Preferred Drug List (PDL)

Transcription

Preferred
Drug List (PDL)
Hawaii
Effective Date: 6/1/16
© 2016 United Healthcare Services, Inc. All rights reserved.
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Preferred Drug List
INTRODUCTION
This PDL is not intended to be a substitute for the
knowledge, expertise, skill and judgment of the medical
provider in their choice of prescription drugs.
UnitedHealthcare is pleased to provide this Preferred Drug
List (PDL) to be used when prescribing for patients
covered by the pharmacy benefit plan offered by
UnitedHealthcare. The drugs listed in this PDL are
intended to provide sufficient options to treat patients who
require treatment with a drug from that pharmacologic or
therapeutic class. The drugs listed in the UnitedHealthcare
PDL have been reviewed and approved by the
UnitedHealthcare Pharmacy and Therapeutics Committee.
The drugs have been selected to provide the most clinically
appropriate and cost-effective medications for patients who
have their drug benefit administered through
UnitedHealthcare. It is also recognized there may be
occasions where an unlisted drug is desired for proper
medical management of a specific patient. In those
infrequent instances, the unlisted medication may be
requested through the Medical prior authorization process.
UnitedHealthcare assumes no responsibility for the actions
or omissions of any medical provider based upon reliance,
in whole or in part, on the information contained herein.
The medical provider should consult the drug
manufacturer’s product literature or standard references for
more detailed information.
National guidelines can be found on the Web sites listed in
the Web site section or go to the National Guideline
Clearinghouse site at http://www.guideline.gov.
The PDL and quarterly updates are also available on our
web site at www.uhccommunityplan.com.
PREFACE
The drugs represented have been reviewed by the
UnitedHealthcare Pharmacy and Therapeutics (P&T)
Committee and are approved for inclusion. The PDL is
reflective of current medical practice as of the date of
review.
The UnitedHealthcare PDL is organized by sections. Each
section includes therapeutic groups identified by either a
drug class or disease state.
Products are listed by generic name. Brand names are
included as a reference to assist in product recognition.
Unless exceptions are noted, generally all applicable
dosage forms and strengths of the drug cited are included in
the PDL. Generics should be considered the first line of
prescribing.
This edition incorporates drugs added to the PDL since the
last edition as well as numerous revisions to the prescribing
information based on changes in pharmacotherapy.
Comments and suggestions from practicing physicians have
also been incorporated to ensure that the UnitedHealthcare
PDL is reflective of current medical practice.
The UnitedHealthcare PDL covers selected over-thecounter (OTC) products. Many are noted in the drug lists;
a complete list is included on page 44. You are encouraged
to prescribe OTC medications when clinically appropriate.
NOTICE
The information contained in this PDL and its appendices is
provided by UnitedHealthcare, solely for the convenience
of medical providers. UnitedHealthcare does not warrant or
assure accuracy of such information nor is it intended to be
comprehensive in nature.
UHC1004a {Released 2/25/11}
i
drug list. There may also be a statement associated with a
drug list that gives additional information about which
specific products or dosage forms are covered.
PHARMACY AND THERAPEUTICS (P&T)
COMMITTEE
The UnitedHealthcare P&T Committee includes physicians
and pharmacists who are not employees or agents of
UnitedHealthcare or its affiliates. They must adhere to the
Ethics Policy standards of the P&T Committee.
UnitedHealthcare medical directors and pharmacists also
participate in the P&T Committee. UnitedHealthcare’s
P&T Committee meets quarterly to discuss a variety of
issues. Those issues pertaining to pharmaceutical selection
and pharmacy program management are communicated
quarterly. This newsletter is distributed to all participating
physicians who have received UnitedHealthcare’s PDL.
PDL decisions are also communicated quarterly on the
UnitedHealthcare internet site.
Products covered include all strengths associated
with the dosage form of the cited brand name
product.
carvedilol
All strengths of Coreg would be covered by this listing.
Extended-release and delayed-release products
require their own entry.
diltiazem sustained release CARDIZEM SR
Dosage forms covered will be consistent with the
category and use where listed.
OUTPATIENT PRESCRIPTION DRUG
BENEFIT-COVERED MEDICATIONS
Medically necessary outpatient prescription drugs are
covered when prescribed by a provider licensed to
prescribe federal legend drugs or medicines. Some items
are covered only with prior authorization. Eligibility for
Outpatient Prescription Drug Benefits and copays are based
on the individual member’s benefit plan.
Neomycin/polymixin B/ Cortisporin
Hydrocortisone
As listed in the OTIC section, this is limited to the otic
solution and suspension. From this entry the ophthalmic
solution and ointment, and the topical cream cannot be
assumed to be on the list unless there are entries for these
products in the OPHTHALMIC and DERMATOLOGY
sections of the PDL.
PRODUCT SELECTION CRITERIA
The UnitedHealthcare P&T Committee considers clinical
information on new-to-market drugs that are typically
included in an outpatient pharmacy benefit. The evaluation
includes all or part of the following:
• Safety
• Efficacy
• Comparison studies
• Approved indications
• Adverse effects
• Contraindications/Warnings/Precautions
• Pharmacokinetics
• Patient administration/compliance considerations
• Medical outcome and pharmacoeconomic
studies
When a new drug is considered for PDL inclusion, it will
be reviewed relative to similar drugs currently included in
the UnitedHealthcare PDL. This review process may result
in deletion of drug(s) in a particular therapeutic class in an
effort to continually promote the most clinically useful and
cost-effective agents.
When a strength or dosage form is specified, only the
specified strength and dosage form is on the PDL.
Other strengths/dosage forms of the reference product
are not
citalopram 40 mg tabs
Celexa tabs
GENERIC SUBSTITUTION
The UnitedHealthcare PDL requires generic substitution
on the majority of products when a generic equivalent is
available.
Generic substitution is a pharmacy action whereby a
generic equivalent is dispensed rather than the brand name
product. The PDL indicates generic availability in the
“Covered Drug” column.
If a brand name drug is medically necessary, please submit
a prior authorization request.
All the information in the PDL is provided as a reference
for drug therapy selection. Specific drug selection for an
individual patient rests solely with the prescriber.
The UnitedHealthcare MAC list sets a ceiling price for the
reimbursement of certain multisource prescription drugs.
This price will typically cover the acquisition of most
generics but not branded versions of the same drug. The
products selected for inclusion on the MAC list are
commonly prescribed and dispensed and have usually gone
through the FDA’s review and approval process. An
important consideration for generic substitution is the
knowledge that all approvals of generic drugs by the FDA
PDL PRODUCT DESCRIPTIONS
To assist in understanding which specific strengths and
dosage forms are covered on the
PDL, examples are noted below. The general principles
shown in the examples can then usually be extended to
other entries in the book. Any exceptions are noted in the
UHC1004a
Coreg
ii
since 1984, and many generic approvals prior to 1984, have
a showing of bioequivalence between the generic versions
and the reference brand product. To gain FDA approval:
• DESI drugs
• Antiobesity agents
• Experimental / research drugs
• Cosmetic drugs
• Immunization agents
• Nutritional / diet supplements
• Blood and blood plasma products
• Agents used to promote fertility
• Agents used for erectile dysfunction
• Agents used for cosmetic hair growth
• Drugs from manufacturers that do not participate
in the FFS Medicaid Drug Rebate Program
• Diagnostic products
• Medical supplies and DME except as listed:
syringes, needles, lancets, alcohol swabs, spacers,
preferred diabetes test strips, peak flow meters
(Astech, Assess, Peak Air brands, max two per
year), vaporizer (limit of 1 per 3 years), humidifier
(limit of 1 per 3 years)
• Mirena
1. The generic drug must contain the same active
ingredient(s), be the same strength and the same dosage
form as the brand name product.
2. The FDA has given the generic an “A” rating compared
to the branded product indicating bioequivalence, and
has determined the generic is therapeutically equivalent
to the reference brand. The ratings of generic drugs are
available by referring to the FDA reference, Approved
Drug Products with Therapeutic Equivalence
Evaluations (Orange Book).
When the above two criteria are met, a generic can be
substituted with the full expectation that the substituted
product will produce the same clinical effect and safety
profile as the prescribed product. Drug products that have a
narrow therapeutic index (NTI) can also be guided by these
principles. It is not necessary for the health care provider to
approach any one therapeutic class of drug products (e.g.,
NTI drugs) differently from any other class, when there has
been a determination of therapeutic equivalence by the
FDA for the drug products under consideration. Also,
additional clinical tests or examinations by the physician
are not needed when a therapeutically equivalent generic
drug product is substituted for the brand name product.
DAYS SUPPLY DISPENSING LIMITATIONS
UnitedHealthcare members may receive up to a one month
supply of a specific medication per prescription order or
prescription refill. A medication may be reordered or
refilled when seventy-five percent (75%) of the medication
has been utilized. If a claim is submitted before 75% of the
medication has been used, based on the original day supply
submitted on the claim, the claim will reject with a "refill
too soon" message. Please call the UnitedHealthcare
Pharmacy Department at 800-310-6826 with questions or
for help with dosage change authorization.
There are now many brand name products that are
repackaged or distributed under a generic label. The generic
label version should always be considered therapeutically
equivalent and substitutable for the source branded product.
MANDATORY GENERIC SUBSTITUTION
DRUG EFFICACY STUDY IMPLEMENTATION
(DESI) DRUGS
The UnitedHealthcare PDL requires mandatory generic
substitution on the vast majority of products when a generic
equivalent is available; however, brand name drugs may be
covered in certain situations by requesting a prior
authorization.
The UnitedHealthcare PDL prior authorization (PA) list
does not include branded items where a generic equivalent
is covered.
Drugs first marketed between 1938 and 1962 were
approved as safe but required no showing of effectiveness
for FDA approval. Beginning in 1962, all new drugs were
required to be both safe and effective before they could be
marketed. This legislation also applied retroactively to all
drugs approved as safe from 1938-1962. The DESI
program was established by the FDA to review the
effectiveness of these pre-1962 drugs for their labeled
indications, and a determination of “fully effective” was
made for most of these products and they remain in the
marketplace. A few DESI products remain classified as
“less than fully effective” while awaiting final
administrative disposition. Also, classified as DESI are
many products listed as identical, similar, or related to
actual DESI products. UnitedHealthcare’s PDL does not
cover DESI “less than fully effective” drug products.
PRIOR AUTHORIZATION OF NON-PDL
MEDICATIONS
The drugs in the UnitedHealthcare PDL have been selected
to provide the most clinically appropriate and cost-effective
medications for patients who have their drug benefit
administered through UnitedHealthcare. It is also
recognized that there may be occasions where an unlisted
drug is desired for the proper medical management of a
specific patient. In those infrequent instances, the prior
authorization process reviews requests for unlisted
medications the physician may consider medically
necessary for patient management.
PLAN EXCLUSIONS
The following drug categories are excluded from coverage
under the outpatient pharmacy benefit and are not part of
the UnitedHealthcare PDL.
UHC1004a
iii
Requests for these exceptions should be made in writing by
the physician and faxed or mailed to:
QUANTITY LIMITATIONS (QL)
Prescriptions for monthly quantities greater than the
indicated limit require a prior authorization request.
UnitedHealthcare
Pharmacy Services Department
Unison Plaza
1001 Brinton Road
Pittsburgh, PA 15221
Fax 866-940-7328
Phone 800-310-6826
Quantity limits based on Efficient Medication Dosing
The Efficient Medication Dosing Program is designed to
consolidate medication dosage to the most efficient daily
quantity to increase adherence to therapy and also promote
the efficient use of health care dollars.
The limits for the program are established based on FDA
approval for dosing and the availability of the total daily
dose in the least amount of tablets or capsules daily.
Quantity Limits in the prescription claims processing
system will limit the dispensing to consolidate dosing. The
pharmacy claims processing system will prompt the
pharmacist to request a new prescription order from the
physician.
A prior authorization request form is available in the
UnitedHealthcare provider manual and should be used for
all prior authorization requests if possible. Appropriate
documentation must be provided to support the medical
necessity of the non-PDL request. The UnitedHealthcare
Pharmacy Department will respond to all requests in
accordance with state requirements.
Controlled Substances
You may fill any FOUR medications from the following
classes in a 30-day period:
• opiate analgesics
• benzodiazepines
• sedative hypnotic agents
• barbiturates
• select muscle relaxants
Additional fills will require prior authorization.
Medications in these classes may also be subject to
individual quantity limits.
Physicians are requested to adhere to this PDL when
prescribing for patients covered by their pharmacy benefit
plan offered by UnitedHealthcare. If a pharmacist receives
a prescription for a non-PDL drug, the pharmacist should
contact the prescribing physician and request that the
prescription be changed to a medication included in this
PDL. If a PDL alternative is not appropriate the physician
should then be instructed to contact the Plan for a prior
authorization.
Please contact the UnitedHealthcare Pharmacy Department
at 800-310-6826 with questions concerning the prior
authorization process.
Additions to the QL program drug list will be made from
time to time and providers notified accordingly. As always,
we recognize that a number of patient-specific variables
must be taken into consideration when drug therapy is
prescribed and therefore overrides will be available through
the medical exception (prior authorization) process. Please
contact the UnitedHealthcare Pharmacy Department at 800310-6826 with questions.
NON-PDL DRUGS 5-DAY AND 15-DAY OVERRIDES
To ensure the use of PDL drugs, all non- PDL drugs should
be discussed with the prescribing physician. If you cannot
speak to the physician immediately, and there is an
immediate need for the medication, the claim processing
system will accept an override to permit a one-time
dispensing of a 5-day supply of the newly prescribed
non-PDL drug. The pharmacy should submit a claim for a
5 day supply, with a PA Type of 8 and Prior Authorization
number of “00000000120”.
Specialty Pharmaceutical Management Program
UnitedHealthcare is continuously looking for ways to
provide high quality cost effective care for Plan members.
The Specialty Pharmaceutical Management Program helps
UnitedHealthcare to achieve these goals.
Injectable medications that are part of this program require
plan authorization and are not available through the retail
pharmacy network.
To obtain authorization, the provider must submit the
appropriate Prior Authorization form to the
UnitedHealthcare Pharmacy Department via fax at 866940-7328.
The UnitedHealthcare Pharmacy Department will review
and respond to all requests in accordance with state
requirements, and if authorized for payment,
UnitedHealthcare will coordinate the delivery of the
product to the member or provider.
Drugs that are part of this program and are on the PDL are
identified in this booklet by the designation "SP".
Please note that non-preferred drugs are available for a 5day supply, however availability is subject to the benefit
design. For assistance, pharmacies may call 800-3106826.
Pharmacies may dispense a one-time, 15-day supply to
members requiring an immediate supply of an ongoing
medication. The pharmacist must contact the plan to
obtain a manual 15-day override. Before the next
dispensing, the pharmacy must contact the physician to
discuss a PDL drug or if a prior authorization request is
warranted. If the prescribing physician feels a drug is
medically necessary, the physician may fax a request for
prior authorization to UnitedHealthcare at 866-940-7328,
Attn: Pharmacy Department.
UHC1004a
iv
DPP4 Inhibitors At least a 90 day trial of 1500mg/day of
(Tradjenta,
metformin.
Jentadueto,
Onglyza, Kombiglyze)
Prior Authorization request forms can be requested by
calling the UnitedHealthcare Pharmacy Department 800310-6826.
MEDICATIONS REQUIRING DIAGNOSIS
UnitedHealthcare requires that the diagnosis for
prescriptions for Antipsychotic and ADHD medications for
UnitedHealthcare Community Plan members match the
FDA-approved use or a use supported by current published
evidence.
The diagnosis will be verified at the point-of-sale by the
pharmacy claims processing system. If a matching
diagnosis is not found in the medical claim file or on the
pharmacy drug claim, the prescription will be rejected at
the pharmacy. The pharmacist may then contact the
prescriber to verify the diagnosis and submit it on the
claim.
Dulera
1) 30 day trial of one inhaled
corticosteroid (e.g. Arnuity Ellipta,
Asmanex) OR 2) 60 day trial of a longacting beta2- agonist (e.g. Arcapta,
Striverdi) OR 60 day trial of an orally
inhaled anticholinergic agent (e.g. Incruse
Ellipta, Atrovent, Combivent, Anoro
Ellipta).
Elidel
Trial of two different topical
corticosteroids. Step therapy only applies
to members 12 years of age and older.
fenofibrate
If the diagnosis provided still does not match the approved
use, prior authorization may be requested through the
standard process by faxing a request to 866-940-7328.
Fill of a statin or 90 days of gemfibrozil
within the previous 180 days.
Gabitril
STEP THERAPY (ST)
The following PDL drugs are routinely covered only after a
sufficient trial of an indicated first-line agent has been
adequately tried and failed. These medications may also be
requested through the Prior authorization process.
While lower cost PDL alternatives may be appropriate in
many instances, other non- PDL alternatives are available
with prior authorization (PA).
30 day trial of two of the following:
lamotrigine, topiramate, carbamazepine,
divalproex, or phenytoin. Step therapy
only applies to members 12 years of age
and older. Members less than 12 require
prior authorization.
GLP-1 Agonists At least a 90 day trial of 1500mg/day of
(Tanzeum,
metformin
Victoza)
STEP Drug
Amerge
Trial at a minimum dose of 50mg of
sumatriptan tablets.
Aricept 23mg
90 day trial of Aricept 10mg daily
Banzel
lamotrigine, divalproex, or
topiramate.
Breo Ellipta
Ditropan XL
UHC1004a
lansoprazole/
30 day trial of omeprazole 40mg and
Prevacid OTC pantoprazole 40mg within
previous 180 days is required first.
First-Line Agent(s)
1) 30 day trial of one inhaled
corticosteroid (e.g. Arnuity Ellipta,
Asmanex) OR 2) 60 day trial of a longacting beta2- agonist (e.g. Arcapta,
Striverdi) OR 60 day trial of an orally
inhaled anticholinergic agent (e.g. Incruse
Ellipta, Atrovent, Combivent, Anoro
Ellipta).
Lantus vials
trial of Toujeo Solostar
levocetirizine
30 day trial of loratadine and cetirizine.
midodrine
Trial of fludrocortisone
Onfi
lamotrigine, divalproex, or
topiramate.
Optivar
14 day trial of ketotifen within previous
90 days required first.
oxymorphone ER 30-day trial of both Fentanyl patch and
morphine sulfate ER at least 200mg per
day
30 day trial of oxybutynin immediate
release. Step Therapy only applies to
members less than 65 years of age.
Potiga
v
30-day trial of two of the following:
Attn: Director of Pharmacy Services
UnitedHealthcare
Unison Plaza
1001 Brinton Road
Fax: 866-940-7328
Protopic 0.03% Trial of two different topical
corticosteroids. Step therapy only applies
to members 12 years of age and older.
Protopic 0.1%
Minimum age of 16. Trial of two
different topical corticosteroids
Ranexa
Trial of one drug from the following
classes: beta blockers, calcium channel
blockers, long acting nitrates
Renvela
8 week trial of calcium acetate.
Providers should furnish adequate documentation, such as
clinical studies from the medical literature, in order for the
request to be considered for PDL addition. This literature
should include information documenting clinical necessity
as well as therapeutic advantages over current PDL
products. Suggestions received by UnitedHealthcare will be
reviewed by the Pharmacy and Therapeutics Committee at
the subsequent P&T Committee meeting.
SGLT-2
At least a 90 day trial of 1500mg/day of
Inhibitors
metformin
(Jardiance,
Invokana,
Invokamet, Synjardy)
tolterodine
trospium
EDITOR
Your comments and suggestions regarding the
UnitedHealthcare PDL are encouraged. Your input is vital
to this PDL’s continued success. All responses will be
reviewed and considered. Please send your comments to:
UnitedHealthcare
Director of Pharmacy Services
Unison Plaza
1001 Brinton Road
Phone: 800-310-6826
Email: [email protected]
Internet: http://www.uhccommunityplan.com
TZD’s
At least a 90 day trial of 1500mg/day of
(ActosPlusMet, metformin
ActoPlusMet XR, Duetact)
Uloric
8 week trial of up to 600mg of
allopurinol required first.
Vancocin
One fill of metronidazole tabs or cap
Vimpat
Xopenex
Respules
30 day trial of Albuterol .083% or .5%
respules.
Zohydro ER
30-day trial of both Fentanyl patch and
morphine sulfate ER at least 200mg per
day
LEGEND
#
Only the dosage forms/strengths of the brand
name products noted are on the PDL
OTC
over-the-counter
delayed-rel delayed-release (also known as enteric coated)
EC
enteric-coated
ext-rel
extended-release (also known as sustainedrelease)
PA
Prior Authorization required
QL
Quantity Limits apply
ST
Step Therapy, see pages V-VI for details
SP
Specialty Pharmaceuticals, see page V for
details
NOTICE
The information contained in this document is proprietary
information. The information may not be copied in whole
or in part without the written permission of
UnitedHealthcare. All rights reserved.
The drug names listed here are the registered and/or
unregistered trademarks of third-party pharmaceutical
companies unrelated to and unaffiliated with
UnitedHealthcare. These trademarked brand names are
included here for informational purposes only and are not
intended to imply or suggest any affiliation between
PDL SUGGESTIONS
Providers who wish to propose PDL suggestions should
forward the information to the UnitedHealthcare Director
of Pharmacy Services by either mail or fax.
UHC1004a
vi
UnitedHealthcare and such third-party pharmaceutical
companies.
If viewing this PDL via the Internet, please be advised that
the PDL is updated periodically and changes may appear
prior to their effective date to allow for notification.
UHC1004a
vii
Table of Contents
Antineoplastics & Immunosuppressants . . . 4
Antineoplastic Agents . . . . . . . . . . . . . . . . . . . . . . 4
Hormonal Antineoplastic Agents . . . . . . . . . . . . . 5
Immunomodulators . . . . . . . . . . . . . . . . . . . . . . . . 5
Immunosuppressants . . . . . . . . . . . . . . . . . . . . . . 5
Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Dermatology . . . . . . . . . . . . . . . . . . . . . . . . . 15
Acne Vulgaris . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Bacterial Infections . . . . . . . . . . . . . . . . . . . . . . . 16
Corticosteroids . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Fungal Infections . . . . . . . . . . . . . . . . . . . . . . . . . 17
Psoriasis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Rosacea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Blood Modifiers - Anticoagulants . . . . . . . . . 6
Scabies and Pediculosis . . . . . . . . . . . . . . . . . . 18
Anticoagulants . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Viral Infections . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Blood Cell Formation . . . . . . . . . . . . . . . . . . . . . . . 7
Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Platelet Inhibitors . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 Ear, Nose & Throat . . . . . . . . . . . . . . . . . . . . 19
Ear . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Cardiovascular Agents . . . . . . . . . . . . . . . . . 7
Nose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Ace Inhibitors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Throat and Mouth . . . . . . . . . . . . . . . . . . . . . . . . 20
Ace Inhibitor/Diuretic Combinations . . . . . . . . . . 7
Adrenolytics, Central . . . . . . . . . . . . . . . . . . . . . . . 8 Endocrinology . . . . . . . . . . . . . . . . . . . . . . . 21
Alpha Blockers . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 Adrenal Corticosteroids . . . . . . . . . . . . . . . . . . . 21
Angiotensin II Receptor Blockers (Antagonists) . 8 Androgens . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Angiotensin II Receptor Blocker Combinations . 8 Diabetes Mellitus . . . . . . . . . . . . . . . . . . . . . . . . . 21
Antiarrhythmics and Cardiac Glycosides . . . . . . 8 Growth Stimulating Agents . . . . . . . . . . . . . . . . 23
Osteoporosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Beta Blockers and Beta Blocker/Diuretic
Combinations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 Thyroid Disease . . . . . . . . . . . . . . . . . . . . . . . . . 23
Calcium Channel Blockers . . . . . . . . . . . . . . . . . . 9 Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Diuretics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Gastrointestinal . . . . . . . . . . . . . . . . . . . . . . 23
Lipid Lowering Agents . . . . . . . . . . . . . . . . . . . . 10 Diarrhea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Nitrates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 Emesis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Potassium-Removing Agents . . . . . . . . . . . . . . 10 Gastroesophageal Reflux Disease (Gerd)/Peptic
Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Ulcers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
Central Nervous System . . . . . . . . . . . . . . . 11
Alzheimer’s Disease . . . . . . . . . . . . . . . . . . . . . . 11
Analgesics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Migraine Acute Therapy . . . . . . . . . . . . . . . . . . . 13
Migraine Prophylactic Therapy . . . . . . . . . . . . . 13
Multiple Sclerosis . . . . . . . . . . . . . . . . . . . . . . . . 13
Myasthenia Gravis . . . . . . . . . . . . . . . . . . . . . . . 13
Parkinson’s Disease . . . . . . . . . . . . . . . . . . . . . . 14
Seizures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Gastrointestinal Spasm . . . . . . . . . . . . . . . . . . . 24
Inflammatory Bowel Disease . . . . . . . . . . . . . . . 25
Laxatives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
Pancreatic Enzymes . . . . . . . . . . . . . . . . . . . . . . 25
Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
Home Infusion Drugs . . . . . . . . . . . . . . . . . . 26
Analgesics - NSAIDS . . . . . . . . . . . . . . . . . . . . . 26
Analgesics - OPIOD . . . . . . . . . . . . . . . . . . . . . . 26
Antibiotics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
Antihistamines . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
2
Diuretics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
Electrolyte Mixtures . . . . . . . . . . . . . . . . . . . . . . . 28
Genitourinary Irrigants . . . . . . . . . . . . . . . . . . . . 28
Minerals & Electrolytes . . . . . . . . . . . . . . . . . . . . 28
Nutrients . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
Vitamins . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
Weight Loss . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
Infectious Diseases . . . . . . . . . . . . . . . . . . . 28
Anthelmintics . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
Antibacterials . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
Antifungals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
Antivirals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
Urological . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
Symptomatic Benign Prostatic Hypertrophy . . 48
Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
Vitamins and Minerals . . . . . . . . . . . . . . . . . . . . 49
Potassium . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
Respiratory Drugs . . . . . . . . . . . . . . . . . . . . 42
Antitussives, Decongestants, Expectorants and
Combinations . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
Asthma/COPD . . . . . . . . . . . . . . . . . . . . . . . . . . 47
Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . 53
Anaphylaxis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
Cystic Fibrosis . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
Hereditary Angioedema . . . . . . . . . . . . . . . . . . . 53
Hyperphosphatemia . . . . . . . . . . . . . . . . . . . . . . 53
Idiopathic Pulmonary Fibrosis (IPF) . . . . . . . . . 53
Immune Thrombocytopenic Purpura . . . . . . . . 53
Medical Devices . . . . . . . . . . . . . . . . . . . . . . . . . 53
Metabolic Modifiers . . . . . . . . . . . . . . . . . . . . . . 53
Vaccine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
Musculoskeletal . . . . . . . . . . . . . . . . . . . . . . 33
Arthritis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
Gout . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
Skeletal Muscle Relaxants . . . . . . . . . . . . . . . . . 34
OB-GYN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
Contraceptives . . . . . . . . . . . . . . . . . . . . . . . . . . 34
Endometriosis . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
Hormone Therapy/Menopause . . . . . . . . . . . . 35
Vaginal Infections . . . . . . . . . . . . . . . . . . . . . . . . 36
Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
OTC MEDICATIONS . . . . . . . . . . . . . . . . . . . 55
Acne . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
Antifungals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
Atopic Dermatitis . . . . . . . . . . . . . . . . . . . . . . . . . 55
Cough/Cold Allergy . . . . . . . . . . . . . . . . . . . . . . 55
Diabetes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
Earwax Removal Products . . . . . . . . . . . . . . . . 56
Family Planning . . . . . . . . . . . . . . . . . . . . . . . . . . 56
First Aid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
Gastrointestinal . . . . . . . . . . . . . . . . . . . . . . . . . . 56
Lice Products . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
Motion Sickness . . . . . . . . . . . . . . . . . . . . . . . . . 57
Ophthalmics . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
Smoking Cessation Products . . . . . . . . . . . . . . 57
Vitamins/Minerals . . . . . . . . . . . . . . . . . . . . . . . . 58
Warts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
Ophthalmic . . . . . . . . . . . . . . . . . . . . . . . . . . 36
Allergy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
Anti-Inflammatories . . . . . . . . . . . . . . . . . . . . . . . 37
Glaucoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
Infections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
Miscellaneous Ophthalmics . . . . . . . . . . . . . . . 39
Psychiatric . . . . . . . . . . . . . . . . . . . . . . . . . . 39
Alcohol Deterrents . . . . . . . . . . . . . . . . . . . . . . . 39
Anxiety . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
Attention Deficit Hyperactivity Disorder (ADHD) Diagnosis required . . . . . . . . . . . . . . . . . . . . . . . 39
Bipolar Disorder . . . . . . . . . . . . . . . . . . . . . . . . . 40
Depression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
Insomnia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
Narcotic Antagonists . . . . . . . . . . . . . . . . . . . . . 41
Psychoses - Diagnosis required . . . . . . . . . . . . 41
Smoking Cessation . . . . . . . . . . . . . . . . . . . . . . 42
Index of Covered Drugs . . . . . . . . . . . . . . . . 59
3
Generic Drug Name
Covered
Drug
Brand Drug Name
Requirements & Limits
Antineoplastics & Immunosuppressants
Antineoplastic Agents
Alkylating Agents
altretamine
busulfan
chlorambucil
cyclophosphamide
estramustine
phosphate sodium
lomustine
melphalan
temozolomide
HEXALEN
MYLERAN
LEUKERAN
CYTOXAN
CEENU
ALKERAN
TEMODAR
generic
brand
generic
capecitabine
fludarabine
mercaptopurine
thioguanine
trifluridine/tipiracil
XELODA
OFORTA
PURINETHOL
TABLOID
LONSURF
generic
brand
generic
brand
brand
PA, SP
PA, SP
panobinostat
vorinostat
FARYDAK
ZOLINZA
brand
brand
PA, SP
PA, SP
afatinib
axitinib
bosutinib
cabozantinib
ceritinib
crizotinib
dabrafenib
dasatinib
erlotinib
GILOTRIF
INLYTA
BOSULIF
COMETRIQ
ZYKADIA
XALKORI
TAFINLAR
SPRYCEL
TARCEVA
AFINITOR
brand
brand
brand
brand
brand
brand
brand
brand
brand
PA, SP
PA, SP
PA, SP
PA, SP
PA, SP
PA, SP
PA, SP
PA, SP
PA, SP
brand
PA, SP
brand
brand
brand
brand
brand
brand
brand
brand
PA, SP
PA, SP
PA, SP
PA, QL, SP
PA, SP
PA, SP
PA, SP
PA, SP
Antimetabolites
brand
brand
brand
generic
EMCYT
brand
Histone Deacetylase Inhibitors
Kinase Inhibitor
everolimus
gefitinib
ibrutinib
idelalisib
imatinib mesylate
lapatinib ditosylate
levatinib
nilotinib
pazopanib
AFINITOR DISPERZ
IRESSA
IMBRUVICA
ZYDELIG TABLET
GLEEVEC
TYKERB
LENVIMA
TASIGNA
VOTRIENT
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
ST = Step Therapy
SP = Specialty Pharmacy
4
PA, SP
QL
PA, SP
Covered
Drug
brand
brand
brand
brand
brand
brand
brand
brand
Generic Drug Name
Brand Drug Name
ponatinib
regorafenib
ruxolitinib
sorafenib
sunitinib
trametinib
vandetanib
vemurafenib
ICLUSIG
STIVARGA
JAKAFI
NEXAVAR
SUTENT
MEKINIST
CAPRELSA
ZELBORAF
abiraterone
ZYTIGA
bicalutamide
flutamide
CASODEX
EULEXIN
generic
generic
tamoxifen
toremifene
NOLVADEX
FARESTON
generic
brand
anastrozole
exemestane
letrozole
ARIMIDEX
AROMASIN
FEMARA
generic
generic
generic
leuprolide
LUPRON
LUPRON DEPOT
generic
PA, SP
leuprolide
LUPRON DEPOT 6-MONTH
brand
PA, SP
Hormonal Antineoplastic Agents
Androgen Biosynthesis Inhibitors
Antiandrogens
Antiestrogens
Aromatase Inhibitors
brand
Gonadotropin Releasing Hormone Analog
Progestin
PA, SP
PA, SP
PA, SP
PA, SP
PA, SP
PA, SP
PA, SP
PA, SP
PA, SP
LUPRON DEPOT-PED
megestrol acetate
MEGACE
interferon alfa-2a
interferon alfa-2b
peginterferon alfa-2b
INTRON A
SYLATRON
brand
brand
brand
PA, SP
PA, SP
PA, SP
lenalidomide
thalidomide
REVLIMID
THALOMID
brand
brand
PA, SP
PA, QL
azathioprine
mycophenolate mofetil
IMURAN
CELLCEPT
generic
generic
Immunomodulators
Interferons
Miscellaneous
Immunosuppressants
Antimetabolites
generic
QL = Quantity Limit
ST = Step Therapy
5
Generic Drug Name
Brand Drug Name
mycophenolate sodium
MYFORTIC
cyclosporine
SANDIMMUNE
GENGRAF
Calcineurin Inhibitors
cyclosporine, modified
tacrolimus
Rapamycin Derivative
Covered
Drug
generic
generic
generic
NEORAL
HECORIA
generic
PROGRAF
sirolimus
sirolimus
RAPAMUNE
RAPAMUNE
generic
brand
everolimus
ZORTRESS
brand
alitretinoin 1% gel
bexarotene caps and
topical gel
cysteamine bitartrate
etoposide
hydroxyurea
hydroxyurea
mitotane
octreotide
olaparib
palbociclib
pasireotide
pomalidomide
procarbazine
sonidegib
tretinoin
vismodegib
PANRETIN
brand
PA
TARGRETIN
brand
PA
Other
Miscellaneous
CYSTAGON
VEPESID
DROXIA
HYDREA
LYSODREN
SANDOSTATIN
LYNPARZA
IBRANCE
SIGNIFOR
POMALYST
MATULANE
ODOMZO
VESANOID
ERIVEDGE
tabs
soln
brand
generic
brand
generic
brand
generic
brand
brand
brand
brand
brand
brand
generic
brand
PA, SP
PA, SP
PA, SP
PA, SP
PA, SP
caps
PA, SP
Blood Modifiers - Anticoagulants
Anticoagulants
apixaban
edoxaban
ELIQUIS
SAVAYSA
brand
brand
enoxaparin
LOVENOX
generic
heparin
rivaroxaban
warfarin
HEPARIN
XARELTO
COUMADIN
generic
brand
generic
QL = Quantity Limit
PA, QL, SP, SP and PA only
applies for quantities greater
than 14 days
ST = Step Therapy
6
Generic Drug Name
Blood Cell Formation
darbepoetin alfa
epoetin alfa
filgrastim
oprelvekin
pegfilgrastim
plerixafor
sargramostim
TBO-filgrastim
Platelet Inhibitors
anagrelide
aspirin
cilostazol
clopidogrel
dipyridamole
Miscellaneous
aminocaproic acid
deferasirox
pentoxifylline
extended-release
Brand Drug Name
ARANESP
EPOGEN
PROCRIT
ZARXIO
NEUMEGA
NEULASTA
MOZOBIL
LEUKINE
GRANIX
AGRYLIN
BAYER
Covered
Drug
brand
PA, SP
brand
PA, SP
brand
brand
brand
brand
brand
brand
PA, SP
PA, SP
PA, SP
PA, SP
PA, SP
PA, SP
generic
ECOTRIN
PLETAL
PLAVIX
PERSANTINE
AMICAR
EXJADE
JADENU
generic
OTC
generic
generic
generic
QL
brand
500 mg tabs only
brand
PA, SP
TRENTAL
generic
benazepril
captopril
enalapril
LOTENSIN
CAPOTEN
VASOTEC
generic
generic
generic
enalapril oral soln
EPANED
fosinopril
lisinopril
quinapril
MONOPRIL
ZESTRIL
ACCUPRIL
generic
generic
generic
LOTENSIN HCT
generic
CAPOZIDE
generic
VASERETIC
generic
Cardiovascular Agents
Ace Inhibitors
brand
Ace Inhibitor/Diuretic Combinations
benazepril/
hydrochlorothiazide
captopril/
hydrochlorothiazide
enalapril/
hydrochlorothiazide
QL = Quantity Limit
Members ≥ 8 years of age will
require prior authorization.
