Preferred Drug List. New Jersey

Transcription

1 Preferred Drug List New Jersey

2 The Health Republic Insurance Preferred Drug List is a guide to available brand and generic drugs that are approved by the Food and Drug Administration (FDA) and is covered through your prescription drug benefit. Generic drugs have the same active ingredient as their brand name counterparts and should be considered the first line of treatment. If there is no generic available, there may be more than one brand name medication to treat a condition. The preferred brand name medications are listed to help identify prescription drugs that are clinically appropriate, safe and cost effective. When viewed on line from our website, this document represents the most current and up-to-date formulary for Health Republic Insurance of New Jersey. A printed document may not represent the most updated information for your specific prescription benefit plan. For example, your plan may not cover certain products or categories, and certain drugs may or may not have prior authorization rules, step therapy programs, or quantity limits applied to them, regardless of their appearance in this document, as the information may not have been recently updated. Please refer to Health Republic Insurance of New Jersey s website to obtain the most recent full list of medications that may be covered under your benefit. Drug List Key: Brand name drugs are listed in CAPS and generic drugs are lower case. To search for a specific drug in this document, press the Control (Ctrl) and F keys at the same time on your keyboard. Enter the name of the drug, and hit Enter. If you have questions about this list please contact Health Republic at (888)

3 Analgesics, Non Steroidal Anti-inflammatory Drugs CELEBREX 2 ST diclofenac sodium 1 diclofenac w/ misoprostol 1 diflunisal 1 etodolac 1 fenoprofen 1 QLL flurbiprofen 1 ibuprofen 1 indomethacin 1 ketoprofen 1 ketorolac tromethamine 1 QLL meclofen sod 1 mefenamic acid 1 meloxicam 1 nabumetone 1 naproxen 1 oxaprozin 1 piroxicam 1 sulindac 1 tolmetin sod 1 tolmetin sodium 1 Analgesics, Opoid Analgesics, Long-Acting EXALGO 2 fentanyl 1 QLL levorphanol 1 methadone 3 morphine sulfate 1 QLL NUCYNTA 2 QLL PA NUCYNTA ER 2 QLL PA oxycodone-ibuprofen 1 OXYCONTIN CR 2 QLL PA OXYMORPHONE ER 3 PA oxymorphone sr 3 PA tramadol biphasic release 1 QLL tramadol sr 1 QLL Analgesics, Opoid Analgesics, Short-Acting acetaminophen w/ codeine 1 QLL butalbital-aspirin-caff w/ codeine 1 QLL butorphanol tartrate 1 codeine sulf 1 fentanyl citrate 1 QLL hydroco/apap 1 QLL Analgesics, Opoid Analgesics, Short-Acting hydrocodone-acetaminophen 1 QLL hydromorphone 1

4 Analgesics, Opoid Analgesics, Short-Acting hydromorphone preservative free 1 meperidine 1 morphine sulfate 1 nalbuphine 1 oxycodone 1 QLL PA oxycodone w/ acetaminophen 1 QLL PA oxymorphone 1 PA TALWIN 3 tramadol 1 QLL tramadol-acetaminophen 1 QLL Anesthetics, Local Anesthetics lidocaine 1 lidocaine-prilocaine 1 LIDODERM 2 PA SYNERA 3 XYLOCAINE 3 Anti-Addiction/Substance Abuse Treatment Agents, Alcohol Deterrents/Anti-craving CAMPRAL 2 disulfiram 1 naltrexone 1 Anti-Addiction/Substance Abuse Treatment Agents, Opoid Antagonists buprenorphine 1 QLL butrans 1 naloxone 1 SUBOXONE 3 QLL PA Anti-Addiction/Substance Abuse Treatment Agents, Smoking Cessation Agents BUPROBAN 0 CHANTIX 0 QLL COMMIT 0 QLL NICOTINE 0 QLL NICOTROL 0 QLL Antibacterials, Aminoglycosides gentam/nacl 1 gentamicin 1 KANAMYCIN 3 neomycin sulfate 1 TOBI 4 PA

5 Antibacterials, Aminoglycosides TOBRA/NACL 4 PA TOBRADEX 3 tobramycin sulfate 4 PA Antibacterials, Antibacterials, Other ALTABAX 2 BACITRACIN 3 clindamycin 1 clindamycin phosphate 1 CUBICIN 3 LINCOCIN 3 methenamine hippurate 1 metronidazole 1 MONUROL 3 mupirocin 1 neomycin-bacitrac zn-polymyx 1 nitrofurantoin 1 polymyxin b-trimethoprim 1 trimethoprim 1 TYGACIL 3 PA vancomycin 1 VIBATIV 3 XIFAXAN 3 PA ZYVOX 2 QLL ST PA Antibacterials, Beta-lactam, Cephalosporins CEDAX 3 cefaclor 1 cefadroxil 1 cefazolin sodium 1 cefdinir 1 ST cefepime 1 cefoxitin sodium 1 cefpodoxime proxetil 1 cefprozil 1 cefuroxime axetil 1 cefuroxime sodium 1 cephalexin 1 SUPRAX 2 ST Antibacterials, Beta-lactam, Other aztreonam 1 Antibacterials, Beta-lactam, Penicillins amoxicillin 1 amoxicillin & k clavulanate 1 amoxicillin (trihydrate) 1 ampicillin 1

