Preferred Drug List (PDL)

Transcription

1 Preferred List (PDL) New York Essential Plan Effective Date: 6/1/ 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 medical providers. UnitedHealthcare does not warrant or assure accuracy of such information nor is it intended to be comprehensive in nature. This PDL is not intended to be a substitute for the knowledge, expertise, skill and judgment of the medical provider in their choice of prescription drugs. UnitedHealthcare assumes no responsibility for the actions or omissions of any medical provider based upon reliance, in whole or in part, on the information contained herein. The medical provider should consult the drug manufacturer s product literature or standard references for more detailed information. National guidelines can be found on the Web sites listed in the Web site section or go to the National Guideline Clearinghouse site at 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 generic name. Brand names are included as a reference to assist in product recognition. Unless exceptions are noted, generally all applicable dosage forms and strengths of the drug cited are included in the PDL. Generics should be considered the first line of prescribing. 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 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. UHC1004a {Released 2/25/11} i

4 OUTPATIENT PRESCRIPTION DRUG BENEFIT-COVERED MEDICATIONS Medically necessary outpatient prescription drugs are covered when prescribed by a provider licensed to prescribe federal legend drugs or medicines. Some items are covered only with prior authorization. Eligibility for Outpatient Prescription Benefits and copays are based on the individual member s benefit plan. PRODUCT SELECTION CRITERIA The P&T Committee considers clinical information on new-to-market drugs that are typically included in an outpatient pharmacy benefit. The evaluation includes all or part of the following: Safety Efficacy Comparison studies Approved indications Adverse effects Contraindications/Warnings/Precautions Pharmacokinetics Patient administration/compliance considerations Medical outcome and pharmacoeconomic studies When a new drug is considered for PDL inclusion, it will be reviewed relative to similar drugs currently included in the UnitedHealthcare PDL. This review process may result in deletion of drug(s) in a particular therapeutic class in an effort to continually promote the most clinically useful and cost-effective agents. All the information in the PDL is provided as a reference for drug therapy selection. Specific drug selection for an individual patient rests solely with the prescriber. PDL PRODUCT DESCRIPTIONS To assist in understanding which specific strengths and dosage forms are covered on the PDL, examples are noted below. The general principles shown in the examples can then usually be extended to other entries in the book. Any exceptions are noted in the drug list. There may also be a statement associated with a drug list that gives additional information about which specific products or dosage forms are covered. Products covered include all strengths associated with the dosage form of the cited brand name product. carvedilol Coreg All strengths of Coreg would be covered by this listing. Extended-release and delayed-release products require their own entry. diltiazem sustained release CARDIZEM SR Dosage forms covered will be consistent with the category and use where listed. Neomycin/polymixin B/ Cortisporin Hydrocortisone As listed in the OTIC section, this is limited to the otic solution and suspension. From this entry the ophthalmic solution and ointment, and the topical cream cannot be assumed to be on the list unless there are entries for these products in the OPHTHALMIC and DERMATOLOGY sections of the PDL. When a strength or dosage form is specified, only the specified strength and dosage form is on the PDL. Other strengths/dosage forms of the reference product are not citalopram 40 mg tabs Celexa tabs GENERIC SUBSTITUTION The UnitedHealthcare PDL requires generic substitution on the majority of products when a generic equivalent is available. Generic substitution is a pharmacy action whereby a generic equivalent is dispensed rather than the brand name product. The PDL indicates generic availability in the column. If a brand name drug is medically necessary, please submit a prior authorization request. The UnitedHealthcare MAC list sets a ceiling price for the reimbursement of certain multisource prescription drugs. This price will typically cover the acquisition of most generics but not branded versions of the same drug. The products selected for inclusion on the MAC list are commonly prescribed and dispensed and have usually gone through the FDA s review and approval process. An important consideration for generic substitution is the knowledge that all approvals of generic drugs by the FDA since 1984, and many generic approvals prior to 1984, have a showing of bioequivalence between the generic versions and the reference brand product. To gain FDA approval: 1. The generic drug must contain the same active ingredient(s), be the same strength and the same dosage form as the brand name product. 2. The FDA has given the generic an A rating compared to the branded product indicating bioequivalence, and has determined the generic is therapeutically equivalent UHC1004a ii

5 to the reference brand. The ratings of generic 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 generic can be substituted with the full expectation that the substituted product will produce the same clinical effect and safety profile as the prescribed product. products that have a narrow therapeutic index (NTI) can also be guided by these principles. It is not necessary for the health care provider to approach any one therapeutic class of drug products (e.g., NTI drugs) differently from any other class, when there has been a determination of therapeutic equivalence by the FDA for the drug products under consideration. Also, additional clinical tests or examinations by the physician are not needed when a therapeutically equivalent generic drug product is substituted for the brand name product. There are now many brand name products that are repackaged or distributed under a generic label. The generic label version should always be considered therapeutically equivalent and substitutable for the source branded product. DRUG EFFICACY STUDY IMPLEMENTATION (DESI) DRUGS s first marketed between 1938 and 1962 were approved as safe but required no showing of effectiveness for FDA approval. Beginning in 1962, all new drugs were required to be both safe and effective before they could be marketed. This legislation also applied retroactively to all drugs approved as safe from The DESI program was established by the FDA to review the effectiveness of these pre-1962 drugs for their labeled indications, and a determination of fully effective was made for most of these products and they remain in the marketplace. A few DESI products remain classified as less than fully effective while awaiting final administrative disposition. Also, classified as DESI are many products listed as identical, similar, or related to actual DESI products. UnitedHealthcare s PDL does not cover DESI less than fully effective drug products. PLAN EXCLUSIONS The following drug categories are excluded from coverage under the outpatient pharmacy benefit and are not part of the UnitedHealthcare PDL. DESI drugs Antiobesity agents Experimental / research drugs Cosmetic drugs Immunization agents Nutritional / diet supplements Blood and blood plasma products Agents used 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 brands, 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. MANDATORY GENERIC SUBSTITUTION The UnitedHealthcare PDL requires mandatory generic substitution on the vast majority of products when a generic equivalent is available; however, brand name drugs may be covered in certain situations by requesting a prior authorization. The UnitedHealthcare PDL prior authorization (PA) list does not include branded items where a generic equivalent is covered. 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 either made in writing by the physician and faxed or called into: 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 necessity of the non-pdl request. The UnitedHealthcare Pharmacy Department will respond to all requests in accordance with state requirements. UHC1004a iii

6 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 Prior Notification Service at with questions concerning the prior authorization process. NON-PDL DRUGS 5-DAY TEMPORARY SUPPLY 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 The pharmacy should 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 QUANTITY LIMITATIONS (QL) Prescriptions for monthly quantities greater than the indicated limit require a prior authorization request. Quantity limits based on Efficient Medication Dosing The Efficient Medication Dosing Program is designed to consolidate medication dosage to the most efficient daily quantity to increase adherence to therapy and also promote the efficient use of health care dollars. The limits for the program are established based on FDA approval for dosing and the availability of the total daily dose in the least amount of tablets or capsules daily. Quantity Limits in the prescription claims processing system will limit the dispensing to consolidate dosing. The pharmacy claims processing system will prompt the pharmacist to request a new prescription order from the physician. Controlled Substances You may fill any FOUR medications from the following classes in a 30-day period: opiate analgesics benzodiazepines sedative hypnotic agents barbiturates UHC1004a iv 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 Prior Notification Service at with questions. Specialty Pharmaceutical Management Program UnitedHealthcare is continuously looking for ways to provide high quality cost effective care for Plan members. The Specialty Pharmaceutical Management Program helps UnitedHealthcare to achieve these goals. Injectable medications that are part of this program require plan authorization and are not available through the retail pharmacy network. To obtain authorization, the provider must submit the appropriate Prior Authorization form to the UnitedHealthcare Pharmacy Department via fax at The UnitedHealthcare Pharmacy Department will review and respond to all requests in accordance with state requirements, and if authorized for payment, UnitedHealthcare will coordinate the delivery of the product to the member or provider. s that are part of this program and are on the PDL are identified in this booklet by the designation "SP". Prior Authorization request forms can be requested by calling the UnitedHealthcare Pharmacy Department at STEP THERAPY (ST) The following PDL drugs are routinely covered only after a sufficient trial of an indicated first-line agent has been adequately tried and failed. These medications may also be requested through the Prior authorization process. While lower cost PDL alternatives may be appropriate in many instances, other non- PDL alternatives are available with prior authorization (PA). STEP Amerge Aricept 23mg Banzel First-Line Agent(s) Trial at a minimum dose of 50mg of sumatriptan tablets. 90 day trial of Aricept 10mg daily 30 day trial of two of the following: lamotrigine, divalproex, or topiramate.

7 Breo Ellipta Ditropan XL 1) 30 day trial of one inhaled corticosteroid (e.g. Arnuity Ellipta, Asmanex) OR 2) 60 day trial of a longacting beta2- agonist (e.g. Arcapta, Striverdi) OR 60 day trial of an orally inhaled anticholinergic agent (e.g. Incruse Ellipta, Atrovent, Combivent, Anoro Ellipta). 30 day trial of oxybutynin immediate release. DPP4 Inhibitors At least a 90 day trial of 1500mg/day of (Tradjenta, metformin. Jentadueto, Onglyza, Kombiglyze) Dulera Elidel fenofibrate Gabitril 1) 30 day trial of one inhaled corticosteroid (e.g. Arnuity Ellipta, Asmanex) OR 2) 60 day trial of a longacting beta2- agonist (e.g. Arcapta, Striverdi) OR 60 day trial of an orally inhaled anticholinergic agent (e.g. Incruse Ellipta, Atrovent, Combivent, Anoro Ellipta). Trial of two different topical corticosteroids. Step therapy only applies to members 12 years of age and older. Fill of a statin or 90 days of gemfibrozil within the previous 180 days. 30 day trial of two of the following: lamotrigine, topiramate, carbamazepine, divalproex, or phenytoin. Step therapy only applies to members 12 years of age and older. Members less than 12 require prior authorization. GLP-1 Agonists At least a 90 day trial of 1500mg/day of (Tanzeum, metformin Victoza) lansoprazole/ 30 day trial of omeprazole 40mg and Prevacid OTC pantoprazole 40mg within previous 180 days is required first Lantus vials trial of Toujeo Solostar Optivar 14 day trial of ketotifen within previous 90 days required first. oxymorphone ER 30-day trial of both Fentanyl patch and morphine sulfate ER at least 200mg per day 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. Protopic 0.03% Trial of two different topical corticosteroids. Step therapy only applies to members 12 years of age and older. Protopic 0.1% Ranexa Renvela Minimum age of 16. Trial of two different topical corticosteroids. Trial of one drug from the following classes: beta blockers, calcium channel blockers, long acting nitrates 8 week trial of calcium acetate SGLT-2 At least a 90 day trial of 1500mg/day of Inhibitors metformin (Jardiance, Invokana, Invokamet, Synjardy) tolterodine trospium 30 day trial of oxybutynin immediate release. Step Therapy only applies to members less than 65 years of age. 30 day trial of oxybutynin immediate release. Step Therapy only applies to members less than 65 years of age. TZD s At least a 90 day trial of 1500mg/day of (ActosPlusMet, metformin ActoPlusMet XR Duetact) Uloric Vancocin 8 week trial of up to 600mg of allopurinol required first. One fill of metronidazole tabs or caps levocetirizine midodrine Onfi 30 day trial of loratadine and cetirizine. Trial of fludrocortisone 30 day trial of two of the following: lamotrigine, divalproex, or topiramate. Vimpat 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. UHC1004a v

8 Xopenex Respules 30 day trial of Albuterol.083% or.5% respules. Zohydro ER 30-day trial of both Fentanyl patch and morphine sulfate ER at least 200mg per day 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 Phone: 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 by UnitedHealthcare Director of Pharmacy Services Unison Plaza 1001 Brinton Road Pittsburgh, PA Phone: LEGEND # Only the dosage forms/strengths of the brand name products noted are on the PDL OTC over-the-counter delayed-rel delayed-release (also known as enteric coated) EC enteric-coated ext-rel extended-release (also known as sustainedrelease) PA Prior Authorization required QL Quantity Limits apply ST 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 UnitedHealthcare. These trademarked brand 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. UHC1004a vi

9 Table of copays for Essential Plans How Displayed in PDL booklet Essential Plan 1 1 (Generics) 1 in column $6 for 30 days $15 for 90 days 2 (Brands) 2 in column $15 for 30 days $37.50 for 90 days Over the Counter (OTCs) DME Supplies Oral Chemotherapy Preventative s Non-Preferred s (not listed in PDL) Compounds (not listed in PDL) OTC listed in OR listed in OTC Medications section DME Supply listed in & Limits oral chemo listed in preventative drug listed in NOT LISTED IN PDL NOT LISTED IN PDL Essential Plan 2 $1 for 30 days $2.50 for 90 days $3 for 30 days $7.50 for 90 Essential Plan 3 $1 for 30 days $2.50 for 90 days $3 for 30 days $7.50 for 90 days days Plan Exclusion Plan Exclusion $1 for 30 days $2.50 for 90 days 5% coinsurance for both 30 & 90 days $0 for both 30 and 90 days $0 for both 30 and 90 days $30 for 30 days $75 for 90 days $30 for 30 days $75 for 90 days $0 for both 30 and 90 days $0 for both 30 and 90 days $0 for both 30 and 90 days $3 for 30 days $7.50 for 90 days $3 for 30 days $7.50 for 90 days $0 for both 30 and 90 days $0 for both 30 and 90 days $0 for both 30 and 90 days $3 for 30 days $7.50 for 90 days $3 for 30 days $7.50 for 90 days Essential Plan 4 $0 for both 30 and 90 days $0 for both 30 and 90 days $0 for both 30 and 90 days $0 for both 30 and 90 days $0 for both 30 and 90 days $0 for both 30 and 90 days $0 for both 30 and 90 days $0 for both 30 and 90 days UHC1004a vii

10 Table of Contents Antineoplastics & Immunosuppressants...4 Antineoplastic Agents...4 Hormonal Antineoplastic Agents....5 Immunomodulators...5 Immunosuppressants...5 Miscellaneous...6 Blood Modifiers - Anticoagulants...6 Anticoagulants...6 Blood Cell Formation...7 Platelet Inhibitors...7 Miscellaneous...7 Cardiovascular Agents...7 Ace Inhibitors...7 Ace Inhibitor/Diuretic Combinations....8 Adrenolytics, Central...8 Alpha Blockers....8 Angiotensin II Receptor Blockers (Antagonists) 8 Angiotensin II Receptor Blocker Combinations. 8 Antiarrhythmics and Cardiac Glycosides...8 Beta Blockers and Beta Blocker/Diuretic Combinations....9 Calcium Channel Blockers....9 Diuretics...10 Lipid Lowering Agents...10 Nitrates...11 Potassium-Removing Agents...11 Miscellaneous...11 Central Nervous System Alzheimer s Disease...11 Analgesics...12 Migraine Acute Therapy...13 Migraine Prophylactic Therapy...14 Multiple Sclerosis Myasthenia Gravis...14 Parkinson s Disease...14 Seizures Miscellaneous...16 Dermatology...16 Acne Vulgaris...16 Bacterial Infections...16 Corticosteroids Fungal Infections...18 Psoriasis...18 Rosacea...18 Scabies and Pediculosis Viral Infections...18 Miscellaneous...19 Ear, Nose & Throat...20 Ear...20 Nose...20 Antihistamine/Decongestant Combinations - First Generation...21 Throat and Mouth...21 Endocrinology Adrenal Corticosteroids...22 Androgens...22 Diabetes Mellitus...22 Growth Stimulating Agents Hormones and Hormone Modifiers...24 Osteoporosis...24 Thyroid Disease...24 Miscellaneous...24 Gastrointestinal Diarrhea Emesis Gastroesophageal Reflux Disease (Gerd)/ Peptic Ulcers...25 Gastrointestinal Spasm...26 Inflammatory Bowel Disease...26 Laxatives...27 Pancreatic Enzymes...27 Probiotic Supplementation Miscellaneous

11 Infectious Diseases...28 Anthelmintics...28 Antibacterials...28 Miscellaneous...29 Antifungals...29 Antivirals...29 Miscellaneous...31 Musculoskeletal...32 Arthritis...32 Gout Skeletal Muscle Relaxants...33 OB-GYN...34 Contraceptives...34 Endometriosis...35 Hormone Therapy/Menopause Vaginal Infections Miscellaneous...36 Ophthalmic...36 Allergy...36 Anti-Inflammatories...37 Glaucoma...37 Infections Miscellaneous...38 Psychiatric Alcohol Deterrents...39 Anxiety Attention Deficit Hyperactivity Disorder (ADHD) Bipolar Disorder Depression...40 Insomnia...40 Narcotic Antagonists...41 Psychoses Smoking Cessation...42 Miscellaneous...42 Urological...48 Symptomatic Benign Prostatic Hypertrophy..48 Miscellaneous...49 Vitamins and Minerals Potassium...53 Miscellaneous...53 Anaphylaxis...53 Cystic Fibrosis...53 Hereditary Angioedema...54 Hyperphosphatemia...54 Immune Thrombocytopenic Purpura Medical Devices Metabolic Modifiers Vaccine...55 OTC MEDICATIONS...56 Acne Antifungals...56 Atopic Dermatitis...56 Cough/Cold Allergy Diabetes...57 Earwax Removal Products...57 Family Planning...57 First Aid...57 Gastrointestinal...57 Lice Products...58 Motion Sickness Ophthalmics...58 Pain...58 Smoking Cessation Products...58 Vitamins/Minerals...59 Warts...59 Miscellaneous Index of covered drugs Respiratory s Antitussives, Decongestants, Expectorants and Combinations Asthma/COPD

12 Generic Name Brand Name Antineoplastics & Immunosuppressants Antineoplastic Agents Alkylating Agents altretamine HEXALEN brand 2 oral chemo busulfan MYLERAN brand 2 oral chemo chlorambucil LEUKERAN brand 2 oral chemo cyclophosphamide CYTOXAN generic 1 oral chemo estramustine phosphate sodium EMCYT brand 2 oral chemo lomustine CEENU generic 1 oral chemo melphalan ALKERAN brand 2 oral chemo temozolomide TEMODAR generic 1 PA, SP, oral chemo Antimetabolites capecitabine XELODA generic 1 PA, SP, oral chemo mercaptopurine PURINETHOL generic 1 oral chemo thioguanine TABLOID brand 2 oral chemo Histone Deacetylase Inhibitors panobinostat FARYDAK brand 2 PA, SP, oral chemo vorinostat ZOLINZA brand 2 PA, SP, oral chemo Kinase Inhibitor afatinib GILOTRIF brand 2 PA, SP, oral chemo axitinib INLYTA brand 2 PA, SP, oral chemo bosutinib BOSULIF brand 2 PA, SP, oral chemo cabozantinib COMETRIQ brand 2 PA, SP, oral chemo ceritinib ZYKADIA brand 2 PA, SP, oral chemo crizotinib XALKORI brand 2 PA, SP, oral chemo dabrafenib TAFINLAR brand 2 PA, SP, oral chemo dasatinib SPRYCEL brand 2 PA, SP, oral chemo erlotinib TARCEVA brand 2 PA, SP, oral chemo everolimus AFINITOR AFINITOR DISPERZ brand 2 PA, SP, oral chemo ibrutinib IMBRUVICA brand 2 PA, SP, oral chemo idelalisib ZYDELIG brand 2 PA, SP, oral chemo imatinib mesylate GLEEVEC generic 1 PA, QL, SP, oral chemo lapatinib ditosylate TYKERB brand 2 PA, SP, oral chemo lenvatinib LENVIMA brand 2 PA, SP, oral chemo nilotinib TASIGNA brand 2 PA, SP, oral chemo palbociclib IBRANCE brand 2 PA, SP, oral chemo pazopanib VOTRIENT brand 2 PA, SP, oral chemo ponatinib ICLUSIG brand 2 PA, SP, oral chemo 4

