Preferred Drug List (PDL)

Preferred List (PDL) Arizona Effective Date: 8/1/15 2015 United Healthcare Services, Inc. All rights reserved.

Preferred List INTRODUCTION UnitedHealthcare is pleased to provide this Preferred List (PDL) to be used when prescribing for patients covered by the pharmacy benefit plan offered by UnitedHealthcare. The drugs listed in this PDL are intended to provide sufficient options to treat patients who require treatment with a drug from that pharmacologic or therapeutic class. The drugs listed in the UnitedHealthcare PDL have been reviewed and approved by the Pharmacy and Therapeutics Committee. The drugs have been selected to provide the most clinically appropriate and cost-effective medications for patients who have their drug benefit administered through UnitedHealthcare. It is also recognized there may be occasions where an unlisted drug is desired for proper medical management of a specific patient. In those infrequent instances, the unlisted medication may be requested through the prior authorization process. The drugs represented have been reviewed by the Pharmacy and Therapeutics (P&T) Committee and are approved for inclusion. The PDL is reflective of current medical practice as of the date of review. This edition incorporates drugs added to the PDL since the last edition as well as numerous revisions to the prescribing information based on changes in pharmacotherapy. Comments and suggestions from practicing physicians have also been incorporated to ensure that the UnitedHealthcare PDL is reflective of current medical practice. NOTICE The information contained in this PDL and its appendices is provided by UnitedHealthcare, solely for the convenience of contracted providers. UnitedHealthcare does not warrant or assure accuracy of such information nor is it intended to be comprehensive in nature. This PDL is not intended to be a substitute for the knowledge, expertise, skill and judgment of the medical provider in their choice of prescription drugs. UnitedHealthcare assumes no responsibility for the actions or omissions of any medical provider based upon reliance, in whole or in part, on the information contained herein. The medical provider should consult the drug manufacturer s product literature or standard references for more detailed information. National guidelines can be found on the websites listed in the website section or go to the National Guideline Clearinghouse site at http://www.guideline.gov. PREFACE The UnitedHealthcare PDL is organized by sections. Each section includes therapeutic groups identified by either a drug class or disease state. Products are listed by name. Brand names are included as a reference to assist in product recognition. Unless exceptions are noted, generally all applicable dosage forms and strengths of the drug cited are included in the PDL. Generics should be considered the first line of prescribing. The UnitedHealthcare PDL covers selected over-thecounter (OTC) products. You are encouraged to prescribe OTC medications when clinically appropriate. PHARMACY AND THERAPEUTICS (P&T) COMMITTEE The P&T Committee includes physicians and pharmacists who are not employees or agents of UnitedHealthcare or its affiliates. They must adhere to the Ethics Policy standards of the P&T Committee. UnitedHealthcare medical directors and pharmacists also participate in the P&T Committee. The P&T Committee meets quarterly to discuss a variety of issues. Those issues pertaining to Doc#: UHC1335a_20110804 i

pharmaceutical selection and pharmacy program management are communicated quarterly. This newsletter is distributed to all participating physicians who have received the PDL. PDL decisions are also communicated quarterly on the UnitedHealthcare internet site. OUTPATIENT PRESCRIPTION DRUG BENEFIT COVERED MEDICATIONS Medically necessary outpatient prescription drugs are covered when prescribed by a provider licensed to prescribe federal legend drugs or medicines. Special formula nutrition needs for metabolic patients are also covered. Some items are covered only with prior authorization. Eligibility for Outpatient Prescription Benefits and copays are based on the individual member s benefit plan. PRODUCT SELECTION CRITERIA The P&T Committee considers clinical information on new-to-market drugs that are typically included in an outpatient pharmacy benefit. The evaluation includes all or part of the following: Safety Efficacy Comparison studies Approved indications Adverse effects Contraindications/Warnings/Precautions Pharmacokinetics Patient administration/compliance considerations Outcome and pharmacoeconomic studies When a new drug is considered for PDL inclusion, it will be reviewed relative to similar drugs currently included in the UnitedHealthcare PDL. This review process may result in deletion of drug(s) in a particular therapeutic class in an effort to continually promote the most clinically useful and cost-effective agents. All the information in the PDL is provided as a reference for drug therapy selection. Specific drug selection for an individual patient rests solely with the prescriber. PDL PRODUCT DESCRIPTIONS To assist in understanding which specific strengths and dosage forms are covered on the PDL, examples are noted below. The general principles shown in the examples can then usually be extended to other entries in the book. Any exceptions are noted in the drug list. There may also be a statement associated with a drug list that gives additional information about which specific products or dosage forms are covered. Products covered include all strengths associated with the dosage form of the cited name product. levetiracetam KEPPRA All strengths of Keppra would be covered by this listing. Dosage forms covered will be consistent with the category and use where listed. Neomycin/polymixin B/ Hydrocortisone CORTISPORIN As listed in the EAR section, this is limited to the otic solution and suspension. From this entry the ophthalmic solution and ointment, and the topical cream cannot be assumed to be on the list unless there are entries for these products in the EYE and DERMATOLOGICAL sections of the PDL. When a strength or dosage form is specified, only the specified strength and dosage form is on the PDL. Other strengths/dosage forms of the reference product are not metoprolol 50mg & 100 mg only LOPRESSOR GENERIC SUBSTITUTION The UnitedHealthcare PDL requires substitution on the majority of products when a equivalent is available. Generic substitution is a pharmacy action whereby a equivalent is dispensed rather than the name product. The PDL indicated availability in the column. If a name drug is medically necessary, please submit a prior authorization request. The UnitedHealthcare Maximum Allowable Cost (MAC) list sets a ceiling price for the reimbursement of certain multisource prescription drugs. This price will typically cover the acquisition of most s but not ed versions of the same drug. The products selected for inclusion on the MAC list are commonly prescribed and dispensed and have usually gone through the FDA s review and approval process. An important consideration for substitution is the knowledge that all approvals of drugs by the FDA since 1984, and many approvals prior to 1984, have a showing of bioequivalence between the versions and the reference product. To gain FDA approval: 1. The drug must contain the same active ingredient(s), be the same strength and the same dosage form as the name product. Doc#: UHC1335a_20110804 ii

2. The FDA has given the an A rating compared to the ed product indicating bioequivalence, and has determined the is therapeutically equivalent to the reference. The ratings of drugs are available by referring to the FDA reference, Approved Products with Therapeutic Equivalence Evaluations (Orange Book). When the above two criteria are met, a can be substituted with the full expectation that the substituted product will produce the same clinical effect and safety profile as the prescribed product. products that have a narrow therapeutic index (NTI) can also be guided by these principles. It is not necessary for the health care provider to approach any one therapeutic class of drug products (e.g., NTI drugs) differently from any other class, when there has been a determination of therapeutic equivalence by the FDA for the drug products under consideration. Also, additional clinical tests or examinations by the physician are not needed when a therapeutically equivalent drug product is substituted for the name product. There are now many name products that are repackaged or distributed under a label. The label version should always be considered therapeutically equivalent and substitutable for the source ed product. DRUG EFFICACY STUDY IMPLEMENTATION (DESI) DRUGS s first marketed between 1938 and 1962 were approved as safe but required no showing of effectiveness for FDA approval. Beginning in 1962, all new drugs were required to be both safe and effective before they could be marketed. This legislation also applied retroactively to all drugs approved as safe from 1938-1962. The DESI program was established by the FDA to review the effectiveness of these pre-1962 drugs for their labeled indications, and a determination of fully effective was made for most of these products and they remain in the marketplace. A few DESI products remain classified as less than fully effective while awaiting final administrative disposition. Also, classified as DESI are many products listed as identical, similar, or related to actual DESI products. UnitedHealthcare PDL does not cover DESI less than fully effective drg products. PLAN EXCLUSIONS The following drug categories are excluded from coverage under the outpatient pharmacy benefit and are not part of the UnitedHealthcare PDL. DESI drugs Antiobesity agents Experimental / research drugs Cosmetic drugs Immunization agents Nutritional / diet supplements Blood and blood plasma products Agents used to promote fertility Doc#: UHC1335a_20110804 iii Agents used for erectile dysfunction Agents used for cosmetic hair growth s from manufacturers that do not participate in the FFS Medicaid Rebate Program Diagnostic products Medical supplies and DME except as listed: syringes, needles, lancets, alcohol swabs, spacers, preferred diabetes test strips, peak flow meters (Astech, Assess, Peak Air s, max two per year), vaporizer (limit of 1 per 3 years), humidifier (limit of 1 per 3 years) Mirena DAYS SUPPLY DISPENSING LIMITATIONS UnitedHealthcare members may receive up to a one month supply of a specific medication per prescription order or prescription refill. A medication may be reordered or refilled when eighty-five percent (85%) of the medication has been utilized. If a claim is submitted before 85% of the medication has been used, based on the original day supply submitted on the claim, the claim will reject with a "refill too soon" message. Please call the UnitedHealthcare Pharmacy Department at 800-310-6826 with questions or for help with dosage change authorization. MANDATORY GENERIC SUBSTITUTION The UnitedHealthcare PDL requires mandatory substitution on the vast majority of products when a equivalent is available; however, name drugs may be covered in certain situations by requesting a prior authorization. The UnitedHealthcare PDL prior authorization (PA) list does not include ed items where a equivalent is covered. PRIOR AUTHORIZATION OF NON-PDL MEDICATIONS The drugs in the UnitedHealthcare PDL have been selected to provide the most clinically appropriate and cost-effective medications for patients who have their drug benefit administered through UnitedHealthcare. It is also recognized that there may be occasions where an unlisted drug is desired for the proper medical management of a specific patient. In those infrequent instances, the prior authorization process reviews requests for unlisted medications the physician may consider medically necessary for patient management. Requests for these exceptions should be made in writing by the physician and faxed to: UnitedHealthcare Pharmacy Services Department Fax 866-940-7328 Phone 800-310-6826 A prior authorization request form is available in the UnitedHealthcare provider manual and should be used for all prior authorization requests if possible. Appropriate documentation must be provided to support the medical

necessity of the non-pdl request. The UnitedHealthcare Pharmacy Department will respond to all requests in accordance with state requirements. Physicians are requested to adhere to this PDL when prescribing for patients covered by their pharmacy benefit plan offered by UnitedHealthcare. If a pharmacist receives a prescription for a non-pdl drug, the pharmacist should contact the prescribing physician and request that the prescription be changed to a medication included in this PDL. If a PDL alternative is not appropriate the physician should then be instructed to contact the Plan for a prior authorization. Please contact the UnitedHealthcare Pharmacy Department at 800-310-6826 with questions concerning the prior authorization process. NON-PDL DRUGS 5-DAY OVERRIDES To ensure the use of PDL drugs, all non- PDL drugs should be discussed with the prescribing physician. If you cannot speak to the physician immediately, and there is an immediate need for the medication, the claim processing system will accept an override to permit a one-time dispensing of a 5-day supply of the newly prescribed non-pdl drug. The pharmacy should submit a claim for a 5 day supply, with a PA Type of 8 and Prior Authorization number of 00000000120. 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 800-310- 6826. Pharmacies may dispense a one-time, 15-day supply to members requiring an immediate supply of an ongoing medication. The pharmacist must contact the plan to obtain a manual 15-day override. Before the next dispensing, the pharmacy must contact the physician to discuss a PDL drug or if a prior authorization request is warranted. If the prescribing physician feels a drug is medically necessary, the physician may fax a request for prior authorization to UnitedHealthcare at 866-940-7328, Attn: Pharmacy Department. QUANTITY LIMITATIONS (QL) Prescriptions for monthly quantities greater than the indicated limit require a prior authorization request. Quantity limits based on Efficient Medication Dosing The Efficient Medication Dosing Program is designed to consolidate medication dosage to the most efficient daily quantity to increase adherence to therapy and also promote the efficient use of health care dollars. The limits for the program are established based on FDA approval for dosing and the availability of the total daily dose in the least amount of tablets or capsules daily. Quantity Limits in the prescription claims processing system will limit the dispensing to consolidate dosing. The Doc#: UHC1335a_20110804 iv pharmacy claims processing system will prompt the pharmacist to request a new prescription order from the physician. Controlled Substances You may fill any FOUR medications from the following classes in a 30-day period: opiate analgesics benzodiazepines sedative hypnotic agents barbiturates select muscle relaxants Additional fills will require prior authorization. Medications in these classes may also be subject to individual quantity limits. Additions to the QL program drug list will be made from time to time and providers notified accordingly. As always, we recognize that a number of patient-specific variables must be taken into consideration when drug therapy is prescribed and therefore overrides will be available through the medical exception (prior authorization) process. Please contact the UnitedHealthcare Pharmacy Department at 800-305-0023 with questions. Specialty Pharmaceutical Management Program UnitedHealthcare is continuously looking for ways to provide high quality cost effective care for Plan members. The Specialty Pharmaceutical Management Program helps UnitedHealthcare to achieve these goals. Injectable medications that are part of this program require plan authorization and are not available through the retail pharmacy network. To obtain authorization, the provider must submit the appropriate prior authorization form to the UnitedHealthcare Prior Authorization Department via fax at 866-940-7328. The UnitedHealthcare Pharmacy Department will review and respond to all requests in accordance with state requirements, and if authorized for payment, UnitedHealthcare, will coordinate delivery of the product to the member or provider. s that are part of this program and are on the PDL are identified in this booklet by the designation "SP". Prior authorization request forms should be faxed to the UnitedHealthcare Pharmacy Department at 866-940-7328. 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 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, Tudorza). Gabitril 30 day trial of two of the following: lamotrigine, topiramate, carbamazepine, divalproex, or phenytoin. Step therapy only applies to members 12 years of age and older. Members less than 12 require prior authorization. GLP-1 Agonists At least a 90 day trial of 1500mg/day of (Tanzeum, metformin Victoza) Angiotensin II 30 day trial of losartan or losartan/hctz Receptor Blockers (Diovan/Diovan HCT, Benicar/Benicar HCT) Aricept 23mg Banzel 90 day trial of Aricept 10mg daily 30 day trial of two of the following: lamotrigine, divalproex, or topiramate. Breo Ellipta 1) 30 day trial of one inhaled 100mcg/25mcg 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, Tudorza). Intuniv levocetirizine midodrine Nucynta ER Onfi Opana ER 30 day trial of one of the following: methylphenidate, methylphenidate SR, Concerta, amphetamine salts, Adderall XR, dextroamphetamine, or dextroamphetamine SA. 30 day trial of loratadine and cetirizine. Trial of fludrocortisone 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. 30 day trial of at least 200mg per day of morphine sulfate ER. Breo Ellipta 30 day trial of one inhaled 200mcg/25mcg corticosteroid (e.g. Flovent, Qvar, Asmanex, Pulmicort, Azmacort) Cymbalta Minimum 2 month trial of 2 PDL antidepressants in the preceding 6 months DPP4 Inhibitors At least a 90 day trial of 1500mg/day of (Tradjenta, metformin. Jentadueto, Januvia, Janumet, Janumet XR, Onglyza, Kombiglyze) Dulera 30 day trial of inhaled corticosteroid Optivar 14 day trial of ketotifen within previous 90 days required first. Oxycodone ER 30 day trial of at least 200mg per day of morphine sulfate ER 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. Elidel fenofibrate 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. Protopic 0.1% Ranexa 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 fentanyl patches 30 day trial of at least 200mg per day of morphine sulfate ER. Renvela 8 week trial of calcium acetate Doc#: UHC1335a_20110804 v

SGLT-2 Inhibitors (Jardiance, Invokana, Invokamet) Strattera Symbicort tolterodine At least a 90 day trial of 1500mg/day of metformin 30 day trial of one of the following: methylphenidate, methylphenidate SR, Concerta, amphetamine salts, Adderall XR, dextroamphetamine, 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, Tudorza). 30 day trial of oxybutynin immediate release. Fax: 866-940-7328 Providers should furnish adequate documentation, such as clinical studies from the medical literature, in order for the request to be considered for PDL addition. This literature should include information documenting clinical necessity as well as therapeutic advantages over current PDL products. Suggestions received by UnitedHealthcare will be reviewed by the Pharmacy and Therapeutics Committee at the subsequent P&T Committee meeting. EDITOR Your comments and suggestions regarding the UnitedHealthcare PDL are encouraged. Your input is vital to this PDL s continued success. All responses will be reviewed and considered. Please send your comments to: UnitedHealthcare Director of Pharmacy Services Unison Plaza 1001 Brinton Road Pittsburgh, PA 15221 Phone: 800-310-6826 TZD s At least a 90 day trial of 1500mg/day of (ActosPlusMet, metformin ActoPlusMet XR, Duetact) Uloric Vancocin Vimpat Vytorin Doc#: UHC1335a_20110804 8 week trial of up to 600mg of allopurinol required first. One fill of metronidazole tabs or cap 30 day trial of two of the following: lamotrigine, topiramate, carbamazepine, divalproex, or phenytoin. Step therapy only applies to members 17 years of age and older. Members less than 17 require prior authorization. 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 15221 vi 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.