6 Antibacterials, Beta-lactam, Penicillins nafcillin sodium 1 oxacillin sodium 1 penicillin v potassium 1 Antibacterials, Macrolides AZASITE 3 azithromycin 1 QLL clarithromycin 1 DIFICID 2 ERY-TAB 3 ERYTHROMYCIN 3 Antibacterials, Quinolones AVELOX 2 BESIVANCE 3 CIPRO I.V. 3 ciprofloxacin 1 FACTIVE 3 levofloxacin 1 QLL NOROXIN 3 ofloxacin 1 zymaxid 1 Antibacterials, Sulfonamides silver sulfadiazine 1 sulfacetamide sodium 1 sulfadiazine 1 sulfamethoxazole-trimethoprim 1 Antibacterials, Tetracyclines demeclocycline 1 doxycycline hyclate 1 QLL minocycline 1 QLL tetracycline 1 QLL

7 Anticonvulsants, Anticonvulsants, Other levetiracetam 1 QLL POTIGA 3 Anticonvulsants, Calcium Channel Modifying Agents CELONTIN 3 ethosuximide 1 LYRICA 2 PA zonisamide 1 Anticonvulsants, Gamma-aminobutryic Acid (GABA) Augmenting Agents clonazepam 1 QLL DIAZEPAM 3 QLL divalproex sodium 1 gabapentin 1 primidone 1 SABRIL 4 QLL PA tiagabine 1 valproate sodium 1 valproic acid 1 Anticonvulsants, Glutamate Reducing Agents felbamate 1 lamotrigine 1 topiramate 1 Anticonvulsants, Sodium Channel Agents BANZEL 2 QLL carbamazepine 1 DILANTIN 2 oxcarbazepine 1 PEGANONE 3 PHENYTEK 3 phenytoin 1 VIMPAT 3 QLL Antidementia Agents, Antidementia Agents, Other ERGOLOID MES 3 Antidementia Agents, Cholinesterase Inhibitors donepezil hydrochloride 1 QLL galantamine hydrobromide 1 QLL rivastigmine tartrate 1 QLL

8 Antidementia Agents, N-methyl-D-aspartate (NMDA) Receptor Antagonist NAMENDA 2 QLL Antidepressants, Antidepressants, Other ABILIFY 2 QLL PA bupropion 1 mirtazapine 1 NEFAZODONE 3 OLEPTRO 3 SEROQUEL XR 2 PA trazodone 1 VIIBRYD 2 QLL ST Antidepressants, Monoamine Oxidase Inhibitors EMSAM 3 MARPLAN 2 phenelzine sulfate 1 tranylcypromine sulfate 1 Antidepressants, Serotonin/Norepinephring Reuptake Inhibitors citalopram hydrobromide 1 QLL CYMBALTA 2 QLL ST escitalopram oxalate 1 QLL fluoxetine 1 fluvoxamine maleate 1 paroxetine 1 QLL PAXIL 3 PRISTIQ 2 QLL ST sertraline 1 QLL venlafaxine 1 QLL Antidepressants, Tricyclics amitriptyline 1 AMOXAPINE 3 clomipramine 1 desipramine 1 doxepin 1 imipramine 1 nortriptylin 1 PERPHEN/AMIT 3 protriptyline 1 trimipramine maleate 1

9 Antiemetics, Antiemetics, Other chlorpromazine 1 hydroxyzine 1 meclizine 1 metoclopramide 1 perphenazine 1 promethazine 1 trimethobenzamide 1 Antiemetics, Emetogenic Therapy Adjuncts ANZEMET 3 PA CESAMET 3 PA dronabinol 1 EMEND 2 QLL granisetron 1 ondansetron 1 QLL ondansetron 1 QLL Antifungals, Antifungals ciclopirox 1 clotrimazole 1 econazole nitrate 1 ERTACZO 3 EXELDERM 3 fluconazole 1 QLL flucytosine 1 griseofulvin 1 GYNAZOLE-1 3 itraconazole 1 PA ketoconazole 1 MICONAZOLE 3 3 QLL NAFTIN 3 NATACYN 2 NOXAFIL 3 nystatin 1 SPORANOX 3 PA terbinafine 1 terconazole 1 QLL voriconazole 1 Antigout Agents, Antigout Agents allopurinol 1 colchicine w/ probenecid 1 COLCRYS 2 QLL probenecid 1 ULORIC 3 ST

10 Antimigraine Agents, Ergot Alkaloids CAFERGOT 2 dihydroergotamine mesylate 2 ERGOMAR 3 ergotamine w/ caffeine 2 MIGRANAL 2 Antimigraine Agents, Prophylactic timolol mal 1 Antimigraine Agents, Serotonin (5-HT) 1b/1d Receptor Agonists AXERT 3 QLL FROVA 3 QLL naratriptan 1 QLL RELPAX 3 QLL rizatriptan benzoate 1 QLL sumatriptan 1 QLL ZOMIG 2 QLL Antimyasthenic Agents, Parasympathomimetics GUANIDINE 2 MESTINON 2 MYTELASE 3 pyridostigmine bromide 1 Antimycobacterials, Antimycobacterials, Other DAPSONE 3 PA MYCOBUTIN 3 PA Antimycobacterials, Antituberculars CAPASTAT SUL 3 ethambutol 1 isoniazid 1 PASER 3 PRIFTIN 3 pyrazinamide 1 RIFAMATE 3 rifampin 1 RIFATER 3 TRECATOR 3 Antineoplastics, Alkylating Agents ALKERAN 2 BUSULFEX 4 PA CEENU 4 PA

