docDepartment of Human Services IOWA Medicaid Program Final PDL
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Department of Human Services IOWA Medicaid Program Final PDL
v Department of Human Services IOWA Medicaid Program Final PDL PDL Effective Date June 1, 2016 (Two Drug Columns) Highlighted categories denote new changes to the PDL since previous update Column Header Explanations: B, G or O: B = Brand G = Generic O = OTC ND = Non Drug Comment Num 3 6 11 13 16 17 19 21 22 23 24 25 28 29 34 36 37 39 43 44 46 47 48 49 50 52 58 59 62 63 64 65 67 68 69 70 72 P, NP, R, or NR: P = Preferred N = Non-Preferred R = Recommended NR = Non-Recommended Key to Color Highlights: Blue = Changes in PDL Status/PA Criteria Pink = New Drugs Blue Underline = Click hyperlink for PA Form Hover to the left of Comment Number for comment text Comment BUSPIRONE 30mg - Use 2 BUSPIRONE 15mg tablets FLUOXETINE HCL 20mg TABS - Use FLUOXETINE HCL 20mg CAPS instead PA Required PA Required > 90 days Grandfathered for Existing Users with previous Actos use or CHF diagnosis PA Required> 12 Units/30 Days supply Preferred < 8yo PROZAC,FLUOXETINE HCL 40mg CAPS - Use two FLUOXETINE HCL 20mg CAPS instead RHEUMATREX - Write METHOTREXATE instead ULTRACET - Use Tramadol & Acetaminophen separately PA Required >= 21 yo. PA Required: > 14 Units/30Days Supply PA required for quantities exceeding 60-4mg tabs, 60-8mg tabs, 4-20ml vials, and 8-2ml vials. PA required for quantities exceeding 60-4mg tabs, 60-8mg tabs. PA required, Limit of 144 for initial fill Payable for members who are 12 years of age and older. Quantity limitations of 12 packets/4 weeks (28 days) or a total of 48 packets/16 weeks ( 112 days). Restricted to persons 40 years of age and older. Grandfather Existing Users PA required for concurrent therapy with long acting injectable and oral antispychotics of the same chemical entity after 12 weeks (84 days) of concomitant therapy. PA required if ACE-I not previously filled. Grandfather for seizure disorder. Preferred with Conditions and allow a one time fill. Those 0-18 should be referred to the Vaccines for Children Program. Preferred for ages 0-12, PA Required ages 13-18, Not covered ages 19 and above. Requires a Selected Brand Name Drug PA Imipramine Pamoate - Use Imipramine HCL PA required limited to package size of #14 for initial fill PA required limited to package size of #110 for initial fill 3 tablets per 60 days allowed. PA required for quantities exceeding this limit Initial fill limited to 15 day supply. Use Multiples of Phenytoin Sodium 100mg Capsules. PA required. Preferred for post surgery DVT prophylaxis only. PA required limited to package size 168 for intial fill PA required limited to package size 40ml for initial fill Payable for members who are 18 years of age and older. Quantity limitations of 30 grams/4 weeks (28 days) or a total of 120 grams/16 weeks (112 days) Payable for members 50 years of age and older without prior authorization Preferred < 2 years of age 73 74 76 77 78 79 80 83 85 87 88 89 90 91 92 93 No manual PA required if one course of treatment of a preferred permethrin or pyrethrins-piperonyl butoxide product is in the member's pharmacy claims history in past 30 days. Trial of Natroba or Ulesfia is required prior to consideration of any non -preferred agent. PA Required < 4 years of age PA Required < 15 years of age PA Required < 6 years of age PA Required < 9 years of age PA Required > 15 units / 30 days. Initial fill limited to 14 day supply. PA Required < 18 years of age PA Required > 12 years of age Preferred product is authorized generic distributed by Watson/Actavis. PA Required >= 21 yo. No manual PA required if HMG-CoA reductase inhibitor found in member’s pharmacy claims history in past 12 months. No manual PA required if a preferred agent of a different chemical entity is found in member’s pharmacy claims history in past 12 months PA Required < 7 years of age No manual PA required if a preferred injectable MS agent is found in member’s pharmacy claims history in past 12 months Authorized Generic Distributed by Teva Pharmaceuticals is Preferred with Prior Authorization Preferred for ages 19 through 64 No PA required for members 6 years of age or older when dosed within established quantity limits Iowa Medicaid Preferred Drug List (PDL) New Drug Process New Drug Entities New drug entities (including new generics and new drug product dosage forms of existing drug entities) will be identified weekly and immediately be coded as "Non-preferred-Prior Authorization required" until presented at the next scheduled P&T [pharmaceutical and therapeutics] Committee meeting. If the drug category requires step therapy, the step therapy requirements must also be met, treating the new drug as a non-preferred, step 3 drug. These prior authorization and step therapy restrictions will continue through the review process, including while committee recommendations are being made, and lasting until DHS makes a final determination. Exceptions to the Non-preferred default policy for new PDL drugs There are two major potential exceptions to the non-preferred default policy for new PDL drugs: A). If a new medication is classified as a priority drug by the FDA, the State may indicate that such a drug is preferred, until the drug is reviewed by the P&T Committee at the nearest scheduled meeting. B). The State may decide to designate a new drug as "draft preferred" and provide immediate access and increased therapeutic choice to physicians until the drug is reviewed by the P&T Committee at the nearest scheduled meeting if: - a new drug is therapeutically equivalent or superior to existing preferred or non-preferred choices, and - is as safe or safer than existing preferred or non-preferred choices, and - the net cost, adjusted for all rebates, is less expensive than all existing preferred choices. Existing PDL Drugs Although the State discourages supplemental rebate offers on existing PDL drugs between annual bidding periods, it may entertain such bids and may accept them if they are determined to represent significant additional savings or if they would replace a delinquent manufacturer's product or a preferred drug pulled from the marketplace or significantly restricted by the FDA. This interim preferred status will remain in effect until the drug is reviewed by the P&T Committee at the next scheduled meeting. Supplemental rebates will only be invoiced for approved drugs under contract. Draft preferred drugs with supplemental rebates will not be invoiced until approved by the Committee and accepted by the State. At that time, the supplemental rebates will be invoiced back to the effective date of the agreement, which is the date the drug began to benefit from preferred status. B, G, or O COM P, N, Therapeutic Category R, or NR PDL Categories ACE AND THIAZIDE COMBO'S G P benazepril & hydrochlorothiazide B N LOTENSIN HCT G P captopril & hydrochlorothiazide G P enalapril maleate & hydrochlorothiazide B N VASERETIC G N fosinopril sodium & hydrochlorothiazide G P lisinopril & hydrochlorothiazide B N ZESTORETIC G N moexipril-hydrochlorothiazide B P UNIRETIC B N ACCURETIC G N quinapril-hydrochlorothiazide ACE INHIBITORS G P benazepril hcl B N LOTENSIN G P captopril G P enalapril maleate P EPANED B 19 B N VASOTEC G N enalaprilat G P fosinopril sodium G P lisinopril B N PRINIVIL B N ZESTRIL G N moexipril hcl B N UNIVASC G N perindopril erbumine B N ACCUPRIL G P quinapril hcl B N ALTACE G P ramipril B N MAVIK G P trandolapril ACE INHIBITORS AND CALCIUM CHANNEL BLOCKERS G P amlodipine besylate-benazepril hcl B N LOTREL B N TARKA G P trandolapril-verapamil hcl ACNE PRODUCTS: ISOTRETINOIN B 11 N ABSORICA G 11 P isotretinoin AGENTS FOR FABRYS DISEASE B P FABRAZYME AGENTS FOR GAUCHER DISEASE B N CERDELGA B N CEREZYME B N ZAVESCA B N ELELYSO B N VPRIV RT45620 B, G, or O COM P , N, R, or NR Therapeutic Category AGENTS FOR PHEOCHROMOCYTOMA B N PHENOXYBENZAMINE G P phentolamine mesylate B N DEMSER ALCOHOL DETERRENTS G P acamprosate calcium B N ANTABUSE G P disulfiram ALLERGENIC EXTRACTS B 11 N GRASTEK B 11 N RAGWITEK B 11 N ORALAIR ALPHA-PROTEINASE INHIBITOR B 11 N ARALAST B 11 N GLASSIA B 11 P PROLASTIN C B 11 N ZEMAIRA ALS DRUG B 11 N RILUTEK G 11 P riluzole ALZHEIMER - CHOLINOMIMETICS B 37 N ARICEPT B 37 N ARICEPT ODT G 37 P donepezil hydrochloride G 37 N donepezil hydrochloride tabs hcl 23mg G 37 N galantamine hydrobromide B 37 N RAZADYNE B 37 N EXELON CAP B 37 P EXELON DIS G 37 P rivastigmine cap G 37 N rivastigmine dis B 37 N NAMENDA B 37 N NAMENDA XR G 37 P memantine B 37 N NAMZARIC AMINO GLYCOSIDES G P amikacin sulfate G P gentamicin sulfate G P gentamicin in saline G P neomycin sulfate G P paromomycin sulfate G P streptomycin sulfate B P BETHKIS B N TOBI B N TOBI PODHALER G N tobramycin neb solution B P KITABIS PAK G P tobramycin sulfate ANALGESICS - MISC. B, G, or O COM P, N, Therapeutic Category R, or NR PDL Categories ANALGESICS - MISC. O P Aspirin G P diflunisal G P salsalate O P Aspirin Buffered O P Acetaminophen G P butalbital-acetaminophen tab 50-325 mg G P butalbital-acetaminophen-caffeine cap 50-325-40 mg G P butalbital-acetaminophen-caffeine tab 50-325-40 mg G P butalbital-aspirin-caffeine ANAPHYLAXIS THERAPY B N ADRENACLICK B N ADRENALIN B N AUVI-Q G N epinephrine B P EPIPEN ANDROGENS - ANABOLICS G N danazol B P ANDROXY B 11 N ANDROID B 11 N METHITEST B 11 N TESTRED B 11 P METHYLTESTOSTERONE B 11 N NATESTO B 11 N DEPO-TESTOSTERONE G 11 P testosterone cypionate G 11 P testosterone enanthate B 11 N AVEED N oxandrolone G ANDROGENS -TOPICAL B 11 P ANDRODERM B 11 N ANDROGEL B 11 N AXIRON B 11 N FORTESTA B 11 N STRIANT B 11 P TESTIM G 11 N testosterone gel B 11 N VOGELXO ANORECTAL - MISC. B N ANUSOL-HC G P hydrocortisone (rectal) B N CORTENEMA G P hydrocortisone (intrarectal) B N CORTIFOAM B N RECTIV G N lidocaine-hydrocortisone acetate (rectal) G N hydrocortisone acetate w/ pramoxine B N PROCTOFOAM HC ANTHELMINTICS B RT45620 P ALBENZA B, G, or O COM P , N, R, or NR Therapeutic Category G P ivermectin B N STROMECTOL P BILTRICIDE - Contd - B ANTI INFECTIVE COMBO'S - MISC. B N BACTRIM G P sulfamethoxazole-trimethoprim ANTIANGINALS B N RANEXA ANTIANGINALS--ISOSORBIDE NITRATE B N DILATRATE SR B N ISORDIL TITRADOSE G P isosorbide dinitrate G P isosorbide mononitrate B N BIDIL ANTIARRHYTHMICS G P disopyramide phosphate B N NORPACE G P procainamide hcl G P quinidine gluconate G P quinidine sulfate G N quinidine sulfate tablet er G N lidocaine hcl (cardiac) B N XYLOCAINE G P mexiletine hcl G P flecainide acetate G P propafenone hcl N RYTHMOL SR B N RYTHMOL TABS G P amiodarone hcl tab 200 mg G