13 Generic Name Brand Name regorafenib STIVARGA brand 2 PA, SP, oral chemo ruxolitinib JAKAFI brand 2 PA, SP, oral chemo sorafenib NEXAVAR brand 2 PA, SP, oral chemo sunitinib SUTENT brand 2 PA, SP, oral chemo trametinib MEKINIST brand 2 PA, SP, oral chemo vandetanib CAPRELSA brand 2 PA, SP, oral chemo vemurafenib ZELBORAF brand 2 PA, SP, oral chemo Hormonal Antineoplastic Agents Androgen Biosynthesis Inhibitors abiraterone ZYTIGA brand 2 PA, SP, oral chemo Antiandrogens bicalutamide CASODEX generic 1 oral chemo flutamide EULEXIN generic 1 oral chemo Antiestrogens tamoxifen NOLVADEX generic 1 oral chemo toremifene FARESTON brand 2 oral chemo Aromatase Inhibitors anastrozole ARIMIDEX generic 1 oral chemo exemestane AROMASIN generic 1 oral chemo letrozole FEMARA generic 1 oral chemo Gonadotropin Releasing Hormone Analog leuprolide LUPRON generic 1 PA, SP LUPRON DEPOT leuprolide LUPRON DEPOT 6-MONTH brand 2 PA, SP LUPRON DEPOT-PED Progestin megestrol acetate MEGACE generic 1 oral chemo Immunomodulators Interferons interferon alfa-2b INTRON A brand 2 PA, SP peginterferon alfa-2b SYLATRON brand 2 PA, SP Miscellaneous lenalidomide REVLIMID brand 2 PA, SP pomalidomide POMALYST brand 2 PA, SP, oral chemo thalidomide THALOMID brand 2 PA, SP Immunosuppressants Antimetabolites azathioprine IMURAN generic 1 mycophenolate mofetil CELLCEPT generic 1 5

14 Generic Name Brand Name mycophenolate sodium MYFORTIC generic 1 Calcineurin Inhibitors cyclosporine SANDIMMUNE generic 1 cyclosporine, modified NEORAL GENGRAF generic 1 tacrolimus HECORIA PROGRAF generic 1 Other everolimus ZORTRESS brand 2 Rapamycin Derivative sirolimus RAPAMUNE generic 1 tabs sirolimus RAPAMUNE brand 2 solution Miscellaneous alitretinoin 1% gel PANRETIN brand 2 PA bexarotene caps TARGRETIN generic 1 PA, SP, oral chemo bexarotene topical gel TARGRETIN brand 2 PA, SP cysteamine bitartrate CYSTAGON brand 2 SP etoposide VEPESID generic 1 oral chemo hydroxyurea DROXIA brand 2 hydroxyurea HYDREA generic 1 oral chemo mesna MESNEX brand 2 oral chemo mitotane LYSODREN brand 2 oral chemo octreotide SANDOSTATIN generic 1 SP olaparib LYNPARZA brand 2 PA, SP, oral chemo pasireotide SIGNIFOR brand 2 PA, SP procarbazine MATULANE brand 2 SP, oral chemo topotecan HYCAMTIN brand 2 PA, SP tretinoin VESANOID generic 1 SP, caps, oral chemo vismodegib ERIVEDGE brand 2 PA, SP, oral chemo Blood Modifiers - Anticoagulants Anticoagulants apixaban ELIQUIS brand 2 edoxaban SAVAYSA brand 2 enoxaparin LOVENOX generic 1 heparin HEPARIN generic 1 rivaroxaban XARELTO brand 2 PA, QL, PA only applies for quantities greater than 14 days 6

15 Generic Name Brand Name warfarin COUMADIN generic 1 Blood Cell Formation darbepoetin alfa ARANESP brand 2 PA, SP epoetin alfa EPOGEN PROCRIT brand 2 PA, SP filgrastim ZARXIO brand 2 PA, SP oprelvekin NEUMEGA brand 2 PA, SP pegfilgrastim NEULASTA brand 2 PA, SP plerixafor MOZOBIL brand 2 PA, SP sargramostim LEUKINE brand 2 PA, SP TBO-filgrastim GRANIX brand 2 PA, SP Platelet Inhibitors anagrelide AGRYLIN generic 1 aspirin BAYER OTC, preventative generic 1 ECOTRIN drug cilostazol PLETAL generic 1 clopidogrel PLAVIX generic 1 QL dipyridamole PERSANTINE generic 1 Miscellaneous aminocaproic acid AMICAR brand mg tabs & syrup only deferasirox pentoxifylline extended-release Cardiovascular Agents EXJADE JADENU TRENTAL generic 1 Ace Inhibitors benazepril LOTENSIN generic 1 captopril CAPOTEN generic 1 enalapril VASOTEC generic 1 enalapril oral soln EPANED brand 2 brand 2 PA, SP Members 8 years of age will require prior authorization. fosinopril MONOPRIL generic 1 QL lisinopril ZESTRIL generic 1 QL quinapril ACCUPRIL generic 1 QL 7

16 Generic Name Brand Name Ace Inhibitor/Diuretic Combinations benazepril/ hydrochlorothiazide LOTENSIN HCT generic 1 captopril/ hydrochlorothiazide CAPOZIDE generic 1 enalapril/ hydrochlorothiazide VASERETIC generic 1 fosinopril/ hydrochlorothiazide MONOPRIL-HCT generic 1 QL lisinopril/ hydrochlorothiazide ZESTORETIC generic 1 QL quinapril/ hydrochlorothiazide ACCURETIC generic 1 QL Adrenolytics, Central clonidine CATAPRES generic 1 tablets guanfacine TENEX generic 1 Alpha Blockers doxazosin CARDURA generic 1 prazosin MINIPRESS generic 1 terazosin HYTRIN generic 1 Angiotensin II Receptor Blockers (Antagonists) losartan COZAAR generic 1 QL Angiotensin II Receptor Blocker Combinations losartan/hctz HYZAAR generic 1 QL Antiarrhythmics and Cardiac Glycosides amiodarone tabs CORDARONE generic mg and 400 mg digoxin LANOXIN generic 1 disopyramide NORPACE generic 1 disopyramide extended-release NORPACE CR brand 2 dofetilide TIKOSYN brand 2 flecainide TAMBOCOR generic 1 mexiletine MEXITIL generic 1 propafenone RYTHMOL generic 1 IR only quinidine gluconate extended-release EXT-REL QUINIDINE GLUCONATE generic 1 quinidine sulfate QUINIDINE SULFATE generic 1 quinidine sulfate QUINIDINE SULFATE extended-release EXT-REL generic 1 8

17 Generic Name Brand Name Beta Blockers and Beta Blocker/Diuretic Combinations acebutalol SECTRAL generic 1 atenolol TENORMIN generic 1 atenolol/chlorthalidone TENORETIC generic 1 bisoprolol ZEBETA generic 1 bisoprolol/ ZIAC generic 1 hydrochlorothiazide carvedilol COREG generic 1 QL labetalol TRANDATE generic 1 metoprolol LOPRESSOR generic 1 metoprolol succinate TOPROL XL generic 1 pindolol PINDOLOL generic 1 propranolol INDERAL generic 1 IR only propranolol/hctz INDERIDE generic 1 sotalol BETAPACE generic 1 timolol maleate generic 1 tablets Calcium Channel Blockers Dihydropyridines amlodipine NORVASC generic 1 QL felodipine extended-release PLENDIL generic 1 QL nicardipine CARDENE generic 1 nifedipine PROCARDIA generic 1 nifedipine ADALAT CC extended-release PROCARDIA XL generic 1 QL nimodipine NIMOTOP generic 1 QL nimodipine oral soln NYMALIZE brand 2 Nondihydropyridines diltiazem CARDIZEM generic 1 diltiazem extended-release CARDIZEM CD generic 1 QL diltiazem DILACOR XR extended-release TIAZAC generic 1 QL diltiazem sustained-release CARDIZEM SR generic 1 QL verapamil CALAN generic 1 verapamil extended-release CALAN SR generic 1 QL 9

18 Generic Name Brand Name Diuretics amiloride MIDAMOR generic 1 amiloride/ hydrochlorothiazide MODURETIC generic 1 bumetanide BUMEX generic 1 chlorthalidone CHLORTHALIDONE generic 1 chlorothiazide DIURIL generic 1 chlorothiazide DIURIL ORAL brand 2 QL SUSPENSION furosemide LASIX generic 1 hydrochlorothiazide HYDROCHLOROTHIAZIDE generic 1 soln, tabs hydrochlorothiazide MICROZIDE generic mg caps indapamide LOZOL generic 1 metolazone ZAROXOLYN generic 1 spironolactone ALDACTONE generic 1 spironolactone/ hydrochlorothiazide ALDACTAZIDE generic 1 torsemide DEMADEX generic 1 triamterene/ DYAZIDE hydrochlorothiazide MAXZIDE generic 1 Lipid Lowering Agents Bile Acid Resin cholestyramine QUESTRAN QUESTRAN-LIGHT generic 1 Only the bulk products are covered (cans). Individual packets are not covered. Fibrates fenofibrate LOFIBRA generic 1 ST gemfibrozil LOPID generic 1 HMG-CoA Reductase Inhibitors and Combinations atorvastatin LIPITOR generic 1 lovastatin MEVACOR generic 1 QL simvastatin ZOCOR generic 1 QL Niacins niacin NIACOR generic 1 niacin extended-release NIASPAN generic 1 Miscellaneous alirocumab PRALUENT brand 2 PA, QL, SP ezetimibe ZETIA brand 2 PA 10

19 Generic Name Brand Name Nitrates Oral isosorbide dinitrate ISORDIL generic 1 isosorbide dinitrate ISOSORBIDE extended-release DINITRATE ER generic 1 isosorbide mononitrate ISMO generic 1 isosorbide mononitrate extended-release IMDUR generic 1 Sublingual isosorbide dinitrate ISORDIL S.L. generic 1 nitroglycerin NITROLINGUAL generic 1 nitroglycerin NITROSTAT brand 2 Transdermal nitroglycerin NITREK generic 1 transdermal, QL NITRO-DUR nitroglycerin NITRO-BID generic 1 oint Potassium-Removing Agents sodium polysterene KAYEXALATE generic 1 susp (susp only) sulfonate Miscellaneous ambrisentan LETAIRIS brand 2 PA, SP bosentan TRACLEER brand 2 PA, SP guanabenz WYTENSIN generic 1 hydralazine APRESOLINE generic 1 lomitapide JUXTAPID brand 2 PA, SP methyldopa ALDOMET generic 1 methyldopa/hctz ALDORIL generic 1 midodrine PROAMATINE generic 1 ST minoxidil LONITEN generic 1 ranolazine RANEXA brand 2 ST sildenafil REVATIO generic 1 PA, SP, tablets Central Nervous System Alzheimer s Disease donepezil ARICEPT generic 1 donepezil ARICEPT generic 1 5 mg and 10 mg, QL, Members <18 years of age will require prior authorization. 23 mg, ST, Members <18 years of age will require prior authorization. 11

20 Generic Name Brand Name galantamine RAZADYNE generic 1 memantine NAMENDA generic 1 rivastigmine EXELON generic 1 QL, Members <18 years of age will require prior authorization. QL, Members <18 years of age will require prior authorization. QL, Members <18 years of age will require prior authorization. Analgesics Barbiturate Non-Narcotic Analgesics butalbital/acetaminophen PHRENILIN generic 1 QL butalbital/acetaminophen SEDAPAP generic 1 QL ESGIC butalbital/acetaminophen/ FIORICET generic 1 QL caffeine ZEBUTAL butalbital/aspirin/caffeine FIORINAL generic 1 QL Non-Narcotic Analgesics acetaminophen TYLENOL generic 1 OTC aspirin/acetaminophen/ caffeine EXCEDRIN MIGRAINE generic mg, OTC tramadol ULTRAM generic 1 QL NSAIDS choline magnesium trisalicylate TRILISATE generic 1 diclofenac sodium delayed-release VOLTAREN generic 1 etodolac LODINE generic 1 IR Only fenoprofen NALFON generic mg ibuprofen ADVIL generic 1 tabs, chew tabs ibuprofen MOTRIN generic 1 and susp, OTC tabs, chew tabs and susp indomethacin INDOCIN generic 1 ketoprofen ORUDIS generic 1 IR only ketorolac tromethamine TORADOL generic 1 QL meloxicam MOBIC generic 1 QL nabumetone RELAFEN generic 1 naproxen NAPROSYN generic 1 Not EC 12

21 Generic Name Brand Name naproxen sodium ANAPROX generic 1 oxaprozin DAYPRO generic 1 piroxicam FELDENE generic 1 sulindac CLINORIL generic 1 Opioids - Narcotic Analgesics butalbital/apap/caff/cod FIORICET W/CODEINE generic 1 QL, mg butalbital/asa/caff/cod FIORINAL W/CODEINE generic 1 QL butorphanol STADOL generic 1 nasal spray, QL codeine sulfate generic 1 QL codeine/acetaminophen TYLENOL W/CODEINE generic 1 QL fentanyl transdermal DURAGESIC generic 1 QL LORCET hydrocodone/ acetaminophen LORTAB LORTAB ELIXIR NORCO VICODIN generic 1 QL VICODIN ES hydrocodone ER ZOHYDRO ER brand 2 ST hydromorphone DILAUDID generic 1 QL meperidine DEMEROL generic 1 QL methadone DOLOPHINE generic 1 QL morphine MSIR generic 1 QL morphine RMS generic 1 QL morphine extended-release MS CONTIN generic 1 QL oxycodone OXYFAST generic 1 soln, QL oxycodone ROXICODONE generic 1 QL oxycodone/ acetaminophen PERCOCET generic 1 5/325, QL oxycodone/aspirin PERCODAN generic 1 QL oxymorphone ER OXYMORPHONE ER generic 1 QL, ST pentazocine/naloxone TALWIN NX generic 1 QL Migraine Acute Therapy Ergotamine Derivatives dihydroergotamine D.H.E. 45 generic 1 inj, QL dihydroergotamine MIGRANAL generic 1 ergotamine/caffeine CAFERGOT generic 1 ergotamine tartrate/ MIGERGOT caffeine SUPPOSITORIES brand 2 QL 13

22 Generic Name Brand Name Selective Serotonin Agonists naratriptan AMERGE generic 1 ST rizatriptan MAXALT/MAXALT MLT generic 1 QL sumatriptan IMITREX generic 1 QL sumatriptan IMITREX generic 1 4 mg and 6 mg inj 4 MG AND 6 MG INJ Migraine Prophylactic Therapy amitriptyline ELAVIL generic 1 divalproex sodium cap sprinkle DEPAKOTE SPRINKLE generic Members 8 years of age will require prior authorization. divalproex sodium delayed-release DEPAKOTE generic 1 Minimum age 2 propranolol INDERAL generic 1 IR only verapamil CALAN generic 1 Multiple Sclerosis dimethyl fumarate TECFIDERA brand 2 PA, QL, SP fingolimod GILENYA brand 2 PA, QL, SP glatiramer acetate COPAXONE brand 2 PA, QL, SP (40mg) glatiramer acetate COPAXONE generic 1 PA, QL, SP (20mg) interferon beta-1a AVONEX/AVONEX PEN brand 2 PA, QL, SP interferon beta-1a REBIF brand 2 PA, QL, SP teriflunomide AUBAGIO brand 2 PA, QL, SP Myasthenia Gravis pyridostigmine MESTINON generic 1 tabs pyridostigmine MESTINON brand 2 syrup pyridostigmine extended-release MESTINON TIMESPAN generic 1 Parkinson s Disease amantadine SYMMETREL generic 1 except tabs benztropine COGENTIN generic 1 carbidopa/levodopa SINEMET generic 1 carbidopa/levodopa extended-release SINEMET CR generic 1 entacapone COMTAN generic 1 pramipexole MIRAPEX generic 1 ropinirole REQUIP generic 1 selegiline ELDEPRYL generic 1 tabs tolcapone TASMAR brand 2 trihexyphenidyl ARTANE generic 1 14

23 Generic Name Brand Name Seizures carbamazepine TEGRETOL generic 1 carbamazepine CARBATROL extended-release TEGRETOL-XR generic 1 clobazam ONFI brand 2 ST clonazepam KLONOPIN generic 1 tabs diazepam DIASTAT ACUDIAL generic 1 rectal gel, QL divalproex sodium cap sprinkle DEPAKOTE SPRINKLE generic 1 Members 8 years of age will require prior authorization. divalproex sodium delayed-release DEPAKOTE generic 1 Minimum age 2 ethosuximide ZARONTIN generic 1 exogabine POTIGA brand 2 Age Limits Apply, ST felbamate FELBATOL generic 1 felbamate oral susp FELBATOL ORAL SUSP generic 1 Members 8 years of age will require prior authorization. gabapentin NEURONTIN generic 1 caps and tabs only lacosamide VIMPAT brand 2 Age Limits Apply, ST lamotrigine LAMICTAL generic 1 QL lamotrigine chew dispersable tab LAMICTAL CD CHEW TAB generic 1 lamotrigine starter kit LAMICTAL STARTER KIT brand 2 levetiracetam KEPPRA methsuximide CELONTIN brand 2 Members 8 years of age will require prior authorization. QL, Maximum age of 9 for solution oxcarbazepine TRILEPTAL generic 1 QL, Maximum age of 9 for suspension phenobarbital PHENOBARBITAL generic 1 phenytoin DILANTIN INFATABS generic 1 phenytoin sodium DILANTIN extended PHENYTEK generic 1 pregabalin LYRICA brand 2 PA pregabalin LYRICA SOLUTION brand 2 oral solution, PA primidone MYSOLINE generic 1 rufinamide BANZEL brand 2 tablets only, QL, ST tiagabine GABITRIL generic 1 Age Limits Apply, ST, 2mg & 4mg 15