11 Antineoplastics, Alkylating Agents CYCLOPHOSPH 4 PA HEXALEN 4 PA LEUKERAN 4 PA MATULANE 4 PA melphalan 1 MYLERAN 4 PA SEROMYCIN 3 Antineoplastics, Antiangiogenic Agents REVLIMID 4 PA THALOMID 4 PA Antineoplastics, Antiestrogens/Modifiers EMCYT 4 PA FARESTON 2 SOLTAMOX 3 PA tamoxifen citrate 1 Antineoplastics, Antimetabolites DROXIA 4 PA HYDROXYUREA 4 TABLOID 4 PA Antineoplastics, Antineoplastics, Other daunorubicin 4 PA DOXIL 4 PA doxorubicin liposomal 4 PA fludarabine phosphate 4 PA idarubicin 4 PA leucovorin 1 ABRAXANE 4 PA ADCETRIS 4 PA ALIMTA 4 PA ARIMIDEX 4 PA AROMASIN 4 PA ARRANON 4 PA ARZERRA 4 PA BEXXAR 4 PA BICNU 4 PA bleomycin sulfate 4 PA BOSULIF 4 PA CAMPATH 4 PA CAMPTOSAR 4 PA carboplatin 4 PA CASODEX 4 PA

12 Antineoplastics, Antineoplastics, Other CERUBIDINE 4 PA cisplatin 4 PA cladribine 4 PA CLOLAR 4 PA COMETRIQ 4 PA COSMEGEN 4 PA cytarabine 4 PA dacarbazine 4 PA DACOGEN 4 PA dactinomycin 4 PA DAUNOXOME 4 PA DEPOCYT 4 PA DOCEFREZ 4 PA DOCETAXEL 4 PA doxorubicin 4 PA ELLENCE 4 PA ELOXATIN 4 PA ELSPAR 4 PA epirubicin 4 PA ERBITUX 4 PA ERIVEDGE 4 PA ERWINAZE 4 PA FASLODEX 4 PA FEMARA 4 PA floxuridine 4 PA FLUDARA 4 PA fluorouracil 4 PA FOLOTYN 4 PA FUDR 4 PA gemcitabine 4 PA GEMZAR 4 PA HALAVEN 4 PA HYCAMTIN 4 PA HYDREA 4 PA IDAMYCIN PFS 4 PA idarubicin 4 PA IFEX 4 PA IFOSFAMIDE 4 PA irinotecan 4 PA ISTODAX 4 PA IXEMPRA 4 PA JAKAFI 4 PA JEVTANA 4 PA KYPROLIS 4 PA MEGACE 3 mitomycin 4 PA

13 Antineoplastics, Antineoplastics, Other MUSTARGEN 4 PA NAVELBINE 4 PA NIPENT 4 PA OFORTA 4 PA ONCASPAR 4 PA ONTAK 4 PA oxaliplatin 4 PA paclitaxel 4 PA pentostatin 4 PA PERJETA 4 PA PHOTOFRIN 4 PA PROLEUKIN 4 PA PURINETHOL 4 PA RHEUMATREX 4 PA RITUXAN 4 PA STIVARGA 4 PA SYNRIBO 4 PA TAXOTERE 4 PA TEMODAR 4 PA THIOTEPA 4 PA TREANDA 4 PA TREXALL 4 PA TRISENOX 4 PA VALSTAR 4 PA VECTIBIX 4 PA VELCADE 4 PA VIDAZA 4 PA VINBLASTINE 4 PA vincristine sulfate 4 PA vinorelbine tartrate 4 PA VUMON 4 PA XELODA 4 PA XTANDI 4 PA YERVOY 4 PA ZALTRAP 4 PA ZANOSAR 4 PA ZOLADEX 4 PA ZOLINZA 4 PA ZYTIGA 4 PA Antineoplastics, Aromatase Inhibitors, 3rd Generation anastrozole 4 PA exemestane 4 PA letrozole 4 PA

14 Antineoplastics, Enzyme Inhibitors ETOPOPHOS 4 PA etoposide 4 PA topotecan 4 PA Antineoplastics, Molecular Target Inhibitors AFINITOR 4 PA CAPRELSA 4 PA GLEEVEC 4 PA INLYTA 4 PA NEXAVAR 4 PA SPRYCEL 4 PA SUTENT 4 PA TARCEVA 4 PA TASIGNA 4 PA TYKERB 4 PA VOTRIENT 4 PA XALKORI 4 PA ZELBORAF 4 PA ZORTRESS 4 PA Antineoplastics, Monoclonal Antibodies AVASTIN 4 PA HERCEPTIN 4 PA RITUXAN 4 PA Antineoplastics, Retinoids PANRETIN 3 TARGRETIN 4 PA tretinoin 1 Antiparasitics, Anthelmintics ALBENZA 3 PA BILTRICIDE 3 PA STROMECTOL 3 PA Antiparasitics, Antiprotozoals ALINIA 2 atovaq/progu 1 atovaquone-proguanil 1 chloroquine phosphate 1 COARTEM 2 DARAPRIM 3 hydroxychloroquine sulfate 1 mefloquine 1 MEPRON 3

