Preferred Drug List (PDL)

Transcription

1 Preferred List (PDL) Michigan Effective Date: 5/1/ United Healthcare Services, Inc. All rights reserved.

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3 Preferred List INTRODUCTION UnitedHealthcare is pleased to provide this Preferred List (PDL) to be used when prescribing for patients covered by the pharmacy benefit plan offered by UnitedHealthcare. The drugs listed in this PDL are intended to provide sufficient options to treat patients who require treatment with a drug from that pharmacologic or therapeutic class. The drugs listed in the UnitedHealthcare PDL have been reviewed and approved by the UnitedHealthcare Pharmacy and Therapeutics Committee. The drugs have been selected to provide the most clinically appropriate and cost-effective medications for patients who have their drug benefit administered through UnitedHealthcare. It has also recognized there may be occasions where an unlisted drug is desired for proper medical management of a specific patient. In those infrequent instances, the unlisted medication may be requested through the Medical prior authorization process. The PDL is reflective of current medical practice as of the date of review. This edition incorporates drugs added to the PDL since the last edition as well as numerous revisions to the prescribing information based on changes in pharmacotherapy. Comments and suggestions from practicing physicians have also been incorporated to ensure the UnitedHealthcare PDL is reflective of current medical practice. NOTICE The information contained in this PDL and its appendices is provided by UnitedHealthcare, solely for the convenience of medical providers. UnitedHealthcare does not warrant or assure accuracy of such information nor is it intended to be comprehensive in nature. This PDL is not intended to be a substitute for the knowledge, expertise, skill and judgment of the medical provider in their choice of prescription drugs. UnitedHealthcare assumes no responsibility for the actions or omissions of any medical provider based upon reliance, in whole or in part, on the information contained herein. The medical provider should consult the drug manufacturer s product literature or standard references for more detailed information. National guidelines can be found on the Web sites listed in the Web site section or go to the National Guideline Clearinghouse site at The PDL and quarterly updates are also available on our website at PREFACE The UnitedHealthcare PDL is organized by sections. Each section includes therapeutic groups identified by either a drug class or disease state. Products are listed by name. Brand names are included as a reference to assist in product recognition. Unless exceptions are noted, generally all applicable dosage forms and strengths of the drug cited are included in the PDL. Generics should be considered the first line of prescribing. The UnitedHealthcare PDL covers selected over-thecounter (OTC) products. Many are noted in the drug lists; a complete list is included on page 37. You are encouraged to prescribe OTC medications when clinically appropriate. UHC1004d {Released 3/16/11} i

4 PHARMACY AND THERAPEUTICS (P&T) COMMITTEE The UnitedHealthcare P&T Committee includes physicians and pharmacists who are not employees or agents of UnitedHealthcare or its affiliates. They must adhere to the Ethics Policy standards of the P&T Committee. UnitedHealthcare medical directors and pharmacists also participate in the P&T Committee. UnitedHealthcare s P&T Committee meets quarterly to discuss a variety of issues. Those issues pertaining to pharmaceutical selection and pharmacy program management are communicated quarterly. This newsletter is distributed to all participating physicians who have received UnitedHealthcare s PDL. PDL decisions are also communicated quarterly on the UnitedHealthcare internet site. OUTPATIENT PRESCRIPTION DRUG BENEFIT-COVERED MEDICATIONS Medically necessary outpatient prescription drugs are covered when prescribed by a provider licensed to prescribe federal legend drugs or medicines. Some items are covered only with prior authorization. Eligibility for Outpatient Prescription Benefits and copays are based on the individual member s benefit plan. PRODUCT SELECTION CRITERIA The UnitedHealthcare P&T Committee considers clinical information on new-to-market drugs that are typically included in an outpatient pharmacy benefit. The evaluation includes all or part of the following: Safety Efficacy Comparison studies Approved indications Adverse effects Contraindications/Warnings/Precautions Pharmacokinetics Patient administration/compliance considerations Medical outcome and pharmacoeconomic studies When a new drug is considered for PDL inclusion, it will be reviewed relative to similar drugs currently included in the UnitedHealthcare PDL. This review process may result in deletion of drug(s) in a particular therapeutic class in an effort to continually promote the most clinically useful and cost-effective agents. All the information in the PDL is provided as a reference for drug therapy selection. Specific drug selection for an individual patient rests solely with the prescriber. PDL PRODUCT DESCRIPTIONS To assist in understanding which specific strengths and dosage forms are covered on the PDL, examples are noted below. The general principles shown in the examples can then usually be extended to other entries in the book. Any exceptions are noted in the drug list. There may also be a statement associated with a drug list that gives additional information about which specific products or dosage forms are covered. Products covered include all strengths associated with the dosage form of the cited name product. carvedilol Coreg All strengths of Coreg would be covered by this listing. Extended-release and delayed-release products require their own entry. diltiazem sustained release CARDIZEM SR Dosage forms covered will be consistent with the category and use where listed. Neomycin/polymixin B/ Cortisporin Hydrocortisone As listed in the OTIC section, this is limited to the otic solution and suspension. From this entry the ophthalmic solution and ointment, and the topical cream cannot be assumed to be on the list unless there are entries for these products in the OPHTHALMIC and DERMATOLOGY sections of the PDL. When a strength or dosage form is specified, only the specified strength and dosage form is on the PDL. Other strengths/dosage forms of the reference product are not cefixime 400mg tabs SUPRAX GENERIC SUBSTITUTION The UnitedHealthcare PDL requires substitution on the majority of products when a equivalent is available. Generic substitution is a pharmacy action whereby a equivalent is dispensed rather than the name product. The PDL indicates availability in the column. If a name drug is medically necessary, please submit a prior authorization request. The UnitedHealthcare MAC list sets a ceiling price for the reimbursement of certain multisource prescription drugs. This price will typically cover the acquisition of most s but not ed versions of the same drug. The products selected for inclusion on the MAC list are commonly prescribed and dispensed and have usually gone through the FDA s review and approval process. An important consideration for substitution is the UHC1004d {Released 3/16/11} ii

5 knowledge that all approvals of drugs by the FDA since 1984, and many approvals prior to 1984, have a showing of bioequivalence between the versions and the reference product. To gain FDA approval: 1. The drug must contain the same active ingredient(s), be the same strength and the same dosage form as the name product. 2. The FDA has given the an A rating compared to the ed product indicating bioequivalence, and has determined the is therapeutically equivalent to the reference. The ratings of drugs are available by referring to the FDA reference, Approved Products with Therapeutic Equivalence Evaluations (Orange Book). When the above two criteria are met, a can be substituted with the full expectation that the substituted product will produce the same clinical effect and safety profile as the prescribed product. products that have a narrow therapeutic index (NTI) can also be guided by these principles. It is not necessary for the health care provider to approach any one therapeutic class of drug products (e.g., NTI drugs) differently from any other class, when there has been a determination of therapeutic equivalence by the FDA for the drug products under consideration. Also, additional clinical tests or examinations by the physician are not needed when a therapeutically equivalent drug product is substituted for the name product. There are now many name products that are repackaged or distributed under a label. The label version should always be considered therapeutically equivalent and substitutable for the source ed product. DRUG EFFICACY STUDY IMPLEMENTATION (DESI) DRUGS s first marketed between 1938 and 1962 were approved as safe but required no showing of effectiveness for FDA approval. Beginning in 1962, all new drugs were required to be both safe and effective before they could be marketed. This legislation also applied retroactively to all drugs approved as safe from The DESI program was established by the FDA to review the effectiveness of these pre-1962 drugs for their labeled indications, and a determination of fully effective was made for most of these products and they remain in the marketplace. A few DESI products remain classified as less than fully effective while awaiting final administrative disposition. Also, classified as DESI are many products listed as identical, similar, or related to actual DESI products. UnitedHealthcare s PDL does not cover DESI less than fully effective drug products. PLAN EXCLUSIONS The following drug categories are excluded from coverage under the outpatient pharmacy benefit and are not part of the UnitedHealthcare PDL. DESI drugs Antiobesity agents Experimental / research drugs Cosmetic drugs Immunization agents Nutritional / diet supplements Blood and blood plasma products Agents used to promote fertility Agents used for erectile dysfunction Agents used for cosmetic hair growth s from manufacturers that do not participate in the FFS Medicaid Rebate Program Diagnostic products Medical supplies and DME except as listed: syringes, needles, lancets, alcohol swabs, spacers, preferred diabetes test strips, peak flow meters (Astech, Assess, Peak Air s, max two per year), vaporizer (limit of 1 per 3 years), humidifier (limit of 1 per 3 years) Mirena DAYS SUPPLY DISPENSING LIMITATIONS UnitedHealthcare members may receive up to a one month supply of a specific medication per prescription order or prescription refill. A medication may be reordered or refilled when seventy-five percent (75%) of the medication has been utilized. If a claim is submitted before 75% of the medication has been used, based on the original day supply submitted on the claim, the claim will reject with a "refill too soon" message. Please call the UnitedHealthcare Pharmacy Department at with questions or for help with dosage change authorization. MANDATORY GENERIC SUBSTITUTION The UnitedHealthcare PDL requires mandatory substitution on the vast majority of products when a equivalent is available; however, name drugs may be covered in certain situations by requesting a prior authorization. The UnitedHealthcare PDL prior authorization (PA) list does not include ed items where a equivalent is covered. PRIOR AUTHORIZATION OF NON-PDL MEDICATIONS The drugs in the UnitedHealthcare PDL have been selected to provide the most clinically appropriate and cost-effective medications for patients who have their drug benefit administered through UnitedHealthcare. It is also recognized that there may be occasions where an unlisted drug is desired for the proper medical management of a specific patient. In those infrequent instances, the prior authorization process reviews requests for unlisted medications the physician may consider medically necessary for patient management. UHC1004d {Released 3/16/11} iii

6 Requests for these exceptions should be made in writing by the physician and faxed or called in to: UnitedHealthcare Pharmacy Prior Notification Service Fax Phone A prior authorization request form is available on our website at and in the UnitedHealthcare provider manual and should be used for all prior authorization requests if possible. Appropriate documentation must be provided to support the medical necessity of the non-pdl request. The UnitedHealthcare Pharmacy Department will respond to all requests in accordance with state requirements. Physicians are requested to adhere to this PDL when prescribing for patients covered by their pharmacy benefit plan offered by UnitedHealthcare. If a pharmacist receives a prescription for a non-pdl drug, the pharmacist should contact the prescribing physician and request that the prescription be changed to a medication included in this PDL. If a PDL alternative is not appropriate the physician should then be instructed to contact the Plan for a prior authorization. Please contact the UnitedHealthcare Pharmacy Department at with questions concerning the prior authorization process. NON-PDL DRUGS 5-DAY AND 15-DAY OVERRIDES To ensure the use of PDL drugs, all non-pdl drugs should be discussed with the prescribing physician. If you cannot speak to the physician immediately, and there is an immediate need for the medication, the claim processing system will accept an override to permit a one-time dispensing of a 5-day supply of the newly prescribed non-pdl drug. The pharmacy should submit a claim for a 5 day supply, with a PA Type of 8 and Prior Authorization number of Please note that non-preferred drugs are available for a 5-day supply, however availability is subject to the benefit design. For assistance, pharmacies may call Pharmacies may dispense a one-time, 15-day supply to members requiring an immediate supply of an ongoing medication. The pharmacist must contact the plan to obtain a manual 15-day override. Before the next dispensing, the pharmacy must contact the physician to discuss a PDL drug or if a prior authorization request is warranted. If the prescribing physician feels a drug is medically necessary, the physician may fax a request for prior authorization to UnitedHealthcare at , Attn: Pharmacy Department. QUANTITY LIMITATIONS (QL) Prescriptions for monthly quantities greater than the indicated limit require a prior authorization request. Quantity limits based on Efficient Medication Dosing The Efficient Medication Dosing Program is designed to consolidate medication dosage to the most efficient daily quantity to increase adherence to therapy and also promote the efficient use of health care dollars. The limits for the program are established based on FDA approval for dosing and the availability of the total daily dose in the least amount of tablets or capsules daily. Quantity Limits in the prescription claims processing system will limit the dispensing to consolidate dosing. The pharmacy claims processing system will prompt the pharmacist to request a new prescription order from the physician. Controlled Substances You may fill any FOUR medications from the following classes in a 30-day period: opiate analgesics select muscle relaxants Additional fills will require prior authorization. Medications in these classes may also be subject to individual quantity limits. Additions to the QL program drug list will be made from time to time and providers notified accordingly. As always, we recognize that a number of patient-specific variables must be taken into consideration when drug therapy is prescribed and therefore overrides will be available through the medical exception (PA) process. Please contact the UnitedHealthcare Pharmacy Department at with questions. Specialty Pharmaceutical Management Program UnitedHealthcare is continuously looking for ways to provide high quality cost effective care for Plan members. The Specialty Pharmaceutical Management Program helps UnitedHealthcare to achieve these goals. Injectable medications that are part of this program require plan authorization and are not available through the retail pharmacy network. To obtain authorization, the provider must submit the appropriate Prior Authorization form to the UnitedHealthcare Pharmacy Department via fax at The UnitedHealthcare Pharmacy Department will review and respond to all requests in accordance with state requirements, and if authorized for payment, UnitedHealthcare will coordinate the delivery of the product to the member or provider. s that are part of this program and are on the PDL are identified in this booklet by the designation "SP". Prior Authorization request forms can be requested by calling the UnitedHealthcare Pharmacy Department at STEP THERAPY (ST) The following PDL drugs are routinely covered only after a sufficient trial of an indicated first-line agent has been UHC1004d {Released 3/16/11} iv

7 adequately tried and failed. These medications may also be requested through the Prior authorization process. While lower cost PDL alternatives may be appropriate in many instances, other non- PDL alternatives are available with prior authorization (PA). STEP First-Line Agent(s) GLP-1 Agonists At least a 90 day trial of 1500mg/day of (Tanzeum, metformin Victoza) lansoprazole/ 30 day trial of omeprazole 40mg and Prevacid OTC pantoprazole 40mg within previous 180 days is required first Advair 1) 30 day trial of one inhaled corticosteroid (e.g. Flovent, Qvar, Asmanex, Pulmicort, Azmacort) OR 2) 60 day trial of a long-acting beta2- agonist (e.g. Arcapta, Striverdi) OR 60 day trial of an orally inhaled anticholinergic agent (e.g. Spiriva, Atrovent, Combivent, Tudorza). levocetirizine midodrine Optivar 30 day trial of loratadine and cetirizine. Trial of Fludrocortisone 14 day trial of ketotifen within previous 90 days required first. oxymorphone ER 30-day trial of both Fentanyl patch and morphine sulfate ER at least 200mg per day Amerge Aricept 23mg Breo Ellipta Ditropan XL Trial at a minimum dose of 50mg of sumatriptan tablets. 90 day trial of Aricept 10mg daily 1) 30 day trial of one inhaled corticosteroid (e.g. Arnuity Ellipta, Asmanex) OR 2) 60 day trial of a longacting beta2- agonist (e.g. Arcapta, Striverdi ) OR 60 day trial of an orally inhaled anticholinergic agent (e.g. Incruse Ellipta, Atrovent, Combivent, Anoro Ellipta). 30 day trial of oxybutynin immediate release. Step Therapy only applies to members less than 65 years of age. DPP4 Inhibitors At least a 90 day trial of 1500mg/day of (Tradjenta, metformin. Jentadueto, Onglyza, Kombiglyze) Dulera Elidel fenofibrate 1) 30 day trial of one inhaled corticosteroid (e.g. Arnuity Ellipta, Asmanex) OR 2) 60 day trial of a longacting beta2- agonist (e.g. Arcapta, Striverdi) OR 60 day trial of an orally inhaled anticholinergic agent (e.g. Incruse Ellipta, Atrovent, Combivent, Anoro Ellipta). Trial of two different topical corticosteroids. Step therapy only applies to members 12 years of age and older. Fill of a statin or 90 days of gemfibrozil within the previous 180 days. Protopic 0.03% Trial of two different topical corticosteroids. Step therapy only applies to members 12 years of age and older. Protopic 0.1% Ranexa Renvela Minimum age of 16. Trial of two different topical corticosteroids. Trial of one drug from the following classes: beta blockers, calcium channel blockers, long acting nitrates 8 week trial of calcium acetate. SGLT-2 At least a 90 day trial of 1500mg/day of Inhibitors metformin (Jardiance, Invokana, Invokamet, Synjardy) Symbicort tolterodine trospium 1) 30 day trial of one inhaled corticosteroid (e.g. Flovent, Qvar, Asmanex, Pulmicort, Azmacort) OR 2) 60 day trial of a long-acting beta2- agonist (e.g. Arcapta, Striverdi) OR 60 day trial of an orally inhaled anticholinergic agent (e.g. Spiriva, Atrovent, Combivent, Tudorza). 30 day trial of oxybutynin immediate release. Step Therapy only applies to members less than 65 years of age. 30 day trial of oxybutynin immediate release. Step Therapy only applies to members less than 65 years of age. UHC1004d {Released 3/16/11} v

8 TZD s At least a 90 day trial of 1500mg/day of (ActosPlusMet, metformin ActoPlusMet XR Duetact) Uloric Vancocin 8 week trial of up to 600mg of allopurinol required first. One fill of metronidazole tabs or caps. Xopenex 30 day trial of Albuterol.083% or.5% Respules respules. Zohydro ER 30-day trial of both Fentanyl patch and morphine sulfate ER at least 200mg per day PDL SUGGESTIONS Providers who wish to propose PDL suggestions should forward the information to the UnitedHealthcare Director of Pharmacy Services by either mail or fax. Attn: Director of Pharmacy Services UnitedHealthcare Unison Plaza 1001 Brinton Road Pittsburgh, PA Fax: Providers should furnish adequate documentation, such as clinical studies from the medical literature, in order for the request to be considered for PDL addition. This literature should include information documenting clinical necessity as well as therapeutic advantages over current PDL products. Suggestions received by UnitedHealthcare will be reviewed by the Pharmacy and Therapeutics Committee at the subsequent P&T Committee meeting. LEGEND # Only the dosage forms/strengths of the name products noted are on the PDL OTC over-the-counter delayed-rel delayed-release (also known as enteric coated) EC enteric-coated ext-rel extended-release (also known as sustainedrelease) PA Prior Authorization required QL Quantity Limits apply ST SP Step Therapy, see pages V-VI for details Specialty Pharmaceuticals, see page V for details NOTICE The information contained in this document is proprietary information. The information may not be copied in whole or in part without the written permission of UnitedHealthcare. All rights reserved. The drug names listed here are the registered and/or unregistered trademarks of third-party pharmaceutical companies unrelated to and unaffiliated with UnitedHealthcare. These trademarked names are included here for informational purposes only and are not intended to imply or suggest any affiliation between UnitedHealthcare and such third-party pharmaceutical companies. If viewing this PDL via the Internet, please be advised that the PDL is updated periodically and changes may appear prior to their effective date to allow for notification. EDITOR Your comments and suggestions regarding the UnitedHealthcare PDL are encouraged. Your input is vital to this PDL s continued success. All responses will be reviewed and considered. Please send your comments to: UnitedHealthcare Director of Pharmacy Services Unison Plaza 1001 Brinton Road Pittsburgh, PA Phone: (800) [email protected] Internet: UHC1004d {Released 3/16/11} vi

