Preferred Drug List (PDL)

Transcription

1 Preferred List (PDL) Mississippi CHIP Effective Date: 10/15/ 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 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 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 substitution on the majority of products when a equivalent is available. Generic substitution is a pharmacy action whereby a equivalent is dispensed rather than the name product. The PDL indicates availability in the column. If a name drug is medically necessary, please submit a prior authorization request. The UnitedHealthcare MAC list sets a ceiling price for the reimbursement of certain multisource prescription drugs. This price will typically cover the acquisition of most s but not ed versions of the same drug. The products selected for inclusion on the MAC list are commonly prescribed and dispensed and have usually gone through the FDA s review and approval process. An important consideration for substitution is the knowledge that all approvals of drugs by the FDA since 1984, and many approvals prior to 1984, have a showing of bioequivalence between the versions and the reference product. To gain FDA approval: 1. The drug must contain the same active ingredient(s), be the same strength and the same dosage form as the name product. 2. The FDA has given the an A rating compared to the ed product indicating bioequivalence, and has determined the is therapeutically equivalent UHC1004a ii

5 to the reference. The ratings of drugs are available by referring to the FDA reference, Approved Products with Therapeutic Equivalence Evaluations (Orange Book). When the above two criteria are met, a can be substituted with the full expectation that the substituted product will produce the same clinical effect and safety profile as the prescribed product. products that have a narrow therapeutic index (NTI) can also be guided by these principles. It is not necessary for the health care provider to approach any one therapeutic class of drug products (e.g., NTI drugs) differently from any other class, when there has been a determination of therapeutic equivalence by the FDA for the drug products under consideration. Also, additional clinical tests or examinations by the physician are not needed when a therapeutically equivalent drug product is substituted for the name product. There are now many name products that are repackaged or distributed under a label. The label version should always be considered therapeutically equivalent and substitutable for the source ed product. DRUG EFFICACY STUDY IMPLEMENTATION (DESI) DRUGS s first marketed between 1938 and 1962 were approved as safe but required no showing of effectiveness for FDA approval. Beginning in 1962, all new drugs were required to be both safe and effective before they could be marketed. This legislation also applied retroactively to all drugs approved as safe from The DESI program was established by the FDA to review the effectiveness of these pre-1962 drugs for their labeled indications, and a determination of fully effective was made for most of these products and they remain in the marketplace. A few DESI products remain classified as less than fully effective while awaiting final administrative disposition. Also, classified as DESI are many products listed as identical, similar, or related to actual DESI products. UnitedHealthcare s PDL does not cover DESI less than fully effective drug products. PLAN EXCLUSIONS The following drug categories are excluded from coverage under the outpatient pharmacy benefit and are not part of the UnitedHealthcare PDL. UHC1004a DESI drugs Antiobesity agents Experimental / research drugs Cosmetic drugs Immunization agents Nutritional / diet supplements Blood and blood plasma products Agents used to promote fertility Agents used for erectile dysfunction Agents used for cosmetic hair growth iii 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, Easivent MDI spacer, preferred diabetes test strips, peak flow meters (Astech, Assess, Peak Air s, max two per year), vaporizer (limit of 1 per 3 years), humidifier (limit of 1 per 3 years) Mirena DAYS SUPPLY DISPENSING LIMITATIONS UnitedHealthcare members may receive up to a one month supply of a specific medication per prescription order or prescription refill. A medication may be reordered or refilled when eighty-five percent (85%) of the medication has been utilized. If a claim is submitted before 85% of the medication has been used, based on the original day supply submitted on the claim, the claim will reject with a "refill too soon" message. MANDATORY GENERIC SUBSTITUTION The UnitedHealthcare PDL requires mandatory substitution on the vast majority of products when a equivalent is available; however, name drugs may be covered in certain situations by requesting a prior authorization. The UnitedHealthcare PDL prior authorization (PA) list does not include ed items where a equivalent is covered. PRIOR AUTHORIZATION OF NON-PDL MEDICATIONS The drugs in the UnitedHealthcare PDL have been selected to provide the most clinically appropriate and cost-effective medications for patients who have their drug benefit administered through UnitedHealthcare. It is also recognized that there may be occasions where an unlisted drug is desired for the proper medical management of a specific patient. In those infrequent instances, the prior authorization process reviews requests for unlisted medications the physician may consider medically necessary for patient management. Requests for these exceptions should be 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. All requests will be responded to within 24 hours of receipt.

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 all requests within 24 hours, 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 Advair Amerge First-Line Agent(s) 1) 30 day trial of one inhaled corticosteroid (e.g. Flovent, Qvar, Asmanex, Pulmicort, Azmacort) OR 2) 60 day trial of a long-acting beta2- agonist (e.g. Foradil, Serevent) OR 60 day trial of an orally inhaled anticholinergic agent (e.g. Spiriva, Atrovent, Combivent). Trial at a minimum dose of 50mg of sumatriptan tablets.

7 Aricept 23mg Banzel Breo Ellipta Cymbalta Ditropan XL 90 day trial of Aricept 10mg daily 30 day trial of two of the following: lamotrigine, divalproex, or topiramate. (1) 60 day trial of a long-acting beta2- agonist (e.g. Foradil, Serevent). OR (2) 60 day trial of an orally inhaled anticholinergic agent (e.g. Spiriva, Atrovent, Combivent). Minimum 2 month trial of 2 PDL antidepressants in the preceding 6 months 30 day trial of oxybutynin immediate release. DPP4 Inhibitors At least a 90 day trial of 1500mg/day of (Januvia, metformin. Janumet, Janumet XR, Onglyza, Kombiglyze) Dulera Elidel fenofibrate 30 day trial of inhaled corticosteroid 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. fentanyl patches 30 day trial of at least 200mg per day of morphine sulfate ER. Gabitril Intuniv levocetirizine 30 day trial of two of the following: lamotrigine, topiramate, carbamazepine, divalproex, or phenytoin. Step therapy only applies to members 12 years of age and older. Members less than 12 require prior authorization. 30 day trial of one of the following: methylphenidate, methylphenidate SR, Concerta, amphetamine salts, Adderall XR, dextroamphetamine, Vyvanse, or dextroamphetamine SA. 30 day trial of loratadine and cetirizine. Opana ER Optivar 30 day trial of at least 200mg per day of morphine sulfate ER. 14 day trial of ketotifen within previous 90 days required first. lansoprazole/ 30 day trial of omeprazole 40mg and Prevacid OTC pantoprazole 40mg within previous 180 days is required first 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 Strattera Symbicort tolterodine Minimum age of 16. Trial of two different topical corticosteroids. Trial of one drug from the following classes: beta blockers, calcium channel blockers, long acting nitrates 8 week trial of calcium acetate 30 day trial of one of the following: methylphenidate, methylphenidate SR, Concerta, amphetamine salts, Adderall XR, dextroamphetamine, Vyvanse, or dextroamphetamine SA. 1) 30 day trial of one inhaled corticosteroid (e.g. Flovent, Qvar, Asmanex, Pulmicort, Azmacort) OR 2) 60 day trial of a long-acting beta2- agonist (e.g. Foradil, Serevent) OR 60 day trial of an orally inhaled anticholinergic agent (e.g. Spiriva, Atrovent, Combivent). 30 day trial of oxybutynin immediate release. Step Therapy only applies to members less than 65 years of age. Maxalt/MLT Nucynta ER Onfi UHC1004a Trial at a minimum dose of 50mg of sumatriptan tablets. 30 day trial of at least 200mg per day of morphine sulfate ER. 30 day trial of two of the following: lamotrigine, divalproex, or topiramate. v trospium 30 day trial of oxybutynin immediate release. Step Therapy only applies to members less than 65 years of age. TZD s (Actos, At least a 90 day trial of 1500mg/day of ActosPlusMet, metformin ActoPlusMet XR Duetact)

8 Uloric Vancocin Vimpat Vytorin 8 week trial of up to 600mg of allopurinol required first. One fill of metronidazole tabs or caps 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. 90 day trial of simvastatin 40mg, simvastatin 80mg or atorvastatin within previous 180 days is required first. Xopenex Respules 30 day trial of Albuterol.083% or.5% respules. 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. LEGEND # Only the dosage forms/strengths of the name products noted are on the PDL OTC over-the-counter delayed-rel delayed-release (also known as enteric coated) EC enteric-coated ext-rel extended-release (also known as sustainedrelease) PA Prior Authorization required QL Quantity Limits apply ST SP Step Therapy, see pages V-VI for details Specialty Pharmaceuticals, see pages IV-V for details NOTICE The information contained in this document is proprietary information. The information may not be copied in whole or in part without the written permission of UnitedHealthcare. All rights reserved. The drug names listed here are the registered and/or unregistered trademarks of third-party pharmaceutical companies unrelated to and unaffiliated with UnitedHealthcare. These trademarked names are included here for informational purposes only and are not intended to imply or suggest any affiliation between UnitedHealthcare and such third-party pharmaceutical companies. If viewing this PDL via the Internet, please be advised that the PDL is updated periodically and changes may appear prior to their effective date to allow for notification. EDITOR Your comments and suggestions regarding the UnitedHealthcare PDL are encouraged. Your input is vital to this PDL s continued success. All responses will be reviewed and considered. Please send your comments to: UnitedHealthcare by UnitedHealthcare Director of Pharmacy Services Unison Plaza 1001 Brinton Road Pittsburgh, PA Phone: UHC1004a vi

9 Table of Contents Antineoplastics & Immunosuppressants 4 Hormonal Antineoplastic Agents....4 Oral Agents...4 Immunosuppressants...5 Immunomodulators...6 Interferons...6 Miscellaneous...6 Blood Modifiers - Anticoagulants Oral...6 Blood Cell Formation...6 Platelet Synthesis Inhibitor....7 Miscellaneous...7 Platelet Aggregation Inhibitors...7 Cardiovascular Agents...7 Ace Inhibitors...7 Ace Inhibitor/Diuretic Combinations....7 Adrenolytics, Central... 8 Alpha Blockers...8 Angiotensin II Receptor Blockers (Antagonists)....8 Angiotensin II Receptor Blocker Combinations...8 Antiarrhythmics And Cardiac Glycosides....8 Beta Blockers And Beta Blocker/ Diuretic Combinations...8 Calcium Channel Blockers...9 Diuretics....9 Nitrates...10 Lipid Lowering Agents...10 Miscellaneous...11 Central Nervous System Alzheimer s Disease...11 Analgesics...12 Abortive Therapy Prophylactic Therapy...14 Multiple Sclerosis...14 Myasthenia Gravis...14 Parkinson s Disease Seizures Miscellaneous...16 Dermatology Acne Vulgaris...16 Bacterial Infections Corticosteroids...16 Fungal Infections Psoriasis...18 Rosacea Scabies And Pediculosis...18 Viral Infections Miscellaneous...18 Ear, Nose & Throat Ear...19 Nose Miscellaneous Nasal Throat And Mouth Endocrinology...21 Adrenal Corticosteroids...21 Androgens Diabetes Mellitus...21 Growth Stimulating Agents...23 Osteoporosis Thyroid Disease...23 Miscellaneous...23 Gastrointestinal...24 Diarrhea...24 Emesis...24 Gastroesophageal reflux disease (gerd)/ peptic ulcers Gastrointestinal Spasm...25 Inflammatory Bowel Disease...25 Pancreatic Enzymes...25 Laxatives...25 Probiotic Supplementation...26 Miscellaneous

10 Infectious Diseases Anthelmintics Antibacterials Antifungals Antivirals...28 Miscellaneous...29 Musculoskeletal Arthritis Gout Skeletal Muscle Relaxants...32 OB-GYN Contraceptives...32 Endometriosis...33 Hormone Therapy/Menopause...33 Vaginal Infections...34 Miscellaneous...34 Ophthalmic...34 Allergy...34 Anti-Inflammatories Glaucoma...35 Infections...36 Miscellaneous Ophthalmics Psychiatric...37 Alcohol Dete rrents Anxiety...37 Miscellaneous...37 Attention Deficit Hyperactivity Disorder (ADHD) Bipolar Disorder...38 Depression...38 Insomnia Narcotic Antagonists...39 Smoking Cessation...39 Psychoses...39 Miscellaneous...40 Respiratory s...40 Antitussives, Decongestants, Expectorants And Combinations...40 Asthma/COPD...45 Potassium...46 Potassium-Removing Agents...47 Vitamins And Minerals...47 Urological...50 Symptomatic Benign Prostatic Hypertrophy.50 Miscellaneous...50 Miscellaneous...51 Anaphylaxis...51 Cystic Fibrosis...51 Hereditary Angioedema...51 Hyperphosphatemia...51 Immune Thrombocytopenic Purpura...51 Medical Devices...52 Metabolic Modifiers...52 OTC MEDICATIONS Acne Antifungals Cough/Cold Allergy...53 Atopic Dermatitis...54 Diabetes...54 Earwax Removal Products...54 Family Planning...54 First Aid...54 Gastrointestinal Lice Products...55 Motion Sickness...55 Ophthalmics...55 Pain...55 Smoking Cessation Products...55 Vitamins/Minerals...55 Warts...56 Miscellaneous...56 Index of s

11 Generic Name Brand Name Antineoplastics & Immunosuppressants Hormonal Antineoplastic Agents Androgen Biosynthesis Inhibitors abiraterone ZYTIGA PA, SP Antiandrogens bicalutamide CASODEX flutamide EULEXIN Antiestrogens tamoxifen NOLVADEX toremifene FARESTON Aromatase Inhibitors anastrozole ARIMIDEX exemestane AROMASIN letrozole FEMARA Progestin megestrol acetate MEGACE Oral Agents Alkylating Agents busulfan MYLERAN chlorambucil LUEKERAN cyclophosphamide CYTOXAN estramustine phosphate sodium EMCYT lomustine CEENU melphalan ALKERAN temozolomide TEMODAR PA, SP Antimetabolites capecitabine XELODA PA, SP fludarabine Oforta PA, SP mercaptopurine PURINETHOL thioguanine THIOGUANINE Tyrosine Kinase Inhibitor afatinib GILOTRIF PA, SP axitinib INLYTA PA, SP 4

12 Generic Name Brand Name bosutinib BOSULIF PA, SP cabozantinib COMETRIQ PA, SP crizotinib XALKORI PA, SP dabrafenib TAFINLAR PA, SP dasatanib SPRYCEL PA, SP erlotinib tarceva PA, SP ibrutinib IMBRUVICA PA, SP imatinib mesylate GLEEVEC PA, QL, SP lapatinib ditosylate TYKERB PA, SP nilotinib TASIGNA PA, SP pazopanib Votrient PA, SP ponatinib ICLUSIG PA, SP regorafenib STIVARGA PA, SP ruxolitinib JAKAFI PA, SP sorafenib NEXAVAR PA, SP sunitinib SUTENT PA, SP trametinib MEKINIST PA, SP vandetanib Vandetanib PA, SP vemurafenib ZELBORAF PA, SP Miscellaneous altretamine hexalen alitretinoin 1% gel PANRETIN PA bexarotene caps and topical gel TARGRETIN PA etoposide VEPESID everolimus afinitor AFINITOR DISPERZ PA, SP hydroxyurea droxia HYDREA mitotane LYSODREN octreotide Sandostatin pasireotide SIGNIFOR PA, SP procarbazine MATULANE tretinoin VESANOID caps vismodegib ERIVEDGE PA, SP vorinostat ZOLINZA PA, SP Immunosuppressants Antimetabolites azathioprine IMURAN 5

