2015 Rx Preferred Drug Guide (3-Tier) Please bring this guide with you to your next doctor visit.

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1 2015 Rx Preferred Drug Guide (3-Tier) Please bring this guide with you to your next doctor visit (Ed. 10/2014)

2 Do you have questions? Call Assurant Health Customer Service at the phone number printed on the back of your medical identification card. Dear Member, To help you know how drugs are covered by your plan, we are pleased to provide you with a copy of our 2015 Rx Preferred Drug Guide. This document provides helpful information on the Assurant Rx Preferred Drug Guide and your pharmacy benefit plan. You may want to take this guide with you when you see your doctor to talk about what is covered under your plan. Many commonly prescribed drugs are listed in this guide. Please remember this is not a complete list of drugs covered under your plan. Because thousands of drugs are included in your pharmacy benefits plan, we only list the most commonly prescribed ones. Most injectable medications are not covered under the prescription drug benefit but paid subject to the cost-sharing requirements (e.g. deductible and coinsurance) that apply to other medical services. Wellness: If required by applicable law, certain medications that are deemed wellness benefits are provided with no cost-sharing to members. Please note that not all drugs listed in this guide are covered by all pharmacy benefit programs. Check your benefit materials or contact Assurant Health by calling the number on the back of your medical identification card to determine if a drug would be covered. Where required by applicable law, members who have coverage for medications which have changed status including tier (i.e drug changed from P (preferred) to NP (non-preferred) on the Rx Preferred Drug Guide, Prior Authorization List, Step Therapy List, or Quantity Limit during the plan year, will continue to have those medications covered at the same benefit level under their plan prior to the addition, removal or change, until January 1st of the following calendar year. 2

3 What is the Assurant Rx Preferred Drug Guide? Our Rx Preferred Drug Guide is meant to give you a general view of drugs covered by your plan. Changes to the list are based on the latest medical findings as well as information from the Food and Drug Administration (FDA) and drug makers. This list includes both brand-name and generic drugs and is updated regularly. Assurant will generally cover the drugs listed on our Rx Preferred Drug Guide as long as they are medically necessary and plan rules are followed. Coverage is not limited to drugs on the Rx Preferred Drug Guide. Your plan has different copay or coinsurance tiers for generic, brandname, preferred and non-preferred drugs. Usually, preferred drugs are covered at a lower copay or coinsurance tier, which means you pay less out of pocket for those drugs. The Rx Preferred Drug Guide is subject to change without notice. Drugs on the list are based on reliable medical data, safety and cost. When you talk to your doctor about what drug may be right for you, it is important to remember that you and your doctor are responsible for making the final decision on your drug therapy. Why is the Rx Preferred Drug Guide subject to change? During the year, we may add or remove drugs from the Rx Preferred Drug Guide. These changes happen for various reasons and may move a drug from one coverage tier to another. As brand-name drugs lose their patents, generic versions may become available. When this happens, the brand-name drug may move to a higher copayment or coinsurance tier. The generic drug may be added to the list and available at a lower copayment or coinsurance tier. The FDA approves many new drugs throughout the year. Your plan generally covers new FDA-approved drugs; however, you may pay a higher copayment or coinsurance tier for these drugs. The new drug(s) also may be subject to prior authorization or step-therapy requirements. Some drugs may also no longer require a prescription. If your drug becomes available over-the-counter (OTC), the drug will generally no longer be covered under your prescription plan. If the FDA removes a drug from the market it will also no longer be covered under your prescription plan. 3

4 Why do some drugs have quantity limits? Your plan may limit the amount of a drug you can receive at one time. These limits help your doctor and pharmacist check that the drugs are used appropriately while promoting patient safety. We use medical guidelines, FDA approval and guidance from drug makers to set these coverage limits. The quantity limits program includes: Dose Efficiency Edits Limits coverage of prescriptions to one dose per day for drugs that are approved for once-daily dosing. Maximum Daily Dose A message is sent to the pharmacy if a prescription is higher than the maximum allowed dose. Quantity Limits Over Time Limits coverage of prescriptions to a specific number of units in a defined amount of time. To get coverage for amounts over the allowed quantity, you, your doctor or the person you appoint to manage your care must request a coverage override by calling the phone number located on your ID card. The quantity limit list is subject to change. What is step-therapy? With step-therapy you must try one or more alternate drugs before your plan will cover a step-therapy drug. These drugs are FDA-approved, treat the same condition(s) and, they may also be available to you at a lower copay or coinsurance tier. If it is necessary for you to use a drug on the step therapy list, you, your doctor, or the person you appoint to manage your care may request a coverage override by calling the phone number located on your ID card. What is the Prior Authorization program? The Prior Authorization program encourages appropriate and cost-effective use of drugs by allowing coverage only when certain conditions are met. A physician, a patient, or a person appointed to manage the patient s care must request prior authorization before drugs on the Prior Authorization List may be covered under a member s pharmacy benefits plan. If the request is approved, the drug will then be covered at the applicable costs associated with the member s plan. The Prior Authorization program is based upon current medical findings, FDAapproved manufacturer labeling information, and cost. To determine if a drug requires prior authorization, refer to the column titled Prior Authorization next to the list of drugs in this guide. The list of drugs requiring prior authorization is subject to change. 4