Table of Contents Antineoplastics & Immunosuppressants 4 Hormonal Antineoplastic Agents....4 Oral Agents...4 Immunosuppressants...6 Immunomodulators...6 Miscellaneous...6 Blood Modifiers - Anticoagulants.... 7 Oral...7 Blood Cell Formation...7 Platelet Synthesis Inhibitor....7 Miscellaneous...7 Platelet Aggregation Inhibitors...7 Cardiovascular Agents...8 Ace Inhibitors...8 Ace Inhibitor/Diuretic Combinations....8 Adrenolytics, Central... 8 Alpha Blockers...8 Angiotensin II Receptor Blockers (Antagonists)... 9 Angiotensin II Receptor Blocker Combinations...9 Antiarrhythmics And Cardiac Glycosides....9 Beta Blockers And Beta Blocker/ Diuretic Combinations...10 Calcium Channel Blockers...10 Diuretics....11 Nitrates...12 Lipid Lowering Agents...12 Miscellaneous...13 Central Nervous System....13 Alzheimer s Disease...13 Analgesics...14 Migraine Acute Therapy...16 Migraine Prophylactic Therapy...16 Multiple Sclerosis...16 Myasthenia Gravis...16 Parkinson s Disease..................... 17 Seizures....17 Miscellaneous...18 Dermatology....18 Acne Vulgaris...18 Bacterial Infections....20 Corticosteroids...20 Fungal Infections....21 Psoriasis...22 Rosacea....22 Scabies And Pediculosis...22 Viral Infections....22 Miscellaneous...22 Ear, Nose & Throat.... 24 Ear...24 Nose....24 Miscellaneous Nasal....26 Throat And Mouth....26 Endocrinology...26 Adrenal Corticosteroids...26 Androgens....27 Diabetes Mellitus...27 Growth Stimulating Agents...29 Osteoporosis....29 Thyroid Disease...29 Miscellaneous...30 Gastrointestinal...30 Diarrhea...30 Emesis...30 Gastroesophageal reflux disease (gerd)/ peptic ulcers...........................30 Gastrointestinal Spasm...31 Inflammatory Bowel Disease...31 Pancreatic Enzymes...32 Laxatives...32 Probiotic Supplementation...32 Miscellaneous...33 2

Infectious Diseases....33 Antibacterials....33 Antifungals....35 Antivirals...35 Miscellaneous...37 Musculoskeletal....38 Arthritis....38 Gout....40 Skeletal Muscle Relaxants...40 OB-GYN....40 Contraceptives...40 Endometriosis...41 Hormone Therapy/Menopause...42 Vaginal Infections...42 Miscellaneous...43 Ophthalmic...43 Allergy...43 Anti-Inflammatories....43 Glaucoma...44 Infections...45 Miscellaneous Ophthalmics....46 Psychiatric...46 Alcohol Deterrents...46 Anxiety...46 Miscellaneous...47 Attention Deficit Hyperactivity Disorder (ADHD)....47 Depression...47 Insomnia....48 Narcotic Antagonists...49 Smoking Cessation...49 Miscellaneous...49 Urological...61 Symptomatic Benign Prostatic Hypertrophy.61 Miscellaneous...61 Miscellaneous...61 Anaphylaxis...61 Cystic Fibrosis...62 Hereditary Angioedema...62 Hyperphosphatemia...62 Idiopathic Pulmonary Fibrosis (IPF)...62 Immune Thrombocytopenic Purpura...62 Medical Devices...62 Metabolic Modifiers...62 Vaccine (oral)...62 OTC MEDICATIONS....63 Acne....63 Antifungals....63 Cough/Cold Allergy...63 Atopic Dermatitis...64 Diabetes...64 Earwax Removal Products...64 Family Planning...64 First Aid...64 Gastrointestinal....65 Lice Products...65 Motion Sickness...65 Ophthalmics...65 Pain...65 Smoking Cessation Products...66 Vitamins/Minerals...66 Warts...66 Miscellaneous...66 Index of s...67 Respiratory s...49 Antitussives, Decongestants, Expectorants And Combinations...49 Asthma/COPD...55 Potassium...56 Potassium-Removing Agents...57 Miscellaneous...57 Vitamins And Minerals...57 3

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 mercaptopurine susp PURIXAN thioguanine THIOGUANINE 4

Generic Name Brand Name Tyrosine Kinase Inhibitor afatinib GILOTRIF PA, SP axitinib INLYTA PA, SP bosutinib BOSULIF PA, SP cabozantinib COMETRIQ PA, SP ceritinib ZYKADIA PA, SP crizotinib XALKORI PA, SP dabrafenib TAFINLAR PA, SP 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 CAPRELSA 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 idelalisib ZYDELIG PA, SP mitotane LYSODREN octreotide SANDOSTATIN pasireotide SIGNIFOR PA, SP procarbazine MATULANE 5

Generic Name Brand Name tretinoin VESANOID caps vismodegib ERIVEDGE PA, SP vorinostat ZOLINZA PA, SP Immunosuppressants Antimetabolites azathioprine IMURAN mycophenolate mofetil CELLCEPT mycophenolate sodium MYFORTIC Calcineurin Inhibitors cyclosporine SANDIMMUNE cyclosporine, modified NEORAL GENGRAF cyclosporine GENGRAF NEORAL SOLUTION modified oral soln 100 mg/ml cyclosporine SANDIMMUME SOLUTION oral soln 100 mg/ml tacrolimus HECORIA PROGRAF Other everolimus ZORTRESS lenalidomide REVLIMID capsules, PA Rapamycin Derivative sirolimus RAPAMUNE Immunomodulators Interferons interferon alfa-2a PA, SP interferon alfa-2b INTRON A PA, SP peginterferon alfa-2b SYLATRON 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 6

Generic Name Brand Name 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 Platelet Synthesis Inhibitor anagrelide AGRYLIN Miscellaneous aminocaproic acid AMICAR 500 mg tabs only apixaban ELIQUIS PA cilostazol PLETAL dabigatran etexilate mesylate PRADAXA capsule, PA 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 ticagrelor BRILINTA PA Platelet Aggregation Inhibitors aspirin BAYER OTC ECOTRIN clopidogrel PLAVIX dipyridamole PERSANTINE Applies to 300 mg tab only, QL 7

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

Generic Name Brand Name Angiotensin II Receptor Blockers (Antagonists) irbesartan AVAPRO losartan COZAAR QL olmesartan BENICAR ST valsartan DIOVAN ST Angiotensin II Receptor Blocker Combinations losartan/hctz HYZAAR QL olmesartan/ hydrochlorothiazide BENICAR HCT ST valsartan/ hydrochlorothiazide DIOVAN HCT ST Antiarrhythmics And Cardiac Glycosides amiodarone tabs CORDARONE 200 mg and 400 mg amiodarone PACERONE digoxin LANOXIN digoxin LANOXICAPS disopyramide NORPACE disopyramide ext-rel NORPACE CR dofetilide TIKOSYN dronedarone MULTAQ PA 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 9

Generic Name Brand Name Beta Blockers And Beta Blocker/Diuretic Combinations acebutalol SECTRAL atenolol TENORMIN atenolol/chlorthalidone TENORETIC bisoprolol ZEBETA bisoprolol/ hydrochlorothiazide ZIAC carvedilol COREG QL labetalol TRANDATE metoprolol LOPRESSOR metoprolol succinate TOPROL XL nadolol CORGARD pindolol PINDOLOL propranolol HEMANGEOL propranolol INDERAL IR only propranolol/hctz INDERIDE sotalol (AFIB/AFL) BETAPACE AF timolol maleate tablets Calcium Channel Blockers Dihydropyridines amlodipine NORVASC QL felodipine ext-rel PLENDIL QL isradipine DYNACIRC nicardipine CARDENE nifedipine PROCARDIA nifedipine ext-rel ADALAT CC QL PROCARDIA XL nimodipine NIMOTOP QL nimodipine oral soln NYMALIZE nisoldipine SULAR sustained release Nondihydropyridines diltiazem CARDIZEM diltiazem ext release CARDIZEM CD QL diltiazem sustained release diltiazem ext-rel CARDIZEM SR QL DILACOR XR TIAZAC QL 10

Generic Name Brand Name diltiazem CARDIZEM SR sustained release, QL diltiazem CARDIZEM LA sustained release coated MATXIM LA beads, QL verapamil CALAN verapamil VERALAN PM sustained release caps, (100 mg, 200 mg and 300 mg only) verapamil ext-rel CALAN SR Applies to 120 mg only, QL Diuretics amiloride MIDAMOR amiloride/ hydrochlorothiazide MODURETIC bumetanide BUMEX chlorothiazide DIURIL chlorthalidone CHLORTHALIDONE furosemide LASIX hydrochlorothiazide MICROZIDE 12.5 mg caps hydrochlorothiazide HYDROCHLOROTHIA- ZIDE soln, tabs indapamide LOZOL metolazone ZAROXOLYN spironolactone ALDACTONE spironolactone SPIRONOLACTONE powder spironolactone/ hydrochlorothiazide ALDACTAZIDE torsemide DEMADEX triamterene/ hydrochlorothiazide DYAZIDE 37.5/25 triamterene/ hydrochlorothiazide MAXZIDE-25 37.5/25 triamterene/ hydrochlorothiazide DYAZIDE 50/25 triamterene/ hydrochlorothiazide MAXZIDE 75/50 11

Generic Name Brand Name Nitrates Oral isosorbide dinitrate ext-rel DILATRATE-SR ISOCHRON 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 transdermal, QL NITRO-DUR niacin NIACOR niacin ext-rel NIASPAN Lipid Lowering Agents Bile Acid Resin Only the bulk products are covered (cans). Individual packets are not covered. cholestyramine QUESTRAN QUESTRAN-LIGHT coliestipol COLESTID (not packets) Fibrates ANTARA LIPOFEN fenofibrate LOFIBRA TRICOR TRIGLIDE gemfibrozil LOPID caps, tabs and micronized caps, ST 12

Generic Name Brand Name HMG-CoA Reductase Inhibitors and Combinations atorvastatin LIPITOR ezetimibe ZETIA PA 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 eplerenone INSPRA PA epoprostenol FLOLAN guanabenz WYTENSIN hydralazine APRESOLINE iloprost VENTAVIS SP, Coverable through Medical Benefit SP, Coverable through Medical Benefit lomitapide JUXTAPID PA, SP methyldopa ALDOMET methyldopa/hctz ALDORIL midodrine PROAMATINE ST minoxidil LONITEN ranolazine RANEXA ST sildenafil REVATIO PA tadalafil (PAH) ADCIRCA PA, SP treprostinil REMODULIN treprostinil TYVASO Central Nervous System SP, Coverable through Medical Benefit SP, Coverable through Medical Benefit Alzheimer s Disease donepezil ARICEPT 5 mg and 10 mg, QL donepezil ARICEPT 23 mg, ST galantamine RAZADYNE QL memantine NAMENDA QL, Members <18 years of age will require prior authorization. memantine SR NAMENDA XR PA, QL rivastigmine EXELON QL 13

Generic Name Brand Name Analgesics Analgesic, Other acetaminophen TYLENOL OTC aspirin/acetaminophen/ caffeine EXCEDRIN MIGRAINE 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 diclofenac sodium SR VOLTAREN XR QL etodolac LODINE IR Only fenoprofen NALFON 400 mg fenoprofen NALFON 600 mg flurbiprofen ANSAID ibuprofen ADVIL tabs, chew tabs ibuprofen MOTRIN and susp, OTC tabs, chew tabs and susp indomethacin INDOCIN ketoprofen ORUDIS IR only ketoprofen SR ORUDIS cap, 200 mg ketorolac tromethamine TORADOL QL meloxicam MOBIC QL nabumetone RELAFEN naproxen NAPROSYN Not EC naproxen sodium ANAPROX oxaprozin DAYPRO piroxicam FELDENE sulindac CLINORIL 14

Generic Name Brand Name Opioids Narcotic analgesics butalbital/apap/caff/cod FIORICET W/CODEINE QL, 50-325-40-30 mg 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 hydrocodone/ acetaminophen LORTAB ELIXIR QL hydrocodone/ acetaminophen LORTAB 2.5/500 2.5/500, QL hydrocodone/ acetaminophen LORTAB 5/500 BANCAP HC VICODIN 5/500 5/500, QL hydrocodone/ acetaminophen LORTAB 7.5/500 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 hydrocodone-ibuprofen tab VICOPROFEN QL hydromorphone DILAUDID QL meperidine DEMEROL QL morphine MSIR QL morphine RMS QL morphine ext-rel MS CONTIN QL oxycodone ROXICODONE QL oxycodone ER OXYCONTIN QL, ST oxycodone/ acetaminophen MAGNACET PERCOCET TYLOX QL 15

Generic Name Brand Name oxycodone/ acetaminophen CR XARTEMIS XR QL oxycodone/aspirin PERCODAN QL oxycodone OXYFAST soln, QL oxymorphone ER OPANA ER QL, ST tapentadol ER NUCYNTA ER ST Migraine Acute Therapy Ergotamine Derivatives dihydroergotamine D.H.E. 45 inj, QL dihydroergotamine MIGRANAL ergotamine/caffeine CAFERGOT ergotamine tartrate/ MIGERGOT caffeine SUPPOSITORIES QL Selective Serotonin Agonists naratriptan AMERGE ST rizatriptan MAXALT/MAXALT MLT QL sumatriptan IMITREX QL Migraine Prophylactic Therapy amitriptyline ELAVIL divalproex sodium cap sprinkle DEPAKOTE SPRINKLE divalproex sodium delayed-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 PA,QL, SP interferon beta-1a AVONEX/AVONEX PEN PA,QL, SP interferon beta-1a REBIF PA,QL, SP interferon beta-1b BETASERON for inj, PA SP teriflunomide AUBAGIO PA, SP Myasthenia Gravis pyridostigmine MESTINON pyridostigmine ext-rel MESTINON TIMESPAN 16

Generic Name Brand Name Parkinson s Disease amantadine SYMMETREL except tabs benztropine COGENTIN biperiden AKINETON bromocriptine PARLODEL carbidopa/levodopa SINEMET carbidopa/levodopa ext-rel SINEMET CR entacapone COMTAN pramipexole MIRAPEX pramipexole dihydrochloride SR MIRAPEX ER 24hr tab ropinirole REQUIP ropinirole hydrochloride SR REQUIP XL 24hr tab selegiline ELDEPRYL tabs tolcapone TASMAR trihexyphenidyl ARTANE Seizures carbamazepine TEGRETOL carbamazepine SR EPITOL EQUATRO carbamazepine ext-rel CARBATROL TEGRETOL-XR clobazam ONFI ST clonazepam KLONOPIN tabs diazepam DIASTAT ACUDIAL rectal gel, QL divalproex sodium cap sprinkle DEPAKOTE SPRINKLE divalproex sodium delayed-rel DEPAKOTE Minimum age 2 ethosuximide ZARONTIN exogabine POTIGA Age Limits Apply, ST felbamate FELBATOL felbamate oral susp FELBATOL ORAL SUSP gabapentin NEURONTIN caps and tabs only lacosamide VIMPAT Age Limits Apply, ST lacosamide solution VIMPAT PA lamotrigine LAMICTAL QL 17

Generic Name Brand Name lamotrigine chew dispersable tab LAMICTAL CD CHEW TAB lamotrigine dispersible tab LAMICTAL ODT KIT PA lamotrigine SR odt LAMICTAL XR ODT KIT PA lamotrigine odt LAMICTAL ODT PA lamotrigine titration kit LAMICTAL XR KIT PA lamotrigine SR LAMICTAL XR tab, PA levetiracetam KEPPRA QL levetiracetam SR KEPPRA XR methsuximide CELONTIN oxcarbazepine TRILEPTAL QL 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 rufinamide suspension BANZEL SUSPENSION PA tiagabine GABITRIL Age Limits Apply, ST topiramate TOPAMAX QL topiramate sprinkle caps TOPAMAX SPRINKLE QL valproic acid DEPAKENE vigabatrin oral solution SABRIL SOLUTION PA, SP zonisamide ZONEGRAN QL Miscellaneous tetrabenazine XENAZINE PA, SP Dermatology Acne Vulgaris Oral isotretinoin ACCUTANE Max Age of 25, PA Topical azelaic acid FINACEA benzoyl peroxide BENZAC AC benzoyl peroxide bar 10% PANOXYL BAR OTC OTC benzoyl peroxide DELOS cleanser 3.5%, OTC 18

Generic Name Brand Name benzoyl peroxide TRIAZ CLOTHS cloth 3%, 6%, 9% benzoyl peroxide PANOXYL CREAM OTC cream 2.5%, OTC benzoyl peroxide creamy wash 8% & benzoyl BPO CREAMY KIT peroxide bar 5% k benzoyl peroxide BENZEFOAM foam 5.3% & 9.8% benzoyl peroxide gel BENZIQ LS BENZIQ 2.75%, 5.25% BREVOXYL benzoyl peroxide BREVOXYL gel 4%, 8% benzoyl peroxide OC8 gel 7%, OTC benzoyl peroxide NEOBENZ MICR LIQ liquid 7% benzoyl peroxide wash 4% & benzoyl peroxide BREVOXYL-4 OTC OTC bar 5% kit clindamycin CLEOCIN T gel clindamycin CLEOCIN T lotion clindamycin CLEOCIN T soln erythromycin/benzoyl peroxide BENZAMYCIN erythromycin ERYGEL gel 2% erythromycin T-STAT soln salicylic acid CLEAN & CLEAR GEL, NEUTROGENA RAPID CLEAR GEL, EXUVI gel 2%, OTC ANCE salicylic acid KERALYT gel 3, 6% salicylic acid STRI-DEX, AVEENO CLEAR PADS OTC pad 0.5%, 1&, 2%, OTC sulfacetamide SULFACET-R sulfacetamide sodium KLARON LOTION SEBIZON lotion 10% sulfacetamide/sulfur PLEXION tretinoin AVITA RETIN-A 19

Generic Name Brand Name Bacterial Infections bacitracin BACITRACIN OTC bacitracin-polymyxinneomycin HC CORTISPORIN OINTMENT oint 1% 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% fluocinolone acetonide CAPEX SHAMOO shampoo 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% fluocinolone acetonide SYNALAR crm, oint 0.025% flurandrenolide CORDRAN tape fluticasone propionate CUTIVATE crm 0.05%, oint 0.005% fluticasone propionate CUTIVATE LOTION lotion 0.05% hydrocortisone butyrate LOCOID crm/lotion/oint 0.1% hydrocortisone valerate WESTCORT OINTMENT oint 0.2% 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% triamcinolone acetonide TRIANEX oint 0.05% High Potency betamethasone augmented dip DIPROLENE AF crm 0.05% betamethasone augmented dip DIPROLENE lotion 0.05% betamethasone dipropionate DIPROSONE crm/lotion/oint 0.05% 20

Generic Name Brand Name diflorasone diacetate PSORCON CREAM cream 0.05% diflorasone diacetate PSORCON OINTMENT 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 crystals CLOTRIMAZOLE clotrimazole LOTRIMIN AF OTC clotrimazole with betamethasone LOTRISONE ketoconazole NIZORAL ketoconazole foam EXTINA 2% ketoconazole gel XOLEGEL 2% ketoconazole gel 2% & pyrithione zinc shampoo XOLEGEL DUO KIT 1% kit ketoconazole gel 2% & hydrocortisone gel 1% XOLEGEL KIT kit ketoconazole shampoo NIZORAL A-D OTC 1% OTC miconazole MICATIN OTC miconazole MONISTAT-DERM miconazole DESENEX POWDER 2% powder miconazole nitrate soln AZOLEN TINCTURE SOLUTION OTC 2% OTC miconazole nitrate lotion ZEASORB-AF 2% OTC miconazole nitrate kit FUNGOID TINCTURE KIT 2% nystatin MYCOSTATIN nystatin/triamcinolone MYCOLOG-II 21

Generic Name Brand Name terbinafine gel LAMISIL GEL 1% terbinafine LAMISIL AT OTC terbinafine hcl LAMISIL SOLUTION soln 1% 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 ivermectin SKLICE lotion 0.5%, PA malathion OVIDE permethrin NIX CREME RINSE 1%, OTC permethrin ELIMITE 5%, QL pyrethrins/piperonyl but. RID SHAMPOO/ BUTOXIDE SHAMPOO 4% OTC spinosad NATROBA susp 0.9%, PA Viral Infections podofilox CONDYLOX SOL sol salicylic acid 17%/ collodion DUOFILM OTC Miscellaneous albendazole ALBENZA aluminum acetate soln/cream, OTC aluminum chloride DRYSOL OTC soln 12%, OTC aluminum chloride hexahydrate HYPERCARE 20% ammonium lactate LAC-HYDRIN 12% calamine lotion/ointment, OTC chloroxine CAPITROL fluorouracil EFUDEX fluorouracil CARAC 0.5% cream 22

Generic Name Brand Name fluorouracil FLUOROPLEX 1% cream hexachlorophene PHISOHEX hydrocortisone PROCTOSOL HC CREAM 2.5%, PROCTOZONE CREAM-HC 2.5%, ANUSOL HC 2.5% hydrocortisone acetate CORTIFOAM AEROSOL rectal foam 90 mg hydrocortisone acetate TUCKS OINTMENT OTC rectal ointment hydrocortisone acetate w/ pramoxine PROCTOFOAM HC FOAM rectal foam 1-1% hydrocortisone PROCTO-PAK CREAM rectal cream 1% 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 patch LIDODERM PATCH 5%, PA lidocaine/prilocaine EMLA 2.5% cream lidocaine-prilocaine EMLA kit 2.5-2.5% imiquimod 5% cream ALDARA PA ivermectin STROMECTOL 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 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 praziquantel BILTRICIDE salicylic acid SALACYN 6% cream, lotion salicylic acid CALICYLIC cream 10% salicylic acid SALAC OTC foam 2%, OTC salicylic acid SALVAX foam 6% salicylic acid P & S SHAMPOO, SELSUN BLUE; DHS SAL SHAMPOO OTC shampoo 2%, 3% OTC salicylic acid SALEX shampoo 6% selenium sulfide SELSUN shampoo 2.5% 23

