CareFirst Formulary 1 (Non

Transcription

CareFirst Formulary 1
(Non-ACA Plans)
2015
Note: The self-administered injectables drug tier may differ based on your prescription
benefit plan. All self-administered injectables are noted with SI. If you have a 4-tier
prescription drug plan then the self-injectable will fall under Tier 4 (excluding insulin). If
you have a 3-tier prescription drug plan, the self-injectable will fall under Tier 3.
PLEASE READ: This document contains information about the drugs
we cover in this plan. This formulary is for members of an employer
group with 51 or more employees OR individuals or families who have a
“grandfathered” plan (purchased before the March 23, 2010 Affordable
Care Act date)
This formulary was updated 01/01/2015. For
more recent information or other questions,
please contact CareFirst Pharmacy Services at
800-241-3371 or visit www.carefirst.com/rx.
CareFirst BlueCross BlueShield is the shared business name of CareFirst of Maryland, Inc. and Group Hospitalization and Medical Services, Inc.
CareFirst BlueCross BlueShield and CareFirst BlueChoice, Inc. are both independent licensees of the Blue Cross and Blue Shield Association.
® Registered trademark of the Blue Cross and Blue Shield Association. ®’ Registered trademark of CareFirst of Maryland, Inc.
LAST UPDATED 01/01/2014
LAST UPDATED 01/01/2015
CareFirst Formulary 1 (Non-ACA Drug List)
(01/01/2015)
WHAT IS THE CAREFIRST FORMULARY 1?........................................................................................................................................................ 4
HOW DO I USE THE CAREFIRST FORMULARY 1? ............................................................................................................................................. 4
DRUG LIST PRODUCT DESCRIPTIONS (FOR HEALTH CARE PROVIDERS) ................................................................................................... 5
GENERIC SUBSTITUTION ...................................................................................................................................................................................... 6
LEGEND ................................................................................................................................................................................................................... 6
NOTICES .................................................................................................................................................................................................................. 6
ANALGESICS........................................................................................................................................................................................................... 8
NSAIDs ........................................................................................................................................................................................................... 8
NSAIDs, COMBINATIONS ............................................................................................................................................................................. 8
NSAIDs, TOPICAL ......................................................................................................................................................................................... 8
COX-2 INHIBITORS ....................................................................................................................................................................................... 8
GOUT ............................................................................................................................................................................................................. 8
OPIOID ANALGESICS ................................................................................................................................................................................... 8
NON-OPIOID ANALGESICS.......................................................................................................................................................................... 9
VISCOSUPPLEMENTS ................................................................................................................................................................................. 9
ANTI-INFECTIVES ................................................................................................................................................................................................... 9
ANTIBACTERIALS ......................................................................................................................................................................................... 9
ANTIFUNGALS ............................................................................................................................................................................................ 10
ANTIMALARIALS ......................................................................................................................................................................................... 10
ANTIRETROVIRAL AGENTS ...................................................................................................................................................................... 10
ANTITUBERCULAR AGENTS ..................................................................................................................................................................... 11
ANTIVIRALS................................................................................................................................................................................................. 11
MISCELLANEOUS ....................................................................................................................................................................................... 12
ANTINEOPLASTIC AGENTS ................................................................................................................................................................................ 12
ALKYLATING AGENTS ............................................................................................................................................................................... 12
ANTIMETABOLITES .................................................................................................................................................................................... 12
HORMONAL ANTINEOPLASTIC AGENTS ................................................................................................................................................. 12
IMMUNOMODULATORS ............................................................................................................................................................................. 13
KINASE INHIBITORS................................................................................................................................................................................... 13
TOPOISOMERASE INHIBITORS ................................................................................................................................................................ 13
MISCELLANEOUS ....................................................................................................................................................................................... 13
CARDIOVASCULAR .............................................................................................................................................................................................. 13
ACE INHIBITORS ........................................................................................................................................................................................ 13
ACE INHIBITOR/CALCIUM CHANNEL BLOCKER COMBINATIONS ........................................................................................................ 14
ACE INHIBITOR/DIURETIC COMBINATIONS ............................................................................................................................................ 14
ADRENOLYTICS, CENTRAL....................................................................................................................................................................... 14
ALDOSTERONE RECEPTOR ANTAGONISTS .......................................................................................................................................... 14
ALPHA BLOCKERS ..................................................................................................................................................................................... 14
ANGIOTENSIN II RECEPTOR ANTAGONISTS/DIURETIC COMBINATIONS ........................................................................................... 14
ANGIOTENSIN II RECEPTOR ANTAGONIST/CALCIUM CHANNEL BLOCKER COMBINATIONS ......................................................... 14
ANGIOTENSIN II RECEPTOR ANTAGONIST/CALCIUM CHANNEL BLOCKER/DIURETIC COMBINATIONS ....................................... 15
ANTIARRHYTHMICS ................................................................................................................................................................................... 15
ANTILIPEMICS............................................................................................................................................................................................. 15
BETA-BLOCKERS ....................................................................................................................................................................................... 16
BETA-BLOCKER/DIURETIC COMBINATIONS ........................................................................................................................................... 16
CALCIUM CHANNEL BLOCKERS .............................................................................................................................................................. 16
CALCIUM CHANNEL BLOCKER/ANTILIPEMIC COMBINATIONS ............................................................................................................ 16
DIGITALIS GLYCOSIDES............................................................................................................................................................................ 16
DIRECT RENIN INHIBITORS/DIURETIC COMBINATIONS ....................................................................................................................... 16
DIRECT RENIN INHIBITOR/CALCIUM CHANNEL BLOCKER COMBINATIONS ...................................................................................... 16
DIRECT RENIN INHIBITOR/CALCIUM CHANNEL BLOCKER/DIURETIC COMBINATIONS .................................................................... 16
DIURETICS .................................................................................................................................................................................................. 17
NITRATES .................................................................................................................................................................................................... 17
NITRATE/VASODILATOR COMBINATIONS .............................................................................................................................................. 17
PULMONARY ARTERIAL HYPERTENSION .............................................................................................................................................. 17
MISCELLANEOUS ....................................................................................................................................................................................... 18
1
CENTRAL NERVOUS SYSTEM ............................................................................................................................................................................ 18
ANTIANXIETY .............................................................................................................................................................................................. 18
ANTICONVULSANTS .................................................................................................................................................................................. 18
ANTIDEMENTIA ........................................................................................................................................................................................... 18
ANTIDEPRESSANTS .................................................................................................................................................................................. 19
ANTIPARKINSONIAN AGENTS .................................................................................................................................................................. 19
ANTIPSYCHOTICS ...................................................................................................................................................................................... 20
ATTENTION DEFICIT HYPERACTIVITY DISORDER ................................................................................................................................ 20
FIBROMYALGIA .......................................................................................................................................................................................... 20
HUNTINGTON'S DISEASE AGENTS .......................................................................................................................................................... 21
HYPNOTICS................................................................................................................................................................................................. 21
MIGRAINE .................................................................................................................................................................................................... 21
MOOD STABILIZERS .................................................................................................................................................................................. 21
MULTIPLE SCLEROSIS AGENTS .............................................................................................................................................................. 21
MUSCULOSKELETAL THERAPY AGENTS ............................................................................................................................................... 22
MYASTHENIA GRAVIS ............................................................................................................................................................................... 22
NARCOLEPSY/CATAPLEXY....................................................................................................................................................................... 22
POSTHERPETIC NEURALGIA (PHN)......................................................................................................................................................... 22
PSYCHOTHERAPEUTIC-MISCELLANEOUS ............................................................................................................................................. 22
ENDOCRINE AND METABOLIC ........................................................................................................................................................................... 22
ANDROGENS .............................................................................................................................................................................................. 22
ANTIDIABETICS .......................................................................................................................................................................................... 22
ANTIOBESITY * ........................................................................................................................................................................................... 24
CALCIUM REGULATORS ........................................................................................................................................................................... 24
CONTRACEPTIVES * .................................................................................................................................................................................. 24
ENDOMETRIOSIS ....................................................................................................................................................................................... 25
ESTROGENS ............................................................................................................................................................................................... 26
ESTROGEN/PROGESTINS......................................................................................................................................................................... 26
ESTROGEN/SELECTIVE ESTROGEN RECEPTOR MODULATOR COMBINATIONS ............................................................................. 26
FERTILITY REGULATORS.......................................................................................................................................................................... 26
GLUCOCORTICOIDS .................................................................................................................................................................................. 26
GLUCOSE ELEVATING AGENTS ............................................................................................................................................................... 26
HUMAN GROWTH HORMONES................................................................................................................................................................. 27
HYPERPARATHYROID TREATMENT, VITAMIN D ANALOGS ................................................................................................................. 27
PHENYLKETONURIA TREATMENT AGENTS ........................................................................................................................................... 27
PHOSPHATE BINDER AGENTS ................................................................................................................................................................. 27
PROGESTINS .............................................................................................................................................................................................. 27
SELECTIVE ESTROGEN RECEPTOR MODULATORS ............................................................................................................................. 27
THYROID AGENTS ..................................................................................................................................................................................... 27
VASOPRESSINS ......................................................................................................................................................................................... 27
MISCELLANEOUS ....................................................................................................................................................................................... 27
GASTROINTESTINAL ........................................................................................................................................................................................... 28
ANTIDIARRHEALS ...................................................................................................................................................................................... 28
ANTIEMETICS ............................................................................................................................................................................................. 28
ANTISPASMODICS ..................................................................................................................................................................................... 28
CHOLELITHOLYTICS .................................................................................................................................................................................. 28
H2 RECEPTOR ANTAGONISTS .................................................................................................................................................................. 28
INFLAMMATORY BOWEL DISEASE .......................................................................................................................................................... 28
IRRITABLE BOWEL SYNDROME ............................................................................................................................................................... 29
LAXATIVES .................................................................................................................................................................................................. 29
PANCREATIC ENZYMES ............................................................................................................................................................................ 29
PROSTAGLANDINS .................................................................................................................................................................................... 29
PROTON PUMP INHIBITORS ..................................................................................................................................................................... 29
SALIVA STIMULANTS ................................................................................................................................................................................. 29
STEROIDS, RECTAL ................................................................................................................................................................................... 29
ULCER THERAPY COMBINATIONS .......................................................................................................................................................... 29
MISCELLANEOUS ....................................................................................................................................................................................... 29
GENITOURINARY .................................................................................................................................................................................................. 30
BENIGN PROSTATIC HYPERPLASIA ........................................................................................................................................................ 30
ERECTILE DYSFUNCTION ......................................................................................................................................................................... 30
URINARY ANTISPASMODICS .................................................................................................................................................................... 30
VAGINAL ANTI-INFECTIVES ...................................................................................................................................................................... 30
MISCELLANEOUS ....................................................................................................................................................................................... 30
2
HEMATOLOGIC ..................................................................................................................................................................................................... 30
ANTICOAGULANTS .................................................................................................................................................................................... 30
HEMATOPOIETIC GROWTH FACTORS .................................................................................................................................................... 31
IDIOPATHIC THROMBOCYTOPENIC PURPURA AGENTS ...................................................................................................................... 31
PAROXYSMAL NOCTURNAL HEMOGLOBINURIA (PNH) AGENTS ........................................................................................................ 31
PLATELET AGGREGATION INHIBITORS .................................................................................................................................................. 31
PLATELET SYNTHESIS INHIBITORS ........................................................................................................................................................ 31
STEM CELL MOBILIZERS........................................................................................................................................................................... 31
MISCELLANEOUS ....................................................................................................................................................................................... 31
IMMUNOLOGIC AGENTS...................................................................................................................................................................................... 31
BIOLOGIC DISEASE-MODIFYING AGENTS .............................................................................................................................................. 31
DISEASE-MODIFYING ANTIRHEUMATIC DRUGS (DMARDs) ................................................................................................................. 31
IMMUNOMODULATORS ............................................................................................................................................................................. 32
IMMUNOSUPPRESSANTS ......................................................................................................................................................................... 32
NUTRITIONAL/SUPPLEMENTS............................................................................................................................................................................ 32
ELECTROLYTES ......................................................................................................................................................................................... 32
VITAMINS AND MINERALS ........................................................................................................................................................................ 32
RESPIRATORY ...................................................................................................................................................................................................... 33
ANAPHYLAXIS TREATMENT AGENTS...................................................................................................................................................... 33
ANTICHOLINERGICS .................................................................................................................................................................................. 33
ANTICHOLINERGIC/BETA AGONIST COMBINATIONS............................................................................................................................ 33
ANTIHISTAMINES, LOW SEDATING.......................................................................................................................................................... 33
ANTIHISTAMINES, SEDATING ................................................................................................................................................................... 33
ANTITUSSIVES............................................................................................................................................................................................ 33
ANTITUSSIVE COMBINATIONS ................................................................................................................................................................. 33
BETA AGONISTS ........................................................................................................................................................................................ 34
CYSTIC FIBROSIS ...................................................................................................................................................................................... 34
LEUKOTRIENE RECEPTOR ANTAGONISTS ............................................................................................................................................ 34
MAST CELL STABILIZERS ......................................................................................................................................................................... 34
NASAL ANTIHISTAMINES .......................................................................................................................................................................... 34
NASAL STEROIDS ...................................................................................................................................................................................... 34
PHOSPHODIESTERASE-4 INHIBITORS .................................................................................................................................................... 34
STEROID/BETA AGONIST COMBINATIONS ............................................................................................................................................. 34
STEROID INHALANTS ................................................................................................................................................................................ 34
XANTHINES ................................................................................................................................................................................................. 35
MISCELLANEOUS ....................................................................................................................................................................................... 35
TOPICAL ................................................................................................................................................................................................................ 35
DERMATOLOGY ......................................................................................................................................................................................... 35
MOUTH/THROAT/DENTAL AGENTS ......................................................................................................................................................... 37
OPHTHALMIC .............................................................................................................................................................................................. 38
OTIC ............................................................................................................................................................................................................. 39
WEBSITES ............................................................................................................................................................................................................. 40
INDEX ..................................................................................................................................................................................................................... 42
3
What is the CareFirst Formulary 1?
The CareFirst Formulary 1 (drug list) is a list of covered drugs and can be used as a reference and
informational tool. It includes safe and clinically effective drug therapies reflecting current medical practices.
The drugs represented have been reviewed by a National Pharmacy and Therapeutics (P&T) committee and
are approved for inclusion by CareFirst. The P&T committee consists of physicians, pharmacists, and a
medical ethicist, all of whom have a broad background of clinical and academic expertise regarding
pharmacy drugs. Your prescription benefit plan will generally cover the drugs listed in our formulary as long
as the drug is medically necessary, the prescription is filled at a participating pharmacy in the CareFirst
network, and other plan rules are followed. Please note this is not an all-inclusive list and is subject to
change.
A Preferred Drug List which represents those preferred drugs that have been identified as the lowest cost,
therapeutic alternatives can be found at www.carefirst.com/rx. The Preferred Drug List can be printed out
and taken to your physician to assist in prescribing a safe and cost effective medication.
How do I use the CareFirst Formulary 1?
The CareFirst formulary was designed for members and health care providers. The formulary is organized by
sections. Each section is divided into therapeutic drug classes such as: analgesics, anti-infectives,
antineoplastic agents, cardiovascular, central nervous system, endocrine and metabolic, gastrointestinal,
genitourinary, hematologic, immunologic agents, nutritional/supplements, respiratory and topical. Note:
references for your physician on practice guidelines and recommendations for treatment are
provided for each therapeutic drug class.
Drugs listed in the formulary are ranked into tiers or categories and the cost you pay for your drug varies
depending on your prescription benefit plan. Our plan covers both generic and brand-name drugs. Generic
drugs are approved by the Food and Drug Administration (FDA) and have the same active ingredients as
their brand-name counterpart. Generic drugs are typically available at the lowest cost-share. Refer to the
Summary of Benefits or Plan Summary for cost-sharing information.
Tier 0: $0 copay drugs include oral chemotherapy drugs, selected diabetic supplies, and drugs classified
as preventative drugs by the Affordable Care Act.
Tier 1: Generic drugs work the same as brand-name drugs, but cost much less. So you’ll pay less to use
them. You should ask your doctor to prescribe a generic drug or choose a generic version of the prescribed
brand-name drug if one is available.
Tier 2: Preferred brand drugs are brand-name drugs that are not yet available in generic form, but are
chosen for their effectiveness and affordability compared to alternatives. They cost more than generics but
less than non-preferred brand drugs. If a generic drug becomes available, the preferred brand drug will be
moved to the non-preferred brand tier or category.
Tier 3: Non-preferred brand drugs are often available in less-expensive forms, either as generic or
preferred brand drugs. You will pay more for drugs in this tier.
Tier 4: Self-administered injectables (excluding insulin) often have the highest out-of-pocket cost. In most
cases, these are high-cost prescription drugs that may require special handling, administration or monitoring.
Note: The self-administered injectables drug tier may differ based on your prescription benefit plan.
All self-administered injectables are noted with SI. If you have a 4-tier prescription drug plan then the
self-injectable will fall under Tier 4 (excluding insulin). If you have a 3-tier prescription drug plan, the
self-injectable will fall under Tier 3.
4
Products on the CareFirst Formulary 1 are listed by generic name with the brand-name listed for reference
only. Generic drugs are listed in lower case.
When a generic drug is available, the brand-name drug and tier will be listed next to the generic form of the
drug. When a generic drug is available for dispensing to replace the brand-name drug, the generic will be
listed in boldface type. For example, under the cardiovascular section, LOTENSIN is listed as a Tier 3 drug
with “benazepril” indicated as the generic form of that drug which can be dispensed in place of the highercost brand-name drug. Note: all strengths or dosage forms may not be available in generic form.
Generics should be considered the first line of prescribing. Unless exceptions are noted, all applicable
dosage forms and strengths of the drug listed are generally included in this list.
Individual pharmacy benefit plans may have additional care management criteria, while some products may
not be covered at all. These criteria may include:
• Prior authorization – Certain medications require advance approval (prior authorization) by
your doctor before they can be filled. Without prior approval, your drugs may not be covered.
• Step therapy ensures lower costs – When similar medications are available in multiple forms,
step therapy guides your doctor to prescribe the lower-cost option first. You may then move up
the cost levels until you find the prescription drug that works best for you. Higher step
prescription drugs will require advance approval (prior authorization) by your doctor before they
can be filled.
• Quantity limits – Limits have been placed on the use of selected drugs for quality, safety or
utilization reasons. Limits may be on the amount of the drug that we cover per prescription or
for a defined period of time.
