1. No category

Preferred
Drug List (PDL)
Lista de Medicamentos
Preferidos (PDL)
Arizona
Effective Date/Vigencia: 10/1/16
© 2016 United Healthcare Services, Inc. All rights reserved.
Introduction
UnitedHealthcare Community Plan is pleased to
provide this Preferred Drug List (PDL) to be used
when prescribing for patients covered by the
pharmacy benefit plan offered by UnitedHealthcare
Community Plan. 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 Community Plan
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 Community Plan. 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 Community
Plan PDL is reflective of current medical practice.
Notice
The information contained in this PDL and its
appendices is provided by UnitedHealthcare
Community Plan, solely for the convenience of
medical providers. UnitedHealthcare Community
Plan 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.
i
UnitedHealthcare Community Plan assumes no
responsibility for the actions or omissions of any
medical provider based upon reliance, in whole
or in part, on the information contained herein.
The medical provider should consult the drug
manufacturer’s product literature or standard
references for more detailed information.
National guidelines can be found on the Web
sites listed in the Web site section or go to
the National Guideline Clearinghouse site at
http://www.guideline.gov.
Preface
The UnitedHealthcare Community Plan PDL is
organized by sections. Each section includes
therapeutic groups identified by either a drug
class or disease state.
Products are listed by generic name. Brand names
are included as a reference to assist in product
recognition. Unless exceptions are noted, generally
all applicable dosage forms and strengths of the
drug cited are included in the PDL. Generics should
be considered the first line of prescribing.
The UnitedHealthcare Community Plan PDL covers
selected over-the-counter (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 Community Plan or its
affiliates. They must adhere to the Ethics Policy
standards of the P&T Committee. UnitedHealthcare
Community Plan medical directors and pharmacists
also participate in the P&T Committee. The P&T
Committee meets quarterly to discuss a variety of
issues. Those issues pertaining to pharmaceutical
selection and pharmacy program management
are communicated quarterly. This newsletter is
distributed to all participating physicians who
have received the PDL. PDL decisions are also
communicated quarterly on the UnitedHealthcare
Community Plan internet site.
Outpatient Prescription Drug BenefitCovered Medications
Medically necessary outpatient prescription
drugs are covered when prescribed by a provider
licensed to prescribe federal legend drugs or
medicines. Some items are covered only with prior
authorization. Eligibility for Outpatient Prescription
Drug 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
PDL Product Descriptions
To assist in understanding which specific
strengths and dosage forms are covered on the
PDL, examples are noted below. The general
principles shown in the examples can then usually
be extended to other entries in the book. Any
exceptions are noted in the drug list. There may also
be a statement associated with a drug list that gives
additional information about which specific products
or dosage forms are covered.
Products covered include all strengths
associated with the dosage form of the
cited brand name product.
carvedilol Coreg
All strengths of Coreg would be covered by
this listing.
•Comparison studies
Extended-release and delayed-release products
require their own entry.
•Approved indications
•Adverse effects
•Contraindications/Warnings/Precautions
•Pharmacokinetics
•Patient administration/compliance
considerations
•Medical outcome and pharmacoeconomic
studies
When a new drug is considered for PDL inclusion,
it will be reviewed relative to similar drugs currently
included in the UnitedHealthcare Community Plan
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.
diltiazem sustained release
Cardizem SR
Dosage forms covered will be consistent with
the category and use where listed.
Neomycin/polymixin B/Cortisporin
Hydrocortisone
As listed in the OTIC section, this is limited to
the otic solution and suspension. From this entry,
the ophthalmic solution and ointment, and the
topical cream, cannot be assumed to be on the
list unless there are entries for these products in
the OPHTHALMIC and DERMATOLOGY sections
of the PDL.
When a strength or dosage form is specified,
only the specified strength and dosage form is
on the PDL. Other strengths/dosage forms of
the reference product are not.
citalopram 40mg tabs
Celexa tabs
ii
Generic Substitution
The UnitedHealthcare Community Plan PDL
requires generic substitution on the majority of
products when a generic equivalent is available.
Generic substitution is a pharmacy action whereby
a generic equivalent is dispensed rather than the
brand name product. The PDL indicates generic
availability in the “Covered Drug” column.
If a brand name drug is medically necessary, please
submit a prior authorization request.
The UnitedHealthcare Community Plan MAC
list sets a ceiling price for the reimbursement of
certain multisource prescription drugs. This price
will typically cover the acquisition of most generics
but not branded versions of the same drug. The
products selected for inclusion on the MAC list
are commonly prescribed and dispensed and
have usually gone through the FDA’s review and
approval process.
An important consideration for generic substitution
is the knowledge that all approvals of generic drugs
by the FDA since 1984, and many generic approvals
prior to 1984, have a showing of bioequivalence
between the generic versions and the reference
brand product. To gain FDA approval:
1. The generic drug must contain the same active
ingredient(s), be the same strength and the
same dosage form as the brand name product.
2. The FDA has given the generic an “A” rating
compared to the branded product indicating
bioequivalence, and has determined the generic
is therapeutically equivalent to the reference
brand. The ratings of generic drugs are available
by referring to the FDA reference, Approved
Drug Products with Therapeutic Equivalence
Evaluations (Orange Book).
iii
When the above two criteria are met, a generic
can be substituted with the full expectation that the
substituted product will produce the same clinical
effect and safety profile as the prescribed product.
Drug products that have a narrow therapeutic index
(NTI) can also be guided by these principles. It is not
necessary for the health care provider to approach
any one therapeutic class of drug products (e.g.,
NTI drugs) differently from any other class, when
there has been a determination of therapeutic
equivalence by the FDA for the drug products
under consideration. Also, additional clinical tests or
examinations by the physician are not needed when
a therapeutically equivalent generic drug product is
substituted for the brand name product.
There are now many brand name products that
are repackaged or distributed under a generic
label. The generic label version should always
be considered therapeutically equivalent and
substitutable for the source branded product.
Drug Efficacy Study Implementation
(DESI) Drugs
Drugs 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 Community Plan’s PDL does not
cover DESI “less than fully effective” drug products.
Plan Exclusions
The following drug categories are excluded
from coverage under the outpatient pharmacy
benefit and are not part of the UnitedHealthcare
Community Plan 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
•Agents used for erectile dysfunction
•Agents used for cosmetic hair growth
•Drugs from manufacturers that do not
participate in the FFS Medicaid Drug
Rebate Program
•Diagnostic products
•Medical supplies and DME except as listed:
syringes, needles, lancets, alcohol swabs,
spacers, preferred diabetes test strips,
peak flow meters (Astech, Assess, Peak
Air brands, max two per year), vaporizer
(limit of one per three years), humidifier
(limit of one per three years)
•Mirena
Days Supply Dispensing Limitations
UnitedHealthcare Community Plan 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 seventy-five percent (75%) of the medication
has been utilized. If a claim is submitted before 75%
of the medication has been used, based on the
original day supply submitted on the claim, the claim
will reject with a “refill too soon” message.
Mandatory Generic Substitution
The UnitedHealthcare Community Plan PDL
requires mandatory generic substitution on the
vast majority of products when a generic equivalent
is available; however, brand name drugs may be
covered in certain situations by requesting a prior
authorization. The UnitedHealthcare Community
Plan PDL prior authorization (PA) list does not
include branded items where a generic equivalent
is covered.
Prior Authorization of
Non-PDL Medications
The drugs in the UnitedHealthcare Community
Plan PDL have been selected to provide the
most clinically appropriate and cost-effective
medications for patients who have their drug benefit
administered through UnitedHealthcare Community
Plan. It is also recognized that there may be
occasions where an unlisted drug is desired for the
proper medical management of a specific patient.
In those infrequent instances, the prior authorization
process reviews requests for unlisted medications
the physician may consider medically necessary for
patient management.
Requests for these exceptions should be either
made in writing by the physician and faxed or called
in to:
UnitedHealthcare Community Plan
Pharmacy Services Department
Fax 1-866-940-7328
Phone 1-800-310-6826
iv
A prior authorization request form is available in the
UnitedHealthcare Community Plan 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
Community Plan. 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 Community
Plan Pharmacy Prior Notification Service at
1-800-310-6826 with questions concerning
the prior authorization process.
Non-PDL Drugs Five-Day Temporary
Supply Overrides
To ensure the use of PDL drugs, all non-PDL
drugs should be discussed with the prescribing
physician. If you cannot speak to the physician
immediately, and there is an immediate need
for the medication, the claim processing
system will accept an override to permit a onetime dispensing of a five-day supply of the
newly prescribed non-PDL drug. The pharmacy
should submit a claim for a five day supply, with
a PA Type of 8 and Prior Authorization number of
“00000000120”. Please note that non-preferred
drugs are available for a five-day supply, however,
availability is subject to the benefit design. For
assistance, pharmacies may call 1-800-310-6826.
v
The pharmacy should contact the physician
to discuss a PDL drug or if a prior authorization
request is warranted. If the prescribing physician
feels a drug is medically necessary, the physician
may fax a request for prior authorization to
UnitedHealthcare Community Plan at
1-866-940-7328.
Quantity Limitations (QL)
Prescriptions for monthly quantities greater
than the indicated limit require a prior
authorization request.
Quantity Limits Based on Efficient
Medication Dosing
The Efficient Medication Dosing Program is
designed to consolidate medication dosage to the
most efficient daily quantity to increase adherence
to therapy and also promote the efficient use of
health care dollars.
The limits for the program are established based on
FDA approval for dosing and the availability
of the total daily dose in the least amount of tablets
or capsules daily. Quantity Limits in the prescription
claims processing system will limit the dispensing
to consolidate dosing. The pharmacy claims
processing system will prompt the pharmacist to
request a new prescription order from the physician.
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 patientspecific 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 Community Plan
Pharmacy Prior Notification Service at
1-800-310-6826 with questions.
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.
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 Drug
First-Line Agent(s)
Advair
(1) 30 day trial of one inhaled
corticosteroid (e.g. Asmanex
Twisthaler, Flovent HFA, QVAR)
OR (2) 60 day trial of a long
acting beta2- agonist (e.g.
Arcapta, Striverdi) OR
60 day trial of an orally
inhaled anticholinergic
agent (e.g. Atrovent, Spiriva).
Amerge
Trial at a minimum dose of
50mg of sumatriptan tablets.
Aricept 23mg
90-day trial of Aricept 10mg daily.
calcipotriene
cream & oint
0.005%
Trial of two topical corticosteroids.
The UnitedHealthcare Pharmacy Department will
review and respond to all requests in accordance
with state requirements, and if authorized for
payment, UnitedHealthcare Community Plan will
coordinate the delivery of the product to the member
or provider.
calcitriol
3mcg/gm
Trial of two topical corticosteroids.
Ditropan XL
30-day trial of oxybutynin
immediate release. Step Therapy
only applies to members less
than 65 years of age.
Drugs that are part of this program and are on
the PDL are identified in this booklet by the
designation “SP”.
DPP4 Inhibitors At least a 90-day trial of
(Tradjenta,
1500mg/day of metformin.
Januvia,
Janumet,
Janumet XR,
Jentadueto)
Specialty Pharmaceutical
Management Program
UnitedHealthcare Community Plan is continuously
looking for ways to provide high-quality costeffective care for Plan members. The Specialty
Pharmaceutical Management Program helps
UnitedHealthcare Community Plan 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 Community Plan Pharmacy
Department via fax at 1-866-940-7328.
Prior Authorization request forms can be requested
by calling the UnitedHealthcare Community Plan
Pharmacy Department at 1-800-310-6826.
vi
vii
STEP Drug
First-Line Agent(s)
STEP Drug
First-Line Agent(s)
Dulera
(1) 30 day trial of one inhaled
corticosteroid (e.g. Asmanex
Twisthaler, Flovent HFA, QVAR).
Symbicort
Elidel
Trial of two different topical
corticosteroids. Step therapy
only applies to members 12
years of age and older.
fenofibrate
Fill of a statin or 90 days of
gemfibrozil within the previous
180 days.
(1) 30 day trial of one inhaled
corticosteroid (e.g. Asmanex
Twisthaler, Flovent HFA,
QVAR) OR (2) 60 day trial of
a long acting beta2- agonist
(e.g. Arcapta, Striverdi) OR 60
day trial of an orally inhaled
anticholinergic agent (e.g.
Incruse Ellipta, Atrovent,
Combivent, Anoro Ellipta).
tacrolimus
0.03%
Trial of two different topical
corticosteroids. Step therapy
only applies to members 12
years of age and older.
tacrolimus
0.1%
Minimum age of 16. Trial of two
different topical corticosteroids.
tolterodine
30 day trial of oxybutynin
immediate release.
Step Therapy only applies
to members less than
65 years of age.
trospium
30 day trial of oxybutynin
immediate release.
Step Therapy only applies
to members less than
65 years of age.
TZD’s
(ActosPlusMet,
ActoPlusMet
XR, Duetact)
At least a 90-day trial of
1500mg/day of metformin.
Uloric
8-week trial of up to 600mg of
allopurinol required first.
GLP-1 Agonists
(Victoza)
At least a 90-day trial of
1500mg/day of metformin.
Midodrine
Tablet
Trial of fludrocortisone.
Optivar
14 day trial of ketotifen within
previous 90 days required first.
oxymorphone
ER (non-crush
resistant)
30-day trial of both Fentanyl
patch and morphine sulfate ER
at least 200mg per day.
Ranexa
Trial of one drug from the
following classes: beta blockers,
calcium channel blockers, long
acting nitrates.
Renvela
8-week trial of calcium acetate.
SGLT-2
Inhibitors
(Jardiance,
Invokana,
Invokamet,
Synjardy)
At least a 90-day trial of
1500mg/day of metformin.
STEP Drug
First-Line Agent(s)
Vancocin
One fill of metronidazole tabs
or caps.
Xopenex
Respules
30-day trial of Albuterol .083% or
.5% respules.
Zohydro ER
30-day trial of both Fentanyl
patch and morphine sulfate ER
at least 200mg per day.
PDL Suggestions
Providers who wish to propose PDL suggestions
should forward the information to the
UnitedHealthcare Community Plan Director of
Pharmacy Services by either mail or fax.
Attn: Director of Pharmacy Services
UnitedHealthcare Community Plan
1001 Brinton Road
Pittsburgh, PA 15221
Fax: 1-866-940-7328
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
Community Plan will be reviewed by the Pharmacy
and Therapeutics Committee at the subsequent
P&T Committee meeting.
Editor
Your comments and suggestions regarding
the UnitedHealthcare Community Plan 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 Community Plan
1001 Brinton Road
Pittsburgh, PA 15221
Fax: 1-866-940-7328
viii
Notice
Legend
ix
#
Only the dosage forms/strengths
of the brand name products noted
are on the PDL
OTC
over-the-counter
delayed-rel
delayed-release (also known as
enteric coated)
EC
enteric-coated
ext-rel
extended-release (also known as
sustained-release)
PA
Prior Authorization required
QL
Quantity Limits apply
ST
Step Therapy, see pages viii - ix for
details
SP
Specialty Pharmaceuticals; see
page vii for details
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 Community Plan.
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 Community Plan.
These trademarked brand names are included
here for informational purposes only and are not
intended to imply or suggest any affiliation between
UnitedHealthcare Community Plan 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.
Introducción
Aviso
UnitedHealthcare Community Plan se complace
en ofrecer esta Lista de medicamentos preferidos
(Preferred Drug List, PDL) que se utilizará al
realizar recetas para los pacientes que tienen
cobertura del plan de beneficios de farmacia
ofrecido por UnitedHealthcare Community Plan.
Los medicamentos incluidos en esta PDL tienen
como finalidad ofrecer opciones suficientes para
tratar a los pacientes que necesitan tratamiento
con un medicamento de dicha clase farmacológica
o terapéutica. Los medicamentos incluidos en la
PDL de UnitedHealthcare Community Plan han
sido revisados y aprobados por el Comité de
Farmacia y Terapéutica. Los medicamentos se
han seleccionado para ofrecer los medicamentos
más apropiados desde el punto de vista clínico y
más asequibles para los pacientes que tienen su
beneficio de medicamentos administrado a través
de UnitedHealthcare Community Plan. También
se reconoce que puede haber ocasiones en
que un medicamento no incluido en la lista se
requiere para el control médico adecuado de
un paciente específico. En estas instancias
poco frecuentes, los medicamentos que no
estén incluidos pueden ser requeridos a través
del proceso de autorización previa.
La información incluida en esta PDL y sus
apéndices es provista por UnitedHealthcare
Community Plan, exclusivamente para la
comodidad de los proveedores médicos.
UnitedHealthcare Community Plan no garantiza
ni asegura la precisión de dicha información ni
pretende ser integral por naturaleza.
Los medicamentos representados han sido
revisados por el Comité de Farmacia y Terapéutica
(Pharmacy and Therapeutics, P&T) y están
aprobados para su inclusión. La PDL refleja la
práctica médica actual desde la fecha de la revisión.
Prólogo
Esta edición incorpora medicamentos agregados
a la PDL desde la última edición así como
numerosas revisiones para la información de
prescripción basada en los cambios en la
farmacoterapia. También se han incorporado
comentarios y sugerencias de médicos practicantes
para garantizar que la PDL de UnitedHealthcare
Community Plan refleje la práctica médica actual.
Esta PDL no tiene la finalidad de sustituir el
conocimiento, la pericia, las habilidades ni el
criterio del proveedor médico en su elección de
medicamentos recetados.
UnitedHealthcare Community Plan no asume
ninguna responsabilidad por las acciones u
omisiones de los proveedores médicos sobre
la base de la confianza, total o parcial, de la
información incluida aquí. El proveedor médico
debe consultar la información del producto del
fabricante del medicamento o las referencias
estándar para obtener información detallada.
Las pautas nacionales pueden encontrarse en
los sitios web que se enumeran en la sección
del sitio web, o bien, visite el sitio del Centro de
Intercambio de Información de Pautas Nacionales
en http://www.guideline.gov.
La PDL de UnitedHealthcare Community Plan está
organizada por secciones. Cada sección incluye
grupos terapéuticos identificados por una clase
de medicamento o estado de la enfermedad.
Los productos están enumerados por nombre
genérico. Las marcas están incluidas como una
referencia para ayudarlo a reconocer el producto. A
menos que se incluyan excepciones, por lo general
todas las formas de dosificación y concentraciones
aplicables del medicamento citado están incluidas
en la PDL. Los medicamentos genéricos deben ser
considerados como medicamentos recetados de
primera línea.
x
La PDL de UnitedHealthcare Community
Plan cubre algunos productos de venta libre
(over-the-counter, OTC). Lo alentamos a
que recete medicamento OTC cuando sea
clínicamente apropiado.
Comité de Farmacia y
Terapéutica (P&T)
El Comité de P&T incluye médicos y farmacéuticos
que no son empleados ni agentes de
UnitedHealthcare Community Plan o sus afiliadas.
Deben respetar los estándares de la Política
sobre ética del Comité de P&T. Los directores
médicos de UnitedHealthcare Community Plan
y los farmacéuticos también participan en el
Comité de P&T. El Comité de P&T se reúne
trimestralmente para analizar diversos temas. Los
temas pertinentes a la selección farmacéutica y
la administración del programa de farmacia se
comunican trimestralmente. Este boletín informativo
se distribuye a todos los médicos participantes
que hayan recibido la PDL. Las decisiones de
PDL también son comunicadas trimestralmente
en el sitio de Internet de UnitedHealthcare
Community Plan.
Beneficio de Medicamentos
Recetados Para Pacientes
Ambulatorios - Medicamentos
Cubiertos
Los medicamentos recetados para pacientes
ambulatorios médicamente necesarios están
cubiertos cuando son recetados por un proveedor
autorizado para recetar medicamentos o fármacos
con leyenda federales. Algunos artículos solo se
cubren con autorización previa. La elegibilidad
para los beneficios de medicamentos recetados
para pacientes ambulatorios y los copagos
están basados en el plan de beneficios del
miembro individual.
xi
Criterios de Selección de Productos
El Comité de P&T considera la información clínica
en los medicamentos nuevos para el mercado
que por lo general se incluyen en el beneficio
de farmacia para pacientes ambulatorios. La
evaluación incluye todo o parte de lo siguiente:
•Seguridad
•Eficacia
•Estudios de comparación
•Indicaciones aprobadas
•Efectos adversos
•Contraindicaciones/Advertencias/
Precauciones
•Farmacocinética
•Administración de pacientes/consideraciones
de cumplimiento
•Resultados médicos y estudios
farmacoeconómicos
Cuando un medicamento nuevo se considera
para su inclusión en la PDL, se revisará en relación
a los medicamentos similares que se incluyen
actualmente en la PDL de UnitedHealthcare
Community Plan. Este proceso de revisión
puede derivar en la supresión de medicamentos
en una clase terapéutica en particular con el
fin de promover continuamente los agentes
más económicos y útiles desde el punto de
vista clínico.
Toda la información que se incluye en la PDL se
proporciona como referencia para la selección
de tratamientos con medicamentos. La selección
de medicamentos específicos para un paciente
individual la realiza exclusivamente el profesional
autorizado para recetar medicamentos.
Descripciones de los Productos
Incluidos en la PDL
A fin de brindar ayuda para entender qué
concentraciones específicas y formas de
dosificación están cubiertas en la PDL, a
continuación se incluyen ejemplos: Los principios
generales que se muestran en los ejemplos
generalmente luego pueden extenderse a otras
entradas del libro. Las excepciones se indican en
la lista de medicamentos. También puede haber
una declaración relacionada con una lista de
medicamentos que ofrece información adicional
acerca de cuáles son los productos específicos o
formas de dosificación que se cubren.
Los productos cubiertos incluyen todas las
concentraciones asociadas con la forma de
dosificación del producto de marca citado.
carvedilol Coreg
Todas las concentraciones de Coreg estarían
cubiertas según esta lista.
Los productos de liberación prolongada
y de liberación retardada requieren su
propia entrada.
diltiazem de liberación
Cardizem SR
Las formas de dosificación cubiertas serán
consistentes con la categoría y el uso en los
casos que se incluyan en la lista.
Neomicina/polimixina B/Cortisporin
Hidrocortisona
Según lo enumerado en la sección de productos
ÓTICOS, se limita a la solución y suspensión
ótica. En esta entrada, no puede suponerse que la
solución oftálmica, el ungüento y la crema tópica
estén incluidos en la lista a menos que existan
entradas para estos productos en las secciones de
productos OFTÁLMICOS y DERMATOLÓGICOS de
la PDL.
En los casos en que se especifique la
concentración y la forma de dosificación, solo
la concentración especificada y la forma de
dosificación se encuentran incluidas en la PDL.
Otras concentraciones o formas de dosificación
del producto de referencia no son.
los comprimidos de citalopram 40 mg
Celexa tabs
Sustitución por Genéricos
La PDL de UnitedHealthcare Community Plan
requiere la sustitución por genéricos en la mayoría
de los productos cuando se encuentra disponible
un equivalente del medicamento genérico.
La sustitución por genéricos es una medida que
toma la farmacia en los casos en que un equivalente
de genérico se dispense en lugar del producto de
marca. El PDL indica la disponibilidad de genéricos
en la columna de “Medicamentos cubiertos”.
Si un medicamento de marca es médicamente
necesario, por favor envíe una solicitud de
autorización previa.
La lista del Consejo de Apelaciones de
Medicare (Medicare Appeals Council, MAC) de
UnitedHealthcare Community Plan establece
un precio máximo para el reembolso de ciertos
medicamentos recetados de múltiples fuentes. Este
precio por lo general cubrirá la adquisición de la
mayoría de los medicamentos genéricos pero no
las versiones de marca del mismo medicamento.
Los productos seleccionados para su inclusión
en la lista del MAC son recetados y dispensados
comúnmente, y por lo general han pasado
por el proceso de revisión y aprobación de la
Administración de Alimentos y Medicamentos (FDA).
xii
Una consideración importante para la sustitución
por genéricos es el conocimiento de que todas
las aprobaciones de medicamentos genéricos
por parte de la FDA desde el año 1984, y muchas
aprobaciones de medicamentos genéricos antes de
este año, demuestran una equivalencia biológica
entre las versiones genéricas y el producto de
marca de referencia. Para obtener la aprobación de
la FDA:
1. El medicamento genérico debe incluir los
mismos ingredientes activos y tener la misma
concentración y forma de dosificación que el
producto de marca.
2. La FDA ha otorgado a los medicamentos
genéricos la calificación “A” en comparación
con los productos de marca que indican la
equivalencia biológica; además, ha determinado
que, desde el punto de vista terapéutico,
el medicamento genérico es equivalente al
medicamento de marca. Las calificaciones de
los medicamentos genéricos están disponibles
al consultar la referencia de la FDA, Productos
farmacéuticos aprobados con evaluaciones de
equivalencia terapéutica (Libro naranja)
En los casos en que se cumpla con los dos
criterios mencionados, un medicamento genérico
puede sustituirse con la total expectativa de que
el producto sustituido producirá el mismo efecto
clínico y tendrá el mismo perfil de seguridad que el
producto recetado. Los productos farmacéuticos
que tengan un índice terapéutico estrecho (NTI)
también pueden ser guiados por estos principios.
No es necesario que el proveedor de atención
médica se aproxime a cualquier clase terapéutica
de los productos farmacéuticos (por ejemplo,
medicamentos con NTI) de forma diferente a la de
cualquier otra clase, cuando la FDA ha determinado
la equivalencia terapéutica de los productos
farmacéuticos en cuestión. Además, no es
necesario que los médicos realicen pruebas clínicas
o exámenes adicionales cuando un producto
farmacológico genérico equivalente desde el punto
de vista terapéutico se sustituye por el producto
de marca.
xiii
Actualmente, hay muchos productos de marca que
cuentan con un envase nuevo o son distribuidos
con etiquetas de medicamento genérico. La versión
con etiqueta de medicamento genérico siempre
debe considerarse como un equivalente desde
el punto de vista terapéutico y sustituible por el
producto de marca original.
Medicamentos del Programa
Implementación del Estudio Sobre
Eficacia de Medicamentos (DESI)
Los medicamentos que se comercializaron por
primera vez entre 1938 y 1962 fueron aprobados
por ser seguros pero no requerían demostración
de eficacia para la aprobación de la FDA. A partir
de 1962, todos los medicamentos nuevos debían
ser seguros y eficaces antes de que pudieran ser
comercializados. Esta legislación también se aplicó
de forma retroactiva a todos los medicamentos
aprobados por su seguridad entre los años 1938
y 1962. El programa DESI fue establecido por la
FDA para revisar la eficacia de estos medicamentos
anteriores a 1962 para las indicaciones de sus
etiquetas, y se realizó una determinación de
eficacia total para la mayoría de estos productos, y
permanecen en el mercado. Unos pocos productos
del programa DESI permanecen clasificados como
“menos que totalmente eficaces” mientras se espera
la disposición administrativa final. Además, muchos
productos incluidos como idénticos, similares o
relacionados con los productos verdaderos del
programa DESI están clasificados como DESI. La
PDL de UnitedHealthcare Community Plan no cubre
los productos farmacéuticos “menos que totalmente
eficaces” de DESI.
Exclusiones del Plan
Las siguientes categorías de medicamentos están
excluidas de la cobertura conforme al beneficio
de farmacia para pacientes ambulatorios y
no son parte de la PDL de UnitedHealthcare
Community Plan.
•Medicamentos del programa DESI
•Agentes contra la obesidad
•Medicamentos experimentales o en
investigación
•Medicamentos usados para fines cosméticos
•Agentes de vacunación
Limitaciones en la Provisión de
Suministros de Días
Los miembros de UnitedHealthcare Community
Plan pueden recibir hasta un suministro de un
mes de un medicamento específico por pedido de
receta o reposición de medicamentos recetados. Un
medicamento puede volver a pedirse o reponerse
cuando se ha utilizado el setenta y cinco por
ciento (75%) del medicamento. Si se presenta una
reclamación antes de haberse utilizado el 75% del
medicamento, según los días de suministro original
presentado en la reclamación, esta será rechazada
con un mensaje de “reposición prematura”.
•Suplementos nutricionales/dietéticos
Sustitución por Genéricos Obligatoria
•Productos de sangre o plasma sanguíneo
La PDL de UnitedHealthcare Community Plan
PDL requiere de la sustitución por genéricos
obligatoria en gran parte de los productos cuando
se encuentra disponible un equivalente genérico; no
obstante, los medicamentos de marca pueden estar
cubiertos en determinadas situaciones al solicitar
una autorización previa. La lista de autorización
previa (PA) de la PDL de UnitedHealthcare
Community Plan no incluye artículos de marca
en los casos en que el equivalente genérico
está cubierto.
•Medicamentos usados para promover
la fertilidad
•Agentes usados para la disfunción eréctil
•Agentes usados con fines cosméticos para el
crecimiento del cabello
•Medicamentos de fabricantes que no
participan en el Programa de descuentos en
medicamentos de Medicaid de FFS
•Productos de diagnóstico
•Suministros médicos y equipo médico
duradero (durable medical equipment,
DME) excepto según se menciona: jeringas,
agujas, lancetas, toallitas con alcohol,
espaciadores, tiras reactivas para medir la
glucosa, medidores de flujo máximo (marcas
Astech, Assess, Peak Air, máx. dos por año),
vaporizador (límite de 1 por cada 3 años),
humidificador (límite de 1 por cada 3 años)
•Mirena
Autorización Previa de Medicamentos
No Incluidos en la PDL
Los medicamentos incluidos en la PDL de
UnitedHealthcare Community Plan PDL han sido
seleccionados para ofrecer los medicamentos
más apropiados desde el punto de vista clínico y
más asequibles para los pacientes que tienen su
beneficio de medicamentos administrado a través
de UnitedHealthcare Community Plan. También
se reconoce que puede haber ocasiones en que
un medicamento no incluido en la lista se requiere
para el control médico adecuado de un paciente
xiv
específico. En estos casos poco frecuentes, el
proceso de autorización previa revisa las solicitudes
para los medicamentos no incluidos en la lista
que el médico puede considerar médicamente
necesario para el control del paciente.
El médico debe realizar las solicitudes de estas
excepciones por escrito y enviarlas por fax, o bien,
debe llamar a:
UnitedHealthcare Community Plan
Pharmacy Services Department
Fax 1-866-940-7328
Teléfono 1-800-310-6826
En el manual de proveedores de UnitedHealthcare
Community Plan se encuentra disponible un
formulario de solicitud de autorización previa y, si
es posible, debe utilizarse para todas las solicitudes
de autorización previa. La documentación
correspondiente debe proporcionarse para
respaldar la necesidad médica de la solicitud de
medicamentos no incluidos en la PDL. El Servicio
de Farmacia de UnitedHealthcare responderá a
todas las solicitudes de acuerdo con los requisitos
del estado.
Los médicos deben respetar esta PDL al realizar
recetas para los pacientes que tienen cobertura
mediante su plan de beneficios de farmacia
ofrecido por UnitedHealthcare Community Plan.
Si un farmacéutico recibe una receta para un
medicamento que no está incluido en la PDL, debe
comunicarse con el médico que realizó la receta
y solicitarle que cambie el medicamento por uno
que esté incluido en la PDL. Si una alternativa de
la PDL no es adecuada, debe indicarse al médico
que se comunique con el plan para solicitar una
autorización previa.
xv
Comuníquese con el Servicio de Notificación Previa
de Farmacia de UnitedHealthcare Community Plan
al 1-800-310-6826 si tiene preguntas relacionadas
con el proceso de autorización previa.
Sustituciones de Suministros
Temporales de 5 Días de
Medicamentos Que No Están
Incluidos en la PDL
Para garantizar el uso de medicamentos incluidos
en la PDL, debe consultar al médico que realiza
la receta acerca de todos los medicamentos que
no están incluidos en la PDL. Si no puede hablar
con el médico de inmediato y necesita el
medicamento de forma urgente, el sistema de
procesamiento de reclamaciones aceptará una
sustitución para permitir una provisión por única
vez de un suministro de 5 días del medicamento
recientemente recetado que no está incluido en
la PDL. La farmacia debe enviar una reclamación
para un suministro de 5 días, con el tipo 8 de PA y
el número de autorización previa “00000000120”.
Tenga en cuenta que los medicamentos no
preferidos están disponibles para un suministro de
5 días, no obstante, la disponibilidad está sujeta al
esquema de beneficios. Para obtener ayuda, las
farmacias pueden llamar al 1-800-310-6826.
La farmacia debe comunicarse con el médico
para analizar el medicamento de la PDL o si
se justifica la solicitud de una autorización previa.
Si el médico que realiza la receta considera que un
medicamento es médicamente necesario, el médico
puede enviar por fax una solicitud de autorización
previa a UnitedHealthcare Community Plan al
1-866-940-7328.
Limitaciones de Cantidad (QL)
•agentes sedantes hipnóticos
Las recetas para cantidades mensuales que
superen el límite indicado requieren de una solicitud
de autorización previa.
•barbitúricos
Límites de cantidad basados en la dosificación
de medicamentos eficaces
El Programa de dosificación de medicamentos
eficaces está diseñado para consolidar la
dosificación del medicamento a la cantidad diaria
más eficaz, para aumentar el seguimiento del
tratamiento y también promover el uso eficaz del
dinero invertido en la atención médica.
Los límites del programa se establecen conforme a
la aprobación de la FDA en cuanto a la dosificación
y la disponibilidad de la dosis diaria total con
la menor cantidad de comprimidos o cápsulas
diarias. Los límites de cantidad en el sistema de
procesamiento de reclamaciones de recetas limitará
la provisión para consolidar la dosificación. El
sistema de procesamiento de reclamaciones de
farmacia indicará al farmacéutico que solicite un
nuevo pedido de receta del médico.
Las adiciones a la lista de medicamentos del
programa de nivel de cantidad (QL) se realizarán de
vez en cuando y se notificará a los proveedores al
respecto. Como siempre, reconocemos que deben
tenerse en cuenta diversas variables específicas
del paciente cuando se indica un tratamiento con
medicamentos y, por consiguiente, las sustituciones
estarán disponibles a través del proceso de
excepción médica (PA). Comuníquese con el
Servicio de Notificación Previa de Farmacia
de UnitedHealthcare Community Plan al
1-800-310-6826 si tiene preguntas.
Sustancias controladas
Puede surtirse con cualquiera de los CUATRO
medicamentos de las siguientes clases en un
período de 30 días:
•analgésicos opioides
•algunos relajantes musculares.
Los surtidos adicionales requieren de autorización
previa. Los medicamentos de estas clases
también pueden estar sujetos a los límites
de cantidad individuales.
Programa de administración de productos
farmacéuticos especiales
UnitedHealthcare Community Plan busca
continuamente formas de ofrecer una atención
asequible de alta calidad para los miembros del
plan. El Programa de administración de productos
farmacéuticos especiales ayuda a UnitedHealthcare
Community Plan a lograr estos objetivos. Los
medicamentos inyectables que forman parte de
este programa requieren de la autorización del
plan y no están disponibles a través de la red de
farmacias minoristas.
Para obtener la autorización, el proveedor debe
enviar por fax el formulario de autorización
previa correspondiente al Departamento de
Farmacia de UnitedHealthcare Community Plan
al 1-866-940-7328.
El Servicio de Farmacia de UnitedHealthcare
revisará y responderá a todas las solicitudes de
acuerdo con los requisitos del estado, y si se
autoriza el pago, UnitedHealthcare Community Plan
coordinará la entrega del producto al miembro
o proveedor.
Los medicamentos que forman parte de este
programa y están incluidos en la PDL están
identificados en este folleto mediante la
designación “SP”.
Los formularios de solicitud de autorización previa
pueden solicitarse llamando al Departamento de
Farmacia de UnitedHealthcare Community Plan al
1-800-310-6826.
•benzodiazepinas
xvi
Terapia Escalonada
(Step Therapy, ST)
Los siguientes medicamentos de la PDL se
cubren rutinariamente solo después de un estudio
suficiente de un agente de primera línea indicado
que se haya estudiado adecuadamente y se haya
desaprobado. Estos medicamentos también
pueden solicitarse a través del proceso
de autorización previa.
Si bien las alternativas de menor costo que se
incluyen en la PDL pueden ser apropiadas en
muchos casos, otras alternativas que no se
incluyen en la PDL se encuentran disponibles
con autorización previa (prior authorization, PA).
Medicamento
para TERAPIA
ESCALONADA
Agentes de primera línea
Advair
(1) Un estudio de 30 días de
un corticoesteroide inhalado
(por ejemplo Asmanex
Twisthaler, Flovent HFA,
QVAR) O (2) un estudio de
60 días de un agonista beta2
de acción prolongada (por
ejemplo Arcapta, Striverdi)
O un estudio de 60 días de
un agente anticolinérgico
inhalado por vía oral (por
ejemplo, Atrovent, Spiriva).
Amerge
Estudio con dosis mínima
de 50 mg de comprimidos
de sumatriptán.
Aricept 23mg
Estudio de 90 días de
Aricept de 10 mg diario.
calcipotriene
crema y ungüento
0.005%
Estudio de dos
corticosteroides tópicos.
calcitriol
3mcg/gm
Estudio de dos
corticosteroides tópicos.
xvii
Medicamento
para TERAPIA
ESCALONADA
Agentes de primera línea
Ditropan XL
Estudio de 30 días de
oxibutinin de liberación
inmediata. La terapia
escalonada se aplica
solamente a los miembros
menores de 65 años de edad.
Inhibidores
de DPP4
(Tradjenta,
Januvia, Janumet,
Janumet XR,
Jentadueto)
Estudio de al menos
90 días de 1500 mg/día
de metformina.
Dulera
(1) Un estudio de 30 días
de un corticoesteroide
inhalado (por ejemplo
Asmanex Twisthaler,
Flovent HFA, QVAR).
Elidel
Estudio de dos
corticosteroides tópicos
diferentes. La terapia
escalonada solo se aplica
a los miembros mayores
de 12 años.
fenofibrato
Surtido de una estatina o 90
días de Gemfibrozil dentro
de los 180 días previos.
Agonistas
GLP-1 (Victoza)
Estudio de por lo menos
90 días de 1500mg/día
de metformina.
Tableta Midodrina
Prueba de fludrocortisona.
Optivar
Se requiere primero un
estudio de 14 días de
ketotifen dentro de los
90 días anteriores.
Medicamento
para TERAPIA
ESCALONADA
Agentes de primera línea
Medicamento
para TERAPIA
ESCALONADA
Agentes de primera línea
oxymorphone ER
(no resistente
al aplastamiento)
Un estudio de 30 días de los
dos, parches de Fentanyl y
sulfato de morfina ER de por
lo menos 200mg al día.
tacrolimus 0.1%
Edad mínimo de 16. Estudio
de dos corticosteroides
tópicos diferentes.
tolterodine
Estudio de 30 días de
oxibutinina de liberación
inmediata. La terapia
escalonada solo se aplica
a los miembros menores
de 65 años.
trospium
Estudio de 30 días de
oxibutinin de liberación
inmediato. La terapia
escalonada solamente
se aplica a los miembros
menores de 65 años
de edad.
TZD’s
(ActosPlusMet,
ActoPlusMet XR,
Duetact)
Un estudio de por lo menos
90 días de 1500mg/día
de metformina.
Uloric
Primero se requiere un
estudio de 8 semanas
de hasta 600 mg
de alopurinol.
Vancocin
Un surtido de comprimidos
o cápsulas de metronidazol.
Ranexa
Estudio de un medicamento
de las siguientes categorías:
bloqueadores beta,
antagonistas del calcio,
nitratos de acción prolongada.
Renvela
Estudio de 8 semanas de
acetato de calcio.
