1. No category

Preferred
Drug List (PDL)
Arizona – CRS
Effective Date: 10/1/16
© 2016 United Healthcare Services, Inc. All rights reserved.
Preferred Drug List
INTRODUCTION
This PDL is not intended to be a substitute for the
knowledge, expertise, skill and judgment of the medical
provider in their choice of prescription drugs.
UnitedHealthcare 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.
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 websites listed in
the website 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.
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.
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.
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.
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
NOTICE
The information contained in this PDL and its appendices is
provided by UnitedHealthcare Community Plan, solely for
the convenience of contracted providers. UnitedHealthcare
Community Plan does not warrant or assure accuracy of
such information nor is it intended to be comprehensive in
nature.
Doc#: UHC1335a_20110804
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
i
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.
Products covered include all strengths associated
with the dosage form of the cited brand name
product.
levetiracetam
KEPPRA
All strengths of Keppra would be covered by this listing.
Dosage forms covered will be consistent with the
category and use where listed.
OUTPATIENT PRESCRIPTION DRUG
BENEFIT COVERED MEDICATIONS
Medically necessary outpatient prescription drugs are
covered when prescribed by a provider licensed to
prescribe federal legend drugs or medicines. Special
formula nutrition needs for metabolic patients are also
covered. Some items are covered only with prior
authorization. Eligibility for Outpatient Prescription Drug
Benefits and copays are based on the individual member’s
benefit plan.
Neomycin/polymixin B/
Hydrocortisone
CORTISPORIN
As listed in the EAR section, this is limited to the otic
solution and suspension. From this entry the ophthalmic
solution and ointment, and the topical cream cannot be
assumed to be on the list unless there are entries for these
products in the EYE and DERMATOLOGICAL sections of
the PDL.
PRODUCT SELECTION CRITERIA
The P&T Committee considers clinical information on
new-to-market drugs that are typically included in an
outpatient pharmacy benefit. The evaluation includes all or
part of the following:
• Safety
• Efficacy
• Comparison studies
• Approved indications
• Adverse effects
• Contraindications/Warnings/Precautions
• Pharmacokinetics
• Patient administration/compliance considerations
• Outcome and pharmacoeconomic studies
When a strength or dosage form is specified, only the
specified strength and dosage form is on the PDL.
Other strengths/dosage forms of the reference product
are not
metoprolol 50mg & 100 mg only LOPRESSOR
GENERIC SUBSTITUTION
The UnitedHealthcare 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.
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.
If a brand name drug is medically necessary, please submit
a prior authorization request.
The UnitedHealthcare Community Plan Maximum
Allowable Cost (MAC) list sets a ceiling price for the
reimbursement of certain multisource prescription drugs.
This price will typically cover the acquisition of most
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:
All the information in the PDL is provided as a reference
for drug therapy selection. Specific drug selection for an
individual patient rests solely with the prescriber.
PDL PRODUCT DESCRIPTIONS
To assist in understanding which specific strengths and
dosage forms are covered on the PDL, examples are noted
below.
The general principles shown in the examples can then
usually be extended to other entries in the book. Any
exceptions are noted in the drug list. There may also be a
statement associated with a drug list that gives additional
information about which specific products or dosage forms
are covered.
Doc#: UHC1335a_20110804
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.
ii
• 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 1 per 3
years), humidifier (limit of 1 per 3 years)
• Mirena
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).
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.
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 eighty-five percent (85%) of
the medication has been utilized. If a claim is submitted
before 85% of the medication has been used, based on the
original day supply submitted on the claim, the claim will
reject with a "refill too soon" message. Please call the
UnitedHealthcare Community Plan Pharmacy Department
at 800-310-6826 with questions or for help with dosage
change authorization.
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.
MANDATORY GENERIC SUBSTITUTION
DRUG EFFICACY STUDY IMPLEMENTATION
(DESI) DRUGS
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.
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
PDL does not cover DESI “less than fully effective” drug
products.
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.
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
• Anti-obesity agents
• Experimental / research drugs
• Cosmetic drugs
• Immunization agents
• Nutritional / diet supplements
• Blood and blood plasma products
Doc#: UHC1335a_20110804
Requests for these exceptions should be made in writing by
the physician and faxed to:
UnitedHealthcare Community Plan
Pharmacy Services Department
Fax 866-940-7328
Phone 800-310-6826
iii
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 Community Plan Pharmacy Department
will respond to all requests in accordance with state
requirements.
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.
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.
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.
Please contact the UnitedHealthcare Community Plan
Pharmacy Department at 800-310-6826 with questions
concerning the prior authorization process.
Additions to the QL program drug list will be made from
time to time and providers notified accordingly. As always,
we recognize that a number of patient-specific variables
must be taken into consideration when drug therapy is
prescribed and therefore overrides will be available through
the medical exception (prior authorization) process. Please
contact the UnitedHealthcare Community Plan Pharmacy
Department at 800-305-0023 with questions.