In addition, over-the-counter (OTC) products, with the exception of insulin and diabetes monitoring products,
are usually, not included in the pharmacy benefit. Pharmacy law requires a valid prescription for the
purchase of needles and syringes in certain states.
Drug list product descriptions (for health care providers)
Examples are noted below to assist in understanding which specific strengths and dosage forms are on
CareFirst Formulary 1. The general principles shown in the examples can usually be extended to other entries
in the list. Any exceptions are noted.
Products on the drug list include all strengths and dosage forms of the cited brand-name product.
aripiprazole
Abilify
Oral tablets, oral disintegrating tablets, solution and all strengths of Abilify would be included in this listing.
When a strength or dosage form is specified, only the specified strength and dosage form is on the drug
list. Other strengths/dosage forms of the reference product are not listed.
acyclovir caps, tabs
Zovirax
The capsules and tablets of Zovirax are on the drug list. From this entry, the cream and ointment cannot be
assumed to be on the list unless there is a specific entry.
Extended-release and delayed-release products require their own entry.
sitagliptin/metformin Janumet
The immediate-release product listing of Janumet alone would not include the extended-release product
Janumet XR.
sitagliptin/metformin ext-rel
Janumet XR
A separate entry for Janumet XR confirms the extended-release product is on the drug list.
Dosage forms on the drug list will be consistent with the category and use where listed.
neomycin/polymyxin B/hydrocortisone
Cortisporin
Since Cortisporin is listed only in the OTIC section, it is limited to the otic solution and suspension. From this
entry the topical cream cannot be assumed to be on the list unless there is an entry for this product in the
DERMATOLOGY section of the drug list.
5
Generic substitution
Generic substitution is a pharmacy action where a generic version is dispensed rather than a prescribed
brand-name product. One way to reduce out-of-pocket costs is by requesting a generic drug. Generic drugs
are usually priced lower than their brand-name equivalents. Prescription generic drugs are:
Approved by the FDA for safety and effectiveness, and are manufactured under the same strict standards that apply to brand-name drugs.
Tested in humans to assure the generic is absorbed into the bloodstream in a similar rate and
extent compared to the brand-name drug. Generics may be different from the brand in size, color,
and inactive ingredients, but this does not alter their effectiveness or ability to be absorbed just like the brand-name drug.
Manufactured in the same strength and dosage form as the brand-name drugs.
When a generic drug is substituted for a brand-name drug, you can expect the generic to produce the same
clinical effect and safety profile as the brand-name drug. Brand-name drugs having a generic available may:
Incur higher copay/coinsurance (tier 3)
Require payment of the difference in price between generic and brand, in addition
to copay/coinsurance
Require mandatory generic substitution
Legend
#
OTC
QL
PA
SI
SP
boldface
delayed-rel
ext-rel
Covered under the medical benefit.
Over-the-counter
Quantity limits
Prior authorization
Self-injectable product; These products may have a higher member
copay/coinsurance. 4th tier benefit may apply.
Specialty product
Indicates generic availability; boldface may not apply to every strength or dosage
form under the listed generic name
Delayed-release (also known as enteric-coated), refer to the reference brand listed
for clarification
Extended-release (also known as sustained-release), refer to the reference brand
listed for clarification
Notices
CareFirst BlueCross BlueShield and CareFirst BlueChoice, Inc. (CareFirst) are both independent licensees
of the Blue Cross and Blue Shield Association.
The information contained in this document is proprietary and may not be copied in whole or in part without
written permission. ©2014. All rights reserved.
This document contains references to brand-name prescription drugs that are trademarks or registered
trademarks of pharmaceutical manufacturers not affiliated with CareFirst.
CareFirst does not operate the websites/organizations listed here, nor are they responsible for the availability
or reliability of the websites' content. These listings do not imply or constitute an endorsement, sponsorship
or recommendation by CareFirst.
6
National guidelines can be found on the National Guideline Clearinghouse site at http://www.guideline.gov,
on the websites listed under each therapeutic class and on the sites listed in the websites section of this
publication. We do not warrant or assure accuracy of such information nor is it intended to be comprehensive
in nature.
This list is not intended to be a substitute for the knowledge, expertise, skill and judgment of the health care
provider in his or her choice of prescription drugs. All the information in this list is provided as a reference for
drug therapy selection. Specific drug selection for an individual patient rests solely with the prescriber.
This document is subject to state-specific regulations and rules, including, but not limited to, those regarding
generic substitution, controlled substance schedules, preference for brands and mandatory generics
whenever applicable.
We assume 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.
When viewing the CareFirst Formulary 1 (drug list) via the Internet, please be advised that this list is
updated periodically and changes may appear prior to their effective date to allow for client
notification.
7
ANALGESICS
Practice guidelines of pain management are available at:
http://www.asahq.org
NSAIDs
diclofenac sodium delayed-rel
diflunisal
etodolac
ibuprofen
nabumetone
meloxicam
naproxen
naproxen sodium
oxaprozin
sulindac
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
NSAIDs, COMBINATIONS
diclofenac sodium delayed-rel/misoprostol
Tier 1
NSAIDs, TOPICAL
diclofenac sodium soln
diclofenac sodium gel
Tier 1
Tier 2 VOLTAREN GEL
COX-2 INHIBITORS
celecoxib
Tier 2 CELEBREX
MOBIC
NAPROSYN
ANAPROX
DAYPRO
CLINORIL
GOUT
probenecid
colchicine
febuxostat
allopurinol
Tier 1
Tier 2 COLCRYS
Tier 2 ULORIC
Tier 3 ZYLOPRIM
OPIOID ANALGESICS
Practice Guidelines for Cancer Pain Management (includes WHO analgesic ladder) are available at:
http://www.nccn.org
Opioid guidelines in the management of chronic non-malignant pain are available at:
http://www.asipp.org/Guidelines.htm
PA
PA
QL
fentanyl transmucosal lozenge
methadone
morphine
morphine supp
oxycodone caps, tabs 5 mg
oxycodone concentrate 20 mg/mL
tramadol ext-rel
buprenorphine transdermal
fentanyl citrate buccal
fentanyl citrate nasal spray
oxycodone ext-rel
oxymorphone ext-rel
tapentadol
tapentadol ext-rel
codeine/acetaminophen
fentanyl transdermal
hydrocodone/acetaminophen
hydromorphone
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 3
Tier 3
Tier 3
Tier 3
BUTRANS
FENTORA
LAZANDA
OXYCONTIN
OPANA ER
NUCYNTA
NUCYNTA ER
TYLENOL w/CODEINE
DURAGESIC
NORCO
DILAUDID
8
hydromorphone ext-rel
morphine ext-rel
morphine ext-rel
morphine ext-rel
oxycodone tabs 15 mg, 30 mg, soln 5 mg/5 mL
oxycodone/acetaminophen 5/325
tramadol
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
EXALGO
AVINZA
KADIAN
MS CONTIN
ROXICODONE
PERCOCET
ULTRAM
NON-OPIOID ANALGESICS
butalbital/acetaminophen/caffeine tabs
butalbital/aspirin/caffeine
Tier 2 ESGIC
Tier 2 FIORINAL
VISCOSUPPLEMENTS
#
sodium hyaluronate
#
sodium hyaluronate
#
sodium hyaluronate
Tier 2 GEL-ONE
Tier 2 HYALGAN
Tier 2 SUPARTZ
ANTI-INFECTIVES
Hepatitis: CDC recommendations on the treatment of hepatitis are available at:
http://www.cdc.gov/hepatitis/Resources/
Guidelines for the management of chronic hepatitis by the American Association for the Study of Liver Disease are available at:
http://www.aasld.org
HIV/AIDS: Guidelines for the treatment of HIV patients by the U.S. Department of Health and Human Services are available at:
http://www.aidsinfo.nih.gov
Infective Endocarditis: American Heart Association recommendations for the prevention of bacterial endocarditis are available at:
http://www.myamericanheart.org
Influenza: Recommendations of the Advisory Committee on Immunization Practices are available at:
http://www.cdc.gov/ncidod/diseases/flu/fluvirus.htm
International Travel: CDC recommendations for international travel are available at:
http://www.cdc.gov/travel
Sexually Transmitted Diseases: CDC Sexually Transmitted Diseases Guidelines are available at:
http://www.cdc.gov/std/treatment/default.htm
Respiratory Tract Infection/Antibiotic Use/Community Acquired Pneumonia/Other: Principles of appropriate antibiotic use
for treatment of nonspecific upper respiratory tract infection in adults are available at:
http://www.cdc.gov/flu/
Practice guidelines and statements developed and endorsed by the Infectious Diseases Society of America are available at:
http://www.idsociety.org
ANTIBACTERIALS
Cephalosporins
First Generation
cefadroxil
cephalexin
Tier 1
Tier 3 KEFLEX
Second Generation
cefprozil
cefuroxime axetil
Tier 1
Tier 3 CEFTIN
9
Third Generation
cefdinir
cefixime
Tier 1
Tier 2 SUPRAX
Erythromycins/Macrolides
erythromycin delayed-rel
erythromycin stearate
erythromycin/sulfisoxazole
fidaxomicin
azithromycin
clarithromycin
clarithromycin ext-rel
erythromycin ethylsuccinate
Tier 1
Tier 1
Tier 1
Tier 2
Tier 3
Tier 3
Tier 3
Tier 3
Fluoroquinolones
ciprofloxacin ext-rel
ciprofloxacin
levofloxacin
moxifloxacin
Tier 1
Tier 3 CIPRO
Tier 3 LEVAQUIN
Tier 3 AVELOX
DIFICID
ZITHROMAX
BIAXIN
BIAXIN XL
E.E.S.
Penicillins
amoxicillin
amoxicillin/clavulanate ext-rel
ampicillin
dicloxacillin
penicillin VK
amoxicillin/clavulanate
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 3 AUGMENTIN
Tetracyclines
doxycycline hyclate 20 mg
tetracycline
doxycycline hyclate
minocycline
Tier 1
Tier 1
Tier 3 VIBRAMYCIN
Tier 3 MINOCIN
ANTIFUNGALS
clotrimazole troches
ketoconazole
nystatin
griseofulvin ultramicrosize
voriconazole
fluconazole
itraconazole
terbinafine tabs
Tier 1
Tier 1
Tier 1
Tier 2
Tier 2
Tier 3
Tier 3
Tier 3
ANTIMALARIALS
mefloquine
artemether/lumefantrine
atovaquone/proguanil
chloroquine
Tier 1
Tier 2 COARTEM
Tier 2 MALARONE
Tier 2 ARALEN
ANTIRETROVIRAL AGENTS
Antiretroviral Combinations
efavirenz/emtricitabine/tenofovir
elvitegravir/cobicistat/emtricitabine/tenofovir
emtricitabine/tenofovir
lamivudine/zidovudine
Tier 2
Tier 2
Tier 2
Tier 2
GRIS-PEG
VFEND
DIFLUCAN
SPORANOX
LAMISIL
ATRIPLA
STRIBILD
TRUVADA
COMBIVIR
10
Fusion Inhibitors
PA, SP, SI enfuvirtide
Tier 4 FUZEON
Integrase Inhibitors
raltegravir
Tier 2 ISENTRESS
Non-nucleoside Reverse Transcriptase Inhibitors
delavirdine
efavirenz
etravirine
nevirapine
nevirapine ext-rel
rilpivirine
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
RESCRIPTOR
SUSTIVA
INTELENCE
VIRAMUNE
VIRAMUNE XR
EDURANT
Nucleoside Reverse Transcriptase Inhibitors
abacavir tabs
didanosine delayed-rel
emtricitabine
lamivudine
stavudine
zidovudine
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
ZIAGEN tabs
VIDEX EC
EMTRIVA
EPIVIR
ZERIT
RETROVIR
Nucleotide Reverse Transcriptase Inhibitors
tenofovir
Tier 2 VIREAD
Protease Inhibitors
atazanavir
darunavir
lopinavir/ritonavir
ritonavir
Tier 2
Tier 2
Tier 2
Tier 2
ANTITUBERCULAR AGENTS
isoniazid
pyrazinamide
ethambutol
rifampin
Tier 1
Tier 1
Tier 2 MYAMBUTOL
Tier 2 RIFADIN
ANTIVIRALS
Cytomegalovirus Agents
valganciclovir
Tier 2 VALCYTE
Hepatitis Agents
Hepatitis B
entecavir
lamivudine
Tier 2 BARACLUDE
Tier 2 EPIVIR-HBV
Hepatitis C
PA, SP
PA, SP
PA, SP
PA, SP
PA, SP
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
boceprevir
ribavirin caps
ribavirin oral soln
ribavirin tabs
sofosbuvir
Herpes Agents
valacyclovir
acyclovir caps, tabs
famciclovir
REYATAZ
PREZISTA
KALETRA
NORVIR
VICTRELIS
REBETOL
REBETOL
COPEGUS
SOVALDI
Tier 1
Tier 3 ZOVIRAX
Tier 3 FAMVIR
11
Influenza Agents
amantadine
QL
oseltamivir
QL
zanamivir
rimantadine
Tier 1
Tier 2 TAMIFLU
Tier 2 RELENZA
Tier 3 FLUMADINE
MISCELLANEOUS
dapsone
sulfamethoxazole/trimethoprim
sulfamethoxazole/trimethoprim DS
trimethoprim
clindamycin
linezolid
nitazoxanide
nitrofurantoin ext-rel
nitrofurantoin macrocrystals
nitrofurantoin susp
PA
rifaximin
tinidazole
vancomycin
metronidazole
Tier 1
Tier 1
Tier 1
Tier 1
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 3
CLEOCIN
ZYVOX
ALINIA
MACROBID
MACRODANTIN
FURADANTIN
XIFAXAN 550 mg
TINDAMAX
VANCOCIN
FLAGYL
ALKYLATING AGENTS
cyclophosphamide
altretamine
busulfan
chlorambucil
lomustine
melphalan
PA, SP
temozolomide
Tier 0
Tier 0
Tier 0
Tier 0
Tier 0
Tier 0
Tier 0
HEXALEN
MYLERAN
LEUKERAN
CEENU
ALKERAN
TEMODAR
ANTIMETABOLITES
PA, SP
capecitabine
mercaptopurine
methotrexate
thioguanine
Tier 0
Tier 0
Tier 0
Tier 0
XELODA
PURINETHOL
TREXALL
TABLOID
HORMONAL ANTINEOPLASTIC AGENTS
Antiandrogens
flutamide
bicalutamide
Tier 0
Tier 0 CASODEX
Antiestrogens
tamoxifen
toremifene
#
fulvestrant
Tier 0
Tier 0 FARESTON
Tier 2 FASLODEX
Aromatase Inhibitors
anastrozole
exemestane
letrozole
Tier 0 ARIMIDEX
Tier 0 AROMASIN
Tier 0 FEMARA
ANTINEOPLASTIC AGENTS
Clinical practice guidelines in oncology are available at:
http://www.asco.org
http://www.nccn.org
12
Luteinizing Hormone-releasing Hormone (LHRH) Agonists
#
goserelin acetate
#
leuprolide acetate
#
triptorelin pamoate
PA, SP, SI leuprolide acetate
Tier 2 ZOLADEX
Tier 2 LUPRON DEPOT
Tier 2 TRELSTAR
Tier 4
Progestins
megestrol acetate
Tier 0 MEGACE
IMMUNOMODULATORS
PA, SP
lenalidomide
PA, SP
pomalidomide
PA, SP
thalidomide
Tier 0 REVLIMID
Tier 0 POMALYST
Tier 0 THALOMID
KINASE INHIBITORS
PA, SP
bosutinib
PA, SP
dasatinib
PA, SP
erlotinib
PA, SP
everolimus
PA, SP
imatinib mesylate
PA, SP
lapatinib
PA, SP
pazopanib
PA, SP
ponatinib
PA, SP
sorafenib
PA, SP
sunitinib
Tier 0
Tier 0
Tier 0
Tier 0
Tier 0
Tier 0
Tier 0
Tier 0
Tier 0
Tier 0
TOPOISOMERASE INHIBITORS
PA, SP
topotecan caps
Tier 0 HYCAMTIN caps
MISCELLANEOUS
PA, SP
bexarotene caps
etoposide
hydroxyurea
mitotane
procarbazine
tretinoin caps
PA, SP
vorinostat
Tier 0
Tier 0
Tier 0
Tier 0
Tier 0
Tier 0
Tier 0
BOSULIF
SPRYCEL
TARCEVA
AFINITOR
GLEEVEC
TYKERB
VOTRIENT
ICLUSIG
NEXAVAR
SUTENT
TARGRETIN caps
HYDREA
LYSODREN
MATULANE
ZOLINZA
CARDIOVASCULAR