24 Generic Name Brand Name tiagabine GABITRIL brand 2 Age Limits Apply, ST, 12 mg & 16mg topiramate TOPAMAX generic 1 QL topiramate sprinkle caps TOPAMAX SPRINKLE generic 1 QL, Members 8 years of age will require prior authorization. valproic acid DEPAKENE generic 1 vigabatrin oral solution SABRIL SOLUTION brand 2 PA, SP zonisamide ZONEGRAN generic 1 QL Miscellaneous tetrabenazine XENAZINE brand 2 PA, SP Dermatology Acne Vulgaris Oral isotretinoin ACCUTANE generic 1 PA Topical azelaic acid FINACEA brand 2 gel benzoyl peroxide BENZAC AC generic 1 clindamycin CLEOCIN T generic 1 gel clindamycin CLEOCIN T generic 1 lotion clindamycin CLEOCIN T generic 1 soln erythromycin ERYGEL generic 1 gel 2% erythromycin T-STAT generic 1 soln erythromycin/benzoyl peroxide BENZAMYCIN generic 1 salicylic acid NEUTROGENA OIL FREE ACNE WASH generic 1 liquid 2%, OTC sulfacetamide/sulfur SULFACET-R generic 1 lotion sulfacetamide/sulfur PLEXION generic 1 ATRALIN tretinoin AVITA generic 1 RETIN-A Bacterial Infections bacitracin BACITRACIN generic 1 OTC gentamicin GENTAK generic 1 mupirocin BACTROBAN generic 1 ointment, 22 gram tube only neomycin/polymyxin B/ bacitracin NEOSPORIN generic 1 OTC silver sulfadiazine SILVADENE generic 1 16

25 Generic Name Brand Name Corticosteroids Low Potency alclometasone ACLOVATE generic % crm/oint fluocinolone acetonide DERMA-SMOOTHE OIL/FS generic 1 oil 0.01% fluocinolone acetonide SYNALAR generic 1 soln/crm 0.01% hydrocortisone CORTIZONE generic 1 crm, oint, lot OTC hydrocortisone HYTONE generic 1 crm 0.5%, 1%, & 2.5% hydrocortisone HYTONE generic 1 lotion 1% & 2.5% hydrocortisone/aloe CORTIZONE-10 INTENSIVE HEALING generic 1 crm 0.5% & 1%, OTC Medium Potency betamethasone val BETA-VAL generic 1 crm/oint/lotion 0.1% fluocinolone acetonide DERMA-SMOOTHE OIL/FS generic 1 oil 0.01% fluocinolone acetonide SYNALAR generic 1 crm, oint 0.025% flurandrenolide CORDRAN brand 2 tape fluticasone propionate CUTIVATE generic 1 crm 0.05%, oint 0.005% hydrocortisone butyrate LOCOID generic 1 crm/oint/soln 0.1% hydrocortisone valerate WESTCORT generic 1 crm 0.2% mometasone furoate ELOCON generic 1 crm/oint/soln 0.1% prednicarbate DERMATOP generic 1 crm 0.1% triamcinolone acetonide KENALOG generic 1 crm/lot/oint 0.025% triamcinolone acetonide KENALOG generic 1 crm/oint/lotion 0.1% High Potency betamethasone augmented dip DIPROLENE generic 1 lotion 0.05% betamethasone DIPROLENE AF generic 1 crm 0.05% augmented dip betamethasone dipropionate fluocinonide LIDEX generic 1 generic 1 crm/lotion/oint 0.05% crm/oint/gel/soln 0.05% fluocinonide emulsified base LIDEX E generic 1 crm 0.05% triamcinolone acetonide KENALOG generic 1 crm 0.5% 17

26 Generic Name Very High Potency betamethasone dip augmented betamethasone dip augmented Brand Name DIPROLENE generic 1 gel 0.05% DIPROLENE generic 1 oint 0.05% clobetasol propionate TEMOVATE generic 1 crm/gel/oint/soln 0.05% Fungal Infections ciclopirox PENLAC SOLUTION 8% generic 1 clotrimazole LOTRIMIN AF generic 1 OTC clotrimazole MYCELEX generic 1 clotrimazole with LOTRISONE generic 1 betamethasone ketoconazole NIZORAL generic 1 miconazole DESENEX generic 1 2% OTC miconazole MICATIN generic 1 OTC miconazole MONISTAT-DERM generic 1 nystatin MYCOSTATIN generic 1 terbinafine LAMISIL AT generic 1 OTC tolnaftate TINACTIN generic 1 OTC Psoriasis acitretin SORIATANE generic 1 oral caps, PA calcipotriene DOVONEX generic 1 calcitriol VECTICAL generic 1 methoxsalen OXSORALEN-ULTRA generic 1 salicylic acid SCALPICIN generic 1 liquid 3% Rosacea brimonidine MIRVASO brand 2 PA metronidazole METROCREAM METROGEL METROLOTION generic 1 Scabies and Pediculosis crotamiton EURAX brand 2 malathion OVIDE generic 1 permethrin ELIMITE generic 1 5%, QL permethrin NIX CREME RINSE generic 1 1%, OTC pyrethrins/piperonyl but RID SHAMPOO/ BUTOXIDE SHAMPOO generic 1 4% OTC Viral Infections podofilox CONDYLOX SOL generic 1 sol salicylic acid 17%/ collodion DUOFILM generic 1 OTC 18

27 Generic Name Brand Name Miscellaneous aluminum acetate brand 2 soln/cream, OTC aluminum chloride hexahydrate HYPERCARE 20% generic 1 ammonium lactate LAC-HYDRIN generic 1 crm 12%, lotion 5% & 12% ammonium lactate LACTINOL generic 1 lotion 10% becaplermin gel REGRANEX brand 2 PA calamine brand 2 lotion/ointment, OTC collagenase oint SANTYL brand 2 QL fluorouracil CARAC generic 1 0.5% cream fluorouracil EFUDEX generic 1 fluorouracil FLUOROPLEX brand 2 1% cream hexachlorophene PHISOHEX brand 2 hydrocortisone PROCTOSOL HC CREAM 2.5% PROCTOZONE CREAM-HC 2.5% generic 1 ANUSOL HC 2.5% imiquimod 5% cream ALDARA generic 1 PA ketoconazole NIZORAL SHAMPOO generic 1 shampoo 2% lidocaine LIDAMANTEL generic 1 3% cream lidocaine LMX-4 generic 1 4% cream (15 gm tubes), QL lidocaine XYLOCAINE generic 1 jelly 2% lidocaine/prilocaine EMLA generic 1 2.5% cream nitroglycerin RECTIV brand 2 0.4% rectal ointment, PA cream QL, ST, Step therapy is not required pimecrolimus ELIDEL brand 2 for members ages 2-11; not covered for members less than 2 years of age selenium sulfide SELSUN generic 1 shampoo 2.5% ointment 0.03% ST, Step therapy is not required for members tacrolimus PROTOPIC 0.03% generic 1 ages 2-11; not covered for members less than 2 years of age 19

28 Generic Name Brand Name tacrolimus PROTOPIC 0.1% generic 1 urea 40% Ear, Nose & Throat UREA 40% CREAM AND LOTION ointment 0.1%, ST (minimum age 16) generic 1 cream and lotion Ear acetic acid VOSOL OTIC generic 1 otic acetic acid/ aluminum acetate DOMEBORO OTIC generic 1 acetic acid/ hydrocortisone VOSOL HC OTIC generic 1 benzocaine/antipyrine BENZOTIC generic 1 carbamide peroxide DEBROX generic 1 6.5%, OTC ciprofloxacin/ dexamethasone CIPRODEX brand 2 PA neomycin/polymyxin B/ hydrocortisone CORTISPORIN OTIC generic 1 otic ofloxacin FLOXIN OTIC generic 1 Nose Antihistamines - First Generation, Sedating chlorpheniramine CHLOR-TRIMETON extended-release ALLERGY generic 1 12 mg, OTC chlorpheniramine maleate CHLOR-TRIMETON SYRUP generic 1 2 mg/5 ml, OTC clemastine CLEMASTINE generic 1 cyproheptadine CYPROHEPTADINE generic 1 diphenhydramine generic 1 diphenhydramine BENADRYL generic 1 OTC hydroxyzine HCL ATARAX generic 1 hydroxyzine pamoate VISTARIL generic 1 Antihistamines - Second Generation, Nonsedating cetirizine ZYRTEC generic 1 OTC cetirizine chew tab ZYRTEC CHEWABLE TAB- LET generic 1 OTC, Members 8 years of age will require prior authorization. levocetirizine XYZAL generic 1 tabs, ST loratadine ALAVERT CLARITIN generic 1 OTC 20

29 Generic Name Brand Name Antihistamines - Others Antihistamine/Decongestant Combinations azelastine ASTELIN generic 1 spray Antihistamine/Decongestant Combinations - First Generation chlorpheniramine/ phenylephrine/ TRIOTANN generic 1 pyrilamine chlorpheniramine/ ACTIFED generic 1 OTC pseudoephedrine Antihistamine/Decongestant Combinations - Second Generation cetirizine hydrochloride/ pseudoephedrine hydrochloride 12 hours extended-release loratadine/ pseudoephedrine extended-release ZYRTEC-D generic 1 5 mg-120 mg tablet ALAVERT-D ALAVERT ALRG TAB/SINUS generic 1 OTC ALLERY/CONG Nasal Steroids fluticasone FLONASE generic 1 triamcinolone nasal spray NASACORT ALLERGY 24 HOUR brand 2 OTC Miscellaneous Nasal Decongestants oxymetazoline AFRIN generic 1 OTC NEO-SYNEPHRINE phenylephrine DIMEATAPP DRO generic 1 OTC DECONGES Miscellaneous Nasal cromolyn sodium NASALCROM generic 1 OTC ipratropium nasal ATROVENT NASAL SPRAY generic 1 QL saline nasal spray 0.65% OCEAN NASAL SPRAY generic 1 OTC Throat and Mouth chlorhexidine gluconate PERIDEX generic 1 lidocaine viscous XYLOCAINE generic 1 pilocarpine SALAGEN generic 1 triamcinolone KENALOG IN ORABASE generic 1 paste 21

30 Generic Name Brand Name Endocrinology Adrenal Corticosteroids cortisone acetate generic 1 dexamethasone DECADRON generic 1 fludrocortisone FLORINEF generic 1 hydrocortisone CORTEF generic 1 methylprednisolone MEDROL generic 1 4mg, 8mg, 16mg, 32mg methylprednisolone MEDROL brand 2 2mg prednisolone prednisolone PRELONE generic 1 syrup prednisolone sodium ORAPRED phosphate PEDIAPRED generic 1 prednisone DELTASONE generic 1 Androgens testosterone cypionate DEPO-TESTOSTERONE generic 1 testosterone enanthate DELATESTRYL generic 1 testosterone gel topical tube, packet, and pump bottle Diabetes Mellitus Glucose Elevating Agents glucagon, human TESTOSTERONE 1% TOPI- CAL GEL Vials only. Disposable syringes not covered. generic 1 PA GLUCAGON brand 2 QL recombinant Insulins insulin aspart NOVOLOG brand 2 QL insulin aspart protamine 70%/ insulin aspart 30% NOVOLOG MIX 70/30 brand 2 QL insulin glargine LANTUS brand 2 QL, ST insulin glargine 300 unit/ml TOUJEO SOLOSTAR brand 2 insulin human NOVOLIN R brand 2 OTC, QL insulin human RELION R brand 2 OTC, QL insulin isophane HUMULIN N brand 2 OTC, QL insulin isophane human NOVOLIN N brand 2 OTC, QL insulin isophane human RELION N brand 2 OTC, QL insulin isophane human 70%/regular 30% insulin isophane human 70%/regular 30% NOVOLIN 70/30 brand 2 OTC, QL RELION 70/30 brand 2 OTC, QL 22

31 Generic Name Brand Name insulin isophane/regular HUMULIN 70/30 brand 2 OTC, QL insulin lisopro pro/lispro HUMALOG MIX 50/50 brand 2 QL insulin lisopro prot/lispro HUMALOG MIX 75/25 brand 2 QL insulin lispro HUMALOG brand 2 QL insulin regular HUMULIN R brand 2 OTC, QL Monitoring - Strips and Kits/Diabetic Supplies ONE TOUCH SYSTEMS (ULTRA 2, ULTRAMINI, VERIO, VERIO FLEX, VERIO IQ, VERIO SYNC) brand 2 ONE TOUCH TEST STRIPS (ULTRA, VERIO) brand 2 QL for insulin dependent or pregnant members: allow testing up to 6 times per day, DME supply QL for insulin dependent or pregnant members: allow testing up to 6 times per day, DME supply Oral Agents acarbose PRECOSE generic 1 canagliflozin INVOKANA brand 2 ST canagliflozin/metformin INVOKAMET brand 2 ST chlorpropamide DIABINESE generic 1 empagliflozin JARDIANCE brand 2 ST empagliflozin/metformin SYNJARDY brand 2 ST glimepiride AMARYL generic 1 glipizide GLUCOTROL generic 1 glipizide ext-rel GLUCOTROL XL generic 1 glyburide MICRONASE generic 1 glyburide, micronized GLYNASE generic 1 linagliptin TRADJENTA brand 2 ST linagliptin/metformin JENTADUETO brand 2 ST metformin GLUCOPHAGE generic 1 metformin ER GLUCOPHAGE ER generic 1 metformin/glyburide GLUCOVANCE generic 1 nateglinide STARLIX generic 1 pioglitazone ACTOS generic 1 QL pioglitazone/glimepiride DUETACT generic 1 ST pioglitazone/metformin ACTOPLUSMET generic 1 QL, ST pioglitazone/metformin ER ACTOPLUS MET XR brand 2 ST repaglinide PRANDIN generic 1 saxagliptin ONGLYZA brand 2 ST saxagliptin/metformin KOMBIGLYZE brand 2 ST 23

32 Generic Name Brand Name tolazamide TOLINASE generic 1 tolbutamide TOLBUTAMIDE generic 1 Miscellaneous Antidiabetic Agents albiglutide TANZEUM brand 2 ST liraglutide VICTOZA brand 2 ST pramlintide SYMLIN brand 2 PA Growth Stimulating Agents mecasermin INCRELEX brand 2 PA, SP somatropin NUTROPIN AQ NUSPIN brand 2 PA, SP Hormones and Hormone Modifiers Gonadotropin Releasing Hormone Receptor Antagonist cetrorelix acetate for inj kit CETROTIDE brand 2 PA, SP ganirelix acetate inj GANIRELIX ACETATE brand 2 PA, SP Ovulation Stimulants choriogonadotropin alfa inj OVIDREL brand 2 PA, SP follitropin alfa for inj GONAL-F GONAL-F RFF PEN brand 2 PA, SP follitropin beta inj FOLLISTIM AQ brand 2 PA, SP menotropins for inj MENOPUR REPRONEX brand 2 PA, SP urofollitropin purified for inj BRAVELLE brand 2 PA, SP Osteoporosis alendronate FOSAMAX generic 1 QL calcitonin-salmon MIACALCIN generic 1 nasal spray, QL calcitonin-salmon FORTICAL brand 2 nasal spray, QL etidronate DIDRONEL generic 1 raloxifene EVISTA generic 1 teriparatide inj FORTEO brand 2 PA, SP Thyroid Disease levothyroxine LEVOXYL generic 1 levothyroxine SYNTHROID generic 1 liothyronine CYTOMEL generic 1 liotrix THYROLAR brand 2 methimazole TAPAZOLE generic 1 propylthiouracil PROPYLTHIOURACIL generic 1 Miscellaneous cabergoline DOSTINEX generic 1 cholic acid CHOLBAM brand 2 PA, SP desmopressin DDAVP generic 1 QL methylergonovine METHERGINE generic 1 24

33 Generic Name Brand Name mifepristone KORLYM brand 2 PA, SP pegvisomant SOMAVERT brand 2 PA, SP sapropterin KUVAN brand 2 PA, SP sapropterin powder KUVAN POWDER FOR SO- LUTION brand 2 PA, SP Gastrointestinal Diarrhea diphenoxylate/atropine LOMOTIL generic 1 loperamide IMODIUM A-D generic 1 OTC loperamide LOPERAMIDE generic 1 Emesis aprepitant EMEND brand 2 QL applies to 40 mg, 80 mg and mg dronabinol MARINOL generic 1 PA meclizine ANTIVERT generic 1 metoclopramide REGLAN generic 1 ondansetron ZOFRAN ZOFRAN ODT generic 1 QL prochlorperazine COMPAZINE generic 1 promethazine PHENERGAN generic 1 trimethobenzamide TIGAN generic mg caps Gastroesophageal Reflux Disease (Gerd)/Peptic Ulcers alginic acid/sodium bicarbonate brand 2 OTC alumina/magnesia MAALOX generic 1 OTC alumina/magnesia/ simethicone MYLANTA generic 1 OTC cimetidine TAGAMET generic 1 esomeprazole NEXIUM 24HR OTC brand 2 PA Members 2 years esomeprazole granules NEXIUM DELAYED of age will require brand 2 RELEASE PACKET prior authorization. famotidine PEPCID PEPCID AC generic 1 OTC Pepcid AC 10 mg and 20 mg also covered/encouraged with written prescription. lansoprazole PREVACID generic 1 PA 25

34 Generic Name lansoprazole delayed-release Brand Name PREVACID SOLUTAB generic 1 orally disintegrating tabs, Members 2 years of age will require prior authorization. QL omeprazole delayed-release PRILOSEC generic 1 Capsules only, QL pantoprazole PROTONIX generic 1 ranitidine ZANTAC generic mg tabs ranitidine syrup ZANTAC generic 1 sucralfate CARAFATE generic 1 sulcralfate CARAFATE SUSPENSION generic 1 Gastrointestinal Spasm dicyclomine BENTYL generic 1 glycopyrrolate ROBINUL generic 1 hyoscyamine sulfate LEVSIN generic 1 hyoscyamine sulfate LEVSINEX generic 1 suspension, Members 10 years of age up to 65 years of age will require prior authorization. extended-release Inflammatory Bowel Disease balsalazide COLAZAL generic 1 budesonide ENTOCORT EC generic 1 PA hydrocortisone COLOCORT generic 1 enema mesalamine ROWASA generic 1 enema only mesalamine extended-release ASACOL HD APRISO DELZICOL LIALDA brand 2 PENTASA mesalamine supp CANASA brand 2 olsalazine sodium DIPENTUM brand 2 sulfasalazine AZULFIDINE generic 1 sulfasalazine delayed-release AZULFIDINE EN-TABS generic 1 26