QL
QL
QL
ST = Step Therapy
7
Brand Drug Name
Covered
Drug
MONOPRIL-HCT
generic
QL
ZESTORETIC
generic
QL
ACCURETIC
generic
QL
clonidine
guanfacine
CATAPRES
TENEX
generic
generic
tablets
doxazosin
prazosin
terazosin
CARDURA
MINIPRESS
HYTRIN
generic
generic
generic
losartan
COZAAR
generic
QL
losartan/HCTZ
HYZAAR
generic
QL
amiodarone tabs
digoxin
disopyramide
disopyramide
extended-release
dofetilide
flecainide
mexiletine
propafenone
quinidine gluconate extended-release
quinidine sulfate
quinidine sulfate
extended-release
CORDARONE
LANOXIN
NORPACE
generic
generic
generic
200 mg and 400 mg
NORPACE CR
brand
TIKOSYN
TAMBOCOR
MEXITIL
RYTHMOL
QUINIDINE GLUCONATE
EXT-REL
QUINIDINE SULFATE
QUINIDINE SULFATE
EXT-REL
brand
generic
generic
generic
acebutalol
atenolol
atenolol/chlorthalidone
bisoprolol
bisoprolol/
hydrochlorothiazide
carvedilol
labetalol
metoprolol
metoprolol succinate
SECTRAL
TENORMIN
TENORETIC
ZEBETA
generic
generic
generic
generic
ZIAC
generic
COREG
TRANDATE
LOPRESSOR
TOPROL XL
generic
generic
generic
generic
Generic Drug Name
fosinopril/
hydrochlorothiazide
lisinopril/
hydrochlorothiazide
quinapril/
hydrochlorothiazide
Adrenolytics, Central
Alpha Blockers
Angiotensin II Receptor Blockers (Antagonists)
Angiotensin II Receptor Blocker Combinations
Antiarrhythmics and Cardiac Glycosides
IR only
generic
generic
generic
Beta Blockers and Beta Blocker/Diuretic Combinations
QL = Quantity Limit
QL
50 mg and 100 mg only
ST = Step Therapy
8
Covered
Drug
generic
generic
generic
generic
generic
Generic Drug Name
Brand Drug Name
pindolol
propranolol
propranolol/HCTZ
sotalol
timolol maleate
PINDOLOL
INDERAL
INDERIDE
BETAPACE
amlodipine
felodipine extended-release
nicardipine
nifedipine
nifedipine
extended-release
nimodipine
nimodipine oral soln
NORVASC
PLENDIL
CARDENE
PROCARDIA
ADALAT CC
diltiazem
diltiazem
extended-release
diltiazem
sustained-release
diltiazem
extended-release
verapamil
verapamil
extended-release
CARDIZEM
generic
CARDIZEM CD
generic
QL
CARDIZEM SR
generic
QL
generic
QL
CALAN SR
generic
amiloride
amiloride/
hydrochlorothiazide
bumetanide
chlorothiazide
MIDAMOR
generic
MODURETIC
generic
BUMEX
DIURIL
DIURIL ORAL
SUSPENSION
CHLORTHALIDONE
LASIX
HYDROCHLOROTHIAZIDE
MICROZIDE
LOZOL
ZAROXOLYN
ALDACTONE
generic
generic
ALDACTAZIDE
generic
Calcium Channel Blockers
Dihydropyridines
Nondihydropyridines
Diuretics
chlorothiazide
chlorthalidone
furosemide
hydrochlorothiazide
hydrochlorothiazide
indapamide
metolazone
spironolactone
spironolactone/
hydrochlorothiazide
PROCARDIA XL
NIMOTOP
NYMALIZE
DILACOR XR
TIAZAC
CALAN
IR only
tablets
generic
generic
generic
generic
QL
QL
generic
QL
generic
brand
QL
generic
QL = Quantity Limit
brand
generic
generic
generic
generic
generic
generic
generic
ST = Step Therapy
9
QL
QL
soln, tabs
12.5 mg caps
Generic Drug Name
Brand Drug Name
torsemide
triamterene/
hydrochlorothiazide
DEMADEX
DYAZIDE
Lipid Lowering Agents
Bile Acid Resin
cholestyramine
Fibrates
Covered
Drug
generic
generic
MAXZIDE
QUESTRAN
generic
QUESTRAN-LIGHT
fenofibrate
gemfibrozil
LOFIBRA
LOPID
generic
generic
atorvastatin
lovastatin
simvastatin
LIPITOR
MEVACOR
ZOCOR
generic
generic
generic
niacin
niacin extended-release
NIACOR
NIASPAN
generic
generic
alirocumab
ezetimibe
PRALUENT
ZETIA
isosorbide dinitrate
extended-release
isosorbide mononitrate
extended-release
ISORDIL
ISOSORBIDE
DINITRATE ER
ISMO
generic
IMDUR
generic
nitroglycerin
nitroglycerin
ISORDIL S.L.
NITROLINGUAL
NITROSTAT
generic
generic
brand
HMG-CoA Reductase Inhibitors and Combinations
Niacins
Miscellaneous
Nitrates
Oral
Sublingual
Transdermal
nitroglycerin
nitroglycerin
ST
QL
QL
PA, QL, SP
PA
generic
generic
NITREK
NITRO-DUR
NITRO-BID
KAYEXALATE
QL = Quantity Limit
Only the bulk products are
covered (cans). Individual
packets are not covered.
brand
brand
Potassium-Removing Agents
sodium polysterene
sulfonate
generic
transdermal, QL
generic
oint
generic
susp (susp only)
ST = Step Therapy
10
Generic Drug Name
Miscellaneous
ambrisentan
bosentan
guanabenz
hydralazine
methyldopa
methyldopa/HCTZ
midodrine
minoxidil
ranolazine
sildenafil
Brand Drug Name
Covered
Drug
LETAIRIS
TRACLEER
WYTENSIN
APRESOLINE
ALDOMET
ALDORIL
PROAMATINE
LONITEN
RANEXA
REVATIO
brand
brand
generic
generic
generic
generic
generic
generic
brand
generic
PA, SP
PA, SP
ST
ST
PA
Central Nervous System
Alzheimer’s Disease
donepezil
ARICEPT
generic
donepezil
ARICEPT
generic
galantamine
RAZADYNE
generic
memantine
NAMENDA
generic
rivastigmine
EXELON
generic
Analgesics
Barbiturate Non-Narcotic Analgesics
butalbital/acetaminophen PHRENILIN
butalbital/acetaminophen SEDAPAP
ESGIC
butalbital/acetaminophen/
FIORICET
caffeine
ZEBUTAL
butalbital/aspirin/caffeine FIORINAL
Non-Narcotic Analgesics
acetaminophen
aspirin/acetaminophen/
caffeine
tramadol
5 mg and 10 mg, QL,
Members <18 years of age
will require prior authorization.
23 mg, ST, Members <18
years of age will require prior
authorization.
QL, Members <18 years
of age will require prior
authorization.
authorization.
authorization.
generic
generic
QL
QL
generic
QL
generic
QL
TYLENOL
generic
OTC
EXCEDRIN MIGRAINE
generic
250-250-65 mg, OTC
ULTRAM
generic
QL
QL = Quantity Limit
ST = Step Therapy
11
Brand Drug Name
Covered
Drug
etodolac
LODINE
generic
ibuprofen
ADVIL
generic
ibuprofen
MOTRIN
generic
Generic Drug Name
NSAIDS
INDOCIN
ORUDIS
TORADOL
MOBIC
RELAFEN
NAPROSYN
ENTERIC COATEDnaproxen delayed release
NAPROSYN
oxaprozin
DAYPRO
piroxicam
FELDENE
sulindac
CLINORIL
indomethacin
ketoprofen
ketorolac tromethamine
meloxicam
nabumetone
naproxen
IR Only
tabs, chew tabs
and susp, OTC
tabs, chew tabs
and susp
generic
generic
generic
generic
generic
generic
IR only
QL
QL
brand
generic
generic
generic
Opioids — Narcotic Analgesics
butalbital/apap/caff/cod
butalbital/asa/caff/cod
butorphanol
codeine/acetaminophen
codeine sulfate
fentanyl transdermal
FIORICET W/CODEINE
FIORINAL W/CODEINE
STADOL
TYLENOL W/CODEINE
generic
generic
generic
generic
generic
generic
QL, 50-325-40-30 mg
QL
nasal spray, QL
QL
QL
QL
generic
QL
VICODIN ES
ZOHYDRO ER
DILAUDID
DEMEROL
DOLOPHINE
DOLOPHINE
MSIR
RMS
brand
generic
generic
generic
generic
generic
generic
ST
QL
QL
conc, soln, QL
tablets, PA, QL
QL
QL
MS CONTIN
generic
QL
OXYFAST
ROXICODONE
generic
generic
soln, QL
QL
DURAGESIC
LORCET
LORTAB
hydrocodone/
acetaminophen
LORTAB ELIXIR
NORCO
VICODIN
hydrocodone ER
hydromorphone
meperidine
methadone
methadone
morphine
morphine
morphine
extended-release
oxycodone
oxycodone
QL = Quantity Limit
ST = Step Therapy
12
Brand Drug Name
Covered
Drug
PERCOCET
generic
5/325, QL
PERCODAN
OXYMORPHONE ER
TALWIN NX
generic
generic
generic
QL
QL, ST
QL
dihydroergotamine
dihydroergotamine
ergotamine/caffeine
ergotamine tartrate/
caffeine
D.H.E. 45
MIGRANAL
CAFERGOT
MIGERGOT
SUPPOSITORIES
generic
generic
generic
inj, QL
brand
QL
naratriptan
rizatriptan
sumatriptan
AMERGE
MAXALT/MAXALT MLT
IMITREX
IMITREX
4 MG AND 6 MG INJ
generic
generic
generic
ST
QL
QL
generic
4 mg and 6 mg inj
amitriptyline
divalproex sodium
cap sprinkle
divalproex sodium
delayed-release
propranolol
verapamil
ELAVIL
generic
DEPAKOTE SPRINKLE
generic
DEPAKOTE
generic
Minimum age 2
INDERAL
CALAN
generic
generic
IR only
dimethyl fumarate
fingolimod
glatiramer acetate
interferon beta-1a
interferon beta-1a
teriflunomide
TECFIDERA
GILENYA
COPAXONE
AVONEX/AVONEX PEN
REBIF
AUBAGIO
brand
brand
brand
brand
brand
brand
PA, QL, SP
PA, QL, SP
PA ,QL, SP
PA ,QL, SP
PA ,QL, SP
PA, QL, SP
pyridostigmine
pyridostigmine
pyridostigmine
extended-release
MESTINON
MESTINON
generic
brand
tabs
syrup
MESTINON TIMESPAN
generic
Generic Drug Name
oxycodone/
acetaminophen
oxycodone/aspirin
oxymorphone ER
pentazocine/naloxone
Migraine Acute Therapy
Ergotamine Derivatives
Selective Serotonin Agonists
sumatriptan
Migraine Prophylactic Therapy
Multiple Sclerosis
Myasthenia Gravis
QL = Quantity Limit
ST = Step Therapy
13
Brand Drug Name
Covered
Drug
amantadine
benztropine
biperiden
carbidopa/levodopa
carbidopa/levodopa
extended-release
entacapone
pramipexole
ropinirole
selegiline
tolcapone
trihexyphenidyl
SYMMETREL
COGENTIN
AKINETON
SINEMET
generic
generic
generic
generic
SINEMET CR
generic
COMTAN
MIRAPEX
REQUIP
ELDEPRYL
TASMAR
ARTANE
generic
generic
generic
generic
brand
generic
carbamazepine
TEGRETOL
carbamazepine
extended-release
clobazam
CARBATROL
clonazepam
KLONOPIN
diazepam
divalproex sodium
cap sprinkle
divalproex sodium
delayed-release
DIASTAT ACUDIAL
ethosuximide
ZARONTIN
exogabine
POTIGA
felbamate
FELBATOL
felbamate oral susp
FELBATOL ORAL SUSP
gabapentin
NEURONTIN
lacosamide
VIMPAT
lamotrigine
LAMICTAL
lamotrigine starter kit
lamotrigine chew
dispersable tab
LAMICTAL STARTER KIT
Generic Drug Name
Parkinson’s Disease
Seizures
TEGRETOL-XR
ONFI
DEPAKOTE SPRINKLE
DEPAKOTE
LAMICTAL CD CHEW TAB
QL = Quantity Limit
brand/
generic
brand/
generic
brand
brand/
generic
generic
brand/
generic
brand/
generic
brand/
generic
brand
brand/
generic
brand/
generic
brand/
generic
brand
brand/
generic
brand
brand/
generic
except tabs
tabs
ST
tabs
rectal gel, QL
Minimum age 2
Age Limits Apply, ST
caps and tabs only
Age Limits Apply, ST
QL
ST = Step Therapy
14
Generic Drug Name
Brand Drug Name
levetiracetam
KEPPRA
methsuximide
CELONTIN
oxcarbazepine
TRILEPTAL
phenobarbital
PHENOBARBITAL
phenytoin
DILANTIN INFATABS
phenytoin sodium
extended
pregabalin
pregabalin
DILANTIN
primidone
MYSOLINE
rufinamide
BANZEL
Covered
Drug
brand/
generic
brand
brand/
generic
brand/
generic
brand/
generic
brand/
generic
brand
brand
brand/
generic
brand
tiagabine
GABITRIL
generic
tiagabine
GABITRIL
brand
topiramate
TOPAMAX
topiramate sprinkle caps
TOPAMAX SPRINKLE
valproic acid
DEPAKENE
vigabatrin oral solution
SABRIL SOLUTION
zonisamide
ZONEGRAN
Miscellaneous
PHENYTEK
LYRICA
LYRICA SOLUTION
brand/
generic
brand/
generic
brand/
generic
brand
brand/
generic
QL, Maximum age of 9
for solution
QL, Maximum age of 9
for suspension
PA
oral solution, PA
tablets only, QL, ST
Age Limits Apply, ST,
2mg & 4mg
Age Limits Apply, ST,
12mg & 16mg
QL
QL, Members ≥ 8 years of age
will require prior authorization.
PA, SP
QL
XENAZINE
brand
PA, SP
isotretinoin
ACCUTANE
generic
PA
azelaic acid
benzoyl peroxide
clindamycin
clindamycin
clindamycin
FINACEA
BENZAC AC
CLEOCIN T
CLEOCIN T
CLEOCIN T
brand
generic
generic
generic
generic
gel
tetrabenazine
Dermatology
Acne Vulgaris
Oral
Topical
QL = Quantity Limit
ST = Step Therapy
15
gel
lotion
soln
Generic Drug Name
erythromycin/benzoyl
peroxide
erythromycin
erythromycin
salicylic acid
sulfacetamide/sulfur
sulfacetamide/sulfur
tretinoin
Bacterial Infections
Brand Drug Name
Covered
Drug
BENZAMYCIN
generic
ERYGEL
T-STAT
NEUTROGENA OIL FREE
ACNE WASH
SULFACET-R
PLEXION
ATRALIN
generic
generic
gel 2%
soln
generic
liquid 2%, OTC
generic
generic
lotion
AVITA
generic
RETIN-A
bacitracin
gentamicin
mupirocin
neomycin/polymyxin B/
bacitracin
silver sulfadiazine
BACITRACIN
GENTAK
BACTROBAN
generic
generic
generic
ointment, 22 gram tube only
NEOSPORIN
generic
OTC
SILVADENE
generic
alclometasone
ACLOVATE
DERMA-SMOOTHE
OIL/FS
SYNALAR
HYTONE
HYTONE
CORTIZONE
CORTIZONE-10 INTENSIVE
HEALING
generic
0.05% crm/oint
generic
oil 0.01%
generic
generic
generic
generic
soln/crm 0.01%
crm 0.5%, 1%, & 2.5%
lotion 1% & 2.5%
crm, oint, lot OTC
generic
crm 0.5% & 1%, OTC
BETA-VAL
SYNALAR
CORDRAN
CUTIVATE
LOCOID
WESTCORT
ELOCON
DERMATOP
KENALOG
generic
generic
brand
generic
generic
generic
generic
generic
generic
crm/oint/lotion 0.1%
crm, oint 0.025%
tape
crm 0.05%, oint 0.005%
crm/oint/soln 0.1%
crm 0.2%
crm/oint/soln 0.1%
crm 0.1%
crm/lot/oint 0.025%
Corticosteroids
Low Potency
fluocinolone acetonide
hydrocortisone
hydrocortisone
hydrocortisone
hydrocortisone/aloe
Medium Potency
betamethasone val
flurandrenolide
fluticasone propionate
hydrocortisone butyrate
hydrocortisone valerate
mometasone furoate
prednicarbate
triamcinolone acetonide
QL = Quantity Limit
OTC
ST = Step Therapy
16
Generic Drug Name
Brand Drug Name
KENALOG
Covered
Drug
generic
DIPROLENE
generic
lotion 0.05%
DIPROLENE AF
generic
crm 0.05%
generic
crm/lotion/oint 0.05%
LIDEX
generic
crm/oint/gel/soln 0.05%
LIDEX E
generic
crm 0.05%
KENALOG
generic
crm 0.5%
DIPROLENE
generic
gel 0.05%
DIPROLENE
generic
oint 0.05%
TEMOVATE
generic
crm/gel/oint/soln 0.05%
ciclopirox
clotrimazole
clotrimazole
clotrimazole with
betamethasone
ketoconazole
miconazole
miconazole
miconazole
nystatin
terbinafine
tolnaftate
PENLAC SOLUTION 8%
LOTRIMIN AF
MYCELEX
generic
generic
generic
OTC
LOTRISONE
generic
NIZORAL
DESENEX
MICATIN
MONISTAT-DERM
MYCOSTATIN
LAMISIL AT
TINACTIN
generic
generic
generic
generic
generic
generic
generic
acitretin
calcipotriene
calcitriol
methoxsalen
salicylic acid
SORIATANE
DOVONEX
VECTICAL
OXSORALEN-ULTRA
SCALPICIN
generic
generic
generic
generic
generic
oral caps, PA
brimonidine
MIRVASO
brand
PA
High Potency
betamethasone
augmented dip
betamethasone
augmented dip
betamethasone
dipropionate
fluocinonide
fluocinonide emulsified
base
Very High Potency
betamethasone dip
augmented
betamethasone dip
augmented
clobetasol propionate
Fungal Infections
Psoriasis
Rosacea
QL = Quantity Limit
crm/oint/lotion 0.1%
ST = Step Therapy
17
2% OTC
OTC
OTC
OTC
liquid 3%
Generic Drug Name
Brand Drug Name
Covered
Drug
metronidazole
METROCREAM
METROGEL
METROLOTION
generic
Scabies and Pediculosis
crotamiton
malathion
permethrin
permethrin
pyrethrins/piperonyl but
Viral Infections
podofilox
salicylic acid 17%/
collodion
EURAX
OVIDE
ELIMITE
NIX CREME RINSE
RID SHAMPOO/
BUTOXIDE SHAMPOO
brand
generic
generic
generic
5%, QL
1%, OTC
generic
4% OTC
CONDYLOX SOL
generic
sol
DUOFILM
generic
OTC
brand
soln/cream, OTC
Miscellaneous
aluminum acetate
aluminum chloride
hexahydrate
ammonium lactate
becaplermin gel
calamine
chloroxine
collagenase oint
fluorouracil
fluorouracil
fluorouracil
hexachlorophene
hydrocortisone
imiquimod 5% cream
ketoconazole
lidocaine
lidocaine
lidocaine
lidocaine/prilocaine
nitroglycerin
HYPERCARE 20%
generic
LAC-HYDRIN
REGRANEX
generic
brand
brand
generic
brand
generic
generic
brand
brand
CAPITROL
SANTYL
CARAC
EFUDEX
FLUOROPLEX
PHISOHEX
PROCTOSOL HC CREAM
2.5%
PROCTOZONE
CREAM-HC 2.5%
ANUSOL HC 2.5%
ALDARA
NIZORAL SHAMPOO
LIDAMANTEL
LMX-4
XYLOCAINE
EMLA
RECTIV
QL = Quantity Limit
crm 12%, lotion 5% & 12%
PA
lotion/ointment, OTC
QL
0.5% cream
1% cream
generic
generic
generic
generic
generic
generic
generic
brand
PA
shampoo 2%
3% cream
4% cream (15 gm tubes), QL
jelly 2%
2.5% cream
0.4% rectal ointment, PA
ST = Step Therapy
18
Generic Drug Name
Covered
Drug
Brand Drug Name
pimecrolimus
ELIDEL
selenium sulfide
SELSUN
tacrolimus
PROTOPIC 0.03%
tacrolimus
PROTOPIC 0.1%
urea 40%
UREA 40% CREAM
AND LOTION
cream QL, ST, Step therapy is not
required for members ages 2-11;
brand
not covered for members less
than 2 years of age
generic
shampoo 2.5%
ointment 0.03% ST, Step
therapy is not required for
generic
members ages 2-11; not
covered for members less
than 2 years of age
ointment 0.1%, ST
generic
(minimum age 16)
generic
cream and lotion
VOSOL OTIC
generic
otic
DOMEBORO OTIC
generic
VOSOL HC OTIC
generic
BENZOTIC
DEBROX
generic
generic
6.5%, OTC
CIPRODEX
brand
PA
CORTISPORIN OTIC
generic
otic
FLOXIN OTIC
generic
Ear, Nose & Throat
Ear
acetic acid
acetic acid/
aluminum acetate
acetic acid/
hydrocortisone
benzocaine/antipyrine
carbamide peroxide
ciprofloxacin/
dexamethasone
hydrocortisone
ofloxacin
Nose
Antihistamines - First Generation, Sedating
CHLOR-TRIMETON
ALLERGY
CHLOR-TRIMETON
chlorpheniramine maleate
SYRUP
clemastine
CLEMASTINE
cyproheptadine
CYPROHEPTADINE
diphenhydramine
diphenhydramine
BENADRYL
hydroxyzine HCL
ATARAX
hydroxyzine pamoate
VISTARIL
chlorpheniramine
extended-release
Antihistamines - Second Generation, Nonsedating
QL = Quantity Limit
generic
12 mg, OTC
generic
2 mg/5 ml, OTC
generic
generic
generic
generic
generic
generic
ST = Step Therapy
19
OTC
Covered
Drug
generic
Generic Drug Name
Brand Drug Name
cetirizine
ZYRTEC
cetirizine chew tab
ZYRTEC CHEWABLE TABLET
levocetirizine
loratadine
XYZAL
ALAVERT
CLARITIN
generic
OTC
OTC, Members ≥ 8 years
authorization.
tabs, ST
generic
OTC
generic
Antihistamines - Others Antihistamine/Decongestant Combinations
azelastine
ASTELIN
generic
TRIOTANN
generic
ACTIFED
generic
spray
Antihistamine/Decongestant Combinations - First Generation
chlorpheniramine/
phenylephrine/
pyrilamine
chlorpheniramine/
pseudoephedrine
OTC
Antihistamine/Decongestant Combinations - Second Generation
cetirizine hydrochloride/
pseudoephedrine
hydrochloride
12 hours
extended-release
ZYRTEC-D
loratadine/
pseudoephedrine
extended-release
ALAVERT ALRG
TAB/SINUS
Nasal Steroids
5 mg-120 mg tablet
generic
OTC
ALAVERT-D
ALLERGY/CONG
FLONASE
NASACORT ALLERGY
triamcinolone nasal spray
24 HOUR
fluticasone
Miscellaneous Nasal
generic
generic
brand
OTC
cromolyn sodium
ipratropium nasal
saline nasal spray 0.65%
NASALCROM
ATROVENT NASAL SPRAY
OCEAN NASAL SPRAY
generic
generic
generic
OTC
QL
OTC
oxymetazoline
AFRIN
NEO-SYNEPHRINE
generic
OTC
phenylephrine
DIMEATAPP DRO
DECONGES
generic
OTC
Miscellaneous Nasal Decongestants
Throat and Mouth
QL = Quantity Limit
ST = Step Therapy
20
Generic Drug Name
Brand Drug Name
chlorhexidine gluconate
lidocaine viscous
pilocarpine
triamcinolone
PERIDEX
XYLOCAINE
SALAGEN
KENALOG IN ORABASE
Covered
Drug
generic
generic
generic
generic
DECADRON
FLORINEF
CORTEF
MEDROL
generic
generic
generic
generic
generic
4mg, 8mg, 16mg, 32mg
generic
syrup
paste
Endocrinology
Adrenal Corticosteroids
cortisone acetate
dexamethasone
fludrocortisone
hydrocortisone
methylprednisolone
prednisolone
prednisolone
prednisolone sodium
phosphate
prednisone
Androgens
PRELONE
ORAPRED
generic
PEDIAPRED
DELTASONE
generic
testosterone cypionate
DEPO-TESTOSTERONE
generic
testosterone enanthate
DELATESTRYL
generic
testosterone gel
topical tube, packet,
and pump bottle
Vials only. Disposable
syringes not covered.
