drug formulary - Health Alliance

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DRUG FORMULARY
EFFECTIVE JANUARY 1, 2015
LAST UPDATED JUNE 22, 2015
TABLE OF CONTENTS
INTRODUCTION .................................................................................................................................................2
HOW TO USE THIS LIST ...................................................................................................................................2
COVERAGE AND LIMITATIONS ....................................................................................................................3
PHARMACY SAVINGS PROGRAMS ..............................................................................................................4
CONTACT US .......................................................................................................................................................5
DRUG FORMULARY LIST ................................................................................................................................6
ANTI-INFECTIVE DRUGS .................................................................................................................................6
AUTOIMMUNE INFLAMMATORY DISORDERS ........................................................................................8
BLOOD MODIFYING DRUGS ...........................................................................................................................8
CANCER DRUGS .................................................................................................................................................9
CENTRAL NERVOUS SYSTEM ........................................................................................................................9
GASTROINTESTINAL DRUGS .......................................................................................................................11
GENITOURINARY DRUGS .............................................................................................................................13
HEART AND CIRCULATORY DRUGS .........................................................................................................14
HORMONES, DIABETES, TEST SUPPLIES, AND RELATED DRUGS ...................................................17
MISCELLANEOUS CATEGORIES (INCLUDES SUPPLIES AND DEVICES) ........................................20
MULTIPLE SCLEROSIS...................................................................................................................................20
NEUROMUSCULAR DRUGS ...........................................................................................................................20
PAIN-RELIEF DRUGS ......................................................................................................................................22
RESPIRATORY AGENTS .................................................................................................................................24
SUPPLEMENTS ..................................................................................................................................................25
TOPICAL DRUGS ..............................................................................................................................................25
MANAGED DOSE LIMITATIONS (MDL) .....................................................................................................30
PREAUTHORIZATION (PA) ...........................................................................................................................32
STEP-THERAPY (ST) ........................................................................................................................................34
WELLNESS MEDICATIONS ...........................................................................................................................37
INDEX ..................................................................................................................................................................39
1
ph-comform-0615-1
Covered brand-name drugs are listed in all
CAPITAL letters, followed by the generic name.
Example: VESICARE - solefenacin
INTRODUCTION
Covered generic drugs appear in lowercase bold
type, followed by their reference brand drug in
parentheses.
This is the 2014 Health Alliance Drug
Formulary. In order to assist members and providers
in choosing covered prescription drugs for
treatment, we encourage members to show this list
to their physicians and pharmacists. In addition, we
encourage prescribers to use this list when
considering treatment options. Final decisions
regarding treatment options are made between the
physician and patient.
The formulary is subject to change at any time.
Members can access the most up-to-date version of
this list by visiting the Pharmacy section of
HealthAlliance.org. In addition, members can login
to CatamaranRx.com to access specific drug
coverage and pricing information.
The formulary does not provide information
about an individual’s specific coverage. Please refer
to your plan documents for complete coverage
details.
Example: atenolol (Tenormin)
Generics
Like brand drugs, generic drugs go through an
approval process by the Food and Drug
Administration (FDA) and must meet similar
standards of effectiveness and chemical make-up as
branded drugs.
The main difference between the reference brand
drug and its generic equivalent is that the generic
often costs much less.
As a general rule, generic drugs have the lowest
member copayment. Typically, when a generic
enters the market the brand drug moves to Tier 3.
Members who choose the brand name after the
release of a generic version may pay the copayment
plus the difference in cost between the brand and
generic drug. Generic drugs can help members save
on out-of-pocket medication costs.
HOW TO USE THIS LIST
Generic Equivalent vs. Generic Alternative
Generic equivalents are medications that contain
the same active ingredient, with the same strength
and dosage form as the brand medication. Generic
equivalents are as safe and effective and produce
the same results as the brand counterpart.
Generic alternatives can produce the same
intended effect on the body as the comparable
brand. Generic alternatives are medications that
work like a particular brand drug and are used to
treat the same condition. However, the active
ingredient in a generic alternative is different from
the brand medication.
This drug list is organized in sections by drug
class or medical condition. Within each section are
subsections to help locate medications. Most drugs
listed, whether generic or brand, are formulary
drugs. There are a few nonformulary drugs listed
and designated as Tier 3.
To search within the PDF, choose the search
function, enter a drug name and click “search” or
“find.” You can also search using the index, which
lists drugs alphabetically.
The list is organized first by therapeutic class.
THERAPEUTIC CLASS
Talk to Your Doctor
If your doctor writes a prescription for a brand
drug that does not have a generic equivalent,
consider asking if an appropriate generic alternative
is available.
As a patient, you can tell your pharmacist you
are interested in generics. In most situations, your
pharmacist can substitute a generic equivalent for
its brand counterpart without a new prescription
from your doctor.
Then by sub-type (if applicable).
SUB-TYPE
And last by additional sub-type (if applicable).
ADDITIONAL SUB-TYPE
2
For more information on generics, visit
AskForGenerics.org.
Medical Exception (varies by plan design)
Medical exception is a process for reviewing
coverage for drugs not on our formulary. Members
may qualify for a medical exception if they meet
one of these:
A. Documented failure of all formulary drugs
within the same therapeutic class
B. Documented allergy to a formulary drug,
with no other formulary choices
C. Successfully maintained condition on a
specific drug where switching to an
alternative drug may cause a health risk:
o Antiarrhythmics
o Theophylline products
o Seizure medications
o Antipsychotics
o Antidepressants
Drugs to Treat Multiple Conditions
Doctors use some drugs to treat more than one
medical condition. Within this document, each drug
is listed according to its first FDA-approved use.
Please check the index if you do not find your
medication in the therapeutic class that corresponds
to your condition.
COVERAGE AND LIMITATIONS
Tier Information
A drug’s copayment tier indicates what you will
pay for the medication with each fill.
•
•
•
The majority of generics are Tier 1. These
are your least expensive prescription drugs.
Formulary brands listed in this document are
available at the lowest brand tier, unless
otherwise noted.
Specialty drugs may have a different
copayment. For a complete listing of
specialty drugs, please click on one of the
links below:
Physicians—Requesting a Medical
Exception
To request a Medical Exception for a
medication on behalf of a member, or to request
further information, please call the Health Alliance
Pharmacy department at 1-800-851-3379, option 4,
or fax the Preauthorization/Medical Exception form
to 217-255-4598. Please provide the following
information when requesting a Medical Exception:
Standard Specialty Drug List
•
State of Illinois Employee Specialty Drug
List
•
•
•
•
Depending on your plan, you may have a threetier or a six-tier copayment structure. Refer to your
description of coverage documents for details. Your
pharmacy benefit includes coverage for the majority
of prescription drugs, though some exclusions may
apply.
Patient name and Health Alliance
identification number
Physician name, address and phone number
Drug name and strength
Patient diagnosis
Chart documentation/documentation of
previous medical history pertaining to the
requested drug
Preventive Health Wellness Benefit
For a complete listing of drugs covered at zero
member cost-share, see our list of Wellness
Medications at the end of this formulary. For more
information about coverage of contraceptives,
please access the policy “Contraceptive Coverage
Under Preventive Health Services in Wellness
Benefit” by logging into MyHealthAlliance.org.
Medical procedures and devices covered at
zero cost-share can be found at the following link:
Utilization Management
Some drugs on this list require utilization
management (UM), i.e. preauthorization, managed
dose limitations and step-therapy. If UM applies to
a drug, it is indicated with one of the following
symbols in the column next to the drug name.
•
•
•
MDL- Managed Dose Limitations
PA- Preauthorization
ST- Step-Therapy
Be Healthy Brochure
3
Retail 90
General Exclusions
A. Over-the-counter (OTC) medications and
their equivalents are not covered, unless
otherwise specified within the Formulary.
Nicotine smoking-cessation products (e.g.,
transdermal nicotine, nicotine gum, nicotine
inhaler) coverage is based on specific
member benefits.
B. Any drugs used for cosmetic purposes are
not covered.
C. Experimental drugs, or any drug product
used in an experimental manner, are not
covered.
D. Replacement of lost or stolen medication is
not covered.
E. Non-self-administered injectable drugs,
unless otherwise noted, are not covered
through the pharmacy benefit. Refer to your
description of coverage materials for details.
F. Foreign drugs and drugs not approved by the
FDA are not covered.
The Retail 90 program allows members to
purchase a 90-day supply of maintenance
medication at a discounted copayment from
participating retail pharmacies. Because this is a
voluntary program designed to increase flexibility,
members who prefer may continue purchasing the
traditional 30-day supply from their pharmacy with
their regular copayment.
Value-Based Benefit
The value-based benefit is designed so that
member copayments are aligned with the value the
drug has for keeping members healthy.
Medications listed below are used to treat
common conditions like asthma, high cholesterol,
high blood pressure and diabetes and are available
to members at a lower cost than other similar
medications.
Value-Based Benefit
Drug Class
Diabetes
PHARMACY SAVINGS PROGRAMS
Health Alliance offers members several
programs to lower the drug costs and to help
members take their medications safely and
correctly.
Asthma
Hypertension
High
Cholesterol
Rxtra
Health Alliance members with prescription
coverage can save money based on where they have
their 30-day-supply of prescriptions filled.
The Rxtra program is simple.
•
•
Drug Name
All generics
Vials, pens and
cartridges for
Lilly insulin
All generics,
Ventolin HFA
All generics
All generics
Formulary
Status
Tier 1
$20 copayment
Tier 1
Tier 1
Tier 1
Blood Glucose Monitors FREE By Mail
Members with diabetes are eligible to receive a
FREE blood glucose meter if they choose one of the
preferred meters listed below and obtain the meter
by mail. If a member picks up a blood glucose
meter at their local pharmacy, the member’s Tier 2
copayment will apply when obtained with a
prescription. Free meters are limited to one meter
per member per year. The FreeStyle InsuLinx
System is limited to one meter every three years.
Preferred—At Preferred pharmacies,
members can get hundreds of common
prescriptions FREE.
Preferred Plus—At Preferred Plus
pharmacies, members have the same
benefits as the Preferred pharmacies
mentioned above. In addition, simvastatin,
pravastatin and Ventolin HFA are FREE.
For a list of participating pharmacies and
available drugs in the Rxtra program, visit the
pharmacy section of HealthAlliance.org.
4
Freestyle Lite and Freestyle InsuLinx
Not all benefit plans include each of the programs
listed above. Please refer to your description of
coverage documents for more detail or contact the
Pharmacy department at 1-800-851-3379, option 4.
FreeStyle Lite System
FreeStyle Freedom Lite System
FreeStyle InsuLinx System
To get an Abbott product, call
1-866-224-8892 and mention Health Alliance
Or visit www.myfreestyle.com/meterprogram
*InsuLinx systems are limited to one free product per
member every three years.
