2015 Washington Marketplace Formulary
2016 Washington Marketplace Formulary (List of Covered Drugs) Please Read: This document contains information about the drugs we cover when you participate in a Kaiser Permanente plan being offered on or off the Washington health insurance marketplace, the Washington Health Benefit Exchange. What is the Kaiser Permanente Washington Marketplace Formulary? A formulary is a list of covered drugs chosen by a group of Kaiser Permanente physicians and pharmacists known as the Formulary and Therapeutics Committee. This committee meets regularly to evaluate and select the safest, most effective medications for our members. This formulary meets the requirements outlined under the Federal regulations for Qualified Health Plans being offered on or off Washington health insurance marketplace, the Washington Health Benefit Exchange. What drugs are covered? Our plan will generally cover the drugs listed on our formulary as long as the drug is medically necessary, the prescription is filled at a Kaiser Permanente or an affiliated pharmacy, and other plan rules are followed. Drugs listed on the formulary are covered by your prescription drug benefit when dispensed for use in an outpatient setting. Some drugs have restrictions. Using drugs on the formulary helps us maintain quality care for our members while keeping the cost of prescription drugs affordable. What drugs are not covered? Drugs not listed on the formulary are not covered unless a Kaiser Permanente or affiliated physician determines that they are medically necessary. Prescriptions for non-formulary medications may be filled at Kaiser Permanente or affiliated pharmacies. The full retail cost of the drug will be charged unless your doctor has obtained an exception. Are there any restrictions on the drugs covered on the formulary? Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include: Quantity Limits: For certain drugs, Kaiser Permanente may limit the drug quantity that is covered. We may also limit the amount of medication dispensed to a certain days supply. Prior Authorization: Our plan may require you or your provider to obtain a prior authorization for certain drugs. This means that you will need to have approval from our plan before you fill your prescription. If you don’t get approval, we may not cover the drug. Medication Exception Process: Upon request, Kaiser Permanente may make an exception to our coverage rules and approve a drug for your prescription benefit that would otherwise not be covered. Last Updated 01/28/2016 This requires the drug to be reviewed through our medication exception process where it must be deemed medically necessary. What is a generic drug? Our plan covers both brand-name drugs and generic drugs. A generic drug is approved by the FDA as having the same active ingredient as the brand-name drug. Generally, generic drugs cost less than brand-name and specialty-tier drugs. What is a brand-name drug? Brand-name drugs are manufactured and sold by the pharmaceutical company that originally researched and developed the drug. When the patent on a brand-name drug expires, other pharmaceutical companies may manufacture and sell an FDA-approved generic version of the drug with the same active ingredient(s) at lower prices. What are specialty-tier drugs? Specialty-tier drugs are very high-cost drugs. What drugs are eligible to be mailed from the mail order pharmacy? Most drugs can be mailed from our mail order pharmacy. Some drugs that are extremely high cost or require special handling may not be eligible for mailing. However, your prescription drug plan may allow you to receive an extended day supply (e.g. 90 day supply) of certain maintenance medications for a reduced copayment if you use the mail order pharmacy. A maintenance medication is one that Kaiser Permanente has determined would be taken long term and for chronic conditions for the majority of the population. Examples would include medications taken for high blood pressure, diabetes, high cholesterol, or asthma. Kaiser Permanente Formulary The formulary list that begins on page four provides coverage information about some of the drugs covered by our plan. The first column of the chart lists the drug name. Brand-name drugs are capitalized (e.g. ALBENZA) and generic drugs are listed in lower-case italics (e.g. amoxicillin). The second column, “Drug Tier,” will indicate what tier number the drug is in. Drugs on our formulary are categorized in one of three tiers. Tier 1 – Generics Tier 2 – Preferred Brands Tier 3 – Non-Preferred Brands Tier 4 – Specialty The third column of the chart will indicate any requirements or limits for that drug. PA = A drug that requires specific medical criteria be met and requires approval by the plan prior to being dispensed for benefit. Last Updated 01/28/2016 QL = A drug that has a quantity limit or is limited to a specific days supply. Contraceptive Drugs and Devices If you are on an Affordable Care Act (ACA) compliant plan, your provider may prescribe as medically necessary any FDA-approved contraceptive drug or device, including those on this formulary, which you will receive at no cost share. Tobacco Cessation Drugs If you are on an Affordable Care Act (ACA) compliant plan, your provider may prescribe as medically necessary any FDA-approved tobacco cessation drug or product, including those on this formulary, which you will receive at no cost share. Note: Varenicline (Chantix®) requires prior authorization. Last Updated 01/28/2016 Drug Name Analgesics Combination Products acetaminophen w/ codeine solution acetaminophen w/ codeine tablet 300-15 mg acetaminophen w/ codeine tablet 300-30 mg acetaminophen w/ codeine tablet 300-60 mg acetaminophencaffeine-dihydrocodeine ascomp with codeine butalbitalacetaminophen-caffeine w/ codeine butalbital-aspirincaffeine carisoprodol w/ aspirin carisoprodol w/ aspirin & codeine DUEXIS endocet endodan FIORINAL WITH CODEINE hydrocodoneacetaminophen elixir hydrocodoneacetaminophen tablet 5325 mg hydrocodoneacetaminophen tablet 10-325 mg hydrocodone-ibuprofen oxycodone w/ acetaminophen oxycodone-aspirin oxycodone-ibuprofen pentazocine w/ naloxone percocet PERCODAN Drug Requirements/ Tier Limits 1 1 1 1 PA 1 1 PA PA 1 PA 1 1 PA 1 3 1 1 PA PA PA, QL PA, QL 3 PA 1 QL 1 QL 1 1 QL PA, QL 1 1 1 QL PA, QL PA, QL 1 1 3 PA PA, QL PA, QL reprexain 1 PA, QL roxicet solution 1 PA, QL SYNALGOS-DC 3 PA tramadolacetaminophen 1 PA ULTRACET 3 PA VIMOVO 3 PA ZUBSOLV 3 PA, QL Nonsteroidal Anti-inflammatory Drugs celecoxib 1 PA diclofenac potassium 1 PA diclofenac sodium 1 PA diflunisal 1 PA etodolac 200 mg 1 PA etodolac 400 mg 1 etodolac 400 mg sr 1 PA etodolac 500 mg 1 PA etodolac 500 mg sr 1 PA etodolac 600 mg sr 1 PA fenoprofen calcium 1 PA FLECTOR 3 PA flurbiprofen 1 PA ibuprofen 800 mg 1 INDOCIN 3 PA indomethacin 1 indomethacin cr 1 ketoprofen 1 PA ketorolac tromethamine 1 PA meclofenamate sodium 1 PA mefenamic acid 1 PA meloxicam suspension 1 PA meloxicam tablet 1 MOBIC 3 PA nabumetone 1 naproxen sodium 275 mg 1 PA naproxen suspension 1 PA naproxen tablet 1 naproxen tablet ec 1 PA oxaprozin 1 PA piroxicam 1 PA PONSTEL 3 PA SPRIX 3 PA sulindac 1 Last Updated 01/28/2016 TIVORBEX 3 tolmetin sodium 1 TREXIMET 3 Opioid Analgesics, Long-acting ABSTRAL 3 ACTIQ 3 astramorph 1 AVINZA 3 BUTRANS 3 CONZIP 3 DOLOPHINE 3 DURAGESIC 3 duramorph 1 EMBEDA 3 EXALGO 3 fentanyl citrate lollipop 1 fentanyl transdermal patch 1 FENTORA 3 HYSINGLA ER 3 KADIAN 3 LAZANDA 3 levorphanol tartrate 1 methadone hcl concentrate 1 METHADONE HCL INJECTION 3 methadone hcl solution 1 methadone hcl tablet 1 methadose 1 morphine sulfate capsule sr 1 morphine sulfate oral soln 1 morphine sulfate (concentrate) soln 100mg/5mL 1 MORPHINE SULFATE TABLET 2 morphine sulfate tablet cr 1 MS CONTIN 3 NUCYNTA 3 OPANA 3 oxymorphone hcl sr 1 PA PA PA PA, QL PA, QL PA PA PA, QL PA PA, QL PA, QL PA PA, QL PA PA, QL QL PA, QL PA, QL PA PA, QL PA, QL QL PA, QL PA, QL QL PA, QL PA PA PA PA, QL PA, QL PA, QL PRIMLEV 3 PA, QL SUBSYS 3 PA, QL tramadol hcl er 1 PA ULTRAM 3 PA XARTEMIS XR 3 PA, QL ZOHYDRO ER 3 PA, QL Opioid Analgesics, Short-acting butorphanol tartrate 1 PA CODEINE SULFATE 3 PA, QL DEMEROL 3 PA, QL DILAUDID 3 PA hydromorphone hcl 1 PA meperidine hcl 1 PA, QL nalbuphine hcl 1 PA OXECTA 3 PA, QL oxycodone hcl capsule 1 PA, QL oxycodone hcl concentrate 1 QL OXYCODONE HCL SOLUTION 2 QL oxycodone hcl tablet 10 mg 1 PA, QL oxycodone hcl tablet 15 mg 1 PA, QL oxycodone hcl tablet 20 mg 1 PA, QL oxycodone hcl tablet 30 mg 1 PA, QL oxycodone hcl tablet 5 mg 1 QL oxymorphone hcl 1 PA, QL ROXICODONE 3 PA, QL tramadol hcl 1 ULTRAM 3 PA Anesthetics Local Anesthetics EMLA 3 PA lidocaine hcl gel 1 lidocaine hcl local preservative free (pf) 1 PA lidocaine hcl solution 1 lidocaine hcl viscous solution 1 lidocaine-prilocaine 1 PA LIDODERM 3 PA Last Updated 01/28/2016 SYNERA 3 PA XYLOCAINE 3 PA Anti-Addiction/Substance Abuse Treatment Agents Alcohol Deterrents/Anti-craving acamprosate 1 antabuse 