9 Table of Contents Antineoplastics & Immunosuppressants 4 Antineoplastic Agents...4 Hormonal Antineoplastic Agents....4 Immunomodulators...5 Immunosuppressants...5 Miscellaneous...6 Blood Modifiers - Anticoagulants Anticoagulants...6 Blood Cell Formation...6 Platelet Inhibitors...7 Miscellaneous...7 Cardiovascular Agents...7 Ace Inhibitors...7 Ace Inhibitor/Diuretic Combinations....7 Adrenolytics, Central... 8 Alpha Blockers...8 Angiotensin II Receptor Blockers (Antagonists) 8 Angiotensin II Receptor Blocker Combinations8 Antiarrhythmics and Cardiac Glycosides...8 Beta Blockers and Beta Blocker/ Diuretic Combinations...8 Calcium Channel Blockers...9 Diuretics....9 Lipid Lowering Agents...10 Nitrates...10 Potassium-Removing Agents...11 Miscellaneous...11 Central Nervous System Alzheimer s Disease...11 Analgesics...12 Migraine Acute Therapy...13 Migraine Prophylactic Therapy...13 Multiple Sclerosis...14 Myasthenia Gravis...14 Miscellaneous...14 Dermatology Acne Vulgaris...14 Bacterial Infections Corticosteroids...15 Fungal Infections Psoriasis...16 Rosacea Scabies and Pediculosis...16 Viral Infections Miscellaneous...16 Ear, Nose & Throat Ear...17 Nose Throat and Mouth Endocrinology...19 Adrenal Corticosteroids...19 Androgens Diabetes Mellitus...20 Growth Stimulating Agents...22 Osteoporosis Thyroid Disease...22 Miscellaneous...22 Gastrointestinal...22 Diarrhea...22 Emesis...22 Gastroesophageal Reflux Disease (Gerd)/ Peptic Ulcers Gastrointestinal Spasm...24 Inflammatory Bowel Disease...24 Laxatives...24 Pancreatic Enzymes...25 Probiotic Supplementation...25 Miscellaneous...25 Home Infusion s...25 Analgesics - NSAIDS...25 Analgesics - OPIOD...25 Antiasthmatic and Bronchodilator Agents...26 Antibiotics...26 Antihistamines Antipsychotics/Antimanic Agents...33

10 Corticosteroids...33 Diuretics Electrolyte Mixtures...34 Gastrointestinal Agents...34 Genitourinary Irrigants...35 Hematological Agents...35 Minerals & Electrolytes Nutrients...37 Vitamins...37 Infectious Diseases Anthelmintics Antibacterials Antifungals Antivirals...39 Miscellaneous...40 Musculoskeletal Arthritis Gout Skeletal Muscle Relaxants...42 OB-GYN Contraceptives...42 Endometriosis...44 Hormone Therapy/Menopause...44 Vaginal Infections...44 Miscellaneous...45 Ophthalmic...45 Allergy...45 Anti-Inflammatories Glaucoma...46 Infections...47 Miscellaneous...47 Psychiatric...47 Insomnia Narcotic Antagonists...47 Psychoses...47 Smoking Cessation...48 Weight Loss...48 Respiratory s...48 Antitussives, Decongestants, Expectorants and Combinations Asthma/COPD...53 Supplements...55 Potassium...55 Urological...55 Symptomatic Benign Prostatic Hypertrophy.55 Miscellaneous...55 Vitamins and Minerals Miscellaneous...59 Anaphylaxis...59 Cystic Fibrosis...59 Hereditary Angioedema...59 Hyperphosphatemia...59 Idiopathic Pulmonary Fibrosis (IPF)...59 Immune Thrombocytopenic Purpura...60 Medical Devices...60 Vaccine...60 OTC MEDICATIONS Acne Antifungals Atopic Dermatitis...61 Cough/Cold Allergy...61 Diabetes...62 Earwax Removal Products...62 Family Planning...62 First Aid...62 Gastrointestinal Lice Products...63 Motion Sickness...63 Ophthalmics...63 Pain...63 Smoking Cessation Products...63 Vitamins/Minerals...64 Warts...64 Miscellaneous...64 Index of s

11 Generic Name Brand Name Antineoplastics & Immunosuppressants Antineoplastic Agents Alkylating Agents altretamine HEXALEN busulfan MYLERAN chlorambucil LEUKERAN cyclophosphamide CYTOXAN estramustine phosphate sodium EMCYT lomustine CEENU melphalan ALKERAN temozolomide TEMODAR PA, SP Antimetabolites capecitabine XELODA PA, SP fludarabine OFORTA PA, SP mercaptopurine PURINETHOL thioguanine TABLOID QL trifluridine/tipiracil LONSURF PA, SP Histone Deacetylase Inhibitors vorinostat ZOLINZA PA, SP Kinase Inhibitor axitinib INLYTA PA, SP cabozantinib COMETRIQ PA, SP everolimus AFINITOR AFINITOR DISPERZ PA, SP ponatinib ICLUSIG PA, SP ruxolitinib JAKAFI PA, SP Hormonal Antineoplastic Agents Androgen Biosynthesis Inhibitors abiraterone ZYTIGA PA, SP Antiandrogens bicalutamide CASODEX flutamide EULEXIN Antiestrogens tamoxifen NOLVADEX toremifene FARESTON 4

12 Generic Name Brand Name Aromatase Inhibitors anastrozole ARIMIDEX exemestane AROMASIN letrozole FEMARA Gonadotropin Releasing Hormone Analog leuprolide LUPRON PA, SP LUPRON DEPOT leuprolide LUPRON DEPOT 6-MONTH PA, SP LUPRON DEPOT-PED Progestin megestrol acetate MEGACE Immunomodulators Interferons interferon alfa-2a PA, SP interferon alfa-2b INTRON A PA, SP peginterferon alfa-2b SYLATRON PA, SP Miscellaneous lenalidomide REVLIMID PA, SP pomalidomide POMALYST PA, SP Immunosuppressants Antimetabolites azathioprine IMURAN mycophenolate mofetil CELLCEPT mycophenolate sodium MYFORTIC Calcineurin Inhibitors cyclosporine SANDIMMUNE cyclosporine, modified NEORAL GENGRAF tacrolimus HECORIA PROGRAF Rapamycin Derivative sirolimus RAPAMUNE Other everolimus ZORTRESS 5

13 Generic Name Brand Name Miscellaneous alitretinoin 1% gel PANRETIN PA bexarotene caps and topical gel TARGRETIN PA cysteamine bitartrate CYSTAGON etoposide VEPESID hydroxyurea DROXIA HYDREA mitotane LYSODREN octreotide SANDOSTATIN pasireotide SIGNIFOR PA, SP procarbazine MATULANE sonidegib ODOMZO PA, SP tretinoin VESANOID caps vismodegib ERIVEDGE PA, SP Blood Modifiers - Anticoagulants Anticoagulants apixaban ELIQUIS edoxaban SAVAYSA enoxaparin LOVENOX PA, QL, SP, SP and PA only applies for quantities greater than 14 days heparin HEPARIN rivaroxaban XARELTO warfarin COUMADIN Blood Cell Formation darbepoetin alfa ARANESP PA, SP epoetin alfa EPOGEN PROCRIT PA, SP filgrastim ZARXIO PA, SP oprelvekin NEUMEGA SP pegfilgrastim NEULASTA PA, SP plerixafor MOZOBIL PA, SP sargramostim LEUKINE PA, SP TBO-filgrastim GRANIX PA, SP 6

14 Generic Name Brand Name Platelet Inhibitors anagrelide AGRYLIN aspirin BAYER ECOTRIN OTC cilostazol PLETAL clopidogrel PLAVIX QL dipyridamole PERSANTINE Miscellaneous deferasirox EXJADE JADENU PA, SP pentoxifylline extended-release TRENTAL Cardiovascular Agents Ace Inhibitors benazepril LOTENSIN captopril CAPOTEN enalapril VASOTEC enalapril oral soln EPANED Members 8 years of age will require prior authorization. fosinopril MONOPRIL QL lisinopril ZESTRIL QL quinapril ACCUPRIL QL Ace Inhibitor/Diuretic Combinations benazepril/ hydrochlorothiazide captopril/ hydrochlorothiazide enalapril/ hydrochlorothiazide fosinopril/ hydrochlorothiazide lisinopril/ hydrochlorothiazide quinapril/ hydrochlorothiazide LOTENSIN HCT CAPOZIDE VASERETIC MONOPRIL-HCT QL ZESTORETIC QL ACCURETIC QL 7

15 Generic Name Brand Name Adrenolytics, Central clonidine CATAPRES guanfacine TENEX Alpha Blockers doxazosin CARDURA prazosin MINIPRESS terazosin HYTRIN Angiotensin II Receptor Blockers (Antagonists) losartan COZAAR QL Angiotensin II Receptor Blocker Combinations losartan/hctz HYZAAR QL Antiarrhythmics and Cardiac Glycosides amiodarone tabs CORDARONE 200 mg and 400 mg digoxin LANOXIN disopyramide NORPACE disopyramide extended-release NORPACE CR dofetilide TIKOSYN flecainide TAMBOCOR mexiletine MEXITIL propafenone RYTHMOL IR only quinidine gluconate QUINIDINE GLUCONATE extended-release EXT-REL quinidine sulfate QUINIDINE SULFATE quinidine sulfate QUINIDINE SULFATE extended-release EXT-REL sotalol BETAPACE Beta Blockers and Beta Blocker/Diuretic Combinations acebutalol SECTRAL atenolol TENORMIN atenolol/chlorthalidone TENORETIC bisoprolol ZEBETA bisoprolol/ hydrochlorothiazide ZIAC carvedilol COREG QL labetalol TRANDATE metoprolol LOPRESSOR metoprolol succinate TOPROL XL 8

16 Generic Name Brand Name pindolol PINDOLOL propranolol INDERAL IR only propranolol/hctz INDERIDE timolol maleate tablets Calcium Channel Blockers Dihydropyridines amlodipine NORVASC QL felodipine extended-release PLENDIL QL nicardipine CARDENE nifedipine PROCARDIA nifedipine ADALAT CC extended-release PROCARDIA XL QL nimodipine NIMOTOP QL nimodipine oral soln NYMALIZE Nondihydropyridines diltiazem CARDIZEM diltiazem extended-release CARDIZEM CD QL diltiazem DILACOR XR extended-release TIAZAC QL diltiazem sustained-release CARDIZEM SR QL verapamil CALAN verapamil extended-release CALAN SR QL Diuretics amiloride MIDAMOR amiloride/ hydrochlorothiazide MODURETIC bumetanide BUMEX chlorothiazide DIURIL chlorothiazide DIURIL ORAL SUSPENSION QL chlorthalidone CHLORTHALIDONE furosemide LASIX hydrochlorothiazide HYDROCHLOROTHIAZIDE soln, tabs 9

17 Generic Name Brand Name hydrochlorothiazide MICROZIDE 12.5 mg caps indapamide LOZOL metolazone ZAROXOLYN spironolactone ALDACTONE spironolactone/ hydrochlorothiazide ALDACTAZIDE torsemide DEMADEX triamterene/ DYAZIDE hydrochlorothiazide MAXZIDE Lipid Lowering Agents Bile Acid Resin cholestyramine QUESTRAN QUESTRAN-LIGHT Only the bulk products are covered (cans). Individual packets are not covered. Fibrates fenofibrate LOFIBRA ST gemfibrozil LOPID HMG-CoA Reductase Inhibitors and Combinations atorvastatin LIPITOR lovastatin MEVACOR QL simvastatin ZOCOR QL Niacins niacin NIACOR niacin extended-release NIASPAN Miscellaneous alirocumab PRALUENT PA, QL, SP ezetimibe ZETIA PA Nitrates Oral isosorbide dinitrate ISORDIL isosorbide dinitrate ISOSORBIDE extended-release DINITRATE ER isosorbide mononitrate ISMO isosorbide mononitrate extended-release IMDUR Sublingual isosorbide dinitrate ISORDIL S.L. nitroglycerin NITROLINGUAL nitroglycerin NITROSTAT 10

18 Generic Name Brand Name Transdermal nitroglycerin NITREK NITRO-DUR transdermal, QL nitroglycerin NITRO-BID oint Potassium-Removing Agents sodium polysterene sulfonate KAYEXALATE susp (susp only) Miscellaneous ambrisentan LETAIRIS PA, SP bosentan TRACLEER PA, SP guanabenz WYTENSIN hydralazine APRESOLINE lomitapide JUXTAPID PA, SP methyldopa ALDOMET methyldopa/hctz ALDORIL midodrine PROAMATINE ST minoxidil LONITEN ranolazine RANEXA ST sildenafil REVATIO PA Central Nervous System Alzheimer s Disease donepezil ARICEPT donepezil ARICEPT galantamine RAZADYNE memantine NAMENDA rivastigmine EXELON 5 mg and 10 mg, QL, Members <18 years of age will require prior authorization. 23 mg, ST, Members <18 years of age will require prior authorization. QL, Members <18 years of age will require prior authorization. QL, Members <18 years of age will require prior authorization. QL, Members <18 years of age will require prior authorization. 11

19 Generic Name Brand Name Analgesics Barbiturate Non-Narcotic Analgesics butalbital/acetaminophen PHRENILIN QL butalbital/acetaminophen SEDAPAP QL butalbital/acetaminophen/ FIORICET caffeine QL butalbital/aspirin/caffeine FIORINAL QL Non-Narcotic Analgesics acetaminophen TYLENOL OTC aspirin/acetaminophen/ caffeine EXCEDRIN MIGRAINE mg, OTC tramadol ULTRAM QL NSAIDS choline magnesium trisalicylate TRILISATE diclofenac sodium delayed release VOLTAREN etodolac LODINE IR Only fenoprofen NALFON 600 mg ibuprofen ADVIL tabs, chew tabs ibuprofen MOTRIN and susp, OTC tabs, chew tabs and susp indomethacin INDOCIN ketoprofen ORUDIS IR only ketorolac tromethamine TORADOL QL meloxicam MOBIC QL nabumetone RELAFEN naproxen NAPROSYN naproxen delayed release ENTERIC CODED- NAPROSYN naproxen sodium ANAPROX oxaprozin DAYPRO piroxicam FELDENE sulindac CLINORIL Opioids - Narcotic Analgesics butalbital/apap/caff/cod FIORICET W/CODEINE QL, mg butalbital/asa/caff/cod FIORINAL W/CODEINE QL butorphanol STADOL nasal spray, QL codeine/acetaminophen TYLENOL W/CODEINE QL 12

20 Generic Name Brand Name codeine sulfate QL fentanyl transdermal DURAGESIC QL LORCET hydrocodone/ acetaminophen LORTAB LORTAB ELIXIR NORCO VICODIN VICODIN ES hydrocodone ER ZOHYDRO ER ST hydromorphone DILAUDID QL meperidine DEMEROL QL methadone DOLOPHINE QL morphine MSIR QL morphine RMS QL morphine extended-release MS CONTIN QL oxycodone OXYFAST soln, QL oxycodone ROXICODONE QL oxycodone/ acetaminophen PERCOCET 5/325, QL oxycodone/aspirin PERCODAN QL oxymorphone OXYMORPHONE ER QL, ST pentazocine/naloxone TALWIN NX QL Migraine Acute Therapy Ergotamine Derivatives dihydroergotamine D.H.E. 45 inj, QL dihydroergotamine MIGRANAL ergotamine/caffeine CAFERGOT Selective Serotonin Agonists naratriptan AMERGE ST rizatriptan MAXALT/MAXALT MLT QL sumatriptan IMITREX QL sumatriptan IMITREX 4 MG AND 6 MG INJ 4 mg and 6 mg inj Migraine Prophylactic Therapy propranolol INDERAL IR only verapamil CALAN QL 13

21 Generic Name Brand Name Multiple Sclerosis dimethyl fumarate TECFIDERA PA, QL, SP fingolimod GILENYA PA, QL, SP glatiramer acetate COPAXONE PA, QL, SP interferon beta-1a AVONEX/AVONEX PEN PA, QL, SP interferon beta-1a REBIF PA, QL, SP teriflunomide AUBAGIO PA, QL, SP Myasthenia Gravis pyridostigmine MESTINON pyridostigmine extended-release MESTINON TIMESPAN Miscellaneous tetrabenazine XENAZINE PA, SP Dermatology Acne Vulgaris Oral isotretinoin ACCUTANE PA Topical azelaic acid FINACEA gel benzoyl peroxide BENZAC AC clindamycin CLEOCIN T gel clindamycin CLEOCIN T lotion clindamycin CLEOCIN T soln erythromycin ERYGEL gel 2% erythromycin T-STAT soln erythromycin/benzoyl peroxide BENZAMYCIN sulfacetamide SULFACET-R sulfacetamide/sulfur PLEXION tretinoin AVITA RETIN-A Bacterial Infections bacitracin BACITRACIN OTC gentamicin GENTAK mupirocin BACTROBAN ointment, 22 gram tube only neomycin/polymyxin B/ bacitracin NEOSPORIN OTC silver sulfadiazine SILVADENE 14

22 Generic Name Brand Name Corticosteroids Low Potency alclometasone ACLOVATE 0.05% crm/oint fluocinolone acetonide DERMA-SMOOTHE OIL/FS oil 0.01% fluocinolone acetonide SYNALAR soln/crm 0.01% hydrocortisone CORTIZONE crm, oint, lot OTC hydrocortisone HYTONE 1% lotion hydrocortisone HYTONE crm 2.5% Medium Potency betamethasone val BETA-VAL crm/oint/lotion 0.1% fluocinolone acetonide SYNALAR crm, oint 0.025% flurandrenolide CORDRAN tape fluticasone propionate CUTIVATE crm 0.05%, oint 0.005% hydrocortisone butyrate LOCOID crm/oint/soln 0.1% mometasone furoate ELOCON crm 0.1% mometasone furoate ELOCON oint 0.1% prednicarbate DERMATOP crm/oint 0.1% triamcinolone acetonide KENALOG crm/lot/oint 0.025% triamcinolone acetonide KENALOG crm/oint/lotion 0.1% High Potency betamethasone augmented dip DIPROLENE lotion 0.05% betamethasone augmented dip DIPROLENE AF crm 0.05% betamethasone dipropionate crm/lotion/oint 0.05% fluocinonide LIDEX crm/oint/gel 0.05% fluocinonide emulsified base LIDEX E crm 0.05% triamcinolone acetonide KENALOG crm 0.5% Very High Potency betamethasone dip augmented DIPROLENE gel 0.05% betamethasone dip augmented DIPROLENE oint 0.05% clobetasol propionate TEMOVATE crm/gel/oint/soln 0.05% 15

23 Generic Name Brand Name Fungal Infections ciclopirox PENLAC SOLUTION 8% clotrimazole LOTRIMIN AF OTC clotrimazole MYCELEX clotrimazole with betamethasone LOTRISONE ketoconazole NIZORAL miconazole DESENEX POWDER 2% powder miconazole MICATIN OTC miconazole MONISTAT-DERM nystatin MYCOSTATIN terbinafine LAMISIL AT OTC tolnaftate TINACTIN OTC Psoriasis acitretin SORIATANE oral caps, PA calcipotriene DOVONEX calcitriol VECTICAL methoxsalen OXSORALEN-ULTRA Rosacea brimonidine MIRVASO PA METROCREAM metronidazole METROGEL METROLOTION Scabies and Pediculosis crotamiton EURAX malathion OVIDE permethrin ELIMITE 5%, QL permethrin NIX CREME RINSE 1%, OTC pyrethrins/piperonyl but RID SHAMPOO/ BUTOXIDE SHAMPOO 4% OTC Viral Infections podofilox CONDYLOX SOL sol salicylic acid 17%/ collodion DUOFILM OTC Miscellaneous aluminum acetate soln/cream, OTC aluminum chloride hexahydrate HYPERCARE 20% ammonium lactate LAC-HYDRIN 12% 16

24 Generic Name Brand Name becaplermin gel REGRANEX PA calamine lotion/ointment, OTC chloroxine CAPITROL collagenase oint SANTYL QL fluorouracil CARAC 0.5% cream fluorouracil EFUDEX fluorouracil FLUOROPLEX 1% cream hexachlorophene PHISOHEX PROCTOSOL HC CREAM 2.5% hydrocortisone PROCTOZONE CREAM-HC 2.5% ANUSOL HC 2.5% imiquimod 5% cream ALDARA PA ketoconazole NIZORAL SHAMPOO shampoo 2% lidocaine LIDAMANTEL 3% cream lidocaine LMX-4 4% cream (15 gm tubes), QL lidocaine XYLOCAINE jelly 2% lidocaine/prilocaine EMLA 2.5% cream nitroglycerin RECTIV 0.4% rectal ointment, PA cream QL, ST, Step therapy is pimecrolimus ELIDEL not required for members ages 2-11; not covered for members less than 2 years of age selenium sulfide SELSUN shampoo 2.5% ointment 0.03% ST, Step therapy is not required for tacrolimus PROTOPIC 0.03% members ages 2-11; not covered for members less than 2 years of age tacrolimus PROTOPIC 0.1% ointment 0.1%, ST (minimum age 16) urea 40% UREA 40% CREAM AND LOTION cream and lotion Ear, Nose & Throat Ear acetic acid VOSOL OTIC otic acetic acid/ aluminum acetate DOMEBORO OTIC acetic acid/ hydrocortisone VOSOL HC OTIC 17