Inhibidores
Estudio de por lo menos
SGLT-2
90 días de 1500mg/día
(Jardiance, Invokana, de metformina.
Invokamet, Synjardy)
Symbicort
tacrolimus 0.03%
(1) Un estudio de 30 días de
un corticoesteroide inhalado
(por ejemplo Asmanex
Twisthaler, Flovent HFA,
QVAR) O (2) un estudio de
60 días de un agonista beta2
de acción prolongada (por
ejemplo Arcapta, Striverdi)
O un estudio de 60 días de
un agente anticolinérgico
inhalado por vía oral (por
ejemplo, Incruse Ellipta,
Atrovent, Combivent,
Anoro Ellipta).
Estudio de dos
corticosteroides tópicos
diferentes. La terapia
escalonada solo se aplica a
los miembros de 12 años de
edad y mayores.
Xopenex Respules Estudio de 30 días de
Albuterol 0.83% o 0.5%
de Respules.
Zohydro ER
Estudio de 30 días de los
dos, parches de Fentanyl y
sulfato de morfina de por lo
menos 200mg al día.
xviii
Sugerencias Sobre la PDL
Los proveedores que deseen hacer sugerencias
sobre la PDL deben enviar la información por
correo o fax al Director de Servicios de Farmacia
de UnitedHealthcare Community Plan.
Attn: Director of Pharmacy Services
UnitedHealthcare Community Plan
1001 Brinton Road
Pittsburgh, PA 15221
Fax: 1-866-940-7328
Los proveedores deben proporcionar la
documentación adecuada, como los estudios
clínicos de la literatura médica, para que la solicitud
sea considerada para la inclusión en la PDL. Esta
literatura debe incluir información que documente la
necesidad clínica así como las ventajas terapéuticas
por sobre los productos actuales incluidos en la PDL.
Las sugerencias recibidas por UnitedHealthcare
Community Plan serán revisadas por el Comité de
Farmacia y Terapéutica en la reunión subsiguiente
del comité.
Editor
Se alienta a que realice sus comentarios y
sugerencias relacionados con la PDL de
UnitedHealthcare Community Plan. Su comentario
es muy importante para el éxito continuo de la PDL.
Todas las respuestas serán revisadas y tomadas en
cuenta. Envíe sus comentarios a:
UnitedHealthcare Community Plan
1001 Brinton Road
Pittsburgh, PA 15221
Fax: 1-866-940-7328
xix
Leyenda
#
Solo las concentraciones o formas
de dosificación de los productos
de marca indicados están
incluidas en la PDL.
OTC
de venta libre
delayed-rel
liberación ret liberación retardada
(también conocido como
recubrimiento entérico)
EC
recubrimiento entérico
ext-rel
liberación prolongada
(también conocida como
liberación sostenida)
PA
Autorización previa requerida
QL
Se aplican límites de cantidad
ST
Terapia escalonada, ver páginas
xviii - xx para obtener detalles
SP
Productos farmacéuticos
especiales, ver página xvii para
obtener detalles
Aviso
La información incluida en este documento es
privada. La información no puede ser copiada
total o parcialmente sin el permiso escrito de
UnitedHealthcare Community Plan. Todos los
derechos reservados.
Los nombres de los medicamentos incluidos
aquí son marcas comerciales registradas y no
registradas de compañías farmacéuticas de terceros
no relacionadas ni afiliadas a UnitedHealthcare
Community Plan. Estas marcas comerciales
registradas se incluyen aquí con fines informativos
solamente y no tienen la finalidad de denotar ni
sugerir afiliación entre Evercare y dichas compañías
farmacéuticas de terceros.
Si ve esta PDL por Internet, tenga en cuenta que la
misma se actualiza periódicamente y es posible que
se incluyan cambios antes de la fecha de vigencia
para permitir su notificación.
xx
10/16 © 2016 United Healthcare Services, Inc. All rights reserved.
Table of Contents
Antineoplastics & Immunosuppressants . . . 4
Antineoplastic Agents . . . . . . . . . . . . . . . . . . . . . . 4
Hormonal Antineoplastic Agents . . . . . . . . . . . . . 5
Immunomodulators . . . . . . . . . . . . . . . . . . . . . . . . 5
Immunosuppressants . . . . . . . . . . . . . . . . . . . . . . 6
Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Dermatology . . . . . . . . . . . . . . . . . . . . . . . . . 17
Acne Vulgaris . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Bacterial Infections . . . . . . . . . . . . . . . . . . . . . . . 18
Corticosteroids . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Fungal Infections . . . . . . . . . . . . . . . . . . . . . . . . . 20
Psoriasis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Rosacea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Scabies and Pediculosis . . . . . . . . . . . . . . . . . . 21
Viral Infections . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Blood Modifiers - Anticoagulants . . . . . . . . . 7
Anticoagulants . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Blood Cell Formation . . . . . . . . . . . . . . . . . . . . . . . 7
Platelet Inhibitors . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Ear, Nose & Throat . . . . . . . . . . . . . . . . . . . . 22
Ear . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
Nose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Throat and Mouth . . . . . . . . . . . . . . . . . . . . . . . . 24
Cardiovascular Agents . . . . . . . . . . . . . . . . . 8
Ace Inhibitors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Ace Inhibitor/Diuretic Combinations . . . . . . . . . . 8
Adrenolytics, Central . . . . . . . . . . . . . . . . . . . . . . . 8
Alpha Blockers . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Angiotensin II Receptor Blockers (Antagonists) . 8
Angiotensin II Receptor Blocker Combinations . 9
Antiarrhythmics and Cardiac Glycosides . . . . . . 9
Beta Blockers and Beta Blocker/Diuretic
Combinations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Calcium Channel Blockers . . . . . . . . . . . . . . . . 10
Diuretics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Lipid Lowering Agents . . . . . . . . . . . . . . . . . . . . 11
Nitrates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Potassium-Removing Agents . . . . . . . . . . . . . . 12
Pulmonary Arterial Hypertension . . . . . . . . . . 12
Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Endocrinology . . . . . . . . . . . . . . . . . . . . . . . 25
Adrenal Corticosteroids . . . . . . . . . . . . . . . . . . . 25
Androgens . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
Diabetes Mellitus . . . . . . . . . . . . . . . . . . . . . . . . . 25
Growth Stimulating Agents . . . . . . . . . . . . . . . . 27
Metabolic Modifiers . . . . . . . . . . . . . . . . . . . . . . 27
Osteoporosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
Thyroid Disease . . . . . . . . . . . . . . . . . . . . . . . . . 27
Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
Gastrointestinal . . . . . . . . . . . . . . . . . . . . . . 28
Diarrhea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
Emesis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
Gastroesophageal Reflux Disease (Gerd)/
Peptic Ulcers . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
Gastrointestinal Spasm . . . . . . . . . . . . . . . . . . . 29
Inflammatory Bowel Disease . . . . . . . . . . . . . . . 29
Laxatives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
Pancreatic Enzymes . . . . . . . . . . . . . . . . . . . . . . 30
Probiotic Supplementation . . . . . . . . . . . . . . . . 30
Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
Central Nervous System . . . . . . . . . . . . . . . 13
Alzheimer’s Disease . . . . . . . . . . . . . . . . . . . . . . 13
Analgesics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Migraine Acute Therapy . . . . . . . . . . . . . . . . . . . 15
Migraine Prophylactic Therapy . . . . . . . . . . . . . 15
Multiple Sclerosis . . . . . . . . . . . . . . . . . . . . . . . . 15
Myasthenia Gravis . . . . . . . . . . . . . . . . . . . . . . . 15
Parkinson’s Disease . . . . . . . . . . . . . . . . . . . . . . 15
Seizures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Home Infusion Drugs . . . . . . . . . . . . . . . . . . 31
Analgesics - NSAIDS . . . . . . . . . . . . . . . . . . . . . 31
Analgesics - OPIOD . . . . . . . . . . . . . . . . . . . . . . 31
Antibiotics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
Antihistamines . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
2
Diuretics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
Electrolyte Mixtures . . . . . . . . . . . . . . . . . . . . . . . 33
Genitourinary Irrigants . . . . . . . . . . . . . . . . . . . . 33
Minerals & Electrolytes . . . . . . . . . . . . . . . . . . . . 33
Nutrients . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
Spasticity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
Vitamins . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
Respiratory Drugs . . . . . . . . . . . . . . . . . . . . 49
Antitussives, Decongestants, Expectorants and
Combinations . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
Asthma/COPD . . . . . . . . . . . . . . . . . . . . . . . . . . 55
Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
Urological . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
Symptomatic Benign Prostatic Hypertrophy . . 56
Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
Infectious Diseases . . . . . . . . . . . . . . . . . . . 33
Antibacterials . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
Antifungals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
Antihelmintics . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
Antivirals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
Vitamins and Minerals . . . . . . . . . . . . . . . . . 57
Potassium . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60
Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . 61
Anaphylaxis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
Cystic Fibrosis . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
Detoxification Agents . . . . . . . . . . . . . . . . . . . . . 61
Hereditary Angioedema . . . . . . . . . . . . . . . . . . . 61
Hyperphosphatemia . . . . . . . . . . . . . . . . . . . . . . 61
Idiopathic Pulmonary Fibrosis (IPF) . . . . . . . . . 62
Immune Thrombocytopenic Purpura . . . . . . . . 62
Medical Devices . . . . . . . . . . . . . . . . . . . . . . . . . 62
Vaccine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62
Musculoskeletal . . . . . . . . . . . . . . . . . . . . . . 38
Arthritis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
Gout . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
Skeletal Muscle Relaxants . . . . . . . . . . . . . . . . . 40
OB-GYN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
Contraceptives . . . . . . . . . . . . . . . . . . . . . . . . . . 40
Endometriosis . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
Hormone Therapy/Menopause . . . . . . . . . . . . 41
Vaginal Infections . . . . . . . . . . . . . . . . . . . . . . . . 42
Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
OTC MEDICATIONS . . . . . . . . . . . . . . . . . . . 64
Acne . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64
Antifungals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64
Atopic Dermatitis . . . . . . . . . . . . . . . . . . . . . . . . . 64
Cough/Cold Allergy . . . . . . . . . . . . . . . . . . . . . . 64
Diabetes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
Earwax Removal Products . . . . . . . . . . . . . . . . 65
Family Planning . . . . . . . . . . . . . . . . . . . . . . . . . . 65
First Aid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
Gastrointestinal . . . . . . . . . . . . . . . . . . . . . . . . . . 66
Lice Products . . . . . . . . . . . . . . . . . . . . . . . . . . . 66
Motion Sickness . . . . . . . . . . . . . . . . . . . . . . . . . 66
Ophthalmics . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66
Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66
Smoking Cessation Products . . . . . . . . . . . . . . . 67
Vitamins/Minerals . . . . . . . . . . . . . . . . . . . . . . . . . 67
Warts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
Ophthalmic . . . . . . . . . . . . . . . . . . . . . . . . . . 43
Allergy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
Anti-Inflammatories . . . . . . . . . . . . . . . . . . . . . . . 43
Glaucoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
Infections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
Psychiatric . . . . . . . . . . . . . . . . . . . . . . . . . . 45
Alcohol Deterrents . . . . . . . . . . . . . . . . . . . . . . . 45
Anxiety . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
Attention Deficit Hyperactivity
Disorder (ADHD) . . . . . . . . . . . . . . . . . . . . . . . . 46
Bipolar Disorder . . . . . . . . . . . . . . . . . . . . . . . . . 47
Depression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
Insomnia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
Narcotic Antagonists . . . . . . . . . . . . . . . . . . . . . 48
Psychoses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
Smoking Cessation . . . . . . . . . . . . . . . . . . . . . . 49
Index of Covered Drugs . . . . . . . . . . . . . . . . 68
3
Generic Drug Name
Covered
Drug
Brand Drug Name
Requirements & Limits
Antineoplastics & Immunosuppressants
Antineoplastic Agents
Alkylating Agents
altretamine
busulfan
chlorambucil
cyclophosphamide
estramustine
phosphate sodium
lomustine
melphalan
temozolomide
HEXALEN
MYLERAN
LEUKERAN
CYTOXAN
GLEOSTINE
ALKERAN
TEMODAR
brand
brand
generic
capecitabine
mercaptopurine
mercaptopurine susp
thioguanine
trifluridine/tipiracil
XELODA
PURINETHOL
PURIXAN
TABLOID
LONSURF
generic
generic
brand
brand
brand
QL
PA, SP
panobinostat
vorinostat
FARYDAK
ZOLINZA
brand
PA, SP
afatinib
alectinib
axitinib
bosutinib
cabozantinib
ceritinib
cobimetinib
crizotinib
dabrafenib
dasatinib
erlotinib
GILOTRIF
ALECENSA
INLYTA
BOSULIF
COMETRIQ
ZYKADIA
COTELLIC
XALKORI
TAFINLAR
SPRYCEL
TARCEVA
AFINITOR
brand
brand
brand
brand
brand
brand
brand
brand
brand
brand
brand
PA, SP
PA, SP
PA, SP
PA, SP
PA, SP
PA, SP
PA, SP
PA, SP
PA, SP
PA, SP
PA, SP
brand
PA, SP
brand
brand
brand
generic
brand
brand
brand
PA, SP
PA, SP
PA, SP
PA, QL, SP
PA, SP
PA, SP
PA, SP
Antimetabolites
brand
brand
brand
generic
EMCYT
brand
Histone Deacetylase Inhibitors
Kinase Inhibitor
everolimus
gefitinib
ibrutinib
idelalisib
imatinib mesylate
lapatinib ditosylate
lenvatinib
nilotinib
AFINITOR DISPERZ
IRESSA
IMBRUVICA
ZYDELIG
GLEEVEC
TYKERB
LENVIMA
TASIGNA
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
ST = Step Therapy
SP = Specialty Pharmacy
4
PA, SP
SP
Covered
Drug
brand
brand
brand
brand
brand
brand
brand
brand
brand
brand
Generic Drug Name
Brand Drug Name
palbociclib
pazopanib
ponatinib
regorafenib
ruxolitinib
sorafenib
sunitinib
trametinib
vandetanib
vemurafenib
IBRANCE
VOTRIENT
ICLUSIG
STIVARGA
JAKAFI
NEXAVAR
SUTENT
MEKINIST
CAPRELSA
ZELBORAF
ixazomib
NINLARO
brand
PA, SP
abiraterone
ZYTIGA
brand
PA, QL, SP
bicalutamide
flutamide
CASODEX
EULEXIN
generic
generic
QL
QL
tamoxifen
toremifene
NOLVADEX
FARESTON
generic
brand
QL
QL
anastrozole
exemestane
letrozole
ARIMIDEX
AROMASIN
FEMARA
generic
generic
generic
QL
QL
QL
leuprolide
LUPRON
LUPRON DEPOT
generic
PA, QL, SP
leuprolide
LUPRON DEPOT 6-MONTH
brand
PA, QL, SP
Proteasome Inhibitors
Hormonal Antineoplastic Agents
Androgen Biosynthesis Inhibitors
Antiandrogens
Antiestrogens
Aromatase Inhibitors
Gonadotropin Releasing Hormone Analog
Progestin
Requirements & Limits
PA, SP
PA, SP
PA, SP
PA, SP
PA, SP
PA, SP
PA, SP
PA, SP
PA, SP
PA, SP
LUPRON DEPOT-PED
megestrol acetate
MEGACE
interferon alfa-2b
peginterferon alfa-2b
INTRON A
SYLATRON
brand
brand
PA, SP
PA, SP
lenalidomide
pomalidomide
thalidomide
REVLIMID
POMALYST
THALOMID
brand
brand
brand
PA, SP
PA, SP
PA, QL, SP
Immunomodulators
Interferons
Miscellaneous
generic
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
ST = Step Therapy
SP = Specialty Pharmacy
5
Generic Drug Name
Immunosuppressants
Antimetabolites
azathioprine
mycophenolate mofetil
mycophenolate sodium
Calcineurin Inhibitors
cyclosporine
cyclosporine
cyclosporine
cyclosporine, modified
tacrolimus
Rapamycin Derivative
Brand Drug Name
Covered
Drug
IMURAN
CELLCEPT
MYFORTIC
generic
generic
generic
GENGRAF
generic
NEORAL SOLUTION
SANDIMMUNE
SANDIMMUME
SOLUTION
NEORAL
brand
oral soln 100 mg/ml
generic
GENGRAF
HECORIA
generic
PROGRAF
RAPAMUNE
RAPAMUNE
generic
brand
everolimus
ZORTRESS
brand
alitretinoin 1% gel
bexarotene caps
bexarotene topical gel
cysteamine bitartrate
etoposide
hydroxyurea
hydroxyurea
mesna
mitotane
octreotide
olaparib
panobinostat
pasireotide
procarbazine
sonidegib
topotecan
tretinoin
vismodegib
PANRETIN
TARGRETIN
TARGRETIN
CYSTAGON
VEPESID
DROXIA
HYDREA
MESNEX
LYSODREN
SANDOSTATIN
LYNPARZA
FARYDAK
SIGNIFOR
MATULANE
ODOMZO
HYCAMTIN
VESANOID
ERIVEDGE
Miscellaneous
modified oral soln 100 mg/ml
generic
sirolimus
sirolimus
Miscellaneous
Requirements & Limits
brand
generic
brand
brand
generic
brand
generic
brand
brand
generic
brand
brand
brand
brand
brand
brand
generic
brand
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
ST = Step Therapy
SP = Specialty Pharmacy
6
tabs
soln
PA
PA, SP
PA, SP
SP
tabs
SP
PA, SP
PA, SP
PA, SP
SP
PA, SP
PA, SP
SP, caps
PA, SP
Generic Drug Name
Brand Drug Name
Covered
Drug
Requirements & Limits
Blood Modifiers - Anticoagulants
Anticoagulants
apixaban
dabigatran etexilate
mesylate
edoxaban
ELIQUIS
brand
QL
PRADAXA
brand
capsule, PA
SAVAYSA
brand
enoxaparin
LOVENOX
generic
heparin
rivaroxaban
warfarin
HEPARIN
XARELTO
COUMADIN
generic
brand
generic
QL
PA, QL
PA only applies for quantities
greater than 14 days
darbepoetin alfa
ARANESP
EPOGEN
Blood Cell Formation
epoetin alfa
filgrastim
oprelvekin
pegfilgrastim
plerixafor
sargramostim
TBO-filgrastim
Platelet Inhibitors
anagrelide
aspirin
cilostazol
clopidogrel
dipyridamole
ticagrelor
Miscellaneous
aminocaproic acid
pentoxifylline
extended-release
PROCRIT
NEUPOGEN
ZARXIO
NEUMEGA
NEULASTA
MOZOBIL
LEUKINE
GRANIX
AGRYLIN
BAYER
QL
QL
brand
PA, SP
brand
PA, SP
brand
PA, SP
brand
brand
brand
brand
brand
PA, SP
PA, SP
PA, SP
PA, SP
PA, SP
generic
generic
ECOTRIN
PLETAL
PLAVIX
PERSANTINE
BRILINTA
generic
generic
generic
brand
AMICAR
brand
TRENTAL
generic
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
ST = Step Therapy
SP = Specialty Pharmacy
7
OTC
QL
PA
tabs & syrup only
Brand Drug Name
Covered
Drug
benazepril
captopril
captopril
enalapril
LOTENSIN
CAPOTEN
CAPTOPRIL POWDER
VASOTEC
generic
generic
generic
generic
enalapril oral soln
EPANED
fosinopril
lisinopril
moexipril
perindopril
quinapril
ramipril
trandolapril
MONOPRIL
ZESTRIL
UNIVASC
ACEON
ACCUPRIL
ALTACE
MAVIK
generic
generic
generic
generic
generic
generic
generic
LOTENSIN HCT
generic
CAPOZIDE
generic
VASERETIC
generic
MONOPRIL-HCT
generic
QL
ZESTORETIC
generic
QL
UNIRETIC
generic
ACCURETIC
generic
QL
clonidine
clonidine transdermal
guanfacine
CATAPRES
CATAPRES-TTS
TENEX
generic
generic
generic
PA
doxazosin
prazosin
terazosin
CARDURA
MINIPRESS
HYTRIN
generic
generic
generic
irbesartan
losartan
valsartan
AVAPRO
COZAAR
DIOVAN
generic
generic
generic
Generic Drug Name
Cardiovascular Agents
Ace Inhibitors
brand
Ace Inhibitor/Diuretic Combinations
benazepril/
hydrochlorothiazide
captopril/
hydrochlorothiazide
enalapril/
hydrochlorothiazide
fosinopril/
hydrochlorothiazide
lisinopril/
hydrochlorothiazide
moexipril/
hydrochlorothiazide
quinapril/
hydrochlorothiazide
Adrenolytics, Central
Alpha Blockers
Angiotensin II Receptor Blockers (Antagonists)
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
Requirements & Limits
(bulk) powder
Members ≥ 8 years of age will
require prior authorization.
QL
QL
ST = Step Therapy
SP = Specialty Pharmacy
8
QL
QL
Generic Drug Name
Brand Drug Name
Angiotensin II Receptor Blocker Combinations
Covered
Drug
Requirements & Limits
QL
PA
losartan/HCTZ
sacubitril/valsartan
valsartan/
hydrochlorothiazide
HYZAAR
ENTRESTO
generic
brand
DIOVAN HCT
generic
amiodarone
amiodarone tabs
digoxin
disopyramide
disopyramide
extended-release
dofetilide
dronedarone
flecainide
mexiletine
propafenone
quinidine gluconate extended-release
quinidine sulfate
quinidine sulfate
extended-release
PACERONE
CORDARONE
LANOXIN
NORPACE
generic
generic
generic
generic
NORPACE CR
brand
TIKOSYN
MULTAQ
TAMBOCOR
MEXITIL
RYTHMOL
QUINIDINE GLUCONATE
EXT-REL
QUINIDINE SULFATE
QUINIDINE SULFATE
EXT-REL
generic
brand
generic
generic
generic
acebutalol
atenolol
atenolol/chlorthalidone
bisoprolol
bisoprolol/
hydrochlorothiazide
carvedilol
labetalol
metoprolol
metoprolol succinate
nadolol
pindolol
propranolol
propranolol
propranolol
extended-release
propranolol/HCTZ
sotalol
sotalol (AFIB/AFL)
timolol maleate
SECTRAL
TENORMIN
TENORETIC
ZEBETA
generic
generic
generic
generic
ZIAC
generic
COREG
TRANDATE
LOPRESSOR
TOPROL XL
CORGARD
PINDOLOL
HEMANGEOL
INDERAL
generic
generic
generic
generic
generic
generic
brand
generic
INDERAL LA
generic
INDERIDE
BETAPACE
BETAPACE AF
generic
generic
generic
generic
Antiarrhythmics and Cardiac Glycosides
200 mg and 400 mg
PA
IR only
generic
generic
generic
Beta Blockers and Beta Blocker/Diuretic Combinations
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
ST = Step Therapy
SP = Specialty Pharmacy
9
QL
IR only
tablets
Generic Drug Name
Brand Drug Name
Calcium Channel Blockers
Dihydropyridines
Covered
Drug
Requirements & Limits
amlodipine
felodipine
extended-release
isradipine
nicardipine
nifedipine
nifedipine
extended-release
nimodipine
nimodipine oral soln
nisoldipine
NORVASC
generic
QL
PLENDIL
generic
QL
DYNACIRC
CARDENE
PROCARDIA
ADALAT CC
generic
generic
generic
diltiazem
CARDIZEM
CARDIZEM LA
Nondihydropyridines
PROCARDIA XL
NIMOTOP
NYMALIZE
SULAR
generic
QL
generic
brand
generic
QL
sustained-release
generic
generic
sustained-release coated
beads, QL
sustained-release, QL
generic
QL
generic
QL
CARDIZEM SR
generic
QL
CALAN
generic
verapamil
VERALAN PM
generic
verapamil
extended-release
sustained-release caps,
(100 mg, 200 mg and
300 mg only)
CALAN SR
generic
QL
MIDAMOR
generic
MODURETIC
generic
BUMEX
CHLORTHALIDONE
DIURIL
DIURIL ORAL
SUSPENSION
LASIX
HYDROCHLOROTHIAZIDE
MICROZIDE
generic
generic
generic
diltiazem
diltiazem
diltiazem
extended-release
diltiazem
extended-release
diltiazem
sustained-release
verapamil
Diuretics
amiloride
amiloride/
hydrochlorothiazide
bumetanide
chlorthalidone
chlorothiazide
chlorothiazide
furosemide
hydrochlorothiazide
hydrochlorothiazide
generic
MATXIM LA
CARDIZEM SR
CARDIZEM CD
DILACOR XR
TIAZAC
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
brand
QL
generic
generic
generic
soln, tabs
12.5 mg caps
ST = Step Therapy
SP = Specialty Pharmacy
10
Generic Drug Name
Brand Drug Name
indapamide
metolazone
spironolactone
spironolactone
spironolactone/
hydrochlorothiazide
torsemide
triamterene/
hydrochlorothiazide
LOZOL
ZAROXOLYN
ALDACTONE
SPIRONOLACTONE
Covered
Drug
generic
generic
generic
generic
ALDACTAZIDE
generic
DEMADEX
DYAZIDE
generic
Lipid Lowering Agents
Bile Acid Resin
cholestyramine
coliestipol
Fibrates
QUESTRAN
generic
QUESTRAN-LIGHT
COLESTID
generic
LOFIBRA
generic
gemfibrozil
TRIGLIDE
LOPID
generic
atorvastatin
lovastatin
pravastatin
simvastatin
LIPITOR
MEVACOR
PRAVACHOL
ZOCOR
generic
generic
generic
generic
niacin
niacin extended-release
NIACOR
NIASPAN
generic
generic
alirocumab
ezetimibe
PRALUENT
ZETIA
isosorbide dinitrate
ISORDIL
DILATRATE-SR
isosorbide dinitrate
extended-release
ISOCHRON
HMG-CoA Reductase Inhibitors and Combinations
Miscellaneous
Nitrates
Oral
isosorbide mononitrate
Only the bulk products are
covered (cans). Individual
packets are not covered.
(not packets)
ANTARA
TRICOR
Niacins
powder
generic
MAXZIDE
LIPOFEN
fenofibrate
Requirements & Limits
brand
brand
generic
generic
ISOSORBIDE
DINITRATE ER
ISMO
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
caps, tabs and micronized
caps, ST
generic
ST = Step Therapy
SP = Specialty Pharmacy
11
QL
QL
QL
PA, QL, SP
PA
Generic Drug Name
isosorbide mononitrate
extended-release
nitroglycerin
extended-release
Sublingual
isosorbide dinitrate
nitroglycerin
nitroglycerin
Transdermal
nitroglycerin
nitroglycerin
Brand Drug Name
Covered
Drug
IMDUR
generic
Requirements & Limits
generic
ISORDIL S.L.
NITROLINGUAL
NITROSTAT
generic
generic
brand
NITREK
NITRO-DUR
NITRO-BID
Potassium-Removing Agents
generic
transdermal, QL
generic
oint
generic
susp (susp only)
sodium polysterene
sulfonate
KAYEXALATE
ambrisentan
bosentan
macitentan
riociguat
sildenafil
tadalafil (PAH)
LETAIRIS
TRACLEER
OPSUMIT
ADEMPAS
REVATIO
ADCIRCA
brand
brand
brand
brand
generic
brand
PA, SP
PA, SP
PA, SP
PA, SP
PA, SP
PA, SP
eplerenone
INSPRA
generic
epoprostenol
FLOLAN
brand
guanabenz
hydralazine
WYTENSIN
APRESOLINE
PA
SP, Coverable through
Medical Benefit
iloprost
VENTAVIS
methyldopa
methyldopa/HCTZ
midodrine
minoxidil
ranolazine
ALDOMET
ALDORIL
PROAMATINE
LONITEN
RANEXA
generic
generic
generic
generic
brand
treprostinil
REMODULIN
brand
treprostinil
TYVASO
brand
Pulmonary Arterial Hypertension
Miscellaneous
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
generic
generic
brand
SP, Coverable through
Medical Benefit
ST
ST
SP, Coverable through
Medical Benefit
SP, Coverable through
Medical Benefit
ST = Step Therapy
SP = Specialty Pharmacy
12
Generic Drug Name
Covered
Drug
Brand Drug Name
Requirements & Limits
Central Nervous System
Alzheimer’s Disease
donepezil
donepezil
galantamine
ARICEPT
ARICEPT
RAZADYNE
generic
generic
generic
memantine
NAMENDA
generic
memantine SR
rivastigmine
NAMENDA XR
EXELON
brand
generic
5 mg and 10 mg, QL
23 mg, ST
QL
QL, Members <18 years
of age will require prior
authorization
PA, QL
QL
generic
generic
QL
QL
generic
QL
generic
QL
TYLENOL
generic
OTC
EXCEDRIN MIGRAINE
generic
OTC
ULTRAM
generic
QL
VOLTAREN
generic
VOLTAREN XR
LODINE
NALFON
NALFON
ANSAID
generic
generic
brand
generic
generic
ibuprofen
ADVIL
generic
ibuprofen
MOTRIN
generic
indomethacin
ketoprofen
ketoprofen SR
ketorolac tromethamine
meloxicam
nabumetone
naproxen
INDOCIN
ORUDIS
ORUDIS
TORADOL
MOBIC
RELAFEN
NAPROSYN
generic
generic
generic
generic
generic
generic
generic
Analgesics
Barbiturate Non-Narcotic Analgesics
butalbital/acetaminophen PHRENILIN
butalbital/acetaminophen SEDAPAP
ESGIC
butalbital/acetaminophen/
FIORICET
caffeine
ZEBUTAL
butalbital/aspirin/caffeine FIORINAL
Non-Narcotic Analgesics
acetaminophen
aspirin/acetaminophen/
caffeine
tramadol
NSAIDS
diclofenac sodium
delayed-release
diclofenac sodium SR
etodolac
fenoprofen
fenoprofen
flurbiprofen
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
ST = Step Therapy
SP = Specialty Pharmacy
13
QL
IR Only
400 mg
600 mg
tabs, chew tabs
and susp, OTC
tabs, chew tabs
and susp
IR only
cap, 200 mg
QL
QL
Generic Drug Name
naproxen delayed release
naproxen sodium
oxaprozin
piroxicam
sulindac
Covered
Drug
Brand Drug Name
ENTERIC COATEDNAPROSYN
ANAPROX
DAYPRO
FELDENE
CLINORIL
generic
generic
generic
generic
generic
Opioids - Narcotic Analgesics
butalbital/apap/caff/cod
butalbital/asa/caff/cod
butorphanol
codeine/acetaminophen
codeine sulfate
fentanyl transdermal
Requirements & Limits
FIORICET W/CODEINE
FIORINAL W/CODEINE
STADOL
TYLENOL W/CODEINE
generic
generic
generic
generic
generic
generic
QL, 50-325-40-30 mg
QL
nasal spray, QL
QL
QL
QL
generic
QL
VICOPROFEN
ZOHYDRO ER
DILAUDID
DEMEROL
DOLOPHINE
MSIR
RMS
brand
generic
generic
generic
generic
generic
QL, ST
QL
QL
QL
QL
QL
MS CONTIN
generic
QL
OXYFAST
ROXICODONE
OXYCONTIN
OXYCONTIN
MAGNACET
generic
generic
brand
generic
soln, QL
QL
PA, QL, 15 mg, 30 mg, 60 mg
PA, QL
generic
QL
brand
QL
generic
generic
QL
QL, ST, non-crush resistant
DURAGESIC
LORCET
LORTAB
hydrocodone/
acetaminophen
LORTAB ELIXIR
NORCO
VICODIN
VICODIN ES
hydrocodone ER
hydromorphone
meperidine
methadone
morphine
morphine
morphine
extended-release
oxycodone
oxycodone
oxycodone ER
oxycodone ER
oxycodone/
acetaminophen
oxycodone/
acetaminophen CR
oxycodone/aspirin
oxymorphone ER
PERCOCET
XARTEMIS XR
PERCODAN
OXYMORPHONE ER
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
ST = Step Therapy
SP = Specialty Pharmacy
14
Generic Drug Name
Migraine Acute Therapy
Ergotamine Derivatives
Covered
Drug
Brand Drug Name
Requirements & Limits
dihydroergotamine
dihydroergotamine
ergotamine/caffeine
ergotamine tartrate/
caffeine
D.H.E. 45
MIGRANAL
CAFERGOT
MIGERGOT
SUPPOSITORIES
generic
generic
generic
inj, QL
brand
QL
naratriptan
rizatriptan
sumatriptan
AMERGE
MAXALT/MAXALT MLT
IMITREX
generic
generic
generic
ST
QL
QL
amitriptyline
divalproex sodium
cap sprinkle
divalproex sodium
delayed-release
propranolol
verapamil
ELAVIL
generic
DEPAKOTE SPRINKLE
generic
DEPAKOTE
generic
Minimum age 2
INDERAL
CALAN
generic
generic
IR only
dimethyl fumarate
fingolimod
glatiramer acetate
TECFIDERA
GILENYA
COPAXONE
COPAXONE
brand
brand
brand
PA, QL, SP
PA, QL, SP
PA, QL, SP (40mg)
generic
PA, QL, SP (20mg)
brand
brand
QL, SP
SP
brand
PA, SP
brand
PA, SP
tabs
syrup
Selective Serotonin Agonists
Migraine Prophylactic Therapy
Multiple Sclerosis
glatiramer acetate
interferon beta-1a
interferon beta-1a
interferon beta-1b
teriflunomide
Myasthenia Gravis
GLATOPA
AVONEX/AVONEX PEN
REBIF
BETASERON
EXTAVIA
AUBAGIO
pyridostigmine
pyridostigmine
pyridostigmine
extended-release
MESTINON
MESTINON
generic
brand
MESTINON TIMESPAN
generic
amantadine
benztropine
bromocriptine
carbidopa/levodopa
carbidopa/levodopa
extended-release
SYMMETREL
COGENTIN
PARLODEL
SINEMET
generic
generic
generic
generic
SINEMET CR
generic
Parkinson’s Disease
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
ST = Step Therapy
SP = Specialty Pharmacy
15
except tabs
Covered
Drug
generic
generic
Generic Drug Name
Brand Drug Name
entacapone
pramipexole
pramipexole
dihydrochloride SR
ropinirole
ropinirole hydrochloride SR
selegiline
tolcapone
trihexyphenidyl
COMTAN
MIRAPEX
REQUIP
REQUIP XL
ELDEPRYL
TASMAR
ARTANE
generic
generic
generic
generic
generic
carbamazepine
carbamazepine
extended-release
TEGRETOL
CARBATROL
generic
Seizures
carbamazepine SR
clobazam
clobazam suspension
clonazepam
clonazepam
diazepam
diazepam
divalproex sodium
cap sprinkle
divalproex sodium
delayed-release
ethosuximide
exogabine
felbamate
gabapentin
lacosamide
lacosamide solution
lamotrigine
lamotrigine chew
dispersable tab
lamotrigine dispersible tab
lamotrigine ODT
lamotrigine SR
lamotrigine SR ODT
lamotrigine starter kit
lamotrigine titration kit
levetiracetam
levetiracetam SR
methsuximide
MIRAPEX ER
brand
24hr tab
24hr tab
tabs
generic
TEGRETOL-XR
EPITOL
brand
EQUATRO
ONFI
ONFI SUSPENSION
KLONOPIN
KLONOPIN
DIASTAT ACUDIAL
DIASTAT PEDIATRIC
brand
brand
generic
generic
brand
brand
DEPAKOTE SPRINKLE
generic
DEPAKOTE
generic
ZARONTIN
POTIGA
FELBATOL
NEURONTIN
VIMPAT
VIMPAT
LAMICTAL
generic
brand
generic
generic
brand
brand
generic
LAMICTAL CD CHEW TAB
generic
LAMICTAL ODT KIT
LAMICTAL ODT
LAMICTAL XR
LAMICTAL XR ODT KIT
LAMICTAL STARTER KIT
LAMICTAL XR KIT
KEPPRA
KEPPRA XR
CELONTIN
brand
brand
generic
brand
brand
brand
generic
generic
brand
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
Requirements & Limits
PA
tabs
ODT tabs
rectal gel, QL
Minimum age 2
Age Limits Apply
caps and tabs only
Age Limits Apply
PA
QL
ST = Step Therapy
SP = Specialty Pharmacy
16
PA
PA
tab
PA
PA
QL
Covered
Drug
generic
generic
generic
Generic Drug Name
Brand Drug Name
oxcarbazepine
phenobarbital
phenytoin
phenytoin sodium
extended
pregabalin
pregabalin
primidone
rufinamide
rufinamide suspension
TRILEPTAL
PHENOBARBITAL
DILANTIN INFATABS
DILANTIN
tiagabine
GABITRIL
generic
tiagabine
GABITRIL
brand
topiramate
topiramate sprinkle caps
valproic acid
vigabatrin oral solution
zonisamide
TOPAMAX
TOPAMAX SPRINKLE
DEPAKENE
SABRIL SOLUTION
ZONEGRAN
tetrabenazine
XENAZINE
brand
PA, SP
isotretinoin
ACCUTANE
generic
Max Age of 25, PA
azelaic acid
benzoyl peroxide
benzoyl peroxide
benzoyl peroxide
benzoyl peroxide
benzoyl peroxide
benzoyl peroxide
benzoyl peroxide
benzoyl peroxide
benzoyl peroxide bar 10%
benzoyl peroxide creamy
wash 8% & benzoyl
peroxide bar 5% k
FINACEA
BENZAC AC
BENZEFOAM
BREVOXYL
DELOS
NEOBENZ MICR LIQ
OC8
PANOXYL CREAM OTC
TRIAZ CLOTHS
PANOXYL BAR OTC
brand
generic
generic
generic
generic
generic
brand
generic
generic
brand
gel
BPO CREAMY KIT
generic
Miscellaneous
PHENYTEK
LYRICA
LYRICA SOLUTION
MYSOLINE
BANZEL
BANZEL SUSPENSION
Requirements & Limits
QL
generic
brand
brand
generic
brand
brand
PA
oral solution, PA
tablets only, QL
PA
Age Limits Apply,
2mg & 4mg
Age Limits Apply,
12mg & 16mg
QL
QL
generic
generic
generic
brand
generic
PA, SP
QL
Dermatology
Acne Vulgaris
Oral
Topical
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
foam 5.3% & 9.8%
gel 4%, 8%
cleanser 3.5%, OTC
liquid 7%
gel 7%, OTC
cream 2.5%, OTC
cloth 3%, 6%, 9%
OTC
ST = Step Therapy
SP = Specialty Pharmacy
17
Generic Drug Name
Covered
Drug
Requirements & Limits
brand
2.75%, 5.25%
BREVOXYL-4 OTC
generic
OTC
CLEOCIN T
CLEOCIN T
CLEOCIN T
ERYGEL
T-STAT
CLEAN & CLEAR GEL
generic
generic
generic
generic
generic
gel
lotion
soln
gel 2%
soln
generic
gel 2%, OTC
brand
gel 3, 6%
generic
pad 0.5%, 1&, 2%, OTC
generic
liquid 2%, OTC
generic
generic
lotion 6%
lotion
generic
lotion 10%
Brand Drug Name
BENZIQ LS
benzoyl peroxide gel
benzoyl peroxide wash 4%
& benzoyl peroxide bar
5% kit
clindamycin
clindamycin
clindamycin
erythromycin
erythromycin
BENZIQ
BREVOXYL
salicylic acid
NEUTROGENA RAPID
CLEAR GEL
salicylic acid
EXUVIANCE
KERALYT
STRI-DEX
salicylic acid
salicylic acid
salicylic acid
sulfacetamide/sulfur
sulfacetamide sodium
AVEENO CLEAR PADS OTC
NEUTROGENA OIL FREE
ACNE WASH
SALEX
SULFACET-R
KLARON LOTION
sulfacetamide/sulfur
SEBIZON
PLEXION
ATRALIN
tretinoin
AVITA
Bacterial Infections
bacitracin
bacitracin-polymyxinneomycin HC
gentamicin
mupirocin
neomycin/polymyxin B/
bacitracin
silver sulfadiazine
generic
generic
RETIN-A
BACITRACIN
generic
OTC
brand
oint 1%
GENTAK
BACTROBAN
generic
generic
ointment, 22 gram tube only
NEOSPORIN
generic
OTC
SILVADENE
generic
CORTISPORIN OINTMENT
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
ST = Step Therapy
SP = Specialty Pharmacy
18
Generic Drug Name
Corticosteroids
Low Potency
alclometasone
fluocinolone acetonide
fluocinolone acetonide
fluocinolone acetonide
hydrocortisone
hydrocortisone
hydrocortisone
hydrocortisone
hydrocortisone/aloe
Medium Potency
betamethasone val
fluocinolone acetonide
flurandrenolide
fluticasone propionate
fluticasone propionate
hydrocortisone butyrate
hydrocortisone valerate
mometasone furoate
prednicarbate
triamcinolone acetonide
triamcinolone acetonide
triamcinolone acetonide
High Potency
betamethasone
augmented dip
betamethasone
augmented dip
betamethasone
dipropionate
diflorasone diacetate
diflorasone diacetate
fluocinonide
fluocinonide emulsified
base
triamcinolone acetonide
Very High Potency
betamethasone dip
augmented
Covered
Drug
Requirements & Limits
ACLOVATE
CAPEX SHAMOO
DERMA-SMOOTHE
OIL/FS
SYNALAR
CORTAID SOLUTION OTC
CORTIZONE
HYTONE
HYTONE
CORTIZONE-10 INTENSIVE
HEALING
generic
brand
0.05% crm/oint
shampoo 0.01%
generic
oil 0.01%
generic
generic
generic
generic
generic
soln/crm 0.01%
soln 1% OTC
crm, oint, lot OTC
lotion 1% & 2.5%
crm 0.5%, 1%, & 2.5%
generic
crm 0.5% & 1%, OTC
BETA-VAL
SYNALAR
CORDRAN
CUTIVATE
CUTIVATE LOTION
LOCOID
WESTCORT
ELOCON
DERMATOP
KENALOG
KENALOG
TRIANEX
generic
generic
brand
generic
generic
generic
generic
generic
generic
generic
generic
brand
crm/oint/lotion 0.1%
crm, oint 0.025%
tape
crm 0.05%, oint 0.005%
lotion 0.05%
crm/lotion/oint 0.1%
crm/oint 0.2%
crm/oint/soln 0.1%
crm 0.1%
crm/lot/oint 0.025%
crm/oint/lotion 0.1%
oint 0.05%
DIPROLENE
generic
lotion 0.05%
DIPROLENE AF
generic
crm 0.05%
DIPROSONE
generic
crm/lotion/oint 0.05%
PSORCON CREAM
PSORCON OINTMENT
LIDEX
generic
generic
generic
cream 0.05%
oint 0.05%
crm/oint/gel/soln 0.05%
LIDEX E
generic
crm 0.05%
KENALOG
generic
crm 0.5%
DIPROLENE
generic
gel 0.05%
Brand Drug Name
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
ST = Step Therapy
SP = Specialty Pharmacy
19
Generic Drug Name
betamethasone dip
augmented
clobetasol propionate
halobetasol
Fungal Infections
ciclopirox
clotrimazole
clotrimazole
clotrimazole crystals
clotrimazole with
betamethasone
ketoconazole
ketoconazole foam
ketoconazole gel
ketoconazole gel 2% &
hydrocortisone gel
1% kit
ketoconazole gel 2% &
pyrithione zinc
shampoo 1% kit
ketoconazole shampoo
miconazole
miconazole
miconazole
miconazole nitrate kit
miconazole nitrate lotion
Brand Drug Name
Covered
Drug
Requirements & Limits
DIPROLENE
generic
oint 0.05%
TEMOVATE
ULTRAVATE
generic
generic
crm/gel/oint/soln 0.05%
cream
PENLAC SOLUTION 8%
LOTRIMIN AF
MYCELEX
CLOTRIMAZOLE
generic
generic
generic
brand
LOTRISONE
generic
NIZORAL
EXTINA
XOLEGEL
generic
generic
brand
XOLEGEL KIT
brand
XOLEGEL DUO KIT
brand
OTC
2%
2%
brand
generic
generic
generic
brand
brand
1% OTC
2% OTC
OTC
brand
2% OTC
nystatin
terbinafine
terbinafine gel
terbinafine HCL
tolnaftate
NIZORAL A-D OTC
DESENEX
MICATIN
MONISTAT-DERM
FUNGOID TINCTURE KIT
ZEASORB-AF
AZOLEN TINCTURE
SOLUTION OTC
MYCOSTATIN
LAMISIL AT
LAMISIL GEL
LAMISIL SOLUTION
TINACTIN
generic
generic
brand
brand
generic
OTC
1%
soln 1%
OTC
acitretin
calcipotriene
calcipotriene
calcitriol
methoxsalen
salicylic acid
SORIATANE
DOVONEX
DOVONEX
VECTICAL
OXSORALEN-ULTRA
SCALPICIN
generic
generic
generic
generic
generic
generic
oral caps, PA
crm/oint, ST
soln
ST
brimonidine
MIRVASO
brand
PA
miconazole nitrate soln
Psoriasis
Rosacea
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
ST = Step Therapy
SP = Specialty Pharmacy
20
2%
2% OTC
liquid 3%
Generic Drug Name
Covered
Drug
Brand Drug Name
Requirements & Limits
METROCREAM
metronidazole
METROGEL
generic
METROLOTION
Scabies and Pediculosis
crotamiton
ivermectin
malathion
permethrin
permethrin
pyrethrins/piperonyl but.