The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure
is available at:
http://www.nhlbi.nih.gov/guidelines/hypertension
Guidelines for the evaluation and management of cardiovascular diseases in adults are available at:
http://www.acc.org
http://www.heartfailureguideline.org
ACE INHIBITORS
Guidelines for the use of ACE inhibitors are available at:
http://professional.diabetes.org
http://www.acc.org
captopril
fosinopril
benazepril
Tier 1
Tier 1
Tier 3 LOTENSIN
13
enalapril
lisinopril
perindopril
quinapril
ramipril
trandolapril
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
VASOTEC
ZESTRIL
ACEON
ACCUPRIL
ALTACE
MAVIK
ACE INHIBITOR/CALCIUM CHANNEL BLOCKER COMBINATIONS
amlodipine/benazepril
trandolapril/verapamil ext-rel
Tier 2 LOTREL
Tier 2 TARKA
ACE INHIBITOR/DIURETIC COMBINATIONS
captopril/hydrochlorothiazide
fosinopril/hydrochlorothiazide
benazepril/hydrochlorothiazide
enalapril/hydrochlorothiazide
lisinopril/hydrochlorothiazide
quinapril/hydrochlorothiazide
Tier 1
Tier 1
Tier 3
Tier 3
Tier 3
Tier 3
ADRENOLYTICS, CENTRAL
clonidine
clonidine transdermal
guanfacine
Tier 2 CATAPRES
Tier 2 CATAPRES-TTS
Tier 2 TENEX
ALDOSTERONE RECEPTOR ANTAGONISTS
eplerenone
spironolactone
Tier 2 INSPRA
Tier 2 ALDACTONE
LOTENSIN HCT
VASERETIC
ZESTORETIC
ACCURETIC
ALPHA BLOCKERS
Guidelines for the use of alpha blockers in various patient populations are available at:
terazosin
doxazosin
Tier 1
Tier 3 CARDURA
ANGIOTENSIN II RECEPTOR ANTAGONISTS/DIURETIC COMBINATIONS
Guidelines for the use of angiotensin II receptor antagonists in various patient populations are available at:
candesartan
candesartan/hydrochlorothiazide
eprosartan
irbesartan
irbesartan/hydrochlorothiazide
valsartan/hydrochlorothiazide
olmesartan
olmesartan/hydrochlorothiazide
losartan
losartan/hydrochlorothiazide
telmisartan
telmisartan/hydrochlorothiazide
valsartan
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 2
Tier 2
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
BENICAR
BENICAR HCT
COZAAR
HYZAAR
MICARDIS
MICARDIS HCT
DIOVAN
ANGIOTENSIN II RECEPTOR ANTAGONIST/CALCIUM CHANNEL BLOCKER COMBINATIONS
amlodipine/olmesartan
Tier 2 AZOR
amlodipine/valsartan
Tier 2 EXFORGE
14
ANGIOTENSIN II RECEPTOR ANTAGONIST/CALCIUM CHANNEL BLOCKER/DIURETIC COMBINATIONS
amlodipine/valsartan/hydrochlorothiazide
Tier 2 EXFORGE HCT
olmesartan/amlodipine/hydrochlorothiazide
Tier 2 TRIBENZOR
ANTIARRHYTHMICS
Guidelines for the use of antiarrhythmics and cardiac glycosides in various patient populations are available at:
http://www.acc.org
PA, SP
amiodarone
disopyramide
disopyramide ext-rel
dofetilide
flecainide
propafenone
propafenone ext-rel
sotalol
sotalol
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
CORDARONE
NORPACE
NORPACE CR
TIKOSYN
TAMBOCOR
RYTHMOL
RYTHMOL SR
BETAPACE
BETAPACE AF
ANTILIPEMICS
The Third Report of the Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult
Treatment Panel III) is available at:
http://www.nhlbi.nih.gov/guidelines/cholesterol/index.htm
Bile Acid Resins
colesevelam
cholestyramine
colestipol
Tier 2 WELCHOL
Tier 3 QUESTRAN/QUESTRAN LIGHT
Tier 3 COLESTID
Cholesterol Absorption Inhibitors
ezetimibe
Tier 2 ZETIA
Fibrates
fenofibrate
fenofibrate
fenofibrate
fenofibrate
fenofibric acid delayed-rel
gemfibrozil
Tier 1
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
ANTARA
LIPOFEN
LOFIBRA
TRILIPIX
LOPID
HMG-CoA Reductase Inhibitors/Combinations
atorvastatin
fluvastatin
ezetimibe/simvastatin
rosuvastatin
lovastatin
pravastatin
simvastatin
Tier 1
Tier 1
Tier 2
Tier 2
Tier 3
Tier 3
Tier 3
VYTORIN
CRESTOR
MEVACOR
PRAVACHOL
ZOCOR
Niacins/Combinations
niacin ext-rel/simvastatin
niacin ext-rel
Tier 2 SIMCOR
Tier 3 NIASPAN
Omega-3 Fatty Acids
PA
omega-3 acid ethyl esters
Tier 2 LOVAZA
15
BETA-BLOCKERS
Guidelines for the use of beta-blockers and beta-blocker combinations in various patient populations are available at:
http://www.acc.org
labetalol
pindolol
propranolol
carvedilol phosphate ext-rel
nebivolol
atenolol
bisoprolol
carvedilol
metoprolol succinate ext-rel
metoprolol tartrate
nadolol
propranolol ext-rel
Tier 1
Tier 1
Tier 1
Tier 2
Tier 2
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
COREG CR
BYSTOLIC
TENORMIN
ZEBETA
COREG
TOPROL-XL
LOPRESSOR
CORGARD
INDERAL LA
BETA-BLOCKER/DIURETIC COMBINATIONS
Guidelines for the use of beta-blockers and diuretic combinations in various patient populations are available at:
http://www.acc.org
atenolol/chlorthalidone
bisoprolol/hydrochlorothiazide
metoprolol/hydrochlorothiazide
Tier 2 TENORETIC
Tier 2 ZIAC
Tier 2 LOPRESSOR HCT
CALCIUM CHANNEL BLOCKERS
Dihydropyridines
amlodipine
felodipine ext-rel
nifedipine ext-rel
nifedipine ext-rel
Tier 1
Tier 1
Tier 3 ADALAT CC
Tier 3 PROCARDIA XL
Nondihydropyridines
diltiazem ext-rel
diltiazem ext-rel
diltiazem ext-rel
verapamil ext-rel
Tier 3
Tier 3
Tier 3
Tier 3
CALCIUM CHANNEL BLOCKER/ANTILIPEMIC COMBINATIONS
amlodipine/atorvastatin
Tier 3 CADUET
DIGITALIS GLYCOSIDES
digoxin ped elixir
digoxin
Tier 1
Tier 2 LANOXIN
DIRECT RENIN INHIBITORS/DIURETIC COMBINATIONS
aliskiren
aliskiren/hydrochlorothiazide
Tier 2 TEKTURNA
Tier 2 TEKTURNA HCT
CARDIZEM CD
CARDIZEM LA
TIAZAC
CALAN SR
DIRECT RENIN INHIBITOR/CALCIUM CHANNEL BLOCKER COMBINATIONS
aliskiren/amlodipine
Tier 2 TEKAMLO
DIRECT RENIN INHIBITOR/CALCIUM CHANNEL BLOCKER/DIURETIC COMBINATIONS
aliskiren/amlodipine/hydrochlorothiazide
Tier 2 AMTURNIDE
16
DIURETICS
Carbonic Anhydrase Inhibitors
acetazolamide
methazolamide
acetazolamide ext-rel
Tier 1
Tier 1
Tier 2 DIAMOX SEQUELS
Loop Diuretics
bumetanide
furosemide
torsemide
Tier 1
Tier 3 LASIX
Tier 3 DEMADEX
Potassium-sparing Diuretics
amiloride
Tier 1
Thiazides and Thiazide-like Diuretics
chlorthalidone
hydrochlorothiazide
indapamide
metolazone
Tier 1
Tier 1
Tier 1
Tier 3 ZAROXOLYN
Diuretic Combinations
amiloride/hydrochlorothiazide
spironolactone-hydrochlorothiazide
triamterene-hydrochlorothiazide
triamterene-hydrochlorothiazide
Tier 1
Tier 3 ALDACTAZIDE
Tier 3 DYAZIDE
Tier 3 MAXZIDE
NITRATES
Oral
isosorbide dinitrate ext-rel tabs
isosorbide mononitrate
isosorbide dinitrate oral
isosorbide mononitrate ext-rel
Tier 1
Tier 1
Tier 2 ISORDIL
Tier 2 IMDUR
nitroglycerin sublingual
nitroglycerin sublingual spray
Tier 2 NITROSTAT
Tier 2 NITROLINGUAL
Sublingual
Transdermal
nitroglycerin transdermal
nitroglycerin transdermal
Tier 1
Tier 2 NITRO-DUR
NITRATE/VASODILATOR COMBINATIONS
isosorbide dinitrate/hydralazine
Tier 2 BIDIL
PULMONARY ARTERIAL HYPERTENSION
Endothelin Receptor Antagonists
PA, SP
ambrisentan
PA, SP
bosentan
Tier 2 LETAIRIS
Tier 2 TRACLEER
Phosphodiesterase Inhibitors
PA, SP
tadalafil
PA, SP
sildenafil
Tier 2 ADCIRCA
Tier 3 REVATIO
Prostaglandin Vasodilators
#
epoprostenol sodium
PA, SP
iloprost
#
treprostinil
PA, SP
treprostinil
Tier 2
Tier 2
Tier 2
Tier 2
FLOLAN
VENTAVIS
REMODULIN
TYVASO
17
MISCELLANEOUS
hydralazine
methyldopa
midodrine
ranolazine ext-rel
Tier 1
Tier 1
Tier 1
Tier 2 RANEXA
CENTRAL NERVOUS SYSTEM
Practice guidelines for psychiatric disorders are available at:
http://www.psych.org
ANTIANXIETY
Benzodiazepines
oxazepam
alprazolam
clonazepam tabs
diazepam
lorazepam
Tier 1
Tier 2
Tier 2
Tier 2
Tier 2
Miscellaneous
buspirone
fluvoxamine
clomipramine
Tier 1
Tier 1
Tier 2 ANAFRANIL
XANAX
KLONOPIN
VALIUM
ATIVAN
ANTICONVULSANTS
Practice guidelines for the treatment of epilepsy are available at:
http://www.aan.com
phenobarbital
lacosamide
lamotrigine ext-rel
lamotrigine orally disintegrating tabs
tiagabine
carbamazepine
carbamazepine ext-rel
carbamazepine ext-rel
diazepam rectal gel
divalproex sodium delayed-rel
divalproex sodium ext-rel
ethosuximide
gabapentin
lamotrigine
levetiracetam
levetiracetam ext-rel
oxcarbazepine
phenytoin
phenytoin sodium extended
primidone
topiramate
valproic acid
zonisamide
Tier 1
Tier 2
Tier 2
Tier 2
Tier 2
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
VIMPAT
LAMICTAL XR
LAMICTAL ODT
GABITRIL
TEGRETOL
CARBATROL
TEGRETOL-XR
DIASTAT
DEPAKOTE
DEPAKOTE ER
ZARONTIN
NEURONTIN
LAMICTAL
KEPPRA
KEPPRA XR
TRILEPTAL
DILANTIN INFATABS
DILANTIN
MYSOLINE
TOPAMAX
DEPAKENE
ZONEGRAN
ANTIDEMENTIA
Practice guidelines for the management of dementia are available at:
http://www.aan.com
memantine
memantine ext-rel
rivastigmine transdermal
Tier 2 NAMENDA
Tier 2 NAMENDA XR
Tier 2 EXELON PATCH
18
donepezil
galantamine
galantamine ext-rel
rivastigmine
Tier 3
Tier 3
Tier 3
Tier 3
ARICEPT
RAZADYNE
RAZADYNE ER
EXELON
ANTIDEPRESSANTS
Although these agents are primarily indicated for depression, some of these are also approved for other indications, including
bipolar disorder, obsessive-compulsive disorder, panic disorder and premenstrual dysphoric disorder.
Guidelines for the evaluation and management of bipolar and depressive disorders are available at:
Monoamine Oxidase Inhibitors (MAOIs)
isocarboxazid
phenelzine
tranylcypromine
Tier 2 MARPLAN
Tier 2 NARDIL
Tier 2 PARNATE
Selective Serotonin Reuptake Inhibitors (SSRIs)
fluoxetine
vilazodone
citalopram
escitalopram
fluoxetine
paroxetine HCl
paroxetine HCl ext-rel
sertraline
Tier 2
Tier 2
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Serotonin Norepinephrine Reuptake Inhibitors (SNRIs)
venlafaxine
desvenlafaxine ext-rel
duloxetine delayed-rel
venlafaxine ext-rel
Tier 1
Tier 2 PRISTIQ
Tier 3 CYMBALTA
Tier 3 EFFEXOR XR
Tricyclic Antidepressants (TCAs)
amitriptyline
doxepin
desipramine
imipramine HCl
nortriptyline
Tier 1
Tier 1
Tier 2 NORPRAMIN
Tier 2 TOFRANIL
Tier 2 PAMELOR
Miscellaneous Agents
trazodone
bupropion
bupropion ext-rel
bupropion ext-rel
mirtazapine
Tier 1
Tier 3
Tier 3
Tier 3
Tier 3
FLUOXETINE 60 mg
VIIBRYD
CELEXA
LEXAPRO
PROZAC
PAXIL
PAXIL CR
ZOLOFT
WELLBUTRIN
WELLBUTRIN SR
WELLBUTRIN XL
REMERON
ANTIPARKINSONIAN AGENTS
Practice guidelines for the diagnosis and treatment of Parkinson's disease are available at:
http://www.aan.com
amantadine
benztropine
selegiline
trihexyphenidyl
bromocriptine
pramipexole ext-rel
rasagiline mesylate
Tier 1
Tier 1
Tier 1
Tier 1
Tier 2 PARLODEL
Tier 2 MIRAPEX ER
Tier 2 AZILECT
19
rotigotine transdermal
selegiline orally disintegrating tabs
carbidopa/levodopa
carbidopa/levodopa ext-rel
carbidopa/levodopa orally disintegrating tabs
carbidopa/levodopa/entacapone
entacapone
pramipexole
ropinirole
ropinirole ext-rel
Tier 2
Tier 2
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
NEUPRO
ZELAPAR
SINEMET
SINEMET CR
PARCOPA
STALEVO
COMTAN
MIRAPEX
REQUIP
REQUIP XL
ANTIPSYCHOTICS
Atypicals
aripiprazole
#
aripiprazole inj
lurasidone
quetiapine ext-rel
#
risperidone long-acting injection
clozapine
olanzapine
quetiapine
risperidone
ziprasidone
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
ABILIFY
ABILIFY injection
LATUDA
SEROQUEL XR
RISPERDAL CONSTA
CLOZARIL
ZYPREXA
SEROQUEL
RISPERDAL
GEODON
Miscellaneous
chlorpromazine
fluphenazine
haloperidol
perphenazine
thiothixene
trifluoperazine
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
ATTENTION DEFICIT HYPERACTIVITY DISORDER
Guidelines for the evaluation and management of attention deficit disorder are available at:
http://www.aacap.org
http://www.aap.org
amphetamine/dextroamphetamine mixed salts
amphetamine/dextroamphetamine mixed salts ext-rel
dextroamphetamine
methylphenidate ext-rel 10 mg
atomoxetine
guanfacine ext-rel
lisdexamfetamine
methylphenidate ext-rel susp
methylphenidate transdermal
dexmethylphenidate
dexmethylphenidate ext-rel
dextroamphetamine ext-rel
methylphenidate
methylphenidate
methylphenidate ext-rel
methylphenidate ext-rel
FIBROMYALGIA
milnacipran
pregabalin
Tier 1
Tier 1
Tier 1
Tier 1
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
STRATTERA
INTUNIV
VYVANSE
QUILLIVANT XR
DAYTRANA
FOCALIN
FOCALIN XR
DEXEDRINE SPANSULE
METHYLIN
RITALIN
CONCERTA
RITALIN LA
Tier 2 SAVELLA
Tier 2 LYRICA
20
HUNTINGTON'S DISEASE AGENTS
PA, SP
tetrabenazine
Tier 2 XENAZINE
HYPNOTICS
Practice parameters for the treatment of sleep disorders and clinical guidelines for the evaluation and management of chronic
insomnia in adults are available at:
http://www.aasmnet.org
Benzodiazepines
temazepam
Tier 3 RESTORIL
Nonbenzodiazepines
eszopiclone
zolpidem
zolpidem ext-rel
Tier 1
Tier 3 AMBIEN
Tier 3 AMBIEN CR
Tricyclics
doxepin
Tier 2 SILENOR
MIGRAINE
Guidelines for prevention and management of migraine headaches are available at:
http://www.aan.com
Ergotamine Derivatives
dihydroergotamine spray
ergotamine/caffeine
SI
dihydroergotamine inj
Tier 2 MIGRANAL
Tier 2 CAFERGOT
Tier 4 D.H.E. 45
Selective Serotonin Agonists
QL
naratriptan
QL
eletriptan
QL
zolmitriptan nasal spray
QL
rizatriptan
QL
sumatriptan
QL
sumatriptan nasal spray
QL
zolmitriptan
QL, SI
sumatriptan inj
QL, SI
sumatriptan inj
Tier 1
Tier 2
Tier 2
Tier 3
Tier 3
Tier 3
Tier 3
Tier 4
Tier 4
RELPAX
ZOMIG
MAXALT
IMITREX
IMITREX
ZOMIG
IMITREX
SUMAVEL DOSEPRO
Selective Serotonin Agonist/Nonsteroidal Anti-inflammatory Drug (NSAID) Combinations
QL
sumatriptan/naproxen sodium
Tier 2 TREXIMET
MOOD STABILIZERS
lithium carbonate
lithium carbonate ext-rel tabs 450 mg
lithium carbonate ext-rel tabs 300 mg
Tier 1
Tier 1
Tier 2 LITHOBID
MULTIPLE SCLEROSIS AGENTS
Practice guidelines for multiple sclerosis are available at:
http://www.aan.com
PA, SP
PA, SP
PA, SP, SI
PA, SP, SI
PA, SP, SI
dimethyl fumarate delayed-rel
fingolimod
glatiramer
interferon beta-1a
interferon beta-1b
Tier 2
Tier 2
Tier 4
Tier 4
Tier 4
TECFIDERA
GILENYA
COPAXONE
AVONEX
EXTAVIA
21
MUSCULOSKELETAL THERAPY AGENTS
baclofen
carisoprodol
cyclobenzaprine
orphenadrine/aspirin/caffeine
chlorzoxazone
dantrolene
metaxalone
methocarbamol
tizanidine
Tier 1
Tier 1
Tier 1
Tier 1
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
MYASTHENIA GRAVIS
pyridostigmine
pyridostigmine ext-rel
Tier 2 MESTINON
Tier 2 MESTINON TIMESPAN
NARCOLEPSY/CATAPLEXY
armodafinil
sodium oxybate
Tier 2 NUVIGIL
Tier 2 XYREM
POSTHERPETIC NEURALGIA (PHN)
gabapentin ext-rel
Tier 2 GRALISE
PSYCHOTHERAPEUTIC-MISCELLANEOUS
Alcohol Deterrents
acamprosate calcium
disulfiram
Tier 2 CAMPRAL
Tier 2 ANTABUSE
Opioid Antagonists
naltrexone
Tier 2 REVIA
Partial Opioid Agonist/Opioid Antagonist Combinations
buprenorphine/naloxone sublingual tabs
buprenorphine/naloxone sublingual tabs
Tier 1
Tier 2 ZUBSOLV
Smoking Deterrents
*
bupropion ext-rel
varenicline
Tier 0 ZYBAN
Tier 0 CHANTIX
PARAFON FORTE DSC
DANTRIUM
SKELAXIN
ROBAXIN
ZANAFLEX tabs
* Brands are not covered when the generic alternative is available.