1 PA CAMPRAL 3 PA disulfiram 250 mg 1 disulfiram 500 mg 1 PA Combination Products SUBOXONE 3 PA, QL Opioid Antagonists BELBUCA 3 PA, QL BUPRENEX 3 PA buprenorphine hcl injection 1 PA, QL buprenorphine hcl sl tablet 1 QL buprenorphine hclnaloxone hcl sl tablet 1 QL EVZIO 3 PA naloxone hcl 1 PA naltrexone hcl 1 revia 1 PA VIVITROL 3 PA Smoking Cessation Agents bupropion (smoking deterrent) 1 CHANTIX 3 PA nicotine gum 1 nicotine lozenge 1 nicotine patch 1 NICOTROL SPRAY 3 NICOTROL INHALER 3 Antibacterials Aminoglycosides amikacin sulfate 1 PA gentak 1 gentamicin injection 1 PA gentamicin sulfate cream 1 gentamicin sulfate ointment 1 gentamicin sulfate ophthalmic solution KITABIS PAK neomycin sulfate paromomycin sulfate streptomycin sulfate TOBI TOBRADEX tobramycin sulfate injection tobramycin sulfate ophthalmic solution TOBREX ZANOSAR Antibacterials, Other acetic acid otic ALTABAX baci-im bacitracin im bacitracin ophthalmic ointment BACTROBAN chloramphenicol sodium succinate CLEOCIN CAPSULE CLEOCIN INJECTION cleocin oral solution CLEOCIN VAGINAL CLEOCIN-T clindacin CLINDAGEL clindamycin hcl clindamycin phosphate foam clindamycin phosphate gel clindamycin phosphate iv solution clindamycin phosphate lotion clindamycin phosphate swab clindamycin phosphate topical solution clindamycin phosphate vaginal Last Updated 01/28/2016 1 4 1 1 1 4 3 PA PA PA PA 1 PA 1 3 3 PA PA 1 3 1 1 PA PA PA 1 3 PA 1 3 3 1 3 3 1 3 1 PA PA PA 1 PA PA PA PA PA 1 1 PA 1 1 PA 1 1 PA colistimethate sodium COLY MYCIN M CUBICIN EVOCLIN FLAGYL HIPREX LINCOCIN linezolid MACROBID MACRODANTIN 100 MG MACRODANTIN 25 MG methenamine hippurate METROCREAM METROGEL METROGEL METROLOTION metronidazole capsule metronidazole cream metronidazole gel metronidazole iv solution metronidazole lotion metronidazole tablet metronidazole vaginal MONUROL mupirocin nitrofurantoin macrocrystal 50 mg nitrofurantoin macrocrystal 100 mg nitrofurantoin suspension polymyxin b sulfate PRIMSOL SIVEXTRO SULFAMYLON trimethoprim TYGACIL VANCOCIN vancomycin hcl capsule vancomycin hcl injection vandazole 1 3 4 3 3 3 3 1 3 PA PA PA PA PA PA PA PA PA 3 PA 2 1 3 3 3 3 1 1 1 1 1 1 1 2 1 PA PA PA PA PA PA PA PA PA 1 1 1 1 3 4 3 1 3 4 1 1 1 PA PA PA PA PA PA PA PA VIBATIV 3 XIFAXAN 3 ZYVOX 4 Beta-lactam, Cephalosporins CEDAX 3 cefaclor 1 cefadroxil 1 cefazolin 1 cefdinir 1 cefepime hcl 1 cefotaxime sodium 1 cefotetan 1 cefoxitin sodium injection 1 CEFOXITIN SODIUM IV SOLUTION 3 cefpodoxime proxetil suspension 1 cefpodoxime proxetil tablet 100 mg 1 cefpodoxime proxetil tablet 200 mg 1 cefprozil 1 ceftazidime injection 1 CEFTAZIDIME IV SOLUTION 3 CEFTIN 3 ceftriaxone sodium 1 cefuroxime axetil 1 cefuroxime sodium 1 cephalexin capsule 1 cephalexin suspension 1 cephalexin tablet 1 claforan injection 20 mg/ml 1 CLAFORAN INJECTION 200 MG/ML 3 CLAFORAN INJECTION 230 MG/ML 3 CLAFORAN INJECTION 330 MG/ML 3 FORTAZ 3 KEFLEX 3 Last Updated 01/28/2016 PA PA, QL PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA rocephin injection 350 mg/ml SPECTRACEF suprax chewable tablet suprax suspension suprax tablet TEFLARO ZINACEF Beta-lactam, Other AZACTAM aztreonam CAYSTON DORIBAX imipenem-cilastatin INVANZ meropenem MERREM PRIMAXIN Beta-lactam, Penicillins amoxicillin & potassium clavulanate chewable amoxicillin & potassium clavulanate suspension 200-28.5 mg/5ml amoxicillin & potassium clavulanate suspension 250-62.5 mg/5ml amoxicillin & potassium clavulanate suspension 400-57 mg/5ml amoxicillin & potassium clavulanate suspension 600-42.9 mg/5ml amoxicillin & potassium clavulanate tab sr amoxicillin & potassium clavulanate tablet 250-125 mg amoxicillin & potassium clavulanate tablet 500-125 mg 1 3 1 1 1 3 3 PA PA PA PA 3 1 4 3 1 3 1 3 3 PA PA PA PA PA PA PA PA PA PA PA 1 1 1 PA 1 1 1 PA 1 PA 1 amoxicillin & potassium clavulanate tablet 875-125 mg amoxicillin (trihydrate) capsule amoxicillin (trihydrate) chewable amoxicillin (trihydrate) suspension 125 mg/5ml amoxicillin (trihydrate) suspension 200 mg/5ml amoxicillin (trihydrate) suspension 250 mg/5ml amoxicillin (trihydrate) suspension 400 mg/5ml amoxicillin (trihydrate) tablet ampicillin ampicillin & sulbactam sodium BICILLIN C-R BICILLIN L-A dicloxacillin sodium MOXATAG NAFCILLIN SODIUM IN DEXTROSE INJECTION nafcillin sodium injection OXACILLIN SODIUM IN DEXTROSE INJECTION oxacillin sodium injection penicillin g potassium injection PENICILLIN G POTASSIUM INJECTION IN DEXTROSE penicillin g procaine penicillin g sodium penicillin v potassium pfizerpen piperacillin sodium piperacillin sodiumtazobactam sodium TIMENTIN Last Updated 01/28/2016 1 1 1 PA 1 1 PA 1 1 1 1 PA PA 1 3 3 1 3 PA PA PA 3 PA 1 PA 3 PA 1 PA 1 PA 3 1 1 1 1 1 PA PA PA 1 3 PA PA PA PA PA UNASYN ZOSYN Combination Products neomycin-polymyxin b irrigation soln SYNERCID Macrolides AKNEMYCIN AZASITE azithromycin iv solution azithromycin suspension azithromycin tablet 250 mg azithromycin tablet 500 mg azithromycin tablet 600 mg clarithromycin suspension clarithromycin tablet 250 mg clarithromycin tablet 500 mg clarithromycin tablet sr DIFICID E.E.S. SUSPENSION e.e.s. tablet ery ERYPED ery-tab 250 mg ery-tab 333 mg ery-tab 500 mg erythrocin lactobionate erythrocin stearate erythromycin ethylsuccinate erythromycin gel erythromycin ophthalmic ointment erythromycin tablet erythromycin topical solution KETEK PCE TRI-PAK 3 3 PA PA 1 3 PA 3 3 1 PA PA PA 1 1 1 PA 1 1 PA 1 PA 1 1 4 2 1 1 3 1 1 1 1 1 PA PA PA PA PA PA PA PA PA 1 1 PA PA 1 1 PA 1 3 3 3 PA PA PA ZMAX Z-PAK Quinolones AVELOX ABC AVELOX INJECTION AVELOX TABLET BESIVANCE CILOXAN ciprofloxacin hcl ophthalmic solution ciprofloxacin hcl sr ciprofloxacin hcl tablet 100 mg ciprofloxacin hcl tablet 250 mg ciprofloxacin hcl tablet 500 mg ciprofloxacin hcl tablet 750 mg ciprofloxacin iv ciprofloxacin suspension FACTIVE LEVAQUIN levofloxacin iv levofloxacin ophthalmic solution levofloxacin oral solution levofloxacin tablet MOXEZA moxifloxacin OCUFLOX ofloxacin ophthalmic solution ofloxacin otic solution ofloxacin tablet VIGAMOX ZYMAXID Sulfonamides BACTRIM BLEPH-10 KLARON SEPTRA SILVADENE Last Updated 01/28/2016 3 3 PA PA 3 3 3 3 3 PA PA PA PA PA 1 1 PA PA 1 PA 1 1 1 1 PA 1 3 3 1 PA PA PA PA 1 PA 1 1 3 1 3 PA PA PA 1 1 1 3 2 3 3 3 3 3 PA PA PA PA PA PA PA silver sulfadiazine ssd sulfacetamide sodium lotion sulfacetamide sodium ophthalmic ointment sulfacetamide sodium ophthalmic solution sulfadiazine sulfamethoxazoletrimethoprim iv sulfamethoxazoletrimethoprim suspension sulfamethoxazoletrimethoprim tablet thermazene Tetracyclines demeclocycline hcl DORYX doxycycline hyclate capsule doxycycline hyclate injection doxycycline hyclate tablet 100 mg doxycycline hyclate tablet 20 mg doxycycline hyclate tablet dr doxycycline monohydrate capsule 75 mg doxycycline monohydrate tablet 100 mg doxycycline monohydrate tablet 150 mg doxycycline monohydrate tablet 50 mg doxycycline monohydrate tablet 75 mg dynacin MINOCIN 1 1 PA 1 PA 1 PA 1 1 1 PA 1 1 1 PA 1 3 PA PA 1 1 PA 1 1 PA 1 PA 1 PA 1 1 PA 1 1 1 3 PA PA PA minocycline hcl capsule 100 mg 1 minocycline hcl capsule 50 mg 1 minocycline hcl capsule 75 mg 1 PA minocycline hcl tablet 1 PA minocycline hcl tablet sr 1 PA MONODOX 3 PA ORACEA 3 PA SOLODYN 3 PA tetracycline hcl 1 PA VIBRAMYCIN 3 PA VIBRAMYCIN 3 PA Anticonvulsants Anticonvulsants, Other FYCOMPA 3 PA, QL KEPPRA 3 PA KEPPRA XR 3 PA levetiracetam injection 1 PA levetiracetam oral solution 1 levetiracetam tablet 1 levetiracetam tablet er 1 POTIGA 3 PA Calcium Channel Modifying Agents CELONTIN 2 ethosuximide 1 LYRICA 3 PA ZARONTIN CAPSULE 3 PA zarontin oral solution 1 PA ZONEGRAN 3 PA zonisamide 1 Gamma-aminobutyric Acid (GABA) Augmenting Agents clonazepam 1 clonazepam orally disintegrating 1 PA DEPACON 3 PA DEPAKENE 3 PA DEPAKOTE 3 PA divalproex sodium 1 gabapentin capsule 1 Last Updated 01/28/2016 gabapentin oral solution 1 gabapentin tablet 1 GABITRIL 2 MG 3 GABITRIL 4 MG 3 GABITRIL 12 MG 2 GABITRIL 16 MG 2 GRALISE 3 HORIZANT 3 KLONOPIN 3 MYSOLINE 3 NEURONTIN 3 ONFI 3 phenobarbital 100 mg 1 phenobarbital 15 mg 1 phenobarbital 16.2 mg 1 phenobarbital 30 mg 1 phenobarbital 32.4 mg 1 phenobarbital 60 mg 1 phenobarbital 64.8 mg 1 phenobarbital 97.2 mg 1 phenobarbital elixir 1 primidone 1 SABRIL 4 tiagabine hcl 1 valproate sodium injection 1 valproate sodium syrup 1 valproic acid 1 Glutamate Reducing Agents felbamate 1 FELBATOL 4 LAMICTAL 3 LAMICTAL XR 3 lamotrigine tablet 1 lamotrigine chewable 1 lamotrigine odt 1 lamotrigine er 1 TOPAMAX 3 topiramate 1 Sodium Channel Agents BANZEL 3 carbamazepine capsule sr 1 PA PA PA PA PA PA PA PA PA PA PA PA PA PA, QL PA PA PA PA PA PA PA PA PA PA carbamazepine chewable 1 carbamazepine suspension 1 carbamazepine tablet 1 carbamazepine tablet sr 1 CARBATROL 3 dilantin capsule 30 mg 1 dilantin capsule 100 mg 1 dilantin chewable 1 DILANTIN SUSPENSION 3 epitol 1 EQUETRO 3 fosphenytoin sodium 1 oxcarbazepine suspension 1 oxcarbazepine tablet 1 PEGANONE 3 phenytek 1 phenytoin chewable 1 phenytoin sodium extended 100 mg 1 phenytoin sodium extended 200 mg 1 phenytoin sodium