TESTOSTERONE 1% TOPICAL GEL
generic
PA
glucagon, human
recombinant
GLUCAGON
brand
QL
NOVOLOG
brand
QL
NOVOLOG MIX 70/30
brand
QL
LANTUS
brand
QL, ST
TOUJEO SOLOSTAR
brand
NOVOLIN R
RELION R
HUMULIN N
NOVOLIN N
RELION N
brand
brand
brand
brand
brand
Diabetes Mellitus
Glucose Elevating Agents
Insulins
insulin aspart
insulin aspart
protamine 70%/
insulin aspart 30%
insulin glargine
insulin glargine
300 units/ml
insulin human
insulin human
insulin isophane
insulin isophane human
QL = Quantity Limit
ST = Step Therapy
21
OTC, QL
OTC, QL
OTC, QL
OTC, QL
OTC, QL
Generic Drug Name
70%/regular 30%
70%/regular 30%
insulin isophane/regular
insulin lisopro pro/lispro
insulin lisopro prot/lispro
insulin lispro
insulin regular
Covered
Drug
NOVOLIN 70/30
brand
OTC, QL
RELION 70/30
brand
OTC, QL
HUMULIN 70/30
HUMALOG MIX 50/50
HUMALOG MIX 75/25
HUMALOG
HUMULIN R
brand
brand
brand
brand
brand
OTC, QL
QL
QL
QL
OTC, QL
Brand Drug Name
Monitoring- Strips and Kits/Diabetic Supplies
ONE TOUCH SYSTEMS (ULTRA 2, ULTRAMINI,
VERIO, VERIO FLEX, VERIO IQ, VERIO SYNC)
brand
ONE TOUCH TEST STRIPS (ULTRA, VERIO)
brand
Oral Agents
acarbose
canagliflozin
canagliflozin/metformin
chlorpropamide
empagliflozin
empagliflozin/metformin
glimepiride
glipizide
glipizide extended-release
glyburide
glyburide, micronized
linagliptin
linagliptin/metformin
metformin
metformin ER
metformin/glyburide
nateglinide
pioglitazone
pioglitazone/glimepiride
pioglitazone/metformin
pioglitazone/metformin ER
repaglinide
saxagliptin
saxagliptin/metformin
tolazamide
tolbutamide
PRECOSE
INVOKANA
INVOKAMET
DIABINESE
JARDIANCE
SYNJARDY
AMARYL
GLUCOTROL
GLUCOTROL XL
MICRONASE
GLYNASE
TRADJENTA
JENTADUETO
GLUCOPHAGE
GLUCOPHAGE ER
GLUCOVANCE
STARLIX
ACTOS
DUETACT
ACTOPLUSMET
ACTOPLUS MET XR
PRANDIN
ONGLYZA
KOMBIGLYZE
TOLINASE
TOLBUTAMIDE
QL = Quantity Limit
QL for insulin dependent or
pregnant members: allow
testing up to 6 times per day
QL for non-insulin
dependent members: allow
once daily testing
generic
brand
brand
generic
brand
brand
generic
generic
generic
generic
generic
brand
brand
generic
generic
generic
generic
generic
generic
generic
brand
generic
brand
brand
generic
generic
ST = Step Therapy
22
ST
ST
ST
ST
ST
ST
QL
ST
QL, ST
ST
ST
ST
Generic Drug Name
Brand Drug Name
Miscellaneous Antidiabetic Agents
Covered
Drug
albiglutide
liraglutide
pramlintide
TANZEUM
VICTOZA
SYMLIN
brand
brand
brand
ST
ST
PA
mecasermin
somatropin
INCRELEX
NUTROPIN AQ NUSPIN
brand
brand
PA, SP
PA, SP
alendronate
calcitonin-salmon
calcitonin-salmon
calcitonin-salmon
etidronate
raloxifene
teriparatide inj
FOSAMAX
MIACALCIN
MIACALCIN
FORTICAL
DIDRONEL
EVISTA
FORTEO
generic
brand
generic
brand
generic
generic
brand
QL
inj
nasal spray, QL
nasal spray, QL
levothyroxine
levothyroxine
liothyronine
liotrix
methimazole
propylthiouracil
LEVOXYL
SYNTHROID
CYTOMEL
THYROLAR
TAPAZOLE
PROPYLTHIOURACIL
generic
generic
generic
brand
generic
generic
cabergoline
cholic acid
desmopressin
methylergonovine
mifeprstone
pegvisomant
sapropterin
DOSTINEX
CHOLBAM
DDAVP
METHERGINE
KORLYM
SOMAVERT
KUVAN
KUVAN POWDER FOR SOLUTION
generic
brand
generic
generic
brand
brand
brand
brand
PA, SP
diphenoxylate/atropine
loperamide
loperamide
LOMOTIL
IMODIUM A-D
LOPERAMIDE
generic
generic
generic
OTC
aprepitant
EMEND
dronabinol
MARINOL
Growth Stimulating Agents
Osteoporosis
Thyroid Disease
Miscellaneous
sapropterin powder
PA, SP
PA, SP
QL
PA, SP
PA, SP
PA, SP
Gastrointestinal
Diarrhea
Emesis
QL = Quantity Limit
brand
generic
QL applies to 40 mg, 80 mg
and 80-125 mg
PA
ST = Step Therapy
23
Generic Drug Name
Brand Drug Name
meclizine
metoclopramide
ANTIVERT
REGLAN
ZOFRAN
ondansetron
prochlorperazine
promethazine
trimethobenzamide
Covered
Drug
generic
generic
generic
QL
generic
generic
generic
300 mg caps
brand
OTC
MAALOX
generic
OTC
MYLANTA
generic
OTC
TAGAMET
NEXIUM 24HR OTC
generic
brand
ZOFRAN ODT
COMPAZINE
PHENERGAN
TIGAN
Gastroesophageal Reflux Disease (Gerd)/Peptic Ulcers
alginic acid/sodium
bicarbonate
alumina/magnesia
alumina/magnesia/
simethicone
cimetidine
esomeprazole
esomeprazole granules
famotidine
NEXIUM DELAYED
RELEASE PACKET
brand
PEPCID
generic
PEPCID AC
PA
Members ≥ 2 years
authorization.
OTC Pepcid AC 10 mg
and 20 mg also covered/
encouraged with written
prescription.
PA
orally disintegrating tabs,
Members ≥ 2 years
authorization. QL
lansoprazole
PREVACID
generic
lansoprazole
delayed-release
PREVACID SOLUTAB
generic
PRILOSEC
generic
PROTONIX
ZANTAC
ZANTAC
CARAFATE
generic
generic
generic
generic
CARAFATE SUSPENSION
generic
suspension, Members 10
years of age up to 65 years
authorization.
BENTYL
generic
tablets only
omeprazole
delayed-release
pantoprazole
ranitidine
ranitidine syrup
sucralfate
sulcralfate
Gastrointestinal Spasm
dicyclomine
QL = Quantity Limit
Capsules only, QL
150 mg tabs
ST = Step Therapy
24
Generic Drug Name
Brand Drug Name
glycopyrrolate
hyoscyamine sulfate
hyoscyamine sulfate
extended-release
ROBINUL
LEVSIN
Covered
Drug
generic
generic
LEVSINEX
generic
balsalazide
budesonide
hydrocortisone
mesalamine
COLAZAL
ENTOCORT EC
COLOCORT
ROWASA
ASACOL HD
Inflammatory Bowel Disease
mesalamine
extended-release
mesalamine supp
olsalazine sodium
sulfasalazine
sulfasalazine
delayed-release
generic
generic
generic
generic
PA
enema
enema only
APRISO
DELZICOL
brand
LIALDA
PENTASA
CANASA
DIPENTUM
AZULFIDINE
brand
brand
generic
AZULFIDINE EN-TABS
generic
Laxatives
casanthranol-docusate
sodium
docusate calcium plus
docusate potasssium
docusate sodium
glycerin
lactulose
peg 3350/electrolytes
peg 3350/sodium
bicarbonate/sodium
chloride
peg 3350/sodium
bicarbonate/sodium
chloride/potassium
chloride
polyethylene glycol 3350
sennosides
Pancreatic Enzymes
generic
OTC
COLACE
GLYCERIN SUPPOSITORY
ENULOSE
COLYTE
generic
generic
generic
generic
generic
generic
OTC
OTC
OTC
suppository, OTC
TRILYTE
generic
NULYTELY
generic
MIRALAX
SENOKOT
generic
generic
QL = Quantity Limit
ST = Step Therapy
25
8.6 mg tab, OTC
Generic Drug Name
Covered
Drug
Brand Drug Name
CREON
pancrelipase
Miscellaneous
CREON 3000 UNIT
brand
ZENPEP
atropine sulfate
bismuth subsalicylate +
metronidazole +
tetracycline
misoprostol
naloxegol
teduglutide
SAL-TROPINE
brand
HELIDAC
brand
CYTOTEC
MOVANTIK
GATTEX
ACTIGALL
generic
brand
brand
ursodiol
URSO
generic
PA
PA, SP
URSO FORTE
Home Infusion Drugs
Analgesics - NSAIDS
im inj
inj
KETOROLAC INJ
brand
KETOROLAC INJ
brand
fentanyl citrate inj
FENTANYL CIT INJ
brand
morphine sulfate inj
ASTRAMOR INJ
brand
DURAMORPH INJ
brand
MORPHINE SUL INJ
brand
MORPHINE SUL INJ
brand
morphine sulfate iv soln
MORPHINE SUL INJ
brand
amikacin sulfate inj
AMIKACIN INJ
brand
cefazolin sodium for inj
ANCEF INJ
brand
ceftriaxone sodium for inj
CEFTRIAXONE INJ
brand
Analgesics - OPIOD
Antibiotics
QL = Quantity Limit
30 mg/ml, Limited to 14 days
supply every 30 days.
0.05 mg/ml, Limited to 14
days supply every 30 days.
250 mg/ml, Limited to 14
1 gm, Limited to 14 days
ST = Step Therapy
26
Generic Drug Name
Brand Drug Name
Covered
Drug
CEFTRIAXONE INJ
brand
CEFTRIAXONE INJ
brand
CEFTRIAX/DEX INJ
brand
CEFTRIAXONE/INJ DEX
brand
ceftriaxone sodium for iv
soln 1 gm and
dextrose 3.74%
ceftriaxone sodium in
dextrose inj
ciprofloxacin 0.2% in d5w CIPRO I.V. SOL
ciprofloxacin iv soln 1%
brand
CIPRO I.V. INJ
brand
clindamycin phosphate inj CLEOCIN PHOS INJ
brand
imipenem-cilastatin
intravenous for soln
brand
IMIPENEM/CIL INJ
levofloxacin in d5w iv soln
brand
500 mg, Limited to 14 days
Limited to 14 days supply
every 30 days.
every 30 days.
every 30 days.
150 mg/ml, Limited to 14
LEVAQUIN INJ
brand
PIPER/TAZOBA INJ
brand
3-0.375 gm, Limited to 14
PIPER/TAZOBA INJ
brand
4-0.5 gm, Limited to 14 days
ZOSYN SOL
brand
vancomycin hcl for inj
VANCOCIN HCL INJ
brand
vancomycin hcl for inj
VANCOCIN HCL INJ
brand
vancomycin hcl in
dextrose inj
VANCOCIN/DEX INJ
brand
BENA-D-50 INJ
brand
levofloxacin iv soln
piperacillin sodiumtazobactam sodium
for inj
for inj
in dex iv sol
Antihistamines
diphenhydramine hcl inj
QL = Quantity Limit
3-0.375 gm/50 ml,
every 30 days.
500 mg/100 ml,
every 30 days.
ST = Step Therapy
27
Generic Drug Name
Brand Drug Name
Covered
Drug
promethazine hcl inj
ANERGAN 25 INJ
brand
DIAQUA-2 INJ
brand
D5W/NACL INJ
brand
every 30 days.
brand
every 30 days.
Diuretics
furosemide inj
Electrolyte Mixtures
dextrose 5% w/ sodium
chloride 0.45%
Genitourinary Irrigants
sodium chloride irrigation
soln 0.9%
Minerals & Electrolytes
sodium chloride inj
BD POSIFLUSH INJ
brand
sodium chloride inj
SOD CHLORIDE INJ
brand
sodium chloride iv soln
SOD CHLORIDE INJ
brand
dextrose inj
DEXTROSE INJ
brand
dextrose inj
DEXTROSE INJ
brand
AQUA-MEPHYTO INJ
brand
ALBENZA
STROMECTOL
BILTRICIDE
brand
brand
brand
Nutrients
Vitamins
phytonadione inj
0.9%, Limited to 14 days
5%, Limited to 14 days supply
every 30 days.
50%, Limited to 14 days
Infectious Diseases
Anthelmintics
albendazole
ivermectin
praziquantel
Antibacterials
Antituberculosis Agents
aminosalicyclic acid
cycloserine
ethambutol
ethionamide
isoniazid
pyazinamide
rifabutin
PASER
SEROMYCIN
MYAMBUTOL
TRECATOR
ISONIAZID
PYRAZINAMIDE
MYCOBUTIN
QL = Quantity Limit
brand
brand
generic
brand
generic
generic
generic
ST = Step Therapy
28
PA
rifampin
rifapentine
RIFADIN
PRIFTIN
Covered
Drug
generic
brand
cefadroxil
cephalexin
DURICEF
KEFLEX
generic
generic
tabs are not covered
cefaclor
cefprozil
cefuroxime axetil
cefuroxime axetil
CECLOR
CEFZIL
CEFTIN
CEFTIN
generic
generic
generic
brand
tabs
suspension
cefdinir
cefixime
OMNICEF
SUPRAX
generic
brand
400 mg caps only, QL
ciprofloxacin
levofloxacin
ofloxacin
CIPRO
LEVAQUIN
FLOXIN
generic
generic
generic
tablets only
tabs
azithromycin
clarithromycin
clarithromycin ER
erythromycin
delayed-release
erythromycin
delayed-release
erythromycin
ethylsuccinate
erythromycin stearate
erythromycin/sulfisoxazole
ZITHROMAX
BIAXIN
BIAXIN XL
generic
generic
generic
ERYC
generic
Generic Drug Name
Brand Drug Name
Cephalosporins - First Generation
Cephalosporins - Second Generation
Cephalosporins - Third Generation
Fluoroquinolones
Macrolides
Penicillins
amoxicillin
amoxicillin
amoxicillin/clavulanate
ampicillin
dicloxacillin
penicillin VK
Sulfonamides
sulfamethoxazole/
trimethoprim, DS
ERY-TAB
QL
brand
E.E.S.
generic
ERYTHROCIN
PEDIAZOLE
generic
generic
AMOXICILLIN CAPSULES
AND CHEWABLES
AMOXIL SUSP
AUGMENTIN
PRINCIPEN
DICLOXACILLIN
VEETIDS
BACTRIM
generic
generic
generic
generic
generic
generic
Except 500 mg and 875 mg
film-coated tabs.
suspension
generic
BACTRIM DS
QL = Quantity Limit
ST = Step Therapy
29
Generic Drug Name
Tetracyclines
Covered
Drug
Brand Drug Name
minocycline
tetracycline
DOXYCYCLINE
MONOHYDRATE
MINOCIN
SUMYCIN
vancomycin HCl
doxycycline monohydrate
generic
generic
generic
capsules, except 75 mg
VANCOCIN HCL
generic
cap, ST
clotrimazole
fluconazole
griseofulvin microsize
griseofulvin ultramicrosize
itraconazole
itraconazole
ketoconazole
nystatin
terbinafine
voriconazole
MYCELEX
DIFLUCAN
GRIFULVIN V
GRIS-PEG
SPORANOX
SPORANOX
NIZORAL
MYCOSTATIN
LAMISIL
VFEND
generic
generic
generic
generic
generic
brand
generic
generic
generic
generic
troches
QL
ganciclovir
valganciclovir
CYTOVENE
VALCYTE
generic
generic
tabs only
enfuvirtide
FUZEON KIT
brand
SP
adefovir
daclatasvir
entecavir
interferon alfa-2b
interferon alfacon-1
lamivudine
ledipasvir/sofosbuvir
peginterferon alfa-2a
peginterferon alfa-2a
HEPSERA
DAKLINZA
BARACLUDE
INTRON A
INFERGEN
EPIVIR HBV
HARVONI
PEGASYS
PEGASYS PROCLICK
brand
brand
brand
brand
brand
brand
brand
brand
brand
ribavirin
REBETOL/COPEGUS
generic
sofosbuvir
telaprevir
SOVALDI
INCIVEK
brand
brand
acyclovir
valacyclovir
ZOVIRAX
VALTREX
generic
generic
Miscellaneous
Antifungals
Antivirals
Cytomegalovirus Treatment
Entry/Fusion Inhibitors
Hepatitis Treatment
Herpes Treatment
QL = Quantity Limit
caps, PA, QL
soln, PA, QL
QL
PA
PA
PA, SP
PA, SP
PA
PA, SP
PA, SP
200 mg caps and tabs only,
PA, SP
PA, SP
PA, SP
caps, tabs, suspension
ST = Step Therapy
30
Brand Drug Name
Covered
Drug
amantadine
oseltamivir
rimantadine
zanamivir
SYMMETREL
TAMIFLU
FLUMADINE
RELENZA
generic
brand
generic
brand
delavirdine
efavirenz
nevirapine
nevirapine ER
rilpivirine
RESCRIPTOR
SUSTIVA
VIRAMUNE
VIRAMUNE XR
EDURANT
brand
brand
generic
brand
brand
abacavir
abacavir/lamivudine
abacavir/lamivudine/
zidovudine
didanosine
didanosine
delayed-release
emtricitabine
emtricitabine/rilpivirine/
tenofovir
lamivudine
lamivudine/zidovudine
stavudine
zalcitabine
zidovudine
ZIAGEN
EPZICOM
generic
brand
TRIZIVIR
generic
Generic Drug Name
Influenza Treatment
Non-Nucleoside Reverse Transcriptase Inhibitors
except tabs
QL
QL
Nucleoside Analogues Nucleoside Reverse-Transcriptase Inhibitors/and Combinations
VIDEX
brand
VIDEX EC
generic
EMTRIVA
brand
COMPLERA
brand
EPIVIR
COMBIVIR
ZERIT
HIVID
RETROVIR
generic
generic
generic
brand
generic
Nucleoside/Nucleotide Reverse-Transcriptase Inhibitor Combination
cobicistat/elvitegravir/ emSTRIBILD
tricitabine/tenofovir
efavirenz/emtricitabine/
ATRIPLA
tenofovir
emtricitabine/tenofovir
TRUVADA
brand
PA
brand
brand
PA
Nucleotide Analogues Nucleotide Reverse-Transcriptase Inhibitor
tenofovir
VIREAD
brand
amprenavir
atazanavir
AGENERASE
REYATAZ
brand
brand
atazanavir
REYATAZ POWDER
PACKET
brand
darunavir
PREZISTA
brand
Protease Inhibitors
QL = Quantity Limit
Members ≥ 8 years of
age will require prior
authorization
ST = Step Therapy
31
Generic Drug Name
Brand Drug Name
fosamprenavir
indinavir
lopinavir/ritonavir
nelfinavir
ritonavir
saquinavir
saquinavir mesylate
tipranavir
LEXIVA
CRIXIVAN
KALETRA
VIRACEPT
NORVIR
FORTOVASE
INVIRASE
APTIVUS
Miscellaneous
abacavir/dolutegravir/
lamivudine
atovaquone
bedaquiline
cobicistat
chloroquine phosphate
clindamycin
dapsone
darunavir/cobicistat
dolutegravir
etravirine
hydroxychloroquine
linezolid
maraviroc
mefloquine
metronidazole
neomycin sulfate
Covered
Drug
brand
brand
brand
brand
brand
brand
brand
brand
TRIUMEQ
brand
MEPRON
SIRTURO
TYBOST
ARALEN
CLEOCIN
DAPSONE
PREZCOBIX
TIVICAY
INTELENCE
PLAQUENIL
ZYVOX
SELZENTRY
LARIAM
FLAGYL
generic
brand
brand
generic
generic
brand
brand
brand
brand
generic
generic
brand
generic
generic
brand
nitazoxanide suspension
ALINIA SUSPENSION
brand
nitazoxanide tablet
nitrofurantoin
extended-release
nitrofurantoin
macrocrystals
ALINIA
brand
nitrofurantoin susp
palivizumab
paromomycin
povidone-iodine
primaquine
MACROBID
generic
MACRODANTIN
generic
FURADANTIN SUSP
25 MG/5 ML
SYNAGIS
HUMATIN
QL = Quantity Limit
generic
brand
generic
generic
generic
PA
PA
150 mg and 300 mg only
PA
tabs only
PA
PA
ST = Step Therapy
32
OTC
Generic Drug Name
Brand Drug Name
pyrimethamine
raltegravir
raltegravir
trimethoprim
DARAPRIM
ISENTRESS
ISENTRESS CHEWABLE
TRIMETHOPRIM
Covered
Drug
brand
brand
brand
generic
PA
chewable tablet
tabs only
Musculoskeletal
Arthritis
Disease Modifying Anti-Rheumatic Drugs
adalimumab
anakinra
auranofin
azathioprine
azathiprine
certolizumab pegol
etanercept
hydroxychloroquine
leflunomide
methotrexate
penicillamine
sulfasalazine
sulfasalazine
delayed-release
HUMIRA
KINERET
RIDAURA
IMURAN
AZASAN
CIMZIA
ENBREL
PLAQUENIL
ARAVA
acetaminophen
TYLENOL
BAYER
DEPEN TITRATABLE
AZULFIDINE
brand
brand
brand
generic
brand
brand
brand
generic
generic
generic
brand
generic
AZULFIDINE EN-TABS
generic
NSAIDs and Other Analgesics
aspirin
capsaicin
celecoxib
ECOTRIN
PA, SP
OTC
generic
OTC
brand
generic
OTC
PA, QL
brand
PA
generic
IR only
tabs, chew tabs
and susp, OTC
tabs, chew tabs and susp
etodolac
ibuprofen
ADVIL
generic
ibuprofen
indomethacin
ketoprofen
meloxicam
naproxen
MOTRIN
INDOCIN
ORUDIS
MOBIC
NAPROSYN
generic
generic
generic
generic
generic
QL = Quantity Limit
PA, SP
PA, SP
generic
CELEBREX
VOLTAREN 1% TOPICAL
GEL
LODINE
diclofenac 1% gel
PA, SP
PA, SP
ST = Step Therapy
33
IR only
QL
Generic Drug Name
Covered
Drug
Brand Drug Name
oxaprozin
piroxicam
sulindac
ENTERIC COATEDNAPROSYN
DAYPRO
FELDENE
CLINORIL
generic
generic
generic
allopurinol
colchicine
febuxostat
probenecid
ZYLOPRIM
MITIGARE
ULORIC
PROBENECID
generic
brand
brand
generic
chlorzoxazone
cyclobenzaprine
methocarbamol
orphenadrine
extended-release
PARAFON FORTE DSC
FLEXERIL
ROBAXIN
generic
generic
generic
NORFLEX
generic
baclofen
dantrolene
diazepam
tizanidine
BACLOFEN
DANTRIUM
VALIUM
ZANAFLEX
generic
generic
generic
generic
QL
tabs only, QL
desogestrel/EE
norethindrone/EE
MIRCETTE
ORTHO-NOVUM 10/11
generic
generic
QL
QL
levonorgestrel
levonorgestrel
PLAN B
PLAN B ONE STEP
generic
generic
QL
1.5 mg tab
levonorgestrel/EE
SEASONALE
generic
QL
medroxyprogesterone
acetate
DEPO-PROVERA
generic
QL
brand
ring, QL
brand
QL
naproxen delayed release
Gout
brand
Skeletal Muscle Relaxants
Muscle Spasm
Spasticity
ST
OB-GYN
Contraceptives
Biphasic
Emergency Contraception
Extended Cycle
Injectable
Intravaginal
etonogestrel/EE
ortho diaphragm
NUVARING
ORTHO COIL
ORTHO FLAT
ORTHO FLEX
QL = Quantity Limit
ST = Step Therapy
34
Generic Drug Name
Brand Drug Name
Monophasic - 20 mcg Estrogen
levonorgestrel/EE
ALESSE
norethindrone acetate/EE LOESTRIN 1/20
norethindrone acetate/EE/
LOESTRIN FE 1/20
iron
Covered
Drug
generic
generic
0.1/20, QL
1/20, QL
generic
1/20, QL
desogestrel/EE
levonorgestrel/EE
norethindrone acetate/EE
norethindrone acetate/EE/
iron
norgestrel/EE
ORTHO-CEPT
NORDETTE
LOESTRIN 1.5/30
generic
generic
generic
0.15/30, QL
0.15/30, QL
1.5/30, QL
LOESTRIN FE 1.5/30
generic
1.5/30, QL
LO/OVRAL
generic
0.3/30, QL
ethynodiol diacetate/EE
norethindrone/EE
norethindrone/EE
norethindrone/EE
norgestimate/EE
ZOVIA 1/35
BALZIVA
MODICON
ORTHO-NOVUM 1/35
ORTHO-CYCLEN
generic
generic
generic
generic
generic
1/35, QL
0.4/35, QL
0.5/35, QL
1/35, QL
0.25/35, QL
ethynodiol diacetate/EE
norethindrone/EE
norethindrone/ME
norgestrel/EE
ZOVIA 1/50
OVCON 50
ORTHO-NOVUM 1/50
OVRAL
generic
generic
generic
generic
1/50, QL
1/50, QL
1/50, QL
0.5/50, QL
norethindrone
norgestrel
ORTHO MICRONOR
OVRETTE
generic
generic
norelgestromin/EE
ORTHO EVRA
generic
desogestrel/EE
levonorgestrel/EE
norethindrone
acetate/EE/iron
norethindrone/EE
norethindrone/EE
norgestimate/EE
CYCLESSA
TRIVORA
generic
generic
QL
QL
ESTROSTEP FE
generic
QL
ORTHO-NOVUM 7/7/7
TRI-NORINYL
ORTHO TRI-CYCLEN
generic
generic
generic
QL
QL
QL
danazol
DANOCRINE
generic
Gender edits apply: for female
patients only
Progestin
Transdermal
Triphasic
Endometriosis
Hormone Therapy/Menopause
Estrogens - Intravaginal
estradiol
estrogens, conjugated
ESTRACE CRM
PREMARIN
QL = Quantity Limit
brand
brand
ST = Step Therapy
35
crm
Brand Drug Name
Covered
Drug
estradiol
estrogens, conjugated
estrogens, conjugated,
synthetic A
synthetic B
estropipate
ESTRACE
PREMARIN
generic
brand
CENESTIN
brand
ENJUVIA
brand
OGEN
generic
estradiol
CLIMARA
generic
Generic Drug Name
Estrogens - Oral
Estrogens - Transdermal
Estrogen/Progestin
estrogens, conjugated/me- PREMPHASE
droxyprogesterone
PREMPRO
QL
brand
Progestins
medroxyprogesterone
acetate
norethindrone acetate
PROVERA
generic
AYGESTIN
generic
fluconazole
metronidazole
DIFLUCAN
FLAGYL
generic
generic
QL
tabs
clindamycin
clotrimazole
CLEOCIN
GYNE-LOTRIMIN
METROGEL-VAGINAL
generic
generic
crm
OTC
Vaginal Infections
Oral
Vaginal
metronidazole
miconazole
miconazole
terconazole
Miscellaneous
conjugated estrogen/
bazedoxifene
methylergonovine
tranexamic acid
generic
METROGEL 1%
MONISTAT
MONISTAT 3
TERAZOL 3/7
generic
generic
generic
DUAVEE
OTC
crm
brand
METHERGINE
LYSTEDA
generic
generic
OPTIVAR
CROLOM
ALAWAY OTC
VASOCLEAR
generic
generic
brand
generic
brand
PA
Ophthalmic
Allergy
azelastine
cromolyn sodium
ketotifen
naphazoline HCL
naphazoline/antazoline
QL = Quantity Limit
ST = Step Therapy
36
ST
QL
soln 0.02%
Generic Drug Name
naphazoline/glycerin
naphazoline/zinc sulfate
tetrahydrozoline/
zinc sulfate
Covered
Drug
Brand Drug Name
CLEAR EYES REDNESS
RELIEF
VASOCLEAR A
VISINE-AC
generic
generic
generic
Anti-Inflammatories
Anti-Infective/Anti-Inflammatory Combinations
gentamicin/prednisolone
acetate
dexamethasone
hydrocortisone
sulfacetamide/pred. phos.
