Preferred Drug List (PDL)

Transcription

1 Preferred List (PDL) Arizona CRS Effective Date: 7/1/ 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 Pharmacy and Therapeutics Committee. The drugs have been selected to provide the most clinically appropriate and cost-effective medications for patients who have their drug benefit administered through UnitedHealthcare. It is also recognized there may be occasions where an unlisted drug is desired for proper medical management of a specific patient. In those infrequent instances, the unlisted medication may be requested through the prior authorization process. The drugs represented have been reviewed by the Pharmacy and Therapeutics (P&T) Committee and are approved for inclusion. The PDL is reflective of current medical practice as of the date of review. This edition incorporates drugs added to the PDL since the last edition as well as numerous revisions to the prescribing information based on changes in pharmacotherapy. Comments and suggestions from practicing physicians have also been incorporated to ensure that the UnitedHealthcare PDL is reflective of current medical practice. NOTICE The information contained in this PDL and its appendices is provided by UnitedHealthcare, solely for the convenience of contracted 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 websites listed in the website section or go to the National Guideline Clearinghouse site 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. You are encouraged to prescribe OTC medications when clinically appropriate. PHARMACY AND THERAPEUTICS (P&T) COMMITTEE The 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. The P&T Committee meets quarterly to discuss a variety of issues. Those issues pertaining to Doc#: UHC1335a_ i

4 pharmaceutical selection and pharmacy program management are communicated quarterly. This newsletter is distributed to all participating physicians who have received the 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. Special formula nutrition needs for metabolic patients are also covered. 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 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 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. levetiracetam KEPPRA All strengths of Keppra would be covered by this listing. Dosage forms covered will be consistent with the category and use where listed. Neomycin/polymixin B/ Hydrocortisone CORTISPORIN As listed in the EAR 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 EYE and DERMATOLOGICAL 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 metoprolol 50mg & 100 mg only LOPRESSOR 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 Maximum Allowable Cost (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 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. Doc#: UHC1335a_ ii

5 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 PDL does not cover DESI less than fully effective drg 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 Doc#: UHC1335a_ iii 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 eighty-five percent (85%) of the medication has been utilized. If a claim is submitted before 85% 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. Requests for these exceptions should be made in writing by the physician and faxed to: UnitedHealthcare Pharmacy Services Department Fax Phone A prior authorization request form is available in the UnitedHealthcare provider manual and should be used for all prior authorization requests if possible. Appropriate documentation must be provided to support the medical

6 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 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 Doc#: UHC1335a_ iv 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 benzodiazepines sedative hypnotic agents barbiturates select muscle relaxants Additional fills will require prior authorization. Medications in these classes may also be subject to individual quantity limits. Additions to the QL program drug list will be made from time to time and providers notified accordingly. As always, we recognize that a number of patient-specific variables must be taken into consideration when drug therapy is prescribed and therefore overrides will be available through the medical exception (prior authorization) process. Please contact the UnitedHealthcare Pharmacy Department at 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 Prior Authorization 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 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 should be faxed to 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 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).

7 STEP Advair First-Line Agent(s) 1) 30 day trial of one inhaled corticosteroid (e.g. Asmanex Twisthaler, Flovent HFA, QVAR) 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. Incruse Ellipta, Atrovent, Combivent, Anoro Ellipta). oxymorphone ER 30-day trial of both Fentanyl patch and morphine sulfate ER at least 200mg per day Potiga 30-day trial of two of the following: lamotrigine, topiramate, carbamazepine, divalproex, or phenytoin. Step therapy only applies to members 18 years of age and older. Members less than 18 require prior authorization. Angiotensin II 30 day trial of losartan or losartan/hctz Receptor Blockers (Benicar HCT) Protopic 0.03% Trial of two different topical corticosteroids. Step therapy only applies to members 12 years of age and older. Aricept 23mg Banzel 90 day trial of Aricept 10mg daily 30 day trial of two of the following: lamotrigine, divalproex, or topiramate. DPP4 Inhibitors At least a 90 day trial of 1500mg/day of (Tradjenta, metformin. Jentadueto, Januvia, Janumet, Janumet XR, Onglyza, Kombiglyze) Dulera Elidel 1) 30 day trial of one inhaled corticosteroid (e.g. Asmanex Twisthaler, Flovent HFA, QVAR) Trial of two different topical corticosteroids. Step therapy only applies to members 12 years of age and older. Protopic 0.1% Ranexa Renvela Symbicort tolterodine 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 1) 30 day trial of one inhaled corticosteroid (e.g. Asmanex Twisthaler, Flovent HFA, QVAR) 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. Incruse Ellipta, Atrovent, Combivent, Anoro Ellipta). 30 day trial of oxybutynin immediate release. fenofibrate Gabitril levocetirizine midodrine Onfi Optivar oxycodone ER Fill of a statin or 90 days of gemfibrozil within the previous 180 days. 30 day trial of two of the following: lamotrigine, topiramate, carbamazepine, divalproex, or phenytoin. Step therapy only applies to members 12 years of age and older. Members less than 12 require prior authorization. 30 day trial of loratadine and cetirizine. Trial of fludrocortisone 30 day trial of two of the following: lamotrigine, divalproex, or topiramate. 14 day trial of ketotifen within previous 90 days required first. 30 day trial of at least 200mg per day of morphine sulfate ER TZD s At least a 90 day trial of 1500mg/day of (ActosPlusMet, metformin ActoPlusMet XR, Duetact) Uloric Vancocin Vimpat 8 week trial of up to 600mg of allopurinol required first. One fill of metronidazole tabs or cap 30 day trial of two of the following: lamotrigine, topiramate, carbamazepine, divalproex, or phenytoin. Step therapy only applies to members 17 years of age and older. Members less than 17 require prior authorization. Xopenex Respules 30 day trial of Albuterol.083% or.5% respules. Doc#: UHC1335a_ v

8 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: 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. 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. 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: 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 pages IV-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 Doc#: UHC1335a_ vi

9 Table of Contents Antineoplastics & Immunosuppressants...4 Antineoplastic Agents...4 Hormonal Antineoplastic Agents....5 Immunomodulators...5 Immunosuppressants...5 Miscellaneous...6 Blood Modifiers - Anticoagulants...7 Anticoagulants...7 Blood Cell Formation...7 Platelet Inhibitors...7 Miscellaneous...7 Cardiovascular Agents...8 Ace Inhibitors...8 Ace Inhibitor/Diuretic Combinations....8 Adrenolytics, Central...8 Alpha Blockers....8 Angiotensin II Receptor Blockers (Antagonists) 8 Angiotensin II Receptor Blocker Combinations. 9 Antiarrhythmics and Cardiac Glycosides...9 Beta Blockers and Beta Blocker/Diuretic Combinations....9 Calcium Channel Blockers Diuretics...10 Lipid Lowering Agents...11 Nitrates...12 Potassium-Removing Agents...12 Miscellaneous...12 Central Nervous System Alzheimer s Disease...13 Analgesics...13 Migraine Acute Therapy...15 Migraine Prophylactic Therapy...15 Multiple Sclerosis Myasthenia Gravis...15 Parkinson s Disease...15 Seizures Miscellaneous...17 Dermatology...17 Acne Vulgaris...17 Bacterial Infections...18 Corticosteroids Fungal Infections...20 Psoriasis...20 Rosacea...21 Scabies and Pediculosis Viral Infections...21 Miscellaneous...21 Ear, Nose & Throat...23 Ear...23 Nose...23 Throat and Mouth...25 Endocrinology Adrenal Corticosteroids...25 Androgens...25 Diabetes Mellitus...26 Growth Stimulating Agents Metabolic Modifiers Osteoporosis...28 Thyroid Disease...28 Miscellaneous...28 Gastrointestinal Diarrhea Emesis Gastroesophageal Reflux Disease (Gerd)/ Peptic Ulcers...29 Gastrointestinal Spasm...30 Inflammatory Bowel Disease...30 Laxatives...31 Pancreatic Enzymes...31 Probiotic Supplementation Miscellaneous...32 Infectious Diseases...32 Anthelmintics

10 Antibacterials...32 Antifungals...34 Antivirals...34 Miscellaneous...36 Metabolics Musculoskeletal...39 Arthritis...39 Gout Skeletal Muscle Relaxants...40 OB-GYN...40 Contraceptives...40 Endometriosis...42 Hormone Therapy/Menopause Vaginal Infections Miscellaneous...43 Ophthalmic...43 Allergy...43 Anti-Inflammatories...43 Glaucoma...44 Infections Miscellaneous...46 Psychiatric Alcohol Deterrents...46 Anxiety Attention Deficit Hyperactivity Disorder (ADHD) Bipolar Disorder Depression...47 Insomnia...48 Narcotic Antagonists...48 Psychoses Smoking Cessation...49 Miscellaneous...49 Respiratory s Antitussives, Decongestants, Expectorants and Combinations Asthma/COPD...55 Miscellaneous...56 Urological...56 Symptomatic Benign Prostatic Hypertrophy..56 Miscellaneous...57 Vitamins and Minerals Potassium...60 Miscellaneous...61 Anaphylaxis...61 Cystic Fibrosis...61 Detoxification Agents Hereditary Angioedema...61 Hyperphosphatemia...61 Idiopathic Pulmonary Fibrosis (IPF)...62 Immune Thrombocytopenic Purpura Medical Devices Metabolic Modifiers Vaccine...62 OTC MEDICATIONS...63 Acne Antifungals...63 Atopic Dermatitis...63 Cough/Cold Allergy Diabetes...64 Earwax Removal Products...64 Family Planning...64 First Aid...64 Gastrointestinal...64 Lice Products...65 Motion Sickness Ophthalmics...65 Pain...65 Smoking Cessation Products...65 Vitamins/Minerals...66 Warts...66 Miscellaneous 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 mercaptopurine PURINETHOL thioguanine TABLOID QL trifluridine/tipiracil LONSURF PA, SP Histone Deacetylase Inhibitors panobinostat FARYDAK PA, SP vorinostat ZOLINZA PA, SP Kinase Inhibitor alectinib ALECENSA PA, SP axitinib INLYTA PA, SP bosutinib BOSULIF PA, SP cabozantinib COMETRIQ PA, SP ceritinib ZYKADIA PA, SP crizotinib XALKORI PA, SP dabrafenib TAFINLAR PA, SP dasatinib SPRYCEL PA, SP erlotinib TARCEVA PA, SP everolimus AFINITOR AFINITOR DISPERZ PA, SP gefitinib IRESSA PA, SP ibrutinib IMBRUVICA PA, SP imatinib mesylate GLEEVEC PA, QL, SP lapatinib ditosylate TYKERB PA, SP lenvatinib LENVIMA PA, SP nilotinib TASIGNA PA, SP palbociclib IBRANCE PA, SP pazopanib VOTRIENT PA, SP ponatinib ICLUSIG PA, SP regorafenib STIVARGA PA, SP 4

12 Generic Name Brand Name ruxolitinib JAKAFI PA, SP sorafenib NEXAVAR PA, SP sunitinib SUTENT PA, SP trametinib MEKINIST PA, SP vandetanib CAPRELSA PA, SP vemurafenib ZELBORAF PA, SP Hormonal Antineoplastic Agents Androgen Biosynthesis Inhibitors abiraterone ZYTIGA PA, SP Antiandrogens bicalutamide CASODEX flutamide EULEXIN Antiestrogens tamoxifen NOLVADEX toremifene FARESTON 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 thalidomide THALOMID PA, QL, SP Immunosuppressants Antimetabolites azathioprine IMURAN mycophenolate mofetil CELLCEPT mycophenolate sodium MYFORTIC 5

13 Generic Name Brand Name Calcineurin Inhibitors cyclosporine GENGRAF NEORAL SOLUTION modified oral soln 100 mg/ml cyclosporine SANDIMMUNE cyclosporine SANDIMMUME SOLUTION oral soln 100 mg/ml cyclosporine, modified NEORAL GENGRAF tacrolimus HECORIA PROGRAF Rapamycin Derivative sirolimus RAPAMUNE tabs sirolimus RAPAMUNE soln Miscellaneous everolimus ZORTRESS Miscellaneous alitretinoin 1% gel PANRETIN PA bexarotene caps TARGRETIN PA, SP bexarotene topical gel TARGRETIN PA, SP cysteamine bitartrate CYSTAGON SP etoposide VEPESID hydroxyurea DROXIA hydroxyurea HYDREA mesna MESNEX tabs mitotane LYSODREN octreotide SANDOSTATIN SP olaparib LYNPARZA PA, SP pasireotide SIGNIFOR PA, SP procarbazine MATULANE SP sonidegib ODOMZO PA, SP tretinoin VESANOID SP, caps vismodegib ERIVEDGE PA, SP 6

14 Generic Name Brand Name Blood Modifiers - Anticoagulants Anticoagulants apixaban ELIQUIS dabigatran etexilate mesylate PRADAXA capsule, PA edoxaban SAVAYSA enoxaparin LOVENOX PA, QL, 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 NEUPOGEN ZARXIO PA, SP pegfilgrastim NEULASTA PA, SP plerixafor MOZOBIL PA, SP sargramostim LEUKINE PA, SP TBO-Filgrastim GRANIX PA, SP Platelet Inhibitors anagrelide AGRYLIN aspirin BAYER OTC ECOTRIN cilostazol PLETAL clopidogrel PLAVIX QL dipyridamole PERSANTINE ticagrelor BRILINTA PA Miscellaneous aminocaproic acid AMICAR tabs & syrup only pentoxifylline extended-release TRENTAL 7

15 Generic Name Brand Name Cardiovascular Agents Ace Inhibitors benazepril LOTENSIN captopril CAPOTEN captopril CAPTOPRIL POWDER (bulk) powder enalapril VASOTEC enalapril oral soln EPANED Members 8 years of age will require prior authorization. fosinopril MONOPRIL QL lisinopril ZESTRIL QL moexipril UNIVASC perindopril ACEON quinapril ACCUPRIL QL ramipril ALTACE trandolapril MAVIK Ace Inhibitor/Diuretic Combinations benazepril/ LOTENSIN HCT hydrochlorothiazide captopril/ hydrochlorothiazide CAPOZIDE enalapril/ hydrochlorothiazide VASERETIC fosinopril/ hydrochlorothiazide MONOPRIL-HCT QL lisinopril/ hydrochlorothiazide ZESTORETIC QL moexipril/ hydrochlorothiazide UNIRETIC quinapril/ hydrochlorothiazide ACCURETIC QL Adrenolytics, Central clonidine CATAPRES clonidine transdermal CATAPRES-TTS PA guanfacine TENEX Alpha Blockers doxazosin CARDURA prazosin MINIPRESS terazosin HYTRIN Angiotensin II Receptor Blockers (Antagonists) irbesartan AVAPRO losartan COZAAR QL valsartan DIOVAN 8

16 Generic Name Brand Name Angiotensin II Receptor Blocker Combinations losartan/hctz HYZAAR QL olmesartan/ hydrochlorothiazide BENICAR HCT ST sacubitril/valsartan ENTRESTO PA valsartan/ hydrochlorothiazide DIOVAN HCT Antiarrhythmics and Cardiac Glycosides amiodarone PACERONE amiodarone tabs CORDARONE 200 mg and 400 mg disopyramide NORPACE disopyramide extended-release NORPACE CR dofetilide TIKOSYN dronedarone MULTAQ PA flecainide TAMBOCOR mexiletine MEXITIL propafenone RYTHMOL IR only quinidine gluconate extended-release EXT-REL QUINIDINE GLUCONATE quinidine sulfate QUINIDINE SULFATE quinidine sulfate QUINIDINE SULFATE extended-release EXT-REL 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 nadolol CORGARD pindolol PINDOLOL propranolol HEMANGEOL propranolol INDERAL IR only propranolol/hctz INDERIDE sotalol BETAPACE sotalol (AFIB/AFL) BETAPACE AF timolol maleate tablets 9

17 Generic Name Brand Name Calcium Channel Blockers Dihydropyridines amlodipine NORVASC QL felodipine extended-release PLENDIL QL isradipine DYNACIRC nicardipine CARDENE nifedipine PROCARDIA nifedipine ADALAT CC extended-release PROCARDIA XL QL nimodipine NIMOTOP QL nimodipine oral soln NYMALIZE nisoldipine SULAR sustained release Nondihydropyridines diltiazem CARDIZEM diltiazem CARDIZEM LA sustained release coated MATXIM LA beads, QL diltiazem CARDIZEM SR sustained release, QL diltiazem extended-release CARDIZEM CD QL diltiazem sustained-release CARDIZEM SR QL diltiazem DILACOR XR extended-release TIAZAC QL verapamil CALAN verapamil VERALAN PM sustained release caps, (100 mg, 200 mg and 300 mg only) 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 hydrochlorothiazide MICROZIDE 12.5 mg caps 10

18 Generic Name Brand Name indapamide LOZOL metolazone ZAROXOLYN spironolactone ALDACTONE spironolactone SPIRONOLACTONE powder spironolactone/ hydrochlorothiazide ALDACTAZIDE torsemide DEMADEX triamterene/ DYAZIDE hydrochlorothiazide MAXZIDE Lipid Lowering Agents Bile Acid Resin cholestyramine QUESTRAN Only the bulk products are covered (cans). Individual QUESTRAN-LIGHT packets are not covered. coliestipol COLESTID Fibrates ANTARA fenofibrate LIPOFEN LOFIBRA TRICOR caps, tabs and micronized caps, ST TRIGLIDE gemfibrozil LOPID HMG-CoA Reductase Inhibitors and Combinations atorvastatin LIPITOR lovastatin MEVACOR QL pravastatin PRAVACHOL QL simvastatin ZOCOR QL Niacins niacin NIACOR niacin extended-release NIASPAN Miscellaneous alirocumab PRALUENT PA, QL, SP ezetimibe ZETIA PA 11