CONTACT US
Health Alliance Pharmacy Department
301 S. Vine St.
Urbana, IL 61801-3347
1-800-851-3379, option 4
HealthAlliance.org
5
DRUG FORMULARY LIST
UTILIZATION
MANAGEMENT
OTHER COVERAGE
NOTES
PA
Specialty
ANTI-INFECTIVE DRUGS
CEPHALOSPORINS
cefdinir (Omnicef)
cefpodoxime (Vantin)
cefprozil (Cefzil)
cefuroxime (Ceftin)
FLUOROQUINOLONES
ciprofloxacin (Cipro)
CIPRO SUSPENSION—ciprofloxacin suspension
levofloxacin (Levaquin)
FUNGAL INFECTIONS
fluconazole (Diflucan)
flucytosine (Ancoban)
griseofulvin microsize (Fulvicin, Grisfulvin)
GRIFULVIN V—griseofulvin
GRIS-PEG—griseofulvin
itraconazole (Sporanox)
ketoconazole tablets (Nizoral)
nystatin oral (Mycostatin)
terbinafine (Lamisil)
voriconazole (Vfend)
HEPATITIS
EPIVIR HBV—lamivudine
MACROLIDES
azithromycin (Zithromax)
clarithromycin (Biaxin)
clarithromycin ER (Biaxin XL)
E.E.S. GRANULES—erythromycin ethylsuccinate
OTHER ANTI-INFECTIVES
erythromycin/sulfisoxazole (Pediazole)
MEPRON{ XE "MEPRON” }—atovaquone suspension
metronidazole (Flagyl)
sulfamethoxazole/trimethoprim (Bactrim)
trimethoprim
vancomycin (Vancocin)
6
UTILIZATION
MANAGEMENT
OTHER COVERAGE
NOTES
PA
PA
PA
Specialty
Specialty
Specialty
PENICILLINS
amoxicillin/potassium clavulanate (Augmentin)
amoxicillin/potassium clavulanate ER (Augmentin XR)
amoxicillin (Amoxil)
dicloxacillin (Dicloxacillin)
penicillin v potassium (Veetids)
TETRACYCLINES
VIBRAMYCIN SYRUP—doxycycline syrup
minocycline (Minocin)
doxycycline hyclate (Vibramycin)
TUBERCULOSIS
ethambutol (Myambutol)
isoniazid (Laniazid, Nydrazid)
isoniazid/rifampin (Rifamate)
MYCOBUTIN—rifabutin
pyrazinamide
rifampin (Rifadin)
VIRAL INFECTIONS
HEPATITIS C
HARVONI—ledipasvir/sofosbuvir
SOVALDI—sofosbuvir
VIEKIRA PAK—ombitasvir/paritaprevir/ritonavir/dasabuvir
HERPES
acyclovir (Zovirax)
famciclovir (Famvir)
valacyclovir (Valtrex)
HIV/AIDS
APTIVUS—tipranavir
CRIXIVAN—indinavir
didanosine DR (Videc EC)
EMTRIVA—emtricitabine
EPZICOM—abacavir-lamivudine
INVIRASE—saquinavir
ISENTRESS—raltegravir
KALETRA—lopinavir-ritonavir
lamivudine (Epivir)
lamivudine/zidovudine (Combivir)
7
UTILIZATION
MANAGEMENT
OTHER COVERAGE
NOTES
PA
PA
PA
Specialty
Specialty
Specialty
NORVIR SOLUTION—ritonavir
stavudine (Zerit)
RESCRIPTOR—delavirdine
REYATAZ—atazanavir
SUSTIVA—efavirenz
VIDEX PEDIATRIC—didanosine solution
VIRAMUNE—nevirapine
VIRAMUNE XR—nevirapine
VIREAD—tenofovir
ZIAGEN—abacavir
zidovudine (Retrovir)
MALARIA
atovaquone/proguanil 250-100 mg (Malarone)
chloroquine phosphate (Aralen)
COARTEM—artemether-lumefantrine
hydroxychloroquine (Plaquenil)
mefloquine (Larium)
primaquine
AUTOIMMUNE INFLAMMATORY DISORDERS
CIMZIA—certolizumab
ENBREL—etanercept
HUMIRA—adalimumab
BLOOD MODIFYING DRUGS
anagrelide (Agrylin)
BRILINTA—ticagrelor
cilostazol (Pletal)
clopidogrel (Plavix)
COUMADIN—warfarin sodium
cyanocobalamin injection
dipyridamole (Persantine)
DROXIA—hydroxyurea
enoxaparin (Lovenox)
folic acid 1 mg tablets
fondaparinux (Arixtra)
FRAGMIN—dalteparin sodium, injection
LOVENOX—enoxaparin sodium, injection
pentoxifylline ER (Trental)
8
PROMACTA—eltrombopag
warfarin (Coumadin)
XARELTO—rivaroxaban
UTILIZATION
MANAGEMENT
OTHER COVERAGE
NOTES
PA
Specialty
CANCER DRUGS
ALKERAN—melphalan
anastrozole (Arimidex)
bicalutamide (Casodex)
CEENU—lomustine
EMCYT— estramustine
exemestane (Aromasin)
flutamide (Eulexin)
FARESTON—toremifene
HEXALEN— altretamine
hydroxyurea (Hydrea)
letrozole (Femara)
leucovorin calcium tablets (Folinic acid)
LEUKERAN— chlorambucil
LYSODREN—mitotane
megestrol (Megace)
mercaptopurine (Purinethol)
MESNEX—mesna
methotrexate (Trexall)
MYLERAN—busulfan
NILANDRON—nilutamide
TABLOID—thioguanine
tamoxifen (Nolvadex)
TREXALL—methotrexate
Wellness
CENTRAL NERVOUS SYSTEM
ANXIETY
amitriptyline (Elavil)
bupropion (Wellbutrin)
alprazolam (Xanax)
buspirone (Buspar)
diazepam (Valium)
hydroxyzine (Atarax, Vistaril)
lorazepam (Ativan)
9
UTILIZATION
MANAGEMENT
OTHER COVERAGE
NOTES
DEPRESSION
bupropion ext-release (Wellbutrin SR, Wellbutrin XL)
citalopram (Celexa)
clomipramine (Anafranil)
desipramine (Norpramin)
doxepin (Sinequan)
escitalopram (Lexapro)
fluoxetine (Prozac)
imipramine hcl (Tofranil)
mirtazapine (Remeron, Remeron SolTab)
nortriptyline (Pamelor)
paroxetine hcl (Paxil)
paroxetine hcl ER (Paxil CR)
PAXIL—paroxetine HCL, oral suspension
phenelzine (Nardil)
sertraline (Zoloft)
tranylcypromine (Parnate)
trazodone (Desyrel)
venlafaxine (Effexor)
venlafaxine ER capsules (Effexor XR)
MDL
MDL
HYPERACTIVITY/NARCOLEPSY
amphetamine/detroamphetamine (Adderall)
amphetamine/detroamphetamine ER (Adderall XR)
dextroamphetamine
dextroamphetamine ER (Dexedrine Spansule)
METHYLIN—methylphenidate HCL
methylphenidate tablets (Ritalin)
methylphenidate ER (Metadate CD, Ritalin LA, Ritalin SR)
NUVIGIL—armodafinil
MDL, PA
OTHER CENTRAL NERVOUS SYSTEM DRUGS
bupropion ER (Zyban)
CHANTIX—varenicline tartrate
disulfiram (Antabuse)
donepezil (Aricept, Aricept ODT)
EMSAM—selegiline
EXELON—rivastigmine
galantamine (Razadyne)
galantamine ER (Razadyne ER)
MDL
10
Tier 3
UTILIZATION
MANAGEMENT
naltrexone (ReVia)
NAMENDA—memantine
NAMENDA XR—memantine
NICOTROL INHALER—nicotine inhaler system
NICOTROL NS—nicotine, nasal spray
SARAFEM—fluoxetine
OTHER COVERAGE
NOTES
MDL
MDL
ST
PSYCHOTIC AND BIPOLAR DISORDER
chlorpromazine (Thorazine)
clozapine (Clozaril)
EQUETRO—carbamazepine
FAZACLO—clozapine
fluphenazine (Prolixin)
haloperidol (Haldol)
LATUDA—lurasidone
LITHOBID—lithium carbonate
lithium carbonate
lithium carbonate ER (Lithobid, Eskalith CR)
loxapine (Loxitane)
olanzapine (Zyprexa, Zyprexa Zydis)
perphenazine (Trilafon)
prochlorperazine (Compazine)
quetiapine (Seroquel)
risperidone (Risperdal, Risperdal-M tablets)
thiothixene (Navane)
trifluoperazine (Stelazine)
ziprasidone (Geodon)
ST
SLEEP AIDS
estazolam (Prosom)
eszopiclone (Lunesta)
phenobarbital
temazepam (Restoril)
zaleplon (Sonata)
zolpidem (Ambien)
zolpidem ER (Ambien CR)
GASTROINTESTINAL DRUGS
DIGESTIVE ENZYMES
CREON—pancrelipase
11
Tier 3
UTILIZATION
MANAGEMENT
ULTRESA—pancrelipase
VIOKACE—pancrelipase
ZENPEP—pancrelipase
OTHER COVERAGE
NOTES
Tier 3
Tier 3
NAUSEA AND VOMITING
ANZEMET—dolasetron desylate
EMEND—aprepitant
granisetron (Kytril)
meclizine (Antivert)
ondansetron (Zofran, Zofran ODT)
SANCUSO—granisetron
trimethobenzamide (Tigan)
MDL
MDL
OTHER GASTROINTESTINAL DRUGS
5-AMINOSALICYLIC ACID—mesalamine powder
AMITIZA—lubiprostone
APRISO—mesalamine
ASACOL—mesalamine
ASACOL HD—mesalamine
balsalazide (Colazal)
CANASA—mesalamine
DELZICOL—mesalamine
DIPENTUM—olsalazine sodium
diphenoxylate/atropine tablets (Lomotil)
lactulose (Enulose)
LINZESS—linaclotide
mesalamine (Rowasa)
metoclopramide (Reglan)
RELISTOR—methylnaltrexone bromide, injection
sulfasalazine (Azulfidine)
sulfasalazine DR (Azulfidine EN-Tabs)
ursodiol (Actigall, Urso 250, Urso Forte)
PA
ULCER/REFLUX
CARAFATE SUSPENSION—sucralfate
cimetidine (Tagamet)
dicyclomine (Bentyl)
famotidine (Pepcid)
glycopyrrolate (Robinul)
hyoscyamine (Anaspaz, Levsin/SL)
hyoscyamine ER (Levbid, Symax Duotab)
12
UTILIZATION
MANAGEMENT
lansoprazole DR (Prevacid)
methscopolamine (Pamine, Pamine Forte)
misoprostol (Cytotec)
Nexium 24HR OTC (esomeprazole)
omeprazole DR (Prilosec)
pantoprazole DR (Protonix)
ranitidine (Zantac)
sucralfate tablets (Carafate)
OTHER COVERAGE
NOTES
Tier 1
GENITOURINARY DRUGS
alfuzosin (Uroxatral)
AVODART—dutasteride
CARDURA XL—doxazosin mesylate
finasteride (Proscar)
JALYN—dutasteride-tamsulosin
tamsulosin (Flomax)
OTHER GENITOURINARY DRUGS
ORACIT—sodium citrate and citric acid
potassium citrate ER (Urocit-K)
potassium citrate/citric acid (Polycitra-K)
sodium citrate/citric acid (Shohls)
UROCIT-K 15—potassium citrate
URINARY TRACT INFECTIONS
MACRODANTIN—nitrofurantoin macrocrystalline
nitrofurantoin (Furadantin)
nitrofurantoin macrocrystalline (Macrodantin)
nitrofurantoin monohydrate/macrocrystalline (Macrobid)
URINARY TRACT SPASMS
VESICARE— solifenacin succinate
MYRBETRIQ—mirabegron
oxybutynin (Ditropan)
oxybutynin ER (Ditropan XL)
VAGINAL PRODUCTS
CLEOCIN—clindamycin phosphate
clindamycin vaginal cream (Cleocin)
ENDOMETRIN—progesterone
ESTRACE—estradiol
ESTRING—estradiol
13
UTILIZATION
MANAGEMENT
OTHER COVERAGE
NOTES
metronidazole (MetroGel-Vaginal)
terconazole (Terazol)
HEART AND CIRCULATORY DRUGS
ANGIOTENSIN CONVERTING ENZYME (ACE) INHIBITORS AND COMBINATIONS
benazepril (Lotensin)
benazepril/hydrochlorothiazide (Lotensin HCT)
captopril (Capoten)
captopril/hydrochlorothiazide (Capozide)
enalapril (Vasotec)
enalapril/hydrochlorothiazide (Vaseretic)
fosinopril (Monopril)
fosinopril/hydrochlorothiazide (Monopril HCT)
lisinopril (Prinivil)
lisinopril/hydrochlorothiazide (Prinizide)
moexipril (Univasc)
moexipril/hydrochlorothiazide (Uniretic)
perindopril (Aceon)
quinapril (Accupril)
quinapril/hydrochlorothiazide (Accuretic)
ramipril (Altace)
trandolapril (Mavik)
ANGIOTENSIN II RECEPTOR ANTAGONISTS (ARBS) AND COMBINATIONS
amlodipine-valsartan (Exforge)
AZOR—amlodipine-olmesartan
BENICAR—olmesartan
BENICAR HCT—olmesartan-hydrochlorothiazide
candesartan (Atacand)
eprosartan (Teveten)
irbesartan (Avapro)
irbesartan/hydrochlorothiazide (Avalide)
losartan (Cozaar)
losartan/hydrochlorothiazide (Hyzaar)
telmisartan (Micardis)
TRIBENZOR—olmesartan-amlodipine-hydrochlorothiazide
valsartan (Diovan)
valsartan/hydrochlorothiazide (Diovan HCT)
BETA BLOCKERS AND COMBINATION AGENTS
acebutolol (Sectral)
14
UTILIZATION
MANAGEMENT
atenolol (Tenormin)
atenolol/chlorthalidone (Tenoretic)
bisoprolol (Zebeta)
bisoprolol/hydrochlorothiazide (Ziac)
carvedilol (Coreg)
labetalol (Trandate)
metoprolol succinate ER (Toprol XL)
metoprolol tartrate (Lopressor)
nadolol (Corgard)
propranolol ER (Inderal LA)
propranolol tablets (Inderal)
CALCIUM CHANNEL BLOCKERS AND COMBINATIONS
amlodipine (Norvasc)
amlodipine/benazepril (Lotrel)
diltiazem ER (Cardizem CD, Cardizem LA, Dilacor XR, Tiazac)
diltiazem (Cardizem)
felodipine ER (Plendil)
nifedipine ER (Adalat CC, Procardia XL)
verapamil (Calan)
verapamil ER (Calan SR, Isoptin SR, Verelan, Verelan PM)
CHEST PAIN
DILATRATE SR—isosorbide dinitrate CR
isosorbide dinitrate (Isordil)
isosorbide mononitrate (Monoket)
isosorbide mononitrate ER (Imdur)
NITRO-BID—nitroglycerin
NITRO-DUR—nitroglycerin patch
nitroglycerin (Nitro-Dur)
NITROMIST—nitroglycerin lingual
NITROSTAT—nitroglycerin SL
CHOLESTEROL LOWERING
atorvastatin (Lipitor)
cholestyramine (Questran, Questran Light)
colestipol (Colestid)
CRESTOR—rosuvastatin
fenofibrate, micronized (Lofibra)
gemfibrozil (Lopid)
lovastatin (Mevacor)
ST
15
OTHER COVERAGE
NOTES
UTILIZATION
MANAGEMENT
niacin CR (Niaspan)
omega 3 (Lovaza)
pravastatin (Pravachol)
simvastatin (Zocor)