Generic Name Brand Name tacrolimus PROTOPIC 0.03% tacrolimus PROTOPIC 0.1% urea 40% UREA 40% CREAM AND LOTION ointment 0.03% ST, Step therapy is not required for members ages 2-11; not covered for members less than 2 years of age ointment 0.1%, ST (minimum age 16) cream and lotion Ear, Nose & Throat Ear acetic acid VOSOL OTIC otic acetic acid/ aluminum acetate acetic acid/ hydrocortisone DOMEBORO OTIC VOSOL HC OTIC antipyrine-benzocaine AURALGAN otic soln 55-14 mg/ml (5.5-1.4%) benzocaine/antipyrine BENZOTIC carbamide peroxide DEBROX 6.5%, OTC ciprofloxacin/ CIPRODEX PA dexamethasone ciprofloxacinhydrocortisone CIPRO HC otic susp 0.2-1% neomycin/polymyxin B/ hydrocortisone CORTISPORIN OTIC otic ofloxacin FLOXIN OTIC Nose Antihistamines - First Generation, Sedating brompheniramine maleate J-TAN PD drops 1 mg/ml brompheniramine maleate RESPA-BR tab SR 12hr 11 mg brompheniramine tannate BROVEX CT chew tab 12 mg chlorpheniramine maleate CHLOR-TRIMETON 2 mg/5 ml, OTC SYRUP chlorpheniramine ext-rel CHLOR-TRIMETON ALLERGY 12 mg, OTC chlorpheniramine maleate CHLORPHENIRAMINE tabs 4 mg chlorpheniramine maleate CHLORPHENIRAMINE drops 2 mg/ml chlorpheniramine tannate CHLORPHENIRAMINE tabs 24

Generic Name Brand Name chlorpheniramine tannate CHLORPHENIRAMINE susp 2 mg/ml clemastine CLEMASTINE cyproheptadine CYPROHEPTADINE dexchlorpheniramine maleate POLARAMINE syrup 2 mg/5ml diphenhydramine BENADRYL OTC diphenhydramine diphenhydramine TRIAMINIC oral strips diphenhydramine BENADRYL tab disp 12.5 mg hydroxyzine HCL ATARAX hydroxyzine pamoate VISTARIL Antihistamines - Second Generation, Nonsedating cetirizine ZYRTEC OTC cetirizine chew tab ZYRTEC CHEWABLE TABLET OTC fexofenadine ALLEGRA tabs levocetirizine XYZAL tabs, ST loratadine ALAVERT CLARITIN OTC loratadine CLARITIN CHEW chew tab 5 mg loratadine CLARITIN RDT ODT 5 mg Antihistamines - Others Antihistamine/Decongestant Combinations azelastine ASTELIN spray Antihistamine/Decongestant Combinations - First Generation brompheniramine/ pseudoephedrine LODRANE D cap 4-60 mg chlorpheniramine/ phenylephrine/ TRIOTANN pyrilamine chlorpheniramine/pseudoephedrine ext-rel DECONAMINE SR triprolidine/ ACTIFED OTC pseudoephedrine Antihistamine/Decongestant Combinations - Second Generation cetirizine hydrochloride/ pseudoephedrine hydrochloride 12 hours extended-release fexofenadine/ pseudoephedrine ZYRTEC-D 5 mg-120 mg tablet ALLEGRA-D SR tabs 25

Generic Name Brand Name ALAVERT-D loratadine/ ALAVERT ALRG pseudoephedrine OTC TAB/SINUS ext-rel ALLERGY/CONG Nasal Steroids fluticasone FLONASE triamcinolone acetonide NASACORT AQ PA triamcinolone nasal spray NASACORT ALLERGY 24 HOUR OTC Miscellaneous Nasal Decongestants oxymetazoline AFRIN OTC phenylephrine NEO-SYNEPHRINE DIMEATAPP DRO OTC DECONGES Miscellaneous Nasal cromolyn sodium NASALCROM OTC ipratropium bromide ATROVENT NS saline nasal spray 0.65% OCEAN NASAL SPRAY OTC Throat And Mouth amlexanox APHTHASOL oral paste 5% artificial saliva OTC chlorhexidine PERIOGARD chlorhexidine gluconate PERIDEX lidocaine viscous XYLOCAINE pilocarpine SALAGEN triamcinolone KENALOG IN ORABASE paste Endocrinology Adrenal Corticosteroids cortisone acetate dexamethasone DECADRON fludrocortisone FLORINEF hydrocortisone CORTEF methylprednisolone MEDROL prednisolone prednisolone sodium ORAPRED phosphate PEDIAPRED prednisolone PRELONE syrup 26

Generic Name Brand Name prednisone DELTASONE prednisone PREDNISONE conc 5 mg/ml prednisone RAYOS tabs delayed release Androgens fluoxymesterone ANDROXY PA testosterone cypionate DEPO-TESTOSTERONE testotesterone ANDROGEL 1% gel (not pump), PA testosterone ANDROGEL 1.62% gel, PA testosterone enanthate DELATESTRYL Vials only. Disposable syringes not covered. testosterone gel TESTIM PA testosterone gel TESTOSTERONE 1% topical tube, packet, PA TOPICAL GEL and pump bottle 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 NOVOLOG FLEXPEN PA, QL insulin aspart protamine NOVOLOG MIX 70/30 70%/insulin aspart 30% QL insulin aspart protamine NOVOLOG MIX 70/30 70%/insulin aspart 30% FLEXPEN PA, QL insulin detemir LEVEMIR QL insulin detemir LEVEMIR FLEXPEN PA, QL insulin glargine LANTUS QL insulin glargine LANTUS SOLOSTAR PA, QL insulin human NOVOLIN R OTC, QL insulin human RELION R OTC, QL insulin isophane HUMULIN N OTC, QL insulin isophane human HUMULIN N PEN PA, QL insulin isophane human NOVOLIN N OTC, QL insulin isophane human RELION N OTC, QL insulin isophane human 70%/regular 30% NOVOLIN 70/30 OTC, QL insulin isophane human 70%/regular 30% RELION 70/30 OTC, QL insulin lisopro pro/lispro HUMALOG MIX 50/50 QL 27

Generic Name Brand Name insulin lispro prot 50%/ HUMALOG MIX 50/50 lispro 50% KWIKPEN PA, QL insulin lisopro prot/lispro HUMALOG MIX 75/25 QL insulin lispro prot 75%/ HUMALOG MIX 72/25 lispro 25% KWIKPEN PA, QL insulin isophane/regular HUMULIN 70/30 OTC, QL insulin lispro HUMALOG QL insulin lispro HUMALOG KWIKPEN PA, QL insulin regular HUMULIN R OTC, QL Monitoring- Strips and Kits/Diabetic Supplies QL for non-insulin ACCU-CHEK TEST STRIPS (AVIVA, dependent members: allow AVIVA PLUS, COMPACT, SMARTVIEW) once daily testing ACCU-CHEK CARE KIT (AVIVA, COMPACT PLUS, NANO SMARTVIEW) ONE TOUCH TEST STRIPS (BASIC/PROFILE, SURESTEP, ULTRA, VERIO) ONE TOUCH SYSTEMS (ULTRA, ULTRASMART, UL- TRA2, ULTRAMINI, VERIO IQ, VERIO SYNC) 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 canagliflozin INVOKANA ST canagliflozin/metformin INVOKAMET ST chlorpropamide DIABINESE empagliflozin JARDIANCE ST glimepiride AMARYL glipizide GLUCOTROL glipizide ext-rel GLUCOTROL XL glipizide/metformin METAGLIP glyburide MICRONASE glyburide, micronized GLYNASE linagliptin TRADJENTA ST linagliptin/metformin JENTADUETO ST metformin GLUCOPHAGE metformin ER GLUCOPHAGE ER metformin/glyburide GLUCOVANCE 28

Generic Name Brand Name nateglinide STARLIX pioglitazone ACTOS QL pioglitazone/glimepiride DUETACT ST pioglitazone/metformin ACTOPLUSMET QL, ST pioglitazone/metformin ER ACTOPLUS MET XR ST repaglinide PRANDIN saxagliptin ONGLYZA ST saxagliptin/metformin KOMBIGLYZE ST sitagliptan JANUVIA QL, ST sitagliptan/metformin JANUMET QL, ST sitagliptan/metformin ER JANUMET XR QL, ST tolazamide TOLINASE tolbutamide TOLBUTAMIDE Miscellaneous Antidiabetic Agents albiglutide TANZEUM ST exenatide BYETTA PA liraglutide VICTOZA ST pramlintide SYMLIN PA Growth Stimulating Agents mecasermin INCRELEX PA, SP somatropin NORDITROPIN PA, SP TEV-TROPIN somatropin SEROSTIM (non-refrigerated) subq, 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 29

Generic Name Brand Name 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 Gastrointestinal Diarrhea diphenoxylate/atropine LOMOTIL loperamide LOPERAMIDE loperamide IMODIUM A-D CHW chew 2 mg loperamide IMODIUM A-D LIQ liq 1 mg/7.5ml loperamide IMODIUM A-D OTC Emesis aprepitant EMEND QL applies to 40 mg, 80 mg and 80-125 mg dolasetron ANZEMET PA dronabinol MARINOL PA granisetron KYTRIL PA SP granisetron KYTRIL oral soln PA meclizine ANTIVERT metoclopramide REGLAN ondansetron ZOFRAN ZOFRAN ODT QL prochlorperazine COMPAZINE promethazine PHENERGAN 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 NEXIUM 24HR OTC PA 30

Generic Name esomeprazole granules famotidine Brand Name 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. famotidine PEPCID AZ CHW chew lansoprazole PREVACID PA lansoprazole del-rel PREVACID SOLUTAB orally disintegrating tabs, QL omeprazole delayed-rel PRILOSEC Capsules only, QL omeprazole delayed-rel PRILOSEC POWDER susp packet pantoprazole PROTONIX pantoprazole delayed-rel PROTONIX PAK susp packet ranitidine ZANTAC 150 mg tabs ranitidine effer ZANTAC tab 25 mg ranitidine syrup ZANTAC sucralfate CARAFATE sulcralfate CARAFATE SUSPENSION suspension, Members 10 years of age up to 65 years of age will require prior authorization. Gastrointestinal Spasm dicyclomine BENTYL glycopyrrolate ROBINUL ROBINUL FORTE hyoscyamine sulfate LEVSIN CYSTOSPAZ hyoscyamine sulfate LEVBID ext-rel LEVSINEX Inflammatory Bowel Disease balsalazide COLAZAL budesonide ENTOCORT EC PA hydrocortisone COLOCORT enema mesalamine APRISO LIALDA PENTASA 31

Generic Name Brand Name mesalamine ext-rel APRISO ASACOL LIALDA PENTASA mesalamine ROWASA enema only mesalamine supp CANASA olsalazine sodium DIPENTUM sulfasalazine AZULFIDINE sulfasalazine delayed-rel AZULFIDINE EN-TABS Pancreatic Enzymes pancrelipase CREON CREON 3000 UNIT ZENPEP pancrelipase PANCREAZE QL pancrealipase DR ZENPEP DR 25000-85000-136000 unit pancrealipase DR CREON DR 36000-114000-180000 unit sacrosidase SUCRAID soln 8500 unit/ml, PA Laxatives casanthranol-docusate sodium OTC docusate calcium plus OTC docusate potasssium OTC glycerin GLYCERIN SUPPOSITORY suppository, OTC lactulose ENULOSE lactulose KRISTALOSE oral packet peg 3350/electrolytes COLYTE peg 3350/sodium bicarbonate/sodium chloride/potassium NULYTELY chloride 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 32

Generic Name Brand Name acidophilus/bifidus ACIDOPHILUS/ BIFIDUS WAFER OTC acidophilus/citrus pectin ACIDOPHILUS/ CITRUS PECTIN tabs, OTC 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 + HELIDAC tetracycline methylnaltrexone RELISTOR PA misoprostol CYTOTEC teduglutide GATTEX PA, SP ursodiol ACTIGALL URSO URSO FORTE Infectious Diseases Antibacterials Cephalosporins - First Generation cefadroxil DURICEF cephalexin KEFLEX tabs are not covered Cephalosporins - Second Generation cefaclor CECLOR cefprozil CEFZIL cefuroxime axetil CEFTIN Cephalosporins - Third Generation cefdinir OMNICEF cefixime SUPRAX QL cefixime SUPRAX susp, QL cefpodoxime VANTIN Fluoroquinolones ciprofloxacin CIPRO levofloxacin LEVAQUIN tablets only ofloxacin FLOXIN tabs 33

Generic Name Brand Name 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 AMOXIL tabs, 500 mg & 875 mg amoxicillin/clavulanate AUGMENTIN amoxicillin/clavulanate AUGMENTIN ES-600 amoxicillin AMOXIL SUSP suspension ampicillin PRINCIPEN dicloxacillin DICLOXACILLIN penicillin VK VEETIDS Sulfonamides sulfadiazine sulfisoxazole sulfamethoxazole/ BACTRIM trimethoprim, DS BACTRIM DS Tetracyclines demeclocycline DECLOMYCIN PA doxycycline delayed release VIBRAMYCIN doxycycline hyclate VIBRAMYCIN doxycycline monohydrate DOXYCYCLINE MONOHYDRATE minocycline MINOCIN caps and tabs minocycline SR MINOCIN 24hr tetracycline SUMYCIN Miscellaneous vancomycin HCl VANCOCIN HCL cap, ST 34

Generic Name Brand Name Antifungals clotrimazole MYCELEX troches fluconazole DIFLUCAN QL flucytosine ANCOBAN PA griseofulvin ultramicrosize GRIS-PEG griseofulvin microsize GRIFULVIN V itraconazole SPORANOX PA, QL itraconazole ONMEL tab 200 mg, PA ketoconazole NIZORAL miconazole buccal MICONAZOLE tab 50 mg (mouth-throat) nystatin MYCOSTATIN posaconazole susp NOXAFIL PA terbinafine LAMISIL QL terbinafine LAMISIL oral granules voriconazole VFEND tabs, PA Antivirals Cytomegalovirus Treatment cidofovir VISTIDE Coverable through Medical foscarnet sodium FOSCAVIR Benefit Coverable through Medical Benefit ganciclovir CYTOVENE valganciclovir VALCYTE valganciclovir VALCYTE soln PA Entry/Fusion Inhibitors enfuvirtide FUZEON PA, SP Hepatitis Treatment adefovir HEPSERA boceprevir VICTRELIS PA, SP entecavir BARACLUDE interferon alfa-2b INTRON A PA, SP interferon alfacon-1 INFERGEN PA, SP lamivudine EPIVIR HBV ledipasvir/sofosbuvir HARVONI PA peginterferon alfa-2a PEGASYS PA, SP peginterferon alfa-2a PEGASYS PROCLICK PA, SP peginterferon alfa-2b PEGINTRON PA, SP ribavirin REBETOL/COPEGUS 200 mg caps and tabs only, PA, SP 35

Generic Name Brand Name simeprevir OLYSIO PA, SP sofosbuvir SOVALDI PA, SP telbivudine TYZEKA PA, SP Herpes Treatment acyclovir ZOVIRAX acyclovir ZOVIRAX CREAM cream 5% acyclovir ZOVIRAX OINTMENT oint 5% acyclovir buccal SITAVIG docosanol ABREVA OTC cream 10%, OTC famciclovir FAMVIR PA penciclovir DENAVIR cream 1% valacyclovir VALTREX Influenza Treatment amantadine SYMMETREL except tabs oseltamivir TAMIFLU QL rimantadine FLUMADINE zanamivir RELENZA QL Non-Nucleoside Reverse Transcriptase Inhibitors delavirdine RESCRIPTOR efavirenz SUSTIVA nevirapine VIRAMUNE nevirapine ER VIRAMUNE XR rilpivirine EDURANT Nucleoside Analogues Nucleoside Reverse-Transcriptase Inhibitors/and Combinations abacavir ZIAGEN abacavir/lamivudine EPZICOM abacavir/lamivudine/ zidovudine TRIZIVIR didanosine VIDEX didanosine delayed-rel VIDEX EC emtricitabine EMTRIVA emtricitabine/rilpivirine/ tenofovir COMPLERA lamivudine EPIVIR lamivudine/zidovudine COMBIVIR stavudine ZERIT zalcitabine HIVID zidovudine RETROVIR 36

Generic Name Brand Name 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 abacavir/dolutegravir/ lamivudine TRIUMEQ artemether-lumefantrine COARTEM atovaquone MEPRON PA atovaquone/proguanil MALARONE bedaquiline SIRTURO PA chloroquine phosphate ARALEN clindamycin CLEOCIN cap, 75 mg clindamycin CLEOCIN tabs cobicistat TYBOST dapsone DAPSONE dolutegravir TIVICAY ethambutol MYAMBUTOL etravirine INTELENCE etravirine INTELENCE tab 25 mg hydroxychloroquine PLAQUENIL isoniazid ISONIAZID linezolid ZYVOX PA maraviroc SELZENTRY 37

Generic Name Brand Name mefloquine LARIAM metronidazole FLAGYL tabs only neomycin sulfate neomycin sulfate soln NEO-FRADIN nitazoxanide tablet ALINIA PA nitazoxanide suspension ALINIA SUSPENSION nitrofurantoin ext-rel MACROBID nitrofurantoin MACRODANTIN macrocrystals MACRODANTIN 25 MG 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. palivizumab SYNAGIS PA paromomycin HUMATIN povidone-iodine OTC primaquine pyrimethamine DARAPRIM pyrazinamide PYRAZINAMIDE quinine sulfate QUALAQUIN 324 mg caps only raltegravir ISENTRESS raltegravir ISENTRESS CHEWABLE chewable tablet rifabutin MYCOBUTIN rifampin RIFADIN trimethoprim TRIMETHOPRIM tabs only Musculoskeletal Arthritis Disease Modifying Anti-Rheumatic s abatacept ORENCIA - IV SP, Coverable through Medical Benefit adalimumab HUMIRA PA, SP anakinra KINERET PA, SP auranofin RIDAURA azathioprine IMURAN certolizumab pegol CIMZIA PA, SP etanercept ENBREL PA, SP infliximab REMICADE SP, Coverable through Medical Benefit 38

Generic Name Brand Name hydroxychloroquine PLAQUENIL leflunomide ARAVA methotrexate METHOTREXATE penicillamine CUPRIMINE sulfasalazine AZULFIDINE sulfasalazine delayed-rel AZULFIDINE EN-TABS NSAIDs and Other Analgesics acetaminophen TYLENOL OTC aspirin BAYER ECOTRIN OTC aspirin HALFPRIN tablet DR aspirin-al hydro-mg hydro- ASCRIPTIN tab ca carb aspirin buffered BUFFERIN capsaicin OTC celecoxib CELEBREX PA, QL choline magnesium trisalicylate TRILISATE diclofenac 1% gel VOLTAREN 1% TOPICAL GEL diclofenac potassium CATAFLAM diclofenac sodium delayed release VOLTAREN diclofenac sodium extended release VOLTAREN XR diflunisal DOLOBID etodolac LODINE IR only fenoprofen NALFON 600 mg ibuprofen ADVIL tabs, chew tabs and susp, OTC ibuprofen MOTRIN tabs, chew tabs and susp indomethacin INDOCIN ketoprofen ORUDIS IR only meloxicam MOBIC QL nabumetone RELAFEN naproxen NAPROSYN not EC naproxen sodium ANAPROX oxaprozin DAYPRO piroxicam FELDENE sulindac CLINORIL 39

Generic Name Brand Name Gout allopurinol ZYLOPRIM colchicine COLCRYS 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 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 40

Generic Name Brand Name Monophasic - 30 mcg estrogen desogestrel/ee ORTHO-CEPT 0.15/30, QL levonorgestrel/ee NORDETTE 0.15/30, QL 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 CAZIANT CESIA CYCLESSA QL VELIVET 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. 41