tobramycin/
dexamethasone
PRED-G
brand
MAXITROL
generic
CORTISPORIN
generic
VASOCIDIN
generic
TOBRADEX
generic
VOLTAREN
OCUFEN
ACULAR/ACULAR LS
generic
generic
generic
DEXASOL
generic
FML
FML FORTE
FML LIQUIFILM
PRED MILD
PRED FORTE
INFLAMASE FORTE
VEXOL
brand
brand
generic
brand
generic
generic
brand
carteolol
levobunolol
metipranolol
timolol
timolol hemihydrate
timolol maleate
BETAGAN
OPTIPRANOLOL
TIMOPTIC XE
BETIMOL
TIMOPTIC
generic
generic
generic
generic
brand
generic
dorzolamide
TRUSOPT
generic
Nonsteroidal
diclofenac sodium
flurbiprofen
ketorolac
Steroidal
dexamethasone sodium
phosphate
fluorometholone
fluorometholone
fluorometholone
prednisolone acetate
prednisolone acetate
prednisolone phosphate
rimexolone
Glaucoma
Beta-Blockers
Carbonic Anhydrase Inhibitors
QL = Quantity Limit
10%/0.25%
oint 0.1%
susp 0.25%
susp 0.1%
0.12%
1%
1%
ophthalmic solution
0.3% ophthalmic solution
gel forming solution
ST = Step Therapy
37
Generic Drug Name
Covered
Drug
Brand Drug Name
Carbonic Anhydrase Inhibitor/Beta-Blocker Combination
dorzolamide/
timolol maleate
COSOPT
ecothiophate
PHOSPHOLINE IODINE
brand
atropine
cyclopentolate
homatropine
scopolamine
ISOPTO ATROPINE
CYCLOGYL
ISOPTO HOMATROPINE
ISOPTO HYOSCINE
generic
generic
generic
brand
acetazolamide
acetazolamide
extended-release
methazolamide
ACETAZOLAMIDE
generic
DIAMOX SEQUELS
generic
NEPTAZANE
generic
latanoprost
XALATAN
generic
pilocarpine
pilocarpine
ISOPTO CARPINE
PILOPINE HS GEL
generic
brand
brimonidine
brimonidine
ALPHAGAN P
BRIMONIDINE
brand
generic
CILOXAN
ERYTHROMYCIN
ZYMAR
GENTAK
generic
generic
generic
brand
generic
NEOSPORIN
generic
OCUFLOX
POLYSPORIN
POLYTRIM
BLEPH-10
generic
generic
generic
generic
Cholinesterase Inhibitor
Mydriatics
Oral
Prostaglandins
generic
Topical - Parasympathomimetics
Topical - Sympathomimetics
Infections
Bacterial
bacitracin
ciprofloxacin
erythromycin
gatifloxin
gentamicin
gramicidin
ofloxacin
polymyxin B/bacitracin
polymyxin B/trimethoprim
sulfacetamide
sulfacetamide/
phenylephrine
tobramycin
Viral
trifluridine
VASOSULF
brand
TOBREX
generic
VIROPTIC
generic
QL = Quantity Limit
ST = Step Therapy
38
QL
0.2%
PA
oint/soln
Covered
Drug
CYSTARAN
brand
PA, SP
MURO 128
generic
soln 5%
acamprosate
disulfiram
naltrexone
CAMPRAL
ANTABUSE
REVIA
brand
generic
generic
alprazolam
chlordiazepoxide
clonazepam
clorazepate
diazepam
lorazepam
oxazepam
XANAX
LIBRIUM
KLONOPIN
TRANXENE
VALIUM
ATIVAN
SERAX
generic
generic
generic
generic
generic
generic
generic
buspirone
fluvoxamine
BUSPAR
LUVOX
generic
generic
ADDERALL
generic
Age Limits Apply, QL
brand
DEXEDRINE
DEXTROSTAT
generic
brand
Age Limits Apply, QL,
DEXEDRINE SPANSULE
generic
INTUNIV
VYVANSE
generic
brand
methylphenidate
RITALIN
generic
methylphenidate
extended-release
CONCERTA
generic
Generic Drug Name
Brand Drug Name
Miscellaneous Ophthalmics
cysteamine 0.44%
ophthalmic solution
sodium chloride
hypertonic
Psychiatric
Alcohol Deterrents
Anxiety
Benzodiazepines
Miscellaneous
QL, IR only
not wafers
QL
QL
QL
Attention Deficit Hyperactivity Disorder (ADHD) - Diagnosis required
amphetamine/
dextroamphetamine
mixed salts
amphetamine/
dextroamphetamine
mixed salts
extended-release
dextroamphetamine
dextroamphetamine
dextroamphetamine
extended-release
guanfacine ER
lisdexamfetamine
ADDERALL XR
(BRAND ADDERALL XR
IS PREFERRED)
QL = Quantity Limit
Age Limits Apply,
tabs only, QL
ST = Step Therapy
39
Generic Drug Name
methylphenidate
extended-release
Bipolar Disorder
divalproex sodium
cap sprinkle
divalproex sodium
delayed-release
lithium carbonate
lithium carbonate
extended-release
Covered
Drug
generic
DEPAKOTE SPRINKLE
generic
DEPAKOTE
generic
Minimum age 2
LITHIUM CARBONATE
ESKALITH CR
generic
Brand Drug Name
METADATE ER
RITALIN-SR
RITALIN LA
LITHOBID
Depression
Monoamine Oxidase Inhibitor (MAOI)
generic
tranylcypromine
PARNATE
generic
citalopram
escitalopram
CELEXA
LEXAPRO
generic
generic
fluoxetine
PROZAC
generic
paroxetine
sertraline
PAXIL
ZOLOFT
generic
generic
10 mg and 20 mg caps and
20 mg soln only
tablets
tablets, QL
duloxetine
venlafaxine
venlafaxine XR
CYMBALTA
EFFEXOR
EFFEXOR XR
generic
generic
generic
QL
QL
QL
amitriptyline
amoxapine
desipramine
doxepin
imipramine HCL
nortriptyline
ELAVIL
generic
generic
generic
generic
generic
generic
tablets
Selective Serotonin Reuptake Inhibitor (SSRIs)
Serotonin Norepinephrine Reuptake Inhibitors (SNRIs)
Tricyclic Antidepressants (TCAs)
NORPRAMIN
SINEQUAN
TOFRANIL
PAMELOR
Tricyclic Antidepressant/Phenothiazine Combination
amitriptyline/perphenazine TRIAVIL
Miscellaneous Agents
bupropion
bupropion
extended-release
bupropion
extended-release
QL
tablets
generic
WELLBUTRIN
generic
WELLBUTRIN SR
generic
QL
WELLBUTRIN XL
generic
150 mg and 300 mg
QL = Quantity Limit
ST = Step Therapy
40
Generic Drug Name
Brand Drug Name
maprotiline
mirtazapine
trazodone
LUDIOMIL
REMERON
DESYREL
Covered
Drug
generic
generic
generic
flurazepam
temazepam
triazolam
DALMANE
RESTORIL
HALCION
generic
generic
generic
QL
15 mg and 30 mg only, QL
QL
chloral hydrate
diphenhydramine
zaleplon
zolpidem
CHLORAL HYDRATE
NYTOL QUICK CAPS
SONATA
AMBIEN
generic
generic
generic
generic
OTC
QL
QL
buprenorphine
SUBUTEX
generic
buprenorphine/naloxone
SUBOXONE
naloxone
naltrexone
NALOXONE INJ
REVIA
aripiprazole
aripiprazole
aripiprazole ER injection
asenapine
ABILIFY
ABILIFY DISCMELT
ABILIFY MAINTENA
SAPHRIS
CLOZARIL
Insomnia
Benzodiazepines
Non-Benzodiazepines
Narcotic Antagonists
brand
generic
generic
Psychoses - Diagnosis required
Atypicals
clozapine
generic
brand
brand
brand
brand and
generic
brand
brand
brand
generic
brand
brand and
generic
generic
brand
brand
brand and
generic
brand
FAZACLO
clozapine oral suspension VERSACLOZ
iloperidone
FANAPT
lurasidone
LATUDA
olanzapine
ZYPREXA
olanzapine
ZYPREXA RELPREVV
olanzapine
ZYPREXA ZYDIS
paliperidone
paliperidone
paliperidone
INVEGA
INVEGA SUSTENNA
INVEGA TRINZA
quetiapine
SEROQUEL
quetiapine
SEROQUEL XR
risperidone
RISPERDAL
risperidone
RISPERDAL CONSTA
QL = Quantity Limit
generic
brand
tabs (not soltabs)
150 mg only
PA, QL
2 mg and 8 mg film only,
PA, QL
QL
Age Limit Applies, tablets
Age Limit Applies
Age Limit Applies, PA, QL
Age Limit Applies
Age Limit Applies
Age Limit Applies
Age Limit Applies
Age Limit Appplies
Age Limit Applies, tablets
Age Limit Applies
Age Limit Applies
Age Limit Applies
Age Limit Applies
Age Limit Applies
Age Limit Applies
Age Limit Applies, QL,
(Not M-Tabs)
Age Limit Applies
ST = Step Therapy
41
Covered
Drug
brand and
generic
generic
Generic Drug Name
Brand Drug Name
risperidone oral soln
RISPERDAL SOLUTION
ziprasidone
GEODON
nicotine
nicotine polacrilex gum
nicotine polacrilex lozenge
varenicline
NICODERM CQ
NICORETTE OTC
COMMITT OTC
CHANTIX
orlistat
ALLI
chlorpromazine
dextromethorphan/
quinidine
fluphenazine
fluphenazine decanoate
haloperidol
haloperidol decanoate
loxapine
molindone
perphenazine
pimozide
prochlorperazine
thioridazine
thiothixene
trifluoperazine
THORAZINE
generic
NUEDEXTA
brand
Smoking Cessation
Weight Loss
Miscellaneous
PROLIXIN
PROLIXIN DECANOATE
HALDOL
HALDOL DECANOATE
LOXITANE
MOBAN
TRILAFON
ORAP
COMPAZINE
MELLARIL
NAVANE
STELAZINE
Age Limit Applies
Age Limit Applies
generic
generic
generic
brand
patches, QL
QL
QL
QL
brand
OTC
PA
generic
generic
generic
generic
generic
brand
generic
generic
generic
generic
generic
generic
Respiratory Drugs
Antitussives, Decongestants, Expectorants and Combinations
benzonatate
brompheniramine &
phenylephrine
brompheniramine/
pseudoephedrine
brompheniramine/
pseudoephedrine
brompheniramine/
pseudoephedrine
TESSALON
DIMETAPP CLD
ELX/ALLERGY
ACCUHIST DROPS
generic
generic
generic
RESPERAL-DM
BROMFENEX PD CAP
DIMETAPP ELX
CLD/ALLE
liquid
generic
UNI-HIST DRO
CARDEC SYP
RONDEC SYRUP
QL = Quantity Limit
generic
ST = Step Therapy
42
syrup
Generic Drug Name
brompheniramine/
pseudoephedrine/
dextromethorphan
brompheniramine/
pseudoephedrine/
dextromethorphan
brompheniramine/
pseudoephedrine/
dextromethorphan
brompheniramine/
pseudoephedrine/
dextromethorphan/
guaifenesin
carbetapentane/
chlorpheniramine/
ephedrine/
phenylephrine
carbinoxamine/
pseudoephedrine
chlorphen-PEmethscopolamine
chlorphen tan/
carbetapentane tan
chlorphen tan/
pseudoeph tan
chlorphen tan/
pyrilamine tan/PE tan
chlorpheniramine/
dextromethorphan
Brand Drug Name
Covered
Drug
ACCUHIST PDX DROPS
generic
liquid
BROMALINE DM
generic
elixir
generic
syrup
HISTACOL DM
generic
syrup
RYNATUSS
generic
RONDEC DROPS
generic
liquid
generic
syrup
TUSSI-12 S
generic
susp
TANAFED
generic
susp
TRIOTANN PEDIATRIC
SUSP
generic
susp
BROMFED DM
DALLERGY DM
CARBOFED
NEO DM
ANAPLEX DM
DURADRYL
QV-ALLERGY
R-TANNAMINE
ROBITUSSIN PED LIQ
CGH/COLD
ROBITUSSIN LIQ
CGH/CLD
generic
DIMETAPP SYP CGH/CLD
CORICIDIN TAB
CGH/CLD
chlorpheniramine maleate ED A-HIST TABLETS AND
phenylephrine HCL
LIQUID
QL = Quantity Limit
generic
ST = Step Therapy
43
Generic Drug Name
Brand Drug Name
chlorpheniramine/
phenylephrine
chlorpheniramine/
phenylephrine
chlorpheniramine/
pseudoephedrine
chlorpheniramine tan/
phenylephrine tan
codeine/
chlorpheniramine/
pseudoephedrine
RONDEC DROPS
codeine/guaifenesin
GG/CODEINE
CARDEC DRO
RONDEC SYRUP
CARDEC SYP
HISTEX
Covered
Drug
generic
liquid
generic
syrup
generic
CPM/PSE
RYNATAN PEDIATRIC SUSP
DIHISTINE DH
generic
susp
generic
PHENYLHIST LIQ DH
GUIATUSS AC
generic
QL
M-CLEAR WC
codeine/guaifenesin/pseuGUIATUSS DAC
doephedrine
PROMETHAZINE
codeine/promethazine
W/CODEINE
codeine/promethazine/
PROMETHAZINE VC
phenylephrine
W/CODEINE
dextromethorphan/
brompheniramine/
BROMETANE DX
pseudoephedrine
dextromethorphan/
carbinoxamine/
CARDEC-DM
pseudoephedrine
dextromethorphanDURATUSS DM ELX
guaifenesin
GG/DM CR
dextromethorphan/
guaifenesin
dextromethorphanguaifenesin
dextromethorphan hbr
dextromethorphan
polistirex
extended-release
generic
QL
generic
QL
generic
MUCINEX DM
ROBITUSSIN DM
TUSSIN DM
ROBITUSSIN LIQ CGH/
CONG
ROBITUSSIN SYP MAX-ST
ROBITUSSIN PED SYP
DELSYM
QL = Quantity Limit
generic
generic
drops
generic
soln 25-225 mg/5 ml
generic
OTC
generic
liq 10-200 mg/ 5 ml
generic
syrup
brand
OTC
ST = Step Therapy
44
Generic Drug Name
Brand Drug Name
dextromethorphan/
promethazine
PHENERGAN DM
guaifenesin
guaifenesin
guaifenesin
extended-release
guaifenesin/
pseudoephedrine
guaifenesin/
pseudoephedrine/
dextromethorphan
guaifenesin/
pseudoephedrine
extended-release
guaifenesin/
pseudoephedrine
extended-release
hydrocodone/
chlorpheniramine/
phenylephrine
hydrocodone/guaifenesin
hydrocodone/
homatropine
loratadine &
pseudoephedrine SR
24 hr
phenyleph/bromphen/
dextromethorphan/
guaifenesin
phenylephrine/
brompheniramine/
dextromethorphan
phenylephrine/
chlorpheniramine
Covered
Drug
PROMETHAZINE SYP DM
ROBITUSSIN SYP
CHST CNG
ROBITUSSIN
MUCINEX
ROBITUSSIN PE
PSE/GG
generic
generic
syrup 100 mg/5 ml
generic
OTC
generic
OTC
generic
syrup, OTC
ROBITUSSIN CF
generic
GUAIFED
generic
GUAIFEN PSE
MUCINEX D
generic
OTC
GG/PSE CR
HISTUSSIN HC
generic
VITUSSIN
HYDROCODO/GG SYP
HYCODAN
HYDROMET SYP
generic
generic
HYDROCODONE/
TAB HOMATROP
ALLERGY/CONG TAB RELIEF
generic
ALLANHIST SYP PDX
generic
generic
QUAL-TUSSIN SYP DC
QL = Quantity Limit
generic
ST = Step Therapy
45
tab 10-240 mg
OTC
Generic Drug Name
Brand Drug Name
phenylephrine/
chlorpheniramine/
dextromethorphan
ATUSS DR
phenylephrine/
chlorpheniramine/
dextromethorphan
STATUSS DM SYP
phenylephrine/
chlorpheniramine/
dextromethorphan
phenylephrine/
chlorpheniramine/
dihydrocodeine
phenylephrine/
dextromethorphan
phenylephrine/
dextromethorphan/
guaifenesin
phenylephrine/
ephed/CPM
w/carbetapentane
phenylephrine/guaifenesin
phenylephrine/
hydrocodone/
guaifenesin
phenylephrine/
pyrilamine/
dextromethorphan
phenylephrine/pyrilamine
w/hydrocodone
phenylephrine tan/
pyrilamine tan/
carbeta tan
promethazine &
phenylephrine
pseudoephedrine/
acetaminophen/
dextromethorphan
DE-CHLOR DM
Covered
Drug
generic
syrup
generic
syrup
generic
liquid
RONDEC DM
CARDEC DM SYP
MINUTUSS DR SYP
RONDEC DM DROPS
CARDEC DM DRO
ROBITUSSIN LIQ
CGH/ALRG
DIHYDRO-PE SYP
generic
DIMETAPP DRO
DCON/CGH
generic
ROBITUSSIN LIQ
CGH/CLD
generic
RYNATUSS PEDIATRIC
SUSP
generic
ROBITUSSIN LIQ
HD/CHST
generic
QUAL-TUSSIN SYP DC
generic
CODAL-DM
generic
CODIMAL DH
generic
syrup
TUSSI 12D S
generic
susp
PROMETH VC SYP
6.25-5/5
generic
syrup 6.25-5 mg/ 5 mg
MAPAP COLD TAB
generic
QL = Quantity Limit
susp
ST = Step Therapy
46
Generic Drug Name
pseudoephedrine/
chlorpheniramine/
dextromethorphan
pseudoephedrine/
dextromethorphan/
guaifenesin
pseudoephedrine/
iburprofen
pseudoephedrine tan/
dexchlorphen tan/
DM tan
pyrilamine tan/
phenyleph tan
tripolidine/
pseudoephedrine
Asthma/COPD
Inhalers - Beta Agonists
Covered
Drug
Brand Drug Name
PEDIACARE LIQ
MULTI-SY
generic
ROBITUSSIN LIQ PED
NGHT
MULTI SYMPTOM TAB
COLD RLF
generic
CHILD IBUPRO
SUS COLD
IBUOROFEN TAB
COLD/SIN
TANAFED DMX
SUSPENSION
generic
generic
susp
generic
susp
TRI-FED X
RYNA-12 S
TRIPROL/PSE SYP
generic
APHEDRID TAB
albuterol sulfate
indacaterol
olodaterol
VENTOLIN HFA
ARCAPTA NEOHALER
STRIVERDI RESPIMAT
brand
brand
brand
QL
fluticasone furoate
fluticasone HFA
mometasone
mometasone inhalation
ARNUITY ELLIPTA
FLOVENT HFA
ASMANEX TWISTHALER
ASMANEX HFA
brand
brand
brand
brand
QL
QL, Age Limit Applies
QL
QL
fluticasone/vilanterol
mometasone/formoterol
BREO ELLIPTA
DULERA
brand
brand
ST
ST
cromolyn
ipratropium/albuterol
ipratropium HFA
nedocromil
omalizumab
umeclidinium inhalation
umeclidinium/vilanterol
INTAL
COMBIVENT
COMBIVENT RESPIMAT
ATROVENT HFA
TILADE
XOLAIR
INCRUSE ELLIPTA
ANORO ELLIPTA
brand
brand
brand
brand
brand
brand
brand
brand
QL
QL
inhaler
Inhalers - Corticosteroids
Inhalers - Corticosteroid/Beta Agonist Combinations
Inhalers - Others
QL = Quantity Limit
ST = Step Therapy
47
PA, SP
Generic Drug Name
Covered
Drug
Brand Drug Name
Inhalers for Nebulization
0.63 mg/3 ml and 1.25 mg /3
ml, Covered for members less
than 8 years of age. Members
≥ 8 years of age will require
soln 0.083%, 0.5%
susp, Members ≥ 5 years
authorization. QL
soln, QL
soln, QL
soln
QL, ST
albuterol
ACCUNEB
generic
albuterol
PROVENTIL
generic
budesonide
PULMICORT RESPULES
generic
cromolyn
ipratropium
levalbuterol HCl
INTAL
ATROVENT
DUONEB
XOPENEX RESPULES
generic
generic
generic
generic
metaproterenol
terbutaline
METAPROTERENOL SYRUP generic
BRETHINE
generic
montelukast
SINGULAIR
generic
QL
theophylline
theophylline
extended-release
theophylline
extended-release
theophylline
extended-release
theophylline
extended-release
THEOPHYLLINE
generic
liquid
brand
caps
THEOCHRON
generic
tabs
THEOPHYLLINE EXT-REL
generic
caps (12 hr)
UNIPHYL
generic
tabs
Oral Agents - Beta Agonists
Oral Agents - Leukotriene Modifiers
Oral Agents - Theophylline
THEO-24
Urological
Symptomatic Benign Prostatic Hypertrophy
alfuzosin ER
doxazosin
finasteride
tamsulosin
terazosin
UROXATRAL
CARDURA
PROSCAR
FLOMAX
HYTRIN
generic
generic
generic
generic
generic
bethanechol
URECHOLINE
generic
Miscellaneous
QL = Quantity Limit
ST = Step Therapy
48
Generic Drug Name
Covered
Drug
Brand Drug Name
hyoscyamine,
methenamine,
phenyl salicylate,
UTIRA C
sodium phosphate
monobasic, methylene
blue
HIPREX
methenamine hippurate
UREX
oxybutynin chloride
DITROPAN XL
oxybutynin IR
DITROPAN
potassium citrate
UROCIT-K
propantheline
phenazopyridine
PYRIDIUM
sodium citrate/citric acid BICITRA
tolterodine
DETROL
trospium
SANCTURA
brand
generic
generic
generic
generic
generic
generic
generic
generic
generic
QL, ST
ST
ST
Vitamins and Minerals
calcitriol
ROCALTROL
generic
calcitriol oral soln
ROCALTROL SOLUTION
generic
calcium
cholecalciferol
generic
brand
cholecalciferol
cholecalciferol
cholecalciferol
cholecalciferol
cholecalciferol
cholecalciferol
OS-CAL
BIO-D DRO-MULSION
BIO-D-MULSIO
DRO FORTE
D3-50 CAP
VITAMIN D CAP 400 UNIT
VITAMIN D CAP 2000 UNIT
VITAMIN D TAB 400 UNIT
cyanocobalamin
VITAMIN B-12
generic
electrolyte
PEDIALYTE
generic
cholecalciferol
QL = Quantity Limit
brand
brand
brand
brand
brand
brand
brand
OTC
drops 400 unit/0.03 ml, OTC
drops 2000 unit/0.03 ml,
OTC
cap 50000 unit, OTC
cap 400 unit, OTC
cap 2000 unit, OTC
tab 400 unit, OTC
tab 1000 unit, OTC
tab 2000 unit, OTC
inj, Coverage for these
medications will be
determined by the member’s
individual benefits.
Please refer to individual
plan documents for coverage
information.
soln, oral, OTC
ST = Step Therapy
49
Generic Drug Name
ergocalciferol (D2)
ferrous bisglycinate/
polysaccarides iron
ferrous sulfate
Covered
Drug
DRISDOL
generic
Coverage for these
medications will be
information.
NIFEREX
generic
caps, OTC
FEOSOL
GEL-KAM
generic
OTC
Coverage for these
medications will be
information.
Brand Drug Name
LURIDE
fluoride
LURIDE LOZI-TABS
generic
PREVIDENT
PHOS-FLUR
folic acid
FOLIC ACID
generic
magnesium oxide
MAG-OX
generic
multivitamins/
fluoride/±iron
POLY-VI-FLOR
generic
multivitamins/minerals
CENTRUM
generic
phytonadione
MEPHYTON
brand
QL = Quantity Limit
OTC, Coverage for these
medications will be
information.
Coverage for these
medications will be
information.
medications will be
information.
ST = Step Therapy
50
Generic Drug Name
polysaccharide iron
complex
prenat-FE Bis-FE
prot succ-FA-CA
& omega 3
prenat-FE Bis-FE
prot succ-FA-CA
& omega 3
prenat-FE Bis-FE
prot succ-FA-CA
& omega 3
prenat-FE bis-FE
prot succ-FA-CA
& omega DR
prenat w/o A w/fecbn-feglDSS-FA & DHA
prenatal vit w/FE
bisglycinate
chelate-FA
prenatal vit w/FE
bisglycinate
chelate-FA
prenatal vit w/FE
bisglycinate
chelate-FA
prenatal vit w/FE
bisglyc-FE prot
succ-FA
prenatal vit w/FE polysac
cmplx-FA
prenatal vit w/iron
carbonyl-FA
prenatal vitamins
w/folic acid
Brand Drug Name
Covered
Drug
NIFEREX
generic
elixir, OTC
COMPLETE NATALCARE
PAK DHA
brand
TRUST NATALCARE
PAK DHA
brand
PRUET DHA PAK
SETONET PAK
brand
PRUET DHAEC PAK
brand
FOLTABS PAK PLUS DHA
RE OB + DHA PAK
brand
GENTEX ADE 28-1 MG
brand
VINATE AZ EX
brand
VITAPHIL
brand
VINATE III
brand
EDGE OB CHW
brand
ATABEX PRENATAL
brand
PRENATAL VITAMINS
W/ FOLIC ACID
CENOGEN OB/ULTRA
MATERNA
generic
NATALCARE
NESTABSCBF/FA/RX
NIFEREX-PN FORTE
QL = Quantity Limit
ST = Step Therapy
51
QL
Covered
Drug
Generic Drug Name
Brand Drug Name
prenatal w/o A w/FE
carbonyl-FE
gluc-DSS-FA
vitamin A
FOLTABS PRENATAL
brand
TRI RX
generic
vitamin ADC/fluoride/±iron
TRI-VI-FLOR
drops
generic
vitamin B complex/
vitamin C/folic acid
generic
NEPHROCAPS
vitamin B-1
vitamin B-6
vitamin C
vitamins pediatric
generic
generic
generic
TRI-VI-SOL
generic
zinc
Potassium
generic
OTC
Coverage for these
medications will be
information.
Coverage for these
medications will be
information.
OTC
OTC
OTC
members <3 years old,
medications will be
information.
OTC
phosphorus
potassium acid phosphate
potassium bicarbonate/
potassium citrate
effervescent
potassium chloride
potassium chloride
K-PHOS NEUTRAL
K-PHOS ORIGINAL
generic
brand
tabs
K-LYTE
generic
tabs
K-LOR
POTASSIUM CHLORIDE
K-DUR 10
generic
generic
powder
liquid
potassium chloride
extended-release
K-DUR 20
generic
tabs
KLOR-CON 8
KLOR-CON 10
QL = Quantity Limit
ST = Step Therapy
52
Generic Drug Name
potassium chloride
extended-release
potassium iodide
Brand Drug Name
Covered
Drug
MICRO-K 10
generic
caps
PIMA
brand
Miscellaneous
Anaphylaxis
epinephrine
EPIPEN
EPIPEN JR.
brand
QL
brand
brand
PA, SP
PA, SP
generic
brand
brand
PA, SP
PA, SP
brand
PA, SP
brand
brand
PA, SP
PA, SP
TWINJECT
Cryopyrin — Associated Periodic Syndromes (CAPS)
canakinumab
rilonacept
ILARIS
ARCALYST
acetylcysteine
aztreonam
dornase alfa
MUCOMYST
CAYSTON
PULMOZYME
KALYDECO
Cystic Fibrosis
ivacaftor
lumacaftor/ivacaftor
tobramycin neb soln
KALYDECO GRANULES
ORKAMBI
BETHKIS
icatibant
C1 Inhibitor, Human
FIRAZYR
BERINERT
brand
brand
PA, SP
PA, SP
calcium acetate
cinacalcet
sevelamer
PHOSLO
SENSIPAR
RENVELA
generic
brand
generic
667 mg tablet only
PA
ST
nintedanib
pirfenidone capsule
OFEV
ESBRIET
brand
brand
PA, SP
PA, SP
eltromobpag
PROMACTA
brand
PA, SP
Hereditary Angioedema
Hyperphosphatemia
Idiopathic Pulmonary Fibrosis (IPF)
Immune Thrombocytopenic Purpura
Medical Devices
Spacers
Metabolic Modifiers
carglumic acid
glycerol phenylbutyrate
sodium phenylbutyrate
oral powder
QL
CARBAGLU
RAVICTI
BUPHENYL ORAL
POWDER
QL = Quantity Limit
brand
brand
PA, SP
PA, SP
generic
PA
ST = Step Therapy
53
Generic Drug Name
Covered
Drug
FLUMIST QUAD
brand
QL
FLUBLOK
brand
QL
AFLURIA, FLUZONE SPLT
brand
QL
FLUZONE HD PF
brand
QL
AFLURIA PF
brand
QL
FLUZONE QUAD
brand
QL
brand
QL
FLUVIRIN
brand
QL
PREVNAR 13
brand
QL
brand
QL
brand
brand
capsules
QL, Age Limits Apply
Brand Drug Name
Vaccine
influenza virus vaccine live
quadrivalent intranasal
influenza virus vaccine
recombinant hemagglutinin (ha)
split
split high-dose pf
split pf
split quadrivalent
influenza virus vaccine tisscult subunit
types a&b surface
antigen
pneumococcal 13-valent
conjugate
pneumococcal vaccine
polyvalent
typhoid vaccine
zoster vaccine live
FLUCELVAX
PNEUMOVAX, PNEUMOVAX 23
VIVOTIF BERNA
ZOSTAVAX
QL = Quantity Limit
ST = Step Therapy
54
Generic Drug Name
Brand Drug Name Examples
OTC MEDICATIONS
The following is a list of OTC products on the PDL. Some OTC products are listed on the drug
list. OTC products covered are restricted to generics when available. Brand names are provided
as reference only.