WELCHOL—olesevelam
OTHER COVERAGE
NOTES
PA
ERECTILE DYSFUNCTION
CAVERJECT—alprostadil for injection
CIALIS—tadalafil
EDEX—alprostadil for injection kit
MUSE—alprostadil urethral pellet
ST
FLUID RETENTION
acetazolamide (Diamox)
acetazolamide ER (Diamox Sequels)
amiloride (Midamor)
amiloride/hydrochlorothiazide (Moduretic)
bumetanide (Bumex)
chlorthalidone (Thalitone)
furosemide (Lasix)
hydrochlorothiazide (Microzide, Hydrodiuril)
indapamide (Lozol)
methazolamide (Neprazane)
metolazone (Zaroxolyn)
spironolactone (Aldactone)
spironolactone/hydrochlorothiazide (Aldactazide)
torsemide (Demadex)
HEART RHYTHM
amiodarone (Cordarone, Pacerone)
clonidine (Catapres, Catapres-TTS)
disopyramide (Norpace)
flecainide (Tambocor)
MULTAQ—dronedarone
NORPACE CR—disopyramide
propafenone (Rythmol)
propafenone ER (Rythmol SR)
quinidine gluconate ER (Quinaglute)
quinidine sulfate (Quinidex)
sotalol (Betapace, Betapace AF)
16
Tier 3
UTILIZATION
MANAGEMENT
OTHER COVERAGE
NOTES
OTHER RELATED DRUGS
digoxin (Lanoxin)
doxazosin (Cardura)
eplerenone (Inspra)
guanfacine (Tenex)
hydralazine (Apresolutionine)
methyldopa (Aldomet)
minoxidil (Loniten)
prazosin (Minipress)
terazosin (Hytrin)
RENIN INHIBITORS AND COMBINATIONS
AMTURNIDE—aliskiren-amlodipine-hydrochlorothiazide
TEKAMLO—aliskiren-amlodipine
TEKTURNA—aliskiren
TEKTURNA HCT—aliskiren-hydrochlorothiazide
HORMONES, DIABETES, TEST SUPPLIES, AND RELATED DRUGS
BIRTH CONTROL
levonorgestrel (Plan B)
norelgestromin-ethinyl estradiol (Ortho Evra)
NUVARING—etonogestrel-ethinyl estradiol
oral contraceptives - all generics
Wellness
Wellness
Wellness
Wellness
CORTICOSTEROIDS
dexamethasone
DEXAMETHASONE INTENSOL—dexamethasone
fludrocortisones (Florinef)
hydrocortisone (Cortef)
methylprednisolone (Medrol)
MILLIPRED— prednisolone
PREDNISONE INTENSOL—prednisone
prednisolone (Prelone)
prednisolone sodium phosphate (Orapred, Pediapred)
prednisone tablets
DIABETES
acarbose (Precose)
BYDUREON—exenatide
BYETTA—exenatide
ST
ST
17
Tier 3
Tier 3
DUETACT—pioglitazone-glimepiride
FARXIGA—dapagliflozin
glimepiride (Amaryl)
glipizide (Glucotrol)
glipizide ER (Glucotrol XL)
GLUCAGEN—glucagon
GLUCAGON EMERGENCY KIT—glucagon
glyburide (Micronase)
glyburide micronized (Glynase)
glyburide/metformin (Glucovance)
INVOKANA—canagliflozin
JANUMET—sitagliptin-metformin
JANUMET XR—sitagliptin-metformin
JANUVIA—sitagliptin
JARDIANCE—empagliflozin
JENTADUETO—linagliptin-metformin
KAZANO—alogliptin-metformin
KOMBIGLYZE XR— saxagliptin-metformin ER
metformin (Glucophage)
metformin ER (Glucophage XR)
nateglinide (Starlix)
NESINA—alogliptin
ONGLYZA—saxagliptin
OSENI—alogliptin-pioglitazone
pioglitazone (Actos)
pioglitazone-metformin (Actoplus met)
pioglitazone-metformin SR (Actoplus met XR)
TRADJENTA—linagliptin
VICTOZA—liraglutide
UTILIZATION
MANAGEMENT
OTHER COVERAGE
NOTES
ST, MDL
Tier 3
ST, MDL
ST, MDL
ST, MDL
ST, MDL
ST
ST, MDL
ST, MDL
ST, MDL
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
ST, MDL
ST, MDL
ST, MDL
ST
ST
ST
ST
ST
Tier 3
Tier 3
Tier 3
DIABETES-INSULINS
BASAL INSULIN
LANTUS—insulin glargine
LANTUS SOLOSTAR—insulin glargine
RAPID ACTING INSULIN
HUMALOG—insulin lispro
SHORT ACTING INSULIN
HUMULIN—insulin human nph, reg
MDL
MDL
MDL
MDL
DIABETES—TESTING SUPPLIES
FREESTYLE LITE BLOOD GLUCOSE MONITORING SYSTEM
(Free by mail)
FREESTYLE FREEDOM LITE BLOOD GLUCOSE SYSTEM
18
MDL
MDL
Tier 3
Tier 3
Tier 3
UTILIZATION
MANAGEMENT
(Free by mail)
FREESTYLE LITE TEST STRIPS
FREESTYLE INSULINX BLOOD GLUCOSE SYSTEM (Free by
mail)
FREESTYLE INSULINX TEST STRIPS
PRECISION XTRA BLOOD GLUCOSE SYSTEM (Free by mail)
OTHER COVERAGE
NOTES
MDL
MDL
MDL
MDL
ESTROGENS*
ALORA—estradiol
estradiol (Climara, Estrace)
estradiol patch (Vivelle Dot)
estradiol/norethindrone acetate (Activella)
estropiopate (Ogen, Ortho-Est)
FEMHRT LOW DOSE—norethindrone acetate-ethinyl estradiol
MENEST—esterified estrogens
MENOSTAR—estradiol
norethindrone acetate/ethinyl estradiol
INFERTILITY
clomiphene (Clomid)
FOLLISTIM AQ—follitropin
PA
PA
Specialty
ANDROGENS†
ANDROGEL—testosterone gel
danazol (Danocrine)
oxandrolone (Oxandrin)
testosterone cypionate (Depo-Testosterone)
testosterone enanthate (Delatestryl)
PA
OTHER HORMONES
alendronate tablets (Fosamax)
cabergoline (Dostinex)
calcitonin-salmon (Miacalcin)
calcitriol (Rocaltrol)
desmopressin (DDVAP)
etidronate (Didronal)
ibandronate oral (Boniva)
OMNITROPE—somatropin
propylthiouracil
raloxifene (Evista)
STIMATE—desmopressin
*
†
Specialty
Wellness
Prior Authorization is required for males.
Prior Authorization is required for females.
19
SYNAREL—nafarelin
zoledronic acid (Reclast)
UTILIZATION
MANAGEMENT
OTHER COVERAGE
NOTES
PA
Specialty
PROGESTINS
medroxyprogesterone acetate (Provera)
norethindrone acetate (Aygestin)
progesterone micronized (Prometrium)
THYROID REGULATION
ARMOUR THYROID—thyroid
levothyroxine (Synthroid, Levoxyl)
liothyronine (Cytomel)
methimazole (Tapazole)
SYNTHROID—levothyroxine
THYROLAR—liotrix (T3-T4)
MISCELLANEOUS CATEGORIES (INCLUDES SUPPLIES AND DEVICES)
MISCELLANEOUS DRUGS
azathioprine (Imuran)
cyclosporine (Sandimmune)
cyclosporine modified capsules
mycophenolate mofetil (Cellcept)
NEORAL—cyclosporine modified
PROGRAF—tacrolimus
RAPAMUNE—sirolimust
SANDIMMUNE—cyclosporine
sodium polystyrene sulfonate
tacrolimus (Prograf)
MULTIPLE SCLEROSIS
BETASERON—interferon beta-1b
COPAXONE—glaitamer
REBIF—interferon beta-1a
PA
PA
PA
NEUROMUSCULAR DRUGS
MUSCLE RELAXANTS
baclofen (Lioresal)
chlorzoxazone (Parafon)
cyclobenzaprine (Flexeril, Fexmid)
dantrolene (Dantrium)
20
Specialty
Specialty
Specialty
UTILIZATION
MANAGEMENT
metaxalone (Skelaxin)
methocarbamol (Robaxin)
orphenadrine citrate ER (Norflex)
orphenadrine/aspirin/caffeine (Norgesic)
tizanidine (Zanaflex)
OTHER NEUROMUSCULAR DRUGS
MESTINON—pyridostigmine bromide
MESTINON TIMESPAN—pyridostigmine bromide
POTABA— potassium aminobenzoate
POTASSIUM P-AMINOBENZOATE—potassium aminobenzoate
powder
pyridostigmine (Mestinon)
PARKINSON'S DISEASE
amantadine (Symmetrel)
benztropine (Cogentin)
bromocriptine (Parlodel)
carbidopa/levodopa (Parcopa, Sinemet)
carbidopa/levodopa ER (Sinemet CR)
pramipexole (Mirapex)
ropinirole (Requip)
ropinirole ER (Requip XL)
selegiline (Eldepryl)
trihexyphenidyl (Artane)
SEIZURES
BANZEL— rufinamide
carbamazepine (Tegretol)
carbamazepine ER (Carbatrol, Tegretol-XR)
CARBATROL—carbamazepine
clonazepam (Klonopin)
DEPAKENE—valproic acid
DEPAKOTE—divalproex sodium
DEPAKOTE SPRINKLES—divalproex sodium
DILANTIN—phenytoin sodium extended
divalproex DR (Depakote Sprinkles, Depakote)
divalproex ER (Depakote ER)
ethosuximide (Zarontin)
FELBATOL— felbamate
gabapentin (Neurontin)
GABITRIL—tiagabine HCL
21
OTHER COVERAGE
NOTES
UTILIZATION
MANAGEMENT
OTHER COVERAGE
NOTES
KLONOPIN—clonazepam
LAMICTAL—lamotrigine
LAMICTAL XR—lamotrigine
lamotrigine (Lamictal)
levetiracetam (Keppra)
MYSOLINE—primidone
NEURONTIN—gabapentin
oxcarbazepine (Trileptal)
phenytoin sodium ER (Dilantin, Phenytek)
phenytoin suspenion (Dilantin)
primidone (Mysolutionine)
TEGRETOL—carbamazepine
TEGRETOL-XR—carbamazepine
topiramate (Topamax Sprinkle, Topamax)
TOPAMAX—topiramate
valproic acide (Depakene)
ZARONTIN—ethosuximide
ZONEGRAN—zonisamide
zonisamide (Zonegran)
PAIN-RELIEF DRUGS
GOUT
allopurinol (Zyloprim)
COLCRYS— colchicine
probenecid (Benemid)
ULORIC--febuxostat
Tier 3
MIGRAINE HEADACHES
acetaminophen/isometheptene/dichloralphenazone (Midrin)
naratriptan (Amerge)
MIGRANAL—dihydroergotamine mesylate
rizatriptan (Maxalt)
sumatriptan injection, tablets (Imitrex)
zolmitriptan (Zomig)
MDL
MDL
MDL
MDL
MDL
NARCOTIC DRUGS
acetaminophen/codeine (Tylenol w/Codeine)
buprenorphine (Subutex)
butalbital/aspirin/caffeine/codeine (Fiorinal w/Codeine)
DILAUDID-5—hydromorphone HCL
fentanyl oral lozenge (Actiq)
22
PA
UTILIZATION
MANAGEMENT
fentanyl patch (Duragesic)
hydrocodone/acetaminophen (Vicodin, Lorcet, Lortab, Norco)
hydrocodone/ibuprofen (Ibudone, Reprexain, Vicoprofen)
hydromorphone tablets (Dilaudid)
methadone solution
methadone tablets (Dolophine)
morphine sulfate ER (MS Contin)
oxycodone (Roxicodone)
oxycodone/acetaminophen (Percocet, Tylox)
oxycodone/aspirin (Percodan)
tramadol (Ultram)
tramadol/acetaminophen (Ultracet)
NON-NARCOTIC DRUGS
butalbital/acetaminophen (Sedapap)
butalbital/acetaminophen/caffeine (Esgic, Esgic Plus, Fioricet)
butalbital/aspirin/caffeine (Fiorinal)
PHRENILIN FORTE—butalbital-acetaminophen
salsalate (Disalcid)
RHEUMATOID AND OSTEOARTHRITIS
diclofenac potassium (Cataflam)
diclofenac sodium DR (Voltaren)
diclofenac sodium ER (Voltaren-XR)
etodolac (Lodine)
ibuprofen (Motrin)
indomethacin (Indocin)
ketoprofen (Oruvail)
leflunomide (Arava)
meloxicam (Mobic)
NALFON—fenoprofen
naproxen (Naprosyn)
naproxen DR (EC-Naprosyn)
naproxen sodium (Anaprox)
oxaprozin (Daypro)
piroxicam (Feldene)
RIDAURA—auranofin
sulindac (Clinoril)
23
MDL
MDL
OTHER COVERAGE
NOTES
UTILIZATION
MANAGEMENT
OTHER COVERAGE
NOTES
RESPIRATORY AGENTS
ASTHMA/COPD
AEROSPAN—flunisolide
albuterol 0.63 mg/3 mL, 1.25 mg/3 ml (Accuneb)
albuterol inhaler solution, 0.0835, 0.5% (Ventolin)
albuterol syrup, tablets (Ventolin)
ASMANEX—mometasone furoate
ATROVENT HFA—ipratropium bromide HFA
budesonide ER (Pulmicort Respules)
COMBIVENT RESPIMAT—ipratropium-albuterol
cromolym sodium inhal solution (Intal)
DULERA—mometasone-formoterol
ELIXOPHYLLIN—theophylline
FORADIL AEROLIZER—formoterol fumarate
ipratropium inhalersolution (Atrovent, Aerovent)
ipratropium/albuterol (Duoneb)
MAXAIR AUTOHALER—pirbuterol acetate
montelukast sodium (Singulair)
PULMICORT—budesonide
QVAR—beclomethasone dipropionate
SEREVENT DISKUS—salmeterol xinafoate
SPIRIVA—tiotropium bromide
SPIRIVA HANDIHALER—tiotropium
STRIVERDI RESPIMAT—oladaterol
SYMBICORT—budesonide-formoterol
terbutaline (Brethine)
THEO-24—theophylline
theophylline ER (Theo-Dur)
TUDORZA —aclidinium bromide
VENTOLIN HFA—albuterol HFA
zafirlukast (Accolate)
BEE STING KITS
AUVI-Q—epinephrine
EPINEPHRINE
EPIPEN—epinephrine
EPIPEN-JR 2-PAK—epinephrine
IMMUNOTHERAPY AGENTS
GRASTEK—timothy grass pollen allergen extract
24
MDL
Tier 1
UTILIZATION
MANAGEMENT
OTHER COVERAGE
NOTES
RAGWITEK—short ragweed pollen allergen extract
NASAL ANTI-INFLAMMATORY STEROIDS
fluticasone (Flonase)
QNASL—beclomethasone dipropionate
triamcinolone (Nasacort AQ)
Tier 3
SUPPLEMENTS
VITAMINS
ergocalciferol (Drisdol)
GALZIN—zinc acetate
MEPHYTON—phytonadione
NASCOBAL—cyanocobalamin
MINERALS AND ELECTROLYTES
potassium bicarbonate/chloride effervescent tablets
potassium chloride
potassium chloride ER
potassium phosphate/sodium phosphates (K-Phos Neutral)
sodium fluoride
MULTIVITAMINS
prenatal vitamin/folic acid - all generics