35 Generic Name Laxatives casanthranol-docusate sodium Brand Name generic 1 OTC docusate calcium plus generic 1 OTC docusate potasssium generic 1 OTC docusate sodium COLACE generic 1 OTC lactulose ENULOSE generic 1 glycerin GLYCERIN SUPPOSITORY generic 1 suppository, OTC peg 3350/electrolytes COLYTE generic 1 peg 3350/sodium bicarbonate/sodium chloride peg 3350/sodium bicarbonate/sodium chloride/potassium chloride TRILYTE generic 1 NULYTELY generic 1 polyethylene glycol 3350 MIRALAX generic 1 sennosides SENOKOT generic mg tab, OTC Pancreatic Enzymes pancrelipase CREON CREON 3000 UNIT brand 2 ZENPEP Probiotic Supplementation acidophilus ACIDOPHILUS brand 2 caps and tabs, OTC acidophilus ACIDOPHILUS XTRA brand 2 OTC acidophilus/bifidus ACIDOPHILUS/ BIFIDUS WAFER brand 2 OTC acidophilus/citrus pectin ACIDOPHILUS/ CITRUS PECTIN brand 2 tabs, OTC acidophilus/pectin ACIDOPHILUS/PECTIN brand 2 caps, OTC lactobacillus FLORANEX brand 2 chewable tablets, OTC probiotic product PROBIOTIC FORMULA brand 2 caps, OTC Miscellaneous atropine sulfate SAL-TROPINE brand 2 bismuth subsalicylate + metronidazole + HELIDAC brand 2 tetracycline misoprostol CYTOTEC generic 1 naloxegol MOVANTIK brand 2 PA teduglutide GATTEX brand 2 PA, SP 27

36 Generic Name ursodiol Infectious Diseases Brand Name ACTIGALL URSO URSO FORTE generic 1 Anthelmintics albendazole ALBENZA brand 2 ivermectin STROMECTOL brand 2 praziquantel BILTRICIDE brand 2 PA Antibacterials Antituberculosis Agents ethambutol MYAMBUTOL generic 1 isoniazid ISONIAZID generic 1 pyrazinamide PYRAZINAMIDE generic 1 rifabutin MYCOBUTIN generic 1 rifampin RIFADIN generic 1 Cephalosporins - First Generation cefadroxil DURICEF generic 1 cephalexin KEFLEX generic 1 tabs are not covered Cephalosporins - Second Generation cefaclor CECLOR generic 1 cefprozil CEFZIL generic 1 cefuroxime axetil CEFTIN generic 1 tabs cefuroxime axetil CEFTIN brand 2 suspension Cephalosporins - Third Generation cefdinir OMNICEF generic 1 cefixime SUPRAX brand mg caps only, QL Fluoroquinolones ciprofloxacin CIPRO generic 1 levofloxacin LEVAQUIN generic 1 tablets only ofloxacin FLOXIN generic 1 tabs Macrolides azithromycin ZITHROMAX generic 1 QL clarithromycin BIAXIN generic 1 clarithromycin ER BIAXIN XL generic 1 erythromycin delayed-release ERYC generic 1 erythromycin delayed-release ERY-TAB brand 2 28

37 Generic Name Brand Name erythromycin ethylsuccinate E.E.S. generic 1 erythromycin stearate ERYTHROCIN generic 1 erythromycin/sulfisoxazole PEDIAZOLE generic 1 Penicillins amoxicillin AMOXICILLIN CAPSULES AND CHEWABLES generic 1 Except 500 mg and 875 mg film-coated tabs. amoxicillin AMOXIL SUSP generic 1 suspension amoxicillin/clavulanate AUGMENTIN generic 1 ampicillin PRINCIPEN generic 1 dicloxacillin DICLOXACILLIN generic 1 penicillin VK VEETIDS generic 1 Sulfonamides sulfamethoxazole/ trimethoprim, DS Tetracyclines doxycycline monohydrate BACTRIM BACTRIM DS DOXYCYCLINE MONOHYDRATE generic 1 generic 1 minocycline MINOCIN generic 1 capsules, except 75 mg tetracycline SUMYCIN generic 1 Miscellaneous vancomycin HCl VANCOCIN HCL generic 1 cap, ST Antifungals clotrimazole MYCELEX generic 1 troches fluconazole DIFLUCAN generic 1 QL griseofulvin microsize GRIFULVIN V generic 1 griseofulvin ultramicrosize GRIS-PEG generic 1 itraconazole SPORANOX generic 1 caps, PA, QL itraconazole SPORANOX brand 2 soln, PA, QL ketoconazole NIZORAL generic 1 nystatin MYCOSTATIN generic 1 terbinafine LAMISIL generic 1 QL voriconazole VFEND generic 1 PA Antivirals Cytomegalovirus Treatment ganciclovir CYTOVENE generic 1 valganciclovir VALCYTE generic 1 tabs only 29

38 Generic Name Brand Name Entry/Fusion Inhibitors enfuvirtide FUZEON KIT brand 2 Hepatitis Treatment adefovir HEPSERA generic 1 SP daclatasvir DAKLINZA brand 2 PA, SP entecavir BARACLUDE brand 2 SP interferon alfa-2b INTRON A brand 2 PA, SP interferon alfacon-1 INFERGEN brand 2 PA, SP lamivudine EPIVIR HBV brand 2 SP, solution lamivudine EPIVIR HBV generic 1 SP, tablets ledipasvir/sofosbuvir HARVONI brand 2 PA, SP peginterferon alfa-2a PEGASYS brand 2 PA, SP peginterferon alfa-2a PEGASYS PROCLICK brand 2 PA, SP ribavirin REBETOL/COPEGUS generic mg caps and tabs only, PA, SP sofosbuvir SOVALDI brand 2 PA, SP Herpes Treatment acyclovir ZOVIRAX generic 1 caps, tabs, suspension valacyclovir VALTREX generic 1 Influenza Treatment amantadine SYMMETREL generic 1 except tabs oseltamivir TAMIFLU brand 2 QL rimantadine FLUMADINE generic 1 zanamivir RELENZA brand 2 QL Non-Nucleoside Reverse Transcriptase Inhibitors delavirdine RESCRIPTOR brand 2 efavirenz SUSTIVA brand 2 nevirapine VIRAMUNE generic 1 nevirapine ER VIRAMUNE XR brand 2 rilpivirine EDURANT brand 2 Nucleoside Analogues Nucleoside Reverse - Transcriptase Inhibitors/and Combinations abacavir ZIAGEN generic 1 abacavir/lamivudine EPZICOM brand 2 abacavir/lamivudine/ zidovudine TRIZIVIR generic 1 didanosine VIDEX brand 2 didanosine delayed-release VIDEX EC generic 1 emtricitabine EMTRIVA brand 2 emtricitabine/rilpivirine/ tenofovir COMPLERA brand 2 lamivudine EPIVIR generic 1 lamivudine/zidovudine COMBIVIR generic 1 30

39 Generic Name Brand Name stavudine ZERIT generic 1 zidovudine RETROVIR generic 1 Nucleoside/Nucleotide Reverse - Transcriptase Inhibitor Combination cobicistat/elvitegravir/ emtricitabine/tenofovir STRIBILD brand 2 PA efavirenz/emtricitabine/ tenofovir ATRIPLA brand 2 emtricitabine/tenofovir TRUVADA brand 2 PA Nucleotide Analogues Nucleotide Reverse - Transcriptase Inhibitor tenofovir VIREAD brand 2 Protease Inhibitors atazanavir REYATAZ brand atazanavir Members 8 years of REYATAZ POWDER brand 2 age will require prior PACKET authorization darunavir PREZISTA brand 2 fosamprenavir LEXIVA brand 2 indinavir CRIXIVAN brand 2 lopinavir/ritonavir KALETRA brand 2 nelfinavir VIRACEPT brand 2 ritonavir NORVIR brand 2 saquinavir mesylate INVIRASE brand 2 tipranavir APTIVUS brand 2 Miscellaneous abacavir/dolutegravir/ lamivudine TRIUMEQ brand 2 atovaquone MEPRON generic 1 PA bedaquiline SIRTURO brand 2 PA chloroquine phosphate ARALEN generic 1 clindamycin CLEOCIN generic mg and 300 mg only cobicistat TYBOST brand 2 dapsone DAPSONE brand 2 darunavir/cobicistat PREZCOBIX brand 2 dolutegravir TIVICAY brand 2 etravirine INTELENCE brand 2 hydroxychloroquine PLAQUENIL generic 1 interferon gamma-1b ACTIMMUNE brand 2 PA, SP linezolid ZYVOX generic 1 PA maraviroc SELZENTRY brand 2 mefloquine LARIAM generic 1 metronidazole FLAGYL generic 1 tabs only neomycin sulfate brand 2 31

40 Generic Name Brand Name Members 8 years of nitazoxanide suspension ALINIA SUSPENSION brand 2 age will require prior authorization. nitazoxanide tablet ALINIA brand 2 PA nitrofurantoin extended-release MACROBID generic 1 nitrofurantoin macrocrystals MACRODANTIN generic 1 nitrofurantoin susp FURADANTIN SUSP 25 MG/5 ML generic 1 Members 8 years of age will require prior authorization. palivizumab SYNAGIS brand 2 PA, SP paromomycin HUMATIN generic 1 povidone-iodine generic 1 OTC primaquine generic 1 pyrimethamine DARAPRIM brand 2 PA, SP raltegravir ISENTRESS brand 2 raltegravir ISENTRESS CHEWABLE brand 2 chewable tablet raltegravir susp ISENTRESS SUSP brand 2 Members 2 years of age will require prior authorization. trimethoprim TRIMETHOPRIM generic 1 tabs only Musculoskeletal Arthritis Disease Modifying Anti-Rheumatic s adalimumab HUMIRA brand 2 PA, SP anakinra KINERET brand 2 PA, SP auranofin RIDAURA brand 2 azathioprine IMURAN generic 1 certolizumab pegol CIMZIA brand 2 PA, SP hydroxychloroquine PLAQUENIL generic 1 leflunomide ARAVA generic 1 methotrexate generic 1 oral chemo penicillamine CUPRIMINE brand 2 SP sulfasalazine AZULFIDINE generic 1 sulfasalazine delayed-release AZULFIDINE EN-TABS generic 1 NSAIDs and Other Analgesics acetaminophen TYLENOL generic 1 OTC aspirin BAYER OTC, preventative generic 1 ECOTRIN drug capsaicin brand 2 OTC 32

41 Generic Name Brand Name celecoxib CELEBREX generic 1 PA, QL choline magnesium trisalicylate TRILISATE generic 1 diclofenac 1% gel VOLTAREN 1% TOPICAL GEL brand 2 PA diclofenac potassium CATAFLAM generic 1 diclofenac sodium delayed-release VOLTAREN generic 1 diclofenac sodium extended-release VOLTAREN XR generic 1 etodolac LODINE generic 1 IR only fenoprofen NALFON generic mg ibuprofen ADVIL generic 1 tabs, chew tabs ibuprofen MOTRIN generic 1 and susp, OTC tabs, chew tabs and susp indomethacin INDOCIN generic 1 ketoprofen ORUDIS generic 1 IR only meloxicam MOBIC generic 1 QL naproxen NAPROSYN generic 1 not EC naproxen sodium ANAPROX generic 1 oxaprozin DAYPRO generic 1 piroxicam FELDENE generic 1 sulindac CLINORIL generic 1 Gout allopurinol ZYLOPRIM generic 1 colchicine MITIGARE brand 2 febuxostat ULORIC brand 2 ST probenecid PROBENECID generic 1 Skeletal Muscle Relaxants Muscle Spasm chlorzoxazone PARAFON FORTE DSC generic 1 cyclobenzaprine FLEXERIL generic 1 methocarbamol ROBAXIN generic 1 orphenadrine NORFLEX generic 1 extended-release Spasticity baclofen BACLOFEN generic 1 dantrolene DANTRIUM generic 1 diazepam VALIUM generic 1 QL tizanidine ZANAFLEX generic 1 tabs only, QL 33

42 Generic Name Brand Name OB-GYN Contraceptives Biphasic desogestrel/ee MIRCETTE generic 1 QL, preventative drug norethindrone/ee ORTHO-NOVUM 10/11 generic 1 QL, preventative drug Emergency Contraception levonorgestrel PLAN B generic 1 QL, preventative drug levonorgestrel PLAN B ONE STEP generic mg tab, preventative drug Extended Cycle levonorgestrel/ee SEASONALE generic 1 QL, preventative drug Injectable medroxyprogesterone acetate Intravaginal DEPO-PROVERA generic 1 QL, preventative drug etonogestrel/ee NUVARING brand 2 ortho diaphragm ORTHO COIL ORTHO FLAT ORTHO FLEX Monophasic - 20 mcg Estrogen levonorgestrel/ee ALESSE generic 1 norethindrone acetate/ee LOESTRIN 1/20 generic 1 norethindrone acetate/ee/ LOESTRIN FE 1/20 iron generic 1 Monophasic - 30 mcg Estrogen desogestrel/ee ORTHO-CEPT generic 1 levonorgestrel/ee NORDETTE generic 1 norethindrone acetate/ee LOESTRIN 1.5/30 generic 1 norethindrone acetate/ee/ iron LOESTRIN FE 1.5/30 generic 1 norgestrel/ee LO/OVRAL generic 1 ring, QL, preventative drug brand 2 QL, preventative drug 0.1/20, QL, preventative drug 1/20, QL, preventative drug 1/20, QL, preventative drug 0.15/30, QL, preventative drug 0.15/30, QL, preventative drug 1.5/30, QL, preventative drug 1.5/30, QL, preventative drug 0.3/30, QL, preventative drug 34

43 Generic Name Monophasic - 35 mcg Estrogen Brand Name ethynodiol diacetate/ee ZOVIA 1/35 generic 1 norethindrone/ee BALZIVA generic 1 norethindrone/ee MODICON generic 1 norethindrone/ee ORTHO-NOVUM 1/35 generic 1 norgestimate/ee ORTHO-CYCLEN generic 1 Monophasic - 50 mcg Estrogen 1/35, QL, preventative drug 0.4/35, QL, preventative drug 0.5/35, QL, preventative drug 1/35, QL, preventative drug 0.25/35, QL, preventative drug ethynodiol diacetate/ee ZOVIA 1/50 generic 1 1/50, QL, preventative drug norethindrone/ee OVCON 50 generic 1 1/50, QL, preventative drug norethindrone/me ORTHO-NOVUM 1/50 generic 1 1/50, QL, preventative drug norgestrel/ee OVRAL generic 1 0.5/50, QL, preventative drug Progestin norethindrone ORTHO MICRONOR generic 1 preventative drug norgestrel OVRETTE generic 1 preventative drug Transdermal norelgestromin/ee ORTHO EVRA generic 1 preventative drug Triphasic desogestrel/ee CYCLESSA generic 1 QL, preventative drug levonorgestrel/ee TRIVORA generic 1 QL, preventative drug norethindrone acetate/ee/iron ESTROSTEP FE generic 1 QL, preventative drug norethindrone/ee TRI-NORINYL generic 1 QL, preventative drug norethindrone/ee ORTHO-NOVUM 7/7/7 generic 1 QL, preventative drug norgestimate/ee ORTHO TRI-CYCLEN generic 1 QL, preventative drug Endometriosis danazol DANOCRINE generic 1 Gender edits apply: for female patients only. Hormone Therapy/Menopause Estrogens - Intravaginal estradiol ESTRACE CRM brand 2 estrogens, conjugated PREMARIN brand 2 crm Estrogens - Oral estradiol ESTRACE generic 1 estrogens, conjugated PREMARIN brand 2 35

44 Generic Name Brand Name estrogens, conjugated, synthetic A CENESTIN brand 2 estrogens, conjugated, synthetic B ENJUVIA brand 2 estropipate OGEN generic 1 Estrogens - Transdermal estradiol CLIMARA generic 1 QL Estrogen/Progestin estrogens, conjugated/medroxyprogesterone PREMPRO PREMPHASE brand 2 Progestins medroxyprogesterone acetate PROVERA generic 1 norethindrone acetate AYGESTIN generic 1 Vaginal Infections Oral fluconazole DIFLUCAN generic 1 QL metronidazole FLAGYL generic 1 tabs Vaginal clotrimazole GYNE-LOTRIMIN generic 1 OTC clindamycin CLEOCIN generic 1 crm metronidazole METROGEL-VAGINAL METROGEL 1% generic 1 miconazole MONISTAT generic 1 OTC miconazole MONISTAT 3 generic 1 terconazole TERAZOL 3/7 generic 1 crm Miscellaneous conjugated estrogen/ bazedoxifene DUAVEE brand 2 methylergonovine METHERGINE generic 1 tranexamic acid LYSTEDA generic 1 PA Ophthalmic Allergy azelastine OPTIVAR generic 1 ST cromolyn sodium CROLOM generic 1 QL ketotifen ALAWAY OTC brand 2 naphazoline/antazoline brand 2 naphazoline/glycerin CLEAR EYES REDNESS RELIEF generic 1 naphazoline HCL VASOCLEAR generic 1 soln 0.02% naphazoline/zinc sulfate VASOCLEAR A generic 1 36

45 Generic Name Brand Name tetrahydrozoline/ zinc sulfate VISINE-AC generic 1 Anti-Inflammatories Nonsteroidal diclofenac sodium VOLTAREN generic 1 flurbiprofen OCUFEN generic 1 ketorolac ACULAR/ACULAR LS generic 1 Steroidal dexamethasone sodium phosphate DEXASOL generic 1 fluorometholone FML brand 2 oint 0.1% fluorometholone FML FORTE brand 2 susp 0.25% fluorometholone FML LIQUIFILM generic 1 susp 0.1% prednisolone acetate PRED FORTE generic 1 1% prednisolone acetate PRED MILD brand % prednisolone phosphate INFLAMASE FORTE generic 1 1% rimexolone VEXOL brand 2 Anti-Infective/Anti-Inflammatory Combinations gentamicin/prednisolone acetate PRED-G brand 2 neomycin/polymyxin B/ hydrocortisone CORTISPORIN generic 1 neomycin/polymyxin B/ dexamethasone MAXITROL generic 1 sulfacetamide/pred phos VASOCIDIN generic 1 10%/0.25% tobramycin/ dexamethasone TOBRADEX generic 1 Glaucoma Beta-Blockers carteolol generic 1 levobunolol BETAGAN generic 1 ophthalmic solution metipranolol OPTIPRANOLOL generic 1 0.3% ophthalmic solution timolol TIMOPTIC XE generic 1 gel forming solution timolol hemihydrate BETIMOL brand 2 timolol maleate TIMOPTIC generic 1 Carbonic Anhydrase Inhibitors dorzolamide TRUSOPT generic 1 Carbonic Anhydrase Inhibitor/Beta-Blocker Combination dorzolamide/ COSOPT generic 1 timolol maleate Cholinesterase Inhibitor ecothiophate PHOSPHOLINE IODINE brand 2 37

46 Generic Name Brand Name Mydriatics atropine ISOPTO ATROPINE generic 1 cyclopentolate CYCLOGYL generic 1 homatropine ISOPTO HOMATROPINE generic 1 scopolamine ISOPTO HYOSCINE brand 2 Oral acetazolamide ACETAZOLAMIDE generic 1 acetazolamide DIAMOX SEQUELS generic 1 extended-release methazolamide NEPTAZANE generic 1 Prostaglandins latanoprost XALATAN generic 1 QL Topical - Parasympathomimetics pilocarpine ISOPTO CARPINE generic 1 pilocarpine PILOPINE HS GEL brand 2 Topical - Sympathomimetics brimonidine ALPHAGAN P brand 2 brimonidine BRIMONIDINE generic 1 0.2% Infections Bacterial bacitracin generic 1 ciprofloxacin CILOXAN generic 1 erythromycin ERYTHROMYCIN generic 1 gatifloxin ZYMAR brand 2 PA gentamicin GENTAK generic 1 neomycin/polymyxin B/ NEOSPORIN generic 1 gramicidin ofloxacin OCUFLOX generic 1 polymyxin B/bacitracin POLYSPORIN generic 1 polymyxin B/trimethoprim POLYTRIM generic 1 sulfacetamide BLEPH-10 generic 1 oint/soln sulfacetamide/ VASOSULF brand 2 phenylephrine tobramycin TOBREX generic 1 Viral trifluridine VIROPTIC generic 1 Miscellaneous cysteamine 0.44% ophthalmic solution sodium chloride hypertonic CYSTARAN brand 2 PA, SP MURO 128 generic 1 soln 5% 38