ENDOCRINE AND METABOLIC
ANDROGENS
Clinical practice guidelines for the treatment of hypogonadism are available at:
http://www.aace.com
#
#
testosterone cypionate
testosterone enanthate
testosterone gel
testosterone soln
testosterone transdermal
Tier 1
Tier 1
Tier 2 FORTESTA
Tier 2 AXIRON
Tier 2 ANDRODERM
ANTIDIABETICS
Guidelines of treatment and management of diabetes are available at:
Alpha-glucosidase Inhibitors
acarbose
Tier 2 PRECOSE
22
Amylin Analogs
SI
pramlintide
Tier 4 SYMLINPEN
Biguanides
metformin
metformin ext-rel
Tier 3 GLUCOPHAGE
Tier 3 GLUCOPHAGE XR
Biguanide/Sulfonylurea Combinations
glipizide/metformin
Tier 3 METAGLIP
Dipeptidyl Peptidase-4 (DPP-4) Inhibitors
linagliptin
sitagliptin phosphate
Tier 2 TRADJENTA
Tier 2 JANUVIA
Dipeptidyl Peptidase-4 (DPP-4) Inhibitor/Biguanide Combinations
linagliptin/metformin
sitagliptin/metformin
sitagliptin/metformin ext-rel
Tier 2 JENTADUETO
Tier 2 JANUMET
Tier 2 JANUMET XR
Incretin Mimetic Agents
SI
exenatide ext-rel
SI
liraglutide
Tier 4 BYDUREON
Tier 4 VICTOZA
Insulins
OTC
OTC
OTC
insulin aspart
insulin aspart protamine 70%/insulin aspart 30%
insulin detemir
insulin glargine
insulin human
insulin human
insulin isophane human
insulin isophane human 70%/regular 30%
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
NOVOLOG
NOVOLOG MIX 70/30
LEVEMIR
LANTUS
HUMULIN R U-500
NOVOLIN R
NOVOLIN N
NOVOLIN 70/30
Insulin Sensitizers
pioglitazone
Tier 1
Insulin Sensitizer/Biguanide Combinations
pioglitazone/metformin
Tier 3 ACTOPLUS MET
Insulin Sensitizer/Sulfonylurea Combinations
pioglitazone/glimepiride
Tier 3 DUETACT
Meglitinides
nateglinide
repaglinide
Tier 1
Tier 3 PRANDIN
Sodium-Glucose Co-transporter 2 (SGLT2) Inhibitors
canagliflozin
Tier 2 INVOKANA
Sodium-Glucose Co-transporter 2 (SGLT2) Inhibitor/Biguanide Combinations
canagliflozin/metformin
Tier 2 INVOKAMET
Sulfonylureas
glyburide
glimepiride
glipizide
glipizide ext-rel
Tier 1
Tier 3 AMARYL
Tier 3 GLUCOTROL
Tier 3 GLUCOTROL XL
23
Supplies *
*
blood glucose continuous monitoring receivers, sensors,
transmitters
OTC, *
blood glucose monitoring kits, test strips
OTC
insulin syringes, needles
OTC
lancets
Tier 0 DEXCOM G4
Tier 0 ONETOUCH kits and test strips
Tier 0 BD insulin syringes and needles
Tier 0 LANCETS
* Blood glucose monitoring kits are covered under the medical benefit.
ANTIOBESITY *
Guidelines of treatment and management of obesity are available at:
http://www.aace.com
http://www.nhlbi.nih.gov/guidelines/obesity/ob_home.htm
Anorexiant Combinations
phentermine/topiramate ext-rel
Tier 2 QSYMIA
* Coverage for weight loss medications may vary depending on the member's benefit plan.
CALCIUM REGULATORS
Guidelines of treatment and management of osteoporosis are available at:
http://www.aace.com
http://www.nof.org
Bisphosphonates
risedronate
risedronate delayed-rel
alendronate
ibandronate
Tier 2
Tier 2
Tier 3
Tier 3
Calcitonins
SI
calcitonin-salmon
Tier 4 MIACALCIN
Parathyroid Hormones
PA, SP, SI teriparatide
Tier 4 FORTEO
ACTONEL
ATELVIA
FOSAMAX
BONIVA
CONTRACEPTIVES *
* Brand drugs will not be covered when the generic alternative is available.
EE = ethinyl estradiol
ME = mestranol
Monophasic
10 mcg Estrogen
norethindrone acetate/EE 1/10 and EE 10 and iron
Tier 0 LO LOESTRIN FE
20 mcg Estrogen
drospirenone/EE 3/20
drospirenone/EE/levomefolate 3/20 and levomefolate
levonorgestrel/EE 0.1/20 - Lessina
norethindrone acetate/EE 1/20
norethindrone acetate/EE 1/20 and iron
norethindrone acetate/EE 1/20 and iron - Lomedia 24 Fe
norethindrone acetate/EE 1/20 and iron chewable
Tier 0
Tier 0
Tier 0
Tier 0
Tier 0
Tier 0
Tier 0
30 mcg Estrogen
desogestrel/EE 0.15/30
drospirenone/EE 3/30
Tier 0 ORTHO-CEPT
Tier 0 YASMIN
YAZ
BEYAZ
LOESTRIN 1/20
LOESTRIN FE 1/20
MINASTRIN 24 FE
24
levonorgestrel/EE 0.15/30 - Levora
norethindrone acetate/EE 1.5/30
norethindrone acetate/EE 1.5/30 and iron
norgestrel/EE 0.3/30 - Low-Ogestrel
Tier 0
Tier 0 LOESTRIN 1.5/30
Tier 0 LOESTRIN FE 1.5/30
Tier 0
35 mcg Estrogen
ethynodiol diacetate/EE 1/35 - Zovia 1/35
norethindrone/EE 0.5/35
norethindrone/EE 0.5/35
norethindrone/EE 1/35
norethindrone/EE 1/35
norgestimate/EE 0.25/35
Tier 0
Tier 0
Tier 0
Tier 0
Tier 0
Tier 0
50 mcg Estrogen
ethynodiol diacetate/EE 1/50 - Zovia 1/50
norethindrone/ME 1/50
Tier 0
Tier 0 NORINYL 1+50
BREVICON
MODICON
NORINYL 1+35
ORTHO-NOVUM 1/35
ORTHO-CYCLEN
Biphasic
desogestrel/EE
Tier 0 MIRCETTE
desogestrel/EE
levonorgestrel/EE - Trivora
norethindrone/EE
norethindrone/EE
norgestimate/EE
norgestimate/EE
Tier 0
Tier 0
Tier 0
Tier 0
Tier 0
Tier 0
estradiol valerate and dienogest/estradiol valerate
Tier 0 NATAZIA
Triphasic
CYCLESSA
ORTHO-NOVUM 7/7/7
TRI-NORINYL
ORTHO TRI-CYCLEN
ORTHO TRI-CYCLEN LO
Four Phase
Extended Cycle
levonorgestrel/EE 0.1/20 and EE 10
levonorgestrel/EE 0.15/30
levonorgestrel/EE 0.15/30 and EE 10
Tier 0 LOSEASONIQUE
Tier 0
Tier 0 SEASONIQUE
Progestin Only
norethindrone
norethindrone
Tier 0 NOR-QD
Tier 0 ORTHO MICRONOR
Injectable
SI
medroxyprogesterone acetate 150 mg/mL
Tier 0 DEPO-PROVERA
Progestin Intrauterine Device
levonorgestrel releasing IUD
Tier 0 MIRENA
Transdermal
norelgestromin/EE
Tier 0 ORTHO EVRA
Vaginal
etonogestrel/EE ring
ENDOMETRIOSIS
danazol
nafarelin
Tier 0 NUVARING
Tier 1
Tier 2 SYNAREL
25
ESTROGENS
Guidelines of treatment and management of hormone therapy and menopause are available at:
http://www.menopause.org
Oral
estropipate
estrogens, conjugated
estradiol
Transdermal
estradiol
estradiol
estradiol
estradiol
estradiol
Tier 1
Tier 2 PREMARIN
Tier 3 ESTRACE
Tier 2
Tier 2
Tier 2
Tier 2
Tier 3
DIVIGEL
EVAMIST
MINIVELLE
VIVELLE-DOT
CLIMARA
Vaginal
estradiol vaginal crm
estradiol vaginal tabs
estrogens, conjugated crm
ESTROGEN/PROGESTINS
Oral
EE/norethindrone acetate - Jinteli
estradiol/norethindrone
estrogens, conjugated/medroxyprogesterone
estrogens, conjugated/medroxyprogesterone
EE/norethindrone acetate
Tier 2 ESTRACE
Tier 2 VAGIFEM
Tier 2 PREMARIN crm
Tier 1
Tier 1
Tier 2 PREMPHASE
Tier 2 PREMPRO
Tier 3 FEMHRT
ESTROGEN/SELECTIVE ESTROGEN RECEPTOR MODULATOR COMBINATIONS
conjugated estrogens/bazedoxifene
Tier 2 DUAVEE
FERTILITY REGULATORS
GNRH/LHRH Antagonists
SI
cetrorelix
SI
ganirelix
Tier 4 CETROTIDE
Tier 4
Ovulation Stimulants, Gonadotropins
SI
choriogonadotropin alfa
SI
chorionic gonadotropin - Novarel
SI
follitropin beta
Tier 4 OVIDREL
Tier 4
Tier 4 FOLLISTIM AQ
Ovulation Stimulants, Synthetic
clomiphene
Tier 2 CLOMID
GLUCOCORTICOIDS
dexamethasone
fludrocortisone
prednisolone sodium phosphate 5 mg/5 mL
prednisone
hydrocortisone
methylprednisolone
prednisolone sodium phosphate
prednisolone syrup
Tier 1
Tier 1
Tier 1
Tier 1
Tier 2
Tier 2
Tier 2
Tier 2
GLUCOSE ELEVATING AGENTS
SI
glucagon, human recombinant
SI
glucagon, human recombinant
Tier 4 GLUCAGEN HYPOKIT
Tier 4 GLUCAGON EMERGENCY KIT
CORTEF
MEDROL
ORAPRED
PRELONE
26
HUMAN GROWTH HORMONES
Guidelines for use of growth hormone are available at:
http://www.aace.com/publications/guidelines
PA, SP, SI somatropin
PA, SP, SI somatropin
Tier 4 HUMATROPE
Tier 4 NORDITROPIN
HYPERPARATHYROID TREATMENT, VITAMIN D ANALOGS
calcitriol (1,25-D3)
doxercalciferol
paricalcitol
Tier 2 ROCALTROL
Tier 2 HECTOROL
Tier 2 ZEMPLAR
PHENYLKETONURIA TREATMENT AGENTS
PA, SP
sapropterin
Tier 2 KUVAN
PHOSPHATE BINDER AGENTS
calcium acetate tabs
calcium acetate
sevelamer carbonate
sucroferric oxyhydroxide
calcium acetate
Tier 1
Tier 2
Tier 2
Tier 2
Tier 3
PHOSLYRA
RENVELA
VELPHORO
PHOSLO
PROGESTINS
Oral
megestrol acetate susp
medroxyprogesterone acetate
norethindrone acetate
progesterone, micronized
Tier 2
Tier 3
Tier 3
Tier 3
MEGACE ES
PROVERA
AYGESTIN
PROMETRIUM
Vaginal
progesterone gel
Tier 2 CRINONE
SELECTIVE ESTROGEN RECEPTOR MODULATORS
ospemifene
raloxifene
Tier 2 OSPHENA
Tier 3 EVISTA
THYROID AGENTS
Antithyroid Agents
propylthiouracil
methimazole
Tier 1
Tier 2 TAPAZOLE
Thyroid Supplements
levothyroxine
levothyroxine - Levoxyl
levothyroxine
liothyronine
Tier 1
Tier 1
Tier 2 SYNTHROID
Tier 2 CYTOMEL
VASOPRESSINS
desmopressin spray, tabs
Tier 2 DDAVP
MISCELLANEOUS
cabergoline
levocarnitine
Tier 1
Tier 2 CARNITOR
27
GASTROINTESTINAL
Guidelines for the treatment and management of various gastrointestinal diseases/conditions are available at:
http://www.acg.gi.org
http://www.gastro.org
ANTIDIARRHEALS
loperamide
diphenoxylate/atropine
Tier 1
Tier 2 LOMOTIL
ANTIEMETICS
granisetron
prochlorperazine
promethazine
doxylamine/pyridoxine delayed-rel
granisetron transdermal
scopolamine
dronabinol
meclizine
metoclopramide
ondansetron
trimethobenzamide
Tier 1
Tier 1
Tier 1
Tier 2
Tier 2
Tier 2
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
ANTISPASMODICS
chlordiazepoxide/clidinium
hyoscyamine sulfate ext-rel caps
hyoscyamine sulfate orally disintegrating tabs
dicyclomine
hyoscyamine sulfate
hyoscyamine sulfate ext-rel
Tier 1
Tier 1
Tier 1
Tier 2 BENTYL
Tier 2 LEVSIN
Tier 2 LEVBID
CHOLELITHOLYTICS
ursodiol
ursodiol
Tier 2 ACTIGALL
Tier 2 URSO
H2 RECEPTOR ANTAGONISTS
cimetidine
famotidine
ranitidine
Tier 1
Tier 3 PEPCID
Tier 3 ZANTAC
INFLAMMATORY BOWEL DISEASE
Oral Agents
balsalazide
budesonide delayed-rel caps
budesonide ext-rel
mesalamine delayed-rel tabs
mesalamine ext-rel caps
mesalamine ext-rel caps
olsalazine
sulfasalazine
sulfasalazine delayed-rel
Tier 1
Tier 1
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 3
Tier 3
UCERIS
LIALDA
APRISO
PENTASA
DIPENTUM
AZULFIDINE
AZULFIDINE EN-TABS
Rectal Agents
hydrocortisone enema
hydrocortisone acetate foam
mesalamine rectal susp
mesalamine supp
mesalamine rectal susp
Tier 1
Tier 2
Tier 2
Tier 2
Tier 3
CORTIFOAM
SFROWASA
CANASA
ROWASA
DICLEGIS
SANCUSO
TRANSDERM SCOP
MARINOL
ANTIVERT
REGLAN
ZOFRAN
TIGAN
28
IRRITABLE BOWEL SYNDROME
Irritable Bowel Syndrome with Constipation
linaclotide
lubiprostone
Tier 2 LINZESS
Tier 2 AMITIZA
Irritable Bowel Syndrome with Diarrhea
*
alosetron
Tier 2 LOTRONEX
* For safety reasons, to prescribe Lotronex, the physician must be enrolled in the Prescribing Program for Lotronex. Physicians
must understand the benefits and risks of treatment with Lotronex for severe diarrhea-predominant IBS, including the
information in the Prescribing Information, Medication Guide and Patient-Physician Agreement for Lotronex.
To enroll or for more information on the Prescribing Program for Lotronex, call toll-free: 1-888-423-5227 or visit
www.lotronex.com to complete the Physician Enrollment Form.