TOPICAL DRUGS
ANORECTAL AGENTS
ANALPRAM E—HC-pramoxine
CORTIFOAM—hydrocortisone acetate rectal foam
hydrocortisone acetate rectal cream, suppository
(Anusolution-HC, Proctocort)
hydrocortisone enema (Cortenema)
EAR
acetic acid ear solution
benzocaine/antipyrine ear solution
hydrocortisone/acetic acid ear solution
neomycin/polymyxin B/hydrocortisone ear solution,
suspension (Cortisporin)
ofloxacin ear solution (Floxin otic)
EYE
ANTI-INFECTIVE
bacitracin/polymyxin B eye ointment
25
UTILIZATION
MANAGEMENT
ciprofloxacin eye solution (Ciloxan)
erythromycin eye ointment
gentamicin eye ointment, solution (Garamycin)
neomycin/polymyxin B/gramicidin eye solution (Neosporin)
neomycin/polymyxin/bacitracin eye ointment
ofloxacin eye solution (Ocuflox)
polymyxin B/trimethoprim eye solution (Polytrim)
sulfacetamide sodium eye solution (Bleph-10)
tobramycin eye solution (Tobrex)
trifluridine eye solution (Viroptic)
TOBREX—tobramycin sulfate, ophthalmic ointment 0.3%
ZYMAXID—gatifloxacin
GLAUCOMA
ALPHAGAN P—brimonidine tartrate
BETOPTIC-S—betaxolol HCL, ophthalmic suspension 0.25%
brimonidine eye solution, 0.15% (Alphagan P)
brimonidine eye solution, 0.2%
carteolol eye solution (Ocupress)
dorzolamide eye solution (Trusopt)
dorzolamide/timolol maleate eye solution (Cosopt)
lantanoprost eye solution (Xalatan)
levobunolol eye solution, 0.5% (Betagan)
LUMIGAN—bimatoprost
metipranolol eye solution (Optipranolol)
pilocarpine eye solution, 1%, 2%, 4% (Isopto Carpine)
timolol maleate eye solution (Timoptic, Timoptic XE)
SIMBRINZA—brinzolamide/brimonidine tartrate, ophthalmic
suspension 1%/0.2%
TIMOPTIC OCUDOSE—timolol maleate, ophthalmic solution
0.25%
TRAVATAN Z—travopost
OTHER EYE PRODUCTS
ALOMIDE—lodoxamide tromethamine
atropine sulfate eye ointment, solution (Isopto Atropine)
azelastine eye solution (Optivar)
cromolyn sodium eye solution (Opticrom)
CYCLOGYL—cyclopentolate HCL
CYCLOMYDRIL—cyclopentolate wtih phenylephrine
cyclopentolate eye solution (Cyclogyl)
diclofenac eye solution (Voltaren)
flurbiprofen eye solution (Ocufen)
26
OTHER COVERAGE
NOTES
Tier 3
Tier 3
UTILIZATION
MANAGEMENT
homatropine eye solution (Isopto Homatropine)
ILEVRO—nepafenac
ISOPTO CARBACHOL—carbachol
ISOPTO HOMATROPINE—homatropine
ketorolac eye solution (Acular, Acular LS)
LASTACAFT—alcaftadine
PATADAY—olopatadine HCL
PHOSPHOLINE IODIDE—echothiophate iodide
PILOPINE HS—pilocarpine HCL
RESTASIS—cyclosporine
tropicamide eye solution (Mydriacyl)
STEROIDS AND COMBINATION PRODUCTS
BLEPHAMIDE S.O.P. —sulfacetamide sodium-prednisolone
dexamethasone sodium phosphate eye solution
FLAREX—fluorometholone acetate
FML FORTE—fluorometholone
fluorometholone eye suspension, 0.1% (FML Liquifilm)
neomycin/polymyxin B/bacitracin/hydrocortisone eye
ointment
neomycin/polymyxin B/dexamethasone eye ointment,
suspenion (Maxitrol)
PRED MILD—prednisolone acetate
PRED-G—gentamicin-prednisolone
PRED-G S.O.P.—gentamicin-prednisolone
prednisolone acetate eye suspenion (Pred Forte)
sulfacetamide sodium/prednisolone eye solution
TOBRADEX—tobramycin-dexamethasone
TOBRADEX ST—tobramycin-dexamethasone
tobramycin/dexamethasone eye suspenion (Tobradex)
VEXOL—rimexolone, ophthalmic suspension 1%
MOUTH AND THROAT—LOCAL
chlorhexidine oral rinse (Peridex)
clotrimazole troche (Mycelex Troche)
lidocaine viscous
nystatin suspension
pilocarpine (Salagen)
sodium fluoride (Prevident)
triamcinolone dental paste (Kenalog in Orabase)
27
OTHER COVERAGE
NOTES
Tier 3
Tier 3
Tier 3
UTILIZATION
MANAGEMENT
SKIN CONDITIONS/PRODUCTS
ACNE
adapalene (Differin)
clindamycin (Cleocin-T)
erythromycin gel, pads, solution
metronidazole (Metrocream, Metrolotion)
metronidazole topical gel (Metrogel)
sulfacetamide sodium/sulfur cloth, cream, emulsion, lotion
tretinoin (Retin-A)
ANTI-INFECTIVES
ciclopirox gel, shampoo (Loprox)
ciclopirox solution (Penlac)
econazole (Spectazole)
ketoconazole (Nizoral)
mupirocin ointment (Bactroban)
nystatatin topical
silver sulfadiazine (Silvadene)
CORTICOSTEROIDS
alclometasone (Aclovate)
amcinonide cream (Cyclocort)
betamethasone dipropionate (Diprosone)
betamethasone dipropionate, augmented (Diprolene)
betamethasone valerate cream, lotion
clobetasol (Olux, Temovate)
desonide (Desowen)
desoximetasone cream, 0.25%; gel; ointment 0.25% (Topicort)
diflorasone ointment
fluocinolone acetonide oil (Derma-Smoothe/FS)
fluocinonide
fluticasone propionate (Cutivate)
halobetasol (Ultravate)
hydrcortisone valerate (Westcort)
hydrocortisone topical
mometasone (Elocon)
triamcinolone cream; lotion; ointment, 0.025%, 0.1%
OTHER SKIN PRODUCTS
8-MOP—methoxsalen, capsule 10 mg
aluminum chloride (Drysol)
calcipotriene solution (Dovonex)
fluorouracil (Efudex)
imiquimod (Aldara)
28
PA
OTHER COVERAGE
NOTES
UTILIZATION
MANAGEMENT
lidocaine topical (Xylocaine)
lindane
OXSORALEN ULTRA—methoxsalen
permethrin
podofilox (Condylox)
selenium sulfide (Selsun)
SORIATANE—acitretin, capsule 10 mg
VOLTAREN GEL—diclofenac
OTHER COVERAGE
NOTES
MDL
Tier 3
29
DRUGS with Managed
Dose Limitations (MDL)
The table below contains the list of drugs with managed dose limitations. Certain products are
subject to managed drug limitations based on FDA-approved dosage recommendations and the
drug manufacturer’s package size. The pupose of these limitations is to encourage safe and costeffective use of drug therapies. MDL quantities may vary depending on plan design.
Drug Class
Acne
Asthma
BEHAVIORAL
HEALTH:
ADHD
BEHAVIORAL
HEALTH:
Depression
Drug Name
isotretinoin oral (Claravis™ and
Amnesteem®)
Arcapta Neohaler™
Asmanex®
Flovent® HFA
QVAR™
Ventolin® HFA
Quillivant XRTM
citalopram
duloxetine®, 30mg or 60mg
duloxetine®, 20mg
sertraline
1
DERMATOLOGY
Aczone® (dapsone)
Elidel® (pimecrolimus)
Finacea® (azelaic acid)
Protopic® (tacrolimus)
Tazorac® (tazarotene)
tretinoin
ENDOCRINE:
blood glucose test strips
Diabetes
insulin vials
insulin pens
FarxigaTM, Invokana®, Janumet® XR,
Januvia®, JuvisyncTM, KobmiglyzeTM
XR, Nesina, Oseni, Tradjenta®
Janumet®, Jentadueto®, Kazano,
OnglyzaTM
Bydureon®, Byetta®, Victoza®
Endocrine:
Caverject®/Edex®/Muse®
Impotency
Cialis®
Levitra®
StaxynTM
StendraTM
Viagra®
GASTROINTESTINAL: Akynzeo®
Emesis
Emend®
Sancuso®
INFECTIOUS
SivextroTM
DISEASE:
Antibacterial
30
30 caps
1 inhaler
24gm (2 inhalers)
2 inhalers
3 inhalers
180ml
90-Day Supply
(Mail Order)*
*maximum of 6
months of treatment
90 caps
3 inhalers
72gm (6 inhalers)
6 inhalers
9 inhalers
N/A
30 tablets
30 capsules
60 capsules
60 tablets
smallest package size
90 tablets
90 capsules
180 capsules
180 tablets
N/A
150 test strips
60ml (6 vials)
4 boxes
30 tablets
450 test strips
180ml (18 vials)
12 boxes
90 tablets
60 tablets
180 tablets
1 box
6 units
4 tablets2
4 tablets2
4 tablets2
4 tablets2
4 tablets2
3 capsules3
6 tablets
1 patch
6 tablets
3 boxes
18 units
12 tablets2
12 tablets2
12 tablets2
12 tablets2
12 tablets2
9 capsules3
18 tablets
3 patches
N/A
30-Day Supply
N/A
continued on next page
90-Day Supply
(Mail Order)*
N/A
N/A
Drug Class
Infectious
Disease:
Hepatitis C
INFECTIOUS
DISEASE:
Influenza
Drug Name
Incivek®
Victrelis®
30-Day Supply
180 tablets
360 tablets
Relenza®
N/A
LOWER GI
DISORDERS: Irritable
Bowel Syndrome
NEUROLOGY:
Migraine
Amitiza®
LinzessTM
1 rx/6 months, max
quant 20 doses
1 rx/6 months, max
quant 10 caps
60 capsules
30 capsules
Axert®
Amerge® (naratriptan)
Frova®
Imitrex®/Sumavel® (sumatriptan) injectable
Imitrex® (sumatriptan) - nasal
9 tablets
9 tablets
9 tablets
2 kits
(4 injections)
6 nasal spray devices
Imitrex® (sumatriptan) - tablets
Maxalt®, Maxalt-MLT® (rizatriptan)
Migranal®
Relpax®
Treximet®
Zomig® (zolmitriptan)
Nuvigil®
Provigil®
Avinza®
Butrans®
Embeda®
Exalgo®
fentanyl patch
Kadian®
Nucynta® ER
Nucynta®
Oxycontin®
Toradol® (ketorolac)
tramadol ER
Sprix® (ketorolac) nasal spray
ZohydroTM ER
nicotine replacement therapy4
Zyban® (bupropion)4
9 tablets
12 tablets
8 units
9 tablets
9 tablets
9 tablets
30 tablets
30 tablets
60 tablets
60 tablets
60 tablets
60 tablets
15 patches
60 tablets
60 tablets
120 tablets
60 tablets
20 tablets
60 tablets
5 nasal spray units
60 capsules
30 units
60 tablets
27 tablets
27 tablets
27 tablets
6 kits
(12 injections)
18 nasal spray
devices
27 tablets
36 tablets
24 units
27 tablets
27 tablets
27 tablets
90 tablets
90 tablets
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
180 tabs/0 refill
NEUROLOGY:
Narcolepsy
PAIN
MANAGEMENT
Smoking
Cessation
Tamiflu®
N/A
180 capsules
90 capsules
Please Note: This applies to most Health Alliance plans. If you have questions, please
contact the Pharmacy Department at 1-800-851-3379, option 4.
This is a partial list of products. Any antibacterial, antifungal, antiviral, steroid or acne product that is available in multiple package sizes is restricted to coverage of only the smallest package size.
1
Quantity may vary depending on plan setup
Iowa State = 6/12
Horizon = 6/12
Federal = 6/12
2
3 capsules per 28 days, 9 capsules per 84 days
3
3 months per year for most plans
9 months per lifetime for most plans
4
ph-MDLdrugs-0415
31
DRUGS Requiring
Preauthorization
The table below outlines the medications requiring a review by the Clinical Pharmacist, and
if necessary, a Health Alliance Medical Director. If a provider wished for coverage of a drug
designated as preauthorization required (PA), they must provide documentation to meet criteria
for that particular medication. Provider must request prior authorization from Health Alliance for
drugs on the following list:
Drug Class
Drug Name
Comments
BEHAVIORAL
HEALTH:
ADHD
Quillivant XR™ (methylphenidate
suspension)
Preauthorization required for age 13
years and older
BEHAVIORAL
HEALTH:
Antidepressants
Brintellix® (vortioxetine)
Fetzima™ (levomilnacipran ER)
Pristiq® (desvenlafaxine)
Viibryd® (vilazodone)
See Behavioral Health policy;
two SSRIs and venlafaxine, or
venlafaxine SR and duloxetine
BEHAVIORAL
HEALTH:
Narcolepsy
Nuvigil® (armodafinil)
Provigil® (modafinil)
See Provigil and Nuvigil policy, only
medically necessary FDA label diagnosis
covered
CARDIOVASCULAR:
Lipotropics
Vytorin® (simvastatin/ezetimibe)
Zetia® (ezetimibe)
See Zetia and Vytorin policy;
LDL goal not met with maximum
tolerated statin OR intolerance/
contraindication to statins
Lovaza® (omega-3-acid ethyl esters)
Vascepa® (icosapent ethyl)
See Fish Oil (Lovaza and Vascepa) policy
CARDIOVASCULAR:
Statins
Advicor® (lovastatin/niacin)
Altoprev® (lovastatin ER)
Caduet® (atorvastatin/amlodipine)
Crestor® (rosuvastatin)
Lescol® XL (fluvastatin)
Livalo® (pitavastatin)
See Brand Name Statin policy
DERMATOLOGY
tretinoin
Documentation of a non-cosmetic
diagnosis (acne, actinic keratosis, etc.)