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

Generic Name Brand Name Vaginal clotrimazole GYNE-LOTRIMIN OTC clindamycin CLEOCIN crm clindamycin CLEOCIN supp metronidazole METROGEL-VAGINAL METROGEL 1% miconazole MONISTAT OTC miconazole MONISTAT 3 miconazole nitrate MICONAZOLE KIT vaginal supp & cream kit sulfanilamide AVC VAGINAL vaginal cream terconazole TERAZOL 3/7 crm Miscellaneous conjugated estrogen/ bazedoxifene DUAVEE methylergonovine METHERGINE tranexamic acid LYSTEDA PA Ophthalmic Allergy azelastine OPTIVAR ST cromolyn sodium CROLOM QL ketotifen ALAWAY OTC naphazoline w/ NAPHCON A pheniramine OPCON A ophth soln 0.027-0.315% naphazoline/antazoline naphazoline/glycerin CLEAR EYES REDNESS RELIEF naphazoline/zinc sulfate VASOCLEAR A naphazoline HCL VASOCLEAR soln 0.02% tetrahydrozoline /zinc sulfate VISINE-AC Anti-Inflammatories Nonsteroidal diclofenac sodium VOLTAREN flurbiprofen OCUFEN ketorolac ACULAR/ACULAR LS 43

Generic Name Brand Name Steroidal dexamethasone MAXIDEX ophth suspension 0.1% 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% sulfacetamide sodiumprednisolone VASOCIDIN BLEPHAMIDE ophth susp 10-0.2% tobramycin/ TOBRADEX dexamethasone tobramycindexamethasone TOBRADEX ST 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 ophth susp technology 0.3-0.05% 44

Generic Name Brand Name Beta-blockers betaxolol BETOPTIC -S ophth suspension 0.25% carteolol levobunolol BETAGAN ophthalmic solution metipranolol OPTIPRANOLOL 0.3% ophthalmic solution timolol TIMOPTIC XE gel forming solution timolol hemihydrate BETIMOL timolol maleate TIMOPTIC Prostaglandins latanoprost XALATAN QL tafluprost ZIOPTAN ophth soln 0.0015%. PA travoprost TRAVATAN Z ophth soln 0.004%, PA travoprost TRAVATAN Z PF ophth soln 0.004% (benzalkonium free), PA Carbonic Anhydrase Inhibitors brinzolamide AZOPT PA dorzolamide TRUSOPT Carbonic Anhydrase Inhibitor/Beta-blocker Combination dorzolamide/ COSOPT timolol maleate dorzolamide hcl-timolol maleate COSOPT PF Cholinesterase Inhibitor ecothiophate PHOSPHOLINE IODINE Mydriatics atropine ISOPTO ATROPINE cyclopentolate CYCLOGYL homatropine ISOPTO HOMATROPINE scopolamine ISOPTO HYOSCINE Infections Bacterial ophth solution preservative free bacitracin ciprofloxacin CILOXAN erythromycin ERYTHROMYCIN gatifloxin ZYMAR PA gentamicin GENTAK moxifloxacin HCl VIGAMOX ophth solution 0.5% neomycin/polymyxin B/ gramicidin NEOSPORIN 45

Generic Name Brand Name ofloxacin OCUFLOX polymyxin B/bacitracin POLYSPORIN polymyxin B/trimethoprim POLYTRIM sulfacetamide/ phenylephrine VASOSULF sulfacetamide BLEPH-10 oint/soln tobramycin TOBREX Fungal trifluridine VIROPTIC Viral natamycin NATACYN ophth suspension 5% Miscellaneous Ophthalmics cyclosporine RESTASIS (ophth) emulsion 0.05%, PA cysteamine 0.44% CYSTARAN PA, SP ophthalmic solution sodium chloride hypertonic Psychiatric MURO 128 soln 5% Alcohol Deterrents acamprosate CAMPRAL disulfiram ANTABUSE naltrexone REVIA Anxiety Benzodiazepines alprazolam XANAX QL, IR only alprazolam XANAX solution alprazolam XANAX tablet SR, QL chlordiazepoxide LIBRIUM clonazepam KLONOPIN not wafers clonazepam KLONOPIN odt tabs clorazepate TRANXENE diazepam VALIUM QL diazepam VALIUM solution, QL lorazepam ATIVAN QL lorazepam ATIVAN solution, QL oxazepam SERAX QL 46

Generic Name Brand Name Miscellaneous buspirone BUSPAR clomipramine ANAFRANIL fluvoxamine LUVOX fluvoxamine SR LUVOX CR Attention Deficit Hyperactivity Disorder (ADHD) amphetamine/dextroam- ADDERALL QL phetamine mixed salts amphetamine/ dextroamphetamine mixed salts ext-rel ADDERALL XR (BRAND ADDERALL XR IS PREFERRED) atomoxetine STRATTERA QL, ST dextroamphetamine DEXEDRINE QL dextroamphetamine DEXTROSTAT QL dextroamphetamine ext-rel DEXEDRINE SPANSULE QL guanfacine INTUNIV ST lisdexamfetamine VYVANSE Age Limits Apply, QL methylphenidate RITALIN tabs only, QL methylphenidate METHYLIN SOLUTION solution, QL methylphenidate ext-rel CONCERTA QL methylphenidate ext-rel METADATE ER RITALIN-SR QL RITALIN LA Depression Monoamine Oxidase Inhibitor (MAOI) tranylcypromine PARNATE Selective Serotonin Reuptake Inhibitor (SSRIs) citalopram CELEXA QL escitalopram LEXAPRO fluoxetine PROZAC QL 10 mg and 20 mg caps and 20 mg soln only paroxetine PAXIL tablets paroxetine PAXIL ORAL SUSP oral susp, QL paroxetine SR PAXIL CR tablets, QL sertraline ZOLOFT tablets, QL 47

Generic Name Brand Name 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 protriptyline VIVACTIL 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 bupropion ext-rel FORFIVO XL 450 mg maprotiline LUDIOMIL mirtazapine REMERON tabs (not soltabs) mirtazapine REMERON ODT odt tablets trazodone DESYREL 150 mg only Insomnia Benzodiazepines estazolam PROSOM QL flurazepam DALMANE QL temazepam RESTORIL 15 mg and 30 mg only, QL triazolam HALCION QL Non-benzodiazepines chloral hydrate CHLORAL HYDRATE diphenhydramine NYTOL QUICK CAPS OTC ramelteon ROZEREM PA zaleplon SONATA QL zolpidem AMBIEN QL 48

Generic Name Brand Name Narcotic Antagonists buprenorphine SUBUTEX PA, QL buprenorphine/naloxone SUBOXONE 2 mg and 8 mg film only, PA, QL naloxone NALOXONE INJ naltrexone REVIA Smoking Cessation bupropion ZYBAN smoking deterrent, QL nicotine NICODERM TD patch, QL nicotine inhaler system NICOTROL QL nicotine polacrilex gum NICORETTE 2 mg & 4 mg, QL nicotine polacrilex lozenge COMMITT 2 mg & 4 mg, QL varenicline CHANTIX QL Miscellaneous chlorpromazine THORAZINE dextromethorphan/ 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 49

Generic Name brompheniramine/ pseudoephedrine brompheniramine/ pseudoephedrine brompheniramine/ pseudoephedrine 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 Brand Name J-TAN D PD drops 1-7.5 mg/ml BROVEX PSB liq 4-20 mg/5 ml ANDEHIST syrup 4-60 mg/5 ml 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 syrup 50

Generic Name chlorpheniramine/ dextromethorphan chlorpheniramine/ pseudoephedrine 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 Brand Name ROBITUSSIN PED LIQ CGH/COLD ROBITUSSIN LIQ CGH/CLD DIMETAPP SYP CGH/CLD CORICIDIN TAB CGH/CLD HISTEX CPM/PSE 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 CHERATUSSIN AC GUIATUSS/AC M-CLEAR WC MYTUSSIN AC GUIATUSS DAC PROMETHAZINE W/CODEINE PROMETHAZINE VC W/CODEINE QL QL QL 51

Generic Name dextromethorphanguaifenesin dextromethorphanguaifenesin dextromethorphan polistirex ext rel dextromethorphan/ guaifenesin dextromethorphan hbr dextromethorphan/ brompheniramine/ pseudoephedrine dextromethorphan/ carbinoxamine/ pseudoephedrine dextromethorphan/ promethazine Brand Name ROBITUSSIN LIQ CGH/ CONG liq 10-200 mg/ 5 ml DURATUSS DM ELX soln 25-225 mg/5 ml DELSYM OTC GG/DM CR MUCINEX DM ROBITUSSIN DM TUSSIN DM ROBITUSSIN SYP MAX-ST ROBITUSSIN PED SYP BROMETANE DX OTC syrup CARDEC-DM drops PHENERGAN DM PROMETHAZINE SYP DM guaifenesin ROBITUSSIN OTC guaifenesin ext-rel MUCINEX OTC guaifenesin MUCINEX KIDS granules packet guaifenesin guaifenesin guaifenesin/pseudoephedrine ext rel guaifenesin/ pseudoephedrine guaifenesin/ pseudoephedrine ext rel guaifenesin/ pseudoephedrine/ dextromethorphan ROBITUSSIN SYP CHST CNG TRIACTIN CHEST CON- GESTION GUAIFED ROBITUSSIN PE PSE/GG GUAIFEN PSE MUCINEX D GG/PSE CR ROBITUSSIN CF syrup 100 mg/5 ml soln 50 mg/5 ml syrup, OTC OTC 52

Generic Name hydrocodone/chlorpheniramine/phenylephrine hydrocodone/guaifenesin hydrocodone/homatropine loratadine & pseudoephedrine SR 24hr phenyleph/bromphen/ dextromethorphan/ guaifenesin phenylephrine/brompheniramine-dm phenylephrine/brompheniramine-dm phenylephrine/brompheniramine-dm phenylephrine/brompheniramine-dm phenylephrine/ brompheniramine/ dextromethorphan phenylephrine/ chlorpheniramine phenylephrine/ chlorpheniramine/ dextromethorphan phenylephrine/ chlorpheniramine/ dextromethorphan phenylephrine/ chlorpheniramine/ dextromethorphan Brand Name HISTUSSIN HC VITUSSIN HYDROCODO/GG SYP HYCODAN HYDROMET SYP HYDROCODONE/ TAB HOMATROP ALLERGY/CONG TAB RELIEF ALLANHIST SYP PDX tab 10-240 mg PRESGEN B liq 10-4-20 mg/5 ml DIMETAPP DM liq 2.5-1-5 mg/5 ml ALAHIST DM liq 7.5-4-15 mg/5 ml LOHIST-DM syrup 5-2-10 mg/5 ml QUAL-TUSSIN SYP DC ATUSS DR DE-CHLOR DM RONDEC DM DROPS CARDEC DM DRO ROBITUSSIN LIQ CGH/ALRG RONDEC DM STATUSS DM SYP CARDEC DM SYP MINUTUSS DR SYP OTC syrup liquid syrup 53

Generic Name Brand Name phenylephrine/chlorpheniramine/dihydrocodeine DIHYDRO-PE SYP phenylephrine/dextromethorphan DCON/CGH DIMETAPP DRO phenylephrine/ dextromethorphan/ ROBITUSSIN PE guaifenesin phenylephrine/ephed/ RYNATUSS PEDIATRIC CPM w/ SUSP carbetapentane susp ROBITUSSIN LIQ phenylephrine/guaifenesin HD/CHST phenylephrine/guaifenesin DECONEX cap 10-390 mg SUPRESS-PE PEDIATRIC phenylephrine/guaifenesin DROPS drops 2.5-50 mg/ml phenylephrine/guaifenesin ENTEX LQ LIQ liq 10-100 mg/5 ml MUCINEX COLD LIQ / phenylephrine/guaifenesin KIDS liq 2.5-100 mg/5 ml TRIAMINIC LIQ CHST/ phenylephrine/guaifenesin NAS liq 2.5-50 mg/5 ml phenylephrine/guaifenesin NARIZ liq 7.5-200 mg/5 ml TRIAMINIC SYR CHST/ phenylephrine/guaifenesin NAS syrup 2.5-50 mg/5 ml phenylephrine/guaifenesin syrup 5-200 mg/5 ml phenylephrine/guaifenesin DECONEX IR tab 10-380 mg phenylephrine/guaifenesin GILPHEX TR tab 10-388 mg phenylephrine/guaifenesin MEDIFIN PE tab 10-400 mg phenylephrine/guaifenesin LIQUIBID PD tab 5-200 mg phenylephrine/hydrocodone/guaifenesin QUAL-TUSSIN SYP DC phenylephrine/pyrilamine/ dextromethorphan CODAL-DM phenylephrine/pyrilamine w/hydrocodone CODIMAL DH syrup phenylephrine tan/pyrilamine tan/ TUSSI 12D S susp carbeta tan promethazine & PROMETH VC SYP phenylephrine 6.25-5/5 syrup 6.25-5 mg/ 5 mg pseudoephedrine SUDAFED 54

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 mometasone inhalation ASMANEX HFA 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 55

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 tiotropium respimat SPIRIVA RESPIMAT Inhalers for Nebulization albuterol ACCUNEB 0.63 mg/3 ml and 1.25 mg /3 ml albuterol PROVENTIL soln 0.083%, 0.5% budesonide PULMICORT RESPULES susp, QL cromolyn INTAL soln, QL ipratropium ATROVENT soln, QL ipratropium/albuterol DUONEB soln levalbuterol HCl XOPENEX RESPULES QL, ST Oral Agents - Beta Agonists albuterol SR tabs VOSPIRE ER metaproterenol METAPROTERENOL SYRUP metaproterenol ALUPENT tabs terbutaline BRETHINE Oral Agents - Leukotriene Modifiers montelukast SINGULAIR QL zafirlukast ACCOLATE tabs 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 potassium bicarbonate/ potassium citrate K-LYTE tabs effervescent potassium chloride ext-rel MICRO-K 10 caps 56

Generic Name Brand Name potassium chloride ext-rel K-DUR 10 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) Miscellaneous alpha1-proteinase SP, Coverable through PROLASTIN inhibitor (human) Medical Benefit alpha1-proteinase SP, Coverable through ARALAST NP inhibitor (human) Medical Benefit 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 50000 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 57

Generic Name Brand Name ergocalciferol (D2) DRISDOL Coverage for these medications will be determined by the member s individual benefits. Please refer to individual plan documents for coverage information. ferrous bisglycinate/polysaccarides iron NIFEREX caps, OTC ferrous sulfate FEOSOL OTC fluoride GEL-KAM LURIDE LURIDE LOZI-TABS PREVIDENT PHOS-FLUR folic acid FOLIC ACID magnesium oxide MAG-OX multivitamins/ fluoride/±iron POLY-VI-FLOR multivitamins/minerals CENTRUM 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 58

Generic Name prenat w/o A w/fecbnfegl-dss-fa & DHA prenatal vit w/ FE bisglyc- FE prot succ-fa prenatal vit w/ FE bisglycinate chelate-fa prenatal vit w/ FE bisglycinate chelate-fa prenatal vit w/ FE bisglycinate chelate-fa prenatal vit w/ FE polysac cmplx-fa prenatal vit w/ iron carbonyl-fa Brand Name FOLTABS PAK PLUS DHA RE OB + DHA PAK VINATE III VITAPHIL GENTEX ADE 28-1 MG VINATE AZ EX EDGE OB CHW ATABEX PRENATAL PRENATAL VITAMINS W/ FOLIC ACID prenatal vitamins w/folic acid CENOGEN OB/ULTRA MATERNA NATALCARE QL NESTABSCBF/FA/RX prenatal vit w/o vit a w/ fe bisglycinate-fa tab 32-1 mg prenatal w/o A w/ FE carbonyl-fe gluc-dss-fa prenat-fe Bis-FE prot succ-fa-ca & omega 3 prenat-fe Bis-FE prot succ-fa-ca & omega 3 prenat-fe Bis-FE prot succ-fa-ca & omega 3 NIFEREX-PN FORTE FOLTABS PRENATAL TRI RX COMPLETE NATALCARE PAK DHA TRUST NATALCARE PAK DHA PRUET DHA PAK SETONET PAK 59

Generic Name omega-3 fatty acids omega-3 fatty acids renat-fe bis-fe prot succ-fa-ca & omega DR Brand Name SUPER OMEGA ESKIMO-3 SEA-OMEGA PRO NUTRIENT HM FISH OIL GNP FISH OIL PRUET DHAEC PAK capsule delayed release capsule vitamin A OTC vitamin ADC/ fluoride/±iron drops vitamin B complex/ vitamin C/folic acid TRI-VI-FLOR NEPHROCAPS Coverage for these medications will be determined by the member s individual benefits. Please refer to individual plan documents for coverage information. Coverage for these medications will be determined by the member s individual benefits. Please refer to individual plan documents for coverage information. vitamin B-1 OTC vitamin 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 60

Generic Name Brand Name Urological Symptomatic Benign Prostatic Hypertrophy alfuzosin ER UROXATRAL doxazosin CARDURA doxazosin SR CARDURA XL finasteride PROSCAR tamsulosin FLOMAX terazosin HYTRIN Miscellaneous bethanechol URECHOLINE hyoscyamine, methenamine, phenyl salicylate, sodium phosphate UTIRA C monobasic, methylene blue methenamine hippurate HIPREX UREX oxybutynin IR DITROPAN oxybutynin chloride DITROPAN XL QL, ST pentosan ELMIRON PA potassium citrate UROCIT-K propantheline phenazopyridine PYRIDIUM sodium citrate/citric acid BICITRA tolterodine DETROL ST tolterodine SR DETROL LA ST trospium SANCTURA ST Miscellaneous Anaphylaxis epinephrine EPIPEN EPIPEN JR. QL TWINJECT Cryopyrin Associated Periodic Syndromes (CAPS) canakinumab ILARIS PA, SP rilonacept ARCALYST PA, SP 61

Generic Name Brand Name 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 667 mg tablet only, PA calcium acetate oral solution PHOSLYRA PA cinacalcet SENSIPAR PA lanthanum carbonate FOSRENOL PA sevelamer RENVELA ST sevelamer hcl RENAGEL tablet, PA Idiopathic Pulmonary Fibrosis (IPF) nintedanib OFEV PA, SP pirfenidone capsule ESBRIET PA, SP Immune Thrombocytopenic Purpura eltromobpag PROMACTA PA, SP Medical Devices Spacers QL Metabolic Modifiers carglumic acid CARBAGLU PA, SP idursulfase ELAPRASE PA, SP,Coverable through Medical Benefit imiglucerase CEREZYME PA, SP, Coverable through Medical Benefit glycerol phenylbutyrate RAVICTI PA, SP sodium phenylbutyrate BUPHENYL ORAL oral powder POWDER PA Vaccine (oral) typhoid vaccine VIVOTIF BERNA capsules 62

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 BREVOXYL-4 CLEARASIL benzoyl peroxide crm, gel, lotion, cleanser, bar, DELOS foam, cloth, wash OC8 PANOXYL BAR PANOXYL CREAM Antifungals clotrimazole MICATIN miconazole crm, soln LOTRIMIN AF tolnaftate TINACTIN MONISTAT vaginal products GYNE-LOTRIMIN Cough/Cold Allergy CHLOR-TRIMETON BENADRYL antihistamines CLARITIN ALAVERT ZYRTEC antihistamine/decongestant combinations ACTIFED DIMETAPP ALAVERT D cetirizine/pesudoephedrine OTC ZYRTEC D ALAVERT ALRG TAB/SINUS loratadine/pseudoephedrine ALLERGY/CONG 63

Generic Name cough/cold Age edit applied. Not covered for members under the age 2. nasal sprays Atopic Dermatitis emollients Diabetes alcohol swabs glucose oral tablets insulin (vials only) Earwax Removal Products carbamide peroxide Family Planning condoms contraceptive foam contraceptive gel condoms - female First Aid Burow s soln, wet dressings dermatological baths hydrocortisone crm, oint topical antibacterials Brand Name Examples ROBITUSSIN ROBITUSSIN DM ROBITUSSIN PE ROBITUSSIN CF DELSYM NEO-SYNEPHRINE AFRIN DIMETAPP DRO DECONGES BETACARE CREAM AND LOTION CETAPHIL CREAM AND LOTION DERMAPHOR OINTMENT E-OINTMENT GLYCERIN TOPICAL CURITY ALCOHOL PADS HUMULIN NOVOLIN DEBROX TROJAN DELFEN GYNOL II CONDOMS OTC DOMEBORO COLLOIDAL OATMEAL BATHS CORTAID NEOSPORIN MYCITRACIN BACITRACIN 64