13 Generic Name Brand Name mycophenolate mofetil CELLCEPT mycophenolate sodium MYFORTIC Calcineurin Inhibitors cyclosporine SANDIMMUNE cyclosporine, modified GENGRAF NEORAL tacrolimus HECORIA PROGRAF Other everolimus Zortress Rapamycin Derivative sirolimus RAPAMUNE Immunomodulators Interferons interferon alfa-2a PA, SP interferon alfa-2b INTRON A PA, SP Other lenalidomide REVLIMID PA, SP Miscellaneous cysteamine bitartrate CYSTAGON leuprolide Lupron Lupron Depot LUPRON DEPOT PA, SP 6-MONTH Lupron Depot-PED pomalidomide POMALYST PA, SP Blood Modifiers - Anticoagulants Oral warfarin COUMADIN Blood Cell Formation darbepoetin alfa ARANESP PA, SP epoetin alfa EPOGEN PROCRIT PA, SP filgrastim NEUPOGEN PA, SP oprelvekin neumega SP pegfilgrastim NEULASTA PA, SP sargramostim leukine PA, SP 6

14 Generic Name Brand Name Platelet Synthesis Inhibitor anagrelide AGRYLIN Miscellaneous aminocaproic acid AMICAR 500 mg tabs only apixaban ELIQUIS PA cilostazol PLETAL deferasirox EXJADE PA, SP enoxaparin LOVENOX PA, QL, SP, SP and PA only applies for quantities greater than 14 days heparin HEPARIN pentoxifylline ext-rel TRENTAL plerixafor mozobil PA, SP rivaroxaban XARELTO PA Platelet Aggregation Inhibitors aspirin BAYER OTC ECOTRIN clopidogrel PLAVIX dipyridamole PERSANTINE Cardiovascular Agents Ace Inhibitors benazepril LOTENSIN captopril CAPOTEN enalapril VASOTEC enalapril oral soln EPANED Applies to 300 mg tab only, QL Members 8 years of age will require prior authorization. fosinopril MONOPRIL QL lisinopril ZESTRIL QL quinapril ACCUPRIL QL Ace Inhibitor/Diuretic Combinations benazepril/ hydrochlorothiazide captopril/ hydrochlorothiazide enalapril/ hydrochlorothiazide LOTENSIN HCT CAPOZIDE VASERETIC 7

15 Generic Name Brand Name fosinopril/ hydrochlorothiazide MONOPRIL-HCT QL lisinopril/ hydrochlorothiazide ZESTORETIC QL quinapril/ hydrochlorothiazide ACCURETIC QL Adrenolytics, Central clonidine CATAPRES guanfacine TENEX Alpha Blockers doxazosin CARDURA prazosin MINIPRESS terazosin HYTRIN Angiotensin II Receptor Blockers (Antagonists) losartan COZAAR QL Angiotensin II Receptor Blocker Combinations losartan/hctz HYZAAR QL Antiarrhythmics And Cardiac Glycosides amiodarone tabs CORDARONE 200 mg and 400 mg digoxin LANOXIN digoxin LANOXICAPS disopyramide NORPACE disopyramide ext-rel NORPACE CR dofetilide tikosyn flecainide tambocor mexiletine MEXITIL moricizine ETHMOZINE procainamide PRONESTYL procainamide ext-rel PROCANBID procainamide ext-rel PROCAINAMIDE EXT-REL propafenone RYTHMOL IR only QUINIDINE GLUCONATE quinidine gluconate ext-rel EXT-REL quinidine sulfate QUINIDINE SULFATE quinidine sulfate ext-rel QUINIDINE SULFATE EXT-REL sotalol BETAPACE Beta Blockers And Beta Blocker/Diuretic Combinations acebutalol SECTRAL atenolol TENORMIN atenolol/chlorthalidone TENORETIC 8

16 Generic Name Brand Name bisoprolol ZEBETA bisoprolol/ hydrochlorothiazide ZIAC carvedilol COREG QL labetalol TRANDATE 50 mg and 100 mg only metoprolol LOPRESSOR metoprolol succinate TOPROL XL pindolol PINDOLOL propranolol INDERAL IR only propranolol/hctz INDERIDE timolol maleate tablets Calcium Channel Blockers Dihydropyridines amlodipine NORVASC QL felodipine ext-rel PLENDIL QL nicardipine CARDENE nifedipine PROCARDIA nifedipine ext-rel ADALAT CC QL PROCARDIA XL nimodipine NIMOTOP QL nimodipine oral soln NYMALIZE Nondihydropyridines diltiazem CARDIZEM diltiazem ext release CARDIZEM CD QL diltiazem sustained release CARDIZEM SR QL diltiazem ext-rel DILACOR XR TIAZAC QL verapamil CALAN verapamil ext-rel CALAN SR Applies to 120 mg only, QL Diuretics amiloride MIDAMOR amiloride/ MODURETIC hydrochlorothiazide bumetanide BUMEX chlorothiazide DIURIL chlorthalidone CHLORTHALIDONE furosemide LASIX hydrochlorothiazide Microzide 12.5 mg caps 9

17 Generic Name Brand Name hydrochlorothiazide HYDROCHLOROTHIA- ZIDE soln, tabs indapamide LOZOL metolazone ZAROXOLYN spironolactone ALDACTONE spironolactone/ hydrochlorothiazide ALDACTAZIDE triamterene/ hydrochlorothiazide DYAZIDE 37.5/25 triamterene/ hydrochlorothiazide MAXZIDE /25 triamterene/ hydrochlorothiazide DYAZIDE 50/25 triamterene/ hydrochlorothiazide MAXZIDE 75/50 Nitrates Oral isosorbide dinitrate ext-rel ISOSORBIDE DINITRATE ER isosorbide dinitrate ISORDIL isosorbide mononitrate ISMO isosorbide mononitrate ext-rel IMDUR nitroglycerin ext-rel Sublingual isosorbide dinitrate ISORDIL S.L. nitroglycerin NITROSTAT nitroglycerin NITROLINGUAL Transdermal nitroglycerin NITRO-BID oint nitroglycerin NITREK NITRO-DUR transdermal, QL niacin NIACOR niacin ext-rel NIASPAN Lipid Lowering Agents Bile Acid Resin cholestyramine QUESTRAN Only the bulk products are covered (cans). Individual QUESTRAN-LIGHT packets are not covered. 10

18 Generic Name Brand Name Fibrates fenofibrate LOFIBRA ST gemfibrozil LOPID HMG-CoA Reductase Inhibitors and Combinations atorvastatin LIPITOR ezetimibe/simvastatin VYTORIN ST lovastatin MEVACOR QL pravastatin PRAVACHOL QL simvastatin ZOCOR QL simvastatin/niacin ER SIMCOR Miscellaneous ambrisentan LETAIRIS PA, SP bosentan TRACLEER PA, SP guanabenz WYTENSIN hydralazine APRESOLINE lomitapide JUXTAPID PA, SP methyldopa ALDOMET methyldopa/hctz aldoril midodrine PROAMATINE minoxidil LONITEN ranolazine RANEXA ST sildenafil REVATIO PA Central Nervous System Alzheimer s Disease donepezil ARICEPT donepezil ARICEPT galantamine RAZADYNE memantine NAMENDA rivastigmine EXELON 5 mg and 10 mg, QL, Members <18 years of age will require prior authorization. 23 mg, ST, Members <18 years of age will require prior authorization. QL, Members <18 years of age will require prior authorization. QL, Members <18 years of age will require prior authorization. QL, Members <18 years of age will require prior authorization. 11

19 Generic Name Brand Name Analgesics Analgesic, Other acetaminophen TYLENOL OTC aspirin/acetaminophen/ caffeine EXCEDRIN MIGRAINE mg, OTC tramadol Ultram QL Miscellaneous Non-Narcotic analgesics butalbital/acetaminophen PHRENILIN QL butalbital/acetaminophen SEDAPAP QL butalbital/acetaminophen/ FIORICET caffeine QL butalbital/aspirin/caffeine FIORINAL QL NSAIDS choline magnesium trisalicylate TRILISATE diclofenac sodium delayed release VOLTAREN etodolac LODINE IR Only fenoprofen NALFON 600 mg ibuprofen ADVIL tabs, chew tabs ibuprofen MOTRIN and susp, OTC tabs, chew tabs and susp indomethacin INDOCIN ketoprofen ORUDIS IR only ketorolac tromethamine Toradol QL meloxicam MOBIC QL naproxen NAPROSYN Not EC naproxen sodium ANAPROX oxaprozin DAYPRO piroxicam FELDENE sulindac CLINORIL Opioids Narcotic analgesics butalbital/apap/caff/cod FIORICET w/codeine QL butalbital/asa/caff/cod FIORINAL w/codeine QL butorphanol STADOL nasal spray, QL codeine sulfate QL codeine/acetaminophen TYLENOL w/codeine QL fentanyl transdermal DURAGESIC QL, ST hydrocodone/ acetaminophen NORCO 5/325, 7.5/325, 10/325, QL 12

20 Generic Name hydrocodone/ acetaminophen hydrocodone/ acetaminophen hydrocodone/ acetaminophen Brand Name LORTAB ELIXIR QL LORTAB 2.5/ /500, QL LORTAB 5/500 BANCAP HC, VICODIN 5/500 5/500, QL hydrocodone/ acetaminophen LORTAB 7.5/ /500, QL hydrocodone/ acetaminophen LORCET PLUS 7.5/650, QL hydrocodone/ acetaminophen VICODIN ES 7.5/750, QL hydrocodone/ acetaminophen LORTAB 10/500 10/500, QL hydrocodone/ acetaminophen LORCET 10/650 10/650, QL hydromorphone DILAUDID QL meperidine DEMEROL QL methadone tablets, PA, QL morphine MSIR QL morphine RMS QL morphine ext-rel MS CONTIN QL oxycodone ROXICODONE QL oxycodone ER OXYCONTIN QL, ST oxycodone/ PERCOCET 5/325, QL acetaminophen oxycodone/ acetaminophen TYLOX 5/500, QL oxycodone/aspirin PERCODAN QL oxycodone OXYFAST soln, QL oxymorphone ER OPANA ER QL, ST tapentadol ER NUCYNTA ER ST Abortive Therapy Ergotamine Derivatives dihydroergotamine D.H.E. 45 inj, QL dihydroergotamine MIGRANAL ergotamine/caffeine CAFERGOT Selective Serotonin Agonists naratriptan Amerge ST rizatriptan MAXALT/MAXALT MLT QL, ST 13

21 Generic Name Brand Name sumatriptan IMITREX QL sumatriptan IMITREX 4 mg and 6 mg INJ Prophylactic Therapy amitriptyline ELAVIL divalproex sodium cap sprinkle DEPAKOTE SPRINKLE 4 mg and 6 mg inj Members 8 years of age will require prior authorization. divalproex sodium delayed-rel DEPAKOTE Minimum age 2 propranolol INDERAL IR only verapamil CALAN Multiple Sclerosis dimethyl fumarate TECFIDERA PA, SP fingolimod GILENYA PA, SP glatiramer acetate COPAXONE 20 mg only, PA,QL, SP interferon beta-1a AVONEX/AVONEX PEN PA,QL, SP interferon beta-1a REBIF PA,QL, SP teriflunomide AUBAGIO PA, SP Myasthenia Gravis pyridostigmine MESTINON pyridostigmine ext-rel MESTINON TIMESPAN Parkinson s Disease amantadine SYMMETREL except tabs benztropine COGENTIN biperiden AKINETON bromocriptine PARLODEL carbidopa/levodopa SINEMET carbidopa/levodopa SINEMET CR ext-rel entacapone COMTAN pramipexole MIRAPEX ropinirole REQUIP selegiline ELDEPRYL tabs tolcapone TASMAR trihexyphenidyl ARTANE Seizures carbamazepine TEGRETOL carbamazepine ext-rel CARBATROL TEGRETOL-XR 14

22 Generic Name Brand Name clobazam ONFI ST clonazepam KLONOPIN tabs diazepam DIASTAT ACUDIAL rectal gel, QL Members 8 years of divalproex sodium DEPAKOTE SPRINKLE age will require prior cap sprinkle authorization. divalproex sodium delayed-rel DEPAKOTE Minimum age 2 ethosuximide ZARONTIN exogabine POTIGA Age Limits Apply, ST felbamate FELBATOL felbamate oral susp FELBATOL ORAL SUSP Members 8 years of age will require prior authorization. gabapentin NEURONTIN caps and tabs only lacosamide vimpat Age Limits Apply, ST lamotrigine LAMICTAL QL lamotrigine chew dispersable tab LAMICTAL CD CHEW TAB levetiracetam Keppra methsuximide CELONTIN Members 8 years of age will require prior authorization. QL, Maximum age of 9 for solution oxcarbazepine TRILEPTAL QL, Maximum age of 9 for suspension phenobarbital PHENOBARBITAL phenytoin DILANTIN INFATABS phenytoin sodium DILANTIN extended PHENYTEK pregabalin LYR ICA PA pregabalin LYRICA SOLUTION oral solution, PA primidone MYSOLINE rufinamide Banzel tablets only, QL, ST tiagabine GABITRIL Age Limits Apply, ST topiramate TOPAMAX QL topiramate sprinkle caps TOPAMAX SPRINKLE QL, Members 8 years of age will require prior authorization. valproic acid DEPAKENE vigabatrin oral solution SABRIL SOLUTION PA, SP zonisamide ZONEGRAN QL 15

23 Generic Name Brand Name Miscellaneous tetrabenazine XENAZINE PA, SP Dermatology Acne Vulgaris Oral isotretinoin ACCUTANE PA Topical azelaic acid FINACEA benzoyl peroxide BENZAC AC clindamycin CLEOCIN T gel clindamycin CLEOCIN T lotion clindamycin CLEOCIN T soln erythromycin/benzoyl peroxide BENZAMYCIN erythromycin ERYGEL gel 2% erythromycin T-STAT soln sulfacetamide SULFACET-R sulfacetamide/sulfur PLEXION tretinoin AVITA RETIN-A Max age 20 Bacterial Infections bacitracin BACITRACIN OTC gentamicin GENTAK mupirocin BACTROBAN ointment, 22 gram tube only neomycin/polymyxin B/ bacitracin NEOSPORIN OTC silver sulfadiazine SILVADENE Corticosteroids Low Potency alclometasone ACLOVATE 0.05% crm/oint fluocinolone acetonide DERMA-SMOOTHE OIL/FS oil 0.01% fluocinolone acetonide SYNALAR soln/crm 0.01% hydrocortisone HYTONE crm 2.5% hydrocortisone HYTONE 1% lotion hydrocortisone CORTIZONE crm, oint, lot OTC Medium Potency betamethasone val. BETA-VAL crm/oint/lotion 0.1% 16

24 Generic Name Brand Name fluocinolone acetonide DERMA-SMOOTHE OIL/ FS oil 0.01% fluocinolone acetonide SYNALAR crm, oint 0.025% flurandrenolide CORDRAN tape fluticasone propionate CUTIVATE crm 0.05%, oint 0.005% hydrocortisone butyrate LOCOID crm/oint/soln 0.1% mometasone furoate ELOCON crm 0.1% mometasone furoate ELOCON oint 0.1% prednicarbate DERMATOP crm/oint 0.1% triamcinolone acetonide KENALOG crm/lot/oint 0.025% triamcinolone acetonide KENALOG crm/oint/lotion 0.1% High Potency betamethasone augmented dip DIPROLENE AF crm 0.05% betamethasone augmented dip DIPROLENE lotion 0.05% betamethasone dipropionate crm/lotion/oint 0.05% fluocinonide LIDEX crm/oint/gel 0.05% fluocinonide emulsified base LIDEX E crm 0.05% triamcinolone acetonide KENALOG crm 0.5% Very High Potency betamethasone dip augmented DIPROLENE gel 0.05% betamethasone dip augmented DIPROLENE oint 0.05% clobetasol propionate TEMOVATE crm/gel/oint/soln 0.05% Fungal Infections ciclopirox PENLAC SOLUTION 8% clotrimazole MYCELEX clotrimazole LOTRIMIN AF OTC clotrimazole with betamethasone Lotrisone econazole SPECTAZOLE ketoconazole NIZORAL miconazole MICATIN OTC miconazole MONISTAT-DERM miconazole DESENEX POWDER 2% powder nystatin MYCOSTATIN terbinafine LAMISIL AT OTC 17