19 Generic Name Brand Name Nitrates Oral isosorbide dinitrate ISORDIL DILATRATE-SR isosorbide dinitrate ISOCHRON extended-release ISOSORBIDE DINITRATE ER isosorbide mononitrate ISMO isosorbide mononitrate extended-release IMDUR nitroglycerin extended-release Sublingual isosorbide dinitrate ISORDIL S.L. nitroglycerin NITROLINGUAL nitroglycerin NITROSTAT 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 eplerenone INSPRA PA epoprostenol FLOLAN SP, Coverable through Medical Benefit guanabenz WYTENSIN hydralazine APRESOLINE iloprost VENTAVIS SP, Coverable through Medical Benefit methyldopa ALDOMET methyldopa/hctz ALDORIL midodrine PROAMATINE ST minoxidil LONITEN ranolazine RANEXA ST sildenafil REVATIO PA, SP tadalafil (PAH) ADCIRCA PA, SP 12

20 Generic Name Brand Name treprostinil REMODULIN treprostinil TYVASO Central Nervous System SP, Coverable through Medical Benefit SP, Coverable through Medical Benefit Alzheimer s Disease donepezil ARICEPT 5 mg and 10 mg, QL donepezil ARICEPT 23 mg, ST galantamine RAZADYNE QL memantine NAMENDA QL, Members <18 years of age will require prior authorization. memantine SR NAMENDA XR PA, QL rivastigmine EXELON QL Analgesics Barbiturate Non-Narcotic Analgesics butalbital/acetaminophen PHRENILIN QL butalbital/acetaminophen SEDAPAP QL ESGIC butalbital/acetaminophen/ FIORICET QL caffeine ZEBUTAL butalbital/aspirin/caffeine FIORINAL QL Non-Narcotic Analgesics acetaminophen TYLENOL OTC aspirin/acetaminophen/ caffeine EXCEDRIN MIGRAINE OTC tramadol ULTRAM QL NSAIDS diclofenac sodium delayed-release VOLTAREN diclofenac sodium SR VOLTAREN XR QL etodolac LODINE IR Only fenoprofen NALFON 400 mg fenoprofen NALFON 600 mg flurbiprofen ANSAID ibuprofen ADVIL tabs, chew tabs ibuprofen MOTRIN and susp, OTC tabs, chew tabs and susp indomethacin INDOCIN ketoprofen ORUDIS IR only 13

21 Generic Name Brand Name ketoprofen SR ORUDIS cap, 200 mg ketorolac tromethamine TORADOL QL meloxicam MOBIC QL nabumetone RELAFEN naproxen NAPROSYN ENTERIC COATEDnaproxen delayed release 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 codeine sulfate QL fentanyl transdermal DURAGESIC QL LORCET hydrocodone/ acetaminophen LORTAB LORTAB ELIXIR NORCO VICODIN VICODIN ES VICOPROFEN 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 ER OXYCONTIN PA, QL, 15 mg, 30 mg, 60 mg oxycodone ER OXYCONTIN PA, QL oxycodone/ MAGNACET acetaminophen PERCOCET QL oxycodone/aspirin PERCODAN QL oxymorphone ER OXYMORPHONE ER QL, ST QL 14

22 Generic Name Brand Name Migraine Acute Therapy Ergotamine Derivatives dihydroergotamine D.H.E. 45 inj, QL dihydroergotamine MIGRANAL ergotamine/caffeine CAFERGOT ergotamine tartrate/ MIGERGOT caffeine SUPPOSITORIES QL Selective Serotonin Agonists naratriptan AMERGE ST rizatriptan MAXALT/MAXALT MLT QL sumatriptan IMITREX QL Migraine Prophylactic Therapy amitriptyline ELAVIL divalproex sodium cap sprinkle DEPAKOTE SPRINKLE divalproex sodium delayed-release DEPAKOTE Minimum age 2 propranolol INDERAL IR only verapamil CALAN Multiple Sclerosis dimethyl fumarate TECFIDERA PA, QL, SP fingolimod GILENYA PA, QL, SP glatiramer acetate COPAXONE PA, QL, SP (40mg) glatiramer acetate COPAXONE GLATOPA PA, QL, SP (20mg) interferon beta-1a AVONEX/AVONEX PEN QL, SP interferon beta-1a REBIF SP interferon beta-1b BETASERON EXTAVIA PA, SP teriflunomide AUBAGIO PA, SP Myasthenia Gravis pyridostigmine MESTINON tabs pyridostigmine MESTINON syrup pyridostigmine extended-release MESTINON TIMESPAN Parkinson s Disease amantadine SYMMETREL except tabs benztropine COGENTIN bromocriptine PARLODEL carbidopa/levodopa SINEMET 15

23 Generic Name Brand Name carbidopa/levodopa extended-release SINEMET CR entacapone COMTAN pramipexole MIRAPEX pramipexole dihydrochloride SR MIRAPEX ER 24hr tab ropinirole REQUIP ropinirole hydrochloride SR REQUIP XL 24hr tab selegiline ELDEPRYL tabs tolcapone TASMAR trihexyphenidyl ARTANE Seizures carbamazepine TEGRETOL carbamazepine CARBATROL extended-release TEGRETOL-XR carbamazepine SR EPITOL EQUATRO clobazam ONFI ST clobazam suspension ONFI SUSPENSION PA clonazepam KLONOPIN ODT tabs clonazepam KLONOPIN tabs diazepam DIASTAT ACUDIAL rectal gel, QL diazepam DIASTAT PEDIATRIC divalproex sodium cap sprinkle DEPAKOTE SPRINKLE divalproex sodium delayed-release DEPAKOTE Minimum age 2 ethosuximide ZARONTIN exogabine POTIGA Age Limits Apply, ST felbamate FELBATOL felbamate oral susp FELBATOL ORAL SUSP gabapentin NEURONTIN caps and tabs only lacosamide VIMPAT Age Limits Apply, ST lacosamide solution VIMPAT PA lamotrigine LAMICTAL QL lamotrigine chew dispersable tab LAMICTAL CD CHEW TAB lamotrigine dispersible tab LAMICTAL ODT KIT PA lamotrigine ODT LAMICTAL ODT PA lamotrigine SR LAMICTAL XR tab lamotrigine SR ODT LAMICTAL XR ODT KIT PA 16

24 Generic Name Brand Name lamotrigine starter kit LAMICTAL STARTER KIT lamotrigine titration kit LAMICTAL XR KIT PA levetiracetam KEPPRA QL levetiracetam SR KEPPRA XR methsuximide CELONTIN oxcarbazepine TRILEPTAL QL phenobarbital PHENOBARBITAL phenytoin DILANTIN INFATABS phenytoin sodium DILANTIN extended PHENYTEK pregabalin LYRICA PA pregabalin LYRICA SOLUTION oral solution, PA primidone MYSOLINE rufinamide BANZEL tablets only, QL, ST rufinamide suspension BANZEL SUSPENSION PA tiagabine GABITRIL ge Limits Apply, ST, 2mg & 4mg tiagabine GABITRIL Age Limits Apply, ST, 12mg & 16mg topiramate TOPAMAX QL topiramate sprinkle caps TOPAMAX SPRINKLE QL valproic acid DEPAKENE vigabatrin oral solution SABRIL SOLUTION PA, SP zonisamide ZONEGRAN QL Miscellaneous tetrabenazine XENAZINE PA, SP Dermatology Acne Vulgaris Oral isotretinoin ACCUTANE Max Age of 25, PA Topical azelaic acid FINACEA gel benzoyl peroxide BENZAC AC benzoyl peroxide BENZEFOAM foam 5.3% & 9.8% benzoyl peroxide BREVOXYL gel 4%, 8% benzoyl peroxide DELOS cleanser 3.5%, OTC benzoyl peroxide NEOBENZ MICR LIQ liquid 7% benzoyl peroxide OC8 gel 7%, OTC benzoyl peroxide PANOXYL CREAM OTC cream 2.5%, OTC benzoyl peroxide TRIAZ CLOTHS cloth 3%, 6%, 9% benzoyl peroxide bar 10% PANOXYL BAR OTC OTC 17

25 Generic Name benzoyl peroxide creamy wash 8% & benzoyl peroxide bar 5% k benzoyl peroxide gel benzoyl peroxide wash 4% & benzoyl peroxide bar 5% kit Brand Name BPO CREAMY KIT BENZIQ LS BENZIQ BREVOXYL 2.75%, 5.25% BREVOXYL-4 OTC OTC clindamycin CLEOCIN T gel clindamycin CLEOCIN T lotion clindamycin CLEOCIN T soln erythromycin ERYGEL gel 2% erythromycin T-STAT soln erythromycin/benzoyl peroxide salicylic acid BENZAMYCIN CLEAN & CLEAR GEL NEUTROGENA RAPID CLEAR GEL gel 2%, OTC EXUVIANCE salicylic acid KERALYT gel 3, 6% salicylic acid STRI-DEX AVEENO CLEAR PADS OTC pad 0.5%, 1&, 2%, OTC salicylic acid NEUTROGENA OIL FREE ACNE WASH liquid 2%, OTC salicylic acid SALEX lotion 6% sulfacetamide/sulfur SULFACET-R lotion sulfacetamide sodium KLARON LOTION SEBIZON lotion 10% sulfacetamide/sulfur PLEXION ATRALIN tretinoin AVITA RETIN-A Bacterial Infections bacitracin BACITRACIN OTC bacitracin-polymyxinneomycin HC CORTISPORIN OINTMENT oint 1% gentamicin GENTAK mupirocin BACTROBAN ointment, 22 gram tube only 18

26 Generic Name Brand Name neomycin/polymyxin B/ bacitracin NEOSPORIN OTC silver sulfadiazine SILVADENE Corticosteroids Low Potency alclometasone ACLOVATE 0.05% crm/oint fluocinolone acetonide DERMA-SMOOTHE OIL/FS oil 0.01% fluocinolone acetonide CAPEX SHAMOO shampoo 0.01% fluocinolone acetonide SYNALAR soln/crm 0.01% hydrocortisone CORTAID SOLUTION OTC soln 1%, OTC hydrocortisone CORTIZONE crm, oint, lot OTC hydrocortisone HYTONE crm 0.5%, 1%, & 2.5% hydrocortisone HYTONE lotion 1% & 2.5% hydrocortisone/aloe CORTIZONE-10 INTENSIVE HEALING crm 0.5% & 1%, OTC 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% fluticasone propionate CUTIVATE LOTION lotion 0.05% hydrocortisone butyrate LOCOID crm/lotion/oint 0.1% hydrocortisone valerate WESTCORT crm/oint 0.2% mometasone furoate ELOCON crm/oint/soln 0.1% prednicarbate DERMATOP crm 0.1% triamcinolone acetonide KENALOG crm/lot/oint 0.025% triamcinolone acetonide KENALOG crm/oint/lotion 0.1% triamcinolone acetonide TRIANEX oint 0.05% High Potency betamethasone augmented dip DIPROLENE lotion 0.05% betamethasone augmented dip DIPROLENE AF crm 0.05% betamethasone dipropionate DIPROSONE crm/lotion/oint 0.05% diflorasone diacetate PSORCON CREAM cream 0.05% diflorasone diacetate PSORCON OINTMENT oint 0.05% fluocinonide LIDEX crm/oint/gel/soln 0.05% fluocinonide emulsified base LIDEX E crm 0.05% triamcinolone acetonide KENALOG crm 0.5% 19

27 Generic Name Brand Name 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% Fungal Infections ciclopirox PENLAC SOLUTION 8% clotrimazole LOTRIMIN AF OTC clotrimazole MYCELEX clotrimazole crystals CLOTRIMAZOLE clotrimazole with LOTRISONE betamethasone ketoconazole NIZORAL ketoconazole foam EXTINA 2% ketoconazole gel XOLEGEL 2% ketoconazole gel 2% & hydrocortisone gel 1% kit ketoconazole gel 2% & pyrithione zinc shampoo 1% kit XOLEGEL KIT XOLEGEL DUO KIT ketoconazole shampoo NIZORAL A-D OTC 1% OTC miconazole DESENEX 2% OTC miconazole MICATIN OTC miconazole MONISTAT-DERM miconazole nitrate kit FUNGOID TINCTURE KIT 2% miconazole nitrate lotion ZEASORB-AF 2% OTC miconazole nitrate soln AZOLEN TINCTURE SOLUTION OTC 2% OTC nystatin MYCOSTATIN terbinafine LAMISIL AT OTC terbinafine gel LAMISIL GEL 1% terbinafine HCL LAMISIL SOLUTION soln 1% tolnaftate TINACTIN OTC Psoriasis acitretin SORIATANE oral caps, PA calcipotriene DOVONEX calcitriol VECTICAL methoxsalen OXSORALEN-ULTRA salicylic acid SCALPICIN liquid 3% 20

28 Generic Name Brand Name Rosacea brimonidine MIRVASO PA METROCREAM metronidazole METROGEL METROLOTION Scabies and Pediculosis crotamiton EURAX ivermectin SKLICE lotion 0.5%, PA malathion OVIDE permethrin ELIMITE 5%, QL permethrin NIX CREME RINSE 1%, OTC pyrethrins/piperonyl but RID SHAMPOO/ BUTOXIDE SHAMPOO 4% OTC spinosad NATROBA susp 0.9%, PA Viral Infections podofilox CONDYLOX SOL sol salicylic acid 17%/collodion DUOFILM OTC Miscellaneous aluminum acetate soln/cream, OTC aluminum chloride DRYSOL OTC soln 12%, OTC aluminum chloride hexahydrate HYPERCARE 20% ammonium lactate LAC-HYDRIN crm 12%, lotion 5% & 12% ammonium lactate LACTINOL lotion 10% becaplermin gel REGRANEX PA calamine lotion/ointment, OTC collagenase oint SANTYL QL fluorouracil CARAC 0.5% cream fluorouracil EFUDEX fluorouracil FLUOROPLEX 1% cream hexachlorophene PHISOHEX hydrocortisone PROCTO-PAK CREAM rectal cream 1% PROCTOSOL HC CREAM 2.5% hydrocortisone PROCTOZONE CREAM-HC 2.5% ANUSOL HC 2.5% hydrocortisone acetate CORTIFOAM AEROSOL rectal foam 90 mg hydrocortisone acetate TUCKS OINTMENT OTC rectal ointment 21

29 Generic Name Brand Name hydrocortisone acetate w/pramoxine PROCTOFOAM HC FOAM rectal foam 1-1% 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 XYLOCAINE oint 5% lidocaine patch LIDODERM PATCH 5%, PA lidocaine/prilocaine EMLA 2.5% cream lidocaine-prilocaine EMLA kit % nitroglycerin RECTIV 0.4% rectal ointment, PA pimecrolimus ELIDEL cream QL, ST, Step therapy is not required for members ages 2-11; not covered for members less than 2 years of age pimecrolimus ELIDEL cream QL, ST, Step therapy is not required for members ages 2-11; not covered for members less than 2 years of age salicylic acid CALICYLIC cream 10% P & S SHAMPOO salicylic acid SELSUN BLUE shampoo 2%, 3% OTC DHS SAL SHAMPOO OTC salicylic acid SALAC OTC foam 2%, OTC salicylic acid SALACYN 6% cream, lotion salicylic acid SALVAX foam 6% salicylic acid SALEX shampoo 6% 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 22

30 Generic Name Brand Name Ear, Nose & Throat Ear acetic acid VOSOL OTIC otic acetic acid/ DOMEBORO OTIC aluminum acetate acetic acid/ hydrocortisone VOSOL HC OTIC antipyrine-benzocaine AURALGAN otic soln mg/ml ( %) benzocaine/antipyrine BENZOTIC carbamide peroxide DEBROX 6.5%, OTC ciprofloxacin/ CIPRODEX PA dexamethasone neomycin/polymyxin B/ hydrocortisone CORTISPORIN OTIC otic ofloxacin FLOXIN OTIC Nose Antihistamines - First Generation, Sedating brompheniramine maleate J-TAN PD drops 1 mg/ml brompheniramine maleate RESPA-BR tab SR 12hr 11 mg brompheniramine tannate BROVEX CT chew tab 12 mg chlorpheniramine CHLOR-TRIMETON extended-release ALLERGY chlorpheniramine maleate CHLOR-TRIMETON 12 mg, OTC 2 mg/5 ml, OTC SYRUP chlorpheniramine maleate CHLORPHENIRAMINE drops 2 mg/ml chlorpheniramine maleate CHLORPHENIRAMINE tabs 4 mg chlorpheniramine tannate CHLORPHENIRAMINE susp 2 mg/ml chlorpheniramine tannate CHLORPHENIRAMINE tabs clemastine CLEMASTINE cyproheptadine CYPROHEPTADINE dexchlorpheniramine POLARAMINE syrup 2 mg/5ml maleate diphenhydramine diphenhydramine BENADRYL OTC diphenhydramine BENADRYL tab disp 12.5 mg diphenhydramine TRIAMINIC oral strips hydroxyzine HCL ATARAX hydroxyzine pamoate VISTARIL 23

31 Generic Name Brand Name Antihistamines - Second Generation, Non-Sedating cetirizine ZYRTEC OTC cetirizine chew tab ZYRTEC CHEWABLE TAB- LET fexofenadine ALLEGRA tabs levocetirizine XYZAL tabs, ST loratadine ALAVERT CLARITIN OTC loratadine CLARITIN CHEW chew tab 5 mg loratadine CLARITIN RDT ODT 5 mg Antihistamines - Others Antihistamine/Decongestant Combinations azelastine ASTELIN spray Antihistamine/Decongestant Combinations - First Generation brompheniramine/ pseudoephedrine LODRANE D cap 4-60 mg chlorpheniramine/ phenylephrine/ TRIOTANN pyrilamine chlorpheniramine/ pseudoephedrine ACTIFED OTC Antihistamine/Decongestant Combinations - Second Generation cetirizine hydrochloride/ pseudoephedrine hydrochloride ZYRTEC-D 5 mg-120 mg tablet 12 hours extended-release fexofenadine/ pseudoephedrine ALLEGRA-D SR tabs loratadine/ pseudoephedrine extended-release ALAVERT-D ALAVERT ALRG TAB/SINUS ALLERGY/CONG Nasal Steroids fluticasone FLONASE triamcinolone acetonide NASACORT AQ PA triamcinolone nasal spray NASACORT ALLERGY 24 HOUR OTC OTC Miscellaneous Nasal cromolyn sodium NASALCROM OTC ipratropium bromide ATROVENT NS saline nasal spray 0.65% OCEAN NASAL SPRAY OTC 24