N amiodarone hcl tabs 400mg B N CORDARONE B P TIKOSYN B P MULTAQ B 11 ANTIASTHMATIC - 5-LIPOXYGENASE INHIBITORS B N ZYFLO ANTIASTHMATIC - ADRENERGIC COMBOS B P COMBIVENT RESPIMAT G P ipratropium-albuterol B P SYMBICORT B P ADVAIR B P ADVAIR HFA B N BREO ELLIPTA B P DULERA B N STIOLTO RESPIMAT B N ANORO ELLIPTA ANTIASTHMATIC - ANTI-CHOLINERGICS B N TUDORZA PRESSAIR G P ipratropium bromide B P ATROVENT HFA B P SPIRIVA HANDIHALER B, G, or O COM P, N, Therapeutic Category R, or NR B, G, or O G PDL Categories ANTIASTHMATIC - ANTI-CHOLINERGICS B N SPIRIVA RESPIMAT B N INCRUSE ELLIPTA ANTIASTHMATIC - ANTIINFLAMMATORY AGENTS G B 11 B P cromolyn sodium N XOLAIR N NUCALA ANTIASTHMATIC - BETA - ADRENERGICS G 72 P albuterol sulfate nebu 0.63mg/3 G P albuterol sulfate soln nebu 0.083% (2.5 mg/3ml) G P albuterol sulfate soln nebu 0.5% (5 mg/ml) G N albuterol sulfate soln nebu 1.25 mg/3ml (base equiv) G P albuterol sulfate syrup 2 mg/5ml G N albuterol sulfate tab 2 mg G N albuterol sulfate tab 4 mg G P albuterol sulfate tab sr 12hr 4 mg G P albuterol sulfate tab sr 12hr 8 mg B P PROAIR HFA B P PROVENTIL HFA B P VENTOLIN HFA B N VOSPIRE ER B N PROAIR RESPICLICK B N BROVANA B N PERFOROMIST B N ARCAPTA NEOHALER B 11 N XOPENEX G 11 N levalbuterol N metaproterenol sulfate N STRIVERDI RESPIMAT P SEREVENT DISKUS G N terbutaline sulfate inj 1 mg/ml G P terbutaline sulfate tab 2.5 mg G P terbutaline sulfate tab 5 mg G B B 74 ANTIASTHMATIC - LEUKOTRIENE RECEPTOR ANTAGONISTS G P montelukast sodium chew tab 4 mg (base equiv) G P montelukast sodium chew tab 5 mg (base equiv) G P montelukast sodium tab 10 mg (base equiv) B N SINGULAIR CHW 4MG B N SINGULAIR CHW 5MG B N SINGULAIR TAB 10MG B N SINGULAIR PACK P montelukast granules B N ACCOLATE G N zafirlukast G 72 ANTIASTHMATIC - MISC. RESPIRATORY INHALANTS ND P sodium chloride soln nebu 0.9% ANTIASTHMATIC - MIXED ADRENERGICS G P epinephrine hcl ANTIASTHMATIC - MUCOLYTICS RT45620 COM P , N, R, or NR - Contd - P Therapeutic Category acetylcysteine ANTIASTHMATIC - NASAL MISC. B N ATROVENT B N ATROVENT NAS SOL 0.06% G P ipratropium bromide (nasal) soln 0.03% G N ipratropium bromide nasal soln 0.06% (42 mcg/spray) ANTIASTHMATIC - STEROID INHALANTS B P QVAR G N budesonide (inhalation) B P PULMICORT INHALER P PULMICORT SUS B N PULMICORT SUS SUSP 1MG/2ML B N ALVESCO B P AEROSPAN B N ARNUITY ELLIPTA B P FLOVENT B P ASMANEX 120 AER 220MCG B P ASMANEX 14 AER 220MCG P ASMANEX 30 AER 110MCG B P ASMANEX 30 AER 220MCG B P ASMANEX 60 AER 220MCG B N ASMANEX 7 AER 110MCG B N ASMANEX HFA B B 19 83 ANTIASTHMATIC - XANTHINES G P aminophylline B P ELIXOPHYLLIN B P THEO-24 G P theophylline ANTIBIOTICS - MISC. G P sulfadiazine B P AZACTAM G N aztreonam B N AZACTAM IN DEXTROSE P CAYSTON B 89 G P colistimethate sodium B N COLY-MYCIN-M B N FLAGYL N FLAGYL ER G N metronidazole caps G P metronidazole tab 250 mg G P metronidazole tab 500 mg B P METRO IV G P metronidazole in nacl B N ORBACTIV B P NEBUPENT B P PENTAM 300 B N XIFAXAN B N VIBATIV G P trimethoprim B P VANCOCIN HCL G P vancomycin hcl G N vancomycin hcl caps G P vancomycin hcl in dextrose B 11 B, G, or O COM P, N, Therapeutic Category R, or NR PDL Categories ANTIBIOTICS - MISC. G N polymyxin b sulfate B P TYGACIL ANTI-CATAPLECTIC AGENTS B 11 N XYREM ANTICOAGULANTS G P heparin sodium (porcine) G P heparin (porcine) in sodium chloride B P FRAGMIN G P enoxaparin sodium syringes G P enoxaparin sodium vials B N LOVENOX SYRINGES B N LOVENOX VIALS B N ARIXTRA G N fondaparinux sodium B P COUMADIN B N COUMADIN SOLR G P warfarin sodium N PRADAXA B 11 B 11 N ELIQUIS B 11 N SAVAYSA B 65 P XARELTO ANTICONVULSANTS B N EQUETRO B 11 N GRALISE B 11 N ONFI P clonazepam G G 11 N clonazepam tablet disperse B 11 N KLONOPIN B P DIASTAT G N diazepam (anticonvulsant) gel G 46 N felbamate B 46 N FELBATOL B P GABITRIL B N SABRIL B N PEGANONE G N fosphenytoin sodium B 46 N DILANTIN INFATABS B 46 N DILANTIN SUSP G P phenytoin susp G P phenytoin infatab G P phenytoin sodium N DILANTIN P DILANTIN CAPS 30MG N PHENYTEK B 46 B B 39 G P phenytoin sodium extended cap 100 mg G 64 N phenytoin sodium extended caps 200mg G 64 N phenytoin sodium extended caps 300mg G N ethosuximide caps G P ethosuximide soln 250 mg/5ml B P ZARONTIN B N ZARONTIN SOLN RT45620 B, G, or O COM P , N, R, or NR B Therapeutic Category N DEPAKOTE N DEPAKOTE ER P DEPAKOTE SPRINKLES G P divalproex sodium G N divalproex sodium cap sprinkle G P divalproex sodium tablet er 24hr B N DEPACON B N DEPAKENE G P valproate sodium G P valproic acid B N FYCOMPA G P carbamazepine G P carbamazepine capsule er 12hr N carbamazepine susp N carbamazepine tablet er 12hr N CARBATROL B P TEGRETOL B P TEGRETOL SUSP B P TEGRETOL XR B N APTIOM B N POTIGA G P gabapentin cap 100 mg G P gabapentin cap 300 mg G P gabapentin cap 400 mg G P gabapentin oral soln 250 mg/5ml G P gabapentin tab 600 mg G P gabapentin tab 800 mg B N NEURONTIN B - Contd - B G 46 46 G B 46 B 46 N NEURONTIN SOLN B 88 P VIMPAT B 46 N LAMICTAL B 11 N LAMICTAL XR P lamotrigine G G 11 N lamotrigine tablet disperse G 11 N lamotrigine tablet er 24hr B 46 N KEPPRA B 46 N KEPPRA XR P levetiracetam N levetiracetam tablet er 24hr G P oxcarbazepine susp G P oxcarbazepine tab 150 mg G P oxcarbazepine tab 300 mg G P oxcarbazepine tab 600 mg N OXTELLAR XR N TRILEPTAL G G B 11 11 B B 46 N TRILEPTAL SUSP B 11 N LYRICA B 39 N MYSOLINE G P primidone B N BANZEL N QUDEXY XR B N TOPAMAX G P topiramate B 11 G 11 N topiramate cs24 B 11 N TROKENDI XR B 46 N ZONEGRAN P zonisamide G B, G, or O COM P, N, Therapeutic Category R, or NR PDL Categories ANTIDEPRESSANTS - MAO INHIBITORS B N NARDIL G P phenelzine sulfate N EMSAM B N PARNATE G P tranylcypromine sulfate B 39 ANTIDEPRESSANTS - SELECTED SSRI'S G G 11 B P mirtazapine N mirtazapine tablet disperse N REMERON B 11 N REMERON SOLTAB G 63 P nefazodone hcl B 11 N OLEPTRO G P trazodone hcl G N trazodone hcl tabs 300mg B 11 N VIIBRYD B 11 N BRINTELLIX B 11 N TRINTELLIX B N CELEXA G P citalopram hydrobromide G P escitalopram oxalate B N LEXAPRO G P fluoxetine hcl G 21 N fluoxetine hcl caps 40mg G 11 N fluoxetine hcl capsule delayed release G 6 N fluoxetine hcl tabs 20mg N PROZAC B N PROZAC WEEKLY G B P fluvoxamine maleate G P paroxetine hcl G P paroxetine hcl er B N PAXIL N PAXIL CR P PAXIL SUSP N PEXEVA G P sertraline hcl B N ZOLOFT B 11 39 B B 63 G 11 N desvenlafaxine B 11 N KHEDEZLA B 11 N PRISTIQ B 11 N CYMBALTA P duloxetine hcl N FETZIMA B N EFFEXOR XR G P venlafaxine hcl G P venlafaxine hcl cap sr 24hr 150 mg (base equivalent) G P venlafaxine hcl cap sr 24hr 37.5 mg (base equivalent) G P venlafaxine hcl cap sr 24hr 75 mg (base equivalent) G N venlafaxine hcl tablet er 24hr P maprotiline hcl G P bupropion hcl tab 100 mg G P bupropion hcl tab 75 mg G P bupropion hcl tab sr 12hr 100 mg G P bupropion hcl tab sr 12hr 150 mg G B G 11 63 RT45620 B, G, or O COM P , N, R, or NR Therapeutic Category G P bupropion hcl tab sr 12hr 200 mg G P bupropion hcl tab sr 24hr 150 mg G P bupropion hcl tab sr 24hr 300 mg N FORFIVO XL B P WELLBUTRIN B N WELLBUTRIN XL B 63 B 11 N APLENZIN G 63 N fluoxetine hcl (pmdd) B 63 N SARAFEM N BRISDELLE N SAVELLA B B 11 ANTIDEPRESSANTS - TRI-CYCLICS G P amitriptyline hcl G P amoxapine B N ANAFRANIL G 63 P clomipramine hcl G 39 N desipramine hcl B N NORPRAMIN G P doxepin hcl G P imipramine hcl B N TOFRANIL G 52 N imipramine pamoate B 52 N TOFRANIL-PM G P nortriptyline hcl B N PAMELOR G N protriptyline hcl B P SURMONTIL B N SILENOR ANTIDOTES G P deferoxamine mesylate B N DESFERAL B N FERRIPROX ANTIDOTES - CHELATING AGENTS B 11 P EXJADE B 11 N JADENU P CHEMET B ANTIEMETIC - 5-HT3 RECEPTOR ANTAGONISTS/ SUBSTANCE P NEUROKININ B 11 N ANZEMET B 11 N SANCUSO G 11 N granisetron hcl G 29 P ondansetron odt B 11 N ZOFRAN ODT G 28 P ondansetron hcl G 11 N ondansetron hcl oral soln 4 mg/5ml B 11 N ZOFRAN B 11 N ALOXI B 11 N EMEND B 11 N AKYNZEO ANTIEMETIC - ANTICHOLINERGIC / DOPAMINERGIC B N PHENERGAN G N promethazine hcl inj 25 mg/ml G N promethazine hcl inj 50 mg/ml B, G, or O COM P, N, Therapeutic Category R, or NR PDL Categories ANTIEMETIC - ANTICHOLINERGIC / DOPAMINERGIC G P promethazine hcl suppos 12.5 mg G P promethazine hcl suppos 25 mg G P promethazine hcl syrup 6.25 mg/5ml G N promethazine hcl tab 12.5 mg G P promethazine hcl tab 25 mg G P promethazine hcl tab 50 mg O P Meclizine HCl B P TRANSDERM-SCOP B N TIGAN G P trimethobenzamide hcl N DICLEGIS B 63 ANTIEMETIC - TETRAHYDROCANNABINOL (THC) DERIVATIVES G N dronabinol B N MARINOL B N CESAMET ANTIFUNGALS - ASSORTED B 13 P AMBISOME B 13 P ANCOBON G 11 N flucytosine G 11 N griseofulvin microsize tabs G 13 P griseofulvin sus B 13 P GRIS-PEG G 11 N griseofulvin ultramicrosize P nystatin G B 11 N LAMISIL G 13 P terbinafine hcl G 11 N ketoconazole B 11 N DIFLUCAN G 13 P fluconazole G 13 P fluconazole in nacl G 13 P fluconazole in dextrose B 11 N CRESEMBA G 11 N itraconazole B 11 N ONMEL B 11 N SPORANOX B 11 N NOXAFIL B 11 N VFEND B 13 P VFEND IV G 13 P voriconazole G 11 N voriconazole solr B 13 P CANCIDAS P MYCAMINE P clotrimazole troche B G 13 ANTIHISTAMINES - NON-SEDATING O P Cetirizine HCl Oral Soln 1 MG/ML (5 MG/5ML) O P Cetirizine HCl Tab 10 MG O P Cetirizine HCl Tab 5 MG B 11 N CLARINEX G 11 N desloratadine G 11 N levocetirizine dihydrochloride B 11 N XYZAL RT45620 B, G, or O COM P , N, R, or NR Therapeutic Category O P Loratadine Syrup 5 MG/5ML O P Loratadine Tab 10 MG N ASTEPRO G P azelastine spr 0.1% G N azelastine spr 0.15% G N olopatadine hcl (nasal) B P PATANASE - Contd - B ANTIHISTAMINES - NON-SEDATING / DECONGESTANTS B 11 N CLARINEX-D ANTIHISTAMINES - OTHER O P Chlorpheniramine Maleate G 11 N carbinoxamine maleate G 11 N clemastine fumarate P diphenhydramine hcl N cyproheptadine hcl G P hydroxyzine hcl soln G P hydroxyzine hcl syrp G P hydroxyzine hcl tab 25 mg G P hydroxyzine hcl tab 50 mg G P hydroxyzine hcl tabs 10mg G P hydroxyzine pamoate G G 11 G 11 N hydroxyzine pamoate caps 100mg B 11 N VISTARIL G P prochlorperazine supp G P prochlorperazine maleate G P prochlorperazine edisylate ANTIHISTAMINES/DECONGESTANTS B N SEMPREX-D ANTIHYPERLIPIDEMICS B N PRALUENT B N REPATHA B N JUXTAPID B N KYNAMRO ANTIHYPERTENSIVE COMBOS B N CLORPRES G P methyldopa & hydrochlorothiazide B N AMTURNIDE ANTIHYPERTENSIVES - CENTRAL B N CATAPRES B P CATAPRES-TTS G N clonidine hcl patch weekly G P clonidine hcl tab 0.1 mg G P clonidine hcl tab 0.2 mg G P clonidine hcl tab 0.3 mg G P guanfacine hcl B N TENEX G P methyldopa B N MINIPRESS G P prazosin hcl G P reserpine G P hydralazine hcl B, G, or O COM P, N, Therapeutic Category R, or NR PDL Categories ANTIHYPERTENSIVES - CENTRAL G P minoxidil ANTI-INFLAMMATORIES, NON-NSAID B 11 N CIMZIA B 11 N REMICADE B 11 N KINERET B 