spinosad
Viral Infections
podofilox
salicylic acid 17%/
collodion
EURAX
SKLICE
OVIDE
ELIMITE
NIX CREME RINSE
RID SHAMPOO/
BUTOXIDE SHAMPOO
NATROBA
brand
brand
generic
generic
generic
hydrocortisone
hydrocortisone acetate
hydrocortisone acetate
hydrocortisone acetate
w/pramoxine
imiquimod 5% cream
ketoconazole
5%, QL
1%, OTC
generic
4% OTC
brand
susp 0.9%, PA
CONDYLOX SOL
generic
sol
DUOFILM
generic
OTC
DRYSOL OTC
brand
generic
soln/cream, OTC
soln 12%, OTC
HYPERCARE 20%
generic
LAC-HYDRIN
LACTINOL
REGRANEX
generic
generic
brand
brand
brand
generic
generic
brand
brand
generic
Miscellaneous
aluminum acetate
aluminum chloride
aluminum chloride
hexahydrate
ammonium lactate
ammonium lactate
becaplermin gel
calamine
collagenase oint
fluorouracil
fluorouracil
fluorouracil
hexachlorophene
hydrocortisone
lotion 0.5%, PA
SANTYL
CARAC
EFUDEX
FLUOROPLEX
PHISOHEX
PROCTO-PAK CREAM
PROCTOSOL HC
CREAM 2.5%
PROCTOZONE
CREAM-HC 2.5%
ANUSOL HC 2.5%
CORTIFOAM AEROSOL
TUCKS OINTMENT OTC
crm 12%, lotion 5% & 12%
lotion 10%
PA
lotion/ointment, OTC
QL
0.5% cream
1% cream
rectal cream 1%
generic
brand
generic
rectal foam 90 mg
rectal ointment
PROCTOFOAM HC FOAM
generic
rectal foam 1-1%
ALDARA
NIZORAL SHAMPOO
generic
generic
PA
shampoo 2%
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
ST = Step Therapy
SP = Specialty Pharmacy
21
Covered
Drug
generic
generic
generic
generic
brand
generic
generic
brand
Generic Drug Name
Brand Drug Name
lidocaine
lidocaine
lidocaine
lidocaine
lidocaine patch
lidocaine/prilocaine
lidocaine-prilocaine
nitroglycerin
LIDAMANTEL
LMX-4
XYLOCAINE
XYLOCAINE
LIDODERM PATCH
EMLA
EMLA
RECTIV
pimecrolimus
ELIDEL
brand
salicylic acid
brand
generic
shampoo 2%, 3% OTC
salicylic acid
salicylic acid
salicylic acid
salicylic acid
selenium sulfide
CALICYLIC
P & S SHAMPOO
SELSUN BLUE
DHS SAL SHAMPOO OTC
SALAC OTC
SALACYN
SALEX
SALVAX
SELSUN
3% cream
4% cream (15 gm tubes), QL
jelly 2%
oint 5%
5%, PA
2.5% cream
kit 2.5-2.5%
0.4% rectal ointment, PA
cream QL, ST, Step therapy is
not required for members ages
2-11; not covered for members
less than 2 years of age
cream 10%
brand
generic
generic
generic
generic
tacrolimus
PROTOPIC 0.03%
generic
tacrolimus
PROTOPIC 0.1%
generic
urea 40%
UREA 40% LOTION
generic
foam 2%, OTC
6% cream, lotion
shampoo 6%
foam 6%
lotion 2.5%
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)
lotion
acetic acid
acetic acid/
aluminum acetate
acetic acid/
hydrocortisone
VOSOL OTIC
generic
otic
DOMEBORO OTIC
generic
VOSOL HC OTIC
generic
antipyrine-benzocaine
AURALGAN
generic
benzocaine/antipyrine
carbamide peroxide
ciprofloxacin/
dexamethasone
BENZOTIC
DEBROX
generic
generic
CIPRODEX
brand
salicylic acid
Requirements & Limits
Ear, Nose & Throat
Ear
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
otic soln 55-14 mg/mL
(5.5-1.4%)
ST = Step Therapy
SP = Specialty Pharmacy
22
6.5%, OTC
PA
Generic Drug Name
neomycin/polymyxin B/
hydrocortisone
ofloxacin
Brand Drug Name
Covered
Drug
Requirements & Limits
CORTISPORIN OTIC
generic
otic
FLOXIN OTIC
generic
Nose
Antihistamines - First Generation, Sedating
J-TAN PD
RESPA-BR
BROVEX CT
CHLOR-TRIMETON
ALLERGY
CHLOR-TRIMETON
chlorpheniramine maleate
SYRUP
chlorpheniramine maleate CHLORPHENIRAMINE
chlorpheniramine maleate CHLORPHENIRAMINE
chlorpheniramine tannate CHLORPHENIRAMINE
chlorpheniramine tannate CHLORPHENIRAMINE
clemastine
CLEMASTINE
cyproheptadine
CYPROHEPTADINE
dexchlorpheniramine malePOLARAMINE
ate
diphenhydramine
diphenhydramine
BENADRYL
diphenhydramine
BENADRYL
diphenhydramine
TRIAMINIC
hydroxyzine HCL
ATARAX
hydroxyzine pamoate
VISTARIL
brompheniramine maleate
brompheniramine maleate
brompheniramine tannate
chlorpheniramine
extended-release
Antihistamines - Second Generation, Nonsedating
cetirizine
cetirizine chew tab
fexofenadine
levocetirizine
loratadine
ZYRTEC
ZYRTEC CHEWABLE TABLET
ALLEGRA
XYZAL
ALAVERT
loratadine
loratadine
CLARITIN
CLARITIN CHEW
CLARITIN RDT
azelastine
ASTELIN
brand
brand
generic
drops 1 mg/mL
tab SR 12hr 11 mg
chew tab 12 mg
generic
12 mg, OTC
generic
2 mg/5 ml, OTC
generic
generic
generic
generic
generic
generic
drops 2 mg/mL
tabs 4 mg
susp 2 mg/mL
tabs
generic
syrup 2 mg/5ml
generic
generic
generic
brand
generic
generic
generic
OTC
generic
OTC
generic
generic
tabs
tabs
generic
OTC
brand
brand
chew tab 5 mg
ODT 5 mg
generic
spray
Antihistamines - Others Antihistamine/Decongestant Combinations
Antihistamine/Decongestant Combinations - First Generation
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
ST = Step Therapy
SP = Specialty Pharmacy
23
OTC
tab disp 12.5 mg
oral strips
Generic Drug Name
brompheniramine/
pseudoephedrine
chlorpheniramine/
phenylephrine/
pyrilamine
chlorpheniramine/
pseudoephedrine
Brand Drug Name
LODRANE D
Covered
Drug
Requirements & Limits
brand
cap 4-60 mg
TRIOTANN
generic
ACTIFED
generic
OTC
Antihistamine/Decongestant Combinations - Second Generation
cetirizine hydrochloride/
pseudoephedrine
ZYRTEC-D
hydrochloride 12 hours
extended-release
fexofenadine/
ALLEGRA-D
pseudoephedrine
ALAVERT-D
loratadine/
ALAVERT ALRG
pseudoephedrine
TAB/SINUS
extended-release
ALLERGY/CONG
generic
5 mg-120 mg tablet
generic
SR tabs
generic
OTC
FLONASE
NASACORT AQ
NASACORT ALLERGY
24 HOUR
generic
generic
PA
brand
OTC
cromolyn sodium
ipratropium bromide
saline nasal spray 0.65%
NASALCROM
ATROVENT NS
OCEAN NASAL SPRAY
generic
generic
generic
OTC
oxymetazoline
AFRIN
NEO-SYNEPHRINE
generic
OTC
phenylephrine
DIMEATAPP DRO
DECONGES
generic
OTC
APHTHASOL
PERIOGARD
PERIDEX
XYLOCAINE
SALAGEN
KENALOG IN ORABASE
brand
generic
generic
generic
generic
generic
oral paste 5%
Nasal Steroids
fluticasone
triamcinolone acetonide
triamcinolone nasal spray
Miscellaneous Nasal
Miscellaneous Nasal Decongestants
Throat and Mouth
amlexanox
chlorhexidine
chlorhexidine gluconate
lidocaine viscous
pilocarpine
triamcinolone
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
ST = Step Therapy
SP = Specialty Pharmacy
24
OTC
paste
Generic Drug Name
Covered
Drug
Brand Drug Name
Requirements & Limits
Endocrinology
Adrenal Corticosteroids
cortisone acetate
dexamethasone
fludrocortisone
hydrocortisone
hydrocortisone inj
methylprednisolone
methylprednisolone
methylprednisolone inj
prednisolone
prednisolone
prednisolone sodium
phosphate
prednisone
prednisone
prednisone
triamcinolone inj
Androgens
generic
generic
generic
generic
generic
generic
brand
generic
DECADRON
FLORINEF
CORTEF
SOLU-CORTEF
MEDROL
MEDROL
SOLU-MEDROL
PRELONE
ORAPRED
4mg, 8mg, 16mg, 32mg
2mg
generic
syrup
generic
PEDIAPRED
DELTASONE
PREDNISONE
RAYOS
KENALOG-40
generic
generic
generic
generic
fluoxymesterone
testosterone
testosterone
testosterone cypionate
ANDROXY
ANDRODERM
ANDROGEL 1.62%
DEPO-TESTOSTERONE
generic
brand
brand
generic
testosterone enanthate
DELATESTRYL
generic
testosterone gel
testosterone gel
topical tube, packet,
and pump bottle
testotesterone
TESTIM
conc 5 mg/mL
tabs delayed-release
PA
patch 2 mg and 4 mg, PA
gel, PA
brand
Vials only. Disposable
syringes not covered.
PA
generic
PA
ANDROGEL 1%
brand
gel (not pump), PA
glucagon, human
recombinant
GLUCAGON
brand
QL
insulin detemir
insulin detemir
insulin glargine
insulin glargine
insulin isophane
insulin lisopro pro/lispro
insulin lisopro prot/lispro
LEVEMIR
LEVEMIR FLEXPEN
LANTUS
LANTUS SOLOSTAR
HUMULIN N
HUMALOG MIX 50/50
HUMALOG MIX 75/25
brand
brand
brand
brand
brand
brand
brand
PA, QL, vials
PA, QL
QL, vials
PA, QL
OTC, QL, vials
QL, vials
QL, vials
Diabetes Mellitus
Glucose Elevating Agents
Insulins
TESTOSTERONE 1% TOPICAL GEL
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
ST = Step Therapy
SP = Specialty Pharmacy
25
Generic Drug Name
Brand Drug Name
insulin lispro prot
50%/lispro 50%
insulin lispro prot
75%/lispro 25%
insulin isophane/regular
insulin lispro
insulin lispro
insulin regular
HUMALOG MIX 50/50
KWIKPEN
HUMALOG MIX 72/25
KWIKPEN
HUMULIN 70/30
HUMALOG
HUMALOG KWIKPEN
HUMULIN R
HUMULIN R 500 U/ML
KWIKPEN
insulin regular (human)
Covered
Drug
Requirements & Limits
brand
PA, QL
brand
PA, QL
brand
brand
brand
brand
OTC, QL, vials
QL, vials
100 U/ml only, PA, QL
OTC, QL, vials
brand
PA
Monitoring - Strips and Kits/Diabetic Supplies
ONE TOUCH SYSTEMS
(ULTRA 2, ULTRAMINI, VERIO, VERIO FLEX,
VERIO IQ, VERIO SYNC)
brand
ONE TOUCH TEST STRIPS (ULTRA, VERIO)
brand
Oral Agents
acarbose
canagliflozin
canagliflozin/metformin
chlorpropamide
empagliflozin
empagliflozin/metformin
glimepiride
glipizide
glipizide extended-release
glipizide/metformin
glyburide
glyburide, micronized
linagliptin
linagliptin/metformin
metformin
metformin ER
metformin/glyburide
nateglinide
pioglitazone
pioglitazone/glimepiride
pioglitazone/metformin
pioglitazone/metformin ER
repaglinide
sitagliptan
sitagliptan/metformin
PRECOSE
INVOKANA
INVOKAMET
DIABINESE
JARDIANCE
SYNJARDY
AMARYL
GLUCOTROL
GLUCOTROL XL
METAGLIP
MICRONASE
GLYNASE
TRADJENTA
JENTADUETO
GLUCOPHAGE
GLUCOPHAGE ER
GLUCOVANCE
STARLIX
ACTOS
DUETACT
ACTOPLUSMET
ACTOPLUS MET XR
PRANDIN
JANUVIA
JANUMET
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
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
generic
brand
brand
generic
brand
brand
generic
generic
generic
generic
generic
generic
brand
brand
generic
generic
generic
generic
generic
generic
generic
brand
generic
brand
brand
ST = Step Therapy
SP = Specialty Pharmacy
26
QL
QL, ST
QL, ST
QL
QL, ST
QL, ST
QL
QL
QL
QL
QL
QL
QL, ST
QL, ST
QL
QL
QL
QL
QL
QL, ST
QL, ST
QL, ST
QL
QL, ST
QL, ST
Covered
Drug
brand
generic
generic
Generic Drug Name
Brand Drug Name
sitagliptan/metformin ER
tolazamide
tolbutamide
JANUMET XR
TOLINASE
TOLBUTAMIDE
albiglutide
exenatide
liraglutide
pramlintide
TANZEUM
BYETTA
VICTOZA
SYMLIN
brand
brand
brand
brand
ST
PA
ST
PA
mecasermin
INCRELEX
GENOTROPIN
brand
PA, SP
somatropin
NORDITROPIN
brand
PA, SP
brand
brand
brand
brand
PA, SP
PA, SP
PA, SP
PA, SP
generic
PA, SP
brand
PA, SP
QL
nasal spray, QL
nasal spray, QL
Miscellaneous Antidiabetic Agents
Growth Stimulating Agents
Metabolic Modifiers
Requirements & Limits
QL, ST
QL
QL
NUTROPIN AQ NUSPIN
carglumic acid
glycerol phenylbutyrate
idursulfase
imiglucerase
sodium phenylbutyrate oral
powder
sodium phenylbutyrate tab
CARBAGLU
RAVICTI
ELAPRASE
CEREZYME
BUPHENYL ORAL
POWDER
BUPHENYL
alendronate
calcitonin-salmon
calcitonin-salmon
etidronate
raloxifene
teriparatide inj
FOSAMAX
MIACALCIN
FORTICAL
DIDRONEL
EVISTA
FORTEO
generic
generic
brand
generic
generic
brand
levothyroxine
levothyroxine
liothyronine
liotrix
methimazole
propylthiouracil
thyroid tab
uridine
LEVOXYL
SYNTHROID
CYTOMEL
THYROLAR
TAPAZOLE
PROPYLTHIOURACIL
ARMOUR THYROID
VISTOGARD
generic
generic
generic
brand
generic
generic
brand
brand
QL
SP
agalsidase
alglucerase
alglucosidase
asfotase alfa
FABRAZYME
CEREDASE
LUMIZYME
STRENSIQ
brand
brand
brand
brand
PA, SP
PA, SP
PA, SP
PA, SP
Osteoporosis
Thyroid Disease
Miscellaneous
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
ST = Step Therapy
SP = Specialty Pharmacy
27
PA, SP
Generic Drug Name
betaine powder for oral
solution
bromocriptine
cabergoline
cholic acid
desmopressin
laronidase
methylergonovine
mifepristone
pegvisomant
sapropterin
Brand Drug Name
CYSTADANE
Covered
Drug
Requirements & Limits
brand
SP
PARLODEL
DOSTINEX
CHOLBAM
DDAVP
ALDURAZYME
METHERGINE
KORLYM
SOMAVERT
KUVAN
KUVAN POWDER FOR SOLUTION
ELELYSO
VPRIV
generic
generic
brand
generic
brand
generic
brand
brand
brand
diphenoxylate/atropine
loperamide
loperamide
loperamide
loperamide
LOMOTIL
IMODIUM A-D
IMODIUM A-D CHW
IMODIUM A-D LIQ
LOPERAMIDE
aprepitant
EMEND
dolasetron
dronabinol
granisetron
granisetron
meclizine
metoclopramide
ANZEMET
MARINOL
KYTRIL
KYTRIL
ANTIVERT
REGLAN
ZOFRAN
sapropterin powder
taliglucerase
velaglucerase alfa
PA, SP
QL
PA, SP
PA, SP
PA, SP
PA, SP
brand
PA, SP
brand
brand
PA, SP
PA, SP
generic
brand
brand
generic
generic
OTC
chew 2 mg
liq 1 mg/7.5ml
Gastrointestinal
Diarrhea
Emesis
ondansetron
prochlorperazine
promethazine
trimethobenzamide
brand
brand
generic
generic
generic
generic
generic
QL applies to 40 mg, 80 mg
and 80-125 mg
PA
PA
PA SP
oral soln PA
generic
QL
generic
generic
generic
300 mg caps
brand
OTC
MAALOX
generic
OTC
MYLANTA
generic
OTC
ZOFRAN ODT
COMPAZINE
PHENERGAN
TIGAN
Gastroesophageal Reflux Disease (Gerd)/Peptic Ulcers
alginic acid/sodium
bicarbonate
alumina/magnesia
alumina/magnesia/
simethicone
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
ST = Step Therapy
SP = Specialty Pharmacy
28
Covered
Drug
generic
brand
Generic Drug Name
Brand Drug Name
cimetidine
esomeprazole
TAGAMET
NEXIUM 24 HR OTC
esomeprazole granules
NEXIUM DELAYEDRELEASE PACKET
Requirements & Limits
famotidine
lansoprazole
lansoprazole
delayed-release
lansoprazole susp
omeprazole
delayed-release
omeprazole
delayed-release
pantoprazole
pantoprazole
delayed-release
ranitidine
ranitidine effer
ranitidine syrup
sucralfate
PEPCID AZ CHW
PREVACID
brand
generic
PA
Members ≥ 2 years
of age will require prior
authorization.
OTC Pepcid AC 10 mg
and 20 mg also covered/
encouraged with written
prescription.
chew
PA
PREVACID SOLUTAB
generic
orally disintegrating tabs, QL
sulcralfate
famotidine
Gastrointestinal Spasm
dicyclomine
glycopyrrolate
hyoscyamine sulfate
hyoscyamine sulfate
extended-release
PEPCID
generic
PEPCID AC
FIRST-LANSOPRAZOLE
PRILOSEC
PRILOSEC POWDER
PROTONIX
brand
generic
Capsules only, QL
brand
susp packet
generic
PROTONIX PAK
brand
susp packet
ZANTAC
ZANTAC
ZANTAC
CARAFATE
generic
brand
generic
generic
150 mg tabs
tab 25 mg
CARAFATE SUSPENSION
generic
BENTYL
ROBINUL
generic
suspension, Members 10
years of age up to 65 years
of age will require prior
authorization.
generic
ROBINUL FORTE
LEVSIN
CYSTOSPAZ
generic
LEVBID
generic
LEVSINEX
Inflammatory Bowel Disease
balsalazide
budesonide
hydrocortisone
mesalamine
brand
COLAZAL
ENTOCORT EC
COLOCORT
ROWASA
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
generic
generic
generic
generic
ST = Step Therapy
SP = Specialty Pharmacy
29
PA
enema
enema only
Generic Drug Name
Covered
Drug
Brand Drug Name
Requirements & Limits
APRISO
mesalamine
extended-release
mesalamine extendedrelease
mesalamine supp
olsalazine sodium
sulfasalazine
sulfasalazine
delayed-release
DELZICOL
brand
LIALDA
PENTASA
ASACOL HD
generic
CANASA
DIPENTUM
AZULFIDINE
brand
brand
generic
QL
AZULFIDINE EN-TABS
generic
QL
generic
OTC
COLACE
GLYCERIN SUPPOSITORY
ENULOSE
KRISTALOSE
COLYTE
generic
generic
generic
generic
generic
brand
generic
OTC
OTC
OTC
suppository, OTC
NULYTELY
generic
TRILYTE
generic
MIRALAX
SENOKOT
generic
generic
Laxatives
casanthranol-docusate
sodium
docusate calcium plus
docusate potasssium
docusate sodium
glycerin
lactulose
lactulose
peg 3350/electrolytes
peg 3350/sodium
bicarbonate/sodium
chloride/potassium
chloride
peg 3350/sodium
bicarbonate/sodium
chloride
polyethylene glycol 3350
sennosides
Pancreatic Enzymes
oral packet
8.6 mg tab, OTC
CREON
pancrelipase
CREON 3000 UNIT
brand
pancrelipase
pancrealipase DR
pancrealipase DR
sacrosidase
ZENPEP
PANCREAZE
ZENPEP DR
CREON DR
SUCRAID
brand
brand
brand
brand
QL
25000-85000-136000 unit
36000-114000-180000 unit
soln 8500 unit/ml, PA, SP
acidophilus
acidophilus
ACIDOPHILUS XTRA
ACIDOPHILUS
brand
brand
OTC
caps and tabs, OTC
Probiotic Supplementation
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
ST = Step Therapy
SP = Specialty Pharmacy
30
Generic Drug Name
acidophilus/bifidus
acidophilus/citrus pectin
acidophilus/pectin
lactobacillus
probiotic product
Miscellaneous
Brand Drug Name
ACIDOPHILUS/BIFIDUS
WAFER
ACIDOPHILUS/CITRUS
PECTIN
ACIDOPHILUS/PECTIN
FLORANEX
PROBIOTIC FORMULA
Covered
Drug
Requirements & Limits
generic
OTC
generic
tabs, OTC
generic
generic
brand
caps, OTC
chewable tabs, OTC
caps, OTC
atropine sulfate
linaclotide
misoprostol
naloxegol
teduglutide
SAL-TROPINE
LINZESS
CYTOTEC
MOVANTIK
GATTEX
ACTIGALL
brand
brand
generic
brand
brand
ursodiol
URSO
generic
PA
PA
PA, SP
URSO FORTE
Home Infusion Drugs
Analgesics - NSAIDS
ketorolac
tromethamine im inj
ketorolac
tromethamine inj
KETOROLAC INJ
brand
KETOROLAC INJ
brand
fentanyl citrate inj
FENTANYL CIT INJ
brand
morphine sulfate inj
ASTRAMOR INJ
brand
morphine sulfate inj
DURAMORPH INJ
brand
morphine sulfate inj
MORPHINE SUL INJ
brand
morphine sulfate inj
MORPHINE SUL INJ
brand
morphine sulfate iv soln
MORPHINE SUL INJ
brand
amikacin sulfate inj
AMIKACIN INJ
brand
cefazolin sodium for inj
ANCEF INJ
brand
Analgesics - OPIOD
Antibiotics
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
30 mg/ml, Limited to 14 days
supply every 30 days.
30 mg/ml, Limited to 14 days
supply every 30 days.
0.05 mg/ml, Limited to 14
days supply every 30 days.
4 mg/ml, Limited to 14 days
supply every 30 days.
10 mg/ml, Limited to 14 days
supply every 30 days.
2 mg/ml, Limited to 14 days
supply every 30 days.
15 mg/ml, Limited to 14 days
supply every 30 days.
50 mg/ml, Limited to 14 days
supply every 30 days.
250 mg/ml, Limited to 14
days supply every 30 days.
1 gm, Limited to 14 days
supply every 30 days.
ST = Step Therapy
SP = Specialty Pharmacy
31
Generic Drug Name
Brand Drug Name
Covered
Drug
ceftriaxone sodium for inj
CEFTRIAXONE INJ
brand
ceftriaxone sodium for inj
CEFTRIAXONE INJ
brand
ceftriaxone sodium for inj
CEFTRIAXONE INJ
brand
CEFTRIAX/DEX INJ
brand
CEFTRIAXONE/ INJ DEX
brand
ceftriaxone sodium for iv
soln 1 gm and
dextrose 3.74%
ceftriaxone sodium in
dextrose inj
ciprofloxacin 0.2% in d5w CIPRO I.V. SOL
ciprofloxacin iv soln 1%
brand
CIPRO I.V. INJ
brand
clindamycin phosphate inj CLEOCIN PHOS INJ
brand
imipenem-cilastatin
intravenous for soln
brand
IMIPENEM/CIL INJ
levofloxacin in d5w iv soln
levofloxacin iv soln
brand
LEVAQUIN INJ
brand
piperacillin sodtazobactam sod in dex ZOSYN SOL
iv sol
piperacillin sodiumtazobactam sodium for PIPER/TAZOBA INJ
inj
piperacillin sodiumtazobactam sodium for PIPER/TAZOBA INJ
inj
brand
Limited to 14 days supply
every 30 days.
20 mg/ml, Limited to 14 days
supply every 30 days.
Limited to 14 days supply
every 30 days.
Limited to 14 days supply
every 30 days.
150 mg/ml, Limited to 14
days supply every 30 days.
500 mg, Limited to 14 days
supply every 30 days.
5 mg/ml, Limited to 14 days
supply every 30 days.
25 mg/ml, Limited to 14 days
supply every 30 days.
3-0.375 gm/50 ml,
Limited to 14 days supply
every 30 days.
3-0.375 gm, Limited to 14
days supply every 30 days.
brand
4-0.5 gm, Limited to 14 days
supply every 30 days.
VANCOCIN HCL INJ
brand
vancomycin hcl for inj
VANCOCIN HCL INJ
brand
vancomycin hcl in
dextrose inj
VANCOCIN/DEX INJ
brand
BENA-D-50 INJ
brand
Antihistamines
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
1 gm, Limited to 14 days
supply every 30 days.
2 gm, Limited to 14 days
supply every 30 days.
500 mg, Limited to 14 days
supply every 30 days.
brand
vancomycin hcl for inj
diphenhydramine hcl inj
Requirements & Limits
500 mg, Limited to 14 days
supply every 30 days.
1000 mg, Limited to 14 days
supply every 30 days.
500 mg/100 ml,
Limited to 14 days supply
every 30 days.
50 mg/ml, Limited to 14 days
supply every 30 days.
ST = Step Therapy
SP = Specialty Pharmacy
32
Generic Drug Name
Brand Drug Name
Covered
Drug
Requirements & Limits
promethazine hcl inj
ANERGAN 25 INJ
brand
25 mg/ml, Limited to 14 days
supply every 30 days.
DIAQUA-2 INJ
brand
10 mg/ml, Limited to 14 days
supply every 30 days.
D5W/NACL INJ
brand
Limited to 14 days supply
every 30 days.
brand
Limited to 14 days supply
every 30 days.
Diuretics
furosemide inj
Electrolyte Mixtures
dextrose 5% w/ sodium
chloride 0.45%
Genitourinary Irrigants
sodium chloride irrigation
soln 0.9%
Minerals & Electrolytes
sodium chloride inj
BD POSIFLUSH INJ
brand
sodium chloride inj
SOD CHLORIDE INJ
brand
sodium chloride iv soln
SOD CHLORIDE INJ
brand
dextrose inj
DEXTROSE INJ
brand
dextrose inj
DEXTROSE INJ
brand
Nutrients
Spasticity
diazepam
VALIUM
AQUA-MEPHYTO INJ
5%, Limited to 14 days supply
every 30 days.
50%, Limited to 14 days
supply every 30 days.
generic
inj 5 mg/ml, QL, Limited to
14 days supply every
30 days.
brand
10 mg/ml, Limited to 14 days
supply every 30 days.
Vitamins
phytonadione inj
0.9%, Limited to 14 days
supply every 30 days.
0.45%, Limited to 14 days
supply every 30 days.
0.9%, Limited to 14 days
supply every 30 days.
Infectious Diseases
Antibacterials
Antituberculosis Agents
aminosalicyclic acid
cycloserine
ethambutol
ethionamide
isoniazid
pyrazinamide
rifabutin
rifampin
rifapentine
PASER
SEROMYCIN
MYAMBUTOL
TRECATOR
ISONIAZID
PYRAZINAMIDE
MYCOBUTIN
RIFADIN
PRIFTIN
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
brand
generic
generic
brand
generic
generic
generic
generic
brand
ST = Step Therapy
SP = Specialty Pharmacy
33
Generic Drug Name
Covered
Drug
Brand Drug Name
Cephalosporins - First Generation
Requirements & Limits
cefadroxil
cephalexin
DURICEF
KEFLEX
generic
generic
tabs are not covered
cefaclor
cefprozil
cefuroxime axetil
cefuroxime axetil
CECLOR
CEFZIL
CEFTIN
CEFTIN
generic
generic
generic
brand
tabs
suspension
cefdinir
cefixime
cefixime
cefpodoxime
OMNICEF
SUPRAX
SUPRAX
VANTIN
generic
generic
generic
generic
ciprofloxacin
levofloxacin
ofloxacin
CIPRO
LEVAQUIN
FLOXIN
generic
generic
generic
azithromycin
clarithromycin
clarithromycin ER
erythromycin
delayed-release
erythromycin
delayed-release
erythromycin
ethylsuccinate
erythromycin stearate
erythromycin/sulfisoxazole
ZITHROMAX
BIAXIN
BIAXIN XL
generic
generic
generic
Cephalosporins - Second Generation
Cephalosporins - Third Generation
Fluoroquinolones
Macrolides
Penicillins
amoxicillin
amoxicillin
amoxicillin
amoxicillin/clavulanate
amoxicillin/clavulanate
ampicillin
dicloxacillin
penicillin VK
Sulfonamides
sulfadiazine
sulfamethoxazole/
trimethoprim, DS
ERY-TAB
tablets only
tabs
QL
brand
ERYC
generic
E.E.S.
generic
ERYTHROCIN
PEDIAZOLE
generic
generic
AMOXICILLIN CAPSULES
AND CHEWABLES
AMOXIL
AMOXIL SUSP
AUGMENTIN
AUGMENTIN ES-600
PRINCIPEN
DICLOXACILLIN
VEETIDS
generic
generic
generic
generic
brand
generic
generic
generic
Except 500 mg and 875 mg
film-coated tabs.
tabs, 500 mg & 875 mg
suspension
generic
BACTRIM
generic
BACTRIM DS
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
QL
susp
ST = Step Therapy
SP = Specialty Pharmacy
34
Brand Drug Name
Covered
Drug
Requirements & Limits
DECLOMYCIN
generic
PA
VIBRAMYCIN
generic
generic
minocycline
minocycline SR
tetracycline
VIBRAMYCIN
DOXYCYCLINE
MONOHYDRATE
MINOCIN
MINOCIN
SUMYCIN
generic
brand
generic
caps and tabs
24hr
vancomycin HCl
VANCOCIN HCL
generic
cap, ST
clotrimazole
fluconazole
flucytosine
griseofulvin microsize
griseofulvin ultramicrosize
itraconazole
itraconazole
itraconazole
ketoconazole
miconazole buccal
nystatin
posaconazole susp
terbinafine
terbinafine
voriconazole
MYCELEX
DIFLUCAN
ANCOBAN
GRIFULVIN V
GRIS-PEG
ONMEL
SPORANOX
SPORANOX
NIZORAL
MICONAZOLE
MYCOSTATIN
NOXAFIL
LAMISIL
LAMISIL
VFEND
generic
generic
generic
generic
generic
brand
generic
brand
generic
brand
generic
brand
brand
generic
generic
troches
QL
PA
albendazole
ivermectin
praziquantel
ALBENZA
STROMECTOL
BILTRICIDE
brand
brand
brand
cidofovir
VISTIDE
brand
foscarnet sodium
FOSCAVIR
generic
ganciclovir
valganciclovir
valganciclovir
CYTOVENE
VALCYTE
VALCYTE
generic
brand
generic
enfuvirtide
FUZEON
Generic Drug Name
Tetracyclines
demeclocycline
doxycycline
delayed-release
doxycycline hyclate
doxycycline monohydrate
Miscellaneous
Antifungals
Antihelmintics
generic
Antivirals
Cytomegalovirus Treatment
Entry/Fusion Inhibitors
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
tab 200 mg, PA
caps, PA, QL
soln, PA, QL
tab 50 mg (mouth-throat)
PA
oral granules
QL
tabs, PA
Coverable through Medical
Benefit
Coverable through Medical
Benefit
brand
ST = Step Therapy
SP = Specialty Pharmacy
35
soln PA
PA
Brand Drug Name
Covered
Drug
Requirements & Limits
adefovir
boceprevir
daclatasvir
elbasvir/grazoprevir
entecavir
interferon alfa-2b
lamivudine
lamivudine
ledipasvir/sofosbuvir
ombitasvir/paritaprevir/
ritonavir
ombitasvir/paritaprevir/ritonavir/dasabuvir
peginterferon alfa-2a
peginterferon alfa-2a
peginterferon alfa-2b
HEPSERA
VICTRELIS
DAKLINZA
ZEPATIER
BARACLUDE
INTRON A
EPIVIR HBV
EPIVIR HBV
HARVONI
generic
brand
brand
brand
brand
brand
brand
generic
brand
QL, SP
PA, SP
PA, QL, SP
PA
QL, SP
PA, SP
SP, solution
QL, SP, tablets
PA, QL, SP
TECHNIVIE
brand
PA
VIEKIRA PAK
brand
PA
PEGASYS
PEGASYS PROCLICK
PEGINTRON
brand
brand
brand
ribavirin
REBETOL/COPEGUS
generic
sofosbuvir
telaprevir
telbivudine
SOVALDI
INCIVEK
TYZEKA
PA, QL, SP
PA, QL, SP
PA, QL, SP
200 mg Ribavirin caps and
tabs only, PA, SP
PA, QL, SP
PA, QL, SP
PA, QL, SP
acyclovir
acyclovir
acyclovir
acyclovir buccal
docosanol
famciclovir
penciclovir
valacyclovir
ZOVIRAX
ZOVIRAX CREAM
ZOVIRAX OINTMENT
SITAVIG
ABREVA OTC
FAMVIR
DENAVIR
VALTREX
generic
brand
generic
brand
brand
generic
brand
generic
amantadine
oseltamivir
rimantadine
zanamivir
SYMMETREL
TAMIFLU
FLUMADINE
RELENZA
generic
brand
generic
brand
delavirdine
efavirenz
nevirapine
nevirapine ER
rilpivirine
RESCRIPTOR
SUSTIVA
VIRAMUNE
VIRAMUNE XR
EDURANT
brand
brand
generic
brand
brand
Generic Drug Name
Hepatitis Treatment
Herpes Treatment
Influenza Treatment
brand
brand
brand
Non-Nucleoside Reverse Transcriptase Inhibitors
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
ST = Step Therapy
SP = Specialty Pharmacy
36
cream 5%
oint 5%
cream 10%, OTC
PA
cream 1%
except tabs
QL
QL
Generic Drug Name
Covered
Drug
Brand Drug Name
Requirements & Limits
Nucleoside Analogues Nucleoside Reverse - Transcriptase Inhibitors/and Combinations
abacavir
abacavir/lamivudine
abacavir/lamivudine/
zidovudine
didanosine
didanosine
delayed-release
emtricitabine
emtricitabine/rilpivirine/
tenofovir
lamivudine
lamivudine/zidovudine
stavudine
zidovudine
ZIAGEN
EPZICOM
generic
brand
TRIZIVIR
generic
VIDEX
brand
VIDEX EC
generic
EMTRIVA
brand
COMPLERA
brand
EPIVIR
COMBIVIR
ZERIT
RETROVIR
generic
generic
generic
generic
Nucleoside/Nucleotide Reverse - Transcriptase Inhibitor Combination
cobicistat/elvitegravir/ emSTRIBILD
tricitabine/tenofovir
efavirenz/emtricitabine/
ATRIPLA
tenofovir
emtricitabine/tenofovir
TRUVADA
brand
PA
brand
brand
Nucleotide Analogues Nucleotide Reverse-Transcriptase Inhibitor
tenofovir
VIREAD
brand
atazanavir
REYATAZ
REYATAZ POWDER
PACKET
PREZISTA
LEXIVA
CRIXIVAN
KALETRA
VIRACEPT
NORVIR
INVIRASE
APTIVUS
brand
Protease Inhibitors
atazanavir
darunavir
fosamprenavir
indinavir
lopinavir/ritonavir
nelfinavir
ritonavir
saquinavir mesylate
tipranavir
Miscellaneous
brand
brand
brand
brand
brand
brand
brand
brand
brand
elvitegravir/cobicistat/
emtricitabine/tenofovir GENVOYA
alafenamide fumarate
brand
Miscellaneous
abacavir/dolutegravir/
lamivudine
artemether-lumefantrine
TRIUMEQ
brand
COARTEM
brand
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
ST = Step Therapy
SP = Specialty Pharmacy
37
PA
Covered
Drug
generic
generic
brand
generic
generic
generic
brand
brand
brand
brand
brand
brand
generic
brand
generic
brand
generic
generic
brand
brand
Generic Drug Name
Brand Drug Name
atovaquone
atovaquone/proguanil
bedaquiline
chloroquine phosphate
clindamycin
clindamycin
cobicistat
dapsone
darunavir/cobicistat
dolutegravir
etravirine
etravirine
hydroxychloroquine
interferon gamma-1b
linezolid
maraviroc
mefloquine
metronidazole
neomycin sulfate
neomycin sulfate soln
MEPRON
MALARONE
SIRTURO
ARALEN
CLEOCIN
CLEOCIN
TYBOST
DAPSONE
PREZCOBIX
TIVICAY
INTELENCE
INTELENCE
PLAQUENIL
ACTIMMUNE
ZYVOX
SELZENTRY
LARIAM
FLAGYL
nitazoxanide suspension
ALINIA SUSPENSION
brand
nitazoxanide tablet
nitrofurantoin
extended-release
nitrofurantoin
macrocrystals
ALINIA
brand
nitrofurantoin susp
palivizumab
paromomycin
povidone-iodine
primaquine
pyrimethamine
quinine sulfate
raltegravir
raltegravir
trimethoprim
NEO-FRADIN
MACROBID
Requirements & Limits
PA
cap, 75 mg
tabs
tab 25 mg
QL
PA, SP
PA
tabs only
Members ≥ 8 years of age will
require prior authorization.