32 Generic Name Brand Name Miscellaneous Nasal Decongestants oxymetazoline AFRIN OTC phenylephrine NEO-SYNEPHRINE DIMEATAPP DRO OTC DECONGES Throat and Mouth amlexanox APHTHASOL oral paste 5% chlorhexidine PERIOGARD chlorhexidine gluconate PERIDEX lidocaine viscous XYLOCAINE pilocarpine SALAGEN triamcinolone KENALOG IN ORABASE paste Endocrinology Adrenal Corticosteroids cortisone acetate dexamethasone DECADRON fludrocortisone FLORINEF hydrocortisone CORTEF hydrocortisone inj SOLU-CORTEF SP, Coverable through Medical Benefit methylprednisolone MEDROL 4mg, 8mg, 16mg, 32mg methylprednisolone MEDROL 2mg methylprednisolone inj SOLU-MEDROL SP, Coverable through Medical Benefit prednisolone prednisolone PRELONE syrup prednisolone sodium ORAPRED phosphate PEDIAPRED prednisone DELTASONE prednisone PREDNISONE conc 5 mg/ml prednisone RAYOS tabs delayed release triamcinolone inj KENALOG-40 SP, Coverable through Medical Benefit Androgens fluoxymesterone ANDROXY PA testosterone ANDRODERM patch 2 mg and 4 mg, PA testosterone ANDROGEL 1.62% gel, PA testosterone cypionate DEPO-TESTOSTERONE testosterone enanthate DELATESTRYL Vials only. Disposable syringes not covered. testosterone gel TESTIM PA 25

33 Generic Name testosterone gel topical tube, packet, and pump bottle Brand Name TESTOSTERONE 1% TOPI- CAL GEL testotesterone ANDROGEL 1% gel (not pump), PA Diabetes Mellitus Glucose Elevating Agents glucagon, human GLUCAGON QL recombinant Insulins insulin aspart NOVOLOG QL insulin aspart NOVOLOG FLEXPEN PA, QL insulin aspart protamine 70%/insulin aspart 30% insulin aspart protamine 70%/insulin aspart 30% NOVOLOG MIX 70/30 QL NOVOLOG MIX 70/30 FL- EXPEN PA PA, QL insulin detemir LEVEMIR PA, QL insulin detemir LEVEMIR FLEXPEN PA, QL insulin glargine LANTUS QL insulin glargine LANTUS SOLOSTAR PA, QL insulin glargine TOUJEO SOLOSTAR 300 units/ml insulin human NOVOLIN R OTC, QL insulin human RELION R OTC, QL insulin isophane HUMULIN N OTC, QL insulin isophane human HUMULIN N PEN PA, QL insulin isophane human NOVOLIN N OTC, QL insulin isophane human RELION N OTC, QL insulin isophane human 70%/regular 30% NOVOLIN 70/30 OTC, QL 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 lispro prot 50%/lispro 50% KWIKPEN HUMALOG MIX 50/50 PA, QL insulin lisopro prot/lispro HUMALOG MIX 75/25 QL insulin lispro HUMALOG QL insulin lispro HUMALOG KWIKPEN PA, QL insulin lispro prot 75%/lispro 25% KWIKPEN HUMALOG MIX 72/25 PA, QL insulin regular HUMULIN R OTC, QL 26

34 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 chlorpropamide DIABINESE empagliflozin/metformin SYNJARDY ST glimepiride AMARYL glipizide GLUCOTROL glipizide extended-release GLUCOTROL XL glipizide/metformin METAGLIP 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 sitagliptan JANUVIA QL, ST sitagliptan/metformin JANUMET QL, ST sitagliptan/metformin ER JANUMET XR QL, ST tolazamide TOLINASE tolbutamide TOLBUTAMIDE Miscellaneous Antidiabetic Agents exenatide BYETTA PA liraglutide VICTOZA ST pramlintide SYMLIN PA 27

35 Generic Name Brand Name Growth Stimulating Agents mecasermin INCRELEX PA, SP GENOTROPIN somatropin NORDITROPIN PA, SP NUTROPIN AQ NUSPIN Metabolic Modifiers carglumic acid CARBAGLU PA, SP glycerol phenylbutyrate RAVICTI PA, SP idursulfase ELAPRASE PA, SP imiglucerase CEREZYME PA, SP sodium phenylbutyrate BUPHENYL ORAL oral powder POWDER PA, SP sodium phenylbutyrate tab BUPHENYL PA, SP Osteoporosis alendronate FOSAMAX QL calcitonin-salmon MIACALCIN nasal spray, QL calcitonin-salmon 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 thyroid tab ARMOUR THYROID QL Miscellaneous agalsidase FABRAZYME PA, SP alglucerase CEREDASE PA, SP alglucosidase LUMIZYME PA, SP betaine powder for oral solution CYSTADANE SP bromocriptine PARLODEL cabergoline DOSTINEX cholic acid CHOLBAM PA, SP desmopressin DDAVP QL laronidase ALDURAZYME PA, SP methylergonovine METHERGINE mifepristone KORLYM PA, SP pegvisomant SOMAVERT PA, SP 28

36 Generic Name Brand Name sapropterin KUVAN PA, SP sapropterin powder KUVAN POWDER FOR SO- LUTION PA, SP taliglucerase ELELYSO PA, SP velaglucerase alfa VPRIV PA, SP Gastrointestinal Diarrhea diphenoxylate/atropine LOMOTIL loperamide IMODIUM A-D OTC loperamide IMODIUM A-D CHW chew 2 mg loperamide IMODIUM A-D LIQ liq 1 mg/7.5ml loperamide LOPERAMIDE Emesis aprepitant EMEND QL applies to 40 mg, 80 mg and mg dolasetron ANZEMET PA dronabinol MARINOL PA granisetron KYTRIL PA SP granisetron KYTRIL oral soln PA meclizine ANTIVERT metoclopramide REGLAN ondansetron ZOFRAN ZOFRAN ODT QL prochlorperazine COMPAZINE promethazine PHENERGAN 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 NEXIUM DELAYED Members 2 years of age will require prior RELEASE PACKET authorization. famotidine PEPCID PEPCID AC OTC Pepcid AC 10 mg and 20 mg also covered/ encouraged with written prescription. famotidine PEPCID AZ CHW chew 29

37 Generic Name Brand Name lansoprazole PREVACID lansoprazole delayed-release PREVACID SOLUTAB orally disintegrating tabs, QL omeprazole delayed-release PRILOSEC Capsules only, QL omeprazole delayed-release PRILOSEC POWDER susp packet pantoprazole PROTONIX pantoprazole delayed-release PROTONIX PAK susp packet ranitidine ZANTAC 150 mg tabs ranitidine effer ZANTAC tab 25 mg ranitidine syrup ZANTAC sucralfate CARAFATE sulcralfate CARAFATE SUSPENSION suspension, Members 10 years of age up to 65 years of age will require prior authorization. Gastrointestinal Spasm dicyclomine BENTYL glycopyrrolate ROBINUL ROBINUL FORTE hyoscyamine sulfate LEVSIN CYSTOSPAZ hyoscyamine sulfate LEVBID extended-release LEVSINEX Inflammatory Bowel Disease balsalazide COLAZAL budesonide ENTOCORT EC PA hydrocortisone COLOCORT enema mesalamine ROWASA enema only APRISO mesalamine extended-release ASACOL HD DELZICOL LIALDA 30 PENTASA mesalamine supp CANASA olsalazine sodium DIPENTUM sulfasalazine AZULFIDINE sulfasalazine delayed-release AZULFIDINE EN-TABS

38 Generic Name Laxatives casanthranol-docusate sodium Brand Name docusate calcium plus OTC docusate potasssium OTC docusate sodium COLACE OTC glycerin GLYCERIN SUPPOSITORY suppository, OTC lactulose ENULOSE lactulose KRISTALOSE oral packet peg 3350/electrolytes COLYTE peg 3350/sodium bicarbonate/sodium chloride peg 3350/sodium bicarbonate/sodium chloride/potassium chloride TRILYTE NULYTELY polyethylene glycol 3350 MIRALAX sennosides SENOKOT 8.6 mg tab, OTC Pancreatic Enzymes pancrelipase CREON CREON 3000 UNIT ZENPEP pancrelipase PANCREAZE QL pancrealipase DR CREON DR unit pancrealipase DR ZENPEP DR unit sacrosidase SUCRAID soln 8500 unit/ml, PA, SP Probiotic Supplementation acidophilus ACIDOPHILUS XTRA OTC acidophilus ACIDOPHILUS caps and tabs, OTC acidophilus/bifidus ACIDOPHILUS/BIFIDUS WAFER OTC acidophilus/citrus pectin ACIDOPHILUS/CITRUS PECTIN tabs, OTC acidophilus/pectin ACIDOPHILUS/PECTIN caps, OTC lactobacillus FLORANEX chewable tabs, OTC probiotic product PROBIOTIC FORMULA caps, OTC OTC 31

39 Generic Name Brand Name Miscellaneous atropine sulfate SAL-TROPINE bismuth subsalicylate + metronidazole + HELIDAC tetracycline linaclotide LINZESS PA misoprostol CYTOTEC naloxegol MOVANTIK PA teduglutide GATTEX PA, SP ACTIGALL ursodiol Infectious Diseases URSO URSO FORTE Anthelmintics albendazole ALBENZA ivermectin STROMECTOL praziquantel BILTRICIDE 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 tabs cefuroxime axetil CEFTIN suspension Cephalosporins - Third Generation cefdinir OMNICEF cefixime SUPRAX QL 32

40 Generic Name Brand Name cefixime SUPRAX susp, QL cefpodoxime VANTIN 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. erythromycin stearate ERYTHROCIN erythromycin/sulfisoxazole PEDIAZOLE Penicillins amoxicillin AMOXICILLIN CAPSULES Except 500 mg and 875 mg AND CHEWABLES film-coated tabs. amoxicillin AMOXIL tabs, 500 mg & 875 mg amoxicillin AMOXIL SUSP suspension amoxicillin/clavulanate AUGMENTIN amoxicillin/clavulanate AUGMENTIN ES-600 ampicillin PRINCIPEN dicloxacillin DICLOXACILLIN penicillin VK VEETIDS Sulfonamides sulfadiazine sulfamethoxazole/ BACTRIM trimethoprim, DS BACTRIM DS Tetracyclines demeclocycline DECLOMYCIN PA doxycycline delayed-release VIBRAMYCIN doxycycline hyclate VIBRAMYCIN doxycycline monohydrate DOXYCYCLINE MONOHYDRATE minocycline MINOCIN caps and tabs minocycline SR MINOCIN 24hr tetracycline SUMYCIN 33

41 Generic Name Brand Name Miscellaneous vancomycin HCl VANCOCIN HCL cap, ST Antifungals clotrimazole MYCELEX troches fluconazole DIFLUCAN QL flucytosine ANCOBAN PA griseofulvin microsize GRIFULVIN V griseofulvin ultramicrosize GRIS-PEG itraconazole ONMEL tab 200 mg, PA itraconazole SPORANOX caps, PA, QL itraconazole SPORANOX soln, PA, QL ketoconazole NIZORAL miconazole buccal MICONAZOLE tab 50 mg (mouth-throat) nystatin MYCOSTATIN posaconazole NOXAFIL tabs, PA posaconazole susp NOXAFIL PA terbinafine LAMISIL QL terbinafine LAMISIL oral granules voriconazole VFEND tabs, PA Antivirals Cytomegalovirus Treatment cidofovir VISTIDE Coverable through Medical foscarnet sodium FOSCAVIR Benefit Coverable through Medical Benefit ganciclovir CYTOVENE valganciclovir VALCYTE soln PA valganciclovir VALCYTE Entry/Fusion Inhibitors enfuvirtide FUZEON PA Hepatitis Treatment adefovir HEPSERA SP boceprevir VICTRELIS PA, SP daclatasvir DAKLINZA PA, SP entecavir BARACLUDE SP interferon alfa-2b INTRON A PA, SP interferon alfacon-1 INFERGEN PA, SP lamivudine EPIVIR HBV SP, solution lamivudine EPIVIR HBV SP, tablets ledipasvir/sofosbuvir HARVONI PA, SP peginterferon alfa-2a PEGASYS PA, SP peginterferon alfa-2a PEGASYS PROCLICK PA, SP peginterferon alfa-2b PEGINTRON PA, SP 34

42 Generic Name Brand Name ribavirin REBETOL/COPEGUS 200 mg caps and tabs only, PA, SP ribavirin soln REBETOL soln, PA, SP sofosbuvir SOVALDI PA, SP telaprevir INCIVEK PA, SP telbivudine TYZEKA PA, SP Herpes Treatment acyclovir ZOVIRAX acyclovir ZOVIRAX CREAM cream 5% acyclovir ZOVIRAX OINTMENT oint 5% docosanol ABREVA OTC cream 10%, OTC famciclovir FAMVIR PA penciclovir DENAVIR cream 1% valacyclovir VALTREX Influenza Treatment amantadine SYMMETREL except tabs oseltamivir TAMIFLU QL rimantadine FLUMADINE zanamivir RELENZA QL Non-Nucleoside Reverse Transcriptase Inhibitors delavirdine RESCRIPTOR efavirenz SUSTIVA nevirapine VIRAMUNE nevirapine ER VIRAMUNE XR rilpivirine EDURANT Nucleoside Analogues Nucleoside Reverse - Transcriptase Inhibitors/and Combinations abacavir ZIAGEN abacavir/lamivudine EPZICOM abacavir/lamivudine/ zidovudine TRIZIVIR didanosine VIDEX didanosine delayed-release VIDEX EC emtricitabine EMTRIVA emtricitabine/rilpivirine/ tenofovir COMPLERA lamivudine EPIVIR lamivudine/zidovudine COMBIVIR stavudine ZERIT zidovudine RETROVIR 35

43 Generic Name Brand Name Nucleoside/Nucleotide Reverse - Transcriptase Inhibitor Combination cobicistat/elvitegravir/ emtricitabine/tenofovir STRIBILD efavirenz/emtricitabine/ tenofovir ATRIPLA emtricitabine/tenofovir TRUVADA Nucleotide Analogues Nucleotide Reverse-Transcriptase Inhibitor tenofovir VIREAD Protease Inhibitors amprenavir AGENERASE atazanavir REYATAZ atazanavir REYATAZ POWDER PACKET darunavir PREZISTA fosamprenavir LEXIVA indinavir CRIXIVAN lopinavir/ritonavir KALETRA nelfinavir VIRACEPT ritonavir NORVIR saquinavir mesylate INVIRASE tipranavir APTIVUS Miscellaneous artemether-lumefantrine COARTEM atovaquone MEPRON PA atovaquone/proguanil MALARONE bedaquiline SIRTURO PA chloroquine phosphate ARALEN clindamycin CLEOCIN cap, 75 mg clindamycin CLEOCIN tabs cobicistat TYBOST dapsone DAPSONE darunavir/cobicistat PREZCOBIX etravirine INTELENCE etravirine INTELENCE tab 25 mg hydroxychloroquine PLAQUENIL interferon gamma-1b ACTIMMUNE PA, SP linezolid ZYVOX PA maraviroc SELZENTRY mefloquine LARIAM metronidazole FLAGYL tabs only neomycin sulfate neomycin sulfate soln NEO-FRADIN 36

44 Generic Name Brand Name nitazoxanide suspension ALINIA SUSPENSION Members 8 years of age will require prior authorization. nitazoxanide tablet ALINIA PA nitrofurantoin extended-release MACROBID nitrofurantoin MACRODANTIN macrocrystals MACRODANTIN 25 MG nitrofurantoin susp FURADANTIN SUSP 25 MG/5 ML palivizumab SYNAGIS PA, SP paromomycin HUMATIN povidone-iodine OTC Members 8 years of age will require prior authorization. primaquine pyrimethamine DARAPRIM PA, SP quinine sulfate QUALAQUIN 324 mg caps only raltegravir ISENTRESS raltegravir ISENTRESS CHEWABLE chewable tablet trimethoprim TRIMETHOPRIM tabs only Metabolics arginine BCAD-1, BCAD-2 betaine CYSTADANE biotin citrulline cyclinex-1, cyclinex-2 cystine essential amino acid (EAA) mix glutarex-1, glutarex-2 glycine HCU cooler, express, gel HCY-1, HCY-2 hominex-1, hominex-2 i-valex-1, i-valex-2 isoleucine ketonex-1, ketonex-2 kionex leucine lipistart lophlex 37

45 Generic Name MCT procal milupa PKU-2, milupa PKU-3 MM/PA express, gel MSUD analog, complex, cooler, express MSUD complex drink mix MSUD maxamum, maxamaid OA-1, OA-2 periflex advance, infant, junior PFD-1, PFD-2 phenex-1, phenex-2 phenylade 40, 60, drink mix phenylade MTE amino acid blend phenylfree-1, phenylfree-2, HP phlexy-10 PKU cooler, express, gel portagen pro-phree powder progestimil lipil propimex-1, propimex-2 provimin sapropterin dihydrochloride sodium benzoate super soluble duocal tolerex TYR cooler, express, gel tyrex-1, tyrex-2 tyros-1, tyros-2 valine WND-1, WND-2 XLEU analog, maxamum, maxamaid XLYS, XTRYP analog, maxamum, maxamaid XMET analog, maxamum, maxamaid Brand Name KUVAN PA, SP 38