47 Generic Name Brand Name Psychiatric Alcohol Deterrents acamprosate CAMPRAL brand 2 disulfiram ANTABUSE generic 1 naltrexone REVIA generic 1 Anxiety Benzodiazepines alprazolam XANAX generic 1 QL, IR only chlordiazepoxide LIBRIUM generic 1 clonazepam KLONOPIN generic 1 not wafers clorazepate TRANXENE generic 1 diazepam VALIUM generic 1 QL lorazepam ATIVAN generic 1 QL oxazepam SERAX generic 1 QL Miscellaneous buspirone BUSPAR generic 1 fluvoxamine LUVOX generic 1 Attention Deficit Hyperactivity Disorder (ADHD) amphetamine/ dextroamphetamine ADDERALL generic 1 Age Limits Apply, QL mixed salts amphetamine/ dextroamphetamine mixed salts extended-release ADDERALL XR (BRAND ADDERALL XR IS PREFERRED) brand 2 Age Limits Apply, QL dextroamphetamine DEXEDRINE generic 1 Age Limits Apply, QL dextroamphetamine DEXTROSTAT brand 2 Age Limits Apply, QL dextroamphetamine extended-release DEXEDRINE SPANSULE generic 1 Age Limits Apply, QL guanfacine ER INTUNIV generic 1 lisdexamfetamine VYVANSE brand 2 Age Limits Apply, QL methylphenidate RITALIN generic 1 Age Limits Apply, tabs only, QL methylphenidate extended-release methylphenidate extended-release CONCERTA generic 1 Age Limits Apply, QL METADATE ER RITALIN-SR RITALIN LA generic 1 Age Limits Apply, QL 39

48 Generic Name Bipolar Disorder divalproex sodium cap sprinkle Brand Name DEPAKOTE SPRINKLE generic 1 Members 8 years of age will require prior authorization. divalproex sodium delayed-release DEPAKOTE generic 1 Minimum age 2 lithium carbonate LITHIUM CARBONATE generic 1 lithium carbonate ESKALITH CR extended-release LITHOBID generic 1 Depression Monoamine Oxidase Inhibitor (MAOI) tranylcypromine PARNATE generic 1 Selective Serotonin Reuptake Inhibitor (SSRIs) citalopram CELEXA generic 1 QL escitalopram LEXAPRO generic 1 fluoxetine PROZAC generic 1 10 mg and 20 mg caps and 20 mg soln only paroxetine PAXIL generic 1 tablets sertraline ZOLOFT generic 1 tablets, QL Serotonin Norepinephrine Reuptake Inhibitors (SNRIs) duloxetine CYMBALTA generic 1 QL venlafaxine EFFEXOR generic 1 QL venlafaxine XR EFFEXOR XR generic 1 QL Tricyclic Antidepressants (TCAs) amitriptyline ELAVIL generic 1 tablets amoxapine generic 1 desipramine NORPRAMIN generic 1 doxepin SINEQUAN generic 1 imipramine HCL TOFRANIL generic 1 tablets nortriptyline PAMELOR generic 1 Tricyclic Antidepressant/Phenothiazine Combination amitriptyline/perphenazine TRIAVIL generic 1 Miscellaneous Agents bupropion WELLBUTRIN generic 1 bupropion WELLBUTRIN SR generic 1 QL, preventative drug extended-release bupropion extended-release WELLBUTRIN XL generic mg and 300 mg maprotiline LUDIOMIL generic 1 mirtazapine REMERON generic 1 tabs (not soltabs) trazodone DESYREL generic mg only Insomnia 40

49 Generic Name Brand Name Benzodiazepines flurazepam DALMANE generic 1 QL temazepam RESTORIL generic 1 15 mg and 30 mg only, QL triazolam HALCION generic 1 QL Non-Benzodiazepines chloral hydrate CHLORAL HYDRATE generic 1 diphenhydramine NYTOL QUICK CAPS generic 1 OTC zaleplon SONATA generic 1 QL zolpidem AMBIEN generic 1 QL Narcotic Antagonists buprenorphine SUBUTEX generic 1 PA, QL buprenorphine/naloxone SUBOXONE brand 2 2 mg and 8 mg film only, PA, QL naloxone NALOXONE INJ generic 1 QL naltrexone REVIA generic 1 Psychoses Atypicals aripiprazole ABILIFY TABLETS generic 1 Age Limit Applies, tablets, PA, QL aripiprazole ER injection ABILIFY MAINTENA brand 2 Age Limit Applies, PA, QL clozapine CLOZARIL generic 1 Age Limit Applies, 100 mg only olanzapine ZYPREXA generic 1 Age Limit Applies, tablets, QL paliperidone INVEGA SUSTENNA brand 2 Age Limit Applies, PA, QL paliperidone INVEGA TRINZA brand 2 Age Limit Applies, PA quetiapine SEROQUEL generic 1 Age Limit Applies, QL risperidone RISPERDAL generic 1 Age Limit Applies, QL, (Not M-Tabs) risperidone RISPERDAL CONSTA brand 2 Age Limit Applies, PA, QL risperidone oral soln RISPERDAL SOLUTION generic 1 QL, Members 8 years of age will require prior authorization. ziprasidone GEODON generic 1 Age Limit Applies, QL 41

50 Generic Name Brand Name Smoking Cessation nicotine NICODERM CQ generic 1 patches, QL, preventative drug nicotine polacrilex gum NICORETTE OTC generic 1 QL, preventative drug nicotine polacrilex lozenge COMMITT OTC generic 1 QL, preventative drug varenicline CHANTIX brand 2 QL, preventative drug Miscellaneous chlorpromazine THORAZINE generic 1 dextromethorphan/ quinidine NUEDEXTA brand 2 PA fluphenazine PROLIXIN generic 1 fluphenazine decanoate PROLIXIN DECANOATE generic 1 haloperidol HALDOL generic 1 haloperidol decanoate HALDOL DECANOATE generic 1 loxapine LOXITANE generic 1 perphenazine TRILAFON generic 1 pimozide ORAP generic 1 thioridazine MELLARIL generic 1 thiothixene NAVANE generic 1 trifluoperazine STELAZINE generic 1 Respiratory s Antitussives, Decongestants, Expectorants and Combinations benzonatate TESSALON generic 1 brompheniramine & DIMETAPP CLD ELX/ phenylephrine ALLERGY generic 1 brompheniramine/ ACCUHIST DROPS pseudoephedrine RESPERAL-DM generic 1 liquid BROMFENEX PD CAP brompheniramine/ pseudoephedrine brompheniramine/ pseudoephedrine brompheniramine/ pseudoephedrine/ dextromethorphan brompheniramine/ pseudoephedrine/ dextromethorphan DIMETAPP ELX CLD/ALLE UNI-HIST DRO CARDEC SYP generic 1 RONDEC SYRUP generic 1 syrup ACCUHIST PDX DROPS generic 1 liquid BROMALINE DM generic 1 elixir 42

51 Generic Name brompheniramine/ pseudoephedrine/ dextromethorphan brompheniramine/ pseudoephedrine/ dextromethorphan/ guaifenesin carbetapentane/ chlorpheniramine/ ephedrine/ phenylephrine carbinoxamine/ pseudoephedrine chlorphen-pemethscopolamine chlorphen tan/ carbetapentane tan chlorphen tan/ pseudoeph tan chlorphen tan/pyrilamine tan/pe tan chlorpheniramine/ dextromethorphan chlorpheniramine maleate phenylephrine HCL chlorpheniramine/ phenylephrine chlorpheniramine/ phenylephrine Brand Name BROMFED DM DALLERGY DM CARBOFED NEO DM ANAPLEX DM generic 1 syrup HISTACOL DM generic 1 syrup RYNATUSS generic 1 RONDEC DROPS generic 1 liquid DURADRYL QV-ALLERGY generic 1 syrup TUSSI-12 S generic 1 susp TANAFED generic 1 susp TRIOTANN PEDIATRIC SUSP R-TANNAMINE ROBITUSSIN PED LIQ CGH/COLD ROBITUSSIN LIQ CGH/CLD DIMETAPP SYP CGH/CLD CORICIDIN TAB CGH/CLD ED A-HIST TABLETS AND LIQUID RONDEC DROPS CARDEC DRO RONDEC SYRUP CARDEC SYP generic 1 susp generic 1 generic 1 generic 1 liquid generic 1 syrup 43

52 Generic Name 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 dextromethorphanguaifenesin dextromethorphan/ guaifenesin dextromethorphanguaifenesin dextromethorphan hbr Brand Name HISTEX CPM/PSE generic 1 RYNATAN PEDIATRIC SUSP generic 1 susp DIHISTINE DH PHENYLHIST LIQ DH GUIATUSS AC GG/CODEINE M-CLEAR WC generic 1 GUIATUSS DAC generic 1 PROMETHAZINE W/CODEINE PROMETHAZINE VC W/CODEINE BROMETANE DX generic 1 generic 1 QL generic 1 QL generic 1 QL CARDEC-DM generic 1 drops DURATUSS DM ELX generic 1 soln mg/5 ml GG/DM CR MUCINEX DM ROBITUSSIN DM TUSSIN DM ROBITUSSIN LIQ CGH/ CONG ROBITUSSIN SYP MAX-ST generic 1 OTC generic 1 liq mg/ 5 ml generic 1 syrup ROBITUSSIN PED SYP dextromethorphan polistirex DELSYM brand 2 OTC extended-release dextromethorphan/ PHENERGAN DM promethazine PROMETHAZINE SYP DM generic 1 guaifenesin ROBITUSSIN generic 1 OTC guaifenesin ROBITUSSIN SYP CHST CNG generic 1 syrup 100 mg/5 ml 44

53 Generic Name guaifenesin extended-release guaifenesin/ pseudoephedrine guaifenesin/ pseudoephedrine/ dextromethorphan guaifenesin/ pseudoephedrine extended-release guaifenesin/ pseudoephedrine extended-release hydrocodone/ chlorpheniramine/ phenylephrine hydrocodone/ guaifenesin hydrocodone/ homatropine loratadine & pseudoephedrine SR 24hr phenyleph/bromphen/ dextromethorphan/ guaifenesin phenylephrine/ brompheniramine/ dextromethorphan phenylephrine/ chlorpheniramine phenylephrine/ chlorpheniramine/ dextromethorphan phenylephrine/ chlorpheniramine/ dextromethorphan Brand Name MUCINEX generic 1 OTC ROBITUSSIN PE PSE/GG ROBITUSSIN CF generic 1 GUAIFED generic 1 GUAIFEN PSE MUCINEX D GG/PSE CR HISTUSSIN HC generic 1 VITUSSIN HYDROCODO/GG SYP HYCODAN HYDROMET SYP HYDROCODONE/ TAB HOMATROP ALLERGY/CONG TAB RE- LIEF generic 1 syrup, OTC generic 1 OTC generic 1 generic 1 ALLANHIST SYP PDX generic 1 QUAL-TUSSIN SYP DC generic 1 generic 1 tab mg generic 1 OTC ATUSS DR generic 1 syrup DE-CHLOR DM generic 1 syrup 45

54 Generic Name phenylephrine/ chlorpheniramine/ dextromethorphan phenylephrine/ chlorpheniramine/ dextromethorphan phenylephrine/ chlorpheniramine/ dihydrocodeine phenylephrine/ dextromethorphan phenylephrine/ dextromethorphan/ guaifenesin phenylephrine/ephed/ CPM w/ carbetapentane phenylephrine/guaifenesin phenylephrine/ hydrocodone/ guaifenesin phenylephrine/pyrilamine/ dextromethorphan phenylephrine/pyrilamine w/hydrocodone phenylephrine tan/ pyrilamine tan/ carbeta tan promethazine & phenylephrine pseudoephedrine/ acetaminophen/ dextromethorphan pseudoephedrine/ chlorpheniramine/ dextromethorphan Brand Name RONDEC DM STATUSS DM SYP CARDEC DM SYP MINUTUSS DR SYP RONDEC DM DROPS CARDEC DM DRO ROBITUSSIN LIQ CGH/ALRG DIHYDRO-PE SYP generic 1 DIMETAPP DRO DCON/CGH ROBITUSSIN LIQ CGH/CLD RYNATUSS PEDIATRIC SUSP ROBITUSSIN LIQ HD/CHST generic 1 syrup generic 1 liquid generic 1 generic 1 generic 1 susp generic 1 QUAL-TUSSIN SYP DC generic 1 CODAL-DM generic 1 CODIMAL DH generic 1 syrup TUSSI 12D S generic 1 susp PROMETH VC SYP /5 generic 1 MAPAP COLD TAB generic 1 PEDIACARE LIQ MULTI-SY ROBITUSSIN LIQ PED NGHT generic 1 syrup mg/ 5 mg 46

55 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 generic 1 generic 1 generic 1 susp RYNA-12 S generic 1 susp TRIPROL/PSE SYP pseudoephedrine APHEDRID TAB generic 1 Asthma/COPD Inhalers - Beta Agonists albuterol sulfate VENTOLIN HFA brand 2 QL indacaterol ARCAPTA NEOHALER brand 2 olodaterol STRIVERDI RESPIMAT brand 2 Inhalers - Corticosteroids fluticasone furoate ARNUITY ELLIPTA brand 2 QL mometasone ASMANEX TWISTHALER brand 2 QL mometasone inhalation ASMANEX HFA brand 2 QL Inhalers - Corticosteroid/Beta Agonist Combinations fluticasone/vilanterol BREO ELLIPTA brand 2 ST mometasone/formoterol DULERA brand 2 ST Inhalers - Others cromolyn INTAL brand 2 QL ipratropium/albuterol COMBIVENT brand 2 QL ipratropium/albuterol COMBIVENT RESPIMAT brand 2 inhaler ipratropium HFA ATROVENT HFA brand 2 nedocromil TILADE brand 2 omalizumab XOLAIR brand 2 PA, SP umeclidinium inhalation INCRUSE ELLIPTA brand 2 umeclidinium/vilanterol ANORO ELLIPTA brand 2 47

56 Generic Name Inhalers for Nebulization Brand Name albuterol ACCUNEB generic mg/3 ml and 1.25 mg /3 ml, for members less than 8 years of age. Members 8 years of age will require prior authorization. albuterol PROVENTIL generic 1 soln 0.083%, 0.5% budesonide PULMICORT RESPULES generic 1 susp, Members 5 years of age will require prior authorization. QL cromolyn INTAL generic 1 soln, QL ipratropium ATROVENT generic 1 soln, QL ipratropium/albuterol DUONEB generic 1 soln levalbuterol HCl XOPENEX RESPULES generic 1 QL, ST Oral Agents - Beta Agonists metaproterenol METAPROTERENOL SYRUP generic 1 terbutaline BRETHINE generic 1 Oral Agents - Leukotriene Modifiers montelukast SINGULAIR generic 1 QL Oral Agents - Theophylline theophylline THEOPHYLLINE generic 1 liquid theophylline extended-release theophylline extended-release theophylline extended-release theophylline extended-release Urological THEO-24 brand 2 caps THEOCHRON generic 1 tabs THEOPHYLLINE EXT-REL generic 1 caps (12 hr) UNIPHYL generic 1 tabs Symptomatic Benign Prostatic Hypertrophy alfuzosin ER UROXATRAL generic 1 doxazosin CARDURA generic 1 finasteride PROSCAR generic 1 tamsulosin FLOMAX generic 1 terazosin HYTRIN generic 1 48

57 Generic Name Brand Name Miscellaneous bethanechol URECHOLINE generic 1 hyoscyamine, methenamine, phenyl salicylate, sodium phosphate UTIRA C brand 2 monobasic, methylene blue methenamine hippurate HIPREX generic 1 UREX oxybutynin chloride DITROPAN XL generic 1 QL, ST oxybutynin IR DITROPAN generic 1 phenazopyridine PYRIDIUM generic 1 potassium citrate UROCIT-K generic 1 propantheline generic 1 sodium citrate/citric acid BICITRA generic 1 tolterodine DETROL generic 1 ST trospium SANCTURA generic 1 ST Vitamins and Minerals calcitriol ROCALTROL generic 1 calcitriol oral soln ROCALTROL SOLUTION generic 1 Members 8 years of age will require prior authorization. calcium OS-CAL generic 1 OTC cholecalciferol BIO-D DRO-MULSION brand 2 drops 400 unit/0.03 ml, OTC drops 2000 unit/0.03 ml, OTC cholecalciferol BIO-D-MULSIO DRO FORTE brand 2 cholecalciferol D3-50 CAP brand 2 cap unit, OTC cholecalciferol VITAMIN D CAP 400 UNIT brand 2 cap 400 unit, OTC cholecalciferol VITAMIN D CAP 2000 UNIT brand 2 cap 2000 unit, OTC cholecalciferol VITAMIN D TAB 400 UNIT brand 2 tab 400 unit, OTC cholecalciferol VITAMIN D TAB 1000 UNIT brand 2 tab 1000 unit, OTC cholecalciferol VITAMIN D TAB 2000 UNIT brand 2 tab 2000 unit, OTC 49

58 Generic Name Brand Name inj, Coverage for these medications will be determined by the member s individual cyanocobalamin VITAMIN B-12 generic 1 benefits. Please refer to individual plan documents for coverage information. electrolyte PEDIALYTE generic 1 soln, oral, OTC ergocalciferol (D2) DRISDOL generic 1 Coverage for these medications will be determined by the member s individual benefits. Please refer to individual plan documents for coverage information. ferrous bisglycinate/ caps, OTC, NIFEREX generic 1 polysaccarides iron preventative drug ferrous sulfate FEOSOL generic 1 OTC, preventative drug Coverage for these GEL-KAM medications will be determined by the LURIDE member s individual fluoride LURIDE LOZI-TABS generic 1 benefits. PREVIDENT Please refer to individual plan PHOS-FLUR documents for coverage information. folic acid FOLIC ACID generic 1 preventative drug magnesium oxide MAG-OX generic 1 OTC, Coverage for these medications will be determined by the member s individual benefits. Please refer to individual plan documents for coverage information. 50