25 Generic Name Brand Name tolnaftate TINACTIN OTC Psoriasis acitretin Soriatane oral caps, PA calcipotriene DOVONEX calcitriol vectical methoxsalen OXSORALEN-ULTRA Rosacea brimonidine Mirvaso PA metronidazole METROCREAM METROGEL METROLOTION Scabies And Pediculosis crotamiton EURAX malathion OVIDE permethrin NIX CREME RINSE 1%, OTC permethrin ELIMITE 5%, QL pyrethrins/piperonyl but. RID SHAMPOO/ BUTOXIDE SHAMPOO 4% OTC Viral Infections podofilox CONDYLOX SOL sol salicylic acid 17%/ collodion DUOFILM OTC Miscellaneous aluminum acetate soln/cream, OTC aluminum chloride hexahydrate HYpercare 20% ammonium lactate LAC-HYDRIN 12% calamine lotion/ointment, OTC chloroxine CAPITROL fluorouracil EFUDEX fluorouracil Carac 0.5% cream fluorouracil FLUOROPLEX 1% cream hexachlorophene PHISOHEX hydrocortisone PROCTOCREAM-HC 2.5% cream ketoconazole NIZORAL SHAMPOO shampoo 2% lidocaine lidamantel 3% cream lidocaine XYLOCAINE jelly 2% lidocaine XYLOCAINE oint 5% lidocaine LMX-4 4% cream (15 gm tubes), QL lidocaine/prilocaine Emla 2.5% cream 18

26 Generic Name Brand Name nitroglycerin RECTIV 0.4% rectal ointment, PA pimecrolimus ELIDEL cream QL, ST, Step therapy is not required for members ages 2-11; not covered for members less than 2 years of age selenium sulfide SELSUN shampoo 2.5% tacrolimus Protopic 0.03% ointment 0.03% ST, Step therapy is not required for members ages 2-11; not covered for members less than 2 years of age tacrolimus Protopic 0.1% ointment 0.1%, ST (minimum age 16) urea 40% Urea 40% cream and lotion cream and lotion Ear, Nose & Throat Ear acetic acid VOSOL OTIC otic acetic acid/ aluminum acetate DOMEBORO OTIC acetic acid/ hydrocortisone VOSOL HC OTIC benzocaine/antipyrine BENZOTIC carbamide peroxide DEBROX 6.5%, OTC ciprofloxacin/ dexamethasone CIPRODEX PA neomycin/polymyxin B/ hydrocortisone CORTISPORIN OTIC otic ofloxacin FLOXIN OTIC Nose Antihistamines - First Generation, Sedating chlorpheniramine maleate CHLOR-TRIMETON SYRUP 2 mg/5 ml, OTC chlorpheniramine ext-rel CHLOR-TRIMETON 12 mg, OTC ALLERGY clemastine CLEMASTINE cyproheptadine CYPROHEPTADINE diphenhydramine BENADRYL OTC diphenhydramine 19

27 Generic Name Brand Name hydroxyzine HCL ATARAX hydroxyzine pamoate VISTARIL Antihistamines - Second Generation, Nonsedating cetirizine zyrtec OTC cetirizine chew tab ZYRTEC CHEWABLE TABLET OTC, Members 8 years of age will require prior authorization. levocetirizine XYZAL tabs, ST loratadine ALAVERT CLARITIN OTC Antihistamines - Others Antihistamine/Decongestant Combinations azelastine ASTELIN spray Antihistamine/Decongestant Combinations - First Generation chlorpheniramine/ phenylephrine/ pyrilamine TRIOTANN chlorpheniramine/pseudoephedrine ext-rel DECONAMINE SR triprolidine/ ACTIFED OTC pseudoephedrine Antihistamine/Decongestant Combinations - Second Generation cetirizine hydrochloride/ pseudoephedrine hydrochloride 12 hours extended-release ZYRTEC-D 5 mg-120 mg tablet ALAVERT-D loratadine/ alavert alrg pseudoephedrine OTC tab/sinus ext-rel allergy/cong Nasal Steroids fluticasone FLONASE triamcinolone nasal spray NASACORT ALLERGY 24 Hour OTC Miscellaneous Nasal Decongestants oxymetazoline AFRIN OTC phenylephrine NEO-SYNEPHRINE dimeatapp dro deconges OTC 20

28 Generic Name Brand Name Miscellaneous Nasal cromolyn sodium Nasalcrom OTC saline nasal spray 0.65% OCEAN NASAL SPRAY OTC Throat And Mouth artificial saliva OTC chlorhexidine gluconate PERIDEX lidocaine viscous XYLOCAINE pilocarpine SALAGEN triamcinolone KENALOG IN ORABASE paste Endocrinology Adrenal Corticosteroids cortisone acetate dexamethasone DECADRON fludrocortisone FLORINEF hydrocortisone CORTEF methylprednisolone MEDROL prednisolone prednisolone sodium ORAPRED phosphate PEDIAPRED prednisolone PRELONE syrup prednisone DELTASONE Androgens testosterone cypionate DEPO-TESTOSTERONE testosterone Androgel 1.62% gel, PA testosterone enanthate DELATESTRYL Vials only. Disposable syringes not covered. testosterone ANDRODERM patch 2 mg and 4 mg, PA Diabetes Mellitus Glucose Elevating Agents glucagon, human GLUCAGON QL recombinant Insulins insulin aspart NOVOLOG QL insulin aspart protamine 70%/ insulin aspart 30% NOVOLOG MIX 70/30 QL insulin detemir LEVEMIR QL insulin glargine LANTUS QL insulin human NOVOLIN R OTC, QL insulin human Relion R OTC, QL 21

29 Generic Name Brand Name insulin isophane HUMULIN N OTC, QL insulin isophane human NOVOLIN N OTC, QL insulin isophane human Relion N OTC, QL insulin isophane human 70%/regular 30% NOVOLIN 70/30 OTC, QL insulin isophane human 70%/regular 30% Relion 70/30 OTC, QL insulin lisopro pro/lispro HUMALOG MIX 50/50 QL insulin lisopro prot/lispro HUMALOG MIX 75/25 QL insulin isophane/regular HUMULIN 70/30 OTC, QL insulin lispro HUMALOG QL insulin regular HUMULIN R OTC, QL Monitoring- Strips and Kits/Diabetic Supplies Accu-Chek Test Strips (Aviva, AVIVA PLUS, Compact, SMARTVIEW) Accu-Chek Care Kit (Aviva, Compact Plus, Nano Smartview) One Touch Test Strips (Basic/Profile, SureStep, Ultra) One Touch Systems (Ultra, UltraSmart, Ultra2, UltraMini) QL for non-insulin dependent members: allow once daily testing QL for insulin dependent or pregnant members: allow testing up to 6 times per day QL for non-insulin dependent members: allow once daily testing QL for insulin dependent or pregnant members: allow testing up to 6 times per day Oral Agents acarbose precose chlorpropamide DIABINESE glimepiride AMARYL glipizide GLUCOTROL glipizide ext-rel GLUCOTROL XL glyburide MICRONASE glyburide, micronized GLYNASE metformin GLUCOPHAGE metformin ER GLUCOPHAGE ER metformin/glyburide GLUCOVANCE nateglinide STARLIX pioglitazone ACTOS QL, ST pioglitazone/metformin ER ACTOPLUS MET XR ST pioglitazone/metformin ACTOPLUSMET QL, ST pioglitazone/glimiperide DUETACT ST 22

30 Generic Name Brand Name repaglinide PRANDIN saxagliptin ONGLYZA ST saxagliptin/metformin KOMBIGLYZE ST sitagliptan JANUVIA QL, ST sitagliptan/metformin JANUMET QL, ST sitagliptan/metformin ER JANUMET XR QL, ST tolazamide TOLINASE tolbutamide tolbutamide Miscellaneous Antidiabetic Agents exenatide BYETTA PA liraglutide Victoza PA pramlintide SYMLIN PA Growth Stimulating Agents mecasermin INCRELEX PA, SP somatropin NORDITROPIN TEV-TROPIN PA, SP Osteoporosis alendronate FOSAMAX QL calcitonin-salmon MIACALCIN inj calcitonin-salmon MIACALCIN FORTICAL nasal spray, QL etidronate DIDRONEL raloxifene EVISTA teriparatide inj FORTEO PA, SP Thyroid Disease levothyroxine LEVOXYL levothyroxine SYNTHROID liothyronine CYTOMEL liotrix THYROLAR methimazole TAPAZOLE propylthiouracil PROPYLTHIOURACIL Miscellaneous bromocriptine PARLODEL desmopressin DDAVP QL methylergonovine METHERGINE mifeprstone KOR LYM PA, SP sapropterin KUVAN PA, SP sapropterin powder KUVAN POWDER FOR SOLUTION PA, SP 23

31 Generic Name Brand Name Gastrointestinal Diarrhea diphenoxylate/atropine LOMOTIL loperamide LOPERAMIDE loperamide IMODIUM A-D OTC Emesis aprepitant EMEND QL applies to 40 mg, 80 mg and mg dronabinol MARINOL PA meclizine ANTIVERT metoclopramide REGLAN ondansetron ZOFRAN ZOFRAN ODT QL prochlorperazine COMPAZINE promethazine PHENERGAN thiethylperazine TORECAN trimethobenzamide Tigan 300 mg caps Gastroesophageal reflux disease (gerd)/ peptic ulcers alginic acid/sodium bicarbonate OTC alumina/magnesia MAALOX OTC alumina/magnesia/ simethicone MYLANTA OTC cimetidine TAGAMET esomeprazole granules famotidine NEXIUM DELAYED RELEASE PACKET PEPCID PEPCID AC Members 2 years of age will require prior authorization. OTC Pepcid AC 10 mg and 20 mg also covered/ encouraged with written prescription. lansoprazole PREVACID PA lansoprazole del-rel PREVACID SOLUTAB omeprazole delayed-rel PRILOSEC orally disintegrating tabs, Members 2 years of age will require prior authorization. QL Capsules only, QL for 20 mg only pantoprazole Protonix ranitidine ZANTAC 150 mg tabs 24

32 Generic Name Brand Name sucralfate CARAFATE sulcralfate CARAFATE SUSPENSION Gastrointestinal Spasm dicyclomine BENTYL glycopyrrolate ROBINUL hyoscyamine sulfate LEVSIN hyoscyamine sulfate LEVSINEX suspension, Members 10 years of age up to 65 years of age will require prior authorization. ext-rel Inflammatory Bowel Disease balsalazide COLAZAL budesonide ENTOCORT EC PA hydrocortisone COLOCORT enema mesalamine APRISO LIALDA mesalamine ext-rel PENTASA mesalamine ROWASA enema only mesalamine supp CANASA olsalazine sodium DIPENTUM sulfasalazine AZULFIDINE sulfasalazine delayed-rel AZULFIDINE EN-TABS Pancreatic Enzymes pancrelipase Laxatives casanthranol-docusate sodium creon CREON 3000 UNIT zenpep OTC docusate calcium plus OTC docusate potasssium OTC lactulose ENULOSE glycerin GLYCERIN SUPPOSITORY suppository, OTC peg 3350/electrolytes COLYTE peg 3350/sodium bicarbonate/sodium chloride/potassium chloride NULYTELY 25

33 Generic Name Brand Name peg 3350/sodium bicarbonate/sodium TRILYTE chloride polyethylene glycol 3350 MIRALAX sennosides SENOKOT 8.6 mg tab, OTC Probiotic Supplementation acidophilus Acidophilus caps and tabs, OTC acidophilus Acidophilus XTRA OTC acidophilus/bifidus Acidophilus/ Bifidus Wafer OTC acidophilus/citrus pectin Acidophilus/ tabs, OTC Citrus Pectin acidophilus/pectin Acidophilus/Pectin caps, OTC lactobacillus Floranex chewable tablets, OTC probiotic product Probiotic Formula caps, OTC Miscellaneous atropine sulfate SAL-TROPINE bismuth subsalicylate + metronidazole + tetracycline HELIDAC methylnaltrexone RELISTOR PA misoprostol CYTOTEC teduglutide GATTEX PA, SP ursodiol Infectious Diseases URSO URSO FORTE ACTIGALL Anthelmintics albendazole ALBENZA PA ivermectin STROMECTOL praziquantel BILTRICIDE PA Antibacterials Cephalosporins - First Generation cefadroxil DURICEF cephalexin KEFLEX tabs are not covered Cephalosporins - Second Generation cefaclor CECLOR cefprozil CEFZIL cefuroxime axetil CEFTIN 26

34 Generic Name Brand Name Cephalosporins - Third Generation cefdinir OMNICEF cefixime SUPRAX 400 mg tabs only, QL Fluoroquinolones ciprofloxacin CIPRO levofloxacin Levaquin tablets only ofloxacin FLOXIN tabs Macrolides azithromycin ZITHROMAX QL clarithromycin Biaxin clarithromycin ER BIAXIN XL erythromycin ethylsuccinate E.E.S. erythromycin delayed-rel ERYC erythromycin delayed-rel ERY-TAB erythromycin stearate ERYTHROCIN erythromycin/sulfisoxazole PEDIAZOLE Penicillins amoxicillin AMOXIcillin capsules Except 500 mg and 875 mg and chewables film-coated tabs. amoxicillin/clavulanate AUGMENTIN amoxicillin/clavulanate AUGMENTIN ES-600 amoxicillin Amoxil Susp suspension ampicillin PRINCIPEN dicloxacillin DICLOXACILLIN penicillin VK VEETIDS Sulfonamides sulfisoxazole sulfamethoxazole/ BACTRIM trimethoprim, DS BACTRIM DS Tetracyclines doxycycline monohydrate DOXYCYCLINE MONOHY- DRATE minocycline MINOCIN capsules, except 75 mg tetracycline SUMYCIN Miscellaneous vancomycin HCl VANCOCIN HCl cap, ST Antifungals clotrimazole MYCELEX troches fluconazole DIFLUCAN QL 27

35 Generic Name Brand Name griseofulvin ultramicrosize GRIS-PEG griseofulvin microsize GRIFULVIN V itraconazole Sporanox PA, QL ketoconazole NIZORAL nystatin MYCOSTATIN terbinafine LAMISIL QL Antivirals Cytomegalovirus Treatment ganciclovir CYTOVENE valganciclovir VALCYTE tabs only Entry/Fusion Inhibitors enfuvirtide Fuzeon Kit SP Hepatitis Treatment adefovir HEPSERA entecavir BARACLUDE interferon alfa-2b INTRON A PA, SP interferon alfacon-1 INFERGEN PA, SP lamivudine Epivir HBV peginterferon alfa-2a PEGASYS PA, SP peginterferon alfa-2a PEGASYS PROCLICK PA, SP peginterferon alfa-2b SYLATRON PA, SP ribavirin REBETOL/COPEGUS 200 mg caps and tabs only, PA, SP simeprevir OLYSIO PA, SP sofosbuvir SOVALDI PA, SP Herpes Treatment acyclovir Zovirax valacyclovir Valtrex Influenza Treatment amantadine SYMMETREL except tabs oseltamivir TAMIFLU QL rimantadine FLUMADINE zanamivir RELENZA QL Non-Nucleoside Reverse Transcriptase Inhibitors delavirdine RESCRIPTOR efavirenz SUSTIVA nevirapine VIRAMUNE nevirapine ER Viramune XR rilpivirine EDURANT 28