5 To initiate a prior authorization request: Call the phone number on the back of the member identification card to obtain more information on the prior authorization review process. What are generic drugs? Drug manufacturers develop and release new drugs under a brand name. When the patent expires, other manufacturers are then able to make duplicate versions of the same drug. Generic drugs are chemically the same as their branded counterparts. They are also the same in dosage, safety, strength, form and intended use. Plus, generics usually cost less than brand-name drugs. Generic drugs are only available after the FDA approves them. When filling your prescription, your pharmacist generally can substitute a generic drug for a brand-name drug when the generic is rated by the FDA as equivalent and also where it is permitted by your doctor and state law. THERAPEUTIC CLASS LIST KEY (on following pages) lower case Generic medication lowest co-payment UPPERCASE Brand-name medication Higher co-payment MED Injectable medication that may be covered under the medical benefit Table of Contents Preferred Drugs by Therapeutic Class Therapeutic Class Page(s) *ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS* 8 *AMEBICIDES* 9 *AMINOGLYCOSIDES 9 *ANALGESICS - ANTI-INFLAMMATORY* 9 *ANALGESICS - NONNARCOTIC* 11 *ANALGESICS - OPIOID* 12 *ANDROGENS-ANABOLIC* 14 *ANORECTAL AGENTS* 15 *ANTHELMINTICS* 15 *ANTIANGINAL AGENTS* 16 5

6 *ANTIANXIETY AGENTS* 16 *ANTIARRHYTHMICS* 17 *ANTIASTHMATIC AND BRONCHODILATOR AGENTS* 17 *ANTICOAGULANTS* 19 *ANTICONVULSANTS* 19 *ANTIDEPRESSANTS* 22 *ANTIDIABETICS* 24 *ANTIDIARRHEALS* 27 *ANTIDOTES* 27 *ANTIEMETICS* 27 *ANTIFUNGALS* 28 *ANTIHISTAMINES* 28 *ANTIHYPERLIPIDEMICS* 29 *ANTIHYPERTENSIVES* 31 *ANTI-INFECTIVE AGENTS - MISC.* 34 *ANTIMALARIALS* 35 *ANTIMYASTHENIC/CHOLINERGIC AGENTS* 35 *ANTIMYCOBACTERIAL AGENTS* 35 *ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES* 35 *ANTIPARKINSON AGENTS* 39 *ANTIPSYCHOTICS/ANTIMANIC AGENTS* 40 *ANTIVIRALS* 42 *ASSORTED CLASSES* 44 *BETA BLOCKERS* 46 *BIOLOGICALS MISC* 46 *CALCIUM CHANNEL BLOCKERS* 47 *CARDIOTONICS* 48 *CARDIOVASCULAR AGENTS - MISC.* 48 *CEPHALOSPORINS* 49 *CONTRACEPTIVES* 49 *CORTICOSTEROIDS* 53 *COUGH/COLD/ALLERGY* 54 *DERMATOLOGICALS* 56 *DIAGNOSTIC PRODUCTS* 66 *DIGESTIVE AIDS* 67 *DIURETICS* 67 *ENDOCRINE AND METABOLIC AGENTS - MISC.* 68 *ESTROGENS* 71 *FLUOROQUINOLONES* 72 *GASTROINTESTINAL AGENTS - MISC.* 73 *GENERAL ANESTHETICS* 74 *GENITOURINARY AGENTS - MISCELLANEOUS* 74 6

7 *GOUT AGENTS* 76 *HEMATOLOGICAL AGENTS - MISC.* 76 *HEMATOPOIETIC AGENTS* 78 *HEMOSTATICS* 78 *HYPNOTICS* 79 *LAXATIVES* 79 *MACROLIDES* 80 *MEDICAL DEVICES* 80 *MIGRAINE PRODUCTS* 81 *MINERALS& ELECTROLYTES* 82 *MOUTH/THROAT/DENTAL AGENTS* 83 *MUSCULOSKELETAL THERAPY AGENTS* 84 *NASAL AGENTS - SYSTEMIC AND TOPICAL* 85 *NEUROMUSCULAR AGENTS* 85 *OPHTHALMIC AGENTS* 85 *OTIC AGENTS* 90 *OXYTOCICS* 91 *PASSIVE IMMUNIZING AGENTS* 91 *PENICILLINS* 92 *PROGESTINS* 93 *PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.* 93 *RESPIRATORY AGENTS - MISC.* 95 *TETRACYCLINES* 95 *THYROID AGENTS* 96 *ULCER DRUGS* 96 *URINARY ANTI-INFECTIVES* 98 *URINARY ANTISPASMODICS* 99 *VAGINAL PRODUCTS* 99 *VASOPRESSORS* 100 *VITAMINS* 100 Medication Name *ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS* *Amphetamines** - *Amphetamine Mixtures*** 3-Tier G = Generic P = Preferred Brand NP = Non Preferred Brand MED = Medical Benefit Prior Authorization Step Therapy Quantity Limit 7