extended 300 mg 1 phenytoin sodium injection 1 phenytoin suspension 1 TEGRETOL 3 TEGRETOL XR 100 MG 2 TEGRETOL XR 200 MG 3 TEGRETOL XR 400 MG 3 TRILEPTAL SUSPENSION 2 TRILEPTAL TABLET 3 VIMPAT 3 Antidementia Agents Antidementia Agents, Other ergoloid mesylates 1 NAMZARIC 3 TEVETEN HCT 3 Last Updated 01/28/2016 PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA, QL PA Cholinesterase Inhibitors donepezil hcl 10 mg 1 donepezil hcl 5 mg 1 donepezil hcl 23 mg 1 PA donepezil hydrochloride orally disintegrating 1 PA EXELON 3 PA galantamine hydrobromide capsule er 1 galantamine hydrobromide solution 1 PA galantamine hydrobromide tablet 1 RAZADYNE 3 PA rivastigmine tartrate 1 PA N-methyl-D-aspartate (NMDA) Receptor Antagonist memantine tablet 1 memantine titration pak 1 PA NAMENDA 3 PA Antidepressants Antidepressants, Other ABILIFY 10 MG 3 PA ABILIFY 15 MG 3 PA ABILIFY 2 MG 3 PA ABILIFY 20 MG 3 PA ABILIFY 30 MG 3 PA ABILIFY 5 MG 3 PA ABILIFY DISCMELT 3 PA ABILIFY INJECTION 3 PA ABILIFY SOLUTION 3 PA APLENZIN 3 PA aripiprazole 10 mg 1 aripiprazole 15 mg 1 aripiprazole 2 mg 1 PA aripiprazole 20 mg 1 aripiprazole 30 mg 1 aripiprazole 5 mg 1 aripiprazole solution 1 PA ARISTADA 4 PA bupropion hcl tab 75 mg 1 bupropion hcl tab 100 mg 1 bupropion hcl sr 100 mg 1 bupropion hcl sr 150 mg 1 bupropion hcl sr 200 mg 1 bupropion hcl xl 150 mg 1 bupropion hcl xl 300 mg 1 FORFIVO 3 PA maprotiline hcl 1 PA mirtazapine 1 mirtazapine orally disintegrating 1 PA OLEPTRO 3 PA REMERON 3 PA REMERON SOLTAB 3 PA REXULTI 3 PA trazodone hcl 100 mg 1 trazodone hcl 150 mg 1 PA trazodone hcl 300 mg 1 PA trazodone hcl 50 mg 1 VIIBRYD 3 PA WELLBUTRIN 3 PA Combination Products chlordiazepoxideamitriptyline 1 PA olanzapine-fluoxetine hcl 1 PA perphenazineamitriptyline 1 PA Monoamine Oxidase Inhibitors EMSAM 3 PA MARPLAN 3 PA NARDIL 3 PA PARNATE 3 PA phenelzine sulfate 1 tranylcypromine sulfate 1 Serotonin/ Norepinephrine Reuptake Inhibitors BRINTELLIX 3 PA citalopram hydrobromide 1 CYMBALTA 3 PA duloxetine 1 Last Updated 01/28/2016 EFFEXOR XR escitalopram oxalate solution escitalopram oxalate tablet fluoxetine hcl capsule 10 mg fluoxetine hcl capsule 20 mg fluoxetine hcl capsule 40 mg fluoxetine hcl capsule dr 90 mg fluoxetine hcl solution 20 mg/5ml fluoxetine hcl tablet 10 mg fluoxetine hcl tablet 20 mg FLUOXETINE HCL TABLET 60 MG fluvoxamine maleate LEXAPRO LUVOX nefazodone hcl paroxetine hcl PAXIL PEXEVA PRISTIQ PROZAC SARAFEM sertraline hcl solution sertraline hcl tablet venlafaxine hcl capsule sr venlafaxine hcl tab sr 150 mg VENLAFAXINE HCL TAB SR 225 MG venlafaxine hcl tab sr 37.5 mg venlafaxine hcl tab sr 75 mg venlafaxine hcl tablet ZOLOFT Tricyclics amitriptyline hcl 3 PA 1 PA 1 1 1 1 PA 1 PA 1 1 PA 1 PA 3 1 3 3 1 1 3 3 3 3 3 1 1 PA PA PA PA PA PA PA PA PA PA 1 1 PA 3 PA 1 PA 1 1 3 PA 1 PA amoxapine ANAFRANIL clomipramine hcl desipramine hcl doxepin hcl 10 mg doxepin hcl 100 mg doxepin hcl 150 mg doxepin hcl 25 mg doxepin hcl 50 mg doxepin hcl 75 mg doxepin hcl solution imipramine hcl imipramine pamoate NORPRAMIN nortriptyline hcl PAMELOR protriptyline hcl SURMONTIL TOFRANIL TOFRANIL-PM trimipramine maleate vivactil Antiemetics Antiemetics, Other chlorpromazine hcl injection chlorpromazine hcl tablet compro diphenhydramine hcl hydroxyzine hcl im solution hydroxyzine hcl syrup hydroxyzine hcl tablet hydroxyzine pamoate 100 mg hydroxyzine pamoate 25 mg hydroxyzine pamoate 50 mg meclizine hcl metoclopramide hcl injection metoclopramide hcl solution Last Updated 01/28/2016 1 3 1 1 1 1 1 1 1 1 1 1 1 3 1 3 1 3 3 3 1 1 PA PA PA 1 PA 1 1 1 PA PA PA PA PA PA PA PA PA PA PA PA PA PA 1 1 1 PA 1 PA 1 1 1 PA 1 PA 1 metoclopramide hcl tablet 1 METOZOLV 3 perphenazine 1 phenadoz 1 phenergan injection 1 prochlorperazine edisylate 1 prochlorperazine maleate 1 prochlorperazine suppository 1 promethazine hcl injection 1 promethazine hcl suppository 1 promethazine hcl syrup 1 promethazine hcl tablet 12.5 mg 1 promethazine hcl tablet 25 mg 1 promethazine hcl tablet 50 mg 1 promethegan suppository 1 REGLAN 3 TIGAN 3 TRANSDERM SCOP 2 trimethobenzamide hcl 1 VISTARIL 3 Emetogenic Therapy Adjuncts AKYNZEO 3 ALOXI 3 ANZEMET 3 CESAMET 3 dronabinol 1 EMEND 3 granisetron hcl 1 granisol 1 MARINOL 3 ondansetron hcl injection 1 ondansetron hcl oral solution 1 ondansetron hcl tablet 24 mg 1 PA PA PA PA PA PA PA PA PA PA PA PA PA PA, QL PA PA PA, QL PA PA PA PA PA PA ondansetron hcl tablet 4 mg ondansetron hcl tablet 8 mg ondansetron orally disintegrating tablet SANCUSO ZOFRAN ZUPLENZ MIS Antifungals ABELCET AMBISOME AMPHOTEC amphotericin b ANCOBON CANCIDAS ciclopirox clotrimazole cream clotrimazole solution clotrimazole troche CRESEMBA DIFLUCAN econazole nitrate ERAXIS ERTACZO EXELDERM fluconazole injection fluconazole suspension fluconazole tablet flucytosine grifulvin v griseofulvin microsize suspension griseofulvin microsize tablet griseofulvin ultramicrosize GRIS-PEG itraconazole ketoconazole cream ketoconazole foam ketoconazole shampoo ketoconazole tablet ketodan LAMISIL Last Updated 01/28/2016 1 1 1 3 3 3 3 4 3 1 4 4 1 1 1 1 4 3 1 3 3 3 1 1 1 1 1 PA, QL PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA 1 1 1 3 1 1 1 1 1 1 3 PA PA PA PA PA PA LOPROX MENTAX MENTAX miconazole nitrate MYCAMINE naftifine NAFTIN NATACYN NIZORAL NOXAFIL nyamyc nystatin cream nystatin ointment nystatin suspension nystatin tablet nystatin topical powder nystop powder ONMEL ORAVIG OXISTAT pedi-dri SPORANOX SPORANOX PULSEPAK terbinafine hcl terconazole vaginal VFEND INJECTION VFEND SUSPENSION VFEND TABLET voriconazole zazole zazole ZOLINZA Antigout Agents allopurinol sodium injection allopurinol tablet ALOPRIM colchicine w/ probenecid COLCRYS MITIGARE probenecid ULORIC 3 3 3 1 3 1 3 2 3 4 1 1 1 1 1 1 1 3 3 3 1 3 PA PA PA PA PA PA PA 3 1 1 3 4 4 1 1 1 4 PA 1 1 3 PA 1 3 3 1 3 PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA, QL PA PA PA PA ZYLOPRIM 3 PA Antimigraine Agents Combination Products migergot 1 Ergot Alkaloids dihydroergotamine mesylate 1 ergomar 1 PA MIGRANAL 2 Prophylactic BOTOX 3 PA DYSPORT 3 PA Serotonin (5-HT) 1b/1d Receptor Agonists ALSUMA 3 PA almotriptan 1 PA AMERGE 3 PA AXERT 3 PA FROVA 3 PA IMITREX 3 PA naratriptan hcl 1 mg 1 PA naratriptan hcl 2.5 mg 1 RELPAX 3 PA rizatriptan benzoate 1 sumatriptan succinate 1 SUMAVEL DOSEPRO 3 PA zolmitriptan 1 PA ZOMIG 3 PA Antimyasthenic Agents Parasympathomimetics GUANIDINE HC 3 PA MESTINON 3 PA MESTINON TIMESPAN 2 pyridostigmine bromide 1 REGONOL 3 PA Antimycobacterials Antimycobacterials, Other ACZONE 3 PA dapsone 1 MYCOBUTIN 3 PA rifabutin 1 Antituberculars CAPASTAT 3 PA ethambutol hcl 1 Last Updated 01/28/2016 isoniazid injection isoniazid syrup isoniazid tablet MYAMBUTOL paser d/r PRIFTIN pyrazinamide rifadin capsule 150 mg RIFADIN CAPSULE 300 MG RIFADIN IV rifamate rifampin capsule 150 mg rifampin capsule 300 mg rifampin injection RIFATER SIRTURO TRECATOR Antineoplastics Alkylating Agents ALKERAN INJECTION ALKERAN TABLET BENDEKA BUSULFEX CEENU cyclophosphamide capsule cyclophosphamide tablet GLEOSTINE HEXALEN LEUKERAN LOMUSTINE MATULANE melphalan hcl injection MYLERAN seromycin TEMODAR SOLUTION temozolomide Antiangiogenic Agents REVLIMID 1 1 1 3 1 3 1 1 PA 3 3 1 PA PA 1 PA 1 1 3 4 2 PA PA PA 3 2 4 3 2 PA PA PA PA PA PA PA 1 1 3 4 2 2 4 1 2 1 PA PA 3 1 PA 4 QL PA PA THALOMID Antiestrogens/Modifiers EMCYT FARESTON FASLODEX SOLTAMOX tamoxifen citrate Antimetabolites capecitabine hydroxyurea gemcitabine hcl GEMZAR LONSURF PURIXAN TABLOID XELODA Antineoplastics, Other ABRAXANE adriamycin ALIMTA amifostine ARRANON AVASTIN BICNU bleomycin sulfate BLINCYTO BOSULIF CAMPTOSAR carboplatin cerubidine cisplatin cladribine CLOLAR COSMEGEN cytarabine dacarbazine DACOGEN dactinomycin daunorubicin hcl decitabine dexrazoxane DOCEFREZ docetaxel Last Updated 01/28/2016 4 PA. QL 3 3 4 3 1 PA PA PA PA 1 1 1 3 4 2 2 3 QL 3 1 3 1 3 3 3 1 4 4 3 1 1 1 1 3 3 1 1 3 1 1 1 1 3 1 PA PA PA PA PA PA PA PA PA PA, QL PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA, QL PA, QL DOXIL doxorubicin hcl ELITEK ELLENCE ELOXATIN epirubicin hcl ERIVEDGE etoposide capsule etoposide injection fludarabine phosphate FOLOTYN FUSILEV HALAVEN HERCEPTIN IDAMYCIN idarubicin hcl IFEX ifosfamide IMLYGIC INLYTA irinotecan hcl ISTODAX IXEMPRA 15 MG IXEMPRA 45 MG JAKAFI JEVTANA KADCYLA KEYTRUDA leucovorin calcium injection leucovorin calcium tablet 10 mg leucovorin calcium tablet 15 mg leucovorin calcium tablet 25 mg leucovorin calcium tablet 5 mg MARQIBO mesna injection MESNEX INJECTION MESNEX TABLET mitomycin mitoxantrone hcl 3 1 3 3 3 1 4 1 1 1 3 3 3 2 3 1 3 1 4 4 1 3 3 4 4 3 4 4 PA PA PA PA PA PA PA, QL 1 PA 1 PA 1 PA 1 PA 1 4 1 3 2 1 1 PA PA, QL PA, QL QL PA PA PA PA PA PA PA PA PA PA PA PA PA, QL PA PA PA PA PA, QL PA PA PA MUSTARGEN 3 PA NIPENT 3 PA ODOMZO 4 PA ONCASPAR 3 PA OPDIVO 4 PA oxaliplatin 1 PA paclitaxel 1 PA pentostatin 1 PA PERJETA 4 PA POMALYST 4 PA, QL PROLEUKIN 4 PA SYNRIBO 4 PA TAXOTERE 3 PA TENIPOSIDE 3 PA thiotepa 1 PA TREANDA 3 PA TRISENOX 3 PA UNITUXIN 4 PA VALCHLOR 4 PA, QL VALSTAR 