LAXATIVES
Tier 1
Tier 2
Tier 2
Tier 2
Tier 2
Tier 3
Tier 3
MOVIPREP
SUCLEAR
MIRALAX
SUPREP
GOLYTELY
NULYTELY
PANCREATIC ENZYMES
pancrelipase
pancrelipase delayed-rel
Tier 2
Tier 2
Tier 2
Tier 2
VIOKACE
CREON
ULTRESA
ZENPEP
PROSTAGLANDINS
misoprostol
Tier 2 CYTOTEC
PROTON PUMP INHIBITORS
lansoprazole delayed-rel
omeprazole/sodium bicarbonate caps
pantoprazole delayed-rel
dexlansoprazole delayed-rel
esomeprazole delayed-rel
omeprazole delayed-rel
Tier 1
Tier 1
Tier 1
Tier 2 DEXILANT
Tier 2 NEXIUM
Tier 3 PRILOSEC
SALIVA STIMULANTS
cevimeline
pilocarpine tabs
Tier 2 EVOXAC
Tier 2 SALAGEN
STEROIDS, RECTAL
hydrocortisone acetate/pramoxine foam
hydrocortisone crm
Tier 2 PROCTOFOAM-HC
Tier 2 ANUSOL-HC
ULCER THERAPY COMBINATIONS
bismuth/metronidazole/tetracycline
lansoprazole + amoxicillin + clarithromycin
Tier 2 PYLERA
Tier 2 PREVPAC
MISCELLANEOUS
sucralfate
SI
methylnaltrexone
Tier 2 CARAFATE
Tier 4 RELISTOR
*
*
*
lactulose
peg 3350/electrolytes
polyethylene glycol 3350
sodium sulfate/potassium sulfate/magnesium sulfate
* Covered at $0 copay for age 50 to 74 years
29
GENITOURINARY
BENIGN PROSTATIC HYPERPLASIA
Guidelines for the management of BPH are available at:
http://www.auanet.org/guidelines
alfuzosin ext-rel
dutasteride
silodosin
finasteride
tamsulosin
Tier 1
Tier 2
Tier 2
Tier 3
Tier 3
AVODART
RAPAFLO
PROSCAR
FLOMAX
ERECTILE DYSFUNCTION
Guidelines for the management of erectile dysfunction are available at:
http://www.auanet.org/guidelines
Alprostadil Agents
QL
alprostadil supp
QL, SI
alprostadil inj
Tier 2 MUSE
Tier 4 EDEX
Phosphodiesterase Inhibitors
QL
sildenafil
QL
tadalafil
Tier 2 VIAGRA
Tier 2 CIALIS
URINARY ANTISPASMODICS
oxybutynin
tolterodine ext-rel
trospium
trospium ext-rel
mirabegron ext-rel
oxybutynin gel
solifenacin succinate
oxybutynin ext-rel
tolterodine
Tier 1
Tier 1
Tier 1
Tier 1
Tier 2
Tier 2
Tier 2
Tier 3
Tier 3
MYRBETRIQ
GELNIQUE
VESICARE
DITROPAN XL
DETROL
VAGINAL ANTI-INFECTIVES
clindamycin crm
clindamycin supp
metronidazole
terconazole
terconazole
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
CLEOCIN
CLEOCIN
METROGEL-VAGINAL
TERAZOL 3
TERAZOL 7
MISCELLANEOUS
bethanechol
pentosan polysulfate sodium
phenazopyridine
potassium citrate ext-rel
Tier 2
Tier 2
Tier 2
Tier 2
URECHOLINE
ELMIRON
PYRIDIUM
UROCIT-K
HEMATOLOGIC
Guidelines of treatment and management of hemophilia are available at:
http://www.hemophilia.org
ANTICOAGULANTS
Injectable
SI
dalteparin
SI
enoxaparin
Tier 4 FRAGMIN
Tier 4 LOVENOX
30
Oral
apixaban
dabigatran etexilate
rivaroxaban
warfarin
Synthetic Heparinoid-like Agents
SI
fondaparinux
Tier 2
Tier 2
Tier 2
Tier 3
ELIQUIS
PRADAXA
XARELTO
COUMADIN
Tier 4 ARIXTRA
HEMATOPOIETIC GROWTH FACTORS
Guidelines for the management of neutropenia are available at:
http://www.asco.org
Guidelines for the management of anemia associated with chronic kidney disease are available at:
http://www.kidney.org/professionals/kdoqi/guidelines_commentaries.cfm#guidelines
PA, SP, SI
PA, SP, SI
PA, SP, SI
PA, SP, SI
darbepoetin alfa
epoetin alfa
filgrastim
pegfilgrastim
Tier 4
Tier 4
Tier 4
Tier 4
ARANESP
PROCRIT
NEUPOGEN
NEULASTA
IDIOPATHIC THROMBOCYTOPENIC PURPURA AGENTS
PA, SP
eltrombopag
Tier 2 PROMACTA
PAROXYSMAL NOCTURNAL HEMOGLOBINURIA (PNH) AGENTS
#
eculizumab
Tier 2 SOLIRIS
PLATELET AGGREGATION INHIBITORS
clopidogrel
dipyridamole
dipyridamole ext-rel/aspirin
prasugrel
ticagrelor
Tier 1
Tier 2
Tier 2
Tier 2
Tier 2
PLATELET SYNTHESIS INHIBITORS
anagrelide
Tier 2 AGRYLIN
STEM CELL MOBILIZERS
#
plerixafor
Tier 2 MOZOBIL
MISCELLANEOUS
cilostazol
Tier 2 PLETAL
PERSANTINE
AGGRENOX
EFFIENT
BRILINTA
IMMUNOLOGIC AGENTS
Guidelines for the management of rheumatic diseases are available at:
http://www.rheumatology.org
BIOLOGIC DISEASE-MODIFYING AGENTS
PA, SP, SI adalimumab
PA, SP, SI anakinra
PA, SP, SI certolizumab pegol
PA, SP, SI etanercept
PA, SP, SI golimumab
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
DISEASE-MODIFYING ANTIRHEUMATIC DRUGS (DMARDs)
methotrexate
hydroxychloroquine
leflunomide
Tier 1
Tier 2 PLAQUENIL
Tier 2 ARAVA
HUMIRA
KINERET
CIMZIA
ENBREL
SIMPONI
31
methotrexate
Tier 2 RHEUMATREX
IMMUNOMODULATORS
CDC recommendations on the treatment of hepatitis are available at:
http://www.cdc.gov/hepatitis/Resources/
Guidelines for the management of hepatitis are available at:
Interferons
PA, SP, SI
PA, SP, SI
PA, SP, SI
PA, SP, SI
interferon alfa-2b
peginterferon alfa-2a
peginterferon alfa-2b
peginterferon alfa-2b
Tier 4
Tier 4
Tier 4
Tier 4
INTRON A
PEGASYS
PEGINTRON
SYLATRON
Miscellaneous
#
canakinumab
Tier 2 ILARIS
IMMUNOSUPPRESSANTS
Antimetabolites
azathioprine
azathioprine
mycophenolate mofetil
mycophenolate sodium delayed-rel
Tier 2
Tier 2
Tier 2
Tier 2
Calcineurin Inhibitors
cyclosporine
cyclosporine, modified
tacrolimus
Tier 2 SANDIMMUNE
Tier 2 NEORAL
Tier 2 PROGRAF
Rapamycin Derivatives
sirolimus
Tier 2 RAPAMUNE
AZASAN
IMURAN
CELLCEPT
MYFORTIC
NUTRITIONAL/SUPPLEMENTS
ELECTROLYTES
Potassium
potassium chloride ext-rel
potassium chloride liquid
Tier 1
Tier 1
VITAMINS AND MINERALS
Folic Acid/Combinations
*
folic acid
folic acid/vitamin B6/vitamin B12
Tier 1
Tier 1
* Covered at $0 for females, ages 55 years and under
Prenatal Vitamins
prenatal vitamins
prenatal vitamins/DHA/docusate/folic acid
prenatal vitamins/docusate/folic acid
prenatal vitamins/docusate/folic acid + DHA
prenatal vitamins/folic acid + pyridoxine
Tier 1
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Miscellaneous
cyanocobalamin inj
multivitamins/fluoride drops, tabs
Tier 1
Tier 1
CITRANATAL 90 DHA
CITRANATAL DHA
CITRANATAL HARMONY
CITRANATAL RX
CITRANATAL ASSURE
CITRANATAL B-CALM
32
*
**
**
multivitamins/fluoride/iron drops, tabs
vitamin ADC/fluoride drops
vitamin ADC/fluoride/iron drops
ergocalciferol (D2)
fluoride drops
fluoride tabs
phytonadione
Tier 1
Tier 1
Tier 1
Tier 2
Tier 2
Tier 2
Tier 2
DRISDOL
LURIDE
LURIDE LOZI-TABS
MEPHYTON
* Covered at $0 for ages 65 years and older.
** Covered at $0 for ages 6 years and under.
RESPIRATORY
Guidelines to the management, prevention, or treatment of COPD and asthma are available at:
http://www.aaaai.org
http://www.ginasthma.com
http://www.goldcopd.com
http://www.nhlbi.nih.gov
The Allergy Report and guidelines for allergy-related conditions are available at:
ANAPHYLAXIS TREATMENT AGENTS
SI
epinephrine
SI
epinephrine
SI
epinephrine
Tier 4 AUVI-Q
Tier 4 EPIPEN
Tier 4 EPIPEN JR.
ANTICHOLINERGICS
ipratropium soln
tiotropium
Tier 1
Tier 2 SPIRIVA
ANTICHOLINERGIC/BETA AGONIST COMBINATIONS
ipratropium/albuterol, CFC-free aerosol
umeclidinium/vilanterol
ipratropium/albuterol soln
Tier 2 COMBIVENT RESPIMAT
Tier 2 ANORO ELLIPTA
Tier 3 DUONEB
ANTIHISTAMINES, LOW SEDATING
levocetirizine
Tier 2 XYZAL
ANTIHISTAMINES, SEDATING
clemastine 2.68 mg
cyproheptadine
hydroxyzine HCl
Tier 1
Tier 1
Tier 1
ANTITUSSIVES
benzonatate
Tier 2 TESSALON
ANTITUSSIVE COMBINATIONS
Opioid
codeine/chlorpheniramine/pseudoephedrine
codeine/guaifenesin liquid
codeine/guaifenesin/pseudoephedrine
codeine/promethazine
codeine/promethazine/phenylephrine
hydrocodone/homatropine
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Non-opioid
dextromethorphan/brompheniramine/pseudoephedrine
dextromethorphan/promethazine
Tier 1
Tier 1
33
BETA AGONISTS
Inhalants
Short Acting
albuterol soln
albuterol sulfate, CFC-free aerosol
Tier 1
Tier 2 PROAIR HFA
Long Acting
formoterol inhalation caps
formoterol inhalation soln
indacaterol
salmeterol xinafoate
Tier 2
Tier 2
Tier 2
Tier 2
FORADIL
PERFOROMIST
ARCAPTA NEOHALER
SEREVENT
albuterol
terbutaline
albuterol ext-rel
Tier 1
Tier 1
Tier 2 VOSPIRE ER
CYSTIC FIBROSIS
PA, SP
dornase alfa
PA, SP
tobramycin inhalation soln
Tier 2 PULMOZYME
Tier 2 TOBI
LEUKOTRIENE RECEPTOR ANTAGONISTS
zafirlukast
montelukast
Tier 1
Tier 3 SINGULAIR
MAST CELL STABILIZERS
cromolyn soln
Tier 1
NASAL ANTIHISTAMINES
azelastine spray
olopatadine spray
azelastine spray
Tier 1
Tier 2 PATANASE
Tier 3 ASTEPRO
NASAL STEROIDS
flunisolide spray
mometasone spray
fluticasone spray
triamcinolone acetonide spray
Tier 1
Tier 2 NASONEX
Tier 3 FLONASE
Tier 3 NASACORT AQ
PHOSPHODIESTERASE-4 INHIBITORS
roflumilast
Tier 2 DALIRESP
STEROID/BETA AGONIST COMBINATIONS
fluticasone/salmeterol
fluticasone/salmeterol, CFC-free aerosol
mometasone/formoterol
fluticasone/vilanterol
Tier 2
Tier 2
Tier 2
Tier 3
ADVAIR
ADVAIR HFA
DULERA
BREO ELLIPTA
STEROID INHALANTS
beclomethasone, CFC-free aerosol
budesonide
fluticasone
fluticasone, CFC-free aerosol
mometasone
budesonide inh susp
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 3
QVAR
PULMICORT FLEXHALER
FLOVENT DISKUS
FLOVENT HFA
ASMANEX
PULMICORT RESPULES
Oral Agents
34
XANTHINES
theophylline ext-rel tabs
theophylline ext-rel caps
theophylline liquid
Tier 1
Tier 2 THEO-24
Tier 2 ELIXOPHYLLIN
MISCELLANEOUS
ipratropium spray
omalizumab
Tier 2 ATROVENT spray
Tier 2 XOLAIR
TOPICAL
DERMATOLOGY
Acne
Guidelines for the care and treatment of acne vulgaris are available at:
http://www.aad.org/education-and-quality-care/clinical-guidelines
Oral
isotretinoin
Tier 1
erythromycin gel 2%
erythromycin soln
sulfacetamide/sulfur crm, gel, lotion, pads
tretinoin
adapalene
adapalene/benzoyl peroxide
clindamycin/benzoyl peroxide
tazarotene
tretinoin
tretinoin gel microsphere
benzoyl peroxide
clindamycin gel, lotion, soln
erythromycin/benzoyl peroxide
sulfacetamide lotion 10%
tretinoin
Tier 1
Tier 1
Tier 1
Tier 1
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Topical
PA
PA
PA
PA
PA
Actinic Keratosis
fluorouracil crm, soln 5%, soln 2%
fluorouracil
imiquimod
ingenol mebutate
AVITA
DIFFERIN
EPIDUO
ACANYA
BENZACLIN
TAZORAC
ATRALIN
RETIN-A MICRO
BENZAC AC
CLEOCIN T
DUAC
BENZAMYCIN
KLARON
RETIN-A
Tier 1
Tier 2 CARAC
Tier 2 ZYCLARA
Tier 2 PICATO
Antibiotics
gentamicin
mupirocin
silver sulfadiazine
Tier 1
Tier 2 BACTROBAN
Tier 2 SILVADENE
clotrimazole
econazole
ketoconazole
nystatin
butenafine
ciclopirox
Tier 1
Tier 1
Tier 1
Tier 1
Tier 2 MENTAX
Tier 3 LOPROX
Antifungals
35
Antipsoriatics
Guidelines of care for the management and treatment of psoriasis with topical therapies are available at:
http://www.aad.org
Injectable
PA, SP, SI ustekinumab
Tier 4 STELARA
Oral
acitretin
methoxsalen oral
Tier 3 SORIATANE
Tier 3 OXSORALEN-ULTRA
calcipotriene
calcipotriene
Tier 2 SORILUX
Tier 3 DOVONEX
Topical
Antiseborrheics
ketoconazole shampoo 2%
selenium sulfide shampoo 2.5%
Tier 2 NIZORAL SHAMPOO
Tier 2 SELSUN
Corticosteroids
Low Potency
fluocinolone acetonide soln 0.01%
hydrocortisone crm 2.5%
hydrocortisone lotion 1%
alclometasone crm, oint 0.05%
desonide crm, lotion, oint 0.05%
Tier 1
Tier 1
Tier 1
Tier 2 ACLOVATE
Tier 2 DESOWEN
Medium Potency
betamethasone valerate crm, lotion, oint 0.1%
fluocinolone acetonide crm, oint 0.025%
triamcinolone acetonide crm, lotion 0.025%
triamcinolone acetonide crm, lotion, oint 0.1%
clocortolone crm 0.1%
desoximetasone oint 0.05%
fluticasone propionate oint 0.005%
hydrocortisone butyrate crm 0.1%
hydrocortisone butyrate lotion 0.1%
hydrocortisone butyrate oint, soln 0.1%
hydrocortisone valerate oint 0.2%
mometasone oint 0.1%
desoximetasone crm 0.05%
fluticasone propionate crm, lotion 0.05%
hydrocortisone butyrate crm 0.1%
hydrocortisone valerate crm 0.2%
mometasone crm, lotion 0.1%
Tier 1
Tier 1
Tier 1
Tier 1
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
CLODERM
TOPICORT LP
CUTIVATE
LOCOID LIPOCREAM
LOCOID
LOCOID
WESTCORT
ELOCON
TOPICORT LP
CUTIVATE
LOCOID
WESTCORT
ELOCON
High Potency
betamethasone dipropionate crm, lotion, oint 0.05%
diflorasone diacetate crm 0.05%
fluocinonide crm, gel, oint, soln 0.05%
triamcinolone acetonide crm 0.5%
desoximetasone oint 0.25%, gel 0.05%
betamethasone dipropionate augmented crm 0.05%
betamethasone dipropionate augmented lotion 0.05%
desoximetasone crm 0.25%
Tier 1
Tier 1
Tier 1
Tier 1
Tier 2
Tier 3
Tier 3
Tier 3
TOPICORT
DIPROLENE AF
DIPROLENE
TOPICORT
36
Very High Potency
clobetasol propionate foam 0.05%
diflorasone diacetate oint 0.05%
betamethasone dipropionate augmented gel, oint 0.05%
clobetasol propionate crm, gel, oint 0.05%
clobetasol propionate lotion, shampoo 0.05%
clobetasol propionate spray 0.05%
halobetasol propionate crm, oint 0.05%
clobetasol propionate soln 0.05%
Tier 1
Tier 1
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 3
DIPROLENE
TEMOVATE
CLOBEX
CLOBEX
ULTRAVATE
TEMOVATE
Emollients
ammonium lactate 12%
Tier 2 LAC-HYDRIN
Immunomodulators
Guidelines for the treatment of atopic dermatitis are available at:
http://www.aad.org
pimecrolimus
tacrolimus
Tier 2 ELIDEL
Tier 2 PROTOPIC
Local Analgesics
lidocaine patch
Tier 2 LIDODERM
Local Anesthetics
lidocaine/prilocaine
Tier 1
Rosacea
metronidazole gel 0.75%
sulfacetamide/sulfur
azelaic acid gel
doxycycline monohydrate
metronidazole crm 0.75%
metronidazole gel 1%
metronidazole lotion 0.75%
Tier 1
Tier 1
Tier 2
Tier 2
Tier 3
Tier 3
Tier 3
FINACEA
ORACEA
METROCREAM
METROGEL
METROLOTION
Scabicides and Pediculicides
permethrin 5%
malathion
Tier 1
Tier 2 OVIDE
Miscellaneous Skin and Mucous Membrane
imiquimod
podofilox
Tier 2 ALDARA
Tier 2 CONDYLOX
MOUTH/THROAT/DENTAL AGENTS
