual PA process
59
Generic Drug Name
Vitamins/Minerals
OS-CAL
CALTRATE
calcium
iron
ferrous fumarate, ferrous, gluconate,
errous sulfate, ferrous bis-glycinate
chelate and polysaccharide iron caps
iron polysaccharides
magnesium oxide
vitamin D 400 IU
TUMS
FERGON
FEOSOL
NIFEREX
MAG-OX
VITAMIN D 400 IU
VI-DAYLIN
vitamins pediatric members <3 years old
POLY-VI-SOL
vitamins prenatal
TRI-VI-SOL
STUART PRENATAL
salicylic acid 17%/collodion
DUOFILM
fluoride dental rinse
PHOS-FLUR
Warts
Miscellaneous
QL = Quantity Limit
ST = Step Therapy
^
manual PA process
60
Index ofof
Covered
Drugs
Index
covered
drugs
A
abacavir . . . . . . . . . . . . 28
abacavir/dolutegravir/
lamivudine . . . . . . . . . 29
abacavir/lamivudine . . . . . 28
abacavir/lamivudine/
zidovudine . . . . . . . . . 29
ABILIFY DISCMELT . . . . . . 38
ABILIFY MAINTENA . . . . . . 42
ABILIFY SOLUTION . . . . . . 39
ABILIFY TABLETS . . . . . . . 42
abiraterone . . . . . . . . . . . 5
acamprosate . . . . . . . . . 36
acarbose . . . . . . . . . . . . 22
ACCUHIST DROPS . . . . . . 43
ACCUHIST PDX DROPS . . . 43
ACCUNEB . . . . . . . . . . . 49
ACCUPRIL . . . . . . . . . . . .8
ACCURETIC . . . . . . . . . . .8
ACCUTANE . . . . . . . . . . 16
acebutalol . . . . . . . . . . . . 9
acetaminophen . . . . 12, 31, 59
acetazolamide . . . . . . . . . 35
ACETAZOLAMIDE . . . . . . . 35
acetazolamide
extended-release . . . . . 35
acetic acid . . . . . . . . . . . 19
acetic acid/aluminum acetate19
acetic acid/hydrocortisone . . 19
acetylcysteine . . . . . . . . . 54
acidophilus . . . . . . . . 25, 26
ACIDOPHILUS . . . . . . . . . 26
acidophilus/bifidus . . . . . . 26
ACIDOPHILUS/
BIFIDUS WAFER . . . . . 26
acidophilus/citrus pectin . . . 26
ACIDOPHILUS/
CITRUS PECTIN . . . . . . 26
acidophilus/pectin . . . . . . 26
ACIDOPHILUS/PECTIN . . . . 26
ACIDOPHILUS XTRA . . . . . 25
acitretin . . . . . . . . . . . . 18
ACLOVATE . . . . . . . . . . . 16
ACTIFED . . . . . . . . . . 20, 57
ACTIGALL . . . . . . . . . . . 26
ACTOPLUSMET . . . . . . . . 22
ACTOPLUS MET XR . . . . . 22
ACTOS . . . . . . . . . . . . . 22
ACULAR/ACULAR LS . . . . 35
acyclovir . . . . . . . . . . . . 28
ADACEL . . . . . . . . . . . . 56
ADALAT CC . . . . . . . . . . . 9
adalimumab . . . . . . . . . . 30
ADASUVE . . . . . . . . . . . 40
ADDERALL . . . . . . . . . . . 37
ADDERALL XR . . . . . . . . 37
adefovir . . . . . . . . . . . . 28
ADEMPAS . . . . . . . . . . . 11
ADVIL . . . . . . . . . 12, 31, 59
ADZENYS XR-ODT . . . . . . 38
afatinib . . . . . . . . . . . . . 4
AFINITOR . . . . . . . . . . . . .4
AFINITOR DISPERZ . . . . . . .4
AFLURIA . . . . . . . . . . . . 55
AFLURIA PF . . . . . . . . . . 55
AFRIN . . . . . . . . . . . 20, 58
AGRYLIN . . . . . . . . . . . . .7
ALAVERT . . . . . . . . . 20, 57
ALAVERT ALRG
TAB/SINUS . . . . . . 20, 57
ALAVERT D . . . . . . . . . . 57
ALAVERT-D . . . . . . . . . . . 20
ALAWAY . . . . . . . . . . . . 59
ALAWAY OTC . . . . . . . . . 34
albendazole . . . . . . . . . . 26
ALBENZA . . . . . . . . . . . . 26
albiglutide . . . . . . . . . . . 23
albuterol . . . . . . . . . . . . 49
albuterol sulfate . . . . . . . . 48
alclometasone . . . . . . . . 16
alcohol swabs . . . . . . . . . 58
ALDACTAZIDE . . . . . . . . . 10
ALDACTONE . . . . . . . . . . 10
ALDARA . . . . . . . . . . . . 18
ALDOMET . . . . . . . . . . . 11
ALDORIL . . . . . . . . . . . . 11
ALECENSA . . . . . . . . . . . .4
alectinib . . . . . . . . . . . . . 4
alendronate . . . . . . . . . . 23
ALL CAPS = Brand-name drug
Lower case = Generic drug
61
ALESSE . . . . . . . . . . . . . 32
alfuzosin ER . . . . . . . . . . 49
alginic acid/sodium
bicarbonate . . . . . . . . 24
ALINIA . . . . . . . . . . . . . 30
ALINIA SUSPENSION . . . . . 30
alirocumab . . . . . . . . . . 10
alitretinoin 1% gel . . . . . . . 6
ALKERAN . . . . . . . . . . . . 4
ALLANHIST SYP PDX . . . . . 46
allergic conjunctivitis . . . . . 59
ALLERGY/CONG . . . . 20, 57
ALLERGY/CONG
TAB RELIEF . . . . . . . . 46
allopurinol . . . . . . . . . . . 31
ALPHAGAN . . . . . . . . . . 36
ALPHAGAN P . . . . . . . . . 36
alprazolam . . . . . . . . . . . 36
alprazolam ODT . . . . . . . . 38
alprazolam tab SR . . . . . . 38
altretamine . . . . . . . . . . . 4
alumina/magnesia . . . . . . 24
alumina/magnesia/
simethicone . . . . . . . . 24
aluminum acetate . . . . . . . 18
aluminum chloride
hexahydrate . . . . . . . . 18
amantadine . . . . . . . . 14, 28
AMARYL . . . . . . . . . . . . 22
AMBIEN . . . . . . . . . . . . 38
ambrisentan . . . . . . . . . . 11
AMERGE . . . . . . . . . . . . 13
AMICAR . . . . . . . . . . . . . 7
amiloride . . . . . . . . . . . . 10
amiloride/hydrochlorothiazide10
aminocaproic acid . . . . . . . 7
aminosalicyclic acid . . . . . 26
amiodarone tabs . . . . . . . . 8
amitriptyline . . . . . . . . 14, 38
amitriptyline/perphenazine . 38
amlodipine . . . . . . . . . . . 9
ammonium lactate . . . . . . 18
amoxapine . . . . . . . . . . . 38
amoxicillin . . . . . . . . . . . 27
Index of Covered Drugs
AMOXICILLIN CAPSULES AND
CHEWABLES . . . . . . . 27
amoxicillin/clavulanate . . . . 27
AMOXIL SUSP . . . . . . . . . 27
amphetamine/dextroamphetamine mixed salts . . . . 37
amphetamine/dextroamphetamine mixed salts
amphetamine sulfate . . . . . 38
amphetamine susp extended
release . . . . . . . . . . . 38
amphetamine tab extended
release dispersible . . . . 38
ampicillin . . . . . . . . . . . 27
ANAFRANIL . . . . . . . . . . 39
anagrelide . . . . . . . . . . . 7
anakinra . . . . . . . . . . . . 30
ANAPLEX DM . . . . . . . . . 44
anastrozole . . . . . . . . . . . 5
ANORO ELLIPTA . . . . . . . 48
ANTABUSE . . . . . . . . . . . 36
antacids liquids, chew tabs . 58
antidiarrheals . . . . . . . . . 58
antihistamines . . . . . . . . . 57
antitussives . . . . . . . . . . 58
ANTIVERT . . . . . . . . . . . 24
ANUSOL HC 2.5% . . . . . . 18
APHEDRID TAB . . . . . . . . 48
apixaban . . . . . . . . . . . . 7
APLENZIN . . . . . . . . . . . 39
aprepitant . . . . . . . . . . . 23
APRESOLINE . . . . . . . . . 11
APRISO . . . . . . . . . . . . . 25
APTENSIO XR . . . . . . . . . 40
APTIVUS . . . . . . . . . . . . 29
ARALEN . . . . . . . . . . . . 29
ARANESP . . . . . . . . . . . . 7
ARAVA . . . . . . . . . . . . . 31
ARCAPTA NEOHALER . . . . 48
ARICEPT . . . . . . . . . . . . 11
ARIMIDEX . . . . . . . . . . . . 5
aripiprazole . . . . . . . . . . 42
aripiprazole ER injection . . . 42
aripiprazole lauroxil
IM ER susp . . . . . . . . 38
aripiprazole ODT . . . . . . . 38
aripiprazole oral solution . . . 39
ARISTADA . . . . . . . . . . . 38
ARNUITY ELLIPTA . . . . . . . 48
AROMASIN . . . . . . . . . . . .5
ARTANE . . . . . . . . . . . . 14
artificial tears . . . . . . . . . 59
ASACOL HD . . . . . . . . . . 25
asenapine maleate sublingual39
asfotase alfa . . . . . . . . . . 23
ASMANEX HFA . . . . . . . . 48
ASMANEX TWISTHALER . . . 48
aspirin . . . . . . . . . . . . 7, 31
aspirin/acetaminophen/
caffeine . . . . . . . . . . 12
aspirin tabs, EC. tabs . . . . . 59
aspirin with buffers tabs . . . 59
ASTELIN . . . . . . . . . . . . 20
ATABEX PRENATAL . . . . . . 52
ATARAX . . . . . . . . . . . . . 20
atazanavir . . . . . . . . . . . 29
atenolol . . . . . . . . . . . . . 9
atenolol/chlorthalidone . . . . 9
ATIVAN . . . . . . . . . . . . . 36
atomoxetine . . . . . . . . . . 37
atorvastatin . . . . . . . . . . 10
atovaquone . . . . . . . . . . 29
ATRALIN . . . . . . . . . . . . 16
ATRIPLA . . . . . . . . . . . . 29
atropine . . . . . . . . . . . . 35
atropine sulfate . . . . . . . . 26
ATROVENT . . . . . . . . . . . 49
ATROVENT HFA . . . . . . . . 48
ATROVENT NASAL SPRAY . . 20
ATUSS DR . . . . . . . . . . . 46
AUBAGIO . . . . . . . . . . . . 14
AUGMENTIN . . . . . . . . . . 27
auranofin . . . . . . . . . . . 30
AVITA . . . . . . . . . . . . . . 16
AVONEX/AVONEX PEN . . . 14
axitinib . . . . . . . . . . . . . 4
AYGESTIN . . . . . . . . . . . 33
azathioprine . . . . . . . . 6, 30
62
azelaic acid . . . . . . . . . . 16
azelastine . . . . . . . . . 20, 34
azithromycin . . . . . . . . . . 27
aztreonam . . . . . . . . . . . 54
AZULFIDINE . . . . . . . 25, 31
AZULFIDINE EN-TABS . . 25, 31
B
bacitracin . . . . . . . . . 16, 36
BACITRACIN . . . . . . . 16, 58
baclofen . . . . . . . . . . . . 31
BACLOFEN . . . . . . . . . . . 31
BACTRIM . . . . . . . . . . . . 27
BACTRIM DS . . . . . . . . . . 27
BACTROBAN . . . . . . . . . 16
balsalazide . . . . . . . . . . 25
BALZIVA . . . . . . . . . . . . 32
BANZEL . . . . . . . . . . . . 15
BARACLUDE . . . . . . . . . . 28
BAYER . . . . . . . . . 7, 31, 59
becaplermin gel . . . . . . . . 18
bedaquiline . . . . . . . . . . 29
BENADRYL . . . . . . . . 20, 57
benazepril . . . . . . . . . . . .8
benazepril/hydrochlorothiazide8
BENTYL . . . . . . . . . . . . 24
BENZAC AC . . . . . . . . . . 16
benzocaine/antipyrine . . . . 19
benzonatate . . . . . . . . . . 43
BENZOTIC . . . . . . . . . . . 19
benzoyl peroxide . . . . . 16, 57
benztropine . . . . . . . . . . 14
BERINERT . . . . . . . . . . . 54
BETACARE CREAM AND
LOTION . . . . . . . . . . . 57
BETAGAN . . . . . . . . . . . 35
betamethasone
augmented dip . . . . . . 17
betamethasone dipropionate 17
betamethasone val . . . . . . 16
BETAPACE . . . . . . . . . . . .9
BETA-VAL . . . . . . . . . . . . 16
bethanechol . . . . . . . . . . 49
BETHKIS . . . . . . . . . . . . 54
bexarotene caps and
topical gel . . . . . . . . . . 6
BIAXIN . . . . . . . . . . . . . 27
BIAXIN XL . . . . . . . . . . . 27
bicalutamide . . . . . . . . . . 5
BICITRA . . . . . . . . . . . . 50
BILTRICIDE . . . . . . . . . . . 26
BIO-D DRO-MULSION . . . . 50
BIO-D-MULSIO DRO FORTE . 50
bisoprolol . . . . . . . . . . . . 9
bisoprolol/hydrochlorothiazide 9
BLEPH-10 . . . . . . . . . . . 36
BONINE . . . . . . . . . . . . 59
BOOSTRIX . . . . . . . . . . . 56
bosentan . . . . . . . . . . . 11
BOSULIF . . . . . . . . . . . . .4
bosutinib . . . . . . . . . . . . 4
BREO ELLIPTA . . . . . . . . . 48
BRETHINE . . . . . . . . . . . 49
brexpiprazole . . . . . . . . . 39
brimonidine . . . . . . . . 18, 36
BROMALINE DM . . . . . . . 43
BROMETANE DX . . . . . . . 45
BROMFED DM . . . . . . . . . 44
BROMFENEX PD CAP . . . . 43
brompheniramine &
phenylephrine . . . . . . . 43
brompheniramine/
pseudoephedrine . . 43, 57
brompheniramine/
pseudoephedrine/
dextromethorphan . . 43, 44
brompheniramine/
pseudoephedrine/dextromethorphan/guaifenesin 44
budesonide . . . . . . . . 25, 49
bumetanide . . . . . . . . . . 10
BUMEX . . . . . . . . . . . . . 10
BUNAVAIL . . . . . . . . . . . 39
BUPHENYL ORAL POWDER 54
buprenorphine . . . . . . . . 42
buprenorphine hcl-naloxone
hcl SL . . . . . . . . . . . 39
buprenorphine hcl-naloxone hcl
SL film . . . . . . . . . . . 39
buprenorphine hcl-naloxone hcl
SL tab . . . . . . . . . . . 39
buprenorphine/naloxone . . . 42
buprenorphine-naloxone
buccal film . . . . . . . . . 39
bupropion . . . . . . . . . . . 38