Generic Name Gastrointestinal antacids liquids, chew tabs antidiarrheals electrolyte rehydrating soln famotidine laxative enemas laxatives psyllium rectal crm, suppositories simethicone stool softeners sugar+orthophosphoric acid Lice Products permethrin piperonyl butoxide gel, liquid shampoo Motion Sickness dimenhydrinate meclizine Ophthalmics allergic conjunctivitis artificial tears decongestants Pain acetaminophen tabs, liquid, drops, suppositories aspirin tabs, EC. tabs aspirin with buffers tabs ibuprofen tabs, chew tabs and susp Brand Name Examples MYLANTA LIQUID MAALOX LIQUID TUMS IMODIUM A-D KAOPECTATE PEDIALYTE PEPCID AC FLEET ENEMA DULCOLAX FLEET PHOSPHO-SODA METAMUCIL PREPARATION H MYLICON COLACE EMETROL NIX PIPERONYL BUTOXIDE DRAMAMINE BONINE ALAWAY HYPOTEARS VISINE MURINE NAPHCON A TYLENOL BAYER ECOTRIN ADVIL MOTRIN IB 65

Generic Name Smoking Cessation Products nicotine Vitamins/Minerals calcium iron ferrous fumarate, ferrous, gluconate, errous sulfate, ferrous bis-glycinate chelate and polysaccharide iron caps iron polysaccharides magnesium oxide vitamin D 400 IU vitamins pediatric members <3 years old vitamins prenatal Warts salicylic acid 17%/collodion salicylic acid film forming liquid 27.5% OTC salicylic acid gel 17% OTC salicylic acid pad 40% OTC salicylic acid plaster 40% salicylic acid soln OTC salicylic acid strip 40% salicylic acid topical patch 15% OTC Miscellaneous fluoride dental rinse Brand Name Examples COMMIT LOZENGES (QUANTITY LIMIT) NICODERM CQ (QUANTITY LIMIT) NICOTINE GUM (QUANTITY LIMIT) NICOTROL (QUANTITY LIMIT) OS-CAL CALTRATE TUMS FERGON FEOSOL NIFEREX MAG-OX VITAMIN D 400 IU VI-DAYLIN POLY-VI-SOL TRI-VI-SOL STUART PRENATAL DUOFILM MOSCO CALLUS/CORN REMOVER OTC DUOPLANT GEL, COMPOUND W, SAL- PLANT OTC CORN/CALLUS REMOVER PAD, CLEAR AWAY, ONE STEP OTC MEDIPLAST MOSCO CALLUS/CORN LIQUID REMOV- ER OTC COMPOUND W STRIPS TRANS-VER-SAL PATCH PHOS-FLUR 66

Index of s A abacavir...36, 37 abacavir/dolutegravir/ lamivudine...37 abacavir/lamivudine...36 abacavir/lamivudine/zidovudine. 36 abatacept...38 abiraterone...4 ABREVA OTC...36 acamprosate...46 acarbose...28 ACCOLATE...56 Accu-Chek Care Kit (Aviva, Compact Plus, Nano Smartview)...28 Accu-Chek Test Strips (Aviva, AVIVA PLUS, Compact, SMARTVIEW)...28 ACCUHIST DROPS...50 ACCUHIST PDX DROPS...50 ACCUNEB...56 ACCUPRIL...8 ACCURETIC...8 ACCUTANE...18 acebutalol...10 ACEON...8 acetaminophen...14-16, 39, 55, 65 acetaminophen tabs, liquid, drops, suppositories...... 65 acetazolamide...44 acetazolamide ext-rel...44 acetic acid...24 acetic acid/aluminum acetate...24 acetic acid/hydrocortisone..24 acetylcysteine...62 acidophilus...32, 33 ALL CAPS = Brand-name drug lower case = Generic drug acidophilus/bifidus...33 Acidophilus/Bifidus Wafer...33 acidophilus/citrus pectin...33 acidophilus/pectin...33 Acidophilus XTRA...32 acitretin...22 aclidinium inhalation...56 ACLOVATE...20 ACTIFED...25, 63 ACTIGALL...33 ACTOPLUS MET XR...29 ACTOPLUSMET...29 ACTOS...29 ACULAR/ACULAR LS...43 acyclovir...36 acyclovir buccal...36 ADALAT CC...10 adalimumab...38 ADCIRCA...13 ADDERALL...47 ADDERALL XR (Brand Adderall XR is preferred)...47 adefovir...35 ADVAIR DISKUS...55 ADVAIR HFA...55 Advair INHAL AEROSOL...55 ADVIL...14, 39, 65 afatinib...5 afinitor...5 AFINITOR DISPERZ...5 AFRIN...26, 64 AGENERASE...37 AGRYLIN...7 AKINETON...17 ALAHIST DM...53 ALAVERT........... 25, 26, 63 ALAVERT-D...26 67 alavert alrg tab/sinus...26, 63 Alavert D...63 Alaway.................. 43, 65 ALAWAY OTC...43 albendazole...22 ALBENZA...22 albiglutide................... 29 albuterol...55, 56 albuterol SR tabs...56 albuterol sulfate...55 alclometasone...20 alcohol swabs...64 ALDACTAZIDE... 11 ALDACTONE... 11 ALDARA...23 ALDOMET...13 aldoril...13 alendronate...29 ALESSE...40 alfuzosin ER...61 alginic acid/sodium bicarbonate...30 ALINIA...38 ALINIA SUSPENSION...38 alitretinoin 1% gel...5 ALKERAN...4 allanhist syp pdx...53 ALLEGRA...25 ALLEGRA-D...25 allergic conjunctivitis...65 allergy/cong... 26, 53, 63 allergy/cong tab relief...53 allopurinol................... 40 alpha1-proteinase inhibitor (human)...57 ALPHAGAN P...44 alprazolam...46 ALTACE...8

Index of s altretamine...5 alumina/magnesia...30 alumina/magnesia/ simethicone...30 aluminum acetate...22, 24 aluminum chloride...22 aluminum chloride hexahydrate...22 ALUPENT...56 amantadine...17, 36 AMARYL...28 AMBIEN...48 ambrisentan...13 Amerge...16 AMICAR...7 amiloride... 11 amiloride/ hydrochlorothiazide... 11 aminocaproic acid...7 amiodarone...9 amiodarone tabs...9 amitriptyline...16, 48 amitriptyline/perphenazine..48 amlexanox...26 amlodipine...10 ammonium lactate...22 amoxapine...48 amoxicillin...34 amoxicillin/clavulanate...34 AMOXIcillin capsules and chewables...34 AMOXIL...34 Amoxil Susp...34 amphetamine/ dextroamphetamine mixed salts...47 amphetamine/ dextroamphetamine mixed salts ext-rel...47 ALL CAPS = Brand-name drug lower case = Generic drug ampicillin.................... 34 amprenavir...37 ANAFRANIL...47 anagrelide...7 anakinra...38 anaplex dm...50 ANAPROX...14, 39 anastrozole...4 ANCOBAN...35 ANDEHIST...50 ANDRODERM...27 ANDROGEL 1%...27 Androgel 1.62%...27 ANDROXY...27 ANSAID...14 ANTABUSE...46 antacids liquids, chew tabs...65 ANTARA...12 antidiarrheals...65 antihistamines... 24, 25, 63 antipyrine-benzocaine...24 ANTIVERT...30 ANUSOL HC 2.5%...23 ANZEMET...30 aphedrid tab...55 APHTHASOL...26 apixaban...7 aprepitant...30 APRESOLINE...13 APRISO...31, 32 APTIVUS...37 Aralast NP...57 ARALEN...37 ARANESP...7 ARAVA...39 ARCALYST.................. 61 ARICEPT...13 ARIMIDEX...4 68 AROMASIN...4 ARTANE...17 artemether-lumefantrine...37 artificial saliva...26 artificial tears...65 ASACOL...32 ASCRIPTIN...39 ASMANEX HFA...55 Asmanex Twisthaler...55 aspirin...7, 14, 16, 39, 65 aspirin-al hydro-mg hydro-ca carb...39 aspirin/acetaminophen/ caffeine...14 aspirin buffered...39 aspirin tabs, EC. tabs...65 aspirin with buffers tabs...65 ASTELIN...25 Atabex Prenatal...59 ATARAX...25 atazanavir...37 atenolol...10 atenolol/chlorthalidone...10 ATIVAN...46 atomoxetine................. 47 atorvastatin...13 atovaquone...37 atovaquone/proguanil...37 ATRIPLA...37 atropine...30, 33, 45 atropine sulfate...33 ATROVENT...26, 56 ATROVENT HFA...56 ATROVENT NS...26 ATUSS DR...53 AUBAGIO...16 AUGMENTIN...34 AUGMENTIN ES-600...34

Index of s AURALGAN...24 auranofin...38 AVAPRO...9 AVC VAGINAL...43 AVITA...19 AVONEX/AVONEX PEN...16 axitinib...5 AYGESTIN...42 azathioprine...6, 38 azelaic acid...18 azelastine...25, 43 azithromycin...34 AZOLEN TINCTURE SOLUTION OTC...21 AZOPT...45 aztreonam...62 AZULFIDINE...32, 39 AZULFIDINE EN-TABS. 32, 39 B bacitracin...20, 45, 46, 64 bacitracin-polymyxinneomycin HC...20 baclofen...40 BACTRIM...34 BACTRIM DS...34 BACTROBAN...20 balsalazide...31 BALZIVA...41 BANCAP HC...15 Banzel...18 BANZEL SUSPENSION...18 BARACLUDE...35 BAYER...7, 39, 65 beclomethasone...55 bedaquiline...37 BENADRYL...25, 63 benazepril...8 ALL CAPS = Brand-name drug lower case = Generic drug benazepril/hydrochlorothiazide.8 BENICAR...9 BENICAR HCT...9 BENTYL...31 BENZAC AC................ 18 BENZAMYCIN.............. 19 BENZEFOAM...19 BENZIQ...19 BENZIQ LS...19 benzocaine/antipyrine...24 benzonatate................. 49 BENZOTIC...24 benzoyl peroxide...18, 19, 63 benzoyl peroxide bar 10%...18 benzoyl peroxide creamy wash 8% & benzoyl peroxide bar 5% k...19 benzoyl peroxide crm, gel, lotion, cleanser, bar, foam, cloth, wash...63 benzoyl peroxide gel...19 benzoyl peroxide wash 4% & benzoyl peroxide bar 5% kit...19 benztropine...17 BERINERT...62 BETA-VAL...20 Betacare Cream and Lotion...64 betagan...45 betamethasone augmented dip...20 betamethasone dip augmented...21 betamethasone dipropionate...20 betamethasone val....20 BETAPACE...9, 10 BETAPACE AF...10 69 BETASERON...16 betaxolol...45 bethanechol................. 61 BETHKIS...62 BETIMOL...45 BETOPTIC -S...45 bexarotene caps and topical gel...5 Biaxin...34 BIAXIN XL...34 bicalutamide...4 BICITRA...61 BILTRICIDE...23 BIO-D-MULSIO DRO FORTE...57 BIO-D DRO-MULSION...57 biperiden...17 bismuth subsalicylate + metronidazole + tetracycline...33 bisoprolol...10 bisoprolol/ hydrochlorothiazide...10 BLEPH-10...46 BLEPHAMIDE...44 boceprevir...35 Bonine...65 bosentan...13 BOSULIF...5 bosutinib...5 BPO CREAMY KIT...19 BREO ELLIPTA...55 BRETHINE...56 BREVOXYL...19 BREVOXYL-4... 19, 63 BREVOXYL-4 OTC...19 BRILINTA...7 brimonidine...22, 44

Index of s brinzolamide...45 bromaline dm...50 BROMETANE DX...52 bromfed dm...50 bromfenex pd cap...49 bromocriptine...17, 30 brompheniramine/ pseudoephedrine...25, 49, 50, 52 brompheniramine/ pseudoephedrine/ dextromethorphan...50 brompheniramine/ pseudoephedrine/ dextromethorphan/ guaifenesin...50 brompheniramine & phenylephrine...49 brompheniramine maleate...24 brompheniramine tannate...24 BROVEX CT...24 BROVEX PSB...50 budesonide...31, 55, 56 budesonide/formoterol...55 BUFFERIN...39 bumetanide... 11 BUMEX... 11 BUPHENYL ORAL POWDER...62 buprenorphine...49 buprenorphine/naloxone...49 bupropion...48, 49 bupropion ext-rel...48 Burow s soln, wet dressings..64 BUSPAR...47 buspirone...47 busulfan...4 butalbital/acetaminophen...14 ALL CAPS = Brand-name drug lower case = Generic drug butalbital/acetaminophen/ caffeine...14 butalbital/apap/caff/cod...15 butalbital/asa/caff/cod...15 butalbital/aspirin/caffeine...14 butorphanol...15 BYETTA...29 C C1 Inhibitor, Human...62 cabozantinib...5 CAFERGOT...16 calamine...22 CALAN...11, 16 CALAN SR... 11 calcipotriene...22 calcitonin-salmon...29 calcitriol...22, 57 calcitriol oral soln...57 calcium...10, 32, 57, 62, 66 calcium acetate...62 calcium acetate oral solution...62 CALICYLIC...23 Caltrate...66 campral...46 canagliflozin...28 canagliflozin/metformin...28 canakinumab...61 CANASA...32 capecitabine...4 CAPEX SHAMOO...20 CAPITROL...22 CAPOTEN...8 CAPOZIDE...8 CAPRELSA...5 capsaicin...39 captopril...8 70 captopril/hydrochlorothiazide. 8 CAPTOPRIL POWDER...8 Carac...22 CARAFATE...31 CARAFATE SUSPENSION..31 CARBAGLU...62 carbamazepine...17 carbamazepine ext-rel...17 carbamazepine SR...17 carbamide peroxide...24, 64 CARBATROL...17 carbetapentane/ chlorpheniramine/ ephedrine/ phenylephrine...50 carbidopa/levodopa...17 carbidopa/levodopa ext-rel..17 carbinoxamine/ pseudoephedrine...50, 52 carbofed...50 CARDEC-DM...52 cardec dm dro...53 cardec dm syp...53 cardec dro...51 cardec syp... 49, 51 CARDENE...10 CARDIZEM...10, 11 CARDIZEM CD...10 CARDIZEM LA... 11 CARDIZEM SR...10, 11 CARDURA...8, 61 CARDURA XL...61 carglumic acid...62 carteolol...45 carvedilol...10 casanthranol-docusate sodium...32 CASODEX...4

Index of s CATAFLAM...39 CATAPRES...8 CATAPRES-TTS...8 CAYSTON...62 CAZIANT...41 CECLOR...33 CEENU...4 cefaclor...33 cefadroxil...33 cefdinir...33 cefixime...33 cefpodoxime...33 cefprozil...33 CEFTIN...33 cefuroxime axetil...33 CEFZIL...33 Celebrex...39 celecoxib...39 CELEXA...47 CELLCEPT...6 CELONTIN...18 CENESTIN...42 Cenogen OB/Ultra...59 CENTRUM...58 cephalexin...33 CEREZYME...62 ceritinib...5 certolizumab pegol...38 CESIA...41 Cetaphil Cream and Lotion..64 cetirizine...25, 63 cetirizine/pesudoephedrine OTC...63 cetirizine chew tab...25 cetirizine hydrochloride/ pseudoephedrine hydrochloride 12 hours extended-release...25 CHANTIX...49 CHERATUSSIN AC...51 child ibupro sus cold...55 Chlor-Trimeton...24, 63 CHLOR-TRIMETON ALLERGY...24 CHLOR-TRIMETON SYRUP...24 chloral hydrate...48 chlorambucil...4 chlordiazepoxide...46 chlorhexidine...26 chlorhexidine gluconate...26 chloroquine phosphate...37 chlorothiazide... 11 chloroxine...22 chlorphen-pemethscopolamine 50 chlorphen tan/ carbetapentane tan...51 chlorphen tan/pseudoeph tan...51 chlorphen tan/pyrilamine tan/pe tan...51 CHLORPHENIRAMINE...24, 25, 50, 51, 53-55 chlorpheniramine/ dextromethorphan...51, 53, 55 chlorpheniramine/ phenylephrine...25, 51, 53 chlorpheniramine/ phenylephrine/ pyrilamine...25 chlorpheniramine/ pseudoephedrine...25, 51 chlorpheniramine/ pseudoephedrine ext-rel...25 chlorpheniramine ext-rel...24 chlorpheniramine maleate...24, 51 chlorpheniramine maleate phenylephrine HCL...51 chlorpheniramine tan/ phenylephrine tan........ 51 chlorpheniramine tannate...24, 25 chlorpromazine...49 chlorpropamide...28 chlorthalidone...10, 11 chlorzoxazone...40 cholecalciferol...57 cholestyramine...12 choline magnesium trisalicylate...14, 39 ciclopirox...21 cidofovir...35 cilostazol...7 CILOXAN...45 cimetidine................... 30 CIMZIA...38 cinacalcet...62 CIPRO.................. 24, 33 CIPRO HC...24 CIPRODEX...24 ciprofloxacin... 24, 33, 45 ciprofloxacinhydrocortisone 24 ciprofloxacin/ dexamethasone...24 citalopram...47 clarithromycin...34 clarithromycin ER...34 CLARITIN...25, 63 CLARITIN CHEW...25 CLARITIN RDT...25 ALL CAPS = Brand-name drug lower case = Generic drug 71

Index of s CLEAN & CLEAR GEL, NEUTROGENA RAPID CLEAR GEL, EXUVIANCE...19 CLEAR EYES REDNESS RELIEF...43 CLEARASIL...63 clemastine...25 CLEOCIN...19, 37, 43 CLEOCIN T...19 CLIMARA................... 42 clindamycin...19, 37, 43 CLINORIL...14, 39 clobazam...17 clobetasol propionate........ 21 clomipramine...47 clonazepam...17, 46 clonidine...8 clonidine transdermal...8 clopidogrel...7 clorazepate...46 clotrimazole...21, 35, 43, 63 clotrimazole crystals...21 clotrimazole with betamethasone...21 COARTEM...37 cobicistat...37 cobicistat/elvitegravir/ emtricitabine/tenofovir...37 codal-dm...54 codeine/acetaminophen...15 codeine/chlorpheniramine/ pseudoephedrine...51 codeine/guaifenesin...51 codeine/guaifenesin/ pseudoephedrine...51 codeine/promethazine...51 codeine/promethazine/ phenylephrine...51 ALL CAPS = Brand-name drug lower case = Generic drug codeine sulfate...15 CODIMAL DH...54 COGENTIN...17 Colace...65 COLAZAL...31 colchicine...40 COLCRYS...40 COLESTID...12 coliestipol...12 Colloidal oatmeal baths...64 COLOCORT...31 COLYTE...32 COMBIVENT...56 COMBIVENT RESPIMAT...56 COMBIVIR...36 COMETRIQ...5 Commit lozenges (Quantity limit)...66 COMMITT...49 COMPAZINE...30 COMPLERA...36 Complete Natalcare Pak DHA...59 COMPOUND W STRIPS...66 COMTAN...17 CONCERTA...47 condoms...64 condoms - female...64 CONDOMS OTC...64 CONDYLOX SOL...22 conjugated estrogen/ bazedoxifene...43 contraceptive foam...64 contraceptive gel...64 COPAXONE...16 CORDARONE...9 CORDRAN...20 COREG...10 72 CORGARD...10 coricidin tab cgh/cld...51 CORN/CALLUS REMOVER PAD, CLEAR AWAY, ONE STEP OTC...66 Cortaid...64 CORTEF...26 CORTIFOAM AEROSOL...23 cortisone acetate...26 CORTISPORIN... 20, 24, 44 CORTISPORIN OINTMENT...20 CORTISPORIN OTIC...24 CORTIZONE...20 COSOPT...45 COSOPT PF...45 CoUMADIN...7 COZAAR...9 cpm/pse...51 creon...32 CREON 3000 UNIT...32 CREON DR...32 CRIXIVAN...37 crizotinib...5 CROLOM...43 cromolyn... 26, 43, 56 cromolyn sodium...26, 43 crotamiton...22 CUPRIMINE...39 Curity Alcohol Pads...64 CUTIVATE...20 CUTIVATE LOTION...20 cyanocobalamin...57 CYCLESSA...41 cyclobenzaprine...40 CYCLOGYL...45 cyclopentolate...45 cyclophosphamide...4