11 P HUMIRA B 11 P HUMIRA PEN B 47 P HUMIRA PEN-CROHNS DISEASESTARTER B 47 P HUMIRA PEN-PSORIASIS STARTER B 11 N SIMPONI B 11 P ENBREL B 11 N ORENCIA B 11 N ACTEMRA B 11 N XELJANZ B 11 N OTEZLA B 11 P COSENTYX B 11 N STELARA ANTILEPROTIC B P THALOMID ANTIMALARIAL AGENTS G P chloroquine phosphate G P hydroxychloroquine sulfate B N PLAQUENIL G P mefloquine hcl B N DARAPRIM B P MALARONE ANTIMYCOBACTERIALS / ANTITUBERCULOSIS B N SIRTURO G N cycloserine G P ethambutol hcl B N MYAMBUTOL B P TRECATOR G P isoniazid G P pyrazinamide B N MYCOBUTIN B N RIFADIN G P rifampin B P PRIFTIN ANTINEOPLASTICS - PROTEIN-TYROSINE KINASE INHIBITORS B 11 P GLEEVEC B 11 N IMATINIB ANTINEOPLASTICS - SELECTIVE RETINOID X RECEPTOR AGONISTS B 63 G P TARGRETIN N bexarotene ANTI-PARKINSONIAN DRUGS G P amantadine hcl cap 100 mg G P amantadine hcl syrup 50 mg/5ml RT45620 B, G, or O COM P , N, R, or NR Therapeutic Category G N amantadine hcl tab 100 mg G N bromocriptine mesylate 5 mg cap P PARLODEL G P bromocriptine mesylate 2.5mg tabs G P carbidopa-levodopa N RYTARY B N SINEMET B N DUOPA G P carbidopa-levodopa-entacapone B N STALEVO B N AZILECT B N ELDEPRYL G P selegiline hcl B N ZELAPAR B N LODOSYN G N atracurium besylate - Contd - B B 11 ANTIPROTOZOAL AGENTS B N TINDAMAX G N tinidazole G N atovaquone B P MEPRON B P ALINIA ANTI-PSORIATICS - NON-BIOLOGICALS G P calcipotriene B N DOVONEX B N SORILUX B N VECTICAL P TAZORAC G N acitretin B N SORIATANE G N methoxsalen rapid B P OXSORALEN ULTRA B 11 ANTIPSYCHOTICS - ATYPICALS Step therapy required. See step therapy in PA criteria chart located at www.iowamedicaidpdl.com under the Prior Authorization Criteria link. Step 1: Preferred generic - no PA required. Step 2: Preferred brand - no PA required with Step 1 history in past 12 months. Step 3: Non-preferred - PA required with prior trials of Step 1 & Step 2 drugs. B 39 N Step 3 - STEP 3 - FANAPT B 11 N Step 3 - INVEGA G 11 N Step 3 - Paliperidone er B 43 P Step 2 - INVEGA SUSTENNA B 43 P Step 2 - INVEGA TRINZA B 43 N Step 3 - RISPERDAL B 11 N Step 3 - RISPERDAL M-TAB G 43 P Step 1 - risperidone G 11 N Step 3 - risperidone tablet disperse B 43 P Step 2 - RISPERDAL CONSTA G P Step 1 - quetiapine fumarate B N Step 3 - SEROQUEL B 11 N Step 3 - SEROQUEL XR B 39 N Step 3 - SAPHRIS G G 11 B B 11 P Step 1 - olanzapine N Step 3 - olanzapine tablet disperse N Step 3 - ZYPREXA N Step 3 - ZYPREXA ZYDIS B, G, or O COM P, N, Therapeutic Category R, or NR PDL Categories ANTIPSYCHOTICS - ATYPICALS Step therapy required. See step therapy in PA criteria chart located at www.iowamedicaidpdl.com under the Prior Authorization Criteria link. Step 1: Preferred generic - no PA required. Step 2: Preferred brand - no PA required with Step 1 history in past 12 months. Step 3: Non-preferred - PA required with prior trials of Step 1 & Step 2 drugs. B 79 P Step 2 - ABILIFY B 11 B 11 N Step 3 - ABILIFY DISCMELT N Step 3 - ABILIFY MAINTENA G N Step 3 - aripiprazole B N Step3 - Aristada N Step 3 - REXULTI B P Step 2 - LATUDA B N Step 3 - GEODON G P Step 1 - ziprasidone hcl B 11 ANTIPSYCHOTICS - SPECIAL ATYPICALS G P clozapine B N CLOZARIL B N FAZACLO B 11 N VERSACLOZ G 11 N clozapine odt ANTIPSYCHOTICS - TYPICAL G 43 P haloperidol B 43 N HALDOL G 43 P haloperidol lactate B 43 N HALDOL DECANOATE 100 B 43 N HALDOL DECANOATE 50 G 43 P haloperidol decanoate G P loxapine succinate B N LOXITANE G N molindone G 39 N chlorpromazine hcl G 43 P fluphenazine hcl G 43 P fluphenazine decanoate G P perphenazine G P thioridazine hcl G P trifluoperazine hcl G P thiothixene ANTISPASMODICS G P oxybutynin syp 5mg/5ml G P oxybutynin tab 5mg N DETROL N tolterodine tartrate B 63 G G 63 N trospium chloride G 63 P flavoxate hcl ANTISPASMODICS - LONG ACTING B 63 N ENABLEX B N TOVIAZ B N OXYTROL N DITROPAN XL N GELNIQUE P oxybutynin chloride er P VESICARE B B 63 G B 63 RT45620 B, G, or O COM P , N, R, or NR Therapeutic Category B 63 N DETROL LA G 63 N tolterodine tartrate 63 N MYRBETRIQ - Contd - B ANTITHYROID THERAPIES G P methimazole B N TAPAZOLE G P propylthiouracil ANXIOLYTICS - BENZODIAZEPINES G P alprazolam B P ALPRAZOLAM INTENSOL G 11 N alprazolam tablet disperse B 11 N XANAX P chlordiazepoxide hcl G G 78 P clorazepate dipotassium B 11 N TRANXENE G B 11 G P diazepam N ATIVAN P lorazepam B 11 N LORAZEPAM INTENSOL G 77 P oxazepam ANXIOLYTICS - LONG ACTING G 11 N alprazolam tab sr 24hr 0.5 mg G 11 N alprazolam tab sr 24hr 1 mg G 11 N alprazolam tab sr 24hr 2 mg G 11 N alprazolam tab sr 24hr 3 mg B 11 N XANAX XR ANXIOLYTICS - MISC. G P buspirone hcl tab 10 mg G P buspirone hcl tab 15 mg G P buspirone hcl tab 5 mg G P buspirone hcl tab 7.5 mg N buspirone hcl tabs 30mg G P droperidol G P meprobamate G 3 ARB COMBINATIONS B 11 N ENTRESTO ARB/CCB B 11 N AZOR G 11 N amlodipine besylate-valsartan B 44 P EXFORGE G 11 N telmisartan-amlodipine B 11 N TWYNSTA ARB/CCB PLUS DIURETICS G 11 N amlodipine-valsartan-hydrochlorothiazide B 44 P EXFORGE HCT B 11 N TRIBENZOR ARB'S B 11 N EDARBI B 11 N ATACAND B, G, or O COM P, N, Therapeutic Category R, or NR PDL Categories G 11 N candesartan cilexetil G 11 N eprosartan mesylate B 11 N TEVETEN B 11 N AVAPRO G 44 P irbesartan B 11 N COZAAR G 44 P losartan potassium B 11 N BENICAR B 44 P MICARDIS G 11 N telmisartan B 11 N DIOVAN G 44 P valsartan ARB'S AND DIURETICS B 11 N EDARBYCLOR B 11 N ATACAND HCT G 11 N candesartan cilexetil-hydrochlorothiazide B 11 N TEVETEN HCT B 11 N AVALIDE G 44 P irbesartan-hydrochlorothiazide B 11 N HYZAAR G 44 P losartan potassium & hydrochlorothiazide B 11 N BENICAR HCT B 44 P MICARDIS HCT G 11 N telmisartan-hydrochlorothiazide B 11 N DIOVAN HCT G 44 P valsartan-hydrochlorothiazide ARTHRITIS - MISC. P RIDAURA B 11 N OTREXUP B 11 N RASUVO B 22 N RHEUMATREX ARTIFICIAL SALIVA/STIMULANTS G N cevimeline hcl B N EVOXAC G P pilocarpine hcl (oral) B N SALAGEN BETA BLOCKERS - ALPHA / BETA G P carvedilol B N COREG TABS N COREG CR G P labetalol hcl B N TRANDATE B 11 BETA BLOCKERS - CARDIO SELECTIVE G P acebutolol hcl B N SECTRAL G P atenolol B N TENORMIN G N betaxolol hcl G P bisoprolol fumarate RT45620 COM P , N, R, or NR Therapeutic Category B N ZEBETA G P metoprolol succinate N TOPROL XL B N LOPRESSOR G P metoprolol tartrate N BYSTOLIC - Contd - B ARB'S B B, G, or O B 11 BETA BLOCKERS - NON SELECTIVE B N CORGARD G P nadolol B P LEVATOL G P pindolol B N HEMANGEOL B N INDERAL LA G P propranolol hcl B N INNOPRAN XL B N BETAPACE G P sotalol hcl B N SOTYLIZE B N BETAPACE AF G P sotalol hcl (afib/afl) G P timolol maleate BETA BLOCKERS AND DIURETIC COMBO'S G P atenolol & chlorthalidone B N TENORETIC G P bisoprolol & hydrochlorothiazide B N ZIAC B N DUTOPROL B N LOPRESSOR HCT G N metoprolol & hydrochlorothiazide B N CORZIDE G N nadolol & bendroflumethiazide G P propranolol & hydrochlorothiazide BETA-LACTAMS / CLAVULANATE COMBO'S G P penicillin g potassium B P PFIZERPEN-G G P penicillin g pot in dextrose B P BICILLIN G P penicillin v potassium G P amoxicillin (trihydrate) cap 250 mg G P amoxicillin (trihydrate) chew tab 125 mg G P amoxicillin (trihydrate) chew tab 250 mg G P amoxicillin (trihydrate) for susp 125 mg/5ml G P amoxicillin (trihydrate) for susp 200 mg/5ml G P amoxicillin (trihydrate) for susp 250 mg/5ml G P amoxicillin (trihydrate) for susp 400 mg/5ml G P amoxicillin (trihydrate) tab 500 mg G P amoxicillin (trihydrate) tab 875 mg G N amoxicillin (trihydrate) tab sr 24hr 775 mg N MOXATAG G P ampicillin G P dicloxacillin sodium G P nafcillin sodium G P oxacillin sodium B P BACTOCILL IN DEXTROSE B 11 B, G, or O COM P, N, Therapeutic Category R, or NR PDL Categories BETA-LACTAMS / CLAVULANATE COMBO'S G N amoxicillin & k clavulanate chew tab 200-28.5 mg G P amoxicillin & k clavulanate chew tab 400-57 mg G P amoxicillin & k clavulanate for susp 200-28.5 mg/5ml G N amoxicillin & k clavulanate for susp 250-62.5 mg/5ml G P amoxicillin & k clavulanate for susp 400-57 mg/5ml G P amoxicillin & k clavulanate for susp 600-42.9 mg/5ml G N amoxicillin & k clavulanate tab 250-125 mg G P amoxicillin & k clavulanate tab 500-125 mg G P amoxicillin & k clavulanate tab 875-125 mg N amoxicillin & pot clavulanate tablet er 12hr B N AUGMENTIN SUS 125/5ML B N AUGMENTIN SUS 250/5ML B N AUGMENTIN SUS ES-600 B N AUGMENTIN TAB 500MG B N AUGMENTIN TAB 875MG G B 11 N AUGMENTIN XR G 11 P ampicillin & sulbactam sodium B N UNASYN B P TIMENTIN G P piperacillin sodium-tazobactam sodium B P ZOSYN BPH B N CARDURA G P doxazosin mesylate G P terazosin hcl N AVODART G N dutasteride B N PROSCAR G P alfuzosin hcl B N UROXATRAL G P finasteride N CARDURA XL B N RAPAFLO B N FLOMAX G P tamsulosin hcl B N JALYN B N DUTASTERIDE-TAMSULOSIN B B 39 11 CALCIUM CHANNEL BLOCKERS--AMLODIPINES G P amlodipine besylate B N NORVASC CALCIUM CHANNEL BLOCKERS--DILTIAZEMS B N CARDIZEM G P diltiazem hcl G P diltiazem hcl extended release beads B N TIAZAC B N CARDIZEM CD B N CARDIZEM LA G N diltiazem hcl coated beads CALCIUM CHANNEL BLOCKERS--FELODIPINES G RT45620 N felodipine B, G, or O COM P , N, R, or NR Therapeutic Category CALCIUM CHANNEL BLOCKERS--ISRADIPINES - Contd - G N isradipine CALCIUM CHANNEL BLOCKERS--NIFEDIPINES B N ADALAT CC G P nifedipine G P nifedipine tab sr 24hr 30 mg G P nifedipine tab sr 24hr 60 mg G P nifedipine tab sr 24hr 90 mg B N PROCARDIA B N PROCARDIA XL B N NYMALIZE CALCIUM CHANNEL BLOCKERS--NISOLDIPINE G N nisoldipine B N SULAR CALCIUM CHANNEL BLOCKERS--VERAPAMILS B N CALAN G P verapamil hcl G N verapamil hcl soln B N VERELAN CARBAPENEMS B P INVANZ G P meropenem B N MERREM G N imipenem-cilastatin B N PRIMAXIN CARDIAC GLYCOSIDES G P digoxin G N digoxin ij N LANOXIN B 39 CARNITINE REPLENISHER - AGENTS B N CARNITOR B P CARNITOR INJ 1GM/5ML SOL 1GM/10ML B P CARNITOR TAB 330MG B P CARNITOR SF SOL 1GM/10ML G P levocarnitine inj 200 mg/ml G N levocarnitine oral soln 1 gm/10ml (10%) G N levocarnitine tab 330 mg CCB / LIPID G N amlodipine besylate-atorvastatin calcium B N CADUET CENTRAL PRECOCIOUS PUBERTY AGENTS B P LUPR DEP-PED INJ 11.25MG B P LUPR DEP-PED INJ 15MG B P LUPR DEP-PED INJ 7.5MG B P LUPRON DEPOT-PED KIT 11.25MG B P LUPRON DEPOT-PED KIT 30MG CEPHALOSPORINS B, G, or O COM P, N, Therapeutic Category R, or NR PDL Categories CEPHALOSPORINS G P cefadroxil cap 500 mg G P cefadroxil for susp 250 mg/5ml G P cefadroxil for susp 500 mg/5ml G N cefadroxil tab 1 gm G P cefazolin sodium G P cefazolin in d5w G P cephalexin G P cephalexin caps 750mg G N cephalexin tabs B N KEFLEX G N cefaclor cap 250 mg G N cefaclor cap 500 mg G N cefaclor for susp 125 mg/5ml G N cefaclor for susp 250 mg/5ml G N cefaclor for susp 375 mg/5ml G N cefaclor monohydrate tab sr 12hr 500 mg G P cefprozil B N CEFTIN G P cefuroxime axetil tab 250 mg G P cefuroxime axetil tab 500 mg G