15 Antiparasitics, Antiprotozoals NEBUPENT 3 PENTAM PRIMAQUINE 3 quinine sulfate 1 Antiparasitics, Pediculicides/Scabicides EURAX 3 lindane 3 PA malathion 1 permethrin 1 SKLICE 3 PA ULESFIA 3 Antiparkinson Agents, Anticholinergics benztropine mesylate 1 trihexyphenidyl 1 Antiparkinson Agents, Antiparkinson Agents, Other amantadine 1 COMTAN 2 QLL TASMAR 3 Antiparkinson Agents, Dopamine Agonists APOKYN 4 PA bromocriptine mesylate 1 NEUPRO 2 pramipexole dihydrochloride 1 ropinirole hydrochloride 1 Antiparkinson Agents, Dopamine Precursors/L-Amino Acid Decarboxylase Inhibitors carb/levo 1 carbidopa & levodopa 1 LODOSYN 3 Antiparkinson Agents, Monomine Oxidase B (MAO-B) Inhibitors AZILECT 2 QLL PA selegiline 1 Antipsychotics, 1st Generation/Typical CHLORPROMAZ 3 fluphenazine 1 haloperidol 1 haloperidol decanoate 1

16 Antipsychotics, 1st Generation/Typical loxapine succinate 1 ORAP 3 prochlorperazine 1 thioridazine 1 thiothixene 1 trifluoperazine 1 Antipsychotics, 2nd Generation/Atypical ABILIFY 2 PA FANAPT 2 QLL INVEGA 2 QLL LATUDA 3 olanzapine 1 quetiapine fumarate 1 RISPERDAL 2 risperidone 1 SAPHRIS 2 ziprasidone 1 Antipsychotics, Treatment-Resistant clozapine 1 Antispasticity Agents, Antispasticity Agents baclofen 1 diazepam 1 QLL tizanidine 1 XEOMIN 3 Antivirals, Anti-cytomegalovirus (CMV) Agents FOSCARNET 3 VALCYTE 2 PA Antivirals, Antihepititis Agents BARACLUDE 4 PA EPIVIR HBV 4 PA HEPSERA 4 PA INCIVEK 4 PA INFERGEN 4 PA INTRON-A 4 PA PEGASYS 4 PA PEG-INTRON 4 PA REBETOL 4 PA ribavirin 1 SYLATRON 4 PA TYZEKA 4 PA

17 Antivirals, Antihepititis Agents VICTRELIS 4 PA VIREAD 2 Antivirals, Antiherpetic Agents acyclovir 1 DENAVIR 3 famciclovir 1 QLL valacyclovir 1 QLL ZOVIRAX 3 QLL Antivirals, Anti-HIV Agents, Non-nucleoside Reverse Transcriptase Inhibitors ATRIPLA 2 EDURANT 2 INTELENCE 2 nevirapine 1 RESCRIPTOR 2 SUSTIVA 2 VIRAMUNE XR 2 Antivirals, Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors abacavir sulfate 1 didanosine 1 EMTRIVA 2 EPIVIR 4 PA EPZICOM 2 lamivudine 4 lamivudine-zidovudine 1 retrovir 1 stavudine 1 TRIZIVIR 2 TRUVADA 2 VIREAD 2 zidovudine 1 Antivirals, Anti-HIV Agents, Other FUZEON 4 PA ISENTRESS 2 SELZENTRY 2 Antivirals, Anti-HIV Agents, Protease Inhibitors APTIVUS 2 CRIXIVAN 2

18 Antivirals, Anti-HIV Agents, Protease Inhibitors INVIRASE 2 KALETRA 2 LEXIVA 2 NORVIR 2 PREZISTA 2 REYATAZ 2 VIRACEPT 2 Antivirals, Anti-influenza Agents RELENZA 2 QLL rimantadine hydrochloride 1 TAMIFLU 2 Anxiolytics, Anxiolytics, Other alprazolam 1 QLL buspirone 1 lorazepam 1 QLL meprobamate 1 Bipolar Agents, Mood Stabilizers EQUETRO 3 lithium carbonate 1 lithium citr 1 Blood Glucose Regulators, Antidiabetic Agents acarbose 1 QLL ACTOPLUS MET 2 QLL ACTOS 2 QLL AVANDIA 3 QLL BYETTA 2 QLL chlorpropam 1 QLL CYCLOSET 3 QLL glimepiride 1 QLL glipizide 1 QLL glipizide-metformin 1 QLL glyburide 1 QLL glyburide-metformin 1 QLL GLYSET 3 QLL JANUVIA 2 QLL ST metformin 1 QLL nateglinide 1 QLL ONGLYZA 3 QLL ST PRANDIMET 3 QLL PRANDIN 2 QLL SYMLINPEN 2 QLL PA

19 Blood Glucose Regulators, Antidiabetic Agents SYMLNPEN 2 QLL PA tolazamide 1 QLL tolbutamide 1 QLL TRADJENTA 2 QLL ST VICTOZA 2 QLL ST WELCHOL 2 QLL Blood Glucose Regulators, Glycemic Agents GLUCAGEN 3 QLL GLUCAGON 3 QLL PROGLYCEM 3 QLL Blood Glucose Regulators, Insulins APIDRA 3 QLL HUMALOG 2 QLL HUMULIN 3 QLL LANTUS 3 QLL LEVEMIR 3 QLL NOVOLIN 2 QLL NOVOLOG 3 QLL Blood Products/Modifiers/Volume Expanders, Anticoagulants COUMADIN 3 enoxaparin sodium 4 QLL PA hep sod/nacl 1 heparin 1 PRADAXA 2 QLL PA warfarin 1 XARELTO 2 PA Blood Products/Modifiers/Volume Expanders, Blood Formation Modifiers anagrelide 1 ARANESP 4 ST PA EPOGEN 4 ST PA LEUKINE 4 PA MOZOBIL 4 PA NEULASTA 4 PA NEUPOGEN 4 QLL PA NPLATE 4 PA PROCRIT 4 ST PA PROMACTA 4 PA Blood Products/Modifiers/Volume Expanders, Coagulants tranexamic acid 1