36 Generic Name Brand Name Nucleoside Analogues Nucleoside Reverse-Transcriptase Inhibitors/and Combinations abacavir ZIAGEN abacavir/lamivudine EPZICOM abacavir/lamivudine/ zidovudine TRIZIVIR didanosine VIDEX didanosine delayed-rel VIDEX EC emtricitabine EMTRIVA emtricitabine/rilpivirine/ tenofovir COMPLERA lamivudine EPIVIR lamivudine/zidovudine COMBIVIR stavudine ZERIT zalcitabine HIVID zidovudine RETROVIR Nucleoside/Nucleotide Reverse-Transcriptase Inhibitor Combination cobicistat/elvitegravir/ STRIBILD emtricitabine/tenofovir PA efavirenz/emtricitabine/ tenofovir ATRIPLA emtricitabine/tenofovir TRUVADA PA Nucleotide Analogues Nucleotide Reverse-Transcriptase Inhibitor tenofovir VIREAD Protease Inhibitors amprenavir AGENERASE atazanavir REYATAZ darunavir PREZISTA fosamprenavir LEXIVA indinavir CRIXIVAN lopinavir/ritonavir KALETRA nelfinavir VIRACEPT ritonavir NORVIR saquinavir FORTOVASE saquinavir mesylate INVIRASE tipranavir APTIVUS Miscellaneous atovaquone MEPRON PA bedaquiline SIRTURO PA chloroquine phosphate ARALEN clindamycin CLEOCIN 150 mg and 300 mg only 29

37 Generic Name Brand Name dapsone DAPSONE dolutegravir TIVICAY ethambutol MYAMBUTOL etravirine INTELENCE hydroxychloroquine PLAQUENIL isoniazid ISONIAZID linezolid ZYVOX PA maraviroc Selzentry mefloquine LARIAM metronidazole FLAGYL tabs only neomycin sulfate nitazoxanide tablet ALINIA PA nitazoxanide suspension ALINIA SUSPENSION nitrofurantoin ext-rel MACROBID nitrofurantoin susp FURADANTIN SUSP 25 mg/5 ml Members 8 years of age will require prior authorization. Members 8 years of age will require prior authorization. nitrofurantoin macrocrystals MACRODANTIN nitrofurantoin macrocrystals MACRODANTIN 25 mg palivizumab Synagis PA paromomycin HUMATIN povidone-iodine OTC primaquine pyrimethamine Daraprim pyrazinamide PYRAZINAMIDE raltegravir ISENTRESS raltegravir ISENTRESS CHEWABLE chewable tablet rifabutin MYCOBUTIN rifampin RIFADIN trimethoprim TRIMETHOPRIM tabs only vancomycin VANCOCIN ST Musculoskeletal Arthritis Disease Modifying Anti-Rheumatic s adalimumab HUMIRA PA, SP anakinra KINERET PA, SP 30

38 Generic Name Brand Name auranofin RIDAURA azathioprine IMURAN etanercept ENBREL PA, SP hydroxychloroquine PLAQUENIL leflunomide ARAVA methotrexate penicillamine CUPRIMINE sulfasalazine AZULFIDINE sulfasalazine delayed-rel AZULFIDINE EN-TABS NSAIDs and Other Analgesics acetaminophen TYLENOL OTC aspirin BAYER OTC ECOTRIN capsaicin OTC celecoxib Celebrex PA, QL choline magnesium trisalicylate TRILISATE diclofenac 1% gel VOLTAREN 1% TOPICAL GEL PA diclofenac potassium CATAFLAM diclofenac sodium delayed release VOLTAREN diclofenac sodium extended release VOLTAREN XR etodolac LODINE IR only fenoprofen NALFON 600 mg ibuprofen ADVIL tabs, chew tabs and susp, OTC ibuprofen MOTRIN tabs, chew tabs and susp indomethacin INDOCIN ketoprofen ORUDIS IR only meloxicam MOBIC QL naproxen NAPROSYN not EC naproxen sodium ANAPROX oxaprozin DAYPRO piroxicam FELDENE sulindac CLINORIL Gout allopurinol ZYLOPRIM colchicine COLCRYS 31

39 Generic Name Brand Name febuxostat Uloric ST probenecid PROBENECID Skeletal Muscle Relaxants Muscle Spasm chlorzoxazone PARAFON FORTE DSC cyclobenzaprine FLEXERIL methocarbamol ROBAXIN orphenadrine ext-rel NORFLEX Spasticity baclofen BACLOFEN dantrolene DANTRIUM diazepam VALIUM QL tizanidine ZANAFLEX tabs only, QL OB-GYN Contraceptives Biphasic desogestrel/ee MIRCETTE QL norethindrone/ee ORTHO-NOVUM 10/11 QL Emergency Contraception levonorgestrel PLAN B QL levonorgestrel PLAN B ONE STEP 1.5 mg tab Extended Cycle levonorgestrel/ee SEASONALE QL Injectable medroxyprogesterone acetate DEPO-PROVERA QL Intravaginal etonogestrel/ee NUVARING ring, QL ortho diaphragm Ortho Coil Ortho Flat QL Ortho Flex Monophasic - 20 mcg estrogen levonorgestrel/ee ALESSE 0.1/20, QL norethindrone acetate/ee LOESTRIN 1/20 1/20, QL norethindrone acetate/ EE/iron LOESTRIN FE 1/20 1/20, QL Monophasic - 30 mcg estrogen desogestrel/ee ORTHO-CEPT 0.15/30, QL levonorgestrel/ee NORDETTE 0.15/30, QL 32

40 Generic Name Brand Name norethindrone acetate/ EE/iron LOESTRIN FE 1.5/30 1.5/30, QL norethindrone acetate/ee LOESTRIN 1.5/30 1.5/30, QL norgestrel/ee LO/OVRAL 0.3/30, QL Monophasic - 35 mcg estrogen ethynodiol diacetate/ee ZOVIA 1/35 1/35, QL norethindrone/ee BALZIVA 0.4/35, QL norethindrone/ee MODICON 0.5/35, QL norethindrone/ee ORTHO-NOVUM 1/35 1/35, QL norgestimate/ee ORTHO-CYCLEN 0.25/35, QL Monophasic - 50 mcg estrogen ethynodiol diacetate/ee ZOVIA 1/50 1/50, QL norethindrone/ee OVCON 50 1/50, QL norethindrone/me ORTHO-NOVUM 1/50 1/50, QL norgestrel/ee OVRAL 0.5/50, QL Progestin norethindrone ORTHO MICRONOR norgestrel OVRETTE Transdermal norelgestromin/ee ORTHO EVRA Triphasic desogestrel/ee CYCLESSA QL levonorgestrel/ee TRIVORA QL norethindrone acetate/ee/iron ESTROSTEP FE QL norethindrone/ee TRI-NORINYL QL norethindrone/ee ORTHO-NOVUM 7/7/7 QL norgestimate/ee ORTHO TRI-CYCLEN QL Endometriosis danazol DANOCRINE Gender edits apply: for female patients only. Hormone Therapy/Menopause Estrogens - Intravaginal estradiol ESTRACE CRM estrogens, conjugated PREMARIN crm Estrogens - Oral estradiol ESTRACE estrogens, conjugated, synthetic A CENESTIN 33

41 Generic Name Brand Name estrogens, conjugated, synthetic B Enjuvia estrogens, conjugated PREMARIN estropipate OGEN Estrogens - Transdermal estradiol CLIMARA QL Estrogen/Progestin estrogens, conjugated/ PREMPHASE medroxyprogesterone PREMPRO Progestins medroxyprogesterone acetate PROVERA norethindrone acetate AYGESTIN Vaginal Infections Oral fluconazole DIFLUCAN QL metronidazole FLAGYL tabs Vaginal clotrimazole GYNE-LOTRIMIN OTC clindamycin CLEOCIN crm clindamycin CLEOCIN supp metronidazole METROGEL-VAGINAL metrogel 1% miconazole MONISTAT OTC miconazole MONISTAT 3 terconazole TERAZOL 3/7 Miscellaneous methylergonovine METHERGINE tranexamic acid Lysteda PA Ophthalmic Allergy azelastine optivar ST cromolyn sodium CROLOM QL ketotifen ALAWAY OTC naphazoline HCL VASOCLEAR soln 0.02% naphazoline/antazoline naphazoline/glycerin CLEAR EYES REDNESS RELIEF naphazoline/zinc sulfate VASOCLEAR A 34

42 Generic Name Brand Name tetrahydrozoline /zinc sulfate VISINE-AC Anti-Inflammatories Nonsteroidal diclofenac sodium VOLTAREN flurbiprofen OCUFEN ketorolac ACULAR/ACULAR LS Steroidal dexamethasone sodium phosphate DEXASOL fluorometholone FML FML SOP 0.1% fluorometholone acetate FLAREX fluorometholone FML FORTE susp 0.25% prednisolone acetate PRED MILD 0.12% prednisolone acetate PRED FORTE 1% prednisolone phosphate INFLAMASE FORTE 1% rimexolone VEXOL Anti-Infective/Anti-Inflammatory Combinations gentamicin/prednisolone acetate PRED-G neomycin/polymyxin B/ dexamethasone MAXITROL neomycin/polymyxin B/ hydrocortisone CORTISPORIN sulfacetamide/pred. phos. VASOCIDIN 10%/0.25% tobramycin/ dexamethasone TOBRADEX Glaucoma Oral acetazolamide ACETAZOLAMIDE acetazolamide ext-rel DIAMOX SEQUELS methazolamide NEPTAZANE Topical - Sympathomimetics brimonidine ALPHAGAN P brimonidine BRIMONIDINE 0.2% Topical - Parasympathomimetics pilocarpine PILOPINE HS GEL pilocarpine ISOPTO CARPINE 35

43 Generic Name Brand Name Beta-blockers carteolol levobunolol betagan ophthalmic solution metipranolol OPTIPRANOLOL 0.3% ophthalmic solution timolol timoptic xe gel forming solution timolol hemihydrate BETIMOL timolol maleate TIMOPTIC Prostaglandins latanoprost XALATAN QL Carbonic Anhydrase Inhibitors dorzolamide TRUSOPT Carbonic Anhydrase Inhibitor/Beta-blocker Combination dorzolamide/ timolol maleate COSOPT Cholinesterase Inhibitor ecothiophate PHOSPHOLINE IODINE Mydriatics atropine ISOPTO ATROPINE cyclopentolate CYCLOGYL homatropine ISOPTO HOMATROPINE scopolamine ISOPTO HYOSCINE Infections Bacterial bacitracin ciprofloxacin CILOXAN erythromycin ERYTHROMYCIN gatifloxin ZYMAR PA gentamicin GENTAK neomycin/polymyxin B/ gramicidin NEOSPORIN ofloxacin OCUFLOX polymyxin B/bacitracin POLYSPORIN polymyxin B/trimethoprim POLYTRIM sulfacetamide/ phenylephrine VASOSULF sulfacetamide BLEPH-10 oint/soln tobramycin TOBREX Viral trifluridine VIROPTIC 36

44 Generic Name Brand Name Miscellaneous Ophthalmics cysteamine 0.44% ophthalmic solution CYSTARAN PA, SP sodium chloride hypertonic MURO 128 soln 5% Psychiatric Alcohol Dete rrents acamprosate campral disulfiram ANTABUSE naltrexone REVIA Anxiety Benzodiazepines alprazolam XANAX QL, IR only chlordiazepoxide LIBRIUM clonazepam KLONOPIN not wafers clorazepate TRANXENE diazepam VALIUM QL lorazepam ATIVAN QL oxazepam SERAX QL Miscellaneous buspirone BUSPAR fluvoxamine LUVOX Attention Deficit Hyperactivity Disorder (ADHD) amphetamine/dextroam- ADDERALL Age Limits Apply, QL phetamine mixed salts amphetamine/ dextroamphetamine mixed salts ext-rel ADDERALL XR (Brand Adderall XR is preferred) Age Limits Apply, QL atomoxetine STRATTERA Age Limits Apply, QL, ST dextroamphetamine DEXEDRINE Age Limits Apply, QL dextroamphetamine DEXtrostat Age Limits Apply, QL dextroamphetamine ext-rel DEXEDRINE SPANSULE Age Limits Apply, QL guanfacine Intuniv Age Limits Apply, ST lisdexamfetamine Vyvanse Age Limits Apply, QL methylphenidate RITALIN Age Limits Apply, tabs only, QL methylphenidate ext-rel CONCERTA Age Limits Apply, QL 37

45 Generic Name methylphenidate ext-rel Bipolar Disorder divalproex sodium cap sprinkle Brand Name MetaDaTe ER RITALIN-SR RITALIN LA DEPAKOTE SPRINKLE Age Limits Apply, QL Members 8 years of age will require prior authorization. divalproex sodium delayed-rel DEPAKOTE Minimum age 2 lithium carbonate LITHIUM CARBONATE lithium carbonate ext-rel ESKALITH CR LITHOBID Depression Monoamine Oxidase Inhibitor (MAOI) tranylcypromine PARNATE Selective Serotonin Reuptake Inhibitor (SSRIs) citalopram CELEXA QL escitalopram LEXAPRO fluoxetine PROZAC 10 mg and 20 mg caps and 20 mg soln only paroxetine PAXIL tablets sertraline ZOLOFT tablets, QL Serotonin Norepinephrine Reuptake Inhibitors (SNRIs) duloxetine CYMBALTA QL, ST venlafaxine EFFEXOR QL venlafaxine XR EFFEXOR XR QL Tricyclic Antidepressants (TCAs) amitriptyline ELAVIL tablets amoxapine desipramine NORPRAMIN doxepin SINEQUAN imipramine HCL TOFRANIL tablets nortriptyline PAMELOR Tricyclic Antidepressant/Phenothiazine combination amitriptyline/perphenazine TRIAVIL Miscellaneous Agents bupropion WELLBUTRIN bupropion ext-rel WELLBUTRIN SR QL bupropion ext-rel WELLBUTRIN XL 150 mg and 300 mg maprotiline LUDIOMIL 38

46 Generic Name Brand Name mirtazapine REMERON tabs (not soltabs) trazodone DESYREL 150 mg only Insomnia Benzodiazepines flurazepam DALMANE QL temazepam RESTORIL 15 mg and 30 mg only, QL triazolam HALCION QL Non-benzodiazepines chloral hydrate CHLORAL HYDRATE diphenhydramine NYTOL QUICK CAPS OTC zaleplon SONATA QL zolpidem AMBIEN QL Narcotic Antagonists buprenorphine SUBUTEX PA, QL buprenorphine/naloxone SUBOXONE 2 mg and 8 mg film only, PA, QL naltrexone REVIA Smoking Cessation nicotine Nicoderm CQ patches, QL nicotine NICOTROL INHALER NICOTROL NS QL nicotine polacrilex gum NICORETTE OTC QL nicotine polacrilex lozenge COMMITT OTC QL varenicline CHANTIX QL Psychoses Atypicals aripiprazole ER injection ABILIFY MAINTENA PA aripiprazole ABILIFY TABLETS Age Limit Applies, tablets, PA, QL, Certain daily doses require half tablet dosing: 5 mg once daily must be dosed as 10 mg tablet, ½ tab once daily 10 mg once daily must be dosed as 20 mg tablet, ½ tab once daily 15 mg once daily must be dosed as 30 mg tablet, ½ tab once daily 39