PA
generic
MACRODANTIN
MACRODANTIN 25 MG
FURADANTIN SUSP
25 MG/5 ML
SYNAGIS
HUMATIN
DARAPRIM
QUALAQUIN
ISENTRESS
ISENTRESS CHEWABLE
TRIMETHOPRIM
generic
generic
brand
generic
generic
generic
brand
generic
brand
brand
generic
Members ≥ 8 years of age will
require prior authorization.
PA, SP
OTC
PA, SP
324 mg caps only
chewable tablet
tabs only
Musculoskeletal
Arthritis
Disease Modifying Anti-Rheumatic Drugs
adalimumab
HUMIRA
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
brand
ST = Step Therapy
SP = Specialty Pharmacy
38
PA, QL, SP
Generic Drug Name
Brand Drug Name
auranofin
azathioprine
etanercept
hydroxychloroquine
leflunomide
methotrexate
penicillamine
penicillamine
sulfasalazine
sulfasalazine
delayed-release
RIDAURA
IMURAN
ENBREL
PLAQUENIL
ARAVA
METHOTREXATE
DEPEN TITRATABLE
CUPRIMINE
AZULFIDINE
Covered
Drug
brand
generic
brand
generic
generic
generic
brand
brand
generic
AZULFIDINE EN-TABS
generic
QL
acetaminophen
TYLENOL
BAYER
generic
OTC
generic
OTC
brand
tablet DR
ASCRIPTIN
brand
tab
BUFFERIN
generic
brand
generic
OTC
PA, QL
NSAIDs and Other Analgesics
aspirin
aspirin
aspirin-al hydro-mg
hydro-ca carb
aspirin buffered
capsaicin
celecoxib
diclofenac 1% gel
diclofenac potassium
diclofenac sodium
delayed-release
diclofenac sodium
extended-release
diflunisal
etodolac
fenoprofen
ECOTRIN
HALFPRIN
CELEBREX
VOLTAREN 1% TOPICAL
GEL
CATAFLAM
generic
generic
VOLTAREN XR
generic
DOLOBID
LODINE
NALFON
generic
generic
generic
ibuprofen
ADVIL
generic
ibuprofen
indomethacin
ketoprofen
meloxicam
naproxen
MOTRIN
INDOCIN
ORUDIS
MOBIC
NAPROSYN
ENTERIC COATEDNAPROSYN
ANAPROX
DAYPRO
FELDENE
generic
generic
generic
generic
generic
naproxen sodium
oxaprozin
piroxicam
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
QL
QL
PA, QL, SP
QL
QL
QL
PA, QL, SP
SP
QL
generic
VOLTAREN
naproxen delayed release
Requirements & Limits
IR only
600 mg
tabs, chew tabs
and susp, OTC
tabs, chew tabs and susp
generic
generic
generic
generic
ST = Step Therapy
SP = Specialty Pharmacy
39
IR only
QL
Generic Drug Name
Brand Drug Name
sulindac
CLINORIL
Covered
Drug
generic
allopurinol
colchicine
colchicine
febuxostat
probenecid
ZYLOPRIM
COLCRYS
MITIGARE
ULORIC
PROBENECID
generic
generic
brand
brand
generic
chlorzoxazone
cyclobenzaprine
methocarbamol
orphenadrine
extended-release
PARAFON FORTE DSC
FLEXERIL
ROBAXIN
generic
generic
generic
NORFLEX
generic
baclofen
dantrolene
diazepam
tizanidine
BACLOFEN
DANTRIUM
VALIUM
ZANAFLEX
generic
generic
generic
generic
QL
tabs only, QL
desogestrel/EE
norethindrone/EE
MIRCETTE
ORTHO-NOVUM 10/11
generic
generic
QL
QL
levonorgestrel
levonorgestrel
PLAN B
PLAN B ONE STEP
generic
generic
QL
1.5 mg tab
medroxyprogesterone
acetate
DEPO-PROVERA
generic
QL
Gout
Skeletal Muscle Relaxants
Muscle Spasm
Spasticity
Requirements & Limits
PA
ST
OB-GYN
Contraceptives
Biphasic
Emergency Contraception
Injectable
Intravaginal
etonogestrel/EE
NUVARING
ORTHO COIL
brand
ring, QL
ortho diaphragm
ORTHO FLAT
brand
QL
generic
generic
0.1/20, QL
1/20, QL
generic
1/20, QL
ORTHO FLEX
Monophasic - 20 mcg Estrogen
levonorgestrel/EE
ALESSE
norethindrone acetate/EE LOESTRIN 1/20
norethindrone acetate/EE/
LOESTRIN FE 1/20
iron
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
ST = Step Therapy
SP = Specialty Pharmacy
40
Generic Drug Name
Brand Drug Name
Monophasic - 30 mcg Estrogen
Covered
Drug
Requirements & Limits
desogestrel/EE
levonorgestrel/EE
norethindrone acetate/EE
norethindrone acetate/EE/
iron
norgestrel/EE
ORTHO-CEPT
NORDETTE
LOESTRIN 1.5/30
generic
generic
generic
0.15/30, QL
0.15/30, QL
1.5/30, QL
LOESTRIN FE 1.5/30
generic
1.5/30, QL
LO/OVRAL
generic
0.3/30, QL
ethynodiol diacetate/EE
norethindrone/EE
norethindrone/EE
norethindrone/EE
norgestimate/EE
ZOVIA 1/35
BALZIVA
MODICON
ORTHO-NOVUM 1/35
ORTHO-CYCLEN
generic
generic
generic
generic
generic
1/35, QL
0.4/35, QL
0.5/35, QL
1/35, QL
0.25/35, QL
ethynodiol diacetate/EE
norethindrone/EE
norethindrone/ME
norgestrel/EE
ZOVIA 1/50
OVCON 50
ORTHO-NOVUM 1/50
OVRAL
generic
generic
generic
generic
1/50, QL
1/50, QL
1/50, QL
0.5/50, QL
norethindrone
norgestrel
ORTHO MICRONOR
OVRETTE
generic
generic
norelgestromin/EE
ORTHO EVRA
generic
Monophasic - 35 mcg Estrogen
Monophasic - 50 mcg Estrogen
Progestin
Transdermal
Triphasic
desogestrel/EE
levonorgestrel/EE
norethindrone
acetate/EE/iron
norethindrone/EE
norethindrone/EE
norgestimate/EE
Endometriosis
danazol
CAZIANT
CESIA
generic
QL
VELIVET
TRIVORA
generic
QL
ESTROSTEP FE
generic
QL
ORTHO-NOVUM 7/7/7
TRI-NORINYL
ORTHO TRI-CYCLEN
generic
generic
generic
QL
QL
QL
DANOCRINE
generic
Gender edits apply: for female
patients only.
CYCLESSA
Hormone Therapy/Menopause
Estrogens - Intravaginal
estradiol
estradiol
estradiol
ESTRACE CRM
ESTRING
VAGIFEM
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
brand
brand
brand
ST = Step Therapy
SP = Specialty Pharmacy
41
vaginal ring
vaginal tablet
Generic Drug Name
Brand Drug Name
estradiol acetate
estrogens, conjugated
FEMRING
PREMARIN
Covered
Drug
brand
brand
esterified estrogens
estradiol
estrogens, conjugated
estrogens, conjugated,
synthetic A
estrogens, conjugated,
synthetic B
estropipate
MENEST
ESTRACE
PREMARIN
brand
generic
brand
CENESTIN
brand
ENJUVIA
brand
OGEN
generic
estradiol
estradiol
CLIMARA
DIVIGEL
ELESTRIN
generic
brand
QL
gel
brand
gel pump 0.06%
brand
brand
brand
brand
generic
emulsion
spray
patch weekly 14 mcg/24hr
patch biweekly
Estrogens - Oral
Estrogens - Transdermal
estradiol
estradiol
estradiol
estradiol
estradiol
estrogen patch
Estrogen/Progestin
ESTROGEL
ESTRASORB
EVAMIST
MENOSTAR
VIVELLE-DOT
ESTRADIOL TDS
estrogens, conjugated/me- PREMPHASE
droxyprogesterone
PREMPRO
Requirements & Limits
vaginal ring, PA
crm
brand
Progestins
medroxyprogesterone
acetate
norethindrone acetate
progesterone micronized
PROVERA
generic
AYGESTIN
PROMETRIUM
generic
generic
fluconazole
metronidazole
DIFLUCAN
FLAGYL
generic
generic
QL
tabs
clotrimazole
clindamycin
clindamycin
GYNE-LOTRIMIN
CLEOCIN
CLEOCIN
METROGEL-VAGINAL
generic
brand
generic
OTC
supp
crm
Vaginal Infections
Oral
Vaginal
metronidazole
miconazole
miconazole
miconazole nitrate
generic
METROGEL 1%
MONISTAT
MONISTAT 3
MICONAZOLE KIT
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
generic
generic
generic
OTC
vaginal supp & cream kit
ST = Step Therapy
SP = Specialty Pharmacy
42
Generic Drug Name
Brand Drug Name
sulfanilamide
terconazole
AVC VAGINAL
TERAZOL 3/7
Miscellaneous
conjugated estrogen/
bazedoxifene
methylergonovine
tranexamic acid
Covered
Drug
brand
generic
DUAVEE
Requirements & Limits
vaginal cream
crm
brand
METHERGINE
LYSTEDA
generic
generic
OPTIVAR
CROLOM
ALAWAY OTC
generic
generic
brand
brand
PA
Ophthalmic
Allergy
azelastine
cromolyn sodium
ketotifen
naphazoline/antazoline
naphazoline/glycerin
naphazoline HCL
naphazoline
w/pheniramine
naphazoline/zinc sulfate
tetrahydrozoline
/zinc sulfate
CLEAR EYES REDNESS
RELIEF
VASOCLEAR
NAPHCON A
OPCON A
VASOCLEAR A
ST
QL
generic
generic
soln 0.02%
generic
ophth soln 0.027-0.315%
generic
VISINE-AC
generic
Anti-Inflammatories
Anti-Infective/Anti-Inflammatory Combinations
gentamicin/prednisolone
acetate
neomycin/polymyxin B/
dexamethasone
neomycin/polymyxin B/
hydrocortisone
sulfacetamide/pred. phos.
sulfacetamide sodiumprednisolone
tobramycin/
dexamethasone
tobramycindexamethasone
Nonsteroidal
diclofenac sodium
flurbiprofen
ketorolac
PRED-G
brand
MAXITROL
generic
CORTISPORIN
generic
VASOCIDIN
BLEPHAMIDE
generic
10%/0.25%
generic
ophth susp 10-0.2%
VASOCIDIN
TOBRADEX
generic
TOBRADEX ST
brand
VOLTAREN
OCUFEN
ACULAR/ACULAR LS
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
ophth susp technology 0.30.05%
generic
generic
generic
ST = Step Therapy
SP = Specialty Pharmacy
43
Generic Drug Name
Steroidal
Brand Drug Name
Covered
Drug
Requirements & Limits
ophth suspension 0.1%
dexamethasone
dexamethasone sodium
phosphate
fluorometholone
fluorometholone
fluorometholone
prednisolone acetate
prednisolone acetate
prednisolone phosphate
rimexolone
MAXIDEX
brand
DEXASOL
generic
FML
FML FORTE
FML LIQUIFILM
PRED FORTE
PRED MILD
INFLAMASE FORTE
VEXOL
brand
brand
generic
generic
brand
generic
brand
oint 0.1%
susp 0.25%
susp 0.1%
1%
0.12%
1%
betaxolol
carteolol
levobunolol
metipranolol
timolol
timolol maleate
BETOPTIC -S
ophth suspension 0.25%
BETAGAN
OPTIPRANOLOL
TIMOPTIC XE
TIMOPTIC
brand
generic
generic
generic
generic
generic
brinzolamide
dorzolamide
AZOPT
TRUSOPT
brand
generic
Glaucoma
Beta-Blockers
Carbonic Anhydrase Inhibitors
Carbonic Anhydrase Inhibitor/Beta-Blocker Combination
dorzolamide HCL-timolol
maleate
dorzolamide/
timolol maleate
Cholinesterase Inhibitor
COSOPT PF
brand
COSOPT
PHOSPHOLINE IODINE
brand
atropine
cyclopentolate
homatropine
scopolamine
ISOPTO ATROPINE
CYCLOGYL
ISOPTO HOMATROPINE
ISOPTO HYOSCINE
generic
generic
generic
brand
acetazolamide
acetazolamide
extended-release
methazolamide
ACETAZOLAMIDE
generic
DIAMOX SEQUELS
generic
NEPTAZANE
generic
latanoprost
tafluprost
travoprost
XALATAN
ZIOPTAN
TRAVATAN Z
generic
brand
brand
Oral
Prostaglandins
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
PA
ophth solution preservative
free
generic
ecothiophate
Mydriatics
ophthalmic solution
0.3% ophthalmic solution
gel forming solution
QL
ophth soln 0.0015%. PA
ophth soln 0.004%, PA
ST = Step Therapy
SP = Specialty Pharmacy
44
Generic Drug Name
Brand Drug Name
Covered
Drug
Requirements & Limits
travoprost
TRAVATAN Z PF
generic
ophth soln 0.004%
(benzalkonium free), PA
Topical - Parasympathomimetics
pilocarpine
pilocarpine
ISOPTO CARPINE
PILOPINE HS GEL
generic
brand
brimonidine
brimonidine
brimonidine
ALPHAGAN P
ALPHAGAN P
ALPHAGAN
brand
generic
generic
CILOXAN
ERYTHROMYCIN
ZYMAR
GENTAK
VIGAMOX
generic
generic
generic
brand
generic
brand
NEOSPORIN
generic
OCUFLOX
POLYSPORIN
POLYTRIM
BLEPH-10
generic
generic
generic
generic
Topical - Sympathomimetics
Infections
Bacterial
bacitracin
ciprofloxacin
erythromycin
gatifloxin
gentamicin
moxifloxacin HCl
neomycin/polymyxin B/
gramicidin
ofloxacin
polymyxin B/bacitracin
polymyxin B/trimethoprim
sulfacetamide
sulfacetamide/
phenylephrine
tobramycin
VASOSULF
0.1%
0.15%
0.2%
PA
ophth solution 0.5%
oint/soln
brand
TOBREX
generic
trifluridine
VIROPTIC
generic
natamycin
NATACYN
brand
ophth suspension 5%
cyclosporine
cysteamine 0.44%
ophthalmic solution
sodium chloride
hypertonic
RESTASIS
brand
(ophth) emulsion 0.05%, PA
CYSTARAN
brand
PA, SP
MURO 128
generic
soln 5%
CAMPRAL
ANTABUSE
REVIA
brand
generic
generic
Fungal
Viral
Miscellaneous
Psychiatric
Alcohol Deterrents
acamprosate
disulfiram
naltrexone
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
ST = Step Therapy
SP = Specialty Pharmacy
45
Brand Drug Name
Covered
Drug
Requirements & Limits
alprazolam
alprazolam
alprazolam
chlordiazepoxide
clonazepam
clonazepam ODT
clorazepate
diazepam
diazepam
diazepam conc
lorazepam
lorazepam
lorazepam conc
oxazepam
XANAX
XANAX
XANAX XR
LIBRIUM
KLONOPIN
KLONOPIN WAFERS
TRANXENE
VALIUM
VALIUM
DIAZEPAM INTENSOL
ATIVAN
ATIVAN
LORAZEPAM INTENSOL
SERAX
generic
generic
generic
generic
generic
generic
generic
generic
generic
generic
generic
generic
generic
generic
QL, IR only
solution
tablet SR, QL
QL
not wafers, QL
ODT tabs, QL
QL
QL
solution, QL
QL
QL
solution, QL
QL
QL
buspirone
clomipramine
fluvoxamine
fluvoxamine SR
BUSPAR
ANAFRANIL
LUVOX
LUVOX CR
generic
generic
generic
generic
QL
ADDERALL
generic
QL
brand
QL
STRATTERA
DEXEDRINE
DEXTROSTAT
brand
generic
brand
PA, QL
QL
QL
DEXEDRINE SPANSULE
generic
QL
INTUNIV
VYVANSE
METHYLIN SOLUTION
RITALIN
generic
brand
generic
generic
Age Limits Apply, QL
solution, QL
tabs only, QL
CONCERTA
generic
QL
Generic Drug Name
Anxiety
Benzodiazepines
Miscellaneous
Attention Deficit Hyperactivity Disorder (ADHD)
amphetamine/
dextroamphetamine
mixed salts
amphetamine/
dextroamphetamine
mixed salts
extended-release
atomoxetine
dextroamphetamine
dextroamphetamine
dextroamphetamine
extended-release
guanfacine ER
lisdexamfetamine
methylphenidate
methylphenidate
methylphenidate
extended-release
ADDERALL XR
(BRAND ADDERALL XR
IS PREFERRED)
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
ST = Step Therapy
SP = Specialty Pharmacy
46
Generic Drug Name
methylphenidate
extended-release
Bipolar Disorder
divalproex sodium
cap sprinkle
divalproex sodium
delayed-release
lithium carbonate
lithium carbonate
extended-release
Brand Drug Name
Covered
Drug
Requirements & Limits
generic
QL
METADATE ER
RITALIN-SR
RITALIN LA
DEPAKOTE SPRINKLE
generic
DEPAKOTE
generic
LITHIUM CARBONATE
ESKALITH CR
generic
LITHOBID
Depression
Monoamine Oxidase Inhibitor (MAOI)
Minimum age 2
generic
tranylcypromine
PARNATE
generic
citalopram
escitalopram
CELEXA
LEXAPRO
generic
generic
fluoxetine
PROZAC
generic
paroxetine
paroxetine
paroxetine SR
sertraline
PAXIL
PAXIL ORAL SUSP
PAXIL CR
ZOLOFT
generic
generic
generic
generic
10 mg and 20 mg caps and
20 mg soln only
tablets
oral susp, QL
tablets, QL
tablets, QL
duloxetine
venlafaxine
venlafaxine XR
CYMBALTA
EFFEXOR
EFFEXOR XR
generic
generic
generic
QL
QL
QL
amitriptyline
amoxapine
desipramine
doxepin
imipramine HCL
nortriptyline
protriptyline
ELAVIL
generic
generic
generic
generic
generic
generic
generic
tablets
Selective Serotonin Reuptake Inhibitor (SSRIs)
Serotonin Norepinephrine Reuptake Inhibitors (SNRIs)
Tricyclic Antidepressants (TCAs)
NORPRAMIN
SINEQUAN
TOFRANIL
PAMELOR
VIVACTIL
Tricyclic Antidepressant/Phenothiazine Combination
amitriptyline/perphenazine TRIAVIL
Miscellaneous Agents
bupropion
bupropion
extended-release
generic
FORFIVO XL
generic
ST = Step Therapy
SP = Specialty Pharmacy
47
tablets
generic
WELLBUTRIN
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
QL
450 mg
Brand Drug Name
Covered
Drug
Requirements & Limits
WELLBUTRIN SR
generic
QL
WELLBUTRIN XL
generic
150 mg and 300 mg
LUDIOMIL
REMERON
REMERON ODT
DESYREL
generic
generic
generic
generic
tabs (not soltabs)
odt tablets
150 mg only
estazolam
flurazepam
temazepam
triazolam
PROSOM
DALMANE
RESTORIL
HALCION
generic
generic
generic
generic
QL
QL
15 mg and 30 mg only, QL
QL
chloral hydrate
diphenhydramine
ramelteon
zaleplon
zolpidem
CHLORAL HYDRATE
NYTOL QUICK CAPS
ROZEREM
SONATA
AMBIEN
generic
generic
brand
generic
generic
OTC
QL, PA
QL
QL
buprenorphine/naloxone
SUBOXONE
naloxone
naloxone
naltrexone
naltrexone for IM extended
release susp
NALOXONE INJ
NARCAN NASAL SPRAY
REVIA
VIVITROL
brand
aripiprazole
ABILIFY TABLETS
brand
aripiprazole ER injection
clozapine
clozapine
(ODT formulation)
olanzapine
olanzapine ODT
paliperidone
paliperidone
quetiapine
quetiapine XR
risperidone
ABILIFY MAINTENA
CLOZARIL
Generic Drug Name
bupropion
extended-release
bupropion
extended-release
maprotiline
mirtazapine
mirtazapine
trazodone
Insomnia
Benzodiazepines
Non-Benzodiazepines
Narcotic Antagonists
brand
generic
brand
generic
Psychoses
Atypicals
FAZACLO
ZYPREXA
ZYPREXA ZYDIS
INVEGA SUSTENNA
INVEGA TRINZA
SEROQUEL
SEROQUEL XR
RISPERDAL
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
2 mg and 8 mg film only,
QL
QL
QL
PA
brand
generic
Age Limit Applies,
tablets, PA, QL
Age Limit Applies, PA, QL
Age Limit Applies, QL
brand
Age Limit Applies, QL
generic
generic
brand
brand
generic
brand
generic
Age Limit Applies, QL
Age Limit Applies, QL
Age Limit Applies, PA, QL
PA
Age Limit Applies, QL
Age Limit Applies, PA, QL
Age Limit Applies, QL
ST = Step Therapy
SP = Specialty Pharmacy
48
RISPERDAL CONSTA
RISPERDAL M-TAB
RISPERDAL SOLUTION
GEODON
Covered
Drug
brand
generic
generic
generic
Age Limit Applies, PA, QL
Age Limit Applies, QL
Age Limit Applies, QL
Age Limit Applies, QL
bupropion
nicotine
nicotine inhaler system
nicotine polacrilex gum
nicotine polacrilex lozenge
varenicline
ZYBAN
NICODERM
NICOTROL
NICORETTE
COMMITT
CHANTIX
brand
generic
brand
generic
generic
brand
smoking deterrent, QL
TD patch, QL
QL
2 mg & 4 mg, QL
2 mg & 4 mg, QL
QL
chlorpromazine
dextromethorphan/
quinidine
fluphenazine
fluphenazine decanoate
haloperidol
haloperidol decanoate
loxapine
perphenazine
pimozide
thioridazine
thiothixene
trifluoperazine
THORAZINE
generic
NUEDEXTA
brand
Generic Drug Name
Brand Drug Name
risperidone
risperidone m-tab
risperidone oral soln
ziprasidone
Smoking Cessation
Miscellaneous
PROLIXIN
PROLIXIN DECANOATE
HALDOL
HALDOL DECANOATE
LOXITANE
TRILAFON
ORAP
MELLARIL
NAVANE
STELAZINE
Requirements & Limits
PA
generic
generic
generic
generic
generic
generic
generic
generic
generic
generic
Respiratory Drugs
Antitussives, Decongestants, Expectorants and Combinations
benzonatate
brompheniramine &
phenylephrine
brompheniramine/
pseudoephedrine
brompheniramine/
pseudoephedrine
brompheniramine/
pseudoephedrine
brompheniramine/
pseudoephedrine
TESSALON
DIMETAPP CLD ELX/
ALLERGY
ACCUHIST DROPS
generic
generic
RESPERAL-DM
ANDEHIST
generic
liquid
brand
syrup 4-60 mg/5 ml
BROMFENEX PD CAP
DIMETAPP ELX
CLD/ALLE
generic
UNI-HIST DRO
CARDEC SYP
BROVEX PSB
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
generic
ST = Step Therapy
SP = Specialty Pharmacy
49
liq 4-20 mg/5 ml
Generic Drug Name
brompheniramine/
pseudoephedrine
brompheniramine/
pseudoephedrine
brompheniramine/
pseudoephedrine/
dextromethorphan
brompheniramine/
pseudoephedrine/
dextromethorphan
brompheniramine/
pseudoephedrine/
dextromethorphan
brompheniramine/
pseudoephedrine/
dextromethorphan/
guaifenesin
carbetapentane/
chlorpheniramine/
ephedrine/
phenylephrine
carbinoxamine/
pseudoephedrine
chlorphen-PEmethscopolamine
chlorphen tan/
carbetapentane tan
chlorphen tan/
pseudoeph tan
chlorphen tan/pyrilamine
tan/PE tan
Brand Drug Name
Covered
Drug
Requirements & Limits
J-TAN D PD
generic
drops 1-7.5 mg/ml
RONDEC SYRUP
generic
syrup
ACCUHIST PDX DROPS
generic
liquid
BROMALINE DM
generic
elixir
generic
syrup
HISTACOL DM
generic
syrup
RYNATUSS
generic
RONDEC DROPS
generic
liquid
generic
syrup
TUSSI-12 S
generic
susp
TANAFED
generic
susp
TRIOTANN PEDIATRIC
SUSP
generic
susp
BROMFED DM
DALLERGY DM
CARBOFED
NEO DM
ANAPLEX DM
DURADRYL
QV-ALLERGY
R-TANNAMINE
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
ST = Step Therapy
SP = Specialty Pharmacy
50
Generic Drug Name
Covered
Drug
Brand Drug Name
Requirements & Limits
ROBITUSSIN PED LIQ
CGH/COLD
chlorpheniramine/
dextromethorphan
ROBITUSSIN LIQ
CGH/CLD
generic
DIMETAPP SYP CGH/CLD
CORICIDIN TAB
CGH/CLD
chlorpheniramine maleate ED A-HIST TABLETS AND
phenylephrine HCL
LIQUID
RONDEC
DROPS
chlorpheniramine/
phenylephrine
CARDEC DRO
RONDEC SYRUP
chlorpheniramine/
phenylephrine
CARDEC SYP
HISTEX
chlorpheniramine/
pseudoephedrine
CPM/PSE
chlorpheniramine tan/
RYNATAN PEDIATRIC SUSP
phenylephrine tan
codeine/
DIHISTINE DH
chlorpheniramine/
PHENYLHIST LIQ DH
pseudoephedrine
CHERATUSSIN AC
codeine/guaifenesin
GUIATUSS/AC
generic
generic
liquid
generic
syrup
generic
generic
susp
generic
generic
M-CLEAR WC
QL
MYTUSSIN AC
codeine/guaifenesin/pseuGUIATUSS DAC
doephedrine
PROMETHAZINE
codeine/promethazine
W/CODEINE
codeine/promethazine/
PROMETHAZINE VC
phenylephrine
W/CODEINE
dextromethorphan/
brompheniramine/
BROMETANE DX
pseudoephedrine
dextromethorphan/
carbinoxamine/
CARDEC-DM
pseudoephedrine
dextromethorphanDURATUSS DM ELX
guaifenesin
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
generic
generic
QL
generic
QL
generic
generic
drops
generic
soln 25-225 mg/5 ml
ST = Step Therapy
SP = Specialty Pharmacy
51
Generic Drug Name
Brand Drug Name
Covered
Drug
Requirements & Limits
generic
OTC
generic
liq 10-200 mg/ 5 ml
generic
syrup
brand
OTC
GG/DM CR
dextromethorphan/
guaifenesin
dextromethorphanguaifenesin
dextromethorphan HBR
dextromethorphan
polistirex
extended-release
dextromethorphan/
promethazine
guaifenesin
guaifenesin
guaifenesin
guaifenesin
guaifenesin
extended-release
guaifenesin/
pseudoephedrine
guaifenesin/
pseudoephedrine/
dextromethorphan
guaifenesin/
pseudoephedrine
extended-release
guaifenesin/
pseudoephedrine
extended-release
hydrocodone/
chlorpheniramine/
phenylephrine
hydrocodone/
guaifenesin
MUCINEX DM
ROBITUSSIN DM
TUSSIN DM
ROBITUSSIN LIQ CGH/
CONG
ROBITUSSIN SYP MAX-ST
ROBITUSSIN PED SYP
DELSYM
PHENERGAN DM
PROMETHAZINE SYP DM
MUCINEX KIDS
ROBITUSSIN
ROBITUSSIN SYP
CHST CNG
TRIACTIN CHEST CONGESTION
MUCINEX
ROBITUSSIN PE
PSE/GG
generic
brand
generic
granules packet
OTC
generic
syrup 100 mg/5 ml
brand
soln 50 mg/5 mL
generic
OTC
generic
syrup, OTC
ROBITUSSIN CF
generic
GUAIFED
generic
GUAIFEN PSE
MUCINEX D
generic
GG/PSE CR
HISTUSSIN HC
generic
VITUSSIN
HYDROCODO/GG SYP
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
generic
ST = Step Therapy
SP = Specialty Pharmacy
52
OTC
Generic Drug Name
Covered
Drug
Brand Drug Name
Requirements & Limits
HYCODAN
hydrocodone/
homatropine
loratadine &
pseudoephedrine SR
24hr
phenyleph/bromphen/
dextromethorphan/
guaifenesin
phenylephrine/
brompheniramine/
dextromethorphan
phenylephrine/
brompheniramine-DM
phenylephrine/
brompheniramine-DM
phenylephrine/
brompheniramine-DM
phenylephrine/
brompheniramine-DM
phenylephrine/
chlorpheniramine
phenylephrine/
chlorpheniramine/
dextromethorphan
phenylephrine/
chlorpheniramine/
dextromethorphan
phenylephrine/
chlorpheniramine/
dextromethorphan
phenylephrine/
chlorpheniramine/
dihydrocodeine
phenylephrine/
dextromethorphan
HYDROMET SYP
generic
HYDROCODONE/
TAB HOMATROP
ALLERGY/CONG TAB RELIEF
generic
ALLANHIST SYP PDX
generic
tab 10-240 mg
generic
OTC
ALAHIST DM
generic
liq 7.5-4-15 mg/5 ml
DIMETAPP DM
generic
liq 2.5-1-5 mg/5 ml
LOHIST-DM
generic
syrup 5-2-10 mg/5 ml
PRESGEN B
generic
liq 10-4-20 mg/5 ml
QUAL-TUSSIN SYP DC
generic
ATUSS DR
DE-CHLOR DM
generic
syrup
generic
syrup
generic
liquid
RONDEC DM
STATUSS DM SYP
CARDEC DM SYP
MINUTUSS DR SYP
RONDEC DM DROPS
CARDEC DM DRO
ROBITUSSIN LIQ
CGH/ALRG
DIHYDRO-PE SYP
generic
DIMETAPP DRO
DCON/CGH
generic
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
ST = Step Therapy
SP = Specialty Pharmacy
53
Generic Drug Name
phenylephrine/
dextromethorphan/
guaifenesin
phenylephrine/
ephed/CPM
w/carbetapentane
phenylephrine/guaifenesin
phenylephrine/guaifenesin
phenylephrine/guaifenesin
phenylephrine/guaifenesin
phenylephrine/guaifenesin
phenylephrine/guaifenesin
phenylephrine/guaifenesin
phenylephrine/guaifenesin
phenylephrine/guaifenesin
phenylephrine/guaifenesin
phenylephrine/guaifenesin
phenylephrine/guaifenesin
phenylephrine/guaifenesin
phenylephrine/
hydrocodone/
guaifenesin
phenylephrine/pyrilamine/
dextromethorphan
phenylephrine/pyrilamine
w/hydrocodone
phenylephrine tan/
pyrilamine tan/
carbeta tan
promethazine &
phenylephrine
pseudoephedrine
pseudoephedrine/
acetaminophen/
dextromethorphan
pseudoephedrine/
chlorpheniramine/
dextromethorphan
Brand Drug Name
Covered
Drug
ROBITUSSIN PE
generic
RYNATUSS PEDIATRIC
SUSP
generic
susp
generic
brand
generic
brand
brand
generic
generic
brand
generic
syrup 5-200 mg/5 ml
cap 10-390 mg
tab 10-380 mg
liq 10-100 mg/5 ml
tab 10-388 mg
tab 5-200 mg
tab 10-400 mg
liq 2.5-100 mg/5 ml
liq 7.5-200 mg/5 ml
DECONEX
DECONEX IR
ENTEX LQ LIQ
GILPHEX TR
LIQUIBID PD
MEDIFIN PE
MUCINEX COLD LIQ /KIDS
NARIZ
ROBITUSSIN LIQ
HD/CHST
SUPRESS-PE PEDIATRIC
DROPS
TRIAMINIC LIQ CHST/NAS
TRIAMINIC SYR CHST/NAS
Requirements & Limits
generic
brand
drops 2.5-50 mg/ml
brand
brand
liq 2.5-50 mg/5 ml
syrup 2.5-50 mg/5 ml
QUAL-TUSSIN SYP DC
generic
CODAL-DM
generic
CODIMAL DH
generic
syrup
TUSSI 12D S
generic
susp
generic
syrup 6.25-5 mg/ 5 mg
PROMETH VC SYP
6.25-5/5
SUDAFED
generic
MAPAP COLD TAB
generic
PEDIACARE LIQ
MULTI-SY
generic
ROBITUSSIN LIQ PED
NGHT
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
ST = Step Therapy
SP = Specialty Pharmacy
54
Generic Drug Name
Brand Drug Name
Covered
Drug
pseudoephedrine/
dextromethorphan/
guaifenesin
MULTI SYMPTOM TAB
COLD RLF
generic
pseudoephedrine/
iburprofen
pseudoephedrine tan/
dexchlorphen tan/
DM tan
pyrilamine tan/phenyleph
tan
tripolidine/
pseudoephedrine
Asthma/COPD
Inhalers - Beta Agonists
CHILD IBUPRO
SUS COLD
Requirements & Limits
generic
IBUOROFEN TAB
COLD/SIN
TANAFED DMX
SUSPENSION
generic
susp
generic
susp
TRI-FED X
RYNA-12 S
TRIPROL/PSE SYP
generic
APHEDRID TAB
albuterol sulfate
formoterol
indacaterol
olodaterol
salmeterol xinafoate
VENTOLIN HFA
FORADIL AEROLIZER
ARCAPTA NEOHALER
STRIVERDI RESPIMAT
SEREVENT DISKUS
brand
brand
brand
brand
brand
PA, QL
beclomethasone
fluticasone HFA
mometasone
QVAR
FLOVENT HFA
ASMANEX TWISTHALER
brand
brand
brand
QL
QL
QL
budesonide/formoterol
fluticasone/salmeterol
mometasone/formoterol
SYMBICORT
ADVAIR DISKUS
DULERA
brand
brand
brand
ST
QL, ST
ST
cromolyn
ipratropium HFA
ipratropium/albuterol
nedocromil
omalizumab
tiotropium
tiotropium respimat
INTAL
ATROVENT HFA
COMBIVENT RESPIMAT
TILADE
XOLAIR
SPIRIVA
SPIRIVA RESPIMAT
brand
brand
brand
brand
brand
brand
brand
QL
albuterol
ACCUNEB
generic
albuterol
budesonide
PROVENTIL
PULMICORT RESPULES
generic
brand
Inhalers - Corticosteroids
Inhalers - Corticosteroid/Beta Agonist Combinations
Inhalers - Others
Inhalers for Nebulization
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
QL
PA
inhaler
PA, SP
0.63 mg/3 ml and 1.25 mg
/3 ml
soln 0.083%, 0.5%
susp, QL
ST = Step Therapy
SP = Specialty Pharmacy
55
Generic Drug Name
Brand Drug Name
cromolyn
ipratropium
ipratropium/albuterol
levalbuterol HCl
INTAL
ATROVENT
DUONEB
XOPENEX RESPULES
Covered
Drug
generic
generic
generic
generic
albuterol SR tabs
metaproterenol
metaproterenol
terbutaline
VOSPIRE ER
ALUPENT
METAPROTERENOL SYRUP
BRETHINE
generic
generic
generic
generic
montelukast
zafirlukast
SINGULAIR
ACCOLATE
generic
generic
QL
tabs
theophylline
theophylline
extended-release
theophylline
extended-release
theophylline
extended-release
theophylline
extended-release
THEOPHYLLINE
generic
liquid
brand
caps
THEOCHRON
generic
tabs
THEOPHYLLINE EXT-REL
generic
caps (12 hr)
UNIPHYL
generic
tabs
Oral Agents - Beta Agonists
Oral Agents - Leukotriene Modifiers
Oral Agents - Theophylline
THEO-24
Miscellaneous
alpha1-proteinase
inhibitor (human)
alpha1-proteinase
inhibitor (human)
ARALAST NP
brand
PROLASTIN
brand
Requirements & Limits
soln, QL
soln, QL
soln
QL, ST
tabs
SP, Coverable through
Medical Benefit
SP, Coverable through
Medical Benefit
Urological
Symptomatic Benign Prostatic Hypertrophy
UROXATRAL
CARDURA
CARDURA XL
PROSCAR
FLOMAX
HYTRIN
generic
generic
brand
generic
generic
generic
bethanechol
URECHOLINE
hyoscyamine,
methenamine,
phenyl salicylate, soUTIRA C
dium phosphate monobasic, methylene blue
generic
alfuzosin ER
doxazosin
doxazosin SR
finasteride
tamsulosin
terazosin
Miscellaneous
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
brand
ST = Step Therapy
SP = Specialty Pharmacy
56
Generic Drug Name
methenamine hippurate
oxybutynin chloride
oxybutynin IR
pentosan
phenazopyridine
potassium citrate
propantheline
sodium citrate/citric acid
tolterodine
tolterodine SR
trospium
Covered
Drug
Brand Drug Name
HIPREX
Requirements & Limits
generic
UREX
DITROPAN XL
DITROPAN
ELMIRON
PYRIDIUM
UROCIT-K
BICITRA
DETROL
DETROL LA
SANCTURA
generic
generic
brand
generic
generic
generic
generic
generic
brand
generic
calcitriol
ROCALTROL
generic
calcitriol oral soln
ROCALTROL SOLUTION
generic
calcium
cholecalciferol
generic
brand
cholecalciferol
cholecalciferol
cholecalciferol
cholecalciferol
cholecalciferol
cholecalciferol
OS-CAL
BIO-D DRO-MULSION
BIO-D-MULSIO
DRO FORTE
D3-50 CAP
VITAMIN D CAP 400 UNIT
VITAMIN D CAP 2000 UNIT
VITAMIN D TAB 400 UNIT
VITAMIN D TAB 1000 UNIT
VITAMIN D TAB 2000 UNIT
cyanocobalamin
VITAMIN B-12
generic
electrolyte
PEDIALYTE
generic
ergocalciferol (D2)
DRISDOL
generic
QL, ST
PA
ST
ST
ST
Vitamins and Minerals
cholecalciferol
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
brand
brand
brand
brand
brand
brand
brand
Members ≥ 8 years of age will
require prior authorization.