bupropion extended-release 38
bupropion hcl tab SR 12hr . 39
bupropion HCL tab SR 24HR39
bupropion hydrobromide . . 39
Burow’s soln, wet dressings . 58
BUSPAR . . . . . . . . . . . . 37
buspirone . . . . . . . . . . . 37
busulfan . . . . . . . . . . . . . 4
butalbital/acetaminophen . . 12
butalbital/acetaminophen/
caffeine . . . . . . . . . . 12
butalbital/apap/caff/cod . . . 12
butalbital/asa/caff/cod . . . . 12
butalbital/aspirin/caffeine . . 12
butorphanol . . . . . . . . . . 13
C
C1 Inhibitor, Human . . . . . 54
cabergoline . . . . . . . . . . 23
cabozantinib . . . . . . . . . . 4
CAFERGOT . . . . . . . . . . 13
calamine . . . . . . . . . . . . 18
CALAN . . . . . . . . . . 10, 14
CALAN SR . . . . . . . . . . . 10
calcipotriene . . . . . . . . . 18
calcitonin-salmon . . . . . . . 23
calcitriol . . . . . . . . . . 18, 50
calcium . . . . . . . . . . 50, 60
calcium acetate . . . . . . . . 54
CALTRATE . . . . . . . . . . . 60
CAMPRAL . . . . . . . . . . . 36
canagliflozin . . . . . . . . . . 22
canagliflozin/metformin . . . 22
canakinumab . . . . . . . . . 54
CANASA . . . . . . . . . . . . 25
capecitabine . . . . . . . . . . 4
CAPOTEN . . . . . . . . . . . . 8
CAPOZIDE . . . . . . . . . . . .8
CAPRELSA . . . . . . . . . . . .5
63
capsaicin . . . . . . . . . . . 31
captopril . . . . . . . . . . . . .8
captopril/hydrochlorothiazide . 8
CARAC . . . . . . . . . . . . . 18
CARAFATE . . . . . . . . . . . 24
CARAFATE SUSPENSION . . 24
CARBAGLU . . . . . . . . . . 54
carbamazepine . . . . . . . . 14
carbamazepine cap SR . . . 39
carbamazepine
carbamide peroxide . . . 19, 58
CARBATROL . . . . . . . . . 14
carbetapentane/chlorpheniramine/ephedrine/
carbidopa/levodopa . . . . . 14
carbidopa/levodopa
carbinoxamine/
pseudoephedrine . . . . . 44
CARBOFED . . . . . . . . . . 44
CARDEC-DM . . . . . . . . . . 45
CARDEC DM DRO . . . . . . 47
CARDEC DM SYP . . . . . . . 47
CARDEC DRO . . . . . . . . . 44
CARDEC SYP . . . . . . . 43, 44
CARDENE . . . . . . . . . . . . 9
CARDIZEM . . . . . . . . . . . .9
CARDIZEM CD . . . . . . . . . .9
CARDIZEM SR . . . . . . . . . .9
CARDURA . . . . . . . . . 8, 49
carglumic acid . . . . . . . . 54
cariprazine . . . . . . . . . . . 39
carteolol . . . . . . . . . . . . 35
carvedilol . . . . . . . . . . . . 9
casanthranol-docusate
sodium . . . . . . . . . . 25
CASODEX . . . . . . . . . . . . 5
CATAPRES . . . . . . . . . . . .8
CAYSTON . . . . . . . . . . . 54
CECLOR . . . . . . . . . . . . 26
cefaclor . . . . . . . . . . . . 26
cefadroxil . . . . . . . . . . . 26
cefdinir . . . . . . . . . . . . . 27
cefixime . . . . . . . . . . . . 27
cefprozil . . . . . . . . . . . . 26
CEFTIN . . . . . . . . . . 26, 27
cefuroxime axetil . . . . . 26, 27
CEFZIL . . . . . . . . . . . . . 26
CELEBREX . . . . . . . . . . . 31
celecoxib . . . . . . . . . . . 31
CELEXA . . . . . . . . . . . . 37
CELLCEPT . . . . . . . . . . . .6
CELONTIN . . . . . . . . . . . 15
CENESTIN . . . . . . . . . . . 33
CENOGEN OB/ULTRA . . . . 52
CENTRUM . . . . . . . . . . . 51
cephalexin . . . . . . . . . . . 26
ceritinib . . . . . . . . . . . . . 4
certolizumab pegol . . . . . . 31
CERVARIX . . . . . . . . . . . 55
CETAPHIL CREAM AND
LOTION . . . . . . . . . . . 57
cetirizine . . . . . . . . . . . . 20
cetirizine chew tab . . . . . . 20
cetirizine hydrochloride/pseudoephedrine hydrochloride
cetirizine/pseudoephedrine
OTC . . . . . . . . . . . . 57
CHANTIX . . . . . . . . . . . . 43
CHILD IBUPRO SUS COLD . 48
chloral hydrate . . . . . . . . 38
CHLORAL HYDRATE . . . . . 38
chlorambucil . . . . . . . . . . 4
chlordiazepoxide . . . . . . . 36
chlordiazepoxideamitriptyline . . . . . . . . 39
chlorhexidine gluconate . . . 21
chloroquine phosphate . . . . 29
chlorothiazide . . . . . . . . . 10
chlorpheniramine/
dextromethorphan . . . . 44
chlorpheniramine
chlorpheniramine maleate . . 19
chlorpheniramine maleate
phenylephrine HCL . . . . 44
chlorpheniramine/
chlorpheniramine/phenylephrine/pyrilamine . . . . . . 20
chlorpheniramine/
pseudoephedrine 20, 45, 57
chlorpheniramine tan/
phenylephrine tan . . . . 44
chlorphen-PEmethscopolamine . . . . 44
chlorphen tan/
carbetapentane tan . . . . 44
chlorphen tan/
pseudoeph tan . . . . . . 44
chlorphen tan/pyrilamine tan/
PE tan . . . . . . . . . . . 44
chlorpromazine . . . . . . . . 43
chlorpropamide . . . . . . . . 22
chlorthalidone . . . . . . . . . 10
CHLORTHALIDONE . . . . . . 10
CHLOR-TRIMETON . . . . . . 57
CHLOR-TRIMETON
ALLERGY . . . . . . . . . 19
CHLOR-TRIMETON SYRUP . 19
chlorzoxazone . . . . . . . . . 31
CHOLBAM . . . . . . . . . . . 23
cholecalciferol . . . . . . . . . 50
cholestyramine . . . . . . . . 10
cholic acid . . . . . . . . . . . 23
ciclopirox . . . . . . . . . . . 17
cilostazol . . . . . . . . . . . . 7
CILOXAN . . . . . . . . . . . . 36
cimetidine . . . . . . . . . . . 24
CIMZIA . . . . . . . . . . . . . 31
cinacalcet . . . . . . . . . . . 54
CIPRO . . . . . . . . . . . . . 27
CIPRODEX . . . . . . . . . . . 19
ciprofloxacin . . . . . . . 27, 36
ciprofloxacin/dexamethasone19
citalopram . . . . . . . . . . . 37
clarithromycin . . . . . . . . . 27
clarithromycin ER . . . . . . . 27
CLARITIN . . . . . . . . . 20, 57
CLEARASIL . . . . . . . . . . 57
64
CLEAR EYES REDNESS
RELIEF . . . . . . . . . . . 34
clemastine . . . . . . . . . . . 19
CLEMASTINE . . . . . . . . . 19
CLEOCIN . . . . . . . . . 29, 34
CLEOCIN T . . . . . . . . . . . 16
CLIMARA . . . . . . . . . . . . 33
clindamycin . . . . . . 16, 29, 34
CLINORIL . . . . . . . . . 12, 31
clobazam . . . . . . . . . . . 14
clobetasol propionate . . . . 17
clomipramine . . . . . . . . . 39
clonazepam . . . . . . . 14, 36
clonazepam ODT . . . . . . . 39
clonidine . . . . . . . . . . . . 8
clonidine HCL tab SR . . . . 39
clopidogrel . . . . . . . . . . . 7
clorazepate . . . . . . . . . . 36
clotrimazole . . . .17, 27, 34, 57
clotrimazole with
betamethasone . . . . . . 17
clozapine . . . . . . . . . . . 39
clozapine . . . . . . . . . . . 42
clozapine ODT . . . . . . . . 39
clozapine susp . . . . . . . . 39
CLOZARIL . . . . . . . . . 39, 42
cobicistat . . . . . . . . . . . 30
cobicistat/elvitegravir/
emtricitabine/tenofovir . . 29
cobimetinib . . . . . . . . . . . 4
CODAL-DM . . . . . . . . . . . 47
codeine/acetaminophen . . . 13
codeine/chlorpheniramine/
codeine/guaifenesin . . . . . 45
codeine/guaifenesin/
codeine/promethazine . . . . 45
codeine/promethazine/
codeine sulfate . . . . . . . . 13
CODIMAL DH . . . . . . . . . 47
COGENTIN . . . . . . . . . . . 14
COLACE . . . . . . . . . 25, 59
COLAZAL . . . . . . . . . . . 25
colchicine . . . . . . . . . . . 31
collagenase . . . . . . . . . . 18
COLLOIDAL OATMEAL
BATHS . . . . . . . . . . . 58
COLOCORT . . . . . . . . . . 25
COLYTE . . . . . . . . . . . . 25
COMBIVENT . . . . . . . . . . 48
COMBIVENT RESPIMAT . . . 48
COMBIVIR . . . . . . . . . . . 29
COMETRIQ . . . . . . . . . . . 4
COMMIT LOZENGES . . . . . 59
COMMITT OTC . . . . . . . . 43
COMPAZINE . . . . . . . . . . 24
COMPLERA . . . . . . . . . . 29
COMPLETE NATALCARE
PAK DHA . . . . . . . . . . 52
COMTAN . . . . . . . . . . . . 14
CONCERTA . . . . . . . . . . 37
condoms . . . . . . . . . . . 58
CONDYLOX SOL . . . . . . . 18
conjugated estrogen/
bazedoxifene . . . . . . . 34
contraceptive foam . . . . . . 58
contraceptive gel . . . . . . . 58
COPAXONE . . . . . . . . . . 14
CORDARONE . . . . . . . . . .8
CORDRAN . . . . . . . . . . . 17
COREG . . . . . . . . . . . . . .9
CORICIDIN TAB CGH/CLD . 44
CORTAID . . . . . . . . . . . . 58
CORTEF . . . . . . . . . . . . 21
cortisone acetate . . . . . . . 21
CORTISPORIN . . . . . . . . . 34
CORTISPORIN OTIC . . . . . 19
CORTIZONE . . . . . . . . . . 16
CORTIZONE-10 INTENSIVE
HEALING . . . . . . . . . . 16
COSOPT . . . . . . . . . . . . 35
COTELLIC . . . . . . . . . . . . 4
COUMADIN . . . . . . . . . . . 7
COZAAR . . . . . . . . . . . . .8
CPM/PSE . . . . . . . . . . . 45
CREON . . . . . . . . . . . . . 25
CRIXIVAN . . . . . . . . . . . . 29
crizotinib . . . . . . . . . . . . 4
CROLOM . . . . . . . . . . . . 34
cromolyn . . . . . . . . . 48, 49
cromolyn sodium . . . . . 20, 34
crotamiton . . . . . . . . . . . 18
CURITY ALCOHOL PADS . . 58
CUTIVATE . . . . . . . . . . . 17
cyanocobalamin . . . . . . . 50
CYCLESSA . . . . . . . . . . . 33
cyclobenzaprine . . . . . . . 31
CYCLOGYL . . . . . . . . . . . 35
cyclopentolate . . . . . . . . . 35
cyclophosphamide . . . . . . . 4
cycloserine . . . . . . . . . . 26
cyclosporine . . . . . . . . . . 6
cyclosporine, modified . . . . . 6
CYMBALTA . . . . . . . . . . . 38
cyproheptadine . . . . . . . . 19
CYPROHEPTADINE . . . . . . 19
CYSTAGON . . . . . . . . . . . 6
CYSTARAN . . . . . . . . . . . 36
cysteamine 0.44%
ophthalmic solution . . . . 36
cysteamine bitartrate . . . . . . 6
CYTOMEL . . . . . . . . . . . 23
CYTOTEC . . . . . . . . . . . 26
CYTOVENE . . . . . . . . . . . 28
CYTOXAN . . . . . . . . . . . . 4
D
D3-50 CAP . . . . . . . . . . . 50
dabrafenib . . . . . . . . . . . 4
DALLERGY DM . . . . . . . . 44
DALMANE . . . . . . . . . . . 38
danazol . . . . . . . . . . . . 33
DANOCRINE . . . . . . . . . . 33
DANTRIUM . . . . . . . . . . . 32
dantrolene . . . . . . . . . . . 32
dapsone . . . . . . . . . . . . 30
DAPSONE . . . . . . . . . . . 30
DARAPRIM . . . . . . . . . . . 30
darbepoetin alfa . . . . . . . . 7
darunavir . . . . . . . . . . . 29
darunavir/cobicistat . . . . . 30
dasatinib . . . . . . . . . . . . 4
DAYPRO . . . . . . . . . . 12, 31
65
DAYTRANA . . . . . . . . . . . 41
DDAVP . . . . . . . . . . . . . 23
DEBROX . . . . . . . . . 19, 58
DECADRON . . . . . . . . . . 21
DE-CHLOR DM . . . . . . . . 46
decongestants . . . . . . . . 59
deferasirox . . . . . . . . . . . 7
DELATESTRYL . . . . . . . . . 21
delavirdine . . . . . . . . . . . 28
DELFEN . . . . . . . . . . . . 58
DELSYM . . . . . . . . . . 45, 58
DELTASONE . . . . . . . . . . 21
DELZICOL . . . . . . . . . . . 25
DEMADEX . . . . . . . . . . . 10
DEMEROL . . . . . . . . . . . 13
DEPAKENE . . . . . . . . . . . 15
DEPAKOTE . . . . . . 14, 15, 37
DEPAKOTE ER . . . . . . . . . 40
DEPAKOTE SPRINKLE . 14, 37
DEPEN TITRATABLE . . . . . 31
DEPO-PROVERA . . . . . . . 32
DEPO-TESTOSTERONE . . . 21
DERMAPHOR OINTMENT . . 57
DERMA-SMOOTHE
OIL/FS . . . . . . . . 16, 17
dermatological baths . . . . . 58
DERMATOP . . . . . . . . . . 17
DESENEX . . . . . . . . . . . 17
desipramine . . . . . . . . . . 38
desmopressin . . . . . . . . . 23
desogestrel/EE . . . . . . 32, 33
DESOXYN . . . . . . . . . . . 40
desvenlafaxine fumarate
tab SR . . . . . . . . . . . 39
DESVENLAFAXINE
FUMARATE TAB SR . . . . 39
desvenlafaxine succinate
tab SR . . . . . . . . . . . 39
desvenlafaxine tab SR . . . . 39
DESYREL . . . . . . . . . 38, 41
DETROL . . . . . . . . . . . . 50
dexamethasone . . . . . . . . 21
dexamethasone sodium
phosphate . . . . . . . . . 35
DEXASOL . . . . . . . . . . . 35