8 ADDERALL NP N Y Y ADDERALL XR CAPSULE NP N Y Y amphetamine-dextroamphet ER G N N Y amphetamine-dextroamphetamine G N N Y *Amphetamines** - *Amphetamines*** DESOXYN NP N Y Y DEXEDRINE NP N Y Y dextroamphetamine G N N Y dextroamphetamine ER G N N Y dextroamphetamine sulfate solution G N N Y methamphetamine G N N Y PROCENTRA NP N Y Y VYVANSE P N N Y zenzedi G N N Y *Analeptics** - *Analeptics*** CAFCIT NP N N Y caffeine citrate solution G N N Y *Attention-Deficit/Hyperactivity Disorder (ADHD) Agents** -*ADHD Agent - Selective Alpha Adrenergic Agonists*** clonidine ER G N N Y INTUNIV NP N Y Y KAPVAY NP N Y Y *Attention-Deficit/Hyperactivity Disorder (ADHD) Agents** -*ADHD Agent - Selective Norepinephrine Reuptake Inhibitor*** STRATTERA P N N Y *Stimulants - Misc.** - *Stimulants - Misc.*** CONCERTA NP N Y Y DAYTRANA NP N Y Y dexmethylphenidate G N N Y dexmethylphenidate ER G N N Y FOCALIN NP N Y Y FOCALIN XR NP N Y Y METADATE CD NP N Y Y metadate ER G N N Y methylin ER G N N Y methylin solution NP N Y Y methylin TABLET G N N Y METHYLIN TABLET CHEWABLE NP N Y Y methylphenidate solution G N N Y methylphenidate ER G N N Y methylphenidate ER (CD) G N N Y methylphenidate ER (LA) G N N Y 8

9 methylphenidate tablet G N N Y modafinil G Y N Y NUVIGIL NP Y N Y PROVIGIL NP Y N Y QUILLIVANT XR NP N Y Y RITALIN LA NP N Y Y RITALIN SR NP N Y Y *AMEBICIDES* *Amebicides** - *Amebicides*** YODOXIN NP N N Y *AMINOGLYCOSIDES* *Aminoglycosides** - *Aminoglycosides*** BETHKIS NP Y N Y NEO-FRADIN NP N N Y neomycin G N N Y paromomycin G N N Y TOBI NP Y N Y TOBI PODHALER P Y N Y tobramycin inhalation solution G Y N Y *ANALGESICS - ANTI-INFLAMMATORY* *Antirheumatic- Enzyme Inhibitors** -*Antirheumatic- Janus Kinase (JAK) Inhibitors*** XELJANZ NP Y N Y *Antirheumatic Antimetabolites** -*Antirheumatic Antimetabolites*** OTREXUP MED Y N Y RHEUMATREX NP N N Y RASUVO MED Y N Y *Anti-TNF-alpha - Monoclonal Antibodies** -*Anti-TNF-alpha- Monoclonal Antibodies*** HUMIRA MED Y N Y *Anti-TNF-alpha - Monoclonoal Antibodies** -*Anti-TNF-alpha - Monoclonoal Antibodies*** SIMPONI MED Y N Y SIMPONI ARIA MED Y N Y STELARA MED Y N Y *Gold Compounds** - *Gold Compounds*** RIDAURA NP N N Y *Interleukin-1 Blockers** - *Interleukin-1 Blockers*** ARCALYST MED Y N Y *Interleukin-1 Receptor Antagonist (IL-1Ra)**-*Interleukin-1 Receptor Antagonist (IL-1Ra)*** KINERET MED Y N Y 9

10 *Interleukin-1beta Blockers** - *Interleukin-1beta Blockers*** ILARIS MED Y N Y *Interleukin-6 Receptor Inhibitors** -*Interleukin-6 Receptor Inhibitors*** ACTEMRA MED Y N Y *Nonsteroidal Anti-inflammatory Agents (NSAIDs)**- *Cyclooxygenase 2 (COX-2) Inhibitors*** CELEBREX NP N N Y *Nonsteroidal Anti-inflammatory Agents (NSAIDs)**- *Nonsteroidal Anti-inflammatory Agent Combinations*** ARTHROTEC NP N N Y diclofenac-misoprostol G N N Y DUEXIS NP N Y Y VIMOVO P N Y Y *Nonsteroidal Anti-inflammatory Agents (NSAIDs)**- *Nonsteroidal Anti-inflammatory Agents (NSAIDs)*** ANAPROX NP N N Y ANAPROX DS NP N N Y CATAFLAM NP N N Y DAYPRO NP N N Y diclofenac potassium G N N Y diclofenac sodium G N N Y diclofenac sodium ER NP N N Y EC-NAPROSYN NP N N Y etodolac G N N Y etodolac ER G N N Y FELDENE NP N N Y flurbiprofen G N N Y ibuprofen G N N Y INDOCIN NP N N Y indomethacin G N N Y indomethacin ER G N N Y ketoprofen G N N Y ketorolac G N N Y mefenamic acid G N N Y meloxicam G N N Y MOBIC NP N N Y nabumetone G N N Y NALFON NP N N Y NAPRELAN NP N N Y NAPROSYN NP N N Y naproxen G N N Y naproxen delayed release G N N Y 10