P cefuroxime sodium B N ZINACEF G P cefdinir G N cefditoren pivoxil B N SPECTRACEF B N SUPRAX B N SUPRAX SUSR 100/5ML B N SUPRAX SUSR 200/5ML G N cefixime oral suspension G N cefpodoxime proxetil G N cefotaxime sodium B P CLAFORAN G P ceftazidime B N FORTAZ B N CEDAX G N ceftibuten G P ceftriaxone sodium G P ceftriaxone sodium in dextrose G P cefepime hcl G N cefepime hcl and dextrose CHELATING AGENTS B P SYPRINE B N CUPRIMINE B P DEPEN TITRATABS CHOLESTEROL - BILE SEQUESTRANTS G P cholestyramine B N QUESTRAN G P cholestyramine light B N WELCHOL B N COLESTID G P colestipol hcl RT45620 B, G, or O COM P , N, R, or NR Therapeutic Category CHOLESTEROL - FIBRIC ACID DERIVATIVES - Contd - B N TRILIPIX G N fenofibrate caps G P fenofibrate tabs B N LIPOFEN B N LOFIBRA B N TRICOR B N TRIGLIDE B N ANTARA G N fenofibrate micronized G P gemfibrozil B N LOPID G N niacin (antihyperlipidemic) N NIASPAN B 11 39 CHOLESTEROL - HMG COA + ABSORB INHIBITORS B B 39 B N LIVALO N SIMCOR N VASCEPA CHOLESTEROL - HMG COA + ABSORB INHIBITORS: HIGH POTENCY DRUGS/COMBINATIONS G P atorvastatin calcium B N LIPITOR B P CRESTOR G P simvastatin tab 10 mg G P simvastatin tab 20 mg G P simvastatin tab 40 mg G P simvastatin tab 5 mg N simvastatin tabs 80mg B N ZOCOR B P VYTORIN G 39 CHOLESTEROL - HMG COA + ABSORB INHIBITORS: LOW POTENCY DRUGS/COMBINATIONS B 87 P ZETIA G N fluvastatin sodium B P LESCOL B P LESCOL XL B N ALTOPREV G P lovastatin B N PRAVACHOL G P pravastatin sodium B N ADVICOR B N LOVAZA G N omega-3-acid ethyl esters CHOLINERGIC G P bethanechol chloride B N URECHOLINE COMPOUNDING MATERIALS ND P sterile dilu sol flolan ND P water for inject, bacteriostatic parabens ND P saline, bacteriostatic CONTRACEPTIVES - BI-PHASIC COMBINATIONS B N NECON 10/11-28 B, G, or O COM P, N, Therapeutic Category R, or NR CONTRACEPTIVES - EMERGENCY CONTRACEPTIVE G P levonorgestrel (emergency oc) B P ELLA CONTRACEPTIVES - INJECTABLE B N DEPO-PROVERA G P medroxyprogesterone acetate (contraceptive) CONTRACEPTIVES - MONOPHASIC COMBINATION O/C'S B P DESOGEN G P desogestrel & ethinyl estradiol tab 0.15 mg-30 mcg B N ORTHO-CEPT G N drospirenone-ethinyl estradiol tab 3-0.02 mg G P drospirenone-ethinyl estradiol tab 3-0.03 mg B N YASMIN 28 B N YAZ G P gianvi G P ethynodiol diacetate & ethinyl estradiol tab 1 mg-35 mcg B P ZOVIA 1/50E G P levonorgestrel & ethinyl estradiol tab 0.1 mg-20 mcg G P levonorgestrel & ethinyl estradiol tab 0.15 mg-30 mcg B N BREVICON-28 B N MODICON G P norethindrone & ethinyl estradiol tab 0.4 mg-35 mcg G P norethindrone & ethinyl estradiol tab 0.5 mg-35 mcg G P norethindrone & ethinyl estradiol tab 1 mg-35 mcg B N NORINYL B N ORTHO-NOVUM TAB 1/35 B N OVCON-35 B N LOESTRIN G N norethindrone acet & eth estra B P NECON 1/50-28 B P NORINYL G P norgestrel & ethinyl estradiol tab 0.3 mg-30 mcg B N OGESTREL B N BEYAZ B P FEMCON FE G N norethindrone & ethinyl estradiol-fe B N LOESTRIN FE 1.5/30 B N LOESTRIN FE 1/20 G P norethindrone ace & ethinyl estradiol-fe tab 1 mg-20 mcg G P norethindrone ace & ethinyl estradiol-fe tab 1.5 mg-30 mcg G P desogestrel-ethinyl estradiol (biphasic) B N MIRCETTE B N LO LOESTRIN FE G N levonorg-eth est tab 0.15-0.03mg(84) & eth est tab 0.01mg(7) G P levonorgestrel-ethinyl estradiol (91-day) tabs B N LOSEASONIQUE B N QUARTETTE B P SEASONIQUE G N levonorgestrel-ethinyl estradiol (continuous) TAB 1/35 RT45620 NATAZIA Therapeutic Category B P ORTHO EVRA G P xulane B P NUVARING CONTRACEPTIVES - PROGESTIN ONLY B N NOR-QD G P norethindrone (contraceptive) B P ORTHO MICRONOR CONTRACEPTIVES - TRI-PHASIC COMBINATIONS B N CYCLESSA G P desogest-ethin est tab 0.1-0.025/0.125-0.025/0.15-0.025mg-mg G P levonorgestrel-eth estra tab 0.05-30/0.075-40/0.125-30mg-mcg G P norethindrone-eth estradiol tab 0.5-35/0.75-35/1-35 mg-mcg G P norethindrone-eth estradiol tab 0.5-35/1-35/0.5-35 mg-mcg B N ORTHO-NOVUM 7/7/7 B N TRI-NORINYL 28 G P norgestimate-eth estrad tab 0.18-35/0.215-35/0.25-35 mg-mcg B P ORTHO TRI-CYCLEN B N ORTHO TRI-CYCLEN LO B P ESTROSTEP FE G N norethindrone ac-ethinyl estrad-fe tab 1-20/1-30/1-35 mg-mcg COUGH/COLD - ANTITUSSIVE-EXPECTORANT O P Dextromethorphan-Guaifenesin Syrup 10-100 MG/5ML COUGH/COLD - SYSTEMIC DECONGESTANTS O P Pseudoephedrine HCl Tab 30 MG O P Pseudoephedrine HCl Tab 60 MG COX 2 INHIBITORS - SELECTIVE TAB 1+50-28 CONTRACEPTIVES - MULTI-PHASIC COMBINATIONS N COM P , N, R, or NR CONTRACEPTIVES - PATCHES/ VAGINAL PRODUCTS PDL Categories B B, G, or O G 11 N ketorolac tromethamine G 11 N ketorolac tromethamine soln 60mg/2ml B 11 N SPRIX G P meloxicam B 11 N MOBIC B 11 N VIVLODEX G P nabumetone B 11 N CELEBREX G 11 N celecoxib CYSTIC FIBROSIS AGENTS B 11 N KALYDECO B 11 P PULMOZYME B 11 N ORKAMBI CYTO-MEGALOVIRUS AGENTS G N cidofovir B N CYTOVENE G N ganciclovir sodium B P VALCYTE G N valganciclovir hcl DENTAL PRODUCTS G P sodium fluoride (dental) B, G, or O COM P, N, Therapeutic Category R, or NR PDL Categories P stannous fluoride DIABETIC - ALPHAGLUCOSIDASE G N acarbose B N PRECOSE B P GLYSET B N NOVOLOG B P LANTUS B N APIDRA B P HUMALOG B P LEVEMIR B N AFREZZA B P HUMULIN R O N NOVOLIN R O P HUMULIN N O N NOVOLIN N B N NOVOLOG MIX 70/30 B P HUMALOG MIX 50/50 B P HUMALOG MIX 75/25 O P HUMULIN 70/30 O N NOVOLIN 70/30 INJ 100/ML DIABETIC - INSULIN PENFILLS B 11 P NOVOLOG B 11 P LANTUS SOLOSTAR B 11 N TOUJEO B 11 N APIDRA B 11 N HUMALOG B 11 P LEVEMIR B 11 N TRESIBA FLEX O 11 N HUMULIN N U-100 PEN B 11 N HUMALOG MIX 50/50 B 11 N HUMALOG MIX 75/25 O 11 N HUMULIN 70/30 PEN DIABETIC - MEGLITINIDES P nateglinide B N STARLIX B N PRANDIN G N repaglinide DIABETIC - NON-INSULIN INJECTABLES B 11 P TANZEUM B 11 N TRULICITY B 11 N BYDUREON B 11 P BYETTA B 11 N VICTOZA DIABETIC - ORAL BIGUANIDES B N FORTAMET G N metformin hcl tab sr osmotic B N GLUCOPHAGE RT45620 Therapeutic Category G P metformin hcl B N GLUCOPHAGE XR P metformin hcl tab sr N RIOMET B B 11 N GLUMETZA G 11 N metformin hcl tab sr modified release DIABETIC - ORAL SULFONYLUREAS DIABETIC - INSULIN G COM P , N, R, or NR - Contd - G DENTAL PRODUCTS G B, G, or O G P chlorpropamide B N AMARYL G P glimepiride G P glipizide B N GLUCOTROL N GLUCOTROL XL B P DIABETA G P glyburide G P glyburide micronized B N GLYNASE G P tolazamide G N tolbutamide B 11 DIABETIC - OTHER B 11 N SYMLINPEN 120 B 11 N SYMLINPEN 60 B N GLUCAGON EMERGENCY KIT B P GLUCAGEN B P PROGLYCEM B 11 N KORLYM B 11 N NESINA B 11 P TRADJENTA B 11 N ONGLYZA B 11 P JANUVIA B 11 N INVOKANA B 11 N FARXIGA B 11 N JARDIANCE B 11 N KAZANO B 11 P JENTADUETO B 11 N KOMBIGLYZE XR B 11 P JANUMET B 11 P JANUMET XR B 11 N OSENI N PRANDIMET B B 11 N INVOKAMET B 11 N XIGDUO XR B 11 N SYNJARDY B 11 N GLYXAMBI DIABETIC - SULFONYLUREA / BIGUANIDE G P glipizide-metformin hcl B N GLUCOVANCE G P glyburide-metformin N AVANDARYL B 16 DIABETIC - THIAZOL B N ACTOS G P pioglitazone hcl N AVANDIA B 16 B, G, or O COM B, G, or O P, N, Therapeutic Category R, or NR G PDL Categories DIABETIC - THIAZOL B 16 G N DUETACT N pioglitazone hcl-glimepiride DIABETIC - THIAZOL / BIGUANIDE COMBO B N ACTOPLUS MET B N ACTOPLUS MET XR G N pioglitazone hcl-metformin hcl N AVANDAMET B 16 DIAGNOSTIC BIOLOGICALS B P APLISOL DIAGNOSTIC DRUGS B N CORTROSYN G N cosyntropin B N THYROGEN DIRECT RENIN INHIBITORS B N TEKTURNA B N TEKTURNA HCT B N TEKAMLO DIURETICS G 11 P eplerenone B 11 N INSPRA G P acetazolamide B P DIAMOX G N methazolamide B N NEPTAZANE G P bumetanide B P EDECRIN G P furosemide B N LASIX B N DEMADEX G P torsemide G P amiloride hcl B N ALDACTONE G P spironolactone G P chlorothiazide tab B N DIURIL G N chlorothiazide sodium G P chlorthalidone G P hydrochlorothiazide B N MICROZIDE G P indapamide G P methyclothiazide G P metolazone B P ZAROXOLYN G P amiloride & hydrochlorothiazide B N ALDACTAZIDE TAB 25/25 B P ALDACTAZIDE TABS 50/50 G P spironolactone & hydrochlorothiazide B N DYAZIDE B N MAXZIDE RT45620 COM P , N, R, or NR - Contd - P Therapeutic Category triamterene & hydrochlorothiazide DOPAMINE RECEPTOR AGONISTS G P cabergoline G N ofloxacin (otic) B N PINNACAINE OTIC B N DERMOTIC G N fluocinolone acetonide (otic) G N hydrocortisone w/acetic acid G P acetic acid (otic) G N acetic acid-aluminum acetate P CIPRODEX B P CIPRO HC G P neomycin-polymyxin-hc (otic) B N COLY-MYCIN S B N CORTISPORIN-TC G P antipyrine-benzocaine EAR B 19 ELECTROLYTES/ NUTRITIONALS ND P *oral electrolyte solution*** G N parenteral electrolytes G P lactated ringer's G P potassium chloride in nacl G P potassium chloride in dextrose G P dextrose w/ sodium chloride G P dextrose in lactated ringers G P potassium chloride in dextrose & sodium chloride G P dextrose B N INTRALIPID B P LIPOSYN G N amino acid infusion G P amino acid infusion soln 6% B P AMINOSYN B P AMINOSYN II B N AMINOSYN-HBC B N AMINOSYN-PF B N FREAMINE III B P PREMASOL B P TRAVASOL B N TROPHAMINE G P amino acid electrolyte infusion B N PROCALAMINE G N albumin, human ENDOCRINE METABOLIC AGENTS B N STRENSIQ ERYTHROPOEISIS STIMULATING AGENTS B 11 N ARANESP ALBUMIN FREE B 11 N EPOGEN B 11 P PROCRIT ESTROGEN COMBOS B P PREMPHASE B P PREMPRO B, G, or O COM P, N, Therapeutic Category R, or NR PDL Categories ESTROGEN COMBOS B N ACTIVELLA B N COMBIPATCH G N estradiol & norethindrone acetate B N FEMHRT B N JINTELI B N ANGELIQ B N CLIMARA PRO B N PREFEST ESTROGENS - PATCHES B P ALORA B N CLIMARA B N DIVIGEL B N ELESTRIN G P estradiol weekly B N EVAMIST B N MENOSTAR B N MINIVELLE B P VIVELLE B N ESTRADIOL BI-WEEKLY ESTROGENS - TABS B P PREMARIN B P CENESTIN B N ENJUVIA B P MENEST B N ESTRACE G P estradiol B P DEPO-ESTRADIOL B N DELESTROGEN G N estradiol valerate G P estropipate B N DUAVEE FLUOROQUINOLONES B N CIPRO (10%) SUS 500MG/5 B N CIPRO (5%) SUS 250MG/5 G P ciprofloxacin iv soln 200 mg/20ml (1%) G P ciprofloxacin iv soln 400 mg/40ml (1%) G P ciprofloxacin-ciprofloxacin hcl B N CIPRO TABS G P ciprofloxacin hcl tab 100 mg (base equiv) G P ciprofloxacin hcl tab 250 mg (base equiv) G P ciprofloxacin hcl tab 500 mg (base equiv) G P ciprofloxacin hcl tab 750 mg (base equiv) B N LEVAQUIN G P levofloxacin G N moxifloxacin hcl G N ofloxacin GI - ANTI - FLATULENTS / GI STIMULANTS B N OSMOPREP O P Sennosides Tab 8.6 MG B N KRISTALOSE RT45620 B, G, or O COM P , N, R, or NR G Therapeutic Category P lactulose P polyethylene glycol 3350 P polyethylene glycol 3350 B P NULYTELY G P peg 3350-potassium chloride-sod bicarbonate-sod chloride B P COLYTE B P GOLYTELY G P peg 3350-kcl-sod bicarb-sod chloride-sod sulfate G P cromolyn sodium (mastocytosis) B P GASTROCROM G P metoclopramide hcl N METOZOLV ODT B N REGLAN G P lactulose (encephalopathy) O - Contd - G B 49 11 GI - ANTIDIARRHEAL / ANTACID - MISC. B N FULYZAQ ND 11 P sodium bicarbonate (antacid) tabs ND 11 P magnesium oxide tab 400 mg G