25 Generic Name Brand Name benzocaine/antipyrine BENZOTIC carbamide peroxide DEBROX 6.5%, OTC ciprofloxacin/ dexamethasone CIPRODEX PA neomycin/polymyxin B/ hydrocortisone CORTISPORIN OTIC otic ofloxacin FLOXIN OTIC Nose Antihistamines - First Generation, Sedating chlorpheniramine CHLOR-TRIMETON extended-release ALLERGY 12 mg, OTC chlorpheniramine maleate CHLOR-TRIMETON SYRUP 2 mg/5 ml, OTC clemastine CLEMASTINE cyproheptadine CYPROHEPTADINE diphenhydramine diphenhydramine BENADRYL OTC hydroxyzine HCL ATARAX hydroxyzine pamoate VISTARIL Antihistamines - Second Generation, Nonsedating cetirizine ZYRTEC OTC cetirizine chew tab ZYRTEC CHEWABLE TABLET OTC, Members 8 years of age will require prior authorization. levocetirizine XYZAL tabs, ST loratadine ALAVERT CLARITIN OTC Antihistamines - Others Antihistamine/Decongestant Combinations azelastine ASTELIN spray Antihistamine/Decongestant Combinations - First Generation chlorpheniramine/ phenylephrine/ pyrilamine chlorpheniramine/ pseudoephedrine chlorpheniramine/ pseudoephedrine extended-release TRIOTANN ACTIFED OTC DECONAMINE SR 18

26 Generic Name Brand Name Antihistamine/Decongestant Combinations - Second Generation cetirizine hydrochloride/ pseudoephedrine hydrochloride 12 hours extended-release ZYRTEC-D 5 mg-120 mg tablet loratadine/ pseudoephedrine extended-release ALAVERT-D ALAVERT ALRG TAB/SINUS OTC ALLERY/CONG Nasal Steroids fluticasone FLONASE triamcinolone nasal spray NASACORT ALLERGY 24 HOUR OTC Miscellaneous Nasal Decongestants oxymetazoline AFRIN OTC NEO-SYNEPHRINE phenylephrine DIMEATAPP DRO OTC DECONGES Miscellaneous Nasal cromolyn sodium NASALCROM OTC saline nasal spray 0.65% OCEAN NASAL SPRAY OTC Throat and Mouth artificial saliva OTC chlorhexidine gluconate PERIDEX lidocaine viscous XYLOCAINE pilocarpine SALAGEN triamcinolone KENALOG IN ORABASE paste Endocrinology Adrenal Corticosteroids cortisone acetate dexamethasone DECADRON fludrocortisone FLORINEF hydrocortisone CORTEF methylprednisolone MEDROL prednisolone 19

27 Generic Name Brand Name prednisolone sodium ORAPRED phosphate PEDIAPRED prednisolone PRELONE syrup prednisone DELTASONE Androgens testosterone cypionate DEPO-TESTOSTERONE testosterone enanthate DELATESTRYL Vials only. Disposable syringes not covered. testosterone gel topical tube, packet, and pump bottle Diabetes Mellitus Glucose Elevating Agents glucagon, human TESTOSTERONE 1% TOPICAL GEL PA GLUCAGON QL recombinant Insulins insulin aspart NOVOLOG QL insulin aspart protamine 70%/ insulin aspart 30% NOVOLOG MIX 70/30 QL insulin glargine LANTUS QL insulin human NOVOLIN R OTC, QL insulin human RELION R OTC, QL insulin isophane HUMULIN N OTC, QL insulin isophane human NOVOLIN N OTC, QL insulin isophane human RELION N OTC, QL insulin isophane human NOVOLIN 70/30 OTC, QL 70%/regular 30% insulin isophane human 70%/regular 30% RELION 70/30 OTC, QL insulin isophane/regular HUMULIN 70/30 OTC, QL insulin lisopro pro/lispro HUMALOG MIX 50/50 QL insulin lisopro prot/lispro HUMALOG MIX 75/25 QL insulin lispro HUMALOG QL insulin regular HUMULIN R OTC, QL 20

28 Generic Name Brand Name Monitoring - Strips and Kits/Diabetic Supplies ONE TOUCH SYSTEMS (ULTRA 2, ULTRAMINI, VERIO, VERIO FLEX, VERIO IQ, VERIO SYNC) ONE TOUCH TEST STRIPS (ULTRA, VERIO) QL for insulin dependent or pregnant members: allow testing up to 6 times per day QL for non-insulin dependent members: allow once daily testing Oral Agents acarbose PRECOSE canagliflozin INVOKANA ST canagliflozin/metformin INVOKAMET ST chlorpropamide DIABINESE empagliflozin JARDIANCE ST empagliflozin/metformin SYNJARDY ST glimepiride AMARYL glipizide GLUCOTROL glipizide extended-release GLUCOTROL XL glyburide MICRONASE glyburide, micronized GLYNASE linagliptin TRADJENTA ST linagliptin/metformin JENTADUETO ST metformin GLUCOPHAGE metformin ER GLUCOPHAGE ER metformin/glyburide GLUCOVANCE nateglinide STARLIX pioglitazone ACTOS QL pioglitazone/glimepiride DUETACT ST pioglitazone/metformin ACTOPLUSMET QL, ST pioglitazone/metformin ER ACTOPLUS MET XR ST repaglinide PRANDIN saxagliptin ONGLYZA ST saxagliptin/metformin KOMBIGLYZE ST tolazamide TOLINASE tolbutamide TOLBUTAMIDE 21

29 Generic Name Brand Name Miscellaneous Antidiabetic Agents albiglutide TANZEUM ST liraglutide VICTOZA ST pramlintide SYMLIN PA Growth Stimulating Agents mecasermin INCRELEX PA, SP somatropin NUTROPIN AQ NUSPIN PA, SP Osteoporosis alendronate FOSAMAX QL calcitonin-salmon MIACALCIN inj calcitonin-salmon MIACALCIN FORTICAL nasal spray, QL etidronate DIDRONEL raloxifene EVISTA teriparatide inj FORTEO PA, SP Thyroid Disease levothyroxine LEVOXYL levothyroxine SYNTHROID liothyronine CYTOMEL liotrix THYROLAR methimazole TAPAZOLE propylthiouracil PROPYLTHIOURACIL Miscellaneous cabergoline DOSTINEX cholic acid CHOLBAM PA, SP desmopressin DDAVP QL methylergonovine METHERGINE mifeprstone KOR LYM PA, SP pegvisomant SOMAVERT PA, SP Gastrointestinal Diarrhea diphenoxylate/atropine LOMOTIL loperamide IMODIUM A-D OTC loperamide LOPERAMIDE Emesis aprepitant EMEND QL applies to 40 mg, 80 mg and mg dronabinol MARINOL PA meclizine ANTIVERT 22

30 Generic Name Brand Name metoclopramide REGLAN ondansetron ZOFRAN ZOFRAN ODT QL prochlorperazine COMPAZINE promethazine PHENERGAN thiethylperazine TORECAN trimethobenzamide TIGAN 300 mg caps Gastroesophageal Reflux Disease (Gerd)/Peptic Ulcers alginic acid/sodium bicarbonate OTC alumina/magnesia MAALOX OTC alumina/magnesia/ simethicone MYLANTA OTC cimetidine TAGAMET esomeprazole NEXIUM 24HR OTC PA esomeprazole granules famotidine NEXIUM DELAYED- RELEASE PACKET PEPCID PEPCID AC Members 2 years of age will require prior authorization. OTC Pepcid AC 10 mg and 20 mg also covered/ encouraged with written prescription. lansoprazole PREVACID PA lansoprazole delayed-release PREVACID SOLUTAB orally disintegrating tabs, Members 2 years of age will require prior authorization. QL omeprazole delayed-release PRILOSEC Capsules only, QL pantoprazole PROTONIX ranitidine ZANTAC 150 mg tabs ranitidine syrup ZANTAC sucralfate CARAFATE sulcralfate CARAFATE SUSPENSION suspension, Members 10 years of age up to 65 years of age will require prior authorization. 23

31 Generic Name Brand Name Gastrointestinal Spasm dicyclomine BENTYL glycopyrrolate ROBINUL hyoscyamine sulfate LEVSIN hyoscyamine sulfate extended-release LEVSINEX Inflammatory Bowel Disease balsalazide COLAZAL budesonide ENTOCORT EC PA hydrocortisone COLOCORT enema mesalamine APRISO LIALDA mesalamine ROWASA enema only mesalamine extended-release PENTASA mesalamine supp CANASA olsalazine sodium DIPENTUM sulfasalazine AZULFIDINE sulfasalazine delayed-release AZULFIDINE EN-TABS Laxatives casanthranol-docusate sodium OTC docusate calcium plus OTC docusate potasssium OTC glycerin GLYCERIN SUPPOSITORY suppository, OTC lactulose ENULOSE peg 3350/electrolytes COLYTE peg 3350/sodium bicarbonate/sodium chloride/potassium chloride peg 3350/sodium bicarbonate/sodium chloride NULYTELY TRILYTE polyethylene glycol 3350 MIRALAX sennosides SENOKOT 8.6 mg tab, OTC 24

32 Generic Name Pancreatic Enzymes pancrelipase Brand Name CREON CREON 3000 UNIT ZENPEP Probiotic Supplementation acidophilus ACIDOPHILUS caps and tabs, OTC acidophilus ACIDOPHILUS XTRA OTC acidophilus/bifidus ACIDOPHILUS/ BIFIDUS WAFER OTC acidophilus/citrus pectin ACIDOPHILUS/ CITRUS PECTIN tabs, OTC acidophilus/pectin ACIDOPHILUS/PECTIN caps, OTC lactobacillus FLORANEX chewable tablets, OTC probiotic product PROBIOTIC FORMULA caps, OTC Miscellaneous atropine sulfate SAL-TROPINE bismuth subsalicylate + metronidazole + HELIDAC tetracycline misoprostol CYTOTEC naloxegol MOVANTIK PA teduglutide GATTEX PA, SP ACTIGALL ursodiol Home Infusion s URSO URSO FORTE Analgesics - NSAIDS ketorolac tromethamine im inj KETOROLAC INJ 30 mg/ml ketorolac tromethamine inj KETOROLAC INJ 30 mg/ml Analgesics - OPIOD fentanyl citrate inj FENTANYL CIT INJ 0.05 mg/ml morphine sulfate inj ASTRAMOR INJ 4 mg/ml morphine sulfate inj DURAMORPH INJ 10 mg/ml morphine sulfate inj MORPHINE SUL INJ 15 mg/ml morphine sulfate inj MORPHINE SUL INJ 2 mg/ml morphine sulfate iv soln MORPHINE SUL INJ 50 mg/ml 25

33 Generic Name Brand Name Antiasthmatic and Bronchodilator Agents epinephrine hcl inj ADRENALIN INJ 1 MG/ML 1 mg/ml Antibiotics acyclovir sodium for inj ACYCLOVIR NA INJ 500 MG 500 mg acyclovir sodium for inj ACYCLOVIR NA INJ 1000 MG 1000 mg acyclovir sodium iv soln ACYCLOVIR NA INJ 50 MG/ML 50 mg/ml amikacin sulfate inj AMIKACIN INJ 250 mg/ml amikacin sulfate inj AMIKACIN INJ 100/2 ML 100 mg/2ml (50 mg/ml) amphotericin b cholesteryl AMPHOTEC INJ 50 MG sulfate complex for inj 50 mg amphotericin b cholesteryl AMPHOTEC INJ 100 MG sulfate complex for inj 100 mg amphotericin b for inj AMPHOTERICIN INJ 50 MG 50 mg amphotericin b lipid inj susp (for iv infusion) ABELCET INJ 5 MG/ML 5 mg/ml amphotericin b liposome iv for susp AMBISOME INJ 50 MG 50 mg ampicillin & sulbactam AMP-SULBACTA INJ gm sodium for inj 1.5 GM ampicillin & sulbactam AMP-SULBACTA INJ sodium for inj 2-1 GM 2-1 gm ampicillin & sulbactam sodium for inj UNASYN INJ 15 GM 10-5 gm ampicillin & sulbactam AMP-SULBACTA INJ sodium for iv soln 1.5 GM gm ampicillin & sulbactam AMP-SULBACTA INJ sodium for iv soln 3 GM 2-1 gm ampicillin sodium for inj AMPICILLIN INJ 1 GM 1 gm ampicillin sodium for inj AMPICILLIN INJ 2 GM 2 gm ampicillin sodium for inj AMPICILLIN INJ 10 GM 10 gm ampicillin sodium for inj AMPICILLIN INJ 125 MG 125 mg ampicillin sodium for inj AMPICILLIN INJ 250 MG 250 mg ampicillin sodium for inj AMPICILLIN INJ 500 MG 500 mg ampicillin sodium for iv soln AMPICILLIN INJ 1 GM 1 gm 26

34 Generic Name Brand Name ampicillin sodium for iv soln AMPICILLIN INJ 2 GM 2 gm azithromycin iv for soln AZITHROMYCIN INJ 500 MG 500 mg aztreonam for inj AZACTAM INJ 1 GM 1 gm aztreonam for inj AZACTAM INJ 2 GM 2 gm aztreonam in dextrose inj AZACTAM/DEX INJ 1 GM 1 gm/50 ml aztreonam in dextrose inj AZACTAM/DEX INJ 2 GM 2 gm/50 ml bacitracin intramuscular for soln BACIIM INJ UNT unit capreomycin sulfate for inj CAPASTAT SUL INJ 1 GM 1 gm caspofungin acetate for iv CANCIDAS INJ 50 MG 50 mg soln caspofungin acetate for iv soln cefazolin in d5w inj CANCIDAS INJ 70 MG 70 mg CEFAZOLIN INJ 1 GM/ 50 ML 1 gm/50 ml cefazolin sodium (bulk) for inj CEFAZOLIN INJ 100 GM 100 gm cefazolin sodium (bulk) for inj CEFAZOLIN INJ 300 GM 300 gm cefazolin sodium for inj ANCEF INJ 1 gm cefazolin sodium for inj CEFAZOLIN INJ 10 GM 10 gm cefazolin sodium for inj CEFAZOLIN INJ 20 GM 20 gm cefazolin sodium for inj CEFAZOLIN INJ 500 MG 500 mg cefazolin sodium for iv soln cefazolin sodium for iv soln 1 gm and dextrose 4% CEFAZOLIN INJ 1 GM 1 gm CEFAZOL/DEX SOL 1 GM cefepime hcl for inj CEFEPIME INJ 1 GM 1 gm cefepime hcl for inj CEFEPIME INJ 2 GM 2 gm cefotaxime sodium for inj CEFOTAXIME INJ 1 GM 1 gm cefotaxime sodium for inj CEFOTAXIME INJ 2 GM 2 gm cefotaxime sodium for inj CEFOTAXIME INJ 10 GM 10 gm cefotaxime sodium for inj CEFOTAXIME INJ 500 MG 500 mg cefotaxime sodium for iv soln cefotaxime sodium for iv soln CLAFORAN INJ 1 GM 1 gm CLAFORAN INJ 2 GM 2 gm 27

35 Generic Name Brand Name cefotaxime sodium in d5w CLAFORAN/D5W INJ iv soln 1 GM 1 gm/50 ml cefotaxime sodium in d5w CLAFORAN/D5W INJ iv soln 2 GM 2 gm/50 ml cefotetan disodium for inj CEFOTETAN INJ 1 GM/10 ML 1 gm cefotetan disodium for inj CEFOTETAN INJ 2 GM/ 20 ML 2 gm cefotetan disodium for inj CEFOTETAN INJ 10 G 10 gm cefoxitin sodium for inj CEFOXITIN INJ 1 GM 1 gm cefoxitin sodium for inj CEFOXITIN INJ 2 GM 2 gm cefoxitin sodium for inj CEFOXITIN INJ 10 GM 10 gm cefoxitin sodium iv for soln CEFOXITIN INJ 1 GM 1 gm and dextrose 4% cefoxitin sodium iv for soln 2 gm and dextrose CEFOXITIN INJ 2 GM 2.2% ceftazidime (bulk) for inj CEFTAZIDIME INJ 100 GM 100 gm ceftazidime for inj CEFTAZIDIME INJ 1 GM 1 gm ceftazidime for inj CEFTAZIDIME INJ 2 GM 2 gm ceftazidime for inj CEFTAZIDIME INJ 6 GM 6 gm ceftazidime for inj FORTAZ INJ 500 MG 500 mg ceftazidime for iv soln FORTAZ INJ 1 GM 1 gm ceftazidime for iv soln FORTAZ INJ 2 GM 2 gm ceftazidime sodium in d5w inj FORTAZ INJ 1 GM 1 gm/50 ml ceftazidime sodium in d5w inj FORTAZ INJ 2 GM 2 gm/50 ml ceftazidime sodium in dextrose inj TAZICEF INJ 1 GM/50 ML 1 gm/50 ml ceftriaxone sodium for inj CEFTRIAXONE INJ 1 gm ceftriaxone sodium for inj CEFTRIAXONE INJ 2 gm ceftriaxone sodium for inj CEFTRIAXONE INJ 10 GM 10 gm ceftriaxone sodium for inj CEFTRIAXONE INJ 500 mg ceftriaxone sodium for iv soln CEFTRIAXONE INJ 1 GM 1 gm ceftriaxone sodium for iv soln CEFTRIAXONE INJ 2 GM 2 gm 28

36 Generic Name ceftriaxone sodium for iv soln 1 gm and dextrose 3.74% ceftriaxone sodium for iv soln 2 gm and dextrose 2.22% ceftriaxone sodium in dextrose inj ceftriaxone sodium in dextrose inj cefuroxime in sterile water inj cefuroxime sodium (bulk) for inj cefuroxime sodium (bulk) for inj cefuroxime sodium 1.5 gm and dextrose 2.9% for iv soln Brand Name CEFTRIAX/DEX INJ CEFTRIAX/DEX INJ 2 GM CEFTRIAXONE/ INJ DEX 20 mg/ml CEFTRIAXONE/ INJ DEX 2 GM ZINACEF/H20 INJ 1.5 GM PB 40 mg/ml 1.5 gm/50 ml CEFUROXIME INJ 75 GM 75 gm CEFUROXIME INJ 225 GM 225 gm CEFUROX/DEXT INJ 1.5 GM cefuroxime sodium for inj CEFUROXIME INJ 1.5 GM 1.5 gm cefuroxime sodium for inj CEFUROXIME INJ 7.5 GM 7.5 gm cefuroxime sodium for inj CEFUROXIME INJ 750 MG 750 mg cefuroxime sodium for iv soln CEFUROXIME INJ 1.5 GM 1.5 gm cefuroxime sodium for iv soln ZINACEF INJ 750 MG 750 mg cefuroxime sodium in d5w ZINACEF/D5W INJ inj 750 MG PB 15 mg/ml chloramphenicol sodium CHLORAMPHEN INJ succinate for iv inj 1 GM 1 gm ciprofloxacin 0.2% in d5w CIPRO I.V. SOL ciprofloxacin iv soln 1% CIPRO I.V. INJ clindamycin phosphate in CLEOCIN/D5W INJ d5w iv soln 300 MG 300 mg/50 ml clindamycin phosphate in d5w iv soln CLEOCIN INJ 600 MG 600 mg/50 ml clindamycin phosphate in d5w iv soln CLEOCIN INJ 900 MG 900 mg/50 ml clindamycin phosphate inj CLEOCIN PHOS INJ 150 mg/ml colistimethate sodium for inj COLISTIMETH INJ 150 MG 150 mg 29