OTC
drops 400 unit/0.03 ml, OTC
drops 2000 unit/0.03 ml,
OTC
cap 50000 unit, OTC
cap 400 unit, OTC
cap 2000 unit, OTC
tab 400 unit, OTC
tab 1000 unit, OTC
tab 2000 unit, OTC
inj, Coverage for these
medications will be
determined by the member’s
individual benefits.
Please refer to individual
plan documents for coverage
information.
soln, oral, OTC
Coverage for these
medications will be
determined by the member’s
individual benefits.
Please refer to individual
plan documents for coverage
information.
ST = Step Therapy
SP = Specialty Pharmacy
57
Generic Drug Name
ferrous bisglycinate/
polysaccarides iron
ferrous sulfate
Brand Drug Name
Covered
Drug
Requirements & Limits
NIFEREX
generic
caps, OTC
FEOSOL
GEL-KAM
generic
OTC
Coverage for these
medications will be
determined by the member’s
individual benefits.
Please refer to individual
plan documents for coverage
information.
LURIDE
fluoride
LURIDE LOZI-TABS
generic
PREVIDENT
folic acid
PHOS-FLUR
FOLIC ACID
generic
magnesium oxide
MAG-OX
generic
multivitamins/
fluoride/±iron
POLY-VI-FLOR
generic
multivitamins/minerals
CENTRUM
generic
SUPER OMEGA
omega-3 fatty acids
ESKIMO-3
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.
generic
capsule
HM FISH OIL
generic
delayed-release capsule
GNP FISH OIL
MEPHYTON
brand
SEA-OMEGA
PRO NUTRIENT
omega-3 fatty acids
phytonadione
polysaccharide iron
complex
NIFEREX
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
generic
ST = Step Therapy
SP = Specialty Pharmacy
58
elixir, OTC
Generic Drug Name
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
prenat w/o A
w/fecbn-fegl-DSS-FA &
DHA
prenatal vit w/FE
bisglyc-FE prot
succ-FA
prenatal vit w/FE
bisglycinate
chelate-FA
prenatal vit w/FE
bisglycinate
chelate-FA
prenatal vit w/FE
bisglycinate
chelate-FA
prenatal vit w/FE
polysac cmplx-FA
prenatal vit w/iron
carbonyl-FA
prenatal w/o A w/ FE
carbonyl-FE
gluc-DSS-FA
prenatal vit w/o vit a w/fe
bisglycinate-fa tab 32-1
mg
Covered
Drug
Brand Drug Name
COMPLETE NATALCARE
PAK DHA
brand
PRUET DHA PAK
SETONET PAK
brand
TRUST NATALCARE
PAK DHA
brand
FOLTABS PAK PLUS DHA
RE OB + DHA PAK
brand
VINATE III
brand
GENTEX ADE 28-1 MG
brand
VINATE AZ EX
brand
VITAPHIL
brand
EDGE OB CHW
brand
ATABEX PRENATAL
brand
FOLTABS PRENATAL
brand
TRI RX
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
Requirements & Limits
generic
ST = Step Therapy
SP = Specialty Pharmacy
59
Generic Drug Name
Brand Drug Name
Covered
Drug
Requirements & Limits
generic
QL
PRENATAL VITAMINS W/
FOLIC ACID
prenatal vitamins
w/folic acid
CENOGEN OB/ULTRA
MATERNA
NATALCARE
NESTABSCBF/FA/RX
renat-FE bis-FE prot succFA-CA & omega DR
vitamin A
NIFEREX-PN FORTE
PRUET DHAEC PAK
brand
generic
vitamin ADC/fluoride/±iron
TRI-VI-FLOR
drops
generic
vitamin B complex/
vitamin C/folic acid
generic
NEPHROCAPS
vitamin B-1
vitamin B-6
vitamin C
vitamins pediatric
generic
generic
generic
TRI-VI-SOL
generic
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
OTC
OTC
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.
OTC
zinc
generic
phosphorus
K-PHOS NEUTRAL
potassium acid phosphate K-PHOS ORIGINAL
potassium bicarbonate/
potassium citrate
K-LYTE
effervescent
generic
brand
tabs
generic
tabs
Potassium
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
ST = Step Therapy
SP = Specialty Pharmacy
60
Generic Drug Name
Brand Drug Name
potassium chloride
potassium chloride
K-LOR
POTASSIUM CHLORIDE
K-DUR 10
potassium chloride
extended-release
K-DUR 20
potassium chloride
extended-release
potassium iodide
KLOR-CON 8
Covered
Drug
generic
generic
Requirements & Limits
powder
liquid
generic
tabs
generic
caps
KLOR-CON 10
MICRO-K 10
PIMA
brand
Miscellaneous
Anaphylaxis
epinephrine
epinephrine
Cystic Fibrosis
acetylcysteine
dornase alfa
ivacaftor
ivacaftor
lumacaftor/ivacaftor
tobramycin neb soln
Detoxification Agents
deferasirox
EPINEPHRINE
AUTO-INJECT BY
IMPAX LABS
EPIPEN
generic
QL
brand
QL
generic
brand
brand
brand
brand
PA, SP
PA, SP
PA, SP
PA, SP
brand
PA, SP
brand
PA, SP
brand
PA, SP
brand
brand
PA, SP
PA, SP
generic
667 mg tablet only, PA
PHOSLYRA
brand
PA
SENSIPAR
FOSRENOL
RENVELA
RENAGEL
brand
brand
generic
brand
PA
PA
ST
tablet, PA
EPIPEN JR.
MUCOMYST
PULMOZYME
KALYDECO
KALYDECO GRANULES
ORKAMBI
BETHKIS
KITABIS
EXJADE
deferiprone
JADENU
FERRIPROX
C1 Inhibitor, Human
icatibant
BERINERT
FIRAZYR
Hereditary Angioedema
Hyperphosphatemia
calcium acetate
calcium acetate oral
solution
cinacalcet
lanthanum carbonate
sevelamer
sevelamer hcl
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
ST = Step Therapy
SP = Specialty Pharmacy
61
Generic Drug Name
Brand Drug Name
Idiopathic Pulmonary Fibrosis (IPF)
Covered
Drug
Requirements & Limits
nintedanib
pirfenidone capsule
OFEV
ESBRIET
brand
brand
PA, SP
PA, SP
eltrombopag
PROMACTA
brand
PA, SP
Immune Thrombocytopenic Purpura
Medical Devices
Spacers
QL
Vaccine
diphtheria-tetanus tox adsorbed (dt) im
hepatitis a vaccine susp
DIP/TET PED INJ
VAQTA
HAVRIX
hepatitis b vaccine (recom- ENGERIX-B
binant)
RECOMBIVAX HB
human papillomavirus
(hpv) 9-valent recomb GARDASIL 9
vac
human papillomavirus
(hpv) bival (type 16, 18) CERVARIX
recmb vac
human papillomavirus
(hpv) quadrivalent
GARDASIL
recombinant vac
influenza virus vaccine
recombinant hemag- FLUBLOK
glutinin (ha)
AFLURIA
influenza virus vaccine split
FLUZONE SPLT
influenza virus vaccine split
FLUZONE HD PF
high-dose pf
influenza virus vaccine split
AFLURIA PF
pf
FLUARIX QUAD
influenza virus vaccine split
FLULAVAL QUAD
quadrivalent
FLUZONE QUAD
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
brand
QL
brand
QL
brand
QL
brand
QL
brand
QL
brand
QL
brand
QL, Age Limits Apply
brand
QL, Age Limits Apply
brand
QL, Age Limits Apply
brand
QL, Age Limits Apply
brand
QL, Age Limits Apply
ST = Step Therapy
SP = Specialty Pharmacy
62
Generic Drug Name
influenza virus vaccine tisscult subunit
influenza virus vaccine
types a&b surface
antigen
measles, mumps & rubella
virus vaccines for inj
meningococcal (a, c, y,
and w-135)
meningococcal (a, c, y,
and w-135) conjugate
vaccine
meningococcal (a, c, y,
and w-135) oligo conj
vac for inj
pneumococcal 13-valent
conjugate
pneumococcal vaccine
polyvalent
tet tox-diph-acell pertuss
ad
tetanus-diphtheria toxoids
(td)
tetanus immune globulin
(human)
typhoid vaccine
varicella virus vac live for
subcutaneous
zoster vaccine live
Covered
Drug
Requirements & Limits
FLUCELVAX
brand
QL, Age Limits Apply
FLUVIRIN
brand
QL, Age Limits Apply
M-M-R II
brand
QL
MENOMUNE
brand
QL
MENACTRA
brand
QL
MENVEO
brand
QL
PREVNAR 13
brand
QL
brand
QL
brand
QL
brand
QL
HYPERTET S/D
brand
QL
VIVOTIF BERNA
brand
capsules
VARIVAX
brand
QL
ZOSTAVAX
brand
QL, Age Limits Apply
Brand Drug Name
PNEUMOVAX
PNEUMOVAX 23
ADACEL
BOOSTRIX
TENIVAC
TET/DIP TOX INJ
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
ST = Step Therapy
SP = Specialty Pharmacy
63
Generic Drug Name
Brand Drug Name Examples
OTC MEDICATIONS
The following is a list of OTC products on the PDL. Some OTC products are listed on the drug
list. OTC products covered are restricted to generics when available. Brand names are provided
as reference only.
Acne
BREVOXYL-4
CLEARASIL
benzoyl peroxide crm, gel, lotion, cleanser, bar, foam, DELOS
cloth, wash
OC8
PANOXYL BAR
PANOXYL CREAM
Antifungals
clotrimazole
MICATIN
miconazole crm, soln
LOTRIMIN AF
tolnaftate
TINACTIN
MONISTAT
vaginal products
GYNE-LOTRIMIN
Atopic Dermatitis
BETACARE CREAM AND LOTION
CETAPHIL CREAM AND LOTION
DERMAPHOR OINTMENT
emollients
E-OINTMENT
GLYCERIN TOPICAL
Cough/Cold Allergy
Antihistamine
CHLOR-TRIMETON
BENADRYL
CLARITIN
antihistamines
ALAVERT
ZYRTEC
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
ST = Step Therapy
SP = Specialty Pharmacy
64
Generic Drug Name
Brand Drug Name Examples
Antihistamine/Decongestant Combinations
brompheniramine/pseudoephedrine
cetirizine/pseudoephedrine OTC
chlorpheniramine/pseudoephedrine
DIMETAPP
ZYRTEC D
ACTIFED
ALAVERT ALRG TAB/SINUS
loratadine/pseudoephedrine
ALAVERT D
ALLERGY/CONG
Cough/Cold
ROBITUSSIN
ROBITUSSIN DM
antitussives
Age edit applied. Not covered for members under ROBITUSSIN PE
the age 2.
ROBITUSSIN CF
DELSYM
NEO-SYNEPHRINE
AFRIN
nasal sprays
DIMETAPP DRO DECONGES
Diabetes
alcohol swabs
glucose oral tablets
insulin (vials only)
CURITY ALCOHOL PADS
carbamide peroxide
DEBROX
condoms
contraceptive foam
contraceptive gel
condoms - female
TROJAN
DELFEN
GYNOL II
CONDOMS OTC
Burow’s soln, wet dressings
dermatological baths
hydrocortisone crm, oint
DOMEBORO
COLLOIDAL OATMEAL BATHS
CORTAID
NEOSPORIN
topical antibacterials
MYCITRACIN
HUMULIN
Earwax Removal Products
Family Planning
First Aid
BACITRACIN
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
ST = Step Therapy
SP = Specialty Pharmacy
65
Generic Drug Name
Brand Drug Name Examples
Gastrointestinal
MYLANTA LIQUID
MAALOX LIQUID
antacids liquids, chew tabs
TUMS
IMODIUM A-D
antidiarrheals
KAOPECTATE
PEDIALYTE
PEPCID AC
FLEET ENEMA
DULCOLAX
electrolyte rehydrating soln
famotidine
laxative enemas
laxatives
psyllium
rectal crm, suppositories
simethicone
stool softeners
sugar+orthophosphoric acid
FLEET PHOSPHO-SODA
METAMUCIL
PREPARATION H
MYLICON
COLACE
EMETROL
permethrin
piperonyl butoxide gel, liquid shampoo
NIX
PIPERONYL BUTOXIDE
dimenhydrinate
meclizine
DRAMAMINE
BONINE
allergic conjunctivitis
artificial tears
ALAWAY
HYPOTEARS
VISINE
decongestants
MURINE
Lice Products
Motion Sickness
Ophthalmics
NAPHCON A
Pain
acetaminophen tabs, liquid,
drops, suppositories
TYLENOL
BAYER
aspirin tabs, EC. tabs
ECOTRIN
aspirin with buffers tabs
ADVIL
ibuprofen tabs, chew tabs and susp
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
MOTRIN IB
ST = Step Therapy
SP = Specialty Pharmacy
66
Generic Drug Name
Brand Drug Name Examples
Smoking Cessation Products
COMMIT LOZENGES (QUANTITY LIMIT)
NICODERM CQ (QUANTITY LIMIT)
nicotine
NICOTINE GUM (QUANTITY LIMIT)
NICOTROL (QUANTITY LIMIT)
Vitamins/Minerals
OS-CAL
CALTRATE
calcium
TUMS
iron
ferrous fumarate, ferrous, gluconate,
errous sulfate, ferrous bis-glycinate
chelate and polysaccharide iron caps
iron polysaccharides
magnesium oxide
vitamin D 400 IU
FERGON
FEOSOL
NIFEREX
MAG-OX
VITAMIN D 400 IU
VI-DAYLIN
vitamins pediatric members <3 years old
POLY-VI-SOL
vitamins prenatal
TRI-VI-SOL
STUART PRENATAL
Warts
salicylic acid strip 40%
salicylic acid topical patch 15% OTC
DUOFILM
MOSCO CALLUS/CORN REMOVER OTC
DUOPLANT GEL, COMPOUND W, SALPLANT OTC
CORN/CALLUS REMOVER PAD, CLEAR
AWAY, ONE STEP OTC
MEDIPLAST
MOSCO CALLUS/CORN LIQUID REMOVER
OTC
COMPOUND W STRIPS
TRANS-VER-SAL PATCH
fluoride dental rinse
PHOS-FLUR
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
Miscellaneous
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
ST = Step Therapy
SP = Specialty Pharmacy
67
Index of
of Covered
CoveredDrugs
Drugs
A
abacavir . . . . . . . . . . . . 37
abacavir/dolutegravir/
lamivudine . . . . . . . . . 37
abacavir/lamivudine . . . . . 37
abacavir/lamivudine/
zidovudine . . . . . . . . . 37
ABILIFY MAINTENA . . . . . . 48
ABILIFY TABLETS . . . . . . . 48
abiraterone . . . . . . . . . . . 5
ABREVA OTC . . . . . . . . . 36
acamprosate . . . . . . . . . 45
acarbose . . . . . . . . . . . . 26
ACCOLATE . . . . . . . . . . . 56
ACCUHIST DROPS . . . . . . 49
ACCUHIST PDX DROPS . . . 50
ACCUNEB . . . . . . . . . . . 55
ACCUPRIL . . . . . . . . . . . .8
ACCURETIC . . . . . . . . . . .8
ACCUTANE . . . . . . . . . . 17
acebutalol . . . . . . . . . . . . 9
ACEON . . . . . . . . . . . . . .8
acetaminophen . . . . 13, 39, 66
acetazolamide . . . . . . . . . 44
ACETAZOLAMIDE . . . . . . . 44
acetazolamide
extended-release . . . . . 44
acetic acid . . . . . . . . . . . 22
acetic acid/aluminum acetate22
acetic acid/hydrocortisone . . 22
acetylcysteine . . . . . . . . . 61
acidophilus . . . . . . . . . . 30
ACIDOPHILUS . . . . . . . . . 30
acidophilus/bifidus . . . . . . 31
ACIDOPHILUS/
BIFIDUS WAFER . . . . . 31
acidophilus/citrus pectin . . . 31
ACIDOPHILUS/
CITRUS PECTIN . . . . . . 31
acidophilus/pectin . . . . . . 31
ACIDOPHILUS/PECTIN . . . . 31
ACIDOPHILUS XTRA . . . . . 30
acitretin . . . . . . . . . . . . 20
ACLOVATE . . . . . . . . . . . 19
ACTIFED . . . . . . . . . . 24, 65
ACTIGALL . . . . . . . . . . . 31
ACTIMMUNE . . . . . . . . . . 38
ACTOPLUSMET . . . . . . . . 26
ACTOPLUS MET XR . . . . . 26
ACTOS . . . . . . . . . . . . . 26
ACULAR/ACULAR LS . . . . 43
acyclovir . . . . . . . . . . . . 36
acyclovir buccal . . . . . . . . 36
ADACEL . . . . . . . . . . . . 63
ADALAT CC . . . . . . . . . . 10
adalimumab . . . . . . . . . . 38
ADCIRCA . . . . . . . . . . . . 12
ADDERALL . . . . . . . . . . . 46
ADDERALL XR . . . . . . . . . 46
adefovir . . . . . . . . . . . . 36
ADEMPAS . . . . . . . . . . . 12
ADVAIR DISKUS . . . . . . . . 55
ADVIL . . . . . . . . . 13, 39, 66
afatinib . . . . . . . . . . . . . 4
AFINITOR . . . . . . . . . . . . .4
AFINITOR DISPERZ . . . . . . .4
AFLURIA . . . . . . . . . . . . 62
AFLURIA PF . . . . . . . . . . 62
AFRIN . . . . . . . . . . . 24, 65
agalsidase . . . . . . . . . . . 27
AGRYLIN . . . . . . . . . . . . .7
ALAHIST DM . . . . . . . . . . 53
ALAVERT . . . . . . . . . 23, 64
ALAVERT ALRG
TAB/SINUS . . . . . . 24, 65
ALAVERT-D . . . . . . . . 24, 65
ALAWAY . . . . . . . . . . . . 66
ALAWAY OTC . . . . . . . . . 43
albendazole . . . . . . . . . . 35
ALBENZA . . . . . . . . . . . . 35
albiglutide . . . . . . . . . . . 27
albuterol . . . . . . . . . . . . 55
albuterol SR tabs . . . . . . . 56
albuterol sulfate . . . . . . . . 55
alclometasone . . . . . . . . 19
alcohol swabs . . . . . . . . . 65
ALDACTAZIDE . . . . . . . . . 11
ALDACTONE . . . . . . . . . . 11
ALDARA . . . . . . . . . . . . 21
ALL CAPS = Brand-name drug
lower case = Generic drug
68
ALDOMET . . . . . . . . . . . 12
ALDORIL . . . . . . . . . . . . 12
ALDURAZYME . . . . . . . . . 28
ALECENSA . . . . . . . . . . . .4
alectinib . . . . . . . . . . . . . 4
alendronate . . . . . . . . . . 27
ALESSE . . . . . . . . . . . . . 40
alfuzosin ER . . . . . . . . . . 56
alginic acid/sodium
bicarbonate . . . . . . . . 28
alglucerase . . . . . . . . . . 27
alglucosidase . . . . . . . . . 27
ALINIA . . . . . . . . . . . . . 38
ALINIA SUSPENSION . . . . . 38
alirocumab . . . . . . . . . . 11
alitretinoin 1% gel . . . . . . . 6
ALKERAN . . . . . . . . . . . . 4
ALLANHIST SYP PDX . . . . . 53
ALLEGRA . . . . . . . . . . . . 23
ALLEGRA-D . . . . . . . . . . 24
allergic conjunctivitis . . . . . 66
ALLERGY/CONG . . . . 24, 65
ALLERGY/CONG
TAB RELIEF . . . . . . . . 53
allopurinol . . . . . . . . . . . 40
alpha1-proteinase inhibitor . . 56
ALPHAGAN . . . . . . . . . . 45
ALPHAGAN P . . . . . . . . . 45
alprazolam . . . . . . . . . . . 46
ALTACE . . . . . . . . . . . . . .8
altretamine . . . . . . . . . . . 4
alumina/magnesia . . . . . . 28
alumina/magnesia/
simethicone . . . . . . . . 28
aluminum acetate . . . . . . . 21
aluminum chloride . . . . . . 21
aluminum chloride
hexahydrate . . . . . . . . 21
ALUPENT . . . . . . . . . . . . 56
amantadine . . . . . . . . 15, 36
AMARYL . . . . . . . . . . . . 26
AMBIEN . . . . . . . . . . . . 48
ambrisentan . . . . . . . . . . 12
AMERGE . . . . . . . . . . . . 15
Index of Covered Drugs
AMICAR . . . . . . . . . . . . . 7
AMIKACIN INJ . . . . . . . . . 31
amikacin sulfate inj . . . . . . 31
amiloride . . . . . . . . . . . . 10
amiloride/hydrochlorothiazide10
aminocaproic acid . . . . . . . 7
aminosalicyclic acid . . . . . 33
amiodarone . . . . . . . . . . . 9
amitriptyline . . . . . . . . 15, 47
amitriptyline/perphenazine . 47
amlexanox . . . . . . . . . . . 24
amlodipine . . . . . . . . . . 10
ammonium lactate . . . . . . 21
amoxapine . . . . . . . . . . . 47
amoxicillin . . . . . . . . . . . 34
AMOXICILLIN CAPSULES AND
CHEWABLES . . . . . . . 34
amoxicillin/clavulanate . . . . 34
AMOXIL . . . . . . . . . . . . . 34
AMOXIL SUSP . . . . . . . . . 34
amphetamine/dextroamphetamine mixed salts . . . . 46
amphetamine/dextroamphetamine mixed salts
extended-release . . . . . 46
ampicillin . . . . . . . . . . . 34
ANAFRANIL . . . . . . . . . . 46
anagrelide . . . . . . . . . . . 7
ANAPLEX DM . . . . . . . . . 50
ANAPROX . . . . . . . . . 14, 39
anastrozole . . . . . . . . . . . 5
ANCEF INJ . . . . . . . . . . . 31
ANCOBAN . . . . . . . . . . . 35
ANDEHIST . . . . . . . . . . . 49
ANDRODERM . . . . . . . . . 25
ANDROGEL 1% . . . . . . . . 25
ANDROGEL 1.62% . . . . . . 25
ANDROXY . . . . . . . . . . . 25
ANERGAN . . . . . . . . . . . 33
ANSAID . . . . . . . . . . . . . 13
ANTABUSE . . . . . . . . . . . 45
antacids liquids, chew tabs . 66
ANTARA . . . . . . . . . . . . 11
antidiarrheals . . . . . . . . . 66
antihistamines . . . . . . . . . 64
antipyrine-benzocaine . . . . 22
antitussives . . . . . . . . . . 65
ANTIVERT . . . . . . . . . . . 28
ANUSOL HC 2.5% . . . . . . 21
ANZEMET . . . . . . . . . . . 28
APHEDRID TAB . . . . . . . . 55
APHTHASOL . . . . . . . . . . 24
apixaban . . . . . . . . . . . . 7
aprepitant . . . . . . . . . . . 28
APRESOLINE . . . . . . . . . 12
APRISO . . . . . . . . . . . . . 30
APTIVUS . . . . . . . . . . . . 37
AQUA-MEPHYTO INJ . . . . . 33
ARALAST NP . . . . . . . . . 56
ARALEN . . . . . . . . . . . . 38
ARANESP . . . . . . . . . . . . 7
ARAVA . . . . . . . . . . . . . 39
ARCAPTA NEOHALER . . . . 55
ARICEPT . . . . . . . . . . . . 13
ARIMIDEX . . . . . . . . . . . . 5
aripiprazole . . . . . . . . . . 48
aripiprazole ER injection . . . 48
ARMOUR THYROID . . . . . . 27
AROMASIN . . . . . . . . . . . .5
ARTANE . . . . . . . . . . . . 16
artemether-lumefantrine . . . 37
artificial tears . . . . . . . . . 66
ASACOL HD . . . . . . . . . . 30
ASCRIPTIN . . . . . . . . . . . 39
asfotase alfa . . . . . . . . . . 27
ASMANEX TWISTHALER . . . 55
aspirin . . . . . . . . . . . . 7, 39
aspirin/acetaminophen/
caffeine . . . . . . . . . . 13
aspirin-al hydro-mg
hydro-ca carb . . . . . . . 39
aspirin buffered . . . . . . . . 39
aspirin tabs, EC. tabs . . . . . 66
aspirin with buffers tabs . . . 66
ASTELIN . . . . . . . . . . . . 23
ASTRAMOR INJ . . . . . . . . 31
ATABEX PRENATAL . . . . . . 59
ATARAX . . . . . . . . . . . . . 23
ALL CAPS = Brand-name drug
lower case = Generic drug
69
atazanavir . . . . . . . . . . . 37
atenolol . . . . . . . . . . . . . 9
atenolol/chlorthalidone . . . . 9
ATIVAN . . . . . . . . . . . . . 46
ATIVAN . . . . . . . . . . . . . 46
atomoxetine . . . . . . . . . . 46
atorvastatin . . . . . . . . . . 11
atovaquone . . . . . . . . . . 38
atovaquone/proguanil . . . . 38
ATRALIN . . . . . . . . . . . . 18
ATRIPLA . . . . . . . . . . . . 37
atropine . . . . . . . . . . . . 44
atropine sulfate . . . . . . . . 31
ATROVENT . . . . . . . . . . . 56
ATROVENT HFA . . . . . . . . 55
ATROVENT NS . . . . . . . . . 24
ATUSS DR . . . . . . . . . . . 53
AUBAGIO . . . . . . . . . . . . 15
AUGMENTIN . . . . . . . . . . 34
AURALGAN . . . . . . . . . . 22
auranofin . . . . . . . . . . . 39
AVAPRO . . . . . . . . . . . . . 8
AVC VAGINAL . . . . . . . . . 43
AVEENO CLEAR PADS OTC . 18
AVITA . . . . . . . . . . . . . . 18
AVONEX/AVONEX PEN . . . 15
axitinib . . . . . . . . . . . . . 4
AYGESTIN . . . . . . . . . . . 42
azathioprine . . . . . . . . 6, 39
azelaic acid . . . . . . . . . . 17
azelastine . . . . . . . . . 23, 43
azithromycin . . . . . . . . . . 34
AZOLEN TINCTURE
SOLUTION OTC . . . . . . 20
AZOPT . . . . . . . . . . . . . 44
AZULFIDINE . . . . . . . 30, 39
AZULFIDINE EN-TABS . . 30, 39
B
bacitracin . . . . . . . . . 18, 45
BACITRACIN . . . . . . . 18, 65
bacitracin-polymyxinneomycin HC . . . . . . . 18
baclofen . . . . . . . . . . . . 40
Index of Covered Drugs
BACLOFEN . . . . . . . . . . . 40
BACTRIM . . . . . . . . . . . . 34
BACTRIM DS . . . . . . . . . . 34
BACTROBAN . . . . . . . . . 18
balsalazide . . . . . . . . . . 29
BALZIVA . . . . . . . . . . . . 41
BANZEL . . . . . . . . . . . . 17
BANZEL SUSPENSION . . . . 17
BARACLUDE . . . . . . . . . . 36
BAYER . . . . . . . . . 7, 39, 66
BD POSIFLUSH INJ . . . . . . 33
becaplermin gel . . . . . . . . 21
beclomethasone . . . . . . . 55
bedaquiline . . . . . . . . . . 38
BENA-D-50 INJ . . . . . . . . 32
BENADRYL . . . . . . . . 23, 64
benazepril . . . . . . . . . . . .8
benazepril/hydrochlorothiazide8
BENTYL . . . . . . . . . . . . 29
BENZAC AC . . . . . . . . . . 17
BENZEFOAM . . . . . . . . . 17
BENZIQ . . . . . . . . . . . . . 18
BENZIQ LS . . . . . . . . . . . 18
benzocaine/antipyrine . . . . 22
benzonatate . . . . . . . . . . 49
BENZOTIC . . . . . . . . . . . 22
benzoyl peroxide . . . . . . . 17
benzoyl peroxide bar 10% . . 17
benzoyl peroxide creamy wash
8% & benzoyl peroxide bar
5% k . . . . . . . . . . . . 17
benzoyl peroxide crm, gel, lotion, cleanser, bar, foam,
cloth, wash . . . . . . . . 64
benzoyl peroxide gel . . . . . 18
benzoyl peroxide wash 4%
& benzoyl peroxide
bar 5% kit . . . . . . . . . 18
benztropine . . . . . . . . . . 15
BERINERT . . . . . . . . . . . 61
BETACARE CREAM AND
LOTION . . . . . . . . . . . 64
BETAGAN . . . . . . . . . . . 44
betaine powder for oral
solution . . . . . . . . . . 28
betamethasone
augmented dip . . . . 19, 20
betamethasone dipropionate 19
betamethasone val . . . . . . 19
BETAPACE . . . . . . . . . . . .9
BETAPACE AF . . . . . . . . . .9
BETASERON . . . . . . . . . . 15
BETA-VAL . . . . . . . . . . . . 19
betaxolol . . . . . . . . . . . . 44
bethanechol . . . . . . . . . . 56
BETHKIS . . . . . . . . . . . . 61
BETOPTIC -S . . . . . . . . . . 44
bexarotene caps . . . . . . . . 6
bexarotene topical gel . . . . . 6
BIAXIN . . . . . . . . . . . . . 34
BIAXIN XL . . . . . . . . . . . 34
bicalutamide . . . . . . . . . . 5
BICITRA . . . . . . . . . . . . 57
BILTRICIDE . . . . . . . . . . . 35
BIO-D DRO-MULSION . . . . 57
BIO-D-MULSIO DRO FORTE . 57
bisoprolol . . . . . . . . . . . . 9
bisoprolol/hydrochlorothiazide 9
BLEPH-10 . . . . . . . . . . . 45
BLEPHAMIDE . . . . . . . . . 43
boceprevir . . . . . . . . . . . 36
BONINE . . . . . . . . . . . . 66
BOOSTRIX . . . . . . . . . . . 63
bosentan . . . . . . . . . . . 12
BOSULIF . . . . . . . . . . . . .4
bosutinib . . . . . . . . . . . . 4
BPO CREAMY KIT . . . . . . 17
BRETHINE . . . . . . . . . . . 56
BREVOXYL . . . . . . . . 17, 18
BREVOXYL-4 . . . . . . . . . . 64
BREVOXYL-4 OTC . . . . . . . 18
BRILINTA . . . . . . . . . . . . .7
brimonidine . . . . . . . . 20, 45
brinzolamide . . . . . . . . . 44
BROMALINE DM . . . . . . . 50
BROMETANE DX . . . . . . . 51
BROMFED DM . . . . . . . . . 50
BROMFENEX PD CAP . . . . 49
ALL CAPS = Brand-name drug
lower case = Generic drug
70
bromocriptine . . . . . . 15, 28
brompheniramine maleate . . 23
brompheniramine &
phenylephrine . . . . . . . 49
brompheniramine/pseudoephedrine . . . 24, 49, 50, 65
brompheniramine/
pseudoephedrine/
dextromethorphan . . . . 50
brompheniramine/
pseudoephedrine/dextromethorphan/guaifenesin 50
brompheniramine tannate . . 23
BROVEX CT . . . . . . . . . . 23
BROVEX PSB . . . . . . . . . 49
budesonide . . . . . . . . 29, 55
budesonide/formoterol . . . . 55
BUFFERIN . . . . . . . . . . . 39
bumetanide . . . . . . . . . . 10
BUMEX . . . . . . . . . . . . . 10
BUPHENYL . . . . . . . . . . 27
BUPHENYL ORAL POWDER 27
buprenorphine/naloxone . . . 48
bupropion . . . . . . . . . 47, 49
bupropion
extended-release . . . 47, 48
Burow’s soln, wet dressings . 65
BUSPAR . . . . . . . . . . . . 46
buspirone . . . . . . . . . . . 46
busulfan . . . . . . . . . . . . . 4
butalbital/acetaminophen . . 13
butalbital/acetaminophen/
caffeine . . . . . . . . . . 13
butalbital/apap/caff/cod . . . 14
butalbital/asa/caff/cod . . . . 14
butalbital/aspirin/caffeine . . 13
butorphanol . . . . . . . . . . 14
BYETTA . . . . . . . . . . . . . 27
C
C1 Inhibitor, Human . . . . . 61
cabergoline . . . . . . . . . . 28
cabozantinib . . . . . . . . . . 4
CAFERGOT . . . . . . . . . . 15
Index of Covered Drugs
calamine . . . . . . . . . . . . 21
CALAN . . . . . . . . . . 10, 15
CALAN SR . . . . . . . . . . . 10
calcipotriene . . . . . . . . . 20
calcitonin-salmon . . . . . . . 27
calcitriol . . . . . . . . . . 20, 57
calcium . . . . . . . . . . 57, 67
calcium acetate . . . . . . . . 61
CALICYLIC . . . . . . . . . . . 22
CALTRATE . . . . . . . . . . . 67
CAMPRAL . . . . . . . . . . . 45
canagliflozin . . . . . . . . . . 26
canagliflozin/metformin . . . 26
CANASA . . . . . . . . . . . . 30
capecitabine . . . . . . . . . . 4
CAPEX SHAMOO . . . . . . . 19
CAPOTEN . . . . . . . . . . . . 8
CAPOZIDE . . . . . . . . . . . .8
CAPRELSA . . . . . . . . . . . .5
capsaicin . . . . . . . . . . . 39
captopril . . . . . . . . . . . . .8
captopril/hydrochlorothiazide . 8
CAPTOPRIL POWDER . . . . . 8
CARAC . . . . . . . . . . . . . 21
CARAFATE . . . . . . . . . . . 29
CARAFATE SUSPENSION . . 29
CARBAGLU . . . . . . . . . . 27
carbamazepine . . . . . . . . 16
carbamazepine
extended-release . . . . . 16
carbamazepine SR . . . . . . 16
carbamide peroxide . . . 22, 65
CARBATROL . . . . . . . . . 16
carbetapentane/chlorpheniramine/ephedrine/
phenylephrine . . . . . . . 50
carbidopa/levodopa . . . . . 15
carbidopa/levodopa
extended-release . . . . . 15
carbinoxamine/
pseudoephedrine . . . . . 50
CARBOFED . . . . . . . . . . 50
CARDEC-DM . . . . . . . . . . 51
CARDEC DM DRO . . . . . . 53
CARDEC DM SYP . . . . . . . 53
CARDEC DRO . . . . . . . . . 51
CARDEC SYP . . . . . . . 49, 51
CARDENE . . . . . . . . . . . 10
CARDIZEM . . . . . . . . . . . 10
CARDIZEM CD . . . . . . . . . 10
CARDIZEM LA . . . . . . . . . 10
CARDIZEM SR . . . . . . . . . 10
CARDURA . . . . . . . . . 8, 56
CARDURA XL . . . . . . . . . 56
carglumic acid . . . . . . . . 27
carteolol . . . . . . . . . . . . 44
carvedilol . . . . . . . . . . . . 9
casanthranol-docusate
sodium . . . . . . . . . . 30
CASODEX . . . . . . . . . . . . 5
CATAFLAM . . . . . . . . . . . 39
CATAPRES . . . . . . . . . . . .8
CATAPRES-TTS . . . . . . . . . 8
CAZIANT . . . . . . . . . . . . 41
CECLOR . . . . . . . . . . . . 34
cefaclor . . . . . . . . . . . . 34
cefadroxil . . . . . . . . . . . 34
cefazolin sodium for inj . . . . 31
cefdinir . . . . . . . . . . . . . 34
cefixime . . . . . . . . . . . . 34
cefpodoxime . . . . . . . . . 34
cefprozil . . . . . . . . . . . . 34
CEFTIN . . . . . . . . . . . . . 34
CEFTRIAX/DEX INJ . . . . . . 32
CEFTRIAXONE INJ . . . . . . 32
CEFTRIAXONE/ INJ DEX . . . 32
ceftriaxone sodium for inj . . 32
ceftriaxone sodium for iv soln 1
gm and dextrose 3.74% . 32
ceftriaxone sodium in
dextrose inj . . . . . . . . 32
cefuroxime axetil . . . . . . . 34
CEFZIL . . . . . . . . . . . . . 34
CELEBREX . . . . . . . . . . . 39
celecoxib . . . . . . . . . . . 39
CELEXA . . . . . . . . . . . . 47
CELLCEPT . . . . . . . . . . . .6
CELONTIN . . . . . . . . . . . 16
ALL CAPS = Brand-name drug
lower case = Generic drug
71
CENESTIN . . . . . . . . . . . 42
CENOGEN OB/ULTRA . . . . 60
CENTRUM . . . . . . . . . . . 58
cephalexin . . . . . . . . . . . 34
CEREDASE . . . . . . . . . . . 27
CEREZYME . . . . . . . . . . 27
ceritinib . . . . . . . . . . . . . 4
CERVARIX . . . . . . . . . . . 62
CESIA . . . . . . . . . . . . . . 41
CETAPHIL CREAM AND
LOTION . . . . . . . . . . . 64
cetirizine . . . . . . . . . . . . 23
cetirizine chew tab . . . . . . 23
cetirizine hydrochloride/pseudoephedrine hydrochloride 12
hours extended-release . . 24
cetirizine/pseudoephedrine
OTC . . . . . . . . . . . . 65
CHANTIX . . . . . . . . . . . . 49
CHERATUSSIN AC . . . . . . 51
CHILD IBUPRO SUS COLD . 55
chloral hydrate . . . . . . . . 48
CHLORAL HYDRATE . . . . . 48
chlorambucil . . . . . . . . . . 4
chlordiazepoxide . . . . . . . 46
chlorhexidine . . . . . . . . . 24
chlorhexidine gluconate . . . 24
chloroquine phosphate . . . . 38
chlorothiazide . . . . . . . . . 10
chlorothiazide . . . . . . . . . 10
CHLORPHENIRAMINE . . . . 23
chlorpheniramine/
dextromethorphan . . . . 51
chlorpheniramine
extended-release . . . . . 23
chlorpheniramine maleate . . 23
chlorpheniramine maleate
phenylephrine HCL . . . . 51
chlorpheniramine/
phenylephrine . . . . . . . 51
chlorpheniramine/phenylephrine/pyrilamine . . . . . . 24
chlorpheniramine/
pseudoephedrine 24, 51, 65
Index of Covered Drugs
chlorpheniramine tannate . . 23
chlorpheniramine tan/
phenylephrine tan . . . . 51