Anesthetics - Topical Oral
lidocaine viscous
Tier 1
Protectants - Mouth/Throat
PA, SP
benzyl alcohol/carbomer 941/glycerin
soy phospholipid/glycerol dioleate
Tier 2 MUGARD
Tier 2 EPISIL
Steroids - Mouth/Throat
triamcinolone paste
Tier 1
37
OPHTHALMIC
Preferred Practice Pattern Guidelines for the treatment of various ophthalmic conditions are available at:
http://one.aao.org
Antiallergics
cromolyn sodium
olopatadine
olopatadine
azelastine
Tier 1
Tier 2 PATADAY
Tier 2 PATANOL
Tier 3 OPTIVAR
Antifungals
natamycin
Tier 2 NATACYN
Anti-infectives
bacitracin
erythromycin
gentamicin
levofloxacin
polymyxin B/bacitracin
sulfacetamide oint 10%
besifloxacin
moxifloxacin
moxifloxacin
ciprofloxacin
neomycin/polymyxin B/gramicidin
ofloxacin
polymyxin B/trimethoprim
sulfacetamide soln 10%
tobramycin
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 2
Tier 2
Tier 2
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
BESIVANCE
MOXEZA
VIGAMOX
CILOXAN
NEOSPORIN
OCUFLOX
POLYTRIM
BLEPH-10
TOBREX
Anti-infective/Anti-inflammatory Combinations
neomycin/polymyxin B/bacitracin/hydrocortisone oint
neomycin/polymyxin B/hydrocortisone susp
sulfacetamide/prednisolone phosphate 10%/0.25%
tobramycin/dexamethasone oint 0.3%/0.1%
tobramycin/dexamethasone susp 0.3%/0.05%
tobramycin/loteprednol
neomycin/polymyxin B/dexamethasone
tobramycin/dexamethasone susp 0.3%/0.1%
Tier 1
Tier 1
Tier 1
Tier 2
Tier 2
Tier 2
Tier 3
Tier 3
TOBRADEX OINTMENT
TOBRADEX ST
ZYLET
MAXITROL
TOBRADEX SUSPENSION
Anti-inflammatories
Nonsteroidal
bromfenac sodium
diclofenac sodium
ketorolac
Tier 1
Tier 1
Tier 3 ACULAR
Steroidal
dexamethasone sodium phosphate
difluprednate
loteprednol 0.2%
loteprednol 0.5%
fluorometholone
prednisolone acetate 1%
prednisolone phosphate 1%
Tier 1
Tier 2
Tier 2
Tier 2
Tier 3
Tier 3
Tier 3
trifluridine
Tier 2 VIROPTIC
DUREZOL
ALREX
LOTEMAX
FML
PRED FORTE
Antivirals
38
Beta-blockers
Nonselective
timolol hemihydrate
levobunolol
metipranolol
timolol maleate
timolol maleate gel
Tier 2
Tier 3
Tier 3
Tier 3
Tier 3
BETIMOL
BETAGAN
OPTIPRANOLOL
TIMOPTIC
TIMOPTIC-XE
Selective
betaxolol
Tier 2 BETOPTIC S
Carbonic Anhydrase Inhibitors
Topical
brinzolamide
dorzolamide
Tier 2 AZOPT
Tier 3 TRUSOPT
Carbonic Anhydrase Inhibitor/Beta-blocker Combinations
dorzolamide/timolol maleate/preservative-free
dorzolamide/timolol maleate
Tier 2 COSOPT PF
Tier 3 COSOPT
Carbonic Anhydrase Inhibitor/Sympathomimetic Combinations
brinzolamide/brimonidine
Tier 2 SIMBRINZA
Immunomodulators
cyclosporine, emulsion
Tier 2 RESTASIS
Prostaglandins
travoprost
tafluprost
travoprost
latanoprost
Tier 1
Tier 2 ZIOPTAN
Tier 2 TRAVATAN Z
Tier 3 XALATAN
Sympathomimetics
brimonidine 0.2%
brimonidine 0.1%
brimonidine 0.15%
Tier 1
Tier 2 ALPHAGAN P
Tier 2 ALPHAGAN P
Sympathomimetic/Beta-blocker Combinations
brimonidine/timolol
Tier 2 COMBIGAN
OTIC
Clinical practice guidelines for the treatment of otitis media are available at:
http://www.aap.org
Anti-infectives
acetic acid
acetic acid/aluminum acetate
ofloxacin otic
Tier 1
Tier 1
Tier 1
Anti-infective/Anti-inflammatory Combinations
ciprofloxacin/dexamethasone
neomycin/polymyxin B/hydrocortisone
Tier 2 CIPRODEX
Tier 2 CORTISPORIN OTIC
39
WEBSITES
Agency for Healthcare Research and Quality
http://www.ahrq.gov
Alzheimer's Association
http://www.alz.org
American Academy of Allergy, Asthma and
Immunology
American Academy of Child & Adolescent Psychiatry
http://www.aacap.org
American Academy of Dermatology
http://www.aad.org
American Academy of Neurology
http://www.aan.com
American Academy of Ophthalmology
http://www.aao.org
American Academy of Pediatrics
http://www.aap.org
American Association for the Study of Liver Disease
American Association of Clinical Endocrinologists
http://www.aace.com
American Association of Diabetes Educators
http://www.diabeteseducator.org
American Cancer Society
http://www.cancer.org
American College of Allergy, Asthma and Immunology
http://www.acaai.org
American College of Cardiology
http://www.acc.org
American College of Chest Physicians
http://www.chestnet.org
American Congress of Obstetricians and
Gynecologists
http://www.acog.org
American Diabetes Association
http://www.diabetes.org
American Gastroenterological Association
http://www.gastro.org
American Headache Society Committee for Headache
Education
http://www.achenet.org
American Heart Association
American Lung Association
http://www.lungusa.org
American Medical Association
http://www.ama-assn.org
American Psychiatric Association
American Society of Anesthesiologists
American Society of Clinical Oncology
http://www.asco.org
American Society of Interventional Pain Physicians
http://www.asipp.org
American Urological Association
http://www.auanet.org
Centers for Disease Control and Prevention
http://www.cdc.gov
Guideline topics: AIDS
http://www.cdc.gov/hiv/resources/guidelines/index.htm
American College of Gastroenterology
http://www.acg.gi.org
Guideline topics: Sexually Transmitted Diseases
http://www.cdc.gov/std/treatment/default.htm
American College of Physicians
http://www.acponline.org
CVS/caremark
http://www.caremark.com
American College of Rheumatology
http://www.rheumatology.org
The Food and Drug Administration
http://www.fda.gov
40
Global Initiative for Asthma
http://www.ginasthma.com
National Foundation for Infectious Diseases
http://www.nfid.org
Infectious Diseases Society of America
http://www.idsociety.org
National Guideline Clearinghouse
http://www.guideline.gov
Institute for Safe Medication Practices
http://www.ismp.org
National Heart, Lung and Blood Institute
http://www.nhlbi.nih.gov
Johns Hopkins AIDS Service
http://www.thebody.com/content/art12096.html
National Institutes of Health
http://www.nih.gov
Juvenile Diabetes Research Foundation International
http://www.jdf.org
National Kidney Foundation
http://www.kidney.org
MedWatch
http://www.fda.gov/medwatch
National Osteoporosis Foundation
http://www.nof.org
National Agricultural Library
http://www.nal.usda.gov
North American Menopause Society
http://www.menopause.org
National Cancer Institute
http://www.cancer.gov/cancerinformation
United States Department of Health and Human
Services
http://www.hhs.gov
National Comprehensive Cancer Network
http://www.nccn.org
World Health Organization
http://www.who.int
41
INDEX
A
abacavir tabs, 11
ABILIFY, 20
ABILIFY injection, 20
acamprosate calcium, 22
ACANYA, 35
acarbose, 22
ACCUPRIL, 14
ACCURETIC, 14
ACEON, 14
acetazolamide, 17
acetazolamide ext-rel, 17
acetic acid, 39
acetic acid/aluminum acetate, 39
acitretin, 36
ACLOVATE, 36
ACTIGALL, 28
ACTONEL, 24
ACTOPLUS MET, 23
ACULAR, 38
acyclovir caps, tabs, 11
ADALAT CC, 16
adalimumab, 31
adapalene, 35
adapalene/benzoyl peroxide, 35
ADCIRCA, 17
ADVAIR, 34
ADVAIR HFA, 34
AFINITOR, 13
AGGRENOX, 31
AGRYLIN, 31
albuterol, 34
albuterol ext-rel, 34
albuterol soln, 34
albuterol sulfate, CFC-free aerosol, 34
alclometasone crm, oint 0.05%, 36
ALDACTAZIDE, 17
ALDACTONE, 14
ALDARA, 37
alendronate, 24
alfuzosin ext-rel, 30
ALINIA, 12
aliskiren, 16
aliskiren/amlodipine, 16
aliskiren/amlodipine/hydrochlorothiazide, 16
aliskiren/hydrochlorothiazide, 16
ALKERAN, 12
allopurinol, 8
alosetron, 29
ALPHAGAN P, 39
alprazolam, 18
alprostadil inj, 30
alprostadil supp, 30
ALREX, 38
ALTACE, 14
altretamine, 12
amantadine, 12, 19
AMARYL, 23
AMBIEN, 21
AMBIEN CR, 21
ambrisentan, 17
amiloride, 17
amiloride/hydrochlorothiazide, 17
amiodarone, 15
AMITIZA, 29
amitriptyline, 19
amlodipine, 16
amlodipine/atorvastatin, 16
amlodipine/benazepril, 14
amlodipine/olmesartan, 14
amlodipine/valsartan, 14
amlodipine/valsartan/hydrochlorothiazide, 15
ammonium lactate 12%, 37
amoxicillin, 10
amoxicillin/clavulanate, 10
amoxicillin/clavulanate ext-rel, 10
amphetamine/dextroamphetamine mixed salts, 20
amphetamine/dextroamphetamine mixed salts ext-rel, 20
ampicillin, 10
AMTURNIDE, 16
ANAFRANIL, 18
anagrelide, 31
anakinra, 31
ANAPROX, 8
anastrozole, 12
ANDRODERM, 22
ANORO ELLIPTA, 33
ANTABUSE, 22
ANTARA, 15
ANTIVERT, 28
ANUSOL-HC, 29
apixaban, 31
APRISO, 28
ARALEN, 10
ARANESP, 31
ARAVA, 31
ARCAPTA NEOHALER, 34
ARICEPT, 19
ARIMIDEX, 12
aripiprazole, 20
aripiprazole inj, 20
ARIXTRA, 31
armodafinil, 22
AROMASIN, 12
artemether/lumefantrine, 10
ASMANEX, 34
ASTEPRO, 34
atazanavir, 11
ATELVIA, 24
atenolol, 16
atenolol/chlorthalidone, 16
ATIVAN, 18
atomoxetine, 20
atorvastatin, 15
atovaquone/proguanil, 10
ATRALIN, 35
ATRIPLA, 10
ATROVENT spray, 35
AUGMENTIN, 10
AUVI-Q, 33
AVELOX, 10
AVINZA, 9
AVITA, 35
AVODART, 30
AVONEX, 21
42
AXIRON, 22
AYGESTIN, 27
AZASAN, 32
azathioprine, 32
azelaic acid gel, 37
azelastine, 38
azelastine spray, 34
AZILECT, 19
azithromycin, 10
AZOPT, 39
AZOR, 14
AZULFIDINE, 28
AZULFIDINE EN-TABS, 28
B
bacitracin, 38
baclofen, 22
BACTROBAN, 35
balsalazide, 28
BARACLUDE, 11
BD insulin syringes and needles, 24
beclomethasone, CFC-free aerosol, 34
benazepril, 13
benazepril/hydrochlorothiazide, 14
BENICAR, 14
BENICAR HCT, 14
BENTYL, 28
BENZAC AC, 35
BENZACLIN, 35
BENZAMYCIN, 35
benzonatate, 33
benzoyl peroxide, 35
benztropine, 19
benzyl alcohol/carbomer 941/glycerin, 37
besifloxacin, 38
BESIVANCE, 38
BETAGAN, 39
betamethasone dipropionate augmented crm 0.05%, 36
betamethasone dipropionate augmented gel, oint 0.05%, 37
betamethasone dipropionate augmented lotion 0.05%, 36
betamethasone dipropionate crm, lotion, oint 0.05%, 36
betamethasone valerate crm, lotion, oint 0.1%, 36
BETAPACE, 15
BETAPACE AF, 15
betaxolol, 39
bethanechol, 30
BETIMOL, 39
BETOPTIC S, 39
bexarotene caps, 13
BEYAZ, 24
BIAXIN, 10
BIAXIN XL, 10
bicalutamide, 12
BIDIL, 17
bismuth/metronidazole/tetracycline, 29
bisoprolol, 16
bisoprolol/hydrochlorothiazide, 16
BLEPH-10, 38
blood glucose continuous monitoring receivers, sensors, transmitters, 24
blood glucose monitoring kits, test strips, 24
boceprevir, 11
BONIVA, 24
bosentan, 17
BOSULIF, 13
bosutinib, 13
BREO ELLIPTA, 34
BREVICON, 25
BRILINTA, 31
brimonidine 0.1%, 39
brimonidine/timolol, 39
brinzolamide, 39
brinzolamide/brimonidine, 39
bromfenac sodium, 38
bromocriptine, 19
budesonide, 34
budesonide delayed-rel caps, 28
budesonide ext-rel, 28
budesonide inh susp, 34
bumetanide, 17
buprenorphine transdermal, 8
buprenorphine/naloxone sublingual tabs, 22
bupropion, 19
bupropion ext-rel, 19, 22
buspirone, 18
busulfan, 12
butalbital/acetaminophen/caffeine tabs, 9
butalbital/aspirin/caffeine, 9
butenafine, 35
BUTRANS, 8
BYDUREON, 23
BYSTOLIC, 16
C
cabergoline, 27
CADUET, 16
CAFERGOT, 21
CALAN SR, 16
calcipotriene, 36
calcitonin-salmon, 24
calcitriol (1,25-D3), 27
calcium acetate, 27
calcium acetate tabs, 27
CAMPRAL, 22
canagliflozin, 23
canagliflozin/metformin, 23
canakinumab, 32
CANASA, 28
candesartan, 14
candesartan/hydrochlorothiazide, 14
capecitabine, 12
captopril, 13
captopril/hydrochlorothiazide, 14
CARAC, 35
CARAFATE, 29
carbamazepine, 18
carbamazepine ext-rel, 18
CARBATROL, 18
carbidopa/levodopa, 20
carbidopa/levodopa ext-rel, 20
carbidopa/levodopa orally disintegrating tabs, 20
carbidopa/levodopa/entacapone, 20
CARDIZEM CD, 16
CARDIZEM LA, 16
CARDURA, 14
carisoprodol, 22
CARNITOR, 27
carvedilol, 16
carvedilol phosphate ext-rel, 16
CASODEX, 12
43
CATAPRES, 14
CATAPRES-TTS, 14
CEENU, 12
cefadroxil, 9
cefdinir, 10
cefixime, 10
cefprozil, 9
CEFTIN, 9
cefuroxime axetil, 9
CELEBREX, 8
celecoxib, 8
CELEXA, 19
CELLCEPT, 32
cephalexin, 9
certolizumab pegol, 31
cetrorelix, 26
CETROTIDE, 26
cevimeline, 29
CHANTIX, 22
chlorambucil, 12
chlordiazepoxide/clidinium, 28
chloroquine, 10
chlorpromazine, 20
chlorthalidone, 17
chlorzoxazone, 22
cholestyramine, 15
choriogonadotropin alfa, 26
chorionic gonadotropin - Novarel, 26
CIALIS, 30
ciclopirox, 35
cilostazol, 31
CILOXAN, 38
cimetidine, 28
CIMZIA, 31
CIPRO, 10
CIPRODEX, 39
ciprofloxacin, 10, 38
ciprofloxacin ext-rel, 10
ciprofloxacin/dexamethasone, 39
citalopram, 19
CITRANATAL 90 DHA, 32
CITRANATAL ASSURE, 32
CITRANATAL B-CALM, 32
CITRANATAL DHA, 32
CITRANATAL HARMONY, 32
CITRANATAL RX, 32
clarithromycin, 10
clarithromycin ext-rel, 10
clemastine 2.68 mg, 33
CLEOCIN, 12, 30
CLEOCIN T, 35
CLIMARA, 26
clindamycin, 12
clindamycin crm, 30
clindamycin gel, lotion, soln, 35
clindamycin supp, 30
clindamycin/benzoyl peroxide, 35
CLINORIL, 8
clobetasol propionate crm, gel, oint 0.05%, 37
clobetasol propionate foam 0.05%, 37
clobetasol propionate lotion, shampoo 0.05%, 37
clobetasol propionate soln 0.05%, 37
clobetasol propionate spray 0.05%, 37
CLOBEX, 37
clocortolone crm 0.1%, 36
CLODERM, 36
CLOMID, 26
clomiphene, 26
clomipramine, 18
clonazepam tabs, 18
clonidine, 14
clonidine transdermal, 14
clopidogrel, 31
clotrimazole, 35
clotrimazole troches, 10
clozapine, 20
CLOZARIL, 20
COARTEM, 10
codeine/acetaminophen, 8
codeine/chlorpheniramine/pseudoephedrine, 33
codeine/guaifenesin liquid, 33
codeine/guaifenesin/pseudoephedrine, 33
codeine/promethazine, 33
codeine/promethazine/phenylephrine, 33
colchicine, 8
COLCRYS, 8
colesevelam, 15
COLESTID, 15
colestipol, 15
COMBIGAN, 39
COMBIVENT RESPIMAT, 33
COMBIVIR, 10
COMTAN, 20
CONCERTA, 20
CONDYLOX, 37
conjugated estrogens/bazedoxifene, 26
COPAXONE, 21
COPEGUS, 11
CORDARONE, 15