dexmethylphenidate . . . . . 39
dexmethylphenidate HCL
cap SR . . . . . . . . . . . 39
dextroamphetamine . . . 37, 40
dextroamphetamine
sulfate oral solution . . . . 40
dextromethorphan/brompheniramine/pseudoephedrine 45
dextromethorphan/carbinoxamine/pseudoephedrine 45
dextromethorphanguaifenesin . . . . . . . . 45
dextromethorphan/
guaifenesin . . . . . . . . 45
dextromethorphan hbr . . . . 45
dextromethorphan polistirex
dextromethorphan/
promethazine . . . . . . . 45
dextromethorphan/quinidine 43
DEXTROSTAT . . . . . . . . . 37
D.H.E. 45 . . . . . . . . . . . . 13
DIABINESE . . . . . . . . . . . 22
DIAMOX SEQUELS . . . . . . 35
DIASTAT ACUDIAL . . . . . . . 14
diazepam . . . . . . . 14, 32, 36
diazepam concentrate
solution . . . . . . . . . . 40
DIAZEPAM INTENSOL . . . . 40
diclofenac 1% gel . . . . . . . 31
diclofenac sodium . . . . . . 35
dicloxacillin . . . . . . . . . . 27
DICLOXACILLIN . . . . . . . . 27
dicyclomine . . . . . . . . . . 24
didanosine . . . . . . . . . . 29
didanosine delayed-release . 29
DIDRONEL . . . . . . . . . . . 23
DIFLUCAN . . . . . . . . 27, 34
digoxin . . . . . . . . . . . . . 8
DIHISTINE DH . . . . . . . . . 45
dihydroergotamine . . . . . . 13
DIHYDRO-PE SYP . . . . . . . 47
DILACOR XR . . . . . . . . . . 9
DILANTIN . . . . . . . . . . . . 15
DILANTIN INFATABS . . . . . 15
DILAUDID . . . . . . . . . . . . 13
diltiazem . . . . . . . . . . . . 9
diltiazem extended-release . . 9
diltiazem sustained-release . . 9
DIMEATAPP DRO
DECONGES . . . . . . . . 20
dimenhydrinate . . . . . . . . 59
DIMETAPP . . . . . . . . . . . 57
DIMETAPP CLD ELX/
ALLERGY . . . . . . . . . 43
DIMETAPP DRO DCON/CGH47
DIMETAPP DRO DECONGES 58
DIMETAPP ELX CLD/ALLE . . 43
DIMETAPP SYP CGH/CLD . . 44
dimethyl fumarate . . . . . . . 14
DIPENTUM . . . . . . . . . . . 25
diphenhydramine . . 19, 20, 38
diphenoxylate/atropine . . . . 23
diphtheria-tetanus tox
adsorbed im . . . . . . . . 54
DIPROLENE . . . . . . . . . . 17
DIPROLENE AF . . . . . . . . 17
DIP/TET PED INJ . . . . . . . 54
dipyridamole . . . . . . . . . . 7
disopyramide . . . . . . . . . . 8
disopyramide extended-release8
disulfiram . . . . . . . . . . . 36
DITROPAN . . . . . . . . . . . 50
DITROPAN XL . . . . . . . . . 50
DIURIL . . . . . . . . . . . . . 10
DIURIL ORAL
SUSPENSION . . . . . . . 10
divalproex sodium
cap sprinkle . . . . . 14, 37
divalproex sodium
delayed-release . . 14, 15, 37
divalproex sodium SR 24hr . 40
docusate calcium plus . . . . 25
docusate potasssium . . . . . 25
docusate sodium . . . . . . . 25
dofetilide . . . . . . . . . . . . 8
DOLOPHINE . . . . . . . . . . 13
dolutegravir . . . . . . . . . . 30
DOMEBORO . . . . . . . . . . 58
DOMEBORO OTIC . . . . . . 19
66
donepezil . . . . . . . . . . . 11
dornase alfa . . . . . . . . . . 54
dorzolamide . . . . . . . . . . 35
dorzolamide/timolol maleate 35
DOSTINEX . . . . . . . . . . . 23
DOVONEX . . . . . . . . . . . 18
doxazosin . . . . . . . . . . 8, 49
doxepin . . . . . . . . . . . . 38
doxycycline monohydrate . . 27
DOXYCYCLINE
MONOHYDRATE . . . . . 27
DRAMAMINE . . . . . . . . . 59
DRISDOL . . . . . . . . . . . . 51
dronabinol . . . . . . . . . . . 23
DROXIA . . . . . . . . . . . . . .6
DUAVEE . . . . . . . . . . . . 34
DUETACT . . . . . . . . . . . . 22
DULCOLAX . . . . . . . . . . 59
DULERA . . . . . . . . . . . . 48
duloxetine . . . . . . . . . 38, 40
DUOFILM . . . . . . . . . 18, 60
DUONEB . . . . . . . . . . . . 49
DURADRYL . . . . . . . . . . 44
DURAGESIC . . . . . . . . . . 13
DURATUSS DM ELX . . . . . 45
DURICEF . . . . . . . . . . . . 26
DYANAVEL XR . . . . . . . . . 38
DYAZIDE . . . . . . . . . . . . 10
E
ecothiophate . . . . . . . . . 35
ECOTRIN . . . . . . . . 7, 31, 59
ED A-HIST TABLETS AND
LIQUID . . . . . . . . . . . 44
EDGE OB CHW . . . . . . . . 52
edoxaban . . . . . . . . . . . . 7
EDURANT . . . . . . . . . . . 28
E.E.S. . . . . . . . . . . . . . . 27
efavirenz . . . . . . . . . . . . 28
efavirenz/emtricitabine/
tenofovir . . . . . . . . . . 29
EFFEXOR . . . . . . . . . . . . 38
EFFEXOR XR . . . . . . . . . . 38
EFUDEX . . . . . . . . . . . . 18
ELAVIL . . . . . . . . . . . 14, 38
elbasvir/grazoprevir . . . . . . 28
ELDEPRYL . . . . . . . . . . . 14
electrolyte . . . . . . . . . . . 50
electrolyte rehydrating soln . . 58
ELIDEL . . . . . . . . . . . . . 19
ELIMITE . . . . . . . . . . . . . 18
ELIQUIS . . . . . . . . . . . . . .7
ELOCON . . . . . . . . . . . . 17
eltrombopag . . . . . . . . . . 54
elvitegravir/cobicistat/emtricitabine/tenofovir alafenamide
fumarate . . . . . . . . . . 29
EMCYT . . . . . . . . . . . . . .4
EMEND . . . . . . . . . . . . . 23
EMETROL . . . . . . . . . . . 59
EMLA . . . . . . . . . . . . . . 19
emollients . . . . . . . . . . . 57
empagliflozin . . . . . . . . . 22
empagliflozin/metformin . . . 22
EMSAM . . . . . . . . . . . . . 41
emtricitabine . . . . . . . . . 29
emtricitabine/rilpivirine/
tenofovir . . . . . . . . . . 29
emtricitabine/tenofovir . . . . 29
EMTRIVA . . . . . . . . . . . . 29
enalapril . . . . . . . . . . . . . 8
enalapril/hydrochlorothiazide . 8
ENBREL . . . . . . . . . . . . 31
enfuvirtide . . . . . . . . . . . 28
ENGERIX-B . . . . . . . . . . . 54
ENJUVIA . . . . . . . . . . . . 33
enoxaparin . . . . . . . . . . . 7
entacapone . . . . . . . . . . 14
entecavir . . . . . . . . . . . . 28
ENTERIC COATEDNAPROSYN . . . . . . 12, 31
ENTOCORT EC . . . . . . . . 25
ENULOSE . . . . . . . . . . . 25
E-OINTMENT . . . . . . . . . 57
EPANED . . . . . . . . . . . . . 8
EPCLUSA . . . . . . . . . . . . 28
epinephrine . . . . . . . . . . 54
EPIPEN . . . . . . . . . . . . . 54
EPIPEN JR. . . . . . . . . . . . 54
EPIVIR . . . . . . . . . . . . . . 29
EPIVIR HBV . . . . . . . . . . . 28
epoetin alfa . . . . . . . . . . . 7
EPOGEN . . . . . . . . . . . . .7
EPZICOM . . . . . . . . . . . . 28
EQUANIL . . . . . . . . . . . . 40
EQUETRO . . . . . . . . . . . 39
ergocalciferol . . . . . . . . . 51
ergotamine/caffeine . . . . . 13
ergotamine tartrate/caffeine . 13
ERIVEDGE . . . . . . . . . . . .6
erlotinib . . . . . . . . . . . . . 4
ERYC . . . . . . . . . . . . . . 27
ERYGEL . . . . . . . . . . . . 16
ERY-TAB . . . . . . . . . . . . 27
ERYTHROCIN . . . . . . . . . 27
erythromycin . . . . . . . 16, 36
ERYTHROMYCIN . . . . . . . 36
erythromycin delayed-release 27
erythromycin ethylsuccinate . 27
erythromycin stearate . . . . . 27
erythromycin/sulfisoxazole . . 27
ESBRIET . . . . . . . . . . . . 54
escitalopram . . . . . . . . . 37
escitalopram 10mg & methylfolate-B12-B6-D thpk . . . . 40
escitalopram oxalate soln . . 40
ESGIC . . . . . . . . . . . . . 12
ESKALITH CR . . . . . . . . . 37
esomeprazole . . . . . . . . . 24
esomeprazole granules . . . 24
ESTRACE . . . . . . . . . . . . 33
estradiol . . . . . . . . . . . . 33
estramustine
phosphate sodium . . . . . 4
estrogens, conjugated . . . . 33
estrogens, conjugated/
medroxyprogesterone . . 33
synthetic A . . . . . . . . . 33
synthetic B . . . . . . . . 33
estropipate . . . . . . . . . . 33
ESTROSTEP FE . . . . . . . . 33
etanercept . . . . . . . . . . . 31
ethambutol . . . . . . . . . . 26
67
ethionamide . . . . . . . . . . 26
ethosuximide . . . . . . . . . 15
ethynodiol diacetate/EE . . . 32
etidronate . . . . . . . . . . . 23
etodolac . . . . . . . . . . 12, 31
etonogestrel/EE . . . . . . . . 32
etoposide . . . . . . . . . . . . 6
etravirine . . . . . . . . . . . . 30
EULEXIN . . . . . . . . . . . . .5
EURAX . . . . . . . . . . . . . 18
EVEKEO . . . . . . . . . . . . 38
everolimus . . . . . . . . . . 4, 6
EVISTA . . . . . . . . . . . . . 23
EVZIO . . . . . . . . . . . . . . 41
EXCEDRIN MIGRAINE . . . . 12
EXELON . . . . . . . . . . . . 12
exemestane . . . . . . . . . . . 5
EXJADE . . . . . . . . . . . . . .7
exogabine . . . . . . . . . . . 15
ezetimibe . . . . . . . . . . . 10
F
famotidine . . . . . . . . 24, 58
FANAPT . . . . . . . . . . . . . 40
FARESTON . . . . . . . . . . . .5
FARYDAK . . . . . . . . . . . . .4
FAZACLO . . . . . . . . . . . . 39
febuxostat . . . . . . . . . . . 31
felbamate . . . . . . . . . . . 15
FELBATOL . . . . . . . . . . . 15
FELDENE . . . . . . . . . 12, 31
felodipine extended-release . . 9
FEMARA . . . . . . . . . . . . .5
fenofibrate . . . . . . . . . . . 10
fentanyl transdermal . . . . . 13
FEOSOL . . . . . . . . . . 51, 60
FERGON . . . . . . . . . . . . 60
ferrous bisglycinate/
polysaccarides iron . . . . 51
ferrous sulfate . . . . . . . . . 51
FETZIMA . . . . . . . . . . . . 40
filgrastim . . . . . . . . . . . . 7
FINACEA . . . . . . . . . . . . 16
finasteride . . . . . . . . . . . 49
fingolimod . . . . . . . . . . . 14
FIORICET . . . . . . . . . . . . 12
FIORICET W/CODEINE . . . . 12
FIORINAL . . . . . . . . . . . . 12
FIORINAL W/CODEINE . . . . 12
FIRAZYR . . . . . . . . . . . . 54
FLAGYL . . . . . . . . . . 30, 34
flecainide . . . . . . . . . . . . 8
FLEET ENEMA . . . . . . . . . 58
FLEET PHOSPHO-SODA . . . 59
FLEXERIL . . . . . . . . . . . . 31
FLOMAX . . . . . . . . . . . . 49
FLONASE . . . . . . . . . . . . 20
FLORANEX . . . . . . . . . . . 26
FLORINEF . . . . . . . . . . . 21
FLOXIN . . . . . . . . . . . . . 27
FLOXIN OTIC . . . . . . . . . . 19
FLUARIX QUAD . . . . . . . . 55
FLUBLOK . . . . . . . . . . . . 55
FLUCELVAX . . . . . . . . . . 55
fluconazole . . . . . . . . 27, 34
fludrocortisone . . . . . . . . 21
FLULAVAL QUAD . . . . . . . 55
FLUMADINE . . . . . . . . . . 28
fluocinolone acetonide . 16, 17
fluocinonide . . . . . . . . . . 17
fluocinonide emulsified base 17
fluoride . . . . . . . . . . . . . 51
fluoride dental rinse . . . . . 60
fluorometholone . . . . . . . 35
FLUOROPLEX . . . . . . . . . 18
fluorouracil . . . . . . . . . . 18
fluoxetine . . . . . . . . . . . 37
FLUOXETINE . . . . . . . . . . 40
fluoxetine capsule . . . . . . . 40
fluoxetine HCL cap
delayed-release . . . . . . 40
fluoxetine HCL tabs . . . . . . 40
fluoxetine tablet . . . . . . . . 40
fluphenazine . . . . . . . . . 43
fluphenazine decanoate . . . 43
flurandrenolide . . . . . . . . 17
flurazepam . . . . . . . . . . 38
flurbiprofen . . . . . . . . . . 35
flutamide . . . . . . . . . . . . 5
fluticasone . . . . . . . . . . . 20
fluticasone furoate . . . . . . 48
fluticasone propionate . . . . 17
fluticasone/vilanterol . . . . . 48
FLUVIRIN . . . . . . . . . . . . 55
fluvoxamine . . . . . . . . . . 37
fluvoxamine maleate cap SR 40
FLUZONE HD PF . . . . . . . 55
FLUZONE QUAD . . . . . . . 55
FLUZONE SPLT . . . . . . . . 55
FML . . . . . . . . . . . . . . 35
FML FORTE . . . . . . . . . . 35
FML LIQUIFILM . . . . . . . . 35
FOCALIN . . . . . . . . . . . . 39
FOCALIN XR . . . . . . . . . . 39
folic acid . . . . . . . . . . . . 51
FOLIC ACID . . . . . . . . . . 51
FOLTABS PAK PLUS DHA RE
OB + DHA PAK . . . . . . 52
FOLTABS PRENATAL . . . . . 52
FORFIVO XL . . . . . . . . . . 39
FORTEO . . . . . . . . . . . . 23
FORTICAL . . . . . . . . . . . 23