20 Blood Products/Modifiers/Volume Expanders, Platelet Modifying Agents AGGRENOX 2 cilostazol 1 clopidogrel bisulfate 1 dipyridamole 1 EFFIENT 2 REOPRO 3 ST ticlopidine 1 Cardiovascular Agents, Alpha-adrenergic Agonists clonidine 1 QLL guanfacine 1 QLL methyldopa 1 QLL midodrine 1 Cardiovascular Agents, Alpha-adrenergic Blocking Agents DIBENZYLINE 3 QLL doxazosin 1 QLL prazosin 1 QLL terazosin 1 Cardiovascular Agents, Angiotensin II Receptor Antagonists ATACAND 3 QLL ST BENICAR 2 QLL ST DIOVAN 2 QLL EDARBI 3 QLL ST irbesartan 1 QLL losartan potassium 1 QLL TEVETEN 3 QLL ST Cardiovascular Agents, Angiotensin-converting Enzyme (ACE) Inhibitors benazepril 1 captopril 1 enalapril 1 fosinopril 1 lisinopril 1 moexipril 1 perindopril erbumine 1 quinapril 1 ramipril 1 trandolapril 1 Cardiovascular Agents, Antiarrhythmics amiodarone 1

21 Cardiovascular Agents, Antiarrhythmics disopyramide phosphate 1 flecainide 1 mexiletine 1 MULTAQ 4 PA PACERONE 3 procainamide 1 QLL propafenone 1 QLL sotalol 1 QLL TIKOSYN 2 Cardiovascular Agents, Beta-adrenergic Blocking Agents acebutolol 1 atenolol 1 betaxolol 1 bisoprolol 1 BYSTOLIC 2 QLL ST carvedilol 1 labetalol 1 LEVATOL 3 QLL ST metoprolol succinate 1 metoprolol tartrate 1 nadolol 1 pindolol 1 propranolol 1 propranolol 1 Cardiovascular Agents, Calcium Channel Blocking Agents amlodipine besylate 1 diltiazem 1 diltiazem 1 felodipine 1 isradipine 1 nicardipine 1 nifedipine 1 nimodipine 1 nisoldipine 1 verapamil 1 verapamil 1 Cardiovascular Agents, Cardiovascular Agents, Other digoxin 1 pentoxifylline 1 QLL RANEXA 2 QLL PA TEKTURNA 2 QLL ST

22 Cardiovascular Agents, Diuretics, Carbonic Anhydrase Inhibitors acetazolamid 1 QLL methazolamide 1 QLL Cardiovascular Agents, Diuretics, Loop bumetanide 1 QLL EDECRIN 3 QLL furosemide 1 torsemide 1 Cardiovascular Agents, Diuretics, Potassium-sparing amiloride 1 DYRENIUM 3 QLL PA eplerenone 1 spironolactone 1 Cardiovascular Agents, Diuretics, Thiazide chlorothiazide 1 chlorthalid 1 hydrochlorothiazide 1 QLL indapamide 1 QLL methyclothia 1 metolazone 1 QLL Cardiovascular Agents, Dyslipidemics, Fibric Acid Derivatives fenofibrate 1 QLL gemfibrozil 1 Cardiovascular Agents, Dyslipidemics, HMG CoA Reductase Inhibitors atorvastatin calcium 1 QLL CRESTOR 2 QLL ST fluvastatin sodium 2 QLL LIVALO 3 QLL lovastatin 1 QLL pravastatin sodium 1 QLL simvastatin 1 QLL Cardiovascular Agents, Dyslipidemics, Other ADVICOR 3 cholestyramine 1 colestipol 1 LOVAZA 2 NIASPAN 2 SIMCOR 2 VYTORIN 2 ST ZETIA 2 ST

23 Cardiovascular Agents, Vasodilators, Direct-acting Arterial BIDIL 2 hydralazine 1 minoxidil 1 RECTIV 3 Cardiovascular Agents, Vasodilators, Direct-acting Arterial/Venous isosorbide 1 NITRO-BID 3 nitroglycerin 1 NITROSTAT 2 QLL Central Nervous System Agents, Attention Deficit Hyperactivity Disorder Agents, Amphetamines amphetamine-dextroamphetamine 1 dextroamphetamine sulfate 1 methamphetamine 3 QLL VYVANSE 2 QLL Central Nervous System Agents, Attention Deficit Hyperactivity Disorder Agents, Non-amphetamines dexmethylphenidate 1 INTUNIV 2 QLL methylphenidate 1 STRATTERA 2 QLL Central Nervous System Agents, Central Nervous System, Other butalbital-acetaminophen-caff w/ cod 1 QLL HORIZANT 3 NUEDEXTA 3 RILUTEK 3 XENAZINE 4 PA Central Nervous System Agents, Fibromyalgia Agents SAVELLA 2 PA Central Nervous System Agents, Multiple Sclerosis Agents AMPYRA 4 PA AVONEX 4 PA BETASERON 4 PA COPAXONE 4 PA EXTAVIA 4 PA GILENYA 4 PA REBIF 4 PA