P atropine sulfate B P ANASPAZ G P hyoscyamine sulfate B N LEVSIN B N CUVPOSA G N glycopyrrolate injection G P glycopyrrolate tabs B N ROBINUL G P methscopolamine bromide G P propantheline bromide B N BENTYL B N BENTYL INJ 10MG/ML B N BENTYL TAB 20MG G P dicyclomine hcl CAP 10MG GI - ANTIPERISTALTIC AGENTS G P diphenoxylate w/ atropine B N LOMOTIL G P loperamide hcl cap 2 mg O P Loperamide HCl Liq 1 MG/5ML (0.2 MG/ML) O P Loperamide HCl Tab 2 MG G N opium tincture G N paregoric B N GATTEX GI - DIGESTIVE ENZYMES B P CREON B N PANCREAZE G P pancrelipase (lipase-protease-amylase) B N PERTZYE B N ULTRESA B N VIOKACE B P ZENPEP GI - H2-ANTAGONISTS G P cimetidine G N ranitidine hcl cap 150 mg G N ranitidine hcl cap 300 mg B, G, or O COM P, N, Therapeutic Category R, or NR B, G, or O PDL Categories - Contd - GI - H2-ANTAGONISTS G P ranitidine hcl inj 150 mg/6ml (25 mg/ml) G P ranitidine hcl inj 50 mg/2ml (25 mg/ml) G P ranitidine hcl syrup 15 mg/ml (75 mg/5ml) G P ranitidine hcl tab 150 mg G P ranitidine hcl tab 300 mg B N ZANTAC G N famotidine for susp 40 mg/5ml G P famotidine tab 20 mg G P famotidine tab 40 mg B N PEPCID B N AXID G N nizatidine GI - INFLAMMATORY BOWEL AGENTS G P balsalazide disodium B N COLAZAL B N GIAZO B P APRISO B N ASACOL HD TAB 800MG B N CANASA SUP 1000MG B N DELZICOL CAP 400MG B N LIALDA G P mesalamine B P PENTASA CAP 250MG CR B N PENTASA CAP 500MG CR B N SFROWASA B P DIPENTUM B N AZULFIDINE G P sulfasalazine TAB 1.2GM ENE 4GM N LOTRONEX G N alosetron GI - MISC. O P Magnesium Hydroxide Susp 400 MG/5ML O P Sennosides Syrup 8.8 MG/5ML O P Sennosides-Docusate Sodium Tab 8.6-50 MG B N PREPOPIK B N SUPREP B N MOVIPREP B N ACTIGALL B N URSO G P ursodiol B N RELISTOR B N CHOLBAM GI - MISC. ANTI-ULCER B N CARAFATE SUS 1GM/10ML B N CARAFATE TAB 1GM G N sucralfate susp 1 gm/10ml G P sucralfate tab 1 gm GI - PROSTAGLANDINS RT45620 N CYTOTEC G P misoprostol GI - PROTON PUMP INHIBITOR B P DEXILANT B 11 N NEXIUM G 11 N esomeprazole strontium G 11 N lansoprazole B 11 N PREVACID B 11 N PREVACID SOLUTAB P omeprazole N PRILOSEC P pantoprazole sodium G B 11 G B 11 N PROTONIX B 11 N ACIPHEX G 11 N rabeprazole sodium G 11 N omeprazole-sodium bicarbonate GI - PROTON PUMP INHIBITOR/NSAID COMBO 11 N VIMOVO GI - ULCER ANTI-INFECTIVE B P PYLERA G N amoxicillin-clarithromycin w/ lansoprazole B N PREVPAC GI, CONSTIPATION - IBS-OIC B 11 N AMITIZA B 11 N LINZESS B 11 N MOVANTIK GLUCOCORTICOIDS - CORTICOTROPIN GI - IRRITABLE BOWEL SYNDROME AGENTS B Therapeutic Category B B CAP 0.375GM COM P , N, R, or NR B 11 N H.P. ACTHAR GLUCOCORTICOIDS - MINERALOCORTICOIDS G P budesonide B N ENTOCORT EC B N UCERIS G P cortisone acetate G P dexamethasone B P DEXAMETHASONE INTENSOL B N DEXPAK G P dexamethasone sodium phosphate B P CORTEF G P hydrocortisone B P A-HYDROCORT B P SOLU-CORTEF B P MEDROL PAK 4MG B N MEDROL TAB 16MG B N MEDROL TAB 2MG B N MEDROL TAB 32MG B P MEDROL TAB 4MG B N MEDROL TAB 8MG G N methylprednisolone tab 16 mg G N methylprednisolone tab 32 mg G P methylprednisolone tab 4 mg G N methylprednisolone tab 8 mg B, G, or O COM P, N, Therapeutic Category R, or NR GLUCOCORTICOIDS - MINERALOCORTICOIDS B N DEPO-MEDROL G P methylprednisolone acetate G P methylprednisolone sod succ B P SOLU-MEDROL B N MILLIPRED TABS G P prednisolone B N MILLIPRED B N ORAPRED B N PEDIAPRED G P prednisolone sodium phosphate B N VERIPRED 20 G N prednisolone odt G P prednisone B N PREDNISONE INTENSOL N RAYOS B P KENALOG B N CELESTONE-SOLUSPAN G P fludrocortisone acetate 11 SOL 10MG/5ML GOUT G P allopurinol B N ZYLOPRIM P colchicine N COLCRYS N ULORIC G P probenecid G P colchicine w/ probenecid G 62 B B 11 GRANULOCYTE CSF B 11 P NEUPOGEN B 11 N ZARXIO B 11 N GRANIX B 11 N NEULASTA B 11 N LEUKINE B 11 N NEUMEGA GROWTH HORMONE B 11 N GENOTROPIN B 11 N HUMATROPE B 11 P NORDITROPIN B 11 P NUTROPIN AQ B 11 N OMNITROPE B 11 N TEV-TROPIN B 11 N SAIZEN B 11 N SEROSTIM B 11 N ZORBTIVE B 11 N INCRELEX HEMOSTATIC G P aminocaproic acid B P AMICAR B N LYSTEDA G N tranexamic acid RT45620 COM P , N, R, or NR Therapeutic Category HEPATITIS B ONLY PDL Categories B B, G, or O - Contd - G N adefovir dipivoxil B P HEPSERA B P BARACLUDE G N entecavir B N TYZEKA HEPATITIS C AGENTS B 11 P VICTRELIS B 11 N DAKLINZA B P PEGASYS B P PEGASYS PROCLICK B P PEG-INTRON B N COPEGUS B N REBETOL B N RIBASPHERE B N RIBASPHERE RIBAPAK G P ribavirin cap 200 mg G P ribavirin tab 200 mg OLYSIO B 11 N B 11 P SOVALDI B 11 P HARVONI B 11 P TECHNIVIE B 11 P VIEKIRA PAK HEREDITARY ANGIOEDEMA AGENTS B N FIRAZYR HEREDITARY TYROSINEMIA TYPE 1 (HT-1) TREATMENT - AGENTS B P ORFADIN HERPES AGENTS G P acyclovir G N acyclovir susp N SITAVIG B N ZOVIRAX B P ZOVIRAX SUS 200/5ML B N ZOVIRAX TAB 400MG B N ZOVIRAX TAB 800MG G P acyclovir sodium G P valacyclovir hcl B N VALTREX G N famciclovir B N FAMVIR B 11 CAP 200MG HYPERPARATHYROID TREATMENT - VITAMIN D ANALOGS G P calcitriol G N doxercalciferol N HECTOROL B 39 HYPERPARATHYROID TREATMENT - VITAMIN D ANALOGS AND CALCIMIMETICS G B B 39 N paricalcitol N ZEMPLAR N SENSIPAR IDIOPATHIC PULMONARY FIBROSIS B, G, or O COM P, N, Therapeutic Category R, or NR PDL Categories IDIOPATHIC PULMONARY FIBROSIS B 11 N ESBRIET B 11 N OFEV N CYTOGAM B N HEPAGAM B B N HYPERHEP B S/D B P HYPERHEP B S/D SOLN B P NABI-HB B N GAMASTAN S/D B P BIVIGAM B P CARIMUNE NANOFILTERED B P FLEBOGAMMA B P GAMMAGARD B N GAMMAPLEX B N OCTAGAM B N PRIVIGEN B N HIZENTRA B N GAMMAKED B P GAMUNEX-C B P HYPERRHO S/D B P MICRHOGAM ULTRA-FILTEREDPLUS B P RHOGAM ULTRA-FILTERED PLUS B P RHOPHYLAC B P WINRHO SDF B P HYPERTET S/D B P HYQVIA G P cyclosporine B P SANDIMMUNE G P cyclosporine modified (for microemulsion) G P gengraf B N NEORAL B N CELLCEPT B P CELLCEPT SUSR G P mycophenolate mofetil G N mycophenolate sodium B P MYFORTIC B N ZORTRESS B P RAPAMUNE G P sirolimus N ASTAGRAF XL B N PROGRAF G P tacrolimus N FLUMADINE G P rimantadine hydrochloride P TAMIFLU P RELENZA DISKHALER B 48 P FLULAVAL B 48 P FLUZONE SPLT INJ 2015-16 B 48 P AFLURIA RT45620 FLUARIX PF INJ 2015-16 P FLUZONE 48 P FLUARIX QUAD INJ 2015-16 B 48 P FLUVIRIN B 48 P FLUVIRIN PF INJ 2015-16 - Contd - B INJ PF 2015-16 INJ 2015-16 N ACTIMMUNE G P sodium polystyrene sulfonate B N SPS B N VELTASSA LHRH/GNRH AGONIST ANALOG PITUITARY SUPPRESSANTS B N LUPANETA PACK LINCOSAMIDES / OXAZOLIDINONES / LEPROSTATICS G N chloramphenicol sodium succinate B N LINCOCIN B N CLEOCIN CAP 150MG B N CLEOCIN CAP 300MG B N CLEOCIN CAP 75MG G P clindamycin hcl cap 150 mg G N clindamycin hcl cap 300 mg B N CLEOCIN PED SOL 75MG/5ML G P clindamycin palmitate hcl for soln 75 mg/5ml (base equiv) B P CLEOCIN IN D5W B 11 N ZYVOX G 91 P linezolid B N SIVEXTRO B N CUBICIN G P dapsone LIPODYSTROPHY AGENTS B N MYALEPT G P lithium carbonate cap 150 mg G P lithium carbonate cap 300 mg G N lithium carbonate cap 600 mg G P lithium carbonate tab 300 mg G P lithium carbonate tab cr 300 mg G P lithium carbonate tab cr 450 mg N LITHOBID B B B P 48 LITHIUM INFLUENZA AGENTS 25 48 B K REMOVING RESINS IMMUNOSUPPRESSANTS B Therapeutic Category B B B 11 COM P , N, R, or NR INTERFERON GAMMA IMMUNE SERUMS B B, G, or O INJ 2015-16 INJ PF 2015-16 39 MACROLIDES / ERYTHROMYCIN'S / KETOLIDES B N ERY-TAB G N erythromycin base B N PCE B N E.E.S. GRANULES B N ERYPED G N erythromycin ethylsuccinate G P azithromycin for susp 100 mg/5ml G P azithromycin for susp 200 mg/5ml G N azithromycin iv for soln 500 mg G P azithromycin powd pack for susp 1 gm B, G, or O COM P, N, Therapeutic Category R, or NR PDL Categories MACROLIDES / ERYTHROMYCIN'S / KETOLIDES G P azithromycin tab 250 mg G P azithromycin tab 500 mg G P azithromycin tab 600 mg B N ZITHROMAX INJ 500MG B N ZITHROMAX POW 1GM PAK B N ZITHROMAX SUS 100/5ML B N ZITHROMAX SUS 200/5ML B N ZITHROMAX TAB 250MG B N ZITHROMAX TAB 500MG B N ZITHROMAX TAB 600MG B N ZITHROMAX TAB TRI-PAK B N ZITHROMAX TAB Z-PAK B N ZMAX SUS 2GM B N BIAXIN SUS 250/5ML B N BIAXIN TAB 250MG B N BIAXIN TAB 500MG G P clarithromycin for susp 125 mg/5ml G P clarithromycin for susp 250 mg/5ml G P clarithromycin tab 250 mg G P clarithromycin tab 500 mg G N clarithromycin tab sr 24hr 500 mg B N DIFICID B N KETEK METABOLIC MODIFIERS - LYSOSOMAL STORAGE DISORDER TREATMENTS B N NAGLAZYME MIGRAINE - ERGOT COMBINATIONS B N CAFERGOT B P MIGERGOT MIGRAINE - ERGOTAMINE DERIVATIVES B N D.H.E. 45 G N dihydroergotamine mesylate B N MIGRANAL MIGRAINE - SELECTIVE SEROTONIN AGONISTS (5HT)--INJECTABLES B 17 P IMITREX SPRAY G 11 N sumatriptan spray B 17 P IMITREX STATDOSE REFILL B 17 P IMITREX STATDOSE SYSTEM G 11 N sumatriptan succinate B 11 N SUMAVEL DOSEPRO B 11 N ZECUITY B 11 N ZOMIG NASAL SPRAY MIGRAINE - SELECTIVE SEROTONIN AGONISTS (5HT)--TABS B 11 N AXERT G 11 N almotriptan B 11 N RELPAX B 11 N FROVA B 11 N AMERGE G 17 P naratriptan hcl B 11 N MAXALT RT45620 B, G, or O COM P , N, R, or NR Therapeutic Category B 11 N MAXALT-MLT G 17 P rizatriptan benzoate 17 P rizatriptan benzoate tablet disperse B 11 N IMITREX G 17 P sumatriptan succinate G 11 N zolmitriptan B 11 N ZOMIG B 11 N ZOMIG ZMT - Contd - G MIGRAINE - SELECTIVE SEROTONIN AGONISTS-5HT COMBINATIONS B 11 N TREXIMET MINERALS P calcium carbonate (antacid) G ND 11 P sodium acetate inj 2 meq/ml G P sodium bicarbonate inj 4.2% G P sodium bicarbonate inj 7.5% G P sodium bicarbonate inj 8.4% calcium carbonate ND 11 P ND 11 P calcium carbonate tab 600 mg ND 11 P calcium carbonate-vitamin d tab 500 mg-200 unit ND N calcium & phosphorus w/ vitamin d tab 105 mg-81 mg-120 unit G P sodium fluoride chew tab 0.25 mg f (from 0.55 mg naf) G P sodium fluoride chew tab 0.5 mg f (from 1.1 mg naf) G P sodium fluoride chew tab 1 mg f (from 2.2 mg naf) G P sodium fluoride soln 0.125 mg/drop f (0.275 mg/drop naf) G P sodium fluoride soln 0.5 mg/ml f (from 1.1 mg/ml naf) B P SSKI G P magnesium sulfate inj 4% G P magnesium sulfate inj 50% P magnesium sulfate inj 8% P MAGNEBIND 400 G P sodium phosphate inj 3 mmole/ml G P pot phosphate monobasic w/ sod phosphate dibasic & monobasic G P potassium acetate inj 2 meq/ml G P potassium bicarbonate effer tab 25 meq B P MICRO-K G P potassium chloride inj 10 meq/100 ml G P potassium chloride inj 10 meq/50 ml G P potassium chloride inj 2 meq/ml G P potassium chloride oral liq 10% (20 meq/15ml) G P potassium chloride oral liq 20% (40 meq/15ml) G P potassium chloride tab cr 10 meq G P potassium chloride tab cr 8 meq (600 mg) G P potassium chloride tablet er 20meq er G P sodium chloride inj 0.45% ND P sodium chloride inj 0.9% G P sodium chloride inj 3% ND P sodium chloride iv soln 0.9% G P trace minerals (cr-cu-mn-se-zn) ND P ferrous sulfate elixir 220 mg/5ml (44 mg/5ml elemental fe) ND P ferrous sulfate soln 75 mg/ml (15 mg/ml elemental fe) ND P ferrous sulfate tab 325 mg (65 mg