59 Generic Name multivitamins/ fluoride/±iron Brand Name POLY-VI-FLOR generic 1 multivitamins/minerals CENTRUM generic 1 phytonadione MEPHYTON brand 2 polysaccharide iron complex NIFEREX generic 1 prenat-fe Bis-FE COMPLETE NATALCARE prot succ-fa-ca PAK DHA & omega 3 brand 2 prenat-fe Bis-FE prot succ-fa-ca & omega 3 prenat-fe Bis-FE prot succ-fa-ca & omega 3 prenat-fe bis-fe prot succ-fa-ca & omega DR prenat w/o A w/fecbn-fegl- DSS-FA & DHA prenatal vit w/fe bisglyc-fe prot succ-fa prenatal vit w/fe bisglycinate chelate-fa TRUST NATALCARE PAK DHA PRUET DHA PAK SETONET PAK brand 2 brand 2 PRUET DHAEC PAK brand 2 FOLTABS PAK PLUS DHA RE OB + DHA PAK brand 2 VINATE III brand 2 VITAPHIL brand 2 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. elixir, OTC, preventative drug 51

60 Generic Name prenatal vit w/fe bisglycinate chelate-fa prenatal vit w/fe bisglycinate chelate-fa prenatal vit w/fe polysac cmplx-fa prenatal vit w/iron carbonyl-fa prenatal vitamins w/folic acid prenatal w/o A w/fe carbonyl-fe gluc-dss-fa Brand Name GENTEX ADE 28-1 MG brand 2 VINATE AZ EX brand 2 EDGE OB CHW brand 2 ATABEX PRENATAL brand 2 PRENATAL VITAMINS W/ FOLIC ACID CENOGEN OB/ULTRA MATERNA NATALCARE NESTABSCBF/FA/RX NIFEREX-PN FORTE FOLTABS PRENATAL TRI RX generic 1 QL brand 2 vitamin A generic 1 OTC vitamin ADC/fluoride/±iron drops vitamin B complex/ vitamin C/folic acid TRI-VI-FLOR generic 1 NEPHROCAPS generic 1 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 generic 1 OTC vitamin B-6 generic 1 OTC vitamin C generic 1 OTC 52

61 Generic Name Brand Name vitamins pediatric TRI-VI-SOL generic 1 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 generic 1 OTC Potassium phosphorus K-PHOS NEUTRAL generic 1 tabs potassium acid phosphate K-PHOS ORIGINAL brand 2 potassium bicarbonate/ potassium citrate effervescent potassium chloride extended-release K-LYTE generic 1 tabs K-DUR 10 K-DUR 20 KLOR-CON 8 generic 1 tabs KLOR-CON 10 potassium chloride extended-release MICRO-K 10 generic 1 caps potassium chloride K-LOR generic 1 powder potassium chloride POTASSIUM CHLORIDE generic 1 liquid potassium iodide PIMA brand 2 Miscellaneous Anaphylaxis epinephrine EPIPEN EPIPEN JR. brand 2 QL TWINJECT Cryopyrin - Associated Periodic Syndromes (CAPS) canakinumab ILARIS brand 2 PA, SP rilonacept ARCALYST brand 2 PA, SP Cystic Fibrosis acetylcysteine MUCOMYST generic 1 aztreonam CAYSTON brand 2 PA, SP dornase alfa PULMOZYME brand 2 PA, SP ivacaftor KALYDECO KALYDECO GRANULES brand 2 PA, SP 53

62 Generic Name Brand Name lumacaftor/ivacaftor ORKAMBI brand 2 PA, SP tobramycin neb soln BETHKIS brand 2 PA, SP Hereditary Angioedema C1 Inhibitor, Human BERINERT brand 2 PA, SP icatibant FIRAZYR brand 2 PA, SP Hyperphosphatemia calcium acetate generic mg tablet only cinacalcet SENSIPAR brand 2 PA sevelamer RENVELA generic 1 ST Idiopathic Pulmonary Fibrosis (IPF) nintedanib OFEV brand 2 PA, SP pirfenidone capsule ESBRIET brand 2 PA, SP Immune Thrombocytopenic Purpura eltrombopag PROMACTA brand 2 PA, SP Medical Devices spacers QL, DME Supply Metabolic Modifiers carglumic acid CARBAGLU brand 2 PA, SP glycerol phenylbutyrate RAVICTI brand 2 PA, SP sodium phenylbutyrate oral powder BUPHENYL ORAL POWDER generic 1 PA, SP 54

63 Generic Name Vaccine influenza virus vaccine live quadrivalent intranasal nfluenza virus vaccine recombinant hemagglutinin (ha) influenza virus vaccine split influenza virus vaccine split high-dose pf influenza virus vaccine split pf influenza virus vaccine split quadrivalent nfluenza virus vaccine tisscult subunit influenza virus vaccine types a&b surface antigen pneumococcal 13-valent conjugate pneumococcal vaccine polyvalent Brand Name FLUMIST QUAD brand 2 QL FLUBLOK brand 2 QL AFLURIA, FLUZONE SPLT brand 2 QL FLUZONE HD PF brand 2 QL AFLURIA PF brand 2 QL FLUZONE QUAD brand 2 QL FLUCELVAX brand 2 QL FLUVIRIN brand 2 QL PREVNAR 13 brand 2 QL PNEUMOVAX, PNEU- MOVAX 23 brand 2 QL typhoid vaccine VIVOTIF BERNA brand 2 capsules, preventative drug zoster vaccine live ZOSTAVAX brand 2 QL, Age Limits Apply 55

64 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 generics when available. Brand names are provided as reference only. Over-the-counter drugs are coverable for Essential Plan 3 and 4 only. Acne benzoyl peroxide crm, gel, lotion Antifungals clotrimazole miconazole crm, soln tolnaftate vaginal products Atopic Dermatitis emollients Cough/Cold Allergy antihistamines Antihistamine/Decongestant Combinations brompheniramine/pseudoephedrine cetirizine/pseudoephedrine OTC chlorpheniramine/pseudoephedrine loratadine/pseudoephedrine CLEARASIL MICATIN LOTRIMIN AF TINACTIN MONISTAT GYNE-LOTRIMIN BETACARE CREAM AND LOTION CETAPHIL CREAM AND LOTION DERMAPHOR OINTMENT E-OINTMENT GLYCERIN TOPICAL CHLOR-TRIMETON BENADRYL CLARITIN ALAVERT ZYRTEC DIMETAPP ZYRTEC D ACTIFED ALAVERT ALRG TAB/SINUS ALAVERT D ALLERGY/CONG 56

65 Generic Name Brand Name Examples Cough/Cold antitussives Age edit applied. Not covered for members under the age 2. nasal sprays Diabetes alcohol swabs (DME Supply) glucose oral tablets insulin (vials only) Earwax Removal Products carbamide peroxide Family Planning condoms (preventative drug) contraceptive foam (preventative drug) contraceptive gel (preventative drug) First Aid Burow s soln, wet dressings dermatological baths hydrocortisone crm, oint topical antibacterials Gastrointestinal antacids liquids, chew tabs antidiarrheals electrolyte rehydrating soln famotidine laxative enemas ROBITUSSIN ROBITUSSIN DM ROBITUSSIN PE ROBITUSSIN CF DELSYM NEO-SYNEPHRINE AFRIN DIMETAPP DRO DECONGES CURITY ALCOHOL PADS HUMULIN NOVOLIN DEBROX TROJAN DELFEN GYNOL II DOMEBORO COLLOIDAL OATMEAL BATHS CORTAID NEOSPORIN MYCITRACIN BACITRACIN MYLANTA LIQUID MAALOX LIQUID TUMS IMODIUM A-D KAOPECTATE PEDIALYTE PEPCID AC FLEET ENEMA 57

66 Generic Name laxatives psyllium rectal hydrocortisone crm, suppositories simethicone stool softeners sugar+orthophosphoric acid Lice Products permethrin piperonyl butoxide gel, liquid shampoo Motion Sickness dimenhydrinate meclizine Ophthalmics allergic conjunctivitis artificial tears decongestants Pain acetaminophen tabs, liquid, drops, suppositories aspirin tabs, EC tabs (preventative drug) aspirin with buffers tabs ibuprofen tabs, chew tabs and susp Smoking Cessation Products nicotine (preventative drug) Brand Name Examples DULCOLAX FLEET PHOSPHO-SODA METAMUCIL PREPARATION H MYLICON COLACE EMETROL NIX PIPERONYL BUTOXIDE DRAMAMINE BONINE ALAWAY HYPOTEARS VISINE MURINE NAPHCON A TYLENOL BAYER ECOTRIN ADVIL MOTRIN IB COMMIT LOZENGES (QUANTITY LIMIT) NICODERM CQ (QUANTITY LIMIT) NICOTINE GUM (QUANTITY LIMIT) NICOTROL (QUANTITY LIMIT) 58

67 Generic Name Vitamins/Minerals calcium iron (preventative drug) ferrous fumarate, ferrous, gluconate, errous sulfate, ferrous bis-glycinate chelate and polysaccharide iron caps iron polysaccharides (preventative drug) magnesium oxide vitamin D 400 IU vitamins pediatric members <3 years old vitamins prenatal Warts salicylic acid 17%/collodion Miscellaneous fluoride dental rinse Brand Name Examples OS-CAL CALTRATE TUMS FERGON FEOSOL NIFEREX MAG-OX VITAMIN D 400 IU VI-DAYLIN POLY-VI-SOL TRI-VI-SOL STUART PRENATAL DUOFILM PHOS-FLUR 59

68 Index of covered s drugs A abacavir abacavir/dolutegravir/ lamivudine abacavir/lamivudine abacavir/lamivudine/ zidovudine ABILIFY MAINTENA ABILIFY TABLETS abiraterone acamprosate acarbose ACCUHIST DROPS ACCUHIST PDX DROPS.. 42 ACCUNEB ACCUPRIL ACCURETIC ACCUTANE acebutalol acetaminophen , 32 acetaminophen tabs, liquid, drops, suppositories acetazolamide ACETAZOLAMIDE acetazolamide extended-release acetic acid acetic acid/aluminum acetate 20 acetic acid/hydrocortisone..20 acetylcysteine acidophilus ACIDOPHILUS acidophilus/bifidus ACIDOPHILUS/ BIFIDUS WAFER acidophilus/citrus pectin...27 ACIDOPHILUS/ CITRUS PECTIN acidophilus/pectin ACIDOPHILUS/PECTIN ACIDOPHILUS XTRA acitretin ACLOVATE ACTIFED , 56 ALL CAPS = Brand-name drug Lower case = Generic drug ACTIGALL ACTIMMUNE ACTOPLUSMET ACTOPLUS MET XR ACTOS ACULAR/ACULAR LS acyclovir ADALAT CC adalimumab ADDERALL ADDERALL XR adefovir ADVIL , 33, 58 afatinib AFINITOR AFINITOR DISPERZ AFLURIA, FLUZONE SPLT.. 55 AFLURIA PF AFRIN , 57 AGRYLIN ALAVERT , 56 ALAVERT ALRG TAB/SINUS , 56 ALAVERT D , 56 ALAWAY ALAWAY OTC albendazole ALBENZA albiglutide albuterol albuterol sulfate alclometasone alcohol swabs ALDACTAZIDE ALDACTONE ALDARA ALDOMET ALDORIL alendronate ALESSE alfuzosin ER alginic acid/sodium bicarbonate ALINIA ALINIA SUSPENSION alirocumab alitretinoin 1% gel ALKERAN ALLANHIST SYP PDX allergic conjunctivitis ALLERGY/CONG ALLERGY/CONG TAB RELIEF ALLERY/CONG allopurinol ALPHAGAN P alprazolam altretamine alumina/magnesia alumina/magnesia/ simethicone aluminum acetate aluminum chloride hexahydrate amantadine , 30 AMARYL AMBIEN ambrisentan AMERGE AMICAR amiloride amiloride/hydrochlorothiazide10 aminocaproic acid amiodarone tabs amitriptyline , 40 amitriptyline/perphenazine. 40 amlodipine ammonium lactate amoxapine amoxicillin AMOXICILLIN CAPSULES AND CHEWABLES amoxicillin/clavulanate AMOXIL SUSP amphetamine/dextroamphetamine mixed salts amphetamine/dextroamphetamine mixed salts extended-release

69 Index of s ampicillin anagrelide anakinra ANAPLEX DM ANAPROX , 33 anastrozole ANORO ELLIPTA ANTABUSE antacids liquids, chew tabs. 57 antidiarrheals antihistamines antitussives ANTIVERT ANUSOL HC 2.5% APHEDRID TAB apixaban aprepitant APRESOLINE APRISO APTIVUS ARALEN ARANESP ARAVA ARCALYST ARCAPTA NEOHALER ARICEPT ARIMIDEX aripiprazole aripiprazole ER injection ARNUITY ELLIPTA AROMASIN ARTANE artificial tears ASACOL HD ASMANEX HFA ASMANEX TWISTHALER.. 47 aspirin , 32 aspirin/acetaminophen/ caffeine aspirin tabs, EC tabs aspirin with buffers tabs ASTELIN ATABEX PRENATAL ATARAX atazanavir ALL CAPS = Brand-name drug Lower case = Generic drug atenolol atenolol/chlorthalidone ATIVAN atorvastatin atovaquone ATRALIN ATRIPLA atropine atropine sulfate ATROVENT ATROVENT HFA ATROVENT NASAL SPRAY. 21 ATUSS DR AUBAGIO AUGMENTIN auranofin AVITA AVONEX/AVONEX PEN axitinib AYGESTIN azathioprine , 32 azelaic acid azelastine , 36 azithromycin aztreonam AZULFIDINE , 32 AZULFIDINE EN-TABS.. 26, 32 B bacitracin , 38 BACITRACIN , 57 baclofen BACLOFEN BACTRIM BACTRIM DS BACTROBAN balsalazide BALZIVA BANZEL BARACLUDE BAYER , 32, 58 becaplermin gel bedaquiline BENADRYL , 56 benazepril benazepril/hydrochlorothiazide8 BENTYL BENZAC AC BENZAMYCIN benzocaine/antipyrine benzonatate BENZOTIC benzoyl peroxide , 56 benztropine BERINERT BETACARE CREAM AND LOTION BETAGAN betamethasone augmented dip....17, 18 betamethasone dipropionate 17 betamethasone val BETAPACE BETA-VAL bethanechol BETHKIS BETIMOL bexarotene caps bexarotene topical gel BIAXIN BIAXIN XL bicalutamide BICITRA BILTRICIDE BIO-D DRO-MULSION BIO-D-MULSIO DRO FORTE bismuth subsalicylate + metronidazole + tetracycline bisoprolol bisoprolol/hydrochlorothiazide 9 BLEPH BONINE bosentan BOSULIF bosutinib BRAVELLE BREO ELLIPTA BRETHINE brimonidine , 38

70 Index of s BRIMONIDINE BROMALINE DM BROMETANE DX BROMFED DM BROMFENEX PD CAP brompheniramine & phenylephrine brompheniramine/ pseudoephedrine.. 42, 56 brompheniramine/ pseudoephedrine/ dextromethorphan..42, 43 brompheniramine/ pseudoephedrine/dextromethorphan/guaifenesin 43 budesonide , 48 bumetanide BUMEX BUPHENYL ORAL POWDER 54 buprenorphine buprenorphine/naloxone...41 bupropion bupropion extended-release 40 Burow s soln, wet dressings. 57 BUSPAR buspirone busulfan butalbital/acetaminophen.. 12 butalbital/acetaminophen/ caffeine butalbital/apap/caff/cod...13 butalbital/asa/caff/cod butalbital/aspirin/caffeine.. 12 butorphanol C C1 Inhibitor, Human cabergoline cabozantinib CAFERGOT calamine CALAN , 14 CALAN SR calcipotriene calcitonin-salmon ALL CAPS = Brand-name drug Lower case = Generic drug calcitriol , 49 calcium , 59 calcium acetate CALTRATE CAMPRAL canagliflozin canagliflozin/metformin canakinumab CANASA capecitabine CAPOTEN CAPOZIDE CAPRELSA capsaicin captopril captopril/hydrochlorothiazide.8 CARAC CARAFATE CARAFATE SUSPENSION. 26 CARBAGLU carbamazepine carbamazepine extended-release carbamide peroxide...20, 57 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 , 43 CARDENE CARDIZEM CARDIZEM CD CARDIZEM SR CARDURA , carglumic acid carteolol carvedilol casanthranol-docusate sodium CASODEX CATAFLAM CATAPRES CAYSTON CECLOR CEENU cefaclor cefadroxil cefdinir cefixime cefprozil CEFTIN cefuroxime axetil CEFZIL CELEBREX celecoxib CELEXA CELLCEPT CELONTIN CENESTIN CENOGEN OB/ULTRA CENTRUM cephalexin ceritinib certolizumab pegol CETAPHIL CREAM AND LOTION cetirizine cetirizine chew tab cetirizine hydrochloride/pseudoephedrine hydrochloride extended-release cetirizine/ pseudoephedrine OTC..56 cetrorelix acetate for inj kit.. 24 CETROTIDE CHANTIX CHILD IBUPRO SUS COLD. 47 chloral hydrate CHLORAL HYDRATE

71 Index of s chlorambucil chlordiazepoxide chlorhexidine gluconate chloroquine phosphate chlorothiazide chlorothiazide chlorpheniramine/ dextromethorphan chlorpheniramine extended-release chlorpheniramine maleate.. 20 chlorpheniramine maleate phenylephrine HCL chlorpheniramine/ phenylephrine chlorpheniramine/ phenylephrine/ pyrilamine chlorpheniramine/ pseudoephedrine 21, 44, 56 chlorpheniramine tan/ phenylephrine tan chlorphen-pemethscopolamine chlorphen tan/ carbetapentane tan chlorphen tan/ pseudoeph tan chlorphen tan/pyrilamine tan/ PE tan chlorpromazine chlorpropamide chlorthalidone CHLORTHALIDONE CHLOR-TRIMETON CHLOR-TRIMETON ALLERGY CHLOR-TRIMETON SYRUP. 20 chlorzoxazone CHOLBAM cholecalciferol cholestyramine cholic acid choline magnesium trisalicylate , 33 ALL CAPS = Brand-name drug Lower case = Generic drug choriogonadotropin alfa inj. 24 ciclopirox cilostazol CILOXAN cimetidine CIMZIA cinacalcet CIPRO CIPRODEX ciprofloxacin , 38 ciprofloxacin/dexamethasone20 citalopram clarithromycin clarithromycin ER CLARITIN , 56 CLEARASIL CLEAR EYES REDNESS RELIEF clemastine CLEMASTINE CLEOCIN , 36 CLEOCIN T CLIMARA clindamycin , 31, 36 CLINORIL , 33 clobazam clobetasol propionate clonazepam , 39 clonidine clopidogrel clorazepate clotrimazole... 18, 29, 36, 56 clotrimazole with betamethasone clozapine CLOZARIL cobicistat cobicistat/elvitegravir/emtricitabine/tenofovir CODAL-DM codeine/acetaminophen...13 codeine/chlorpheniramine/ pseudoephedrine codeine/guaifenesin codeine/guaifenesin/ pseudoephedrine codeine/promethazine codeine/promethazine/ phenylephrine codeine sulfate CODIMAL DH COGENTIN COLACE , 58 COLAZAL colchicine collagenase oint COLLOIDAL OATMEAL BATHS COLOCORT COLYTE COMBIVENT COMBIVENT RESPIMAT.. 47 COMBIVIR COMETRIQ COMMIT LOZENGES COMMITT OTC COMPAZINE COMPLERA COMPLETE NATALCARE PAK DHA COMTAN CONCERTA condoms CONDYLOX SOL conjugated estrogen/ bazedoxifene contraceptive foam contraceptive gel COPAXONE CORDARONE CORDRAN COREG CORICIDIN TAB CGH/CLD. 43 CORTAID CORTEF cortisone acetate CORTISPORIN CORTISPORIN OTIC CORTIZONE