24 Dental and Oral Agents, Dental and Oral Agents ARESTIN 4 PA chlorhexidine gluconate 1 KEPIVANCE 4 pilocarpine 1 triamcinolone acetonide 1 Dermatological Agents, Dermatological Agents adapalene 1 AMEVIVE 4 AZELEX 3 benzoyl peroxide 1 benzoyl peroxide-erythromycin 1 QLL calcipotrien 1 QLL calcipotriene 1 QLL calcitriol 1 QLL claravis 1 clindamycin phosphate 1 clindamycin phosphate-benzoyl peroxide 1 clotrimazole w/ betamethasone 1 cortisporin 1 DIFFERIN 2 PA ELIDEL 2 QLL ST erythromycin 1 FINACEA 2 fluorouracil 1 QLL imiquimod 1 isotretinoin 1 QLL lactic acid (ammonium lactate) 1 LAVOCLEN-4 3 nystat/triam 1 nystatin-triamcinolone 1 OXSORALEN-UL 2 QLL PICATO 2 podofilox 1 PROTOPIC 2 ST SANTYL 3 selenium sulfide 1 QLL SOLARAZE 2 QLL SORIATANE 2 QLL spinosad 1 STELARA 4 PA sulfacetamide sodium 1 QLL TACLONEX 3 TAZORAC 2 PA tretinoin 1 PA UVADEX 4 VEREGEN 3 VOLTAREN 2 ZONALON 3

25 Enzyme Replacement/Modifiers, Enzyme Replacement/Modifiers ADAGEN 4 QLL PA ALDURAZYME 4 QLL PA BUPHENYL 3 QLL CREON 2 QLL CYSTADANE 4 QLL PA CYSTAGON 3 QLL KUVAN 4 QLL PA ORFADIN 4 PA Gastrointestinal Agents, Antispasmodics, Gastrointestinal atropine sulfate 1 QLL dicyclomine 1 QLL glycopyrrolate 1 methscopolamine bromide 1 TRANSDERM-SC 2 Gastrointestinal Agents, Gastrointestinal Agents, Other diphenoxylate w/ atropine 1 ENTEREG 3 PA loperamide 1 metoclopramide 1 QLL MOTOFEN 3 PA RELISTOR 2 PA ursodiol 1 XIFAXAN 3 ST PA Gastrointestinal Agents, Histamine2 (H2) receptor Antagonists cimetidine 1 famotidine 1 nizatidine 1 ranitidine 1 Gastrointestinal Agents, Irritable Bowel Syndrome Agents AMITIZA 2 LOTRONEX 2 Gastrointestinal Agents, Laxatives lactulose 1 MOVIPREP 2 OSMOPREP 3 PREPOPIK 3 Gastrointestinal Agents, Protectants CARAFATE 2 misoprostol 1 sucralfate 1

26 Gastrointestinal Agents, Proton Pump Inhibitors ACIPHEX 3 QLL ST DEXILANT 2 QLL ST lansoprazole 1 QLL NEXIUM 2 QLL ST omeprazole 1 QLL pantoprazole sodium 1 QLL Genitourinary Agents, Antospasmodics, Urinary DETROL LA 3 ST ENABLEX 3 ST flavoxate 1 oxybutynin chloride 1 tolterodine tartrate 1 TOVIAZ 3 ST trospium chloride 1 VESICARE 2 ST Genitourinary Agents, Benign Prostatic Hypertrophy Agents alfuzosin 1 AVODART 2 QLL ST CIALIS 3 PA finasteride 1 RAPAFLO 2 ST tamsulosin 1 Genitourinary Agents, Genitourinary Agents, Other bethanechol chloride 1 QLL CUPRIMINE 3 ELMIRON 2 Genitourinary Agents, Phosphate Binders calcium acetate 1 FOSRENOL 2 ST PHOSLYRA 2 RENAGEL 3 Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal), Glucorticoids/Mineralocorticoids alclometasone 1 AMCINONIDE 3 betamethasone 1 budesonide 1 clobetasol propionate 1 CLODERM 3 CORDRAN 3 cortisone ac 1 DEPO-MEDROL 3

27 Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal), Glucorticoids/Mineralocorticoids desonide 1 desoximetas 1 desoximetasone 1 dexamethasone 1 diflorasone 1 fludrocortisone 1 fluocinolone 1 fluocinonide 1 fluticasone 1 halobetasol 1 HALOG 3 hydrocortisone 1 methylprednisolone 1 MILLIPRED 3 mometasone furoate 1 ORAPRED 3 prednicarbate 1 prednisolone 1 prednisolone sod phosphate 1 prednisone 1 SOLU-CORTEF 3 SOLU-MEDROL 3 triamcinolone acetonide 1 VERIPRED 20 3 Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary), Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary) chorionic gonadotropin 4 desmopressin 1 GENOTROPIN 4 PA HUMATROPE 4 PA INCRELEX 4 PA NORDITROPIN 4 PA NUTROPIN 4 PA OMNITROPE 4 PA SAIZEN 4 PA SEROSTIM 4 PA STIMATE 4 PA TEV-TROPIN 4 PA ZORBTIVE 4 PA Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers), Anabolic Steroids ANADROL-50 3 oxandrolone 1