11 naproxen sodium G N N Y oxaprozin G N N Y piroxicam G N N Y PONSTEL NP N N Y SPRIX NP N N Y sulindac G N N Y tolmetin G N N Y VOLTAREN-XR NP N N Y ZIPSOR NP N N Y ZORVOLEX NP N Y Y *Phosphodiesterase 4 (PDE4) Inhibitors** -*Phosphodiesterase 4 (PDE4) Inhibitors*** OTEZLA NP Y N Y OTEZLA STARTER PACK NP Y N Y *Pyrimidine Synthesis Inhibitors** - *Pyrimidine Synthesis Inhibitors*** leflunomide G N N Y *Selective Costimulation Modulators** -*Selective Costimulation Modulators*** ORENCIA MED Y N Y *Soluble Tumor Necrosis Factor Receptor Agents** -*Soluble Tumor Necrosis Factor Receptor Agents*** ENBREL MED Y N Y *ANALGESICS - NonNarcotic* *Analgesic Combinations** - *Analgesics-Sedatives*** alagesic capsule G N N Y ALAGESIC LQ SOLUTION NP N N Y anolor 300 CAPSULE MG ORAL G N N Y BUPAP NP N N Y butalbital-acetaminophen G N N Y butalbital-apap-caffeine G N N Y butalbital-asa-caffeine G N N Y capacet G N N Y EQUAGESIC NP N N Y ESGIC NP N N Y FIORICET NP N N Y FIORINAL NP N N Y margesic G N N Y marten-tab G N N Y ORBIVAN CF NP N N Y REPAN G N N Y TENCON G N N Y ZEBUTAL G N N Y 11

12 *Analgesics-Peptide Channel Blockers** - *Selective N-Type Neuronal Calcium Channel Blockers*** PRIALT MED Y N Y *Salicylates** - *Salicylate Combinations*** choline & mag trisalicylate G N N Y *Salicylates** - *Salicylates*** diflunisal G N N Y MST 600 NP N N Y salsalate G N N Y *ANALGESICS - OPIOID* *Opioid Agonists** - *Opioid Agonists*** ABSTRAL NP Y N Y ACTIQ LOLLIPOP NP Y N Y AVINZA NP N N Y CONZIP NP N N Y DEMEROL NP N N Y DILAUDID NP N N Y DOLOPHINE NP N N Y DURAGESIC NP N N Y EXALGO NP N Y Y fentanyl citrate lollipop G Y N Y fentanyl patch G N N Y FENTORA NP Y N Y hydromorphone G N N Y KADIAN NP N N Y LAZANDA NP Y N Y meperidine G N N Y meperitab G N N Y methadone G N N Y METHADOSE NP N N Y morphine sulfate ER G N N Y MS CONTIN NP N N Y NUCYNTA P N N Y NUCYNTA ER P N N Y OPANA NP N N Y OPANA ER P N N Y OXECTA NP N N Y oxycodone G N N Y OXYCONTIN P N N Y oxymorphone G N N Y oxymorphone ER G N N Y ROXICODONE NP N N Y 12

13 SUBSYS NP Y Y Y tramadol G N N Y tramadol ER G N N Y ULTRAM NP N N Y ULTRAM ER NP N N Y ZOHYDRO ER NP N N Y *Opioid Combinations** - *Codeine Combinations*** acetaminophen-codeine G N N Y ascomp-codeine G N N Y butalbital compound/codeine G N N Y butalbital-apap-caff-codeine G N N Y butalbital-asa-caff-codeine G N N Y CAPITAL/CODEINE P N N Y FIORICET/CODEINE NP N N Y FIORINAL/CODEINE NP N N Y TYLENOL WITH CODEINE NP N N Y *Opioid Combinations** - *Dihydrocodeine Combinations*** SYANLGOS-DC NP N N Y *Opioid Combinations** - *Hydrocodone Combinations*** HYCET NP N N Y hydrocodone-acetaminophen G N N Y hydrocodone-ibuprofen G N N Y IBUDONE NP N N Y LORCET G N N Y LORCET HD G N N Y LORTAB NP N N Y NORCO NP N N Y reprexain G N N Y vicodin G N N Y vicodin es G N N Y vicodin hp G N N Y VICOPROFEN NP N N Y XODOL NP N N Y ZAMICET NP N N Y ZOLVIT NP N N Y *Opioid Combinations** - *Opioid Combinations*** endocet G N N Y endodan G N N Y oxycodone-acetaminophen G N N Y oxycodone-aspirin G N N Y oxycodone-ibuprofen G N N Y 13

14 PERCOCET NP N N Y PERCODAN NP N N Y PRIMLEV NP N N Y ROXICET SOLUTION P N N Y roxicet tablet G N N Y XARTEMIS XR NP N N Y *Opioid Combinations** - *Tramadol Combinations*** tramadol-acetaminophen G N N Y ULTRACET NP N N Y *Opioid Partial Agonists** - *Opioid Partial Agonists*** BUNAVAIL NP Y Y Y buprenorphine sublingual G Y N Y buprenorphine-naloxone sublingual G Y N Y butorphanol nasal spray G N N Y BUTRANS PATCH P N N Y SUBOXONE FILM NP Y N Y SUBOXONE TABLET NP Y N Y ZUBSOLV TABLET NP Y Y Y *ANDROGENS-ANABOLIC* *Anabolic Steroids** - *Anabolic Steroids*** ANADROL-50 NP Y N Y OXANDRIN NP Y N Y oxandrolone G Y N Y *Androgens** - *Androgens*** ANDRODERM NP Y Y Y ANDROGEL P Y N Y ANDROID P Y N Y androxy G Y N Y AXIRON NP Y Y Y danazol G N N Y FIRST TESTOSTERONE CREAM NP Y Y Y FIRST TESTOSTERONE OINTMENT NP Y Y Y FORTESTA NP Y Y Y METHITEST P Y N Y STRIANT NP Y Y Y TESTIM P Y N Y testosterone gel G Y N Y VOGELXO NP Y Y Y AVEED MED Y N Y *ANORECTAL AGENTS* *Intrarectal Steroids** - *Intrarectal Steroids*** 14