FOSAMAX . . . . . . . . . . . 23
fosamprenavir . . . . . . . . . 29
fosinopril . . . . . . . . . . . . 8
fosinopril/hydrochlorothiazide 8
FURADANTIN SUSP . . . . . 30
furosemide . . . . . . . . . . 10
FUZEON KIT . . . . . . . . . . 28
G
gabapentin . . . . . . . . . . 15
GABITRIL . . . . . . . . . . . . 15
galantamine . . . . . . . . . . 12
ganciclovir . . . . . . . . . . . 28
GARDASIL . . . . . . . . . . . 55
GARDASIL 9 . . . . . . . . . . 55
gatifloxin . . . . . . . . . . . . 36
GATTEX . . . . . . . . . . . . 26
gefitinib . . . . . . . . . . . . . 4
GEL-KAM . . . . . . . . . . . . 51
gemfibrozil . . . . . . . . . . . 10
GENGRAF . . . . . . . . . . . .6
GENTAK . . . . . . . . . . 16, 36
gentamicin . . . . . . . . 16, 36
68
gentamicin/prednisolone
acetate . . . . . . . . . . . 34
GENTEX ADE . . . . . . . . . 52
GENVOYA . . . . . . . . . . . 29
GEODON . . . . . . . . . . . . 42
GG/CODEINE . . . . . . . . . 45
GG/DM CR . . . . . . . . . . . 45
GG/PSE CR . . . . . . . . . . 46
GILENYA . . . . . . . . . . . . 14
GILOTRIF . . . . . . . . . . . . .4
glatiramer acetate . . . . . . . 14
GLEEVEC . . . . . . . . . . . . 4
GLEOSTINE . . . . . . . . . . . 4
glimepiride . . . . . . . . . . 22
glipizide . . . . . . . . . . . . 22
glipizide extended-release . . 22
GLUCAGON . . . . . . . . . . 21
glucagon, human
recombinant . . . . . . . . 21
GLUCOPHAGE . . . . . . . . 22
GLUCOPHAGE ER . . . . . . 22
glucose oral tablets . . . . . . 58
GLUCOTROL . . . . . . . . . 22
GLUCOTROL XL . . . . . . . . 22
GLUCOVANCE . . . . . . . . 22
glyburide . . . . . . . . . . . . 22
glyburide, micronized . . . . . 22
glycerin . . . . . . . . . . . . 25
GLYCERIN SUPPOSITORY . . 25
GLYCERIN TOPICAL . . . . . 57
glycerol phenylbutyrate . . . . 54
glycopyrrolate . . . . . . . . . 24
GLYNASE . . . . . . . . . . . . 22
GRIFULVIN V . . . . . . . . . . 27
griseofulvin microsize . . . . . 27
griseofulvin ultramicrosize . . 27
GRIS-PEG . . . . . . . . . . . 27
GUAIFED . . . . . . . . . . . . 46
guaifenesin . . . . . . . . . . 45
guaifenesin extended-release 45
guaifenesin/
guaifenesin/pseudoephedrine/
guaifenesin/pseudoephedrine
GUAIFEN PSE . . . . . . . . . 46
guanabenz . . . . . . . . . . 11
guanfacine . . . . . . . . . . . 8
guanfacine ER . . . . . . . . 37
GUIATUSS AC . . . . . . . . . 45
GUIATUSS DAC . . . . . . . . 45
GYNE-LOTRIMIN . . . . . 34, 57
GYNOL II . . . . . . . . . . . . 58
H
HALCION . . . . . . . . . . . . 38
HALDOL . . . . . . . . . . . . 43
HALDOL CONCENTRATE . . 40
HALDOL DECANOATE . . . . 43
halobetasol . . . . . . . . . . 17
haloperidol . . . . . . . . . . 43
haloperidol decanoate . . . . 43
haloperidol lactate oral conc 40
HAVRIX . . . . . . . . . . . . . 54
HECORIA . . . . . . . . . . . . 6
heparin . . . . . . . . . . . . . 7
HEPARIN . . . . . . . . . . . . .7
hepatitis a vaccine susp . . . 54
hepatitis b vaccine . . . . . . 54
HEPSERA . . . . . . . . . . . 28
hexachlorophene . . . . . . . 18
HEXALEN . . . . . . . . . . . . 4
HIPREX . . . . . . . . . . . . . 50
HISTACOL DM . . . . . . . . . 44
HISTEX . . . . . . . . . . . . . 45
HISTUSSIN HC . . . . . . . . 46
homatropine . . . . . . . . . . 35
HUMALOG . . . . . . . . . . . 22
HUMALOG MIX 50/50 . . . . 22
HUMALOG MIX 75/25 . . . . 22
human papillomavirus (hpv)
9-valent recomb vac . . . 55
bival (type 16, 18)
recmb vac . . . . . . . . . 55
quadrivalent recombinant
vac . . . . . . . . . . . . . 55
HUMATIN . . . . . . . . . . . . 30
HUMIRA . . . . . . . . . . . . 30
HUMULIN . . . . . . . . . . . 58
HUMULIN 70/30 . . . . . . . 22
HUMULIN N . . . . . . . . . . 21
HUMULIN R . . . . . . . . . . 22
HYCAMTIN . . . . . . . . . . . .6
HYCODAN . . . . . . . . . . . 46
hydralazine . . . . . . . . . . 11
HYDREA . . . . . . . . . . . . . 6
hydrochlorothiazide . . . . . . 10
HYDROCHLOROTHIAZIDE . 10
HYDROCODO/GG SYP . . . 46
hydrocodone/acetaminophen13
hydrocodone/chlorpheniramine/
hydrocodone ER . . . . . . . 13
hydrocodone/guaifenesin . . 46
hydrocodone/homatropine . 46
HYDROCODONE/
TAB HOMATROP . . . . . 46
hydrocortisone . .16, 18, 21, 25
hydrocortisone/aloe . . . . . 16
hydrocortisone butyrate . . . 17
hydrocortisone crm, oint . . . 58
hydrocortisone valerate . . . 17
HYDROMET SYP . . . . . . . 46
hydromorphone . . . . . . . . 13
hydroxychloroquine . . . 30, 31
hydroxyurea . . . . . . . . . . 6
hydroxyzine HCL . . . . . . . 20
hydroxyzine pamoate . . . . . 20
hyoscyamine, methenamine,
phenyl salicylate, sodium
phosphate monobasic,
methylene blue . . . . . . 50
hyoscyamine sulfate . . . . . 24
hyoscyamine sulfate
HYPERCARE 20% . . . . . . . 18
HYPERTET S/D . . . . . . . . 56
HYPOTEARS . . . . . . . . . . 59
HYTONE . . . . . . . . . . . . 16
HYTRIN . . . . . . . . . . . 8, 49
HYZAAR . . . . . . . . . . . . . 8
69
I
IBRANCE . . . . . . . . . . . . .5
ibrutinib . . . . . . . . . . . . . 4
IBUOROFEN TAB COLD/SIN 48
ibuprofen . . . . . . . 12, 31, 59
icatibant . . . . . . . . . . . . 54
ICLUSIG . . . . . . . . . . . . . 5
idelalisib . . . . . . . . . . . . . 4
ILARIS . . . . . . . . . . . . . . 54
iloperidone . . . . . . . . . . 40
imatinib mesylate . . . . . . . . 4
IMBRUVICA . . . . . . . . . . . 4
IMDUR . . . . . . . . . . . . . 11
imipramine HCL . . . . . . . 38
imipramine pamoate . . . . . 40
imiquimod 5% cream . . . . . 18
IMITREX . . . . . . . . . . . . 13
IMODIUM A-D . . . . . . . 23, 58
IMURAN . . . . . . . . . . . 6, 30
INCRELEX . . . . . . . . . . . 23
INCRUSE ELLIPTA . . . . . . 48
indacaterol . . . . . . . . . . . 48
indapamide . . . . . . . . . . 10
INDERAL . . . . . . . . . . 9, 14
INDERIDE . . . . . . . . . . . . 9
indinavir . . . . . . . . . . . . 29
INDOCIN . . . . . . . . . 12, 31
indomethacin . . . . . . . 12, 31
INFLAMASE FORTE . . . . . . 35
influenza virus vaccine recombinant hemagglutinin (ha) . 55
influenza virus vaccine split . 55
influenza virus vaccine split highdose pf . . . . . . . . . . 55
influenza virus vaccine split pf55
influenza virus vaccine split
quadrivalent . . . . . . . . 55
influenza virus vaccine tiss-cult
subunit . . . . . . . . . . . 55
influenza virus vaccine types
a&b surface antigen . . . 55
INLYTA . . . . . . . . . . . . . . 4
insulin aspart . . . . . . . . . 21
insulin aspart protamine 70%/
insulin aspart 30% . . . . 21
insulin glargine . . . . . . . . 21
insulin human . . . . . . . . . 21
insulin isophane . . . . . . . . 21
insulin isophane human . 21, 22
insulin isophane human 70%/
regular 30% . . . . . . . . 22
insulin isophane/regular . . . 22
insulin lisopro pro/lispro . . . 22
insulin lisopro prot/lispro . . . 22
insulin lispro . . . . . . . . . . 22
insulin regular . . . . . . . . . 22
insulin . . . . . . . . . . . . . 58
INTAL . . . . . . . . . . . 48, 49
INTELENCE . . . . . . . . . . 30
interferon alfa-2b . . . . . . 5, 28
interferon beta-1a . . . . . . . 14
INTRON A . . . . . . . . . . 5, 28
INTUNIV . . . . . . . . . . . . 37
INVEGA . . . . . . . . . . . . . 41
INVEGA SUSTENNA . . . . . 42
INVEGA TRINZA . . . . . . . . 42
INVIRASE . . . . . . . . . . . . 29
INVOKAMET . . . . . . . . . . 22
INVOKANA . . . . . . . . . . . 22
ipratropium . . . . . . . . . . 49
ipratropium/albuterol . . 48, 49
ipratropium HFA . . . . . . . 48
ipratropium nasal . . . . . . . 20
IRENKA . . . . . . . . . . . . . 40
IRESSA . . . . . . . . . . . . . .4
iron . . . . . . . . . . . . . . . 60
iron polysaccharides . . . . . 60
ISENTRESS . . . . . . . . . . 30
ISENTRESS CHEWABLE . . . 30
ISENTRESS SUSP . . . . . . . 30
ISMO . . . . . . . . . . . . . . 11
isocarboxazid . . . . . . . . . 40
isoniazid . . . . . . . . . . . . 26
ISONIAZID . . . . . . . . . . . 26
ISOPTO ATROPINE . . . . . . 35
ISOPTO CARPINE . . . . . . . 35
ISOPTO HOMATROPINE . . . 35
ISOPTO HYOSCINE . . . . . . 35
ISORDIL . . . . . . . . . . . . 11
ISORDIL S.L. . . . . . . . . . . 11
isosorbide dinitrate . . . . . . 11
ISOSORBIDE DINITRATE ER . 11
isosorbide mononitrate . . . . 11
isotretinoin . . . . . . . . . . . 16
itraconazole . . . . . . . . 27, 28
ivacaftor . . . . . . . . . . . . 54
ivermectin . . . . . . . . . . . 26
ixazomib . . . . . . . . . . . . 5
J
JADENU . . . . . . . . . . . . . 7
JAKAFI . . . . . . . . . . . . . . 5
JARDIANCE . . . . . . . . . . 22
JENTADUETO . . . . . . . . . 22
K
KALETRA . . . . . . . . . . . . 29
KALYDECO . . . . . . . . . . . 54
KAOPECTATE . . . . . . . . . 58
KAPVAY . . . . . . . . . . . . . 39
KAYEXALATE . . . . . . . . . 11
K-DUR 10 . . . . . . . . . . . . 53
K-DUR 20 . . . . . . . . . . . . 53
KEFLEX . . . . . . . . . . . . . 26
KENALOG . . . . . . . . . . . 17
KENALOG IN ORABASE . . . 21
KEPPRA . . . . . . . . . . . . 15
ketoconazole . . . . . 17, 19, 28
ketoprofen . . . . . . . . 12, 31
ketorolac . . . . . . . . . . . . 35
ketorolac tromethamine . . . 12
ketotifen . . . . . . . . . . . . 34
KHEDEZLA . . . . . . . . . . . 39
KINERET . . . . . . . . . . . . 30
KLONOPIN . . . . . . . . 14, 36
KLONOPIN WAFER . . . . . . 39
K-LOR . . . . . . . . . . . . . . 53
KLOR-CON 8 . . . . . . . . . 53
KLOR-CON 10 . . . . . . . . . 53
K-LYTE . . . . . . . . . . . . . 53
KOMBIGLYZE . . . . . . . . . 22
70
KORLYM . . . . . . . . . . . . 23
K-PHOS NEUTRAL . . . . . . 53
K-PHOS ORIGINAL . . . . . . 53
KUVAN . . . . . . . . . . . . . 23
L
labetalol . . . . . . . . . . . . . 9
LAC-HYDRIN . . . . . . . . . . 18
lacosamide . . . . . . . . . . 15
LACTINOL . . . . . . . . . . . 18
lactobacillus . . . . . . . . . . 26
lactulose . . . . . . . . . . . . 25
LAMICTAL . . . . . . . . . . . 15
LAMICTAL CD CHEW TAB . . 15
LAMICTAL ODT . . . . . . . . 40
LAMICTAL STARTER KIT . . . 15
LAMICTAL XR . . . . . . . . . 40
LAMISIL . . . . . . . . . . . . . 28
LAMISIL AT . . . . . . . . . . . 17
lamivudine . . . . . . . . 28, 29
lamivudine/zidovudine . . . . 29
lamotrigine . . . . . . . . . . 15
lamotrigine chew
dispersable tab . . . . . . 15
lamotrigine ODT . . . . . . . 40
lamotrigine SR 24hr . . . . . 40
lamotrigine starter kit . . . . . 15
LANOXIN . . . . . . . . . . . . .8
lansoprazole . . . . . . . . . . 24
lansoprazole delayed-release 24
LANTUS . . . . . . . . . . . . 21
lapatinib ditosylate . . . . . . . 4
LARIAM . . . . . . . . . . . . . 30
LASIX . . . . . . . . . . . . . . 10
latanoprost . . . . . . . . . . 35
LATUDA . . . . . . . . . . . . 40
laxative enemas . . . . . . . . 58
laxatives . . . . . . . . . . . . 59
leflunomide . . . . . . . . . . 31
lenalidomide . . . . . . . . . . 5
lenvatinib . . . . . . . . . . . . 4
LENVIMA . . . . . . . . . . . . .4
LETAIRIS . . . . . . . . . . . . 11
letrozole . . . . . . . . . . . . . 5
LEUKERAN . . . . . . . . . . . .4
LEUKINE . . . . . . . . . . . . .7
leuprolide . . . . . . . . . . . . 5
levalbuterol HCl . . . . . . . . 49
LEVAQUIN . . . . . . . . . . . 27
levetiracetam . . . . . . . . . 15
levobunolol . . . . . . . . . . 35
levocetirizine . . . . . . . . . 20
levofloxacin . . . . . . . . . . 27