28 Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers), Androgens ANDRODERM 2 PA ANDROXY 3 PA danazol 1 PA METHITEST 3 PA Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers), Estrogens AMETHIA 0 AMETHYST 0 APRI 0 ARANELLE 0 AVIANE 0 AZURETTE 0 BALZIVA 0 BRIELLYN 0 CAMRESE 0 CAZIANT 0 CENESTIN 3 CESIA 0 CLIMARA PRO 3 QLL CRYSELLE-28 0 CYCLAFEM 0 DASETTA 0 DEPO-ESTRADI 3 DIVIGEL 3 ELESTRIN 3 ELINEST 0 EMOQUETTE 0 ENJUVIA 3 ENPRESSE-28 0 ESTRACE VAG 3 estradiol 1 ESTRASORB 3 ESTROGEL 3 estropipate 1 EVAMIST 3 FEMRING 3 GIANVI 0 JOLESSA 0 JUNEL 0 KARIVA 0 KELNOR 0 KURVELO 0 LEENA 0 LESSINA 0 LEVONEST 0 LEVORA-28 0

29 Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers), Estrogens LOESTRIN 24 0 LORYNA 0 LOW-OGESTREL 0 LUTERA 0 MENEST 3 MENOSTAR 3 MICROGESTIN 0 MONO-LINYAH 0 MONONESSA 0 MYZILRA 0 NATAZIA 0 NECON 0 NORTREL 0 NUVARING 0 OCELLA 0 OGESTREL 3 ORTHO EVRA 0 ORTHO TRI- 0 PHILITH 0 PORTIA-28 0 PREMARIN 2 PREMPHASE 2 PREMPRO 2 QLL PREVIFEM 0 QUASENSE 0 RECLIPSEN 0 SAFYRAL 0 SPRINTEC 28 0 SRONYX 0 SYEDA 0 TILIA FE 0 TRI-LEGEST 0 TRINESSA 0 TRI-PREVIFEM 0 TRI-SPRINTEC 0 TRIVORA-28 0 VELIVET 0 VESTURA 0 VIVELLE-DOT 3 WERA 0 ZARAH 0 ZENCHENT 0 ZEOSA 0 ZOVIA 0

30 Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers), Progestins CAMILA 0 CRINONE 3 ELLA 0 ENDOMETRIN 2 HEATHER 0 JOLIVETTE 0 levonorgestrel 0 MEDROXYPR 4 medroxyprogesterone 1 PA MEGACE ES 4 PA megestrol 4 PA NORETHIN ACE 0 PROCHIEVE 3 progesterone 1 Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers), Selective Estrogen Receptor Modifying Agents EVISTA 2 QLL Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid), Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) levothyroxin 1 levothyroxine 1 liothyronine 1 THYROLAR 3 Hormonal Agents, Suppressant (Adrenal), Hormonal Agents, Suppressant (Adrenal) LYSODREN 4 PA Hormonal Agents, Suppressant (Parathyroid), Hormonal Agents, Suppressant (Parathyroid) SENSIPAR 4 PA cabergoline 1 Hormonal Agents, Suppressant (Pituitary), Hormonal Agents, Suppressant (Pituitary) ELIGARD 4 PA leuprolide 4 PA LUPR DEP-PED 4 PA LUPRON DEPOT 4 PA octreotide 4 PA

31 Hormonal Agents, Suppressant (Pituitary), Hormonal Agents, Suppressant (Pituitary) SOMATULINE 4 PA SOMAVERT 4 PA SYNAREL 4 PA TRELSTAR 4 PA Hormonal Agents, Suppressant (Sex Hormones/Modifiers), Antiandrogens bicalutamide 4 PA finasteride 1 flutamide 4 PA NILANDRON 3 QLL Hormonal Agents, Suppressant (Thyroid), Antithyroid Agents methimazole 1 propylthiouracil 1 Immunological Agents, Immune Suppressants AZASAN 3 azathioprine 1 CIMZIA 4 PA cyclosporine 1 ENBREL 4 PA HUMIRA 4 PA mercaptopurine 4 PA methotrexate 1 mycophenolate 1 MYFORTIC 2 NULOJIX 4 PA ORENCIA 4 PA PROGRAF 2 RAPAMUNE 2 tacrolimus 1 Immunological Agents, Immunizing Agents, Passive GAMMAGARD 4 PA Immunological Agents, Immunomodulators ACTEMRA 4 PA ACTIMMUNE 4 PA ARCALYST 4 PA leflunomide 1 QLL RIDAURA 3 PA Inflammatory Bowel Disease Agents, Aminosalicylates APRISO 2

32 Inflammatory Bowel Disease Agents, Aminosalicylates ASACOL 2 QLL balsalazide 1 CANASA 2 DIPENTUM 2 LIALDA 2 mesalamine 1 PENTASA 2 Inflammatory Bowel Disease Agents, Glucocorticoids KENALOG-40 3 MEDROL 3 methylprednisolone 1 Inflammatory Bowel Disease Agents, Sulfonamides sulfasalazine 1 Metabolic Bone Disease Agents, Metabolic Bone Disease Agents alendronate 1 QLL BONIVA 4 PA calcitonin 1 QLL etidron 1 FORTEO 4 PA HECTOROL 2 ibandronate 1 pamidronate 4 PA PROLIA 4 PA SKELID 3 XGEVA 4 PA ZEMPLAR 4 PA Ophthalmic Agents, Ophthalmic Prostaglandin and Prostamide Analogs latanoprost 1 LUMIGAN 3 ST TRAVATAN Z 2 ST Ophthalmic Agents, Ophthalmic Agents, Other naphazoline 1 proparacaine 1 RESTASIS 2 PA tropicamide 1 Ophthalmic Agents, Ophthalmic Anti-Allergy Agents ALOCRIL 3 PA ALOMIDE 3 PA azelastine 1