15 colocort G N N Y CORTENEMA NP N N Y CORTIFOAM NP N N Y hydrocortisone enema G N N Y *Rectal Combinations** - *Rectal Anesthetic/Steroids*** ANALPRAM-HC NP N N Y HC pram G N N Y hydrocortisone-pramoxine G N N Y lidazone HC G N N Y lidocaine-hydrocortisone G N N Y lidocort KIT G N N Y pramcort G N N Y PROCORT NP N N Y PROCTOFOAM HC NP N N Y *Rectal Steroids** - *Rectal Steroids*** anucort-hc G N N Y ANUSOL-HC 2.5 % NP N N Y GRx hicort G N N Y hemorrhoidal-hc G N N Y hemril-30 G N N Y hydrocortisone acetate suppository G N N Y proctocare-hc G N N Y proctocream HC G N N Y procto-pak G N N Y proctosol HC G N N Y proctozone-hc G N N Y rectacort-hc G N N Y *Vasodilating Agents** - *Nitrate Vasodilating Agents*** RECTIV NP N N Y *ANTHELMINTICS* *Anthelmintics** - *Anthelmintics*** ALBENZA NP N N Y BILTRICIDE NP N N Y STROMECTOL NP N N Y *ANTIANGINAL AGENTS* *Antianginals-Other** - *Antianginals-Other*** RANEXA P N Y Y *Nitrates** - *Nitrates*** DILATRATE-SR NP N N Y IMDUR NP N N Y isochron G N N Y 15

16 isoditrate ER G N N Y ISORDIL NP N N Y isosorbide dinitrate G N N Y isosorbide dinitrate ER G N N Y isosorbide mononitrate G N N Y isosorbide mononitrate ER G N N Y minitran G N N Y NITRO-BID NP N N Y NITRO-DUR NP N N Y nitroglycerin ER G N N Y nitroglycerin patch G N N Y nitroglycerin translingual spray G N N Y NITROLINGUAL SPRAY NP N N Y NITROMIST SPRAY NP N N Y NITROSTAT P N N Y nitro-time G N N Y *ANTIANXIETY AGENTS* *Antianxiety Agents - Misc.** - *Antianxiety Agents - Misc.*** buspirone G N N Y hydroxyzine HCL syrup G N N Y hydroxyzine HCL tablet G N N Y hydroxyzine pamoate G N N Y meprobamate G N N Y VISTRIL NP N N Y *Benzodiazepines** - *Benzodiazepines*** alprazolam G N N Y alprazolam dispersible tablet G N N Y alprazolam ER G N N Y ALPRAZOLAM INTENSOL CONCENTRATE NP N N Y alprazolam XR G N N Y ATIVAN NP N N Y chlordiazepoxide G N N Y clorazepate G N N Y diazepam G N N Y DIAZEPAM INTENSOL CONCENTRATE NP N N Y lorazepam G N N Y LORAZEPAM INTENSOL CONCENTRATE NP N N Y lorazepam TABLET 0.5 MG ORAL G N N Y NIRAVAM NP N N Y oxazepam G N N Y TRANXENE-T NP N N Y 16

17 VALIUM NP N N Y XANAX NP N N Y XANAX XR NP N N Y *ANTIARRHYTHMICS* *Antiarrhythmics Type I-A** - *Antiarrhythmics Type I-A*** disopyramide G N N Y NORPACE NP N N Y NORPACE CR NP N N Y quinidine gluconate ER G N N Y quinidine sulfate G N N Y *Antiarrhythmics Type I-B** - *Antiarrhythmics Type I-B*** mexiletine G N N Y *Antiarrhythmics Type I-C** - *Antiarrhythmics Type I-C*** flecainide G N N Y propafenone G N N Y propafenone ER G N N Y RYTHMOL NP N N Y RYTHMOL SR NP N N Y *Antiarrhythmics Type III** - *Antiarrhythmics Type III*** amiodarone G N N Y CORDARONE NP N N Y MULTAQ P N N Y pacerone G N N Y TIKOSYN NP Y N Y *ANTIASTHMATIC AND BRONCHODILATOR AGENTS* *Antiasthmatic- Monoclonal Antibodies** -*Anti-IgE Monoclonal Antibodies*** XOLAIR MED Y N Y *Anti-Inflammatory Agents** - *Anti-Inflammatory Agents*** cromolyn sodium concentrate G N N Y *Asthma and Bronchodilator Agent Combinations** -*Xanthine- Expectorants*** difil-g forte G N N Y *Bronchodilators- Anticholinergics** -*Bronchodilators- Anticholinergics*** ATROVENT HFA NP N N Y ipratropium inhalation solution G N N Y SPIRIVA HANDIHALER P N N Y TUDORZA PRESSAIR NP N Y Y *Leukotriene Modulators** - *5-Lipoxygenase Inhibitors*** ZYFLO CR TABLET EXTENDED RELEASE 12 HR NP N N Y ZYFLO TABLET NP N N Y 17