47 Generic Name Brand Name clozapine CLOZARIL Age Limit Applies, 100 mg only olanzapine ZYPREXA Age Limit Applies, tablets, QL paliperidone Invega Sustenna Age Limit Applies, PA, QL quetiapine SEROQUEL Age Limit Applies, QL risperidone RISPERDAL CONSTA Age Limit Applies, PA, QL risperidone RISPERDAL Age Limit Applies, QL, risperidone oral soln RISPERDAL SOLUTION (Not M-Tabs) QL, Members 8 years of age will require prior authorization. ziprasidone GEODON Age Limit Applies, QL Miscellaneous chlorpromazine THORAZINE dextromethorphan/ Nuedexta PA quinidine fluphenazine PROLIXIN fluphenazine decanoate PROLIXIN DECANOATE haloperidol HALDOL haloperidol decanoate HALDOL DECANOATE loxapine LOXITANE perphenazine TRILAFON pimozide ORAP thioridazine MELLARIL thiothixene NAVANE trifluoperazine STELAZINE Respiratory s Antitussives, Decongestants, Expectorants And Combinations benzonatate TESSALON brompheniramine & dimetapp cld elx/ phenylephrine allergy bromfenex pd cap brompheniramine/ pseudoephedrine dimetapp elx cld/alle uni-hist dro cardec syp 40

48 Generic Name brompheniramine/ pseudoephedrine /dextromethorphan brompheniramine/ pseudoephedrine /dextromethorphan brompheniramine/ pseudoephedrine/ dextromethorphan/ guaifenesin brompheniramine/ pseudoephedrine brompheniramine/ pseudoephedrine/ dextromethorphan brompheniramine/ pseudoephedrine carbetapentane/ chlorpheniramine/ ephedrine/ phenylephrine carbinoxamine/ pseudoephedrine chlorphen-pemethscopolamine chlorpheniramine/ dextromethorphan chlorpheniramine/ pseudoephedrine Brand Name bromaline dm elixir bromfed dm dallergy dm carbofed neo dm anaplex dm syrup histacol dm syrup ACCUHIST DROPS resperal-dm liquid ACCUHIST PDX DROPS liquid RONDEC SYRUP syrup RYNATUSS RONDEC DROPS liquid duradryl qv-allergy robitussin ped liq cgh/cold robitussin liq cgh/cld dimetapp syp cgh/cld coricidin tab cgh/cld HISTEX cpm/pse syrup 41

49 Generic Name chlorpheniramine/ phenylephrine chlorpheniramine/ phenylephrine chlorpheniramine maleate phenylephrine HCL chlorpheniramine tan/ phenylephrine tan chlorphen tan/ pseudoeph tan chlorphen tan/pyrilamine tan/pe tan chlorphen tan/ carbetapentane tan codeine/ chlorpheniramine/ pseudoephedrine codeine/guaifenesin codeine/guaifenesin/ pseudoephedrine codeine/promethazine codeine/promethazine/ phenylephrine dextromethorphanguaifenesin dextromethorphanguaifenesin dextromethorphan polistirex ext rel dextromethorphan/ guaifenesin Brand Name RONDEC DROPS cardec dro RONDEC SYRUP cardec syp Ed A-Hist tablets and liquid RYNATAN PEDIATRIC SUSP liquid syrup susp TANAFED susp TRIOTANN PEDIATRIC SUSP r-tannamine susp TUSSI-12 S susp DIHISTINE DH phenylhist liq dh GUIATUSS AC gg/codeine m-clear wc GUIATUSS DAC PROMETHAZINE w/codeine PROMETHAZINE VC w/codeine robitussin liq cgh/ cong QL QL QL liq mg/ 5 ml Duratuss dm elx soln mg/5 ml DELSYM OTC gg/dm cr MUCINEX DM ROBITUSSIN DM tussin dm OTC 42

50 Generic Name dextromethorphan hbr dextromethorphan/ brompheniramine/ pseudoephedrine dextromethorphan/ carbinoxamine/ pseudoephedrine dextromethorphan/ promethazine Brand Name ROBITUSSIN syp max-st robitussin ped syp BROMETANE DX syrup CARDEC-DM drops PHENERGAN DM promethazine syp dm guaifenesin ROBITUSSIN OTC guaifenesin ext-rel MUCINEX OTC guaifenesin ROBITUSSIN syp chst cng guaifenesin/pseudoephedrine ext rel guaifenesin/ pseudoephedrine guaifenesin/ pseudoephedrine ext rel guaifenesin/ pseudoephedrine/ dextromethorphan hydrocodone/chlorpheniramine/phenylephrine GUAIFED ROBITUSSIN PE pse/gg GUAIFEN PSE mucinex d gg/pse cr ROBITUSSIN CF HISTUSSIN HC hydrocodone/guaifenesin VITUSSIN hydrocodo/gg syp HYCODAN hydromet syp hydrocodone/homatropine hydrocodone/ tab homatrop loratadine & pseudoephedrine SR 24hr relief allergy/cong tab phenyleph/bromphen/ dextromethorphan/ allanhist syp pdx guaifenesin syrup 100 mg/5 ml syrup, OTC OTC tab mg 43

51 Generic Name Brand Name phenylephrine/ephed/ CPM w/ carbetapentane phenylephrine/guaifenesin phenylephrine/ brompheniramine/ dextromethorphan phenylephrine/ qual-tussin syp dc chlorpheniramine phenylephrine/ ATUSS DR chlorpheniramine/ dextromethorphan DE-CHLOR DM RONDEC DM DROPS phenylephrine/ cardec dm dro chlorpheniramine/ dextromethorphan robitussin liq cgh/alrg RONDEC DM phenylephrine/ statuss dm syp chlorpheniramine/ dextromethorphan cardec dm syp minutuss dr syp phenylephrine/chlorpheniramine/dihydrocodeine dihydro-pe syp phenylephrine/dextromethorphan dcon/cgh dimetapp dro phenylephrine/ robitussin liq dextromethorphan/ cgh/cld guaifenesin phenylephrine/hydrocodone/guaifenesin phenylephrine/pyrilamine/ dextromethorphan phenylephrine/pyrilamine w/hydrocodone phenylephrine tan/pyrilamine tan/ carbeta tan promethazine & phenylephrine RYNATUSS PEDIATRIC SUSP robitussin liq hd/chst qual-tussin syp dc codal-dm OTC syrup liquid syrup susp CODIMAL DH syrup TUSSI 12D S susp prometh vc syp /5 syrup mg/ 5 mg 44

52 Generic Name pseudoephedrine/ acetaminophen/ dextromethorphan pseudoephedrine/ chlorpheniramine/ dextromethorphan pseudoephedrine/ dextromethorphan/ guaifenesin pseudoephedrine/ iburprofen pseudoephedrine tan/ dexchlorphen tan/ DM tan pyrilamine tan/phenyleph tan tripolidine/ pseudoephedrine Brand Name mapap cold tab pediacare liq multi-sy robitussin liq ped nght multi symptom tab cold rlf child ibupro sus cold ibuorofen tab cold/sin TANAFED DMX SUSPENSION tri-fed x susp ryna-12 s susp triprol/pse syp aphedrid tab Asthma/COPD Inhalers - Beta Agonists albuterol sulfate VENTOLIN HFA QL formoterol FORADIL AEROLIZER inhalation caps salmeterol xinafoate SEREVENT DISKUS QL Inhalers - Corticosteroids beclomethasone QVAR QL budesonide PULMICORT FLEXHALER fluticasone HFA FLOVENT HFA QL fluticasone propionate FLOVENT Diskus QL mometasone Asmanex Twisthaler QL Inhalers -Corticosteroid/Beta Agonist Combinations budesonide/formoterol SYMBICORT ST fluticasone/salmeterol ADVAIR DISKUS ADVAIR HFA Advair INHAL AEROSOL fluticasone/vilanterol BREO ELLIPTA ST mometasone/formoterol Dulera ST QL, ST 45

53 Generic Name Brand Name Inhalers - Others aclidinium inhalation TUDORZA PRESSAIR cromolyn INTAL QL ipratropium HFA ATROVENT HFA ipratropium/albuterol COMBIVENT QL ipratropium/albuterol COMBIVENT RESPIMAT inhaler nedocromil TILADE omalizumab XOLAIR PA, SP tiotropium SPIRIVA Inhalers for Nebulization albuterol ACCUNEB 0.63 mg/3 ml and 1.25 mg /3 ml, for members less than 8 years of age. Members 8 years of age will require prior authorization. albuterol PROVENTIL soln 0.083%, 0.5% budesonide PULMICORT RESPULES susp, Members 5 years of age will require prior authorization. QL cromolyn INTAL soln, QL ipratropium ATROVENT soln, QL ipratropium/albuterol DUONEB soln levalbuterol HCl XOPENEX Respules QL, ST Oral Agents - Beta Agonists metaproterenol metaproterenol syrup terbutaline BRETHINE Oral Agents - Leukotriene Modifiers montelukast SINGULAIR QL Oral Agents - Theophylline theophylline ext-rel THEOPHYLLINE EXT-REL caps (12 hr) theophylline ext-rel THEOCHRON tabs theophylline THEOPHYLLINE liquid theophylline ext-rel THEO-24 caps theophylline ext-rel UNIPHYL tabs Potassium phosphorus K-PHOS NEUTRAL tabs potassium acid phosphate K-PHOS ORIGINAL 46

54 Generic Name Brand Name potassium bicarbonate/ potassium citrate K-LYTE tabs effervescent potassium chloride ext-rel MICRO-K 10 caps K-DUR 10 potassium chloride ext-rel K-DUR 20 KLOR-CON 8 tabs KLOR-CON 10 potassium chloride POTASSIUM CHLORIDE liquid potassium chloride K-LOR powder potassium iodide PIMA Potassium-Removing Agents sodium polysterene sulfonate KAYEXALATE susp (susp only) Vitamins And Minerals calcitriol ROCALTROL calcitriol oral soln ROCALTROL SOLUTION Members 8 years of age will require prior authorization. calcium OS-CAL OTC cholecalciferol VITAMIN D TAB 400 UNIT tab 400 unit, OTC cholecalciferol VITAMIN D TAB 1000 UNIT tab 1000 unit, OTC cholecalciferol VITAMIN D TAB 2000 UNIT tab 2000 unit, OTC cholecalciferol VITAMIN D CAP 400 UNIT cap 400 unit, OTC cholecalciferol VITAMIN D CAP 2000 UNIT cap 2000 unit, OTC cholecalciferol D3-50 CAP cap unit, OTC cholecalciferol BIO-D DRO-MULSION drops 400 unit/0.03 ml, OTC cholecalciferol BIO-D-MULSIO drops 2000 unit/0.03 ml, DRO FORTE OTC cyanocobalamin VITAMIN B-12 inj, Coverage for these medications will be determined by the member s individual benefits. Please refer to individual plan documents for coverage information. electrolyte PEDIALYTE soln, oral, OTC 47

55 Generic Name Brand Name ergocalciferol (D2) DRISDOL Coverage for these medications will be determined by the member s individual benefits. Please refer to individual plan documents for coverage information. ferrous bisglycinate/polysaccarides iron NIFEREX caps, OTC ferrous sulfate FEOSOL OTC fluoride GEL-KAM LURIDE LURIDE LOZI-TABS PREVIDENT PHOS-FLUR folic acid FOLIC ACID magnesium oxide MAG-OX ultivitamins/fluoride/±iron POLY-VI-FLOR multivitamins/minerals CENTRUM Coverage for these medications will be determined by the member s individual benefits. Please refer to individual plan documents for coverage information. OTC, Coverage for these medications will be determined by the member s individual benefits. Please refer to individual plan documents for coverage information. Coverage for these medications will be determined by the member s individual benefits. Please refer to individual plan documents for coverage information. OTC, Coverage for these medications will be determined by the member s individual benefits. Please refer to individual plan documents for coverage information. phytonadione MEPHYTON polysaccharide iron complex NIFEREX elixir, OTC 48

56 Generic Name Brand Name prenat w/o A w/fecbnfegl-dss-fa & DHA RE OB + DHA Pak Foltabs Pak Plus DHA prenatal vit w/ FE bisglyc- Vinate III FE prot succ-fa prenatal vit w/ FE bisglycinate chelate-fa Vitaphil prenatal vit w/ FE bisglycinate chelate-fa Gentex ADE 28-1 mg prenatal vit w/ FE bisglycinate chelate-fa Vinate AZ EX prenatal vit w/ FE polysac Edge OB Chw cmplx-fa prenatal vit w/ iron Atabex Prenatal carbonyl-fa PRENATAL VITAMINS w/ FOLIC ACID Cenogen OB/Ultra prenatal vitamins Materna w/folic acid Natalcare NestabsCBF/FA/RX Niferex-PN Forte prenatal vit w/o vit a w/ fe bisglycinate-fa tab 32-1 mg prenatal w/o A w/ FE Foltabs Prenatal carbonyl-fe gluc-dss-fa Tri RX prenat-fe Bis-FE Complete Natalcare prot succ-fa-ca Pak DHA & omega 3 prenat-fe Bis-FE prot succ-fa-ca & omega 3 prenat-fe Bis-FE prot succ-fa-ca & omega 3 prenat-fe bis-fe prot succ-fa-ca & omega DR Trust Natalcare Pak DHA Pruet DHA Pak Setonet Pak Pruet DHAEC Pak 49 vitamin A OTC QL

57 Generic Name vitamin ADC/ fluoride/±iron drops vitamin B complex/ vitamin C/folic acid Brand Name TRI-VI-FLOR NEPHROCAPS 50 Coverage for these medications will be determined by the member s individual benefits. Please refer to individual plan documents for coverage information. Coverage for these medications will be determined by the member s individual benefits. Please refer to individual plan documents for coverage information. vitamin B-1 OTC vitamin C OTC vitamin B-6 OTC vitamins pediatric TRI-VI-SOL members <3 years old, OTC, Coverage for these medications will be determined by the member s individual benefits. Please refer to individual plan documents for coverage information. zinc OTC Urological Symptomatic Benign Prostatic Hypertrophy alfuzosin ER UROXATRAL doxazosin CARDURA finasteride PROSCAR tamsulosin Flomax terazosin HYTRIN Miscellaneous bethanechol URECHOLINE hyoscyamine, methenamine, phenyl salicylate, sodium phosphate monobasic, methylene blue Utira C

58 Generic Name Brand Name methenamine hippurate Hiprex UREX oxybutynin IR DITROPAN oxybutynin chloride Ditropan Xl QL, ST potassium citrate UROCIT-K propantheline phenazopyridine PYRIDIUM sodium citrate/citric acid BICITRA tolterodine DETROL ST trospium SANCTURA ST Miscellaneous Anaphylaxis epinephrine Adrenaclick QL epinephrine EPIPEN EPIPEN JR. QL Twinject Cryopyrin Associated Periodic Syndromes (CAPS) canakinumab Ilaris PA, SP rilonacept ARCALYST PA, SP Cystic Fibrosis acetylcysteine MUCOMYST aztreonam CAYSTON PA, SP dornase alfa PULMOZYME PA, SP ivacaftor KALYDECO PA, SP tobramycin neb soln BETHKIS PA, SP Hereditary Angioedema C1 Inhibitor, Human BERINERT PA, SP icatibant FIRAZYR PA, SP Hyperphosphatemia calcium acetate PHOSLO 667 mg tablet only cinacalcet Sensipar PA sevelamer Renvela ST Immune Thrombocytopenic Purpura eltromobpag PROMACTA PA, SP 51