COREG, 16
COREG CR, 16
CORGARD, 16
CORTEF, 26
CORTIFOAM, 28
CORTISPORIN OTIC, 39
COSOPT, 39
COSOPT PF, 39
COUMADIN, 31
COZAAR, 14
CREON, 29
CRESTOR, 15
CRINONE, 27
cromolyn sodium, 38
cromolyn soln, 34
CUTIVATE, 36
cyanocobalamin inj, 32
CYCLESSA, 25
cyclobenzaprine, 22
cyclophosphamide, 12
cyclosporine, 32
cyclosporine, emulsion, 39
cyclosporine, modified, 32
CYMBALTA, 19
cyproheptadine, 33
CYTOMEL, 27
CYTOTEC, 29
D
D.H.E. 45, 21
dabigatran etexilate, 31
DALIRESP, 34
dalteparin, 30
44
danazol, 25
DANTRIUM, 22
dantrolene, 22
dapsone, 12
darbepoetin alfa, 31
darunavir, 11
dasatinib, 13
DAYPRO, 8
DAYTRANA, 20
DDAVP, 27
delavirdine, 11
DEMADEX, 17
DEPAKENE, 18
DEPAKOTE, 18
DEPAKOTE ER, 18
DEPO-PROVERA, 25
desipramine, 19
desmopressin spray, tabs, 27
desogestrel/EE, 25
desogestrel/EE 0.15/30, 24
desonide crm, lotion, oint 0.05%, 36
DESOWEN, 36
desoximetasone crm 0.05%, 36
desoximetasone crm 0.25%, 36
desoximetasone oint 0.05%, 36
desoximetasone oint 0.25%, gel 0.05%, 36
desvenlafaxine ext-rel, 19
DETROL, 30
dexamethasone, 26
dexamethasone sodium phosphate, 38
DEXCOM G4, 24
DEXEDRINE SPANSULE, 20
DEXILANT, 29
dexlansoprazole delayed-rel, 29
dexmethylphenidate, 20
dexmethylphenidate ext-rel, 20
dextroamphetamine, 20
dextroamphetamine ext-rel, 20
dextromethorphan/brompheniramine/pseudoephedrine, 33
dextromethorphan/promethazine, 33
DIAMOX SEQUELS, 17
DIASTAT, 18
diazepam, 18
diazepam rectal gel, 18
DICLEGIS, 28
diclofenac sodium, 38
diclofenac sodium delayed-rel, 8
diclofenac sodium delayed-rel/misoprostol, 8
diclofenac sodium gel, 8
diclofenac sodium soln, 8
dicloxacillin, 10
dicyclomine, 28
didanosine delayed-rel, 11
DIFFERIN, 35
DIFICID, 10
diflorasone diacetate crm 0.05%, 36
diflorasone diacetate oint 0.05%, 37
DIFLUCAN, 10
diflunisal, 8
difluprednate, 38
digoxin, 16
digoxin ped elixir, 16
dihydroergotamine inj, 21
dihydroergotamine spray, 21
DILANTIN, 18
DILANTIN INFATABS, 18
DILAUDID, 8
diltiazem ext-rel, 16
dimethyl fumarate delayed-rel, 21
DIOVAN, 14
DIPENTUM, 28
diphenoxylate/atropine, 28
DIPROLENE, 36, 37
DIPROLENE AF, 36
dipyridamole, 31
dipyridamole ext-rel/aspirin, 31
disopyramide, 15
disopyramide ext-rel, 15
disulfiram, 22
DITROPAN XL, 30
divalproex sodium delayed-rel, 18
divalproex sodium ext-rel, 18
DIVIGEL, 26
dofetilide, 15
donepezil, 19
dornase alfa, 34
dorzolamide, 39
dorzolamide/timolol maleate, 39
dorzolamide/timolol maleate/preservative-free, 39
DOVONEX, 36
doxazosin, 14
doxepin, 19, 21
doxercalciferol, 27
doxycycline hyclate, 10
doxycycline hyclate 20 mg, 10
doxycycline monohydrate, 37
doxylamine/pyridoxine delayed-rel, 28
DRISDOL, 33
dronabinol, 28
drospirenone/EE 3/20, 24
drospirenone/EE 3/30, 24
drospirenone/EE/levomefolate 3/20 and levomefolate, 24
DUAC, 35
DUAVEE, 26
DUETACT, 23
DULERA, 34
duloxetine delayed-rel, 19
DUONEB, 33
DURAGESIC, 8
DUREZOL, 38
dutasteride, 30
DYAZIDE, 17
E
E.E.S., 10
econazole, 35
eculizumab, 31
EDEX, 30
EDURANT, 11
EE/norethindrone acetate, 26
EE/norethindrone acetate - Jinteli, 26
efavirenz, 11
efavirenz/emtricitabine/tenofovir, 10
EFFEXOR XR, 19
EFFIENT, 31
eletriptan, 21
ELIDEL, 37
ELIQUIS, 31
ELIXOPHYLLIN, 35
ELMIRON, 30
ELOCON, 36
eltrombopag, 31
45
elvitegravir/cobicistat/emtricitabine/tenofovir, 10
emtricitabine, 11
emtricitabine/tenofovir, 10
EMTRIVA, 11
enalapril, 14
enalapril/hydrochlorothiazide, 14
ENBREL, 31
enfuvirtide, 11
enoxaparin, 30
entacapone, 20
entecavir, 11
EPIDUO, 35
epinephrine, 33
EPIPEN, 33
EPIPEN JR., 33
EPISIL, 37
EPIVIR, 11
EPIVIR-HBV, 11
eplerenone, 14
epoetin alfa, 31
epoprostenol sodium, 17
eprosartan, 14
ergocalciferol (D2), 33
ergotamine/caffeine, 21
erlotinib, 13
erythromycin, 38
erythromycin delayed-rel, 10
erythromycin ethylsuccinate, 10
erythromycin gel 2%, 35
erythromycin soln, 35
erythromycin stearate, 10
erythromycin/benzoyl peroxide, 35
erythromycin/sulfisoxazole, 10
escitalopram, 19
ESGIC, 9
esomeprazole delayed-rel, 29
ESTRACE, 26
estradiol, 26
estradiol vaginal crm, 26
estradiol vaginal tabs, 26
estradiol valerate and dienogest/estradiol valerate, 25
estradiol/norethindrone, 26
estrogens, conjugated, 26
estrogens, conjugated crm, 26
estrogens, conjugated/medroxyprogesterone, 26
estropipate, 26
eszopiclone, 21
etanercept, 31
ethambutol, 11
ethosuximide, 18
ethynodiol diacetate/EE 1/35 - Zovia 1/35, 25
ethynodiol diacetate/EE 1/50 - Zovia 1/50, 25
etodolac, 8
etonogestrel/EE ring, 25
etoposide, 13
etravirine, 11
EVAMIST, 26
everolimus, 13
EVISTA, 27
EVOXAC, 29
EXALGO, 9
EXELON, 19
EXELON PATCH, 18
exemestane, 12
exenatide ext-rel, 23
EXFORGE, 14
EXFORGE HCT, 15
EXTAVIA, 21
ezetimibe, 15
ezetimibe/simvastatin, 15
F
famciclovir, 11
famotidine, 28
FAMVIR, 11
FARESTON, 12
FASLODEX, 12
febuxostat, 8
felodipine ext-rel, 16
FEMARA, 12
FEMHRT, 26
fenofibrate, 15
fenofibric acid delayed-rel, 15
fentanyl citrate buccal, 8
fentanyl citrate nasal spray, 8
fentanyl transdermal, 8
fentanyl transmucosal lozenge, 8
FENTORA, 8
fidaxomicin, 10
filgrastim, 31
FINACEA, 37
finasteride, 30
fingolimod, 21
FIORINAL, 9
FLAGYL, 12
flecainide, 15
FLOLAN, 17
FLOMAX, 30
FLONASE, 34
FLOVENT DISKUS, 34
FLOVENT HFA, 34
fluconazole, 10
fludrocortisone, 26
FLUMADINE, 12
flunisolide spray, 34
fluocinolone acetonide crm, oint 0.025%, 36
fluocinolone acetonide soln 0.01%, 36
fluocinonide crm, gel, oint, soln 0.05%, 36
fluoride drops, 33
fluoride tabs, 33
fluorometholone, 38
fluorouracil, 35
fluorouracil crm, soln 5%, soln 2%, 35
fluoxetine, 19
FLUOXETINE 60 mg, 19
fluphenazine, 20
flutamide, 12
fluticasone, 34
fluticasone propionate crm, lotion 0.05%, 36
fluticasone propionate oint 0.005%, 36
fluticasone spray, 34
fluticasone, CFC-free aerosol, 34
fluticasone/salmeterol, 34
fluticasone/salmeterol, CFC-free aerosol, 34
fluticasone/vilanterol, 34
fluvastatin, 15
fluvoxamine, 18
FML, 38
FOCALIN, 20
FOCALIN XR, 20
folic acid, 32
folic acid/vitamin B6/vitamin B12, 32
46
FOLLISTIM AQ, 26
follitropin beta, 26
fondaparinux, 31
FORADIL, 34
formoterol inhalation caps, 34
formoterol inhalation soln, 34
FORTEO, 24
FORTESTA, 22
FOSAMAX, 24
fosinopril, 13
fosinopril/hydrochlorothiazide, 14
FRAGMIN, 30
fulvestrant, 12
FURADANTIN, 12
furosemide, 17
FUZEON, 11
G
gabapentin, 18
gabapentin ext-rel, 22
GABITRIL, 18
galantamine, 19
galantamine ext-rel, 19
ganirelix, 26
GELNIQUE, 30
GEL-ONE, 9
gemfibrozil, 15
gentamicin, 35, 38
GEODON, 20
GILENYA, 21
glatiramer, 21
GLEEVEC, 13
glimepiride, 23
glipizide, 23
glipizide ext-rel, 23
glipizide/metformin, 23
GLUCAGEN HYPOKIT, 26
GLUCAGON EMERGENCY KIT, 26
glucagon, human recombinant, 26
GLUCOPHAGE, 23
GLUCOPHAGE XR, 23
GLUCOTROL, 23
GLUCOTROL XL, 23
glyburide, 23
golimumab, 31
GOLYTELY, 29
goserelin acetate, 13
GRALISE, 22
granisetron, 28
granisetron transdermal, 28
griseofulvin ultramicrosize, 10
GRIS-PEG, 10
guanfacine, 14
guanfacine ext-rel, 20
H
halobetasol propionate crm, oint 0.05%, 37
haloperidol, 20
HECTOROL, 27
HEXALEN, 12
HUMATROPE, 27
HUMIRA, 31
HUMULIN R U-500, 23
HYALGAN, 9
HYCAMTIN caps, 13
hydralazine, 18
HYDREA, 13
hydrochlorothiazide, 17
hydrocodone/acetaminophen, 8
hydrocodone/homatropine, 33
hydrocortisone, 26
hydrocortisone acetate foam, 28
hydrocortisone acetate/pramoxine foam, 29
hydrocortisone butyrate crm 0.1%, 36
hydrocortisone butyrate lotion 0.1%, 36
hydrocortisone butyrate oint, soln 0.1%, 36
hydrocortisone crm, 29
hydrocortisone crm 2.5%, 36
hydrocortisone enema, 28
hydrocortisone lotion 1%, 36
hydrocortisone valerate crm 0.2%, 36
hydrocortisone valerate oint 0.2%, 36
hydromorphone, 8
hydromorphone ext-rel, 9
hydroxychloroquine, 31
hydroxyurea, 13
hydroxyzine HCl, 33
hyoscyamine sulfate, 28
hyoscyamine sulfate ext-rel, 28
hyoscyamine sulfate ext-rel caps, 28
hyoscyamine sulfate orally disintegrating tabs, 28
HYZAAR, 14
I
ibandronate, 24
ibuprofen, 8
ICLUSIG, 13
ILARIS, 32
iloprost, 17
imatinib mesylate, 13
IMDUR, 17
imipramine HCl, 19
imiquimod, 35, 37
IMITREX, 21
IMURAN, 32
indacaterol, 34
indapamide, 17
INDERAL LA, 16
ingenol mebutate, 35
INSPRA, 14
insulin aspart, 23
insulin aspart protamine 70%/insulin aspart 30%, 23
insulin detemir, 23
insulin glargine, 23
insulin human, 23
insulin isophane human, 23
insulin isophane human 70%/regular 30%, 23
insulin syringes, needles, 24
INTELENCE, 11
interferon alfa-2b, 32
interferon beta-1a, 21
interferon beta-1b, 21
INTRON A, 32
INTUNIV, 20
INVOKAMET, 23
INVOKANA, 23
ipratropium soln, 33
ipratropium spray, 35
ipratropium/albuterol soln, 33
ipratropium/albuterol, CFC-free aerosol, 33
irbesartan, 14
irbesartan/hydrochlorothiazide, 14
ISENTRESS, 11
47
isocarboxazid, 19
isoniazid, 11
ISORDIL, 17
isosorbide dinitrate ext-rel tabs, 17
isosorbide dinitrate oral, 17
isosorbide dinitrate/hydralazine, 17
isosorbide mononitrate, 17
isosorbide mononitrate ext-rel, 17
isotretinoin, 35
itraconazole, 10
J
JANUMET, 23
JANUMET XR, 23
JANUVIA, 23
JENTADUETO, 23
K
KADIAN, 9
KALETRA, 11
KEFLEX, 9
KEPPRA, 18
KEPPRA XR, 18
ketoconazole, 10, 35
ketoconazole shampoo 2%, 36
ketorolac, 38
KINERET, 31
KLARON, 35
KLONOPIN, 18
KUVAN, 27
L
labetalol, 16
LAC-HYDRIN, 37
lacosamide, 18
lactulose, 29
LAMICTAL, 18
LAMICTAL ODT, 18
LAMICTAL XR, 18
LAMISIL, 10
lamivudine, 11
lamivudine/zidovudine, 10
lamotrigine, 18
lamotrigine ext-rel, 18
lamotrigine orally disintegrating tabs, 18
lancets, 24
LANCETS, 24
LANOXIN, 16
lansoprazole + amoxicillin + clarithromycin, 29
lansoprazole delayed-rel, 29
LANTUS, 23
lapatinib, 13
LASIX, 17
latanoprost, 39
LATUDA, 20
LAZANDA, 8
leflunomide, 31
lenalidomide, 13
LETAIRIS, 17
letrozole, 12
LEUKERAN, 12
leuprolide acetate, 13
LEVAQUIN, 10
LEVBID, 28
LEVEMIR, 23
levetiracetam, 18
levetiracetam ext-rel, 18
levobunolol, 39
levocarnitine, 27
levocetirizine, 33
levofloxacin, 10, 38
levonorgestrel releasing IUD, 25
levonorgestrel/EE - Trivora, 25
levonorgestrel/EE 0.1/20 - Lessina, 24
levonorgestrel/EE 0.1/20 and EE 10, 25
levonorgestrel/EE 0.15/30, 25
levonorgestrel/EE 0.15/30 - Levora, 25
levonorgestrel/EE 0.15/30 and EE 10, 25
levothyroxine, 27
levothyroxine - Levoxyl, 27
LEVSIN, 28
LEXAPRO, 19
LIALDA, 28
lidocaine patch, 37
lidocaine viscous, 37
lidocaine/prilocaine, 37
LIDODERM, 37
linaclotide, 29
linagliptin, 23
linagliptin/metformin, 23
linezolid, 12
LINZESS, 29
liothyronine, 27
LIPOFEN, 15
liraglutide, 23
lisdexamfetamine, 20
lisinopril, 14
lisinopril/hydrochlorothiazide, 14
lithium carbonate, 21
lithium carbonate ext-rel tabs 300 mg, 21
lithium carbonate ext-rel tabs 450 mg, 21
LITHOBID, 21
LO LOESTRIN FE, 24
LOCOID, 36
LOCOID LIPOCREAM, 36
LOESTRIN 1.5/30, 25
LOESTRIN 1/20, 24
LOESTRIN FE 1.5/30, 25
LOESTRIN FE 1/20, 24
LOFIBRA, 15
LOMOTIL, 28
lomustine, 12
loperamide, 28
LOPID, 15
lopinavir/ritonavir, 11
LOPRESSOR, 16
LOPRESSOR HCT, 16
LOPROX, 35
lorazepam, 18
losartan, 14
losartan/hydrochlorothiazide, 14
LOSEASONIQUE, 25
LOTEMAX, 38
LOTENSIN, 13
LOTENSIN HCT, 14
loteprednol 0.2%, 38
loteprednol 0.5%, 38
LOTREL, 14
LOTRONEX, 29
lovastatin, 15
LOVAZA, 15
LOVENOX, 30
lubiprostone, 29
48
LUPRON DEPOT, 13
lurasidone, 20
LURIDE, 33
LURIDE LOZI-TABS, 33
LYRICA, 20
LYSODREN, 13
M
MACROBID, 12
MACRODANTIN, 12
MALARONE, 10
malathion, 37
MARINOL, 28
MARPLAN, 19
MATULANE, 13
MAVIK, 14
MAXALT, 21
MAXITROL, 38
MAXZIDE, 17
meclizine, 28
MEDROL, 26
medroxyprogesterone acetate, 27
medroxyprogesterone acetate 150 mg/mL, 25
mefloquine, 10
MEGACE, 13
MEGACE ES, 27
megestrol acetate, 13
megestrol acetate susp, 27
meloxicam, 8
melphalan, 12
memantine, 18
memantine ext-rel, 18
MENTAX, 35
MEPHYTON, 33
mercaptopurine, 12
mesalamine delayed-rel tabs, 28
mesalamine ext-rel caps, 28
mesalamine rectal susp, 28
mesalamine supp, 28
MESTINON, 22
MESTINON TIMESPAN, 22
METAGLIP, 23
metaxalone, 22
metformin, 23
metformin ext-rel, 23
methadone, 8
methazolamide, 17
methimazole, 27
methocarbamol, 22
methotrexate, 12, 31, 32
methoxsalen oral, 36
methyldopa, 18
METHYLIN, 20
methylnaltrexone, 29
methylphenidate, 20
methylphenidate ext-rel, 20
methylphenidate ext-rel 10 mg, 20
methylphenidate ext-rel susp, 20
methylphenidate transdermal, 20
methylprednisolone, 26
metipranolol, 39
metoclopramide, 28
metolazone, 17
metoprolol succinate ext-rel, 16
metoprolol tartrate, 16
metoprolol/hydrochlorothiazide, 16
METROCREAM, 37
METROGEL, 37
METROGEL-VAGINAL, 30
METROLOTION, 37
metronidazole, 12, 30
metronidazole crm 0.75%, 37
metronidazole gel 0.75%, 37
metronidazole gel 1%, 37
metronidazole lotion 0.75%, 37
MEVACOR, 15
MIACALCIN, 24
MICARDIS, 14
MICARDIS HCT, 14
midodrine, 18
MIGRANAL, 21
milnacipran, 20
MINASTRIN 24 FE, 24
MINIVELLE, 26
MINOCIN, 10
minocycline, 10
mirabegron ext-rel, 30
MIRALAX, 29
MIRAPEX, 20
MIRAPEX ER, 19
MIRCETTE, 25
MIRENA, 25
mirtazapine, 19
misoprostol, 29
mitotane, 13
MOBIC, 8
MODICON, 25
mometasone, 34
mometasone crm, lotion 0.1%, 36
mometasone oint 0.1%, 36
mometasone spray, 34
mometasone/formoterol, 34
montelukast, 34
morphine, 8
morphine ext-rel, 9
morphine supp, 8
MOVIPREP, 29
MOXEZA, 38
moxifloxacin, 10, 38
MOZOBIL, 31
MS CONTIN, 9
MUGARD, 37
multivitamins/fluoride drops, tabs, 32
multivitamins/fluoride/iron drops, tabs, 33
mupirocin, 35
MUSE, 30
MYAMBUTOL, 11
mycophenolate mofetil, 32