18 *Leukotriene Modulators** - *Leukotriene Receptor Antagonists*** ACCOLATE TABLET NP N N Y montelukast G N N Y SINGULAIR NP N N Y zafirlukast G N N Y *Selective Phosphodiesterase 4 (PDE4) Inhibitors** -*Selective Phosphodiesterase 4 (PDE4) Inhibitors*** DALIRESP NP N Y Y *Steroid Inhalants** - *Steroid Inhalants*** AEROSPAN NP N Y Y ALVESCO NP N Y Y ASMANEX P N N Y budesonide inhalation suspension G N N Y FLOVENT DISKUS P N N Y FLOVENT HFA P N N Y PULMICORT FLEXHALER NP N Y Y PULMICORT INHALATION SUSPENSION NP N N Y QVAR P N N Y *Sympathomimetics** - *Adrenergic Combinations*** ADVAIR DISKUS P N N Y ADVAIR HFA P N N Y ANORO ELLIPTA NP N Y Y BREO ELLIPTA NP N Y Y COMBIVENT RESPIMAT P N N Y DULERA AEROSOL P N N Y DUONEB INHALATION SOLUTION NP N N Y ipratropium-albuterol inhalation solution G N N Y SYMBICORT P N N Y *Sympathomimetics** - *Beta Adrenergics*** albuterol sulfate ER tablet G N N Y albuterol sulfate inhalation solution G N N Y albuterol sulfate syrup G N N Y albuterol sulfate tablet G N N Y ARCAPTA NEOHALER NP N Y Y BROVANA NP N Y Y FORADIL P N N Y levalbuterol inhalation solution G N N Y PERFOROMIST NP N Y Y PROAIR HFA P N N Y PROVENTIL HFA NP N Y Y SEREVENT DISKUS P N N Y terbutaline sulfate G N N Y 18

19 VENTOLIN HFA P N N Y VOSPIRE ER NP N N Y XOPENEX HFA NP N Y Y XOPENEX INHALATION SOLUTION NP N N Y *Xanthines** - *Xanthines*** ELIXOPHYLLIN NP N N Y LUFYLLIN NP N N Y THEO-24 NP N N Y theochron G N N Y theophylline ER G N N Y theophylline solution G N N Y *ANTICOAGULANTS* *Coumarin Anticoagulants** - *Coumarin Anticoagulants*** COUMADIN NP N N Y jantoven G N N Y warfarin G N N Y *Direct Factor Xa Inhibitors** - *Direct Factor Xa Inhibitors*** ELIQUIS P N N Y XARELTO P N N Y *Heparins And Heparinoid-Like Agents** -*Low Molecular Weight Heparins*** enoxaparin G N N Y FRAGMIN NP N N Y LOVENOX NP N N Y *Heparins And Heparinoid-Like Agents** -*Synthetic Heparinoid-Like Agents*** ARIXTRA NP N N Y fondaparinux G N N Y *Thrombin Inhibitors** - *Thrombin Inhibitors - Hirudin Type*** IPRIVASK NP N N Y *Thrombin Inhibitors** -*Thrombin Inhibitors - Selective Direct & Reversible*** PRADAXA P N N Y *ANTICONVULSANTS* *AMPA Glutamate Receptor Antagonists** -*AMPA Glutamate Receptor Antagonists*** FYCOMPA NP N N Y *Anticonvulsants - Benzodiazepines** -*Anticonvulsants- Benzodiazepines*** clonazepam G N N Y clonazepam dispersible tablet G N N Y DIASTAT ACUDIAL NP N N Y KLONOPIN NP N N Y 19

20 ONFI NP N N Y *Anticonvulsants - Misc.** - *Anticonvulsants - Misc.*** APTIOM NP N N Y BANZEL NP N N Y carbamazepine chewable tablet G N N Y carbamazepine ER G N N Y carbamazepine suspension G N N Y carbamazepine tablet G N N Y CARBATROL NP N N Y epitol G N N Y gabapentin G N N Y KEPPRA SOLUTION NP N N Y KEPPRA TABLET NP N N Y KEPPRA XR NP N N Y LAMICTAL NP N N Y LAMICTAL CHEWABLE TABLET NP N N Y LAMICTAL ODT NP N N Y LAMICTAL ODT KIT NP N N Y LAMICTAL STARTER KIT NP N N Y LAMICTAL XR NP N N Y LAMICTAL XR KIT NP N N Y lamotrigine G N N Y lamotrigine chewable tablet G N N Y lamotrigine ER G N N Y levetiracetam G N N Y levetiracetam ER G N N Y levetiracetam solution G N N Y LYRICA NP N Y Y MYSOLINE NP N N Y NEURONTIN NP N N Y NEURONTIN SOLUTION NP N N Y oxcarbazepine G N N Y oxcarbazepine suspension G N N Y OXTELLAR XR NP N N Y POTIGA TABLET NP N N Y primidone G N N Y ropiramate G N N Y TEGRETOL NP N N Y TEGRETOL SUSPENSION NP N N Y TEGRETOL-XR NP N N Y TOPAMAX NP N N Y 20