72 Index of s CORTIZONE-10 INTENSIVE HEALING COSOPT COUMADIN COZAAR CPM/PSE CREAM 2.5% CREON CRIXIVAN crizotinib CROLOM cromolyn , 48 cromolyn sodium , 36 crotamiton CUPRIMINE CURITY ALCOHOL PADS.. 57 CUTIVATE cyanocobalamin CYCLESSA cyclobenzaprine CYCLOGYL cyclopentolate cyclophosphamide cyclosporine cyclosporine, modified CYMBALTA cyproheptadine CYPROHEPTADINE CYSTAGON CYSTARAN cysteamine 0.44% ophthalmic solution cysteamine bitartrate CYTOMEL CYTOTEC CYTOVENE CYTOXAN D D3-50 CAP 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 , 33 DDAVP DEBROX , 57 DECADRON DE-CHLOR DM decongestants deferasirox DELATESTRYL delavirdine DELFEN DELSYM , 57 DELTASONE DELZICOL DEMADEX DEMEROL DEPAKENE DEPAKOTE , 15, 40 DEPAKOTE SPRINKLE , 15, 40 DEPO-PROVERA DEPO-TESTOSTERONE DERMAPHOR OINTMENT. 56 DERMA-SMOOTHE OIL/FS. 17 dermatological baths DERMATOP DESENEX desipramine desmopressin desogestrel/ee , 35 DESYREL DETROL dexamethasone dexamethasone sodium phosphate DEXASOL DEXEDRINE DEXEDRINE SPANSULE.. 39 dextroamphetamine dextroamphetamine extended-release dextromethorphan/brompheniramine/pseudoephedrine. 44 dextromethorphan/carbinoxamine/pseudoephedrine 44 dextromethorphanguaifenesin dextromethorphan/ guaifenesin dextromethorphan hbr dextromethorphan polistirex extended-release44 dextromethorphan/ promethazine dextromethorphan/ quinidine DEXTROSTAT D.H.E DIABINESE DIAMOX SEQUELS DIASTAT ACUDIAL diazepam , 33, 39 diclofenac 1% gel diclofenac potassium diclofenac sodium diclofenac sodium delayed-release....12, 33 dicloxacillin DICLOXACILLIN dicyclomine didanosine didanosine delayed-release. 30 DIDRONEL DIFLUCAN , 36 digoxin DIHISTINE DH dihydroergotamine DIHYDRO-PE SYP DILACOR XR DILANTIN

73 Index of s DILAUDID diltiazem diltiazem extended-release.. 9 diltiazem sustained-release..9 DIMEATAPP DRO DECONGES dimenhydrinate DIMETAPP DIMETAPP CLD ELX/ ALLERGY DIMETAPP DRO DCON/CGH 46 DIMETAPP DRO DECONGES 57 DIMETAPP ELX CLD/ALLE. 42 DIMETAPP SYP CGH/CLD. 43 dimethyl fumarate DIPENTUM diphenhydramine , 41 diphenoxylate/atropine DIPROLENE , 18 DIPROLENE AF dipyridamole disopyramide disopyramide extended-release8 disulfiram DITROPAN DITROPAN XL DIURIL DIURIL ORAL SUSPENSION 10 divalproex sodium cap sprinkle... 14, 15, 40 divalproex sodium delayed-release. 14, 15, 40 docusate calcium plus docusate potasssium docusate sodium dofetilide DOLOPHINE dolutegravir DOMEBORO DOMEBORO OTIC donepezil dornase alfa dorzolamide dorzolamide/timolol maleate 37 DOSTINEX ALL CAPS = Brand-name drug Lower case = Generic drug DOVONEX doxazosin , 48 doxepin doxycycline monohydrate.. 29 DOXYCYCLINE MONOHYDRATE DRAMAMINE DRISDOL dronabinol DROXIA DUAVEE DUETACT DULCOLAX DULERA duloxetine DUOFILM , 59 DUONEB DURADRYL DURAGESIC DURATUSS DM ELX DURICEF DYAZIDE E ecothiophate ECOTRIN , 32, 58 ED A-HIST TABLETS AND LIQUID EDGE OB CHW edoxaban EDURANT E.E.S efavirenz efavirenz/emtricitabine/ tenofovir EFFEXOR EFFEXOR XR EFUDEX ELAVIL , 40 ELDEPRYL electrolyte electrolyte rehydrating soln..57 ELIDEL ELIMITE ELIQUIS ELOCON eltrombopag EMCYT EMEND EMETROL EMLA emollients empagliflozin empagliflozin/metformin emtricitabine emtricitabine/rilpivirine/ tenofovir emtricitabine/tenofovir EMTRIVA enalapril enalapril/hydrochlorothiazide.8 enfuvirtide ENJUVIA enoxaparin entacapone entecavir ENTOCORT EC ENULOSE E-OINTMENT EPANED epinephrine EPIPEN EPIPEN JR EPIVIR EPIVIR HBV epoetin alfa EPOGEN EPZICOM ergocalciferol (D2) ergotamine/caffeine ergotamine tartrate/caffeine. 13 ERIVEDGE erlotinib ERYC ERYGEL ERY-TAB ERYTHROCIN erythromycin , 38 ERYTHROMYCIN

74 Index of s erythromycin/ benzoyl peroxide erythromycin delayed-release 28 erythromycin ethylsuccinate. 29 erythromycin stearate erythromycin/sulfisoxazole..29 ESBRIET escitalopram ESGIC ESKALITH CR esomeprazole ESTRACE estradiol , 36 estramustine phosphate sodium estrogens, conjugated estrogens, conjugated/ medroxyprogesterone.. 36 estrogens, conjugated, synthetic A estrogens, conjugated, synthetic B estropipate ESTROSTEP FE ethambutol ethosuximide ethynodiol diacetate/ee etidronate etodolac , 33 etonogestrel/ee etoposide etravirine EULEXIN EURAX everolimus , 6 EVISTA EXCEDRIN MIGRAINE EXELON exemestane EXJADE exogabine ezetimibe ALL CAPS = Brand-name drug Lower case = Generic drug F famotidine , 57 FARESTON FARYDAK febuxostat felbamate FELBATOL FELDENE , 33 felodipine extended-release..9 FEMARA fenofibrate fenoprofen , 33 fentanyl transdermal FEOSOL , 59 FERGON ferrous bisglycinate/ polysaccarides iron ferrous sulfate filgrastim FINACEA finasteride fingolimod FIORICET FIORICET W/CODEINE FIORINAL FIORINAL W/CODEINE FIRAZYR FLAGYL , 36 flecainide FLEET ENEMA FLEET PHOSPHO-SODA.. 58 FLEXERIL FLOMAX FLONASE FLORANEX FLORINEF FLOXIN FLOXIN OTIC FLUBLOK FLUCELVAX fluconazole , 36 fludrocortisone FLUMADINE FLUMIST QUAD fluocinolone acetonide fluocinonide fluocinonide emulsified base fluoride fluoride dental rinse fluorometholone FLUOROPLEX fluorouracil fluoxetine fluphenazine fluphenazine decanoate flurandrenolide flurazepam flurbiprofen flutamide fluticasone fluticasone furoate fluticasone propionate fluticasone/vilanterol FLUVIRIN fluvoxamine FLUZONE HD PF FLUZONE QUAD FML FML FORTE FML LIQUIFILM folic acid FOLIC ACID FOLLISTIM AQ follitropin alfa for inj follitropin beta inj FOLTABS PAK PLUS DHA RE OB + DHA PAK FOLTABS PRENATAL FORTEO FORTICAL FOSAMAX fosamprenavir fosinopril fosinopril/hydrochlorothiazide 8 FURADANTIN SUSP furosemide FUZEON KIT G gabapentin GABITRIL , 16 galantamine

75 Index of s ganciclovir GANIRELIX ACETATE ganirelix acetate inj gatifloxin GATTEX GEL-KAM gemfibrozil GENGRAF GENTAK , 38 gentamicin , 38 gentamicin/prednisolone acetate GENTEX ADE GEODON GG/CODEINE GG/DM CR GG/PSE CR GILENYA GILOTRIF glatiramer acetate GLEEVEC glimepiride glipizide glipizide ext-rel GLUCAGON glucagon, human recombinant GLUCOPHAGE GLUCOPHAGE ER glucose oral tablets GLUCOTROL GLUCOTROL XL GLUCOVANCE glyburide glyburide, micronized glycerin GLYCERIN SUPPOSITORY. 27 GLYCERIN TOPICAL glycerol phenylbutyrate glycopyrrolate GLYNASE GONAL-F GONAL-F RFF PEN GRANIX GRIFULVIN V ALL CAPS = Brand-name drug Lower case = Generic drug griseofulvin microsize griseofulvin ultramicrosize.. 29 GRIS-PEG GUAIFED guaifenesin guaifenesin extended-release 45 guaifenesin/pseudoephedrine45 guaifenesin/pseudoephedrine/ dextromethorphan guaifenesin/pseudoephedrine extended-release GUAIFEN PSE guanabenz guanfacine guanfacine ER GUIATUSS AC GUIATUSS DAC GYNE-LOTRIMIN , 56 GYNOL II H HALCION HALDOL HALDOL DECANOATE haloperidol haloperidol decanoate HARVONI HECORIA HELIDAC heparin HEPARIN HEPSERA hexachlorophene HEXALEN HIPREX HISTACOL DM HISTEX HISTUSSIN HC homatropine HUMALOG HUMALOG MIX 50/ HUMALOG MIX 75/ HUMATIN HUMIRA HUMULIN HUMULIN 70/ HUMULIN N HUMULIN R HYCAMTIN HYCODAN hydralazine HYDREA hydrochlorothiazide HYDROCHLOROTHIAZIDE. 10 HYDROCODO/GG SYP hydrocodone/ acetaminophen hydrocodone/chlorpheniramine/phenylephrine hydrocodone ER hydrocodone/guaifenesin.. 45 hydrocodone/homatropine. 45 HYDROCODONE/ TAB HOMATROP hydrocortisone. 17, 19, 22, 26 hydrocortisone/aloe hydrocortisone butyrate hydrocortisone crm, oint hydrocortisone valerate HYDROMET SYP hydromorphone hydroxychloroquine... 31, 32 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 , 48 HYZAAR

76 Index of s I IBRANCE ibrutinib IBUOROFEN TAB COLD/SIN 47 ibuprofen , 33, 58 icatibant ICLUSIG idelalisib ILARIS imatinib mesylate IMBRUVICA IMDUR imipramine HCL imiquimod 5% cream IMITREX IMODIUM A-D , 57 IMURAN , 32 INCRELEX INCRUSE ELLIPTA indacaterol indapamide INDERAL , 14 INDERIDE indinavir INDOCIN , 33 indomethacin , 33 INFERGEN INFLAMASE FORTE influenza virus vaccine live quadrivalent intranasal..55 influenza virus vaccine split. 55 influenza virus vaccine split high-dose pf influenza virus vaccine split pf55 influenza virus vaccine split quadrivalent influenza virus vaccine types a&b surface antigen INLYTA insulin aspart insulin aspart protamine 70%/ insulin aspart 30% insulin glargine insulin human insulin isophane ALL CAPS = Brand-name drug Lower case = Generic drug insulin isophane human insulin isophane human 70%/ regular 30% insulin isophane/regular insulin lisopro pro/lispro insulin lisopro prot/lispro...23 insulin lispro insulin regular insulin INTAL , 48 INTELENCE interferon alfa-2b , 30 interferon alfacon interferon beta-1a interferon gamma-1b INTRON A , 30 INTUNIV INVEGA SUSTENNA INVEGA TRINZA INVIRASE INVOKAMET INVOKANA ipratropium ipratropium/albuterol.. 47, 48 ipratropium HFA ipratropium nasal iron polysaccharides iron ISENTRESS ISENTRESS CHEWABLE.. 32 ISENTRESS SUSP ISMO isoniazid ISONIAZID ISOPTO ATROPINE ISOPTO CARPINE ISOPTO HOMATROPINE.. 38 ISOPTO HYOSCINE ISORDIL ISORDIL S.L isosorbide dinitrate ISOSORBIDE DINITRATE ER 11 isosorbide dinitrate extended-release isosorbide mononitrate isosorbide mononitrate extended-release isotretinoin itraconazole ivacaftor ivermectin J JADENU JAKAFI JARDIANCE JENTADUETO JUXTAPID K KALETRA KALYDECO KAOPECTATE KAYEXALATE K-DUR K-DUR KEFLEX KENALOG KENALOG IN ORABASE.. 21 KEPPRA ketoconazole , 19, 29 ketoprofen , 33 ketorolac ketorolac tromethamine ketotifen KINERET KLONOPIN , 39 K-LOR KLOR-CON KLOR-CON K-LYTE KOMBIGLYZE KORLYM K-PHOS NEUTRAL K-PHOS ORIGINAL KUVAN L labetalol LAC-HYDRIN

77 Index of s lacosamide LACTINOL lactobacillus lactulose LAMICTAL LAMICTAL CD CHEW TAB. 15 LAMICTAL STARTER KIT.. 15 LAMISIL LAMISIL AT lamivudine lamivudine/zidovudine lamotrigine lamotrigine chew dispersable tab lamotrigine starter kit LANOXIN lansoprazole lansoprazole delayed-release 26 LANTUS lapatinib ditosylate LARIAM LASIX latanoprost laxative enemas laxatives ledipasvir/sofosbuvir leflunomide lenalidomide lenvatinib LENVIMA LETAIRIS letrozole LEUKERAN LEUKINE leuprolide levalbuterol HCl LEVAQUIN levetiracetam levobunolol levocetirizine levofloxacin levonorgestrel levonorgestrel/ee , 35 levothyroxine LEVOXYL ALL CAPS = Brand-name drug Lower case = Generic drug LEVSIN LEVSINEX LEXAPRO LEXIVA LIALDA LIBRIUM LIDAMANTEL LIDEX LIDEX E lidocaine lidocaine/prilocaine lidocaine viscous linagliptin linagliptin/metformin linezolid liothyronine liotrix LIPITOR liraglutide lisdexamfetamine lisinopril lisinopril/hydrochlorothiazide.8 lithium carbonate LITHIUM CARBONATE lithium carbonate extended-release LITHOBID LMX LOCOID LODINE , 33 LOESTRIN 1.5/ LOESTRIN 1/ LOESTRIN FE 1.5/ LOESTRIN FE 1/ LOFIBRA lomitapide LOMOTIL lomustine LONITEN LO/OVRAL loperamide loperamide LOPERAMIDE LOPID lopinavir/ritonavir LOPRESSOR loratadine loratadine/pseudoephedrine 56 loratadine/pseudoephedrine extended-release loratadine & pseudoephedrine SR lorazepam LORCET LORTAB LORTAB ELIXIR losartan losartan/hctz LOTENSIN LOTENSIN HCT LOTRIMIN AF , 56 LOTRISONE lovastatin LOVENOX loxapine LOXITANE LOZOL LUDIOMIL lumacaftor/ivacaftor LUPRON LUPRON DEPOT LUPRON DEPOT-PED LURIDE LUVOX LYNPARZA LYRICA LYSODREN LYSTEDA M MAALOX , 57 MACROBID MACRODANTIN magnesium oxide , 59 MAG-OX , 59 malathion MAPAP COLD TAB maprotiline maraviroc MARINOL

78 Index of s MATERNA MATULANE MAXALT/MAXALT MLT MAXITROL MAXZIDE M-CLEAR WC mecasermin meclizine , 58 MEDROL medroxyprogesterone acetate , 36 mefloquine MEGACE megestrol acetate MEKINIST MELLARIL meloxicam , 33 melphalan memantine MENOPUR menotropins for inj meperidine MEPHYTON MEPRON mercaptopurine mesalamine mesalamine extended-release26 mesalamine supp mesna MESNEX MESTINON MESTINON TIMESPAN METADATE ER METAMUCIL metaproterenol METAPROTERENOL SYRUP 48 metformin metformin ER metformin/glyburide methadone methazolamide methenamine hippurate METHERGINE , 36 methimazole methocarbamol ALL CAPS = Brand-name drug Lower case = Generic drug methotrexate methoxsalen methsuximide methyldopa methyldopa/hctz methylergonovine , 36 methylphenidate methylphenidate extended-release methylprednisolone metipranolol metoclopramide metolazone metoprolol metoprolol succinate METROCREAM METROGEL METROGEL 1% METROGEL-VAGINAL METROLOTION metronidazole , 31, 36 MEVACOR mexiletine MEXITIL MIACALCIN MICATIN , 56 miconazole , 36, 56 MICRO-K MICRONASE MICROZIDE MIDAMOR midodrine mifepristone MIGERGOT SUPPOSITORIES13 MIGRANAL MINIPRESS MINOCIN minocycline minoxidil MINUTUSS DR SYP MIRALAX MIRAPEX MIRCETTE mirtazapine MIRVASO misoprostol MITIGARE mitotane MOBIC , 33 MODICON MODURETIC mometasone mometasone/formoterol mometasone furoate mometasone inhalation MONISTAT , 56 MONISTAT MONISTAT-DERM MONOPRIL MONOPRIL-HCT montelukast morphine morphine extended-release. 13 MOTRIN , 33 MOTRIN IB MOVANTIK MOZOBIL MS CONTIN MSIR MUCINEX MUCINEX D MUCINEX DM MUCOMYST MULTI SYMPTOM TAB COLD RLF multivitamins/fluoride/±iron. 51 multivitamins/minerals mupirocin MURINE MURO MYAMBUTOL MYCELEX , 29 MYCITRACIN MYCOBUTIN mycophenolate mofetil mycophenolate sodium....6 MYCOSTATIN , 29 MYFORTIC MYLANTA , 57 MYLERAN