37 Generic Name Brand Name doxycycline hyclate for inj DOXYCYCL HYC INJ 100 MG 100 mg ertapenem sodium for inj INVANZ INJ 1 GM 1 gm (base equivalent) erythromycin lactobionate ERYTHROCIN INJ for inj 500 MG 500 mg erythromycin lactobionate ERYTHROCIN INJ for inj 1000 MG 1000 mg fluconazole in dextrose inj FLUCONAZOLE/ INJ DEX mg/100 ml foscarnet sodium inj FOSCARNET INJ 24 MG/ML 24 mg/ml ganciclovir sodium for inj CYTOVENE INJ 500 MG 500 mg gentamicin in saline inj GENTAM/NACL INJ 80 MG 0.8 mg/ml gentamicin in saline inj GENTAM/NACL INJ 80 MG 1.6 mg/ml gentamicin in saline inj GENTAM/NACL INJ 100 MG 1 mg/ml gentamicin in saline inj GENTAM/NACL INJ 120 MG 1.2 mg/ml gentamicin in saline inj GENTAM/NACL INJ 100 MG PB 2 mg/ml gentamicin in saline inj GENTAM/NACL INJ 0.9 MG/ML 0.9 mg/ml gentamicin in saline inj GENTAM/NACL INJ 1.4 MG/ML 1.4 mg/ml gentamicin sulfate inj GENTAMICIN INJ 10 MG/ML 10 mg/ml gentamicin sulfate inj GENTAMICIN INJ 40 MG/ML 40 mg/ml gentamicin sulfate iv soln GENTAMICIN INJ 10 MG/ML 10 mg/ml imipenem-cilastatin intravenous for soln IMIPENEM/CIL INJ 500 mg imipenem-cilastatin IMIPENEM/CIL INJ 250 intravenous for soln MG 250 mg isoniazid inj ISONIAZID INJ 100 MG/ML 100 mg/ml kanamycin sulfate inj KANAMYCIN INJ 333 MG/ML 333 mg/ml levofloxacin iv soln LEVAQUIN INJ 25 mg/ml 30

38 Generic Name Brand Name levofloxacin in d5w iv soln 5 mg/ml lincomycin hcl inj LINCOCIN INJ 300 MG/ML 300 mg/ml linezolid iv soln ZYVOX SOL 2 MG/ML 2 mg/ml meropenem iv for soln MEROPENEM INJ 1 GM 1 gm meropenem iv for soln MEROPENEM INJ 500 MG 500 mg metronidazole in nacl METRO IV INJ 5 MG/ML 500 mg/100 ml 0.74% iv soln metronidazole in nacl METRON/NACL INJ % iv soln MG micafungin sodium for iv soln MYCAMINE INJ 50 MG 50 mg minocycline hcl iv for soln MINOCIN INJ 100 MG 100 mg moxifloxacin hcl 400 mg/250 ml in sodium chloride 0.8% inj AVELOX INJ 500 mg/100 ml nafcillin sodium for inj NAFCILLIN INJ 1 GM 1 gm nafcillin sodium for inj NAFCILLIN INJ 2 GM 2 gm nafcillin sodium for inj NAFCILLIN INJ 10 GM 10 gm nafcillin sodium for iv soln NAFCILLIN INJ 1 GM 1 gm nafcillin sodium for iv soln NAFCILLIN INJ 2 GM 2 gm nafcillin sodium in NALLPEN/DEX INJ dextrose inj 1 GM/50 ML 1 gm/50 ml nafcillin sodium in dextrose inj NALLPEN/DEX INJ 2 GM 2 gm/50 ml oxacillin sodium for inj OXACILLIN INJ 1 GM 1 gm oxacillin sodium for inj OXACILLIN INJ 2 GM 2 gm oxacillin sodium for inj OXACILLIN INJ 10 GM 10 gm oxacillin sodium in dextrose inj oxacillin sodium in dextrose inj penicillin g benzathine & procaine inj penicillin g benzathine intramuscular susp penicillin g potassium for inj BACTOCILL INJ DEX 1 GM BACTOCILL INJ DEX 2 GM BICILLIN C-R INJ 900/300 1 gm/50 ml 2 gm/50 ml unt/2 ml BICILLIN L-A INJ unit/ml PENICILLN GK INJ 20 MU unit 31

39 Generic Name Brand Name penicillin g potassium for inj PENICILLN GK INJ 5 MU unit penicillin g potassium inj PENICILL GK/ INJ DEX 1 MU unit/ml in dextrose penicillin g potassium inj PENICILL GK/ INJ DEX 2 MU unit/ml in dextrose penicillin g potassium inj PENICILL GK/ INJ DEX 3 MU unit/ml in dextrose penicillin g procaine intramuscular susp PEN G PROC INJ unit/ml penicillin g sodium for inj PEN G SOD INJ unit pentamidine isethionate for soln PENTAM 300 INJ 300 MG 300 mg piperacillin sodiumtazobactam sodium PIPER/TAZOBA INJ gm for inj piperacillin sodiumtazobactam sodium PIPER/TAZOBA INJ gm for inj piperacillin sodium- PIPER/TAZOBA INJ tazobactam sodium GM for inj gm piperacillin sodiumtazobactam sodium for inj piperacillin sodtazobactam sod in dex iv sol piperacillin sodtazobactam sod in dex iv soln PIPER/TAZOBA INJ GM gm ZOSYN SOL gm/50 ml ZOSYN SOL GM gm/50ml polymyxin b sulfate for inj POLYMYXIN B INJ unit rifampin for inj RIFADIN INJ 600 MG 600 mg streptomycin sulfate for inj STREPTOMYCIN INJ 1GM 1 gm sulfamethoxazole- trimethoprim iv soln ticarcillin & k clavulanate for inj ticarcillin & k clavulanate inj SMZ-TMP INJ / mg/5 ml TIMENTIN INJ 3.1 GM 3.1 gm TIMENTIN INJ 3.1 GM 3.1 gm/100 ml 32

40 Generic Name Brand Name ticarcillin & k clavulanate for inj TIMENTIN INJ 31 GM 31 gm tobramycin sulfate for inj TOBRAMYCIN INJ 1.2 GM 1.2 gm tobramycin sulfate inj TOBRA/NACL INJ 60/ mg/ml in saline tobramycin sulfate inj TOBRA/NACL INJ 80/ mg/ml in saline tobramycin sulfate inj TOBRAMYCIN INJ 10 MG/ML 10 mg/ml vancomycin hcl for inj VANCOCIN HCL INJ 500 mg vancomycin hcl for inj VANCOCIN HCL INJ 1000 mg vancomycin hcl in dextrose inj VANCOCIN/DEX INJ 500 mg/100 ml Antihistamines diphenhydramine hcl inj BENA-D-50 INJ 50 mg/ml promethazine hcl inj ANERGAN 25 INJ 25 mg/ml promethazine hcl inj PHENERGAN NJ 50 MG/ML 50 mg/ml Antipsychotics/Antimanic Agents prochlorperazine PROCHLORPER INJ edisylate inj 5 MG/ML 5 mg/ml Corticosteroids betamethasone sod BETA-PHOS/AC INJ phosphate & acetate 3-3MG/ML inj susp 6 (3-3) mg/ml dexamethasone sodium DEXAMETH PHO INJ phosphate inj 4 MG/ML 4 mg/ml dexamethasone sodium DEXAMETH PHO INJ phosphate inj 10 MG/ML 10 mg/ml hydrocortisone sodium A-HYDROCORT INJ succinate for inj 100 MG 100 mg hydrocortisone sodium SOLU-CORTEF INJ succinate for inj 250 MG 250 mg hydrocortisone sodium SOLU-CORTEF INJ succinate for inj 500 MG 500 mg hydrocortisone sodium SOLU-CORTEF INJ succinate for inj 1000 MG 1000 mg methylprednisolone DEPO-MEDROL INJ acetate inj susp 20 MG/ML 20 mg/ml methylprednisolone DEPO-MEDROL INJ 40 mg/ml acetate inj susp methylprednisolone acetate inj susp 40 MG/ML DEPO-MEDROL INJ 80 MG/ML 80 mg/ml 33

41 Generic Name methylprednisolone sodium succinate for inj methylprednisolone sodium succinate for inj methylprednisolone sodium succinate for inj methylprednisolone sodium succinate for inj methylprednisolone sodium succinate for inj triamcinolone acetonide inj susp triamcinolone acetonide inj susp triamcinolone hexacetonide inj susp triamcinolone Brand Name A-METHAPRED INJ 40 MG A-METHAPRED INJ 125 MG METHYLPR SS INJ 1000 MG 40 mg 125 mg 1000 mg SOLU-MEDROL INJ 2 GM 2000 mg METHYLPR SS INJ 500 MG KENALOG-10 INJ 10 MG/ML KENALOG-40 INJ 40 MG/ML ARISTOSPAN INJ 5 MG/ML ARISTOSPAN INJ 20 MG/ML 500 mg 10 mg/ml 40 mg/ml 5 mg/ml 20 mg/ml hexacetonide inj susp Diuretics furosemide inj DIAQUA-2 INJ 10 mg/ml Electrolyte Mixtures dextrose 5% w/ sodium chloride 0.45% D5W/NACL INJ Gastrointestinal Agents cimetidine hcl inj CIMETIDINE INJ 150 MG/ML 150 mg/ml cimetidine in saline inj CIMETID/NACL INJ 300/50 ML 6 mg/ml dicyclomine hcl inj BENTYL INJ 10 MG/ML 10 mg/ml dimenhydrinate inj DIMENHYDRIN INJ 50 MG/ML 50 mg/ml esomeprazole sodium for intravenous soln esomeprazole sodium for intravenous soln NEXIUM I.V. INJ 20 MG 20 mg NEXIUM I.V. INJ 40 MG 40 mg 34

42 Generic Name famotidine in nacl 0.9% iv soln famotidine inj granisetron hcl inj metoclopramide hcl inj pantoprazole sodium for iv soln ranitidine hcl in nacl 0.45% iv soln Genitourinary Irrigants sodium chloride irrigation soln 0.9% Brand Name FAMOTIDINE INJ 20 MG/ 50 M FAMOTIDINE INJ 10 MG/ML GRANISETRON INJ 0.1 MG/ML METOCLOPRAM INJ 5 MG/ML 20 mg/50 ml 10 mg/ml 0.1 mg/ml 5 mg/ml PROTONIX INJ 40 MG 40 mg (base equiv) ZANTAC INJ 50/50 ML 50 mg/50 ml Hematological Agents alteplase for inj ACTIVASE INJ 50 MG 50 mg alteplase for inj ACTIVASE INJ 100 MG 100 mg alteplase for inj CATHFLO ACTI INJ VASE 2 mg Minerals & Electrolytes electrolyte-48 in d5w soln D5W/LYTES INJ #48 PLASMA-LYTE INJ 56/ electrolyte-56 in d5w soln D5W electrolyte-148 in d5w soln PLASMA-LYTE INJ /D5W electrolyte-b in d5w soln IONOSOL-B/ INJ D5W electrolyte-h in d5w soln ISOLYTE-H INJ /D5W electrolyte-m in d5w soln ISOLYTE-M INJ /D5W electrolyte-mb in d5w IONOSOL-MB INJ /D5W soln electrolyte-p in d5w soln ISOLYTE-P INJ /D5W electrolyte-r in d5w soln NORMOSOL -R INJ /D5W electrolyte-s in d5w soln ISOLYTE-S INJ /D5W dextrose 2.5% w/sodium chloride 0.45% D2.5W/NACL INJ 0.45% dextrose 5% in lactated ringers D5W/LR INJ dextrose 5% in ringers D5W/RINGERS INJ dextrose 5% w/sodium chloride 0.2% D5W/NACL INJ 0.2% 35

43 Generic Name dextrose 5% w/sodium chloride 0.225% dextrose 5% w/sodium chloride 0.33% dextrose 5% w/sodium chloride 0.9% dextrose 10% w/sodium chloride 0.2% dextrose 10% w/sodium chloride 0.45% dextrose 10% w/sodium chloride 0.9% kcl 10 meq/l (0.075%) in dextrose 5% & nacl 0.2% inj kcl 10 meq/l (0.075%) in dextrose 5% & nacl 0.45% inj kcl 20 meq/l (0.15%) in dextrose 5% & nacl 0.2% inj kcl 20 meq/l (0.15%) in dextrose 5% & nacl 0.225% inj kcl 20 meq/l (0.15%) in dextrose 5% & nacl 0.33% inj kcl 20 meq/l (0.15%) in dextrose 5% & nacl 0.45% inj kcl 20 meq/l (0.15%) in dextrose 5% & nacl 0.9% inj kcl 30 meq/l (0.224%) in dextrose 5% & nacl 0.2% inj kcl 30 meq/l (0.224%) in dextrose 5% & nacl 0.45% inj Brand Name D5W/NACL INJ 0.225% D5W/NACL INJ 0.33% D5W/NACL INJ 0.9% D10W/NACL INJ 0.2% D10W/NACL INJ 0.45% D10W/NACL INJ 0.9% KCL/D5W/NACL INJ.075/.2% KCL/D5W/NACL INJ.075/.45 KCL/D5W/NACL INJ 0.15/0.2 KCL/D5W/NACL INJ 0.15/0.2 KCL/D5W/NACL INJ.15/.33% KCL/D5W/NACL INJ % KCL/D5W/NACL INJ 0.15/0.9 KCL/D5W/NACL INJ.224/0.2 KCL/D5W/NACL INJ.22/.45 36

44 Generic Name kcl 40 meq/l (0.3%) in dextrose 5% & nacl 0.2% inj kcl 40 meq/l (0.3%) in dextrose 5% & nacl 0.45% inj kcl 40 meq/l (0.3%) in dextrose 5% & nacl 0.9% inj potassium chloride 20 meq/l (0.15%) in d5w lactated ringers potassium chloride 20 meq/l (0.15%) in dextrose 5% inj potassium chloride 30 meq/l (0.224%) in dextrose 5% inj potassium chloride 40 meq/l (0.3%) in d5w lactated ringers potassium chloride 40 meq/l (0.3%) in dextrose 5% inj Brand Name KCL/D5W/NACL INJ 0.3/0.2% KCL/D5W/NACL INJ 0.3/0.45 KCL/D5W/NACL INJ 0.3/0.9% KCL/D5W/LR INJ 0.15% KCL/D5W INJ 0.15% KCL/D5W INJ 0.224% KCL/D5W/LR INJ 0.3% KCL/D5W INJ 0.3% sodium chloride inj 0.45% SOD CHLORIDE INJ sodium chloride inj 0.9% BD POSIFLUSH INJ sodium chloride iv soln 0.9% SOD CHLORIDE INJ Nutrients dextrose inj DEXTROSE INJ 2.5% 2.5% dextrose inj DEXTROSE INJ 5% 5% dextrose inj DEXTROSE INJ 10% 10% dextrose inj DEXTROSE INJ 20% 20% dextrose inj DEXTROSE INJ 25% 25% dextrose inj DEXTROSE INJ 30% 30% dextrose inj DEXTROSE INJ 40% 40% dextrose inj DEXTROSE INJ 50% 50% dextrose inj DEXTROSE INJ 70% 70% Vitamins phytonadione inj AQUA-MEPHYTO INJ 10 mg/ml 37

45 Generic Name Brand Name Infectious Diseases Anthelmintics albendazole ALBENZA ivermectin STROMECTOL praziquantel BILTRICIDE PA Antibacterials Antituberculosis Agents aminosalicyclic acid PASER cycloserine SEROMYCIN ethambutol MYAMBUTOL ethionamide TRECATOR isoniazid ISONIAZID pyrazinamide PYRAZINAMIDE rifabutin MYCOBUTIN rifampin RIFADIN rifapentine PRIFTIN Cephalosporins - First Generation cefadroxil DURICEF cephalexin KEFLEX tabs are not covered Cephalosporins - Second Generation cefaclor CECLOR cefprozil CEFZIL cefuroxime axetil CEFTIN Cephalosporins - Third Generation cefdinir OMNICEF cefixime SUPRAX 400 mg caps only, QL Fluoroquinolones ciprofloxacin CIPRO levofloxacin LEVAQUIN tablets only ofloxacin FLOXIN tabs Macrolides azithromycin ZITHROMAX QL clarithromycin BIAXIN clarithromycin ER BIAXIN XL erythromycin delayed-release ERYC erythromycin delayed-release ERY-TAB erythromycin ethylsuccinate E.E.S. 38

46 Generic Name Brand Name erythromycin stearate ERYTHROCIN erythromycin/sulfisoxazole PEDIAZOLE Penicillins amoxicillin AMOXICILLIN CAPSULES Except 500 mg and 875 mg film-coated tabs. AND CHEWABLES amoxicillin AMOXIL SUSP suspension amoxicillin/clavulanate AUGMENTIN ampicillin PRINCIPEN dicloxacillin DICLOXACILLIN penicillin VK VEETIDS Sulfonamides sulfamethoxazole/ trimethoprim, DS BACTRIM BACTRIM DS sulfisoxazole Tetracyclines doxycycline monohydrate DOXYCYCLINE MONOHYDRATE minocycline MINOCIN capsules, except 75 mg tetracycline SUMYCIN Miscellaneous vancomycin HCl VANCOCIN HCL cap, ST Antifungals clotrimazole MYCELEX troches fluconazole DIFLUCAN QL griseofulvin microsize GRIFULVIN V griseofulvin ultramicrosize GRIS-PEG itraconazole SPORANOX PA, QL ketoconazole NIZORAL nystatin MYCOSTATIN terbinafine LAMISIL QL voriconazole VFEND PA Antivirals Cytomegalovirus Treatment ganciclovir CYTOVENE valganciclovir VALCYTE tabs only Entry/Fusion Inhibitors enfuvirtide FUZEON KIT SP 39

47 Generic Name Brand Name Hepatitis Treatment adefovir HEPSERA entecavir BARACLUDE interferon alfa-2b INTRON A PA, SP interferon alfacon-1 INFERGEN PA, SP lamivudine EPIVIR HBV peginterferon alfa-2a PEGASYS PA, SP peginterferon alfa-2a PEGASYS PROCLICK PA, SP ribavirin REBETOL/COPEGUS 200 mg caps and tabs only, PA, SP Herpes Treatment acyclovir ZOVIRAX valacyclovir VALTREX Influenza Treatment amantadine SYMMETREL except tabs oseltamivir TAMIFLU QL rimantadine FLUMADINE zanamivir RELENZA QL Miscellaneous atovaquone MEPRON PA bedaquiline SIRTURO PA chloroquine phosphate ARALEN clindamycin CLEOCIN 150 mg and 300 mg only dapsone DAPSONE dolutegravir TIVICAY etravirine INTELENCE hydroxychloroquine PLAQUENIL linezolid ZYVOX PA mefloquine LARIAM metronidazole FLAGYL tabs only neomycin sulfate nitazoxanide suspension ALINIA SUSPENSION Members 8 years of age will require prior authorization. nitazoxanide tablet ALINIA PA nitrofurantoin extended-release MACROBID nitrofurantoin macrocrystals MACRODANTIN nitrofurantoin macrocrystals MACRODANTIN 25 MG 40

48 Generic Name nitrofurantoin susp Brand Name FURADANTIN SUSP 25 MG/5 ML Members 8 years of age will require prior authorization. palivizumab SYNAGIS PA paromomycin HUMATIN povidone-iodine OTC primaquine pyrimethamine DARAPRIM PA trimethoprim TRIMETHOPRIM tabs only Musculoskeletal Arthritis Disease Modifying Anti-Rheumatic s adalimumab HUMIRA PA, SP auranofin RIDAURA azathioprine IMURAN certolizumab pegol CIMZIA PA, SP hydroxychloroquine PLAQUENIL leflunomide ARAVA methotrexate penicillamine CUPRIMINE penicillamine DEPEN TITRATABLE PA, SP sulfasalazine AZULFIDINE sulfasalazine delayed-release AZULFIDINE EN-TABS NSAIDs and Other Analgesics acetaminophen TYLENOL OTC aspirin BAYER OTC ECOTRIN capsaicin OTC celecoxib CELEBREX PA, QL choline magnesium trisalicylate TRILISATE diclofenac 1% gel VOLTAREN 1% TOPICAL GEL PA diclofenac potassium CATAFLAM diclofenac sodium delayed-release VOLTAREN diclofenac sodium extended-release VOLTAREN XR etodolac LODINE IR only 41

49 Generic Name Brand Name fenoprofen NALFON 600 mg ibuprofen ADVIL tabs, chew tabs and susp, OTC ibuprofen MOTRIN tabs, chew tabs and susp indomethacin INDOCIN ketoprofen ORUDIS IR only meloxicam MOBIC QL naproxen NAPROSYN naproxen delayed release ENTERIC CODED- NAPROSYN naproxen sodium ANAPROX oxaprozin DAYPRO piroxicam FELDENE sulindac CLINORIL Gout allopurinol ZYLOPRIM colchicine MITIGARE febuxostat ULORIC ST probenecid PROBENECID Skeletal Muscle Relaxants Muscle Spasm chlorzoxazone PARAFON FORTE DSC cyclobenzaprine FLEXERIL methocarbamol ROBAXIN orphenadrine extended-release NORFLEX Spasticity baclofen BACLOFEN dantrolene DANTRIUM diazepam VALIUM QL tizanidine ZANAFLEX tabs only, QL OB-GYN Contraceptives Biphasic desogestrel/ee MIRCETTE QL norethindrone/ee ORTHO-NOVUM 10/11 QL Emergency Contraception levonorgestrel PLAN B QL levonorgestrel PLAN B ONE STEP 1.5 mg tab 42