59 Generic Name Brand Name Medical Devices EasiVent Mask EASIVENT MASK QL EasiVent valved holding chamber EASIVENT CHAMBER QL Inspirease INSPIREASE Metabolic Modifiers carglumic acid CARBAGLU PA, SP glycerol phenylbutyrate RAVICTI PA, SP sodium phenylbutyrate oral powder BUPHENYL ORAL POWDER PA 52

60 Generic Name Brand Name Examples OTC MEDICATIONS The following is a list of OTC products on the PDL. Some OTC products are listed on the drug list. OTC products covered are restricted to s when available. Brand names are provided as reference only. Acne benzoyl peroxide crm, gel, lotion Antifungals clotrimazole miconazole crm, soln tolnaftate vaginal products Cough/Cold Allergy antihistamines antihistamine/decongestant combinations cetirizine/pesudoephedrine OTC loratadine/pseudoephedrine cough/cold Age edit applied. Not covered for members under the age 2. nasal sprays 53 Clearasil Micatin Lotrimin AF TINACTIN Monistat Gyne-Lotrimin Chlor-Trimeton Benadryl Claritin Alavert ZYRTEC Actifed Dimetapp Alavert D zyrtec d Alavert alrg tab/sinus allergy/cong Robitussin Robitussin DM Robitussin PE Robitussin CF Delsym Neo-Synephrine Afrin dimetapp dro deconges

61 Generic Name Atopic Dermatitis emollients Diabetes alcohol swabs glucose oral tablets insulin (vials only) Earwax Removal Products carbamide peroxide Family Planning condoms contraceptive foam contraceptive gel First Aid Burow s soln, wet dressings dermatological baths hydrocortisone crm, oint topical antibacterials Gastrointestinal antacids liquids, chew tabs antidiarrheals electrolyte rehydrating soln famotidine laxative enemas laxatives psyllium Brand Name Examples Betacare Cream and Lotion Cetaphil Cream and Lotion Dermaphor Ointment E-Ointment Glycerin topical 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 Dulcolax Fleet Phospho-Soda Metamucil 54

62 Generic Name rectal crm, suppositories simethicone stool softeners sugar+orthophosphoric acid Lice Products permethrin piperonyl butoxide gel, liquid shampoo Motion Sickness dimenhydrinate meclizine Ophthalmics allergic conjunctivitis artificial tears decongestants Pain acetaminophen tabs, liquid, drops, suppositories aspirin tabs, EC. tabs aspirin with buffers tabs ibuprofen tabs, chew tabs and susp Smoking Cessation Products nicotine Vitamins/Minerals calcium iron ferrous fumarate, ferrous, gluconate, errous sulfate, ferrous bis-glycinate chelate and polysaccharide iron caps iron polysaccharides Brand Name Examples 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) Os-Cal Caltrate Tums Fergon Feosol Niferex 55

63 Generic Name 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 Mag-Ox Vitamin D 400 IU Vi-Daylin Poly-Vi-Sol Tri-Vi-Sol Stuart Prenatal Duofilm Phos-Flur 56

64 Index of s a abacavir abacavir/lamivudine abacavir/lamivudine/ zidovudine ABILIFY MAINTENA ABILIFY TABLETS abiraterone acamprosate acarbose Accu-Chek Care Kit ( Aviva, Compact Plus, Nano Smartview).. 22 Accu-Chek Test Strips (Aviva, AVIVA PLUS, Compact, SMARTVIEW) ACCUHIST DROPS ACCUHIST PDX DROPS.. 41 ACCUNEB ACCUPRIL ACCURETIC ACCUTANE acebutalol acetaminophen , 31 acetaminophen tabs, liquid, drops, suppositories.. 55 acetazolamide ACETAZOLAMIDE acetazolamide ext-rel acetic acid acetic acid/aluminum acetate19 acetic acid/hydrocortisone. 19 acetylcysteine acidophilus Acidophilus acidophilus/bifidus Acidophilus/ Bifidus Wafer ALL CAPS = Brand-name drug Lower case = Generic drug acidophilus/citrus pectin.. 26 Acidophilus/ Citrus Pectin acidophilus/pectin Acidophilus/Pectin.. 26 Acidophilus XTRA acitretin aclidinium inhalation ACLOVATE Actifed , 53 ACTIGALL ACTOPLUSMET ACTOPLUS MET XR ACTOS ACULAR/ACULAR LS acyclovir ADALAT CC adalimumab ADDERALL ADDERALL XR adefovir Adrenaclick ADVAIR DISKUS ADVAIR HFA Advair INHAL AEROSOL 45 Advil , 31, 55 afatinib afinitor AFINITOR DISPERZ Afrin , 53 AGENERASE AGRYLIN AKINETON Alavert , 53 alavert alrg tab/sinus , 53 Alavert D , Alaway ALAWAY OTC albendazole ALBENZA albuterol albuterol sulfate alclometasone alcohol swabs ALDACTAZIDE ALDACTONE ALDOMET aldoril alendronate ALESSE alfuzosin ER alginic acid/sodium bicarbonate ALINIA ALINIA SUSPENSION alitretinoin 1% gel ALKERAN allanhist syp pdx allergic conjunctivitis allergy/cong , 53 allergy/cong tab relief allopurinol ALPHAGAN P alprazolam altretamine alumina/magnesia alumina/magnesia/ simethicone aluminum acetate aluminum chloride hexahydrate amantadine , 28 AMARYL

65 Index of s AMBIEN ambrisentan Amerge AMICAR amiloride amiloride/hydrochlorothiazide 9 aminocaproic acid amiodarone tabs amitriptyline , 38 amitriptyline/perphenazine. 38 amlodipine ammonium lactate amoxapine amoxicillin AMOXIcillin capsules and chewables amoxicillin/clavulanate Amoxil Susp amphetamine/dextroamphetamine mixed salts amphetamine/dextroamphetamine mixed salts ext-rel 37 ampicillin amprenavir anagrelide anakinra anaplex dm ANAPROX , 31 anastrozole ANDRODERM Androgel 1.62% ANTABUSE antacids liquids, chew tabs. 54 antidiarrheals antihistamines ANTIVERT aphedrid tab ALL CAPS = Brand-name drug Lower case = Generic drug apixaban aprepitant APRESOLINE APRISO APTIVUS ARALEN ARANESP ARAVA ARCALYST ARICEPT ARIMIDEX aripiprazole aripiprazole ER injection.. 39 AROMASIN ARTANE artificial saliva artificial tears Asmanex Twisthaler. 45 aspirin , 31 aspirin/acetaminophen/ caffeine aspirin tabs, EC. tabs aspirin with buffers tabs.. 55 ASTELIN Atabex Prenatal ATARAX atazanavir atenolol atenolol/chlorthalidone....8 ATIVAN atomoxetine atorvastatin atovaquone ATRIPLA atropine atropine sulfate ATROVENT ATROVENT HFA ATUSS DR AUBAGIO AUGMENTIN auranofin AVITA AVONEX/AVONEX PEN.. 14 axitinib AYGESTIN azathioprine , 31 azelaic acid azelastine , 34 azithromycin aztreonam AZULFIDINE , 31 AZULFIDINE EN-TABS.25, 31 b bacitracin , 36 Bacitracin , 54 baclofen BACLOFEN BACTRIM BACTRIM DS BACTROBAN balsalazide BALZIVA BANCAP HC, VICODIN 5/ Banzel BARACLUDE Bayer , 31, 55 beclomethasone bedaquiline Benadryl , 53 benazepril benazepril/hydrochlorothiazide7

66 Index of s BENTYL BENZAC AC BENZAMYCIN benzocaine/antipyrine benzonatate BENZOTIC benzoyl peroxide , 53 benztropine BERINERT Betacare Cream and Lotion betagan betamethasone augmented dip betamethasone dipropionate 17 betamethasone val BETAPACE BETA-VAL bethanechol BETHKIS BETIMOL bexarotene caps and topical gel Biaxin BIAXIN XL bicalutamide BICITRA BILTRICIDE BIO-D DRO-MULSION BIO-D-MULSIO DRO FORTE biperiden bismuth subsalicylate + metronidazole + tetracycline. 26 bisoprolol bisoprolol/ hydrochlorothiazide....9 BLEPH ALL CAPS = Brand-name drug Lower case = Generic drug Bonine bosentan BOSULIF bosutinib BREO ELLIPTA BRETHINE brimonidine , 35 BRIMONIDINE bromaline dm BROMETANE DX bromfed dm bromfenex pd cap bromocriptine , 23 brompheniramine & phenylephrine brompheniramine/ pseudoephedrine..40, 41 brompheniramine/ pseudoephedrine /dextromethorphan brompheniramine/pseudoephedrine/dextromethorphan/guaifenesin budesonide , 45, 46 budesonide/formoterol bumetanide BUMEX BUPHENYL ORAL POWDER buprenorphine buprenorphine/naloxone.. 39 bupropion bupropion ext-rel Burow s soln, wet dressings 54 BUSPAR buspirone busulfan butalbital/acetaminophen butalbital/acetaminophen.. 12 butalbital/acetaminophen/ caffeine butalbital/apap/caff/cod.. 12 butalbital/asa/caff/cod butalbital/aspirin/caffeine.. 12 butorphanol BYETTA c C1 Inhibitor, Human cabozantinib CAFERGOT calamine CALAN , 14 CALAN SR calcipotriene calcitonin-salmon calcitriol , 47 calcium , 55 calcium acetate Caltrate campral canakinumab CANASA capecitabine CAPITROL CAPOTEN CAPOZIDE capsaicin captopril captopril/hydrochlorothiazide.7 Carac CARAFATE CARAFATE SUSPENSION. 25 CARBAGLU carbamazepine

67 Index of s carbamazepine ext-rel carbamide peroxide...19, 54 CARBATROL carbetapentane/chlorpheniramine/ephedrine/ phenylephrine carbidopa/levodopa carbidopa/levodopa ext-rel. 14 carbinoxamine/ pseudoephedrine carbofed CARDEC-DM cardec dm dro cardec dm syp cardec dro cardec syp , 42 CARDENE CARDIZEM CARDIZEM CD CARDIZEM SR CARDURA , 50 carglumic acid carteolol carvedilol casanthranol-docusate sodium CASODEX CATAFLAM CATAPRES CAYSTON CECLOR CEENU cefaclor cefadroxil cefdinir cefixime cefprozil ALL CAPS = Brand-name drug Lower case = Generic drug CEFTIN cefuroxime axetil CEFZIL Celebrex celecoxib CELEXA CELLCEPT CELONTIN CENESTIN Cenogen OB/Ultra.. 49 CENTRUM cephalexin Cetaphil Cream and Lotion cetirizine cetirizine hydrochloride/ pseudoephedrine hydrochloride cetirizine/pesudoephedrine OTC CHANTIX child ibupro sus cold 45 chloral hydrate CHLORAL HYDRATE chlorambucil chlordiazepoxide chlorhexidine gluconate chloroquine phosphate chlorothiazide chloroxine chlorpheniramine/ dextromethorphan chlorpheniramine ext-rel.. 19 chlorpheniramine maleate. 19 chlorpheniramine maleate phenylephrine HCL chlorpheniramine/ phenylephrine chlorpheniramine/phenylephrine/pyrilamine chlorpheniramine/ pseudoephedrine chlorpheniramine/pseudoephedrine ext-rel 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 19 chlorzoxazone cholecalciferol cholestyramine choline magnesium trisalicylate , 31 ciclopirox cilostazol CILOXAN cimetidine cinacalcet CIPRO CIPRODEX ciprofloxacin , 36 ciprofloxacin/ dexamethasone

68 Index of s citalopram clarithromycin clarithromycin ER Claritin , 53 Clearasil CLEAR EYES REDNESS RELIEF clemastine CLEMASTINE CLEOCIN , 34 CLEOCIN T CLIMARA clindamycin , 29, 34 CLINORIL , 31 clobazam clobetasol propionate clonazepam , 37 clonidine clopidogrel clorazepate clotrimazole... 17, 27, 34, 53 clotrimazole with betamethasone clozapine CLOZARIL cobicistat/elvitegravir/ emtricitabine/tenofovir. 29 codal-dm codeine/acetaminophen.. 12 codeine/chlorpheniramine/ pseudoephedrine codeine/guaifenesin codeine/guaifenesin/ pseudoephedrine codeine/promethazine codeine/promethazine/ phenylephrine codeine sulfate ALL CAPS = Brand-name drug Lower case = Generic drug CODIMAL DH COGENTIN Colace COLAZAL colchicine COLCRYS Colloidal oatmeal baths COLOCORT COLYTE COMBIVENT COMBIVENT RESPIMAT.. 46 COMBIVIR COMETRIQ Commit lozenges COMMITT OTC COMPAZINE COMPLERA Complete Natalcare Pak DHA COMTAN CONCERTA condoms CONDYLOX SOL contraceptive foam contraceptive gel COPAXONE CORDARONE CORDRAN COREG coricidin tab cgh/cld 41 Cortaid CORTEF cortisone acetate CORTISPORIN CORTISPORIN OTIC CORTIZONE COSOPT cough/cold COUMADIN COZAAR cpm/pse creon CRIXIVAN crizotinib CROLOM cromolyn cromolyn sodium , 34 crotamiton CUPRIMINE Curity Alcohol Pads. 54 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

69 Index of s d D3-50 CAP dabrafenib dallergy dm DALMANE danazol DANOCRINE DANTRIUM dantrolene dapsone DAPSONE Daraprim darbepoetin alfa darunavir dasatanib DAYPRO , 31 DDAVP Debrox , 54 DECADRON DE-CHLOR DM DECONAMINE SR decongestants deferasirox DELATESTRYL delavirdine Delfen Delsym , 53 DELTASONE DEMEROL DEPAKENE DEPAKOTE , 15, 38 DEPAKOTE SPRINKLE , 15, 38 DEPO-PROVERA DEPO-TESTOSTERONE.. 21 Dermaphor Ointment 54 ALL CAPS = Brand-name drug Lower case = Generic drug DERMA-SMOOTHE OIL/FS , 17 dermatological baths DERMATOP DESENEX POWDER 2%.. 17 desipramine desmopressin desogestrel/ee , 33 DESYREL DETROL dexamethasone dexamethasone sodium phosphate DEXASOL DEXEDRINE DEXEDRINE SPANSULE. 37 dextroamphetamine dextroamphetamine ext-rel. 37 dextromethorphan/brompheniramine/pseudoephedrine 43 dextromethorphan/carbinoxamine/pseudoephedrine 43 dextromethorphanguaifenesin dextromethorphan/ guaifenesin dextromethorphan hbr dextromethorphan polistirex ext rel dextromethorphan/ promethazine dextromethorphan/quinidine 40 DEXtrostat D.H.E DIABINESE DIAMOX SEQUELS DIASTAT ACUDIAL diazepam , 32, diclofenac 1% gel diclofenac potassium diclofenac sodium diclofenac sodium delayed release...12, 31 dicloxacillin DICLOXACILLIN dicyclomine didanosine didanosine delayed-rel DIDRONEL DIFLUCAN , 34 digoxin DIHISTINE DH dihydroergotamine dihydro-pe syp DILACOR XR DILANTIN DILAUDID diltiazem diltiazem ext-rel diltiazem ext release diltiazem sustained release..9 dimeatapp dro deconges dimenhydrinate Dimetapp dimetapp cld elx/ allergy dimetapp dro dcon/cgh dimetapp dro deconges dimetapp elx cld/alle 40 dimetapp syp cgh/cld 41 dimethyl fumarate DIPENTUM diphenhydramine....19, 39