46 Generic Name XMTVI analog, maxamum, maxamaid Musculoskeletal Brand Name Arthritis Disease Modifying Anti-Rheumatic s adalimumab HUMIRA PA, SP auranofin RIDAURA azathioprine IMURAN etanercept ENBREL PA, SP hydroxychloroquine PLAQUENIL leflunomide ARAVA methotrexate METHOTREXATE penicillamine CUPRIMINE SP penicillamine DEPEN TITRATABLE PA, SP sulfasalazine AZULFIDINE sulfasalazine delayed-release AZULFIDINE EN-TABS NSAIDs and Other Analgesics acetaminophen TYLENOL OTC aspirin BAYER ECOTRIN OTC aspirin HALFPRIN tablet DR aspirin-al hydro-mg hydro-ca carb ASCRIPTIN tab aspirin buffered BUFFERIN ca carb-mg carb-mg ox capsaicin OTC celecoxib CELEBREX PA, QL diclofenac 1% gel VOLTAREN 1% TOPICAL GEL diclofenac potassium CATAFLAM diclofenac sodium delayed-release VOLTAREN diclofenac sodium extended-release VOLTAREN XR diflunisal DOLOBID etodolac LODINE IR only fenoprofen NALFON 600 mg ibuprofen ADVIL tabs, chew tabs and susp, OTC ibuprofen MOTRIN tabs, chew tabs and susp 39

47 Generic Name Brand Name indomethacin INDOCIN ketoprofen ORUDIS IR only meloxicam MOBIC QL naproxen NAPROSYN naproxen delayed release ENTERIC COATED- NAPROSYN naproxen sodium ANAPROX oxaprozin DAYPRO piroxicam FELDENE sulindac CLINORIL Gout allopurinol ZYLOPRIM colchicine COLCRYS PA 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 Injectable medroxyprogesterone acetate DEPO-PROVERA QL Intravaginal diaphragm WIDE-SEAL wide seal etonogestrel/ee NUVARING ring, QL 40

48 Generic Name ortho diaphragm Brand Name ORTHO COIL 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/ LOESTRIN FE 1/20 iron 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/ LOESTRIN FE 1.5/30 iron 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 Triphasic CAZIANT desogestrel/ee CESIA CYCLESSA VELIVET levonorgestrel/ee TRIVORA QL norethindrone acetate/ee/iron ESTROSTEP FE QL norethindrone/ee ORTHO-NOVUM 7/7/7 QL QL QL 41

49 Generic Name Brand Name 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 estradiol ESTRING vaginal ring estradiol VAGIFEM vaginal tablet estradiol acetate FEMRING vaginal ring, PA estrogens, conjugated PREMARIN crm Estrogens - Oral esterified estrogens MENEST estradiol ESTRACE estrogens, conjugated PREMARIN estrogens, conjugated, synthetic A CENESTIN estrogens, conjugated, synthetic B ENJUVIA estropipate OGEN Estrogens - Transdermal estradiol CLIMARA QL estradiol DIVIGEL gel estradiol ELESTRIN gel pump 0.06% ESTROGEL estradiol ESTRASORB emulsion estradiol EVAMIST spray estradiol MENOSTAR patch weekly 14 mcg/24hr estradiol VIVELLE-DOT patch biweekly estrogen patch ESTRADIOL TDS Estrogen/Progestin estrogens, conjugated/medroxyprogesterone Progestins medroxyprogesterone acetate PREMPHASE PREMPRO PROVERA norethindrone acetate AYGESTIN progesterone micronized PROMETRIUM 42

50 Generic Name Brand Name Vaginal Infections Oral fluconazole DIFLUCAN QL metronidazole FLAGYL tabs Vaginal clotrimazole GYNE-LOTRIMIN OTC clindamycin CLEOCIN crm clindamycin CLEOCIN supp metronidazole METROGEL-VAGINAL METROGEL 1% miconazole MONISTAT OTC miconazole MONISTAT 3 miconazole nitrate MICONAZOLE KIT vaginal supp & cream kit sulfanilamide AVC VAGINAL vaginal cream terconazole TERAZOL 3/7 crm Miscellaneous methylergonovine METHERGINE tranexamic acid LYSTEDA PA 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 NAPHCON A w/pheniramine OPCON A ophth soln % 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% 43

51 Generic Name Brand Name sulfacetamide sodiumprednisolone VASOCIDIN BLEPHAMIDE ophth susp % tobramycin/ dexamethasone TOBRADEX tobramycin- ophth susp technology 0.3- TOBRADEX ST dexamethasone 0.05% Nonsteroidal diclofenac sodium VOLTAREN flurbiprofen OCUFEN ketorolac ACULAR/ACULAR LS Steroidal dexamethasone MAXIDEX ophth suspension 0.1% 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 betaxolol BETOPTIC -S ophth suspension 0.25% 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 brinzolamide AZOPT PA dorzolamide TRUSOPT Carbonic Anhydrase Inhibitor/Beta-Blocker Combination dorzolamide/ COSOPT timolol maleate dorzolamide hcl-timolol maleate COSOPT PF Cholinesterase Inhibitor ecothiophate PHOSPHOLINE IODINE Mydriatics atropine ISOPTO ATROPINE cyclopentolate CYCLOGYL ophth solution preservative free 44

52 Generic Name Brand Name homatropine ISOPTO HOMATROPINE scopolamine ISOPTO HYOSCINE Oral acetazolamide ACETAZOLAMIDE acetazolamide extended-release DIAMOX SEQUELS methazolamide NEPTAZANE Prostaglandins latanoprost XALATAN QL tafluprost TRAVATAN Z ophth soln 0.004%, PA tafluprost TRAVATAN Z PF ophth soln 0.004% (benzalkonium free), PA tafluprost ZIOPTAN ophth soln %. PA Topical - Parasympathomimetics pilocarpine PILOPINE HS GEL pilocarpine ISOPTO CARPINE Topical - Sympathomimetics brimonidine ALPHAGAN P brimonidine BRIMONIDINE 0.2% Infections Bacterial bacitracin ciprofloxacin CILOXAN erythromycin ERYTHROMYCIN gatifloxin ZYMAR PA gentamicin GENTAK moxifloxacin HCl VIGAMOX ophth solution 0.5% 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 Fungal trifluridine VIROPTIC Viral natamycin NATACYN ophth suspension 5% 45

53 Generic Name Brand Name Miscellaneous cyclosporine RESTASIS (ophth) emulsion 0.05%, PA cysteamine 0.44% CYSTARAN PA, SP ophthalmic solution sodium chloride hypertonic Psychiatric MURO 128 soln 5% Alcohol Deterrents acamprosate CAMPRAL disulfiram ANTABUSE naltrexone REVIA Anxiety Benzodiazepines alprazolam XANAX QL, IR only alprazolam XANAX solution alprazolam XANAX XR tablet SR, QL chlordiazepoxide LIBRIUM QL clonazepam KLONOPIN not wafers, QL clonazepam ODT KLONOPIN WAFERS ODT tabs, QL clorazepate TRANXENE QL diazepam VALIUM QL diazepam VALIUM solution, QL diazepam conc DIAZEPAM INTENSOL QL lorazepam ATIVAN QL lorazepam ATIVAN solution, QL lorazepam conc LORAZEPAM INTENSOL QL oxazepam SERAX QL Miscellaneous buspirone BUSPAR QL clomipramine ANAFRANIL fluvoxamine LUVOX fluvoxamine SR LUVOX CR Attention Deficit Hyperactivity Disorder (ADHD) amphetamine/ dextroamphetamine ADDERALL QL mixed salts amphetamine/ dextroamphetamine mixed salts extended-release ADDERALL XR (BRAND ADDERALL XR IS PREFERRED) atomoxetine STRATTERA PA, QL dextroamphetamine DEXEDRINE QL QL 46

54 Generic Name Brand Name dextroamphetamine DEXTROSTAT QL dextroamphetamine extended-release DEXEDRINE SPANSULE QL guanfacine ER INTUNIV lisdexamfetamine VYVANSE Age Limits Apply, QL methylphenidate METHYLIN SOLUTION solution, QL methylphenidate RITALIN tabs only, QL methylphenidate extended-release CONCERTA QL methylphenidate extended-release METADATE ER RITALIN-SR RITALIN LA Bipolar Disorder divalproex sodium cap sprinkle DEPAKOTE SPRINKLE divalproex sodium delayed-release DEPAKOTE Minimum age 2 lithium carbonate LITHIUM CARBONATE lithium carbonate ESKALITH CR extended-release LITHOBID Depression Monoamine Oxidase Inhibitor (MAOI) tranylcypromine PARNATE Selective Serotonin Reuptake Inhibitor (SSRIs) citalopram CELEXA QL escitalopram LEXAPRO fluoxetine PROZAC QL 10 mg and 20 mg caps and 20 mg soln only paroxetine PAXIL tablets paroxetine PAXIL ORAL SUSP oral susp, QL paroxetine SR PAXIL CR tablets, QL sertraline ZOLOFT tablets, QL Serotonin Norepinephrine Reuptake Inhibitors (SNRIs) duloxetine CYMBALTA QL venlafaxine EFFEXOR QL venlafaxine XR EFFEXOR XR QL Tricyclic Antidepressants (TCAs) amitriptyline ELAVIL tablets amoxapine desipramine NORPRAMIN doxepin SINEQUAN imipramine HCL TOFRANIL tablets 47

55 Generic Name Brand Name nortriptyline PAMELOR protriptyline VIVACTIL Tricyclic Antidepressant/Phenothiazine combination amitriptyline/perphenazine TRIAVIL Miscellaneous Agents bupropion WELLBUTRIN bupropion extended-release FORFIVO XL 450 mg bupropion extended-release WELLBUTRIN SR QL bupropion extended-release WELLBUTRIN XL 150 mg and 300 mg maprotiline LUDIOMIL mirtazapine REMERON tabs (not soltabs) mirtazapine REMERON ODT odt tablets trazodone DESYREL 150 mg only Insomnia Benzodiazepines estazolam PROSOM QL flurazepam DALMANE QL temazepam RESTORIL 15 mg and 30 mg only, QL triazolam HALCION QL Non-Benzodiazepines chloral hydrate CHLORAL HYDRATE diphenhydramine NYTOL QUICK CAPS OTC ramelteon ROZEREM QL, PA zaleplon SONATA QL zolpidem AMBIEN QL Narcotic Antagonists buprenorphine SUBUTEX PA, QL buprenorphine/naloxone SUBOXONE 2 mg and 8 mg film only, PA, QL naloxone NALOXONE INJ QL naltrexone REVIA Psychoses Atypicals aripiprazole ABILIFY TABLETS PA, QL aripiprazole ER injection ABILIFY MAINTENA Age Limit Applies, PA, QL clozapine CLOZARIL clozapine (ODT formulation) FAZACLO olanzapine ZYPREXA QL 48

56 Generic Name Brand Name olanzapine ODT ZYPREXA ZYDIS QL paliperidone INVEGA SUSTENNA Age Limit Applies, PA, QL quetiapine SEROQUEL QL quetiapine XR SEROQUEL XR Age Limit Applies, PA, QL risperidone RISPERDAL QL risperidone RISPERDAL CONSTA Age Limit Applies, PA, QL risperidone m-tab RISPERDAL M-TAB QL risperidone oral soln RISPERDAL SOLUTION QL ziprasidone GEODON QL Smoking Cessation bupropion ZYBAN smoking deterrent, QL nicotine NICODERM TD patch, QL nicotine inhaler system NICOTROL QL nicotine polacrilex gum NICORETTE 2 mg & 4 mg, QL nicotine polacrilex lozenge COMMITT 2 mg & 4 mg, QL varenicline CHANTIX QL Miscellaneous chlorpromazine THORAZINE dextromethorphan/ quinidine NUEDEXTA PA fluphenazine PROLIXIN fluphenazine decanoate PROLIXIN DECANOATE haloperidol HALDOL haloperidol decanoate HALDOL DECANOATE loxapine LOXITANE perphenazine TRILAFON pimozide ORAP thioridazine MELLARIL thiothixene NAVANE trifluoperazine STELAZINE Respiratory s Antitussives, Decongestants, Expectorants and Combinations benzonatate TESSALON brompheniramine & DIMETAPP CLD ELX/ phenylephrine ALLERGY brompheniramine/ ACCUHIST DROPS pseudoephedrine RESPERAL-DM liquid brompheniramine/ pseudoephedrine ANDEHIST syrup 4-60 mg/5 ml 49

57 Generic Name brompheniramine/ pseudoephedrine brompheniramine/ pseudoephedrine brompheniramine/ pseudoephedrine brompheniramine/ pseudoephedrine brompheniramine/ pseudoephedrine/ dextromethorphan brompheniramine/ pseudoephedrine/ dextromethorphan brompheniramine/ pseudoephedrine/ dextromethorphan brompheniramine/ pseudoephedrine/ dextromethorphan/ guaifenesin carbetapentane/ chlorpheniramine/ ephedrine/ phenylephrine carbinoxamine/ pseudoephedrine chlorphen-pemethscopolamine chlorphen tan/ carbetapentane tan chlorphen tan/ pseudoeph tan Brand Name BROMFENEX PD CAP DIMETAPP ELX CLD/ALLE UNI-HIST DRO CARDEC SYP BROVEX PSB liq 4-20 mg/5 ml J-TAN D PD drops mg/ml RONDEC SYRUP syrup ACCUHIST PDX DROPS liquid BROMALINE DM elixir BROMFED DM DALLERGY DM CARBOFED NEO DM ANAPLEX DM syrup HISTACOL DM syrup RYNATUSS RONDEC DROPS liquid DURADRYL QV-ALLERGY syrup TUSSI-12 S susp TANAFED susp 50

58 Generic Name 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 codeine/guaifenesin/pseudoephedrine codeine/promethazine codeine/promethazine/ phenylephrine dextromethorphan/ brompheniramine/ pseudoephedrine dextromethorphan/ carbinoxamine/ pseudoephedrine Brand Name 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 susp liquid syrup RYNATAN PEDIATRIC SUSP susp DIHISTINE DH PHENYLHIST LIQ DH CHERATUSSIN AC GUIATUSS/AC M-CLEAR WC MYTUSSIN AC GUIATUSS DAC PROMETHAZINE W/CODEINE PROMETHAZINE VC W/CODEINE BROMETANE DX QL QL QL CARDEC-DM drops 51

59 Generic Name dextromethorphanguaifenesin dextromethorphan/ guaifenesin Brand Name DURATUSS DM ELX soln mg/5 ml GG/DM CR MUCINEX DM ROBITUSSIN DM OTC TUSSIN DM dextromethorphan- ROBITUSSIN LIQ CGH/ guaifenesin CONG liq mg/ 5 ml dextromethorphan HBR ROBITUSSIN SYP MAX-ST ROBITUSSIN PED SYP syrup dextromethorphan/ PHENERGAN DM promethazine PROMETHAZINE SYP DM dextromethorphan polistirex DELSYM OTC extended-release guaifenesin MUCINEX KIDS granules packet guaifenesin ROBITUSSIN OTC guaifenesin ROBITUSSIN SYP CHST CNG syrup 100 mg/5 ml guaifenesin TRIACTIN CHEST CONGESTION soln 50 mg/5 ml guaifenesin extended-release MUCINEX OTC guaifenesin/ ROBITUSSIN PE pseudoephedrine PSE/GG syrup, OTC guaifenesin/ pseudoephedrine/ ROBITUSSIN CF dextromethorphan guaifenesin/ pseudoephedrine GUAIFED extended-release guaifenesin/ GUAIFEN PSE pseudoephedrine MUCINEX D OTC extended-release GG/PSE CR hydrocodone/ chlorpheniramine/ HISTUSSIN HC phenylephrine hydrocodone/guaifenesin VITUSSIN HYDROCODO/GG SYP 52

60 Generic Name hydrocodone/homatropine loratadine & pseudoephedrine SR 24hr phenyleph/bromphen/ dextromethorphan/ guaifenesin phenylephrine/ brompheniramine-dm phenylephrine/ brompheniramine-dm phenylephrine/ brompheniramine-dm phenylephrine/ brompheniramine-dm phenylephrine/ brompheniramine/ dextromethorphan phenylephrine/ chlorpheniramine phenylephrine/ chlorpheniramine/ dextromethorphan phenylephrine/ chlorpheniramine/ dextromethorphan phenylephrine/ chlorpheniramine/ dextromethorphan phenylephrine/ chlorpheniramine/ dihydrocodeine phenylephrine/ dextromethorphan Brand Name HYCODAN HYDROMET SYP HYDROCODONE/ TAB HOMATROP ALLERGY/CONG TAB RE- LIEF ALLANHIST SYP PDX tab mg ALAHIST DM liq mg/5 ml DIMETAPP DM liq mg/5 ml LOHIST-DM syrup mg/5 ml PRESGEN B liq mg/5 ml QUAL-TUSSIN SYP DC ATUSS DR DE-CHLOR DM RONDEC DM STATUSS DM SYP CARDEC DM SYP MINUTUSS DR SYP RONDEC DM DROPS CARDEC DM DRO ROBITUSSIN LIQ CGH/ALRG DIHYDRO-PE SYP DIMETAPP DRO DCON/CGH OTC syrup syrup liquid 53

61 Generic Name phenylephrine/ dextromethorphan/ guaifenesin phenylephrine/ephed/ CPM w/ Brand Name ROBITUSSIN PE RYNATUSS PEDIATRIC SUSP carbetapentane phenylephrine/guaifenesin syrup mg/5 ml phenylephrine/guaifenesin DECONEX cap mg phenylephrine/guaifenesin DECONEX IR tab mg phenylephrine/guaifenesin ENTEX LQ LIQ liq mg/5 ml phenylephrine/guaifenesin GILPHEX TR tab mg phenylephrine/guaifenesin LIQUIBID PD tab mg phenylephrine/guaifenesin MEDIFIN PE tab mg phenylephrine/guaifenesin MUCINEX COLD LIQ /KIDS liq mg/5 ml phenylephrine/guaifenesin NARIZ liq mg/5 ml ROBITUSSIN LIQ phenylephrine/guaifenesin HD/CHST SUPRESS-PE PEDIATRIC phenylephrine/guaifenesin DROPS drops mg/ml phenylephrine/guaifenesin TRIAMINIC LIQ CHST/NAS liq mg/5 ml phenylephrine/guaifenesin TRIAMINIC SYR CHST/NAS syrup mg/5 ml phenylephrine/ hydrocodone/ guaifenesin phenylephrine/pyrilamine/ dextromethorphan phenylephrine/pyrilamine w/hydrocodone phenylephrine tan/ pyrilamine tan/ carbeta tan QUAL-TUSSIN SYP DC CODAL-DM susp CODIMAL DH syrup TUSSI 12D S susp promethazine & PROMETH VC SYP phenylephrine /5 pseudoephedrine SUDAFED pseudoephedrine/ acetaminophen/ MAPAP COLD TAB dextromethorphan pseudoephedrine/ chlorpheniramine/ dextromethorphan PEDIACARE LIQ MULTI-SY ROBITUSSIN LIQ PED NGHT syrup mg/ 5 mg 54