Aczone® (dapsone)
Finacea® (azelaic acid)
Picato® (ingenol mebutate)
Tazorac® (tazarotene)
Documentation of a non-cosmetic
diagnosis (acne, actinic keratosis, etc.);
trial of two Tier 1 agents
DIABETES:
DPP4 Inhibitors
Juvisync® (sitagliptin-simvastatin)
See Diabetes Drug Therapy policy;
Type 2 DM; metformin or a sulfonylurea;
HBA1c greater than 6.5% and less than
9%; trial of Tradjenta required on new
starts and existing members not at goal
on non-preferred DPP4
DIABETES, MISC.
Becaplermin® (Regranex)
Diagnosis of diabetic ulcers with failure
on conventional (dressings, soaks,
debridement, etc.)
ENDOCRINE:
Estrogen Replacement
Therapy
All estrogen and estrogen-containing
medications
Use in males requires prior
authorization; see Hormone
Replacement Therapy in Gender
Reassignment policy
32
Drug Class
Drug Name
Comments
Endocrine:
Testosterone
Replacement Therapy
All testosterone and testosteronecontaining medications
Use in females requires prior
authorization; see Hormone
Replacement Therapy in Gender
Reassignment policy
Endocrine:
Testosterone
Replacement
Androderm® (testosterone transdermal)
Androgel® (testosterone gel)
Axiron® (testosterone topical)
Fortesta® (testosterone gel)
Striant® (testosterone buccal)
testosterone injection
Testim® (testosterone gel)
See Testosterone (Implantable, Topical,
Oral, Intra-muscular) policy
INFECTIOUS
DISEASE:
Antibacterial, Misc
Xifaxan® (rifaximin)
See Xifaxan policy
INFLAMMATORY
DISEASE:
NSAIDs
Celebrex® (celecoxib)
See Celebrex policy, age greater than 65
exempt. Trial of three NSAID classes or a
qualifying risk factor (see policy)
LOWER GI
DISORDERS:
Irritable Bowel
Syndrome
Lotronex® (alosetron)
LOWER GI
DISORDERS:
Narcotic antagonists
Movantik™ (naloxegol)
See Movantik policy for opioid induced
constipation
Relistor® (methylnaltrexone)
See Relistor policy for opioid induced
constipation
LOWER GI
DISORDERS:
other
Fulyzaq™ (crofelemer)
See Fulyzaq policy
NASAL AGENTS
Dymista™ (azelastine/fluticasone)
See Dymista policy
NEUROLOGICAL
DISEASE: GABA
analogs
Gratise (gabapentin ER)
Horizant® (gabapentin ER)
Lyrica® (pregabalin)
See Gabapentin Coverage Requirement
policy; FDA label diagnosis specific to
product, and trial of Gabapentin
NEUROLOGICAL
DISEASE: Botulinum
toxins
Botox® (onabotulinumtoxinA)
Myobloc® (rimabotulinumtoxinB)
Xeomin® (incoboluminumtoxinA)
Medical benefit see Botulinum Toxins
policy
NEUROLOGICAL
DISEASE:
Fibromyalgia agents
Savella® (milnacipran)
Trial of TCA, muscle relaxant,
gabapentin, duloxetine, and nonpharmacologic therapy
PAIN
MANAGEMENT:
Analgesics, Narcotics
Abstral® (fentanyl sublingual tablet)
Actiq® (fentanyl citrate)
Fentora® (fentanyl citrate)
Onsolis® (fentalyl buccal film)
Subsys® (fentanyl sublingual spray)
See Fentanyl® Oral Dosage Formulation
policy; limited to cancer diagnosis and
inability to swallow and concurrent long
acting agent requiring breakthrough
agent
®
UPPER GI
Aciphex® (rabeprazole);
DISORDERS:
Dexilant® (dexlansoprazole);
Anti-ulcer preparations Nexium® (esomeprazole) (prescription
only);
Zegerid® (omeprazole/sod bicarb)
See PPI policy; trial of three generic
PPIs and Nexium® 24HR OTC (at least
14 days in duration) in addition to
qualifying diagnosis
Note: This is an incomplete list. Products with one year or less from the date of
product launch are excluded from coverage.
Please Note: This applies to most Health Alliance plans. If you have questions,
please contact the Pharmacy Department at 1-800-851-3379, option 4.
33
ph-preauthdrugs-0415
DRUGS Requiring
Step-Therapy
Step-Therapy (ST)
If a drug is covered as a “step-therapy” medication, one or more “prerequisite” medications must
be tried first before the step-therapy medication will be covered under the pharmacy benefit.
Prerequisite medications and their corresponding step-therapy medications are used to treat the
same conditions. If it is medically necessary, a step-therapy medication can be obtained without
trying a prerequisite medication first. In this case, the member’s physician must request coverage for
a step-therapy medication as a medical exception.
Drug Class
Step-Therapy (ST)
Medication
Prerequisite Medication
Asthma
Combination Inhaler
Advair (fluticasone/ salmeterol)
New start prescriptions require
Dulera® and Symbicort®
ASTHMA
Inhaled Corticosteroid
Flovent® (fluticasone)
New start prescriptions require
Aerospan™, Asmanex®, Pulmicort®,
AND QVar®
Behavioral health
Anti-anxiety
Niravam® (alprazolam)
alprazolam
BEHAVIORAL HEALTH
Atypical antipsychotic
Symbyax®
(olanzapine and fluoxetine)
olanzapine and fluoxetine
Abilify® (aripiprazole)
Invega® (paliperidone)
Seroquel® XR (quetiapine)
Fanapt® (iloperidone)
Latuda® (lurasidone)
Saphris® (asenapine)
risperidone, olanzapine, quetiapine
or ziprasidone
Behavioral health
Antidepressants NDRI
Aplenzin® (bupropion)
bupropion
Behavioral health
Antidepressants SARI
Oleptro™ (trazodone)
trazodone
BEHAVIORAL HEALTH
Opioid dependence
Suboxone® Film (buprenorphine
and naloxone)
generic buprenorphine/naloxone
tablets
CENTRAL NERVOUS SYSTEM
Anticonvulsant
Aptiom® (eslicarbazepine acetate)
oxcarbazepine
Qudexy™ XR (topiramate ER)
Trokendi™ XR (topiramate ER)
topiramate
CARDIOVASCULAR
Platelet Aggregation Inhibitor
Zontivity™ (vorapaxar)
clopidogrel
COPD (Chronic Obstructive
Pulmonary Disease)
Advair® (fluticasone/ salmeterol)
Symbicort®
Anoro™ Ellipta™
(umeclidinium/ vilanterol)
Tudorza®, Serevent® or Spiriva ®
Breo® Ellipta™ (fluticasone/
vilanterol)
Symbicort®
Daliresp® (roflumilast)
ICS (inhaled corticosteroid) or ICS
combo, Asmanex®, QVar®, Aerobid®,
Aerobid-M®, Alvesco®, Azmacort®,
Pulmicort®, Symbicort® or Dulera®
®
34
Drug Class
Dermatology
Topical anti-infective
Step-Therapy (ST)
Medication
Denavir (penciclovir)
acyclovir
Mirvaso (brimonidine)
metronidazole cream, lotion, or gel
®
®
All brand name topical anti-fungal Tier 1 generic topical antifungal
DERMATOLOGY
Local anesthetic
Lidoderm® (lidocaine)
gabapentin
DERMATOLOGY
Topical anti-inflammatory
Flector® patch (diclofenac)
Pennsaid® (diclofenac)
Voltaren® gel
Diabetes
TZDs (Thiazolidinedione)
Actos® (pioglitazone)
Actoplus Met®
Actoplus Met® XR
Duetact®
Avandia® (rosiglitazone)
Avandaryl®
Avandamet®
metformin or a sulfonylurea
(glimepiride, chlorpropamide,
glipizide, glyburide, tolbutamide,
tolazamide)
Diabetes
DPP4 (Dipeptidyl/Peptidase IV)
Jentadueto® (linagliptin/
metformin)
Kazano™ (alogliptin/ metformin)
Nesina™ (alogliptin)
Oseni™ (alogliptin/ pioglitazone)
Tradjenta® (linagliptin)
Diabetes
DPP4 (Dipeptidyl/Peptidase IV)
Janumet® (sitagliptin/ metformin) metformin or a sulfonylurea AND
Januvia® (sitagliptin)
Tradjenta, Jentadueto, Nesina, Oseni,
Kombiglyze™ (saxagliptin/
or Kazano
metformin)
Kombiglyze™ XR (saxagliptinmetformin ER)
Onglyza® (saxagliptin)
Diabetes
GLP-1 (Glucagon-like peptide-1)
Bydureon® (exenatide)
Byetta® (exenatide)
Victoza® (liraglutide)
Diabetes
SGLT-2 (Sodium glucose cotransporter 2 inhibitor)
Farxiga™ (dapagliflozin)
Invokana® (canagliflozin)
Jardiance® (empagliflozin)
Endocrine
Bone
Actonel® (risedronate)
Atelvia® (risedronate)
Binosto™ (alendronate)
alendronate or ibandronate
ENDOCRINE
Other
Osphena™ (ospemifene)
Tier 1 or Tier 2 estrogen
HEMATOLOGICAL DISORDER
Anti-Platelet
Brilinta® (ticagrelor)
Effient® (prasugrel)
New start prescriptions are restricted
to cardiologists
Plavix® (clopidogrel)
clopidogrel
Hematological disorder
Thrombin Inhibitors
Eliquis® (apixaban)
Pradaxa® (dabigatran)
Savaysa™ (edoxaban)
warfarin and Xarelto®
Hyperparathyroid agent
Zemplar® (paricalcitol)
calcitriol or Vitamin D
Infectious Disease
Antibiotic
Dificid (fidaxomicin)
metronidazole or vancomycin
Infectious Disease
Antiviral
Tybost® (cobicistat)
Requires concurrent treatment with
Reyataz® or Prezista®
Inflammatory disease
Vimovo™ (esomeprazole/
naproxen)
naproxen and Nexium®
®
35
Drug Class
Step-Therapy (ST)
Medication
PAIN MANAGEMENT
Long Acting Opioid
Avinza (morphine ER)
Butrans® (buprenorphine)
Embeda® (morphine/ naltrexone)
Exalgo® (hydromorphone ER)
Kadian® (morphine ER)
Nucynta® ER (tapentadol ER)
Opana® ER (oxymorphone ER)
Oxycontin® (oxycodone)
Zohydro™ ER (hydrocodone ER)
morphine sulfate ER or fentanyl
PAIN MANAGEMENT
Short Acting Opioid
Nucynta® (tapentadol)
Tier 1 opioid
Ryzolt® (tramadol)
tramadol ER
tramadol IR
Sedative-Hypnotics
ZolpiMist™ (zolpidem)
Silenor® (doxepin)
zolpidem/zolpidem ER and
zaleplon
Skeletal muscle disorder
Fexmid® (cyclobenzaprine)
®
Urinary tract
Cialis® (tadalafil) once daily
BPH (Benign Prostatic Hypertrophy)
ph-stdruglistMEMB-0415
36
cyclobenzaprine
tamsulosin, alfuzosin, Rapaflo®,
finasteride, Avodart® or Jalyn®
(dutasteride/tamsulosin)
WELLNESS MEDICATIONS
Health Alliance emphasizes prevention through comprehensive
wellness coverage, which includes these preventive health
medications.
All listed medications are covered at a $0 copay.