Index of s cyclosporine...6, 46 cyclosporine, modified...6 CYMBALTA...48 cyproheptadine...25 CYSTAGON...6 CYSTARAN...46 cysteamine 0.44% ophthalmic solution...46 cysteamine bitartrate...6 CYSTOSPAZ...31 CYTOMEL...29 CYTOTEC...33 CYTOVENE...35 CYTOXAN...4 D D3-50 CAP...57 D.H.E. 45...16 dabigatran etexilate mesylate...7 dabrafenib...5 dallergy dm...50 DALMANE...48 danazol...41 DANOCRINE...41 DANTRIUM...40 dantrolene...40 dapsone...37 Daraprim...38 darbepoetin alfa...7 darunavir...37 dasatanib...5 DAYPRO...14, 39 DDAVP...30 DE-CHLOR DM...53 DEBROX...24, 64 DECADRON...26 DECLOMYCIN...34 ALL CAPS = Brand-name drug lower case = Generic drug DECONAMINE SR...25 DECONEX...54 DECONEX IR...54 decongestants...26, 49, 65 deferasirox...7 DELATESTRYL...27 delavirdine...36 Delfen...64 DELOS... 18, 63 DELSYM...52, 64 DELTASONE...27 DEMADEX... 11 demeclocycline...34 DEMEROL...15 DENAVIR...36 DEPAKENE...18 DEPAKOTE...16, 17 DEPAKOTE SPRINKLE..16, 17 DEPO-PROVERA...40 DEPO-TESTOSTERONE...27 DERMA-SMOOTHE OIL/FS...20 Dermaphor Ointment...64 dermatological baths...64 DERMATOP...20 DESENEX POWDER 2%...21 desipramine...48 desmopressin...30 desogestrel/ee...40, 41 DESYREL...48 DETROL...61 DETROL LA...61 dexamethasone... 24, 26, 44 dexamethasone sodium phosphate...44 DEXASOL...44 dexchlorpheniramine maleate...25 73 DEXEDRINE...47 DEXEDRINE SPANSULE...47 dextroamphetamine...47 dextroamphetamine ext-rel..47 dextromethorphanguaifenesin 52 dextromethorphan/ brompheniramine/ pseudoephedrine...52 dextromethorphan/ carbinoxamine/ pseudoephedrine...52 dextromethorphan/ guaifenesin...50, 52-55 dextromethorphan/ promethazine...52 dextromethorphan/ quinidine...49 dextromethorphan hbr...52 dextromethorphan polistirex ext rel...52 DEXtrostat...47 DHS SAL SHAMPOO OTC..23 DIABINESE...28 DIAMOX SEQUELS...44 DIASTAT ACUDIAL...17 diazepam...17, 40, 46 diclofenac 1% gel...39 diclofenac potassium...39 diclofenac sodium...14, 39, 43 diclofenac sodium delayed release...14, 39 diclofenac sodium extended release...39 diclofenac sodium SR...14 dicloxacillin...34 dicyclomine...31 didanosine...36 didanosine delayed-rel...36

Index of s DIDRONEL...29 diflorasone diacetate...21 DIFLUCAN...35, 42 diflunisal...39 digoxin...9 DIHISTINE DH...51 dihydro-pe syp...54 dihydroergotamine...16 DILACOR XR...10 DILANTIN...18 DILANTIN INFATABS...18 DILATRATE-SR...12 DILAUDID...15 diltiazem...10, 11 diltiazem ext-rel...10 diltiazem ext release...10 diltiazem sustained release..10 dimeatapp dro deconges...26 dimenhydrinate.............. 65 Dimetapp... 49, 51, 53, 54, 63, 64 dimetapp cld elx/allergy...49 DIMETAPP DM...53 dimetapp dro dcon/cgh...54 dimetapp dro deconges...64 dimetapp elx cld/alle...49 dimetapp syp cgh/cld...51 dimethyl fumarate...16 DIOVAN...9 DIOVAN HCT...9 DIPENTUM...32 diphenhydramine...25, 48 diphenoxylate/atropine...30 DIPROLENE...20, 21 DIPROLENE AF...20 DIPROSONE...20 dipyridamole...7 disopyramide...9 ALL CAPS = Brand-name drug lower case = Generic drug disopyramide ext-rel...9 disulfiram...46 DITROPAN...61 Ditropan Xl...61 DIURIL... 11 divalproex sodium cap sprinkle...16, 17 divalproex sodium delayed-rel...16, 17 DIVIGEL...42 docosanol................... 36 docusate calcium plus...32 docusate potasssium...32 dofetilide...9 dolasetron...30 DOLOBID...39 dolutegravir...37 Domeboro...24, 64 DOMEBORO OTIC...24 donepezil...13 dornase alfa...62 dorzolamide...45 dorzolamide/timolol maleate...45 dorzolamide hcl-timolol maleate...45 DOVONEX...22 doxazosin...8, 61 doxazosin SR...61 doxepin...48 doxycycline delayed release...34 doxycycline hyclate...34 doxycycline monohydrate...34 Dramamine...65 DRISDOL...58 dronabinol...30 dronedarone...9 74 droxia...5 DRYSOL OTC...22 DUAVEE...43 DUETACT...29 Dulcolax...65 Dulera...55 duloxetine...48 DUOFILM...22, 66 DUONEB...56 DUOPLANT GEL, COMPOUND W, SAL-PLANT OTC...66 duradryl...50 DURAGESIC...15 Duratuss dm elx...52 DURICEF...33 DYAZIDE... 11 DYNACIRC...10 E E-Ointment...64 E.E.S....34 ecothiophate...45 ECOTRIN...7, 39, 65 Ed A-Hist tablets and liquid..51 Edge OB Chw...59 EDURANT...36 efavirenz...36, 37 efavirenz/emtricitabine/ tenofovir...37 EFFEXOR...48 EFFEXOR XR...48 EFUDEX...22 ELAPRASE...62 ELAVIL...16, 48 ELDEPRYL...17 electrolyte...57, 65 electrolyte rehydrating soln..65

Index of s ELESTRIN...42 ELIDEL...23 ELIMITE...22 ELIQUIS...7 ELMIRON...61 ELOCON...20 eltromobpag...62 EMCYT...4 EMEND...30 Emetrol...65 Emla...23 emollients...64 empagliflozin...28 emtricitabine...36, 37 emtricitabine/rilpivirine/ tenofovir...36 emtricitabine/tenofovir...37 EMTRIVA...36 enalapril...8 enalapril/hydrochlorothiazide. 8 enalapril oral soln...8 ENBREL...38 enfuvirtide...35 Enjuvia...................... 42 enoxaparin...7 entacapone...17 entecavir...35 ENTEX LQ LIQ...54 ENTOCORT EC...31 ENULOSE...32 EPANED...8 epinephrine...61 EPIPEN...61 EPIPEN JR....61 EPITOL...17 EPIVIR...35, 36 Epivir HBV...35 eplerenone...13 ALL CAPS = Brand-name drug lower case = Generic drug epoetin alfa...7 EPOGEN...7 epoprostenol...13 EPZICOM...36 EQUATRO...17 ergocalciferol (D2)...58 ergotamine/caffeine...16 ergotamine tartrate/ caffeine...16 ERIVEDGE...6 erlotinib...5 ERY-TAB...34 ERYC...34 ERYGEL...19 ERYTHROCIN...34 erythromycin...19, 34, 45 erythromycin/benzoyl peroxide...19 erythromycin/sulfisoxazole..34 erythromycin delayed-rel..... 34 erythromycin ethylsuccinate. 34 erythromycin stearate...34 ESBRIET...62 escitalopram...47 ESKIMO-3.................. 60 esomeprazole...30, 31 esomeprazole granules...31 estazolam...48 esterified estrogens...42 ESTRACE...42 ESTRACE CRM...42 estradiol...42 estradiol acetate...42 ESTRADIOL TDS...42 estramustine phosphate sodium...4 ESTRASORB...42 ESTRING...42 75 ESTROGEL...42 estrogen patch...42 estrogens, conjugated...42 estrogens, conjugated/ medroxyprogesterone...42 estrogens, conjugated, synthetic A...42 estrogens, conjugated, synthetic B...42 estropipate...42 ESTROSTEP FE...41 etanercept...38 ethambutol...37 ETHMOZINE...9 ethosuximide...17 ethynodiol diacetate/ee...41 etidronate...29 etodolac...14, 39 etonogestrel/ee...40 etoposide...5 etravirine...37 EULEXIN...4 EURAX...22 EVAMIST...42 everolimus...5, 6 EVISTA...29 EXCEDRIN MIGRAINE...14 EXELON...13 exemestane...4 exenatide...29 EXJADE...7 exogabine...17 EXTINA...21 ezetimibe...13 ezetimibe/simvastatin...13 F famciclovir...36

Index of s famotidine...31, 65 FAMVIR...36 FARESTON...4 febuxostat...40 felbamate...17 felbamate oral susp...17 FELBATOL...17 FELBATOL ORAL SUSP...17 FELDENE...14, 39 felodipine ext-rel...10 FEMARA...4 FEMRING...42 fenofibrate...12 fenoprofen...14, 39 fentanyl transdermal...15 FEOSOL...58, 66 Fergon...66 ferrous bisglycinate/ polysaccarides iron...58 ferrous fumarate, ferrous, gluconate, errous sulfate, ferrous bis-glycinate chelate and polysaccharide iron caps...66 ferrous sulfate...58 fexofenadine...25 fexofenadine/ pseudoephedrine...25 filgrastim...7 FINACEA...18 finasteride...61 fingolimod...16 FIORICET...14, 15 FIORICET w/codeine...15 FIORINAL...14, 15 FIORINAL w/codeine...15 FIRAZYR...62 FLAGYL...38, 42 ALL CAPS = Brand-name drug lower case = Generic drug FLAREX...44 flecainide...9 Fleet Enema...65 Fleet Phospho-Soda...65 FLEXERIL...40 FLOLAN...13 Flomax...61 FLONASE...26 Floranex...33 FLORINEF...26 FLOVENT Diskus...55 FLOVENT HFA...55 FLOXIN...24, 33 FLOXIN OTIC...24 fluconazole...35, 42 flucytosine...35 fludarabine...4 fludrocortisone...26 FLUMADINE...36 fluocinolone acetonide...20 fluocinonide...21 fluocinonide emulsified base...21 fluoride...58, 60, 66 fluoride dental rinse...66 fluorometholone...44 fluorometholone acetate...44 FLUOROPLEX...23 fluorouracil...22, 23 fluoxetine...47 fluoxymesterone...27 fluphenazine...49 fluphenazine decanoate...49 flurandrenolide...20 flurazepam...48 flurbiprofen... 14, 43 flutamide...4 fluticasone... 20, 26, 55 76 fluticasone/salmeterol...55 fluticasone/vilanterol...55 fluticasone HFA...55 fluticasone propionate...20, 55 fluvoxamine...47 fluvoxamine SR...47 FML...44 FML FORTE...44 FML SOP...44 folic acid...58-60 Foltabs Pak Plus DHA RE OB + DHA Pak...59 Foltabs Prenatal...59 FORADIL AEROLIZER...55 FORFIVO XL...48 formoterol...55 FORTEO...29 FORTICAL...29 FORTOVASE...37 FOSAMAX...29 fosamprenavir...37 foscarnet sodium...35 FOSCAVIR...35 fosinopril...8 fosinopril/ hydrochlorothiazide...8 FOSRENOL...62 FUNGOID TINCTURE KIT..21 FURADANTIN SUSP 25 mg/5 ml...38 furosemide... 11 Fuzeon...35 G gabapentin...17 GABITRIL...18 galantamine...13 ganciclovir...35

Index of s gatifloxin...45 GATTEX...33 GEL-KAM...58 gemfibrozil...12 GENGRAF...6 GENTAK...20, 45 gentamicin... 20, 44, 45 gentamicin/prednisolone acetate...44 Gentex ADE 28-1 mg...59 gg/dm cr...52 gg/pse cr...52 GILENYA...16 GILOTRIF.................... 5 GILPHEX TR...54 glatiramer acetate...16 GLEEVEC...5 glimepiride...28, 29 glipizide...28 glipizide/metformin...28 glipizide ext-rel...28 GLUCAGON...27 glucagon, human recombinant...27 GLUCOPHAGE...28 GLUCOPHAGE ER...28 glucose oral tablets...64 GLUCOTROL...28 GLUCOTROL XL...28 GLUCOVANCE...28 glyburide...28 glyburide, micronized...28 glycerin... 32, 43, 64 GLYCERIN SUPPOSITORY...32 Glycerin topical.............. 64 glycerol phenylbutyrate...62 glycopyrrolate...31 ALL CAPS = Brand-name drug lower case = Generic drug GLYNASE...28 GNP FISH OIL...60 granisetron...30 GRIFULVIN V...35 GRIS-PEG...35 griseofulvin microsize...35 griseofulvin ultramicrosize...35 GUAIFED...52 GUAIFEN PSE...52 guaifenesin...50-55 guaifenesin/ pseudoephedrine...51, 52 guaifenesin/ pseudoephedrine/ dextromethorphan...52 guaifenesin/ pseudoephedrine ext rel. 52 guaifenesin ext-rel...52 guanabenz...13 guanfacine...8, 47 GUIATUSS/AC...51 GUIATUSS DAC...51 GYNE-LOTRIMIN...43, 63 Gynol II...64 H HALCION................... 48 HALDOL...49 HALDOL DECANOATE...49 HALFPRIN...39 haloperidol...49 haloperidol decanoate...49 HARVONI...35 HECORIA...6 HELIDAC...33 HEMANGEOL...10 heparin...7 HEPSERA...35 77 hexachlorophene...23 hexalen...5 Hiprex...61 histacol dm...50 HISTEX...51 HISTUSSIN HC...53 HIVID...36 HM FISH OIL...60 homatropine...45, 53 HUMALOG...27, 28 HUMALOG KWIKPEN...28 HUMALOG MIX 50/50..27, 28 HUMALOG MIX 50/50 KWIKPEN...28 HUMALOG MIX 72/25 KWIKPEN...28 HUMALOG MIX 75/25...28 HUMATIN...38 HUMIRA...38 HUMULIN...27, 28, 64 HUMULIN 70/30...28 HUMULIN N...27 HUMULIN N PEN...27 HUMULIN R...28 HYCODAN...53 hydralazine...13 HYDREA...5 hydrochlorothiazide...8-11 hydrocodo/gg syp...53 hydrocodone-ibuprofen tab..15 hydrocodone/ acetaminophen...15 hydrocodone/ chlorpheniramine/ phenylephrine...53 hydrocodone/ guaifenesin...53, 54 hydrocodone/homatropine..53

Index of s hydrocodone/tab homatrop...53 hydrocortisone... 20, 21, 23, 24, 26, 31, 44, 64 hydrocortisone acetate...23 hydrocortisone acetate w/ pramoxine...23 hydrocortisone butyrate...20 hydrocortisone crm, oint...64 hydrocortisone valerate...20 hydromet syp...53 hydromorphone...15 hydroxychloroquine...37, 39 hydroxyurea...5 hydroxyzine HCL...25 hydroxyzine pamoate...25 hyoscyamine, methenamine, phenyl salicylate, sodium phosphate monobasic, methylene blue...61 hyoscyamine sulfate...31 hyoscyamine sulfate ext-rel..31 HYpercare 20%...22 HypoTears...65 HYTONE...20 HYTRIN...8, 61 HYZAAR...9 I ibrutinib...5 ibuorofen tab cold/sin...55 ibuprofen...14, 39, 65 ibuprofen tabs, chew tabs and susp...65 icatibant...62 ICLUSIG...5 idelalisib...5 idursulfase...62 Ilaris...61 ALL CAPS = Brand-name drug lower case = Generic drug iloprost...13 imatinib mesylate...5 IMBRUVICA...5 IMDUR...12 imiglucerase...62 imipramine HCL............. 48 imiquimod 5% cream...23 IMITREX...16 IMODIUM A-D...30, 65 IMODIUM A-D CHW...30 IMODIUM A-D LIQ...30 IMURAN...6, 38 INCRELEX...29 indapamide... 11 INDERAL................10, 16 INDERIDE...10 indinavir...37 INDOCIN...14, 39 indomethacin...14, 39 INFERGEN...35 INFLAMASE FORTE...44 infliximab...38 INLYTA...5 INSPRA...13 insulin (vials only)...64 insulin aspart...27 insulin aspart protamine 70%/insulin aspart 30%...27 insulin detemir...27 insulin glargine...27 insulin human...27 insulin isophane...27, 28 insulin isophane/regular...28 insulin isophane human...27 insulin isophane human 70%/regular 30%...27 insulin lisopro pro/lispro...27 78 insulin lisopro prot/lispro...28 insulin lispro...28 insulin lispro prot 50%/ lispro 50%...28 insulin lispro prot 75%/ lispro 25%...28 insulin regular...28 INTAL...56 INTELENCE...37 interferon alfa-2a............. 6 interferon alfa-2b...6, 35 interferon alfacon-1...35 interferon beta-1a...16 interferon beta-1b...16 INTRON A...6, 35 Intuniv...47 INVIRASE...37 INVOKAMET...28 INVOKANA...28 ipratropium...26, 56 ipratropium/albuterol...56 ipratropium bromide...26 ipratropium HFA...56 irbesartan...9 iron...40, 41, 58-60, 66 iron polysaccharides...66 ISENTRESS...38 ISENTRESS CHEWABLE...38 ISMO...12 ISOCHRON...12 isoniazid...37 ISOPTO ATROPINE...45 ISOPTO CARPINE...44 ISOPTO HOMATROPINE...45 ISOPTO HYOSCINE...45 ISORDIL...12 ISORDIL S.L....12 isosorbide dinitrate...12

Index of s ISOSORBIDE DINITRATE ER...12 isosorbide dinitrate ext-rel...12 isosorbide mononitrate...12 isosorbide mononitrate ext-rel...12 isotretinoin...18 isradipine...10 itraconazole...35 ivacaftor...62 ivermectin............... 22, 23 ALL CAPS = Brand-name drug lower case = Generic drug J J-TAN D PD...50 J-TAN PD...24 JAKAFI...5 JANUMET...29 JANUMET XR...29 JANUVIA...29 JARDIANCE...28 JENTADUETO...28 JUXTAPID...13 K K-DUR 10...57 K-DUR 20...57 K-LOR...57 K-LYTE...56 K-PHOS NEUTRAL...56 K-PHOS ORIGINAL...56 KALETRA...37 KALYDECO...62 Kaopectate...65 KAYEXALATE...57 KEFLEX...33 KENALOG...20, 21, 26 KENALOG IN ORABASE...26 Keppra...18 KEPPRA XR................ 18 KERALYT...19 ketoconazole...21, 23, 35 ketoconazole foam...21 ketoconazole gel...21 ketoconazole gel 2% &...21 ketoconazole gel 2% & hydrocortisone gel 1% kit...21 ketoconazole shampoo...21 ketoprofen...14, 39 ketoprofen SR...14 ketorolac... 14, 43 ketorolac tromethamine...14 ketotifen...43 KINERET...38 KLARON LOTION........... 19 KLONOPIN...17, 46 KLOR-CON 10...57 KLOR-CON 8...57 KOMBIGLYZE...29 KORLYM...30 KRISTALOSE...32 KUVAN...30 KUVAN POWDER FOR SOLUTION...30 KYTRIL...30 L labetalol...10 LAC-HYDRIN...22 lacosamide...17 lacosamide solution...17 lactobacillus................. 33 lactulose...32 LAMICTAL...17, 18 LAMICTAL CD CHEW TAB..18 LAMICTAL ODT...18 79 LAMICTAL ODT KIT...18 LAMICTAL XR...18 LAMICTAL XR KIT...18 LAMICTAL XR ODT KIT...18 LAMISIL...22, 35 LAMISIL AT...22 LAMISIL GEL...22 LAMISIL SOLUTION...22 lamivudine...35-37 lamivudine/zidovudine...36 lamotrigine...17, 18 lamotrigine chew dispersable tab...18 lamotrigine dispersible tab...18 lamotrigine odt...18 lamotrigine SR...18 lamotrigine SR odt...18 lamotrigine titration kit...18 LANOXICAPS...9 LANOXIN...9 lansoprazole...31 lansoprazole del-rel.......... 31 lanthanum carbonate...62 LANTUS...27 LANTUS SOLOSTAR...27 lapatinib ditosylate...5 LARIAM...38 LASIX... 11 latanoprost...45 laxative enemas...65 laxatives...32, 65 ledipasvir/sofosbuvir...35 leflunomide...39 lenalidomide...6 LETAIRIS...13 letrozole...4 leukine...7 leuprolide...6