33 Ophthalmic Agents, Ophthalmic Anti-Allergy Agents BEPREVE 3 PA cromolyn 1 EMADINE 3 PA epinastine 1 LASTACAFT 2 PA PATADAY 2 PATANOL 3 PA Ophthalmic Agents, Ophthalmic Antiglaucoma Agents apraclonidine 1 AZOPT 2 QLL betaxolol 1 QLL brimonidine 1 QLL carteolol 1 COMBIGAN 2 dorzolamide 1 QLL dorzolamide -timolol 1 QLL IOPIDINE 3 levobunolol 1 QLL metipranolol 1 PHOSPHOLINE 3 pilocarpine 1 timolol 1 ZIOPTAN 3 Ophthalmic Agents, Ophthalmic Anti-inflammatories ALREX 2 BROMDAY 2 BROMFENAC 3 CIPRODEX 2 dexamethasone sodium phosphate 1 DUREZOL 2 fluorometholone 1 flurbiprofen 1 FML 3 FML FORTE 3 ILEVRO 3 LOTEMAX 2 MAXIDEX 3 neomycin-polymyxin-dexamethasone 1 NEVANAC 3 PRED 3 prednisolone 1 VEXOL 3 Otic Agents, Otic Agents acetic acid 1 antipyrine-benzocaine 1

34 Otic Agents, Otic Agents CIPRO HC 3 COLY-MYCIN 3 CORTISPORIN 3 DERMOTIC 2 hydrocortisone w/ acetic acid 1 neo/poly/hc 1 neomycin-polymyxin-hc 1 Respiratory Tract Agents, Antihistamines ASTEPRO 2 azelastine 1 QLL carbinoxamine 1 clemastine fumarate 1 cyproheptadine 1 desloratadine 1 DEXCHLORPHEN 3 levocetirizine dihydrochloride 1 QLL Respiratory Tract Agents, Anti-inflammatories, Inhaled Corticosteroids ADVAIR 2 QLL ALVESCO 3 ASMANEX 2 budesonide 3 FLOVENT HFA 3 QLL flunisolide 1 QLL NASONEX 2 PULMICORT 2 QVAR 2 RHINOCORT 2 ST Respiratory Tract Agents, Antileukotrienes montelukast 1 zafirlukast 1 QLL ZYFLO CR 3 QLL Respiratory Tract Agents, Bronchodilators, Anticholinergic ATROVENT HFA 3 QLL ipratropium bromide 1 QLL SPIRIVA 2 QLL Respiratory Tract Agents, Bronchodilators, Phosphodiesterase Inhibitors (Xanthines) LUFYLLIN 3 theophylline 1

35 Respiratory Tract Agents, Bronchodilators, Sympathomimetic albuterol 1 ARCAPTA 2 BROVANA 3 epinephrine 1 EPIPEN 2 QLL FORADIL 2 levalbuterol 1 MAXAIR 3 metaproteren 1 PROVENTIL 2 SEREVENT 2 QLL terbutaline sulfate 1 VENTOLIN HFA 3 QLL XOPENEX HFA 3 QLL ST Respiratory Tract Agents, Mast Cell Stabilizers cromolyn 1 QLL Respiratory Tract Agents, Pulmonary Antihypertensives ADCIRCA 4 PA LETAIRIS 4 PA REVATIO 4 PA sildenafil 4 PA TRACLEER 4 QLL PA Respiratory Tract Agents, Respiratory Tract Agents, Other acetylcysteine 1 ARALAST 4 PA PULMOZYME 4 PA SURFAXIN 4 PA TYZINE 3 XOLAIR 4 PA Skeletal Muscle Relaxants, Skeletal Muscle Relaxants carisoprodol 1 chlorzoxazone 1 cyclobenzaprine 1 QLL metaxalone 1 methocarbamol 1 orphenadrine 1 Sleep Disorder Agents, GABA Receptor Modulators LUNESTA 3 QLL ST zaleplon 1 QLL zolpidem 1 QLL

36 Sleep Disorder Agents, Sleep Disorders, Other modafinil 1 QLL PA NUVIGIL 2 QLL PA phenobarb 1 phenobarbital 1 ROZEREM 3 QLL ST XYREM 4 QLL PA Therapeutic Nutrients/Minerals/Electrolytes, Electrolyte/Mineral Modifiers EXJADE 4 PA FERRIPROX 3 KIONEX 1 SAMSCA 4 PA sodium polystyrene sulfonate 1 SYPRINE 3 Therapeutic Nutrients/Minerals/Electrolytes, Electrolyte/Mineral Replacement acetic acid irrigation 1 AMMONIUM 3 calcium 1 CLINIMIX 3 d5w/lytes 1 dextrose 1 dianeal 1 glycine irrigation 1 hypersal 1 ionosol 1 isolyte 1 kcl 1 kcl/d10/nacl 1 kcl/d5w 1 kcl/d5w/nacl 1 klor-con 1 k-tabs 1 lactated 1 magnesium 1 nebusal 1 normosol 1 physiolyte 1 physiosol 1 plasma-lyte 1 potassium 1 ultrabag/ 1