elemental fe) ND P ferrous gluconate tab 324 mg (38 mg elemental iron) ND P ferrous fumarate tab 325 mg (106 mg elemental fe) G P iron dextran ND P saline w/ benzyl alcohol G B 11 B, G, or O COM P, N, Therapeutic Category R, or NR B PDL Categories MOUTH - ANESTHETICS TOPICAL ORAL G P lidocaine hcl viscous soln 2% MOUTH - STEROIDS G P triamcinolone acetonide dental paste 0.1% MOUTH ANTI-INFECTIVES G P nystatin susp 100000 unit/ml MOUTH ANTISEPTICS G P chlorhexidine gluconate soln 0.12% MUCOPOLYSACCHARIDOSIS B P ALDURAZYME MULTIPLE SCLEROSIS AGENTS G B 11 N glatopa N TECFIDERA B P AVONEX B P AVONEX PEN B P REBIF B P REBIF REBIDOSE B P REBIF REBIDOSE TITRATIONPACK B P BETASERON B N EXTAVIA B N PLEGRIDY B N PLEGRIDY STARTER PACK MULTIPLE SCLEROSIS AGENTS – NON-INTERFERONS B N COPAXONE B P COPAXONE SOSY 20MG/ML N AUBAGIO 11 B 11 N AMPYRA B 90 P GILENYA INJ 40MG/ML MUSCLE RELAXANT -COMBINATIONS G 11 N carisoprodol w/ aspirin G 11 N carisoprodol w/ aspirin & codeine MUSCLE RELAXANTS G P baclofen B P GABLOFEN B P LIORESAL INTRATHECAL G 11 N carisoprodol B 11 N SOMA P chlorzoxazone G B 11 N PARAFON FORTE DSC B 11 N AMRIX P cyclobenzaprine hcl G B 11 N FEXMID G 11 N metaxalone B 11 N SKELAXIN P methocarbamol G RT45620 COM P , N, R, or NR 11 Therapeutic Category N ROBAXIN G P orphenadrine citrate G P tizanidine hcl B 11 N ZANAFLEX B 11 N DANTRIUM G 11 N dantrolene sodium NARCOTIC - ANTAGONISTS G P naloxone hcl B N VIVITROL G P naltrexone hcl B N REVIA NARCOTICS - MISC. G P codeine sulfate B 11 N SUBSYS B 11 N ABSTRAL B 11 N ACTIQ G 11 N fentanyl citrate G MULTIPLE SCLEROSIS AGENTS – INTERFERONS B B, G, or O P fentanyl citrate soln B 11 N FENTORA B 11 N SUBLIMAZE B 11 N DILAUDID G 11 N hydromorphone hcl inj G P hydromorphone hcl tab 2 mg G P hydromorphone hcl tab 4 mg G P hydromorphone hcl tab 8 mg B 11 N DEMEROL G 11 N meperidine hcl soln G P meperidine hcl tab 100 mg G P meperidine hcl tab 50 mg G P morphine sulfate G P oxycodone hcl B 11 N ROXICODONE B 11 N OPANA G N oxymorphone hcl B 11 N NUCYNTA B 11 N BUTRANS G 11 N buprenorphine hcl B 11 N BELBUCA B 11 N BUNAVAIL G 11 N buprenorphine hcl-naloxone hcl dihydrate B 11 P SUBOXONE B 11 N ZUBSOLV G 11 N pentazocine w/ naloxone G 11 N oxycodone w/ acetaminophen tab 10-325 mg G P oxycodone w/ acetaminophen tab 5-325 mg G P oxycodone w/ acetaminophen tabs 2.5-325 G N oxycodone w/ acetaminophen tabs 7.5-325 N PRIMLEV G P oxycodone-aspirin B P PERCODAN G N oxycodone-ibuprofen G P acetaminophen w/ codeine CAPITAL/CODEINE B 11 B 11 N B 11 N TYLENOL/CODEINE G 11 N butalbital-acetaminophen-caff w/ cod cap 50-300-40-30 mg B, G, or O COM P, N, Therapeutic Category R, or NR PDL Categories NARCOTICS - MISC. G P butalbital-acetaminophen-caff w/ cod cap 50-325-40-30 mg B 11 N FIORICET/CODEINE G 11 N butalbital-aspirin-caffeine w/cod B 11 N FIORINAL/CODEINE #3 B 11 N SYNALGOS-DC B 11 N HYCET P hydrocodone-acetaminophen G G 11 N hydrocodone-acetaminophen tabs 10-300mg G 11 N hydrocodone-acetaminophen tabs 5-300mg G 11 N hydrocodone-acetaminophen tabs 7.5-300 B 11 N NORCO B 11 N XODOL G 11 N hydrocodone-ibuprofen B 11 N IBUDONE B 11 N VICOPROFEN NARCOTICS - SELECTED N CONZIP B B 11 N RYBIX ODT G P tramadol hcl G N tramadol hcl tab sr 24hr biphasic release 100 mg G N tramadol hcl tab sr 24hr biphasic release 200 mg G N tramadol hcl tab sr 24hr biphasic release 300 mg G 11 N tramadol hcl tablet er 24hr B 11 N ULTRAM B 11 N BUPRENEX G 11 N buprenorphine hcl G 11 P butorphanol tartrate P nalbuphine hcl G G 23 N tramadol-acetaminophen B 23 N ULTRACET NARCOTICS -LONG ACTING B 11 N DURAGESIC G P fentanyl 25mcg G P fentanyl 50mcg G P fentanyl 75mcg G P fentanyl 100mcg G 11 N fentanyl 12mcg G 11 N fentanyl 37.5mcg G 11 N fentanyl 62.5mcg G 11 N fentanyl 87.5mcg B 11 N HYSINGLA ER B 11 N ZOHYDRO ER B 11 N EXALGO B 11 N DOLOPHINE G P methadone hcl conc G P methadone hcl soln G P methadone hcl tab 10 mg G P methadone hcl tab 5 mg B P METHADOSE CON 10MG/ML B P METHADOSE SF CON 10MG/ML G 11 G RT45620 N morphine sul cap er P morphine sul tab er B, G, or O COM P , N, R, or NR G Therapeutic Category P morphine sulfate 11 N MS CONTIN 11 N KADIAN 10MG B 11 N KADIAN 40MG B 11 N KADIAN 130MG B 11 N KADIAN 150MG B P KADIAN 20MG B P KADIAN 30MG B P KADIAN 50MG B P KADIAN 60MG B P KADIAN 70MG B P KADIAN 80MG B P KADIAN 100MG B P KADIAN 200MG B P EMBEDA 11 N oxycodone hcl er B 11 N OXYCONTIN B 11 N OPANA ER (CRUSH RESISTANT) G 11 N oxymorphone hcl B 11 N NUCYNTA ER B 11 N XARTEMIS XR B - Contd - B G NASAL STEROID/ANTIHISTAMINE COMBOS B N DYMISTA NASAL STEROIDS B N QNASL B N BECONASE AQ G N budesonide (nasal) B N RHINOCORT AQUA B N OMNARIS B N ZETONNA G N flunisolide (nasal) B N VERAMYST B N FLONASE G P fluticasone propionate (nasal) B P NASONEX G N triamcinolone acetonide (nasal) NEUROLOGICS - MISC. G P ergoloid mesylates B P ORAP G N pimozide G N tetrabenazine B N XENAZINE N NUEDEXTA B P MESTINON B N MESTINON TABS B P MESTINON TIMESPAN G P pyridostigmine bromide B P REGONOL G N pyridostigmine er B 11 SYP 60MG/5ML NEUROMUSCULAR BLOCKING AGENTS B N DYSPORT B N BOTOX B N MYOBLOC B, G, or O COM P, N, Therapeutic Category R, or NR NEUROMUSCULAR BLOCKING AGENTS N XEOMIN NICARDIPINES G N nicardipine hcl NICOTINE REPLACEMENT THERAPY O 58 N NICODERM CQ O 58 P Nicotine TD Patch 24HR 14 MG/24HR O 58 P Nicotine TD Patch 24HR 21 MG/24HR O 58 P Nicotine TD Patch 24HR 7 MG/24HR B 67 N NICOTROL B 68 N NICOTROL SOLN O 59 N NICORETTE O 34 N NICORETTE LOZG O 34 N NICORETTE MINI O 59 N NICORETTE STARTER KIT O 59 P Nicotine Polacrilex O 34 P Nicotine Polacrilex LOZG NITRO - OINTMENT/CAP/CR P NITRO-BID G P nitroglycerin G N nitroglycerin in d5w NITRO - PATCHES B N NITRO-DUR DIS 0.1MG/HR B N NITRO-DUR DIS 0.2MG/HR B N NITRO-DUR DIS 0.3MG/HR B N NITRO-DUR DIS 0.4MG/HR B N NITRO-DUR DIS 0.6MG/HR B P NITRO-DUR DIS 0.8MG/HR G P nitroglycerin NITRO - SUBLINGUAL/ SPRAY G N nitroglycerin soln B N NITROLINGUAL B N NITROMIST B P NITROSTAT NSAIDS 11 G B 11 G N ZORVOLEX P diclofenac potassium N ZIPSOR P diclofenac sodium G 11 N diclofenac sodium tablet er 24hr B 11 N VOLTAREN-XR G 11 N etodolac caps G P etodolac tab 400 mg G P etodolac tab 500 mg N etodolac tab sr 24hr 400 mg G 11 G 11 N etodolac tab sr 24hr 500 mg G 11 N etodolac tab sr 24hr 600 mg G 11 N fenoprofen calcium B 11 N NALFON RT45620 Therapeutic Category P flurbiprofen N CALDOLOR N ibuprofen susp 100 mg/5ml O P Ibuprofen Susp 100 MG/5ML O P Ibuprofen Tab 200 MG G P ibuprofen tab 400 mg G P ibuprofen tab 600 mg G P ibuprofen tab 800 mg N INDOCIN P indomethacin B - Contd - G B 11 11 G G 11 N indomethacin cpcr B 11 N TIVORBEX P ketoprofen G G 11 N ketoprofen capsule er 24hr G 11 N meclofenamate sodium G 11 N mefenamic acid B 11 N PONSTEL B 11 N EC-NAPROSYN B 11 N NAPROSYN B P NAPROSYN SUSP G P naproxen B 11 N ANAPROX B 11 N NAPRELAN P naproxen sodium tab 550 mg naproxen sodium tabs 275mg G B B COM P , N, R, or NR G PDL Categories B B, G, or O G 11 N B 11 N DAYPRO G 11 N oxaprozin B 11 N FELDENE G 11 N piroxicam P sulindac G G 11 N tolmetin sodium B 11 N ARTHROTEC G 11 N diclofenac w/ misoprostol B 11 N DUEXIS B 11 N CAMBIA B 11 N FLECTOR G 11 N diclofenac sodium (topical) B 11 N PENNSAID B 11 N VOLTAREN GEL OP. ANTIALLERGICS - ANTIHISTAMINES B N LASTACAFT G N azelastine hcl (ophth) B N OPTIVAR G N azelastine dro 0.05% B N BEPREVE B N EMADINE B N ELESTAT G N epinastine hcl (ophth) B P PATADAY B P PATANOL B N PAZEO OP. ANTIALLERGICS - MAST CELL STABILIZERS G P cromolyn sodium (ophth) B N ALOMIDE B N ALOCRIL B, G, or O COM P, N, Therapeutic Category R, or NR PDL Categories OP. ANTIBIOTICS B N AZASITE G N bacitracin (ophthalmic) G P erythromycin (ophth) G P gentamicin sulfate (ophth) G P tobramycin (ophth) B N TOBREX B N BLEPH-10 G P sulfacetamide sodium (ophth) B N ZIRGAN G P trifluridine B N VIROPTIC G P bacitracin-polymyxin b (ophth) G P polymyxin b-trimethoprim B N POLYTRIM G N neomycin-bacitracin zn-polymyxin G N neomycin-polymyxin-gramicidin B N NEOSPORIN OP. ANTIINFLAMMATORY / STEROIDS OPHTH. B P MAXIDEX G P dexamethasone sodium phosphate (ophth) B N DUREZOL G P fluorometholone (ophth) B P FML B N FML LIQUIFILM B N FML FORTE B P FLAREX B P ALREX B P LOTEMAX B N OMNIPRED B N PRED FORTE B P PRED MILD G P prednisolone acetate (ophth) G P prednisolone sodium phosphate (ophth) B P VEXOL B P PRED-G B P ZYLET B P BLEPHAMIDE B P BLEPHAMIDE S.O.P. G N sulfacetamide sod-prednisolone B P TOBRADEX B N TOBRADEX ST G N tobramycin-dexamethasone B N MAXITROL G P neomycin-polymy-dexameth G N neomycin-polymyxin-hc (ophth) G N bacitracin-poly-neomycin-hc OP. BETA - BLOCKERS G N betaxolol hcl (ophth) B P BETOPTIC-S G P carteolol hcl (ophth) G P metipranolol B N BETAGAN RT45620 B, G, or O COM P , N, R, or NR Therapeutic Category G P levobunolol hcl B N BETIMOL B N ISTALOL G P timolol maleate ophth gel forming soln 0.25% G P timolol maleate ophth gel forming soln 0.5% G P timolol maleate ophth soln 0.25% G P timolol maleate ophth soln 0.5% B N TIMOPTIC B N TIMOPTIC-XE OP. CARBONIC ANHYDRASE INHIBITORS/COMBO B P COMBIGAN B N COSOPT B N COSOPT PF G P dorzolamide hcl-timolol maleate B P AZOPT G P dorzolamide hcl B N TRUSOPT OP. CYCLOPLEGICS G P B N atropine sulfate (ophthalmic) CYCLOGYL G P cyclopentolate hcl B N MYDRIACYL G P tropicamide B N CYCLOMYDRIL OP. MIOTICS - DIRECT ACTING B N ISOPTO CARPINE G P pilocarpine hcl B P PILOPINE HS B P PHOSPHOLINE IODIDE O P Artificial Tear Solution O P Artificial Tear Ointment G P naphazoline hcl B P MYDFRIN G P phenylephrine hcl (ophth) B N RESTASIS B N ALCAINE G P proparacaine hcl G P tetracaine hcl (ophth) O P Sodium Chloride Hypertonic Ophth Oint 5% O P Sodium Chloride Hypertonic Ophth Soln 5% B N CYSTARAN OP. MISC OP. NSAID'S G N bromfenac sodium (ophth) B N PROLENSA G P diclofenac sodium (ophth) G P flurbiprofen sodium B N OCUFEN B N ACULAR B N ACUVAIL G P ketorolac tromethamine (ophth) B N ILEVRO B, G, or O COM P, N, Therapeutic Category R, or NR B, G, or O PDL Categories - Contd - OP. NSAID'S B P NEVANAC N LUMIGAN G N bimatoprost G P latanoprost B N XALATAN B N ZIOPTAN B P TRAVATAN Z G N travoprost B N RESCULA P BESIVANCE B P CILOXAN OIN 0.3% OP B N CILOXAN SOL 0.3% OP G P ciprofloxacin hcl (ophth) G N levofloxacin ophth soln 0.5% B N OCUFLOX G P ofloxacin (ophth) OP. QUINOLONES FOURTH GENERATION G N gatifloxacin (ophth) B N ZYMAXID B N MOXEZA B P VIGAMOX raloxifene hcl OXYTOCICS P methylergonovine maleate G N benztropine mesylate inj 1 mg/ml G P benztropine mesylate tab 0.5 mg G P benztropine mesylate tab 1 mg G P benztropine mesylate tab 2 mg G P trihexyphenidyl hcl B N TASMAR G N tolcapone B N COMTAN G P entacapone PARKINSONS - SELECTED DOPAMIN AGONISTS B P APOKYN B N MIRAPEX N MIRAPEX ER P pramipexole dihydrochloride N