Acne
CLEARASIL
benzoyl peroxide crm, gel, lotion
Antifungals
clotrimazole
MICATIN
miconazole crm, soln
LOTRIMIN AF
tolnaftate
TINACTIN
MONISTAT
vaginal products
GYNE-LOTRIMIN
Atopic Dermatitis
BETACARE CREAM AND LOTION
CETAPHIL CREAM AND LOTION
DERMAPHOR OINTMENT
emollients
E-OINTMENT
GLYCERIN TOPICAL
Cough/Cold Allergy
Antihistamines
CHLOR-TRIMETON
BENADRYL
CLARITIN
antihistamines
ALAVERT
ZYRTEC
QL = Quantity Limit
ST = Step Therapy
55
Generic Drug Name
Antihistamine/Decongestant Combinations
brompheniramine/pseudoephedrine
cetirizine/pseudoephedrine OTC
chlorpheniramine/pseudoephedrine
DIMETAPP
ZYRTEC D
ACTIFED
ALAVERT ALRG TAB/SINUS
loratadine/pseudoephedrine
ALAVERT D
ALLERGY/CONG
Cough/Cold
ROBITUSSIN
ROBITUSSIN DM
antitussives
Age edit applied. Not covered for members under ROBITUSSIN PE
the age 2.
ROBITUSSIN CF
DELSYM
NEO-SYNEPHRINE
AFRIN
nasal sprays
DIMETAPP DRO DECONGES
Diabetes
CURITY ALCOHOL PADS
alcohol swabs
glucose oral tablets
HUMULIN
insulin (vials only)
NOVOLIN
Earwax Removal Products
carbamide peroxide
DEBROX
condoms
contraceptive foam
contraceptive gel
TROJAN
DELFEN
GYNOL II
Burow’s soln, wet dressings
dermatological baths
hydrocortisone crm, oint
DOMEBORO
COLLOIDAL OATMEAL BATHS
CORTAID
NEOSPORIN
topical antibacterials
MYCITRACIN
Family Planning
First Aid
BACITRACIN
Gastrointestinal
QL = Quantity Limit
ST = Step Therapy
56
Generic Drug Name
MYLANTA LIQUID
MAALOX LIQUID
antacids liquids, chew tabs
TUMS
IMODIUM A-D
antidiarrheals
KAOPECTATE
PEDIALYTE
PEPCID AC
FLEET ENEMA
DULCOLAX
electrolyte rehydrating soln
famotidine
laxative enemas
laxatives
psyllium
rectal crm, suppositories
simethicone
stool softeners
sugar+orthophosphoric acid
FLEET PHOSPHO-SODA
METAMUCIL
PREPARATION H
MYLICON
COLACE
EMETROL
permethrin
piperonyl butoxide gel, liquid shampoo
NIX
PIPERONYL BUTOXIDE
dimenhydrinate
meclizine
DRAMAMINE
BONINE
allergic conjunctivitis
artificial tears
ALAWAY
HYPOTEARS
VISINE
decongestants
MURINE
Lice Products
Motion Sickness
Ophthalmics
NAPHCON A
Pain
acetaminophen tabs, liquid,
drops, suppositories
TYLENOL
BAYER
aspirin tabs, EC. tabs
ECOTRIN
aspirin with buffers tabs
ADVIL
ibuprofen tabs, chew tabs and susp
MOTRIN IB
Smoking Cessation Products
QL = Quantity Limit
ST = Step Therapy
57
Generic Drug Name
COMMIT LOZENGES (QUANTITY LIMIT)
NICODERM CQ (QUANTITY LIMIT)
nicotine
NICOTINE GUM (QUANTITY LIMIT)
NICOTROL (QUANTITY LIMIT)
Vitamins/Minerals
OS-CAL
CALTRATE
calcium
TUMS
iron
ferrous fumarate, ferrous, gluconate,
errous sulfate, ferrous bis-glycinate
chelate and polysaccharide iron caps
iron polysaccharides
magnesium oxide
vitamin D 400 IU
FERGON
FEOSOL
NIFEREX
MAG-OX
VITAMIN D 400 IU
VI-DAYLIN
vitamins pediatric members <3 years old
POLY-VI-SOL
vitamins prenatal
TRI-VI-SOL
STUART PRENATAL
salicylic acid 17%/collodion
DUOFILM
fluoride dental rinse
PHOS-FLUR
Warts
Miscellaneous
QL = Quantity Limit
ST = Step Therapy
58
Index of
of Covered
CoveredDrugs
Drugs
A
abacavir . . . . . . . . . . . . 31
abacavir/dolutegravir/
lamivudine . . . . . . . . . 32
abacavir/lamivudine . . . . . 31
abacavir/lamivudine/
zidovudine . . . . . . . . . 31
ABILIFY . . . . . . . . . . . . . 41
ABILIFY DISCMELT . . . . . . 41
ABILIFY MAINTENA . . . . . . 41
abiraterone . . . . . . . . . . . 5
acamprosate . . . . . . . . . 39
acarbose . . . . . . . . . . . . 22
ACCUHIST DROPS . . . . . . 42
ACCUHIST PDX DROPS . . . 43
ACCUNEB . . . . . . . . . . . 48
ACCUPRIL . . . . . . . . . . . .7
ACCURETIC . . . . . . . . . . .8
ACCUTANE . . . . . . . . . . 15
acebutalol . . . . . . . . . . . . 8
acetaminophen . . . . 11, 33, 57
acetazolamide . . . . . . . . . 38
ACETAZOLAMIDE . . . . . . . 38
acetazolamide
extended-release . . . . . 38
acetic acid . . . . . . . . . . . 19
acetic acid/aluminum acetate19
acetic acid/hydrocortisone . . 19
acetylcysteine . . . . . . . . . 53
acitretin . . . . . . . . . . . . 17
ACLOVATE . . . . . . . . . . . 16
ACTIFED . . . . . . . . . . 20, 56
ACTIGALL . . . . . . . . . . . 26
ACTOPLUSMET . . . . . . . . 22
ACTOPLUS MET XR . . . . . 22
ACTOS . . . . . . . . . . . . . 22
ACULAR/ACULAR LS . . . . 37
acyclovir . . . . . . . . . . . . 30
ADALAT CC . . . . . . . . . . . 9
adalimumab . . . . . . . . . . 33
ADDERALL . . . . . . . . . . . 39
ADDERALL XR . . . . . . . . 39
adefovir . . . . . . . . . . . . 30
ADVIL . . . . . . . . . 12, 33, 57
afatinib . . . . . . . . . . . . . 4
AFINITOR . . . . . . . . . . . . .4
AFINITOR DISPERZ . . . . . . .4
AFLURIA, FLUZONE SPLT . . 54
AFLURIA PF . . . . . . . . . . 54
AFRIN . . . . . . . . . . . 20, 56
AGENERASE . . . . . . . . . . 31
AGRYLIN . . . . . . . . . . . . .7
AKINETON . . . . . . . . . . . 14
ALAVERT . . . . . . . . . 20, 55
ALAVERT ALRG
TAB/SINUS . . . . . . 20, 56
ALAVERT D . . . . . . . . . . 56
ALAVERT-D . . . . . . . . . . . 20
ALAWAY . . . . . . . . . . . . 57
ALAWAY OTC . . . . . . . . . 36
albendazole . . . . . . . . . . 28
ALBENZA . . . . . . . . . . . . 28
albiglutide . . . . . . . . . . . 23
albuterol . . . . . . . . . . . . 48
albuterol sulfate . . . . . . . . 47
alclometasone . . . . . . . . 16
alcohol swabs . . . . . . . . . 56
ALDACTAZIDE . . . . . . . . . .9
ALDACTONE . . . . . . . . . . .9
ALDARA . . . . . . . . . . . . 18
ALDOMET . . . . . . . . . . . 11
ALDORIL . . . . . . . . . . . . 11
alendronate . . . . . . . . . . 23
ALESSE . . . . . . . . . . . . . 35
alfuzosin ER . . . . . . . . . . 48
alginic acid/sodium
bicarbonate . . . . . . . . 24
ALINIA . . . . . . . . . . . . . 32
ALINIA SUSPENSION . . . . . 32
alirocumab . . . . . . . . . . 10
alitretinoin 1% gel . . . . . . . 6
ALKERAN . . . . . . . . . . . . 4
ALLANHIST SYP PDX . . . . . 45
allergic conjunctivitis . . . . . 57
ALLERGY/CONG . . . . 20, 56
ALLERGY/CONG
TAB RELIEF . . . . . . . . 45
ALLI . . . . . . . . . . . . . . . 42
allopurinol . . . . . . . . . . . 34
ALL CAPS = Brand-name drug
lower case = Generic drug
59
ALPHAGAN P . . . . . . . . . 38
alprazolam . . . . . . . . . . . 39
altretamine . . . . . . . . . . . 4
alumina/magnesia . . . . . . 24
alumina/magnesia/
simethicone . . . . . . . . 24
aluminum acetate . . . . . . . 18
aluminum chloride
hexahydrate . . . . . . . . 18
amantadine . . . . . . . . 14, 31
AMARYL . . . . . . . . . . . . 22
AMBIEN . . . . . . . . . . . . 41
ambrisentan . . . . . . . . . . 11
AMERGE . . . . . . . . . . . . 13
AMICAR . . . . . . . . . . . . . 7
AMIKACIN INJ . . . . . . . . . 26
amikacin sulfate inj . . . . . . 26
amiloride . . . . . . . . . . . . 9
amiloride/hydrochlorothiazide 9
aminocaproic acid . . . . . . . 7
aminosalicyclic acid . . . . . 28
amiodarone tabs . . . . . . . . 8
amitriptyline . . . . . . . . 13, 40
amitriptyline/perphenazine . 40
amlodipine . . . . . . . . . . . 9
ammonium lactate . . . . . . 18
amoxapine . . . . . . . . . . . 40
amoxicillin . . . . . . . . . . . 29
AMOXICILLIN CAPSULES AND
CHEWABLES . . . . . . . 29
amoxicillin/clavulanate . . . . 29
AMOXIL SUSP . . . . . . . . . 29
amphetamine/dextroamphetamine mixed salts . . . . 39
amphetamine/dextroamphetamine mixed salts
ampicillin . . . . . . . . . . . 29
amprenavir . . . . . . . . . . 31
anagrelide . . . . . . . . . . . 7
anakinra . . . . . . . . . . . . 33
ANAPLEX DM . . . . . . . . . 43
anastrozole . . . . . . . . . . . 5
ANCEF INJ . . . . . . . . . . . 26
Index of Covered Drugs
ANERGAN . . . . . . . . . . . 28
ANORO ELLIPTA . . . . . . . 47
ANTABUSE . . . . . . . . . . . 39
antacids liquids, chew tabs . 57
antidiarrheals . . . . . . . . . 57
antihistamines . . . . . . . . . 55
antitussives. . . . . . . . . . . 56
ANTIVERT . . . . . . . . . . . 24
ANUSOL HC 2.5% . . . . . . 18
APHEDRID TAB . . . . . . . . 47
apixaban . . . . . . . . . . . . 6
aprepitant . . . . . . . . . . . 23
APRESOLINE . . . . . . . . . 11
APRISO . . . . . . . . . . . . . 25
APTIVUS . . . . . . . . . . . . 32
AQUA-MEPHYTO INJ . . . . . 28
ARALEN . . . . . . . . . . . . 32
ARANESP . . . . . . . . . . . . 7
ARAVA . . . . . . . . . . . . . 33
ARCALYST . . . . . . . . . . . 53
ARCAPTA NEOHALER . . . . 47
ARICEPT . . . . . . . . . . . . 11
ARIMIDEX . . . . . . . . . . . . 5
aripiprazole . . . . . . . . . . 41
aripiprazole ER injection . . . 41
ARNUITY ELLIPTA . . . . . . . 47
AROMASIN . . . . . . . . . . . .5
ARTANE . . . . . . . . . . . . 14
artificial tears . . . . . . . . . 57
ASACOL HD . . . . . . . . . . 25
asenapine . . . . . . . . . . . 41
ASMANEX HFA . . . . . . . . 47
ASMANEX TWISTHALER . . . 47
aspirin . . . . . . . . . . . . 7, 33
aspirin/acetaminophen/
caffeine . . . . . . . . . . 11
aspirin tabs, EC. tabs . . . . . 57
aspirin with buffers tabs . . . 57
ASTELIN . . . . . . . . . . . . 20
ASTRAMOR INJ . . . . . . . . 26
ATABEX PRENATAL . . . . . . 51
ATARAX . . . . . . . . . . . . . 19
atazanavir . . . . . . . . . . . 31
atenolol . . . . . . . . . . . . . 8
atenolol/chlorthalidone . . . . 8
ATIVAN . . . . . . . . . . . . . 39
atorvastatin . . . . . . . . . . 10
atovaquone . . . . . . . . . . 32
ATRALIN . . . . . . . . . . . . 16
ATRIPLA . . . . . . . . . . . . 31
atropine . . . . . . . . . . . . 38
atropine sulfate . . . . . . . . 26
ATROVENT . . . . . . . . . . . 48
ATROVENT HFA . . . . . . . . 47
ATROVENT NASAL SPRAY . . 20
ATUSS DR . . . . . . . . . . . 46
AUBAGIO . . . . . . . . . . . . 13
AUGMENTIN . . . . . . . . . . 29
auranofin . . . . . . . . . . . 33
AVITA . . . . . . . . . . . . . . 16
AVONEX/AVONEX PEN . . . 13
axitinib . . . . . . . . . . . . . 4
AYGESTIN . . . . . . . . . . . 36
AZASAN . . . . . . . . . . . . 33
azathioprine . . . . . . . . 5, 33
azathiprine . . . . . . . . . . . 33
azelaic acid . . . . . . . . . . 15
azelastine . . . . . . . . . 20, 36
azithromycin . . . . . . . . . . 29
aztreonam . . . . . . . . . . . 53
AZULFIDINE . . . . . . . 25, 33
AZULFIDINE EN-TABS . . 25, 33
B
bacitracin . . . . . . . . . 16, 38
BACITRACIN . . . . . . . 16, 56
baclofen . . . . . . . . . . . . 34
BACLOFEN . . . . . . . . . . . 34
BACTRIM . . . . . . . . . . . . 29
BACTRIM DS . . . . . . . . . . 29
BACTROBAN . . . . . . . . . 16
balsalazide . . . . . . . . . . 25
BALZIVA . . . . . . . . . . . . 35
BANZEL . . . . . . . . . . . . 15
BARACLUDE . . . . . . . . . . 30
BAYER . . . . . . . . . 7, 33, 57
BD POSIFLUSH INJ . . . . . . 28
becaplermin gel . . . . . . . . 18
bedaquiline . . . . . . . . . . 32
BENA-D-50 INJ . . . . . . . . 27
60
BENADRYL . . . . . . . . 19, 55
benazepril . . . . . . . . . . . .7
benazepril/hydrochlorothiazide7
BENTYL . . . . . . . . . . . . 24
BENZAC AC . . . . . . . . . . 15
BENZAMYCIN . . . . . . . . . 16
benzocaine/antipyrine . . . . 19
benzonatate . . . . . . . . . . 42
BENZOTIC . . . . . . . . . . . 19
benzoyl peroxide . . . . . 15, 55
benztropine . . . . . . . . . . 14
BERINERT . . . . . . . . . . . 53
BETACARE CREAM AND
LOTION . . . . . . . . . . . 55
BETAGAN . . . . . . . . . . . 37
betamethasone
augmented dip . . . . . . 17
betamethasone dipropionate 17
betamethasone val . . . . . . 16
BETAPACE . . . . . . . . . . . .9
BETA-VAL . . . . . . . . . . . . 16
bethanechol . . . . . . . . . . 48
BETHKIS . . . . . . . . . . . . 53
BETIMOL . . . . . . . . . . . . 37
bexarotene caps and
topical gel . . . . . . . . . . 6
BIAXIN . . . . . . . . . . . . . 29
BIAXIN XL . . . . . . . . . . . 29
bicalutamide . . . . . . . . . . 5
BICITRA . . . . . . . . . . . . 49
BILTRICIDE . . . . . . . . . . . 28
BIO-D DRO-MULSION . . . . 49
BIO-D-MULSIO DRO FORTE . 49
biperiden . . . . . . . . . . . 14
bismuth subsalicylate + metronidazole + tetracycline . . . 26
bisoprolol . . . . . . . . . . . . 8
bisoprolol/hydrochlorothiazide 8
BLEPH-10 . . . . . . . . . . . 38
BONINE . . . . . . . . . . . . 57
bosentan . . . . . . . . . . . 11
BOSULIF . . . . . . . . . . . . .4
bosutinib . . . . . . . . . . . . 4
BREO ELLIPTA . . . . . . . . . 47
BRETHINE . . . . . . . . . . . 48
brimonidine . . . . . . . . 17, 38
BRIMONIDINE . . . . . . . . . 38
BROMALINE DM . . . . . . . 43
BROMETANE DX . . . . . . . 44
BROMFED DM . . . . . . . . . 43
BROMFENEX PD CAP . . . . 42
brompheniramine &
phenylephrine . . . . . . . 42
brompheniramine/
pseudoephedrine . . 42, 56
brompheniramine/
pseudoephedrine/
dextromethorphan . . . . 43
brompheniramine/
pseudoephedrine/dextromethorphan/guaifenesin 43
budesonide . . . . . . . . 25, 48
bumetanide . . . . . . . . . . . 9
BUMEX . . . . . . . . . . . . . .9
BUPHENYL ORAL
POWDER . . . . . . . . . . 53
buprenorphine . . . . . . . . 41
buprenorphine/naloxone . . . 41
bupropion . . . . . . . . . . . 40
bupropion extended-release 40
Burow’s soln, wet dressings . 56
BUSPAR . . . . . . . . . . . . 39
buspirone . . . . . . . . . . . 39
busulfan . . . . . . . . . . . . . 4
butalbital/acetaminophen . . 11
butalbital/acetaminophen/
caffeine . . . . . . . . . . 11
butalbital/apap/caff/cod . . . 12
butalbital/asa/caff/cod . . . . 12
butalbital/aspirin/caffeine . . 11
butorphanol . . . . . . . . . . 12
C
C1 Inhibitor, Human . . . . . 53
cabergoline . . . . . . . . . . 23
cabozantinib . . . . . . . . . . 4
CAFERGOT . . . . . . . . . . 13
calamine . . . . . . . . . . . . 18
CALAN . . . . . . . . . . . 9, 13
CALAN SR . . . . . . . . . . . .9
calcipotriene . . . . . . . . . 17
calcitonin-salmon . . . . . . . 23
calcitriol . . . . . . . . . . 17, 49
calcium . . . . . . . . . . 49, 58
calcium acetate . . . . . . . . 53
CALTRATE . . . . . . . . . . . 58
CAMPRAL . . . . . . . . . . . 39
canagliflozin . . . . . . . . . . 22
canagliflozin/metformin . . . 22
canakinumab . . . . . . . . . 53
CANASA . . . . . . . . . . . . 25
capecitabine . . . . . . . . . . 4
CAPITROL . . . . . . . . . . . 18
CAPOTEN . . . . . . . . . . . . 7
CAPOZIDE . . . . . . . . . . . .7
CAPRELSA . . . . . . . . . . . .5
capsaicin . . . . . . . . . . . 33
captopril . . . . . . . . . . . . .7
captopril/hydrochlorothiazide . 7
CARAC . . . . . . . . . . . . . 18
CARAFATE . . . . . . . . . . . 24
CARAFATE SUSPENSION . . 24
CARBAGLU . . . . . . . . . . 53
carbamazepine . . . . . . . . 14
carbamazepine
carbamide peroxide . . . 19, 56
CARBATROL . . . . . . . . . 14
carbetapentane/chlorpheniramine/ephedrine/
carbidopa/levodopa . . . . . 14
carbidopa/levodopa
carbinoxamine/
pseudoephedrine . . . . . 43
CARBOFED . . . . . . . . . . 43
CARDEC-DM . . . . . . . . . . 44
CARDEC DM DRO . . . . . . 46
CARDEC DM SYP . . . . . . . 46
CARDEC DRO . . . . . . . . . 44
CARDEC SYP . . . . . . . 42, 44
CARDENE . . . . . . . . . . . . 9
CARDIZEM . . . . . . . . . . . .9
CARDIZEM CD . . . . . . . . . .9
61
CARDIZEM SR . . . . . . . . . .9
CARDURA . . . . . . . . . 8, 48
carglumic acid . . . . . . . . 53
carteolol . . . . . . . . . . . . 37
carvedilol . . . . . . . . . . . . 8
casanthranol-docusate
sodium . . . . . . . . . . 25
CASODEX . . . . . . . . . . . . 5
CATAPRES . . . . . . . . . . . .8
CAYSTON . . . . . . . . . . . 53
CECLOR . . . . . . . . . . . . 29
CEENU . . . . . . . . . . . . . .4
cefaclor . . . . . . . . . . . . 29
cefadroxil . . . . . . . . . . . 29
cefazolin sodium for inj . . . . 26
cefdinir . . . . . . . . . . . . . 29
cefixime . . . . . . . . . . . . 29
cefprozil . . . . . . . . . . . . 29
CEFTIN . . . . . . . . . . . . . 29
CEFTRIAX/DEX INJ . . . . . . 27
CEFTRIAXONE INJ . . . . 26, 27
CEFTRIAXONE/INJ DEX . . . 27
ceftriaxone sodium for inj 26, 27
ceftriaxone sodium for iv soln 1
gm and dextrose 3.74% . 27
ceftriaxone sodium in
dextrose inj . . . . . . . . 27
cefuroxime axetil . . . . . . . 29
CEFZIL . . . . . . . . . . . . . 29
CELEBREX . . . . . . . . . . . 33
celecoxib . . . . . . . . . . . 33
CELEXA . . . . . . . . . . . . 40
CELLCEPT . . . . . . . . . . . .5
CELONTIN . . . . . . . . . . . 15
CENESTIN . . . . . . . . . . . 36
CENOGEN OB/ULTRA . . . . 51
CENTRUM . . . . . . . . . . . 50
cephalexin . . . . . . . . . . . 29
ceritinib . . . . . . . . . . . . . 4
certolizumab pegol . . . . . . 33
CETAPHIL CREAM AND
LOTION . . . . . . . . . . . 55
cetirizine . . . . . . . . . . . . 20
cetirizine hydrochloride/
pseudoephedrine
hydrochloride
cetirizine/pseudoephedrine
OTC . . . . . . . . . . . . 56
CHANTIX . . . . . . . . . . . . 42
CHILD IBUPRO SUS COLD . 47
chloral hydrate . . . . . . . . 41
CHLORAL HYDRATE . . . . . 41
chlorambucil . . . . . . . . . . 4
chlordiazepoxide . . . . . . . 39
chlorhexidine gluconate . . . 21
chloroquine phosphate . . . . 32
chlorothiazide . . . . . . . . . 9
chloroxine . . . . . . . . . . . 18
chlorpheniramine/
chlorpheniramine
chlorpheniramine maleate . . 19
chlorpheniramine maleate
phenylephrine HCL . . . . 43
chlorpheniramine/
chlorpheniramine/phenylephrine/pyrilamine . . . . . . 20
chlorpheniramine/
chlorpheniramine/
chlorpheniramine/
chlorpheniramine tan/
phenylephrine tan . . . . 44
chlorphen-PEmethscopolamine . . . . 43
chlorphen tan/
carbetapentane tan . . . . 43
chlorphen tan/
pseudoeph tan . . . . . . 43
chlorphen tan/
pyrilamine tan/PE tan . . 43
chlorpromazine . . . . . . . . 42
chlorpropamide . . . . . . . . 22
chlorthalidone . . . . . . . . . 9
CHLORTHALIDONE . . . . . . .9
CHLOR-TRIMETON . . . . . . 55
CHLOR-TRIMETON
ALLERGY . . . . . . . . . 19
CHLOR-TRIMETON SYRUP . 19
chlorzoxazone . . . . . . . . . 34
CHOLBAM . . . . . . . . . . . 23
cholecalciferol . . . . . . . . . 49
cholestyramine . . . . . . . . 10
cholic acid . . . . . . . . . . . 23
ciclopirox . . . . . . . . . . . 17
cilostazol . . . . . . . . . . . . 7
CILOXAN . . . . . . . . . . . . 38
cimetidine . . . . . . . . . . . 24
CIMZIA . . . . . . . . . . . . . 33
cinacalcet . . . . . . . . . . . 53
CIPRO . . . . . . . . . . . . . 29
CIPRODEX . . . . . . . . . . . 19
ciprofloxacin . . . . . . . 29, 38
ciprofloxacin 0.2% in d5w . . 27
ciprofloxacin/dexamethasone19
ciprofloxacin iv soln 1% . . . 27
CIPRO I.V. . . . . . . . . . . . 27
citalopram . . . . . . . . . . . 40
clarithromycin . . . . . . . . . 29
clarithromycin ER . . . . . . . 29
CLARITIN . . . . . . . . . 20, 55
CLEARASIL . . . . . . . . . . 55
CLEAR EYES REDNESS
RELIEF . . . . . . . . . . . 37
clemastine . . . . . . . . . . . 19
CLEMASTINE . . . . . . . . . 19
CLEOCIN . . . . . . . . . 32, 36
CLEOCIN PHOS INJ . . . . . 27
CLEOCIN T . . . . . . . . . . . 15
CLIMARA . . . . . . . . . . . . 36
clindamycin . . . . . . 15, 32, 36
clindamycin phosphate inj . . 27
CLINORIL . . . . . . . . . 12, 34
clobazam . . . . . . . . . . . 14
clobetasol propionate . . . . 17
clonazepam . . . . . . . 14, 39
clonidine . . . . . . . . . . . . 8
clopidogrel . . . . . . . . . . . 7
62
clorazepate . . . . . . . . . . 39
clotrimazole . . . .17, 30, 36, 55
clotrimazole with
betamethasone . . . . . . 17
clozapine . . . . . . . . . . . 41
clozapine oral suspension . . 41
CLOZARIL . . . . . . . . . . . 41
cobicistat . . . . . . . . . . . 32
cobicistat/elvitegravir/emtricitabine/tenofovir . . . . . . 31
CODAL-DM . . . . . . . . . . . 46
codeine/acetaminophen . . . 12
codeine/chlorpheniramine/
codeine/guaifenesin . . . . . 44
codeine/guaifenesin/
codeine/promethazine . . . . 44
codeine/promethazine/
codeine sulfate . . . . . . . . 12
CODIMAL DH . . . . . . . . . 46
COGENTIN . . . . . . . . . . . 14
COLACE . . . . . . . . . 25, 57
COLAZAL . . . . . . . . . . . 25
colchicine . . . . . . . . . . . 34
collagenase oint . . . . . . . 18
COLLOIDAL OATMEAL
BATHS . . . . . . . . . . . 56
COLOCORT . . . . . . . . . . 25
COLYTE . . . . . . . . . . . . 25
COMBIVENT . . . . . . . . . . 47
COMBIVENT RESPIMAT . . . 47
COMBIVIR . . . . . . . . . . . 31
COMETRIQ . . . . . . . . . . . 4
COMMIT LOZENGES . . . . . 58
COMMITT OTC . . . . . . . . 42
COMPAZINE . . . . . . . 24, 42
COMPLERA . . . . . . . . . . 31
COMPLETE NATALCARE
PAK DHA . . . . . . . . . . 51
COMTAN . . . . . . . . . . . . 14
CONCERTA . . . . . . . . . . 39
condoms . . . . . . . . . . . 56
CONDYLOX SOL . . . . . . . 18
conjugated estrogen/
bazedoxifene . . . . . . . 36
contraceptive foam . . . . . . 56
contraceptive gel . . . . . . . 56
COPAXONE . . . . . . . . . . 13
CORDARONE . . . . . . . . . .8
CORDRAN . . . . . . . . . . . 16
COREG . . . . . . . . . . . . . .8
CORICIDIN TAB CGH/CLD . 43
CORTAID . . . . . . . . . . . . 56
CORTEF . . . . . . . . . . . . 21
cortisone acetate . . . . . . . 21
CORTISPORIN . . . . . . . . . 37
CORTISPORIN OTIC . . . . . 19
CORTIZONE . . . . . . . . . . 16
CORTIZONE-10 INTENSIVE
HEALING . . . . . . . . . . 16
COSOPT . . . . . . . . . . . . 38
COUMADIN . . . . . . . . . . . 6
COZAAR . . . . . . . . . . . . .8
CPM/PSE . . . . . . . . . . . 44
CREON . . . . . . . . . . . . . 26
CRIXIVAN . . . . . . . . . . . . 32
crizotinib . . . . . . . . . . . . 4
CROLOM . . . . . . . . . . . . 36
cromolyn . . . . . . . . . 47, 48
cromolyn sodium . . . . . 20, 36
crotamiton . . . . . . . . . . . 18
CURITY ALCOHOL PADS . . 56
CUTIVATE . . . . . . . . . . . 16
cyanocobalamin . . . . . . . 49
CYCLESSA . . . . . . . . . . . 35
cyclobenzaprine . . . . . . . 34
CYCLOGYL . . . . . . . . . . . 38
cyclopentolate . . . . . . . . . 38
cyclophosphamide . . . . . . . 4
cycloserine . . . . . . . . . . 28
cyclosporine . . . . . . . . . . 6
cyclosporine, modified . . . . . 6
CYMBALTA . . . . . . . . . . . 40