chlorphen-PEmethscopolamine . . . . 50
chlorphen tan/
carbetapentane tan . . . . 50
chlorphen tan/
pseudoeph tan . . . . . . 50
chlorphen tan/pyrilamine tan/
PE tan . . . . . . . . . . . 50
chlorpromazine . . . . . . . . 49
chlorpropamide . . . . . . . . 26
chlorthalidone . . . . . . . . . 10
CHLORTHALIDONE . . . . . . 10
CHLOR-TRIMETON . . . . . . 64
CHLOR-TRIMETON
ALLERGY . . . . . . . . . 23
CHLOR-TRIMETON SYRUP . 23
chlorzoxazone . . . . . . . . . 40
CHOLBAM . . . . . . . . . . . 28
cholecalciferol . . . . . . . . . 57
cholestyramine . . . . . . . . 11
cholic acid . . . . . . . . . . . 28
ciclopirox . . . . . . . . . . . 20
cidofovir . . . . . . . . . . . . 35
cilostazol . . . . . . . . . . . . 7
CILOXAN . . . . . . . . . . . . 45
cimetidine . . . . . . . . . . . 29
cinacalcet . . . . . . . . . . . 61
CIPRO . . . . . . . . . . . . . 34
CIPRODEX . . . . . . . . . . . 22
ciprofloxacin . . . . . . . 34, 45
ciprofloxacin 0.2% in d5w . . 32
ciprofloxacin/dexamethasone22
ciprofloxacin iv soln 1% . . . 32
CIPRO I.V. INJ . . . . . . . . . 32
CIPRO I.V. SOL . . . . . . . . . 32
citalopram . . . . . . . . . . . 47
clarithromycin . . . . . . . . . 34
clarithromycin ER . . . . . . . 34
CLARITIN . . . . . . . . . 23, 64
CLARITIN CHEW . . . . . . . 23
CLARITIN RDT . . . . . . . . . 23
CLEAN & CLEAR GEL . . . . 18
CLEARASIL . . . . . . . . . . 64
CLEAR EYES REDNESS
RELIEF . . . . . . . . . . . 43
clemastine . . . . . . . . . . . 23
CLEMASTINE . . . . . . . . . 23
CLEOCIN . . . . . . . . . 38, 42
CLEOCIN PHOS INJ . . . . . 32
CLEOCIN T . . . . . . . . . . . 18
CLIMARA . . . . . . . . . . . . 42
clindamycin . . . . . . 18, 38, 42
clindamycin phosphate inj . . 32
CLINORIL . . . . . . . . . 14, 40
clobazam . . . . . . . . . . . 16
clobazam suspension . . . . 16
clobetasol propionate . . . . 20
clomipramine . . . . . . . . . 46
clonazepam . . . . . . . 16, 46
clonazepam ODT . . . . . . . 46
clonidine . . . . . . . . . . . . 8
clonidine transdermal . . . . . 8
clopidogrel . . . . . . . . . . . 7
clorazepate . . . . . . . . . . 46
clotrimazole . . . .20, 35, 42, 64
CLOTRIMAZOLE . . . . . . . . 20
clotrimazole crystals . . . . . 20
clotrimazole with
betamethasone . . . . . . 20
clozapine . . . . . . . . . . . 48
CLOZARIL . . . . . . . . . . . 48
COARTEM . . . . . . . . . . . 37
cobicistat . . . . . . . . . . . 38
cobicistat/elvitegravir/
emtricitabine/tenofovir . . 37
cobimetinib . . . . . . . . . . . 4
CODAL-DM . . . . . . . . . . . 54
codeine/acetaminophen . . . 14
codeine/chlorpheniramine/
pseudoephedrine . . . . . 51
codeine/guaifenesin . . . . . 51
codeine/guaifenesin/
pseudoephedrine . . . . . 51
codeine/promethazine . . . . 51
ALL CAPS = Brand-name drug
lower case = Generic drug
72
codeine/promethazine/
phenylephrine . . . . . . . 51
codeine sulfate . . . . . . . . 14
CODIMAL DH . . . . . . . . . 54
COGENTIN . . . . . . . . . . . 15
COLACE . . . . . . . . . 30, 66
COLAZAL . . . . . . . . . . . 29
colchicine . . . . . . . . . . . 40
COLCRYS . . . . . . . . . . . 40
COLESTID . . . . . . . . . . . 11
coliestipol . . . . . . . . . . . 11
collagenase oint . . . . . . . 21
COLLOIDAL OATMEAL
BATHS . . . . . . . . . . . 65
COLOCORT . . . . . . . . . . 29
COLYTE . . . . . . . . . . . . 30
COMBIVENT RESPIMAT . . . 55
COMBIVIR . . . . . . . . . . . 37
COMETRIQ . . . . . . . . . . . 4
COMMIT LOZENGES . . . . . 67
COMMITT . . . . . . . . . . . 49
COMPAZINE . . . . . . . . . . 28
COMPLERA . . . . . . . . . . 37
COMPLETE NATALCARE
PAK DHA . . . . . . . . . . 59
COMPOUND W STRIPS . . . 67
COMTAN . . . . . . . . . . . . 16
CONCERTA . . . . . . . . . . 46
condoms . . . . . . . . . . . 65
condoms - female . . . . . . . 65
CONDOMS OTC . . . . . . . . 65
CONDYLOX SOL . . . . . . . 21
conjugated estrogen/
bazedoxifene . . . . . . . 43
contraceptive foam . . . . . . 65
contraceptive gel . . . . . . . 65
COPAXONE . . . . . . . . . . 15
CORDARONE . . . . . . . . . .9
CORDRAN . . . . . . . . . . . 19
COREG . . . . . . . . . . . . . .9
CORGARD . . . . . . . . . . . .9
CORICIDIN TAB CGH/CLD . 51
Index of Covered Drugs
CORN/CALLUS REMOVER
PAD, CLEAR AWAY, ONE
STEP OTC . . . . . . . . . 67
CORTAID . . . . . . . . . . . . 65
CORTAID SOLUTION OTC . . 19
CORTEF . . . . . . . . . . . . 25
CORTIFOAM AEROSOL . . . 21
cortisone acetate . . . . . . . 25
CORTISPORIN . . . . . . 18, 43
CORTISPORIN OTIC . . . . . 23
CORTIZONE . . . . . . . . . . 19
CORTIZONE-10 INTENSIVE
HEALING . . . . . . . . . . 19
COSOPT . . . . . . . . . . . . 44
COSOPT PF . . . . . . . . . . 44
COTELLIC . . . . . . . . . . . . 4
COUMADIN . . . . . . . . . . . 7
COZAAR . . . . . . . . . . . . .8
CPM/PSE . . . . . . . . . . . 51
CREON . . . . . . . . . . . . . 30
CREON DR . . . . . . . . . . . 30
CRIXIVAN . . . . . . . . . . . . 37
crizotinib . . . . . . . . . . . . 4
CROLOM . . . . . . . . . . . . 43
cromolyn . . . . . . . . . 55, 56
cromolyn sodium . . . . . 24, 43
crotamiton . . . . . . . . . . . 21
CUPRIMINE . . . . . . . . . . 39
CURITY ALCOHOL PADS . . 65
CUTIVATE . . . . . . . . . . . 19
CUTIVATE LOTION . . . . . . 19
cyanocobalamin . . . . . . . 57
CYCLESSA . . . . . . . . . . . 41
cyclobenzaprine . . . . . . . 40
CYCLOGYL . . . . . . . . . . . 44
cyclopentolate . . . . . . . . . 44
cyclophosphamide . . . . . . . 4
cycloserine . . . . . . . . . . 33
cyclosporine . . . . . . . . 6, 45
cyclosporine, modified . . . . . 6
CYMBALTA . . . . . . . . . . . 47
cyproheptadine . . . . . . . . 23
CYPROHEPTADINE . . . . . . 23
CYSTADANE . . . . . . . . . . 28
CYSTAGON . . . . . . . . . . . 6
CYSTARAN . . . . . . . . . . . 45
cysteamine 0.44%
ophthalmic solution . . . . 45
cysteamine bitartrate . . . . . . 6
CYSTOSPAZ . . . . . . . . . . 29
CYTOMEL . . . . . . . . . . . 27
CYTOTEC . . . . . . . . . . . 31
CYTOVENE . . . . . . . . . . . 35
CYTOXAN . . . . . . . . . . . . 4
D
D3-50 CAP . . . . . . . . . . . 57
D5W/NACL INJ . . . . . . . . 33
dabigatran etexilate mesylate . 7
dabrafenib . . . . . . . . . . . 4
daclatasvir . . . . . . . . . . . 36
DAKLINZA . . . . . . . . . . . 36
DALLERGY DM . . . . . . . . 50
DALMANE . . . . . . . . . . . 48
danazol . . . . . . . . . . . . 41
DANOCRINE . . . . . . . . . . 41
DANTRIUM . . . . . . . . . . . 40
dantrolene . . . . . . . . . . . 40
dapsone . . . . . . . . . . . . 38
DAPSONE . . . . . . . . . . . 38
DARAPRIM . . . . . . . . . . . 38
darbepoetin alfa . . . . . . . . 7
darunavir . . . . . . . . . . . 37
darunavir/cobicistat . . . . . 38
dasatinib . . . . . . . . . . . . 4
DAYPRO . . . . . . . . . . 14, 39
DDAVP . . . . . . . . . . . . . 28
DEBROX . . . . . . . . . 22, 65
DECADRON . . . . . . . . . . 25
DE-CHLOR DM . . . . . . . . 53
DECLOMYCIN . . . . . . . . . 35
DECONEX . . . . . . . . . . . 54
DECONEX IR . . . . . . . . . . 54
decongestants . . . . . . . . 66
deferasirox . . . . . . . . . . . 61
deferiprone . . . . . . . . . . 61
DELATESTRYL . . . . . . . . . 25
delavirdine . . . . . . . . . . . 36
ALL CAPS = Brand-name drug
lower case = Generic drug
73
DELFEN . . . . . . . . . . . . 65
DELOS . . . . . . . . . . . 17, 64
DELSYM . . . . . . . . . . 52, 65
DELTASONE . . . . . . . . . . 25
DELZICOL . . . . . . . . . . . 30
DEMADEX . . . . . . . . . . . 11
demeclocycline . . . . . . . . 35
DEMEROL . . . . . . . . . . . 14
DENAVIR . . . . . . . . . . . . 36
DEPAKENE . . . . . . . . . . . 17
DEPAKOTE . . . . . . 15, 16, 47
DEPAKOTE
SPRINKLE . . . . 15, 16, 47
DEPEN TITRATABLE . . . . . 39
DEPO-PROVERA . . . . . . . 40
DEPO-TESTOSTERONE . . . 25
DERMAPHOR OINTMENT . . 64
DERMA-SMOOTHE OIL/FS . 19
dermatological baths . . . . . 65
DERMATOP . . . . . . . . . . 19
DESENEX . . . . . . . . . . . 20
desipramine . . . . . . . . . . 47
desmopressin . . . . . . . . . 28
desogestrel/EE . . . . . . 40, 41
DESYREL . . . . . . . . . . . . 48
DETROL . . . . . . . . . . . . 57
DETROL LA . . . . . . . . . . 57
dexamethasone . . . . . 25, 44
dexamethasone sodium
phosphate . . . . . . . . . 44
DEXASOL . . . . . . . . . . . 44
dexchlorpheniramine maleate23
DEXEDRINE . . . . . . . . . . 46
DEXEDRINE SPANSULE . . . 46
dextroamphetamine . . . . . 46
dextroamphetamine
extended-release . . . . . 46
dextromethorphan/
brompheniramine/
pseudoephedrine . . . . . 51
dextromethorphan/
carbinoxamine/
pseudoephedrine . . . . . 51
Index of Covered Drugs
dextromethorphanguaifenesin . . . . . . 51, 52
dextromethorphan/
guaifenesin . . . . . . . . 52
dextromethorphan HBR . . . 52
dextromethorphan polistirex
extended-release . . . . . 52
dextromethorphan/
promethazine . . . . . . . 52
dextromethorphan/quinidine 49
dextrose 5% w/ sodium
chloride 0.45% . . . . . . 33
dextrose inj . . . . . . . . . . 33
dextrose inj . . . . . . . . . . 33
DEXTROSE INJ . . . . . . . . 33
DEXTROSTAT . . . . . . . . . 46
D.H.E. 45 . . . . . . . . . . . . 15
DHS SAL SHAMPOO OTC . . 22
DIABINESE . . . . . . . . . . . 26
DIAMOX SEQUELS . . . . . . 44
DIAQUA-2 INJ . . . . . . . . . 33
DIASTAT ACUDIAL . . . . . . . 16
DIASTAT PEDIATRIC . . . . . 16
diazepam . . . . .16, 33, 40, 46
DIAZEPAM INTENSOL . . . . 46
diclofenac 1% gel . . . . . . . 39
diclofenac potassium . . . . . 39
diclofenac sodium . . . . . . 43
diclofenac sodium
delayed-release . . . . 13, 39
diclofenac sodium
extended-release . . . . . 39
diclofenac sodium SR . . . . 13
dicloxacillin . . . . . . . . . . 34
DICLOXACILLIN . . . . . . . . 34
dicyclomine . . . . . . . . . . 29
didanosine . . . . . . . . . . 37
didanosine delayed-release . 37
DIDRONEL . . . . . . . . . . . 27
diflorasone diacetate . . . . . 19
DIFLUCAN . . . . . . . . 35, 42
diflunisal . . . . . . . . . . . . 39
digoxin . . . . . . . . . . . . . 9
DIHISTINE DH . . . . . . . . . 51
dihydroergotamine . . . . . . 15
DIHYDRO-PE SYP . . . . . . . 53
DILACOR XR . . . . . . . . . 10
DILANTIN . . . . . . . . . . . . 17
DILANTIN INFATABS . . . . . 17
DILATRATE-SR . . . . . . . . . 11
DILAUDID . . . . . . . . . . . . 14
diltiazem . . . . . . . . . . . . 10
diltiazem extended-release . . 10
diltiazem sustained-release . 10
DIMEATAPP DRO
DECONGES . . . . . . . . 24
dimenhydrinate . . . . . . . . 66
DIMETAPP . . . . . . . . . . . 65
DIMETAPP CLD ELX/
ALLERGY . . . . . . . . . 49
DIMETAPP DM . . . . . . . . . 53
DIMETAPP DRO DCON/CGH53
DIMETAPP DRO DECONGES 65
DIMETAPP ELX CLD/ALLE . . 49
DIMETAPP SYP CGH/CLD . . 51
dimethyl fumarate . . . . . . . 15
DIOVAN . . . . . . . . . . . . . .8
DIOVAN HCT . . . . . . . . . . .9
DIPENTUM . . . . . . . . . . . 30
diphenhydramine . . . . 23, 48
diphenhydramine hcl inj . . . 32
diphenoxylate/atropine . . . . 28
diphtheria-tetanus tox
adsorbed (dt) im . . . . . 62
DIPROLENE . . . . . . . 19, 20
DIPROLENE AF . . . . . . . . 19
DIPROSONE . . . . . . . . . . 19
DIP/TET PED INJ . . . . . . . 62
dipyridamole . . . . . . . . . . 7
disopyramide . . . . . . . . . . 9
disopyramide extended-release9
disulfiram . . . . . . . . . . . 45
DITROPAN . . . . . . . . . . . 57
DITROPAN XL . . . . . . . . . 57
DIURIL . . . . . . . . . . . . . 10
DIURIL ORAL SUSPENSION . 10
divalproex sodium
cap sprinkle . . . 15, 16, 47
ALL CAPS = Brand-name drug
lower case = Generic drug
74
divalproex sodium
delayed-release . . 15, 16, 47
DIVIGEL . . . . . . . . . . . . . 42
docosanol . . . . . . . . . . . 36
docusate calcium plus . . . . 30
docusate potasssium . . . . . 30
docusate sodium . . . . . . . 30
dofetilide . . . . . . . . . . . . 9
dolasetron . . . . . . . . . . . 28
DOLOBID . . . . . . . . . . . . 39
DOLOPHINE . . . . . . . . . . 14
dolutegravir . . . . . . . . . . 38
DOMEBORO . . . . . . . . . . 65
DOMEBORO OTIC . . . . . . 22
donepezil . . . . . . . . . . . 13
dornase alfa . . . . . . . . . . 61
dorzolamide . . . . . . . . . . 44
dorzolamide HCL-timolol
maleate . . . . . . . . . . 44
dorzolamide/timolol maleate 44
DOSTINEX . . . . . . . . . . . 28
DOVONEX . . . . . . . . . . . 20
doxazosin . . . . . . . . . . 8, 56
doxazosin SR . . . . . . . . . 56
doxepin . . . . . . . . . . . . 47
doxycycline delayed-release . 35
doxycycline hyclate . . . . . . 35
doxycycline monohydrate . . 35
DOXYCYCLINE
MONOHYDRATE . . . . . 35
DRAMAMINE . . . . . . . . . 66
DRISDOL . . . . . . . . . . . . 57
dronabinol . . . . . . . . . . . 28
dronedarone . . . . . . . . . . 9
DROXIA . . . . . . . . . . . . . .6
DRYSOL OTC . . . . . . . . . 21
DUAVEE . . . . . . . . . . . . 43
DUETACT . . . . . . . . . . . . 26
DULCOLAX . . . . . . . . . . 66
DULERA . . . . . . . . . . . . 55
duloxetine . . . . . . . . . . . 47
DUOFILM . . . . . . . . . 21, 67
DUONEB . . . . . . . . . . . . 56
DUOPLANT GEL, COMPOUND
W, SAL-PLANT OTC . . . . 67
Index of Covered Drugs
DURADRYL . . . . . . . . . . 50
DURAGESIC . . . . . . . . . . 14
DURAMORPH INJ . . . . . . . 31
DURATUSS DM ELX . . . . . 51
DURICEF . . . . . . . . . . . . 34
DYAZIDE . . . . . . . . . . . . 11
DYNACIRC . . . . . . . . . . . 10
E
ecothiophate . . . . . . . . . 44
ECOTRIN . . . . . . . . 7, 39, 66
ED A-HIST TABLETS AND
LIQUID . . . . . . . . . . . 51
EDGE OB CHW . . . . . . . . 59
edoxaban . . . . . . . . . . . . 7
EDURANT . . . . . . . . . . . 36
E.E.S. . . . . . . . . . . . . . . 34
efavirenz . . . . . . . . . . . . 36
efavirenz/emtricitabine/
tenofovir . . . . . . . . . . 37
EFFEXOR . . . . . . . . . . . . 47
EFFEXOR XR . . . . . . . . . . 47
EFUDEX . . . . . . . . . . . . 21
ELAPRASE . . . . . . . . . . . 27
ELAVIL . . . . . . . . . . . 15, 47
elbasvir/grazoprevir . . . . . . 36
ELDEPRYL . . . . . . . . . . . 16
electrolyte . . . . . . . . . 57, 66
ELELYSO . . . . . . . . . . . . 28
ELESTRIN . . . . . . . . . . . 42
ELIDEL . . . . . . . . . . . . . 22
ELIMITE . . . . . . . . . . . . . 21
ELIQUIS . . . . . . . . . . . . . .7
ELMIRON . . . . . . . . . . . . 57
ELOCON . . . . . . . . . . . . 19
eltrombopag . . . . . . . . . . 62
elvitegravir/cobicistat/emtricitabine/tenofovir alafenamide fumarate . . . . . . 37
EMCYT . . . . . . . . . . . . . .4
EMEND . . . . . . . . . . . . . 28
EMETROL . . . . . . . . . . . 66
EMLA . . . . . . . . . . . . . . 22
emollients . . . . . . . . . . . 64
empagliflozin . . . . . . . . . 26
empagliflozin/metformin . . . 26
emtricitabine . . . . . . . . . 37
emtricitabine/rilpivirine/
tenofovir . . . . . . . . . . 37
emtricitabine/tenofovir . . . . 37
EMTRIVA . . . . . . . . . . . . 37
enalapril . . . . . . . . . . . . . 8
enalapril/hydrochlorothiazide . 8
ENBREL . . . . . . . . . . . . 39
enfuvirtide . . . . . . . . . . . 35
ENGERIX-B . . . . . . . . . . . 62
ENJUVIA . . . . . . . . . . . . 42
enoxaparin . . . . . . . . . . . 7
entacapone . . . . . . . . . . 16
entecavir . . . . . . . . . . . . 36
ENTERIC COATEDNAPROSYN . . . . . . 14, 39
ENTEX LQ LIQ . . . . . . . . . 54
ENTOCORT EC . . . . . . . . 29
ENTRESTO . . . . . . . . . . . .9
ENULOSE . . . . . . . . . . . 30
E-OINTMENT . . . . . . . . . 64
EPANED . . . . . . . . . . . . . 8
epinephrine . . . . . . . . . . 61
EPINEPHRINE AUTO-INJECT BY
IMPAX LABS . . . . . . . . 61
EPIPEN . . . . . . . . . . . . . 61
EPIPEN JR. . . . . . . . . . . . 61
EPITOL . . . . . . . . . . . . . 16
EPIVIR . . . . . . . . . . . . . . 37
EPIVIR HBV . . . . . . . . . . . 36
eplerenone . . . . . . . . . . 12
epoetin alfa . . . . . . . . . . . 7
EPOGEN . . . . . . . . . . . . .7
epoprostenol . . . . . . . . . 12
EPZICOM . . . . . . . . . . . . 37
EQUATRO . . . . . . . . . . . 16
ergocalciferol . . . . . . . . . 57
ergotamine/caffeine . . . . . 15
ergotamine tartrate/caffeine . 15
ERIVEDGE . . . . . . . . . . . .6
erlotinib . . . . . . . . . . . . . 4
ERYC . . . . . . . . . . . . . . 34
ALL CAPS = Brand-name drug
lower case = Generic drug
75
ERYGEL . . . . . . . . . . . . 18
ERY-TAB . . . . . . . . . . . . 34
ERYTHROCIN . . . . . . . . . 34
erythromycin . . . . . . . 18, 45
ERYTHROMYCIN . . . . . . . 45
erythromycin delayed-release 34
erythromycin ethylsuccinate . 34
erythromycin stearate . . . . . 34
erythromycin/sulfisoxazole . . 34
ESBRIET . . . . . . . . . . . . 62
escitalopram . . . . . . . . . 47
ESGIC . . . . . . . . . . . . . 13
ESKALITH CR . . . . . . . . . 47
ESKIMO-3 . . . . . . . . . . . 58
esomeprazole . . . . . . . . . 29
estazolam . . . . . . . . . . . 48
esterified estrogens . . . . . . 42
ESTRACE . . . . . . . . . 41, 42
estradiol . . . . . . . . . . 41, 42
estradiol acetate . . . . . . . 42
ESTRADIOL TDS . . . . . . . 42
estramustine
phosphate sodium . . . . . 4
ESTRASORB . . . . . . . . . . 42
ESTRING . . . . . . . . . . . . 41
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 . . . . . . . . . . . 39
ethambutol . . . . . . . . . . 33
ethionamide . . . . . . . . . . 33
ethosuximide . . . . . . . . . 16
ethynodiol diacetate/EE . . . 41
etidronate . . . . . . . . . . . 27
etodolac . . . . . . . . . . 13, 39
etonogestrel/EE . . . . . . . . 40
Index of Covered Drugs
etoposide . . . . . . . . . . . . 6
etravirine . . . . . . . . . . . . 38
EULEXIN . . . . . . . . . . . . .5
EURAX . . . . . . . . . . . . . 21
EVAMIST . . . . . . . . . . . . 42
everolimus . . . . . . . . . . 4, 6
EVISTA . . . . . . . . . . . . . 27
EXCEDRIN MIGRAINE . . . . 13
EXELON . . . . . . . . . . . . 13
exemestane . . . . . . . . . . . 5
exenatide . . . . . . . . . . . 27
EXJADE . . . . . . . . . . . . . 61
exogabine . . . . . . . . . . . 16
EXTAVIA . . . . . . . . . . . . 15
EXTINA . . . . . . . . . . . . . 20
EXUVIANCE . . . . . . . . . . 18
ezetimibe . . . . . . . . . . . 11
F
FABRAZYME . . . . . . . . . . 27
famciclovir . . . . . . . . . . . 36
famotidine . . . . . . . . 29, 66
FAMVIR . . . . . . . . . . . . . 36
FARESTON . . . . . . . . . . . .5
FARYDAK . . . . . . . . . . . 4, 6
FAZACLO . . . . . . . . . . . . 48
febuxostat . . . . . . . . . . . 40
felbamate . . . . . . . . . . . 16
FELBATOL . . . . . . . . . . . 16
FELDENE . . . . . . . . . 14, 39
felodipine extended-release . 10
FEMARA . . . . . . . . . . . . .5
FEMRING . . . . . . . . . . . . 42
fenofibrate . . . . . . . . . . . 11
fenoprofen . . . . . . . . 13, 39
FENTANYL CIT INJ . . . . . . 31
fentanyl citrate inj . . . . . . . 31
fentanyl transdermal . . . . . 14
FEOSOL . . . . . . . . . . 58, 67
FERGON . . . . . . . . . . . . 67
FERRIPROX . . . . . . . . . . 61
ferrous bisglycinate/
polysaccarides iron . . . . 58
ferrous sulfate . . . . . . . . . 58
fexofenadine . . . . . . . . . . 23
fexofenadine/
pseudoephedrine . . . . . 24
filgrastim . . . . . . . . . . . . 7
FINACEA . . . . . . . . . . . . 17
finasteride . . . . . . . . . . . 56
fingolimod . . . . . . . . . . . 15
FIORICET . . . . . . . . . . . . 13
FIORICET W/CODEINE . . . . 14
FIORINAL . . . . . . . . . . . . 13
FIORINAL W/CODEINE . . . . 14
FIRAZYR . . . . . . . . . . . . 61
FIRST-LANSOPRAZOLE . . . 29
FLAGYL . . . . . . . . . . 38, 42
flecainide . . . . . . . . . . . . 9
FLEET ENEMA . . . . . . . . . 66
FLEET PHOSPHO-SODA . . . 66
FLEXERIL . . . . . . . . . . . . 40
FLOLAN . . . . . . . . . . . . 12
FLOMAX . . . . . . . . . . . . 56
FLONASE . . . . . . . . . . . . 24
FLORANEX . . . . . . . . . . . 31
FLORINEF . . . . . . . . . . . 25
FLOVENT HFA . . . . . . . . . 55
FLOXIN . . . . . . . . . . . . . 34
FLOXIN OTIC . . . . . . . . . . 23
FLUARIX QUAD . . . . . . . . 62
FLUBLOK . . . . . . . . . . . . 62
FLUCELVAX . . . . . . . . . . 63
fluconazole . . . . . . . . 35, 42
flucytosine . . . . . . . . . . . 35
fludrocortisone . . . . . . . . 25
FLULAVAL QUAD . . . . . . . 62
FLUMADINE . . . . . . . . . . 36
fluocinolone acetonide . . . . 19
fluocinonide . . . . . . . . . . 19
fluoride . . . . . . . . . . . . . 58
fluoride dental rinse . . . . . 67
fluorometholone . . . . . . . 44
FLUOROPLEX . . . . . . . . . 21
fluorouracil . . . . . . . . . . 21
fluoxetine . . . . . . . . . . . 47
fluoxymesterone . . . . . . . 25
fluphenazine . . . . . . . . . 49
fluphenazine decanoate . . . 49
ALL CAPS = Brand-name drug
lower case = Generic drug
76
flurandrenolide . . . . . . . . 19
flurazepam . . . . . . . . . . 48
flurbiprofen . . . . . . . . 13, 43
flutamide . . . . . . . . . . . . 5
fluticasone . . . . . . . . . . . 24
fluticasone HFA . . . . . . . . 55
fluticasone propionate . . . . 19
fluticasone/salmeterol . . . . 55
FLUVIRIN . . . . . . . . . . . . 63
fluvoxamine . . . . . . . . . . 46
fluvoxamine SR . . . . . . . . 46
FLUZONE HD PF . . . . . . . 62
FLUZONE QUAD . . . . . . . 62
FLUZONE SPLT . . . . . . . . 62
FML . . . . . . . . . . . . . . 44
FML FORTE . . . . . . . . . . 44
FML LIQUIFILM . . . . . . . . 44
folic acid . . . . . . . . . . . . 58
FOLIC ACID . . . . . . . . . . 58
FOLTABS PAK PLUS DHA RE
OB + DHA PAK . . . . . . 59
FOLTABS PRENATAL . . . . . 59
FORADIL AEROLIZER . . . . 55
FORFIVO XL . . . . . . . . . . 47
formoterol . . . . . . . . . . . 55
FORTEO . . . . . . . . . . . . 27
FORTICAL . . . . . . . . . . . 27
FOSAMAX . . . . . . . . . . . 27
fosamprenavir . . . . . . . . . 37
foscarnet sodium . . . . . . . 35
FOSCAVIR . . . . . . . . . . . 35
fosinopril . . . . . . . . . . . . 8
fosinopril/hydrochlorothiazide 8
FOSRENOL . . . . . . . . . . 61
FUNGOID TINCTURE KIT . . 20
FURADANTIN SUSP . . . . . 38
furosemide . . . . . . . . . . 10
furosemide inj . . . . . . . . . 33
FUZEON . . . . . . . . . . . . 35
G
gabapentin . . . . . . . . . . 16
GABITRIL . . . . . . . . . . . . 17
galantamine . . . . . . . . . . 13
Index of Covered Drugs
ganciclovir . . . . . . . . . . . 35
GARDASIL . . . . . . . . . . . 62
GARDASIL 9 . . . . . . . . . . 62
gatifloxin . . . . . . . . . . . . 45
GATTEX . . . . . . . . . . . . 31
gefitinib . . . . . . . . . . . . . 4
GEL-KAM . . . . . . . . . . . . 58
gemfibrozil . . . . . . . . . . . 11
GENGRAF . . . . . . . . . . . .6
GENOTROPIN . . . . . . . . . 27
GENTAK . . . . . . . . . . 18, 45
gentamicin . . . . . . . . 18, 45
gentamicin/prednisolone
acetate . . . . . . . . . . . 43
GENTEX ADE . . . . . . . . . 59
GENVOYA . . . . . . . . . . . 37
GEODON . . . . . . . . . . . . 49
GG/DM CR . . . . . . . . . . . 52
GG/PSE CR . . . . . . . . . . 52
GILENYA . . . . . . . . . . . . 15
GILOTRIF . . . . . . . . . . . . .4
GILPHEX TR . . . . . . . . . . 54
glatiramer acetate . . . . . . . 15
GLATOPA . . . . . . . . . . . . 15
GLEEVEC . . . . . . . . . . . . 4
GLEOSTINE . . . . . . . . . . . 4
glimepiride . . . . . . . . . . 26
glipizide . . . . . . . . . . . . 26
glipizide extended-release . . 26
glipizide/metformin . . . . . . 26
GLUCAGON . . . . . . . . . . 25
glucagon, human
recombinant . . . . . . . . 25
GLUCOPHAGE . . . . . . . . 26
GLUCOPHAGE ER . . . . . . 26
glucose oral tablets . . . . . . 65
GLUCOTROL . . . . . . . . . 26
GLUCOTROL XL . . . . . . . . 26
GLUCOVANCE . . . . . . . . 26
glyburide . . . . . . . . . . . . 26
glyburide, micronized . . . . . 26
glycerin . . . . . . . . . . . . 30
GLYCERIN SUPPOSITORY . . 30
GLYCERIN TOPICAL . . . . . 64
glycerol phenylbutyrate . . . . 27
glycopyrrolate . . . . . . . . . 29
GLYNASE . . . . . . . . . . . . 26
GNP FISH OIL . . . . . . . . . 58
granisetron . . . . . . . . . . 28
GRANIX . . . . . . . . . . . . . .7
GRIFULVIN V . . . . . . . . . . 35
griseofulvin microsize . . . . . 35
griseofulvin ultramicrosize . . 35
GRIS-PEG . . . . . . . . . . . 35
GUAIFED . . . . . . . . . . . . 52
guaifenesin . . . . . . . . . . 52
guaifenesin extended-release 52
guaifenesin/
pseudoephedrine . . . . . 52
guaifenesin/
pseudoephedrine/
dextromethorphan . . . . 52
guaifenesin/pseudoephedrine
extended-release . . . . . 52
GUAIFEN PSE . . . . . . . . . 52
guanabenz . . . . . . . . . . 12
guanfacine . . . . . . . . . . . 8
guanfacine ER . . . . . . . . 46
GUIATUSS/AC . . . . . . . . . 51
GUIATUSS DAC . . . . . . . . 51
GYNE-LOTRIMIN . . . . . 42, 64
GYNOL II . . . . . . . . . . . . 65
H
HALCION . . . . . . . . . . . . 48
HALDOL . . . . . . . . . . . . 49
HALDOL DECANOATE . . . . 49
HALFPRIN . . . . . . . . . . . 39
halobetasol . . . . . . . . . . 20
haloperidol . . . . . . . . . . 49
haloperidol decanoate . . . . 49
HARVONI . . . . . . . . . . . . 36
HAVRIX . . . . . . . . . . . . . 62
HECORIA . . . . . . . . . . . . 6
HEMANGEOL . . . . . . . . . .9
heparin . . . . . . . . . . . . . 7
HEPARIN . . . . . . . . . . . . .7
ALL CAPS = Brand-name drug
lower case = Generic drug
77
hepatitis a vaccine susp . . . 62
hepatitis b vaccine . . . . . . 62
HEPSERA . . . . . . . . . . . 36
hexachlorophene . . . . . . . 21
HEXALEN . . . . . . . . . . . . 4
HIPREX . . . . . . . . . . . . . 57
HISTACOL DM . . . . . . . . . 50
HISTEX . . . . . . . . . . . . . 51
HISTUSSIN HC . . . . . . . . 52
HM FISH OIL . . . . . . . . . . 58
homatropine . . . . . . . . . . 44
HUMALOG . . . . . . . . . . . 26
HUMALOG KWIKPEN . . . . 26
HUMALOG MIX 50/50 . . . . 25
HUMALOG MIX 50/50
KWIKPEN . . . . . . . . . 26
HUMALOG MIX 72/25
KWIKPEN . . . . . . . . . 26
HUMALOG MIX 75/25 . . . . 25
human papillomavirus (hpv)
9-valent recomb vac . . . 62
human papillomavirus (hpv)
bival (type 16, 18) recmb
vac . . . . . . . . . . . . . 62
human papillomavirus (hpv)
quadrivalent recombinant
vac . . . . . . . . . . . . . 62
HUMATIN . . . . . . . . . . . . 38
HUMIRA . . . . . . . . . . . . 38
HUMULIN . . . . . . . . . . . 65
HUMULIN 70/30 . . . . . . . 26
HUMULIN N . . . . . . . . . . 25
HUMULIN R . . . . . . . . . . 26
HUMULIN R 500 U/ML
KWIKPEN . . . . . . . . . 26
HYCAMTIN . . . . . . . . . . . .6
HYCODAN . . . . . . . . . . . 53
hydralazine . . . . . . . . . . 12
HYDREA . . . . . . . . . . . . . 6
hydrochlorothiazide . . . . . . 10
HYDROCHLOROTHIAZIDE . 10
HYDROCODO/GG SYP . . . 52
hydrocodone/
acetaminophen . . . . . . 14
Index of Covered Drugs
hydrocodone/chlorpheniramine/phenylephrine . . . 52
hydrocodone ER . . . . . . . 14
hydrocodone/guaifenesin . . 52
hydrocodone/homatropine . 53
HYDROCODONE/
TAB HOMATROP . . . . . 53
hydrocortisone . .19, 21, 25, 29
hydrocortisone acetate . . . . 21
hydrocortisone acetate
w/pramoxine . . . . . . . 21
hydrocortisone/aloe . . . . . 19
hydrocortisone butyrate . . . 19
hydrocortisone crm, oint . . . 65
hydrocortisone inj . . . . . . . 25
hydrocortisone valerate . . . 19
HYDROMET SYP . . . . . . . 53
hydromorphone . . . . . . . . 14
hydroxychloroquine . . . 38, 39
hydroxyurea . . . . . . . . . . 6
hydroxyzine HCL . . . . . . . 23
hydroxyzine pamoate . . . . . 23
hyoscyamine, methenamine,
phenyl salicylate, sodium
phosphate monobasic,
methylene blue . . . . . . 56
hyoscyamine sulfate . . . . . 29
hyoscyamine sulfate
extended-release . . . . . 29
HYPERCARE 20% . . . . . . . 21
HYPERTET S/D . . . . . . . . 63
HYPOTEARS . . . . . . . . . . 66
HYTONE . . . . . . . . . . . . 19
HYTRIN . . . . . . . . . . . 8, 56
HYZAAR . . . . . . . . . . . . . 9
I
IBRANCE . . . . . . . . . . . . .5
ibrutinib . . . . . . . . . . . . . 4
IBUOROFEN TAB COLD/SIN 55
ibuprofen . . . . . . . 13, 39, 66
icatibant . . . . . . . . . . . . 61
ICLUSIG . . . . . . . . . . . . . 5
idelalisib . . . . . . . . . . . . . 4
idursulfase . . . . . . . . . . . 27
iloprost . . . . . . . . . . . . . 12
imatinib mesylate . . . . . . . . 4
IMBRUVICA . . . . . . . . . . . 4
IMDUR . . . . . . . . . . . . . 12
imiglucerase . . . . . . . . . . 27
imipenem-cilastatin
intravenous for soln . . . . 32
IMIPENEM/CIL INJ . . . . . . 32
imipramine HCL . . . . . . . 47
imiquimod 5% cream . . . . . 21
IMITREX . . . . . . . . . . . . 15
IMODIUM A-D . . . . . . . 28, 66
IMODIUM A-D CHW . . . . . . 28
IMODIUM A-D LIQ . . . . . . . 28
IMURAN . . . . . . . . . . . 6, 39
INCIVEK . . . . . . . . . . . . 36
INCRELEX . . . . . . . . . . . 27
indacaterol . . . . . . . . . . . 55
indapamide . . . . . . . . . . 11
INDERAL . . . . . . . . . . 9, 15
INDERAL LA . . . . . . . . . . .9
INDERIDE . . . . . . . . . . . . 9
indinavir . . . . . . . . . . . . 37
INDOCIN . . . . . . . . . 13, 39
indomethacin . . . . . . . 13, 39
INFLAMASE FORTE . . . . . . 44
influenza virus vaccine recombinant hemagglutinin (ha) . 62
influenza virus vaccine split . 62
influenza virus vaccine split
high-dose pf . . . . . . . . 62
influenza virus vaccine split pf62
influenza virus vaccine split
quadrivalent . . . . . . . . 62
influenza virus vaccine
tiss-cult subunit . . . . . . 63
influenza virus vaccine types
a&b surface antigen . . . 63
INLYTA . . . . . . . . . . . . . . 4
INSPRA . . . . . . . . . . . . . 12
insulin detemir . . . . . . . . 25
insulin glargine . . . . . . . . 25