Index of s levalbuterol HCl...56 Levaquin...33 LEVBID...31 LEVEMIR...27 LEVEMIR FLEXPEN...27 levetiracetam...18 levetiracetam SR...18 levobunolol...45 levocetirizine...25 levofloxacin...33 levonorgestrel...40, 41 levonorgestrel/ee...40, 41 levothyroxine...29 LEVOXYL...29 LEVSIN...31 LEVSINEX...31 LEXAPRO...47 LEXIVA...37 LIALDA...31, 32 LIBRIUM...46 lidamantel................... 23 LIDEX...21 LIDEX E...21 lidocaine...23, 26 lidocaine-prilocaine...23 lidocaine/prilocaine...23 lidocaine patch...23 lidocaine viscous...26 LIDODERM PATCH...23 linagliptin...28 linagliptin/metformin...28 linezolid...37 liothyronine...29 liotrix...29 LIPITOR...13 LIPOFEN...12 LIQUIBID PD...54 liraglutide...29 ALL CAPS = Brand-name drug lower case = Generic drug lisdexamfetamine...47 lisinopril...8, 93 lisinopril/hydrochlorothiazide..8 LMX-4...23 LO/OVRAL...41 LOCOID...20 LODINE...14, 39 LODRANE D...25 LOESTRIN 1/20...40 LOESTRIN 1.5/30...41 LOESTRIN FE 1/20...40 LOESTRIN FE 1.5/30...41 LOFIBRA...12 LOHIST-DM...53 lomitapide...13 LOMOTIL...30 lomustine...4 LONITEN...13 loperamide...30 LOPID...12 lopinavir/ritonavir...37 LOPRESSOR...10 loratadine...25, 26, 53, 63 loratadine/pseudoephedrine... 26, 53, 63 loratadine/pseudoephedrine ext-rel...26 loratadine & pseudoephedrine SR 24hr...53 lorazepam................... 46 LORCET 10/650...15 LORCET PLUS...15 LORTAB 10/500...15 LORTAB 2.5/500...15 LORTAB 5/500...15 LORTAB 7.5/500...15 LORTAB ELIXIR...15 losartan...9 80 losartan/hctz...9 LOTENSIN...8 LOTENSIN HCT...8 LOTRIMIN AF...21, 63 Lotrisone...21 lovastatin...13 LOVENOX...7 loxapine...49 LOXITANE...49 LOZOL... 11 LUDIOMIL...48 LUEKERAN...4 Lupron...6 Lupron Depot...6 Lupron Depot-PED...6 LUPRON DEPOT 6-MONTH...6 LURIDE...58 LURIDE LOZI-TABS...58 LUVOX...47 LUVOX CR...47 LYRICA...18 LYRICA SOLUTION...18 LYSODREN...5 Lysteda...43 M M-CLEAR WC...51 MAALOX...30, 65 Maalox liquid...65 MACROBID...38 MACRODANTIN...38 MACRODANTIN 25 mg...38 MAG-OX...58, 66 MAGNACET...15 magnesium oxide...58, 66 MALARONE...37 malathion...22

Index of s mapap cold tab...55 maprotiline...48 maraviroc...37 MARINOL...30 Materna...59 MATULANE...5 MATXIM LA... 11 MAVIK...8 MAXALT/MAXALT MLT...16 MAXIDEX...44 MAXITROL...44 MAXZIDE... 11 MAXZIDE-25... 11 mecasermin...29 meclizine................ 30, 65 MEDIFIN PE................ 54 MEDIPLAST...66 MEDROL...26 medroxyprogesterone acetate...40, 42 mefloquine...38 MEGACE...4 megestrol acetate...4 MEKINIST...5 MELLARIL...49 meloxicam...14, 39 melphalan...4 memantine...13 memantine SR...13 MENEST...42 MENOSTAR...42 meperidine...15 MEPHYTON...58 MEPRON...37 mercaptopurine...4 mercaptopurine susp...4 mesalamine...31, 32 mesalamine ext-rel...32 ALL CAPS = Brand-name drug lower case = Generic drug mesalamine supp...32 MESTINON...16 MESTINON TIMESPAN...16 MetaDaTe ER...47 METAGLIP...28 Metamucil...65 metaproterenol...56 metaproterenol syrup...56 metformin...28, 29 metformin/glyburide......... 28 metformin ER...28, 29 methazolamide...44 methenamine hippurate...61 METHERGINE...30, 43 methimazole...29 methocarbamol...40 methotrexate...39 methoxsalen...22 methsuximide...18 methyldopa...13 methyldopa/hctz...13 methylergonovine...30, 43 METHYLIN SOLUTION...47 methylnaltrexone...33 methylphenidate...47 methylphenidate ext-rel...47 methylprednisolone...26 metipranolol................. 45 metoclopramide...30 metolazone... 11 metoprolol...10 metoprolol succinate...10 METROCREAM...22 METROGEL...22, 43 METROGEL-VAGINAL...43 metrogel 1%...43 METROLOTION...22 81 metronidazole...22, 33, 38, 42, 43 MEVACOR...13 mexiletine...9 MEXITIL...9 MIACALCIN...29 MICATIN...21, 63 miconazole...21, 35, 43, 63 miconazole buccal...35 miconazole crm, soln...63 MICONAZOLE KIT...43 miconazole nitrate...21, 43 miconazole nitrate kit...21 miconazole nitrate lotion...21 miconazole nitrate soln...21 MICRO-K 10...56 MICRONASE...28 Microzide... 11 MIDAMOR... 11 midodrine...13 mifeprstone...30 MIGERGOT SUPPOSITORIES...16 MIGRANAL...16 MINIPRESS...8 MINOCIN...34 minocycline...34 minocycline SR...34 minoxidil...13 minutuss dr syp...53 MIRALAX...32 MIRAPEX...17 MIRAPEX ER...17 MIRCETTE...40 mirtazapine...48 Mirvaso...22 misoprostol...33 mitotane...5

Index of s MOBIC...14, 39 MODICON...41 MODURETIC... 11 moexipril...8 moexipril/ hydrochlorothiazide...8 mometasone...20, 55 mometasone/formoterol...55 mometasone furoate...20 mometasone inhalation...55 MONISTAT...43, 63 MONISTAT-DERM...21 MONISTAT 3...43 MONOPRIL...8 MONOPRIL-HCT...8 montelukast................. 56 moricizine...9 morphine...15 morphine ext-rel...15 MOSCO CALLUS/CORN LIQUID REMOVER OTC...66 MOSCO CALLUS/CORN REMOVER OTC...66 MOTRIN...14, 39, 65 Motrin IB...65 moxifloxacin HCl...45 mozobil...7 MS CONTIN...15 MSIR...15 MUCINEX...52, 54 MUCINEX COLD LIQ / KIDS...54 mucinex d...52 MUCINEX DM...52 MUCINEX KIDS...52 MUCOMYST...62 MULTAQ...9 ALL CAPS = Brand-name drug lower case = Generic drug multi symptom tab cold rlf...55 multivitamins/fluoride/ ±iron...58 multivitamins/minerals....... 58 mupirocin...20 Murine...65 MURO 128...46 MYAMBUTOL...37 MYCELEX...21, 35 Mycitracin...64 MYCOBUTIN...38 MYCOLOG-II...21 mycophenolate mofetil...6 mycophenolate sodium...6 MYCOSTATIN...21, 35 MYFORTIC...6 MYLANTA...30, 65 Mylanta liquid...65 MYLERAN...4 Mylicon...65 MYSOLINE...18 MYTUSSIN AC...51 N nabumetone...14, 39 nadolol...10 NALFON...14, 39 naloxone...49 NALOXONE INJ...49 naltrexone...46, 49 NAMENDA...13 NAMENDA XR...13 naphazoline/antazoline...43 naphazoline/glycerin...43 naphazoline/zinc sulfate...43 naphazoline HCL...43 naphazoline w/pheniramine. 43 NAPHCON A...43, 65 82 NAPROSYN...14, 39 naproxen...14, 39 naproxen sodium...14, 39 naratriptan...16 NARIZ...54 NASACORT ALLERGY 24 Hour...26 NASACORT AQ...26 nasal sprays...64 Nasalcrom...26 NATACYN...46 Natalcare...59 natamycin...46 nateglinide...29 NATROBA...22 NAVANE...49 nedocromil...56 nelfinavir...37 NEO-FRADIN...38 NEO-SYNEPHRINE...26, 64 neo dm...50 NEOBENZ MICR LIQ...19 neomycin/polymyxin B/ bacitracin...20 neomycin/polymyxin B/ dexamethasone...44 neomycin/polymyxin B/ gramicidin...45 neomycin/polymyxin B/ hydrocortisone...24, 44 neomycin sulfate...38 neomycin sulfate soln...38 NEORAL...6 NEORAL SOLUTION...6 NEOSPORIN... 20, 45, 64 NEPHROCAPS...60 NEPTAZANE...44 NestabsCBF/FA/RX...59

Index of s NEULASTA...7 neumega...7 NEUPOGEN...7 NEURONTIN...17 nevirapine................... 36 nevirapine ER...36 NEXAVAR...5 NEXIUM 24HR OTC...30 NEXIUM DELAYED RELEASE PACKET...31 niacin...12, 13 niacin ext-rel...12 NIACOR...12 NIASPAN...12 nicardipine...10 Nicoderm...49, 66 Nicoderm CQ (Quantity limit)...66 NICORETTE...49 nicotine...49, 66 Nicotine Gum (Quantity limit)...66 nicotine inhaler system...49 nicotine polacrilex gum...49 nicotine polacrilex lozenge...49 NICOTROL...49, 66 Nicotrol (Quantity limit)...66 nifedipine...10 nifedipine ext-rel...10 NIFEREX...58, 66 Niferex-PN Forte...59 nilotinib...5 nimodipine...10 nimodipine oral soln...10 NIMOTOP...10 nintedanib....62 nisoldipine...10 nitazoxanide suspension...38 ALL CAPS = Brand-name drug lower case = Generic drug nitazoxanide tablet...38 NITREK...12 NITRO-BID...12 NITRO-DUR...12 nitrofurantoin ext-rel...38 nitrofurantoin macrocrystals. 38 nitrofurantoin susp...38 nitroglycerin... 12, 23 nitroglycerin ext-rel...12 NITROLINGUAL...12 NITROSTAT...12 Nix 22, 65 NIX CREME RINSE...22 NIZORAL...21, 23, 35 NIZORAL A-D OTC...21 NIZORAL SHAMPOO...23 NOLVADEX...4 NORCO...15 NORDETTE...41 NORDITROPIN...29 norelgestromin/ee...41 norethindrone...40-42 norethindrone/ee...40, 41 norethindrone/me...41 norethindrone acetate...40-42 norethindrone acetate/ EE...40, 41 norethindrone acetate/ EE/iron...40, 41 NORFLEX...40 norgestimate/ee............ 41 norgestrel...41 norgestrel/ee...41 NORPACE...9 NORPACE CR...9 NORPRAMIN...48 nortriptyline...48 NORVASC...10 83 NORVIR...37 Novolin...27, 64 NOVOLIN 70/30...27 NOVOLIN N...27 NOVOLIN R...27 NOVOLOG...27 NOVOLOG FLEXPEN...27 NOVOLOG MIX 70/30...27 NOVOLOG MIX 70/30 FLEXPEN...27 NOXAFIL...35 NUCYNTA ER...16 Nuedexta...49 NULYTELY...32 NUVARING...40 NYMALIZE...10 nystatin...21, 35 nystatin/triamcinolone...21 NYTOL QUICK CAPS...48 O OC8... 19, 63 OCEAN NASAL SPRAY...26 octreotide...5 OCUFEN...43 OCUFLOX...46 OFEV...62 ofloxacin...24, 33, 46 Oforta...4 OGEN...42 olmesartan...9 olmesartan/ hydrochlorothiazide...9 olsalazine sodium...32 OLYSIO...36 omalizumab...56 omega-3 fatty acids...60 omeprazole delayed-rel...31

Index of s OMNICEF...33 ondansetron...30 One Touch Systems (ULTRA, ULTRASMART, ULTRA2, ULTRAMINI, VERIO IQ, VERIO SYNC)...28 One Touch Test Strips (BASIC/PROFILE, SURESTEP, ULTRA, VERIO)...28 ONFI...17 ONGLYZA...29 ONMEL...35 OPANA ER...16 OPCON A...43 oprelvekin.................... 7 OPTIPRANOLOL...45 optivar...43 ORAP...49 ORAPRED...26 ORENCIA - IV...38 orphenadrine ext-rel...40 ORTHO-CEPT...41 ORTHO-CYCLEN...41 ORTHO-NOVUM 1/35...41 ORTHO-NOVUM 1/50...41 ORTHO-NOVUM 10/11...40 ORTHO-NOVUM 7/7/7...41 Ortho Coil...40 ortho diaphragm...40 ORTHO EVRA...41 Ortho Flat...40 Ortho Flex...40 ORTHO MICRONOR...41 ORTHO TRI-CYCLEN...41 ORUDIS...14, 39 OS-CAL...57, 66 oseltamivir...36 ALL CAPS = Brand-name drug lower case = Generic drug OVCON 50...41 OVIDE...22 OVRAL...41 OVRETTE...41 oxaprozin...14, 39 oxazepam...46 oxcarbazepine...18 OXSORALEN-ULTRA...22 oxybutynin chloride...61 oxybutynin IR...61 oxycodone...15, 16 oxycodone/ acetaminophen...15, 16 oxycodone/ acetaminophen CR...16 oxycodone/aspirin...16 oxycodone ER...15 OXYCONTIN...15 OXYFAST...16 oxymetazoline...26 oxymorphone ER...16 P P & S SHAMPOO, SELSUN BLUE PACERONE...9 palivizumab...38 PAMELOR...48 pancrealipase DR...32 PANCREAZE...32 pancrelipase...32 PANOXYL BAR... 18, 63 PANOXYL BAR OTC...18 PANOXYL CREAM... 19, 63 PANOXYL CREAM OTC...19 PANRETIN...5 pantoprazole...31 pantoprazole delayed-rel..... 31 84 PARAFON FORTE DSC...40 PARLODEL...17, 30 PARNATE...47 paromomycin...38 paroxetine...47 paroxetine SR...47 pasireotide...5 PAXIL...47 PAXIL CR...47 PAXIL ORAL SUSP...47 pazopanib...5 pediacare liq multi-sy...55 PEDIALYTE...57, 65 PEDIAPRED...26 PEDIAZOLE...34 peg 3350/electrolytes...32 peg 3350/sodium bicarbonate/sodium chloride...32 peg 3350/sodium bicarbonate/sodium chloride/potassium chloride...32 PEGASYS...35 PEGASYS PROCLICK...35 pegfilgrastim...7 peginterferon alfa-2a...35 peginterferon alfa-2b...6, 35 PEGINTRON...35 penciclovir...36 penicillamine...39 penicillin VK...34 PENLAC SOLUTION 8%...21 PENTASA...31, 32 pentosan...61 pentoxifylline ext-rel...7 PEPCID...31, 65 PEPCID AC...31, 65

Index of s PEPCID AZ CHW...31 PERCOCET...15 PERCODAN...16 PERIDEX................... 26 perindopril...8 PERIOGARD...26 permethrin...22, 65 perphenazine...48, 49 PERSANTINE...7 phenazopyridine...61 PHENERGAN...30, 52 PHENERGAN DM...52 phenobarbital...18 phenyleph/bromphen/ dextromethorphan/ guaifenesin...53 phenylephrine.25, 26, 46, 49-51, 53, 54 phenylephrine/ brompheniramine-dm...53 phenylephrine/ brompheniramine/ dextromethorphan...53 phenylephrine/chlorpheniramine 53, 54 phenylephrine/ chlorpheniramine/ dextromethorphan...53 phenylephrine/ chlorpheniramine/ dihydrocodeine...54 phenylephrine/ dextromethorphan...54 phenylephrine/ dextromethorphan/ guaifenesin...54 phenylephrine/ephed/cpm w/ carbetapentane...54 phenylephrine/guaifenesin..54 ALL CAPS = Brand-name drug lower case = Generic drug phenylephrine/hydrocodone/ guaifenesin...54 phenylephrine/pyrilamine/ dextromethorphan...54 phenylephrine/pyrilamine w/ hydrocodone...54 phenylephrine tan/pyrilamine tan/carbeta tan...54 phenylhist liq dh...51 PHENYTEK...18 phenytoin...18 phenytoin sodium extended..18 PHISOHEX...23 PHOS-FLUR...58, 66 PHOSLYRA...62 PHOSPHOLINE IODINE...45 phosphorus...56 PHRENILIN...14 phytonadione...58 pilocarpine...26, 44 PILOPINE HS GEL...44 PIMA...57 pimecrolimus...23 pimozide...49 pindolol...10 pioglitazone...29 pioglitazone/glimepiride...29 pioglitazone/metformin...29 pioglitazone/metformin ER..29 Piperonyl Butoxide...65 piperonyl butoxide gel, liquid shampoo...65 pirfenidone capsule...62 piroxicam...14, 39 PLAN B...40 PLAN B ONE STEP...40 PLAQUENIL...37, 39 PLAVIX...7 85 PLENDIL...10 plerixafor...7 PLETAL...7 PLEXION...19 podofilox...22 POLARAMINE...25 POLY-VI-FLOR...58 Poly-Vi-Sol...66 polyethylene glycol 3350...32 polymyxin B/bacitracin..20, 46 polymyxin B/trimethoprim...46 polysaccharide iron complex...58 POLYSPORIN...46 POLYTRIM...46 pomalidomide...6 POMALYST...6 ponatinib...5 posaconazole susp...35 potassium acid phosphate...56 potassium bicarbonate/ potassium citrate effervescent...56 potassium chloride...32, 56, 57 potassium chloride ext-rel...56, 57 potassium citrate...56, 61 potassium iodide...57 POTIGA...17 povidone-iodine...38 PRADAXA...7 pramipexole...17 pramipexole dihydrochloride SR...17 pramlintide...29 PRANDIN...29 PRAVACHOL...13 pravastatin...13