levomilnacipran . . . . . . . . 40
levonorgestrel . . . . . . . . . 32
levonorgestrel/EE . . . . 32, 33
levothyroxine . . . . . . . . . 23
LEVOXYL . . . . . . . . . . . . 23
LEVSIN . . . . . . . . . . . . . 24
LEVSINEX . . . . . . . . . . . 25
LEXAPRO . . . . . . . . . . . 37
LEXAPRO ORAL SOLUTION . 40
LEXIVA . . . . . . . . . . . . . 29
LIALDA . . . . . . . . . . . . . 25
LIBRIUM . . . . . . . . . . . . 36
LIDAMANTEL . . . . . . . . . 19
LIDEX . . . . . . . . . . . . . . 17
LIDEX E . . . . . . . . . . . . . 17
lidocaine . . . . . . . . . . . . 19
lidocaine/prilocaine . . . . . 19
lidocaine viscous . . . . . . . 21
LIMBITROL DS . . . . . . . . . 39
linagliptin . . . . . . . . . . . 22
linagliptin/metformin . . . . . 22
linezolid . . . . . . . . . . . . 30
liothyronine . . . . . . . . . . 23
liotrix . . . . . . . . . . . . . . 23
LIPITOR . . . . . . . . . . . . . 10
liraglutide . . . . . . . . . . . 23
lisdexamfetamine . . . . . . . 37
lisinopril . . . . . . . . . . . . . 8
lisinopril/hydrochlorothiazide . 8
lithium carbonate . . . . . . . 37
LITHIUM CARBONATE . . . . 37
lithium carbonate
LITHOBID . . . . . . . . . . . . 37
LMX-4 . . . . . . . . . . . . . . 19
LOCOID . . . . . . . . . . . . . 17
LODINE . . . . . . . . . . 12, 31
LOESTRIN 1.5/30 . . . . . . . 32
LOESTRIN 1/20 . . . . . . . . 32
LOESTRIN FE 1.5/30 . . . . . 32
LOESTRIN FE 1/20 . . . . . . 32
LOFIBRA . . . . . . . . . . . . 10
LOMOTIL . . . . . . . . . . . . 23
lomustine . . . . . . . . . . . . 4
LONITEN . . . . . . . . . . . . 11
LONSURF . . . . . . . . . . . . 4
LO/OVRAL . . . . . . . . . . . 32
loperamide . . . . . . . . . . 23
LOPERAMIDE . . . . . . . . . 23
LOPID . . . . . . . . . . . . . . 10
lopinavir/ritonavir . . . . . . . 29
LOPRESSOR . . . . . . . . . . .9
loratadine . . . . . . . . . . . 20
loratadine/pseudoephedrine 57
loratadine/pseudoephedrine
loratadine &
pseudoephedrine SR . . 46
lorazepam . . . . . . . . . . . 36
lorazepam concentrate
solution . . . . . . . . . . 40
LORAZEPAM INTENSOL . . . 40
LORCET . . . . . . . . . . . . 13
LORTAB . . . . . . . . . . . . 13
LORTAB ELIXIR . . . . . . . . 13
losartan . . . . . . . . . . . . . 8
losartan/HCTZ . . . . . . . . . 8
LOTENSIN . . . . . . . . . . . . 8
LOTENSIN HCT . . . . . . . . . 8
LOTRIMIN AF . . . . . . . 17, 57
LOTRISONE . . . . . . . . . . 17
lovastatin . . . . . . . . . . . . 10
LOVENOX . . . . . . . . . . . . 7
loxapine . . . . . . . . . . . . 43
loxapine aerosol powder
breath activated . . . . . 40
LOXITANE . . . . . . . . . . . 43
LOZOL . . . . . . . . . . . . . 10
LUDIOMIL . . . . . . . . . . . 38
lumacaftor/ivacaftor . . . . . 54
LUPRON . . . . . . . . . . . . .5
LUPRON DEPOT . . . . . . . . 5
71
LUPRON DEPOT 6-MONTH . .5
LUPRON DEPOT-PED . . . . . .5
lurasidone . . . . . . . . . . . 40
LURIDE . . . . . . . . . . . . . 51
LURIDE LOZI-TABS . . . . . . 51
LUVOX . . . . . . . . . . . . . 37
LUVOX CR . . . . . . . . . . . 40
LYNPARZA . . . . . . . . . . . .6
LYRICA . . . . . . . . . . . . . 15
LYSODREN . . . . . . . . . . . .6
LYSTEDA . . . . . . . . . . . . 34
M
MAALOX . . . . . . . . . 24, 58
macitentan . . . . . . . . . . 11
MACROBID . . . . . . . . . . 30
MACRODANTIN . . . . . . . . 30
magnesium oxide . . . . 51, 60
MAG-OX . . . . . . . . . . 51, 60
malathion . . . . . . . . . . . 18
MAPAP COLD TAB . . . . . . 47
maprotiline . . . . . . . . . . 38
maraviroc . . . . . . . . . . . 30
MARINOL . . . . . . . . . . . . 23
MARPLAN . . . . . . . . . . . 40
MATERNA . . . . . . . . . . . 52
MATULANE . . . . . . . . . . . 6
MAXALT/MAXALT MLT . . . . 13
MAXITROL . . . . . . . . . . . 34
MAXZIDE . . . . . . . . . . . . 10
M-CLEAR WC . . . . . . . . . 45
measles, mumps & rubella virus
vaccines for inj . . . . . . 55
mecasermin . . . . . . . . . . 23
meclizine . . . . . . . . . 24, 59
MEDROL . . . . . . . . . . . . 21
medroxyprogesterone
acetate . . . . . . . . 32, 33
mefloquine . . . . . . . . . . 30
MEGACE . . . . . . . . . . . . .5
megestrol acetate . . . . . . . 5
MEKINIST . . . . . . . . . . . . 5
MELLARIL . . . . . . . . . . . 43
meloxicam . . . . . . . . 12, 31
melphalan . . . . . . . . . . . 4
memantine . . . . . . . . . . 12
MENACTRA . . . . . . . . . . 55
meningococcal
(a, c, y, and w-135) . . . . 55
meningococcal (a, c, y, and
w-135) conjugate vaccine 55
and w-135) oligo conj
vac for inj . . . . . . . . . 55
MENOMUNE . . . . . . . . . . 55
MENVEO . . . . . . . . . . . . 55
meperidine . . . . . . . . . . 13
MEPHYTON . . . . . . . . . . 51
meprobamate tablet . . . . . 40
MEPRON . . . . . . . . . . . . 29
mercaptopurine . . . . . . . . 4
mesalamine . . . . . . . . . . 25
mesalamine extended-release25
mesna . . . . . . . . . . . . . . 6
MESNEX . . . . . . . . . . . . .6
MESTINON . . . . . . . . . . . 14
MESTINON TIMESPAN . . . . 14
METADATE CD . . . . . . . . 41
METADATE ER . . . . . . . . . 37
METAMUCIL . . . . . . . . . . 59
metaproterenol . . . . . . . . 49
METAPROTERENOL SYRUP 49
metformin . . . . . . . . . . . 22
metformin ER . . . . . . . . . 22
metformin/glyburide . . . . . 22
methadone . . . . . . . . . . 13
methamphetamine . . . . . . 40
methazolamide . . . . . . . . 35
methenamine hippurate . . . 50
METHERGINE . . . . . . 23, 34
methimazole . . . . . . . . . . 23
methocarbamol . . . . . . . . 31
methotrexate . . . . . . . . . 31
methoxsalen . . . . . . . . . . 18
methsuximide . . . . . . . . . 15
methyldopa . . . . . . . . . . 11
methyldopa/HCTZ . . . . . . 11
methylergonovine . . . . 23, 34
METHYLIN . . . . . . . . . . . 40
methylphenidate . . . . . . . 37
methylphenidate chew tabs . 40
methylphenidate
extended-release . . . 37, 40
methylphenidate extendedrelease suspension . . . . 41
methylphenidate HCL
cap CR . . . . . . . . . . 41
methylphenidate hcl chew tab
extended release . . . . . 41
methylphenidate patch . . . . 41
methylprednisolone . . . . . . 21
metipranolol . . . . . . . . . . 35
metoclopramide . . . . . . . 24
metolazone . . . . . . . . . . 10
metoprolol . . . . . . . . . . . 9
metoprolol succinate . . . . . . 9
METROCREAM . . . . . . . . 18
METROGEL . . . . . . . . . . 18
METROGEL 1% . . . . . . . . 34
METROGEL-VAGINAL . . . . 34
METROLOTION . . . . . . . . 18
metronidazole . . . . 18, 30, 34
MEVACOR . . . . . . . . . . . 10
mexiletine . . . . . . . . . . . . 9
MEXITIL . . . . . . . . . . . . . .9
MIACALCIN . . . . . . . . . . 23
MICATIN . . . . . . . . . . 17, 57
miconazole . . . . . . 17, 34, 57
MICRO-K 10 . . . . . . . . . . 53
MICRONASE . . . . . . . . . . 22
MICROZIDE . . . . . . . . . . 10
MIDAMOR . . . . . . . . . . . 10
midodrine . . . . . . . . . . . 11
mifepristone . . . . . . . . . . 23
MIGERGOT SUPPOSITORIES13
MIGRANAL . . . . . . . . . . . 13
MINIPRESS . . . . . . . . . . . .8
MINOCIN . . . . . . . . . . . . 27
minocycline . . . . . . . . . . 27
minoxidil . . . . . . . . . . . . 11
MINUTUSS DR SYP . . . . . . 47
MIRALAX . . . . . . . . . . . . 25
MIRAPEX . . . . . . . . . . . . 14
MIRCETTE . . . . . . . . . . . 32
mirtazapine . . . . . . . . . . 38
72
mirtazapine ODT . . . . . . . 41
MIRVASO . . . . . . . . . . . . 18
misoprostol . . . . . . . . . . 26
MITIGARE . . . . . . . . . . . 31
mitotane . . . . . . . . . . . . . 6
M-M-R II . . . . . . . . . . . . . 55
MOBAN . . . . . . . . . . . . . 41
MOBIC . . . . . . . . . . 12, 31
MODICON . . . . . . . . . . . 32
MODURETIC . . . . . . . . . . 10
molindone . . . . . . . . . . . 41
mometasone . . . . . . . . . 48
mometasone/formoterol . . . 48
mometasone furoate . . . . . 17
mometasone inhalation . . . 48
MONISTAT . . . . . . . . 34, 57
MONISTAT 3 . . . . . . . . . . 34
MONISTAT-DERM . . . . . . . 17
MONOPRIL . . . . . . . . . . . 8
MONOPRIL-HCT . . . . . . . . .8
montelukast . . . . . . . . . . 49
morphine . . . . . . . . . . . 13
morphine extended-release . 13
MOTRIN . . . . . . . . . . 12, 31
MOTRIN IB . . . . . . . . . . . 59
MOVANTIK . . . . . . . . . . . 26
MOZOBIL . . . . . . . . . . . . .7
MS CONTIN . . . . . . . . . . 13
MSIR . . . . . . . . . . . . . . 13
MUCINEX . . . . . . . . . . . 45
MUCINEX D . . . . . . . . . . 46
MUCINEX DM . . . . . . . . . 45
MUCOMYST . . . . . . . . . . 54
MULTI SYMPTOM TAB
COLD RLF . . . . . . . . . 48
multivitamins/fluoride/±iron . 51
multivitamins/minerals . . . . 51
mupirocin . . . . . . . . . . . 16
MURINE . . . . . . . . . . . . 59
MURO 128 . . . . . . . . . . . 36
MYAMBUTOL . . . . . . . . . 26
MYCELEX . . . . . . . . . 17, 27
MYCITRACIN . . . . . . . . . . 58
MYCOBUTIN . . . . . . . . . . 26
mycophenolate mofetil . . . . .6
mycophenolate sodium . . . . 6
MYCOSTATIN . . . . . . . 17, 28
MYFORTIC . . . . . . . . . . . .6
MYLANTA . . . . . . . . . 24, 58
MYLERAN . . . . . . . . . . . . 4
MYLICON . . . . . . . . . . . 59
MYSOLINE . . . . . . . . . . . 15
N
nabumetone . . . . . . . . . . 12
naloxegol . . . . . . . . . . . 26
naloxone . . . . . . . . . . . . 42
naloxone hcl solution
auto-injector . . . . . . . . 41
NALOXONE INJ . . . . . . . . 42
naltrexone . . . . . . . . . 36, 42
NAMENDA . . . . . . . . . . . 12
naphazoline/antazoline . . . 34
naphazoline/glycerin . . . . . 34
naphazoline HCL . . . . . . . 34
naphazoline/zinc sulfate . . . 34
NAPHCON A . . . . . . . . . . 59
NAPROSYN . . . . . . . . 12, 31
naproxen . . . . . . . . . 12, 31
naproxen delayed release 12, 31
naratriptan . . . . . . . . . . . 13
NARCAN NASAL SPRAY . . . 42
NARDIL . . . . . . . . . . . . . 41
NASACORT ALLERGY . . . . 20
NASALCROM . . . . . . . . . 20
nasal sprays . . . . . . . . . . 58
NATALCARE . . . . . . . . . . 52
nateglinide . . . . . . . . . . . 22
NAVANE . . . . . . . . . . . . 43
nedocromil . . . . . . . . . . 48
nefazodone . . . . . . . . . . 41
nelfinavir . . . . . . . . . . . . 29
NEO DM . . . . . . . . . . . . 44
bacitracin . . . . . . . . . 16
dexamethasone . . . . . . 34
gramicidin . . . . . . . . . 36
hydrocortisone . . . . 19, 34
neomycin sulfate . . . . . . . 30
NEORAL . . . . . . . . . . . . . 6
NEOSPORIN . . . . . 16, 36, 58
NEO-SYNEPHRINE . . . 20, 58
NEPHROCAPS . . . . . . . . 53
NEPTAZANE . . . . . . . . . . 35
NESTABSCBF/FA/RX . . . . . 52
NEULASTA . . . . . . . . . . . .7
NEUMEGA . . . . . . . . . . . .7
NEURONTIN . . . . . . . . . . 15
NEUTROGENA OIL FREE
ACNE WASH . . . . . . . . 16
nevirapine . . . . . . . . . . . 28
nevirapine ER . . . . . . . . . 28
NEXAVAR . . . . . . . . . . . . .5
NEXIUM 24HR OTC . . . . . . 24
NEXIUM DELAYED
RELEASE PACKET . . . . 24
niacin . . . . . . . . . . . . . 10
niacin extended-release . . . 10
NIACOR . . . . . . . . . . . . 10
NIASPAN . . . . . . . . . . . . 10
nicardipine . . . . . . . . . . . 9
NICODERM CQ . . . . . 42, 59
NICORETTE OTC . . . . . . . 42
nicotine . . . . . . . . . . 42, 59
NICOTINE GUM . . . . . . . . 59
nicotine inhaler system . . . . 41
nicotine nasal spray . . . . . . 41
nicotine polacrilex gum . . . . 42
nicotine polacrilex lozenge . . 43
nicotine TD patch 24 HR kit . 41