62 Generic Name pseudoephedrine/ dextromethorphan/ guaifenesin pseudoephedrine/ iburprofen pseudoephedrine tan/ dexchlorphen tan/ DM tan pyrilamine tan/phenyleph tan tripolidine/ Brand Name MULTI SYMPTOM TAB COLD RLF CHILD IBUPRO SUS COLD IBUOROFEN TAB COLD/SIN TANAFED DMX SUSPENSION TRI-FED X susp RYNA-12 S susp TRIPROL/PSE SYP pseudoephedrine APHEDRID TAB Asthma/COPD Inhalers - Beta Agonists albuterol sulfate VENTOLIN HFA QL formoterol FORADIL AEROLIZER PA indacaterol ARCAPTA NEOHALER olodaterol STRIVERDI RESPIMAT salmeterol xinafoate SEREVENT DISKUS PA, QL Inhalers - Corticosteroids beclomethasone QVAR QL fluticasone HFA FLOVENT HFA QL mometasone ASMANEX TWISTHALER QL Inhalers -Corticosteroid/Beta Agonist Combinations budesonide/formoterol SYMBICORT ST fluticasone/salmeterol ADVAIR DISKUS QL, ST mometasone/formoterol DULERA ST Inhalers for Nebulization albuterol ACCUNEB 0.63 mg/3 ml and 1.25 mg /3 ml albuterol PROVENTIL soln 0.083%, 0.5% budesonide PULMICORT RESPULES susp, QL cromolyn INTAL soln, QL ipratropium ATROVENT soln, QL ipratropium/albuterol DUONEB soln levalbuterol HCl XOPENEX RESPULES QL, ST Inhalers - Others aclidinium inhalation TUDORZA PRESSAIR cromolyn INTAL QL 55

63 Generic Name Brand Name ipratropium/albuterol COMBIVENT QL ipratropium/albuterol COMBIVENT RESPIMAT inhaler ipratropium HFA ATROVENT HFA nedocromil TILADE omalizumab XOLAIR PA, SP tiotropium SPIRIVA umeclidinium inhalation INCRUSE ELLIPTA umeclidinium/vilanterol ANORO ELLIPTA Oral Agents - Beta Agonists albuterol SR tabs VOSPIRE ER metaproterenol ALUPENT tabs metaproterenol METAPROTERENOL SYRUP terbutaline BRETHINE Oral Agents - Leukotriene Modifiers montelukast SINGULAIR QL zafirlukast ACCOLATE tabs Oral Agents - Theophylline theophylline THEOPHYLLINE liquid theophylline extended-release THEO-24 caps theophylline extended-release THEOCHRON tabs theophylline extended-release THEOPHYLLINE EXT-REL caps (12 hr) theophylline extended-release UNIPHYL tabs Miscellaneous alpha1-proteinase SP, Coverable through ARALAST NP inhibitor (human) Medical Benefit alpha1-proteinase SP, Coverable through PROLASTIN inhibitor (human) Medical Benefit Urological Symptomatic Benign Prostatic Hypertrophy alfuzosin ER UROXATRAL doxazosin CARDURA doxazosin SR CARDURA XL finasteride PROSCAR tamsulosin FLOMAX terazosin HYTRIN 56

64 Generic Name Brand Name 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 pentosan ELMIRON PA potassium citrate UROCIT-K propantheline phenazopyridine PYRIDIUM sodium citrate/citric acid BICITRA tolterodine DETROL ST tolterodine SR DETROL LA 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 57

65 Generic Name Brand Name 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 fluoride 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 omega-3 fatty acids SUPER OMEGA ESKIMO-3 SEA-OMEGA 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. capsule 58

66 Generic Name omega-3 fatty acids Brand Name PRO NUTRIENT HM FISH OIL delayed release capsule GNP FISH OIL phytonadione MEPHYTON polysaccharide iron complex NIFEREX elixir, OTC prenat w/o A FOLTABS PAK PLUS DHA w/fecbn-fegl-dss-fa & RE OB + DHA PAK DHA prenatal vit w/fe bisglycinate GENTEX ADE 28-1 MG chelate-fa prenatal vit w/fe bisglycinate VINATE AZ EX chelate-fa prenatal vit w/fe bisglycinate VITAPHIL chelate-fa prenatal vit w/fe bisglyc-fe VINATE III prot succ-fa prenatal vit w/fe polysac cmplx-fa prenatal vit w/folic acid prenatal vit w/iron carbonyl-fa prenatal vit w/o vit a w/fe bisglycinate-fa tab 32-1 mg prenatal w/o A w/ FE carbonyl-fe gluc-dss-fa EDGE OB CHW PRENATAL VITAMINS W/ FOLIC ACID CENOGEN OB/ULTRA MATERNA NATALCARE NESTABSCBF/FA/RX NIFEREX-PN FORTE ATABEX PRENATAL FOLTABS PRENATAL TRI RX QL 59

67 Generic Name prenat-fe Bis-FE prot succ-fa-ca & omega 3 prenat-fe Bis-FE prot succ-fa-ca & omega 3 prenat-fe Bis-FE prot succ-fa-ca & omega 3 renat-fe bis-fe prot succ- FA-CA & omega DR Brand Name COMPLETE NATALCARE PAK DHA TRUST NATALCARE PAK DHA PRUET DHA PAK SETONET PAK PRUET DHAEC PAK vitamin A OTC vitamin ADC/fluoride/±iron drops vitamin B complex/ vitamin C/folic acid TRI-VI-FLOR NEPHROCAPS 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. 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 Potassium phosphorus K-PHOS NEUTRAL tabs potassium acid phosphate K-PHOS ORIGINAL 60

68 Generic Name Brand Name 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 KLOR-CON 10 potassium chloride extended-release MICRO-K 10 caps potassium iodide PIMA Miscellaneous Anaphylaxis epinephrine EPINEPHRINE AUTO-INJECT BY QL IMPAX LABS epinephrine EPIPEN EPIPEN JR. QL Cystic Fibrosis acetylcysteine MUCOMYST dornase alfa PULMOZYME PA, SP ivacaftor KALYDECO PA, SP ivacaftor KALYDECO GRANULES PA, SP lumacaftor/ivacaftor ORKAMBI PA, SP tobramycin neb soln BETHKIS KITABIS PA, SP Detoxification Agents deferasirox EXJADE JADENU PA, SP deferiprone FERRIPROX PA, SP Hereditary Angioedema C1 Inhibitor, Human BERINERT PA, SP icatibant FIRAZYR PA, SP Hyperphosphatemia calcium acetate 667 mg tablet only, PA calcium acetate oral solution PHOSLYRA PA cinacalcet SENSIPAR PA lanthanum carbonate FOSRENOL PA tabs 61

69 Generic Name Brand Name sevelamer RENVELA ST sevelamer HCL RENAGEL tablet, PA Idiopathic Pulmonary Fibrosis (IPF) nintedanib OFEV PA, SP pirfenidone capsule ESBRIET PA, SP Immune Thrombocytopenic Purpura eltrombopag PROMACTA PA, SP Medical Devices Spacers QL Metabolic Modifiers carglumic acid CARBAGLU PA, SP glycerol phenylbutyrate RAVICTI PA, SP sodium phenylbutyrate BUPHENYL ORAL oral powder POWDER PA, SP sodium phenylbutyrate tab BUPHENYL PA, SP Vaccine influenza virus vaccine live FLUMIST QUAD quadrivalent intranasal QL, Age Limits Apply influenza virus vaccine recombinant hemagglutinin FLUBLOK QL, Age Limits Apply (ha) influenza virus vaccine split AFLURIA, FLUZONE SPLT QL, Age Limits Apply influenza virus vaccine split high-dose pf FLUZONE HD PF QL, Age Limits Apply influenza virus vaccine split pf AFLURIA PF QL, Age Limits Apply influenza virus vaccine split quadrivalent FLUZONE QUAD QL, Age Limits Apply influenza virus vaccine tisscult subunit FLUCELVAX QL, Age Limits Apply influenza virus vaccine types a&b surface FLUVIRIN QL, Age Limits Apply 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 62

70 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, cleanser, bar, foam, cloth, wash Antifungals clotrimazole miconazole crm, soln tolnaftate vaginal products Atopic Dermatitis emollients Cough/Cold Allergy Antihistamine antihistamines BREVOXYL-4 CLEARASIL DELOS OC8 PANOXYL BAR PANOXYL CREAM 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 63

71 Generic Name Brand Name Examples Antihistamine/Decongestant Combinations brompheniramine/pseudoephedrine cetirizine/pseudoephedrine OTC chlorpheniramine/pseudoephedrine loratadine/pseudoephedrine 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 condoms - female First Aid Burow s soln, wet dressings dermatological baths hydrocortisone crm, oint topical antibacterials Gastrointestinal DIMETAPP ZYRTEC D ACTIFED ALAVERT ALRG TAB/SINUS ALAVERT D ALLERGY/CONG ROBITUSSIN ROBITUSSIN DM ROBITUSSIN PE ROBITUSSIN CF DELSYM NEO-SYNEPHRINE AFRIN DIMETAPP DRO DECONGES CURITY ALCOHOL PADS HUMULIN NOVOLIN DEBROX TROJAN DELFEN GYNOL II CONDOMS OTC DOMEBORO COLLOIDAL OATMEAL BATHS CORTAID NEOSPORIN MYCITRACIN BACITRACIN 64

72 Generic Name antacids liquids, chew tabs antidiarrheals electrolyte rehydrating soln famotidine laxative enemas 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 with buffers tabs aspirin tabs, EC. tabs ibuprofen tabs, chew tabs and susp Smoking Cessation Products Brand Name Examples MYLANTA LIQUID MAALOX LIQUID TUMS IMODIUM A-D KAOPECTATE PEDIALYTE PEPCID AC FLEET ENEMA 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 65

73 Generic Name nicotine 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 salicylic acid film forming liquid 27.5% OTC salicylic acid gel 17% OTC salicylic acid pad 40% OTC salicylic acid plaster 40% salicylic acid soln OTC salicylic acid strip 40% salicylic acid topical patch 15% OTC Miscellaneous fluoride dental rinse Brand Name Examples COMMIT LOZENGES (QUANTITY LIMIT) NICODERM CQ (QUANTITY LIMIT) NICOTINE GUM (QUANTITY LIMIT) NICOTROL (QUANTITY LIMIT) OS-CAL CALTRATE TUMS FERGON FEOSOL NIFEREX MAG-OX VITAMIN D 400 IU VI-DAYLIN POLY-VI-SOL TRI-VI-SOL STUART PRENATAL DUOFILM MOSCO CALLUS/CORN REMOVER OTC DUOPLANT GEL, COMPOUND W, SAL- PLANT OTC CORN/CALLUS REMOVER PAD, CLEAR AWAY, ONE STEP OTC MEDIPLAST MOSCO CALLUS/CORN LIQUID REMOVER OTC COMPOUND W STRIPS TRANS-VER-SAL PATCH PHOS-FLUR 66

74 Index of s A abacavir abacavir/lamivudine abacavir/lamivudine/ zidovudine ABILIFY MAINTENA ABILIFY TABLETS abiraterone ABREVA OTC acamprosate acarbose ACCOLATE ACCUHIST DROPS ACCUHIST PDX DROPS.. 50 ACCUNEB ACCUPRIL ACCURETIC ACCUTANE acebutalol ACEON acetaminophen... 13, 39, 65 acetazolamide ACETAZOLAMIDE acetazolamide extended-release acetic acid acetic acid/aluminum acetate 23 acetic acid/hydrocortisone..23 acetylcysteine acidophilus ACIDOPHILUS acidophilus/bifidus ACIDOPHILUS/ BIFIDUS WAFER acidophilus/citrus pectin...31 ACIDOPHILUS/ CITRUS PECTIN acidophilus/pectin ACIDOPHILUS/PECTIN ACIDOPHILUS XTRA acitretin aclidinium inhalation ACLOVATE ACTIFED ALL CAPS = Brand-name drug lower case = Generic drug ACTIFED ACTIGALL ACTIMMUNE ACTOPLUSMET ACTOPLUS MET XR ACTOS ACULAR/ACULAR LS acyclovir ADALAT CC adalimumab ADCIRCA ADDERALL ADDERALL XR adefovir ADVAIR DISKUS ADVIL , 39, 65 AFINITOR AFINITOR DISPERZ AFLURIA, FLUZONE SPLT.. 62 AFLURIA PF AFRIN , 64 agalsidase AGENERASE AGRYLIN ALAHIST DM ALAVERT , 63 ALAVERT ALRG TAB/SINUS , 64 ALAVERT D , 64 ALAWAY ALAWAY OTC albendazole ALBENZA albuterol albuterol SR tabs albuterol sulfate alclometasone alcohol swabs ALDACTAZIDE ALDACTONE ALDARA ALDOMET ALDORIL ALDURAZYME ALECENSA alectinib alendronate ALESSE alfuzosin ER alginic acid/sodium bicarbonate alglucerase alglucosidase ALINIA ALINIA SUSPENSION alirocumab alitretinoin 1% gel ALKERAN ALLANHIST SYP PDX ALLEGRA ALLEGRA-D allergic conjunctivitis ALLERGY/CONG , 64 ALLERGY/CONG TAB RELIEF allopurinol alpha1-proteinase inhibitor..56 ALPHAGAN P alprazolam ALTACE altretamine alumina/magnesia alumina/magnesia/ simethicone aluminum acetate aluminum chloride aluminum chloride hexahydrate ALUPENT amantadine ,35 AMARYL AMBIEN ambrisentan AMERGE AMICAR amiloride amiloride/hydrochlorothiazide10 aminocaproic acid

75 Index of s aminosalicyclic acid amiodarone amitriptyline , 47 amitriptyline/perphenazine. 48 amlexanox amlodipine ammonium lactate amoxapine amoxicillin AMOXICILLIN CAPSULES AND CHEWABLES amoxicillin/clavulanate AMOXIL amphetamine/dextroamphetamine mixed salts amphetamine/dextroamphetamine mixed salts extended-release ampicillin amprenavir ANAFRANIL anagrelide ANAPLEX DM ANAPROX , 40 anastrozole ANCOBAN ANDEHIST ANDRODERM ANDROGEL 1% ANDROGEL 1.62% ANDROXY ANORO ELLIPTA ANSAID ANTABUSE antacids liquids, chew tabs. 65 ANTARA antidiarrheals antihistamines antipyrine-benzocaine antitussives ANTIVERT ANUSOL HC 2.5% ANZEMET APHEDRID TAB ALL CAPS = Brand-name drug lower case = Generic drug APHTHASOL apixaban aprepitant APRESOLINE APRISO APTIVUS ARALAST NP ARALEN ARANESP ARAVA ARCAPTA NEOHALER arginine ARICEPT ARIMIDEX aripiprazole aripiprazole ER injection ARMOUR THYROID AROMASIN ARTANE artemether-lumefantrine artificial tears ASACOL HD ASCRIPTIN ASMANEX TWISTHALER.. 55 aspirin , 39 aspirin/acetaminophen/ caffeine aspirin-al hydro-mg hydro-ca carb aspirin buffered aspirin tabs, EC. tabs aspirin with buffers tabs ASTELIN ATABEX PRENATAL ATARAX atazanavir atenolol atenolol/chlorthalidone ATIVAN atomoxetine atorvastatin atovaquone atovaquone/proguanil ATRALIN , atropine atropine sulfate ATROVENT ATROVENT HFA ATROVENT NS ATUSS DR AUBAGIO AUGMENTIN AURALGAN auranofin AVAPRO AVC VAGINAL AVEENO CLEAR PADS OTC 18 AVITA AVONEX/AVONEX PEN axitinib AYGESTIN azathioprine , 39 azelaic acid azelastine , 43 azithromycin AZOLEN TINCTURE SOLUTION OTC AZOPT AZULFIDINE , 39 AZULFIDINE EN-TABS.. 30, 39 B bacitracin , 45 BACITRACIN , 64 bacitracin-polymyxinneomycin HC baclofen BACLOFEN BACTRIM BACTRIM DS BACTROBAN balsalazide BALZIVA BANZEL BANZEL SUSPENSION BARACLUDE BAYER , 39, 65 BCAD-1, BCAD