Index of s praziquantel...23 prazosin...8 precose...28 PRED-G...44 PRED FORTE...44 PRED MILD...44 prednicarbate...20 prednisolone...26, 44 prednisolone acetate...44 prednisolone phosphate...44 prednisolone sodium phosphate...26 prednisone...27 pregabalin...18 PRELONE...26 PREMARIN...42 PREMPHASE...42 PREMPRO...42 prenat-fe Bis-FE prot succ-fa-ca & omega 3..59 prenat w/o A w/fecbnfegl-dss-fa & DHA...59 prenatal vit w/ FE bisglyc- FE prot succ-fa...59 prenatal vit w/ FE bisglycinate chelate-fa..59 prenatal vit w/ FE polysac cmplx-fa...59 prenatal vit w/ iron carbonyl-fa...59 prenatal vit w/o vit a w/fe bisglycinate-fa tab 32-1 mg...59 PRENATAL VITAMINS w/ FOLIC ACID...59 prenatal vitamins w/folic acid...59 prenatal w/o A w/ FE carbonyl-fe gluc-dss-fa...59 ALL CAPS = Brand-name drug lower case = Generic drug Preparation H...65 PRESGEN B...53 PREVACID...31 PREVACID SOLUTAB...31 PREVIDENT...58 PREZISTA...37 PRILOSEC...31 PRILOSEC POWDER...31 primaquine...38 primidone...18 PRINCIPEN...34 PRO NUTRIENT...60 PROAMATINE...13 probenecid...40 Probiotic Formula...33 probiotic product...33 procainamide...9 procainamide ext-rel...9 PROCANBID...9 procarbazine...5 PROCARDIA...10 PROCARDIA XL...10 prochlorperazine...30 PROCRIT...7 PROCTO-PAK CREAM...23 PROCTOFOAM HC FOAM..23 PROCTOSOL HC CREAM 2.5%...23 PROCTOZONE CREAM-HC 2.5%...23 progesterone micronized...42 PROGRAF...6 PROLASTIN...57 PROLIXIN...49 PROLIXIN DECANOATE...49 PROMACTA...62 prometh vc syp 6.25-5/5...54 promethazine...30, 51, 52, 54 86 promethazine & phenylephrine...51, 54 promethazine syp dm...52 PROMETHAZINE VC w/codeine...51 PROMETHAZINE w/codeine...51 PROMETRIUM...42 PRONESTYL...9 propafenone...9 propantheline...61 propranolol...10, 16 propranolol/hctz...10 propylthiouracil...29 PROSCAR...61 PROSOM...48 Protonix...31 PROTONIX PAK...31 Protopic 0.03%...24 Protopic 0.1%...24 protriptyline...48 PROVENTIL...56 PROVERA...42 PROZAC...47 Pruet DHA Pak Setonet Pak...59 PRUET DHAEC PAK...60 pse/gg...52 pseudoephedrine...25, 26, 49-55, 63 pseudoephedrine/ acetaminophen/ dextromethorphan...55 pseudoephedrine/ chlorpheniramine/ dextromethorphan...55 pseudoephedrine/ dextromethorphan/ guaifenesin...50, 55

Index of s pseudoephedrine/ iburprofen...55 pseudoephedrine tan/ dexchlorphen tan/ DM tan...55 PSORCON CREAM...21 PSORCON OINTMENT...21 psyllium...65 PULMICORT FLEXHALER. 55 PULMICORT RESPULES...56 PULMOZYME...62 PURINETHOL...4 PURIXAN...4 pyrazinamide...38 pyrethrins/piperonyl but....22 PYRIDIUM...61 pyridostigmine...16 pyridostigmine ext-rel...16 pyrilamine tan/phenyleph tan.55 pyrimethamine...38 pyrithione zinc shampoo 1% kit...21 Q qual-tussin syp dc...53, 54 QUALAQUIN...38 QUESTRAN...12 QUESTRAN-LIGHT...12 quinapril...8 quinapril/hydrochlorothiazide. 8 quinidine gluconate ext-rel...9 quinidine sulfate.............. 9 quinidine sulfate ext-rel...9 quinine sulfate...38 qv-allergy...50 QVAR...55 R r-tannamine...51 ALL CAPS = Brand-name drug lower case = Generic drug raloxifene...29 raltegravir...38 ramelteon...48 ramipril...8 RANEXA...13 ranitidine...31 ranitidine effer...31 ranitidine syrup...31 ranolazine...13 RAPAMUNE...6 RAVICTI...62 RAYOS...27 RAZADYNE...13 REBETOL/COPEGUS...35 REBIF...16 rectal crm, suppositories...65 RECTIV...23 REGLAN...30 regorafenib...5 RELAFEN...14, 39 RELENZA...36 Relion 70/30...27 Relion N...27 Relion R...27 RELISTOR...33 REMERON...48 REMERON ODT...48 REMICADE...38 REMODULIN...13 RENAGEL...62 renat-fe bis-fe prot succ-fa-ca & omega DR...60 Renvela...62 repaglinide...29 REQUIP...17 REQUIP XL...17 RESCRIPTOR...36 87 RESPA-BR...24 resperal-dm...50 RESTASIS...46 RESTORIL...48 RETIN-A...19 RETROVIR...36 REVATIO...13 REVIA...46, 49 REVLIMID...6 REYATAZ...37 ribavirin...35 RID SHAMPOO/BUTOXIDE SHAMPOO...22 RIDAURA...38 rifabutin...38 RIFADIN...38 rifampin...38 rilonacept...61 rilpivirine...36 rimantadine...36 rimexolone...44 RITALIN...47 RITALIN-SR...47 RITALIN LA...47 ritonavir...37 rivaroxaban...7 rivastigmine...13 rizatriptan...16 RMS...15 ROBAXIN...40 ROBINUL...31 ROBINUL FORTE...31 ROBITUSSIN...51-55, 64 ROBITUSSIN CF...52, 64 ROBITUSSIN DM...52, 64 robitussin liq cgh/alrg...53 robitussin liq cgh/cld...51 robitussin liq cgh/cong...52

Index of s robitussin liq hd/chst...54 robitussin liq ped nght...55 ROBITUSSIN PE... 52, 54, 64 robitussin ped liq cgh/cold...51 robitussin ped syp...52 ROBITUSSIN syp chst cng..52 ROBITUSSIN syp max-st...52 ROCALTROL...57 ROCALTROL SOLUTION...57 RONDEC DM...53 RONDEC DM DROPS...53 RONDEC DROPS...50, 51 RONDEC SYRUP...50, 51 ropinirole...17 ropinirole hydrochloride SR..17 ROWASA...32 ROXICODONE...15 ROZEREM...48 rufinamide...18 rufinamide suspension...18 ruxolitinib...5 ryna-12 s...55 RYNATAN PEDIATRIC SUSP...51 RYNATUSS...50, 54 RYNATUSS PEDIATRIC SUSP...54 RYTHMOL...9 S SABRIL SOLUTION...18 sacrosidase...32 SAL-TROPINE...33 SALAC OTC...23 SALACYN...23 SALAGEN...26 SALEX...23 salicylic acid...19, 22, 23, 66 ALL CAPS = Brand-name drug lower case = Generic drug salicylic acid 17%/ collodion...22, 66 salicylic acid film forming liquid 27.5% OTC...66 salicylic acid gel 17% OTC...66 salicylic acid pad 40% OTC..66 salicylic acid plaster 40%...66 salicylic acid soln OTC...66 salicylic acid strip 40%...66 salicylic acid topical patch 15% OTC................ 66 saline nasal spray 0.65%...26 salmeterol xinafoate...55 SALVAX...23 SANCTURA...61 SANDIMMUME SOLUTION..6 SANDIMMUNE...6 Sandostatin...5 sapropterin...30 sapropterin powder...30 saquinavir...37 saquinavir mesylate...37 sargramostim...7 saxagliptin...29 saxagliptin/metformin...29 scopolamine...45 SEA-OMEGA...60 SEBIZON...19 SECTRAL...10 SEDAPAP...14 selegiline...17 selenium sulfide...23 SELSUN...23 Selzentry...37 sennosides...32 SENOKOT...32 Sensipar...62 SERAX...46 88 SEREVENT DISKUS...55 SEROSTIM...29 sertraline...47 sevelamer...62 sevelamer hcl...62 SIGNIFOR...5 sildenafil...13 SILVADENE...20 silver sulfadiazine...20 SIMCOR...13 simeprevir................... 36 simethicone...30, 65 simvastatin...13 simvastatin/niacin ER...13 SINEMET...17 SINEMET CR...17 SINEQUAN...48 SINGULAIR...56 sirolimus...6 SIRTURO...37 sitagliptan................... 29 sitagliptan/metformin...29 sitagliptan/metformin ER...29 SITAVIG...36 SKLICE...22 sodium chloride hypertonic..46 sodium citrate/citric acid...61 sodium phenylbutyrate oral powder...62 sodium polysterene sulfonate...57 sofosbuvir............... 35, 36 somatropin...29 SONATA...48 sorafenib...5 Soriatane...22 sotalol...9, 10 sotalol (AFIB/AFL)...10

Index of s SOVALDI...36 Spacers...62 spinosad...22 SPIRIVA...56 SPIRIVA RESPIMAT...56 spironolactone... 11 spironolactone/ hydrochlorothiazide... 11 Sporanox...35 SPRYCEL...5 STADOL...15 STARLIX...29 statuss dm syp...53 stavudine...36 STELAZINE...49 STIVARGA...5 stool softeners...65 STRATTERA...47 STRI-DEX, AVEENO CLEAR PADS OTC...19 STRIBILD...37 STROMECTOL...23 Stuart Prenatal...66 SUBOXONE...49 SUBUTEX...49 SUCRAID...32 sucralfate...31 SUDAFED...54 sugar+orthophosphoric acid...65 SULAR...10 sulcralfate...31 SULFACET-R...19 sulfacetamide...19, 44, 46 sulfacetamide/ phenylephrine...46 sulfacetamide/pred. phos....44 sulfacetamide/sulfur...19 ALL CAPS = Brand-name drug lower case = Generic drug sulfacetamide sodium...19 sulfacetamide sodiumprednisolone...44 sulfadiazine...20, 34 sulfamethoxazole/ trimethoprim, DS...34 sulfanilamide...43 sulfasalazine...32, 39 sulfasalazine delayed-rel...32, 39 sulfisoxazole...34 sulindac...14, 39 sumatriptan...16 SUMYCIN...34 sunitinib...5 SUPER OMEGA...60 SUPRAX...33 SUPRESS-PE PEDIATRIC DROPS...54 SUSTIVA...36 SUTENT...5 SYLATRON...6 SYMBICORT...55 SYMLIN...29 SYMMETREL...17, 36 Synagis...38 SYNALAR...20 SYNTHROID...29 T T-STAT...19 tacrolimus...6, 24 tadalafil (PAH)...13 TAFINLAR...5 tafluprost...45 TAGAMET...30 tambocor...9 TAMIFLU...36 89 tamoxifen...4 tamsulosin...61 TANAFED...51, 55 TANAFED DMX SUSPENSION...55 TANZEUM...29 TAPAZOLE...29 tapentadol ER...16 tarceva...5 TARGRETIN...5 TASIGNA...5 TASMAR...17 TECFIDERA...16 teduglutide...33 TEGRETOL...17 TEGRETOL-XR...17 telbivudine...36 temazepam...48 TEMODAR...4 TEMOVATE...21 temozolomide...4 TENEX...8 tenofovir...36, 37 TENORETIC...10 TENORMIN...10 TERAZOL 3/7...43 terazosin...8, 61 terbinafine...22, 35 terbinafine gel...22 terbinafine hcl...22 terbutaline...56 terconazole...43 teriflunomide...16 teriparatide inj...29 TESSALON...49 TESTIM...27 testosterone...27

Index of s TESTOSTERONE 1% TOPICAL GEL...27 testosterone cypionate...27 testosterone enanthate...27 testosterone gel...27 testosterone gel topical tube, packet, and pump bottle. 27 testotesterone...27 tetrabenazine...18 tetracycline...33, 34 tetrahydrozoline/zinc sulfate...43 TEV-TROPIN...29 THEO-24...56 THEOCHRON...56 theophylline...56 theophylline ext-rel...56 thiethylperazine...30 thioguanine...4 thioridazine...49 thiothixene...49 THORAZINE...49 THYROLAR...29 tiagabine...18 TIAZAC...10 ticagrelor...7 Tigan...30 tikosyn...9 TILADE...56 timolol...10, 45 timolol hemihydrate...45 timolol maleate...10, 45 TIMOPTIC...45 timoptic xe...45 TINACTIN...22, 63 tiotropium...56 tiotropium respimat...56 tipranavir...37 ALL CAPS = Brand-name drug lower case = Generic drug TIVICAY...37 tizanidine...40 TOBRADEX...44 TOBRADEX ST...44 tobramycin...44, 46, 62 tobramycindexamethasone...44 tobramycin/ dexamethasone...44 tobramycin neb soln...62 TOBREX...46 TOFRANIL...48 tolazamide...29 tolbutamide...29 tolcapone...17 TOLINASE...29 tolnaftate...22, 63 tolterodine...61 tolterodine SR...61 TOPAMAX...18 TOPAMAX SPRINKLE...18 topical antibacterials......... 64 topiramate...18 topiramate sprinkle caps...18 TOPROL XL...10 Toradol...14 TORECAN...30 toremifene...4 torsemide... 11 TRACLEER...13 TRADJENTA...28 tramadol...14 trametinib...5 TRANDATE...10 trandolapril...8 tranexamic acid...43 TRANS-VER-SAL PATCH...66 TRANXENE...46 90 tranylcypromine...47 TRAVATAN Z...45 TRAVATAN Z PF...45 travoprost...45 trazodone...48 TRENTAL...7 treprostinil...13 tretinoin...6, 19 tri-fed x...55 TRI-NORINYL...41 TRI-VI-FLOR...60 TRI-VI-SOL...60, 66 Tri RX....................... 59 TRIACTIN CHEST CONGESTION...52 triamcinolone...20, 21, 26 triamcinolone acetonide. 20, 21, 26 triamcinolone nasal spray...26 TRIAMINIC...25, 54 TRIAMINIC LIQ CHST/ NAS...54 TRIAMINIC SYR CHST/ NAS...54 triamterene/ hydrochlorothiazide... 11 TRIANEX...20 TRIAVIL...48 TRIAZ CLOTHS...19 triazolam...48 TRICOR...12 trifluoperazine...49 trifluridine...46 TRIGLIDE...12 trihexyphenidyl...17 TRILAFON...49 TRILEPTAL...18 TRILISATE...14, 39

Index of s TRILYTE...32 trimethobenzamide...30 trimethoprim...34, 38, 46 TRIOTANN...25, 51 TRIOTANN PEDIATRIC SUSP...51 tripolidine/ pseudoephedrine...55 triprol/pse syp...55 triprolidine/ pseudoephedrine...25 TRIUMEQ...37 TRIVORA...41 TRIZIVIR...36 Trojan...64 trospium...61 TRUSOPT...45 Trust Natalcare Pak DHA...59 TRUVADA...37 TUCKS OINTMENT OTC...23 TUDORZA PRESSAIR...56 Tums...65, 66 TUSSI-12 S...51 TUSSI 12D S...54 tussin dm...52 Twinject...61 TYBOST...37 TYKERB...5 TYLENOL...14, 15, 39, 65 TYLENOL w/codeine...15 TYLOX...15 typhoid vaccine...62 TYVASO...13 TYZEKA...36 U Uloric...40 Ultram...14 ALL CAPS = Brand-name drug lower case = Generic drug uni-hist dro.................. 49 UNIPHYL...56 UNIRETIC...8 UNIVASC...8 urea 40%...24 Urea 40% cream and lotion. 24 URECHOLINE...61 UREX...61 UROCIT-K...61 UROXATRAL...61 URSO...33 URSO FORTE...33 ursodiol...33 Utira C...61 V VAGIFEM...42 vaginal products...63 valacyclovir...36 VALCYTE...35 valganciclovir...35 VALIUM...40, 46 valproic acid...18 valsartan...9 valsartan/hydrochlorothiazide. 9 Valtrex...36 VANCOCIN HCl...34 vancomycin HCl...34 vandetanib...5 VANTIN...33 varenicline...49 VASERETIC...8 VASOCIDIN...44 VASOCLEAR...43 VASOCLEAR A...43 VASOSULF...46 VASOTEC...8 vectical...22 91 VEETIDS...34 VELIVET...41 vemurafenib.................. 5 venlafaxine...48 venlafaxine XR...48 VENTAVIS...13 VENTOLIN HFA...55 VEPESID...5 VERALAN PM... 11 verapamil...11, 16 verapamil ext-rel... 11 VESANOID...6 VEXOL...44 VFEND...35 Vi-Daylin...66 VIBRAMYCIN...34 VICODIN 5/500...15 VICODIN ES...15 VICOPROFEN...15 Victoza...29 VICTRELIS...35 VIDEX...36 VIDEX EC...36 vigabatrin oral solution...18 VIGAMOX...45 vimpat...17 Vinate AZ EX...59 Vinate III...59 VIRACEPT...37 VIRAMUNE................. 36 Viramune XR...36 VIREAD...37 VIROPTIC...46 Visine...65 VISINE-AC...43 vismodegib...6 VISTARIL...25 Vistide...35

Index of s vitamin A...60 vitamin ADC/fluoride/±iron drops...60 vitamin B-1...60 VITAMIN B-12...57 vitamin B-6...60 vitamin B complex/vitamin C/ folic acid...60 vitamin C...60 vitamin D 400 IU...66 VITAMIN D CAP 2000 UNIT.57 VITAMIN D CAP 400 UNIT..57 VITAMIN D TAB 1000 UNIT. 57 VITAMIN D TAB 2000 UNIT. 57 VITAMIN D TAB 400 UNIT..57 vitamins pediatric...60, 66 vitamins pediatric members <3 years old............. 66 vitamins prenatal...66 Vitaphil...59 VITUSSIN...53 VIVACTIL...48 VIVELLE-DOT...42 VIVOTIF BERNA...62 VOLTAREN...14, 39, 43 VOLTAREN 1% TOPICAL GEL...39 VOLTAREN XR...14, 39 voriconazole...35 vorinostat...6 VOSOL HC OTIC...24 VOSOL OTIC...24 VOSPIRE ER...56 Votrient...5 VYTORIN...13 Vyvanse...47 W ALL CAPS = Brand-name drug lower case = Generic drug warfarin...7 WELLBUTRIN...48 WELLBUTRIN SR...48 WELLBUTRIN XL...48 WESTCORT OINTMENT...20 WYTENSIN...13 X XALATAN...45 XALKORI...5 XANAX...46 XARELTO...7 XARTEMIS XR...16 XELODA...4 XENAZINE...18 XOLAIR...56 XOLEGEL...21 XOLEGEL DUO KIT...21 XOLEGEL KIT...21 XOPENEX Respules...56 XYLOCAINE...23, 26 XYZAL...25 Z zafirlukast...56 zalcitabine...36 zaleplon...48 ZANAFLEX...40 zanamivir...36 ZANTAC...31 ZARONTIN...17 ZAROXOLYN... 11 ZEASORB-AF...21 ZEBETA...10 ZELBORAF.................. 5 zenpep...32 ZENPEP DR...32 ZERIT...36 92 ZESTORETIC...8 ZESTRIL...8 ZETIA...13 ZIAC...10 ZIAGEN...36 zidovudine...36 zinc...21, 43, 60 ZIOPTAN...45 ZITHROMAX...34 ZOCOR...13 ZOFRAN...30 ZOFRAN ODT...30 ZOLINZA...6 ZOLOFT...47 zolpidem...48 ZONEGRAN...18 zonisamide...18 Zortress...6 ZOVIA 1/35...41 ZOVIA 1/50...41 Zovirax...36 ZOVIRAX CREAM...36 ZOVIRAX OINTMENT...36 ZYBAN...49 ZYDELIG...5 ZYKADIA...5 ZYLOPRIM...40 ZYMAR...45 zyrtec...25, 63 ZYRTEC-D...25 ZYRTEC CHEWABLE TABLET...25 zyrtec d...63 ZYTIGA...4 ZYVOX...37

Notes 93

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, 20 mg Tier 1 High blood pressure One tablet daily Dr. Johnson 94

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