insulin isophane . . . . . . . . 25
insulin isophane/regular . . . 26
ALL CAPS = Brand-name drug
lower case = Generic drug
78
insulin lisopro pro/lispro . . . 25
insulin lisopro prot/lispro . . . 25
insulin lispro . . . . . . . . . . 26
insulin lispro prot
50%/lispro 50% . . . . . . 26
insulin lispro prot
75%/lispro 25% . . . . . . 26
insulin regular . . . . . . . . . 26
insulin . . . . . . . . . . . . . 65
INTAL . . . . . . . . . . . 55, 56
INTELENCE . . . . . . . . . . 38
interferon alfa-2b . . . . . . 5, 36
interferon beta-1a . . . . . . . 15
interferon beta-1b . . . . . . . 15
interferon gamma-1b . . . . . 38
INTRON A . . . . . . . . . . 5, 36
INTUNIV . . . . . . . . . . . . 46
INVEGA SUSTENNA . . . . . 48
INVEGA TRINZA . . . . . . . . 48
INVIRASE . . . . . . . . . . . . 37
INVOKAMET . . . . . . . . . . 26
INVOKANA . . . . . . . . . . . 26
ipratropium . . . . . . . . . . 56
ipratropium/albuterol . . 55, 56
ipratropium bromide . . . . . 24
ipratropium HFA . . . . . . . 55
irbesartan . . . . . . . . . . . . 8
IRESSA . . . . . . . . . . . . . .4
iron . . . . . . . . . . . . . . . 67
iron polysaccharides . . . . . 67
ISENTRESS . . . . . . . . . . 38
ISMO . . . . . . . . . . . . . . 11
ISOCHRON . . . . . . . . . . 11
isoniazid . . . . . . . . . . . . 33
ISONIAZID . . . . . . . . . . . 33
ISOPTO ATROPINE . . . . . . 44
ISOPTO CARPINE . . . . . . . 45
ISOPTO HOMATROPINE . . . 44
ISOPTO HYOSCINE . . . . . . 44
ISORDIL . . . . . . . . . . . . 11
ISORDIL S.L. . . . . . . . . . . 12
isosorbide dinitrate . . . . 11, 12
ISOSORBIDE
DINITRATE ER . . . . . . . 11
Index of Covered Drugs
isosorbide dinitrate
extended-release . . . . . 11
isosorbide mononitrate . . . . 11
isosorbide mononitrate
extended-release . . . . . 12
isotretinoin . . . . . . . . . . . 17
isradipine . . . . . . . . . . . 10
itraconazole . . . . . . . . . . 35
ivacaftor . . . . . . . . . . . . 61
ivermectin . . . . . . . . . 21, 35
ixazomib . . . . . . . . . . . . 5
JADENU . . . . . . . . . . . . 61
JAKAFI . . . . . . . . . . . . . . 5
JANUMET . . . . . . . . . . . 26
JANUMET XR . . . . . . . . . 27
JANUVIA . . . . . . . . . . . . 26
JARDIANCE . . . . . . . . . . 26
JENTADUETO . . . . . . . . . 26
J-TAN D PD . . . . . . . . . . . 50
J-TAN PD . . . . . . . . . . . . 23
ketoconazole shampoo . . . 20
ketoprofen . . . . . . . . 13, 39
ketoprofen SR . . . . . . . . . 13
ketorolac . . . . . . . . . . . . 43
KETOROLAC INJ . . . . . . . 31
ketorolac tromethamine . . . 13
ketorolac tromethamine im inj31
ketotifen . . . . . . . . . . . . 43
KITABIS . . . . . . . . . . . . . 61
KLARON LOTION . . . . . . . 18
KLONOPIN . . . . . . . . 16, 46
KLONOPIN WAFERS . . . . . 46
K-LOR . . . . . . . . . . . . . . 61
KLOR-CON 8 . . . . . . . . . 61
KLOR-CON 10 . . . . . . . . . 61
K-LYTE . . . . . . . . . . . . . 60
KORLYM . . . . . . . . . . . . 28
K-PHOS NEUTRAL . . . . . . 60
K-PHOS ORIGINAL . . . . . . 60
KRISTALOSE . . . . . . . . . . 30
KUVAN . . . . . . . . . . . . . 28
KYTRIL . . . . . . . . . . . . . 28
K
L
KALETRA . . . . . . . . . . . . 37
KALYDECO . . . . . . . . . . . 61
KAOPECTATE . . . . . . . . . 66
KAYEXALATE . . . . . . . . . 12
K-DUR 10 . . . . . . . . . . . . 61
K-DUR 20 . . . . . . . . . . . . 61
KEFLEX . . . . . . . . . . . . . 34
KENALOG . . . . . . . . . . . 19
KENALOG-40 . . . . . . . . . 25
KENALOG IN ORABASE . . . 24
KEPPRA . . . . . . . . . . . . 16
KEPPRA XR . . . . . . . . . . 16
KERALYT . . . . . . . . . . . . 18
ketoconazole . . . . . 20, 21, 35
ketoconazole foam . . . . . . 20
ketoconazole gel . . . . . . . 20
ketoconazole gel 2% & hydrocortisone gel 1% kit . . . 20
ketoconazole gel 2% & pyrithione zinc shampoo 1% kit 20
labetalol . . . . . . . . . . . . . 9
LAC-HYDRIN . . . . . . . . . . 21
lacosamide . . . . . . . . . . 16
LACTINOL . . . . . . . . . . . 21
lactobacillus . . . . . . . . . . 31
lactulose . . . . . . . . . . . . 30
LAMICTAL . . . . . . . . . . . 16
LAMICTAL CD CHEW TAB . . 16
LAMICTAL ODT . . . . . . . . 16
LAMICTAL ODT KIT . . . . . . 16
LAMICTAL STARTER KIT . . . 16
LAMICTAL XR . . . . . . . . . 16
LAMICTAL XR KIT . . . . . . . 16
LAMICTAL XR ODT KIT . . . . 16
LAMISIL . . . . . . . . . . . . . 35
LAMISIL AT . . . . . . . . . . . 20
LAMISIL GEL . . . . . . . . . . 20
LAMISIL SOLUTION . . . . . . 20
lamivudine . . . . . . . . 36, 37
lamivudine/zidovudine . . . . 37
J
ALL CAPS = Brand-name drug
lower case = Generic drug
79
lamotrigine . . . . . . . . . . 16
lamotrigine chew
dispersable tab . . . . . . 16
lamotrigine dispersible tab . . 16
lamotrigine ODT . . . . . . . 16
lamotrigine SR . . . . . . . . 16
lamotrigine SR ODT . . . . . 16
lamotrigine starter kit . . . . . 16
lamotrigine titration kit . . . . 16
LANOXIN . . . . . . . . . . . . .9
lansoprazole . . . . . . . . . . 29
lansoprazole delayed-release 29
lansoprazole susp . . . . . . 29
lanthanum carbonate . . . . . 61
LANTUS . . . . . . . . . . . . 25
LANTUS SOLOSTAR . . . . . 25
lapatinib ditosylate . . . . . . . 4
LARIAM . . . . . . . . . . . . . 38
laronidase . . . . . . . . . . . 28
LASIX . . . . . . . . . . . . . . 10
latanoprost . . . . . . . . . . 44
laxative enemas . . . . . . . . 66
laxatives . . . . . . . . . . . . 66
ledipasvir/sofosbuvir . . . . . 36
leflunomide . . . . . . . . . . 39
lenalidomide . . . . . . . . . . 5
lenvatinib . . . . . . . . . . . . 4
LENVIMA . . . . . . . . . . . . .4
LETAIRIS . . . . . . . . . . . . 12
letrozole . . . . . . . . . . . . . 5
LEUKERAN . . . . . . . . . . . .4
LEUKINE . . . . . . . . . . . . .7
leuprolide . . . . . . . . . . . . 5
levalbuterol HCl . . . . . . . . 56
LEVAQUIN . . . . . . . . 32, 34
LEVBID . . . . . . . . . . . . . 29
LEVEMIR . . . . . . . . . . . . 25
LEVEMIR FLEXPEN . . . . . . 25
levetiracetam . . . . . . . . . 16
levetiracetam SR . . . . . . . 16
levobunolol . . . . . . . . . . 44
levocetirizine . . . . . . . . . 23
levofloxacin . . . . . . . . . . 34
levofloxacin in d5w iv soln . . 32
Index of Covered Drugs
levofloxacin iv soln . . . . . . 32
levonorgestrel . . . . . . . . . 40
levonorgestrel/EE . . . . 40, 41
levothyroxine . . . . . . . . . 27
LEVOXYL . . . . . . . . . . . . 27
LEVSIN . . . . . . . . . . . . . 29
LEVSINEX . . . . . . . . . . . 29
LEXAPRO . . . . . . . . . . . 47
LEXIVA . . . . . . . . . . . . . 37
LIALDA . . . . . . . . . . . . . 30
LIBRIUM . . . . . . . . . . . . 46
LIDAMANTEL . . . . . . . . . 22
LIDEX . . . . . . . . . . . . . . 19
LIDEX E . . . . . . . . . . . . . 19
lidocaine . . . . . . . . . . . . 22
lidocaine patch . . . . . . . . 22
lidocaine-prilocaine . . . . . . 22
lidocaine/prilocaine . . . . . 22
lidocaine viscous . . . . . . . 24
LIDODERM PATCH . . . . . . 22
linaclotide . . . . . . . . . . . 31
linagliptin . . . . . . . . . . . 26
linagliptin/metformin . . . . . 26
linezolid . . . . . . . . . . . . 38
LINZESS . . . . . . . . . . . . 31
liothyronine . . . . . . . . . . 27
liotrix . . . . . . . . . . . . . . 27
LIPITOR . . . . . . . . . . . . . 11
LIPOFEN . . . . . . . . . . . . 11
LIQUIBID PD . . . . . . . . . . 54
liraglutide . . . . . . . . . . . 27
lisdexamfetamine . . . . . . . 46
lisinopril . . . . . . . . . . . . . 8
lisinopril/hydrochlorothiazide . 8
lithium carbonate . . . . . . . 47
LITHIUM CARBONATE . . . . 47
lithium carbonate
extended-release . . . . . 47
LITHOBID . . . . . . . . . . . . 47
LMX-4 . . . . . . . . . . . . . . 22
LOCOID . . . . . . . . . . . . . 19
LODINE . . . . . . . . . . 13, 39
LODRANE D . . . . . . . . . . 24
LOESTRIN 1.5/30 . . . . . . . 41
LOESTRIN 1/20 . . . . . . . . 40
LOESTRIN FE 1.5/30 . . . . . 41
LOESTRIN FE 1/20 . . . . . . 40
LOFIBRA . . . . . . . . . . . . 11
LOHIST-DM . . . . . . . . . . . 53
LOMOTIL . . . . . . . . . . . . 28
lomustine . . . . . . . . . . . . 4
LONITEN . . . . . . . . . . . . 12
LONSURF . . . . . . . . . . . . 4
LO/OVRAL . . . . . . . . . . . 41
loperamide . . . . . . . . . . 28
LOPERAMIDE . . . . . . . . . 28
LOPID . . . . . . . . . . . . . . 11
lopinavir/ritonavir . . . . . . . 37
LOPRESSOR . . . . . . . . . . .9
loratadine . . . . . . . . . . . 23
loratadine/pseudoephedrine 65
loratadine/pseudoephedrine
extended-release . . . . . 24
loratadine &
pseudoephedrine SR . . 53
lorazepam . . . . . . . . . . . 46
LORAZEPAM INTENSOL . . . 46
LORCET . . . . . . . . . . . . 14
LORTAB . . . . . . . . . . . . 14
LORTAB ELIXIR . . . . . . . . 14
losartan . . . . . . . . . . . . . 8
losartan/HCTZ . . . . . . . . . 9
LOTENSIN . . . . . . . . . . . . 8
LOTENSIN HCT . . . . . . . . . 8
LOTRIMIN AF . . . . . . . 20, 64
LOTRISONE . . . . . . . . . . 20
lovastatin . . . . . . . . . . . . 11
LOVENOX . . . . . . . . . . . . 7
loxapine . . . . . . . . . . . . 49
LOXITANE . . . . . . . . . . . 49
LOZOL . . . . . . . . . . . . . 11
LUDIOMIL . . . . . . . . . . . 48
lumacaftor/ivacaftor . . . . . 61
LUMIZYME . . . . . . . . . . . 27
LUPRON . . . . . . . . . . . . .5
LUPRON DEPOT . . . . . . . . 5
LUPRON DEPOT 6-MONTH . .5
LUPRON DEPOT-PED . . . . . .5
LURIDE . . . . . . . . . . . . . 58
ALL CAPS = Brand-name drug
lower case = Generic drug
80
LURIDE LOZI-TABS . . . . . . 58
LUVOX . . . . . . . . . . . . . 46
LUVOX CR . . . . . . . . . . . 46
LYNPARZA . . . . . . . . . . . .6
LYRICA . . . . . . . . . . . . . 17
LYSODREN . . . . . . . . . . . .6
LYSTEDA . . . . . . . . . . . . 43
M
MAALOX . . . . . . . . . 28, 66
macitentan . . . . . . . . . . 12
MACROBID . . . . . . . . . . 38
MACRODANTIN . . . . . . . . 38
MAGNACET . . . . . . . . . . 14
magnesium oxide . . . . 58, 67
MAG-OX . . . . . . . . . . 58, 67
MALARONE . . . . . . . . . . 38
malathion . . . . . . . . . . . 21
MAPAP COLD TAB . . . . . . 54
maprotiline . . . . . . . . . . 48
maraviroc . . . . . . . . . . . 38
MARINOL . . . . . . . . . . . . 28
MATERNA . . . . . . . . . . . 60
MATULANE . . . . . . . . . . . 6
MATXIM LA . . . . . . . . . . . 10
MAVIK . . . . . . . . . . . . . . .8
MAXALT/MAXALT MLT . . . . 15
MAXIDEX . . . . . . . . . . . . 44
MAXITROL . . . . . . . . . . . 43
MAXZIDE . . . . . . . . . . . . 11
M-CLEAR WC . . . . . . . . . 51
measles, mumps & rubella virus
vaccines for inj . . . . . . 63
mecasermin . . . . . . . . . . 27
meclizine . . . . . . . . . 28, 66
MEDIFIN PE . . . . . . . . . . 54
MEDIPLAST . . . . . . . . . . 67
MEDROL . . . . . . . . . . . . 25
medroxyprogesterone
acetate . . . . . . . . 40, 42
mefloquine . . . . . . . . . . 38
MEGACE . . . . . . . . . . . . .5
megestrol acetate . . . . . . . 5
MEKINIST . . . . . . . . . . . . 5
Index of Covered Drugs
MELLARIL . . . . . . . . . . . 49
meloxicam . . . . . . . . 13, 39
melphalan . . . . . . . . . . . 4
memantine . . . . . . . . . . 13
memantine SR . . . . . . . . 13
MENACTRA . . . . . . . . . . 63
MENEST . . . . . . . . . . . . 42
meningococcal (a, c, y, and
w-135) . . . . . . . . . . . 63
meningococcal (a, c, y, and
w-135) conjugate vaccine 63
meningococcal (a, c, y,
and w-135) oligo conj
vac for inj . . . . . . . . . 63
MENOMUNE . . . . . . . . . . 63
MENOSTAR . . . . . . . . . . 42
MENVEO . . . . . . . . . . . . 63
meperidine . . . . . . . . . . 14
MEPHYTON . . . . . . . . . . 58
MEPRON . . . . . . . . . . . . 38
mercaptopurine . . . . . . . . 4
mesalamine . . . . . . . . . . 29
mesalamine
extended-release . . . . . 30
mesalamine supp . . . . . . . 30
mesna . . . . . . . . . . . . . . 6
MESNEX . . . . . . . . . . . . .6
MESTINON . . . . . . . . . . . 15
MESTINON TIMESPAN . . . . 15
METADATE ER . . . . . . . . . 47
METAGLIP . . . . . . . . . . . 26
METAMUCIL . . . . . . . . . . 66
metaproterenol . . . . . . . . 56
METAPROTERENOL SYRUP 56
metformin . . . . . . . . . . . 26
metformin ER . . . . . . . . . 26
metformin/glyburide . . . . . 26
methadone . . . . . . . . . . 14
methazolamide . . . . . . . . 44
methenamine hippurate . . . 57
METHERGINE . . . . . . 28, 43
methimazole . . . . . . . . . . 27
methocarbamol . . . . . . . . 40
methotrexate . . . . . . . . . 39
METHOTREXATE . . . . . . . 39
methoxsalen . . . . . . . . . . 20
methsuximide . . . . . . . . . 16
methyldopa . . . . . . . . . . 12
methyldopa/HCTZ . . . . . . 12
methylergonovine . . . . 28, 43
METHYLIN SOLUTION . . . . 46
methylphenidate . . . . . . . 46
methylphenidate
extended-release . . . 46, 47
methylprednisolone . . . . . . 25
metipranolol . . . . . . . . . . 44
metoclopramide . . . . . . . 28
metolazone . . . . . . . . . . 11
metoprolol . . . . . . . . . . . 9
metoprolol succinate . . . . . . 9
METROCREAM . . . . . . . . 21
METROGEL . . . . . . . . . . 21
METROGEL 1% . . . . . . . . 42
METROGEL-VAGINAL . . . . 42
METROLOTION . . . . . . . . 21
metronidazole . . . . 21, 38, 42
MEVACOR . . . . . . . . . . . 11
mexiletine . . . . . . . . . . . . 9
MEXITIL . . . . . . . . . . . . . .9
MIACALCIN . . . . . . . . . . 27
MICATIN . . . . . . . . . . 20, 64
miconazole . . . . . . . . 20, 42
MICONAZOLE . . . . . . . . . 35
miconazole buccal . . . . . . 35
miconazole crm, soln . . . . . 64
MICONAZOLE KIT . . . . . . . 42
miconazole nitrate . . . . . . 42
miconazole nitrate kit . . . . . 20
miconazole nitrate lotion . . . 20
miconazole nitrate soln . . . . 20
MICRO-K 10 . . . . . . . . . . 61
MICRONASE . . . . . . . . . . 26
MICROZIDE . . . . . . . . . . 10
MIDAMOR . . . . . . . . . . . 10
midodrine . . . . . . . . . . . 12
mifepristone . . . . . . . . . . 28
MIGERGOT SUPPOSITORIES15
MIGRANAL . . . . . . . . . . . 15
MINIPRESS . . . . . . . . . . . .8
ALL CAPS = Brand-name drug
lower case = Generic drug
81
MINOCIN . . . . . . . . . . . . 35
minocycline . . . . . . . . . . 35
minocycline SR . . . . . . . . 35
minoxidil . . . . . . . . . . . . 12
MINUTUSS DR SYP . . . . . . 53
MIRALAX . . . . . . . . . . . . 30
MIRAPEX . . . . . . . . . . . . 16
MIRAPEX ER . . . . . . . . . . 16
MIRCETTE . . . . . . . . . . . 40
mirtazapine . . . . . . . . . . 48
MIRVASO . . . . . . . . . . . . 20
misoprostol . . . . . . . . . . 31
MITIGARE . . . . . . . . . . . 40
mitotane . . . . . . . . . . . . . 6
M-M-R II . . . . . . . . . . . . . 63
MOBIC . . . . . . . . . . 13, 39
MODICON . . . . . . . . . . . 41
MODURETIC . . . . . . . . . . 10
moexipril . . . . . . . . . . . . 8
moexipril/ hydrochlorothiazide 8
mometasone . . . . . . . . . 55
mometasone/formoterol . . . 55
mometasone furoate . . . . . 19
MONISTAT . . . . . . . . 42, 64
MONISTAT 3 . . . . . . . . . . 42
MONISTAT-DERM . . . . . . . 20
MONOPRIL . . . . . . . . . . . 8
MONOPRIL-HCT . . . . . . . . .8
montelukast . . . . . . . . . . 56
morphine . . . . . . . . . . . 14
morphine extended-release . 14
morphine sulfate inj . . . . . . 31
morphine sulfate iv soln . . . 31
MORPHINE SUL INJ . . . . . 31
MOSCO CALLUS/CORN LIQUID REMOVER OTC . . . 67
MOSCO CALLUS/CORN REMOVER OTC . . . . . . . . 67
MOTRIN . . . . . . . . . . 13, 39
MOTRIN IB . . . . . . . . . . . 66
MOVANTIK . . . . . . . . . . . 31
moxifloxacin HCl . . . . . . . 45
MOZOBIL . . . . . . . . . . . . .7
MS CONTIN . . . . . . . . . . 14
Index of Covered Drugs
MSIR . . . . . . . . . . . . . . 14
MUCINEX . . . . . . . . . . . 52
MUCINEX COLD LIQ /KIDS . 54
MUCINEX D . . . . . . . . . . 52
MUCINEX DM . . . . . . . . . 52
MUCINEX KIDS . . . . . . . . 52
MUCOMYST . . . . . . . . . . 61
MULTAQ . . . . . . . . . . . . . 9
MULTI SYMPTOM TAB
COLD RLF . . . . . . . . . 55
multivitamins/fluoride/±iron . 58
multivitamins/minerals . . . . 58
mupirocin . . . . . . . . . . . 18
MURINE . . . . . . . . . . . . 66
MURO 128 . . . . . . . . . . . 45
MYAMBUTOL . . . . . . . . . 33
MYCELEX . . . . . . . . . 20, 35
MYCITRACIN . . . . . . . . . . 65
MYCOBUTIN . . . . . . . . . . 33
mycophenolate mofetil . . . . .6
mycophenolate sodium . . . . 6
MYCOSTATIN . . . . . . . 20, 35
MYFORTIC . . . . . . . . . . . .6
MYLANTA . . . . . . . . . 28, 66
MYLERAN . . . . . . . . . . . . 4
MYLICON . . . . . . . . . . . 66
MYSOLINE . . . . . . . . . . . 17
MYTUSSIN AC . . . . . . . . . 51
N
nabumetone . . . . . . . . . . 13
nadolol . . . . . . . . . . . . . 9
NALFON . . . . . . . . . . 13, 39
naloxegol . . . . . . . . . . . 31
naloxone . . . . . . . . . . . . 48
NALOXONE INJ . . . . . . . . 48
naltrexone . . . . . . . . . 45, 48
naltrexone for IM extended
release susp . . . . . . . . 48
NAMENDA . . . . . . . . . . . 13
NAMENDA XR . . . . . . . . . 13
naphazoline/antazoline . . . 43
naphazoline/glycerin . . . . . 43
naphazoline HCL . . . . . . . 43
naphazoline w/pheniramine 43
naphazoline/zinc sulfate . . . 43
NAPHCON A . . . . . . . 43, 66
NAPROSYN . . . . . . . . 13, 39
naproxen . . . . . . . . . 13, 39
naproxen delayed release 14, 39
naproxen sodium . . . . 14, 39
naratriptan . . . . . . . . . . . 15
NARCAN NASAL SPRAY . . . 48
NARIZ . . . . . . . . . . . . . . 54
NASACORT ALLERGY . . . . 24
NASACORT AQ . . . . . . . . 24
NASALCROM . . . . . . . . . 24
nasal sprays . . . . . . . . . . 65
NATACYN . . . . . . . . . . . . 45
NATALCARE . . . . . . . . . . 60
natamycin . . . . . . . . . . . 45
nateglinide . . . . . . . . . . . 26
NATROBA . . . . . . . . . . . 21
NAVANE . . . . . . . . . . . . 49
nedocromil . . . . . . . . . . 55
nelfinavir . . . . . . . . . . . . 37
NEOBENZ MICR LIQ . . . . . 17
NEO DM . . . . . . . . . . . . 50
NEO-FRADIN . . . . . . . . . . 38
neomycin/polymyxin B/
bacitracin . . . . . . . . . 18
neomycin/polymyxin B/
dexamethasone . . . . . . 43
neomycin/polymyxin B/
gramicidin . . . . . . . . . 45
neomycin/polymyxin B/
hydrocortisone . . . . 23, 43
neomycin sulfate . . . . . . . 38
NEORAL . . . . . . . . . . . . . 6
NEOSPORIN . . . . . 18, 45, 65
NEO-SYNEPHRINE . . . 24, 65
NEPHROCAPS . . . . . . . . 60
NEPTAZANE . . . . . . . . . . 44
NESTABSCBF/FA/RX . . . . . 60
NEULASTA . . . . . . . . . . . .7
NEUMEGA . . . . . . . . . . . .7
NEUPOGEN . . . . . . . . . . .7
NEURONTIN . . . . . . . . . . 16
ALL CAPS = Brand-name drug
lower case = Generic drug
82
NEUTROGENA OIL FREE ACNE
WASH . . . . . . . . . . . 18
NEUTROGENA RAPID CLEAR
GEL . . . . . . . . . . . . . 18
nevirapine . . . . . . . . . . . 36
nevirapine ER . . . . . . . . . 36
NEXAVAR . . . . . . . . . . . . .5
NEXIUM 24 HR OTC . . . . . 29
NEXIUM DELAYEDRELEASE PACKET . . . . 29
niacin . . . . . . . . . . . . . 11
niacin extended-release . . . 11
NIACOR . . . . . . . . . . . . 11
NIASPAN . . . . . . . . . . . . 11
nicardipine . . . . . . . . . . 10
NICODERM . . . . . . . . . . 49
NICODERM CQ . . . . . . . . 67
NICORETTE . . . . . . . . . . 49
nicotine . . . . . . . . . . 49, 67
NICOTINE GUM . . . . . . . . 67
nicotine inhaler system . . . . 49
nicotine polacrilex gum . . . . 49
nicotine polacrilex lozenge . . 49
NICOTROL . . . . . . . . 49, 67
nifedipine . . . . . . . . . . . 10
nifedipine extended-release . 10
NIFEREX . . . . . . . . . 58, 67
NIFEREX-PN FORTE . . . . . 60
nilotinib . . . . . . . . . . . . . 4
nimodipine . . . . . . . . . . 10
NIMOTOP . . . . . . . . . . . 10
NINLARO . . . . . . . . . . . . .5
nintedanib . . . . . . . . . . . 62
nisoldipine . . . . . . . . . . . 10
nitazoxanide suspension . . . 38
nitazoxanide tablet . . . . . . 38
NITREK . . . . . . . . . . . . 12
NITRO-BID . . . . . . . . . . . 12
NITRO-DUR . . . . . . . . . . 12
nitrofurantoin
extended-release . . . . . 38
nitrofurantoin macrocrystals . 38
nitrofurantoin susp . . . . . . 38
nitroglycerin . . . . . . . .12, 22
Index of Covered Drugs
nitroglycerin extended-release12
NITROLINGUAL . . . . . . . . 12
NITROSTAT . . . . . . . . . . . 12
NIX . . . . . . . . . . . . . . . 66
NIX CREME RINSE . . . . . . 21
NIZORAL . . . . . . . . . 20, 35
NIZORAL A-D OTC . . . . . . 20
NIZORAL SHAMPOO . . . . . 21
NOLVADEX . . . . . . . . . . . .5
NORCO . . . . . . . . . . . . . 14
NORDETTE . . . . . . . . . . 41
NORDITROPIN . . . . . . . . 27
norelgestromin/EE . . . . . . 41
norethindrone . . . . . . . . . 41
norethindrone acetate . . . . 42
norethindrone acetate/EE40, 41
norethindrone
acetate/EE/iron . . . 40, 41
norethindrone/EE . . . . 40, 41
norethindrone/ME . . . . . . 41
NORFLEX . . . . . . . . . . . 40
norgestimate/EE . . . . . . . 41
norgestrel . . . . . . . . . . . 41
norgestrel/EE . . . . . . . . . 41
NORPACE . . . . . . . . . . . . 9
NORPACE CR . . . . . . . . . .9
NORPRAMIN . . . . . . . . . . 47
nortriptyline . . . . . . . . . . 47
NORVASC . . . . . . . . . . . 10
NORVIR . . . . . . . . . . . . . 37
NOXAFIL . . . . . . . . . . . . 35
NUEDEXTA . . . . . . . . . . . 49
NULYTELY . . . . . . . . . . . 30
NUTROPIN AQ NUSPIN . . . 27
NUVARING . . . . . . . . . . . 40
NYMALIZE . . . . . . . . . . . 10
nystatin . . . . . . . . . . 20, 35
NYTOL QUICK CAPS . . . . . 48
O
OC8 . . . . . . . . . . . . 17, 64
OCEAN NASAL SPRAY . . . . 24
octreotide . . . . . . . . . . . . 6
OCUFEN . . . . . . . . . . . . 43
OCUFLOX . . . . . . . . . . . 45
ODOMZO . . . . . . . . . . . . .6
OFEV . . . . . . . . . . . . . . 62
ofloxacin . . . . . . . 23, 34, 45
OGEN . . . . . . . . . . . . . . 42
olanzapine . . . . . . . . . . . 48
olanzapine ODT . . . . . . . . 48
olaparib . . . . . . . . . . . . . 6
olodaterol . . . . . . . . . . . 55
olsalazine sodium . . . . . . . 30
omalizumab . . . . . . . . . . 55
ombitasvir/paritaprevir/
ritonavir . . . . . . . . . . 36
ombitasvir/paritaprevir/
ritonavir/dasabuvir . . . . 36
omega-3 fatty acids . . . . . . 58
omeprazole delayed-release 29
OMNICEF . . . . . . . . . . . . 34
ondansetron . . . . . . . . . . 28
ONE TOUCH SYSTEMS
(ULTRA 2, ULTRAMINI, VERIO, VERIO FLEX,
VERIO IQ, VERIO SYNC) . 26
ONE TOUCH TEST STRIPS
(ULTRA, VERIO) . . . . . . 26
ONFI . . . . . . . . . . . . . . 16
ONFI SUSPENSION . . . . . . 16
ONMEL . . . . . . . . . . . . . 35
OPCON A . . . . . . . . . . . 43
oprelvekin . . . . . . . . . . . . 7
OPSUMIT . . . . . . . . . . . . 12
OPTIPRANOLOL . . . . . . . 44
OPTIVAR . . . . . . . . . . . . 43
ORAP . . . . . . . . . . . . . . 49
ORAPRED . . . . . . . . . . . 25
ORKAMBI . . . . . . . . . . . 61
orphenadrine
extended-release . . . . . 40
ORTHO-CEPT . . . . . . . . . 41
ORTHO COIL . . . . . . . . . 40
ORTHO-CYCLEN . . . . . . . 41
ortho diaphragm . . . . . . . 40
ORTHO EVRA . . . . . . . . . 41
ORTHO FLAT . . . . . . . . . 40
ALL CAPS = Brand-name drug
lower case = Generic drug
83
ORTHO FLEX . . . . . . . . . 40
ORTHO MICRONOR . . . . . 41
ORTHO-NOVUM 1/35 . . . . 41
ORTHO-NOVUM 1/50 . . . . 41
ORTHO-NOVUM 7/7/7 . . . . 41
ORTHO-NOVUM 10/11 . . . 40
ORTHO TRI-CYCLEN . . . . . 41
ORUDIS . . . . . . . . . . 13, 39
OS-CAL . . . . . . . . . . 57, 67
oseltamivir . . . . . . . . . . . 36
OVCON 50 . . . . . . . . . . . 41
OVIDE . . . . . . . . . . . . . . 21
OVRAL . . . . . . . . . . . . . 41
OVRETTE . . . . . . . . . . . . 41
oxaprozin . . . . . . . . . 14, 39
oxazepam . . . . . . . . . . . 46
oxcarbazepine . . . . . . . . 17
OXSORALEN-ULTRA . . . . . 20
oxybutynin chloride . . . . . . 57
oxybutynin IR . . . . . . . . . 57
oxycodone . . . . . . . . . . 14
oxycodone/acetaminophen . 14
oxycodone/
acetaminophen CR . . . . 14
oxycodone/aspirin . . . . . . 14
oxycodone ER . . . . . . . . 14
OXYCONTIN . . . . . . . . . . 14
OXYFAST . . . . . . . . . . . . 14
oxymetazoline . . . . . . . . . 24
oxymorphone ER . . . . . . . 14
OXYMORPHONE ER . . . . . 14
P
PACERONE . . . . . . . . . . . 9
palbociclib . . . . . . . . . . . 5
paliperidone . . . . . . . . . . 48
palivizumab . . . . . . . . . . 38
PAMELOR . . . . . . . . . . . 47
pancrealipase DR . . . . . . . 30
PANCREAZE . . . . . . . . . . 30
pancrelipase . . . . . . . . . 30
panobinostat . . . . . . . . .4, 6
PANOXYL BAR . . . . . . . . 64
PANOXYL BAR OTC . . . . . 17
Index of Covered Drugs
PANOXYL CREAM . . . . . . 64
PANOXYL CREAM OTC . . . 17
PANRETIN . . . . . . . . . . . .6
pantoprazole . . . . . . . . . 29
pantoprazole delayed-release 29
PARAFON FORTE DSC . . . . 40
PARLODEL . . . . . . . . 15, 28
PARNATE . . . . . . . . . . . . 47
paromomycin . . . . . . . . . 38
paroxetine . . . . . . . . . . . 47
paroxetine SR . . . . . . . . . 47
PASER . . . . . . . . . . . . . 33
pasireotide . . . . . . . . . . . 6
PAXIL . . . . . . . . . . . . . . 47
PAXIL CR . . . . . . . . . . . . 47
PAXIL ORAL SUSP . . . . . . 47
pazopanib . . . . . . . . . . . 5
PEDIACARE LIQ MULTI-SY . . 54
PEDIALYTE . . . . . . . . 57, 66
PEDIAPRED . . . . . . . . . . 25
PEDIAZOLE . . . . . . . . . . 34
peg 3350/electrolytes . . . . 30
peg 3350/sodium bicarbonate/
sodium chloride . . . . . 30
peg 3350/sodium
bicarbonate/sodium chloride/potassium chloride . 30
PEGASYS . . . . . . . . . . . . 36
PEGASYS PROCLICK . . . . 36
pegfilgrastim . . . . . . . . . . 7
peginterferon alfa-2a . . . . . 36
peginterferon alfa-2b . . . 5, 36
PEGINTRON . . . . . . . . . . 36
pegvisomant . . . . . . . . . 28
penciclovir . . . . . . . . . . . 36
penicillamine . . . . . . . . . 39
penicillin VK . . . . . . . . . . 34
PENLAC SOLUTION 8% . . . 20
PENTASA . . . . . . . . . . . . 30
pentosan . . . . . . . . . . . . 57
pentoxifylline
extended-release . . . . . . 7
PEPCID . . . . . . . . . . . . . 29
PEPCID AC . . . . . . . . 29, 66
PEPCID AZ CHW . . . . . . . 29
PERCOCET . . . . . . . . . . 14
PERCODAN . . . . . . . . . . 14
PERIDEX . . . . . . . . . . . . 24
perindopril . . . . . . . . . . . 8
PERIOGARD . . . . . . . . . . 24
permethrin . . . . . . . . 21, 66
perphenazine . . . . . . . . . 49
PERSANTINE . . . . . . . . . . 7
phenazopyridine . . . . . . . 57
PHENERGAN . . . . . . . . . 28
PHENERGAN DM . . . . . . . 52
phenobarbital . . . . . . . . . 17
PHENOBARBITAL . . . . . . . 17
phenyleph/bromphen/dextromethorphan/guaifenesin 53
phenylephrine . . . . . . . . . 24
phenylephrine/
brompheniramine/
dextromethorphan . . . . 53
phenylephrine/
brompheniramine-DM . . 53
phenylephrine/
chlorpheniramine . . . . . 53
phenylephrine/
chlorpheniramine/
dextromethorphan . . . . 53
phenylephrine/chlorpheniramine/dihydrocodeine . . 53
phenylephrine/
dextromethorphan . . . . 53
phenylephrine/dextromethorphan/guaifenesin . . . . 54
phenylephrine/ephed/CPM
w/carbetapentane . . . . 54
phenylephrine/guaifenesin . . 54
phenylephrine/hydrocodone/
guaifenesin . . . . . . . . 54
phenylephrine/pyrilamine/
dextromethorphan . . . . 54
phenylephrine/pyrilamine
w/hydrocodone . . . . . . 54
phenylephrine tan/pyrilamine
tan/carbeta tan . . . . . . 54
ALL CAPS = Brand-name drug
lower case = Generic drug
84
PHENYLHIST LIQ DH . . . . . 51
PHENYTEK . . . . . . . . . . . 17
phenytoin . . . . . . . . . . . 17
phenytoin sodium extended . 17
PHISOHEX . . . . . . . . . . . 21
PHOS-FLUR . . . . . . . . 58, 67
PHOSLYRA . . . . . . . . . . . 61
PHOSPHOLINE IODINE . . . 44
phosphorus . . . . . . . . . . 60
PHRENILIN . . . . . . . . . . . 13
phytonadione . . . . . . . 33, 58
pilocarpine . . . . . . . . 24, 45
PILOPINE HS GEL . . . . . . . 45
PIMA . . . . . . . . . . . . . . 61
pimecrolimus . . . . . . . . . 22
pimozide . . . . . . . . . . . . 49
pindolol . . . . . . . . . . . . . 9
PINDOLOL . . . . . . . . . . . .9
pioglitazone . . . . . . . . . . 26
pioglitazone/glimepiride . . . 26
pioglitazone/metformin . . . 26
pioglitazone/metformin ER . 26
piperacillin sodiumtazobactam sodium for inj 32
piperacillin sod-tazobactam sod
in dex iv sol . . . . . . . . 32
PIPERONYL BUTOXIDE . . . 66
piperonyl butoxide gel, liquid
shampoo . . . . . . . . . 66
PIPER/TAZOBA INJ . . . . . . 32
pirfenidone capsule . . . . . 62
piroxicam . . . . . . . . . 14, 39
PLAN B . . . . . . . . . . . . . 40
PLAQUENIL . . . . . . . . 38, 39
PLAVIX . . . . . . . . . . . . . . 7
PLENDIL . . . . . . . . . . . . 10
plerixafor . . . . . . . . . . . . 7
PLETAL . . . . . . . . . . . . . .7
PLEXION . . . . . . . . . . . . 18
pneumococcal 13-valent
conjugate . . . . . . . . . 63
pneumococcal vaccine
polyvalent . . . . . . . . . 63
PNEUMOVAX . . . . . . . . . 63
Index of Covered Drugs
PNEUMOVAX 23 . . . . . . . 63
podofilox . . . . . . . . . . . . 21
POLARAMINE . . . . . . . . . 23
polyethylene glycol 3350 . . . 30
polymyxin B/bacitracin . . . . 45
polymyxin B/trimethoprim . . 45
polysaccharide iron complex 58
POLYSPORIN . . . . . . . . . 45
POLYTRIM . . . . . . . . . . . 45
POLY-VI-FLOR . . . . . . . . . 58
POLY-VI-SOL . . . . . . . . . . 67
pomalidomide . . . . . . . . . 5
POMALYST . . . . . . . . . . . .5
ponatinib . . . . . . . . . . . . 5
posaconazole susp . . . . . . 35
potassium acid phosphate . . 60