21 TOPAMAX SPRINKLE NP N N Y topiragen G N N Y topiramate sprinkle G N N Y TRILEPTAL SUSPENSION NP N N Y TRILEPTAL TABLET NP N N Y TROKENDI XR NP N Y Y VIMPAT NP N N Y ZONEGRAN NP N N Y zonisamide G N N Y *Carbamates** - *Carbamates*** felbamate G N N Y felbamate suspension G N N Y FELBATOL SUSPENSION NP N N Y FELBATOL TABLET NP N N Y *GABA Modulators** - *GABA Modulators*** GABATRIL NP N N Y SABRIL PACKET NP Y N Y SABRIL TABLET NP Y N Y tiagabine G N N Y *Hydantoins** - *Hydantoins*** DILANTIN NP N N Y DILANTIN INFATABS NP N N Y DILANTIN SUSPENSION NP N N Y PEGANONE NP N N Y PHENYTEK NP N N Y phenytoin chewable G N N Y phenytoin ER G N N Y phenytoin infatabs G N N Y phenytoin suspension G N N Y *Succinimides** - *Succinimides*** CELONTIN NP N N Y ethosuximide G N N Y ethosuximide solution G N N Y ZARONTIN NP N N Y ZARONTIN SOLUTION NP N N Y *Valproic Acid** - *Valproic Acid*** DEPAKENE NP N N Y DEPAKENE SYRUP NP N N Y DEPAKOTE DR NP N N Y DEPAKOTE ER NP N N Y DEPAKOTE SPRINKLES NP N N Y 21

22 divalproex DR G N N Y divalproex ER G N N Y divalproex sprinkle G N N Y STAVZOR NP N N Y valproic acid G N N Y valproic acid solution G N N Y valproic acid syrup G N N Y *ANTIDEPRESSANTS* *Alpha-2 Receptor Antagonists (Tetracyclics)**- *Alpha-2 Receptor Antagonists (Tetracyclics)*** mirtazapine G N N Y REMERON NP N N Y *Antidepressants - Misc.** - *Antidepressants - Misc.*** APLENZIN NP N Y Y budeprion SR G N N Y budeprion XL G N N Y bupropion HCl G N N Y bupropion HCL ER (SR) G N N Y bupropion HCl ER (XL) G N N Y FORFIVO XL NP N Y Y WELLBUTRIN NP N N Y WELLBUTRIN SR NP N N Y WELLBUTRIN XL NP N N Y *Modified Cyclics** - *Modified Cyclics*** BRINTELLIX NP N Y Y VIIBRYD NP N Y Y VIIBRYD KIT NP N Y Y *Monoamine Oxidase Inhibitors (MAOIs)**-*Monoamine Oxidase Inhibitors (MAOIs)*** EMSAM NP N N Y MARPLAN NP N N Y NARDIL NP N N Y PARNATE NP N N Y phenelzine G N N Y tranylcypromine G N N Y *Selective Serotonin Reuptake Inhibitors (SSRIs)**-*Selective Serotonin Reuptake Inhibitors (SSRIs)*** CELEXA NP N N Y citalopram G N N Y citalopram solution G N N Y escitalopram G N N Y fluoxetine G N N Y 22

23 fluoxetine solution G N N Y fluvoxamine G N N Y fluvoxamine ER G N N Y LEXAPRO NP N N Y LUVOX CR NP N N Y paroxetine G N N Y paroxetine ER G N N Y PAXIL NP N N Y PAXIL CR NP N N Y PEXEVA TABLET NP N Y Y PROZAC NP N N Y PROZAC WEEKLY CAPSULE DELAYED RELEASE NP N N Y sertraline G N N Y ZOLOFT NP N N Y fluoxetine delayed release G N N Y *Serotonin Modulators** - *Serotonin Modulators*** nefazodone NP N N Y trazodone G N N Y *Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs)**-*Serotonin- Norepinephrine Reuptake Inhibitors (SNRIs)*** CYMBALTA NP N N Y DESVENLAFAXINE ER TABLET NP N Y Y duloxetine G N N Y EFFEXOR XR NP N N Y FETZIMA NP N Y Y FETZIMA TITRATION PACK NP N Y Y KHEDEZLA NP N Y Y PRISTIQ NP N Y Y venlafaxine G N N Y venlafaxine er capsule G N N Y VENLAFAXINE HCl ER TABLET NP N Y Y *Tricyclic Agents** - *Tricyclic Agents*** amitriptyline G N N Y ANAFRANIL NP N N Y clomipramine G N N Y desipramine G N N Y doxepin G N N Y imipramine hcl G N N Y imipramine pamoate G N N Y NORPRAMIN NP N N Y nortriptyline G N N Y PAMELOR NP N N Y 23