mycophenolate sodium delayed-rel, 32
MYFORTIC, 32
MYLERAN, 12
MYRBETRIQ, 30
MYSOLINE, 18
N
nabumetone, 8
nadolol, 16
nafarelin, 25
naltrexone, 22
NAMENDA, 18
NAMENDA XR, 18
NAPROSYN, 8
49
naproxen, 8
naproxen sodium, 8
naratriptan, 21
NARDIL, 19
NASACORT AQ, 34
NASONEX, 34
NATACYN, 38
natamycin, 38
NATAZIA, 25
nateglinide, 23
nebivolol, 16
neomycin/polymyxin B/bacitracin/hydrocortisone oint, 38
neomycin/polymyxin B/dexamethasone, 38
neomycin/polymyxin B/gramicidin, 38
neomycin/polymyxin B/hydrocortisone, 39
neomycin/polymyxin B/hydrocortisone susp, 38
NEORAL, 32
NEOSPORIN, 38
NEULASTA, 31
NEUPOGEN, 31
NEUPRO, 20
NEURONTIN, 18
nevirapine, 11
nevirapine ext-rel, 11
NEXAVAR, 13
NEXIUM, 29
niacin ext-rel, 15
niacin ext-rel/simvastatin, 15
NIASPAN, 15
nifedipine ext-rel, 16
nitazoxanide, 12
NITRO-DUR, 17
nitrofurantoin ext-rel, 12
nitrofurantoin macrocrystals, 12
nitrofurantoin susp, 12
nitroglycerin sublingual, 17
nitroglycerin sublingual spray, 17
nitroglycerin transdermal, 17
NITROLINGUAL, 17
NITROSTAT, 17
NIZORAL SHAMPOO, 36
NORCO, 8
NORDITROPIN, 27
norelgestromin/EE, 25
norethindrone, 25
norethindrone acetate, 27
norethindrone acetate/EE 1.5/30, 25
norethindrone acetate/EE 1.5/30 and iron, 25
norethindrone acetate/EE 1/10 and EE 10 and iron, 24
norethindrone acetate/EE 1/20, 24
norethindrone acetate/EE 1/20 and iron, 24
norethindrone acetate/EE 1/20 and iron - Lomedia 24 Fe, 24
norethindrone acetate/EE 1/20 and iron chewable, 24
norethindrone/EE, 25
norethindrone/EE 0.5/35, 25
norethindrone/EE 1/35, 25
norethindrone/ME 1/50, 25
norgestimate/EE, 25
norgestimate/EE 0.25/35, 25
norgestrel/EE 0.3/30 - Low-Ogestrel, 25
NORINYL 1+35, 25
NORINYL 1+50, 25
NORPACE, 15
NORPACE CR, 15
NORPRAMIN, 19
NOR-QD, 25
nortriptyline, 19
NORVIR, 11
NOVOLIN 70/30, 23
NOVOLIN N, 23
NOVOLIN R, 23
NOVOLOG, 23
NOVOLOG MIX 70/30, 23
NUCYNTA, 8
NUCYNTA ER, 8
NULYTELY, 29
NUVARING, 25
NUVIGIL, 22
nystatin, 10, 35
O
OCUFLOX, 38
ofloxacin, 38
ofloxacin otic, 39
olanzapine, 20
olmesartan, 14
olmesartan/amlodipine/hydrochlorothiazide, 15
olmesartan/hydrochlorothiazide, 14
olopatadine, 38
olopatadine spray, 34
olsalazine, 28
omalizumab, 35
omega-3 acid ethyl esters, 15
omeprazole delayed-rel, 29
omeprazole/sodium bicarbonate caps, 29
ondansetron, 28
ONETOUCH kits and test strips, 24
OPANA ER, 8
OPTIPRANOLOL, 39
OPTIVAR, 38
ORACEA, 37
ORAPRED, 26
orphenadrine/aspirin/caffeine, 22
ORTHO EVRA, 25
ORTHO MICRONOR, 25
ORTHO TRI-CYCLEN, 25
ORTHO TRI-CYCLEN LO, 25
ORTHO-CEPT, 24
ORTHO-CYCLEN, 25
ORTHO-NOVUM 1/35, 25
ORTHO-NOVUM 7/7/7, 25
oseltamivir, 12
ospemifene, 27
OSPHENA, 27
OVIDE, 37
OVIDREL, 26
oxaprozin, 8
oxazepam, 18
oxcarbazepine, 18
OXSORALEN-ULTRA, 36
oxybutynin, 30
oxybutynin ext-rel, 30
oxybutynin gel, 30
oxycodone caps, tabs 5 mg, 8
oxycodone concentrate 20 mg/mL, 8
oxycodone ext-rel, 8
oxycodone tabs 15 mg, 30 mg, soln 5 mg/5 mL, 9
oxycodone/acetaminophen 5/325, 9
OXYCONTIN, 8
oxymorphone ext-rel, 8
P
PAMELOR, 19
50
pancrelipase, 29
pancrelipase delayed-rel, 29
pantoprazole delayed-rel, 29
PARAFON FORTE DSC, 22
PARCOPA, 20
paricalcitol, 27
PARLODEL, 19
PARNATE, 19
paroxetine HCl, 19
paroxetine HCl ext-rel, 19
PATADAY, 38
PATANASE, 34
PATANOL, 38
PAXIL, 19
PAXIL CR, 19
pazopanib, 13
peg 3350/electrolytes, 29
PEGASYS, 32
pegfilgrastim, 31
peginterferon alfa-2a, 32
peginterferon alfa-2b, 32
PEGINTRON, 32
penicillin VK, 10
PENTASA, 28
pentosan polysulfate sodium, 30
PEPCID, 28
PERCOCET, 9
PERFOROMIST, 34
perindopril, 14
permethrin 5%, 37
perphenazine, 20
PERSANTINE, 31
phenazopyridine, 30
phenelzine, 19
phenobarbital, 18
phentermine/topiramate ext-rel, 24
phenytoin, 18
phenytoin sodium extended, 18
PHOSLO, 27
PHOSLYRA, 27
phytonadione, 33
PICATO, 35
pilocarpine tabs, 29
pimecrolimus, 37
pindolol, 16
pioglitazone, 23
pioglitazone/glimepiride, 23
pioglitazone/metformin, 23
PLAQUENIL, 31
plerixafor, 31
PLETAL, 31
podofilox, 37
polyethylene glycol 3350, 29
polymyxin B/bacitracin, 38
polymyxin B/trimethoprim, 38
POLYTRIM, 38
pomalidomide, 13
POMALYST, 13
ponatinib, 13
potassium chloride ext-rel, 32
potassium chloride liquid, 32
potassium citrate ext-rel, 30
PRADAXA, 31
pramipexole, 20
pramipexole ext-rel, 19
pramlintide, 23
PRANDIN, 23
prasugrel, 31
PRAVACHOL, 15
pravastatin, 15
PRECOSE, 22
PRED FORTE, 38
prednisolone acetate 1%, 38
prednisolone phosphate 1%, 38
prednisolone sodium phosphate, 26
prednisolone sodium phosphate 5 mg/5 mL, 26
prednisolone syrup, 26
prednisone, 26
pregabalin, 20
PRELONE, 26
PREMARIN, 26
PREMARIN crm, 26
PREMPHASE, 26
PREMPRO, 26
prenatal vitamins, 32
prenatal vitamins/DHA/docusate/folic acid, 32
prenatal vitamins/docusate/folic acid, 32
prenatal vitamins/docusate/folic acid + DHA, 32
prenatal vitamins/folic acid + pyridoxine, 32
PREVPAC, 29
PREZISTA, 11
PRILOSEC, 29
primidone, 18
PRISTIQ, 19
PROAIR HFA, 34
probenecid, 8
procarbazine, 13
PROCARDIA XL, 16
prochlorperazine, 28
PROCRIT, 31
PROCTOFOAM-HC, 29
progesterone gel, 27
progesterone, micronized, 27
PROGRAF, 32
PROMACTA, 31
promethazine, 28
PROMETRIUM, 27
propafenone, 15
propafenone ext-rel, 15
propranolol, 16
propranolol ext-rel, 16
propylthiouracil, 27
PROSCAR, 30
PROTOPIC, 37
PROVERA, 27
PROZAC, 19
PULMICORT FLEXHALER, 34
PULMICORT RESPULES, 34
PULMOZYME, 34
PURINETHOL, 12
PYLERA, 29
pyrazinamide, 11
PYRIDIUM, 30
pyridostigmine, 22
pyridostigmine ext-rel, 22
Q
QSYMIA, 24
QUESTRAN/QUESTRAN LIGHT, 15
quetiapine, 20
quetiapine ext-rel, 20
QUILLIVANT XR, 20
51
quinapril, 14
quinapril/hydrochlorothiazide, 14
QVAR, 34
R
raloxifene, 27
raltegravir, 11
ramipril, 14
RANEXA, 18
ranitidine, 28
ranolazine ext-rel, 18
RAPAFLO, 30
RAPAMUNE, 32
rasagiline mesylate, 19
RAZADYNE, 19
RAZADYNE ER, 19
REBETOL, 11
REGLAN, 28
RELENZA, 12
RELISTOR, 29
RELPAX, 21
REMERON, 19
REMODULIN, 17
RENVELA, 27
repaglinide, 23
REQUIP, 20
REQUIP XL, 20
RESCRIPTOR, 11
RESTASIS, 39
RESTORIL, 21
RETIN-A, 35
RETIN-A MICRO, 35
RETROVIR, 11
REVATIO, 17
REVIA, 22
REVLIMID, 13
REYATAZ, 11
RHEUMATREX, 32
ribavirin caps, 11
ribavirin oral soln, 11
ribavirin tabs, 11
RIFADIN, 11
rifampin, 11
rifaximin, 12
rilpivirine, 11
rimantadine, 12
risedronate, 24
risedronate delayed-rel, 24
RISPERDAL, 20
RISPERDAL CONSTA, 20
risperidone, 20
risperidone long-acting injection, 20
RITALIN, 20
RITALIN LA, 20
ritonavir, 11
rivaroxaban, 31
rivastigmine, 19
rivastigmine transdermal, 18
rizatriptan, 21
ROBAXIN, 22
ROCALTROL, 27
roflumilast, 34
ropinirole, 20
ropinirole ext-rel, 20
rosuvastatin, 15
rotigotine transdermal, 20
ROWASA, 28
ROXICODONE, 9
RYTHMOL, 15
RYTHMOL SR, 15
S
SALAGEN, 29
salmeterol xinafoate, 34
SANCUSO, 28
SANDIMMUNE, 32
sapropterin, 27
SAVELLA, 20
scopolamine, 28
SEASONIQUE, 25
selegiline, 19
selegiline orally disintegrating tabs, 20
selenium sulfide shampoo 2.5%, 36
SELSUN, 36
SEREVENT, 34
SEROQUEL, 20
SEROQUEL XR, 20
sertraline, 19
sevelamer carbonate, 27
SFROWASA, 28
sildenafil, 17, 30
SILENOR, 21
silodosin, 30
SILVADENE, 35
silver sulfadiazine, 35
SIMBRINZA, 39
SIMCOR, 15
SIMPONI, 31
simvastatin, 15
SINEMET, 20
SINEMET CR, 20
SINGULAIR, 34
sirolimus, 32
sitagliptin phosphate, 23
sitagliptin/metformin, 23
sitagliptin/metformin ext-rel, 23
SKELAXIN, 22
sodium hyaluronate, 9
sodium oxybate, 22
sodium sulfate/potassium sulfate/magnesium sulfate, 29
sofosbuvir, 11
solifenacin succinate, 30
SOLIRIS, 31
somatropin, 27
sorafenib, 13
SORIATANE, 36
SORILUX, 36
sotalol, 15
SOVALDI, 11
soy phospholipid/glycerol dioleate, 37
SPIRIVA, 33
spironolactone, 14
spironolactone-hydrochlorothiazide, 17
SPORANOX, 10
SPRYCEL, 13
STALEVO, 20
stavudine, 11
STELARA, 36
STRATTERA, 20
STRIBILD, 10
SUCLEAR, 29
sucralfate, 29
52
sucroferric oxyhydroxide, 27
sulfacetamide lotion 10%, 35
sulfacetamide oint 10%, 38
sulfacetamide soln 10%, 38
sulfacetamide/prednisolone phosphate 10%/0.25%, 38
sulfacetamide/sulfur, 37
sulfacetamide/sulfur crm, gel, lotion, pads, 35
sulfamethoxazole/trimethoprim, 12
sulfamethoxazole/trimethoprim DS, 12
sulfasalazine, 28
sulfasalazine delayed-rel, 28
sulindac, 8
sumatriptan, 21
sumatriptan inj, 21
sumatriptan nasal spray, 21
sumatriptan/naproxen sodium, 21
SUMAVEL DOSEPRO, 21
sunitinib, 13
SUPARTZ, 9
SUPRAX, 10
SUPREP, 29
SUSTIVA, 11
SUTENT, 13
SYLATRON, 32
SYMLINPEN, 23
SYNAREL, 25
SYNTHROID, 27
T
TABLOID, 12
tacrolimus, 32, 37
tadalafil, 17, 30
tafluprost, 39
TAMBOCOR, 15
TAMIFLU, 12
tamoxifen, 12
tamsulosin, 30
TAPAZOLE, 27
tapentadol, 8
tapentadol ext-rel, 8
TARCEVA, 13
TARGRETIN caps, 13
TARKA, 14
tazarotene, 35
TAZORAC, 35
TECFIDERA, 21
TEGRETOL, 18
TEGRETOL-XR, 18
TEKAMLO, 16
TEKTURNA, 16
TEKTURNA HCT, 16
telmisartan, 14
telmisartan/hydrochlorothiazide, 14
temazepam, 21
TEMODAR, 12
TEMOVATE, 37
temozolomide, 12
TENEX, 14
tenofovir, 11
TENORETIC, 16
TENORMIN, 16
TERAZOL 3, 30
TERAZOL 7, 30
terazosin, 14
terbinafine tabs, 10
terbutaline, 34
terconazole, 30
teriparatide, 24
TESSALON, 33
testosterone cypionate, 22
testosterone enanthate, 22
testosterone gel, 22
testosterone soln, 22
testosterone transdermal, 22
tetrabenazine, 21
tetracycline, 10
thalidomide, 13
THALOMID, 13
THEO-24, 35
theophylline ext-rel caps, 35
theophylline ext-rel tabs, 35
theophylline liquid, 35
thioguanine, 12
thiothixene, 20
tiagabine, 18
TIAZAC, 16
ticagrelor, 31
TIGAN, 28
TIKOSYN, 15
timolol hemihydrate, 39
timolol maleate, 39
timolol maleate gel, 39
TIMOPTIC, 39
TIMOPTIC-XE, 39
TINDAMAX, 12
tinidazole, 12
tiotropium, 33
tizanidine, 22
TOBI, 34
TOBRADEX OINTMENT, 38
TOBRADEX ST, 38
TOBRADEX SUSPENSION, 38
tobramycin, 38
tobramycin inhalation soln, 34
tobramycin/dexamethasone oint 0.3%/0.1%, 38
tobramycin/dexamethasone susp 0.3%/0.05%, 38
tobramycin/dexamethasone susp 0.3%/0.1%, 38
tobramycin/loteprednol, 38
TOBREX, 38
TOFRANIL, 19
tolterodine, 30
tolterodine ext-rel, 30
TOPAMAX, 18
TOPICORT, 36
TOPICORT LP, 36
topiramate, 18
topotecan caps, 13
TOPROL-XL, 16
toremifene, 12
torsemide, 17
TRACLEER, 17
TRADJENTA, 23
tramadol, 9
tramadol ext-rel, 8
trandolapril, 14
trandolapril/verapamil ext-rel, 14
TRANSDERM SCOP, 28
tranylcypromine, 19
TRAVATAN Z, 39
travoprost, 39
trazodone, 19
TRELSTAR, 13
53
treprostinil, 17
tretinoin, 35
tretinoin caps, 13
tretinoin gel microsphere, 35
TREXALL, 12
TREXIMET, 21
triamcinolone acetonide crm 0.5%, 36
triamcinolone acetonide crm, lotion 0.025%, 36
triamcinolone acetonide crm, lotion, oint 0.1%, 36
triamcinolone acetonide spray, 34
triamcinolone paste, 37
triamterene-hydrochlorothiazide, 17
TRIBENZOR, 15
trifluoperazine, 20
trifluridine, 38
trihexyphenidyl, 19
TRILEPTAL, 18
TRILIPIX, 15
trimethobenzamide, 28
trimethoprim, 12
TRI-NORINYL, 25
triptorelin pamoate, 13
trospium, 30
trospium ext-rel, 30
TRUSOPT, 39
TRUVADA, 10
TYKERB, 13
TYLENOL w/CODEINE, 8
TYVASO, 17
U
UCERIS, 28
ULORIC, 8
ULTRAM, 9
ULTRAVATE, 37
ULTRESA, 29
umeclidinium/vilanterol, 33
URECHOLINE, 30
UROCIT-K, 30
URSO, 28
ursodiol, 28
ustekinumab, 36
V
VAGIFEM, 26
valacyclovir, 11
VALCYTE, 11
valganciclovir, 11
VALIUM, 18
valproic acid, 18
valsartan, 14
valsartan/hydrochlorothiazide, 14
VANCOCIN, 12
vancomycin, 12
varenicline, 22
VASERETIC, 14
VASOTEC, 14
VELPHORO, 27
venlafaxine, 19
venlafaxine ext-rel, 19
VENTAVIS, 17
verapamil ext-rel, 16
VESICARE, 30
VFEND, 10
VIAGRA, 30
VIBRAMYCIN, 10
VICTOZA, 23
VICTRELIS, 11
VIDEX EC, 11
VIGAMOX, 38
VIIBRYD, 19
vilazodone, 19
VIMPAT, 18
VIOKACE, 29
VIRAMUNE, 11
VIRAMUNE XR, 11
VIREAD, 11
VIROPTIC, 38
vitamin ADC/fluoride drops, 33
vitamin ADC/fluoride/iron drops, 33
VIVELLE-DOT, 26
VOLTAREN GEL, 8
voriconazole, 10
vorinostat, 13
VOSPIRE ER, 34
VOTRIENT, 13
VYTORIN, 15
VYVANSE, 20
W
warfarin, 31
WELCHOL, 15
WELLBUTRIN, 19
WELLBUTRIN SR, 19
WELLBUTRIN XL, 19
WESTCORT, 36
X
XALATAN, 39
XANAX, 18
XARELTO, 31
XELODA, 12
XENAZINE, 21
XIFAXAN 550 mg, 12
XOLAIR, 35
XYREM, 22
XYZAL, 33
Y
YASMIN, 24
YAZ, 24
Z
zafirlukast, 34
ZANAFLEX tabs, 22
zanamivir, 12
ZANTAC, 28
ZARONTIN, 18
ZAROXOLYN, 17
ZEBETA, 16
ZELAPAR, 20
ZEMPLAR, 27
ZENPEP, 29
ZERIT, 11
ZESTORETIC, 14
ZESTRIL, 14
ZETIA, 15
ZIAC, 16
ZIAGEN tabs, 11
zidovudine, 11
ZIOPTAN, 39
ziprasidone, 20
ZITHROMAX, 10
ZOCOR, 15
ZOFRAN, 28
54
ZOLADEX, 13
ZOLINZA, 13
zolmitriptan, 21
zolmitriptan nasal spray, 21
ZOLOFT, 19
zolpidem, 21
zolpidem ext-rel, 21
ZOMIG, 21
ZONEGRAN, 18
zonisamide, 18
ZOVIRAX, 11
ZUBSOLV, 22
ZYBAN, 22
ZYCLARA, 35
ZYLET, 38
ZYLOPRIM, 8
ZYPREXA, 20
ZYVOX, 12
55
This formulary was updated 01/01/2015. For more recent information or other questions,
please contact CareFirst Pharmacy Services at 800-241-3371 or visit www.carefirst.com/rx.
The CareFirst BlueCross BlueShield
family of health care plans
10455 Mill Run Circle
Owings Mills, MD 21117
www.carefirst.com/rx
CareFirst BlueCross BlueShield is the shared business name of CareFirst of Maryland, Inc. and Group Hospitalization and Medical Services, Inc. CareFirst BlueCross BlueShield and CareFirst BlueChoice, Inc. are both independent licensees of the Blue Cross and Blue Shield Association. ® Registered trademark of the Blue Cross and Blue Shield Association. ®’ Registered trademark of CareFirst of Maryland, Inc.
SUM2358-1S (9/14)

CareFirst Formulary 1 (Non

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