3 PA VANTAS 3 PA VELCADE 2 VIDAZA 3 PA vinblastine sulfate 1 PA vincasar 1 PA vincristine sulfate 1 PA vinorelbine tartrate 1 PA XALKORI 4 PA, QL XTANDI 4 PA, QL ZALTRAP 4 PA ZINECARD 3 PA Aromatase Inhibitors, 3rd Generation anastrozole 1 ARIMIDEX 3 PA AROMASIN 3 PA exemestane 1 PA FEMARA 3 PA letrozole 1 Enzyme Inhibitors ALECENSA 4 PA BELEODAQ 4 PA COTELLIC 4 PA ETOPOFOS 3 PA Last Updated 01/28/2016 FARYDAK 4 GILOTRIF 4 HYCAMTIN CAPSULE 3 HYCAMTIN INJECTION 3 IBRANCE 4 IRESSA 4 KYPROLIS 4 LENVIMA 4 LYNPARZA 4 MEKINIST 4 NINLARO 4 ONIVYDE 4 TAFINLAR 4 TAGRISSO 4 toposar 1 topotecan hcl 1 ZYDELIG 4 ZYKADIA 4 Molecular Target Inhibitors AFINITOR 4 AFINITOR DISPERZ 4 CAPRELSA 3 COMETRIQ 4 GLEEVEC 4 ICLUSIG 4 IMBRUVICA 4 NEXAVAR 4 SPRYCEL 100 MG 4 SPRYCEL 140 MG 4 SPRYCEL 20 MG 4 SPRYCEL 50 MG 4 SPRYCEL 70 MG 4 SPRYCEL 80 MG 4 STIVARGA 4 SUTENT 12.5 MG 4 SUTENT 25 MG 4 SUTENT 37.5 MG 4 SUTENT 50 MG 4 TARCEVA 4 TASIGNA 4 TYKERB 4 VOTRIENT 4 PA, QL PA, QL PA, QL PA PA, QL PA PA PA, QL PA, QL PA, QL PA PA PA, QL PA PA PA PA, QL PA, QL PA, QL PA PA, QL PA, QL QL PA, QL PA, QL QL QL QL QL QL QL PA, QL PA, QL QL QL PA, QL QL QL PA, QL QL QL YONDELIS ZELBORAF Monoclonal Antibodies ARZERRA CYRAMZA DARZALEX EMPLICITI ERBITUX GAZYVA NUCALA PORTRAZZA RITUXAN SYLVANT VECTIBIX YERVOY Retinoids adapalene ATRALIN avita bexarotene DIFFERIN 0.1% CREAM DIFFERIN 0.1% GEL DIFFERIN 0.1% LOTION DIFFERIN 0.3% GEL PANRETIN RETIN-A CREAM RETIN-A GEL RETIN-A MICRO 0.04% GEL RETIN-A MICRO 0.1% GEL TARGRETIN CAPSULE TARGRETIN TOPICAL GEL tretin x cream tretinoin capsule tretinoin cream tretinoin gel Antiparasitics Anthelmintics ALBENZA BILTRICIDE Last Updated 01/28/2016 4 4 PA QL 3 4 4 4 3 4 4 4 3 4 3 3 PA PA PA PA PA PA PA PA PA PA PA PA 1 3 1 1 PA PA PA PA, QL 2 2 3 3 4 2 2 PA PA PA 3 PA 2 4 PA, QL 3 1 1 1 1 PA, QL PA 2 2 PA PA SKLICE STROMECTOL Antiprotozoals ALINIA SUSPENSION ALINIA TABLET atovaquone atovaquone-proguanil hcl chloroquine phosphate 250 mg chloroquine phosphate 500 mg COARTEM DARAPRIM hydroxychloroquine sulfate LACRISERT mefloquine hcl MEPRON NEBUPENT PENTAM PLAQUENIL PRIMAQUINE PHOSPHATE QUALAQUIN quinine sulfate tinidazole Pediculicides/ Scabicides EURAX lindane malathion OVIDE permethrin cream ULESFIA Antiparkinson Agents Anticholinergics benztropine mesylate injection benztropine mesylate tablet COGENTIN trihexyphenidyl hcl elixir trihexyphenidyl hcl tablet 3 3 PA PA 2 3 1 PA 1 1 PA 1 2 2 1 3 1 4 3 3 3 2 3 1 1 PA PA PA PA PA PA PA PA 3 1 1 3 1 3 PA PA PA PA 1 PA 1 3 PA 1 PA 1 PA Antiparkinson Agents, Other amantadine hcl capsule 1 amantadine hcl syrup 1 amantadine hcl tablet 1 PA COMTAN 3 PA entacapone 1 NORTHERA 4 PA, QL TASMAR 3 PA tolcapone 1 PA Combination Products carbidopa-levodopaentacapone 1 STALEVO 3 PA Dopamine Agonists APOKYN 4 PA bromocriptine mesylate 2.5 mg 1 bromocriptine mesylate 5 mg 1 PA MIRAPEX 3 PA MIRAPEX ER 3 PA NEUPRO 3 PA pramipexole dihydrochloride 1 pramipexole dihydrochloride er 1 PA REQUIP 3 PA REQUIP SR 3 PA ropinirole hcl 1 ropinirole hcl sr 1 PA Dopamine Precursors/ L-Amino Acid Decarboxylase Inhibitors carbidopa/levodopa 1 DUOPA 3 PA LODOSYN 2 parcopa 1 PA SINEMET 3 PA SINEMET CR 3 PA Monoamine Oxidase B (MAO-B) Inhibitors AZILECT 3 PA ELDEPRYL 3 PA selegiline hcl 1 ZELAPAR 3 PA Antipsychotics 1st Generation/Typical Last Updated 01/28/2016 fluphenazine decanoate injection fluphenazine hcl 1 mg fluphenazine hcl 10 mg fluphenazine hcl 2.5 mg fluphenazine hcl 5 mg fluphenazine hcl elixir fluphenazine hcl injection fluphenazine hcl oral concentrate haloperidol 0.5 mg haloperidol 1 mg haloperidol 10 mg haloperidol 2 mg haloperidol 20 mg haloperidol 5 mg haloperidol decanoate im solution haloperidol lactate injection haloperidol lactate oral concentrate loxapine succinate ORAP thioridazine hcl thiothixene trifluoperazine hcl 2nd Generation/Atypical FANAPT INVEGA SUSTENNA LATUDA olanzapine injection olanzapine orally disintegrating tablet olanzapine tablet paliperidone er quetiapine fumarate RISPERDAL risperidone orally disintegrating tablet risperidone oral solution risperidone tablet SEROQUEL 1 1 1 1 1 1 PA 1 PA 1 1 1 1 1 1 1 PA 1 PA 1 PA 1 1 3 1 1 1 PA PA 3 3 3 1 PA PA PA PA 1 1 1 1 3 PA 1 PA 1 1 3 PA PA PA PA PA ziprasidone hcl 1 Treatment-Resistant clozapine 1 clozapine odt 1 PA CLOZARIL 3 PA FAZACLO 3 PA Antispasticity Agents baclofen 1 DANTRIUM 3 PA dantrolene sodium 1 GABLOFEN 3 PA LIORESAL 3 PA tizanidine hcl capsule 1 PA tizanidine hcl tablet 2 mg 1 PA tizanidine hcl tablet 4 mg 1 ZANAFLEX 3 PA Antivirals Anti-cytomegalovirus (CMV) Agents cidofovir iv 1 PA CYTOVENE 3 PA foscarnet sodium 1 PA ganciclovir sodium 1 PA VALCYTE FOR SOLUTION 2 VALCYTE TABLET 4 PA, QL valganciclovir 1 QL VISTIDE 4 PA ZIRGAN 3 PA Antihepatitis Agents BARACLUDE ORAL SOLUTION 3 PA BARACLUDE TABLET 4 PA COPEGUS 3 PA DAKLINZA 4 PA, QL entecavir 1 EPIVIR HBV SOLUTION 3 PA HARVONI 4 PA, QL HEPSERA 4 PA INCIVEK 4 PA, QL INFERGEN 4 PA, QL INTRON-A 4 PA, QL Last Updated 01/28/2016 lamivudine (HBV) 1 OLYSIO 4 PA, QL PEGASYS 4 QL PEGINTRON 4 QL REBETOL 3 PA ribasphere 1 PA ribavirin capsule 1 ribavirin tablet 1 PA SOVALDI 4 QL TECHNIVIE 4 PA, QL TYZEKA 3 PA VICTRELIS 4 PA, QL VIEKIRA 4 PA, QL VIRAZOLE 3 PA Antiherpetic Agents acyclovir 1 acyclovir sodium for injection 1 PA DENAVIR 3 PA famciclovir 1 PA FAMVIR 3 PA trifluridine ophthalmic solution 1 valacyclovir hcl 1 PA VALTREX 3 PA VIROPTIC 3 PA Anti-HIV Agents, Non-nucleoside Reverse Transcriptase Inhibitors EDURANT 4 INTELENCE TABLET 100 MG 4 INTELENCE TABLET 200 MG 4 INTELENCE TABLET 25 MG 3 PA nevirapine suspension 1 PA nevirapine tablet 100 mg er 1 PA nevirapine tablet 200 mg 1 nevirapine tablet 400 mg er 1 PA RESCRIPTOR 2 SUSTIVA 2 Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors abacavir sulfate abacavir sulfatelamivudine-zidovudine COMBIVIR didanosine delayed release capsule EMTRIVA EPZICOM lamivudine lamivudine-zidovudine RETROVIR stavudine TRIZIVIR TRUVADA VIDEX VIDEX EC VIDEX FOR SOLUTION VIREAD TABLET 150 MG VIREAD TABLET 200 MG VIREAD TABLET 250 MG VIREAD TABLET 300 MG VIREAD POWDER 40 MG/GM ZERIT ZIAGEN SOLUTION ZIAGEN TABLET zidovudine Anti-HIV Agents, Other ATRIPLA COMPLERA FUZEON GENVOYA ISENTRESS POWDER ISENTRESS TABLET CHEWABLE 100 MG ISENTRESS TABLET CHEWABLE 25 MG ISENTRESS TABLET 400 MG SELZENTRY STRIBILD Last Updated 01/28/2016 1 1 4 1 3 4 1 1 3 1 4 4 3 3 3 PA PA PA PA PA PA PA PA 4 4 PA 4 PA 4 4 3 2 3 1 4 4 4 4 3 2 2 4 4 4 PA PA QL PA PA TIVICAY 4 TRIUMEQ 4 PA TYBOST 3 PA VITEKTA 4 PA Anti-HIV Agents, Protease Inhibitors APTIVUS 4 PA CRIXIVAN 3 PA EVOTAZ 4 INVIRASE CAPSULE 3 PA INVIRASE TABLET 4 PA KALETRA SOLUTION 4 KALETRA TABLET 100-25 MG 2 KALETRA TABLET 200-50 MG 4 LEXIVA TABLET 4 LEXIVA SUSPENSION 3 PA NORVIR 2 PREZCOBIX 4 PREZISTA SUSPENSION 3 PA PREZISTA TABLET 150 MG 2 PREZISTA TABLET 400 MG 4 PA PREZISTA TABLET 600 MG 4 PREZISTA TABLET 75 MG 2 PREZISTA TABLET 800 MG 4 REYATAZ CAPSULE 100 MG 3 PA REYATAZ CAPSULE 150 MG 4 REYATAZ CAPSULE 200 MG 4 REYATAZ CAPSULE 300 MG 4 VIRACEPT 4 Anti-influenza Agents RAPIVAB 4 PA RELENZA 2 rimantadine hcl 1 TAMIFLU CAPSULE 30 MG TAMIFLU CAPSULE 45 MG TAMIFLU CAPSULE 75 MG TAMIFLU SUSPENSION Anxiolytics Anxiolytics, Other alprazolam alprazolam concentrate alprazolam orally disintegrating tablet alprazolam sr ATIVAN buspirone hcl tablet 10 mg buspirone hcl tablet 15 mg buspirone hcl tablet 30 mg buspirone hcl tablet 5 mg buspirone hcl tablet 7.5 mg chlordiazepoxide hcl clorazepate dipotassium diazepam diazepam conc 5 mg/ml diazepam rectal gel delivery system 10 mg diazepam rectal gel delivery system 2.5 mg diazepam rectal gel delivery system 20 mg diazepam solution HETLIOZ lorazepam meprobamate NIRAVAM oxazepam TRANXENE VALIUM XANAX Bipolar Agents Last Updated 01/28/2016 2 3 PA 2 2 1 1 PA 1 1 3 PA PA PA 1 1 1 PA 1 1 1 1 1 1 PA 1 1 1 1 4 1 1 3 1 3 3 3 PA PA, QL PA PA PA PA PA Bipolar Agents, Other SAPHRIS Mood Stabilizers lithium carbonate capsule 150 mg lithium carbonate capsule 300 mg lithium carbonate capsule 600 mg lithium carbonate tablet 300 mg lithium carbonate tablet cr 300 mg lithium carbonate tablet cr 450 mg LITHIUM CITRATE ORAL SOLUTION LITHOBID Blood Glucose Regulators Antidiabetic Agents acarbose tablet 100 mg acarbose tablet 25 mg acarbose tablet 50 mg ACTOS AMARYL AVANDIA BYDUREON BYETTA chlorpropamide CYCLOSET DIABETA FARXIGA FORTAMET GATTEX glimepiride glipizide glipizide sr GLUCOPHAGE GLUCOPHAGE XR GLUCOTROL GLUMETZA glyburide glyburide micronized GLYNASE GLYSET 3 PA 1 1 1 PA 1 PA 1 1 3 3 1 1 1 3 3 3 3 3 1 3 3 3 3 4 1 1 1 3 3 3 3 1 1 3 3 PA PA PA PA PA PA PA PA PA PA PA PA PA, QL PA PA PA PA PA PA PA INVOKANA JANUVIA JARDIANCE KORLYM metformin hcl metformin hcl sr nateglinide ONGLYZA pioglitazone hcl PRANDIN PRECOSE repaglinide RIOMET STARLIX SYMLIN tolazamide tolbutamide TRADJENTA VICTOZA Combination Products ACTOPLUS MET ACTOPLUS MET SR AVANDAMET AVANDARYL DUETACT glipizide-metformin hcl GLUCOVANCE glyburide-metformin hcl GLYXAMBI INVOKAMET JANUMET JENTADUETO KOMBIGLYZE pioglitazone hclglimepiride pioglitazone