76 Index of s becaplermin gel beclomethasone bedaquiline BENADRYL , 63 benazepril benazepril/hydrochlorothiazide8 BENICAR HCT BENTYL BENZAC AC BENZAMYCIN BENZEFOAM BENZIQ BENZIQ LS benzocaine/antipyrine benzonatate BENZOTIC benzoyl peroxide benzoyl peroxide bar 10%.. 17 benzoyl peroxide creamy wash 8% & benzoyl peroxide bar 5% k benzoyl peroxide crm, gel, lotion, cleanser, bar, foam, cloth, wash benzoyl peroxide gel benzoyl peroxide wash 4% & benzoyl peroxide bar 5% kit benztropine BERINERT BETACARE CREAM AND LOTION BETAGAN betaine betaine powder for oral solution betamethasone augmented dip....19, 20 betamethasone dipropionate 19 betamethasone val BETAPACE BETAPACE AF BETASERON BETA-VAL ALL CAPS = Brand-name drug lower case = Generic drug betaxolol bethanechol BETHKIS BETIMOL BETOPTIC -S bexarotene caps bexarotene topical gel BIAXIN BIAXIN XL bicalutamide BICITRA BILTRICIDE BIO-D DRO-MULSION BIO-D-MULSIO DRO FORTE biotin bismuth subsalicylate + metronidazole + tetracycline bisoprolol bisoprolol/hydrochlorothiazide 9 BLEPH BLEPHAMIDE boceprevir BONINE bosentan BOSULIF bosutinib BPO CREAMY KIT BRETHINE BREVOXYL , 18 BREVOXYL BREVOXYL-4 OTC BRILINTA brimonidine , 45 BRIMONIDINE brinzolamide BROMALINE DM BROMETANE DX BROMFED DM BROMFENEX PD CAP bromocriptine , 28 brompheniramine maleate..23 brompheniramine & phenylephrine brompheniramine/pseudoephedrine.. 24, 49, 50, 64 brompheniramine/ pseudoephedrine/ dextromethorphan brompheniramine/ pseudoephedrine/dextromethorphan/guaifenesin 50 brompheniramine tannate.. 23 BROVEX CT BROVEX PSB budesonide , 55 budesonide/formoterol BUFFERIN bumetanide BUMEX BUPHENYL , 62 BUPHENYL ORAL POWDER , 62 buprenorphine buprenorphine/naloxone...48 bupropion , 49 bupropion extended-release 48 Burow s soln, wet dressings. 64 BUSPAR buspirone busulfan butalbital/acetaminophen.. 13 butalbital/acetaminophen/ caffeine butalbital/apap/caff/cod...14 butalbital/asa/caff/cod butalbital/aspirin/caffeine.. 13 butorphanol BYETTA C C1 Inhibitor, Human cabergoline cabozantinib CAFERGOT calamine CALAN , 15 CALAN SR

77 Index of s calcipotriene calcitonin-salmon calcitriol , 57 calcium , 66 calcium acetate calcium acetate oral solution 61 CALICYLIC CALTRATE CAMPRAL CANASA capecitabine CAPEX SHAMOO CAPOTEN CAPOZIDE CAPRELSA capsaicin captopril captopril/hydrochlorothiazide.8 CAPTOPRIL POWDER CARAC CARAFATE CARAFATE SUSPENSION. 30 CARBAGLU , 62 carbamazepine carbamazepine extended-release carbamazepine SR carbamide peroxide...23, 64 CARBATROL carbetapentane/chlorpheniramine/ephedrine/ phenylephrine carbidopa/levodopa carbidopa/levodopa extended-release carbinoxamine/ pseudoephedrine CARBOFED CARDEC-DM CARDEC DM DRO CARDEC DM SYP CARDEC DRO CARDEC SYP , 51 CARDENE ALL CAPS = Brand-name drug lower case = Generic drug CARDIZEM CARDIZEM CD CARDIZEM LA CARDIZEM SR CARDURA , 56 CARDURA XL carglumic acid , 62 carteolol carvedilol casanthranol-docusate sodium CASODEX CATAFLAM CATAPRES CATAPRES-TTS CAZIANT CECLOR CEENU cefaclor cefadroxil cefdinir cefixime , 33 cefpodoxime cefprozil CEFTIN cefuroxime axetil CEFZIL CELEBREX celecoxib CELEXA CELLCEPT CELONTIN CENESTIN CENOGEN OB/ULTRA CENTRUM cephalexin CEREDASE CEREZYME ceritinib CESIA CETAPHIL CREAM AND LOTION cetirizine cetirizine hydrochloride/ pseudoephedrine hydrochloride extended-release cetirizine/pseudoephedrine OTC CHANTIX CHERATUSSIN AC CHILD IBUPRO SUS COLD chloral hydrate CHLORAL HYDRATE chlorambucil chlordiazepoxide chlorhexidine chlorhexidine gluconate chloroquine phosphate chlorothiazide CHLORPHENIRAMINE chlorpheniramine/ dextromethorphan chlorpheniramine extended-release chlorpheniramine maleate.. 23 chlorpheniramine maleate phenylephrine HCL chlorpheniramine/ phenylephrine chlorpheniramine/phenylephrine/pyrilamine chlorpheniramine/ pseudoephedrine.. 24, 51 chlorpheniramine/ pseudoephedrine chlorpheniramine tannate.. 23 chlorpheniramine tan/ phenylephrine tan chlorphen-pemethscopolamine chlorphen tan/ carbetapentane tan chlorphen tan/ pseudoeph tan chlorphen tan/pyrilamine tan/ PE tan

78 Index of s chlorpromazine chlorpropamide chlorthalidone CHLORTHALIDONE CHLOR-TRIMETON CHLOR-TRIMETON ALLERGY CHLOR-TRIMETON SYRUP. 23 chlorzoxazone CHOLBAM cholecalciferol cholestyramine cholic acid ciclopirox cidofovir cilostazol CILOXAN cimetidine cinacalcet CIPRO CIPRODEX ciprofloxacin , 45 ciprofloxacin/dexamethasone23 citalopram citrulline clarithromycin clarithromycin ER CLARITIN , 63 CLARITIN CHEW CLARITIN RDT CLEAN & CLEAR GEL CLEARASIL CLEAR EYES REDNESS RELIEF clemastine CLEMASTINE CLEOCIN , 43 CLEOCIN T CLIMARA clindamycin , 36, 43 CLINORIL , 40 clobazam clobazam suspension clobetasol propionate ALL CAPS = Brand-name drug lower case = Generic drug clomipramine clonazepam , 46 clonazepam ODT clonidine clonidine transdermal clopidogrel clorazepate clotrimazole... 20, 34, 43, 63 CLOTRIMAZOLE clotrimazole crystals clotrimazole with betamethasone clozapine CLOZARIL COARTEM cobicistat cobicistat/elvitegravir/emtricitabine/tenofovir CODAL-DM codeine/acetaminophen...14 codeine/chlorpheniramine/ pseudoephedrine codeine/guaifenesin codeine/guaifenesin/ pseudoephedrine codeine/promethazine codeine/promethazine/ phenylephrine codeine sulfate CODIMAL DH COGENTIN COLACE , 65 COLAZAL colchicine COLCRYS COLESTID coliestipol collagenase oint COLLOIDAL OATMEAL BATHS COLOCORT COLYTE COMBIVENT COMBIVENT RESPIMAT COMBIVIR COMETRIQ COMMIT LOZENGES COMMITT COMPAZINE COMPLERA COMPLETE NATALCARE PAK DHA COMPOUND W STRIPS.. 66 COMTAN CONCERTA condoms condoms - female CONDOMS OTC CONDYLOX SOL contraceptive foam contraceptive gel COPAXONE CORDARONE CORDRAN COREG CORGARD CORICIDIN TAB CGH/CLD. 51 CORN/CALLUS REMOVER PAD, CLEAR AWAY, ONE STEP OTC CORTAID CORTAID SOLUTION OTC. 19 CORTEF CORTIFOAM AEROSOL cortisone acetate CORTISPORIN CORTISPORIN OINTMENT. 18 CORTISPORIN OTIC CORTIZONE CORTIZONE-10 INTENSIVE HEALING COSOPT COSOPT PF COUMADIN COZAAR CPM/PSE CREON CREON DR

79 Index of s CRIXIVAN crizotinib CROLOM cromolyn cromolyn sodium , 43 crotamiton CUPRIMINE CURITY ALCOHOL PADS.. 64 CUTIVATE CUTIVATE LOTION cyanocobalamin CYCLESSA cyclinex-1, cyclinex cyclobenzaprine CYCLOGYL cyclopentolate cyclophosphamide cycloserine cyclosporine , 46 cyclosporine, modified CYMBALTA cyproheptadine CYPROHEPTADINE CYSTADANE , 37 CYSTAGON CYSTARAN cysteamine 0.44% ophthalmic solution cysteamine bitartrate cystine CYSTOSPAZ CYTOMEL CYTOTEC CYTOVENE CYTOXAN D D3-50 CAP dabigatran etexilate mesylate.7 dabrafenib daclatasvir DAKLINZA DALLERGY DM DALMANE ALL CAPS = Brand-name drug lower case = Generic drug danazol DANOCRINE DANTRIUM dantrolene dapsone DAPSONE DARAPRIM darbepoetin alfa darunavir darunavir/cobicistat dasatinib DAYPRO , 40 DDAVP DEBROX , 64 DECADRON DE-CHLOR DM DECLOMYCIN DECONEX DECONEX IR decongestants deferasirox deferiprone DELATESTRYL delavirdine DELFEN DELOS , 63 DELSYM , 64 DELTASONE DELZICOL DEMADEX demeclocycline DEMEROL DENAVIR DEPAKENE DEPAKOTE , 16, 47 DEPAKOTE SPRINKLE , 16, 47 DEPEN TITRATABLE DEPO-PROVERA DEPO-TESTOSTERONE DERMAPHOR OINTMENT. 63 DERMA-SMOOTHE OIL/FS. 19 dermatological baths DERMATOP DESENEX desipramine desmopressin desogestrel/ee , 41 DESYREL DETROL DETROL LA dexamethasone , 44 dexamethasone sodium phosphate DEXASOL dexchlorpheniramine maleate23 DEXEDRINE DEXEDRINE SPANSULE.. 47 dextroamphetamine...46, 47 dextroamphetamine extended-release dextromethorphan/brompheniramine/pseudoephedrine 51 dextromethorphan/ carbinoxamine/ pseudoephedrine dextromethorphanguaifenesin dextromethorphan/ guaifenesin dextromethorphan HBR dextromethorphan polistirex extended-release dextromethorphan/ promethazine dextromethorphan/ quinidine DEXTROSTAT D.H.E DHS SAL SHAMPOO OTC. 22 DIABINESE DIAMOX SEQUELS diaphragm DIASTAT ACUDIAL DIASTAT PEDIATRIC diazepam , 40, 46 diazepam conc DIAZEPAM INTENSOL

80 Index of s diclofenac 1% gel diclofenac potassium diclofenac sodium diclofenac sodium delayed-release....13, 39 diclofenac sodium extended-release diclofenac sodium SR dicloxacillin DICLOXACILLIN dicyclomine didanosine didanosine delayed-release. 35 DIDRONEL diflorasone diacetate DIFLUCAN , 43 diflunisal DIHISTINE DH dihydroergotamine DIHYDRO-PE SYP DILACOR XR DILANTIN DILATRATE-SR DILAUDID diltiazem diltiazem extended-release..10 diltiazem sustained-release. 10 DIMEATAPP DRO DECONGES dimenhydrinate DIMETAPP DIMETAPP CLD ELX/ ALLERGY DIMETAPP DM DIMETAPP DRO DCON/CGH 53 DIMETAPP DRO DECONGES 64 DIMETAPP ELX CLD/ALLE. 50 DIMETAPP SYP CGH/CLD. 51 dimethyl fumarate DIOVAN DIOVAN HCT DIPENTUM diphenhydramine , 48 diphenoxylate/atropine ALL CAPS = Brand-name drug lower case = Generic drug DIPROLENE , 20 DIPROLENE AF DIPROSONE dipyridamole disopyramide disopyramide extended-release9 disulfiram DITROPAN DITROPAN XL DIURIL DIURIL ORAL SUSPENSION divalproex sodium cap sprinkle... 15, 16, 47 divalproex sodium delayed-release. 15, 16, 47 DIVIGEL docosanol docusate calcium plus docusate potasssium docusate sodium dofetilide dolasetron DOLOBID DOLOPHINE DOMEBORO DOMEBORO OTIC donepezil dornase alfa dorzolamide dorzolamide hcl-timolol maleate dorzolamide/timolol maleate 44 DOSTINEX DOVONEX doxazosin , 56 doxazosin SR doxepin doxycycline delayed-release. 33 doxycycline hyclate doxycycline monohydrate.. 33 DOXYCYCLINE MONOHYDRATE DRAMAMINE DRISDOL dronabinol dronedarone DROXIA DRYSOL OTC DUETACT DULCOLAX DULERA duloxetine DUOFILM , 66 DUONEB DUOPLANT GEL, COMPOUND W, SAL-PLANT OTC DURADRYL DURAGESIC DURATUSS DM ELX DURICEF DYAZIDE DYNACIRC E ecothiophate ECOTRIN , 39, 65 ED A-HIST TABLETS AND LIQUID EDGE OB CHW edoxaban EDURANT E.E.S efavirenz efavirenz/emtricitabine/ tenofovir EFFEXOR EFFEXOR XR EFUDEX ELAPRASE ELAVIL , 47 ELDEPRYL electrolyte electrolyte rehydrating soln..65 ELELYSO ELESTRIN ELIDEL ELIMITE

81 Index of s ELIQUIS ELMIRON ELOCON eltrombopag EMCYT EMEND EMETROL EMLA emollients empagliflozin/metformin emtricitabine emtricitabine/rilpivirine/ tenofovir emtricitabine/tenofovir EMTRIVA enalapril enalapril/hydrochlorothiazide.8 ENBREL enfuvirtide ENJUVIA enoxaparin entacapone entecavir ENTERIC COATED- NAPROSYN , 40 ENTEX LQ LIQ ENTOCORT EC ENTRESTO ENULOSE E-OINTMENT EPANED epinephrine epinephrine EPINEPHRINE AUTO-INJECT BY IMPAX LABS EPIPEN EPIPEN JR EPITOL EPIVIR EPIVIR HBV eplerenone epoetin alfa EPOGEN epoprostenol ALL CAPS = Brand-name drug lower case = Generic drug EPZICOM EQUATRO ergocalciferol (D2) ergotamine/caffeine ergotamine tartrate/caffeine. 15 ERIVEDGE erlotinib ERYC ERYGEL ERY-TAB ERYTHROCIN erythromycin , 45 ERYTHROMYCIN erythromycin/ benzoyl peroxide erythromycin delayed-release 33 erythromycin ethylsuccinate. 33 erythromycin stearate erythromycin/sulfisoxazole..33 ESBRIET escitalopram ESGIC ESKALITH CR ESKIMO esomeprazole esomeprazole granules essential amino acid mix...37 estazolam esterified estrogens ESTRACE estradiol estradiol acetate ESTRADIOL TDS estramustine phosphate sodium ESTRASORB ESTRING ESTROGEL estrogen patch estrogens, conjugated estrogens, conjugated/ medroxyprogesterone.. 42 estrogens, conjugated, synthetic A estrogens, conjugated, synthetic B estropipate ESTROSTEP FE etanercept ethambutol ethionamide ethosuximide ethynodiol diacetate/ee etidronate etodolac , 39 etonogestrel/ee etoposide etravirine EULEXIN EURAX EVAMIST everolimus , 6 EVISTA EXCEDRIN MIGRAINE EXELON exemestane exenatide EXJADE exogabine EXTAVIA EXTINA EXUVIANCE ezetimibe F FABRAZYME famciclovir famotidine , 65 FAMVIR FARESTON FARYDAK FAZACLO febuxostat felbamate FELBATOL FELDENE , 40 felodipine extended-release. 10 FEMARA

82 Index of s FEMRING fenofibrate fenoprofen , 39 fentanyl transdermal FEOSOL , 66 FERGON FERRIPROX ferrous bisglycinate/ polysaccarides iron ferrous sulfate fexofenadine fexofenadine/ pseudoephedrine filgrastim FINACEA finasteride fingolimod FIORICET FIORICET W/CODEINE FIORINAL FIORINAL W/CODEINE FIRAZYR FLAGYL , 43 flecainide FLEET ENEMA FLEET PHOSPHO-SODA.. 65 FLEXERIL FLOLAN FLOMAX FLONASE FLORANEX FLORINEF FLOVENT HFA FLOXIN FLOXIN OTIC FLUBLOK FLUCELVAX fluconazole , 43 flucytosine fludrocortisone FLUMADINE FLUMIST QUAD fluocinolone acetonide fluocinonide ALL CAPS = Brand-name drug lower case = Generic drug fluocinonide emulsified base 19 fluoride fluoride dental rinse fluorometholone FLUOROPLEX fluorouracil fluoxetine fluoxymesterone fluphenazine fluphenazine decanoate flurandrenolide flurazepam flurbiprofen flurbiprofen flutamide fluticasone fluticasone HFA fluticasone propionate fluticasone/salmeterol FLUVIRIN fluvoxamine fluvoxamine SR FLUZONE HD PF FLUZONE QUAD FML FML FORTE FML LIQUIFILM folic acid FOLIC ACID FOLTABS PAK PLUS DHA RE OB + DHA PAK FOLTABS PRENATAL FORADIL AEROLIZER FORFIVO XL formoterol FORTEO FORTICAL FOSAMAX fosamprenavir foscarnet sodium FOSCAVIR fosinopril fosinopril/hydrochlorothiazide 8 FOSRENOL FUNGOID TINCTURE KIT.. 20 FURADANTIN SUSP furosemide FUZEON G gabapentin GABITRIL galantamine ganciclovir gatifloxin GATTEX gefitinib GEL-KAM gemfibrozil GENGRAF GENOTROPIN GENTAK , 45 gentamicin , 45 gentamicin/prednisolone acetate GENTEX ADE GEODON GG/DM CR GG/PSE CR GILENYA GILPHEX TR glatiramer acetate GLATOPA GLEEVEC glimepiride glipizide glipizide extended-release.. 27 glipizide/metformin GLUCAGON glucagon, human recombinant GLUCOPHAGE GLUCOPHAGE ER glucose oral tablets GLUCOTROL GLUCOTROL XL GLUCOVANCE glutarex-1, glutarex