NICOTINE TD PATCH
24 HR KIT . . . . . . . . . 41
NICOTROL INHALER . . . . . 41
NICOTROL NS . . . . . . . . . 41
nifedipine . . . . . . . . . . . . 9
nifedipine extended-release . . 9
NIFEREX . . . . . . . . . 51, 60
NIFEREX-PN FORTE . . . . . 52
nilotinib . . . . . . . . . . . . . 4
nimodipine . . . . . . . . . . . 9
NIMOTOP . . . . . . . . . . . . 9
73
NINLARO . . . . . . . . . . . . .5
nintedanib . . . . . . . . . . . 54
NIRAVAM . . . . . . . . . . . . 38
nitazoxanide suspension . . . 30
nitazoxanide tablet . . . . . . 30
NITREK . . . . . . . . . . . . 11
NITRO-BID . . . . . . . . . . . 11
NITRO-DUR . . . . . . . . . . 11
nitrofurantoin
nitrofurantoin macrocrystals . 30
nitrofurantoin susp . . . . . . 30
nitroglycerin . . . . . . . .11, 19
NITROLINGUAL . . . . . . . . 11
NITROSTAT . . . . . . . . . . . 11
NIX . . . . . . . . . . . . . . . 59
NIX CREME RINSE . . . . . . 18
NIZORAL . . . . . . . . . 17, 28
NIZORAL SHAMPOO . . . . . 19
NOLVADEX . . . . . . . . . . . .5
NORCO . . . . . . . . . . . . . 13
NORDETTE . . . . . . . . . . 32
norelgestromin/EE . . . . . . 33
norethindrone . . . . . . . . . 33
norethindrone acetate . . . . 33
norethindrone acetate/EE . . 32
norethindrone
acetate/EE/iron . . . 32, 33
norethindrone/EE . . . . 32, 33
norethindrone/ME . . . . . . 33
NORFLEX . . . . . . . . . . . 31
norgestimate/EE . . . . . 32, 33
norgestrel . . . . . . . . . . . 33
norgestrel/EE . . . . . . . 32, 33
NORPACE . . . . . . . . . . . . 8
NORPACE CR . . . . . . . . . .8
NORPRAMIN . . . . . . . . . . 38
nortriptyline . . . . . . . . . . 38
NORVASC . . . . . . . . . . . . 9
NORVIR . . . . . . . . . . . . . 29
NOVOLIN . . . . . . . . . . . . 58
NOVOLIN 70/30 . . . . . . . . 22
NOVOLIN N . . . . . . . . . . 21
NOVOLIN R . . . . . . . . . . 21
NOVOLOG . . . . . . . . . . . 21
NOVOLOG MIX 70/30 . . . . 21
NUEDEXTA . . . . . . . . . . . 43
NULYTELY . . . . . . . . . . . 25
NUPLAZID . . . . . . . . . . . 41
NUTROPIN AQ NUSPIN . . . 23
NUVARING . . . . . . . . . . . 32
NYMALIZE . . . . . . . . . . . .9
nystatin . . . . . . . . . . 17, 28
NYTOL QUICK CAPS . . . . . 38
O
OCEAN NASAL SPRAY . . . . 21
octreotide . . . . . . . . . . . . 6
OCUFEN . . . . . . . . . . . . 35
OCUFLOX . . . . . . . . . . . 36
ODOMZO . . . . . . . . . . . . .6
OFEV . . . . . . . . . . . . . . 54
ofloxacin . . . . . . . 19, 27, 36
OGEN . . . . . . . . . . . . . . 33
olanzapine . . . . . . . . . . . 42
olanzapine-fluoxetine . . . . . 41
olanzapine INJ . . . . . . . . 41
olanzapine ODT . . . . . . . . 41
olanzapine pamoate for extended-release IM sus . . . . . 41
olaparib . . . . . . . . . . . . . 6
olodaterol . . . . . . . . . . . 48
olsalazine sodium . . . . . . . 25
omalizumab . . . . . . . . . . 48
omeprazole delayed-release 24
OMNICEF . . . . . . . . . . . . 27
ondansetron . . . . . . . . . . 24
ONE TOUCH SYSTEMS (ULTRA
2, ULTRAMINI, VERIO, VERIO FLEX, VERIO IQ,
VERIO SYNC) . . . . . . . 22
ONE TOUCH TEST STRIPS
(ULTRA, VERIO) . . . . . . 22
ONFI . . . . . . . . . . . . . . 14
ONGLYZA . . . . . . . . . . . 22
oprelvekin . . . . . . . . . . . . 7
OPSUMIT . . . . . . . . . . . . 11
OPTIPRANOLOL . . . . . . . 35
OPTIVAR . . . . . . . . . . . . 34
ORAP . . . . . . . . . . . . . . 43
ORAPRED . . . . . . . . . . . 21
ORKAMBI . . . . . . . . . . . 54
orphenadrine
ORTHO-CEPT . . . . . . . . . 32
ORTHO COIL . . . . . . . . . 32
ORTHO-CYCLEN . . . . . . . 32
ortho diaphragm . . . . . . . 32
ORTHO EVRA . . . . . . . . . 33
ORTHO FLAT . . . . . . . . . 32
ORTHO FLEX . . . . . . . . . 32
ORTHO MICRONOR . . . . . 33
ORTHO-NOVUM 1/35 . . . . 32
ORTHO-NOVUM 1/50 . . . . 33
ORTHO-NOVUM 7/7/7 . . . . 33
ORTHO-NOVUM 10/11 . . . 32
ORTHO TRI-CYCLEN . . . . . 33
ORUDIS . . . . . . . . . . 12, 31
OS-CAL . . . . . . . . . . 50, 60
oseltamivir . . . . . . . . . . . 28
OVCON 50 . . . . . . . . . . . 33
OVIDE . . . . . . . . . . . . . . 18
OVRAL . . . . . . . . . . . . . 33
OVRETTE . . . . . . . . . . . . 33
oxaprozin . . . . . . . . . 12, 31
oxazepam . . . . . . . . . . . 37
oxcarbazepine . . . . . . . . 15
OXSORALEN-ULTRA . . . . . 18
oxybutynin chloride . . . . . . 50
oxybutynin IR . . . . . . . . . 50
oxycodone . . . . . . . . . . 13
oxycodone/acetaminophen . 13
oxycodone/aspirin . . . . . . 13
OXYFAST . . . . . . . . . . . . 13
oxymetazoline . . . . . . . . . 20
oxymorphone ER . . . . . . . 13
OXYMORPHONE ER . . . . . 13
P
palbociclib . . . . . . . . . . . 5
paliperidone . . . . . . . . . . 42
paliperidone tab SR . . . . . 41
palivizumab . . . . . . . . . . 30
PAMELOR . . . . . . . . . . . 38
pancrelipase . . . . . . . . . 25
74
panobinostat . . . . . . . . . . 4
PANRETIN . . . . . . . . . . . .6
pantoprazole . . . . . . . . . 24
PARAFON FORTE DSC . . . . 31
PARNATE . . . . . . . . . . . . 37
paromomycin . . . . . . . . . 30
paroxetine . . . . . . . . . . . 37
paroxetine HCL oral susp . . 41
paroxetine HCL tab SR . . . . 41
paroxetine mesylate tab . . . 41
PASER . . . . . . . . . . . . . 26
pasireotide . . . . . . . . . . . 6
PAXIL . . . . . . . . . . . 37, 41
PAXIL CR . . . . . . . . . . . . 41
pazopanib . . . . . . . . . . . 5
PEDIACARE LIQ MULTI-SY . . 48
PEDIALYTE . . . . . . . . 50, 58
PEDIAPRED . . . . . . . . . . 21
PEDIAZOLE . . . . . . . . . . 27
peg 3350/electrolytes . . . . 25
peg 3350/sodium bicarbonate/
sodium chloride . . . . . 25
peg 3350/sodium
bicarbonate/sodium chloride/potassium chloride . 25
PEGASYS . . . . . . . . . . . . 28
PEGASYS PROCLICK . . . . 28
pegfilgrastim . . . . . . . . . . 7
peginterferon alfa-2a . . . . . 28
peginterferon alfa-2b . . . . . . 5
pegvisomant . . . . . . . . . 23
penicillamine . . . . . . . . . 31
penicillin VK . . . . . . . . . . 27
PENLAC SOLUTION 8% . . . 17
PENTASA . . . . . . . . . . . . 25
pentoxifylline extended-release 7
PEPCID . . . . . . . . . . . . . 24
PEPCID AC . . . . . . . . 24, 58
PERCOCET . . . . . . . . . . 13
PERCODAN . . . . . . . . . . 13
PERIDEX . . . . . . . . . . . . 21
permethrin . . . . . . . . 18, 59
perphenazine . . . . . . . . . 43
PERSANTINE . . . . . . . . . . 7
PEXEVA . . . . . . . . . . . . . 41
phenazopyridine . . . . . . . 50
phenelzine . . . . . . . . . . . 41
PHENERGAN . . . . . . . . . 24
PHENERGAN DM . . . . . . . 45
phenobarbital . . . . . . . . . 15
PHENOBARBITAL . . . . . . . 15
phenyleph/bromphen/dextromethorphan/guaifenesin 46
phenylephrine . . . . . . . . . 20
phenylephrine/brompheniramine/dextromethorphan 46
phenylephrine/
chlorpheniramine . . . . . 46
phenylephrine/
chlorpheniramine/
dextromethorphan . . 46, 47
phenylephrine/
chlorpheniramine/
dihydrocodeine . . . . . . 47
phenylephrine/
phenylephrine/dextromethorphan/guaifenesin . . . . 47
phenylephrine/ephed/CPM
w/carbetapentane . . . . 47
phenylephrine/guaifenesin . . 47
phenylephrine/hydrocodone/
guaifenesin . . . . . . . . 47
phenylephrine/pyrilamine/
phenylephrine/pyrilamine
w/hydrocodone . . . . . . 47
phenylephrine tan/pyrilamine
tan/carbeta tan . . . . . . 47
PHENYLHIST LIQ DH . . . . . 45
PHENYTEK . . . . . . . . . . . 15
phenytoin . . . . . . . . . . . 15
phenytoin sodium extended . 15
PHISOHEX . . . . . . . . . . . 18
PHOS-FLUR . . . . . . . . 51, 60
PHOSLO . . . . . . . . . . . . 54
PHOSPHOLINE IODINE . . . 35
phosphorus . . . . . . . . . . 53
PHRENILIN . . . . . . . . . . . 12
phytonadione . . . . . . . . . 51
pilocarpine . . . . . . . . 21, 35
PILOPINE HS GEL . . . . . . . 35
PIMA . . . . . . . . . . . . . . 53
pimavanserin . . . . . . . . . 41
pimecrolimus . . . . . . . . . 19
pimozide . . . . . . . . . . . . 43
pindolol . . . . . . . . . . . . . 9
PINDOLOL . . . . . . . . . . . .9
pioglitazone . . . . . . . . . . 22
pioglitazone/glimepiride . . . 22
pioglitazone/metformin . . . 22
pioglitazone/metformin ER . 22
PIPERONYL BUTOXIDE . . . 59
piperonyl butoxide gel, liquid
shampoo . . . . . . . . . 59
pirfenidone capsule . . . . . 54
piroxicam . . . . . . . . . 12, 31
PLAN B . . . . . . . . . . . . . 32
PLAQUENIL . . . . . . . . 30, 31
PLAVIX . . . . . . . . . . . . . 7
PLENDIL . . . . . . . . . . . . . 9
plerixafor . . . . . . . . . . . . 7
PLETAL . . . . . . . . . . . . . .7
PLEXION . . . . . . . . . . . . 16
pneumococcal 13-valent
conjugate . . . . . . . . . 55
pneumococcal vaccine
polyvalent . . . . . . . . . 55
PNEUMOVAX . . . . . . . . . 55
PNEUMOVAX 23 . . . . . . . 55
podofilox . . . . . . . . . . . . 18
polyethylene glycol 3350 . . . 25
polymyxin B/bacitracin . . . . 36
polymyxin B/trimethoprim . . 36
polysaccharide iron complex 51
POLYSPORIN . . . . . . . . . 36
POLYTRIM . . . . . . . . . . . 36
POLY-VI-FLOR . . . . . . . . . 51
POLY-VI-SOL . . . . . . . . . . 60
pomalidomide . . . . . . . . . 5
POMALYST . . . . . . . . . . . .5
ponatinib . . . . . . . . . . . . 5
potassium acid phosphate . . 53
potassium bicarbonate/potassium citrate effervescent 53
75
potassium chloride . . . . . . 53
POTASSIUM CHLORIDE . . . 53
potassium chloride
potassium citrate . . . . . . . 50
potassium iodide . . . . . . . 53
POTIGA . . . . . . . . . . . . . 15
povidone-iodine . . . . . . . . 30
PRALUENT . . . . . . . . . . . 10
pramipexole . . . . . . . . . . 14
pramlintide . . . . . . . . . . 23
PRAMLYTE . . . . . . . . . . . 40
PRANDIN . . . . . . . . . . . . 22
praziquantel . . . . . . . . . . 26
prazosin . . . . . . . . . . . . . 8
PRECOSE . . . . . . . . . . . 22
PRED FORTE . . . . . . . . . 35
PRED-G . . . . . . . . . . . . . 34
PRED MILD . . . . . . . . . . 35
prednicarbate . . . . . . . . . 17
prednisolone . . . . . . . . . 21
prednisolone acetate . . . . . 35
prednisolone phosphate . . . 35
prednisolone sodium
phosphate . . . . . . . . . 21
prednisone . . . . . . . . . . 21
pregabalin . . . . . . . . . . . 15
PRELONE . . . . . . . . . . . 21
PREMARIN . . . . . . . . . . . 33
PREMPHASE . . . . . . . . . 33
PREMPRO . . . . . . . . . . . 33
prenatal vitamins w/folic acid 52
PRENATAL VITAMINS W/
FOLIC ACID . . . . . . . . 52
prenatal vit w/FE bisglyc-FE prot
succ-FA . . . . . . . . . . 52
prenatal vit w/FE bisglycinate
chelate-FA . . . . . . . . . 52
prenatal vit w/FE b
isglycinate chelate-FA . . 52
prenatal vit w/FE
polysac cmplx-FA . . . . . 52
prenatal vit w/ iron
carbonyl-FA . . . . . . . . 52
prenatal vit w/o vit a w/fe
bisglycinate-fa . . . . . . . 52
prenatal w/o A w/ FE carbonylFE gluc-DSS-FA . . . . . . 52
prenat-FE Bis-FE prot succ-FACA & omega 3 . . . . . . 52
prenat-FE bis-FE prot succ-FACA & omega DR . . . . . 52
prenat w/o A w/fecbn-fegl-DSSFA & DHA . . . . . . . . . 52
PREPARATION H . . . . . . . 59
PREVACID . . . . . . . . . . . 24
PREVIDENT . . . . . . . . . . 51
PREVNAR 13 . . . . . . . . . 55
PREZCOBIX . . . . . . . . . . 30
PREZISTA . . . . . . . . . . . . 29
PRIFTIN . . . . . . . . . . . . . 26
PRILOSEC . . . . . . . . . . . 24
primaquine . . . . . . . . . . 30
primidone . . . . . . . . . . . 15
PRINCIPEN . . . . . . . . . . . 27
PRISTIQ . . . . . . . . . . . . . 39