hclmetformin hcl PRANDIMET XIGDUO XR Glycemic Agents GLUCAGEN GLUCAGON PROGLYCEM Insulins Last Updated 01/28/2016 3 3 3 4 1 1 1 3 1 3 3 1 3 3 3 1 1 3 3 PA PA PA PA, QL 3 3 3 3 3 1 3 1 3 3 3 3 3 PA PA PA PA PA PA PA PA PA PA PA PA PA 1 PA 1 3 3 PA PA PA 3 2 3 PA PA PA PA PA PA PA PA PA PA PA PA AFREZZA 3 PA APIDRA 3 PA HUMALOG MIX 50/50 PEN 3 PA HUMALOG MIX 50/50 VIAL 3 PA HUMALOG MIX 75/25 PEN 3 PA HUMALOG MIX 75/25 VIAL 3 PA HUMALOG PEN 3 PA HUMALOG VIAL 3 PA HUMULIN 70/30 PEN 3 PA HUMULIN 70/30 VIAL 2 HUMULIN N PEN 3 PA HUMULIN N VIAL 2 HUMULIN R PEN 3 PA HUMULIN R VIAL 2 LANTUS 3 PA LEVEMIR 3 PA NOVOLIN 70/30 VIAL 3 PA NOVOLIN N VIAL 3 PA NOVOLIN R VIAL 3 PA NOVOLOG 3 PA TOUJEO 3 PA Blood Products/Modifiers/Volume Expanders Anticoagulants ARGATROBAN IN NS IV SOLUTION 125 MG/125ML 3 PA argatroban injection 100 mg/ml 1 PA ARIXTRA 3 PA, QL COUMADIN 3 PA ELIQUIS 3 PA enoxaparin sodium inj 1 PA, QL fondaparinux sodium inj 1 PA FRAGMIN 3 PA, QL HEPARIN SODIUM (PORCINE) 100 UNIT/ML IN 1/2NS 3 PA heparin sodium (porcine) 2 unit/ml in ns 1 PA heparin sodium (porcine) 40 unit/ml in d5w 1 HEPARIN SODIUM (PORCINE) 50 UNIT/ML IN 1/2NS 3 heparin sodium (porcine) inj 1000 unit/ml 1 heparin sodium (porcine) inj 10000 unit/ml 1 heparin sodium (porcine) inj 20000 unit/ml 1 heparin sodium (porcine) inj 5000 unit/ml 1 jantoven 1 LOVENOX 2 PRADAXA 75 MG 2 PRADAXA 110 MG 3 PRADAXA 150 MG 2 SAVAYSA 3 warfarin sodium 1 XARELTO 10 MG 2 XARELTO 15 MG 3 XARELTO 20 MG 3 Blood Formation Modifiers AGRYLIN 3 anagrelide hcl 0.5 mg 1 anagrelide hcl 1 mg 1 ARANESP 3 CINRYZE 4 EPOGEN 3 FIRAZYR 4 GRANIX 3 LEUKINE 3 MIRCERA 3 MOZOBIL 3 NEULASTA 4 NEUMEGA 4 NEUPOGEN 4 PROCRIT 2 PROMACTA 12.5 MG 4 Last Updated 01/28/2016 PA PA PA PA PA PA PA QL PA PA PA PA PA PA PA, QL PA, QL PA, QL PA, QL PA PA PA, QL PA PA, QL QL QL PA, QL PROMACTA 25 MG 4 QL PROMACTA 50 MG 4 QL PROMACTA 75 MG 4 QL RUCONEST 4 PA. QL ZARXIO 4 QL Coagulants CYKLOKAPRON 3 PA PRAXBIND 4 PA tranexamic acid 1 PA Platelet Modifying Agents aspirin-dipyridamole er 1 BRILINTA 3 PA cilostazol 1 clopidogrel bisulfate 75 mg 1 clopidogrel bisulfate 300 mg 1 PA dipyridamole 1 EFFIENT 2 PERSANTINE 3 PA PLAVIX 3 PA PLETAL 3 PA ticlopidine hcl 1 PA ZONTIVITY 3 PA Cardiovascular Agents Alpha-adrenergic Agonists CATAPRES 3 PA CATAPRES-TTS 3 PA clonidine hcl tablet 1 clonidine hcl transdermal patch 1 PA guanfacine hcl 1 KAPVAY 3 PA methyldopa 1 methyldopate hcl 1 PA midodrine hcl 10 mg 1 PA midodrine hcl 2.5 mg 1 midodrine hcl 5 mg 1 TENEX 3 PA Alpha-adrenergic Blocking Agents CARDURA 3 PA CARDURA XL 3 PA DIBENZYLINE 2 doxazosin mesylate 1 MINIPRESS 3 PA phenoxybenzamine 1 PA prazosin hcl 1 terazosin hcl 1 Angiotensin II Receptor Antagonists ATACAND 3 PA BENICAR 3 PA candesartan cilexetil 1 PA COZAAR 3 PA DIOVAN 3 PA eprosartan mesylate 1 PA irbesartan 1 PA losartan potassium 1 MICARDIS 3 PA telmisartan 1 PA TEVETEN 3 PA valsartan 1 Angiotensin-converting Enzyme (ACE) Inhibitors ACCUPRIL 3 PA ACEON 3 PA ALTACE 3 PA benazepril hcl 1 captopril 1 EDARBI 3 PA enalapril maleate tablet 10 mg 1 enalapril maleate tablet 2.5 mg 1 PA enalapril maleate tablet 5 mg 1 enalapril maleate tablet 20 mg 1 EPANED 2 fosinopril sodium 1 PA lisinopril 10 mg 1 lisinopril 2.5 mg 1 lisinopril 20 mg 1 lisinopril 30 mg 1 PA lisinopril 40 mg 1 lisinopril 5 mg 1 moexipril hcl 1 PA perindopril erbumine 1 PA quinapril hcl 1 PA Last Updated 01/28/2016 ramipril 1 PA trandolapril 1 PA Antiarrhythmics amiodarone hcl 200 mg 1 amiodarone hcl 400 mg 1 PA amiodarone hcl injection 1 PA CORDARONE 3 PA disopyramide phosphate 1 flecainide acetate 100 mg 1 flecainide acetate 150 mg 1 PA flecainide acetate 50 mg 1 mexiletine hcl 1 MULTAQ 3 PA NEXTERONE 3 PA NORPACE 3 PA NORPACE CR 2 pacerone 1 PA procainamide hcl 1 PA propafenone hcl 1 propafenone hcl sr 1 PA QUINIDINE GLUCONATE INJECTION 3 PA quinidine gluconate tablet cr 1 quinidine sulfate 200 mg 1 quinidine sulfate 300 mg 1 PA quinidine sulfate cr 1 PA RYTHMOL 3 PA RYTHMOL SR 3 PA TIKOSYN 2 Beta-adrenergic Blocking Agents acebutolol hcl 1 atenolol 1 BETAPACE 3 PA betaxolol hcl 1 PA bisoprolol fumarate 1 BYSTOLIC 3 PA carvedilol 1 COREG COREG CR CORGARD INNOPRAN labetalol hcl iv solution labetalol hcl tablet LEVATOL metoprolol succinate sr metoprolol tartrate injection metoprolol tartrate tablet nadolol pindolol propranolol hcl injection 1 mg/ml propranolol hcl oral solution 20 mg/5ml propranolol hcl oral solution 40 mg/5ml propranolol hcl sr propranolol hcl tablet 10 mg propranolol hcl tablet 20 mg propranolol hcl tablet 40 mg propranolol hcl tablet 60 mg propranolol hcl tablet 80 mg SECTRAL sorine sotalol hcl (afib/afl) tab 120 mg SOTALOL HCL INJECTION sotalol hcl tablet 160 mg sotalol hcl tablet 240 mg sotalol hcl tablet 80 mg SOTYLIZE TENORMIN timolol maleate TOPROL XL TRANDATE Last Updated 01/28/2016 3 3 3 3 1 1 3 1 PA PA PA PA PA 1 PA 1 1 1 PA 1 PA 1 PA 1 1 PA PA PA 1 1 1 1 PA 1 3 1 PA PA 1 3 PA 1 1 1 2 3 1 3 3 PA PA PA PA PA ZEBETA 3 PA Calcium Channel Blocking Agents ADALAT 3 PA afeditab cr 1 PA amlodipine besylate 1 CALAN 3 PA cartia-xt 1 PA dilacor-xr 1 PA dilt-cd 1 PA diltiazem hcl 1 diltiazem hcl coated beads sr 120 mg 1 diltiazem hcl coated beads sr 240 mg 1 diltiazem hcl coated beads sr 300 mg 1 PA diltiazem hcl extended release beads sr 180 mg 1 diltiazem hcl extended release beads sr 360 mg 1 PA diltiazem hcl iv solution 1 PA diltiazem hcl sr 12hr 1 PA dilt-xr 1 felodipine 1 PA isradipine 1 PA matzim-la 1 PA nicardipine hcl 1 PA nifedipine 1 PA nifedipine er 1 nimodipine 1 nisoldipine sr 1 PA NORVASC 3 PA SULAR 3 PA taztia 1 PA TIAZAC 3 PA verapamil hcl 120 mg 1 verapamil hcl 40 mg 1 PA verapamil hcl 80 mg 1 verapamil hcl cr 120 mg 1 PA verapamil hcl cr 180 mg 1 verapamil hcl cr 240 mg 1 verapamil hcl iv solution 1 verapamil hcl sr 1 VERELAN 3 Cardiovascular Agents, Other CORLANOR 3 DEMSER 3 digoxin injection 1 DIGOXIN ORAL SOLN 2 digoxin tablet 1 MYALEPT 4 pentoxifylline 1 RANEXA 3 RESERPINE 3 TEKTURNA 3 Combination Products ACCURETIC 3 ADVICOR 3 ALDACTAZIDE 3 amiloride & hydrochlorothiazide 1 amlodipine besylateatorvastatin 1 amlodipine besylatebenazepril hcl 1 amlodipine besylatevalsartan 1 amlodipine-valsartanhydrochlorothiazide 1 AMTURNIDE 3 ATACAND HCT 3 atenolol & chlorthalidone 1 AZOR 3 benazepril & hydrochlorothiazide 1 BENICAR HCT 3 bisoprolol & hydrochlorothiazide 1 CADUET 3 candesartan cilexetilhydrochlorothiazide 1 captopril & hydrochlorothiazide 1 clorpres 1 Last Updated 01/28/2016 PA PA PA PA PA PA PA, QL PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA CORZIDE DIOVAN HCT DYAZIDE EDARBYCLOR enalapril maleate & hydrochlorothiazide ENTRESTO fosinopril sodium & hydrochlorothiazide HYZAAR irbesartanhydrochlorothiazide lisinopril & hydrochlorothiazide losartan potassium & hydrochlorothiazide LOTREL MAXZIDE methyldopa & hydrochlorothiazide metoprolol & hydrochlorothiazide MICARDIS-HCT moexiprilhydrochlorothiazide nadolol & bendroflumethiazide propranolol & hydrochlorothiazide quinaprilhydrochlorothiazide SIMCOR spironolactone & hydrochlorothiazide TEKAMLO TEKTURNA HCT telmisartan & amlodipine telmisartan & hydrochlorothiazide TENORETIC TEVETEN HCT trandolapril-verapamil triamterene & hydrochlorothiazide TRIBENZOR TWYNSTA 3 3 3 3 PA PA PA PA 1 3 PA PA 1 3 PA PA 1 PA 1 1 3 3 PA PA 1 PA 1 3 PA PA 1 PA 1 PA 1 PA 1 3 PA PA 1 3 3 PA PA 1 PA 1 3 3 1 PA PA PA PA 1 3 3 PA PA valsartanhydrochlorothiazide 8012.5 mg 1 valsartanhydrochlorothiazide 160-12.5 mg 1 valsartanhydrochlorothiazide 160-25 mg 1 valsartanhydrochlorothiazide 320-12.5 mg 1 valsartanhydrochlorothiazide 320-25 mg 1 PA VASERETIC 3 PA VYTORIN 3 PA ZIAC 3 PA Diuretics, Carbonic Anhydrase Inhibitors acetazolamide capsule sr 1 acetazolamide sodium for injection 1 PA acetazolamide tablet 1 DIAMOX 2 KEVEYIS 4 PA methazolamide tablet 25 mg 1 PA methazolamide tablet 50 mg 1 Diuretics, Loop bumetanide injection 1 PA bumetanide tablet 1 DEMADEX 3 PA EDECRIN 3 PA furosemide injection 1 PA furosemide oral solution 10 mg/ml 1 furosemide oral solution 8 mg/ml 1 PA furosemide tablet 1 LASIX 3 PA torsemide iv solution 1 PA torsemide tablet 10 mg 1 torsemide tablet 100 mg 1 torsemide tablet 20 mg 1 torsemide tablet 5 mg 1 PA Last Updated 01/28/2016 Diuretics, Potassium-sparing ALDACTONE 3 PA amiloride hcl 1 PA DYRENIUM 100 MG 2 DYRENIUM 50 MG 3 PA eplerenone 1 PA spironolactone 1 Diuretics, Thiazide chlorothiazide 1 PA chlorthalidone 1 DIURIL FOR INJECTION 3 PA DIURIL SUSPENSION 2 hydrochlorothiazide capsule 1 PA hydrochlorothiazide tablet 12.5 mg 1 PA hydrochlorothiazide tablet 25 mg 1 hydrochlorothiazide tablet 50 mg 1 indapamide 1 methyclothiazide 1 PA metolazone 1 MICROZIDE 3 PA Dyslipidemics, Fibric Acid Derivatives ALTOPREV 3 PA fenofibrate 145 mg 1 PA fenofibrate 160 mg 1 fenofibrate 48 mg 1 PA fenofibrate 54 mg 1 fenofibrate micronized 1 PA FENOGLIDE 3 PA FIBRICOR 3 PA gemfibrozil 1 LIPOFEN 3 PA lofibra 1 PA LOPID 3 PA TRICOR 3 PA TRILIPIX 3 PA Dyslipidemics, HMG CoA Reductase Inhibitors ALTOPREV 3 PA atorvastatin calcium 1 CRESTOR 3 PA fluvastatin sodium 1 