cyproheptadine . . . . . . . . 19
CYPROHEPTADINE . . . . . . 19
CYSTAGON . . . . . . . . . . . 6
CYSTARAN . . . . . . . . . . . 39
cysteamine 0.44%
ophthalmic solution . . . . 39
cysteamine bitartrate . . . . . . 6
CYTOMEL . . . . . . . . . . . 23
CYTOTEC . . . . . . . . . . . 26
CYTOVENE . . . . . . . . . . . 30
CYTOXAN . . . . . . . . . . . . 4
D
D3-50 CAP . . . . . . . . . . . 49
D5W/NACL INJ . . . . . . . . 28
dabrafenib . . . . . . . . . . . 4
daclatasvir . . . . . . . . . . . 30
DAKLINZA . . . . . . . . . . . 30
DALLERGY DM . . . . . . . . 43
DALMANE . . . . . . . . . . . 41
danazol . . . . . . . . . . . . 35
DANOCRINE . . . . . . . . . . 35
DANTRIUM . . . . . . . . . . . 34
dantrolene . . . . . . . . . . . 34
dapsone . . . . . . . . . . . . 32
DAPSONE . . . . . . . . . . . 32
DARAPRIM . . . . . . . . . . . 33
darbepoetin alfa . . . . . . . . 7
darunavir . . . . . . . . . . . 31
darunavir/cobicistat . . . . . 32
dasatinib . . . . . . . . . . . . 4
DAYPRO . . . . . . . . . . 12, 34
DDAVP . . . . . . . . . . . . . 23
DEBROX . . . . . . . . . 19, 56
DECADRON . . . . . . . . . . 21
DE-CHLOR DM . . . . . . . . 46
decongestants . . . . . . . . 57
deferasirox . . . . . . . . . . . 7
DELATESTRYL . . . . . . . . . 21
delavirdine . . . . . . . . . . . 31
DELFEN . . . . . . . . . . . . 56
DELSYM . . . . . . . . . . 44, 56
DELTASONE . . . . . . . . . . 21
DELZICOL . . . . . . . . . . . 25
DEMADEX . . . . . . . . . . . 10
DEMEROL . . . . . . . . . . . 12
DEPAKENE . . . . . . . . . . . 15
DEPAKOTE . . . . . . 13, 14, 40
63
DEPAKOTE
SPRINKLE . . . . 13, 14, 40
DEPEN TITRATABLE . . . . . 33
DEPO-PROVERA . . . . . . . 34
DEPO-TESTOSTERONE . . . 21
DERMAPHOR OINTMENT . . 55
DERMA-SMOOTHE OIL/FS . 16
dermatological baths . . . . . 56
DERMATOP . . . . . . . . . . 16
DESENEX . . . . . . . . . . . 17
desipramine . . . . . . . . . . 40
desmopressin . . . . . . . . . 23
desogestrel/EE . . . . . . 34, 35
DESYREL . . . . . . . . . . . . 41
DETROL . . . . . . . . . . . . 49
dexamethasone . . . . . . . . 21
dexamethasone sodium
phosphate . . . . . . . . . 37
DEXASOL . . . . . . . . . . . 37
DEXEDRINE . . . . . . . . . . 39
DEXEDRINE SPANSULE . . . 39
dextroamphetamine . . . . . 39
dextroamphetamine
dextromethorphan/brompheniramine/pseudoephedrine 44
dextromethorphan/carbinoxamine/pseudoephedrine 44
dextromethorphanguaifenesin . . . . . . . . 44
dextromethorphan/
guaifenesin . . . . . . . . 44
dextromethorphan hbr . . . . 44
dextromethorphan polistirex
dextromethorphan/
promethazine . . . . . . . 45
dextromethorphan/quinidine 42
dextrose 5% w/ sodium
chloride 0.45% . . . . . . 28
dextrose inj . . . . . . . . . . 28
DEXTROSE INJ . . . . . . . . 28
DEXTROSTAT . . . . . . . . . 39
D.H.E. 45 . . . . . . . . . . . . 13
DIABINESE . . . . . . . . . . . 22
DIAMOX SEQUELS . . . . . . 38
DIAQUA-2 INJ . . . . . . . . . 28
DIASTAT ACUDIAL . . . . . . . 14
diazepam . . . . . . . 14, 34, 39
diclofenac 1% gel . . . . . . . 33
diclofenac sodium . . . . . . 37
dicloxacillin . . . . . . . . . . 29
DICLOXACILLIN . . . . . . . . 29
dicyclomine . . . . . . . . . . 24
didanosine . . . . . . . . . . 31
didanosine delayed-release . 31
DIDRONEL . . . . . . . . . . . 23
DIFLUCAN . . . . . . . . 30, 36
digoxin . . . . . . . . . . . . . 8
DIHISTINE DH . . . . . . . . . 44
dihydroergotamine . . . . . . 13
DIHYDRO-PE SYP . . . . . . . 46
DILACOR XR . . . . . . . . . . 9
DILANTIN . . . . . . . . . . . . 15
DILAUDID . . . . . . . . . . . . 12
diltiazem . . . . . . . . . . . . 9
diltiazem extended-release . . 9
diltiazem sustained-release . . 9
DIMEATAPP DRO
DECONGES . . . . . . . . 20
dimenhydrinate . . . . . . . . 57
DIMETAPP . . . . . . . . . . . 56
DIMETAPP CLD
ELX/ALLERGY . . . . . . . 42
DIMETAPP DRO DCON/CGH46
DIMETAPP DRO DECONGES 56
DIMETAPP ELX CLD/ALLE . . 42
DIMETAPP SYP CGH/CLD . . 43
dimethyl fumarate . . . . . . . 13
DIPENTUM . . . . . . . . . . . 25
diphenhydramine . . . . 19, 41
diphenhydramine hcl inj . . . 27
diphenoxylate/atropine . . . . 23
DIPROLENE . . . . . . . . . . 17
DIPROLENE AF . . . . . . . . 17
dipyridamole . . . . . . . . . . 7
disopyramide . . . . . . . . . . 8
disopyramide extended-release8
disulfiram . . . . . . . . . . . 39
DITROPAN . . . . . . . . . . . 49
DITROPAN XL . . . . . . . . . 49
DIURIL . . . . . . . . . . . . . . 9
DIURIL ORAL SUSPENSION . . 9
divalproex sodium
cap sprinkle . . . 13, 14, 40
divalproex sodium
delayed-release . . 13, 14, 40
docusate calcium plus . . . . 25
docusate potasssium . . . . . 25
docusate sodium . . . . . . . 25
dofetilide . . . . . . . . . . . . 8
DOLOPHINE . . . . . . . . . . 12
dolutegravir . . . . . . . . . . 32
DOMEBORO . . . . . . . . . . 56
DOMEBORO OTIC . . . . . . 19
donepezil . . . . . . . . . . . 11
dornase alfa . . . . . . . . . . 53
dorzolamide . . . . . . . . . . 37
dorzolamide/timolol maleate 38
DOSTINEX . . . . . . . . . . . 23
DOVONEX . . . . . . . . . . . 17
doxazosin . . . . . . . . . . 8, 48
doxepin . . . . . . . . . . . . 40
doxycycline monohydrate . . 30
DOXYCYCLINE
MONOHYDRATE . . . . . 30
DRAMAMINE . . . . . . . . . 57
DRISDOL . . . . . . . . . . . . 50
dronabinol . . . . . . . . . . . 23
DROXIA . . . . . . . . . . . . . .6
DUAVEE . . . . . . . . . . . . 36
DUETACT . . . . . . . . . . . . 22
DULCOLAX . . . . . . . . . . 57
DULERA . . . . . . . . . . . . 47
duloxetine . . . . . . . . . . . 40
DUOFILM . . . . . . . . . 18, 58
DUONEB . . . . . . . . . . . . 48
DURADRYL . . . . . . . . . . 43
DURAGESIC . . . . . . . . . . 12
DURAMORPH INJ . . . . . . . 26
DURATUSS DM ELX . . . . . 44
DURICEF . . . . . . . . . . . . 29
DYAZIDE . . . . . . . . . . . . 10
64
E
ecothiophate . . . . . . . . . 38
ECOTRIN . . . . . . . . 7, 33, 57
ED A-HIST TABLETS AND
LIQUID . . . . . . . . . . . 43
EDGE OB CHW . . . . . . . . 51
edoxaban . . . . . . . . . . . . 6
EDURANT . . . . . . . . . . . 31
E.E.S. . . . . . . . . . . . . . . 29
efavirenz . . . . . . . . . . . . 31
efavirenz/emtricitabine/
tenofovir . . . . . . . . . . 31
EFFEXOR . . . . . . . . . . . . 40
EFFEXOR XR . . . . . . . . . . 40
EFUDEX . . . . . . . . . . . . 18
ELAVIL . . . . . . . . . . . 13, 40
ELDEPRYL . . . . . . . . . . . 14
electrolyte . . . . . . . . . 49, 57
ELIDEL . . . . . . . . . . . . . 19
ELIMITE . . . . . . . . . . . . . 18
ELIQUIS . . . . . . . . . . . . . .6
ELOCON . . . . . . . . . . . . 16
eltromobpag . . . . . . . . . . 53
EMCYT . . . . . . . . . . . . . .4
EMEND . . . . . . . . . . . . . 23
EMETROL . . . . . . . . . . . 57
EMLA . . . . . . . . . . . . . . 18
emollients . . . . . . . . . . . 55
empagliflozin . . . . . . . . . 22
empagliflozin/metformin . . . 22
emtricitabine . . . . . . . . . 31
emtricitabine/rilpivirine/
tenofovir . . . . . . . . . . 31
emtricitabine/tenofovir . . . . 31
EMTRIVA . . . . . . . . . . . . 31
enalapril . . . . . . . . . . . . . 7
enalapril/hydrochlorothiazide . 7
ENBREL . . . . . . . . . . . . 33
enfuvirtide . . . . . . . . . . . 30
ENJUVIA . . . . . . . . . . . . 36
enoxaparin . . . . . . . . . . . 6
entacapone . . . . . . . . . . 14
entecavir . . . . . . . . . . . . 30
ENTERIC COATEDNAPROSYN . . . . . . 12, 34
ENTOCORT EC . . . . . . . . 25
ENULOSE . . . . . . . . . . . 25
E-OINTMENT . . . . . . . . . 55
EPANED . . . . . . . . . . . . . 7
epinephrine . . . . . . . . . . 53
EPIPEN . . . . . . . . . . . . . 53
EPIPEN JR. . . . . . . . . . . . 53
EPIVIR . . . . . . . . . . . . . . 31
EPIVIR HBV . . . . . . . . . . . 30
epoetin alfa . . . . . . . . . . . 7
EPOGEN . . . . . . . . . . . . .7
EPZICOM . . . . . . . . . . . . 31
ergocalciferol (D2) . . . . . . 50
ergotamine/caffeine . . . . . 13
ergotamine tartrate/caffeine . 13
ERIVEDGE . . . . . . . . . . . .6
erlotinib . . . . . . . . . . . . . 4
ERYC . . . . . . . . . . . . . . 29
ERYGEL . . . . . . . . . . . . 16
ERY-TAB . . . . . . . . . . . . 29
ERYTHROCIN . . . . . . . . . 29
erythromycin . . . . . . . 16, 38
ERYTHROMYCIN . . . . . . . 38
erythromycin/
benzoyl peroxide . . . . . 16
erythromycin delayed-release 29
erythromycin ethylsuccinate . 29
erythromycin stearate . . . . . 29
erythromycin/sulfisoxazole . . 29
ESBRIET . . . . . . . . . . . . 53
escitalopram . . . . . . . . . 40
ESGIC . . . . . . . . . . . . . 11
ESKALITH CR . . . . . . . . . 40
esomeprazole . . . . . . . . . 24
ESTRACE . . . . . . . . . 35, 36
estradiol . . . . . . . . . . 35, 36
estramustine
phosphate sodium . . . . . 4
estrogens, conjugated . . 35, 36
estrogens, conjugated/
medroxyprogesterone . . 36
synthetic A . . . . . . . . . 36
synthetic B . . . . . . . . 36
estropipate . . . . . . . . . . 36
ESTROSTEP FE . . . . . . . . 35
etanercept . . . . . . . . . . . 33
ethambutol . . . . . . . . . . 28
ethionamide . . . . . . . . . . 28
ethosuximide . . . . . . . . . 14
ethynodiol diacetate/EE . . . 35
etidronate . . . . . . . . . . . 23
etodolac . . . . . . . . . . 12, 33
etonogestrel/EE . . . . . . . . 34
etoposide . . . . . . . . . . . . 6
etravirine . . . . . . . . . . . . 32
EULEXIN . . . . . . . . . . . . .5
EURAX . . . . . . . . . . . . . 18
everolimus . . . . . . . . . . 4, 6
EVISTA . . . . . . . . . . . . . 23
EXCEDRIN MIGRAINE . . . . 11
EXELON . . . . . . . . . . . . 11
exemestane . . . . . . . . . . . 5
EXJADE . . . . . . . . . . . . . .7
exogabine . . . . . . . . . . . 14
ezetimibe . . . . . . . . . . . 10
F
famotidine . . . . . . . . 24, 57
FANAPT . . . . . . . . . . . . . 41
FARESTON . . . . . . . . . . . .5
FARYDAK . . . . . . . . . . . . .4
FAZACLO . . . . . . . . . . . . 41
febuxostat . . . . . . . . . . . 34
felbamate . . . . . . . . . . . 14
FELBATOL . . . . . . . . . . . 14
FELDENE . . . . . . . . . 12, 34
felodipine extended-release . . 9
FEMARA . . . . . . . . . . . . .5
fenofibrate . . . . . . . . . . . 10
FENTANYL CIT INJ . . . . . . 26
fentanyl citrate inj . . . . . . . 26
fentanyl transdermal . . . . . 12
FEOSOL . . . . . . . . . . 50, 58
FERGON . . . . . . . . . . . . 58
ferrous bisglycinate/
polysaccarides iron . . . . 50
ferrous sulfate . . . . . . . . . 50
filgrastim . . . . . . . . . . . . 7
65
FINACEA . . . . . . . . . . . . 15
finasteride . . . . . . . . . . . 48
fingolimod . . . . . . . . . . . 13
FIORICET . . . . . . . . . . . . 11
FIORICET W/CODEINE . . . . 12
FIORINAL . . . . . . . . . . . . 11
FIORINAL W/CODEINE . . . . 12
FIRAZYR . . . . . . . . . . . . 53
FLAGYL . . . . . . . . . . 32, 36
flecainide . . . . . . . . . . . . 8
FLEET ENEMA . . . . . . . . . 57
FLEET PHOSPHO-SODA . . . 57
FLEXERIL . . . . . . . . . . . . 34
FLOMAX . . . . . . . . . . . . 48
FLONASE . . . . . . . . . . . . 20
FLORINEF . . . . . . . . . . . 21
FLOVENT HFA . . . . . . . . . 47
FLOXIN . . . . . . . . . . . . . 29
FLOXIN OTIC . . . . . . . . . . 19
FLUBLOK . . . . . . . . . . . . 54
FLUCELVAX . . . . . . . . . . 54
fluconazole . . . . . . . . 30, 36
fludarabine . . . . . . . . . . . 4
fludrocortisone . . . . . . . . 21
FLUMADINE . . . . . . . . . . 31
FLUMIST QUAD . . . . . . . . 54
fluocinolone acetonide . . . . 16
fluocinonide . . . . . . . . . . 17
fluocinonide emulsified base 17
fluoride . . . . . . . . . . . . . 50
fluoride dental rinse . . . . . 58
fluorometholone . . . . . . . 37
FLUOROPLEX . . . . . . . . . 18
fluorouracil . . . . . . . . . . 18
fluoxetine . . . . . . . . . . . 40
fluphenazine . . . . . . . . . 42
fluphenazine decanoate . . . 42
flurandrenolide . . . . . . . . 16
flurazepam . . . . . . . . . . 41
flurbiprofen . . . . . . . . . . 37
flutamide . . . . . . . . . . . . 5
fluticasone . . . . . . . . . . . 20
fluticasone furoate . . . . . . 47
fluticasone HFA . . . . . . . . 47
fluticasone propionate . . . . 16
fluticasone/vilanterol . . . . . 47
FLUVIRIN . . . . . . . . . . . . 54
fluvoxamine . . . . . . . . . . 39
FLUZONE HD PF . . . . . . . 54
FLUZONE QUAD . . . . . . . 54
FML . . . . . . . . . . . . . . 37
FML FORTE . . . . . . . . . . 37
FML LIQUIFILM . . . . . . . . 37
folic acid . . . . . . . . . . . . 50
FOLIC ACID . . . . . . . . . . 50
FOLTABS PAK PLUS DHA RE
OB + DHA PAK . . . . . . 51
FOLTABS PRENATAL . . . . . 52
FORTEO . . . . . . . . . . . . 23
FORTICAL . . . . . . . . . . . 23
FORTOVASE . . . . . . . . . . 32
FOSAMAX . . . . . . . . . . . 23
fosamprenavir . . . . . . . . . 32
fosinopril . . . . . . . . . . . . 7
fosinopril/hydrochlorothiazide 8
FURADANTIN SUSP . . . . . 32
furosemide . . . . . . . . . . . 9
furosemide inj . . . . . . . . . 28
FUZEON KIT . . . . . . . . . . 30
G
gabapentin . . . . . . . . . . 14
GABITRIL . . . . . . . . . . . . 15
galantamine . . . . . . . . . . 11
ganciclovir . . . . . . . . . . . 30
gatifloxin . . . . . . . . . . . . 38
GATTEX . . . . . . . . . . . . 26
gefitinib . . . . . . . . . . . . . 4
GEL-KAM . . . . . . . . . . . . 50
gemfibrozil . . . . . . . . . . . 10
GENGRAF . . . . . . . . . . . .6
GENTAK . . . . . . . . . . 16, 38
gentamicin . . . . . . . . 16, 38
gentamicin/prednisolone
acetate . . . . . . . . . . . 37
GENTEX ADE . . . . . . . . . 51
GEODON . . . . . . . . . . . . 42
GG/CODEINE . . . . . . . . . 44
GG/DM CR . . . . . . . . . . . 44
GG/PSE CR . . . . . . . . . . 45
GILENYA . . . . . . . . . . . . 13
GILOTRIF . . . . . . . . . . . . .4
glatiramer acetate . . . . . . . 13
GLEEVEC . . . . . . . . . . . . 4
glimepiride . . . . . . . . . . 22
glipizide . . . . . . . . . . . . 22
glipizide extended-release . . 22
GLUCAGON . . . . . . . . . . 21
glucagon, human
recombinant . . . . . . . . 21
GLUCOPHAGE . . . . . . . . 22
GLUCOPHAGE ER . . . . . . 22
glucose oral tablets . . . . . . 56
GLUCOTROL . . . . . . . . . 22
GLUCOTROL XL . . . . . . . . 22
GLUCOVANCE . . . . . . . . 22
glyburide . . . . . . . . . . . . 22
glyburide, micronized . . . . . 22
glycerin . . . . . . . . . . . . 25
GLYCERIN SUPPOSITORY . . 25
GLYCERIN TOPICAL . . . . . 55
glycerol phenylbutyrate . . . . 53
glycopyrrolate . . . . . . . . . 25
GLYNASE . . . . . . . . . . . . 22
GRANIX . . . . . . . . . . . . . .7
GRIFULVIN V . . . . . . . . . . 30
griseofulvin microsize . . . . . 30
griseofulvin ultramicrosize . . 30
GRIS-PEG . . . . . . . . . . . 30
GUAIFED . . . . . . . . . . . . 45
guaifenesin . . . . . . . . . . 45
guaifenesin extended-release 45
guaifenesin/
guaifenesin/
pseudoephedrine/
guaifenesin/
pseudoephedrine
GUAIFEN PSE . . . . . . . . . 45
guanabenz . . . . . . . . . . 11
guanfacine . . . . . . . . . . . 8
guanfacine ER . . . . . . . . 39
GUIATUSS AC . . . . . . . . . 44
66
GUIATUSS DAC . . . . . . . . 44
GYNE-LOTRIMIN . . . . . 36, 55
GYNOL II . . . . . . . . . . . . 56
H
HALCION . . . . . . . . . . . . 41
HALDOL . . . . . . . . . . . . 42
HALDOL DECANOATE . . . . 42
haloperidol . . . . . . . . . . 42
haloperidol decanoate . . . . 42
HARVONI . . . . . . . . . . . . 30
HECORIA . . . . . . . . . . . . 6
HELIDAC . . . . . . . . . . . . 26
heparin . . . . . . . . . . . . . 6
HEPARIN . . . . . . . . . . . . .6
HEPSERA . . . . . . . . . . . 30
hexachlorophene . . . . . . . 18
HEXALEN . . . . . . . . . . . . 4
HIPREX . . . . . . . . . . . . . 49
HISTACOL DM . . . . . . . . . 43
HISTEX . . . . . . . . . . . . . 44
HISTUSSIN HC . . . . . . . . 45
HIVID . . . . . . . . . . . . . . 31
homatropine . . . . . . . . . . 38
HUMALOG . . . . . . . . . . . 22
HUMALOG MIX 50/50 . . . . 22
HUMALOG MIX 75/25 . . . . 22
HUMATIN . . . . . . . . . . . . 32
HUMIRA . . . . . . . . . . . . 33
HUMULIN . . . . . . . . . . . 56
HUMULIN 70/30 . . . . . . . 22
HUMULIN N . . . . . . . . . . 21
HUMULIN R . . . . . . . . . . 22
HYCODAN . . . . . . . . . . . 45
hydralazine . . . . . . . . . . 11
HYDREA . . . . . . . . . . . . . 6
hydrochlorothiazide . . . . . . 9
HYDROCHLOROTHIAZIDE . . 9
HYDROCODO/GG SYP . . . 45
hydrocodone/
acetaminophen . . . . . . 12
hydrocodone/chlorpheniramine/phenylephrine . . . 45
hydrocodone ER . . . . . . . 12
hydrocodone/guaifenesin . . 45
hydrocodone/homatropine . 45
HYDROCODONE/
TAB HOMATROP . . . . . 45
hydrocortisone . .16, 18, 21, 25
hydrocortisone/aloe . . . . . 16
hydrocortisone butyrate . . . 16
hydrocortisone crm, oint . . . 56
hydrocortisone valerate . . . 16
HYDROMET SYP . . . . . . . 45
hydromorphone . . . . . . . . 12
hydroxychloroquine . . . 32, 33
hydroxyurea . . . . . . . . . . 6
hydroxyzine HCL . . . . . . . 19
hydroxyzine pamoate . . . . . 19
hyoscyamine, methenamine,
phenyl salicylate, sodium
phosphate monobasic,
methylene blue . . . . . . 49
hyoscyamine sulfate . . . . . 25
hyoscyamine sulfate
HYPERCARE 20% . . . . . . . 18
HYPOTEARS . . . . . . . . . . 57
HYTONE . . . . . . . . . . . . 16
HYTRIN . . . . . . . . . . . 8, 48
HYZAAR . . . . . . . . . . . . . 8
I
IBRANCE . . . . . . . . . . . . .6
ibrutinib . . . . . . . . . . . . . 4
IBUOROFEN TAB COLD/SIN 47
ibuprofen . . . . . . . 12, 33, 57
icatibant . . . . . . . . . . . . 53
ICLUSIG . . . . . . . . . . . . . 5
idelalisib . . . . . . . . . . . . . 4
ILARIS . . . . . . . . . . . . . . 53
iloperidone . . . . . . . . . . 41
imatinib mesylate . . . . . . . . 4
IMBRUVICA . . . . . . . . . . . 4
IMDUR . . . . . . . . . . . . . 10
imipenem-cilastatin
intravenous for soln . . . . 27
IMIPENEM/CIL INJ . . . . . . 27
imipramine HCL . . . . . . . 40
imiquimod 5% cream . . . . . 18
IMITREX . . . . . . . . . . . . 13
IMODIUM A-D . . . . . . . 23, 57
IMURAN . . . . . . . . . . . 5, 33
INCIVEK . . . . . . . . . . . . 30
INCRELEX . . . . . . . . . . . 23
INCRUSE ELLIPTA . . . . . . 47
indacaterol . . . . . . . . . . . 47
indapamide . . . . . . . . . . . 9
INDERAL . . . . . . . . . . 9, 13
INDERIDE . . . . . . . . . . . . 9
indinavir . . . . . . . . . . . . 32
INDOCIN . . . . . . . . . 12, 33
indomethacin . . . . . . . 12, 33
INFERGEN . . . . . . . . . . . 30
INFLAMASE FORTE . . . . . . 37
influenza virus vaccine live
quadrivalent intranasal . . 54
influenza virus vaccine recombinant hemagglutinin . . . . 54
influenza virus vaccine split . 54
influenza virus vaccine split
high-dose pf . . . . . . . . 54
influenza virus vaccine split pf54
influenza virus vaccine split
quadrivalent . . . . . . . . 54
influenza virus vaccine tiss-cult
subunit . . . . . . . . . . . 54
influenza virus vaccine types
a&b surface antigen . . . 54
INLYTA . . . . . . . . . . . . . . 4
insulin aspart . . . . . . . . . 21
insulin aspart protamine 70%/
insulin aspart 30% . . . . 21
insulin glargine . . . . . . . . 21
insulin human . . . . . . . . . 21
insulin isophane . . . . . . . . 21
insulin isophane human . . . 21
insulin isophane human 70%/
regular 30% . . . . . . . . 22
insulin isophane/regular . . . 22
insulin lisopro pro/lispro . . . 22
insulin lisopro prot/lispro . . . 22
insulin lispro . . . . . . . . . . 22
insulin regular . . . . . . . . . 22
insulin . . . . . . . . . . . . . 56
67
INTAL . . . . . . . . . . . 47, 48
INTELENCE . . . . . . . . . . 32
interferon alfa-2a . . . . . . . . 5
interferon alfa-2b . . . . . . 5, 30
interferon alfacon-1 . . . . . . 30
interferon beta-1a . . . . . . . 13
INTRON A . . . . . . . . . . 5, 30
INTUNIV . . . . . . . . . . . . 39
INVEGA . . . . . . . . . . . . . 41
INVEGA SUSTENNA . . . . . 41
INVEGA TRINZA . . . . . . . . 41
INVIRASE . . . . . . . . . . . . 32
INVOKAMET . . . . . . . . . . 22
INVOKANA . . . . . . . . . . . 22
ipratropium . . . . . . . . . . 48
ipratropium/albuterol . . 47, 48
ipratropium HFA . . . . . . . 47
ipratropium nasal . . . . . . . 20
IRESSA . . . . . . . . . . . . . .4
iron . . . . . . . . . . . . . . . 58
iron polysaccharides . . . . . 58
ISENTRESS . . . . . . . . . . 33
ISMO . . . . . . . . . . . . . . 10
isoniazid . . . . . . . . . . . . 28
ISONIAZID . . . . . . . . . . . 28
ISOPTO ATROPINE . . . . . . 38
ISOPTO CARPINE . . . . . . . 38
ISOPTO HOMATROPINE . . . 38
ISOPTO HYOSCINE . . . . . . 38
ISORDIL . . . . . . . . . . . . 10
ISORDIL S.L. . . . . . . . . . . 10
isosorbide dinitrate . . . . . . 10
ISOSORBIDE
DINITRATE ER . . . . . . . 10
isosorbide mononitrate . . . . 10
isotretinoin . . . . . . . . . . . 15
itraconazole . . . . . . . . . . 30
ivacaftor . . . . . . . . . . . . 53
ivermectin . . . . . . . . . . . 28
J
JADENU . . . . . . . . . . . . . 7
JAKAFI . . . . . . . . . . . . . . 5
JARDIANCE . . . . . . . . . . 22
JENTADUETO . . . . . . . . . 22
K
KALETRA . . . . . . . . . . . . 32
KALYDECO . . . . . . . . . . . 53
KAOPECTATE . . . . . . . . . 57
KAYEXALATE . . . . . . . . . 10
K-DUR 10 . . . . . . . . . . . . 52
K-DUR 20 . . . . . . . . . . . . 52
KEFLEX . . . . . . . . . . . . . 29
KENALOG . . . . . . . . . 16, 17
KENALOG IN ORABASE . . . 21
KEPPRA . . . . . . . . . . . . 15
ketoconazole . . . . . 17, 18, 30
ketoprofen . . . . . . . . 12, 33
ketorolac . . . . . . . . . . . . 37
KETOROLAC INJ . . . . . . . 26
ketorolac tromethamine . . . 12
ketorolac tromethamine im inj26
inj . . . . . . . . . . . . . 26
ketotifen . . . . . . . . . . . . 36
KINERET . . . . . . . . . . . . 33
KLONOPIN . . . . . . . . 14, 39
K-LOR . . . . . . . . . . . . . . 52
KLOR-CON 8 . . . . . . . . . 52
KLOR-CON 10 . . . . . . . . . 52
K-LYTE . . . . . . . . . . . . . 52
KOMBIGLYZE . . . . . . . . . 22
KORLYM . . . . . . . . . . . . 23
K-PHOS NEUTRAL . . . . . . 52