50 Generic Name Brand Name Extended Cycle levonorgestrel/ee SEASONALE QL Injectable medroxyprogesterone acetate DEPO-PROVERA QL Intravaginal etonogestrel/ee NUVARING ring, QL ORTHO COIL ortho diaphragm ORTHO FLAT ORTHO FLEX Monophasic - 20 mcg Estrogen levonorgestrel/ee ALESSE 0.1/20, QL norethindrone acetate/ee LOESTRIN 1/20 1/20, QL norethindrone acetate/ EE/iron LOESTRIN FE 1/20 1/20, QL Monophasic - 30 mcg Estrogen desogestrel/ee ORTHO-CEPT 0.15/30, QL levonorgestrel/ee NORDETTE 0.15/30, QL norethindrone acetate/ee LOESTRIN 1.5/30 1.5/30, QL norethindrone acetate/ EE/iron LOESTRIN FE 1.5/30 1.5/30, QL norgestrel/ee LO/OVRAL 0.3/30, QL Monophasic - 35 mcg Estrogen ethynodiol diacetate/ee ZOVIA 1/35 1/35, QL norethindrone/ee BALZIVA 0.4/35, QL norethindrone/ee MODICON 0.5/35, QL norethindrone/ee ORTHO-NOVUM 1/35 1/35, QL norgestimate/ee ORTHO-CYCLEN 0.25/35, QL Monophasic - 50 mcg Estrogen ethynodiol diacetate/ee ZOVIA 1/50 1/50, QL norethindrone/ee OVCON 50 1/50, QL norethindrone/me ORTHO-NOVUM 1/50 1/50, QL norgestrel/ee OVRAL 0.5/50, QL Progestin norethindrone ORTHO MICRONOR norgestrel OVRETTE Transdermal norelgestromin/ee ORTHO EVRA QL 43

51 Generic Name Brand Name Triphasic desogestrel/ee CYCLESSA QL levonorgestrel/ee TRIVORA QL norethindrone acetate/ee/iron ESTROSTEP FE QL norethindrone/ee ORTHO-NOVUM 7/7/7 QL norethindrone/ee TRI-NORINYL QL norgestimate/ee ORTHO TRI-CYCLEN QL Endometriosis danazol DANOCRINE Gender edits apply: for female patients only. Hormone Therapy/Menopause Estrogens - Intravaginal estradiol ESTRACE CRM estrogens, conjugated PREMARIN crm Estrogens - Oral estradiol ESTRACE estrogens, conjugated PREMARIN estrogens, conjugated, CENESTIN synthetic A estrogens, conjugated, synthetic B ENJUVIA estropipate OGEN Estrogens - Transdermal estradiol CLIMARA QL Estrogen/Progestin estrogens, conjugated/ medroxyprogesterone PREMPHASE PREMPRO Progestins medroxyprogesterone acetate PROVERA norethindrone acetate AYGESTIN Vaginal Infections Oral fluconazole DIFLUCAN QL metronidazole FLAGYL tabs Vaginal clindamycin CLEOCIN crm clotrimazole GYNE-LOTRIMIN OTC 44

52 Generic Name Brand Name metronidazole METROGEL-VAGINAL METROGEL 1% miconazole MONISTAT OTC miconazole MONISTAT 3 terconazole TERAZOL 3/7 crm Miscellaneous conjugated estrogen/ bazedoxifene DUAVEE methylergonovine METHERGINE Ophthalmic Allergy azelastine OPTIVAR ST cromolyn sodium CROLOM QL ketotifen ALAWAY OTC naphazoline/antazoline naphazoline/glycerin CLEAR EYES REDNESS RELIEF naphazoline HCL VASOCLEAR soln 0.02% naphazoline/zinc sulfate VASOCLEAR A tetrahydrozoline/ zinc sulfate VISINE-AC Anti-Inflammatories Anti-Infective/Anti-Inflammatory Combinations gentamicin/prednisolone acetate PRED-G neomycin/polymyxin B/ dexamethasone MAXITROL neomycin/polymyxin B/ hydrocortisone CORTISPORIN sulfacetamide/pred phos VASOCIDIN 10%/0.25% tobramycin/ dexamethasone TOBRADEX Nonsteroidal diclofenac sodium VOLTAREN flurbiprofen OCUFEN ketorolac ACULAR/ACULAR LS 45

53 Generic Name Brand Name Steroidal dexamethasone sodium phosphate DEXASOL fluorometholone FML oint 0.1% fluorometholone FML FORTE susp 0.25% fluorometholone FML LIQUIFILM susp 0.1% prednisolone acetate PRED FORTE 1% prednisolone acetate PRED MILD 0.12% prednisolone phosphate INFLAMASE FORTE 1% rimexolone VEXOL Glaucoma Beta-Blockers carteolol levobunolol BETAGAN ophthalmic solution metipranolol OPTIPRANOLOL 0.3% ophthalmic solution timolol TIMOPTIC XE gel forming solution timolol hemihydrate BETIMOL timolol maleate TIMOPTIC Carbonic Anhydrase Inhibitors dorzolamide TRUSOPT Carbonic Anhydrase Inhibitor/Beta-Blocker Combination dorzolamide/ timolol maleate COSOPT Cholinesterase Inhibitor ecothiophate PHOSPHOLINE IODINE Mydriatics atropine ISOPTO ATROPINE cyclopentolate CYCLOGYL homatropine ISOPTO HOMATROPINE scopolamine ISOPTO HYOSCINE Oral acetazolamide ACETAZOLAMIDE acetazolamide extended-release DIAMOX SEQUELS methazolamide NEPTAZANE Prostaglandins latanoprost XALATAN QL Topical - Parasympathomimetics pilocarpine ISOPTO CARPINE pilocarpine PILOPINE HS GEL 46

54 Generic Name Brand Name Topical - Sympathomimetics brimonidine ALPHAGAN P brimonidine BRIMONIDINE 0.2% Infections Bacterial bacitracin ciprofloxacin CILOXAN erythromycin ERYTHROMYCIN gatifloxin ZYMAR PA gentamicin GENTAK neomycin/polymyxin B/ gramicidin NEOSPORIN ofloxacin OCUFLOX polymyxin B/bacitracin POLYSPORIN polymyxin B/trimethoprim POLYTRIM sulfacetamide BLEPH-10 oint/soln sulfacetamide/ phenylephrine VASOSULF tobramycin TOBREX Viral trifluridine VIROPTIC Miscellaneous cysteamine 0.44% CYSTARAN PA, SP ophthalmic solution sodium chloride hypertonic Psychiatric MURO 128 soln 5% Insomnia Non-Benzodiazepines diphenhydramine NYTOL QUICK CAPS OTC Narcotic Antagonists naloxone NALOXONE INJ Psychoses dextromethorphan/ quinidine NUEDEXTA PA 47

55 Generic Name Brand Name Smoking Cessation nicotine NICODERM CQ patches, QL nicotine polacrilex gum NICORETTE OTC QL nicotine polacrilex lozenge COMMITT OTC QL varenicline CHANTIX QL Weight Loss orlistat ALLI OTC, PA Respiratory s Antitussives, Decongestants, Expectorants and Combinations benzonatate TESSALON brompheniramine & DIMETAPP CLD ELX/ phenylephrine ALLERGY brompheniramine/ ACCUHIST DROPS pseudoephedrine RESPERAL-DM BROMFENEX PD CAP brompheniramine/ pseudoephedrine brompheniramine/ pseudoephedrine brompheniramine/ pseudoephedrine/ dextromethorphan brompheniramine/ pseudoephedrine/ dextromethorphan brompheniramine/ pseudoephedrine/ dextromethorphan brompheniramine/ pseudoephedrine/ dextromethorphan/ guaifenesin DIMETAPP ELX CLD/ALLE UNI-HIST DRO CARDEC SYP liquid RONDEC SYRUP syrup ACCUHIST PDX DROPS liquid BROMALINE DM elixir BROMFED DM DALLERGY DM CARBOFED NEO DM ANAPLEX DM syrup HISTACOL DM syrup 48

56 Generic Name carbetapentane/ chlorpheniramine/ ephedrine/ phenylephrine carbinoxamine/ pseudoephedrine chlorphen-pemethscopolamine chlorphen tan/ carbetapentane tan chlorphen tan/ pseudoeph tan chlorphen tan/pyrilamine tan/pe tan chlorpheniramine/ dextromethorphan chlorpheniramine maleate phenylephrine HCL chlorpheniramine/ phenylephrine chlorpheniramine/ phenylephrine chlorpheniramine/ pseudoephedrine chlorpheniramine tan/ phenylephrine tan codeine/ chlorpheniramine/ pseudoephedrine codeine/guaifenesin Brand Name RYNATUSS RONDEC DROPS liquid DURADRYL QV-ALLERGY syrup TUSSI-12 S susp TANAFED susp TRIOTANN PEDIATRIC SUSP R-TANNAMINE ROBITUSSIN PED LIQ CGH/COLD ROBITUSSIN LIQ CGH/CLD DIMETAPP SYP CGH/CLD CORICIDIN TAB CGH/CLD ED A-HIST TABLETS AND LIQUID RONDEC DROPS CARDEC DRO RONDEC SYRUP CARDEC SYP HISTEX CPM/PSE RYNATAN PEDIATRIC SUSP DIHISTINE DH PHENYLHIST LIQ DH GUIATUSS AC GG/CODEINE M-CLEAR WC susp liquid syrup susp QL 49

57 Generic Name codeine/guaifenesin/ pseudoephedrine codeine/promethazine codeine/promethazine/ phenylephrine dextromethorphan/ brompheniramine/ pseudoephedrine dextromethorphan/ carbinoxamine/ pseudoephedrine dextromethorphanguaifenesin dextromethorphan/ guaifenesin dextromethorphanguaifenesin dextromethorphan hbr Brand Name GUIATUSS DAC PROMETHAZINE W/CODEINE PROMETHAZINE VC W/CODEINE BROMETANE DX QL QL CARDEC-DM drops DURATUSS DM ELX soln mg/5 ml GG/DM CR MUCINEX DM ROBITUSSIN DM TUSSIN DM ROBITUSSIN LIQ CGH/ CONG ROBITUSSIN SYP MAX-ST OTC liq mg/ 5 ml syrup ROBITUSSIN PED SYP dextromethorphan polistirex DELSYM OTC extended-release dextromethorphan/ PHENERGAN DM promethazine PROMETHAZINE SYP DM guaifenesin ROBITUSSIN OTC guaifenesin ROBITUSSIN SYP CHST CNG syrup 100 mg/5 ml guaifenesin extended-release MUCINEX OTC guaifenesin/ ROBITUSSIN PE pseudoephedrine PSE/GG syrup, OTC guaifenesin/ pseudoephedrine/ ROBITUSSIN CF dextromethorphan 50

58 Generic Name guaifenesin/ pseudoephedrine extended-release guaifenesin/ pseudoephedrine extended-release hydrocodone/ chlorpheniramine/ phenylephrine hydrocodone/guaifenesin hydrocodone/homatropine loratadine & pseudoephedrine SR 24hr phenyleph/bromphen/ dextromethorphan/ guaifenesin phenylephrine/ brompheniramine/ dextromethorphan phenylephrine/ chlorpheniramine phenylephrine/ chlorpheniramine/ dextromethorphan phenylephrine/ chlorpheniramine/ dextromethorphan phenylephrine/ chlorpheniramine/ dextromethorphan Brand Name GUAIFED GUAIFEN PSE MUCINEX D GG/PSE CR HISTUSSIN HC VITUSSIN HYDROCODO/GG SYP HYCODAN HYDROMET SYP HYDROCODONE/ TAB HOMATROP ALLERGY/CONG TAB RELIEF ALLANHIST SYP PDX QUAL-TUSSIN SYP DC OTC tab mg OTC ATUSS DR syrup DE-CHLOR DM syrup RONDEC DM STATUSS DM SYP CARDEC DM SYP MINUTUSS DR SYP syrup 51

59 Generic Name phenylephrine/ chlorpheniramine/ dextromethorphan phenylephrine/ chlorpheniramine/ dihydrocodeine phenylephrine/ dextromethorphan phenylephrine/ dextromethorphan/ guaifenesin phenylephrine/ ephed/cpm w/carbetapentane phenylephrine/guaifenesin phenylephrine/ hydrocodone/ guaifenesin phenylephrine/pyrilamine/ dextromethorphan phenylephrine/pyrilamine w/hydrocodone phenylephrine tan/ pyrilamine tan/ carbeta tan promethazine & phenylephrine pseudoephedrine/ acetaminophen/ dextromethorphan pseudoephedrine/ chlorpheniramine/ dextromethorphan pseudoephedrine/ dextromethorphan/ guaifenesin Brand Name RONDEC DM DROPS CARDEC DM DRO ROBITUSSIN LIQ CGH/ALRG DIHYDRO-PE SYP DIMETAPP DRO DCON/CGH ROBITUSSIN LIQ CGH/CLD RYNATUSS PEDIATRIC SUSP ROBITUSSIN LIQ HD/CHST QUAL-TUSSIN SYP DC CODAL-DM liquid susp CODIMAL DH syrup TUSSI 12D S susp PROMETH VC SYP /5 MAPAP COLD TAB PEDIACARE LIQ MULTI-SY ROBITUSSIN LIQ PED NGHT MULTI SYMPTOM TAB COLD RLF syrup mg/ 5 mg 52

60 Generic Name pseudoephedrine/ iburprofen pseudoephedrine tan/ dexchlorphen tan/ DM tan pyrilamine tan/phenyleph tan tripolidine/ pseudoephedrine Brand Name CHILD IBUPRO SUS COLD IBUOROFEN TAB COLD/SIN TANAFED DMX SUSPENSION TRI-FED X susp RYNA-12 S susp TRIPROL/PSE SYP APHEDRID TAB Asthma/COPD Inhalers - Beta Agonists albuterol sulfate VENTOLIN HFA QL indacaterol ARCAPTA NEOHALER olodaterol STRIVERDI RESPIMAT Inhalers - Corticosteroids beclomethasone QVAR QL budesonide PULMICORT FLEXHALER QL fluticasone furoate ARNUITY ELLIPTA QL fluticasone HFA FLOVENT HFA QL fluticasone propionate FLOVENT DISKUS QL mometasone ASMANEX TWISTHALER QL mometasone inhalation ASMANEX HFA QL Inhalers -Corticosteroid/Beta Agonist Combinations budesonide/formoterol SYMBICORT ST fluticasone/salmeterol ADVAIR DISKUS ADVAIR HFA QL, ST ADVAIR INHAL AEROSOL fluticasone/vilanterol BREO ELLIPTA ST mometasone/formoterol DULERA ST Inhalers - Others aclidinium inhalation TUDORZA PRESSAIR cromolyn INTAL QL ipratropium/albuterol COMBIVENT QL ipratropium/albuterol COMBIVENT RESPIMAT inhaler ipratropium HFA ATROVENT HFA nedocromil TILADE omalizumab XOLAIR PA, SP 53

61 Generic Name Brand Name tiotropium SPIRIVA tiotropium respimat SPIRIVA RESPIMAT umeclidinium inhalation INCRUSE ELLIPTA umeclidinium/vilanterol ANORO ELLIPTA Inhalers for Nebulization albuterol ACCUNEB 0.63 mg/3 ml and 1.25 mg /3 ml, for members less than 8 years of age. Members 8 years of age will require prior authorization. albuterol PROVENTIL soln 0.083%, 0.5% budesonide PULMICORT RESPULES susp, for members less than 5 years of age. Members 5 years of age will require prior authorization. QL cromolyn INTAL soln, QL ipratropium ATROVENT soln, QL ipratropium/albuterol DUONEB soln levalbuterol HCl XOPENEX RESPULES QL, ST Oral Agents - Beta Agonists metaproterenol METAPROTERENOL SYRUP terbutaline BRETHINE Oral Agents - Leukotriene Modifiers montelukast SINGULAIR QL Oral Agents - Theophylline theophylline THEOPHYLLINE liquid theophylline extended-release theophylline extended-release theophylline extended-release theophylline extended-release THEO-24 caps THEOCHRON tabs THEOPHYLLINE EXT-REL caps (12 hr) UNIPHYL tabs 54

62 Generic Name Brand Name Supplements Potassium phosphorus K-PHOS NEUTRAL tabs potassium acid phosphate K-PHOS ORIGINAL potassium bicarbonate/ potassium citrate K-LYTE tabs effervescent potassium chloride K-LOR powder potassium chloride POTASSIUM CHLORIDE liquid K-DUR 10 potassium chloride extended-release K-DUR 20 KLOR-CON 8 tabs KLOR-CON 10 potassium chloride extended-release MICRO-K 10 caps potassium iodide PIMA Urological Symptomatic Benign Prostatic Hypertrophy alfuzosin ER UROXATRAL doxazosin CARDURA finasteride PROSCAR tamsulosin FLOMAX terazosin HYTRIN Miscellaneous bethanechol URECHOLINE hyoscyamine, methenamine, phenyl salicylate, sodium phosphate UTIRA C monobasic, methylene blue methenamine hippurate HIPREX UREX oxybutynin chloride DITROPAN XL QL, ST oxybutynin IR DITROPAN potassium citrate UROCIT-K propantheline 55

63 Generic Name Brand Name phenazopyridine PYRIDIUM sodium citrate/citric acid BICITRA tolterodine DETROL ST trospium SANCTURA ST Vitamins and Minerals calcitriol ROCALTROL calcitriol oral soln ROCALTROL SOLUTION Members 8 years of age will require prior authorization. calcium OS-CAL OTC cholecalciferol BIO-D DRO-MULSION drops 400 unit/0.03 ml, OTC cholecalciferol BIO-D-MULSIO drops 2000 unit/0.03 ml, DRO FORTE OTC cholecalciferol D3-50 CAP cap unit, OTC cholecalciferol VITAMIN D CAP 400 UNIT cap 400 unit, OTC cholecalciferol VITAMIN D CAP 2000 UNIT cap 2000 unit, OTC cholecalciferol VITAMIN D TAB 400 UNIT tab 400 unit, OTC cholecalciferol VITAMIN D TAB 1000 UNIT tab 1000 unit, OTC cholecalciferol VITAMIN D TAB 2000 UNIT tab 2000 unit, OTC cyanocobalamin VITAMIN B-12 inj, Coverage for these medications will be determined by the member s individual benefits. Please refer to individual plan documents for coverage information. electrolyte PEDIALYTE soln, oral, OTC ergocalciferol (D2) DRISDOL Coverage for these medications will be determined by the member s individual benefits. Please refer to individual plan documents for coverage information. ferrous bisglycinate/ polysaccarides iron NIFEREX caps, OTC ferrous sulfate FEOSOL OTC 56

64 Generic Name fluoride Brand Name GEL-KAM LURIDE LURIDE LOZI-TABS PREVIDENT PHOS-FLUR folic acid FOLIC ACID magnesium oxide MAG-OX multivitamins/ fluoride/±iron POLY-VI-FLOR multivitamins/minerals CENTRUM Coverage for these medications will be determined by the member s individual benefits. Please refer to individual plan documents for coverage information. OTC, Coverage for these medications will be determined by the member s individual benefits. Please refer to individual plan documents for coverage information. Coverage for these medications will be determined by the member s individual benefits. Please refer to individual plan documents for coverage information. OTC, Coverage for these medications will be determined by the member s individual benefits. Please refer to individual plan documents for coverage information. phytonadione MEPHYTON polysaccharide iron complex NIFEREX elixir, OTC prenat-fe Bis-FE COMPLETE NATALCARE prot succ-fa-ca PAK DHA & omega 3 prenat-fe Bis-FE prot succ-fa-ca & omega 3 prenat-fe Bis-FE prot succ-fa-ca & omega 3 TRUST NATALCARE PAK DHA PRUET DHA PAK SETONET PAK 57