79 Index of s MYLICON MYSOLINE N nabumetone NALFON , 33 naloxegol naloxone NALOXONE INJ naltrexone , 41 NAMENDA naphazoline/antazoline naphazoline/glycerin naphazoline HCL naphazoline/zinc sulfate NAPHCON A NAPROSYN , 33 naproxen , 33 naproxen sodium , 33 naratriptan NASACORT ALLERGY NASALCROM nasal sprays NATALCARE nateglinide NAVANE nedocromil nelfinavir NEO DM neomycin/polymyxin B/ bacitracin neomycin/polymyxin B/ dexamethasone neomycin/polymyxin B/ gramicidin neomycin/polymyxin B/ hydrocortisone....20, 37 neomycin sulfate NEORAL NEOSPORIN , 38, 57 NEO-SYNEPHRINE... 21, 57 NEPHROCAPS NEPTAZANE NESTABSCBF/FA/RX NEULASTA ALL CAPS = Brand-name drug Lower case = Generic drug NEUMEGA NEURONTIN NEUTROGENA OIL FREE ACNE WASH nevirapine nevirapine ER NEXAVAR NEXIUM 24HR OTC NEXIUM DELAYED RELEASE PACKET nfluenza virus vaccine recombinant hemagglutinin nfluenza virus vaccine tiss-cult subunit niacin niacin extended-release NIACOR NIASPAN nicardipine NICODERM CQ , 58 NICORETTE OTC nicotine NICOTINE GUM nicotine polacrilex gum nicotine polacrilex lozenge..42 nicotine NICOTROL nifedipine nifedipine extended-release..9 NIFEREX , 51, 59 NIFEREX-PN FORTE nilotinib nimodipine NIMOTOP nintedanib nitazoxanide suspension...32 nitazoxanide tablet NITREK NITRO-BID NITRO-DUR nitrofurantoin extended-release nitrofurantoin macrocrystals. 32 nitrofurantoin susp nitroglycerin , NITROLINGUAL NITROSTAT NIX , 58 NIZORAL , 29 NIZORAL SHAMPOO NOLVADEX NORCO NORDETTE norelgestromin/ee norethindrone norethindrone acetate norethindrone acetate/ee.. 34 norethindrone acetate/ee/iron... 34, 35 norethindrone/ee , 35 norethindrone/me NORFLEX norgestimate/ee norgestrel norgestrel/ee , 35 NORPACE NORPACE CR NORPRAMIN nortriptyline NORVASC NORVIR NOVOLIN NOVOLIN 70/ NOVOLIN N NOVOLIN R NOVOLOG NOVOLOG MIX 70/ NUEDEXTA NULYTELY NUTROPIN AQ NUSPIN NUVARING NYMALIZE nystatin , 29 NYTOL QUICK CAPS O OCEAN NASAL SPRAY octreotide OCUFEN OCUFLOX

80 Index of s OFEV ofloxacin , 28, 38 OGEN olanzapine olaparib olodaterol olsalazine sodium omalizumab omeprazole delayed-release OMNICEF ondansetron ONE TOUCH SYSTEMS (ULTRA 2, ULTRAMINI, VERIO, VE- RIO FLEX, VERIO IQ, VERIO SYNC) ONE TOUCH TEST STRIPS (ULTRA, VERIO) ONFI ONGLYZA oprelvekin 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/ ORTHO-NOVUM 7/7/ ORTHO-NOVUM 10/ ORTHO TRI-CYCLEN ORUDIS , 33 OS-CAL , 59 oseltamivir OVCON ALL CAPS = Brand-name drug Lower case = Generic drug OVIDE OVIDREL OVRAL OVRETTE oxaprozin , 33 oxazepam oxcarbazepine OXSORALEN-ULTRA oxybutynin chloride oxybutynin IR oxycodone oxycodone/acetaminophen. 13 oxycodone/aspirin OXYFAST oxymetazoline oxymorphone ER OXYMORPHONE ER P palbociclib paliperidone palivizumab PAMELOR pancrelipase panobinostat PANRETIN pantoprazole PARAFON FORTE DSC PARNATE paromomycin paroxetine pasireotide PAXIL pazopanib PEDIACARE LIQ MULTI-SY. 46 PEDIALYTE , 57 PEDIAPRED PEDIAZOLE peg 3350/electrolytes peg 3350/sodium bicarbonate/ sodium chloride peg 3350/sodium bicarbonate/ sodium chloride/potassium chloride PEGASYS PEGASYS PROCLICK pegfilgrastim peginterferon alfa-2a peginterferon alfa-2b pegvisomant penicillamine penicillin VK PENLAC SOLUTION 8%.. 18 PENTASA pentazocine/naloxone pentoxifylline extended-release PEPCID PEPCID AC , 57 PERCOCET PERCODAN PERIDEX permethrin , 58 perphenazine PERSANTINE phenazopyridine PHENERGAN PHENERGAN DM phenobarbital PHENOBARBITAL phenyleph/bromphen/dextromethorphan/guaifenesin 45 phenylephrine phenylephrine/ brompheniramine/ dextromethorphan phenylephrine/ chlorpheniramine phenylephrine/ chlorpheniramine/ dextromethorphan..45, 46 phenylephrine/ chlorpheniramine/ dihydrocodeine phenylephrine/ dextromethorphan phenylephrine/ dextromethorphan/ guaifenesin

81 Index of s phenylephrine/ephed/cpm w/ carbetapentane phenylephrine/guaifenesin..46 phenylephrine/hydrocodone/ guaifenesin phenylephrine/pyrilamine/ dextromethorphan phenylephrine/pyrilamine w/hydrocodone phenylephrine tan/ pyrilamine tan/ carbeta tan PHENYLHIST LIQ DH PHENYTEK phenytoin phenytoin sodium extended. 15 PHISOHEX PHOS-FLUR , 59 PHOSPHOLINE IODINE phosphorus PHRENILIN phytonadione pilocarpine , 38 PILOPINE HS GEL PIMA pimecrolimus pimozide pindolol PINDOLOL pioglitazone pioglitazone/glimepiride pioglitazone/metformin pioglitazone/metformin ER. 23 PIPERONYL BUTOXIDE piperonyl butoxide gel, liquid shampoo pirfenidone capsule piroxicam , 33 PLAN B PLAQUENIL , 32 PLAVIX PLENDIL plerixafor PLETAL PLEXION ALL CAPS = Brand-name drug Lower case = Generic drug pneumococcal 13-valent conjugate pneumococcal vaccine polyvalent PNEUMOVAX, PNEUMOVAX podofilox polyethylene glycol polymyxin B/bacitracin polymyxin B/trimethoprim.. 38 polysaccharide iron complex POLYSPORIN POLYTRIM POLY-VI-FLOR POLY-VI-SOL pomalidomide POMALYST ponatinib potassium acid phosphate..53 potassium bicarbonate/ potassium citrate effervescent potassium chloride POTASSIUM CHLORIDE.. 53 potassium chloride extended-release potassium citrate potassium iodide POTIGA povidone-iodine PRALUENT pramipexole pramlintide PRANDIN praziquantel prazosin PRECOSE PRED FORTE PRED-G PRED MILD prednicarbate prednisolone prednisolone acetate prednisolone phosphate prednisolone sodium phosphate prednisone pregabalin PRELONE PREMARIN PREMPHASE PREMPRO prenatal vitamins w/folic acid 52 PRENATAL VITAMINS W/ FOLIC ACID prenatal vit w/fe bisglyc-fe prot succ-fa prenatal vit w/fe bisglycinate chelate-fa , 52 prenatal vit w/fe polysac cmplx-fa prenatal vit w/iron carbonyl-fa prenatal w/o A w/fe carbonyl- FE gluc-dss-fa prenat-fe Bis-FE prot succ-fa-ca & omega prenat-fe bis-fe prot succ-fa-ca & omega DR prenat w/o A w/fecbn-fegl- DSS-FA & DHA PREPARATION H PREVACID , 26 PREVIDENT PREVNAR PREZCOBIX PREZISTA PRILOSEC primaquine primidone PRINCIPEN PROAMATINE probenecid PROBENECID PROBIOTIC FORMULA probiotic product

82 Index of s procarbazine PROCARDIA PROCARDIA XL prochlorperazine PROCRIT PROCTOSOL HC PROCTOZONE CREAM-HC 2.5% PROGRAF PROLIXIN PROLIXIN DECANOATE PROMACTA promethazine promethazine & phenylephrine PROMETHAZINE SYP DM. 44 PROMETHAZINE VC W/CODEINE PROMETHAZINE W/CODEINE PROMETH VC SYP propafenone propantheline propranolol , 14 propranolol/hctz propylthiouracil PROPYLTHIOURACIL PROSCAR PROTONIX PROTOPIC 0.1% PROTOPIC 0.03% PROVENTIL PROVERA PROZAC PRUET DHAEC PAK PRUET DHA PAK SETONET PAK PSE/GG pseudoephedrine/ acetaminophen/ dextromethorphan pseudoephedrine/ chlorpheniramine/ dextromethorphan ALL CAPS = Brand-name drug Lower case = Generic drug pseudoephedrine/dextromethorphan/guaifenesin pseudoephedrine/iburprofen 47 pseudoephedrine tan/dexchlorphen tan/dm tan psyllium PULMICORT RESPULES.. 48 PULMOZYME PURINETHOL pyrazinamide PYRAZINAMIDE pyrethrins/piperonyl but PYRIDIUM pyridostigmine pyridostigmine extended-release pyrilamine tan/phenyleph tan 47 pyrimethamine Q QUAL-TUSSIN SYP DC. 45, 46 QUESTRAN QUESTRAN-LIGHT quetiapine quinapril quinapril/hydrochlorothiazide.8 quinidine gluconate extended-release QUINIDINE GLUCONATE EXT-REL quinidine sulfate QUINIDINE SULFATE quinidine sulfate extended-release QUINIDINE SULFATE EXT-REL QV-ALLERGY R raloxifene raltegravir RANEXA ranitidine ranolazine RAPAMUNE RAVICTI RAZADYNE REBETOL/COPEGUS REBIF rectal hydrocortisone crm, suppositories RECTIV REGLAN regorafenib REGRANEX RELAFEN RELENZA RELION 70/ RELION N RELION R REMERON RENVELA repaglinide REPRONEX REQUIP RESCRIPTOR RESPERAL-DM RESTORIL RETIN-A RETROVIR REVATIO REVIA , 41 REVLIMID REYATAZ REYATAZ POWDER PACKET 31 ribavirin RIDAURA RID SHAMPOO/ BUTOXIDE SHAMPOO. 18 rifabutin RIFADIN rifampin rilonacept rilpivirine rimantadine rimexolone RISPERDAL RISPERDAL CONSTA RISPERDAL SOLUTION risperidone

83 Index of s RITALIN RITALIN LA RITALIN-SR ritonavir rivaroxaban rivastigmine rizatriptan RMS ROBAXIN ROBINUL ROBITUSSIN , 57 ROBITUSSIN CF , 57 ROBITUSSIN DM , 57 ROBITUSSIN LIQ CGH/ALRG ROBITUSSIN LIQ CGH/CLD , 46 ROBITUSSIN LIQ CGH/CONG ROBITUSSIN LIQ HD/CHST 46 ROBITUSSIN LIQ PED NGHT 46 ROBITUSSIN PE , 57 ROBITUSSIN PED LIQ CGH/COLD ROBITUSSIN PED SYP ROBITUSSIN SYP CHST CNG ROBITUSSIN SYP MAX-ST. 44 ROCALTROL ROCALTROL SOLUTION.. 49 RONDEC DM RONDEC DROPS RONDEC SYRUP , 43 ropinirole ROWASA ROXICODONE R-TANNAMINE rufinamide ruxolitinib RYNA-12 S RYNATAN PEDIATRIC SUSP 44 RYNATUSS RYNATUSS PEDIATRIC SUSP46 RYTHMOL ALL CAPS = Brand-name drug Lower case = Generic drug S SABRIL SOLUTION SALAGEN salicylic acid , 18 salicylic acid 17%/ collodion , 59 saline nasal spray 0.65%...21 SAL-TROPINE SANCTURA SANDIMMUNE SANDOSTATIN SANTYL sapropterin sapropterin powder saquinavir mesylate sargramostim SAVAYSA saxagliptin saxagliptin/metformin SCALPICIN scopolamine SEASONALE SECTRAL SEDAPAP selegiline selenium sulfide SELSUN SELZENTRY sennosides SENOKOT SENSIPAR SERAX SEROQUEL sertraline sevelamer SIGNIFOR sildenafil SILVADENE silver sulfadiazine simethicone simvastatin SINEMET SINEMET CR SINEQUAN SINGULAIR sirolimus sirolimus SIRTURO sodium chloride hypertonic. 38 sodium citrate/citric acid...49 sodium phenylbutyrate oral powder sodium polysterene sulfonate sofosbuvir somatropin SOMAVERT SONATA sorafenib SORIATANE sotalol SOVALDI spacers spironolactone spironolactone/ hydrochlorothiazide SPORANOX SPRYCEL STADOL STARLIX STATUSS DM SYP stavudine STELAZINE STIVARGA stool softeners STRIBILD STRIVERDI RESPIMAT STROMECTOL STUART PRENATAL SUBOXONE SUBUTEX sucralfate sugar+orthophosphoric acid 58 sulcralfate sulfacetamide sulfacetamide/phenylephrine 38 sulfacetamide/pred phos.. 37 sulfacetamide/sulfur SULFACET-R

84 Index of s sulfamethoxazole/ trimethoprim, DS sulfasalazine , 32 sulfasalazine delayed-release....26, 32 sulindac , 33 sumatriptan SUMYCIN sunitinib SUPRAX SUSTIVA SUTENT SYLATRON SYMLIN SYMMETREL , 30 SYNAGIS SYNALAR SYNJARDY SYNTHROID T TABLOID tacrolimus , 19, 20 TAFINLAR TAGAMET TALWIN NX TAMBOCOR TAMIFLU tamoxifen tamsulosin TANAFED TANAFED DMX SUSPENSION TANZEUM TAPAZOLE TARCEVA TARGRETIN TASIGNA TASMAR TBO-filgrastim TECFIDERA teduglutide TEGRETOL TEGRETOL-XR temazepam ALL CAPS = Brand-name drug Lower case = Generic drug TEMODAR TEMOVATE temozolomide TENEX tenofovir TENORETIC TENORMIN TERAZOL 3/ terazosin , 48 terbinafine , 29 terbutaline terconazole teriflunomide teriparatide inj TESSALON TESTOSTERONE 1% TOPICAL GEL testosterone cypionate testosterone enanthate testosterone gel topical tube, packet, and pump bottle 22 tetrabenazine tetracycline tetrahydrozoline/zinc sulfate. 37 thalidomide THALOMID THEO THEOCHRON theophylline THEOPHYLLINE theophylline extended-release THEOPHYLLINE EXT-REL.. 48 thioguanine thioridazine thiothixene THORAZINE THYROLAR tiagabine , 16 TIAZAC TIGAN TIKOSYN TILADE timolol timolol hemihydrate timolol maleate , 37 TIMOPTIC TIMOPTIC XE TINACTIN , 56 tipranavir TIVICAY tizanidine TOBRADEX tobramycin tobramycin/ dexamethasone tobramycin neb soln TOBREX TOFRANIL tolazamide tolbutamide TOLBUTAMIDE tolcapone TOLINASE tolnaftate , 56 tolterodine TOPAMAX TOPAMAX SPRINKLE topical antibacterials topiramate topiramate sprinkle caps...16 topotecan TOPROL XL TORADOL toremifene torsemide TOUJEO SOLOSTAR TRACLEER TRADJENTA tramadol trametinib TRANDATE tranexamic acid TRANXENE tranylcypromine trazodone TRENTAL tretinoin , 16 triamcinolone triamcinolone acetonide... 17

85 Index of s triamcinolone nasal spray.. 21 triamterene/ hydrochlorothiazide TRIAVIL triazolam TRI-FED X trifluoperazine trifluridine trihexyphenidyl TRILAFON TRILEPTAL TRILISATE , 33 TRILYTE trimethobenzamide trimethoprim TRIMETHOPRIM TRI-NORINYL TRIOTANN TRIOTANN PEDIATRIC SUSP 43 tripolidine/pseudoephedrine 47 TRIPROL/PSE SYP TRI RX TRIUMEQ TRI-VI-FLOR TRI-VI-SOL , 59 TRIVORA TRIZIVIR TROJAN trospium TRUSOPT TRUST NATALCARE PAK DHA TRUVADA T-STAT TUMS , 59 TUSSI 12D S TUSSI-12 S TUSSIN DM TWINJECT TYBOST TYKERB TYLENOL , 32, 58 TYLENOL W/CODEINE typhoid vaccine ALL CAPS = Brand-name drug Lower case = Generic drug U ULORIC ULTRAM umeclidinium inhalation umeclidinium/vilanterol UNI-HIST DRO UNIPHYL urea 40% UREA 40% CREAM AND LOTION URECHOLINE UREX UROCIT-K urofollitropin purified for inj UROXATRAL URSO ursodiol URSO FORTE UTIRA C V vaginal products valacyclovir VALCYTE valganciclovir VALIUM , 39 valproic acid VALTREX VANCOCIN HCL vancomycin HCl vandetanib varenicline VASERETIC VASOCIDIN VASOCLEAR VASOCLEAR A VASOSULF VASOTEC VECTICAL VEETIDS vemurafenib venlafaxine venlafaxine XR VENTOLIN HFA VEPESID verapamil , 14 verapamil extended-release..9 VESANOID VEXOL VFEND VICODIN VICODIN ES VICTOZA VI-DAYLIN VIDEX VIDEX EC vigabatrin oral solution VIMPAT VINATE AZ EX VINATE III VIRACEPT VIRAMUNE VIRAMUNE XR VIREAD VIROPTIC VISINE VISINE-AC vismodegib VISTARIL vitamin A vitamin ADC/fluoride/±iron drops vitamin B vitamin B VITAMIN B vitamin B complex/ vitamin C/folic acid vitamin C vitamin D VITAMIN D , 59 vitamins pediatric , 59 vitamins prenatal VITAPHIL VITUSSIN VIVOTIF BERNA VOLTAREN , 33, 37 VOLTAREN 1% TOPICAL GEL33 VOLTAREN XR voriconazole

86 Index of s vorinostat VOSOL HC OTIC VOSOL OTIC VOTRIENT VYVANSE W warfarin WELLBUTRIN WELLBUTRIN SR WELLBUTRIN XL WESTCORT WYTENSIN X XALATAN XALKORI XANAX XARELTO XELODA XENAZINE XOLAIR XOPENEX RESPULES XYLOCAINE , 21 XYZAL Z zaleplon ZANAFLEX zanamivir ZANTAC ZARONTIN ZAROXOLYN ZARXIO ZEBETA ZEBUTAL ZELBORAF ZENPEP ZERIT ZESTORETIC ZESTRIL ZETIA ZIAC ZIAGEN zidovudine ALL CAPS = Brand-name drug Lower case = Generic drug zinc ziprasidone ZITHROMAX ZOCOR ZOFRAN ZOFRAN ODT ZOHYDRO ER ZOLINZA ZOLOFT zolpidem ZONEGRAN zonisamide ZORTRESS ZOSTAVAX zoster vaccine live ZOVIA 1/ ZOVIA 1/ ZOVIRAX ZYDELIG ZYKADIA ZYLOPRIM ZYMAR ZYPREXA ZYRTEC , 56 ZYRTEC D , 56 ZYTIGA ZYVOX

87 Notes 79

88 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 I Take This Medicine For Directions Doctor Example: Lisinopril, 20mg 1 High blood pressure One tablet daily Dr. Johnson 80

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