PROAMATINE . . . . . . . . . 11
probenecid . . . . . . . . . . 31
PROBENECID . . . . . . . . . 31
PROBIOTIC FORMULA . . . . 26
probiotic product . . . . . . . 26
procarbazine . . . . . . . . . . 6
PROCARDIA . . . . . . . . . . .9
PROCARDIA XL . . . . . . . . .9
PROCENTRA . . . . . . . . . 40
prochlorperazine . . . . . . . 24
PROCRIT . . . . . . . . . . . . .7
PROCTOSOL HC
CREAM 2.5% . . . . . . . 18
PROCTOZONE
CREAM-HC 2.5% . . . . . 18
PROGRAF . . . . . . . . . . . . 6
PROLIXIN . . . . . . . . . . . . 43
PROLIXIN DECANOATE . . . 43
PROMACTA . . . . . . . . . . 54
promethazine . . . . . . . . . 24
promethazine &
PROMETHAZINE SYP DM . . 45
PROMETHAZINE VC
W/CODEINE . . . . . . . . 45
PROMETHAZINE
W/CODEINE . . . . . . . . 45
PROMETH VC SYP 6.25-5/5 . 47
propafenone . . . . . . . . . . 9
propantheline . . . . . . . . . 50
propranolol . . . . . . . . . 9, 14
propranolol/HCTZ . . . . . . . 9
propylthiouracil . . . . . . . . 23
PROPYLTHIOURACIL . . . . . 23
PROSCAR . . . . . . . . . . . 49
PROTONIX . . . . . . . . . . . 24
PROTOPIC 0.1% . . . . . . . . 19
PROTOPIC 0.03% . . . . . . . 19
protriptyline . . . . . . . . . . 41
PROVENTIL . . . . . . . . . . 49
PROVERA . . . . . . . . . . . 33
PROZAC . . . . . . . . . . 37, 40
PROZAC WEEKLY . . . . . . . 40
PRUET DHAEC PAK . . . . . 52
PRUET DHA PAK
SETONET PAK . . . . . . 52
PSE/GG . . . . . . . . . . . . 46
pseudoephedrine/
acetaminophen/
pseudoephedrine/
chlorpheniramine/
pseudoephedrine/dextromethorphan/guaifenesin . . . . 48
pseudoephedrine/iburprofen 48
pseudoephedrine tan/
dexchlorphen tan/DM tan 48
psyllium . . . . . . . . . . . . 59
PULMICORT RESPULES . . . 49
PULMOZYME . . . . . . . . . 54
PURINETHOL . . . . . . . . . . 4
pyrazinamide . . . . . . . . . 26
PYRAZINAMIDE . . . . . . . . 26
pyrethrins/piperonyl but . . . 18
PYRIDIUM . . . . . . . . . . . 50
pyridostigmine . . . . . . . . 14
76
pyridostigmine
pyrilamine tan/phenyleph tan 48
pyrimethamine . . . . . . . . 30
Q
QUAL-TUSSIN SYP DC . 46, 47
QUESTRAN . . . . . . . . . . 10
QUESTRAN-LIGHT . . . . . . 10
quetiapine . . . . . . . . . . . 42
quetiapine fumarate tab SR . 41
QUILLICHEW ER . . . . . . . 41
QUILLIVANT XR . . . . . . . . 41
quinapril . . . . . . . . . . . . . 8
quinapril/hydrochlorothiazide . 8
quinidine gluconate
extended-release . . . . . . 9
QUINIDINE GLUCONATE
EXT-REL . . . . . . . . . . . 9
quinidine sulfate . . . . . . . . 9
QUINIDINE SULFATE . . . . . .9
quinidine sulfate
extended-release . . . . . . 9
QUINIDINE SULFATE EXT-REL 9
QV-ALLERGY . . . . . . . . . 44
R
raloxifene . . . . . . . . . . . 23
raltegravir . . . . . . . . . . . 30
RANEXA . . . . . . . . . . . . 11
ranitidine . . . . . . . . . . . . 24
ranolazine . . . . . . . . . . . 11
RAPAMUNE . . . . . . . . . . . 6
RAVICTI . . . . . . . . . . . . . 54
RAZADYNE . . . . . . . . . . 12
REBETOL/COPEGUS . . . . 28
REBIF . . . . . . . . . . . . . . 14
RECOMBIVAX HB . . . . . . . 54
rectal hydrocortisone crm,
suppositories . . . . . . . 59
RECTIV . . . . . . . . . . . . . 19
REGLAN . . . . . . . . . . . . 24
regorafenib . . . . . . . . . . . 5
REGRANEX . . . . . . . . . . 18
RELAFEN . . . . . . . . . . . . 12
RELENZA . . . . . . . . . . . . 28
RELION 70/30 . . . . . . . . . 22
RELION N . . . . . . . . . . . 22
RELION R . . . . . . . . . . . 21
REMERON . . . . . . . . . . . 38
REMERON SOLTAB . . . . . . 41
RENVELA . . . . . . . . . . . . 54
repaglinide . . . . . . . . . . 22
REQUIP . . . . . . . . . . . . . 14
RESCRIPTOR . . . . . . . . . 28
RESPERAL-DM . . . . . . . . . 43
RESTORIL . . . . . . . . . . . 38
RETIN-A . . . . . . . . . . . . 16
RETROVIR . . . . . . . . . . . 29
REVATIO . . . . . . . . . . . . 11
REVIA . . . . . . . . . . . 36, 42
REVLIMID . . . . . . . . . . . . 5
REXULTI . . . . . . . . . . . . 39
REYATAZ . . . . . . . . . . . . 29
REYATAZ POWDER PACKET 29
ribavirin . . . . . . . . . . . . 28
RIDAURA . . . . . . . . . . . . 30
RID SHAMPOO/
BUTOXIDE SHAMPOO . . 18
rifabutin . . . . . . . . . . . . 26
RIFADIN . . . . . . . . . . . . . 26
rifampin . . . . . . . . . . . . 26
rifapentine . . . . . . . . . . 26
rilpivirine . . . . . . . . . . . . 28
rimantadine . . . . . . . . . . 28
rimexolone . . . . . . . . . . . 35
riociguat . . . . . . . . . . . . 11
RISPERDAL . . . . . . . . . . 42
RISPERDAL CONSTA . . . . . 42
RISPERDAL M-TAB . . . . . . 41
RISPERDAL SOLUTION . . . 42
risperidone . . . . . . . . . . 42
risperidone ODT . . . . . . . 41
risperidone oral soln . . . . . 42
RITALIN . . . . . . . . . . . . . 37
RITALIN LA . . . . . . . . . . . 37
RITALIN-SR . . . . . . . . . . . 37
ritonavir . . . . . . . . . . . . 29
rivaroxaban . . . . . . . . . . . 7
rivastigmine . . . . . . . . . . 12
rizatriptan . . . . . . . . . . . 13
RMS . . . . . . . . . . . . . . . 13
ROBAXIN . . . . . . . . . . . . 31
ROBINUL . . . . . . . . . . . . 24
ROBITUSSIN . . . . . . . 45, 58
ROBITUSSIN CF . . . . . 46, 58
ROBITUSSIN DM . . . . . 45, 58
ROBITUSSIN LIQ
CGH/ALRG . . . . . . . . 47
ROBITUSSIN LIQ
CGH/CLD . . . . . . . 44, 47
ROBITUSSIN LIQ
CGH/CONG . . . . . . . . 45
ROBITUSSIN LIQ HD/CHST . 47
ROBITUSSIN LIQ PED NGHT 48
ROBITUSSIN PE . . . . . 46, 58
ROBITUSSIN PED LIQ
CGH/COLD . . . . . . . . 44
ROBITUSSIN PED SYP . . . . 45
ROBITUSSIN SYP
CHST CNG . . . . . . . . . 45
ROBITUSSIN SYP MAX-ST . . 45
ROCALTROL . . . . . . . . . . 50
RONDEC DM . . . . . . . . . 47
RONDEC DROPS . . . . . . . 44
RONDEC SYRUP . . . . . 43, 44
ropinirole . . . . . . . . . . . 14
ROWASA . . . . . . . . . . . . 25
ROXICODONE . . . . . . . . . 13
R-TANNAMINE . . . . . . . . . 44
rufinamide . . . . . . . . . . . 15
ruxolitinib . . . . . . . . . . . . 5
RYNA-12 S . . . . . . . . . . . 48
RYNATAN PEDIATRIC SUSP . 44
RYNATUSS . . . . . . . . . . . 44
RYNATUSS PEDIATRIC SUSP47
RYTHMOL . . . . . . . . . . . .9
S
SABRIL SOLUTION . . . . . . 15
SALAGEN . . . . . . . . . . . 21
salicylic acid . . . . . . . 16, 18
salicylic acid 17%/
collodion . . . . . . . 18, 60
saline nasal spray 0.65% . . . 21
77
SAL-TROPINE . . . . . . . . . 26
SANCTURA . . . . . . . . . . 50
SANDIMMUNE . . . . . . . . . .6
SANDOSTATIN . . . . . . . . . .6
SANTYL . . . . . . . . . . . . 18
SAPHRIS . . . . . . . . . . . . 39
sapropterin . . . . . . . . . . 23
sapropterin powder . . . . . . 23
saquinavir mesylate . . . . . . 29
SARAFEM . . . . . . . . . . . 40
sargramostim . . . . . . . . . . 7
SAVAYSA . . . . . . . . . . . . .7
saxagliptin . . . . . . . . . . . 22
saxagliptin/metformin . . . . 22
SCALPICIN . . . . . . . . . . . 18
scopolamine . . . . . . . . . 35
SEASONALE . . . . . . . . . . 32
SECTRAL . . . . . . . . . . . . .9
SEDAPAP . . . . . . . . . . . . 12
selegiline . . . . . . . . . . . 14
selegiline td patch . . . . . . 41
selenium sulfide . . . . . . . . 19
SELSUN . . . . . . . . . . . . 19
SELZENTRY . . . . . . . . . . 30
sennosides . . . . . . . . . . 25
SENOKOT . . . . . . . . . . . 25
SENSIPAR . . . . . . . . . . . 54
SERAX . . . . . . . . . . . . . 37
SEROMYCIN . . . . . . . . . . 26
SEROQUEL . . . . . . . . . . 42
SEROQUEL XR . . . . . . . . 41
sertraline . . . . . . . . . . . . 37
SERZONE . . . . . . . . . . . 41
sevelamer . . . . . . . . . . . 54
SIGNIFOR . . . . . . . . . . . . 6
sildenafil . . . . . . . . . . . . 11
SILVADENE . . . . . . . . . . . 16
silver sulfadiazine . . . . . . . 16
simethicone . . . . . . . . . . 59
simvastatin . . . . . . . . . . . 10
SINEMET . . . . . . . . . . . . 14
SINEMET CR . . . . . . . . . . 14
SINEQUAN . . . . . . . . . . . 38
SINGULAIR . . . . . . . . . . . 49
sirolimus . . . . . . . . . . . . 6
SIRTURO . . . . . . . . . . . . 29
sodium chloride hypertonic . 36
sodium citrate/citric acid . . . 50
sodium phenylbutyrate
oral powder . . . . . . . . 54
sodium polysterene sulfonate 11
sofosbuvir . . . . . . . . . . . 28
sofosbuvir/velpatasvir . . . . 28
somatropin . . . . . . . . . . 23
SOMAVERT . . . . . . . . . . 23
SONATA . . . . . . . . . . . . 38
sonidegib . . . . . . . . . . . . 6
sorafenib . . . . . . . . . . . . 5
SORIATANE . . . . . . . . . . 18
sotalol . . . . . . . . . . . . . . 9
SOVALDI . . . . . . . . . . . . 28
spacers . . . . . . . . . . . . 54
spironolactone . . . . . . . . 10
spironolactone/
hydrochlorothiazide . . . 10
SPORANOX . . . . . . . . 27, 28
SPRYCEL . . . . . . . . . . . . .4
STADOL . . . . . . . . . . . . 13
STARLIX . . . . . . . . . . . . 22
STATUSS DM SYP . . . . . . . 47
stavudine . . . . . . . . . . . 29
STAVZOR . . . . . . . . . . . . 42
STELAZINE . . . . . . . . . . . 43
STIVARGA . . . . . . . . . . . . 5
stool softeners . . . . . . . . 59
STRATTERA . . . . . . . . . . 37
STRENSIQ . . . . . . . . . . . 23
STRIBILD . . . . . . . . . . . . 29
STRIVERDI RESPIMAT . . . . 48
STROMECTOL . . . . . . . . . 26
STUART PRENATAL . . . . . . 60
SUBOXONE . . . . . . . . 39, 42
SUBUTEX . . . . . . . . . . . 42
sucralfate . . . . . . . . . . . 24
sugar+orthophosphoric acid 59
sulcralfate . . . . . . . . . . . 24
sulfacetamide . . . . . . . . . 36
sulfacetamide/phenylephrine 36
sulfacetamide/pred phos . . 34
sulfacetamide/sulfur . . . . . 16
SULFACET-R . . . . . . . . . . 16
sulfamethoxazole/
trimethoprim, DS . . . . . 27
sulfasalazine . . . . . . . 25, 31
sulfasalazine
delayed-release . . . . 25, 31
sulindac . . . . . . . . . . 12, 31
sumatriptan . . . . . . . . . . 13
sunitinib . . . . . . . . . . . . . 5
SUPRAX . . . . . . . . . . . . 27
SURMONTIL . . . . . . . . . . 41
SUSTIVA . . . . . . . . . . . . 28
SUTENT . . . . . . . . . . . . . 5
SYLATRON . . . . . . . . . . . .5
SYMBYAX . . . . . . . . . . . 41
SYMLIN . . . . . . . . . . . . . 23
SYMMETREL . . . . . . . 14, 28
SYNAGIS . . . . . . . . . . . . 30
SYNALAR . . . . . . . . . 16, 17
SYNJARDY . . . . . . . . . . . 22
SYNTHROID . . . . . . . . . . 23
T
TABLOID . . . . . . . . . . . . . 4
tacrolimus . . . . . . . . . . 6, 19
TAFINLAR . . . . . . . . . . . . 4
TAGAMET . . . . . . . . . . . 24
TAMBOCOR . . . . . . . . . . .8
TAMIFLU . . . . . . . . . . . . 28
tamoxifen . . . . . . . . . . . . 5
tamsulosin . . . . . . . . . . . 49
TANAFED . . . . . . . . . . . . 44
TANAFED DMX
SUSPENSION . . . . . . . 48
TANZEUM . . . . . . . . . . . 23
TAPAZOLE . . . . . . . . . . . 23
TARCEVA . . . . . . . . . . . . .4
TARGRETIN . . . . . . . . . . . 6
TASIGNA . . . . . . . . . . . . .4
TASMAR . . . . . . . . . . . . 14
TECFIDERA . . . . . . . . . . 14
teduglutide . . . . . . . . . . 26
TEGRETOL . . . . . . . . . . . 14
TEGRETOL-XR . . . . . . . . . 14
temazepam . . . . . . . . . . 38
78
TEMODAR . . . . . . . . . . . .4
TEMOVATE . . . . . . . . . . . 17
temozolomide . . . . . . . . . 4
TENEX . . . . . . . . . . . . . . 8
TENIVAC . . . . . . . . . . . . 56
tenofovir . . . . . . . . . . . . 29
TENORETIC . . . . . . . . . . .9
TENORMIN . . . . . . . . . . . .9
TERAZOL 3/7 . . . . . . . . . 34
terazosin . . . . . . . . . . 8, 49
terbinafine . . . . . . . . 17, 28
terbutaline . . . . . . . . . . . 49