FAMILY PLANNING
BIRTH CONTROL
ALTAVERA
ALYACEN 1/35
ALYACEN 7/7/7
AMETHIA
AMETHIA LO
APRI
ARANELLE
AUBRA
AVIANE
AZURETTE
BALZIVA
BRIELLYN
CAMILA
CAMRESE
CAMRESE LO
CAZIANT
CESIA
CHATEAL
CRYSELLE-28
CYCLAFEM 1/35
CYCLAFEM 7/7/7
DASETTA 1/35
DASETTA 7/7/7
DAYSEE
DESOGESTREL/ETHINYL
ESTRADIOL
DROSPIRENONE/ETHINYL
ESTRADIOL
ELINEST
ELLA
EMOQUETTE
ENPRESSE-28
ENSKYCE
ERRIN
ESTARYLLA
FALMINA
GIANVI
GILDAGIA
GILDESS 1.5/30
GILDESS 1/20
GILDESS FE 1.5/30
GILDESS FE 1/20
HEATHER
INTROVALE
JENCYCLA
JOLESSA
JOLIVETTE
JUNEL 1.5/30
JUNEL 1/20
JUNEL FE 1.5/30
JUNEL FE 1/20
KARIVA
KELNOR 1/35
KURVELO
LARIN 1/20
LARIN FE 1.5/30
LARIN FE 1/20
LEENA
LESSINA
LESSINA-28
LEVONEST
LEVONORGESTREL (PLAN B)
LEVONORGESTREL/ETHINYL
ESTRADIOL
LEVORA 0.15/30-28
LORYNA
LOW-OGESTREL
LUTERA
LYZA
MARLISSA
MEDROXYPROGESTERONE
(DEPO-PROVERA)
MICROGESTIN 1.5/30
MICROGESTIN 1/20
MICROGESTIN FE
MICROGESTIN FE 1.5/30
MONO-LINYAH
MONONESSA
MYZILRA
NECON 0.5/35-28
NECON 1/35
NECON 7/7/7
NORA-BE
37
NORETHINDRONE
NORGESTIMATE/ETHINYL
ESTRADIOL
NORELGESTROMIN/ETHINYL
ESTRADIOL PATCH
NORGESTREL/ETHINYL
ESTRADIOL
NORTREL 0.5/35 (28)
NORTREL 1/35
NORTREL 1/35 (28)
NORTREL 7/7/7
NUVARING
OCELLA
ORSYTHIA
PHILITH
PIMTREA
PIRMELLA 1/35
PIRMELLA 7/7/7
PORTIA-28
PREVIFEM
QUASENSE
RECLIPSEN
SOLIA
SPRINTEC 28
SRONYX
SYEDA
TILIA FE
TRI-ESTARYLLA
TRI-LEGEST FE
TRI-LINYAH
TRI-LO-SPRINTEC
TRINESSA
TRI-PREVIFEM
TRI-SPRINTEC
TRIVORA-28
VELIVET
VESTURA
VIORELE
VYFEMLA
WERA
WYMZYA FE
XULANE
ZARAH
ZENCHENT
ZENCHENT FE
ZEOSA
ZOVIA 1/35E
OVER-THE-COUNTER
Condoms - Female
Condoms - Male
Nonoxynol Spermicide
Octoxynol Spermicide
BOWEL PREP KITS*
PEG-3350/Electrolytes
PEG-3350/NaCl/Na Bicarbonate/KCl
BREAST CANCER RISK
REDUCTION
Raloxifene
Tamoxifen 10 MG
Tamoxifen 20 MG
SMOKING CESSATION
Bupropion Hydrochloride (Zyban®)
Chantix®
Nicotine Replacement Gum
Nicotine Replacement Lozenges
Nicotine Replacement Patches
Nicotrol® Inhaler
Nicotrol® Nasal Spray
*Covered for patients age 50 and over; limit 1 kit per year.
ph-wellnessmeds-0615
38
OVER-THE-COUNTER
ANALGESICS - NON NARCOTIC
Aspirin Tablet 81 MG
Aspirin Buffered (Ca Carb-Mg CarbMg Ox) Tablet 325 MG
Aspirin-Al Hydro-Mg Hydro-Ca Carb
Tablet 325-50-50-87 MG
Children’s Chewable Aspirin 81 MG
VITAMINS, MINERALS &
ELECTROLYTES
Dialyvite Vitamin D Capsule 5000
Units
Dialyvite Vitamin D3 Max Capsule
50,000 Units
Folic Acid Capsule 0.8 MG
Folic Acid Tablet 400 & 800 MCG
Vitamin D 400, 1000, 2000, 5000, &
10,000 Units
INDEX
ANDROGEL ................................................................................... 19
ANZEMET ...................................................................................... 12
APRISO .......................................................................................... 12
APTIVUS .......................................................................................... 7
ARMOUR THYROID ..................................................................... 20
ASACOL ......................................................................................... 12
ASACOL HD .................................................................................. 12
ASMANEX ...................................................................................... 24
atenolol (Tenormin) ....................................................................... 15
atenolol/chlorthalidone (Tenoretic) .............................................. 15
atorvastatin (Lipitor)....................................................................... 15
atovaquone/proguanil 250-100 mg (Malarone) .......................... 8
atropine sulfate eye ointment, solution (Isopto Atropine)......... 26
ATROVENT HFA........................................................................... 24
AUVI-Q ............................................................................................ 24
AVODART ...................................................................................... 13
azathioprine (Imuran) .................................................................... 20
azelastine eye solution (Optivar) ................................................. 26
azithromycin (Zithromax) ................................................................ 6
AZOR .............................................................................................. 14
5
5-AMINOSALICYLIC ACID..........................................................12
8
8-MOP .............................................................................................28
A
acarbose (Precose) .......................................................................17
acebutolol (Sectral) ........................................................................14
acetaminophen (Ultracet) ............................................................23
acetaminophen/codeine ................................................................22
acetaminophen/isometheptene/dichloralphenazone (Midrin) .22
acetazolamide (Diamox) ...............................................................16
acetazolamide ER (Diamox Sequels) .........................................16
acetic acid ear solution..................................................................25
acyclovir (Zovirax) ............................................................................7
AEROSPAN ...................................................................................24
ainocycline (Minocin) .......................................................................7
albuterol...........................................................................................24
albuterol inhaler solution ...............................................................24
albuterol syrup, tablets ..................................................................24
alclometasone (Aclovate) .............................................................28
alendronate tablets (Fosamax) ....................................................19
alfuzosin (Uroxatral) ......................................................................13
ALKERAN ........................................................................................9
allopurinol (Zyloprim) .....................................................................22
ALOMIDE........................................................................................26
ALORA ............................................................................................19
ALPHAGAN P ................................................................................26
alprazolam (Xanax)..........................................................................9
amantadine (Symmetrel)...............................................................21
amiloride (Midamor).......................................................................16
amiloride/hydrochlorothiazide (Moduretic) ................................16
amiodarone (Cordarone, Pacerone) .........................................16
AMITIZA ..........................................................................................12
amitriptyline .......................................................................................9
amlodipine (Norvasc) ....................................................................15
amlodipine/benazepril (Lotrel) ......................................................15
amlodipine-valsartan (Exforge) ....................................................14
amoxicillin (Amoxil) ..........................................................................7
amoxicillin/potassium clavulanate (Augmentin) ...........................7
amoxicillin/potassium clavulanate ER (Augmentin XR)..............7
amphetamine/detroamphetamine (Adderall)..............................10
amphetamine/detroamphetamine ER (Adderall XR).................10
AMTURNIDE ..................................................................................17
anagrelide (Agrylin)..........................................................................8
ANALPRAM E ...............................................................................25
anastrozole (Arimidex) ....................................................................9
B
baclofen (Lioresal) ......................................................................... 20
balsalazide (Colazal) ..................................................................... 12
BANZEL ......................................................................................... 21
benazepril (Lotensin)..................................................................... 14
benazepril/hydrochlorothiazide (Lotensin HCT) ........................ 14
BENICAR ....................................................................................... 14
BENICAR HCT .............................................................................. 14
benztropine (Cogentin) ................................................................. 21
betamethasone dipropionate (Diprosone).................................. 28
betamethasone dipropionate, augmented (Diprolene) ............. 28
betamethasone valerate cream, lotion ....................................... 28
BETASERON ................................................................................. 20
BETOPTIC-S.................................................................................. 26
bicalutamide (Casodex) .................................................................. 9
bisoprolol (Zebeta)......................................................................... 15
bisoprolol/hydrochlorothiazide (Ziac) .......................................... 15
BLEPHAMIDE S.O.P. ................................................................... 27
BRILINTA ......................................................................................... 8
brimonidine eye solution, 0.2%.................................................... 26
bromocriptine (Parlodel) ............................................................... 21
budesonide ER (Pulmicort Respules) ......................................... 24
bumetanide (Bumex) ..................................................................... 16
buprenorphine (Subutex) .............................................................. 22
bupropion (Wellbutrin) ................................................................... 9
bupropion ER (Zyban) .................................................................. 10
bupropion ext-release (Wellbutrin SR, Wellbutrin XL) .......... 10
buspar (Valium)................................................................................ 9
buspirone (Buspar) .......................................................................... 9
butalbital/acetaminophen.............................................................. 23
39
butalbital/acetaminophen/caffeine (Esgic, Esgic Plus,
Fioricet) .....................................................................................23
butalbital/aspirin/caffeine (Fiorinal) ..............................................23
butalbital/aspirin/caffeine/codeine ...............................................22
BYDUREON ...................................................................................17
BYETTA ..........................................................................................17
clonazepam (Klonopin) ................................................................. 21
clonidine (Catapres, Catapres-TTS) ........................................... 16
clopidogrel (Plavix) .......................................................................... 8
clozapine (Clozaril) ........................................................................ 11
COARTEM........................................................................................ 8
COLCRYS ...................................................................................... 22
colestipol (Colestid) ....................................................................... 15
COMBIVENT .................................................................................. 24
COPAXONE ................................................................................... 20
CORTIFOAM.................................................................................. 25
COUMADIN ...................................................................................... 8
CREON ........................................................................................... 11
CRESTOR ...................................................................................... 15
CRIXIVAN ......................................................................................... 7
cromolym sodium inhal solution (Intal) ....................................... 24
cyanocobalmin injection.................................................................. 8
cyclobenzaprine (Flexeril, Fexmid) ........................................... 20
CYCLOGYL.................................................................................... 26
CYCLOMYDRIL............................................................................. 26
cyclopentolate eye solution (Cyclogyl) ....................................... 26
cyclosporine (Sandimmune)......................................................... 20
cyclosporine modified capsules ................................................... 20
C
cabergoline (Dostinex) ..................................................................19
calcipotriene solution (Dovonex) ..................................................28
calcitonin-salmon (Miacalcin) .......................................................19
calcitriol (Rocaltrol) ........................................................................19
CANASA .........................................................................................12
candesartan (Atacand) ..................................................................14
captopril (Capoten) ........................................................................14
captopril/hydrochlorothiazide (Capozide) ...................................14
CARAFATE SUSPENSION .........................................................12
carbamazepine (Tegretol).............................................................21
carbamazepine ER (Carbatrol, Tegretol-XR) .............................21
CARBATROL .................................................................................21
carbidopa/levodopa (Parcopa, Sinemet) ....................................21
carbidopa/levodopa ER (Sinemet CR) ........................................21
CARDURA XL ................................................................................13
carteolol eye solution (Ocupress) ................................................26
carvedilol (Coreg)...........................................................................15
CAVERJECT ..................................................................................16
CEENU ..............................................................................................9
cefdinir (Omnicef).............................................................................6
cefpodoxime (Vantin) ......................................................................6
cefprozil (Cefzil) ...............................................................................6
cefuroxime (Ceftin) ..........................................................................6
CHANTIX ........................................................................................10
chlorhexidine oral rinse (Peridex) ................................................27
chloroquine phosphate (Aralen) ....................................................8
chlorpromazine (Thorazaine) .......................................................11
chlorthalidone 25 mg, 50 mg (Thalitone) ....................................16
chlorzoxazone (Parafon) ..............................................................20
cholestyramine (Questran, Questran Light) ...............................15
CIALIS .............................................................................................16
ciclopirox gel, shampoo (Loprox) .................................................28
cilostazol (Pletal) ..............................................................................8
cimetidine (cimetidine)...................................................................12
CIMZIA ..............................................................................................8
CIPRO SUSPENSION ....................................................................6
ciprofloxacin (Cipro).........................................................................6
citalopram (Celexa)........................................................................10
clarithromycin (Biaxin) .....................................................................6
clarithromycin ER (Biaxin XL) ........................................................6
CLEOCIN ........................................................................................13
clindamycin vaginal cream (Cleocin)..........................................13
clobetasolution (Olux, Temovate) ................................................28
clomiphene (Clomid)......................................................................19
clomipramine (Anafranil) ...............................................................10
D
danazol (Danocrine) ...................................................................... 19
dantrolene (Dantrium) ................................................................... 20
DELZICOL ...................................................................................... 12
DEPAKENE.................................................................................... 21
DEPAKOTE.................................................................................... 21
DEPAKOTE SPRINKLES ............................................................ 21
desipramine (Norpramin) .............................................................. 10
desmopressin (DDVAP)................................................................ 19
desonide (Desowen) ..................................................................... 28
desoximetasone cream, 0.25%; gel; ointment 0.25% (Topicort)
.................................................................................................... 28
DEXAMETHASONE INTENSOL ................................................ 17
dextroamphetamine....................................................................... 10
dextroamphetamine ER (Dexedrine Spansule) ......................... 10
diclofenac eye solution (Voltaren) ............................................... 26
diclofenac potassium..................................................................... 23
diclofenac sodium DR (Voltaren)................................................ 23
diclofenac sodium ER ................................................................... 23
dicloxacillin (Dicloxacillin) ............................................................... 7
dicyclomine (Bentyl) ...................................................................... 12
didanosine DR (Videc EC) ............................................................. 7
diflorasone ointment ...................................................................... 28
digoxin (Lanoxin) ........................................................................... 17
DILANTIN ....................................................................................... 21
DILATRATE SR............................................................................. 15
DILAUDID-5 ................................................................................... 22
diltiazem ER ................................................................................... 15
diltizaem (Cardizem) ..................................................................... 15
DIPENTUM ..................................................................................... 12
40
ethosuximide (Zarontin) ................................................................ 21
etidronate (Didronal) ..................................................................... 19
etodolac (Lodine) .......................................................................... 23
EXELON ......................................................................................... 10
exemestane (Aromasin).................................................................. 9
diphenoxylate/atropine tablets (Lomotil) .....................................12
dipyridamole (Persantine) ...............................................................8
disopyramide (Norpace)................................................................16
disulfiram (Antabuse) ....................................................................10
divalproex DR (Depakote Sprinkles, Depakote) ........................21
divalproex ER (Depakote ER) ......................................................21
donepezil (Aricept, Aricept ODT) .................................................10
dorzolamide eye solution (Trusopt) .............................................26
dorzolamide/timolol maleate eye solution (Cosopt) ..................26
doxazosin (Cardura) ......................................................................17
doxepin (Sinequan) ......................................................................10
doxycycline hyclate (Vibramycin)...................................................7
DROXIA ............................................................................................8
DUETACT .......................................................................................18
DULERA .........................................................................................24
F
famciclovir (Famvir) ......................................................................... 7
famotidine (Pepcid) ....................................................................... 12
FARESTON ...................................................................................... 9
FARXIGA ........................................................................................ 18
FAZACLO ....................................................................................... 11
FELBATOL .................................................................................... 21
felodipine ER (Plendil) .................................................................. 15
FEMHRT LOW DOSE .................................................................. 19
fenofibrate, micronized (Liofibra) ................................................. 15
fentanyl oral lozenge (Actiq) ....................................................... 22
fentanyl patch (Duragesic) .......................................................... 23
finasteride (Proscar) ...................................................................... 13
FLAREX .......................................................................................... 27
flecainide (Tambocor) ................................................................... 16
fluconazole (Diflucan)...................................................................... 6
flucytosine (Ancoban)...................................................................... 6
fludrocortisones (Florinef) ............................................................. 17
fluocinonide .................................................................................... 28
fluorometholone eye suspenion, 0.1% (FML Liquifilm) ............ 27