pramipexole dihydrochloride tablet er 24hr N REQUIP N REQUIP XL P ropinirole hydrochloride N ropinirole hydrochloride tablet er 24hr N NEUPRO B 11 G G 11 B B 11 G G OP. SELECTIVE ALPHA ADRENERGIC AGONISTS G N apraclonidine hcl B N IOPIDINE B N ALPHAGAN P SOL 0.1% B P ALPHAGAN P SOLN 0.15% G P brimonidine tartrate ophth soln 0.2% G N brimonidine tartrate soln 0.15% B P SIMBRINZA OSTEOPOROSIS G P alendronate sodium G N alendronate sodium soln N BINOSTO B N FOSAMAX G N etidronate disodium B N BONIVA G N ibandronate sodium G N pamidronate disodium B N ACTONEL B N ATELVIA G N risedronate B N ZOMETA G P calcitonin (salmon) B N FORTICAL B N MIACALCIN INJ 200/ML B N MIACALCIN SPR 200/ACT B N FORTEO RT45620 EVISTA N PARKINSONS - COMT INHIBITORS B 11 N G PARKINSONS - ANTICHOLINERGICS OP. QUINOLONES B Therapeutic Category B G OP. PROSTAGLANDINS B COM P , N, R, or NR TAB 70MG 11 B PERIPHERAL VASODILATORS G P papaverine hcl PHENYLKETONURIA N B KUVAN PHOSPHATE BINDERS G P calcium acetate (phosphate binder) B P ELIPHOS B N PHOSLO B P PHOSLYRA B N AURYXIA B N FOSRENOL B N RENVELA G N sevelamer carbonate B P RENAGEL TAB 400MG B P RENAGEL TAB 800MG B N VELPHORO PHOSPHODIESTERASE INHIBITORS SPR 200/ACT G N milrinone lactate G N milrinone in dextrose N DALIRESP B 11 PLATELET AGGR. INHIBITORS / COMBO'S - MISC. G P cilostazol B, G, or O COM P, N, Therapeutic Category R, or NR PDL Categories PLATELET AGGR. INHIBITORS / COMBO'S - MISC. B N PLETAL N ZONTIVITY B N AGRYLIN G P anagrelide hcl B P AGGRENOX G N asa/dipyridamole G P pentoxifylline B 11 PLATELET AGGREGATION INHIBITORS G P dipyridamole B N PERSANTINE G P clopidogrel bisulfate G N clopidogrel bisulfate tabs 300mg B N PLAVIX B N EFFIENT G N ticlopidine hcl B N BRILINTA POWDERS ND P progesterone powder ND P progesterone micronized powder ND P metronidazole powder PRESSORS G N ephedrine sulfate (pressors) G P midodrine hcl PROGESTINS G P medroxyprogesterone acetate B N PROVERA B N MEGACE ES B N AYGESTIN G P norethindrone acetate tab 5 mg G N progesterone im in oil 50 mg/ml G N progesterone micronized capsule B N PROMETRIUM PSYCHOTHERAPEUTIC COMBINATION G P chlordiazepoxide-amitriptyline G P perphenazine-amitriptyline G 39 N olanzapine-fluoxetine hcl B 39 N SYMBYAX N NATPARA PTH B PULMONARY ANTI-HYPERTENSIVES B 11 N ADEMPAS B 11 N REVATIO B 11 N REVATIO SUSR G 11 P sildenafil citrate (pulmonary hypertension) B 39 N ADCIRCA G 11 P epoprostenol sodium B 11 N FLOLAN RT45620 B, G, or O COM P , N, R, or NR Therapeutic Category B 11 N VELETRI B 11 P VENTAVIS 11 N TYVASO B 11 N ORENITRAM B 11 N REMODULIN - Contd - B PULMONARY ANTI-HYPERTENSIVES-ENDOTHELIN RECEPTOR ANTAGONIST B 11 P LETAIRIS B 11 P TRACLEER B 11 N OPSUMIT PURINE ANALOG B P AZASAN G P azathioprine B N IMURAN RESTLESS LEG SYNDROME AGENTS B 11 N HORIZANT RHEUMATOID ARTHRITIS - NON-BIOLOGICALS B N ARAVA G P leflunomide RSV PROPHYLAXIS B 11 P SYNAGIS SEDATIVE/HYPNOTICS - BARBITURATE B N BUTISOL SODIUM G P phenobarbital G N phenobarbital sodium B N SECONAL SEDATIVE/HYPNOTICS - BENZODIAZEPINES G P estazolam G 76 P flurazepam hcl G 11 N midazolam hcl P midazolam hcl syrp G B 11 N DORAL B 11 N RESTORIL G P temazepam cap 15 mg G P temazepam cap 30 mg G 11 N temazepam caps 22.5mg G 11 N temazepam caps 7.5mg B 11 N HALCION G 11 N triazolam SEDATIVE/HYPNOTICS - NON-BENZODIAZEPINES G P eszopiclone B 11 N LUNESTA B 11 N SONATA G P zaleplon B 11 N AMBIEN B 11 N AMBIEN CR B 11 N EDLUAR B 11 N INTERMEZZO P zolpidem tartrate N zolpidem tartrate tablet er G G 11 B, G, or O COM P, N, Therapeutic Category R, or NR PDL Categories SEDATIVE/HYPNOTICS - NON-BENZODIAZEPINES B 11 N ZOLPIMIST B 11 N ROZEREM B 11 N HETLIOZ B 11 N BELSOMRA SINUS NODE INHIBITORS B N CORLANOR SMOKING CESSATION (ORAL) G 11 P bupropion hcl (smoking deterrent) B 11 P CHANTIX B 11 P CHANTIX CONTINUING MONTHPAK B 11 P CHANTIX STARTING MONTH PAK SOMATOSTATIC AGENTS G N octreotide acetate B P SANDOSTATIN B N SIGNIFOR B N SOMAVERT STIMULANTS B 11 N EVEKEO B 11 N PROCENTRA B 11 N DESOXYN G 11 N methamphetamine hcl STIMULANTS - AMPHETAMINES - LONG ACTING B 11 N DEXEDRINE G 11 N dextroamphetamine sulfate B 24 P VYVANSE B 39 N ADDERALL XR G 11 N amphetamine-dextroamphetamine er STIMULANTS - AMPHETAMINES - SHORT ACTING G 11 N dextroamphetamine sulfate B 11 N ADDERALL G 24 P amphetamine-dextroamphetamine STIMULANTS - METHYLPHENIDATE G 24 P dexmethylphenidate hcl B 11 N FOCALIN G 24 P methylphenidate hcl B 11 N RITALIN B 24 P METHYLIN ORAL SOLUTION STIMULANTS - METHYLPHENIDATE - LONG ACTING G 11 N dexmethylphenidate hcl B 24 P FOCALIN XR B 24 P DAYTRANA B 11 N CONCERTA B 24 P METADATE G 11 N methylphenidate hcl capsule er 24hr G 85 P methylphenidate hcl tab sa osm 18 mg G 85 P methylphenidate hcl tab sa osm 27 mg RT45620 B, G, or O COM P , N, R, or NR Therapeutic Category G 85 P methylphenidate hcl tab sa osm 36 mg G 85 P methylphenidate hcl tab sa osm 54 mg - Contd - G 11 N methylphenidate hcl tablet er 10mg er G 11 N methylphenidate tab 20mg cr B 24 P QUILLIVANT XR B 24 P RITALIN LA B 11 N APTENSIO XR STIMULANTS - OTHER STIMULANTS / LIKE STIMULANTS G 11 N clonidine hcl (adhd) B 11 N KAPVAY B 11 N INTUNIV G 11 P guanfacine er B 24 P STRATTERA B 11 N NUVIGIL G 24 P modafinil B 11 N PROVIGIL TETRACYCLINES G N demeclocycline hcl N ADOXA G N doxycycline (monohydrate) G P doxycycline (monohydrate) caps 100mg G P doxycycline (monohydrate) caps 50mg B N VIBRAMYCIN SUSR N DORYX N doxycycline hyclate N doxycycline hyclate tbec B N VIBRAMYCIN CAP 100MG B P VIBRAMYCIN SYRP G P minocycline hcl cap 100 mg G P minocycline hcl cap 50 mg G P minocycline hcl cap 75 mg G N minocycline hcl tab 100 mg G N minocycline hcl tab 50 mg G N minocycline hcl tab 75 mg B B 11 11 G G 11 G 11 N minocycline hcl tablet er 24hr B 11 N SOLODYN G N tetracycline hcl B N ORACEA THROMBOPOEITIN RECEPTOR AGONISTS B 11 P PROMACTA B 11 N NPLATE THYROID HORMONES G N levothyroxine sodium for iv inj 500 mcg G P levothyroxine sodium tab 100 mcg G P levothyroxine sodium tab 112 mcg G P levothyroxine sodium tab 125 mcg G P levothyroxine sodium tab 137 mcg G P levothyroxine sodium tab 150 mcg G P levothyroxine sodium tab 175 mcg G P levothyroxine sodium tab 200 mcg G P levothyroxine sodium tab 25 mcg G P levothyroxine sodium tab 300 mcg G P levothyroxine sodium tab 50 mcg B, G, or O COM P, N, Therapeutic Category R, or NR PDL Categories G P levothyroxine sodium tab 75 mcg G P levothyroxine sodium tab 88 mcg B N SYNTHROID B N TIROSINT B P CYTOMEL G N liothyronine sodium B P TRIOSTAT B P THYROLAR N ARMOUR THYROID 39 TISSUE PLASMINOGEN ACTIVATOR B P ACTIVASE B P CATHFLO ACTIVASE TOPICAL - ACNE PREPARATIONS B 11 P DIFFERIN CRE 0.1% B 11 P DIFFERIN GEL 0.1% B 11 P DIFFERIN GEL 0.3% B 11 N DIFFERIN LOTN G 11 N adapalene cream G 11 P adapalene gel 0.1% G 11 P adapalene gel 0.3% G 11 N adapalene lotion B 11 P AZELEX P Benzoyl Peroxide O B 11 P BENZOYL PEROXIDE 7% CLEANSER B 11 N CLEOCIN-T B 11 N CLINDAGEL G 11 P clindamycin phosphate (topical) B 11 N EVOCLIN B 11 N AKNE-MYCIN G 11 P erythromycin (acne aid) B 11 N KLARON G 11 N sulfacetamide sodium (acne) B 11 P EPIDUO B 11 N BENZAMYCIN B 11 N BENZAMYCIN GEL PAK G 11 P benzoyl peroxide-erythromycin B 11 N ACANYA B 11 P BENZACLIN B 11 N BENZACLIN GEL 1-5% G 11 N clindamycin phosphate-benzoyl peroxide B 11 N ONEXTON B 11 N DUAC B 11 N VELTIN B 11 N ZIANA G 11 N sulfacetamide sodium w/ sulfur B 11 N SUMAXIN B 11 N SUMAXIN TS B 11 N FINACEA B 11 N SOOLANTRA B 11 N METROCREAM B 11 P METROGEL B 11 P METROLOTION RT45620 COM P , N, R, or NR G 11 N metronidazole (topical) lotn 11 P metronidazole cream 0.75% 11 N metronidazole gel 0.75% 11 N NORITATE B TOPICAL - ANTIBIOTIC O P Bacitracin (Topical) G P gentamicin sulfate (topical) B N BACTROBAN OINT B N CENTANY AT G P mupirocin oint B N BACTROBAN G N mupirocin calcium cream 2% B N ALTABAX O P Neomycin-Bacitracin-Polymyxin B N CORTISPORIN CRE 2% TOPICAL - ANTIFUNGALS B N MENTAX G N ciclopirox gel 0.77% G N ciclopirox shampoo 1% G P ciclopirox solution 8% B N LOPROX SHAMPOO B N PENLAC NAIL LACQUER G P ciclopirox olamine B N NAFTIN G N nystatin cream 100000 unit/gm G P nystatin oint 100000 unit/gm O P Tolnaftate G P clotrimazole (topical) N econazole nitrate N JUBLIA B N EXTINA G P ketoconazole (topical) G N ketoconazole (topical) foam B N NIZORAL SHAMPOO O P Miconazole Nitrate Cream 2% B N OXISTAT B N ERTACZO B N EXELDERM N KERYDIN G P clotrimazole w/ betamethasone B N LOTRISONE G N nystatin-triamcinolone N VUSION G GEL 1-5%PUMP Therapeutic Category G - Contd - G THYROID HORMONES B B, G, or O B B B 11 11 11 TOPICAL - ANTINEOPLASTICS B N CARAC B P EFUDEX G N fluorouracil cream 5% G P fluorouracil soln 2% G P fluorouracil soln 5% G N diclofenac sodium (actinic keratoses) B N SOLARAZE B N PICATO TOPICAL - ANTIPRURITICS B, G, or O COM P, N, Therapeutic Category R, or NR PDL Categories TOPICAL - ANTIPRURITICS B N PRUDOXIN B P ZONALON G P selenium sulfide G P sulfacetamide sodium liquid 10% G P selenium sulfide-pyrithione zinc in urea vehicle TOPICAL - ANTIVIRALS G N acyclovir topical B N ZOVIRAX CRE 5% B N ZOVIRAX OIN 5% B N DENAVIR B N XERESE TOPICAL - ASTRINGENTS / PROTECTANTS P XERAC AC TOPICAL - BURN PRODUCTS B N SULFAMYLON B N SILVADENE G P silver sulfadiazine TOPICAL - CAUTERIZING AGENTS G P silver nitrate TOPICAL - CORTICOSTEROIDS - HIGH POTENCY G 11 N amcinonide cream 0.1% G 11 N amcinonide lotn G 11 N amcinonide oint G P betamethasone dipropionate (topical) oint G P betamethasone dipropionate cream 0.05% G P betamethasone dipropionate augmented cream 0.05% G 11 N betamethasone dipropionate augmented gel 0.05% G 11 N betamethasone dipropionate augmented lotion 0.05% G 11 N betamethasone dipropionate augmented oint 0.05% B 11 N DIPROLENE AF CRE 0.05% B 11 N DIPROLENE OINT G 11 N clobetasol propionate G P clobetasol propionate soln B P CLOBEX B N CLOBEX LIQD B P OLUX B P TEMOVATE G P clobetasol propionate emollient base N clobetasol propionate emulsion foam P OLUX-E G 11 11 B G 11 N desoximetasone B 11 N TOPICORT G 11 N diflorasone diacetate cream 0.05% G 11 N diflorasone diacetate oint 0.05% P fluocinonide cream 0.05% N fluocinonide cream 0.1% P fluocinonide gel 0.05% G G 11 G RT45620 COM P , N, R, or NR Therapeutic Category G P fluocinonide oint 0.05% G P fluocinonide soln 0.05% N VANOS P fluocinonide emulsified base - Contd - B 11 G TOPICAL - ANTISEBORRHEICS O B, G, or O B 11 N HALOG G 11 N halobetasol propionate B 11 N ULTRAVATE TOPICAL - CORTICOSTEROIDS - LOW POTENCY G 11 N alclometasone dipropionate B 11 N DESONATE G 11 N desonide B 11 N DESOWEN G P hydrocortisone cream 1% G P hydrocortisone cream 2.5% G P hydrocortisone lotion 2.5% G P hydrocortisone oint 1% G P hydrocortisone oint 2.5% B 11 N TEXACORT G 11 