65 Generic Name prenat-fe bis-fe prot succ-fa-ca & omega DR prenat w/o A w/fecbn-fegl-dss-fa & DHA prenatal vit w/fe bisglycinate chelate-fa prenatal vit w/fe bisglyc-fe prot succ-fa prenatal vit w/fe bisglycinate chelate-fa prenatal vit w/fe bisglycinate chelate-fa prenatal vit w/fe polysac cmplx-fa prenatal vit w/iron carbonyl-fa prenatal vitamins w/folic acid prenatal w/o A w/ FE carbonyl-fe gluc-dss-fa Brand Name PRUET DHAEC PAK FOLTABS PAK PLUS DHA RE OB + DHA PAK GENTEX ADE 28-1 MG VINATE III VINATE AZ EX VITAPHIL EDGE OB CHW ATABEX PRENATAL PRENATAL VITAMINS W/ FOLIC ACID CENOGEN OB/ULTRA MATERNA NATALCARE NESTABSCBF/FA/RX NIFEREX-PN FORTE FOLTABS PRENATAL TRI RX vitamin A OTC vitamin ADC/ fluoride/±iron drops TRI-VI-FLOR QL Coverage for these medications will be determined by the member s individual benefits. Please refer to individual plan documents for coverage information. 58

66 Generic Name vitamin B complex/ vitamin C/folic acid Brand Name NEPHROCAPS Coverage for these medications will be determined by the member s individual benefits. Please refer to individual plan documents for coverage information. vitamin B-1 OTC vitamin B-6 OTC vitamin C OTC vitamins pediatric TRI-VI-SOL members <3 years old, OTC, Coverage for these medications will be determined by the member s individual benefits. Please refer to individual plan documents for coverage information. zinc OTC Miscellaneous Anaphylaxis epinephrine EPIPEN EPIPEN JR. TWINJECT Cystic Fibrosis acetylcysteine MUCOMYST aztreonam CAYSTON PA, SP dornase alfa PULMOZYME PA, SP tobramycin neb soln BETHKIS PA, SP Hereditary Angioedema icatibant FIRAZYR PA, SP Hyperphosphatemia calcium acetate 667 mg tablet only cinacalcet SENSIPAR PA sevelamer RENVELA ST Idiopathic Pulmonary Fibrosis (IPF) nintedanib OFEV PA, SP pirfenidone capsule ESBRIET PA, SP QL 59

67 Generic Name Brand Name Immune Thrombocytopenic Purpura eltromobpag PROMACTA PA, SP Medical Devices Spacers QL Vaccine influenza virus vaccine live FLUMIST QUAD quadrivalent intranasal QL influenza virus vaccine recombinant hemagglutinin FLUBLOK QL (ha) influenza virus vaccine split AFLURIA, FLUZONE SPLT QL influenza virus vaccine split high-dose pf FLUZONE HD PF QL influenza virus vaccine split pf AFLURIA PF QL influenza virus vaccine split quadrivalent FLUZONE QUAD QL influenza virus vaccine tiss-cult subunit FLUCELVAX QL influenza virus vaccine types a&b surface FLUVIRIN QL antigen pneumococcal 13-valent conjugate PREVNAR 13 QL pneumococcal vaccine PNEUMOVAX, PNEUpolyvalent MOVAX 23 QL typhoid vaccine VIVOTIF BERNA capsules zoster vaccine live ZOSTAVAX QL, Age Limits Apply 60

68 Generic Name Brand Name Examples OTC MEDICATIONS The following is a list of OTC products on the PDL. Some OTC products are listed on the drug list. OTC products covered are restricted to s when available. Brand names are provided as reference only. Acne benzoyl peroxide crm, gel, lotion Antifungals clotrimazole miconazole crm, soln tolnaftate vaginal products Atopic Dermatitis emollients Cough/Cold Allergy antihistamines Antihistamine/Decongestant Combinations brompheniramine/pseudoephedrine cetirizine/pseudoephedrine OTC chlorpheniramine/pseudoephedrine loratadine/pseudoephedrine CLEARASIL MICATIN LOTRIMIN AF TINACTIN MONISTAT GYNE-LOTRIMIN BETACARE CREAM AND LOTION CETAPHIL CREAM AND LOTION DERMAPHOR OINTMENT E-OINTMENT GLYCERIN TOPICAL CHLOR-TRIMETON BENADRYL CLARITIN ALAVERT ZYRTEC DIMETAPP ZYRTEC D ACTIFED ALAVERT ALRG TAB/SINUS ALAVERT D ALLERGY/CONG 61

69 Generic Name Cough/Cold antitussives Age edit applied. Not covered for members under the age 2. nasal sprays Diabetes alcohol swabs glucose oral tablets insulin (vials only) Earwax Removal Products carbamide peroxide Family Planning condoms contraceptive foam contraceptive gel First Aid Burow s soln, wet dressings dermatological baths hydrocortisone crm, oint topical antibacterials Gastrointestinal antacids liquids, chew tabs antidiarrheals electrolyte rehydrating soln famotidine laxative enemas Brand Name Examples ROBITUSSIN ROBITUSSIN DM ROBITUSSIN PE ROBITUSSIN CF DELSYM NEO-SYNEPHRINE AFRIN DIMETAPP DRO DECONGES CURITY ALCOHOL PADS HUMULIN NOVOLIN DEBROX TROJAN DELFEN GYNOL II DOMEBORO COLLOIDAL OATMEAL BATHS CORTAID NEOSPORIN MYCITRACIN BACITRACIN MYLANTA LIQUID MAALOX LIQUID TUMS IMODIUM A-D KAOPECTATE PEDIALYTE PEPCID AC FLEET ENEMA 62

70 Generic Name laxatives psyllium rectal crm, suppositories simethicone stool softeners sugar+orthophosphoric acid Lice Products permethrin piperonyl butoxide gel, liquid shampoo Motion Sickness dimenhydrinate meclizine Ophthalmics allergic conjunctivitis artificial tears decongestants Pain acetaminophen tabs, liquid, drops, suppositories aspirin tabs, EC. tabs aspirin with buffers tabs ibuprofen tabs, chew tabs and susp Smoking Cessation Products nicotine Brand Name Examples DULCOLAX FLEET PHOSPHO-SODA METAMUCIL PREPARATION H MYLICON COLACE EMETROL NIX PIPERONYL BUTOXIDE DRAMAMINE BONINE ALAWAY HYPOTEARS VISINE MURINE NAPHCON A TYLENOL BAYER ECOTRIN ADVIL MOTRIN IB COMMIT LOZENGES (QUANTITY LIMIT) NICODERM CQ (QUANTITY LIMIT) NICOTINE GUM (QUANTITY LIMIT) NICOTROL (QUANTITY LIMIT) 63

71 Generic Name Vitamins/Minerals calcium iron ferrous fumarate, ferrous, gluconate, errous sulfate, ferrous bis-glycinate chelate and polysaccharide iron caps iron polysaccharides magnesium oxide vitamin D 400 IU vitamins pediatric members <3 years old vitamins prenatal Warts salicylic acid 17%/collodion Miscellaneous fluoride dental rinse Brand Name Examples OS-CAL CALTRATE TUMS FERGON FEOSOL NIFEREX MAG-OX VITAMIN D 400 IU VI-DAYLIN POLY-VI-SOL TRI-VI-SOL STUART PRENATAL DUOFILM PHOS-FLUR 64

72 Index of s A ABELCET INJ abiraterone acarbose ACCUHIST DROPS ACCUHIST PDX DROPS.. 48 ACCUNEB ACCUPRIL ACCURETIC ACCUTANE acebutalol acetaminophen.. 12, 41, 63 acetazolamide ACETAZOLAMIDE acetazolamide extended-release acetic acid acetic acid/aluminum acetate17 acetic acid/hydrocortisone. 17 acetylcysteine acidophilus ACIDOPHILUS acidophilus/bifidus ACIDOPHILUS/ BIFIDUS WAFER acidophilus/citrus pectin.. 25 ACIDOPHILUS/ CITRUS PECTIN acidophilus/pectin ACIDOPHILUS/PECTIN.. 25 ACIDOPHILUS XTRA acitretin aclidinium inhalation ACLOVATE ACTIFED , 61 ACTIGALL ACTIVASE INJ ACTOPLUSMET ALL CAPS = Brand-name drug lower case = Generic drug ACTOPLUS MET XR ACTOS ACULAR/ACULAR LS acyclovir ACYCLOVIR NA INJ acyclovir sodium for inj acyclovir sodium iv soln ADALAT CC adalimumab adefovir ADRENALIN INJ ADVAIR DISKUS ADVAIR HFA ADVAIR INHAL AEROSOL 53 ADVIL , 42, 63 AFINITOR AFINITOR DISPERZ AFLURIA, FLUZONE SPLT 60 AFLURIA PF AFRIN , 62 AGRYLIN A-HYDROCORT INJ ALAVERT , 61 ALAVERT ALRG TAB/SINUS , 61 ALAVERT D ALAVERT-D ALAWAY ALAWAY OTC albendazole ALBENZA albiglutide albuterol albuterol sulfate alclometasone alcohol swabs ALDACTAZIDE ALDACTONE ALDARA ALDOMET ALDORIL alendronate ALESSE alfuzosin ER alginic acid/sodium bicarbonate ALINIA ALINIA SUSPENSION alirocumab alitretinoin 1% gel ALKERAN ALLANHIST SYP PDX allergic conjunctivitis ALLERGY/CONG ALLERGY/CONG TAB RELIEF ALLERY/CONG ALLI allopurinol ALPHAGAN P alteplase for inj altretamine alumina/magnesia alumina/magnesia/ simethicone aluminum acetate aluminum chloride hexahydrate amantadine AMARYL AMBISOME INJ ambrisentan AMERGE A-METHAPRED INJ AMIKACIN INJ amikacin sulfate inj amiloride

73 Index of s amiloride/hydrochlorothiazide 9 aminosalicyclic acid amiodarone tabs amlodipine ammonium lactate amoxicillin AMOXICILLIN CAPSULES AND CHEWABLES amoxicillin/clavulanate AMOXIL SUSP AMPHOTEC INJ amphotericin b cholesteryl sulfate complex for inj.. 26 amphotericin b for inj amphotericin b lipid inj susp 26 amphotericin b liposome iv for susp AMPHOTERICIN INJ ampicillin AMPICILLIN INJ , 27 ampicillin sodium for inj ampicillin sodium for iv soln , 27 ampicillin & sulbactam sodium for inj AMP-SULBACTA INJ anagrelide ANAPLEX DM ANAPROX , 42 anastrozole ANCEF INJ ANERGAN ANORO ELLIPTA antacids liquids, chew tabs. 62 antidiarrheals antihistamines antitussives ANTIVERT ANUSOL HC 2.5% ALL CAPS = Brand-name drug lower case = Generic drug APHEDRID TAB apixaban aprepitant APRESOLINE APRISO AQUA-MEPHYTO INJ ARALEN ARANESP ARAVA ARCAPTA NEOHALER ARICEPT ARIMIDEX ARISTOSPAN INJ ARNUITY ELLIPTA AROMASIN artificial saliva artificial tears ASMANEX HFA ASMANEX TWISTHALER. 53 aspirin , 41 aspirin/acetaminophen/ caffeine aspirin tabs, EC. tabs aspirin with buffers tabs.. 63 ASTELIN ASTRAMOR INJ ATABEX PRENATAL ATARAX atenolol atenolol/chlorthalidone....8 atorvastatin atovaquone atropine atropine sulfate ATROVENT ATROVENT HFA ATUSS DR AUBAGIO AUGMENTIN auranofin AVELOX INJ AVITA AVONEX/AVONEX PEN.. 14 axitinib AYGESTIN AZACTAM/DEX INJ AZACTAM INJ azathioprine , 41 azelaic acid azelastine , 45 azithromycin AZITHROMYCIN INJ azithromycin iv for soln aztreonam aztreonam for inj aztreonam in dextrose inj. 277 AZULFIDINE , 41 AZULFIDINE EN-TABS.24, 41 B BACIIM INJ bacitracin , 47 BACITRACIN , 62 bacitracin intramuscular for soln baclofen BACLOFEN BACTOCILL INJ DEX BACTRIM BACTRIM DS BACTROBAN balsalazide BALZIVA BARACLUDE BAYER , 41, 63 BD POSIFLUSH INJ

74 Index of s becaplermin gel beclomethasone bedaquiline BENA-D-50 INJ BENADRYL , 61 benazepril benazepril/hydrochlorothiazide7 BENTYL , 34 BENZAC AC BENZAMYCIN benzocaine/antipyrine benzonatate BENZOTIC benzoyl peroxide , 61 BETACARE CREAM AND LOTION BETAGAN betamethasone augmented dip betamethasone dipropionate 15 betamethasone sod phosphate & acetate inj susp betamethasone val BETAPACE BETA-PHOS/AC INJ BETA-VAL bethanechol BETHKIS BETIMOL bexarotene caps and topical gel BIAXIN BIAXIN XL bicalutamide BICILLIN C-R INJ 900/ BICILLIN L-A INJ BICITRA BILTRICIDE BIO-D DRO-MULSION ALL CAPS = Brand-name drug lower case = Generic drug BIO-D-MULSIO DRO FORTE bismuth subsalicylate + metronidazole + tetracycline. 25 bisoprolol bisoprolol/hydrochlorothiazide 8 BLEPH BONINE bosentan BREO ELLIPTA BRETHINE brimonidine , 47 BRIMONIDINE BROMALINE DM BROMETANE DX BROMFED DM BROMFENEX PD CAP brompheniramine & phenylephrine brompheniramine/ pseudoephedrine brompheniramine/ pseudoephedrine brompheniramine/ pseudoephedrine/ dextromethorphan brompheniramine/ pseudoephedrine/dextromethorphan/guaifenesin 48 budesonide , 53, 54 budesonide/formoterol bumetanide BUMEX Burow s soln, wet dressings 62 busulfan butalbital/acetaminophen.. 12 butalbital/acetaminophen/ caffeine butalbital/apap/caff/cod.. 12 butalbital/asa/caff/cod butalbital/aspirin/caffeine.. 12 butorphanol C cabergoline cabozantinib CAFERGOT calamine CALAN , 13 CALAN SR calcipotriene calcitonin-salmon calcitriol , 56 calcium , calcium acetate CALTRATE canagliflozin canagliflozin/metformin CANASA CANCIDAS INJ CAPASTAT SUL INJ capecitabine CAPITROL CAPOTEN CAPOZIDE capreomycin sulfate for inj. 27 capsaicin captopril captopril/hydrochlorothiazide.7 CARAC CARAFATE CARAFATE SUSPENSION. 23 carbamide peroxide...18, 62 carbetapentane/chlorpheniramine/ephedrine/ phenylephrine carbinoxamine/ pseudoephedrine CARBOFED

75 Index of s CARDEC-DM CARDEC DM DRO CARDEC DM SYP CARDEC DRO CARDEC SYP , 49 CARDENE CARDIZEM CARDIZEM CD CARDIZEM SR CARDURA , 55 carteolol carvedilol casanthranol-docusate sodium CASODEX caspofungin acetate for iv soln CATAFLAM CATAPRES CATHFLO ACTI INJ VASE. 35 CAYSTON CECLOR CEENU cefaclor cefadroxil CEFAZOL/DEX SOL cefazolin in d5w inj CEFAZOLIN INJ cefazolin sodium (bulk) for inj27 cefazolin sodium for inj cefazolin sodium for iv soln. 27 cefazolin sodium for iv soln 1 gm and dextrose 4%. 27 cefdinir cefepime hcl for inj CEFEPIME INJ cefixime CEFOTAXIME INJ cefotaxime sodium for inj.. 27 cefotaxime sodium for iv soln 27 cefotaxime sodium in d5w iv soln cefotetan disodium for inj.. 28 CEFOTETAN INJ CEFOXITIN INJ cefoxitin sodium for inj cefoxitin sodium iv for soln 1 gm and dextrose 4%.. 28 cefoxitin sodium iv for soln 2 gm and dextrose 2.2%. 28 cefprozil ceftazidime ceftazidime for inj ceftazidime for iv soln CEFTAZIDIME INJ ceftazidime sodium in d5w inj ceftazidime sodium in dextrose inj CEFTIN CEFTRIAX/DEX INJ CEFTRIAXONE INJ CEFTRIAXONE/ INJ DEX. 29 ceftriaxone sodium for inj.. 28 ceftriaxone sodium for iv soln28 ceftriaxone sodium for iv soln 1 gm and dextrose 3.74% 29 ceftriaxone sodium for iv soln 2 gm and dextrose 2.22% 29 ceftriaxone sodium in dextrose inj CEFUROX/DEXT INJ cefuroxime axetil CEFUROXIME INJ cefuroxime in sterile water inj 29 cefuroxime sodium 1.5 gm and dextrose 2.9% for iv soln 29 cefuroxime sodium (bulk) for inj cefuroxime sodium for inj.. 29 cefuroxime sodium for iv soln29 cefuroxime sodium in d5w inj29 CEFZIL CELEBREX celecoxib CELLCEPT CENESTIN CENOGEN OB/ULTRA.. 58 CENTRUM cephalexin certolizumab pegol CETAPHIL CREAM AND LOTION cetirizine cetirizine chew tab cetirizine hydrochloride/pseudoephedrine hydrochloride cetirizine/pseudoephedrine OTC CHANTIX CHILD IBUPRO SUS COLD chlorambucil chloramphenicol sodium succinate for iv inj CHLORAMPHEN INJ chlorhexidine gluconate chloroquine phosphate chlorothiazide chloroxine chlorpheniramine/ dextromethorphan chlorpheniramine extended-release chlorpheniramine maleate. 18 ALL CAPS = Brand-name drug lower case = Generic drug 68

76 Index of s chlorpheniramine maleate phenylephrine HCL chlorpheniramine/ phenylephrine chlorpheniramine/phenylephrine/pyrilamine chlorpheniramine/ pseudoephedrine..18, 49 chlorpheniramine/ pseudoephedrine chlorpheniramine/ pseudoephedrine extended-release chlorpheniramine tan/ phenylephrine tan chlorphen-pemethscopolamine chlorphen tan/ carbetapentane tan chlorphen tan/ pseudoeph tan chlorphen tan/pyrilamine tan/ PE tan chlorpropamide chlorthalidone CHLORTHALIDONE CHLOR-TRIMETON CHLOR-TRIMETON ALLERGY CHLOR-TRIMETON SYRUP chlorzoxazone CHOLBAM cholecalciferol cholestyramine cholic acid choline magnesium trisalicylate , 41 ciclopirox cilostazol CILOXAN cimetidine cimetidine hcl inj CIMETIDINE INJ cimetidine in saline inj CIMETID/NACL INJ CIMZIA cinacalcet CIPRO CIPRODEX ciprofloxacin , 47 ciprofloxacin 0.2% in d5w. 29 ciprofloxacin/ dexamethasone ciprofloxacin iv soln 1% CIPRO I.V. INJ CIPRO I.V. SOL CLAFORAN/D5W INJ CLAFORAN INJ clarithromycin clarithromycin ER CLARITIN , 61 CLEARASIL CLEAR EYES REDNESS RELIEF clemastine CLEMASTINE CLEOCIN , 44 CLEOCIN/D5W INJ CLEOCIN INJ CLEOCIN PHOS INJ CLEOCIN T CLIMARA clindamycin , 40, 44 clindamycin phosphate in d5w iv soln clindamycin phosphate inj. 29 CLINORIL , 42 clobetasol propionate clonidine clopidogrel clotrimazole.. 16, 39, 44, 61 clotrimazole with betamethasone CODAL-DM codeine/acetaminophen.. 12 codeine/chlorpheniramine/ pseudoephedrine codeine/guaifenesin codeine/guaifenesin/ pseudoephedrine codeine/promethazine codeine/promethazine/ phenylephrine codeine sulfate CODIMAL DH COLACE COLAZAL colchicine colistimethate sodium for inj 29 COLISTIMETH INJ collagenase oint COLLOIDAL OATMEAL BATHS COLOCORT COLYTE COMBIVENT COMBIVENT RESPIMAT.. 53 COMETRIQ COMMIT LOZENGES COMMITT OTC COMPAZINE COMPLETE NATALCARE PAK DHA condoms CONDYLOX SOL ALL CAPS = Brand-name drug lower case = Generic drug 69