terconazole . . . . . . . . . . 34
teriflunomide . . . . . . . . . 14
teriparatide inj . . . . . . . . . 23
TESSALON . . . . . . . . . . . 43
TESTOSTERONE 1%
TOPICAL GEL . . . . . . . 21
testosterone cypionate . . . . 21
testosterone enanthate . . . . 21
testosterone gel topical tube,
packet, and pump bottle 21
tetanus-diphtheria toxoids . . 56
tetanus immune globulin . . . 56
TET/DIP TOX INJ . . . . . . . 56
tetrabenazine . . . . . . . . . 15
tetrahydrozoline/zinc sulfate . 34
tet tox-diph-acell pertuss ad . 56
thalidomide . . . . . . . . . . . 5
THALOMID . . . . . . . . . . . .5
THEO-24 . . . . . . . . . . . . 49
THEOCHRON . . . . . . . . . 49
theophylline . . . . . . . . . . 49
THEOPHYLLINE . . . . . . . . 49
theophylline
THEOPHYLLINE EXT-REL . . 49
thioguanine . . . . . . . . . . . 4
thioridazine . . . . . . . . . . 43
thiothixene . . . . . . . . . . . 43
THORAZINE . . . . . . . . . . 43
THYROLAR . . . . . . . . . . 23
tiagabine . . . . . . . . . . . . 15
TIAZAC . . . . . . . . . . . . . .9
TIGAN . . . . . . . . . . . . . . 24
TIKOSYN . . . . . . . . . . . . .8
TILADE . . . . . . . . . . . . . 48
timolol . . . . . . . . . . . . . 35
timolol maleate . . . . . . . 9, 35
TIMOPTIC . . . . . . . . . . . 35
TIMOPTIC XE . . . . . . . . . 35
TINACTIN . . . . . . . . . 17, 57
tipranavir . . . . . . . . . . . . 29
TIVICAY . . . . . . . . . . . . . 30
tizanidine . . . . . . . . . . . 32
TOBRADEX . . . . . . . . . . 34
tobramycin . . . . . . . . . . 36
tobramycin/dexamethasone 34
tobramycin neb soln . . . . . 54
TOBREX . . . . . . . . . . . . 36
TOFRANIL . . . . . . . . . . . 38
TOFRANIL-PM . . . . . . . . . 40
tolazamide . . . . . . . . . . . 22
tolbutamide . . . . . . . . . . 23
TOLBUTAMIDE . . . . . . . . 23
tolcapone . . . . . . . . . . . 14
TOLINASE . . . . . . . . . . . 22
tolnaftate . . . . . . . . . 17, 57
tolterodine . . . . . . . . . . . 50
TOPAMAX . . . . . . . . . . . 15
TOPAMAX SPRINKLE . . . . . 15
topical antibacterials . . . . . 58
topiramate . . . . . . . . . . . 15
topiramate sprinkle caps . . . 15
topotecan . . . . . . . . . . . . 6
TOPROL XL . . . . . . . . . . . 9
TORADOL . . . . . . . . . . . 12
toremifene . . . . . . . . . . . 5
torsemide . . . . . . . . . . . 10
TOUJEO SOLOSTAR . . . . . 21
TRACLEER . . . . . . . . . . . 11
TRADJENTA . . . . . . . . . . 22
tramadol . . . . . . . . . . . . 12
trametinib . . . . . . . . . . . . 5
TRANDATE . . . . . . . . . . . .9
tranexamic acid . . . . . . . . 34
TRANXENE . . . . . . . . . . . 36
tranylcypromine . . . . . . . . 37
trazodone . . . . . . . . . 38, 41
TRECATOR . . . . . . . . . . . 26
TRENTAL . . . . . . . . . . . . .7
tretinoin . . . . . . . . . . . 6, 16
triamcinolone . . . . . . . . . 21
triamcinolone acetonide . . . 17
triamcinolone nasal spray . . 20
triamterene/
hydrochlorothiazide . . . 10
TRIAVIL . . . . . . . . . . . . . 38
triazolam . . . . . . . . . . . . 38
TRI-FED X . . . . . . . . . . . . 48
trifluoperazine . . . . . . . . . 43
trifluridine . . . . . . . . . . . 36
trifluridine/tipiracil . . . . . . . 4
trihexyphenidyl . . . . . . . . 14
TRILAFON . . . . . . . . . . . 43
TRILEPTAL . . . . . . . . . . . 15
TRILYTE . . . . . . . . . . . . 25
trimethobenzamide . . . . . . 24
trimethoprim . . . . . . . . . . 30
TRIMETHOPRIM . . . . . . . . 30
trimipramine . . . . . . . . . . 41
TRI-NORINYL . . . . . . . . . 33
TRINTELLIX . . . . . . . . . . 42
TRIOTANN . . . . . . . . . . . 20
TRIOTANN PEDIATRIC SUSP 44
tripolidine/pseudoephedrine 48
TRIPROL/PSE SYP . . . . . . 48
TRI RX . . . . . . . . . . . . . 52
TRIUMEQ . . . . . . . . . . . . 29
TRI-VI-FLOR . . . . . . . . . . 53
TRI-VI-SOL . . . . . . . . 53, 60
TRIVORA . . . . . . . . . . . . 33
TRIZIVIR . . . . . . . . . . . . 29
TROJAN . . . . . . . . . . . . 58
trospium . . . . . . . . . . . . 50
TRUSOPT . . . . . . . . . . . 35
TRUST NATALCARE
PAK DHA . . . . . . . . . . 52
TRUVADA . . . . . . . . . . . . 29
T-STAT . . . . . . . . . . . . . 16
TUMS . . . . . . . . . . . 58, 60
79
TUSSI 12D S . . . . . . . . . . 47
TUSSI-12 S . . . . . . . . . . . 44
TUSSIN DM . . . . . . . . . . 45
TWINJECT . . . . . . . . . . . 54
TYBOST . . . . . . . . . . . . 30
TYKERB . . . . . . . . . . . . . 4
TYLENOL . . . . . . . 12, 31, 59
TYLENOL W/CODEINE . . . 13
typhoid vaccine . . . . . . . . 56
U
ULORIC . . . . . . . . . . . . . 31
ULTRAM . . . . . . . . . . . . 12
ULTRAVATE . . . . . . . . . . 17
umeclidinium inhalation . . . 48
umeclidinium/vilanterol . . . 48
UNI-HIST DRO . . . . . . . . . 43
UNIPHYL . . . . . . . . . . . . 49
UREA . . . . . . . . . . . . . . 19
urea 40% . . . . . . . . . . . 19
URECHOLINE . . . . . . . . . 49
UREX . . . . . . . . . . . . . . 50
uridine . . . . . . . . . . . . . 23
UROCIT-K . . . . . . . . . . . 50
UROXATRAL . . . . . . . . . . 49
URSO . . . . . . . . . . . . . 26
ursodiol . . . . . . . . . . . . 26
URSO FORTE . . . . . . . . . 26
UTIRA C . . . . . . . . . . . . 50
V
vaginal products . . . . . . . 57
valacyclovir . . . . . . . . . . 28
VALCYTE . . . . . . . . . . . . 28
valganciclovir . . . . . . . . . 28
VALIUM . . . . . . . . . . 32, 36
valproic acid . . . . . . . . . . 15
valproic acid cap
delayed-release . . . . . . 42
VALTREX . . . . . . . . . . . . 28
VANCOCIN HCL . . . . . . . . 27
vancomycin HCl . . . . . . . 27
vandetanib . . . . . . . . . . . 5
VAQTA . . . . . . . . . . . . . 54
varenicline . . . . . . . . . . . 43
varicella virus vac live for
subcutaneous . . . . . . . 56
VARIVAX . . . . . . . . . . . . 56
VASERETIC . . . . . . . . . . . 8
VASOCIDIN . . . . . . . . . . . 34
VASOCLEAR . . . . . . . . . . 34
VASOCLEAR A . . . . . . . . 34
VASOSULF . . . . . . . . . . . 36
VASOTEC . . . . . . . . . . . . .8
VECTICAL . . . . . . . . . . . 18
VEETIDS . . . . . . . . . . . . 27
vemurafenib . . . . . . . . . . 5
venlafaxine . . . . . . . . . . 38
venlafaxine HCL tab SR . . . 42
VENLAFAXINE HCL TAB SR . 42
venlafaxine XR . . . . . . . . 38
VENTOLIN HFA . . . . . . . . 48
VEPESID . . . . . . . . . . . . . 6
verapamil . . . . . . . . . 10, 14
verapamil extended-release . 10
VERSACLOZ . . . . . . . . . . 39
VESANOID . . . . . . . . . . . .6
VEXOL . . . . . . . . . . . . . 35
VFEND . . . . . . . . . . . . . 28
VICODIN . . . . . . . . . . . . 13
VICODIN ES . . . . . . . . . . 13
VICTOZA . . . . . . . . . . . . 23
VI-DAYLIN . . . . . . . . . . . . 60
VIDEX . . . . . . . . . . . . . . 29
VIDEX EC . . . . . . . . . . . . 29
vigabatrin oral solution . . . . 15
VIIBRYD . . . . . . . . . . . . . 42
vilazodone . . . . . . . . . . . 42
VIMPAT . . . . . . . . . . . . . 15
VINATE AZ EX . . . . . . . . . 52
VINATE III . . . . . . . . . . . . 52
VIRACEPT . . . . . . . . . . . 29
VIRAMUNE . . . . . . . . . . . 28
VIRAMUNE XR . . . . . . . . . 28
VIREAD . . . . . . . . . . . . . 29
VIROPTIC . . . . . . . . . . . . 36
VISINE . . . . . . . . . . . . . 59
VISINE-AC . . . . . . . . . . . 34
vismodegib . . . . . . . . . . . 6
VISTARIL . . . . . . . . . . . . 20
VISTOGARD . . . . . . . . . . 23
vitamin A . . . . . . . . . . . . 53
vitamin ADC/fluoride/±iron
drops . . . . . . . . . . . 53
vitamin B-1 . . . . . . . . . . 53
vitamin B-6 . . . . . . . . . . 53
VITAMIN B-12 . . . . . . . . . 50
vitamin B complex/
vitamin C/folic acid . . . . 53
vitamin C . . . . . . . . . . . 53
vitamin D . . . . . . . . . . . . 60
VITAMIN D . . . . . . . . . 50, 60
vitamins pediatric . . . . 53, 60
vitamins prenatal . . . . . . . 60
VITAPHIL . . . . . . . . . . . . 52
VITUSSIN . . . . . . . . . . . . 46
VIVACTIL . . . . . . . . . . . . 41
VIVOTIF BERNA . . . . . . . . 56
VOLTAREN . . . . . . . . . . . 35
VOLTAREN 1% TOPICAL GEL31
voriconazole . . . . . . . . . . 28
vorinostat . . . . . . . . . . . . 4
vortioxetine . . . . . . . . . . 42
VOSOL HC OTIC . . . . . . . 19
VOSOL OTIC . . . . . . . . . . 19
VOTRIENT . . . . . . . . . . . . 5
VRAYLAR . . . . . . . . . . . . 39
VYVANSE . . . . . . . . . . . . 37
80
W
warfarin . . . . . . . . . . . . . 7
WELLBUTRIN . . . . . . . . . 38
WELLBUTRIN SR . . . . . . . 38
WELLBUTRIN XL . . . . . . . 38
WESTCORT . . . . . . . . . . 17
WYTENSIN . . . . . . . . . . . 11
X
XALATAN . . . . . . . . . . . . 35
XALKORI . . . . . . . . . . . . .4
XANAX . . . . . . . . . . . . . 36
XANAX XR . . . . . . . . . . . 38
XARELTO . . . . . . . . . . . . .7
XELODA . . . . . . . . . . . . . 4
XENAZINE . . . . . . . . . . . 15
XOLAIR . . . . . . . . . . . . . 48
XOPENEX RESPULES . . . . 49
XYLOCAINE . . . . . . . . 19, 21
XYZAL . . . . . . . . . . . . . 20
Z
zaleplon . . . . . . . . . . . . 38
ZANAFLEX . . . . . . . . . . . 32
zanamivir . . . . . . . . . . . 28
ZANTAC . . . . . . . . . . . . 24
ZARONTIN . . . . . . . . . . . 15
ZAROXOLYN . . . . . . . . . . 10
ZARXIO . . . . . . . . . . . . . .7
ZEBETA . . . . . . . . . . . . . .9
ZEBUTAL . . . . . . . . . . . . 12
ZELBORAF . . . . . . . . . . . .5
ZENPEP . . . . . . . . . . . . 25
ZENZEDI . . . . . . . . . . . . 40
ZEPATIER . . . . . . . . . . . . 28
ZERIT . . . . . . . . . . . . . . 29
ZESTORETIC . . . . . . . . . . .8
ZESTRIL . . . . . . . . . . . . . 8
ZETIA . . . . . . . . . . . . . . 10
ZIAC . . . . . . . . . . . . . . . .9
ZIAGEN . . . . . . . . . . . . . 28
zidovudine . . . . . . . . . . . 29
zinc . . . . . . . . . . . . . . . 53
ziprasidone . . . . . . . . . . 42
ZITHROMAX . . . . . . . . . . 27
ZOCOR . . . . . . . . . . . . . 10
ZOFRAN . . . . . . . . . . . . 24
ZOFRAN ODT . . . . . . . . . 24
ZOHYDRO ER . . . . . . . . . 13
ZOLINZA . . . . . . . . . . . . .4
ZOLOFT . . . . . . . . . . . . 37
zolpidem . . . . . . . . . . . . 38
ZONEGRAN . . . . . . . . . . 15
zonisamide . . . . . . . . . . 15
ZORTRESS . . . . . . . . . . . .6
ZOSTAVAX . . . . . . . . . . . 56
zoster vaccine live . . . . . . . 56
ZOVIA 1/35 . . . . . . . . . . 32
ZOVIA 1/50 . . . . . . . . . . 32
ZOVIRAX . . . . . . . . . . . . 28
ZUBSOLV . . . . . . . . . . . . 39
ZYBAN . . . . . . . . . . . . . 39
ZYDELIG . . . . . . . . . . . . .4
ZYKADIA . . . . . . . . . . . . .4
ZYLOPRIM . . . . . . . . . . . 31
ZYMAR . . . . . . . . . . . . . 36
ZYPREXA . . . . . . . . 41, 42
ZYPREXA RELPREVV . . . . 41
ZYPREXA ZYDIS . . . . . . . 41
ZYRTEC . . . . . . . . . . 20, 57
ZYRTEC D . . . . . . . . 20, 57
ZYTIGA . . . . . . . . . . . . . .5
ZYVOX . . . . . . . . . . . . . 30
81
Notes
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82
“My Medications” worksheet
Take this worksheet with you each time you visit a doctor. Each of your doctors should be aware of
every drug you take and you should have a list as well.
Name of Medicine
and Strength
Drug
Tier
I Take This
Medicine For
Directions
Doctor
Example: Lisinopril, 20mg
Tier 1
High blood pressure
One tablet daily
Dr. Johnson
83
© 2016 United HealthCare Services, Inc. All rights reserved.
10/16

Preferred Drug List (PDL)

Transcription

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