K-PHOS ORIGINAL . . . . . . 52
KUVAN . . . . . . . . . . . . . 23
L
labetalol . . . . . . . . . . . . . 8
LAC-HYDRIN . . . . . . . . . . 18
lacosamide . . . . . . . . . . 14
lactulose . . . . . . . . . . . . 25
LAMICTAL . . . . . . . . . . . 14
LAMICTAL CD CHEW TAB . . 14
LAMICTAL STARTER KIT . . . 14
LAMISIL . . . . . . . . . . . . . 30
LAMISIL AT . . . . . . . . . . . 17
lamivudine . . . . . . . . 30, 31
lamivudine/zidovudine . . . . 31
lamotrigine . . . . . . . . . . 14
lamotrigine chew
dispersable tab . . . . . . 14
lamotrigine starter kit . . . . 14
LANOXIN . . . . . . . . . . . . .8
lansoprazole . . . . . . . . . . 24
lansoprazole delayed-release 24
LANTUS . . . . . . . . . . . . 21
lapatinib ditosylate . . . . . . . 4
LARIAM . . . . . . . . . . . . . 32
LASIX . . . . . . . . . . . . . . .9
latanoprost . . . . . . . . . . 38
LATUDA . . . . . . . . . . . . 41
laxative enemas . . . . . . . . 57
laxatives . . . . . . . . . . . . 57
ledipasvir/sofosbuvir . . . . . 30
leflunomide . . . . . . . . . . 33
lenalidomide . . . . . . . . . . 5
LENVIMA . . . . . . . . . . . . .4
LETAIRIS . . . . . . . . . . . . 11
letrozole . . . . . . . . . . . . . 5
LEUKERAN . . . . . . . . . . . .4
LEUKINE . . . . . . . . . . . . .7
leuprolide . . . . . . . . . . . . 5
levalbuterol HCl . . . . . . . . 48
LEVAQUIN . . . . . . . . 27, 29
levatinib . . . . . . . . . . . . . 4
levetiracetam . . . . . . . . . 15
levobunolol . . . . . . . . . . 37
levocetirizine . . . . . . . . . 20
levofloxacin . . . . . . . . . . 29
levofloxacin in d5w iv soln . . 27
levofloxacin iv soln . . . . . . 27
levonorgestrel . . . . . . . . . 34
levonorgestrel/EE . . . . 34, 35
levothyroxine . . . . . . . . . 23
LEVOXYL . . . . . . . . . . . . 23
LEVSIN . . . . . . . . . . . . . 25
LEVSINEX . . . . . . . . . . . 25
68
LEXAPRO . . . . . . . . . . . 40
LEXIVA . . . . . . . . . . . . . 32
LIALDA . . . . . . . . . . . . . 25
LIBRIUM . . . . . . . . . . . . 39
LIDAMANTEL . . . . . . . . . 18
LIDEX . . . . . . . . . . . . . . 17
LIDEX E . . . . . . . . . . . . . 17
lidocaine . . . . . . . . . . . . 18
lidocaine/prilocaine . . . . . 18
lidocaine viscous . . . . . . . 21
linagliptin . . . . . . . . . . . 22
linagliptin/metformin . . . . . 22
linezolid . . . . . . . . . . . . 32
liothyronine . . . . . . . . . . 23
liotrix . . . . . . . . . . . . . . 23
LIPITOR . . . . . . . . . . . . . 10
liraglutide . . . . . . . . . . . 23
lisdexamfetamine . . . . . . . 39
lisinopril . . . . . . . . . . . . . 7
lisinopril/hydrochlorothiazide . 8
lithium carbonate . . . . . . . 40
LITHIUM CARBONATE . . . . 40
lithium carbonate
LITHOBID . . . . . . . . . . . . 40
LMX-4 . . . . . . . . . . . . . . 18
LOCOID . . . . . . . . . . . . . 16
LODINE . . . . . . . . . . 12, 33
LOESTRIN 1.5/30 . . . . . . . 35
LOESTRIN 1/20 . . . . . . . . 35
LOESTRIN FE 1.5/30 . . . . . 35
LOESTRIN FE 1/20 . . . . . . 35
LOFIBRA . . . . . . . . . . . . 10
LOMOTIL . . . . . . . . . . . . 23
lomustine . . . . . . . . . . . . 4
LONITEN . . . . . . . . . . . . 11
LONSURF . . . . . . . . . . . . 4
LO/OVRAL . . . . . . . . . . . 35
loperamide . . . . . . . . . . 23
loperamide . . . . . . . . . . 23
LOPERAMIDE . . . . . . . . . 23
LOPID . . . . . . . . . . . . . . 10
lopinavir/ritonavir . . . . . . . 32
LOPRESSOR . . . . . . . . . . .8
loratadine . . . . . . . . . . . 20
loratadine/pseudoephedrine 56
loratadine/pseudoephedrine
loratadine & pseudoephedrine
SR . . . . . . . . . . . . . 45
lorazepam . . . . . . . . . . . 39
LORCET . . . . . . . . . . . . 12
LORTAB . . . . . . . . . . . . 12
LORTAB ELIXIR . . . . . . . . 12
losartan . . . . . . . . . . . . . 8
losartan/HCTZ . . . . . . . . . 8
LOTENSIN . . . . . . . . . . . . 7
LOTENSIN HCT . . . . . . . . . 7
LOTRIMIN AF . . . . . . . 17, 55
LOTRISONE . . . . . . . . . . 17
lovastatin . . . . . . . . . . . . 10
LOVENOX . . . . . . . . . . . . 6
loxapine . . . . . . . . . . . . 42
LOXITANE . . . . . . . . . . . 42
LOZOL . . . . . . . . . . . . . . 9
LUDIOMIL . . . . . . . . . . . 41
lumacaftor/ivacaftor . . . . . 53
LUPRON . . . . . . . . . . . . .5
LUPRON DEPOT . . . . . . . . 5
LUPRON DEPOT-PED . . . . . .5
lurasidone . . . . . . . . . . . 41
LURIDE . . . . . . . . . . . . . 50
LUVOX . . . . . . . . . . . . . 39
LYNPARZA . . . . . . . . . . . .6
LYRICA . . . . . . . . . . . . . 15
LYSODREN . . . . . . . . . . . .6
LYSTEDA . . . . . . . . . . . . 36
M
MAALOX . . . . . . . . . 24, 57
MACROBID . . . . . . . . . . 32
MACRODANTIN . . . . . . . . 32
magnesium oxide . . . . 50, 58
MAG-OX . . . . . . . . . . 50, 58
malathion . . . . . . . . . . . 18
MAPAP COLD TAB . . . . . . 46
maprotiline . . . . . . . . . . 41
maraviroc . . . . . . . . . . . 32
MARINOL . . . . . . . . . . . . 23
MATERNA . . . . . . . . . . . 51
MATULANE . . . . . . . . . . . 6
MAXALT/MAXALT MLT . . . . 13
MAXITROL . . . . . . . . . . . 37
MAXZIDE . . . . . . . . . . . . 10
M-CLEAR WC . . . . . . . . . 44
mecasermin . . . . . . . . . . 23
meclizine . . . . . . . . . 24, 57
MEDROL . . . . . . . . . . . . 21
medroxyprogesterone
acetate . . . . . . . . 34, 36
mefloquine . . . . . . . . . . 32
MEGACE . . . . . . . . . . . . .5
megestrol acetate . . . . . . . 5
MEKINIST . . . . . . . . . . . . 5
MELLARIL . . . . . . . . . . . 42
meloxicam . . . . . . . . 12, 33
melphalan . . . . . . . . . . . 4
memantine . . . . . . . . . . 11
meperidine . . . . . . . . . . 12
MEPHYTON . . . . . . . . . . 50
MEPRON . . . . . . . . . . . . 32
mercaptopurine . . . . . . . . 4
mesalamine . . . . . . . . . . 25
mesalamine extended-release25
MESTINON . . . . . . . . . . . 13
MESTINON TIMESPAN . . . . 13
METADATE ER . . . . . . . . . 40
METAMUCIL . . . . . . . . . . 57
metaproterenol . . . . . . . . 48
METAPROTERENOL SYRUP 48
metformin . . . . . . . . . . . 22
metformin ER . . . . . . . . . 22
metformin/glyburide . . . . . 22
methadone . . . . . . . . . . 12
methazolamide . . . . . . . . 38
methenamine hippurate . . . 49
METHERGINE . . . . . . 23, 36
methimazole . . . . . . . . . . 23
methocarbamol . . . . . . . . 34
methotrexate . . . . . . . . . 33
methoxsalen . . . . . . . . . . 17
methsuximide . . . . . . . . . 15
methyldopa . . . . . . . . . . 11
methyldopa/HCTZ . . . . . . 11
methylergonovine . . . . 23, 36
69
methylphenidate . . . . . . . 39
methylphenidate
extended-release . . . 39, 40
methylprednisolone . . . . . . 21
metipranolol . . . . . . . . . . 37
metoclopramide . . . . . . . 24
metolazone . . . . . . . . . . . 9
metoprolol . . . . . . . . . . . 8
metoprolol succinate . . . . . . 8
METROCREAM . . . . . . . . 18
METROGEL . . . . . . . . . . 18
METROGEL 1% . . . . . . . . 36
METROGEL-VAGINAL . . . . 36
METROLOTION . . . . . . . . 18
metronidazole . . . . 18, 32, 36
MEVACOR . . . . . . . . . . . 10
mexiletine . . . . . . . . . . . . 8
MEXITIL . . . . . . . . . . . . . .8
MIACALCIN . . . . . . . . . . 23
MICATIN . . . . . . . . . . 17, 55
miconazole . . . . . . 17, 36, 55
MICRO-K 10 . . . . . . . . . . 53
MICRONASE . . . . . . . . . . 22
MICROZIDE . . . . . . . . . . . 9
MIDAMOR . . . . . . . . . . . . 9
midodrine . . . . . . . . . . . 11
mifeprstone . . . . . . . . . . 23
MIGERGOT
SUPPOSITORIES . . . . . 13
MIGRANAL . . . . . . . . . . . 13
MINIPRESS . . . . . . . . . . . .8
MINOCIN . . . . . . . . . . . . 30
minocycline . . . . . . . . . . 30
minoxidil . . . . . . . . . . . . 11
MINUTUSS DR SYP . . . . . . 46
MIRALAX . . . . . . . . . . . . 25
MIRAPEX . . . . . . . . . . . . 14
MIRCETTE . . . . . . . . . . . 34
mirtazapine . . . . . . . . . . 41
MIRVASO . . . . . . . . . . . . 17
misoprostol . . . . . . . . . . 26
MITIGARE . . . . . . . . . . . 34
mitotane . . . . . . . . . . . . . 6
MOBAN . . . . . . . . . . . . . 42
MOBIC . . . . . . . . . . 12, 33
MODICON . . . . . . . . . . . 35
MODURETIC . . . . . . . . . . .9
molindone . . . . . . . . . . . 42
mometasone . . . . . . . . . 47
mometasone/formoterol . . . 47
mometasone furoate . . . . . 16
mometasone inhalation . . . 47
MONISTAT . . . . . . . . 36, 55
MONISTAT 3 . . . . . . . . . . 36
MONISTAT-DERM . . . . . . . 17
MONOPRIL . . . . . . . . . . . 7
MONOPRIL-HCT . . . . . . . . .8
montelukast . . . . . . . . . . 48
morphine . . . . . . . . . . . 12
morphine extended-release . 12
morphine sulfate inj . . . . . . 26
morphine sulfate iv soln . . . 26
MORPHINE SUL INJ . . . . . 26
MOTRIN . . . . . . . . . . 12, 33
MOTRIN IB . . . . . . . . . . . 57
MOVANTIK . . . . . . . . . . . 26
MOZOBIL . . . . . . . . . . . . .7
MS CONTIN . . . . . . . . . . 12
MSIR . . . . . . . . . . . . . . 12
MUCINEX . . . . . . . . . . . 45
MUCINEX D . . . . . . . . . . 45
MUCINEX DM . . . . . . . . . 44
MUCOMYST . . . . . . . . . . 53
MULTI SYMPTOM TAB
COLD RLF . . . . . . . . . 47
multivitamins/fluoride/±iron . 50
multivitamins/minerals . . . . 50
mupirocin . . . . . . . . . . . 16
MURINE . . . . . . . . . . . . 57
MURO 128 . . . . . . . . . . . 39
MYAMBUTOL . . . . . . . . . 28
MYCELEX . . . . . . . . . 17, 30
MYCITRACIN . . . . . . . . . . 56
MYCOBUTIN . . . . . . . . . . 28
mycophenolate mofetil . . . . .5
mycophenolate sodium . . . . 6
MYCOSTATIN . . . . . . . 17, 30
MYFORTIC . . . . . . . . . . . .6
MYLANTA . . . . . . . . . 24, 57
MYLERAN . . . . . . . . . . . . 4
MYLICON . . . . . . . . . . . 57
MYSOLINE . . . . . . . . . . . 15
N
nabumetone . . . . . . . . . . 12
naloxegol . . . . . . . . . . . 26
naloxone . . . . . . . . . . . . 41
NALOXONE INJ . . . . . . . . 41
naltrexone . . . . . . . . . 39, 41
NAMENDA . . . . . . . . . . . 11
naphazoline/antazoline . . . 36
naphazoline/glycerin . . . . . 37
naphazoline HCL . . . . . . . 36
naphazoline/zinc sulfate . . . 37
NAPHCON A . . . . . . . . . . 57
NAPROSYN . . . . . . . . 12, 33
naproxen . . . . . . . . . 12, 33
naproxen delayed release 12, 34
naratriptan . . . . . . . . . . . 13
NASACORT ALLERGY . . . . 20
NASALCROM . . . . . . . . . 20
nasal sprays . . . . . . . . . . 56
NATALCARE . . . . . . . . . . 51
nateglinide . . . . . . . . . . . 22
NAVANE . . . . . . . . . . . . 42
nedocromil . . . . . . . . . . 47
nelfinavir . . . . . . . . . . . . 32
NEO DM . . . . . . . . . . . . 43
bacitracin . . . . . . . . . 16
dexamethasone . . . . . . 37
gramicidin . . . . . . . . . 38
hydrocortisone . . . . 19, 37
neomycin sulfate . . . . . . . 32
NEORAL . . . . . . . . . . . . . 6
NEOSPORIN . . . . . 16, 38, 56
NEO-SYNEPHRINE . . . 20, 56
NEPHROCAPS . . . . . . . . 52
NEPTAZANE . . . . . . . . . . 38
NESTABSCBF/FA/RX . . . . . 51
NEULASTA . . . . . . . . . . . .7
NEUMEGA . . . . . . . . . . . .7
70
NEURONTIN . . . . . . . . . . 14
NEUTROGENA OIL FREE
ACNE WASH . . . . . . . . 16
nevirapine . . . . . . . . . . . 31
nevirapine ER . . . . . . . . . 31
NEXAVAR . . . . . . . . . . . . .5
NEXIUM 24HR OTC . . . . . . 24
NEXIUM DELAYED
RELEASE PACKET . . . . 24
niacin . . . . . . . . . . . . . 10
niacin extended-release . . . 10
NIACOR . . . . . . . . . . . . 10
NIASPAN . . . . . . . . . . . . 10
nicardipine . . . . . . . . . . . 9
NICODERM CQ . . . . . 42, 58
NICORETTE OTC . . . . . . . 42
nicotine . . . . . . . . . . 42, 58
NICOTINE GUM . . . . . . . . 58
nicotine polacrilex gum . . . . 42
nicotine polacrilex lozenge . . 42
NICOTROL . . . . . . . . . . . 58
nifedipine . . . . . . . . . . . . 9
nifedipine extended-release . . 9
NIFEREX . . . . . . . 50, 51, 58
NIFEREX-PN FORTE . . . . . 51
nilotinib . . . . . . . . . . . . . 4
nimodipine . . . . . . . . . . . 9
NIMOTOP . . . . . . . . . . . . 9
nintedanib . . . . . . . . . . . 53
nitazoxanide suspension . . . 32
nitazoxanide tablet . . . . . . 32
NITREK . . . . . . . . . . . . 10
NITRO-BID . . . . . . . . . . . 10
NITRO-DUR . . . . . . . . . . 10
nitrofurantoin
nitrofurantoin macrocrystals . 32
nitrofurantoin susp . . . . . . 32
nitroglycerin . . . . . . . .10, 18
NITROLINGUAL . . . . . . . . 10
NITROSTAT . . . . . . . . . . . 10
NIX . . . . . . . . . . . . . 18, 57
NIZORAL . . . . . . . . . 17, 30
NIZORAL SHAMPOO . . . . . 18
NOLVADEX . . . . . . . . . . . .5
NORCO . . . . . . . . . . . . . 12
NORDETTE . . . . . . . . . . 35
norelgestromin/EE . . . . . . 35
norethindrone . . . . . . . . . 35
norethindrone acetate . . . . 36
norethindrone acetate/EE . . 35
norethindrone
acetate/EE/iron . . . . . . 35
norethindrone/EE . . . . 34, 35
norethindrone/ME . . . . . . 35
NORFLEX . . . . . . . . . . . 34
norgestimate/EE . . . . . . . 35
norgestrel . . . . . . . . . . . 35
norgestrel/EE . . . . . . . . . 35
NORPACE . . . . . . . . . . . . 8
NORPACE CR . . . . . . . . . .8
NORPRAMIN . . . . . . . . . . 40
nortriptyline . . . . . . . . . . 40
NORVASC . . . . . . . . . . . . 9
NORVIR . . . . . . . . . . . . . 32
NOVOLIN . . . . . . . . . . . . 56
NOVOLIN 70/30 . . . . . . . . 22
NOVOLIN N . . . . . . . . . . 21
NOVOLIN R . . . . . . . . . . 21
NOVOLOG . . . . . . . . . . . 21
NOVOLOG MIX 70/30 . . . . 21
NUEDEXTA . . . . . . . . . . . 42
NULYTELY . . . . . . . . . . . 25
NUTROPIN AQ NUSPIN . . . 23
NUVARING . . . . . . . . . . . 34
NYMALIZE . . . . . . . . . . . .9
nystatin . . . . . . . . . . 17, 30
NYTOL QUICK CAPS . . . . . 41
O
OCEAN NASAL SPRAY . . . . 20
octreotide . . . . . . . . . . . . 6
OCUFEN . . . . . . . . . . . . 37
OCUFLOX . . . . . . . . . . . 38
ODOMZO . . . . . . . . . . . . .6
OFEV . . . . . . . . . . . . . . 53
ofloxacin . . . . . . . 19, 29, 38
OFORTA . . . . . . . . . . . . . 4
OGEN . . . . . . . . . . . . . . 36
olanzapine . . . . . . . . . . . 41
olaparib . . . . . . . . . . . . . 6
olodaterol . . . . . . . . . . . 47
olsalazine sodium . . . . . . . 25
omalizumab . . . . . . . . . . 47
omeprazole delayed-release 24
OMNICEF . . . . . . . . . . . . 29
ondansetron . . . . . . . . . . 24
ONE TOUCH SYSTEMS (ULTRA
2, ULTRAMINI, VERIO, VERIO FLEX, VERIO IQ,
VERIO SYNC) . . . . . . . 22
ONE TOUCH TEST STRIPS
(ULTRA, VERIO) . . . . . . 22
ONFI . . . . . . . . . . . . . . 14
ONGLYZA . . . . . . . . . . . 22
oprelvekin . . . . . . . . . . . . 7
OPTIPRANOLOL . . . . . . . 37
OPTIVAR . . . . . . . . . . . . 36
ORAP . . . . . . . . . . . . . . 42
ORAPRED . . . . . . . . . . . 21
ORKAMBI . . . . . . . . . . . 53
orlistat . . . . . . . . . . . . . 42
orphenadrine
ORTHO-CEPT . . . . . . . . . 35
ORTHO COIL . . . . . . . . . 34
ORTHO-CYCLEN . . . . . . . 35
ortho diaphragm . . . . . . . 34
ORTHO EVRA . . . . . . . . . 35
ORTHO FLAT . . . . . . . . . 34
ORTHO FLEX . . . . . . . . . 34
ORTHO MICRONOR . . . . . 35
ORTHO-NOVUM 1/35 . . . . 35
ORTHO-NOVUM 1/50 . . . . 35
ORTHO-NOVUM 7/7/7 . . . . 35
ORTHO-NOVUM 10/11 . . . 34
ORTHO TRI-CYCLEN . . . . . 35
ORUDIS . . . . . . . . . . 12, 33
OS-CAL . . . . . . . . . . 49, 58
oseltamivir . . . . . . . . . . . 31
OVCON 50 . . . . . . . . . . . 35
OVIDE . . . . . . . . . . . . . . 18
OVRAL . . . . . . . . . . . . . 35
OVRETTE . . . . . . . . . . . . 35
oxaprozin . . . . . . . . . 12, 34
71
oxazepam . . . . . . . . . . . 39
oxcarbazepine . . . . . . . . 15
OXSORALEN-ULTRA . . . . . 17
oxybutynin chloride . . . . . . 49
oxybutynin IR . . . . . . . . . 49
oxycodone . . . . . . . . . . 12
oxycodone/acetaminophen . 13
oxycodone/aspirin . . . . . . 13
OXYFAST . . . . . . . . . . . . 12
oxymetazoline . . . . . . . . . 20
oxymorphone ER . . . . . . . 13
OXYMORPHONE ER . . . . . 13
P
palbociclib . . . . . . . . . . . 6
paliperidone . . . . . . . . . . 41
palivizumab . . . . . . . . . . 32
PAMELOR . . . . . . . . . . . 40
pancrelipase . . . . . . . . . 26
panobinostat . . . . . . . . . . 4
PANRETIN . . . . . . . . . . . .6
pantoprazole . . . . . . . . . 24
PARAFON FORTE DSC . . . . 34
PARNATE . . . . . . . . . . . . 40
paromomycin . . . . . . . . . 32
paroxetine . . . . . . . . . . . 40
PASER . . . . . . . . . . . . . 28
pasireotide . . . . . . . . . . . 6
PAXIL . . . . . . . . . . . . . . 40
pazopanib . . . . . . . . . . . 4
PEDIACARE LIQ MULTI-SY . . 47
PEDIALYTE . . . . . . . . 49, 57
PEDIAPRED . . . . . . . . . . 21
PEDIAZOLE . . . . . . . . . . 29
peg 3350/electrolytes . . . . 25
peg 3350/sodium bicarbonate/
sodium chloride . . . . . 25
peg 3350/sodium bicarbonate/
sodium chloride/potassium
chloride . . . . . . . . . . 25
PEGASYS . . . . . . . . . . . . 30
pegfilgrastim . . . . . . . . . . 7
peginterferon alfa-2a . . . . . 30
peginterferon alfa-2b . . . . . . 5
pegvisomant . . . . . . . . . 23
penicillamine . . . . . . . . . 33
penicillin VK . . . . . . . . . . 29
PENLAC SOLUTION 8% . . . 17
PENTASA . . . . . . . . . . . . 25
pentazocine/naloxone . . . . 13
pentoxifylline
extended-release . . . . . . 7
PEPCID . . . . . . . . . . . . . 24
PEPCID AC . . . . . . . . 24, 57
PERCOCET . . . . . . . . . . 13
PERCODAN . . . . . . . . . . 13
PERIDEX . . . . . . . . . . . . 21
permethrin . . . . . . . . 18, 57
perphenazine . . . . . . . . . 42
PERSANTINE . . . . . . . . . . 7
phenazopyridine . . . . . . . 49
PHENERGAN . . . . . . . . . 24
PHENERGAN DM . . . . . . . 45
phenobarbital . . . . . . . . . 15
PHENOBARBITAL . . . . . . . 15
phenyleph/bromphen/dextromethorphan/guaifenesin 45
phenylephrine . . . . . . . . . 20
phenylephrine/
brompheniramine/
phenylephrine/
chlorpheniramine . . . . . 45
phenylephrine/
chlorpheniramine/
phenylephrine/
chlorpheniramine/
dihydrocodeine . . . . . . 46
phenylephrine/
phenylephrine/dextromethorphan/guaifenesin . . . . 46
phenylephrine/ephed/CPM
w/carbetapentane . . . . 46
phenylephrine/guaifenesin . . 46
phenylephrine/hydrocodone/
guaifenesin . . . . . . . . 46
phenylephrine/pyrilamine/
phenylephrine/pyrilamine w/hydrocodone . . . . . . . . 46
phenylephrine tan/pyrilamine
tan/carbeta tan . . . . . . 46
PHENYLHIST LIQ DH . . . . . 44
PHENYTEK . . . . . . . . . . . 15
phenytoin . . . . . . . . . . . 15
phenytoin sodium extended . 15
PHISOHEX . . . . . . . . . . . 18
PHOS-FLUR . . . . . . . . 50, 58
PHOSLO . . . . . . . . . . . . 53
PHOSPHOLINE IODINE . . . 38
phosphorus . . . . . . . . . . 52
PHRENILIN . . . . . . . . . . . 11
phytonadione . . . . . . . 28, 50
pilocarpine . . . . . . . . 21, 38
PILOPINE HS GEL . . . . . . . 38
PIMA . . . . . . . . . . . . . . 53
pimecrolimus . . . . . . . . . 19
pimozide . . . . . . . . . . . . 42
pindolol . . . . . . . . . . . . . 9
PINDOLOL . . . . . . . . . . . .9
pioglitazone . . . . . . . . . . 22
pioglitazone/glimepiride . . . 22
pioglitazone/metformin . . . 22
pioglitazone/metformin ER . 22
piperacillin sodium-tazobactam
sodium for inj . . . . . . . 27
sodium for inj . . . . . . . 27
sodium in dex iv sol . . . 27
PIPERONYL BUTOXIDE . . . 57
piperonyl butoxide gel,
liquid shampoo . . . . . . 57
PIPER/TAZOBA INJ . . . . . . 27
pirfenidone capsule . . . . . 53
piroxicam . . . . . . . . . 12, 34
PLAN B . . . . . . . . . . . . . 34
PLAQUENIL . . . . . . . . 32, 33
PLAVIX . . . . . . . . . . . . . . 7
PLENDIL . . . . . . . . . . . . . 9
plerixafor . . . . . . . . . . . . 7
PLETAL . . . . . . . . . . . . . .7
PLEXION . . . . . . . . . . . . 16
72
pneumococcal 13-valent
conjugate . . . . . . . . . 54
pneumococcal vaccine
polyvalent . . . . . . . . . 54
PNEUMOVAX,
PNEUMOVAX 23 . . . . . 54
podofilox . . . . . . . . . . . . 18
polyethylene glycol 3350 . . . 25
polymyxin B/bacitracin . . . . 38
polymyxin B/trimethoprim . . 38
polysaccharide iron
complex . . . . . . . . . . 51
POLYSPORIN . . . . . . . . . 38
POLYTRIM . . . . . . . . . . . 38
POLY-VI-FLOR . . . . . . . . . 50
POLY-VI-SOL . . . . . . . . . . 58
pomalidomide . . . . . . . . . 6
POMALYST . . . . . . . . . . . .6
ponatinib . . . . . . . . . . . . 5
potassium acid phosphate . . 52
potassium bicarbonate/potassium citrate effervescent 52
potassium chloride . . . . . . 52
potassium chloride . . . . . . 52
POTASSIUM CHLORIDE . . . 52
potassium chloride
extended-release . . . 52, 53
potassium citrate . . . . . . . 49
potassium iodide . . . . . . . 53
POTIGA . . . . . . . . . . . . . 14
povidone-iodine . . . . . . . . 32
PRALUENT . . . . . . . . . . . 10
pramipexole . . . . . . . . . . 14
pramlintide . . . . . . . . . . 23
PRANDIN . . . . . . . . . . . . 22
praziquantel . . . . . . . . . . 28
prazosin . . . . . . . . . . . . . 8
PRECOSE . . . . . . . . . . . 22
PRED FORTE . . . . . . . . . 37
PRED-G . . . . . . . . . . . . . 37
PRED MILD . . . . . . . . . . 37
prednicarbate . . . . . . . . . 16
prednisolone . . . . . . . . . 21
prednisolone acetate . . . . . 37
prednisolone phosphate . . . 37
prednisolone sodium
phosphate . . . . . . . . . 21
prednisone . . . . . . . . . . 21
pregabalin . . . . . . . . . . . 15
PRELONE . . . . . . . . . . . 21
PREMARIN . . . . . . . . 35, 36
PREMPHASE . . . . . . . . . 36
PREMPRO . . . . . . . . . . . 36
prenatal vitamins w/folic acid 51
PRENATAL VITAMINS
W/ FOLIC ACID . . . . . . 51
prenatal vit w/FE bisglyc-FE prot
succ-FA . . . . . . . . . . 51
prenatal vit w/FE bisglycinate
chelate-FA . . . . . . . . . 51
prenatal vit w/FE polysac
cmplx-FA . . . . . . . . . 51
prenatal vit w/iron
carbonyl-FA . . . . . . . . 51
prenatal w/o A w/FE carbonylFE gluc-DSS-FA . . . . . . 52
prenat-FE Bis-FE prot succ-FACA & omega 3 . . . . . . 51
prenat-FE bis-FE prot succ-FACA & omega DR . . . . . 51