77 Index of s conjugated estrogen/ bazedoxifene contraceptive foam contraceptive gel COPAXONE CORDARONE CORDRAN COREG CORICIDIN TAB CGH/CLD 49 CORTAID CORTEF cortisone acetate CORTISPORIN CORTISPORIN OTIC CORTIZONE COSOPT COUMADIN COZAAR CPM/PSE CREON CROLOM cromolyn , 54 cromolyn sodium , 45 crotamiton CUPRIMINE CURITY ALCOHOL PADS. 62 CUTIVATE cyanocobalamin CYCLESSA cyclobenzaprine CYCLOGYL cyclopentolate cyclophosphamide cycloserine cyclosporine cyclosporine, modified cyproheptadine CYPROHEPTADINE ALL CAPS = Brand-name drug lower case = Generic drug CYSTAGON CYSTARAN cysteamine 0.44% ophthalmic solution cysteamine bitartrate CYTOMEL CYTOTEC CYTOVENE , 39 CYTOXAN D D2.5W/NACL INJ 0.45%.. 35 D3-50 CAP D5W/LR INJ D5W/LYTES INJ # D5W/NACL INJ... 34, 35, 36 D5W/RINGERS INJ D10W/NACL INJ DALLERGY DM danazol DANOCRINE DANTRIUM dantrolene dapsone DAPSONE DARAPRIM darbepoetin alfa DAYPRO , 42 DDAVP DEBROX , 62 DECADRON DE-CHLOR DM DECONAMINE SR decongestants deferasirox DELATESTRYL DELFEN DELSYM , DELTASONE DEMADEX DEMEROL DEPEN TITRATABLE DEPO-MEDROL INJ DEPO-PROVERA DEPO-TESTOSTERONE.. 20 DERMAPHOR OINTMENT 61 DERMA-SMOOTHE OIL/FS 15 dermatological baths DERMATOP DESENEX POWDER 2%.. 16 desmopressin desogestrel/ee.. 42, 43, 44 DETROL dexamethasone dexamethasone sodium phosphate , 46 DEXAMETH PHO INJ DEXASOL dextromethorphan/ brompheniramine/ pseudoephedrine dextromethorphan/ carbinoxamine/ pseudoephedrine dextromethorphanguaifenesin dextromethorphan/ guaifenesin dextromethorphan hbr dextromethorphan polistirex extended-release dextromethorphan/ promethazine dextromethorphan/ quinidine dextrose 2.5% w/sodium chloride 0.45%

78 Index of s dextrose 5% in lactated ringers dextrose 5% in ringers dextrose 5% w/sodium chloride 0.2% dextrose 5% w/sodium chloride 0.9% dextrose 5% w/sodium chloride 0.33% dextrose 5% w/ sodium chloride 0.45% dextrose 5% w/sodium chloride 0.225% dextrose 10% w/sodium chloride 0.2% dextrose 10% w/sodium chloride 0.9% dextrose 10% w/sodium chloride 0.45% dextrose inj DEXTROSE INJ D.H.E DIABINESE DIAMOX SEQUELS DIAQUA-2 INJ diazepam diclofenac 1% gel diclofenac potassium diclofenac sodium diclofenac sodium delayed release...12, 41 diclofenac sodium extended-release dicloxacillin DICLOXACILLIN dicyclomine dicyclomine hcl inj DIDRONEL DIFLUCAN , 44 digoxin ALL CAPS = Brand-name drug lower case = Generic drug DIHISTINE DH dihydroergotamine DIHYDRO-PE SYP DILACOR XR DILAUDID diltiazem diltiazem extended-release..9 diltiazem sustained-release..9 DIMEATAPP DRO DECONGES dimenhydrinate dimenhydrinate inj DIMENHYDRIN INJ DIMETAPP DIMETAPP CLD ELX/ ALLERGY DIMETAPP DRO DCON/CGH DIMETAPP DRO DECONGES DIMETAPP ELX CLD/ALLE 48 DIMETAPP SYP CGH/CLD 49 dimethyl fumarate DIPENTUM diphenhydramine....18, 47 diphenhydramine hcl inj diphenoxylate/atropine DIPROLENE DIPROLENE AF dipyridamole disopyramide disopyramide extended-release DITROPAN DITROPAN XL DIURIL DIURIL ORAL SUSPENSION 9 docusate calcium plus docusate potasssium dofetilide DOLOPHINE dolutegravir DOMEBORO DOMEBORO OTIC donepezil dornase alfa dorzolamide dorzolamide/timolol maleate 46 DOSTINEX DOVONEX doxazosin , 55 DOXYCYCL HYC INJ doxycycline hyclate for inj.. 30 doxycycline monohydrate.. 39 DOXYCYCLINE MONOHYDRATE DRAMAMINE DRISDOL dronabinol DROXIA DUAVEE DUETACT DULCOLAX DULERA DUOFILM , 64 DUONEB DURADRYL DURAGESIC DURAMORPH INJ DURATUSS DM ELX DURICEF DYAZIDE E ecothiophate ECOTRIN , 41, 63 ED A-HIST TABLETS AND LIQUID

79 Index of s EDGE OB CHW edoxaban E.E.S EFUDEX electrolyte electrolyte-48 in d5w soln. 35 electrolyte-56 in d5w soln. 35 electrolyte-148 in d5w soln 35 electrolyte-b in d5w soln.. 35 electrolyte-h in d5w soln.. 35 electrolyte-mb in d5w soln. 35 electrolyte-m in d5w soln.. 35 electrolyte-p in d5w soln.. 35 electrolyte rehydrating soln. 62 electrolyte-r in d5w soln.. 35 electrolyte-s in d5w soln.. 35 ELIDEL ELIMITE ELIQUIS ELOCON eltromobpag EMCYT EMEND EMETROL EMLA emollients empagliflozin empagliflozin/metformin.. 21 enalapril enalapril/hydrochlorothiazide.7 enfuvirtide ENJUVIA enoxaparin entecavir ENTERIC CODED- NAPROSYN , 42 ENTOCORT EC ENULOSE ALL CAPS = Brand-name drug lower case = Generic drug E-OINTMENT EPANED epinephrine epinephrine hcl inj EPIPEN EPIPEN JR EPIVIR HBV epoetin alfa EPOGEN ergocalciferol (D2) ergotamine/caffeine ERIVEDGE ertapenem sodium for inj.. 30 ERYC ERYGEL ERY-TAB ERYTHROCIN , 39 erythromycin , 47 ERYTHROMYCIN erythromycin/ benzoyl peroxide erythromycin delayed-release erythromycin ethylsuccinate erythromycin lactobionate for inj erythromycin stearate erythromycin/sulfisoxazole. 39 ESBRIET esomeprazole esomeprazole granules esomeprazole sodium for intravenous soln ESTRACE estradiol estramustine phosphate sodium estrogens, conjugated estrogens, conjugated/ medroxyprogesterone.. 44 estrogens, conjugated, synthetic A estrogens, conjugated, synthetic B estropipate ESTROSTEP FE ethambutol ethionamide ethynodiol diacetate/ee.. 43 etidronate etodolac , 41 etonogestrel/ee etoposide etravirine EULEXIN EURAX everolimus , 5 EVISTA EXCEDRIN MIGRAINE EXELON exemestane EXJADE ezetimibe F famotidine , 35, 62 FAMOTIDINE INJ famotidine in nacl 0.9% iv soln FARESTON febuxostat FELDENE , 42 felodipine extended-release. 9 FEMARA fenofibrate fenoprofen , 42 FENTANYL CIT INJ

80 Index of s fentanyl citrate inj fentanyl transdermal FEOSOL , 64 FERGON ferrous bisglycinate/ polysaccarides iron ferrous sulfate filgrastim FINACEA finasteride fingolimod FIORICET FIORICET W/CODEINE...12 FIORINAL FIORINAL W/CODEINE.. 12 FIRAZYR FLAGYL , 44 flecainide FLEET ENEMA FLEET PHOSPHO-SODA. 63 FLEXERIL FLOMAX FLONASE FLORANEX FLORINEF FLOVENT DISKUS FLOVENT HFA FLOXIN FLOXIN OTIC FLUBLOK FLUCELVAX fluconazole , 44 fluconazole in dextrose inj. 30 FLUCONAZOLE/ INJ DEX fludarabine fludrocortisone FLUMADINE ALL CAPS = Brand-name drug lower case = Generic drug FLUMIST QUAD fluocinolone acetonide fluocinonide fluocinonide emulsified base 15 fluoride fluoride dental rinse fluorometholone FLUOROPLEX fluorouracil flurandrenolide flurbiprofen flutamide fluticasone fluticasone furoate fluticasone HFA fluticasone propionate. 15, 53 fluticasone/salmeterol fluticasone/vilanterol FLUVIRIN FLUZONE HD PF FLUZONE QUAD FML FML FORTE FML LIQUIFILM folic acid FOLIC ACID FOLTABS PAK PLUS DHA RE OB + DHA PAK FOLTABS PRENATAL FORTAZ INJ FORTEO FORTICAL FOSAMAX FOSCARNET INJ foscarnet sodium inj fosinopril fosinopril/hydrochlorothiazide 7 73 FURADANTIN SUSP furosemide furosemide inj FUZEON KIT G galantamine ganciclovir ganciclovir sodium for inj.. 30 gatifloxin GATTEX GEL-KAM gemfibrozil GENGRAF GENTAK , 47 gentamicin , 47 GENTAMICIN INJ gentamicin in saline inj gentamicin/prednisolone acetate gentamicin sulfate inj gentamicin sulfate iv soln.. 30 GENTAM/NACL INJ GENTEX ADE GG/CODEINE GG/DM CR GG/PSE CR GILENYA glatiramer acetate glimepiride glipizide glipizide extended-release. 21 GLUCAGON glucagon, human recombinant GLUCOPHAGE GLUCOPHAGE ER glucose oral tablets GLUCOTROL

81 Index of s GLUCOTROL XL GLUCOVANCE glyburide glyburide, micronized glycerin GLYCERIN SUPPOSITORY 24 GLYCERIN TOPICAL glycopyrrolate GLYNASE granisetron hcl inj GRANISETRON INJ GRANIX GRIFULVIN V griseofulvin microsize griseofulvin ultramicrosize. 39 GRIS-PEG GUAIFED guaifenesin guaifenesin extended-release guaifenesin/ pseudoephedrine guaifenesin/ pseudoephedrine/ dextromethorphan guaifenesin/ pseudoephedrine extended-release guaifenesin/pseudoephedrine extended-release GUAIFEN PSE guanabenz guanfacine GUIATUSS AC GUIATUSS DAC GYNE-LOTRIMIN , 61 GYNOL II H HECORIA HELIDAC heparin HEPARIN HEPSERA hexachlorophene HEXALEN HIPREX HISTACOL DM HISTEX HISTUSSIN HC homatropine HUMALOG HUMALOG MIX HUMATIN HUMIRA HUMULIN HUMULIN 70/ HUMULIN N HUMULIN R HYCODAN hydralazine HYDREA hydrochlorothiazide... 9, 10 HYDROCHLOROTHIAZIDE.9 HYDROCODO/GG SYP...51 hydrocodone/ acetaminophen hydrocodone/chlorpheniramine/ phenylephrine hydrocodone ER hydrocodone/guaifenesin.. 51 hydrocodone/homatropine. 51 HYDROCODONE/ TAB HOMATROP hydrocortisone. 15, 17, 19, 24 hydrocortisone butyrate hydrocortisone crm, oint.. 62 hydrocortisone sodium succinate for inj HYDROMET SYP hydromorphone hydroxychloroquine...40, 41 hydroxyurea hydroxyzine HCL hydroxyzine pamoate hyoscyamine, methenamine, phenyl salicylate, sodium phosphate monobasic, methylene blue hyoscyamine sulfate hyoscyamine sulfate extended-release HYPERCARE 20% HYPOTEARS HYTONE HYTRIN , 55 HYZAAR I IBUOROFEN TAB COLD/SIN ibuprofen , 42, 63 icatibant ICLUSIG IMDUR imipenem-cilastatin intravenous for soln IMIPENEM/CIL INJ imiquimod 5% cream IMITREX IMODIUM A-D , 62 IMURAN , 41 INCRELEX INCRUSE ELLIPTA indacaterol ALL CAPS = Brand-name drug lower case = Generic drug 74

82 Index of s indapamide INDERAL , 13 INDERIDE INDOCIN , 42 indomethacin , 42 INFERGEN INFLAMASE FORTE influenza virus vaccine live quadrivalent intranasal. 60 influenza virus vaccine recombinant hemagglutinin influenza virus vaccine split. 60 influenza virus vaccine split high-dose pf influenza virus vaccine split pf influenza virus vaccine split quadrivalent influenza virus vaccine tiss-cult subunit influenza virus vaccine types a&b surface antigen INLYTA insulin aspart insulin aspart protamine 70%/ insulin aspart 30% insulin glargine insulin human insulin isophane insulin isophane human insulin isophane human 70%/ regular 30% insulin isophane/regular.. 20 insulin lisopro pro/lispro.. 20 insulin lisopro prot/lispro.. 20 insulin lispro insulin regular insulin INTAL , 54 ALL CAPS = Brand-name drug lower case = Generic drug INTELENCE interferon alfa-2a interferon alfa-2b.... 5, 40 interferon alfacon interferon beta-1a INTRON A , 40 INVANZ INJ 1 GM INVOKAMET INVOKANA IONOSOL-B/ INJ D5W IONOSOL-MB INJ /D5W.. 35 ipratropium ipratropium/albuterol..53, 54 ipratropium HFA iron iron polysaccharides ISMO ISOLYTE-H INJ /D5W ISOLYTE-M INJ /D5W ISOLYTE-P INJ /D5W ISOLYTE-S INJ /D5W isoniazid ISONIAZID isoniazid inj ISONIAZID INJ ISOPTO ATROPINE ISOPTO CARPINE ISOPTO HOMATROPINE.. 46 ISOPTO HYOSCINE ISORDIL ISORDIL S.L isosorbide dinitrate ISOSORBIDE DINITRATE ER isosorbide dinitrate extended-release isosorbide mononitrate isosorbide mononitrate extended-release isotretinoin itraconazole ivermectin J JADENU JAKAFI JARDIANCE JENTADUETO JUXTAPID K KANAMYCIN INJ kanamycin sulfate inj KAOPECTATE KAYEXALATE kcl 10 meq/l (0.075%) in dextrose 5% & nacl 0.2% inj 36 kcl 10 meq/l (0.075%) in dextrose 5% & nacl 0.45% inj kcl 20 meq/l (0.15%) in dextrose 5% & nacl 0.2% inj 36 kcl 20 meq/l (0.15%) in dextrose 5% & nacl 0.9% inj 36 kcl 20 meq/l (0.15%) in dextrose 5% & nacl 0.33% inj kcl 20 meq/l (0.15%) in dextrose 5% & nacl 0.45% inj kcl 20 meq/l (0.15%) in dextrose 5% & nacl 0.225% inj kcl 30 meq/l (0.224%) in dextrose 5% & nacl 0.2% inj 36 kcl 30 meq/l (0.224%) in dextrose 5% & nacl 0.45% inj

83 Index of s kcl 40 meq/l (0.3%) in dextrose 5% & nacl 0.2% inj kcl 40 meq/l (0.3%) in dextrose 5% & nacl 0.9% inj kcl 40 meq/l (0.3%) in dextrose 5% & nacl 0.45% inj.. 37 KCL/D5W INJ KCL/D5W/NACL INJ. 36, 37 K-DUR K-DUR KEFLEX KENALOG KENALOG-10 INJ KENALOG-40 INJ KENALOG IN ORABASE.. 19 ketoconazole , 17, 39 ketoprofen , 42 ketorolac KETOROLAC INJ ketorolac tromethamine ketorolac tromethamine im inj ketorolac tromethamine inj. 25 ketotifen K-LOR KLOR-CON KLOR-CON K-LYTE KOMBIGLYZE KOR LYM K-PHOS NEUTRAL K-PHOS ORIGINAL ALL CAPS = Brand-name drug lower case = Generic drug L labetalol LAC-HYDRIN lactobacillus lactulose LAMISIL LAMISIL AT lamivudine LANOXIN lansoprazole lansoprazole delayed-release23 LANTUS LARIAM LASIX latanoprost laxative enemas laxatives leflunomide lenalidomide LETAIRIS letrozole LEUKERAN LEUKINE leuprolide levalbuterol HCl LEVAQUIN , 38 levobunolol levocetirizine levofloxacin levofloxacin in d5w iv soln. 31 levofloxacin iv soln levonorgestrel levonorgestrel/ee....43, 44 levothyroxine LEVOXYL LEVSIN LEVSINEX LIALDA LIDAMANTEL LIDEX LIDEX E lidocaine lidocaine/prilocaine lidocaine viscous linagliptin linagliptin/metformin LINCOCIN INJ lincomycin hcl inj linezolid linezolid iv soln liothyronine liotrix LIPITOR liraglutide lisinopril lisinopril/hydrochlorothiazide.7 LMX LOCOID LODINE , 41 LOESTRIN 1.5/ LOESTRIN 1/ LOESTRIN FE 1.5/ LOESTRIN FE 1/ LOFIBRA lomitapide LOMOTIL lomustine LONITEN LONSURF LO/OVRAL loperamide LOPERAMIDE LOPID LOPRESSOR loratadine loratadine/pseudoephedrine 61 loratadine/pseudoephedrine extended-release loratadine & pseudoephedrine SR 24hr LORCET LORTAB

84 Index of s LORTAB ELIXIR losartan losartan/hctz LOTENSIN LOTENSIN HCT LOTRIMIN AF , 61 LOTRISONE lovastatin LOVENOX LOZOL LUPRON LUPRON DEPOT LUPRON DEPOT-PED....5 LURIDE LYSODREN M MAALOX , 62 MACROBID MACRODANTIN magnesium oxide , 64 MAG-OX , 64 malathion MAPAP COLD TAB MARINOL MATERNA MATULANE MAXALT/MAXALT MLT MAXITROL MAXZIDE M-CLEAR WC mecasermin meclizine , 63 MEDROL medroxyprogesterone acetate , 44 mefloquine MEGACE ALL CAPS = Brand-name drug lower case = Generic drug megestrol acetate meloxicam , 42 melphalan memantine meperidine MEPHYTON MEPRON mercaptopurine MEROPENEM INJ meropenem iv for soln mesalamine mesalamine extended-release mesalamine supp MESTINON MESTINON TIMESPAN METAMUCIL metaproterenol METAPROTERENOL SYRUP metformin metformin ER metformin/glyburide methadone methazolamide methenamine hippurate METHERGINE , 45 methimazole methocarbamol methotrexate methoxsalen methyldopa methyldopa/hctz methylergonovine....22, 45 methylprednisolone methylprednisolone acetate inj susp methylprednisolone sodium succinate for inj METHYLPR SS INJ metipranolol metoclopramide metoclopramide hcl inj METOCLOPRAM INJ metolazone metoprolol metoprolol succinate METROCREAM METROGEL METROGEL 1% METROGEL-VAGINAL METRO IV INJ 5 MG/ML.. 31 METROLOTION metronidazole. 16, 40, 44, 45 metronidazole in nacl 0.74% iv soln metronidazole in nacl 0.79% iv soln METRON/NACL INJ MEVACOR mexiletine MEXITIL MIACALCIN micafungin sodium for iv soln31 MICATIN , 61 miconazole , 45, 61 MICRO-K MICRONASE MICROZIDE MIDAMOR midodrine mifeprstone MIGRANAL MINIPRESS MINOCIN , 39 minocycline minocycline hcl iv for soln. 31