potassium bicarbonate/potassium citrate effervescent 60
potassium chloride . . . . . . 61
POTASSIUM CHLORIDE . . . 61
potassium chloride
extended-release . . . . . 61
potassium citrate . . . . . . . 57
potassium iodide . . . . . . . 61
POTIGA . . . . . . . . . . . . . 16
povidone-iodine . . . . . . . . 38
PRADAXA . . . . . . . . . . . . 7
PRALUENT . . . . . . . . . . . 11
pramipexole . . . . . . . . . . 16
pramipexole
dihydrochloride SR . . . . 16
pramlintide . . . . . . . . . . 27
PRANDIN . . . . . . . . . . . . 26
PRAVACHOL . . . . . . . . . . 11
pravastatin . . . . . . . . . . . 11
praziquantel . . . . . . . . . . 35
prazosin . . . . . . . . . . . . . 8
PRECOSE . . . . . . . . . . . 26
PRED FORTE . . . . . . . . . 44
PRED-G . . . . . . . . . . . . . 43
PRED MILD . . . . . . . . . . 44
prednicarbate . . . . . . . . . 19
prednisolone . . . . . . . . . 25
prednisolone acetate . . . . . 44
prednisolone acetate . . . . . 44
prednisolone phosphate . . . 44
prednisolone sodium
phosphate . . . . . . . . . 25
prednisone . . . . . . . . . . 25
PREDNISONE . . . . . . . . . 25
pregabalin . . . . . . . . . . . 17
PRELONE . . . . . . . . . . . 25
PREMARIN . . . . . . . . . . . 42
PREMPHASE . . . . . . . . . 42
PREMPRO . . . . . . . . . . . 42
prenatal vitamins w/folic acid 60
PRENATAL VITAMINS W/
FOLIC ACID . . . . . . . . 60
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 . . . . 59
prenatal w/o A w/ FE carbonylFE gluc-DSS-FA . . . . . . 59
prenat-FE Bis-FE prot succ-FA
CA & omega 3 . . . . . . 59
prenat w/o A w/fecbn-fegl-DSSFA & DHA . . . . . . . . . 59
PREPARATION H . . . . . . . 66
PRESGEN B . . . . . . . . . . 53
PREVACID . . . . . . . . . . . 29
PREVIDENT . . . . . . . . . . 58
PREVNAR 13 . . . . . . . . . 63
PREZCOBIX . . . . . . . . . . 38
PREZISTA . . . . . . . . . . . . 37
PRIFTIN . . . . . . . . . . . . . 33
PRILOSEC . . . . . . . . . . . 29
primaquine . . . . . . . . . . 38
primidone . . . . . . . . . . . 17
PRINCIPEN . . . . . . . . . . . 34
PROAMATINE . . . . . . . . . 12
probenecid . . . . . . . . . . 40
ALL CAPS = Brand-name drug
lower case = Generic drug
85
PROBENECID . . . . . . . . . 40
PROBIOTIC FORMULA . . . . 31
probiotic product . . . . . . . 31
procarbazine . . . . . . . . . . 6
PROCARDIA . . . . . . . . . . 10
PROCARDIA XL . . . . . . . . 10
prochlorperazine . . . . . . . 28
PROCRIT . . . . . . . . . . . . .7
PROCTOFOAM HC FOAM . . 21
PROCTO-PAK CREAM . . . . 21
PROCTOSOL HC
CREAM 2.5% . . . . . . . 21
PROCTOZONE
CREAM-HC 2.5% . . . . . 21
progesterone micronized . . . 42
PROGRAF . . . . . . . . . . . . 6
PROLASTIN . . . . . . . . . . 56
PROLIXIN . . . . . . . . . . . . 49
PROLIXIN DECANOATE . . . 49
PROMACTA . . . . . . . . . . 62
promethazine . . . . . . . . . 28
promethazine hcl inj . . . . . 33
promethazine &
phenylephrine . . . . . . . 54
PROMETHAZINE SYP DM . . 52
PROMETHAZINE VC
W/CODEINE . . . . . . . . 51
PROMETHAZINE
W/CODEINE . . . . . . . . 51
PROMETH VC SYP . . . . . . 54
PROMETRIUM . . . . . . . . . 42
PRO NUTRIENT . . . . . . . . 58
propafenone . . . . . . . . . . 9
propantheline . . . . . . . . . 57
propranolol . . . . . . . . . 9, 15
propranolol extended-release . 9
propranolol/HCTZ . . . . . . . 9
propylthiouracil . . . . . . . . 27
PROPYLTHIOURACIL . . . . . 27
PROSCAR . . . . . . . . . . . 56
PROSOM . . . . . . . . . . . . 48
PROTONIX . . . . . . . . . . . 29
PROTONIX PAK . . . . . . . . 29
PROTOPIC 0.1% . . . . . . . . 22
Index of Covered Drugs
PROTOPIC 0.03% . . . . . . . 22
protriptyline . . . . . . . . . . 47
PROVENTIL . . . . . . . . . . 55
PROVERA . . . . . . . . . . . 42
PROZAC . . . . . . . . . . . . 47
PRUET DHAEC PAK . . . . . 60
PRUET DHA PAK
SETONET PAK . . . . . . 59
PSE/GG . . . . . . . . . . . . 52
pseudoephedrine . . . . . . . 54
pseudoephedrine/acetaminophen/dextromethorphan 54
pseudoephedrine/chlorpheniramine/dextromethorphan 54
pseudoephedrine/dextromethorphan/guaifenesin . . . . 55
pseudoephedrine/iburprofen 55
pseudoephedrine tan/ dexchlorphen tan/DM tan . . . . . 55
PSORCON CREAM . . . . . . 19
PSORCON OINTMENT . . . . 19
P & S SHAMPOO . . . . . . . 22
psyllium . . . . . . . . . . . . 66
PULMICORT RESPULES . . . 55
PULMOZYME . . . . . . . . . 61
PURINETHOL . . . . . . . . . . 4
PURIXAN . . . . . . . . . . . . .4
pyrazinamide . . . . . . . . . 33
PYRAZINAMIDE . . . . . . . . 33
pyrethrins/piperonyl but. . . . 21
PYRIDIUM . . . . . . . . . . . 57
pyridostigmine . . . . . . . . 15
pyridostigmine
extended-release . . . . . 15
pyrilamine tan/phenyleph tan 55
pyrimethamine . . . . . . . . 38
Q
QUALAQUIN . . . . . . . . . . 38
QUAL-TUSSIN SYP DC . 53, 54
QUESTRAN . . . . . . . . . . 11
QUESTRAN-LIGHT . . . . . . 11
quetiapine . . . . . . . . . . . 48
quetiapine XR . . . . . . . . . 48
quinapril . . . . . . . . . . . . . 8
quinapril/hydrochlorothiazide . 8
quinidine gluconate
extended-release . . . . . . 9
QUINIDINE GLUCONATE
EXT-REL . . . . . . . . . . . 9
quinidine sulfate . . . . . . . . 9
QUINIDINE SULFATE . . . . . .9
quinidine sulfate
extended-release . . . . . . 9
QUINIDINE SULFATE EXT-REL 9
quinine sulfate . . . . . . . . . 38
QV-ALLERGY . . . . . . . . . 50
QVAR . . . . . . . . . . . . . . 55
R
raloxifene . . . . . . . . . . . 27
raltegravir . . . . . . . . . . . 38
ramelteon . . . . . . . . . . . 48
ramipril . . . . . . . . . . . . . 8
RANEXA . . . . . . . . . . . . 12
ranitidine . . . . . . . . . . . . 29
ranitidine effer . . . . . . . . . 29
ranitidine syrup . . . . . . . . 29
ranolazine . . . . . . . . . . . 12
RAPAMUNE . . . . . . . . . . . 6
RAVICTI . . . . . . . . . . . . . 27
RAYOS . . . . . . . . . . . . . 25
RAZADYNE . . . . . . . . . . 13
REBETOL/COPEGUS . . . . 36
REBIF . . . . . . . . . . . . . . 15
RECOMBIVAX HB . . . . . . . 62
rectal crm, suppositories . . . 66
RECTIV . . . . . . . . . . . . . 22
REGLAN . . . . . . . . . . . . 28
regorafenib . . . . . . . . . . . 5
REGRANEX . . . . . . . . . . 21
RELAFEN . . . . . . . . . . . . 13
RELENZA . . . . . . . . . . . . 36
REMERON . . . . . . . . . . . 48
REMERON ODT . . . . . . . . 48
REMODULIN . . . . . . . . . . 12
RENAGEL . . . . . . . . . . . 61
ALL CAPS = Brand-name drug
lower case = Generic drug
86
renat-FE bis-FE prot succ-FACA & omega DR . . . . . 60
RENVELA . . . . . . . . . . . . 61
repaglinide . . . . . . . . . . 26
REQUIP . . . . . . . . . . . . . 16
REQUIP XL . . . . . . . . . . . 16
RESCRIPTOR . . . . . . . . . 36
RESPA-BR . . . . . . . . . . . 23
RESPERAL-DM . . . . . . . . . 49
RESTASIS . . . . . . . . . . . . 45
RESTORIL . . . . . . . . . . . 48
RETIN-A . . . . . . . . . . . . 18
RETROVIR . . . . . . . . . . . 37
REVATIO . . . . . . . . . . . . 12
REVIA . . . . . . . . . . . 45, 48
REVLIMID . . . . . . . . . . . . 5
REYATAZ . . . . . . . . . . . . 37
ribavirin . . . . . . . . . . . . 36
RIDAURA . . . . . . . . . . . . 39
RID SHAMPOO/
BUTOXIDE SHAMPOO . . 21
rifabutin . . . . . . . . . . . . 33
RIFADIN . . . . . . . . . . . . . 33
rifampin . . . . . . . . . . . . 33
rifapentine . . . . . . . . . . . 33
rilpivirine . . . . . . . . . . . . 36
rimantadine . . . . . . . . . . 36
rimexolone . . . . . . . . . . . 44
riociguat . . . . . . . . . . . . 12
RISPERDAL . . . . . . . . . . 48
RISPERDAL CONSTA . . . . . 49
RISPERDAL M-TAB . . . . . . 49
RISPERDAL SOLUTION . . . 49
risperidone . . . . . . . . 48, 49
risperidone m-tab . . . . . . . 49
RITALIN . . . . . . . . . . . . . 46
RITALIN LA . . . . . . . . . . . 47
RITALIN-SR . . . . . . . . . . . 47
ritonavir . . . . . . . . . . . . 37
rivaroxaban . . . . . . . . . . . 7
rivastigmine . . . . . . . . . . 13
rizatriptan . . . . . . . . . . . 15
RMS . . . . . . . . . . . . . . . 14
ROBAXIN . . . . . . . . . . . . 40
Index of Covered Drugs
ROBINUL . . . . . . . . . . . . 29
ROBINUL FORTE . . . . . . . 29
ROBITUSSIN . . . . . . . 52, 65
ROBITUSSIN CF . . . . . 52, 65
ROBITUSSIN DM . . . . . 52, 65
ROBITUSSIN LIQ
CGH/ALRG . . . . . . . . 53
ROBITUSSIN LIQ CGH/CLD . 51
ROBITUSSIN LIQ
CGH/CONG . . . . . . . . 52
ROBITUSSIN LIQ HD/CHST . 54
ROBITUSSIN LIQ PED NGHT 54
ROBITUSSIN PE . . . 52, 54, 65
ROBITUSSIN PED LIQ
CGH/COLD . . . . . . . . 51
ROBITUSSIN PED SYP . . . . 52
ROBITUSSIN SYP
CHST CNG . . . . . . . . . 52
ROBITUSSIN SYP MAX-ST . . 52
ROCALTROL . . . . . . . . . . 57
RONDEC DM . . . . . . . . . 53
RONDEC DROPS . . . . 50, 51
RONDEC SYRUP . . . . . 50, 51
ropinirole . . . . . . . . . . . 16
ropinirole hydrochloride SR . 16
ROWASA . . . . . . . . . . . . 29
ROXICODONE . . . . . . . . . 14
ROZEREM . . . . . . . . . . . 48
R-TANNAMINE . . . . . . . . . 50
rufinamide . . . . . . . . . . . 17
rufinamide suspension . . . . 17
ruxolitinib . . . . . . . . . . . . 5
RYNA-12 S . . . . . . . . . . . 55
RYNATAN PEDIATRIC SUSP . 51
RYNATUSS . . . . . . . . . . . 50
RYNATUSS PEDIATRIC SUSP54
RYTHMOL . . . . . . . . . . . .9
S
SABRIL SOLUTION . . . . . . 17
sacrosidase . . . . . . . . . . 30
sacubitril/valsartan . . . . . . . 9
SALAC OTC . . . . . . . . . . 22
SALACYN . . . . . . . . . . . 22
SALAGEN . . . . . . . . . . . 24
SALEX . . . . . . . . . . . 18, 22
salicylic acid . . . . . 18, 20, 22
salicylic acid 17%/
collodion . . . . . . . 21, 67
salicylic acid film forming liquid
27.5% OTC . . . . . . . . 67
salicylic acid gel 17% OTC . . 67
salicylic acid pad 40% OTC . 67
salicylic acid plaster 40% . . 67
salicylic acid soln OTC . . . . 67
salicylic acid strip 40% . . . . 67
salicylic acid topical patch
15% OTC . . . . . . . . . 67
saline nasal spray 0.65% . . . 24
salmeterol xinafoate . . . . . 55
SAL-TROPINE . . . . . . . . . 31
SALVAX . . . . . . . . . . . . . 22
SANCTURA . . . . . . . . . . 57
SANDIMMUNE . . . . . . . . . .6
SANDOSTATIN . . . . . . . . . .6
SANTYL . . . . . . . . . . . . 21
sapropterin . . . . . . . . . . 28
sapropterin powder . . . . . . 28
saquinavir mesylate . . . . . . 37
sargramostim . . . . . . . . . . 7
SAVAYSA . . . . . . . . . . . . .7
SCALPICIN . . . . . . . . . . . 20
scopolamine . . . . . . . . . 44
SEA-OMEGA . . . . . . . . . . 58
SEBIZON . . . . . . . . . . . . 18
SECTRAL . . . . . . . . . . . . .9
SEDAPAP . . . . . . . . . . . . 13
selegiline . . . . . . . . . . . 16
selenium sulfide . . . . . . . . 22
SELSUN . . . . . . . . . . . . 22
SELSUN BLUE . . . . . . . . . 22
SELZENTRY . . . . . . . . . . 38
sennosides . . . . . . . . . . 30
SENOKOT . . . . . . . . . . . 30
SENSIPAR . . . . . . . . . . . 61
SERAX . . . . . . . . . . . . . 46
SEREVENT DISKUS . . . . . . 55
SEROMYCIN . . . . . . . . . . 33
SEROQUEL . . . . . . . . . . 48
ALL CAPS = Brand-name drug
lower case = Generic drug
87
SEROQUEL XR . . . . . . . . 48
sertraline . . . . . . . . . . . . 47
sevelamer . . . . . . . . . . . 61
sevelamer hcl . . . . . . . . . 61
SIGNIFOR . . . . . . . . . . . . 6
sildenafil . . . . . . . . . . . . 12
SILVADENE . . . . . . . . . . . 18
silver sulfadiazine . . . . . . . 18
simethicone . . . . . . . . . . 66
simvastatin . . . . . . . . . . . 11
SINEMET . . . . . . . . . . . . 15
SINEMET CR . . . . . . . . . . 15
SINEQUAN . . . . . . . . . . . 47
SINGULAIR . . . . . . . . . . . 56
sirolimus . . . . . . . . . . . . 6
SIRTURO . . . . . . . . . . . . 38
sitagliptan . . . . . . . . . . . 26
sitagliptan/metformin . . . . . 26
sitagliptan/metformin ER . . . 27
SITAVIG . . . . . . . . . . . . . 36
SKLICE . . . . . . . . . . . . . 21
SOD CHLORIDE INJ . . . . . 33
sodium chloride hypertonic . 45
sodium chloride inj . . . . . . 33
sodium chloride irrigation
soln 0.9% . . . . . . . . . 33
sodium chloride iv soln . . . . 33
sodium citrate/citric acid . . . 57
sodium phenylbutyrate oral
powder . . . . . . . . . . 27
sodium phenylbutyrate tab . . 27
sodium polysterene sulfonate 12
sofosbuvir . . . . . . . . . . . 36
SOLU-CORTEF . . . . . . . . 25
SOLU-MEDROL . . . . . . . . 25
somatropin . . . . . . . . . . 27
SOMAVERT . . . . . . . . . . 28
SONATA . . . . . . . . . . . . 48
sonidegib . . . . . . . . . . . . 6
sorafenib . . . . . . . . . . . . 5
SORIATANE . . . . . . . . . . 20
sotalol . . . . . . . . . . . . . . 9
SOVALDI . . . . . . . . . . . . 36
Spacers . . . . . . . . . . . . 62
Index of Covered Drugs
spinosad . . . . . . . . . . . . 21
SPIRIVA . . . . . . . . . . . . . 55
SPIRIVA RESPIMAT . . . . . . 55
spironolactone . . . . . . . . 11
SPIRONOLACTONE . . . . . 11
spironolactone/
hydrochlorothiazide . . . 11
SPORANOX . . . . . . . . . . 35
SPRYCEL . . . . . . . . . . . . .4
STADOL . . . . . . . . . . . . 14
STARLIX . . . . . . . . . . . . 26
STATUSS DM SYP . . . . . . . 53
stavudine . . . . . . . . . . . 37
STELAZINE . . . . . . . . . . . 49
STIVARGA . . . . . . . . . . . . 5
stool softeners . . . . . . . . 66
STRATTERA . . . . . . . . . . 46
STRENSIQ . . . . . . . . . . . 27
STRIBILD . . . . . . . . . . . . 37
STRI-DEX . . . . . . . . . . . . 18
STRIVERDI RESPIMAT . . . . 55
STROMECTOL . . . . . . . . . 35
STUART PRENATAL . . . . . . 67
SUBOXONE . . . . . . . . . . 48
SUCRAID . . . . . . . . . . . . 30
sucralfate . . . . . . . . . . . 29
SUDAFED . . . . . . . . . . . 54
sugar+orthophosphoric acid 66
SULAR . . . . . . . . . . . . . 10
sulcralfate . . . . . . . . . . . 29
sulfacetamide . . . . . . . . . 45
sulfacetamide/
phenylephrine . . . . . . . 45
sulfacetamide/pred. phos. . . 43
sulfacetamide sodium . . . . 18
sulfacetamide sodiumprednisolone . . . . . . . 43
sulfacetamide/sulfur . . . . . 18
SULFACET-R . . . . . . . . . . 18
sulfadiazine . . . . . . . . . . 34
sulfamethoxazole/
trimethoprim, DS . . . . . 34
sulfanilamide . . . . . . . . . 43
sulfasalazine . . . . . . . 30, 39
sulfasalazine
delayed-release . . . . 30, 39
sulindac . . . . . . . . . . 14, 40
sumatriptan . . . . . . . . . . 15
SUMYCIN . . . . . . . . . . . . 35
sunitinib . . . . . . . . . . . . . 5
SUPER OMEGA . . . . . . . . 58
SUPRAX . . . . . . . . . . . . 34
SUPRESS-PE PEDIATRIC
DROPS . . . . . . . . . . . 54
SUSTIVA . . . . . . . . . . . . 36
SUTENT . . . . . . . . . . . . . 5
SYLATRON . . . . . . . . . . . .5
SYMBICORT . . . . . . . . . . 55
SYMLIN . . . . . . . . . . . . . 27
SYMMETREL . . . . . . . 15, 36
SYNAGIS . . . . . . . . . . . . 38
SYNALAR . . . . . . . . . . . 19
SYNJARDY . . . . . . . . . . . 26
SYNTHROID . . . . . . . . . . 27
T
TABLOID . . . . . . . . . . . . . 4
tacrolimus . . . . . . . . . . 6, 22
tadalafil . . . . . . . . . . . . 12
TAFINLAR . . . . . . . . . . . . 4
tafluprost . . . . . . . . . . . . 44
TAGAMET . . . . . . . . . . . 29
taliglucerase . . . . . . . . . . 28
TAMBOCOR . . . . . . . . . . .9
TAMIFLU . . . . . . . . . . . . 36
tamoxifen . . . . . . . . . . . . 5
tamsulosin . . . . . . . . . . . 56
TANAFED . . . . . . . . . . . . 50
TANAFED DMX
SUSPENSION . . . . . . . 55
TANZEUM . . . . . . . . . . . 27
TAPAZOLE . . . . . . . . . . . 27
TARCEVA . . . . . . . . . . . . .4
TARGRETIN . . . . . . . . . . . 6
TASIGNA . . . . . . . . . . . . .4
TASMAR . . . . . . . . . . . . 16
TBO-filgrastim . . . . . . . . . 7
TECFIDERA . . . . . . . . . . 15
ALL CAPS = Brand-name drug
lower case = Generic drug
88
TECHNIVIE . . . . . . . . . . . 36
teduglutide . . . . . . . . . . 31
TEGRETOL . . . . . . . . . . . 16
TEGRETOL-XR . . . . . . . . . 16
telaprevir . . . . . . . . . . . . 36
telbivudine . . . . . . . . . . . 36
temazepam . . . . . . . . . . 48
TEMODAR . . . . . . . . . . . .4
TEMOVATE . . . . . . . . . . . 20
temozolomide . . . . . . . . . 4
TENEX . . . . . . . . . . . . . . 8
TENIVAC . . . . . . . . . . . . 63
tenofovir . . . . . . . . . . . . 37
TENORETIC . . . . . . . . . . .9
TENORMIN . . . . . . . . . . . .9
TERAZOL 3/7 . . . . . . . . . 43
terazosin . . . . . . . . . . 8, 56
terbinafine . . . . . . . . 20, 35
terbinafine gel . . . . . . . . . 20
terbinafine HCL . . . . . . . . 20
terbutaline . . . . . . . . . . . 56
terconazole . . . . . . . . . . 43
teriflunomide . . . . . . . . . 15
teriparatide inj . . . . . . . . . 27
TESSALON . . . . . . . . . . . 49
TESTIM . . . . . . . . . . . . . 25
testosterone . . . . . . . . . . 25
TESTOSTERONE 1%
TOPICAL GEL . . . . . . . 25
testosterone cypionate . . . . 25
testosterone enanthate . . . . 25
testosterone gel . . . . . . . . 25
testosterone gel topical tube,
packet, and pump bottle 25
testotesterone . . . . . . . . . 25
tetanus-diphtheria toxoids . . 63
tetanus immune globulin . . . 63
TET/DIP TOX INJ . . . . . . . 63
tetrabenazine . . . . . . . . . 17
tetracycline . . . . . . . . . . 35
tetrahydrozoline/zinc sulfate . 43
tet tox-diph-acell pertuss ad . 63
thalidomide . . . . . . . . . . . 5
THALOMID . . . . . . . . . . . .5
Index of Covered Drugs
THEO-24 . . . . . . . . . . . . 56
THEOCHRON . . . . . . . . . 56
theophylline . . . . . . . . . . 56
THEOPHYLLINE . . . . . . . . 56
theophylline extended-release56
THEOPHYLLINE EXT-REL . . 56
thioguanine . . . . . . . . . . . 4
thioridazine . . . . . . . . . . 49
thiothixene . . . . . . . . . . . 49
THORAZINE . . . . . . . . . . 49
thyroid tab . . . . . . . . . . . 27
THYROLAR . . . . . . . . . . 27
tiagabine . . . . . . . . . . . . 17
TIAZAC . . . . . . . . . . . . . 10
ticagrelor . . . . . . . . . . . . 7
TIGAN . . . . . . . . . . . . . . 28
TIKOSYN . . . . . . . . . . . . .9
TILADE . . . . . . . . . . . . . 55
timolol . . . . . . . . . . . . . 44
timolol maleate . . . . . . . 9, 44
TIMOPTIC . . . . . . . . . . . 44
TIMOPTIC XE . . . . . . . . . 44
TINACTIN . . . . . . . . . 20, 64
tiotropium . . . . . . . . . . . 55
tiotropium respimat . . . . . . 55
tipranavir . . . . . . . . . . . . 37
TIVICAY . . . . . . . . . . . . . 38
tizanidine . . . . . . . . . . . 40
TOBRADEX . . . . . . . . . . 43
TOBRADEX ST . . . . . . . . . 43
tobramycin . . . . . . . . . . 45
tobramycin-dexamethasone . 43
tobramycin/dexamethasone 43
tobramycin neb soln . . . . . 61
TOBREX . . . . . . . . . . . . 45
TOFRANIL . . . . . . . . . . . 47
tolazamide . . . . . . . . . . . 27
tolbutamide . . . . . . . . . . 27
TOLBUTAMIDE . . . . . . . . 27
tolcapone . . . . . . . . . . . 16
TOLINASE . . . . . . . . . . . 27
tolnaftate . . . . . . . . . 20, 64
tolterodine . . . . . . . . . . . 57
tolterodine SR . . . . . . . . . 57
TOPAMAX . . . . . . . . . . . 17
TOPAMAX SPRINKLE . . . . . 17
topical antibacterials . . . . . 65
topiramate . . . . . . . . . . . 17
topiramate sprinkle caps . . . 17
topotecan . . . . . . . . . . . . 6
TOPROL XL . . . . . . . . . . . 9
TORADOL . . . . . . . . . . . 13
toremifene . . . . . . . . . . . 5
torsemide . . . . . . . . . . . 11
TRACLEER . . . . . . . . . . . 12
TRADJENTA . . . . . . . . . . 26
tramadol . . . . . . . . . . . . 13
trametinib . . . . . . . . . . . . 5
TRANDATE . . . . . . . . . . . .9
trandolapril . . . . . . . . . . . 8
tranexamic acid . . . . . . . . 43
TRANS-VER-SAL PATCH . . . 67
TRANXENE . . . . . . . . . . . 46
tranylcypromine . . . . . . . . 47
TRAVATAN Z . . . . . . . . . . 44
TRAVATAN Z PF . . . . . . . . 45
travoprost . . . . . . . . . 44, 45
trazodone . . . . . . . . . . . 48
TRECATOR . . . . . . . . . . . 33
TRENTAL . . . . . . . . . . . . .7
treprostinil . . . . . . . . . . . 12
tretinoin . . . . . . . . . . . 6, 18
TRIACTIN CHEST
CONGESTION . . . . . . . 52
triamcinolone . . . . . . . . . 24
triamcinolone acetonide . 19, 24
triamcinolone inj . . . . . . . 25
triamcinolone nasal spray . . 24
TRIAMINIC . . . . . . . . . . . 23
TRIAMINIC LIQ CHST/NAS . 54
TRIAMINIC SYR CHST/NAS . 54
triamterene/
hydrochlorothiazide . . . 11
TRIANEX . . . . . . . . . . . . 19
TRIAVIL . . . . . . . . . . . . . 47
TRIAZ CLOTHS . . . . . . . . 17
triazolam . . . . . . . . . . . . 48
TRICOR . . . . . . . . . . . . . 11
ALL CAPS = Brand-name drug
lower case = Generic drug
89
TRI-FED X . . . . . . . . . . . . 55
trifluoperazine . . . . . . . . . 49
trifluridine . . . . . . . . . . . 45
trifluridine/tipiracil . . . . . . . 4
TRIGLIDE . . . . . . . . . . . . 11
trihexyphenidyl . . . . . . . . 16
TRILAFON . . . . . . . . . . . 49
TRILEPTAL . . . . . . . . . . . 17
TRILYTE . . . . . . . . . . . . 30
trimethobenzamide . . . . . . 28
trimethoprim . . . . . . . . . . 38
TRIMETHOPRIM . . . . . . . . 38
TRI-NORINYL . . . . . . . . . 41
TRIOTANN . . . . . . . . . . . 24
TRIOTANN PEDIATRIC SUSP 50
tripolidine/pseudoephedrine 55
TRIPROL/PSE SYP . . . . . . 55
TRI RX . . . . . . . . . . . . . 59
TRIUMEQ . . . . . . . . . . . . 37
TRI-VI-FLOR . . . . . . . . . . 60
TRI-VI-SOL . . . . . . . . 60, 67
TRIVORA . . . . . . . . . . . . 41
TRIZIVIR . . . . . . . . . . . . 37
TROJAN . . . . . . . . . . . . 65
trospium . . . . . . . . . . . . 57
TRUSOPT . . . . . . . . . . . 44
TRUST NATALCARE
PAK DHA . . . . . . . . . . 59
TRUVADA . . . . . . . . . . . . 37
T-STAT . . . . . . . . . . . . . 18
TUCKS OINTMENT OTC . . . 21
TUMS . . . . . . . . . . . 66, 67
TUSSI 12D S . . . . . . . . . . 54
TUSSI-12 S . . . . . . . . . . . 50
TUSSIN DM . . . . . . . . . . 52
TYBOST . . . . . . . . . . . . 38
TYKERB . . . . . . . . . . . . . 4
TYLENOL . . . . . . . 13, 39, 66
TYLENOL W/CODEINE . . . 14
typhoid vaccine . . . . . . . . 63
TYVASO . . . . . . . . . . . . 12
TYZEKA . . . . . . . . . . . . 36
Index of Covered Drugs
U
ULORIC . . . . . . . . . . . . . 40
ULTRAM . . . . . . . . . . . . 13
ULTRAVATE . . . . . . . . . . 20
UNI-HIST DRO . . . . . . . . . 49
UNIPHYL . . . . . . . . . . . . 56
UNIRETIC . . . . . . . . . . . . 8
UNIVASC . . . . . . . . . . . . .8
urea 40% . . . . . . . . . . . 22
UREA 40% LOTION . . . . . . 22
URECHOLINE . . . . . . . . . 56
UREX . . . . . . . . . . . . . . 57
uridine . . . . . . . . . . . . . 27
UROCIT-K . . . . . . . . . . . 57
UROXATRAL . . . . . . . . . . 56
URSO . . . . . . . . . . . . . 31
ursodiol . . . . . . . . . . . . 31
URSO FORTE . . . . . . . . . 31
UTIRA C . . . . . . . . . . . . 56
V
VAGIFEM . . . . . . . . . . . . 41
vaginal products . . . . . . . 64
valacyclovir . . . . . . . . . . 36
VALCYTE . . . . . . . . . . . . 35
valganciclovir . . . . . . . . . 35
VALIUM . . . . . . . . 33, 40, 46
valproic acid . . . . . . . . . . 17
valsartan . . . . . . . . . . . . 8
valsartan/hydrochlorothiazide 9
VALTREX . . . . . . . . . . . . 36
VANCOCIN/DEX INJ . . . . . 32
VANCOCIN HCL . . . . . . . . 35
VANCOCIN HCL INJ . . . . . 32
vancomycin HCl . . . . . . . 35
vancomycin hcl for inj . . . . 32
vancomycin hcl in
dextrose inj . . . . . . . . 32
vandetanib . . . . . . . . . . . 5
VANTIN . . . . . . . . . . . . . 34
VAQTA . . . . . . . . . . . . . 62
varenicline . . . . . . . . . . . 49
varicella virus vac live for
subcutaneous . . . . . . . 63
VARIVAX . . . . . . . . . . . . 63
VASERETIC . . . . . . . . . . . 8
VASOCIDIN . . . . . . . . . . . 43
VASOCLEAR . . . . . . . . . . 43
VASOCLEAR A . . . . . . . . 43
VASOSULF . . . . . . . . . . . 45
VASOTEC . . . . . . . . . . . . .8
VECTICAL . . . . . . . . . . . 20
VEETIDS . . . . . . . . . . . . 34
velaglucerase alfa . . . . . . . 28
VELIVET . . . . . . . . . . . . 41
vemurafenib . . . . . . . . . . 5
venlafaxine . . . . . . . . . . 47
venlafaxine XR . . . . . . . . 47
VENTAVIS . . . . . . . . . . . . 12
VENTOLIN HFA . . . . . . . . 55
VEPESID . . . . . . . . . . . . . 6
VERALAN PM . . . . . . . . . 10
verapamil . . . . . . . . . 10, 15
verapamil extended-release . 10
VESANOID . . . . . . . . . . . .6
VEXOL . . . . . . . . . . . . . 44
VFEND . . . . . . . . . . . . . 35
VIBRAMYCIN . . . . . . . . . . 35
VICODIN . . . . . . . . . . . . 14
VICODIN ES . . . . . . . . . . 14
VICOPROFEN . . . . . . . . . 14
VICTOZA . . . . . . . . . . . . 27
VICTRELIS . . . . . . . . . . . 36
VI-DAYLIN . . . . . . . . . . . . 67
VIDEX . . . . . . . . . . . . . . 37
VIDEX EC . . . . . . . . . . . . 37
VIEKIRA PAK . . . . . . . . . . 36
vigabatrin oral solution . . . . 17
VIGAMOX . . . . . . . . . . . . 45
VIMPAT . . . . . . . . . . . . . 16
VINATE AZ EX . . . . . . . . . 59
VINATE III . . . . . . . . . . . . 59
VIRACEPT . . . . . . . . . . . 37
ALL CAPS = Brand-name drug
lower case = Generic drug
90
VIRAMUNE . . . . . . . . . . . 36
VIRAMUNE XR . . . . . . . . . 36
VIREAD . . . . . . . . . . . . . 37
VIROPTIC . . . . . . . . . . . . 45
VISINE . . . . . . . . . . . . . 66
VISINE-AC . . . . . . . . . . . 43
vismodegib . . . . . . . . . . . 6
VISTARIL . . . . . . . . . . . . 23
VISTIDE . . . . . . . . . . . . . 35
VISTOGARD . . . . . . . . . . 27
vitamin A . . . . . . . . . . . . 60
vitamin ADC/fluoride/±iron
drops . . . . . . . . . . . 60
vitamin B-1 . . . . . . . . . . 60
vitamin B-6 . . . . . . . . . . 60
VITAMIN B-12 . . . . . . . . . 57
vitamin B complex/
vitamin C/folic acid . . . . 60
vitamin C . . . . . . . . . . . 60
vitamin D . . . . . . . . . . . . 67
VITAMIN D . . . . . . . . . 57, 67
vitamins pediatric . . . . 60, 67
vitamins prenatal . . . . . . . 67
VITAPHIL . . . . . . . . . . . . 59
VITUSSIN . . . . . . . . . . . . 52
VIVACTIL . . . . . . . . . . . . 47
VIVELLE-DOT . . . . . . . . . 42
VIVITROL . . . . . . . . . . . . 48
VIVOTIF BERNA . . . . . . . . 63
VOLTAREN . . . . . . 13, 39, 43
VOLTAREN 1% TOPICAL GEL39
VOLTAREN XR . . . . . . . . . 13
VOLTAREN XR . . . . . . . . . 39
voriconazole . . . . . . . . . . 35
vorinostat . . . . . . . . . . . . 4
VOSOL HC OTIC . . . . . . . 22
VOSOL OTIC . . . . . . . . . . 22
VOSPIRE ER . . . . . . . . . . 56
VOTRIENT . . . . . . . . . . . . 5
VPRIV . . . . . . . . . . . . . . 28
VYVANSE . . . . . . . . . . . . 46
Index of Covered Drugs
W
warfarin . . . . . . . . . . . . . 7
WELLBUTRIN . . . . . . . . . 47
WELLBUTRIN SR . . . . . . . 48
WELLBUTRIN XL . . . . . . . 48
WESTCORT . . . . . . . . . . 19
WYTENSIN . . . . . . . . . . . 12
X
XALATAN . . . . . . . . . . . . 44
XALKORI . . . . . . . . . . . . .4
XANAX . . . . . . . . . . . . . 46
XANAX XR . . . . . . . . . . . 46
XARELTO . . . . . . . . . . . . .7
XARTEMIS XR . . . . . . . . . 14
XELODA . . . . . . . . . . . . . 4
XENAZINE . . . . . . . . . . . 17
XOLAIR . . . . . . . . . . . . . 55
XOLEGEL . . . . . . . . . . . . 20
XOLEGEL DUO KIT . . . . . . 20
XOLEGEL KIT . . . . . . . . . 20
XOPENEX RESPULES . . . . 56
XYLOCAINE . . . . . . . . 22, 24
XYZAL . . . . . . . . . . . . . 23
Z
zafirlukast . . . . . . . . . . . 56
zaleplon . . . . . . . . . . . . 48
ZANAFLEX . . . . . . . . . . . 40
zanamivir . . . . . . . . . . . 36
ZANTAC . . . . . . . . . . . . 29
ZARONTIN . . . . . . . . . . . 16
ZAROXOLYN . . . . . . . . . . 11
ZARXIO . . . . . . . . . . . . . .7
ZEASORB-AF . . . . . . . . . 20
ZEBETA . . . . . . . . . . . . . .9
ZEBUTAL . . . . . . . . . . . . 13
ZELBORAF . . . . . . . . . . . .5
ZENPEP . . . . . . . . . . . . 30
ZENPEP DR . . . . . . . . . . 30
ZEPATIER . . . . . . . . . . . . 36
ZERIT . . . . . . . . . . . . . . 37
ZESTORETIC . . . . . . . . . . .8
ZESTRIL . . . . . . . . . . . . . 8
ZETIA . . . . . . . . . . . . . . 11
ZIAC . . . . . . . . . . . . . . . .9
ZIAGEN . . . . . . . . . . . . . 37
zidovudine . . . . . . . . . . . 37
zinc . . . . . . . . . . . . . . . 60
ZIOPTAN . . . . . . . . . . . . 44
ziprasidone . . . . . . . . . . 49
ZITHROMAX . . . . . . . . . . 34
ZOCOR . . . . . . . . . . . . . 11
ZOFRAN . . . . . . . . . . . . 28
ZOFRAN ODT . . . . . . . . . 28
ZOHYDRO ER . . . . . . . . . 14
ZOLINZA . . . . . . . . . . . . .4
ZOLOFT . . . . . . . . . . . . 47
zolpidem . . . . . . . . . . . . 48
ZONEGRAN . . . . . . . . . . 17
zonisamide . . . . . . . . . . 17
ZORTRESS . . . . . . . . . . . .6
ZOSTAVAX . . . . . . . . . . . 63
zoster vaccine live . . . . . . . 63
ZOSYN SOL . . . . . . . . . . 32
ZOVIA 1/35 . . . . . . . . . . 41
ZOVIA 1/50 . . . . . . . . . . 41
ZOVIRAX . . . . . . . . . . . . 36
ZYBAN . . . . . . . . . . . . . 49
ZYDELIG . . . . . . . . . . . . .4
ZYKADIA . . . . . . . . . . . . .4
ZYLOPRIM . . . . . . . . . . . 40
ZYMAR . . . . . . . . . . . . . 45
ZYPREXA . . . . . . . . . . . . 48
ZYPREXA ZYDIS . . . . . . . 48
ZYRTEC . . . . . . . . . . 23, 64
ZYRTEC D . . . . . . . . 24, 65
ZYTIGA . . . . . . . . . . . . . .5
ZYVOX . . . . . . . . . . . . . 38
ALL CAPS = Brand-name drug
lower case = Generic drug
91
Notes
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92
“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
Drug
Tier
I Take This
Medicine For
Directions
Doctor
Example: Lisinopril, 20 mg
Tier 1
High blood pressure
One tablet daily
Dr. Johnson
93
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10/16