83 Index of s glyburide glyburide, micronized glycerin GLYCERIN SUPPOSITORY. 31 GLYCERIN TOPICAL glycerol phenylbutyrate. 28, 62 glycine glycopyrrolate GLYNASE GNP FISH OIL granisetron GRANIX GRIFULVIN V griseofulvin microsize griseofulvin ultramicrosize.. 34 GRIS-PEG GUAIFED guaifenesin guaifenesin extended-release 52 guaifenesin/ pseudoephedrine guaifenesin/ pseudoephedrine/ dextromethorphan guaifenesin/ pseudoephedrine extended-release GUAIFEN PSE guanabenz guanfacine guanfacine ER GUIATUSS/AC GUIATUSS DAC GYNE-LOTRIMIN , 63 GYNOL II H HALCION HALDOL HALDOL DECANOATE HALFPRIN haloperidol haloperidol decanoate HARVONI ALL CAPS = Brand-name drug lower case = Generic drug HCU cooler, express, gel...37 HCY-1, HCY HECORIA HELIDAC HEMANGEOL heparin HEPARIN HEPSERA hexachlorophene HEXALEN HIPREX HISTACOL DM HISTEX HISTUSSIN HC HM FISH OIL homatropine hominex-1, hominex HUMALOG HUMALOG KWIKPEN HUMALOG MIX 50/ HUMALOG MIX 50/50 KWIKPEN HUMALOG MIX 72/25 KWIKPEN HUMALOG MIX 75/ HUMATIN HUMIRA HUMULIN HUMULIN 70/ HUMULIN N HUMULIN N PEN HUMULIN R HYCODAN hydralazine HYDREA hydrochlorothiazide HYDROCHLOROTHIAZIDE. 10 HYDROCODO/GG SYP hydrocodone/ acetaminophen hydrocodone/chlorpheniramine/phenylephrine hydrocodone ER hydrocodone/guaifenesin hydrocodone/homatropine. 53 HYDROCODONE/ TAB HOMATROP hydrocortisone. 19, 21, 25, 30 hydrocortisone acetate hydrocortisone acetate w/pramoxine hydrocortisone/aloe hydrocortisone butyrate hydrocortisone crm, oint hydrocortisone inj hydrocortisone valerate HYDROMET SYP hydromorphone hydroxychloroquine... 36, 39 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 , 56 HYZAAR I IBRANCE ibrutinib IBUOROFEN TAB COLD/SIN ibuprofen , 39, 65 icatibant ICLUSIG idursulfase iloprost imatinib mesylate IMBRUVICA IMDUR

84 Index of s imiglucerase imipramine HCL imiquimod 5% cream IMITREX IMODIUM A-D , 65 IMURAN , 39 INCIVEK INCRELEX INCRUSE ELLIPTA indacaterol indapamide INDERAL , 15 INDERIDE indinavir INDOCIN , 40 indomethacin , 40 INFERGEN INFLAMASE FORTE influenza virus vaccine live quadrivalent intranasal..62 influenza virus vaccine recombinant hemagglutinin influenza virus vaccine split. 62 influenza virus vaccine split high-dose pf influenza virus vaccine split pf62 influenza virus vaccine split quadrivalent influenza virus vaccine tiss-cult subunit influenza virus vaccine types a&b surface antigen INLYTA INSPRA insulin aspart insulin aspart protamine 70%/ insulin aspart 30% insulin detemir insulin glargine insulin human insulin isophane insulin isophane human insulin isophane human 70%/ regular 30% ALL CAPS = Brand-name drug lower case = Generic drug insulin isophane/regular insulin lisopro pro/lispro insulin lisopro prot/lispro...26 insulin lispro insulin lispro prot 50%/lispro 50% insulin lispro prot 75%/lispro 25% insulin regular insulin INTAL INTELENCE interferon alfa-2a interferon alfa-2b , 34 interferon alfacon interferon beta-1a interferon beta-1b interferon gamma-1b INTRON A , 34 INTUNIV INVEGA SUSTENNA INVIRASE ipratropium ipratropium/albuterol ipratropium bromide ipratropium HFA irbesartan IRESSA iron iron polysaccharides ISENTRESS ISMO ISOCHRON isoleucine isoniazid ISONIAZID ISOPTO ATROPINE ISOPTO CARPINE ISOPTO HOMATROPINE.. 45 ISOPTO HYOSCINE ISORDIL ISORDIL S.L isosorbide dinitrate ISOSORBIDE DINITRATE ER isosorbide dinitrate extended-release isosorbide mononitrate isosorbide mononitrate extended-release isotretinoin isradipine itraconazole ivacaftor i-valex-1, i-valex ivermectin , 32 J JADENU JAKAFI JANUMET JANUMET XR JANUVIA JENTADUETO J-TAN D PD J-TAN PD KALETRA K KALYDECO KAOPECTATE KAYEXALATE K-DUR K-DUR KEFLEX KENALOG KENALOG KENALOG IN ORABASE.. 25 KEPPRA KEPPRA XR KERALYT ketoconazole , 22, 34 ketoconazole foam ketoconazole gel ketoconazole gel 2% & hydrocortisone gel 1% kit ketoconazole gel 2% & pyrithione zinc shampoo 1% kit

85 Index of s ketoconazole shampoo ketonex-1, ketonex ketoprofen , 40 ketoprofen SR ketorolac ketorolac tromethamine ketotifen kionex KITABIS KLARON LOTION KLONOPIN , 46 KLONOPIN WAFERS K-LOR KLOR-CON KLOR-CON K-LYTE KOMBIGLYZE KORLYM K-PHOS NEUTRAL K-PHOS ORIGINAL KRISTALOSE KUVAN , 38 KYTRIL ALL CAPS = Brand-name drug lower case = Generic drug L labetalol LAC-HYDRIN lacosamide LACTINOL lactobacillus lactulose LAMICTAL LAMICTAL CD CHEW TAB. 16 LAMICTAL ODT LAMICTAL ODT KIT LAMICTAL STARTER KIT.. 17 LAMICTAL XR LAMICTAL XR KIT LAMICTAL XR ODT KIT LAMISIL LAMISIL AT LAMISIL GEL LAMISIL SOLUTION lamivudine , 35 lamivudine/zidovudine lamotrigine lamotrigine chew dispersable tab lamotrigine dispersible tab..16 lamotrigine ODT lamotrigine SR lamotrigine SR ODT lamotrigine starter kit lamotrigine titration kit lansoprazole lansoprazole delayed-release 30 lanthanum carbonate LANTUS LANTUS SOLOSTAR lapatinib ditosylate LARIAM laronidase LASIX latanoprost laxative enemas laxatives ledipasvir/sofosbuvir leflunomide lenalidomide lenvatinib LENVIMA LETAIRIS letrozole leucine LEUKERAN LEUKINE leuprolide levalbuterol HCl LEVAQUIN LEVBID LEVEMIR LEVEMIR FLEXPEN levetiracetam levetiracetam SR levobunolol levocetirizine levofloxacin levonorgestrel levonorgestrel/ee levothyroxine LEVOXYL LEVSIN LEVSINEX LEXAPRO LEXIVA LIALDA LIBRIUM LIDAMANTEL LIDEX LIDEX E lidocaine lidocaine patch lidocaine-prilocaine lidocaine/prilocaine lidocaine viscous LIDODERM PATCH linaclotide linagliptin linagliptin/metformin linezolid LINZESS liothyronine liotrix lipistart LIPITOR LIPOFEN LIQUIBID PD liraglutide lisdexamfetamine lisinopril lisinopril/ hydrochlorothiazide....8 lithium carbonate LITHIUM CARBONATE lithium carbonate extended-release LITHOBID LMX LOCOID LODINE , 39 LODRANE D LOESTRIN 1.5/

86 Index of s LOESTRIN 1/ LOESTRIN FE 1.5/ LOESTRIN FE 1/ LOFIBRA LOHIST-DM LOMOTIL lomustine LONITEN LONSURF LO/OVRAL loperamide LOPERAMIDE lophlex LOPID lopinavir/ritonavir LOPRESSOR loratadine loratadine/pseudoephedrine 64 loratadine/pseudoephedrine extended-release loratadine & pseudoephedrine SR lorazepam LORAZEPAM INTENSOL.. 46 LORCET LORTAB LORTAB ELIXIR losartan losartan/hctz LOTENSIN LOTENSIN HCT LOTRIMIN AF , 63 LOTRISONE lovastatin LOVENOX loxapine LOXITANE LOZOL LUDIOMIL lumacaftor/ivacaftor LUMIZYME LUPRON LUPRON DEPOT LUPRON DEPOT 6-MONTH. 5 ALL CAPS = Brand-name drug lower case = Generic drug LUPRON DEPOT-PED LURIDE LURIDE LOZI-TABS LUVOX LUVOX CR LYNPARZA LYRICA LYSODREN LYSTEDA M MAALOX , 65 MACROBID MACRODANTIN MAGNACET magnesium oxide , 66 MAG-OX , 66 MALARONE malathion MAPAP COLD TAB maprotiline maraviroc MARINOL MATERNA MATULANE MATXIM LA MAVIK MAXALT/MAXALT MLT MAXIDEX MAXITROL MAXZIDE M-CLEAR WC MCT procal mecasermin meclizine , 65 MEDIFIN PE MEDIPLAST MEDROL medroxyprogesterone acetate , 42 mefloquine MEGACE megestrol acetate MEKINIST MELLARIL meloxicam , 40 melphalan memantine memantine SR MENEST MENOSTAR meperidine MEPHYTON MEPRON mercaptopurine mesalamine mesalamine extended-release mesna MESNEX MESTINON MESTINON TIMESPAN METADATE ER METAGLIP METAMUCIL metaproterenol METAPROTERENOL SYRUP 56 metformin metformin ER metformin/glyburide methadone methazolamide methenamine hippurate METHERGINE , 43 methimazole methocarbamol methotrexate METHOTREXATE methoxsalen methsuximide methyldopa methyldopa/hctz methylergonovine , 43 METHYLIN SOLUTION methylphenidate methylphenidate extended-release methylprednisolone

87 Index of s metipranolol metoclopramide metolazone metoprolol metoprolol succinate METROCREAM METROGEL METROGEL 1% METROGEL-VAGINAL METROLOTION metronidazole , 36, 43 MEVACOR mexiletine MEXITIL MIACALCIN MICATIN , 63 miconazole , 43 MICONAZOLE miconazole buccal miconazole crm, soln MICONAZOLE KIT miconazole nitrate miconazole nitrate kit miconazole nitrate lotion miconazole nitrate soln MICRO-K MICRONASE MICROZIDE MIDAMOR midodrine mifepristone MIGERGOT SUPPOSITORIES MIGRANAL milupa PKU-2, milupa PKU-3 38 MINIPRESS MINOCIN minocycline minocycline SR minoxidil MINUTUSS DR SYP MIRALAX MIRAPEX MIRAPEX ER ALL CAPS = Brand-name drug lower case = Generic drug MIRCETTE mirtazapine MIRVASO misoprostol MITIGARE mitotane MM/PA express, gel MOBIC , 40 MODICON MODURETIC moexipril moexipril/ hydrochlorothiazide 8 mometasone mometasone/formoterol mometasone furoate MONISTAT , 63 MONISTAT MONISTAT-DERM MONOPRIL MONOPRIL-HCT montelukast morphine morphine extended-release. 14 MOSCO CALLUS/CORN LIQ- UID REMOVER OTC MOSCO CALLUS/CORN RE- MOVER OTC MOTRIN , 39 MOTRIN IB MOVANTIK moxifloxacin HCl MOZOBIL MS CONTIN MSIR MSUD analog, complex, cooler, express MSUD complex drink mix.. 38 MSUD maxamum, maxamaid 38 MUCINEX MUCINEX COLD LIQ /KIDS 54 MUCINEX D MUCINEX DM MUCINEX KIDS MUCOMYST MULTAQ MULTI SYMPTOM TAB COLD RLF multivitamins/fluoride/±iron. 58 multivitamins/minerals mupirocin MURINE MURO MYAMBUTOL MYCELEX , 34 MYCITRACIN MYCOBUTIN mycophenolate mofetil mycophenolate sodium....5 MYCOSTATIN , 34 MYFORTIC MYLANTA , 65 MYLERAN MYLICON MYSOLINE MYTUSSIN AC N nabumetone nadolol NALFON , 39 naloxegol naloxone NALOXONE INJ naltrexone , 48 NAMENDA NAMENDA XR naphazoline/antazoline naphazoline/glycerin naphazoline HCL naphazoline w/pheniramine 43 naphazoline/zinc sulfate NAPHCON A , 65 NAPROSYN , 40 naproxen , 40 naproxen delayed release 14, 40 naproxen sodium , 40 naratriptan NARIZ

88 Index of s NASACORT ALLERGY NASACORT AQ NASALCROM nasal sprays NATACYN NATALCARE natamycin nateglinide NATROBA NAVANE nedocromil nelfinavir NEOBENZ MICR LIQ NEO DM NEO-FRADIN neomycin/polymyxin B/ bacitracin neomycin/polymyxin B/ dexamethasone neomycin/polymyxin B/ gramicidin neomycin/polymyxin B/ hydrocortisone....23, 43 neomycin sulfate NEORAL NEOSPORIN , 45, 64 NEO-SYNEPHRINE... 25, 64 NEPHROCAPS NEPTAZANE NESTABSCBF/FA/RX NEULASTA NEUPOGEN NEURONTIN NEUTROGENA OIL FREE ACNE WASH NEUTROGENA RAPID CLEAR GEL nevirapine nevirapine ER NEXAVAR NEXIUM 24HR OTC NEXIUM DELAYED RELEASE PACKET niacin ALL CAPS = Brand-name drug lower case = Generic drug niacin extended-release NIACOR NIASPAN nicardipine NICODERM NICODERM CQ NICORETTE nicotine , 66 NICOTINE GUM nicotine inhaler system nicotine polacrilex gum nicotine polacrilex lozenge..49 NICOTROL , 66 nifedipine nifedipine extended-release. 10 NIFEREX , 59, 66 NIFEREX-PN FORTE nilotinib nimodipine NIMOTOP nintedanib nisoldipine nitazoxanide suspension...37 nitazoxanide tablet NITREK NITRO-BID NITRO-DUR nitrofurantoin extended-release nitrofurantoin macrocrystals nitrofurantoin susp nitroglycerin , 22 nitroglycerin extended-release12 NITROLINGUAL NITROSTAT NIX NIX CREME RINSE NIZORAL , 34 NIZORAL A-D OTC NIZORAL SHAMPOO NOLVADEX NORCO NORDETTE NORDITROPIN norelgestromin/ee norethindrone norethindrone acetate norethindrone acetate/ee.. 41 norethindrone acetate/ee/iron norethindrone/ee.. 40, 41, 42 norethindrone/me NORFLEX norgestimate/ee , 42 norgestrel norgestrel/ee NORPACE NORPACE CR NORPRAMIN nortriptyline NORVASC NORVIR NOVOLIN NOVOLIN 70/ NOVOLIN N NOVOLIN R NOVOLOG NOVOLOG FLEXPEN NOVOLOG MIX 70/ NOVOLOG MIX 70/30 FLEXPEN NOXAFIL NUEDEXTA NULYTELY NUTROPIN AQ NUSPIN NUVARING NYMALIZE nystatin , 34 NYTOL QUICK CAPS O OA-1, OA OC , 63 OCEAN NASAL SPRAY octreotide OCUFEN OCUFLOX

89 Index of s ODOMZO OFEV ofloxacin , 33, 45 OGEN olanzapine olanzapine ODT olaparib olmesartan/ hydrochlorothiazide....9 olodaterol olsalazine sodium omalizumab omega-3 fatty acids... 58, 59 omeprazole delayed-release 30 OMNICEF ondansetron ONE TOUCH SYSTEMS (ULTRA 2, ULTRAMINI, VERIO, VE- RIO FLEX, VERIO IQ, VERIO SYNC) ONE TOUCH TEST STRIPS (ULTRA, VERIO) ONFI ONFI SUSPENSION ONGLYZA ONMEL OPCON A OPTIPRANOLOL OPTIVAR ORAP ORAPRED ORKAMBI 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/ ALL CAPS = Brand-name drug lower case = Generic drug ORTHO-NOVUM 7/7/ ORTHO-NOVUM 10/ ORTHO TRI-CYCLEN ORUDIS , 14, 40 OS-CAL , 66 oseltamivir OVCON OVIDE OVRAL OVRETTE oxaprozin , 40 oxazepam oxcarbazepine OXSORALEN-ULTRA oxybutynin chloride oxybutynin IR oxycodone oxycodone/acetaminophen. 14 oxycodone/aspirin oxycodone ER OXYCONTIN OXYFAST oxymetazoline oxymorphone ER OXYMORPHONE ER P PACERONE palbociclib paliperidone palivizumab PAMELOR pancrealipase DR PANCREAZE pancrelipase panobinostat PANOXYL BAR PANOXYL BAR OTC PANOXYL CREAM PANOXYL CREAM OTC PANRETIN pantoprazole pantoprazole delayed-release 30 PARAFON FORTE DSC PARLODEL , 28 PARNATE paromomycin paroxetine paroxetine SR PASER pasireotide PAXIL PAXIL CR PAXIL ORAL SUSP pazopanib PEDIACARE LIQ MULTI-SY. 54 PEDIALYTE , 65 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... 5, 34 PEGINTRON pegvisomant penciclovir penicillamine penicillin VK PENLAC SOLUTION 8%.. 20 PENTASA pentosan pentoxifylline extended-release PEPCID PEPCID AC , 65 PEPCID AZ CHW PERCOCET PERCODAN PERIDEX periflex advance, infant, junior38 perindopril PERIOGARD