85 Index of s minoxidil MINUTUSS DR SYP MIRALAX MIRCETTE MIRVASO misoprostol MITIGARE mitotane MOBIC , 42 MODICON MODURETIC mometasone mometasone/formoterol.. 53 mometasone furoate mometasone inhalation MONISTAT , 61 MONISTAT MONISTAT-DERM MONOPRIL MONOPRIL-HCT montelukast morphine morphine extended-release. 13 morphine sulfate inj morphine sulfate iv soln MORPHINE SUL INJ MOTRIN , 42 MOTRIN IB MOVANTIK moxifloxacin hcl 400 mg/250 ml in sodium chloride 0.8% inj MOZOBIL MS CONTIN MSIR MUCINEX MUCINEX D MUCINEX DM ALL CAPS = Brand-name drug lower case = Generic drug MUCOMYST MULTI SYMPTOM TAB COLD RLF multivitamins/fluoride/±iron. 57 multivitamins/minerals mupirocin MURINE MURO MYAMBUTOL MYCAMINE INJ MYCELEX , 39 MYCITRACIN MYCOBUTIN mycophenolate mofetil....5 mycophenolate sodium....5 MYCOSTATIN , 39 MYFORTIC MYLANTA , 62 MYLERAN MYLICON N nabumetone NAFCILLIN INJ nafcillin sodium for inj nafcillin sodium for iv soln. 31 nafcillin sodium in dextrose inj NALFON , 42 NALLPEN/DEX INJ naloxegol naloxone NALOXONE INJ NAMENDA naphazoline/antazoline naphazoline/glycerin naphazoline HCL naphazoline/zinc sulfate.. 45 NAPHCON A NAPROSYN , 42 naproxen , 42 naproxen delayed release , 42 naproxen sodium , 42 naratriptan NASACORT ALLERGY NASALCROM nasal sprays NATALCARE nateglinide nedocromil NEO DM neomycin/polymyxin B/ bacitracin neomycin/polymyxin B/ dexamethasone neomycin/polymyxin B/ gramicidin neomycin/polymyxin B/ hydrocortisone... 18, 45 neomycin sulfate NEORAL NEOSPORIN , 47, 62 NEO-SYNEPHRINE..19, 62 NEPHROCAPS NEPTAZANE NESTABSCBF/FA/RX NEULASTA NEUMEGA NEXIUM 24HR OTC NEXIUM DELAYED- RELEASE PACKET NEXIUM I.V. INJ niacin niacin extended-release...10 NIACOR NIASPAN nicardipine

86 Index of s NICODERM CQ , 63 NICORETTE OTC nicotine , 63 NICOTINE GUM nicotine polacrilex gum nicotine polacrilex lozenge. 48 NICOTROL nifedipine nifedipine extended-release. 9 NIFEREX , 57, 64 NIFEREX-PN FORTE nimodipine NIMOTOP nintedanib nitazoxanide suspension.. 40 nitazoxanide tablet NITREK NITRO-BID NITRO-DUR nitrofurantoin extended-release nitrofurantoin macrocrystals 40 nitrofurantoin susp nitroglycerin , 11, 17 NITROLINGUAL NITROSTAT NIX , 63 NIZORAL , 39 NIZORAL SHAMPOO NOLVADEX NORCO NORDETTE norelgestromin/ee norethindrone norethindrone acetate norethindrone acetate/ee. 43 norethindrone acetate/ee/iron...43, 44 ALL CAPS = Brand-name drug lower case = Generic drug norethindrone/ee. 42, 43, 44 NORFLEX norgestimate/ee , 44 norgestrel norgestrel/ee NORMOSOL -R INJ /D5W 35 NORPACE NORPACE CR NORVASC NOVOLIN NOVOLIN 70/ NOVOLIN N NOVOLIN R NOVOLOG NOVOLOG MIX 70/ NUEDEXTA NULYTELY NUTROPIN AQ NUSPIN.. 22 NUVARING NYMALIZE nystatin , 39 NYTOL QUICK CAPS O OCEAN NASAL SPRAY...19 octreotide OCUFEN OCUFLOX ODOMZO OFEV ofloxacin , 38, 47 OFORTA OGEN olodaterol olsalazine sodium omalizumab omeprazole delayed-release 23 OMNICEF ondansetron ONE TOUCH SYSTEMS (ULTRA 2, ULTRAMINI, VERIO, VERIO FLEX, VERIO IQ, VERIO SYNC) 21 ONE TOUCH TEST STRIPS (ULTRA, VERIO) ONGLYZA oprelvekin OPTIPRANOLOL OPTIVAR ORAPRED orlistat orphenadrine extended-release ORTHO-CEPT ORTHO COIL ORTHO-CYCLEN ortho diaphragm ORTHO EVRA ORTHO FLAT ORTHO FLEX ORTHO MICRONOR ORTHO-NOVUM 1/ ORTHO-NOVUM 1/ ORTHO-NOVUM 7/7/ ORTHO-NOVUM 10/ ORTHO TRI-CYCLEN ORUDIS , 42 OS-CAL , 64 oseltamivir OVCON OVIDE OVRAL OVRETTE OXACILLIN INJ oxacillin sodium for inj oxacillin sodium in dextrose inj

87 Index of s oxaprozin , 42 OXSORALEN-ULTRA oxybutynin chloride oxybutynin IR oxycodone oxycodone/acetaminophen. 13 oxycodone/aspirin OXYFAST oxymetazoline oxymorphone OXYMORPHONE ER P palivizumab pancrelipase PANRETIN pantoprazole pantoprazole sodium for iv soln PARAFON FORTE DSC paromomycin PASER pasireotide PEDIACARE LIQ MULTI-SY 52 PEDIALYTE , 62 PEDIAPRED PEDIAZOLE peg 3350/electrolytes peg 3350/sodium bicarbonate/ sodium chloride peg 3350/sodium bicarbonate/ sodium chloride/potassium chloride PEGASYS PEGASYS PROCLICK pegfilgrastim peginterferon alfa-2a peginterferon alfa-2b pegvisomant ALL CAPS = Brand-name drug lower case = Generic drug PEN G PROC INJ PEN G SOD INJ penicillamine PENICILL GK/ INJ DEX.. 32 penicillin g benzathine intramuscular susp penicillin g benzathine & procaine inj penicillin g potassium for inj , 32 penicillin g potassium inj.. 32 penicillin g procaine intramuscular susp penicillin g sodium for inj.. 32 penicillin VK PENICILLN GK INJ...31, 32 PENLAC SOLUTION 8%.. 16 PENTAM 300 INJ pentamidine isethionate for soln PENTASA pentazocine/naloxone pentoxifylline extended-release7 PEPCID PEPCID AC , 62 PERCOCET PERCODAN PERIDEX permethrin , 63 PERSANTINE phenazopyridine PHENERGAN PHENERGAN DM PHENERGAN NJ phenyleph/bromphen/dextromethorphan/guaifenesin 51 phenylephrine phenylephrine/brompheniramine/dextromethorphan phenylephrine/ chlorpheniramine phenylephrine/ chlorpheniramine/ dextromethorphan..51, 52 phenylephrine/ dextromethorphan phenylephrine/dextromethorphan/guaifenesin phenylephrine/ephed/cpm w/carbetapentane phenylephrine/guaifenesin. 52 phenylephrine/hydrocodone/ guaifenesin phenylephrine/pyrilamine/ dextromethorphan phenylephrine/pyrilamine w/ hydrocodone phenylephrine tan/pyrilamine tan/carbeta tan PHENYLHIST LIQ DH PHISOHEX PHOS-FLUR , 64 PHOSPHOLINE IODINE.. 46 phosphorus PHRENILIN phytonadione , 57 pilocarpine , 46 PILOPINE HS GEL PIMA pimecrolimus pindolol PINDOLOL pioglitazone pioglitazone/glimepiride.. 21 pioglitazone/metformin pioglitazone/metformin ER. 21 piperacillin sodiumtazobactam sodium for inj

88 Index of s piperacillin sodtazobactam sod in dex iv sol PIPERONYL BUTOXIDE.. 63 piperonyl butoxide gel, liquid shampoo PIPER/TAZOBA INJ pirfenidone capsule piroxicam , 42 PLAN B PLAQUENIL , 41 PLASMA-LYTE INJ 56/D5W35 PLASMA-LYTE INJ /D5W. 35 PLAVIX PLENDIL plerixafor PLETAL PLEXION pneumococcal 13-valent conjugate pneumococcal vaccine polyvalent PNEUMOVAX, PNEUMOVAX podofilox polyethylene glycol polymyxin B/bacitracin POLYMYXIN B INJ polymyxin b sulfate for inj.. 32 polymyxin B/trimethoprim.. 47 polysaccharide iron complex 57 POLYSPORIN POLYTRIM POLY-VI-FLOR POLY-VI-SOL pomalidomide POMALYST ponatinib potassium acid phosphate. 55 ALL CAPS = Brand-name drug lower case = Generic drug potassium bicarbonate/potassium citrate effervescent 55 potassium chloride POTASSIUM CHLORIDE.. 55 potassium chloride 20 meq/l (0.15%) in d5w lactated ringers potassium chloride 20 meq/l (0.15%) in dextrose 5% inj potassium chloride 30 meq/l (0.224%) in dextrose 5% inj potassium chloride 40 meq/l (0.3%) in d5w lactated ringers potassium chloride 40 meq/l (0.3%) in dextrose 5% inj potassium chloride extended-release potassium citrate potassium iodide povidone-iodine PRALUENT pramlintide PRANDIN praziquantel prazosin PRECOSE PRED FORTE PRED-G PRED MILD prednicarbate prednisolone , 20 prednisolone acetate prednisolone phosphate.. 46 prednisolone sodium phosphate prednisone PRELONE PREMARIN PREMPHASE PREMPRO prenatal vitamins w/folic acid 58 PRENATAL VITAMINS W/ FOLIC ACID prenatal vit w/fe bisglyc-fe prot succ-fa prenatal vit w/fe bisglycinate chelate-fa prenatal vit w/fe polysac cmplx-fa prenatal vit w/iron carbonyl-fa prenatal w/o A w/ FE carbonyl- FE gluc-dss-fa prenat-fe Bis-FE prot succ-fa-ca & omega prenat-fe bis-fe prot succ- FA-CA & omega DR.. 58 prenat w/o A w/fecbn-fegl- DSS-FA & DHA PREPARATION H PREVACID PREVIDENT PREVNAR PRIFTIN PRILOSEC primaquine PRINCIPEN PROAMATINE probenecid PROBENECID PROBIOTIC FORMULA.. 25 probiotic product procarbazine PROCARDIA PROCARDIA XL

89 Index of s prochlorperazine prochlorperazine edisylate inj PROCHLORPER INJ PROCRIT PROCTOSOL HC CREAM 2.5% PROCTOZONE CREAM-HC 2.5% PROGRAF PROMACTA promethazine promethazine hcl inj promethazine & phenylephrine PROMETHAZINE SYP DM 50 PROMETHAZINE VC W/CODEINE PROMETHAZINE W/CODEINE PROMETH VC SYP propafenone propantheline propranolol , 13 propranolol/hctz propylthiouracil PROPYLTHIOURACIL PROSCAR PROTONIX , 35 PROTOPIC PROVENTIL PROVERA PRUET DHAEC PAK PRUET DHA PAK SETONET PAK PSE/GG pseudoephedrine/ acetaminophen/ dextromethorphan ALL CAPS = Brand-name drug lower case = Generic drug pseudoephedrine/ chlorpheniramine/ dextromethorphan pseudoephedrine/dextromethorphan/guaifenesin. 52 pseudoephedrine/iburprofen 53 pseudoephedrine tan/ dexchlorphen tan/dm tan53 psyllium PULMICORT FLEXHALER 53 PULMICORT RESPULES. 54 PULMOZYME PURINETHOL pyrazinamide PYRAZINAMIDE pyrethrins/piperonyl but PYRIDIUM pyridostigmine pyridostigmine extended-release pyrilamine tan/phenyleph tan 53 pyrimethamine Q QUAL-TUSSIN SYP DC.51, 52 QUESTRAN QUESTRAN-LIGHT quinapril quinapril/hydrochlorothiazide.7 quinidine gluconate extended-release QUINIDINE GLUCONATE EXT-REL quinidine sulfate QUINIDINE SULFATE quinidine sulfate extended-release QUINIDINE SULFATE EXT-REL QV-ALLERGY QVAR R raloxifene RANEXA ranitidine ranitidine hcl in nacl 0.45% iv soln ranitidine syrup ranolazine RAPAMUNE RAZADYNE REBETOL/COPEGUS REBIF rectal crm, suppositories.. 63 RECTIV REGLAN REGRANEX RELAFEN RELENZA RELION 70/ RELION N RELION R RENVELA repaglinide RESPERAL-DM RETIN-A REVATIO REVLIMID ribavirin RIDAURA RID SHAMPOO/ BUTOXIDE SHAMPOO 16 rifabutin RIFADIN , 38 rifampin , 38 rifapentine rimantadine rimexolone

90 Index of s rivaroxaban rivastigmine rizatriptan RMS ROBAXIN ROBINUL ROBITUSSIN , 62 ROBITUSSIN CF , 62 ROBITUSSIN DM , 62 ROBITUSSIN LIQ CGH/ALRG ROBITUSSIN LIQ CGH/CLD , 52 ROBITUSSIN LIQ CGH/CONG ROBITUSSIN LIQ HD/CHST ROBITUSSIN LIQ PED NGHT ROBITUSSIN PE , 62 ROBITUSSIN PED LIQ CGH/COLD ROBITUSSIN PED SYP.. 50 ROBITUSSIN SYP CHST CNG ROBITUSSIN SYP MAX-ST 50 ROCALTROL ROCALTROL SOLUTION.. 56 RONDEC DM , 52 RONDEC DROPS RONDEC SYRUP , 49 ROWASA ROXICODONE R-TANNAMINE ruxolitinib RYNA-12 S RYNATAN PEDIATRIC SUSP RYNATUSS ALL CAPS = Brand-name drug lower case = Generic drug RYNATUSS PEDIATRIC SUSP RYTHMOL S SALAGEN salicylic acid 17%/ collodion , 64 saline nasal spray 0.65%.. 19 SAL-TROPINE SANCTURA SANDIMMUNE SANDOSTATIN SANTYL sargramostim SAVAYSA saxagliptin saxagliptin/metformin scopolamine SEASONALE SECTRAL SEDAPAP selenium sulfide SELSUN sennosides SENOKOT SENSIPAR SEROMYCIN sevelamer SIGNIFOR sildenafil SILVADENE silver sulfadiazine simethicone simvastatin SINGULAIR sirolimus SIRTURO SMZ-TMP INJ / SOD CHLORIDE INJ sodium chloride hypertonic. 47 sodium chloride inj 0.9%.. 37 sodium chloride inj 0.45%. 37 sodium chloride irrigation soln 0.9% sodium chloride iv soln 0.9% 37 sodium citrate/citric acid.. 56 sodium polysterene sulfonate SOLU-CORTEF INJ SOLU-MEDROL INJ somatropin SOMAVERT sonidegib SORIATANE sotalol Spacers SPIRIVA SPIRIVA RESPIMAT spironolactone spironolactone/ hydrochlorothiazide SPORANOX STADOL STARLIX STATUSS DM SYP stool softeners STREPTOMYCIN INJ streptomycin sulfate for inj. 32 STRIVERDI RESPIMAT STROMECTOL STUART PRENATAL sucralfate sugar+orthophosphoric acid 63 sulcralfate sulfacetamide , 47 sulfacetamide/ phenylephrine

91 Index of s sulfacetamide/pred phos.. 45 sulfacetamide/sulfur SULFACET-R sulfamethoxazole/ trimethoprim, DS sulfamethoxazoletrimethoprim iv soln sulfasalazine , 41 sulfasalazine delayed-release...24, 41 sulfisoxazole sulindac , 42 sumatriptan SUMYCIN SUPRAX SYLATRON SYMBICORT SYMLIN SYMMETREL SYNAGIS SYNALAR SYNJARDY SYNTHROID ALL CAPS = Brand-name drug lower case = Generic drug T TABLOID tacrolimus , 17 TAGAMET TALWIN NX TAMBOCOR TAMIFLU tamoxifen tamsulosin TANAFED TANAFED DMX SUSPENSION TANZEUM TAPAZOLE TARGRETIN TAZICEF INJ TBO-filgrastim TECFIDERA teduglutide TEMODAR TEMOVATE temozolomide TENEX TENORETIC TENORMIN TERAZOL 3/ terazosin , 55 terbinafine , 39 terbutaline terconazole teriflunomide teriparatide inj TESSALON TESTOSTERONE 1% TOPICAL GEL testosterone cypionate testosterone enanthate testosterone gel tetrabenazine tetracycline tetrahydrozoline/zinc sulfate 45 THEO THEOCHRON theophylline THEOPHYLLINE theophylline extended-release THEOPHYLLINE EXT-REL 54 thiethylperazine thioguanine THYROLAR TIAZAC ticarcillin & k clavulanate for inj , 33 ticarcillin & k clavulanate inj. 32 TIGAN TIKOSYN TILADE TIMENTIN INJ , 33 timolol timolol hemihydrate timolol maleate , 46 TIMOPTIC TIMOPTIC XE TINACTIN , 61 tiotropium tiotropium respimat TIVICAY tizanidine TOBRADEX tobramycin tobramycin/dexamethasone 45 TOBRAMYCIN INJ tobramycin neb soln tobramycin sulfate for inj.. 33 tobramycin sulfate inj TOBRA/NACL INJ TOBREX tolazamide tolbutamide TOLBUTAMIDE TOLINASE tolnaftate , 61 tolterodine topical antibacterials TOPROL XL TORADOL TORECAN toremifene torsemide

92 Index of s TRACLEER TRADJENTA tramadol TRANDATE TRECATOR TRENTAL tretinoin , 14 triamcinolone triamcinolone acetonide.. 15 triamcinolone acetonide inj susp triamcinolone hexacetonide inj susp triamcinolone nasal spray.. 19 triamterene/ hydrochlorothiazide TRI-FED X trifluridine trifluridine/tipiracil TRILISATE , 41 TRILYTE trimethobenzamide trimethoprim TRIMETHOPRIM TRI-NORINYL TRIOTANN , 49 tripolidine/pseudoephedrine 53 TRIPROL/PSE SYP TRI RX TRI-VI-FLOR TRI-VI-SOL , 64 TRIVORA TROJAN trospium TRUSOPT TRUST NATALCARE PAK DHA T-STAT ALL CAPS = Brand-name drug lower case = Generic drug TUDORZA PRESSAIR TUMS , 64 TUSSI 12D S TUSSI-12 S TUSSIN DM TWINJECT TYLENOL , 41, 63 TYLENOL W/CODEINE.. 12 typhoid vaccine U ULORIC ULTRAM umeclidinium inhalation umeclidinium/vilanterol UNASYN INJ 15 GM UNI-HIST DRO UNIPHYL urea 40% UREA 40% CREAM AND LOTION URECHOLINE UREX UROCIT-K UROXATRAL URSO ursodiol URSO FORTE UTIRA C V vaginal products valacyclovir VALCYTE valganciclovir VALIUM VALTREX VANCOCIN/DEX INJ VANCOCIN HCL , vancomycin HCl vancomycin hcl for inj vancomycin hcl in dextrose inj varenicline VASERETIC VASOCIDIN VASOCLEAR VASOCLEAR A VASOSULF VASOTEC VECTICAL VEETIDS VENTOLIN HFA VEPESID verapamil , 13 verapamil extended-release. 9 VESANOID VEXOL VFEND VICODIN VICODIN ES VICTOZA VI-DAYLIN VINATE AZ EX VINATE III VIROPTIC VISINE VISINE-AC vismodegib VISTARIL vitamin A vitamin ADC/fluoride/ ±iron drops vitamin B vitamin B VITAMIN B

93 Index of s vitamin B complex/ vitamin C/folic acid vitamin C vitamin D VITAMIN D , 64 vitamins pediatric....59, 64 vitamins prenatal VITAPHIL VITUSSIN VIVOTIF BERNA VOLTAREN , 41, 45 VOLTAREN 1% TOPICAL GEL VOLTAREN XR voriconazole vorinostat VOSOL HC OTIC VOSOL OTIC W warfarin WYTENSIN X XALATAN XARELTO XELODA XENAZINE XOLAIR XOPENEX RESPULES XYLOCAINE , 19 XYZAL Z ZANAFLEX zanamivir ZANTAC , 35 ZAROXOLYN ZARXIO ZEBETA ZENPEP ZESTORETIC ZESTRIL ZETIA ZIAC ZINACEF/D5W INJ ZINACEF/H20 INJ ZINACEF INJ zinc ZITHROMAX ZOCOR ZOFRAN ZOFRAN ODT ZOHYDRO ER ZOLINZA ZORTRESS ZOSTAVAX zoster vaccine live ZOSYN SOL ZOVIA 1/ ZOVIA 1/ ZOVIRAX ZYLOPRIM ZYMAR ZYRTEC , 61 ZYRTEC CHEWABLE TABLET ZYRTEC D ZYRTEC-D ZYTIGA ZYVOX , 40 ALL CAPS = Brand-name drug lower case = Generic drug 86

94 Notes 87

95 My Medications worksheet Take this worksheet with you each time you visit a doctor. Each of your doctors should be aware of every drug you take and you should have a list as well. Name of Medicine and Strength Tier I Take This Medicine For Directions Doctor Example: Lisinopril, 20mg Tier 1 High blood pressure One tablet daily Dr. Johnson 88

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