70 Index of s diphenoxylate/atropine DIPROLENE DIPROLENE AF dipyridamole disopyramide disopyramide ext-rel disulfiram DITROPAN Ditropan Xl DIURIL divalproex sodium cap sprinkle.. 14, 15, 38 divalproex sodium delayed-rel... 14, 15, 38 docusate calcium plus docusate potasssium dofetilide dolutegravir Domeboro DOMEBORO OTIC donepezil dornase alfa dorzolamide dorzolamide/timolol maleate 36 DOVONEX doxazosin , 50 doxepin doxycycline monohydrate.. 27 DOXYCYCLINE MONOHYDRATE Dramamine DRISDOL dronabinol droxia DUETACT Dulcolax Dulera ALL CAPS = Brand-name drug Lower case = Generic drug duloxetine Duofilm , 56 DUONEB duradryl DURAGESIC Duratuss dm elx DURICEF DYAZIDE e EASIVENT CHAMBER EasiVent Mask EASIVENT MASK EasiVent valved holding chamber econazole ecothiophate Ecotrin , 31, 55 Ed A-Hist tablets and liquid Edge OB Chw EDURANT E.E.S efavirenz efavirenz/emtricitabine/ tenofovir EFFEXOR EFFEXOR XR EFUDEX ELAVIL , 38 ELDEPRYL electrolyte , 54 ELIDEL ELIMITE ELIQUIS ELOCON eltromobpag EMCYT EMEND Emetrol Emla emollients emtricitabine emtricitabine/rilpivirine/ tenofovir emtricitabine/tenofovir EMTRIVA enalapril enalapril/hydrochlorothiazide.7 ENBREL enfuvirtide Enjuvia enoxaparin entacapone entecavir ENTOCORT EC ENULOSE E-Ointment EPANED epinephrine EPIPEN EPIPEN JR EPIVIR Epivir HBV epoetin alfa EPOGEN EPZICOM ergocalciferol ergotamine/caffeine ERIVEDGE erlotinib ERYC ERYGEL ERY-TAB ERYTHROCIN

71 Index of s erythromycin , 36 ERYTHROMYCIN erythromycin/benzoyl peroxide erythromycin delayed-rel.. 27 erythromycin ethylsuccinate 27 erythromycin stearate erythromycin/sulfisoxazole. 27 escitalopram ESKALITH CR esomeprazole granules ESTRACE estradiol , 34 estramustine phosphate sodium estrogens, conjugated. 33, 34 estrogens, conjugated/ medroxyprogesterone.. 34 estrogens, conjugated, synthetic A estrogens, conjugated, synthetic B estropipate ESTROSTEP FE etanercept ethambutol ETHMOZINE ethosuximide ethynodiol diacetate/ee.. 33 etidronate etodolac , 31 etonogestrel/ee etoposide etravirine EULEXIN EURAX everolimus , 6 EVISTA ALL CAPS = Brand-name drug Lower case = Generic drug EXCEDRIN MIGRAINE EXELON exemestane exenatide EXJADE exogabine ezetimibe/simvastatin f famotidine , 54 FARESTON febuxostat felbamate FELBATOL FELDENE , 31 felodipine ext-rel FEMARA fenofibrate , 12, 31 fentanyl transdermal Feosol , 55 Fergon ferrous bisglycinate/ polysaccarides iron ferrous sulfate filgrastim FINACEA finasteride fingolimod FIORICET FIORICET w/codeine...12 FIORINAL FIORINAL w/codeine.. 12 FIRAZYR FLAGYL , 34 FLAREX flecainide Fleet Enema Fleet Phospho-Soda. 54 FLEXERIL Flomax FLONASE Floranex FLORINEF FLOVENT Diskus FLOVENT HFA FLOXIN FLOXIN OTIC fluconazole , 34 fludarabine fludrocortisone FLUMADINE fluocinolone acetonide. 16, 17 fluocinonide fluocinonide emulsified base 17 fluoride fluoride dental rinse fluorometholone fluorometholone acetate.. 35 FLUOROPLEX fluorouracil fluoxetine fluphenazine fluphenazine decanoate.. 40 flurandrenolide flurazepam flurbiprofen flutamide fluticasone fluticasone HFA fluticasone propionate. 17, 45 fluticasone/salmeterol fluticasone/vilanterol fluvoxamine FML

72 Index of s FML FORTE FML SOP folic acid FOLIC ACID Foltabs Pak Plus DHA RE OB + DHA Pak Foltabs Prenatal FORADIL AEROLIZER formoterol FORTEO FORTICAL FORTOVASE FOSAMAX fosamprenavir fosinopril fosinopril/hydrochlorothiazide 8 FURADANTIN SUSP furosemide Fuzeon Kit g gabapentin GABITRIL galantamine ganciclovir gatifloxin GATTEX GEL-KAM gemfibrozil GENGRAF GENTAK , 36 gentamicin , 36 gentamicin/prednisolone acetate Gentex ADE GEODON gg/codeine gg/dm cr ALL CAPS = Brand-name drug Lower case = Generic drug 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 25 Glycerin topical glycerol phenylbutyrate glycopyrrolate GLYNASE GRIFULVIN V griseofulvin microsize griseofulvin ultramicrosize. 28 GRIS-PEG GUAIFED guaifenesin guaifenesin ext-rel guaifenesin/ pseudoephedrine guaifenesin/ pseudoephedrine/ dextromethorphan guaifenesin/pseudoephedrine ext rel GUAIFEN PSE guanabenz guanfacine , 37 GUIATUSS AC GUIATUSS DAC Gyne-Lotrimin , 53 Gynol II h HALCION HALDOL HALDOL DECANOATE haloperidol haloperidol decanoate HECORIA HELIDAC heparin HEPARIN HEPSERA hexachlorophene hexalen Hiprex histacol dm HISTEX HISTUSSIN HC HIVID homatropine HUMALOG HUMALOG MIX 50/ HUMALOG MIX 75/ HUMATIN HUMIRA HUMULIN HUMULIN 70/ HUMULIN N

73 Index of s HUMULIN R HYCODAN hydralazine HYDREA hydrochlorothiazide... 9, 10 HYDROCHLOROTHIAZIDE 10 hydrocodo/gg syp.. 43 hydrocodone/ acetaminophen...12, 13 hydrocodone/chlorpheniramine/ phenylephrine hydrocodone/guaifenesin.. 43 hydrocodone/homatropine. 43 hydrocodone/ tab homatrop hydrocortisone. 16, 18, 21, 25 hydrocortisone butyrate hydrocortisone crm, oint.. 54 hydromet syp hydromorphone hydroxychloroquine...30, 31 hydroxyurea hydroxyzine HCL hydroxyzine pamoate hyoscyamine, methenamine, phenyl salicylate, sodium phosphate monobasic, methylene blue hyoscyamine sulfate hyoscyamine sulfate ext-rel. 25 HYpercare 20% HypoTears HYTONE HYTRIN , 50 HYZAAR i ibrutinib ibuorofen tab cold/sin ibuprofen , 31, 55 icatibant ICLUSIG Ilaris imatinib mesylate IMBRUVICA IMDUR imipramine HCL IMITREX Imodium A-D , 54 IMURAN , 31 INCRELEX indapamide INDERAL , 14 INDERIDE indinavir INDOCIN , 31 indomethacin , 31 INFERGEN INFLAMASE FORTE INLYTA Inspirease INSPIREASE insulin aspart insulin aspart protamine 70%/ insulin aspart 30% insulin detemir insulin glargine insulin human insulin isophane insulin isophane human insulin isophane human 70%/ regular 30% insulin isophane/regular.. 22 insulin lisopro pro/lispro.. 22 insulin lisopro prot/lispro.. 22 insulin lispro insulin regular insulin INTAL INTELENCE interferon alfa-2a interferon alfa-2b.... 6, 28 interferon alfacon interferon beta-1a INTRON A , 28 Intuniv Invega Sustenna INVIRASE ipratropium ipratropium/albuterol ipratropium HFA iron iron polysaccharides ISENTRESS ISENTRESS CHEWABLE. 30 ISMO isoniazid ISONIAZID ISOPTO ATROPINE ISOPTO CARPINE ISOPTO HOMATROPINE.. 36 ISOPTO HYOSCINE ISORDIL ISORDIL S.L isosorbide dinitrate ISOSORBIDE DINITRATE ER isosorbide dinitrate ext-rel..10 isosorbide mononitrate isosorbide mononitrate ext-rel ALL CAPS = Brand-name drug Lower case = Generic drug 66

74 Index of s isotretinoin itraconazole ivacaftor ivermectin ALL CAPS = Brand-name drug Lower case = Generic drug j JAKAFI JANUMET JANUMET XR JANUVIA JUXTAPID k KALETRA KALYDECO Kaopectate KAYEXALATE K-DUR K-DUR KEFLEX KENALOG KENALOG IN ORABASE.. 21 Keppra ketoconazole , 18, 28 ketoprofen , 31 ketorolac ketorolac tromethamine ketotifen KINERET KLONOPIN , 37 K-LOR KLOR-CON KLOR-CON K-LYTE KOMBIGLYZE KOR LYM K-PHOS NEUTRAL K-PHOS ORIGINAL KUVAN l labetalol LAC-HYDRIN lacosamide lactobacillus lactulose LAMICTAL LAMISIL LAMISIL AT lamivudine , 29 lamivudine/zidovudine lamotrigine lamotrigine chew dispersable tab LANOXICAPS LANOXIN lansoprazole lansoprazole del-rel LANTUS lapatinib ditosylate LARIAM LASIX latanoprost laxative enemas laxatives leflunomide lenalidomide LETAIRIS letrozole leukine leuprolide levalbuterol HCl Levaquin LEVEMIR levetiracetam levobunolol levocetirizine levofloxacin levonorgestrel levonorgestrel/ee....32, 33 levothyroxine LEVOXYL LEVSIN LEVSINEX LEXAPRO LEXIVA LIALDA LIBRIUM lidamantel LIDEX LIDEX E lidocaine lidocaine/prilocaine lidocaine viscous linezolid liothyronine liotrix LIPITOR liraglutide lisdexamfetamine lisinopril lisinopril/hydrochlorothiazide.8 lithium carbonate LITHIUM CARBONATE lithium carbonate ext-rel.. 38 LITHOBID LMX LOCOID LODINE , 31 LOESTRIN 1.5/ LOESTRIN 1/ LOESTRIN FE 1.5/

75 Index of s LOESTRIN FE 1/ LOFIBRA lomitapide LOMOTIL lomustine LONITEN LO/OVRAL loperamide loperamide LOPERAMIDE LOPID lopinavir/ritonavir LOPRESSOR loratadine loratadine/pseudoephedrine 53 loratadine/pseudoephedrine ext-rel loratadine & pseudoephedrine SR lorazepam LORCET 10/ LORCET PLUS LORTAB 2.5/ LORTAB 5/ LORTAB 7.5/ LORTAB 10/ LORTAB ELIXIR losartan losartan/hctz LOTENSIN LOTENSIN HCT Lotrimin AF , 53 Lotrisone lovastatin LOVENOX loxapine LOXITANE ALL CAPS = Brand-name drug Lower case = Generic drug LOZOL LUDIOMIL LUEKERAN Lupron Lupron Depot Lupron Depot-PED....6 LURIDE LUVOX LYR ICA LYSODREN Lysteda m MAALOX , 54 MACROBID MACRODANTIN magnesium oxide....48, 56 Mag-Ox , 56 malathion mapap cold tab maprotiline maraviroc MARINOL Materna MATULANE MAXALT/MAXALT MLT MAXITROL MAXZIDE m-clear wc mecasermin meclizine , 55 MEDROL medroxyprogesterone acetate , 34 mefloquine MEGACE megestrol acetate MEKINIST MELLARIL meloxicam , 31 melphalan memantine meperidine MEPHYTON MEPRON mercaptopurine mesalamine mesalamine ext-rel mesalamine supp MESTINON MESTINON TIMESPAN MetaDaTe ER Metamucil metaproterenol metaproterenol syrup metformin metformin ER metformin/glyburide methadone methazolamide methenamine hippurate METHERGINE , 34 methimazole methocarbamol methotrexate methoxsalen methsuximide methyldopa methyldopa/hctz methylergonovine....23, 34 methylnaltrexone methylphenidate methylphenidate ext-rel... 37

76 Index of s methylphenidate ext-rel methylprednisolone metipranolol metoclopramide metolazone metoprolol metoprolol succinate METROCREAM METROGEL metrogel 1% METROGEL-VAGINAL METROLOTION metronidazole... 18, 30, 34 MEVACOR mexiletine MEXITIL MIACALCIN Micatin , 53 miconazole , 34, 53 MICRO-K MICRONASE Microzide MIDAMOR midodrine mifeprstone MIGRANAL MINIPRESS MINOCIN minocycline minoxidil minutuss dr syp MIRALAX MIRAPEX MIRCETTE mirtazapine Mirvaso misoprostol ALL CAPS = Brand-name drug Lower case = Generic drug mitotane MOBIC , 31 MODICON MODURETIC mometasone mometasone/formoterol.. 45 mometasone furoate Monistat , 53 MONISTAT MONISTAT-DERM MONOPRIL MONOPRIL-HCT montelukast moricizine morphine morphine ext-rel MOTRIN , 31 Motrin IB mozobil MS CONTIN MSIR MUCINEX mucinex d MUCINEX DM MUCOMYST multi symptom tab cold rlf multivitamins/minerals mupirocin Murine MURO MYAMBUTOL MYCELEX , 27 Mycitracin MYCOBUTIN mycophenolate mofetil....6 mycophenolate sodium MYCOSTATIN , 28 MYFORTIC MYLANTA , 54 MYLERAN Mylicon MYSOLINE n NALFON , 31 naltrexone , 39 NAMENDA naphazoline/antazoline naphazoline/glycerin naphazoline HCL naphazoline/zinc sulfate.. 34 Naphcon A NAPROSYN , 31 naproxen , 31 naproxen sodium , 31 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... 19, 35 neomycin sulfate

77 Index of s NEORAL Neosporin , 36, 54 Neo-Synephrine.. 20, 53 NEPHROCAPS NEPTAZANE NestabsCBF/FA/RX NEULASTA neumega NEUPOGEN NEURONTIN nevirapine nevirapine ER NEXAVAR NEXIUM DELAYED RELEASE PACKET niacin niacin ext-rel NIACOR NIASPAN nicardipine Nicoderm CQ , 55 NICORETTE OTC nicotine , 55 Nicotine Gum nicotine polacrilex gum nicotine polacrilex lozenge. 39 NICOTROL INHALER NICOTROL NS Nicotrol nifedipine nifedipine ext-rel Niferex , 55 Niferex-PN Forte nilotinib nimodipine NIMOTOP nitazoxanide suspension.. 30 ALL CAPS = Brand-name drug Lower case = Generic drug nitazoxanide tablet NITREK NITRO-BID NITRO-DUR nitrofurantoin ext-rel nitrofurantoin macrocrystals 30 nitrofurantoin susp nitroglycerin , 19 nitroglycerin ext-rel NITROLINGUAL NITROSTAT Nix , 55 NIZORAL , 28 NIZORAL SHAMPOO NOLVADEX NORCO NORDETTE NORDITROPIN norelgestromin/ee norethindrone norethindrone acetate norethindrone acetate/ee , 33 norethindrone acetate/ee/iron...32, 33 norethindrone/ee....32, 33 norethindrone/me NORFLEX norgestimate/ee norgestrel norgestrel/ee NORPACE NORPACE CR NORPRAMIN nortriptyline NORVASC NORVIR Novolin NOVOLIN 70/ NOVOLIN N NOVOLIN R NOVOLOG NOVOLOG MIX 70/ NUCYNTA ER Nuedexta NULYTELY NUVARING NYMALIZE nystatin , 28 NYTOL QUICK CAPS o OCEAN NASAL SPRAY...21 octreotide OCUFEN OCUFLOX ofloxacin , 27, 36 Oforta OGEN olanzapine olsalazine sodium OLYSIO omalizumab omeprazole delayed-rel OMNICEF ondansetron One Touch Systems (Ultra, UltraSmart, Ultra2, UltraMini). 22 One Touch Test Strips (Basic/Profile, SureStep, Ultra) ONFI ONGLYZA OPANA ER