N hydrocortisone valerate TOPICAL - CORTICOSTEROIDS - MEDIUM POTENCY G 11 N betamethasone dipropionate (topical) lotn B 11 N DIPROLENE P betamethasone valerate G LOT 0.05% G 11 N betamethasone valerate foam B 11 N LUXIQ B 11 N CLODERM B P CAPEX B 11 N DERMA-SMOOTHE/FS BODY B 11 N DERMA-SMOOTHE/FS SCALP G 11 N fluocinolone acetonide G 11 N fluocinolone acetonide oil 0.01% (body oil) G 11 N fluocinolone acetonide oil 0.01% (scalp oil) B 11 N CORDRAN B 11 N CUTIVATE P fluticasone propionate G G 11 N fluticasone propionate lotn G 11 N hydrocortisone butyrate B 11 N ELOCON CRE 0.1% B 11 N ELOCON LOT 0.1% B 11 N ELOCON OIN 0.1% P mometasone furoate G B 11 N DERMATOP G 11 N prednicarbate B 11 N KENALOG G P triamcinolone acetonide (topical) G P triamcinolone acetonide (topical) lotn N TRIANEX B 11 TOPICAL - EMOLLIENTS G N lactic acid (ammonium lactate) cream 12% ND P lactic acid (ammonium lactate) lotion 12% B N UMECTA B N UMECTA NAIL FILM B N URAMAXIN G N urea cream 50% B, G, or O COM P, N, Therapeutic Category R, or NR PDL Categories TOPICAL - EMOLLIENTS G N urea foam 40% G N urea gel 40% G N urea gel 45% G P urea lotion 40% G N urea lotion 45% TOPICAL - ENZYMES / KERATOLYTICS / UREA B P SANTYL B N PODOCON 25 B N SALEX G P salicylic acid cream 6% G P salicylic acid lotion 6% G P salicylic acid shampoo 6% G P salicylic acid soln 26% TOPICAL - GENITAL WARTS B G N CONDYLOX N podofilox B 69 P VEREGEN B 36 N ALDARA G 36 P imiquimod B N ZYCLARA B N ZYCLARA PUMP TOPICAL - IMMUNOMODULATORS B 11 N ELIDEL B 11 N PROTOPIC G 11 N tacrolimus (topical) TOPICAL - LOCAL ANESTHETICS B P MARCAINE B P MARCAINE W/O EPI G N bupivacaine in dextrose G P lidocaine hcl local inj 1% G P lidocaine hcl local inj 1.5% G P lidocaine hcl local inj 2% G P lidocaine hcl local inj 4% G P lidocaine hcl local preservative free (pf) inj 0.5% G P lidocaine hcl local preservative free (pf) inj 1% G P lidocaine hcl local preservative free (pf) inj 2% B N XYLOCAINE-MPF B N CARBOCAINE G N mepivacaine hcl G P lidocaine w/ epinephrine B P XYLOCAINE/EPINEPHRINE G P lidocaine oint 5% B N LIDODERM G 11 P lidocaine hcl cream 3% G P lidocaine hcl gel 2% G P lidocaine hcl lotion 3% G P lidocaine hcl soln 4% B N SYNERA G P lidocaine-prilocaine RT45620 B, G, or O COM P , N, R, or NR Therapeutic Category TOPICAL - NASAL ANTIBIOTICS - Contd - B P BACTROBAN NASAL TOPICAL - SCABICIDES AND PEDICULICIDES B 73 P NATROBA B 73 P ULESFIA B N EURAX B N SKLICE G N lindane G N malathion B N OVIDE B N ELIMITE G P permethrin cream 5% O P Permethrin Lotion 1% G N spinosad O P Pyrethrins-Piperonyl Butoxide TOPICAL - STEROID COMBINATIONS G N calcipotriene-betamethasone dipropionate B N TACLONEX B N ENSTILAR B N U-CORT TOPICAL - STEROID LOCAL ANESTHETICS G P lidocaine-hydrocortisone acetate (rectal) B N EPIFOAM TOPICAL - TRETINOIDS B 11 N FABIOR B 11 N ATRALIN B 11 P RETIN-A G 11 N tretinoin B 11 N RETIN-A MICRO B 11 N RETIN-A MICRO PUMP G 11 N tretinoin microsphere TOPICAL - WOUND / DECUBITUS CARE B 11 N REGRANEX UREA CYCLE DISORDER - AGENTS B N RAVICTI B N AMMONUL B N BUPHENYL UROLOGICAL - MISC. B P MONUROL G P methenamine mandelate B N HIPREX G N methenamine hippurate B N FURADANTIN G P nitrofurantoin suspension B N MACRODANTIN G N nitrofurantoin macrocrystal 25mg G P nitrofurantoin macrocrystal 50mg G P nitrofurantoin macrocrystal 100mg B N MACROBID B, G, or O COM P, N, Therapeutic Category R, or NR PDL Categories B, G, or O G N nitrofurantoin monohyd macro G N methenamine-hyosc-methylene blue-sod phos-phenyl sal B P K-PHOS G P potassium citrate (alkalinizer) B P UROCIT B P ORACIT G P sodium citrate & citric acid G P phenazopyridine hcl B N CYSTAGON B N PROCYSBI B N ELMIRON B N LITHOSTAT B N THIOLA B P RENACIDIN G P acetic acid G P sodium chloride (gu irrigant) G P neomycin/polymyxin b gu B P NEOSPORIN GU IRRIGANT TAB NO 2 VACCINES G 11 P desmopressin acetate refrigerated 11 P desmopressin acetate spray refrigerated 11 N DDAVP 11 P desmopressin acetate spray B N PITRESSIN SYNTHETIC G N vasopressin inj 20 unit/ml B N SAMSCA G 70 P ZOSTAVAX INJ B 92 P PNEUMOVAX B 92 P TENIVAC VAGINAL - ANTI FUNGALS B N CLINDESSE O P Miconazole Nitrate Vaginal Cream 2% O P Miconazole Nitrate Vaginal Suppos 100 MG B N TERAZOL G P terconazole vaginal cream 0.4% G P terconazole vaginal cream 0.8% G N terconazole vaginal suppos 80 mg VAGINAL - ANTIBACTERIALS B N CLEOCIN CRE 2% VAG B P CLEOCIN SUP 100MG G P clindamycin phosphate vaginal B P METROGEL-VAGINAL G P metronidazole vaginal B N NUVESSA VAGINAL - ESTROGENS SPR 0.01% VITAMINS G P Thiamine Injection ND 11 N niacin tab 100 mg ND 11 N niacin tab 250 mg ND 11 N niacin tab 50 mg ND 11 N niacin tab 500 mg ND 11 N ergocalciferol soln 8000 unit/ml G 11 N ergocalciferol 50000 unit G 11 N cholecalciferol tab 50000 unit B P MEPHYTON G P phytonadione G P cyanocobalamin inj 1000 mcg/ml ND 11 N cyanocobalamin tab 1000 mcg ND 11 N cyanocobalamin tab cr 1000 mcg P folic acid tab 1 mg G B Therapeutic Category G - Contd - B UROLOGICAL - MISC. COM P , N, R, or NR VITAMINS - MISC. ND 11 P *B-Complex w/ C & Folic Acid Tab 1 MG*** ND 11 P B-Complex w/ C & Folic Acid B 11 P DIALYVITE/ TAB ZINC B 11 P NEPHPLEX RX ND 11 P AQUADEKS ND 11 P Pediatric Multiple Vitamin w/ Minerals & C B P PNV FOLIC AC TAB + IRON B P PRENATAL VIT TAB PLUS B P TRINATAL RX 1 B P VOL-NATE B P VOL-PLUS B P TRINATAL GT B P PNV FERROUS FUMARATE/DOCUSATE/FOLIC ACID B P SE-NATAL 19 CHEW TABLET P ferrous fumarate w/ b12-vit c-fa-ifc G 11 TAB RDL Categories ANTIHEMOPHILIC AGENTS B R HEMOFIL M B R KOATE-DVI B N ESTRACE B R MONOCLATE-P B N ESTRING B R HELIXATE FS B N VAGIFEM B NR KOGENATE FS B N FEMRING B NR KOGENATE FS BIO-SET B P PREMARIN B R RECOMBINATE B NR NOVOEIGHT B NR NUWIQ B NR ADVATE VASOPRESSINS B 11 N DDAVP B 11 N DDAVP TABS B R XYNTHA G 93 P desmopressin acetate B NR ELOCTATE B 11 P STIMATE B NR ADYNOVATE B 11 N DDAVP B NR OBIZUR RT45620 INJ 4MCG/ML SOL 0.01% B, G, or O COM P, N, Therapeutic Category R, or NR RDL Categories ANTIHEMOPHILIC AGENTS B R ALPHANATE B R HUMATE-P B R WILATE B NR FEIBA B R NOVOSEVEN B R ALPHANINE SD B R MONONINE B R BENEFIX B NR RIXUBIS B NR IXINITY B NR ALPROLIX B R BEBULIN B R PROFILNINE SD B NR COAGADEX ANTINEOPLASTICS - ALKYLATING AGENTS B R BUSULFEX B R MYLERAN G R cisplatin ANTINEOPLASTICS - ANDROGEN BIOSYNTHESIS INHIBITOR. B 80 NR ZYTIGA ANTINEOPLASTICS - ANTIADRENALS B R LYSODREN ANTINEOPLASTICS - ANTIANDROGENS G R bicalutamide B 50 NR CASODEX B 63 NR XTANDI G NR flutamide B R NILANDRON ANTINEOPLASTICS - ANTIBIOTICS G R bleomycin sulfate G R doxorubicin hcl B R DOXIL ANTINEOPLASTICS - ANTIESTROGENS B NR SOLTAMOX G R tamoxifen citrate B R FARESTON ANTINEOPLASTICS - ANTIMETABOLITES B R VIDAZA G 11 N capecitabine B 11 P XELODA G NR cytarabine B NR DEPOCYT G R fluorouracil G P gemcitabine hcl B N GEMZAR G P mercaptopurine G P methotrexate sodium RT45620 B, G, or O COM P , N, R, or NR Therapeutic Category B N TREXALL B R ARRANON R ALIMTA B R FOLOTYN B R TABLOID B R AVASTIN - Contd - B B 11 R ERBITUX B 11 R HERCEPTIN B 11 NR ODOMZO B 11 NR ERIVEDGE ANTINEOPLASTICS - AROMATASE INHIBITORS G R anastrozole B NR ARIMIDEX B N AROMASIN G P exemestane B N FEMARA P letrozole G 70 ANTINEOPLASTICS - CARDIAC PROTECTIVE AGENTS G R dexrazoxane B R ZINECARD ANTINEOPLASTICS - COMBINATIONS G B 11 R ifosfamide & mesna NR LONSURF ANTINEOPLASTICS - ESTROGEN RECEPTOR ANTAGONIST B R FASLODEX ANTINEOPLASTICS - ESTROGENS B R EMCYT ANTINEOPLASTICS - FOLIC ACID ANTAGONISTS RESCUE AGENTS G R leucovorin calcium ANTINEOPLASTICS - IMIDAZOTETRAZINES B 11 R TEMODAR G 11 NR temozolomide ANTINEOPLASTICS - INTERLEUKINS B R PROLEUKIN ANTINEOPLASTICS - LHRH ANALOGS B B R 80 ZOLADEX R ELIGARD G NR leuprolide acetate B R LUPRON DEPOT B R TRELSTAR ANTINEOPLASTICS - MISC. B 11 NR POMALYST NR FARYDAK NR istodax B NR ICLUSIG B N HYDREA G P hydroxyurea B G 11 B, G, or O COM P, N, Therapeutic Category R, or NR RDL Categories ANTINEOPLASTICS - MISC. B R MATULANE B NR INTRON-A B NR SYLATRON B NR DROXIA R REVLIMID B 11 ANTINEOPLASTICS - MITOTIC INHIBITORS B R TAXOTERE G NR etoposide G NR paclitaxel B R ABRAXANE G R vincristine sulfate G R vinblastine sulfate B N NAVELBINE G P vinorelbine tartrate ANTINEOPLASTICS - NITROGEN MUSTARDS B R LEUKERAN G NR cyclophosphamide B R ALKERAN G NR melphalan hcl ANTINEOPLASTICS - NITROSOUREAS B R GLIADEL WAFER G P lomustine B N GLEOSTINE ANTINEOPLASTICS - PARP INHIBITORS B 11 NR LYNPARZA ANTINEOPLASTICS - PROGESTINS B B 50 G R DEPO-PROVERA NR MEGACE ORAL R megestrol acetate ANTINEOPLASTICS - PROTEIN-TYROSINE KINASE INHIBITORS B 11 R IBRANCE B 63 NR ZOLINZA B 11 NR TAFINLAR B 11 NR ZELBORAF B 11 R AFINITOR B 11 NR STIVARGA B 11 NR NEXAVAR B 11 R SUTENT B 11 NR COTELLIC B 11 NR MEKINIST B 11 NR GILOTRIF B 11 NR ALECENSA B 11 NR INLYTA B 11 B NR BOSULIF NR COMETRIQ B 11 NR ZYKADIA B 11 NR XALKORI B 11 NR SPRYCEL RT45620 B, G, or O COM P , N, R, or NR Therapeutic Category B 11 R TARCEVA B 11 NR IMBRUVICA 11 NR TYKERB NR LENVIMA - Contd - B B B 11 R TASIGNA B 11 NR TAGRISSO B 11 R VOTRIENT B 63 R CAPRELSA R VELCADE B B 11 NR NINLARO B 80 R JAKAFI B 11 NR ZYDELIG ANTINEOPLASTICS - RETINOIDS G 11 R tretinoin (chemotherapy) ANTINEOPLASTICS - TOPOISOMERASE I INHIBITORS B N CAMPTOSAR G P irinotecan hcl R HYCAMTIN B 11 ANTINEOPLASTICS - URINARY TRACT PROTECTIVE AGENTS G NR amifostine crystalline G NR mesna B R MESNEX ANTIRETROVIRALS B NR SELZENTRY B P TIVICAY B NR VITEKTA B P ISENTRESS CHW 100MG B P ISENTRESS B P ISENTRESS TABS B R PREZISTA B NR TYBOST B P EPZICOM B P TRUVADA B R ATRIPLA CHW 25MG ANTIRETROVIRALS - COMBINATIONS B P EVOTAZ B N PREZCOBIX B N COMBIVIR G P lamivudine-zidovudine B R KALETRA N TRIUMEQ G NR abacavir sulfate-lamivudine-zidovudine B R TRIZIVIR N COMPLERA P GENVOYA N STRIBILD B B 39 39 B B 39 ANTIRETROVIRALS - FUSION INHIBITORS B R FUZEON ANTIRETROVIRALS - PROTEASE INHIBITORS B R REYATAZ B, G, or O COM P, N, Therapeutic Category R, or NR B, G, or O RDL Categories ANTIRETROVIRALS - PROTEASE INHIBITORS B R LEXIVA B R CRIXIVAN B R VIRACEPT B R NORVIR CAP 100MG B R NORVIR SOL 80MG/ML B R NORVIR TABS B R INVIRASE B R APTIVUS ANTIRETROVIRALS - RTI-NON-NUCLEOSIDE ANALOGUES B R RESCRIPTOR B R SUSTIVA B NR INTELENCE G R nevirapine G NR nevirapine susp NR VIRAMUNE B R VIRAMUNE SUSP B R VIRAMUNE XR P EDURANT B B 50 80 ANTIRETROVIRALS - RTI-NUCLEOSIDE ANALOGUES-PURINES G NR abacavir sulfate B R ZIAGEN G R didanosine B R VIDEX ANTIRETROVIRALS - RTI-NUCLEOSIDE ANALOGUES-PYRIMIDINES B R EMTRIVA B R EPIVIR G NR lamivudine ANTIRETROVIRALS - RTI-NUCLEOSIDE ANALOGUES-THYMIDINES G R stavudine B 50 NR ZERIT B 50 NR RETROVIR R zidovudine G ANTIRETROVIRALS - RTI-NUCLEOTIDE ANALOGUES B RT45620 R VIREAD - Contd - COM P , N, R, or NR Therapeutic Category