24 protriptyline G N N Y SURMONTIL NP N N Y TOFRANIL NP N N Y TOFRANIL-PM NP N N Y VIVACTIL NP N N Y *ANTIDIABETICS* *Alpha-Glucosidase Inhibitors** - *Alpha-Glucosidase Inhibitors*** acarbose G N N Y GLYSET NP N N Y PRECOSE NP N N Y *Antidiabetic - Amylin Analogs** - *Antidiabetic - Amylin Analogs*** SYMLIN PEN P N N Y *Antidiabetic Combinations** -*Dipeptidyl Peptidase-4 Inhibitor- Biguanide Combinations*** JANUMET P N N Y JANUMET XR P N N Y JENTADUETO P N N Y KAZANO NP N Y Y KOMBIGLYZE XR P N N Y *Antidiabetic Combinations** -*DPP-4 Inhibitor-Thiazolidinedione Combinations*** OSENI NP N Y Y *Antidiabetic Combinations** -*Meglitinide-Biguanide Combinations*** PRANDIMET NP N N Y *Antidiabetic Combinations** -*Sulfonylurea-Biguanide Combinations*** glipizide-metformin G N N Y GLUCOVANCE NP N N Y glyburide-metformin G N N Y *Antidiabetic Combinations** -*Sulfonylurea-Thiazolidinedione Combinations*** AVANDARYL NP N N Y DUETACT NP N N Y pioglitazone-glimepiride G N N Y *Antidiabetic Combinations** -*Thiazolidinedione-Biguanide Combinations*** ACTOPLUS MET NP N N Y ACTOPLUS MET XR NP N N Y AVANDAMET NP N N Y pioglitazone-metformin G N N Y *Biguanides** - *Biguanides*** GLUCOPHAGE NP N N Y GLUCOPHAGE XR NP N N Y 24

25 GLUMETZA NP N N Y metformin G N N Y metformin ER G N N Y RIOMET NP N N Y *Diabetic Other** - *Diabetic Other*** GLUCAGEN NP N N Y GLUCAGON NP N N Y PROGLYCEM P N N Y *Diabetic Other** - *Progesterone Receptor Antagonists*** KORLYM NP Y N Y *Dipeptidyl Peptidase-4 (DPP-4) Inhibitors** -*Dipeptidyl Peptidase-4 (DPP-4) Inhibitors*** JANUVIA P N N Y NESINA NP N Y Y ONGLYZA P N N Y TRADJENTA P N N Y *Dopamine Receptor Agonists - Antidiabetic** -*Dopamine Receptor Agonists - Ergot Derivatives*** CYCLOSET P N N Y *Incretin Mimetic Agents (GLP-1 Receptor Agonists)** -*Incretin Mimetic Agents (GLP-1 Receptor Agonists)*** BYDUREON P N N Y BYETTA NP N N Y TANZEUM NP N Y Y VICTOZA P N N Y TRULICITY NP N Y Y *Insulin Sensitizing Agents** - *Thiazolidinediones*** ACTOS NP N N Y AVANDIA NP N N Y pioglitazone G N N Y *Insulin** - *Human Insulin*** APIDRA NP N N Y APIDRA SOLOSTAR NP N N Y HUMALOG KWIKPEN P N N Y HUMALOG MIX 50/50 P N N Y HUMALOG MIX 50/50 KWIKPEN P N N Y HUMALOG MIX 50/50 PEN P N N Y HUMALOG MIX 75/25 P N N Y HUMALOG Mix 75/25 KWIKPEN P N N Y HUMALOG MIX 75/25 PEN P N N Y HUMALOG PEN P N N Y HUMULIN 70/30 KWIKPEN P N N Y 25

26 HUMULIN 70/30 PEN P N N Y HUMULIN N KWIKPEN P N N Y HUMULIN N Pen P N N Y HUMULIN R U-500 P N N Y LANTUS P N N Y LANTUS SOLOSTAR P N N Y LEVEMIR P N N Y LEVEMIR FLEXPEN P N N Y NOVOLOG P N N Y NOVOLOG FLEXPEN P N N Y NOVOLOG MIX 70/30 * P N N Y NOVOLOG MIX 70/30 FLEXPEN P N N Y *Meglitinide Analogues** - *Meglitinide Analogues*** nateglinide G N N Y PRANDIN NP N N Y repaglinide G N N Y STARLIX NP N N Y *Sodium-Glucose Co-Transporter 2 (SGLT2) Inhibitors** -*Sodium- Glucose Co-Transporter 2 (SGLT2) Inhibitors*** FARXIGA NP N Y Y INVOKANA P N Y Y *Sulfonylureas** - *Sulfonylureas*** AMARYL NP N N Y chlorpropamide G N N Y DIABETA NP N N Y glimepiride G N N Y glipizide G N N Y glipizide ER G N N Y glipizide XL G N N Y GLUCOTROL NP N N Y GLUCOTROL XL NP N N Y glyburide G N N Y glyburide micronized G N N Y glycron G N N Y GLYNASE NP N N Y tolazamide G N N Y *ANTIDIARRHEALS* *Antidiarrheal - Chloride Channel Antagonists** -*Antidiarrheal - Chloride Channel Antagonists*** FULYZAQ NP N N Y *Antiperistaltic Agents** - *Antiperistaltic Agents*** diphenatol G N N Y 26

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