PA LESCOL 3 PA LIPITOR 3 PA LIVALO 3 PA lovastatin 1 MEVACOR 3 PA PRAVACHOL 3 PA pravastatin sodium 1 simvastatin 10 mg 1 PA simvastatin 20 mg 1 simvastatin 40 mg 1 simvastatin 5 mg 1 PA simvastatin 80 mg 1 ZOCOR 3 PA Dyslipidemics, Other cholestyramine 1 cholestyramine light 1 PA colestipol hcl granules 1 PA colestipol hcl tablet 1 JUXTAPID 4 PA, QL KYNAMRO 4 PA, QL LOVAZA 3 PA niacor 1 PA NIASPAN 3 PA PRALUENT 4 PA, QL prevalite 1 REPATHA 4 PA, QL WELCHOL 3 PA ZETIA 3 PA Vasodilators, Direct-acting Arterial hydralazine hcl injection 1 PA hydralazine hcl tablet 1 minoxidil 1 PA VELETRI 4 Vasodilators, Direct-acting Arterial/Venous DILATRATE 3 PA ISORDIL 40 MG 2 ISORDIL 5 MG 3 PA isosorbide dinitrate cr 1 isosorbide dinitrate sublingual 1 PA isosorbide dinitrate tablet 10 mg 1 Last Updated 01/28/2016 isosorbide dinitrate tablet 20 mg 1 isosorbide dinitrate tablet 30 mg 1 PA isosorbide dinitrate tablet 5 mg 1 isosorbide mononitrate 1 PA isosorbide mononitrate sr 1 minitran 1 PA nitro-bid 1 NITRO-DUR 3 PA nitroglycerin iv solution 1 PA nitroglycerin lingual spray 1 nitroglycerin transdermal patch 1 NITROLINGUAL 3 PA NITROMIST 3 PA NITROSTAT 2 Central Nervous System Agents Attention Deficit Hyperactivity Disorder Agents, Amphetamines ADDERALL XR 2 PA amphetaminedextroamphetamine sr 1 PA amphetaminedextroamphetamine tablet 10 mg 1 amphetaminedextroamphetamine tablet 12.5 mg 1 PA amphetaminedextroamphetamine tablet 15 mg 1 PA amphetaminedextroamphetamine tablet 20 mg 1 amphetaminedextroamphetamine tablet 30 mg 1 amphetaminedextroamphetamine tablet 5 mg 1 amphetaminedextroamphetamine tablet 7.5 mg 1 PA DESOXYN 3 PA dextroamphetamine sulfate capsule er 1 PA dextroamphetamine sulfate tablet 1 EVEKEO 3 PA methamphetamine hcl 1 PA VYVANSE 3 PA Attention Deficit Hyperactivity Disorder Agents, Non-amphetamines APTENSIO XR 3 PA DAYTRANA 3 PA dexmethylphenidate hcl 1 PA FOCALIN XR 3 PA INTUNIV 3 PA methylphenidate hcl capsule cd 1 PA methylphenidate hcl capsule cr 1 PA methylphenidate hcl capsule sr 1 PA methylphenidate hcl chewable 1 PA METHYLPHENIDATE HCL FOR ER SUSP 25 MG/5ML (5 MG/ML) 3 PA methylphenidate hcl soln 10 mg/5ml 1 PA methylphenidate hcl soln 5 mg/5ml 1 PA methylphenidate hcl tablet 1 methylphenidate hcl tablet cr 1 PA modafinil 1 PA STRATTERA 3 PA Central Nervous System Agents, Other NUEDEXTA 3 PA, QL PROSTIGMIN 3 PA riluzole 1 tetrabenazine 1 PA, QL XENAZINE 4 PA, QL Fibromyalgia Agents SAVELLA 3 PA Multiple Sclerosis Agents AMPYRA 4 PA, QL AVONEX 4 QL Last Updated 01/28/2016 BETASERON COPAXONE EXTAVIA GILENYA glatopa LEMTRADA PLEGRIDY REBIF TECFIDERA TYSABRI Contraceptives, Other IMPLANON methylergonovine maleate MIFEPREX MIRENA (HORMONAL IUD) NEXPLANON PARAGARD (COPPER IUD) plan b one step SKYLA (HORMONAL IUD) Dental and Oral Agents APHTHASOL cevimeline hcl chlorhexidine gluconate EVOXAC KEPIVANCE periogard pilocarpine hcl (oral) Dermatological Agents 8-MOP ABSORBICA acitretin 10 mg acitretin 17.5 mg acitretin 25 mg ADRUCIL ALDARA amnesteem AZELEX calcipotriene cream 0.005% calcipotriene ointment 0.005% 4 4 4 4 1 4 4 4 4 4 PA, QL PA, QL PA, QL PA, QL QL PA PA, QL QL PA, QL PA 3 PA 1 3 PA 2 2 2 1 3 PA 3 1 1 3 4 1 1 PA PA 3 3 1 1 1 4 3 1 2 PA PA, QL 1 PA 1 PA PA PA PA PA PA PA PA, QL calcipotriene solution 0.005% CARAC claravis CONDYLOX COSENTYX diclofenac sodium gel 3% DIFFERIN CREAM 0.1% DIFFERIN GEL 0.1% DIFFERIN GEL 0.3% DOVONEX EFUDEX ELIDEL FINACEA FLUOROPLEX fluorouracil cream fluorouracil injection fluorouracil solution 2% fluorouracil solution 5% imiquimod cream LAC-HYDRIN lactic acid (ammonium lactate) cream lactic acid (ammonium lactate) lotion NATROBA OXSORALEN LOTION OXSORALEN-ULTRA PICATO podofilox PROTOPIC RECTIV REGRANEX SANTYL selenium sulfide SORIATANE SORILUX spinosad STELARA TAZORAC Last Updated 01/28/2016 1 3 1 2 4 1 2 2 3 3 3 2 2 3 1 1 PA QL QL PA PA PA PA PA PA 1 1 1 3 PA PA 1 PA 1 3 PA PA 3 2 3 1 3 3 4 3 1 4 3 1 4 2 PA PA PA PA PA PA PA PA PA PA UVADEX 3 PA VECTICAL 2 VEREGEN 3 PA VOLTAREN GEL 3 PA ZONALON 3 PA ZYCLARA 3 PA PHISOHEX 3 PA Combination Products ACANYA 3 PA BENZAMYCIN 3 PA benzoyl peroxideerythromycin 1 PA clindamycin phosphatebenzoyl peroxide 1 PA clotrimazole w/ betamethasone 1 PA CORTISPORIN 3 PA EPIDUO 3 PA LOTRISONE 3 PA mometasone furoate 1 PA nystatin-triamcinolone cream 1 nystatin-triamcinolone ointment 1 pramosone 1 TACLONEX OINTMENT 4 PA TACLONEX SUSPENSION 3 PA VELTIN 3 PA XERESE 3 PA ZIANA 3 PA Enzyme Replacement/Modifiers ADAGEN 3 PA ALDURAZYME 3 PA BUPHENYL 4 PA, QL CARBAGLU 3 PA CEREZYME 4 PA CREON 3 PA CYSTADANE 3 PA, QL CYSTAGON 3 PA, QL ELAPRASE 4 PA ELELYSO 4 PA, QL FABRAZYME 4 PA KANUMA 4 PA KUVAN 4 PA, QL LUMIZYME 4 PA MYOZYME 4 PA NAGLAZYME 4 PA ORFADIN 4 PA, QL PANCREAZE 3 PA PERTZYE 3 PA STRENSIQ 4 PA ULTRESA 3 PA VIOKACE 3 PA VPRIV 4 PA ZAVESCA 4 PA ZENPEP 10 2 ZENPEP 15 2 ZENPEP 20 2 ZENPEP 25 3 PA ZENPEP 3 3 PA ZENPEP 5 2 Gastrointestinal Agents Antispasmodics, Gastrointestinal ATROPINE SULFATE INJECTION 0.05 MG/ML 3 PA atropine sulfate injection 0.1 mg/ml 1 PA BENTYL 3 PA CANTIL 3 PA CUVPOSA 3 PA dicyclomine hcl 1 glycopyrrolate 1 methscopolamine bromide 1 PA PAMINE 3 PA PAMINE FORTE 3 PA Combination Products COLYTE 3 PA gaviltye-g 1 PA gavilyte-c 1 gavilyte-n 1 PA GOLYTELY 3 PA HELIDAC THERAPY 3 PA NULYTELY 3 PA OMECLAMOX 3 PA Last Updated 01/28/2016 lansoprazoleamoxicillinclarithromycin 1 PA omeprazole-sodium bicarbonate 1 PA PREVPAC 3 PA PYLERA 3 PA trilyte 1 PA ZEGERID 3 PA Gastrointestinal Agents, Other ACTIGALL 3 PA chenodal 1 PA CHOLBAM 4 PA diphenoxylate w/ atropine 1 ENTEREG 3 PA LINZESS 3 PA LOMOTIL 3 PA loperamide hcl 1 PA MOTOFEN 3 PA MOVANTIK 3 PA propantheline bromide 1 RELISTOR 3 PA URSO FORTE 3 PA ursodiol capsule 1 PA ursodiol tablet 1 Histamine2 (H2) Receptor Antagonists cimetidine hcl 1 PA famotidine injection 1 PA famotidine suspension 1 PA famotidine tablet 1 nizatidine 1 PA PEPCID 3 PA ranitidine hcl capsule 1 PA ranitidine hcl injection 1 PA ranitidine hcl syrup 1 ranitidine hcl tablet 1 Irritable Bowel Syndrome Agents alosetron hcl 1 PA, QL AMITIZA 3 PA LOTRONEX 3 PA, QL VIBERZI 4 PA Laxatives constulose 1 PA enulose generlac kristalose lactulose MOVIPREP polyethylene glycol PREPOPIK Protectants CARAFATE CYTOTEC CYTOTEC misoprostol sucralfate Proton Pump Inhibitors ACIPHEX DEXILANT lansoprazole NEXIUM IV INJECTION omeprazole 10 mg pantoprazole sodium ec tablet pantoprazole sodium iv solution PREVACID PROTONIX PROTONIX PAK rabeprazole sodium Genitourinary Agents Antispasmodics, Urinary DITROPAN XL ENABLEX flavoxate hcl GELNIQUE MYRBETRIQ oxybutynin chloride OXYTROL SANCTURA SANCTURA XR tolterodine tartrate TOVIAZ trospium chloride trospium chloride sr VESICARE Last Updated 01/28/2016 1 1 1 1 3 1 3 PA PA PA 3 3 3 1 1 PA PA PA 3 3 1 PA PA PA 3 1 PA PA PA PA 1 1 3 3 2 1 PA PA PA 3 3 1 3 3 1 2 3 3 1 3 1 1 3 PA PA PA PA PA PA PA PA PA PA PA PA Benign Prostatic Hypertrophy Agents alfuzosin hcl 1 PA AVODART 3 PA CIALIS 3 PA, QL dutasteride 1 PA finasteride 1 FLOMAX 3 PA PROSCAR 3 PA RAPAFLO 3 PA tamsulosin hcl 1 Genitourinary Agents, Other bethanechol chloride 10 mg 1 PA bethanechol chloride 25 mg 1 bethanechol chloride 5 mg 1 PA bethanechol chloride 50 mg 1 PA DEPEN 3 PA ELMIRON 2 JALYN 3 PA urecholine 1 PA Phosphate Binders calcium acetate 1 PA eliphos 1 FOSRENOL 4 PA PHOSLO 3 PA PHOSLYRA 2 RENAGEL 3 PA RENVELA PAK 0.8 GM 3 PA RENVELA PAK 2.4 GM 2 RENVELA TABLET 2 Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal) Glucocorticoids/ Mineralocorticoids a-hydrocort 1 PA ala-cort 1 PA ala-scalp 1 PA alclometasone dipropionate 1 amcinonide 1 PA anusol hc betamethasone dipropionate augmented cream betamethasone dipropionate augmented lotion betamethasone dipropionate augmented ointment betamethasone dipropionate cream betamethasone dipropionate lotion betamethasone dipropionate ointment betamethasone valerate aerosol foam betamethasone valerate cream betamethasone valerate lotion betamethasone valerate ointment budesonide CAPEX CELESTONE clobetasol propionate emollient clobetasol propionate foam clobetasol propionate gel clobetasol propionate lotion clobetasol propionate ointment clobetasol propionate shampoo clobetasol propionate solution clobetasol propionate spray CLOBEX CLODERM colocort CORDRAN LOTION CORDRAN TAPE Last Updated 01/28/2016 1 PA 1 1 PA 1 1 1 1 1 PA 1 1 1 1 3 3 PA PA PA 1 1 PA 1 PA 1 PA 1 1 PA 1 1 2 3 1 3 2 PA PA PA CORTEF CORTIFOAM cortisone acetate CUTIVATE LOTION DEPO-MEDROL DERMA-SMOOTH/FS DESONATE desonide DESOWEN CREAM desowen lotion desoximetasone cream 0.05% desoximetasone cream 0.25% desoximetasone gel DESOXIMETASONE OINTMENT 0.05% desoximetasone ointment 0.25% dexamethasone 0.5 mg dexamethasone 0.75 mg dexamethasone 1 mg dexamethasone 1.5 mg dexamethasone 2 mg dexamethasone 4 mg dexamethasone 6 mg dexamethasone concentrate dexamethasone elixir dexamethasone sodium phosphate injection dexpak taperpak diflorasone diacetate ELOCON ENTOCORT EC FLO-PRED fludrocortisone acetate fluocinolone acetonide cream fluocinolone acetonide oil fluocinolone