90 Index of s permethrin , 65 perphenazine PERSANTINE PFD-1, PFD phenazopyridine PHENERGAN PHENERGAN DM phenex-1, phenex phenobarbital PHENOBARBITAL phenylade 40, 60, drink mix 38 phenylade MTE amino acid blend phenyleph/bromphen/dextromethorphan/guaifenesin 53 phenylephrine phenylephrine/brompheniramine/dextromethorphan 53 phenylephrine/ brompheniramine-dm.. 53 phenylephrine/ chlorpheniramine phenylephrine/ chlorpheniramine/ dextromethorphan phenylephrine/ dextromethorphan phenylephrine/dextromethorphan/guaifenesin phenylephrine/ephed/cpm w/carbetapentane phenylephrine/guaifenesin..54 phenylephrine/hydrocodone/ guaifenesin phenylephrine/pyrilamine/ dextromethorphan phenylephrine/pyrilamine w/hydrocodone phenylephrine tan/pyrilamine tan/carbeta tan phenylfree-1, phenylfree-2, HP PHENYLHIST LIQ DH PHENYTEK ALL CAPS = Brand-name drug lower case = Generic drug phenytoin phenytoin sodium extended. 17 PHISOHEX phlexy PHOS-FLUR , 66 PHOSLYRA PHOSPHOLINE IODINE phosphorus PHRENILIN phytonadione pilocarpine , 45 PILOPINE HS GEL PIMA pimecrolimus pimozide pindolol PINDOLOL pioglitazone pioglitazone/glimepiride pioglitazone/metformin pioglitazone/metformin ER. 27 PIPERONYL BUTOXIDE piperonyl butoxide gel, liquid shampoo pirfenidone capsule piroxicam , 40 PKU cooler, express, gel PLAN B PLAQUENIL , 39 PLAVIX PLENDIL plerixafor PLETAL PLEXION pneumococcal 13-valent conjugate pneumococcal vaccine polyvalent PNEUMOVAX, PNEUMOVAX podofilox POLARAMINE polyethylene glycol polymyxin B/bacitracin polymyxin B/trimethoprim polysaccharide iron complex 59 POLYSPORIN POLYTRIM POLY-VI-FLOR POLY-VI-SOL pomalidomide POMALYST ponatinib portagen posaconazole potassium acid phosphate..60 potassium bicarbonate/ potassium citrate effervescent potassium chloride potassium chloride POTASSIUM CHLORIDE.. 61 potassium chloride extended-release potassium citrate potassium iodide POTIGA povidone-iodine PRADAXA PRALUENT pramipexole pramipexole dihydrochloride SR pramlintide PRANDIN PRAVACHOL pravastatin praziquantel prazosin PRECOSE PRED FORTE PRED-G PRED MILD prednicarbate prednisolone prednisolone acetate prednisolone phosphate prednisolone sodium phosphate

91 Index of s prednisone PREDNISONE pregabalin PRELONE PREMARIN PREMPHASE PREMPRO 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/folic acid prenatal vit w/iron carbonyl-fa prenatal vit w/o vit a w/fe bisglycinate-fa tab 59 prenatal w/o A w/ FE carbonyl- FE gluc-dss-fa prenat-fe Bis-FE prot succ-fa- CA & omega prenat w/o A w/fecbn-fegl-dss- FA & DHA PREPARATION H PRESGEN B PREVACID PREVIDENT PREVNAR PREZCOBIX PREZISTA PRIFTIN PRILOSEC PRILOSEC POWDER primaquine primidone PRINCIPEN PROAMATINE probenecid PROBENECID PROBIOTIC FORMULA probiotic product ALL CAPS = Brand-name drug lower case = Generic drug procarbazine PROCARDIA PROCARDIA XL prochlorperazine PROCRIT PROCTOFOAM HC FOAM. 22 PROCTO-PAK CREAM PROCTOSOL HC CREAM 2.5% PROCTOZONE CREAM-HC 2.5% progesterone micronized...42 progestimil lipil PROGRAF PROLASTIN PROLIXIN PROLIXIN DECANOATE PROMACTA promethazine promethazine & phenylephrine PROMETHAZINE SYP DM. 52 PROMETHAZINE VC W/CODEINE PROMETHAZINE W/CODEINE PROMETH VC SYP PROMETRIUM PRO NUTRIENT propafenone propantheline pro-phree powder propimex-1, propimex propranolol , 15 propranolol/hctz propylthiouracil PROPYLTHIOURACIL PROSCAR PROSOM PROTONIX PROTONIX PAK PROTOPIC 0.1% PROTOPIC 0.03% protriptyline PROVENTIL PROVERA provimin PROZAC PRUET DHAEC PAK PRUET DHA PAK SETONET PAK PSE/GG pseudoephedrine pseudoephedrine/ acetaminophen/ dextromethorphan pseudoephedrine/ chlorpheniramine/ dextromethorphan pseudoephedrine/dextromethorphan/guaifenesin pseudoephedrine/iburprofen 55 pseudoephedrine tan/dexchlorphen tan/dm tan PSORCON CREAM PSORCON OINTMENT P & S SHAMPOO psyllium PULMICORT RESPULES.. 55 PULMOZYME PURINETHOL pyrazinamide PYRAZINAMIDE pyrethrins/piperonyl but PYRIDIUM pyridostigmine pyridostigmine extended-release pyrilamine tan/phenyleph tan 55 pyrimethamine Q QUALAQUIN QUAL-TUSSIN SYP DC. 53, 54 QUESTRAN QUESTRAN-LIGHT quetiapine quetiapine XR

92 Index of s quinapril quinapril/hydrochlorothiazide.8 quinidine gluconate extendedrelease QUINIDINE GLUCONATE EXT-REL quinidine sulfate QUINIDINE SULFATE quinidine sulfate extended-release QUINIDINE SULFATE EXT-REL 9 quinine sulfate QV-ALLERGY QVAR R raloxifene raltegravir ramelteon ramipril RANEXA ranitidine ranitidine effer ranitidine syrup ranolazine RAPAMUNE RAVICTI , 62 RAYOS RAZADYNE REBETOL REBETOL/COPEGUS REBIF rectal crm, suppositories...65 RECTIV REGLAN regorafenib REGRANEX RELAFEN RELENZA RELION 70/ RELION N RELION R REMERON REMERON ODT ALL CAPS = Brand-name drug lower case = Generic drug REMODULIN RENAGEL renat-fe bis-fe prot succ-fa-ca & omega DR RENVELA repaglinide REQUIP REQUIP XL RESCRIPTOR RESPA-BR RESPERAL-DM RESTASIS RESTORIL RETIN-A RETROVIR REVATIO REVIA , 48 REVLIMID REYATAZ REYATAZ POWDER PACKET 36 ribavirin ribavirin soln RIDAURA RID SHAMPOO/ BUTOXIDE SHAMPOO. 21 rifabutin RIFADIN rifampin rifapentine rilpivirine rimantadine rimexolone RISPERDAL RISPERDAL CONSTA RISPERDAL M-TAB RISPERDAL SOLUTION risperidone risperidone m-tab risperidone oral soln RITALIN RITALIN LA RITALIN-SR ritonavir rivaroxaban rivastigmine rizatriptan RMS ROBAXIN ROBINUL ROBINUL FORTE ROBITUSSIN , 64 ROBITUSSIN CF , 64 ROBITUSSIN DM , 64 ROBITUSSIN LIQ CGH/ALRG53 ROBITUSSIN LIQ CGH/CLD 51 ROBITUSSIN LIQ CGH/CONG ROBITUSSIN LIQ HD/CHST 54 ROBITUSSIN LIQ PED NGHT 54 ROBITUSSIN PE...52, 54, 64 ROBITUSSIN PED LIQ CGH/COLD ROBITUSSIN PED SYP ROBITUSSIN SYP CHST CNG ROBITUSSIN SYP MAX-ST. 52 ROCALTROL RONDEC DM RONDEC DROPS , 51 RONDEC SYRUP , 51 ropinirole ropinirole hydrochloride SR. 16 ROWASA ROXICODONE ROZEREM R-TANNAMINE rufinamide rufinamide suspension ruxolitinib RYNA-12 S RYNATAN PEDIATRIC SUSP 51 RYNATUSS RYNATUSS PEDIATRIC SUSP54 RYTHMOL S SABRIL SOLUTION sacrosidase

93 Index of s sacubitril/valsartan SALAC OTC SALACYN SALAGEN SALEX , 22 salicylic acid , 20, 22 salicylic acid 17%/collodion....21, 66 salicylic acid film forming liquid 27.5% OTC salicylic acid gel 17% OTC..66 salicylic acid pad 40% OTC. 66 salicylic acid plaster 40%.. 66 salicylic acid soln OTC salicylic acid strip 40% salicylic acid topical patch 15% OTC saline nasal spray 0.65%...24 salmeterol xinafoate SAL-TROPINE SALVAX SANCTURA SANDIMMUNE SANDOSTATIN SANTYL sapropterin sapropterin dihydrochloride. 38 sapropterin powder saquinavir mesylate sargramostim SAVAYSA saxagliptin saxagliptin/metformin SCALPICIN scopolamine SEA-OMEGA SEBIZON SECTRAL SEDAPAP selegiline selenium sulfide SELSUN SELSUN BLUE SELZENTRY ALL CAPS = Brand-name drug lower case = Generic drug sennosides SENOKOT SENSIPAR SERAX SEREVENT DISKUS SEROMYCIN SEROQUEL SEROQUEL XR sertraline sevelamer sevelamer HCL SIGNIFOR sildenafil SILVADENE silver sulfadiazine simethicone simvastatin SINEMET SINEMET CR SINEQUAN SINGULAIR sirolimus SIRTURO sitagliptan sitagliptan/metformin sitagliptan/metformin ER...27 SKLICE sodium benzoate sodium chloride hypertonic sodium citrate/citric acid...57 sodium phenylbutyrate oral powder , 62 sodium phenylbutyrate tab , 62 sodium polysterene sulfonate 12 sofosbuvir SOLU-CORTEF SOLU-MEDROL somatropin SOMAVERT SONATA sonidegib sorafenib SORIATANE sotalol SOVALDI Spacers spinosad SPIRIVA spironolactone SPIRONOLACTONE spironolactone/ hydrochlorothiazide SPORANOX SPRYCEL STADOL STARLIX STATUSS DM SYP stavudine STELAZINE STIVARGA stool softeners STRATTERA STRIBILD STRI-DEX STRIVERDI RESPIMAT STROMECTOL STUART PRENATAL SUBOXONE SUBUTEX SUCRAID sucralfate SUDAFED sugar+orthophosphoric acid 65 SULAR sulcralfate sulfacetamide sulfacetamide/phenylephrine 45 sulfacetamide/pred phos.. 43 sulfacetamide sodium sulfacetamide sodiumprednisolone sulfacetamide/sulfur SULFACET-R sulfadiazine sulfamethoxazole/ trimethoprim, DS

94 Index of s sulfanilamide sulfasalazine , 39 sulfasalazine delayed-release....30, 39 sulindac , 40 sumatriptan SUMYCIN sunitinib SUPER OMEGA super soluble duocal SUPRAX , 33 SUPRESS-PE PEDIATRIC DROPS SUSTIVA SUTENT SYLATRON SYMBICORT SYMLIN SYMMETREL , 35 SYNAGIS SYNALAR SYNJARDY SYNTHROID T TABLOID tacrolimus , 22 tadalafil TAFINLAR tafluprost TAGAMET taliglucerase TAMBOCOR TAMIFLU tamoxifen tamsulosin TANAFED TANAFED DMX SUSPENSION TAPAZOLE TARCEVA TARGRETIN TASIGNA TASMAR ALL CAPS = Brand-name drug lower case = Generic drug TBO-Filgrastim TECFIDERA teduglutide TEGRETOL TEGRETOL-XR telaprevir telbivudine temazepam TEMODAR TEMOVATE temozolomide TENEX tenofovir TENORETIC TENORMIN TERAZOL 3/ terazosin , 56 terbinafine , 34 terbinafine gel terbinafine HCL terbutaline terconazole teriflunomide teriparatide inj TESSALON TESTIM testosterone TESTOSTERONE 1% TOPICAL GEL testosterone cypionate testosterone enanthate testosterone gel testosterone gel topical tube, packet, and pump bottle 26 testotesterone tetrabenazine tetracycline tetrahydrozoline/zinc sulfate. 43 thalidomide THALOMID THEO THEOCHRON theophylline THEOPHYLLINE theophylline extended-release56 THEOPHYLLINE EXT-REL.. 56 thioguanine thioridazine thiothixene THORAZINE thyroid tab THYROLAR tiagabine TIAZAC ticagrelor TIGAN TIKOSYN TILADE timolol timolol hemihydrate timolol maleate , 44 TIMOPTIC TIMOPTIC XE TINACTIN , 63 tiotropium tipranavir tizanidine TOBRADEX TOBRADEX ST tobramycin , 61 tobramycin-dexamethasone. 44 tobramycin/dexamethasone 44 TOBREX TOFRANIL tolazamide tolbutamide TOLBUTAMIDE tolcapone tolerex TOLINASE tolnaftate , 63 tolterodine tolterodine SR TOPAMAX TOPAMAX SPRINKLE topical antibacterials topiramate topiramate sprinkle caps...17

95 Index of s TOPROL XL TORADOL toremifene torsemide TOUJEO SOLOSTAR TRACLEER TRADJENTA tramadol trametinib TRANDATE trandolapril tranexamic acid TRANS-VER-SAL PATCH.. 66 TRANXENE tranylcypromine TRAVATAN Z TRAVATAN Z PF trazodone TRECATOR TRENTAL treprostinil tretinoin , 18 TRIACTIN CHEST CONGESTION triamcinolone triamcinolone acetonide.19, 24 triamcinolone inj triamcinolone nasal spray.. 24 TRIAMINIC TRIAMINIC LIQ CHST/NAS. 54 TRIAMINIC SYR CHST/NAS 54 triamterene/ hydrochlorothiazide TRIANEX TRIAVIL TRIAZ CLOTHS triazolam TRICOR TRI-FED X trifluoperazine trifluridine trifluridine/tipiracil TRIGLIDE trihexyphenidyl ALL CAPS = Brand-name drug lower case = Generic drug TRILAFON TRILEPTAL TRILYTE trimethobenzamide trimethoprim TRIMETHOPRIM TRI-NORINYL TRIOTANN TRIOTANN PEDIATRIC SUSP 51 tripolidine/pseudoephedrine 55 TRIPROL/PSE SYP TRI RX TRI-VI-FLOR TRI-VI-SOL , 66 TRIVORA TRIZIVIR TROJAN trospium TRUSOPT TRUST NATALCARE PAK DHA TRUVADA T-STAT TUCKS OINTMENT OTC.. 21 TUDORZA PRESSAIR TUMS , 66 TUSSI 12D S TUSSI-12 S TUSSIN DM TYBOST TYKERB TYLENOL , 39, 65 TYLENOL W/CODEINE typhoid vaccine TYR cooler, express, gel tyrex-1, tyrex tyros-1, tyros TYVASO TYZEKA U ULORIC ULTRAM umeclidinium inhalation umeclidinium/vilanterol UNI-HIST DRO UNIPHYL UNIRETIC UNIVASC urea 40% UREA 40% CREAM AND LOTION URECHOLINE UREX UROCIT-K UROXATRAL URSO ursodiol URSO FORTE UTIRA C V VAGIFEM vaginal products valacyclovir VALCYTE valganciclovir valine VALIUM , 46 valproic acid valsartan valsartan/hydrochlorothiazide 9 VALTREX VANCOCIN HCL vancomycin HCl vandetanib VANTIN varenicline VASERETIC VASOCIDIN , 44 VASOCLEAR VASOCLEAR A VASOSULF VASOTEC VECTICAL VEETIDS velaglucerase alfa VELIVET

96 Index of s vemurafenib venlafaxine venlafaxine XR VENTAVIS VENTOLIN HFA VEPESID VERALAN PM verapamil , 15 verapamil extended-release. 10 VESANOID VEXOL VFEND VIBRAMYCIN VICODIN VICODIN ES VICOPROFEN VICTOZA VICTRELIS VI-DAYLIN VIDEX VIDEX EC vigabatrin oral solution VIGAMOX VIMPAT VINATE AZ EX VINATE III VIRACEPT VIRAMUNE VIRAMUNE XR VIREAD VIROPTIC VISINE VISINE-AC vismodegib VISTARIL VISTIDE vitamin A vitamin ADC/fluoride/ ±iron drops vitamin B vitamin B VITAMIN B vitamin B complex/ vitamin C/folic acid ALL CAPS = Brand-name drug lower case = Generic drug vitamin C vitamin D VITAMIN D 400 IU , 66 vitamins pediatric , 66 vitamins prenatal VITAPHIL VITUSSIN VIVACTIL VIVELLE-DOT VIVOTIF BERNA VOLTAREN , 39, 44 VOLTAREN 1% TOPICAL GEL39 VOLTAREN XR , 39 voriconazole vorinostat VOSOL HC OTIC VOSOL OTIC VOSPIRE ER VOTRIENT VPRIV VYVANSE W warfarin WELLBUTRIN WELLBUTRIN SR WELLBUTRIN XL WESTCORT WIDE-SEAL WND-1, WND WYTENSIN X XALATAN XALKORI XANAX XANAX XR XARELTO XELODA XENAZINE XLEU analog, maxamum, maxamaid XLYS, XTRYP analog, maxamum, maxamaid XMET analog, maxamum, maxamaid XMTVI analog, maxamum, maxamaid XOLAIR XOLEGEL XOLEGEL DUO KIT XOLEGEL KIT XOPENEX RESPULES XYLOCAINE , 25 XYZAL Z zafirlukast zaleplon ZANAFLEX zanamivir ZANTAC ZARONTIN ZAROXOLYN ZARXIO ZEASORB-AF ZEBETA ZEBUTAL ZELBORAF ZENPEP ZENPEP DR ZERIT ZESTORETIC ZESTRIL ZETIA ZIAC ZIAGEN zidovudine zinc ZIOPTAN ziprasidone ZITHROMAX ZOCOR ZOFRAN ZOFRAN ODT ZOHYDRO ER ZOLINZA ZOLOFT zolpidem

97 Index of s ZONEGRAN zonisamide ZORTRESS ZOSTAVAX zoster vaccine live ZOVIA 1/ ZOVIA 1/ ZOVIRAX ZOVIRAX CREAM ZOVIRAX OINTMENT ZYBAN ZYKADIA ZYLOPRIM ZYMAR ZYPREXA ZYPREXA ZYDIS ZYRTEC , 63 ZYRTEC D , 64 ZYTIGA ZYVOX ALL CAPS = Brand-name drug lower case = Generic drug 90

98 Notes 91

99 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 92

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