prenat w/o A w/fecbn-feglDSS-FA & DHA . . . . . . 51
PREPARATION H . . . . . . . 57
PREVACID . . . . . . . . . . . 24
PREVIDENT . . . . . . . . . . 50
PREVNAR 13 . . . . . . . . . 54
PREZCOBIX . . . . . . . . . . 32
PREZISTA . . . . . . . . . . . . 31
PRIFTIN . . . . . . . . . . . . . 29
PRILOSEC . . . . . . . . . . . 24
primaquine . . . . . . . . . . 32
primidone . . . . . . . . . . . 15
PRINCIPEN . . . . . . . . . . . 29
PROAMATINE . . . . . . . . . 11
probenecid . . . . . . . . . . 34
PROBENECID . . . . . . . . . 34
procarbazine . . . . . . . . . . 6
PROCARDIA . . . . . . . . . . .9
PROCARDIA XL . . . . . . . . .9
prochlorperazine . . . . . 24, 42
PROCRIT . . . . . . . . . . . . .7
PROCTOSOL HC
CREAM 2.5% . . . . . . . 18
PROCTOZONE
CREAM-HC 2.5% . . . . . 18
PROGRAF . . . . . . . . . . . . 6
PROLIXIN . . . . . . . . . . . . 42
PROLIXIN DECANOATE . . . 42
PROMACTA . . . . . . . . . . 53
promethazine . . . . . . . . . 24
promethazine hcl inj . . . . . 28
promethazine &
PROMETHAZINE SYP DM . . 45
PROMETHAZINE VC
W/CODEINE . . . . . . . . 44
PROMETHAZINE
W/CODEINE . . . . . . . . 44
PROMETH VC SYP . . . . . . 46
propafenone . . . . . . . . . . 8
propantheline . . . . . . . . . 49
propranolol . . . . . . . . . 9, 13
propranolol/HCTZ . . . . . . . 9
propylthiouracil . . . . . . . . 23
PROPYLTHIOURACIL . . . . . 23
PROSCAR . . . . . . . . . . . 48
PROTONIX . . . . . . . . . . . 24
PROTOPIC 0.1% . . . . . . . . 19
PROTOPIC 0.03% . . . . . . . 19
PROVENTIL . . . . . . . . . . 48
PROVERA . . . . . . . . . . . 36
PROZAC . . . . . . . . . . . . 40
PRUET DHAEC PAK . . . . . 51
PRUET DHA PAK
SETONET PAK . . . . . . 51
PSE/GG . . . . . . . . . . . . 45
pseudoephedrine/
acetaminophen/
pseudoephedrine/
chlorpheniramine/
pseudoephedrine/dextromethorphan/guaifenesin . . . . 47
73
pseudoephedrine/
iburprofen . . . . . . . . . 47
pseudoephedrine tan/
dexchlorphen tan/DM tan 47
psyllium . . . . . . . . . . . . 57
PULMICORT RESPULES . . . 48
PULMOZYME . . . . . . . . . 53
PURINETHOL . . . . . . . . . . 4
pyazinamide . . . . . . . . . . 28
PYRAZINAMIDE . . . . . . . . 28
pyrethrins/piperonyl but . . . 18
PYRIDIUM . . . . . . . . . . . 49
pyridostigmine . . . . . . . . 13
pyridostigmine
pyrilamine tan/phenyleph tan 47
pyrimethamine . . . . . . . . 33
Q
QUAL-TUSSIN SYP DC . 45, 46
QUESTRAN . . . . . . . . . . 10
QUESTRAN-LIGHT . . . . . . 10
quetiapine . . . . . . . . . . . 41
quinapril . . . . . . . . . . . . . 7
quinapril/hydrochlorothiazide . 8
quinidine gluconate
QUINIDINE GLUCONATE
EXT-REL . . . . . . . . . . . 8
quinidine sulfate . . . . . . . . 8
QUINIDINE SULFATE . . . . . .8
quinidine sulfate
QUINIDINE SULFATE EXT-REL 8
QV-ALLERGY . . . . . . . . . 43
R
raloxifene . . . . . . . . . . . 23
raltegravir . . . . . . . . . . . 33
RANEXA . . . . . . . . . . . . 11
ranitidine . . . . . . . . . . . . 24
ranolazine . . . . . . . . . . . 11
RAPAMUNE . . . . . . . . . . . 6
RAVICTI . . . . . . . . . . . . . 53
RAZADYNE . . . . . . . . . . 11
REBETOL/COPEGUS . . . . 30
REBIF . . . . . . . . . . . . . . 13
rectal crm, suppositories . . . 57
RECTIV . . . . . . . . . . . . . 18
REGLAN . . . . . . . . . . . . 24
regorafenib . . . . . . . . . . . 5
REGRANEX . . . . . . . . . . 18
RELAFEN . . . . . . . . . . . . 12
RELENZA . . . . . . . . . . . . 31
RELION 70/30 . . . . . . . . . 22
RELION N . . . . . . . . . . . 21
RELION R . . . . . . . . . . . 21
REMERON . . . . . . . . . . . 41
RENVELA . . . . . . . . . . . . 53
repaglinide . . . . . . . . . . 22
REQUIP . . . . . . . . . . . . . 14
RESCRIPTOR . . . . . . . . . 31
RESPERAL-DM . . . . . . . . . 42
RESTORIL . . . . . . . . . . . 41
RETIN-A . . . . . . . . . . . . 16
RETROVIR . . . . . . . . . . . 31
REVATIO . . . . . . . . . . . . 11
REVIA . . . . . . . . . . . 39, 41
REVLIMID . . . . . . . . . . . . 5
REYATAZ . . . . . . . . . . . . 31
REYATAZ POWDER PACKET 31
ribavirin . . . . . . . . . . . . 30
RIDAURA . . . . . . . . . . . . 33
RID SHAMPOO/
BUTOXIDE SHAMPOO . . 18
rifabutin . . . . . . . . . . . . 28
RIFADIN . . . . . . . . . . . . . 29
rifampin . . . . . . . . . . . . 29
rifapentine . . . . . . . . . . . 29
rilonacept . . . . . . . . . . . 53
rilpivirine . . . . . . . . . . . . 31
rimantadine . . . . . . . . . . 31
rimexolone . . . . . . . . . . . 37
RISPERDAL . . . . . . . . . . 41
RISPERDAL CONSTA . . . . . 41
RISPERDAL SOLUTION . . . 42
risperidone . . . . . . . . 41, 42
RITALIN . . . . . . . . . . . . . 39
RITALIN LA . . . . . . . . . . . 40
RITALIN-SR . . . . . . . . . . . 40
ritonavir . . . . . . . . . . . . 32
rivaroxaban . . . . . . . . . . . 6
rivastigmine . . . . . . . . . . 11
rizatriptan . . . . . . . . . . . 13
RMS . . . . . . . . . . . . . . . 12
ROBAXIN . . . . . . . . . . . . 34
ROBINUL . . . . . . . . . . . . 25
ROBITUSSIN . . . . . . . 45, 56
ROBITUSSIN CF . . . . . 45, 56
ROBITUSSIN DM . . . . . 44, 56
ROBITUSSIN LIQ CGH/ALRG46
ROBITUSSIN LIQ
CGH/CLD . . . . . . . 43, 46
ROBITUSSIN LIQ
CGH/CONG . . . . . . . . 44
ROBITUSSIN LIQ HD/CHST . 46
ROBITUSSIN LIQ PED NGHT 47
ROBITUSSIN PE . . . . . 45, 56
ROBITUSSIN PED
LIQ CGH/COLD . . . . . . 43
ROBITUSSIN PED SYP . . . . 44
ROBITUSSIN SYP
CHST CNG . . . . . . . . . 45
ROBITUSSIN SYP MAX-ST . . 44
ROCALTROL . . . . . . . . . . 49
RONDEC DM . . . . . . . . . 46
RONDEC DROPS . . . . 43, 44
RONDEC SYRUP . . . . . 42, 44
ropinirole . . . . . . . . . . . 14
ROWASA . . . . . . . . . . . . 25
ROXICODONE . . . . . . . . . 12
R-TANNAMINE . . . . . . . . . 43
rufinamide . . . . . . . . . . . 15
ruxolitinib . . . . . . . . . . . . 5
RYNA-12 S . . . . . . . . . . . 47
RYNATAN PEDIATRIC SUSP . 44
RYNATUSS . . . . . . . . . . . 43
RYNATUSS PEDIATRIC SUSP46
RYTHMOL . . . . . . . . . . . .8
S
SABRIL SOLUTION . . . . . . 15
SALAGEN . . . . . . . . . . . 21
salicylic acid . . . . . . . 16, 17
74
salicylic acid 17%/
collodion . . . . . . . 18, 58
saline nasal spray 0.65% . . . 20
SAL-TROPINE . . . . . . . . . 26
SANCTURA . . . . . . . . . . 49
SANDIMMUNE . . . . . . . . . .6
SANDOSTATIN . . . . . . . . . .6
SANTYL . . . . . . . . . . . . 18
SAPHRIS . . . . . . . . . . . . 41
sapropterin . . . . . . . . . . 23
sapropterin powder . . . . . . 23
saquinavir . . . . . . . . . . . 32
saquinavir mesylate . . . . . . 32
sargramostim . . . . . . . . . . 7
SAVAYSA . . . . . . . . . . . . .6
saxagliptin . . . . . . . . . . . 22
saxagliptin/metformin . . . . 22
SCALPICIN . . . . . . . . . . . 17
scopolamine . . . . . . . . . 38
SEASONALE . . . . . . . . . . 34
SECTRAL . . . . . . . . . . . . .8
SEDAPAP . . . . . . . . . . . . 11
selegiline . . . . . . . . . . . 14
selenium sulfide . . . . . . . . 19
SELSUN . . . . . . . . . . . . 19
SELZENTRY . . . . . . . . . . 32
sennosides . . . . . . . . . . 25
SENOKOT . . . . . . . . . . . 25
SENSIPAR . . . . . . . . . . . 53
SERAX . . . . . . . . . . . . . 39
SEROMYCIN . . . . . . . . . . 28
SEROQUEL . . . . . . . . . . 41
SEROQUEL XR . . . . . . . . 41
sertraline . . . . . . . . . . . . 40
sevelamer . . . . . . . . . . . 53
SIGNIFOR . . . . . . . . . . . . 6
sildenafil . . . . . . . . . . . . 11
SILVADENE . . . . . . . . . . . 16
silver sulfadiazine . . . . . . . 16
simethicone . . . . . . . . . . 57
simvastatin . . . . . . . . . . . 10
SINEMET . . . . . . . . . . . . 14
SINEMET CR . . . . . . . . . . 14
SINEQUAN . . . . . . . . . . . 40
SINGULAIR . . . . . . . . . . . 48
sirolimus . . . . . . . . . . . . 6
SIRTURO . . . . . . . . . . . . 32
SOD CHLORIDE INJ . . . . . 28
sodium chloride hypertonic . 39
sodium chloride inj . . . . . . 28
sodium chloride irrigation
soln 0.9% . . . . . . . . . 28
sodium chloride iv soln . . . . 28
sodium citrate/citric acid . . . 49
sodium phenylbutyrate oral
powder . . . . . . . . . . 53
sodium polysterene sulfonate 10
sofosbuvir . . . . . . . . . . . 30
somatropin . . . . . . . . . . 23
SOMAVERT . . . . . . . . . . 23
SONATA . . . . . . . . . . . . 41
sonidegib . . . . . . . . . . . . 6
sorafenib . . . . . . . . . . . . 5
SORIATANE . . . . . . . . . . 17
sotalol . . . . . . . . . . . . . . 9
SOVALDI . . . . . . . . . . . . 30
Spacers . . . . . . . . . . . . 53
spironolactone . . . . . . . . . 9
spironolactone/
hydrochlorothiazide . . . . 9
SPORANOX . . . . . . . . . . 30
SPORANOX . . . . . . . . . . 30
SPRYCEL . . . . . . . . . . . . .4
STADOL . . . . . . . . . . . . 12
STARLIX . . . . . . . . . . . . 22
STATUSS DM SYP . . . . . . . 46
stavudine . . . . . . . . . . . 31
STELAZINE . . . . . . . . . . . 42
STIVARGA . . . . . . . . . . . . 5
stool softeners . . . . . . . . 57
STRIBILD . . . . . . . . . . . . 31
STRIVERDI RESPIMAT . . . . 47
STROMECTOL . . . . . . . . . 28
STUART PRENATAL . . . . . . 58
SUBOXONE . . . . . . . . . . 41
SUBUTEX . . . . . . . . . . . 41
sucralfate . . . . . . . . . . . 24
sugar+orthophosphoric acid 57
sulcralfate . . . . . . . . . . . 24
sulfacetamide . . . . . . . . . 38
sulfacetamide/
sulfacetamide/pred. phos. . . 37
sulfacetamide/sulfur . . . . . 16
sulfacetamide/sulfur . . . . . 16
SULFACET-R . . . . . . . . . . 16
sulfamethoxazole/
trimethoprim, DS . . . . . 29
sulfasalazine . . . . . . . 25, 33
sulfasalazine
delayed-release . . . . 25, 33
sulindac . . . . . . . . . . 12, 34
sumatriptan . . . . . . . . . . 13
SUMYCIN . . . . . . . . . . . . 30
sunitinib . . . . . . . . . . . . . 5
SUPRAX . . . . . . . . . . . . 29
SUSTIVA . . . . . . . . . . . . 31
SUTENT . . . . . . . . . . . . . 5
SYLATRON . . . . . . . . . . . .5
SYMLIN . . . . . . . . . . . . . 23
SYMMETREL . . . . . . . 14, 31
SYNAGIS . . . . . . . . . . . . 32
SYNALAR . . . . . . . . . . . 16
SYNJARDY . . . . . . . . . . . 22
SYNTHROID . . . . . . . . . . 23
T
TABLOID . . . . . . . . . . . . . 4
tacrolimus . . . . . . . . . . 6, 19
TAFINLAR . . . . . . . . . . . . 4
TAGAMET . . . . . . . . . . . 24
TALWIN NX . . . . . . . . . . . 13
TAMBOCOR . . . . . . . . . . .8
TAMIFLU . . . . . . . . . . . . 31
tamoxifen . . . . . . . . . . . . 5
tamsulosin . . . . . . . . . . . 48
TANAFED . . . . . . . . . . . . 43
TANAFED DMX
SUSPENSION . . . . . . . 47
TANZEUM . . . . . . . . . . . 23
TAPAZOLE . . . . . . . . . . . 23
TARCEVA . . . . . . . . . . . . .4
TARGRETIN . . . . . . . . . . . 6
TASIGNA . . . . . . . . . . . . .4
75
TASMAR . . . . . . . . . . . . 14
TBO-filgrastim . . . . . . . . . 7
TECFIDERA . . . . . . . . . . 13
teduglutide . . . . . . . . . . 26
TEGRETOL . . . . . . . . . . . 14
TEGRETOL-XR . . . . . . . . . 14
telaprevir . . . . . . . . . . . . 30
temazepam . . . . . . . . . . 41
TEMODAR . . . . . . . . . . . .4
TEMOVATE . . . . . . . . . . . 17
temozolomide . . . . . . . . . 4
TENEX . . . . . . . . . . . . . . 8
tenofovir . . . . . . . . . . . . 31
TENORETIC . . . . . . . . . . .8
TENORMIN . . . . . . . . . . . .8
TERAZOL 3/7 . . . . . . . . . 36
terazosin . . . . . . . . . . 8, 48
terbinafine . . . . . . . . 17, 30
terbutaline . . . . . . . . . . . 48
terconazole . . . . . . . . . . 36
teriflunomide . . . . . . . . . 13
teriparatide inj . . . . . . . . . 23
TESSALON . . . . . . . . . . . 42
TESTOSTERONE 1%
TOPICAL GEL . . . . . . . 21
testosterone cypionate . . . . 21
testosterone enanthate . . . . 21
testosterone gel topical tube,
packet, and pump bottle 21
tetrabenazine . . . . . . . . . 15
tetracycline . . . . . . . . . . 30
tetrahydrozoline/zinc sulfate . 37
thalidomide . . . . . . . . . . . 5
THALOMID . . . . . . . . . . . .5
THEO-24 . . . . . . . . . . . . 48
THEOCHRON . . . . . . . . . 48
theophylline . . . . . . . . . . 48
THEOPHYLLINE . . . . . . . . 48
theophylline extended-release48
THEOPHYLLINE EXT-REL . . 48
thioguanine . . . . . . . . . . . 4
thioridazine . . . . . . . . . . 42
thiothixene . . . . . . . . . . . 42
THORAZINE . . . . . . . . . . 42
THYROLAR . . . . . . . . . . 23
tiagabine . . . . . . . . . . . . 15
TIAZAC . . . . . . . . . . . . . .9
TIGAN . . . . . . . . . . . . . . 24
TIKOSYN . . . . . . . . . . . . .8
TILADE . . . . . . . . . . . . . 47
timolol . . . . . . . . . . . . . 37
timolol hemihydrate . . . . . . 37
timolol maleate . . . . . . . 9, 37
TIMOPTIC . . . . . . . . . . . 37
TIMOPTIC XE . . . . . . . . . 37
TINACTIN . . . . . . . . . 17, 55
tipranavir . . . . . . . . . . . . 32
TIVICAY . . . . . . . . . . . . . 32
tizanidine . . . . . . . . . . . 34
TOBRADEX . . . . . . . . . . 37
tobramycin . . . . . . . . . . 38
tobramycin/dexamethasone 37
tobramycin neb soln . . . . . 53
TOBREX . . . . . . . . . . . . 38
TOFRANIL . . . . . . . . . . . 40
tolazamide . . . . . . . . . . . 22
tolbutamide . . . . . . . . . . 22
TOLBUTAMIDE . . . . . . . . 22
tolcapone . . . . . . . . . . . 14
TOLINASE . . . . . . . . . . . 22
tolnaftate . . . . . . . . . 17, 55
tolterodine . . . . . . . . . . . 49
TOPAMAX . . . . . . . . . . . 15
TOPAMAX SPRINKLE . . . . . 15
topical antibacterials . . . . . 56
topiramate . . . . . . . . . . . 15
topiramate sprinkle caps . . . 15
TOPROL XL . . . . . . . . . . . 8
TORADOL . . . . . . . . . . . 12
toremifene . . . . . . . . . . . 5
torsemide . . . . . . . . . . . 10
TOUJEO SOLOSTAR . . . . . 21
TRACLEER . . . . . . . . . . . 11
TRADJENTA . . . . . . . . . . 22
tramadol . . . . . . . . . . . . 11
trametinib . . . . . . . . . . . . 5
TRANDATE . . . . . . . . . . . .8
tranexamic acid . . . . . . . . 36
TRANXENE . . . . . . . . . . . 39
tranylcypromine . . . . . . . . 40
trazodone . . . . . . . . . . . 41
TRECATOR . . . . . . . . . . . 28
TRENTAL . . . . . . . . . . . . .7
tretinoin . . . . . . . . . . . 6, 16
triamcinolone . . . . . . . . . 21
triamcinolone acetonide . 16, 17
triamcinolone nasal spray . . 20
triamterene/
hydrochlorothiazide . . . 10
TRIAVIL . . . . . . . . . . . . . 40
triazolam . . . . . . . . . . . . 41
TRI-FED X . . . . . . . . . . . . 47
trifluoperazine . . . . . . . . . 42
trifluridine . . . . . . . . . . . 38
trifluridine/tipiracil . . . . . . . 4
trihexyphenidyl . . . . . . . . 14
TRILAFON . . . . . . . . . . . 42
TRILEPTAL . . . . . . . . . . . 15
TRILYTE . . . . . . . . . . . . 25
trimethobenzamide . . . . . . 24
trimethoprim . . . . . . . . . . 33
TRIMETHOPRIM . . . . . . . . 33
TRI-NORINYL . . . . . . . . . 35
TRIOTANN . . . . . . . . . . . 20
TRIOTANN PEDIATRIC SUSP 43
tripolidine/pseudoephedrine 47
TRIPROL/PSE SYP . . . . . . 47
TRI RX . . . . . . . . . . . . . 52
TRIUMEQ . . . . . . . . . . . . 32
TRI-VI-FLOR . . . . . . . . . . 52
TRI-VI-SOL . . . . . . . . 52, 58
TRIVORA . . . . . . . . . . . . 35
TRIZIVIR . . . . . . . . . . . . 31
TROJAN . . . . . . . . . . . . 56
trospium . . . . . . . . . . . . 49
TRUSOPT . . . . . . . . . . . 37
TRUST NATALCARE
PAK DHA . . . . . . . . . . 51
TRUVADA . . . . . . . . . . . . 31
T-STAT . . . . . . . . . . . . . 16
TUMS . . . . . . . . . . . 57, 58
TUSSI 12D S . . . . . . . . . . 46
TUSSI-12 S . . . . . . . . . . . 43
TUSSIN DM . . . . . . . . . . 44
TWINJECT . . . . . . . . . . . 53
76
TYBOST . . . . . . . . . . . . 32
TYKERB . . . . . . . . . . . . . 4
TYLENOL . . . . . . . 11, 33, 57
TYLENOL W/CODEINE . . . 12
typhoid vaccine . . . . . . . . 54
U
ULORIC . . . . . . . . . . . . . 34
ULTRAM . . . . . . . . . . . . 11
umeclidinium inhalation . . . 47
umeclidinium/vilanterol . . . 47
UNI-HIST DRO . . . . . . . . . 42
UNIPHYL . . . . . . . . . . . . 48
urea 40% . . . . . . . . . . . 19
UREA 40% CREAM
AND LOTION . . . . . . . 19
URECHOLINE . . . . . . . . . 48
UREX . . . . . . . . . . . . . . 49
UROCIT-K . . . . . . . . . . . 49
UROXATRAL . . . . . . . . . . 48
URSO . . . . . . . . . . . . . 26
ursodiol . . . . . . . . . . . . 26
URSO FORTE . . . . . . . . . 26
UTIRA C . . . . . . . . . . . . 49
V
vaginal products . . . . . . . 55
valacyclovir . . . . . . . . . . 30
VALCYTE . . . . . . . . . . . . 30
valganciclovir . . . . . . . . . 30
VALIUM . . . . . . . . . . 34, 39
valproic acid . . . . . . . . . . 15
VALTREX . . . . . . . . . . . . 30
VANCOCIN/DEX INJ . . . . . 27
VANCOCIN HCL . . . . . . . . 30
VANCOCIN HCL INJ . . . . . 27
vancomycin HCl . . . . . . . 30
vancomycin hcl for inj . . . . 27
vancomycin hcl in dextrose inj27
vandetanib . . . . . . . . . . . 5
varenicline . . . . . . . . . . . 42
VASERETIC . . . . . . . . . . . 7
VASOCIDIN . . . . . . . . . . . 37
VASOCLEAR . . . . . . . . . . 36
VASOCLEAR A . . . . . . . . 37
VASOSULF . . . . . . . . . . . 38
VASOTEC . . . . . . . . . . . . .7
VECTICAL . . . . . . . . . . . 17
VEETIDS . . . . . . . . . . . . 29
vemurafenib . . . . . . . . . . 5
venlafaxine . . . . . . . . . . 40
venlafaxine XR . . . . . . . . 40
VENTOLIN HFA . . . . . . . . 47
VEPESID . . . . . . . . . . . . . 6
verapamil . . . . . . . . . . 9, 13
verapamil extended-release . . 9
VERSACLOZ . . . . . . . . . . 41
VESANOID . . . . . . . . . . . .6
VEXOL . . . . . . . . . . . . . 37
VFEND . . . . . . . . . . . . . 30
VICODIN . . . . . . . . . . . . 12
VICODIN ES . . . . . . . . . . 12
VICTOZA . . . . . . . . . . . . 23
VI-DAYLIN . . . . . . . . . . . . 58
VIDEX . . . . . . . . . . . . . . 31
VIDEX EC . . . . . . . . . . . . 31
vigabatrin oral solution . . . . 15
VIMPAT . . . . . . . . . . . . . 14
VINATE AZ EX . . . . . . . . . 51
VINATE III . . . . . . . . . . . . 51
VIRACEPT . . . . . . . . . . . 32
VIRAMUNE . . . . . . . . . . . 31
VIRAMUNE XR . . . . . . . . . 31
VIREAD . . . . . . . . . . . . . 31
VIROPTIC . . . . . . . . . . . . 38
VISINE . . . . . . . . . . . . . 57
VISINE-AC . . . . . . . . . . . 37
vismodegib . . . . . . . . . . . 6
VISTARIL . . . . . . . . . . . . 19
vitamin A . . . . . . . . . . . . 52
vitamin ADC/fluoride/±iron
drops . . . . . . . . . . . 52
vitamin B-1 . . . . . . . . . . 52
vitamin B-6 . . . . . . . . . . 52
VITAMIN B-12 . . . . . . . . . 49
vitamin B complex/
vitamin C/folic acid . . . . 52
vitamin C . . . . . . . . . . . 52
vitamin D . . . . . . . . . . . . 58
VITAMIN D . . . . . . . . . 49, 58
vitamins pediatric . . . . 52, 58
vitamins prenatal . . . . . . . 58
VITAPHIL . . . . . . . . . . . . 51
VITUSSIN . . . . . . . . . . . . 45
VIVOTIF BERNA . . . . . . . . 54
VOLTAREN . . . . . . . . . . . 37
VOLTAREN 1% TOPICAL GEL33
voriconazole . . . . . . . . . . 30
vorinostat . . . . . . . . . . . . 4
VOSOL HC OTIC . . . . . . . 19
VOSOL OTIC . . . . . . . . . . 19
VOTRIENT . . . . . . . . . . . . 4
VYVANSE . . . . . . . . . . . . 39
W
warfarin . . . . . . . . . . . . . 6
WELLBUTRIN . . . . . . . . . 40
WELLBUTRIN SR . . . . . . . 40
WELLBUTRIN XL . . . . . . . 40
WESTCORT . . . . . . . . . . 16
WYTENSIN . . . . . . . . . . . 11
X
XALATAN . . . . . . . . . . . . 38
XALKORI . . . . . . . . . . . . .4
XANAX . . . . . . . . . . . . . 39
XARELTO . . . . . . . . . . . . .6
XELODA . . . . . . . . . . . . . 4
XENAZINE . . . . . . . . . . . 15
XOLAIR . . . . . . . . . . . . . 47
XOPENEX RESPULES . . . . 48
XYLOCAINE . . . . . . . . 18, 21
XYZAL . . . . . . . . . . . . . 20
Z
zalcitabine . . . . . . . . . . . 31
zaleplon . . . . . . . . . . . . 41
ZANAFLEX . . . . . . . . . . . 34
zanamivir . . . . . . . . . . . 31
ZANTAC . . . . . . . . . . . . 24
ZARONTIN . . . . . . . . . . . 14
ZAROXOLYN . . . . . . . . . . .9
ZARXIO . . . . . . . . . . . . . .7
ZEBETA . . . . . . . . . . . . . .8
77
ZEBUTAL . . . . . . . . . . . . 11
ZELBORAF . . . . . . . . . . . .5
ZENPEP . . . . . . . . . . . . 26
ZERIT . . . . . . . . . . . . . . 31
ZESTORETIC . . . . . . . . . . .8
ZESTRIL . . . . . . . . . . . . . 7
ZETIA . . . . . . . . . . . . . . 10
ZIAC . . . . . . . . . . . . . . . .8
ZIAGEN . . . . . . . . . . . . . 31
zidovudine . . . . . . . . . . . 31
zinc . . . . . . . . . . . . . . . 52
ziprasidone . . . . . . . . . . 42
ZITHROMAX . . . . . . . . . . 29
ZOCOR . . . . . . . . . . . . . 10
ZOFRAN . . . . . . . . . . . . 24
ZOFRAN ODT . . . . . . . . . 24
ZOHYDRO ER . . . . . . . . . 12
ZOLINZA . . . . . . . . . . . . .4
ZOLOFT . . . . . . . . . . . . 40
zolpidem . . . . . . . . . . . . 41
ZONEGRAN . . . . . . . . . . 15
zonisamide . . . . . . . . . . 15
ZORTRESS . . . . . . . . . . . .6
ZOSTAVAX . . . . . . . . . . . 54
zoster vaccine live . . . . . . . 54
ZOSYN SOL . . . . . . . . . . 27
ZOVIA 1/35 . . . . . . . . . . 35
ZOVIA 1/50 . . . . . . . . . . 35
ZOVIRAX . . . . . . . . . . . . 30
ZYDELIG TABLET . . . . . . . .4
ZYKADIA . . . . . . . . . . . . .4
ZYLOPRIM . . . . . . . . . . . 34
ZYMAR . . . . . . . . . . . . . 38
ZYPREXA . . . . . . . . . . . . 41
ZYPREXA RELPREVV . . . . 41
ZYPREXA ZYDIS . . . . . . . 41
ZYRTEC . . . . . . . . . . 20, 55
ZYRTEC D . . . . . . . . 20, 56
ZYTIGA . . . . . . . . . . . . . .5
ZYVOX . . . . . . . . . . . . . 32
“My Medications” worksheet
Take this worksheet with you each time you visit a doctor. Each of your doctors should be aware of
every drug you take and you should have a list as well.
Name of Medicine
and Strength
Drug
Tier
I Take This
Medicine For
Directions
Doctor
Example: Lisinopril, 20 mg
Tier 1
High blood pressure
One tablet daily
Dr. Johnson
78
© 2016 United HealthCare Services, Inc. All rights reserved.
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Preferred Drug List (PDL)

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