acetonide ointment fluocinolone acetonide solution fluocinonide cream 3 3 1 3 3 3 3 1 3 1 PA PA PA PA PA PA PA PA PA PA 1 PA 1 1 PA 3 PA 1 1 1 1 1 1 1 1 PA PA PA PA PA 1 1 1 1 1 3 4 3 1 PA PA PA PA PA PA 1 1 PA 1 1 1 PA fluocinonide emulsified cream fluocinonide gel fluocinonide ointment fluocinonide solution fluticasone propionate halobetasol propionate HALOG hydrocortisone 10 mg hydrocortisone 20 mg hydrocortisone 5 mg hydrocortisone butyrate cream hydrocortisone butyrate lipophilic cream hydrocortisone butyrate ointment hydrocortisone butyrate solution hydrocortisone cream 1% hydrocortisone cream 2.5% hydrocortisone enema hydrocortisone lotion hydrocortisone ointment 1% hydrocortisone ointment 2.5% hydrocortisone valerate KENALOG AEROSOL SPRAY LOCOID LOTION lokara LUXIQ MEDROL MEDROL DOSEPAK methylprednisolone tablet methylprednisolone acetate injection methylprednisolone dose pack methylprednisolone sodium succinate injection millipred Last Updated 01/28/2016 1 1 1 1 1 1 3 1 1 1 PA 1 PA PA PA PA PA 1 1 PA 1 PA 1 PA 1 1 1 PA 1 PA 1 1 PA 2 3 1 3 3 3 PA PA PA PA PA 1 PA 1 PA 1 PA 1 1 PA PA mometasone furoate cream mometasone furoate ointment mometasone furoate solution (lotion) OLUX orapred ORAPRED ODT PANDEL prednicarbate cream prednicarbate ointment prednisolone sodium phosphate oral solution 15 mg/5ml prednisolone sodium phosphate oral solution 6.7 mg/5ml prednisone oral solution prednisone tablet procto-pak RAYOS SOLU-CORTEF SOLU-MEDROL TEMOVATE topicort cream topicort gel TOPICORT OINTMENT 0.05% topicort ointment 0.25% triamcinolone acetonide cream 0.025% triamcinolone acetonide cream 0.1% triamcinolone acetonide cream 0.5% triamcinolone acetonide dental paste triamcinolone acetonide lotion triamcinolone acetonide ointment 0.025% triamcinolone acetonide ointment 0.1% triamcinolone acetonide ointment 0.5% 1 1 1 3 1 3 3 1 1 PA PA PA PA PA PA 1 1 PA 1 1 1 3 3 3 3 1 1 PA 3 1 PA PA PA PA PA PA PA PA PA 1 1 1 1 1 1 1 1 PA triderm 1 PA UCERIS 4 PA, QL ULTRAVATE 3 PA VERDESO 3 PA veripred 1 PA WESTCORT 3 PA Hormonal Agents, Stimulant/ Replacement/ Modifying (Pituitary) ACTHAR 4 PA chorionic gonadotropin 1 PA desmopressin acetate injection 1 PA desmopressin acetate nasal spray 1 desmopressin acetate nasal spray (refrigerated) 1 PA desmopressin acetate solution (refrigerated) 1 desmopressin acetate tablet 1 EGRIFTA 4 PA GENOTROPIN 5 MG 4 PA, QL GENOTROPIN 12 MG 3 PA, QL GENOTROPIN MINIQUICK 3 PA, QL HUMATROPE 4 PA, QL INCRELEX 4 PA, QL NORDITROPIN 4 PA, QL novarel 1 NUTROPIN 4 PA, QL OMNITROPE 2 QL pregnyl 1 PA SAIZEN 4 PA, QL SEROSTIM 4 PA, QL SIGNIFOR 4 PA, QL SIGNIFOR LAR 4 PA STIMATE 3 PA TEV TROPIN 4 PA, QL ZOMACTON 4 PA ZORBTIVE 4 PA, QL Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers) Anabolic Steroids Last Updated 01/28/2016 ANADROL-50 oxandrolone Androgens ANDRODERM ANDROGEL android androxy AXIRON danazol depo-testosterone FORTESTA methitest NATESTO STRIANT TESTIM testosterone cypionate testosterone enanthate testred Combination Products ACTIVELLA amethia amethyst ANGELIQ apri aranelle aviane balziva BEYAZ BREVICON briellyn CLIMARA PRO COMBIPATCH cryselle cyclafem CYCLESSA DESOGEN DUAVEE emoquette enpresse esterified estrogens & methyltestosterone estradiol & norethindrone acetate ESTROSTEP FE 3 1 PA PA 3 3 1 1 3 1 1 3 1 3 3 3 1 1 1 PA PA PA PA PA 3 1 1 3 1 1 1 1 3 3 1 3 3 1 1 3 3 3 1 1 PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA 1 1 3 PA PA FEMCON FE GENERESS FE gianvi introvale jinteli junel junel fe kariva kelnor 1/35 leena lessina levonorgestrel & ethinyl estradiol levora LO LOESTRIN FE LOESTRIN 24 FE LOSEASONIQUE low-ogestrel lutera marlissa microgestin microgestin fe MINASTRIN MODICON mononessa necon 0.5/35 necon 1/35 necon 10/11 necon 7/7/7 norethindrone acetateethinyl estradiol NORINYL nortrel NUVARING ocella ogestrel orsythia ORTHO TRI-CYCLEN ORTHO TRI-CYCLEN LO ORTHO-CEPT ORTHO-CYCLEN ORTHO-NOVUM ovcon 35 Last Updated 01/28/2016 3 3 1 1 1 1 1 1 1 1 1 PA PA PA PA PA PA PA PA 1 1 3 3 3 1 1 1 1 1 3 3 1 1 1 1 1 PA 1 3 1 3 1 1 1 3 PA PA PA PA PA PA PA PA 3 3 3 3 1 PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA portia prefest PREMPHASE PREMPRO previfem quasense reclipsen SAFYRAL SEASONIQUE sprintec sronyx tri-legest trinessa TRI-NORINYL tri-previfem tri-sprintec trivora velivet vestura xulane YASMIN YAZ zenchent fe zeosa zovia 1/35e zovia 1/50e Estrogens ALORA CENESTIN CLIMARA DELESTROGEN INJECTION 10MG/ML depo-estradiol DIVIGEL ELESTRIN ENJUVIA estrace estradiol estradiol transdermal patch weekly estradiol valerate ESTRING estropipate EVAMIST 1 1 3 3 1 1 1 3 3 1 1 1 1 3 1 1 1 1 1 1 3 3 1 1 1 1 PA PA PA PA PA PA PA PA PA 3 3 2 PA PA 3 1 3 3 3 1 1 PA 1 1 2 1 3 PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA FEMRING 3 PA menest 1 PA MENOSTAR 3 PA MINIVELLE 3 PA PREMARIN INJECTION 3 PA PREMARIN TABLET 3 PA PREMARIN VAGINAL CREAM 2 VAGIFEM 3 PA VIVELLE 3 PA Progestins aygestin 1 PA camila 1 PA CRINONE 3 PA DEPO-PROVERA 3 PA DEPO-SUBQ PROVERA 3 PA ELLA 2 ENDOMETRIN 3 PA errin 1 PA jolivette 1 PA MAKENA 3 PA, QL medroxyprogesterone acetate injection 1 PA medroxyprogesterone acetate tablet 1 MEGACE 3 PA megestrol acetate 1 nora-be 1 norethindrone acetate 1 NOR-QD 3 PA ORTHO MICRONOR 3 PA progesterone micronized 1 PA PROMETRIUM 3 PA PROVERA 3 PA Selective Estrogen Receptor Modifying Agents EVISTA 3 PA raloxifene hcl 1 PA Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) CYTOMEL 3 PA levothroid 1 PA levothyroxine sodium 1 Last Updated 01/28/2016 levoxyl 1 PA liothyronine sodium iv solution 1 PA liothyronine sodium tablet 1 SYNTHROID 3 PA THYROLAR 3 PA TIROSINT 3 PA unithroid 1 PA Hormonal Agents, Suppressant (Adrenal) LYSODREN 2 Hormonal Agents, Suppressant (Parathyroid) SENSIPAR 30 MG 3 PA SENSIPAR 60 MG 4 PA SENSIPAR 90 MG 4 PA Hormonal Agents, Suppressant (Pituitary) cabergoline 1 ELIGARD 3 PA FIRMAGON 3 PA leuprolide acetate 1 PA LUPRON 3 PA octreotide acetate 100 mcg/ml 1 octreotide acetate 1000 mcg/ml 1 octreotide acetate 200 mcg/ml 1 octreotide acetate 50 mcg/ml 1 PA octreotide acetate 500 mcg/ml 1 SANDOSTATIN 3 PA SANDOSTATIN LAR 4 PA SOMATULINE 3 PA SOMAVERT 4 PA, QL SYNAREL 2 TRELSTAR 3 PA Hormonal Agents, Suppressant (Sex Hormones/ Modifiers) Antiandrogens bicalutamide 1 CASODEX 3 PA flutamide 1 NILANDRON 3 PA ZYTIGA 4 QL Hormonal Agents, Suppressant (Thyroid) Antithyroid Agents methimazole 1 propylthiouracil 1 tapazole 1 PA Immunological Agents SYNAGIS 4 PA Immune Suppressants ATGAM 3 PA azasan 1 PA azathioprine sodium injection 1 PA azathioprine tablet 1 BENLYSTA 4 PA CELLCEPT 3 PA CIMZIA 4 PA, QL CUPRIMINE 3 PA cyclosporine 1 PA cyclosporine modified 1 PA ENBREL 4 QL ENBREL SURECLICK 4 QL gengraf capsule 1 gengraf solution 1 PA HUMIRA 10MG/0.2 4 PA HUMIRA 20MG/0.4 4 PA, QL HUMIRA 40MG/0.8 4 QL HUMIRA PEN 4 QL IMURAN 3 PA KINERET 4 PA, QL mercaptopurine 1 methotrexate sodium for injection 1 PA methotrexate sodium injection preservativefree 1 methotrexate sodium tablet 1 mycophenolate mofetil 1 mycophenolic acid 1 PA MYFORTIC 3 PA NEORAL CAPSULE 3 PA NEORAL SOLUTION 2 NULOJIX 4 PA Last Updated 01/28/2016 ORENCIA 4 PROGRAF 3 PURINETHOL 3 RAPAMUNE SOLUTION 2 RAPAMUNE TABLET 3 RASUVO 2 REMICADE 4 RHEUMATREX 3 SANDIMMUNE CAPSULE 2 SANDIMMUNE IV SOLUTION 3 SANDIMMUNE SOLUTION 3 SIMPONI 4 SIMULECT 3 sirolimus 0.5 mg 1 sirolimus 1 mg 1 sirolimus 2 mg 1 tacrolimus 1 TORISEL 3 trexall 1 XELJANZ 4 ZORTRESS 0.25 MG 2 ZORTRESS 0.5 MG 4 ZORTRESS 0.75 MG 4 Immunizing Agents, Passive CARIMUNE 3 GAMASTAN 3 GAMMAGARD 3 GAMMAPLEX 3 GAMUNEX 3 HIZENTRA 3 HYQVIA 4 OCTAGAM 3 PRIVIGEN 3 THYMOGLOBULIN 3 Immunomodulators ACTEMRA 4 ACTIMMUNE 4 ARAVA 3 ARCALYST 4 AUBAGIO 4 QL PA PA PA PA PA PA PA PA, QL PA PA PA PA PA, QL PA PA PA PA PA PA PA, QL PA PA PA PA, QL PA PA PA, QL PA, QL ILARIS 4 PA, QL leflunomide 1 OTEZLA 4 PA, QL RIDAURA 2 SYLATRON 3 PA Vaccines TETANUS TOXOID ADSORBED 3 PA Inflammatory Bowel Disease Agents Aminosalicylates APRISO 3 PA ASACOL 400 MG 2 ASACOL 800 MG 3 PA balsalazide disodium 1 CANASA 2 COLAZAL 3 PA DIPENTUM 4 PA GIAZO 3 PA LIALDA 2 mesalamine enema 1 PENTASA 3 PA ROWASA 3 PA Glucocorticoids Sulfonamides AZULFIDINE 3 PA sulfasalazine 1 Metabolic Bone Disease Agents ACTONEL 3 PA alendronate sodium 10 mg 1 alendronate sodium 35 mg 1 PA alendronate sodium 40 mg 1 alendronate sodium 5 mg 1 PA alendronate sodium 70 mg 1 ATELVIA 3 PA BONIVA 3 PA calcitonin (salmon) nasal solution 1 calcitriol capsule 1 calcitriol injection 1 PA calcitriol solution 1 PA Last Updated 01/28/2016 etidronate disodium FORTEO FOSAMAX HECTOROL ibandronate sodium MIACALCIN INJECTION NATPARA pamidronate disodium paricalcitol PROLIA RECLAST risedronate sodium ROCALTROL CAPSULE ROCALTROL SOLUTION XGEVA ZOMETA Miscellaneous ALCOHOL SWABS CERDELGA HYPERSAL NEB PROCYSBI RAVICTI Ophthalmic Agents Combination Products bacitracin-polymyxin b bacitracin-polymyxinneomycin-hc blephamide ointment BLEPHAMIDE SUSPENSION MAXITROL neomycin-bacitracinpolymyxin neomycin-polymyxin bgramicidin neomycin-polymyxindexamethasone neomycin-polymyxinhydrocortisone