78 Index of s oprelvekin OPTIPRANOLOL optivar ORAP ORAPRED orphenadrine ext-rel 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 , 31 Os-Cal , 55 oseltamivir OVCON OVIDE OVRAL OVRETTE oxaprozin , 31 oxazepam oxcarbazepine OXSORALEN-ULTRA oxybutynin chloride oxybutynin IR oxycodone oxycodone/acetaminophen. 13 oxycodone/aspirin oxycodone ER OXYCONTIN ALL CAPS = Brand-name drug Lower case = Generic drug OXYFAST oxymetazoline oxymorphone ER p paliperidone palivizumab PAMELOR pancrelipase PANRETIN pantoprazole PARAFON FORTE DSC PARLODEL , 23 PARNATE paromomycin paroxetine pasireotide PAXIL pazopanib pediacare liq multi-sy 45 Pedialyte , 54 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 penicillamine penicillin VK PENLAC SOLUTION 8%.. 17 PENTASA pentoxifylline ext-rel PEPCID Pepcid AC , 54 PERCOCET PERCODAN PERIDEX permethrin , 55 perphenazine PERSANTINE phenazopyridine PHENERGAN PHENERGAN DM phenobarbital PHENOBARBITAL phenyleph/bromphen/dextromethorphan/guaifenesin 43 phenylephrine phenylephrine/ brompheniramine/ dextromethorphan phenylephrine/ chlorpheniramine phenylephrine/ chlorpheniramine/ dextromethorphan phenylephrine/chlorpheniramine/dihydrocodeine.. 44 phenylephrine/ dextromethorphan phenylephrine/ dextromethorphan/ guaifenesin phenylephrine/ephed/cpm w/carbetapentane phenylephrine/guaifenesin. 44 phenylephrine/hydrocodone/ guaifenesin phenylephrine/pyrilamine/ dextromethorphan

79 Index of s phenylephrine/pyrilamine w/ hydrocodone phenylephrine tan/pyrilamine tan/carbeta tan phenylhist liq dh PHENYTEK phenytoin phenytoin sodium extended 15 PHISOHEX Phos-Flur , 56 PHOSLO PHOSPHOLINE IODINE.. 36 phosphorus PHRENILIN phytonadione pilocarpine , 35 PILOPINE HS GEL PIMA pimecrolimus pimozide pindolol PINDOLOL pioglitazone pioglitazone/glimiperide.. 22 pioglitazone/metformin pioglitazone/metformin ER. 22 Piperonyl Butoxide.. 55 piperonyl butoxide gel, liquid shampoo piroxicam , 31 PLAN B PLAQUENIL , 31 PLAVIX PLENDIL plerixafor PLETAL PLEXION ALL CAPS = Brand-name drug Lower case = Generic drug podofilox polyethylene glycol polymyxin B/bacitracin polymyxin B/trimethoprim.. 36 polysaccharide iron complex 48 POLYSPORIN POLYTRIM POLY-VI-FLOR Poly-Vi-Sol pomalidomide POMALYST ponatinib potassium acid phosphate. 46 potassium bicarbonate/potassium citrate effervescent 47 potassium chloride POTASSIUM CHLORIDE.. 47 potassium chloride ext-rel. 47 potassium citrate potassium iodide POTIGA povidone-iodine pramipexole pramlintide PRANDIN PRAVACHOL pravastatin praziquantel prazosin precose PRED FORTE PRED-G PRED MILD prednicarbate prednisolone prednisolone acetate prednisolone phosphate prednisolone sodium phosphate prednisone pregabalin PRELONE PREMARIN , 34 PREMPHASE PREMPRO prenatal vitamins w/folic acid 49 PRENATAL VITAMINS w/ FOLIC ACID prenatal vit w/ FE bisglyc-fe prot succ-fa prenatal vit w/ FE bisglycinate chelate-fa prenatal vit w/ FE polysac cmplx-fa prenatal vit w/ iron carbonyl-fa prenatal vit w/o vit a w/fe bisglycinate-fa tab 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 PREVIDENT PREZISTA PRILOSEC primaquine primidone PRINCIPEN PROAMATINE probenecid

80 Index of s PROBENECID Probiotic Formula.. 26 probiotic product procainamide procainamide ext-rel PROCAINAMIDE EXT-REL. 8 PROCANBID procarbazine PROCARDIA PROCARDIA XL prochlorperazine PROCRIT PROCTOCREAM-HC 2.5% 18 PROGRAF PROLIXIN PROLIXIN DECANOATE.. 40 PROMACTA promethazine promethazine & phenylephrine promethazine syp dm 43 PROMETHAZINE VC w/codeine PROMETHAZINE w/codeine prometh vc syp PRONESTYL 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 pseudoephedrine/dextromethorphan/guaifenesin pseudoephedrine/iburprofen 45 pseudoephedrine tan/ dexchlorphen tan/dm tan psyllium PULMICORT FLEXHALER 45 PULMICORT RESPULES. 46 PULMOZYME PURINETHOL pyrazinamide PYRAZINAMIDE pyrethrins/piperonyl but PYRIDIUM pyridostigmine pyridostigmine ext-rel pyrilamine tan/phenyleph tan 45 pyrimethamine q qual-tussin syp dc QUESTRAN QUESTRAN-LIGHT quetiapine quinapril quinapril/hydrochlorothiazide.8 quinidine gluconate ext-rel..8 QUINIDINE GLUCONATE EXT-REL quinidine sulfate QUINIDINE SULFATE quinidine sulfate ext-rel....8 QUINIDINE SULFATE EXT-REL qv-allergy QVAR r raloxifene raltegravir RANEXA ranitidine ranolazine RAPAMUNE RAVICTI RAZADYNE REBETOL/COPEGUS REBIF rectal crm, suppositories.. 55 RECTIV REGLAN regorafenib RELENZA Relion 70/ Relion N Relion R RELISTOR REMERON Renvela repaglinide REQUIP RESCRIPTOR ALL CAPS = Brand-name drug Lower case = Generic drug 73

81 Index of s resperal-dm RESTORIL RETIN-A RETROVIR REVATIO REVIA , 39 REVLIMID REYATAZ ribavirin RIDAURA RID SHAMPOO/ BUTOXIDE SHAMPOO 18 rifabutin RIFADIN rifampin rilonacept rilpivirine rimantadine rimexolone RISPERDAL RISPERDAL CONSTA risperidone RITALIN RITALIN LA RITALIN-SR ritonavir rivaroxaban rivastigmine rizatriptan RMS ROBAXIN ROBINUL Robitussin , 53 Robitussin CF , 53 Robitussin DM , 53 robitussin liq cgh/alrg ALL CAPS = Brand-name drug Lower case = Generic drug robitussin liq cgh/cld , 44 robitussin liq cgh/cong robitussin liq hd/chst robitussin liq ped nght Robitussin PE , 53 robitussin ped liq cgh/cold robitussin ped syp.. 43 ROBITUSSIN syp chst cng ROBITUSSIN syp max-st 43 ROCALTROL RONDEC DM RONDEC DROPS....41, 42 RONDEC SYRUP , 42 ropinirole ROWASA ROXICODONE r-tannamine rufinamide ruxolitinib ryna-12 s RYNATAN PEDIATRIC SUSP RYNATUSS RYNATUSS PEDIATRIC SUSP RYTHMOL s SABRIL SOLUTION SALAGEN salicylic acid 17%/ collodion , 56 saline nasal spray 0.65% salmeterol xinafoate SAL-TROPINE SANCTURA SANDIMMUNE Sandostatin sapropterin saquinavir saquinavir mesylate sargramostim saxagliptin saxagliptin/metformin scopolamine SEASONALE SECTRAL SEDAPAP selegiline selenium sulfide SELSUN Selzentry sennosides SENOKOT Sensipar SERAX SEREVENT DISKUS SEROQUEL sertraline sevelamer SIGNIFOR sildenafil SILVADENE silver sulfadiazine SIMCOR simeprevir simethicone simvastatin simvastatin/niacin ER SINEMET

82 Index of s SINEMET CR SINEQUAN SINGULAIR sirolimus SIRTURO sitagliptan sitagliptan/metformin sitagliptan/metformin ER.. 23 sodium chloride hypertonic. 37 sodium citrate/citric acid.. 51 sodium phenylbutyrate oral powder sodium polysterene sulfonate sofosbuvir somatropin SONATA sorafenib Soriatane sotalol SOVALDI SPECTAZOLE SPIRIVA spironolactone spironolactone/ hydrochlorothiazide Sporanox SPRYCEL STADOL STARLIX statuss dm syp stavudine STELAZINE STIVARGA stool softeners STRATTERA STRIBILD ALL CAPS = Brand-name drug Lower case = Generic drug STROMECTOL Stuart Prenatal SUBOXONE SUBUTEX sucralfate sugar+orthophosphoric acid 55 sulcralfate sulfacetamide , 36 sulfacetamide/phenylephrine 36 sulfacetamide/pred. phos.. 35 sulfacetamide/sulfur SULFACET-R sulfamethoxazole/ trimethoprim, DS sulfasalazine , 31 sulfasalazine delayed-rel 25, 31 sulfisoxazole sulindac , 31 sumatriptan SUMYCIN sunitinib SUPRAX SUSTIVA SUTENT SYLATRON SYMBICORT SYMLIN SYMMETREL , 28 Synagis SYNALAR , 17 SYNTHROID t tacrolimus , 19 TAFINLAR TAGAMET tambocor TAMIFLU tamoxifen tamsulosin TANAFED TANAFED DMX SUSPENSION TAPAZOLE tapentadol ER tarceva TARGRETIN TASIGNA TASMAR TECFIDERA teduglutide TEGRETOL TEGRETOL-XR temazepam TEMODAR TEMOVATE temozolomide TENEX tenofovir TENORETIC TENORMIN TERAZOL 3/ terazosin , 50 terbinafine , 28 terbutaline terconazole teriflunomide teriparatide inj TESSALON testosterone testosterone cypionate testosterone enanthate tetrabenazine tetracycline

83 Index of s tetrahydrozoline/zinc sulfate 35 TEV-TROPIN THEO THEOCHRON theophylline THEOPHYLLINE theophylline ext-rel THEOPHYLLINE EXT-REL 46 thiethylperazine thioguanine THIOGUANINE thioridazine thiothixene THORAZINE THYROLAR tiagabine TIAZAC Tigan tikosyn TILADE timolol timolol hemihydrate timolol maleate , 36 TIMOPTIC timoptic xe TINACTIN , 53 tiotropium tipranavir TIVICAY tizanidine TOBRADEX tobramycin , 51 tobramycin/dexamethasone 35 TOBREX TOFRANIL tolazamide tolbutamide ALL CAPS = Brand-name drug Lower case = Generic drug tolbutamide tolcapone TOLINASE tolnaftate , 53 tolterodine TOPAMAX TOPAMAX SPRINKLE topical antibacterials topiramate topiramate sprinkle caps.. 15 TOPROL XL Toradol TORECAN toremifene TRACLEER tramadol trametinib TRANDATE tranexamic acid TRANXENE tranylcypromine trazodone TRENTAL tretinoin , 16 triamcinolone triamcinolone acetonide.. 17 triamcinolone nasal spray.. 20 triamterene/ hydrochlorothiazide TRIAVIL triazolam tri-fed x trifluoperazine trifluridine trihexyphenidyl TRILAFON TRILEPTAL TRILISATE , 31 TRILYTE trimethobenzamide trimethoprim TRIMETHOPRIM TRI-NORINYL TRIOTANN TRIOTANN PEDIATRIC SUSP tripolidine/ pseudoephedrine..20, 45 triprol/pse syp Tri RX TRI-VI-FLOR Tri-Vi-Sol , 56 TRIVORA TRIZIVIR Trojan trospium TRUSOPT Trust Natalcare Pak DHA TRUVADA T-STAT TUDORZA PRESSAIR Tums , 55 TUSSI 12D S TUSSI-12 S tussin dm Twinject TYKERB Tylenol , 31, 55 TYLENOL w/codeine.. 12 TYLOX u Uloric ultivitamins/fluoride/±iron.. 48

84 Index of s Ultram uni-hist dro UNIPHYL urea 40% Urea 40% cream and lotion URECHOLINE UREX UROCIT-K UROXATRAL URSO ursodiol URSO FORTE Utira C v vaginal products valacyclovir VALCYTE valganciclovir VALIUM , 37 valproic acid Valtrex VANCOCIN VANCOCIN HCl vancomycin vancomycin HCl vandetanib Vandetanib varenicline VASERETIC VASOCIDIN VASOCLEAR VASOCLEAR A VASOSULF VASOTEC vectical VEETIDS vemurafenib venlafaxine venlafaxine XR VENTOLIN HFA VEPESID verapamil , 14 verapamil ext-rel VESANOID VEXOL 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 , 56 vitamins pediatric vitamins pediatric members <3 years old vitamins prenatal Vitaphil VITUSSIN VOLTAREN , 31, 35 VOLTAREN 1% TOPICAL GEL VOLTAREN XR vorinostat VOSOL HC OTIC VOSOL OTIC Votrient VYTORIN Vyvanse w warfarin WELLBUTRIN WELLBUTRIN SR WELLBUTRIN XL WYTENSIN x XALATAN XALKORI XANAX XARELTO XELODA XENAZINE XOLAIR XOPENEX Respules XYLOCAINE , 21 XYZAL ALL CAPS = Brand-name drug Lower case = Generic drug 77

85 Index of s z zalcitabine zaleplon ZANAFLEX zanamivir ZANTAC ZARONTIN ZAROXOLYN ZEBETA ZELBORAF zenpep ZERIT ZESTORETIC ZESTRIL ZIAC ZIAGEN zidovudine zinc ziprasidone ZITHROMAX ZOCOR ZOFRAN ZOFRAN ODT ZOLINZA ZOLOFT zolpidem ZONEGRAN zonisamide Zortress ZOVIA 1/ ZOVIA 1/ Zovirax ZYLOPRIM ZYMAR ZYPREXA zyrtec , 53 ZYRTEC CHEWABLE TABLET zyrtec d ZYRTEC-D ZYTIGA ZYVOX ALL CAPS = Brand-name drug Lower case = Generic drug 78

86 Notes 79

87 My Medications worksheet Take this worksheet with you each time you visit a doctor. Each of your doctors should be aware of every drug you take and you should have a list as well. Name of Medicine and Strength Tier I Take This Medicine For Directions Doctor Example: Lisinopril, 20mg Tier 1 High blood pressure One tablet daily Dr. Johnson 80

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