FLUOROQUINOLONES ................................................................. 6
fluorouracil (Efudex) ...................................................................... 28
fluoxetine (Prozac)......................................................................... 10
fluphenazine hcl tablets (Prolixin)................................................ 11
flurbiprofen eye solution (Ocufen) ............................................... 26
flutamide (Eulexin) ........................................................................... 9
fluticasone (Flonase) ..................................................................... 25
fluticasone propionate (Cutivate)................................................. 28
FML FORTE ................................................................................... 27
folic acid 1 mg tablets...................................................................... 8
FOLLISTIM AQ .............................................................................. 19
fondaparinux (Arixtra)...................................................................... 8
FORADIL AEROLIZER ................................................................ 24
fosinopril (Monopril) ....................................................................... 14
FRAGMIN ......................................................................................... 8
FREESTYLE FREEDOM LITE BLOOD GLUCOSE SYSTEM 18
FREESTYLE INSULINX BLOOD GLUCOSE SYST ............... 19
FREESTYLE INSULINX TEST STRIPS..................................... 19
FREESTYLE LITE BLOOD GLUCOSE MONITORING
SYSTEM .................................................................................... 18
FREESTYLE LITE TEST STRIPS .............................................. 19
furosemide (Lasix) ......................................................................... 16
E
E.E.S. GRANULES .........................................................................6
econazole (Spectazole).................................................................28
EDEX ...............................................................................................16
ELIXOPHYLLIN .............................................................................24
EMCYT ..............................................................................................9
EMEND............................................................................................12
EMSAM ...........................................................................................10
EMTRIVA ..........................................................................................7
enalapril (Vasotec) .........................................................................14
enalapril/hydrochlorothiazide (Vaseretic) ...................................14
ENBREL ............................................................................................8
ENDOMETRIN ...............................................................................13
enoxaparin (Lovenox) ......................................................................8
EPINEPHRINE ...............................................................................24
EPIPEN ...........................................................................................24
EPIPEN-JR 2-PAK ........................................................................24
EPIVIR HBV .....................................................................................6
eplerenone (Inspra) .......................................................................17
eprosartan (Teveten) .....................................................................14
EPZICOM ..........................................................................................7
EQUETRO ......................................................................................11
ergocalciferol (Drisdol) ..................................................................25
erythromycin eye ointment ...........................................................26
erythromycin gel, pads, solution ..................................................28
erythromycin/sulfisoxazole (Pediazole) ........................................6
escitalopram (Lexapro) .................................................................10
estazolam (Prosom) ......................................................................11
ESTRACE .......................................................................................13
estradiol (Climara, Estrace) ..........................................................19
estradiol patch (Vivelle Dot)..........................................................19
estradiol/norethindrone acetate (Activella) ...............................19
ESTRING ........................................................................................13
estropiopate (Ogen, Ortho-Est)....................................................19
eszopiclone (Lunesta) ...................................................................11
ethambutol (Myambutol) .................................................................7
G
gabapentin (Neurontin) ................................................................. 21
GABITRIL ....................................................................................... 21
41
imipramine hcl (Tofranil) ............................................................... 10
imiquimod (Aldara) ........................................................................ 28
indapamide (Lozol) ........................................................................ 16
INVIRASE ......................................................................................... 7
INVOKANA .................................................................................... 18
ipratropium inhale rsolution (Atrovent, Aerovent)...................... 24
ipratropium/albuterol (Duoneb) .................................................... 24
irbesartan (Avapro)........................................................................ 14
irbesartan/hydrochlorothiazide (Avalide) .................................... 14
ISENTRESS ..................................................................................... 7
isoniazid (Laniazid, Nydrazid) ........................................................ 7
isoniazid/rifampin (Rifamate) ......................................................... 7
ISOPTO CARBACHOL ................................................................ 27
ISOPTO HOMATROPINE ............................................................ 27
isosorbide dinitrate (Isordil) .......................................................... 15
isosorbide mononitrate (Monoket) ............................................... 15
isosorbide mononitrate ER (Imdur) ............................................. 15
itraconazole (Sporanox).................................................................. 6
galantamine (Razadyne) ...............................................................10
galantamine ER (Razadyne ER) ..................................................10
GALZIN ...........................................................................................25
gemfibrozil (Lopid) ........................................................................15
gentamicin eye ointment, solution (Garamycin) ........................26
glimepiride (Amaryl) .......................................................................18
glipizde (Glucotrol) .........................................................................18
glipizde ER (Glucotrol XL) ............................................................18
GLUCAGEN ...................................................................................18
GLUCAGON EMERGENCY KIT .................................................18
glyburide (Micronase) ....................................................................18
glyburide micronized (Glynase) ...................................................18
glyburide/metformin (Glucovance)...............................................18
granisetron (Kytril)..........................................................................12
GRASTEK ......................................................................................24
GRIFULVIN V ...................................................................................6
griseofulvin microsize (Fulvicin, Grisfulvin) ..................................6
GRIS-PEG ........................................................................................6
guanfacine (Tenex) ........................................................................17
J
H
JALYN............................................................................................. 13
JANUMET ...................................................................................... 18
JANUMET XR ................................................................................ 18
JANUVIA ........................................................................................ 18
JARDIANCE .................................................................................. 18
JENTADUETO ............................................................................... 18
halobetasolution (Ultravate)..........................................................28
haloperidol (Haldol)........................................................................11
HARVONI..........................................................................................7
HEXALEN .........................................................................................9
hlycopyrrolate (Robinul) ................................................................12
homatropine eye solution (Isopto Homatropine) .......................27
HUMALOG .....................................................................................18
HUMIRA ............................................................................................8
HUMULIN........................................................................................18
hydralazine (Apresolutionine).......................................................17
hydrcortisone valerate (Westcort)................................................28
hydrochlorothiazide (Microzide, Hydrodiuril) ..........................16
hydrocodone/acetaminophen (Vicodin, Lorcet, Lortab,
Norco) ........................................................................................23
hydrocodone/ibuprofen (Ibudone, Reprexain, Vicoprofen) ..23
hydrocortisone (Cortef).................................................................17
hydrocortisone acetate ..................................................................25
hydrocortisone enema (Cortenema) ...........................................25
hydrocortisone topical ...................................................................28
hydrocortisone/acetic acid ear solution.......................................25
hydromorphone tablets .................................................................23
hydroxychloroquine..........................................................................8
hydroxyurea (Hydrea)......................................................................9
hydroxyzine (Atarax, Vistaril)..........................................................9
hyoscyamine (Anaspaz, Levsin/SL) ............................................12
hyoscyamine ER (Levbid, Symax Duotab) ..............................12
K
KALETRA......................................................................................... 7
KAZANO......................................................................................... 18
ketoconazole (Nizoral) .................................................................. 28
ketoconazole tablets (Nizoral) ....................................................... 6
ketoprofen (Oruvail) ..................................................................... 23
ketorolac eye solution (Acular, Acular LS) ................................. 27
KLONOPIN— ................................................................................. 22
KOMBIGLYZE XR......................................................................... 18
L
labetalol (Trandate) ....................................................................... 15
lactulose (Enulose) ....................................................................... 12
LAMICTAL ..................................................................................... 22
LAMICTAL XR ............................................................................... 22
lamivudine (Epivir) ........................................................................... 7
lamivudine/zidovudine (Combivir) ................................................ 7
lamotrigine (Lamictal) .................................................................... 22
lansoprazole DR (Prevacid) ........................................................ 13
lantanoprost eye solution (Xalatan) ............................................ 26
LANTUS ......................................................................................... 18
LANTUS SOLOSTAR .................................................................. 18
LASTACAFT —alcaftadine ........................................................ 27
LATUDA—lurasidone ................................................................. 11
I
ibandronate oral (Boniva) .............................................................19
ibuprofen (Motrin)..........................................................................23
ILEVRO ...........................................................................................27
42
methotrexate (Trexall) ..................................................................... 9
methscopolamine (Pamine, Pamine Forte)................................ 13
methyldopa (Aldomet) ................................................................... 17
METHYLIN ..................................................................................... 10
methylphenidate ER (Metadate CD, Ritalin LA, Ritalin SR) .... 10
methylphenidate tablets (Ritalin) ................................................. 10
methylprednisolone (Medrol)....................................................... 17
metipranolol eye solution (Optipranolol) ..................................... 26
metoclopramide (Reglan) ............................................................. 12
metolazone (Zaroxolyn) ................................................................ 16
metoprolol succinate ER............................................................... 15
metoprolol tartrate (Lopressor) .................................................... 15
metronidazole (Flagyl) .................................................................... 6
metronidazole (Metrocream, Metrolotion) .................................. 28
metronidazole (MetroGel-Vaginal) ............................................ 14
metronidazole topical gel (Metrogel) ........................................... 28
MIGRANAL .................................................................................... 22
MILLIPRED .................................................................................... 17
minoxidil (Loniten) ......................................................................... 17
mirtazapine (Remeron, Remeron SolTab) ................................. 10
misoprostol (Cytotec) .................................................................... 13
moexipril (Univasc) ........................................................................ 14
moexipril/hydrochlorothiazide (Uniretic) ..................................... 14
mometasone................................................................................... 28
montelukast sodium ...................................................................... 24
MOP ................................................................................................ 28
morphine sulfate ER (MS Contin) .............................................. 23
MULTAQ......................................................................................... 16
mupirocin ointment (Bactroban) .................................................. 28
MUSE .............................................................................................. 16
MYCOBUTIN.................................................................................... 7
mycophenolate mofetil (Cellcept) ................................................ 20
MYLERAN ........................................................................................ 9
MYRBETRIQ .................................................................................. 13
MYSOLINE ..................................................................................... 22
leflunomide (Arava) .......................................................................23
letrozole (Femara)............................................................................9
leucovorin calcium tablets...............................................................9
LEUKERAN ......................................................................................9
levetiracetam (Keppra) ..................................................................22
levobunolol eye solution, 0.5% (Betagan) ..................................26
levofloxacin (Levaquin) ...................................................................6
levonorgestrel (Plan B)..................................................................17
levothyroxine (Synthroid, Levoxyl) ...........................................20
lidocaine topical (Xylocaine) .........................................................29
lidocaine viscous ............................................................................27
lindane .............................................................................................29
LINZESS .........................................................................................12
liothyronine (Cytomel) ...................................................................20
lisinopril............................................................................................14
lisinopril/hydrochlorothiazide (Prinizide) .....................................14
lithium carbonate ............................................................................11
lithium carbonate ER (Lithobid, Eskalith CR) .............................11
LITHOBID .......................................................................................11
lorazepam (Ativan)...........................................................................9
losartan (Cozaar) ...........................................................................14
losartan/hydrochlorothiazide (Hyzaar) ........................................14
lovastatin (Mevacor) ......................................................................15
LOVENOX ........................................................................................8
loxapine (Loxitane) ........................................................................11
LUMIGAN .......................................................................................26
LYSODREN ......................................................................................9
M
MACRODANTIN ............................................................................13
MAXAIR AUTOHALER ................................................................24
meclizine (Antivert) .......................................................................12
medroxyprogesterone acetate (Provera) ...................................20
mefloquine (Larium)........................................................................8
megestrol (Megace) .........................................................................9
meloxicam (Mobic) ........................................................................23
MENEST .........................................................................................19
MENOSTAR ...................................................................................19
MEPHYTON ...................................................................................25
mercaptopurine (Purinethol) ...........................................................9
mesalamine (Rowasa)...................................................................12
MESNEX ...........................................................................................9
MESTINON .....................................................................................21
MESTINON TIMESPAN ...............................................................21
metaxalone (Skelaxin) ...................................................................21
metformin (Glucophage) ...............................................................18
metformin ER (Glucophage XR) ..................................................18
methadone solution .......................................................................23
methadone tablets .........................................................................23
methazolamide (Neprazane) ........................................................16
methimazole (Tapaxzole) .............................................................20
methocarbamol (Robaxin) ............................................................21
N
nadolol (Corgard) ........................................................................... 15
NALFON ......................................................................................... 23
naltrexone (ReVia)......................................................................... 11
NAMENDA ..................................................................................... 11
NAMENDA XR ............................................................................... 11
naproxen (Naprosyn) ................................................................... 23
naproxen DR (EC-Naprosyn) ..................................................... 23
naproxen sodium (Anaprox) ....................................................... 23
naratriptan (Amerge) ..................................................................... 22
NASCOBAL ................................................................................... 25
nateglinide (Starlix) ........................................................................ 18
neomycin/polymyxin B/bacitracin/hydrocortisone eye ointment
.................................................................................................... 27
neomycin/polymyxin B/dexamethasone eye ointment,
suspenion (Maxitrolo) .............................................................. 27
neomycin/polymyxin B/gramicidin eye solution (Neosporin) ... 26
43
oxycodone (Roxicodone) ............................................................ 23
oxycodone/acetaminophen .......................................................... 23
oxycodone/aspirin (Percodan) ..................................................... 23
neomycin/polymyxin B/hydrocortisone ear solution, suspension
(Cortisporin) ...............................................................................25
neomycin/polymyxin/bacitracin eye ointment.............................26
NEORAL .........................................................................................20
NESINA ...........................................................................................18
NEURONTIN ..................................................................................22