neosporin polymyxin btrimethoprim POLYTRIM 1 4 3 3 1 PA, QL PA PA PA 2 4 1 1 3 3 1 PA, QL PA PA PA PA PA 2 3 4 3 PA PA, QL PA 3 4 2 4 4 PA QL PA, QL PA, QL 1 1 1 3 3 PA PA 1 1 PA 1 1 1 PA PA 1 3 PA PRED-G OINTMENT 3 PA PRED-G SUSPENSION 2 sulfacetamide sodiumprednisolone 1 TOBRADEX 3 PA tobramycindexamethasone 1 PA ZYLET 3 PA Ophthalmic Prostaglandin and Prostamide Analogs bimatoprost 1 PA latanoprost 1 LUMIGAN 3 PA TRAVATAN 3 PA XALATAN 3 PA ZIOPTAN 3 PA Ophthalmic Agents, Other ak-con 1 PA alcaine 1 PA atropine sulfate 1% (ophthalmic) 1 ISOPTO CARBACHOL 2 ISOPTOHOMATROPINE 3 PA proparacaine hcl 1 PA RESTASIS 3 PA tropicamide 1 PA Ophthalmic Anti-allergy Agents ALOCRIL 3 PA ALOMIDE 3 PA azelastine hcl 1 PA BEPREVE 3 PA cromolyn sodium 1 ELESTAT 3 PA EMADINE 3 PA epinastine hcl 1 PA LASTACAFT 3 PA OPTIVAR 3 PA PATADAY 3 PA PATANOL 3 PA Ophthalmic Antiglaucoma Agents ALPHAGAN 3 PA apraclonidine hcl 1 PA Last Updated 01/28/2016 AZOPT 3 PA BETAGAN 3 PA betaxolol hcl 1 BETIMOL 3 PA BETOPTIC S 3 PA brimonidine tartrate 0.15% 1 PA brimonidine tartrate 0.2% 1 carteolol hcl 1 PA COMBIGAN 3 PA COSOPT 3 PA dorzolamide hcl 1 dorzolamide hcl-timolol maleate 1 IOPIDINE 3 PA ISTALOL 3 PA levobunolol hcl 1 metipranolol 1 PA phenylephrine hcl 2.5% (ophthalmic) 1 PHOSPHOLINE IODIDE 2 pilocarpine hcl (ophthalmic) 1 PA RESCULA 3 PA timolol maleate gel forming solution 1 PA timolol maleate solution 1 TIMOPTIC 3 PA TRUSOPT 3 PA Ophthalmic Anti-inflammatories ACUVAIL 3 PA ALREX 3 PA bromfenac sodium 1 PA dexamethasone sodium phosphate 1 diclofenac sodium 1 DUREZOL 3 PA FLAREX 3 PA fluorometholone 1 flurbiprofen sodium 1 FML FORTE LIQUIFILM 3 PA FML OINTMENT 2 FML SUSPENSION ILEVRO ketorolac tromethamine LOTEMAX MAXIDEX millipred NEVANAC OCUFEN OMNIPRED ORAPRED PRED FORTE PRED MILD prednisolone acetate prednisolone sodium phosphate VEXOL Otic Agents DERMOTIC fluocinolone acetonide (otic) Combination Products acetasol hc acetic acid-aluminum acetate antipyrine/benzocaine CIPRO HC CIPRODEX COLY MYCIN S CORTISPORIN OTIC CORTISPORIN-TC hydrocortisone w/ acetic acid neomycin-polymyxinhydrocortisone Respiratory Tract Agents Antihistamines ASTELIN ASTEPRO azelastine hcl 0.1% spray azelastine hcl 0.15% spray carbinoxamine maleate cetirizine hcl syrup CLARINEX Last Updated 01/28/2016 3 3 1 3 3 1 3 3 3 3 3 2 1 PA PA PA PA PA PA PA PA PA PA PA 1 3 PA PA 3 PA 1 PA 1 PA 1 1 3 2 3 3 3 1 PA PA PA PA PA 1 3 3 PA PA 1 1 1 1 3 PA PA PA PA CLARINEX-D 3 PA clemastine fumarate 1 PA cyproheptadine hcl 1 desloratadine 1 PA levocetirizine dihydrochloride 1 PA olopatadine hcl spray 1 PA palgic 1 PA PATANASE 3 PA Anti-inflammatories, Inhaled Corticosteroids ALVESCO 3 PA ASMANEX 110 MCG/INH 30 DOSES 2 ASMANEX 220 MCG/INH 120 DOSES 2 ASMANEX 220 MCG/INH 14 DOSES 3 PA ASMANEX 220 MCG/INH 30 DOSES 3 PA ASMANEX 220 MCG/INH 60 DOSES 2 ASMANEX NASAL SUSPENSION 3 PA budesonide inhalation suspension 1 PA FLONASE 3 PA FLOVENT 3 PA FLOVENT HFA 3 PA flunisolide (nasal) 1 fluticasone propionate (nasal) 1 OMNARIS 3 PA PULMICORT INHALATION SUSPENSION 3 PA PULMICORT INHALER 180 MCG/ACT 2 PULMICORT INHALER 90 MCG/ACT 3 PA QVAR 40 MCG 3 PA QVAR 80 MCG 2 RHINOCORT 3 PA VERAMYST 3 PA ZETONNA 3 PA Antileukotrienes ACCOLATE 3 PA montelukast chewable 1 montelukast pack 1 PA montelukast tablet 1 zafirlukast 1 PA ZYFLO 3 PA ZYFLO CR 4 PA Bronchodilators, Anticholinergic ATROVENT 2 ipratropium bromide 1 SPIRIVA HANDIHALER 3 PA SPIRIVA RESPIMAT 2 Bronchodilators, Phosphodiesterase Inhibitors (Xanthines) aminophylline injection 1 PA elixophyllin 1 PA LUFYLLIN 3 PA theophylline tablet er 100 mg 1 theophylline tablet er 200 mg 1 theophylline tablet er 300 mg 1 theophylline tablet er 400 mg 1 PA theophylline tablet er 450 mg 1 PA theophylline tablet er 600 mg 1 PA theophylline elixir 1 PA Bronchodilators, Sympathomimetic ACCUNEB 3 PA albuterol sulfate nebulizer solution 0.083% 1 albuterol sulfate nebulizer solution 0.5% 1 albuterol sulfate nebulizer solution 0.63 mg/3ml 1 PA albuterol sulfate nebulizer solution 1.25 mg/3ml 1 PA albuterol sulfate syrup 1 PA albuterol sulfate tablet 1 PA Last Updated 01/28/2016 albuterol sulfate tablet sr ARCAPTA AUVI-Q BROVANA epinephrine hcl autoinjector epinephrine hcl injection EPIPEN FORADIL levalbuterol hcl MAXAIR metaproterenol sulfate PERFOROMIST PROAIR HFA SEREVENT STRIVERDI RESPIMAT terbutaline sulfate injection terbutaline sulfate tablet TWINJECT vospire XOPENEX Combination Products ADVAIR ADVAIR HFA ANORO ELLIPTA BREO ELLIPTA COMBIVENT COMBIVENT RESPIMAT DULERA DUONEB ipratropium-albuterol nebulizer solution promethazine & phenylephrine SEMPREX-D SYMBICORT Mast Cell Stabilizers cromolyn sodium nebulizer solution 1 3 3 3 PA PA PA PA 1 1 3 3 1 3 1 3 2 2 PA PA PA PA PA PA PA 2 1 PA 1 3 1 3 PA PA PA 2 3 3 3 3 PA PA PA PA 2 2 3 PA 1 1 3 3 PA PA 1 PA cromolyn sodium oral concentrate 1 PA GASTROCROM 3 PA Pulmonary Antihypertensives ADCIRCA 4 PA ADEMPAS 4 PA, QL LETAIRIS 4 OPSUMIT 4 PA, QL ORENITRAM TABLET 0.125 MG 3 PA, QL ORENITRAM TABLET 0.25 MG 4 PA, QL ORENITRAM TABLET 1 MG 4 PA, QL ORENITRAM TABLET 2.5 MG 4 PA, QL REMODULIN 4 PA REVATIO 4 PA sildenafil citrate (pulmonary hypertension) 1 PA TRACLEER 4 VENTAVIS 4 PA Respiratory Tract Agents, Other acetylcysteine 1 ARALAST 4 PA DALIRESP 3 PA DYMISTA 3 PA ESBRIET 4 PA, QL GLASSIA 4 PA KALYDECO 4 PA, QL OFEV 4 PA, QL ORKAMBI 4 PA, QL PROLASTIN 4 PA PULMOZYME 4 TUDORZA 3 PA tyzine 1 PA XOLAIR 4 PA Skeletal Muscle Relaxants AMRIX 3 PA carisoprodol 1 PA chlorzoxazone 1 PA cyclobenzaprine hcl tablet 10 mg 1 Last Updated 01/28/2016 cyclobenzaprine hcl tablet 5 mg 1 cyclobenzaprine hcl tablet 7.5 mg 1 PA fexmid 1 PA lorzone 1 PA metaxalone 1 PA methocarbamol 1 orphenadrine citrate 1 PA PARAFON FORTE DSC 3 PA SKELAXIN 3 PA SOMA 3 PA Sleep Disorder Agents GABA Receptor Modulators EDLUAR 3 PA eszopiclone 1 PA INTERMEZZO 3 PA LUNESTA 3 PA SONATA 3 PA zaleplon 1 PA zolpidem tartrate 1 zolpidem tartrate cr 1 PA ZOLPIMIST 3 PA Sleep Disorders, Other BELSOMRA 3 PA BUTISOL SODIUM TABLET 3 PA estazolam 1 PA flurazepam hcl 1 PA HALCION 3 PA modafinil 1 PA NUVIGIL 3 PA PROVIGIL 3 PA RESTORIL 3 PA ROZEREM 3 PA SILENOR 3 PA temazepam 15 mg 1 temazepam 22.5 mg 1 PA temazepam 30 mg 1 temazepam 7.5 mg 1 PA triazolam 1 PA XYREM 4 PA, QL Therapeutic Nutrients/Minerals/Electrolytes fomepizole levocarnitine Combination Products AMINOSYN 3.5 % M, SULFITE FREE aminosyn 8.5 % with electrolytes AMINOSYN II 10 % AMINOSYN II 15% AMINOSYN II 7 %, SULFITE-FREE aminosyn ii 8.5 % with electrolytes AMINOSYN II 8.5 %, SULFITE-FREE AMINOSYN-HBC 7 %, SULFITE-FREE AMINOSYN-PF 10 %, SULFITE-FREE AMINOSYN-PF 7% CLINIMIX CLINIMIX E clinisol 15 DEXTROSE 10% W/ SODIUM CHLORIDE dextrose 2.5% w/ sodium chloride dextrose 5% in lactated ringers dextrose 5% w/ sodium chloride 0.2% DEXTROSE 5% W/ SODIUM CHLORIDE 0.225% dextrose 5% w/ sodium chloride 0.33% dextrose 5% w/ sodium chloride 0.45% dextrose 5% w/ sodium chloride 0.9% dextrose injection hepatamine 8 hepatasol 8 IONOSOL-B IONOSOL-MB ISOLYTE P Last Updated 01/28/2016 1 1 PA PA 3 PA 1 3 3 PA PA PA 3 PA 1 PA 3 PA 3 PA 3 3 3 3 1 PA PA PA PA PA 3 PA 1 PA 1 PA 1 PA 3 PA 1 PA 1 PA 1 1 1 1 3 3 3 PA PA PA PA PA PA PA kcl 10 meq/l in dextrose 5% & nacl 0.45% inj 1 kcl 20 meq/l in dextrose 5% & nacl 0.2% inj 1 KCL 20 MEQ/L IN DEXTROSE 5% & NACL 0.225% INJ 3 kcl 20 meq/l in dextrose 5% & nacl 0.33% inj 1 kcl 20 meq/l in dextrose 5% & nacl 0.45% inj 1 kcl 20 meq/l in dextrose 5% & nacl 0.9% inj 1 kcl 30 meq/l in dextrose 5% & nacl 0.45% inj 1 kcl 40 meq/l in dextrose 5% & nacl 0.45% inj 1 KCL 40 MEQ/L IN DEXTROSE 5% & NACL 0.9% INJ 3 lactated ringer's 1 LIPOSYN III 3 NEPHRAMINE 3 NORMOSOL-M 3 NORMOSOL-R 3 nutrilyte ii 1 parenteral electrolyte concentrate 1 PLASMA-LYTE 3 POTASSIUM CHLORIDE IN D5W LACTATED RINGERS 3 premasol 1 PRENATAL VITAMIN W/ MINERALS & FOLIC ACID > 0.8 MG 3 PROCALAMINE 3 PROSOL 3 ringer's solution 1 SODIUM LACTATE 3 travasol 10 1 TROPHAMINE 3 water for irrigation 1 Electrolyte/Mineral Modifiers CHEMET 3 PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA EXJADE 4 PA, QL FERRIPROX 4 PA, QL JADENU 4 PA, QL KAYEXALATE 3 PA kionex powder 1 PA kionex suspension 1 SAMSCA 3 PA, QL SYPRINE 3 PA Electrolyte/Mineral Replacement ammonium chloride 1 PA isolyte s 1 PA k-effervescent tablet 1 PA kcl 20 meq/l injection 1 PA KCL 40 MEQ/L INJECTION 3 PA klor-con powder 1 klor-con tablet 1 PA K-TAB 2 magnesium sulfate 1 PA NORMOSOL-R 3 PA OSMOPREP 3 PA physiolyte 1 PA physiosol 1 PA PLASMA-LYTE 3 PA PLASMA-LYTE 148 3 PA PLASMALYTE A 3 PA potassium chloride capsule cr 1 PA potassium chloride injection 1 PA potassium chloride liquid 1 PA potassium chloride microcrystal tablet cr 1 PA potassium chloride tablet er 1 PA potassium citrate tablet er 540 mg 1 potassium citrate tablet er 1080 mg 1 potassium citrate tablet er 1620 mg 1 PA sodium chloride injection 1 PA sodium fluoride chewable 1 Last Updated 01/28/2016 sodium fluoride drops UROCIT-K 1 3 VISICOL PA Last Updated 01/28/2016 3 PA
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