Nexium 24HR OTC ........................................................................13
niacin CR (Niaspan) ......................................................................16
NICOTROL INHALER...................................................................11
NICOTROL NS...............................................................................11
nifedipine ER (Adalat CC, Procardia XL)....................................15
NILANDRON ....................................................................................9
NITRO-BID—nitroglycerin..........................................................15
NITRO-DUR—nitroglycerin patch ............................................15
nitrofurantoin (Furadantin) ............................................................13
nitrofurantoin macrocrystalline (Macrodantin)............................13
nitrofurantoin monohydrate/macrocrystalline (Macrobid) .........13
nitroglycerin (Nitro-Dur) .................................................................15
NITROMIST ....................................................................................15
NITROSTAT—nitroglycerin SL .................................................15
norelgestromin-ethinyl estradiol (Ortho Evra) ............................17
norethindrone acetate (Aygestin) ................................................20
norethindrone acetate/ethinyl estradiol .......................................19
NORPACE CR— ...........................................................................16
nortriptyline (Pamelor) ...................................................................10
NORVIR SOLUTION .......................................................................8
NUVARING .....................................................................................17
NUVIGIL ..........................................................................................10
nystatatin topical ............................................................................28
nystatin oral (Mycostatin) ................................................................6
nystatin suspenion .........................................................................27
P
pantoprazole DR (Protonix) .......................................................... 13
paroxetine hcl (Paxil)..................................................................... 10
paroxetine hcl ER (Paxil CR) ....................................................... 10
PATADAY —olopatadine ........................................................... 27
PAXIL .............................................................................................. 10
penicillin v potassium (Veetids) ..................................................... 7
pentoxifylline ER (Trental) .............................................................. 8
perindopril (Aceon) ........................................................................ 14
permethrin....................................................................................... 29
perphenazine (Trilafon)................................................................. 11
phenelzine (Nardil) ....................................................................... 10
phenobarbital.................................................................................. 11
phenytoin sodium ER (Dilantin, Phenytek) ................................ 22
phenytoin suspenion (Dilantin) .................................................... 22
PHOSPHOLINE IODIDE .............................................................. 27
PHRENILIN FORTE ...................................................................... 23
pilocarpine (Salagen) .................................................................... 27
pilocarpine eye solution, 1%, 2%, 4% (Isopto Carpine) ........... 26
PILOPINE HS ................................................................................ 27
pioglitazone (Actos) ...................................................................... 18
pioglitazone-metformin (Actoplus met) ..................................... 18
pioglitazone-metformin SR ........................................................... 18
piroxicam (Feldene) ...................................................................... 23
podofilox (Condylox) ..................................................................... 29
polymyxin B/trimethoprim eye solution (Polytrim) ..................... 26
POTABA ......................................................................................... 21
potassium chloride ER .................................................................. 25
potassium citrate ER (Urocit-K) ................................................... 13
potassium citrate/citric acid (Polycitra-K) ................................... 13
POTASSIUM P-AMINOBENZOATE .......................................... 21
potassium phosphate/sodium phosphates (K-Phos Neutral) .. 25
pramipexole (Mirapex) .................................................................. 21
pravastatin (Pravachol) ................................................................. 16
prazosin (Minipress) ...................................................................... 17
PRECISION XTRA BLOOD GLUCOSE SYSTEM ................... 19
PRED MILD .................................................................................... 27
PRED-G .......................................................................................... 27
PRED-G S.O.P. ............................................................................. 27
prednisolone (Prelone)................................................................. 17
prednisolutionone acetate eye suspenion (Pred Forte) ........... 27
prednisolutionone sodium phosphate (Orapred, Pediapred)... 17
PREDNISONE INTENSOL .......................................................... 17
prednisone tablets ......................................................................... 17
prenatal vitamin/folic acid - all generics...................................... 25
primaquine ........................................................................................ 8
primidone (Mysolutionine) ............................................................ 22
probenecid (Benemid)................................................................... 22
O
ofloxacin ear solution (Floxin otic) ...............................................25
ofloxacin eye solution (Ocuflox) ...................................................26
triamcinolone cream; lotion...........................................................28
olanzapine (Zyprexa, Zyprexa Zydis) ..........................................11
omega 3 (Lovaza) ..........................................................................16
omeprazole DR (Prilosec).............................................................13
OMNITROPE ..................................................................................19
ondansetron (Zofran, Zofran ODT) ..............................................12
ONGLYZA ......................................................................................18
ORACIT ...........................................................................................13
oral contraceptives......................................................................17
orphenadrine citrate ER (Norflex) ................................................21
orphenadrine/aspirin/caffeine (Norgesic)....................................21
OSENI..............................................................................................18
oxandrolone (Oxandrin) ................................................................19
oxaprozin (Daypro) .......................................................................23
oxcarbazepine (Trileptal) ..............................................................22
OXSORALEN ULTR .....................................................................29
oxybutynin (Ditropan) ...................................................................13
oxybutynin ER (Ditropan XL) ......................................................13
44
simvastatin (Zocor) ........................................................................ 16
sodium citrate/citric acid (Shohls)................................................ 13
sodium fluoride ............................................................................... 25
sodium fluoride (Prevident) .......................................................... 27
sodium polystyrene sulfonate ...................................................... 20
SORIATANE .................................................................................. 29
sotalol (Betapace, Betapace AF) ................................................. 16
SOVALDI .......................................................................................... 7
SPIRIVA .......................................................................................... 24
SPIRIVA HANDIHALER .............................................................. 24
spironolactone (Aldactone)........................................................... 16
spironolactone/hydrochlorothiazide ............................................ 16
stavudine (Zerit) ............................................................................... 8
STIMATE ........................................................................................ 19
STRIVERDI RESPIMAT ............................................................... 24
sucralfate (Carafate) ..................................................................... 13
sulfacetamide sodium eye solution (Bleph-10).......................... 26
sulfacetamide sodium/prednisolutionone eye solution ............. 27
sulfacetamide sodium/sulfur cloth, cream, emulsion, lotion ... 28
sulfamethoxazole/trimethoprim (Bactrim)..................................... 6
sulfasalazine (Azulfidine) .............................................................. 12
sulfasalazine DR (Azulfidine EN-Tabs) ...................................... 12
sulindac (Clinoril).......................................................................... 23
sumatriptan injection, tablets (Imitrex) ....................................... 22
SUSTIVA .......................................................................................... 8
SUSTIVA—efavirenz ..................................................................... 8
SYMBICORT .................................................................................. 24
SYNAREL....................................................................................... 20
SYNTHROID .................................................................................. 20
prochlorperazine (Compazine).....................................................11
progesterone micronized (Prometrium) ....................................20
PROGRAF ......................................................................................20
PROMACTA .....................................................................................9
propafenone (Rythmol) .................................................................16
propafenone ER (Rythmol SR) ....................................................16
propranolol ER (Inderal LA) ..........................................................15
propranolol tablets (Inderal)..........................................................15
propylthiouracil ...............................................................................19
PULMICORT ..................................................................................24
pyrazinamide ....................................................................................7
pyridostigmine (Mestinon).............................................................21
Q
QNASL ............................................................................................25
quetiapine (Seroquel) ....................................................................11
quinapril (Accupril) .........................................................................14
quinapril/hydrochlorothiazide (Accuretic)....................................14
quinidine gluconate ER (Quinaglute) ..........................................16
quinidine sulfate (Quinidex).........................................................16
QVAR ..............................................................................................24
R
RAGWITEK ....................................................................................25
raloxifene (Evista) ..........................................................................19
ramipril (Altace) ..............................................................................14
ranitidine (Zantac) ..........................................................................13
RAPAMUNE ...................................................................................20
REBIF ..............................................................................................20
RELISTOR ......................................................................................12
RESCRIPTOR ..................................................................................8
RESTASIS ......................................................................................27
REYATAZ .........................................................................................8
RIDAURA........................................................................................23
rifampin (Rifadin) ..............................................................................7
risperidone (Risperdal, Risperdal-M tablets) ..............................11
rizatriptan (Maxalt) .........................................................................22
ropinirole (Requip) .........................................................................21
ropinirole ER (Requip XL) .............................................................21
T
TABLOID .......................................................................................... 9
tacrolimus (Prograf) ....................................................................... 20
tamoxifen (Nolvadex) ...................................................................... 9
tamsulosin (Flomax) ...................................................................... 13
TEGRETOL .................................................................................... 22
TEGRETOL-XR ............................................................................. 22
TEKAMLO ...................................................................................... 17
TEKTURNA .................................................................................... 17
TEKTURNA HCT........................................................................... 17
telmisartan (Micardis) .................................................................... 14
temazepam (Restoril) .................................................................... 11
terazosin (Hytrin) ........................................................................... 17
terbinafine (Lamisil) ......................................................................... 6
terbutaline (Brethine)..................................................................... 24
terconazole (Terazol).................................................................... 14
testosterone cypionate (Depo-Testosterone) ............................ 19
testosterone enanthate (Delatestryl) ........................................... 19
THEO-24 ......................................................................................... 24
theophylline ER (Theo-Dur) ......................................................... 24
thiothixene (Navane) ..................................................................... 11
THYROLAR.................................................................................... 20
S
salsalate (Disalcid) .......................................................................23
SANCUSO ......................................................................................12
SANDIMMUNE...............................................................................20
SARAFEM ......................................................................................11
selegiline (Eldepryl) .......................................................................21
selenium sulfide (Selsun) ..............................................................29
SEREVENT DISKUS ....................................................................24
sertraline (Zoloft) ............................................................................10
silver sulfadiazine (Silvadene)......................................................28
SIMBRINZA ....................................................................................26
45
venlafaxine (Effexor) ..................................................................... 10
venlafaxine ER capsules (Effexor XR) ....................................... 10
VENTOLIN HFA ............................................................................ 24
verapamil (Calan) .......................................................................... 15
verapamil ER (Calan SR, Isoptin SR, Verelan, Verelan PM) .. 15
VESICARE ..................................................................................... 13
VEXOL ............................................................................................ 27
VIBRAMYCIN SYRUP .................................................................... 7
VICTOZA ........................................................................................ 18
VIDEX PEDIATRIC ......................................................................... 8
VIEKIRA PAK .................................................................................. 7
VIOKACE ....................................................................................... 12
VIRAMUNE ...................................................................................... 8
VIRAMUNE XR ................................................................................ 8
VIREAD............................................................................................. 8
VOLTAREN GEL........................................................................... 29
voriconazole (Vfend) ....................................................................... 6
timolol maleate eye solution (Timoptic, Timoptic XE) ...............26
TIMOPTIC OCUDOSE ..................................................................26
tizanidine (Zanaflex) ......................................................................21
TOBRADEX ....................................................................................27
TOBRADEX ST .............................................................................27
tobramycin eye solution (Tobrex) ................................................26
tobramycin/dexamethasone eye suspenion (Tobradex) ..........27
TOBREX .........................................................................................26
TOPAMAX ......................................................................................22
topiramate (Topamax Sprinkle, Topamax) .................................22
torsemide (Demadex) ....................................................................16
TRADJENTA ..................................................................................18
tramadol (Ultram) ..........................................................................23
trandolapril (Mavik) ........................................................................14
tranylcypromine (Parnate) ............................................................10
TRAVATAN Z .................................................................................26
trazodone (Desyrel) .......................................................................10
tretinoin (Retin-A) ...........................................................................28
TREXALL..........................................................................................9
triamcinolone (Nasacort AQ) ........................................................25
triamcinolone dental paste (Kenalog in Orabase) .....................27
TRIBENZOR ...................................................................................14
trifluoperazine (Stelazine) .............................................................11
trifluridine eye solution (Viroptic)..................................................26
trihexyphenidyl (Artane) ................................................................21
trimethobenzamide (Tigan)...........................................................12
trimethoprim ......................................................................................6
tropicamide eye solution (Mydriacyl) ...........................................27
TUDORZA ......................................................................................24
W
warfarin (Coumadin) ........................................................................ 9
WELCHOL...................................................................................... 16
X
XARELTO ......................................................................................... 9
Z
zafirlukast (Accolate ..................................................................... 24
zaleplon (Sonata)........................................................................... 11
ZARONTIN ..................................................................................... 22
ZENPEP .......................................................................................... 12
ZIAGEN............................................................................................. 8
zidovudine (Retrovir) ....................................................................... 8
ziprasidone (Geodon).................................................................... 11
zoledronic acid (Reclast) .............................................................. 20
zolmitriptan (Zomig)....................................................................... 22
zolpidem (Ambien)......................................................................... 11
zolpidem ER(Ambien CR) ............................................................ 11
ZONEGRAN ................................................................................... 22
zonisamide (Zonegran) ................................................................. 22
ZYMAXID —gatifloxacin ............................................................. 26
U
ULORIC ...........................................................................................22
ULTRESA .......................................................................................12
UROCIT-K 15 .................................................................................13
urosdiol (Actigall, Urso 250, Urso Forte) ....................................12
V
valacyclovir (Valtrex) ......................................................................7
valproic acide (Depakene) ............................................................22
valsartan (Diovan) ..........................................................................14
valsartan/hydrochlorothiazide (Diovan HCT) .............................14
vancomycin (Vancocin) ...................................................................6
46

drug formulary - Health Alliance

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