NON-PDL DRUGS 5-DAY OVERRIDES
To ensure the use of PDL drugs, all non- PDL drugs should
be discussed with the prescribing physician. If you cannot
speak to the physician immediately, and there is an
immediate need for the medication, the claim processing
system will accept an override to permit a one-time
dispensing of a 5-day supply of the newly prescribed
non-PDL drug. The pharmacy should submit a claim for a
5 day supply, with a PA Type of 8 and Prior Authorization
number of “00000000120”.
Specialty Pharmaceutical Management Program
UnitedHealthcare Community Plan is continuously looking
for ways to provide high quality cost effective 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 Prior Authorization
Department via fax at 866-940-7328. The
UnitedHealthcare Community Plan Pharmacy Department
will review and respond to all requests in accordance with
state requirements, and if authorized for payment,
UnitedHealthcare Community Plan, will coordinate
delivery of the product to the member or provider.
Drugs that are part of this program and are on the PDL are
identified in this booklet by the designation "SP".
Prior authorization request forms should be faxed to the
UnitedHealthcare Community Plan Pharmacy Department
at 866-940-7328.
Please note that non-preferred drugs are available for a 5day supply, however availability is subject to the benefit
design. For assistance, pharmacies may call 800-3106826.
Pharmacies may dispense a one-time, 15-day supply to
members requiring an immediate supply of an ongoing
medication. The pharmacist must contact the plan to
obtain a manual 15-day override. Before the next
dispensing, the pharmacy must contact the physician to
discuss a PDL drug or if a prior authorization request is
warranted. If the prescribing physician feels a drug is
medically necessary, the physician may fax a request for
prior authorization to UnitedHealthcare Community Plan at
866-940-7328,
Attn: Pharmacy Department.
QUANTITY LIMITATIONS (QL)
Prescriptions for monthly quantities greater than the
indicated limit require a prior authorization request.
Quantity limits based on Efficient Medication Dosing
The Efficient Medication Dosing Program is designed to
consolidate medication dosage to the most efficient daily
quantity to increase adherence to therapy and also promote
the efficient use of health care dollars.
Doc#: UHC1335a_20110804
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.
iv
Renvela
While lower cost PDL alternatives may be appropriate in
many instances, other non- PDL alternatives are available
with prior authorization (PA).
STEP Drug
Advair
8 week trial of calcium acetate
SGLT-2
At least a 90 day trial of 1500mg/day of
Inhibitors
metformin
(Jardiance,
Invokana,
Invokamet, Synjardy)
First-Line Agent(s)
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 Handihaler).
Symbicort
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 Handihaler).
Aricept 23mg
90 day trial of Aricept 10mg daily
calcipotriene
cream & oint
0.005%
Trial of two topical corticosteroids
tacrolimus 0.03%Trial of two different topical
corticosteroids. Step therapy only applies
to members 12 years of age and older.
calcitriol
3mcg/gm
Trial of two topical corticosteroids
tacrolimus 0.1% Minimum age of 16. Trial of two
different topical corticosteroids
tolterodine
DPP4 Inhibitors At least a 90 day trial of 1500mg/day of
(Tradjenta,
metformin.
Jentadueto,
Januvia,
Janumet, Janumet XR)
Dulera
Elidel
fenofibrate
TZD’s
At least a 90 day trial of 1500mg/day of
(ActosPlusMet, metformin
ActoPlusMet XR,
Duetact)
1) 30 day trial of one inhaled
corticosteroid (e.g. Asmanex Twisthaler,
Flovent HFA, QVAR)
Trial of two different topical
corticosteroids. Step therapy only applies
to members 12 years of age and older.
Uloric
8 week trial of up to 600mg of
allopurinol required first.
Vancocin
One fill of metronidazole tabs or cap
Xopenex Respules 30 day trial of Albuterol .083% or .5%
respules.
Fill of a statin or 90 days of gemfibrozil
within the previous 180 days.
Zohydro ER
GLP-1 Agonist At least a 90 day trial of 1500mg/day of
(Victoza)
metformin
midodrine
Trial of fludrocortisone
Optivar
14 day trial of ketotifen within previous
90 days required first.
oxycodone ER
30 day trial of at least 200mg per day of
morphine sulfate ER
Attn: Director of Pharmacy Services
UnitedHealthcare Community Plan
1001 Brinton Road
Pittsburgh, PA 15221
Fax: 866-940-7328
Email: [email protected]
Trial of one drug from the following
classes: beta blockers, calcium channel
blockers, long acting nitrates
Doc#: UHC1335a_20110804
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.
oxymorphone ER 30-day trial of both Fentanyl patch and
(non-crush
morphine sulfate ER at least 200mg per
resistant)
day
Ranexa
30 day trial of oxybutynin immediate
release.
v
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
Director of Pharmacy Services
1001 Brinton Road
Pittsburgh, PA 15221
Phone: 800-310-6826
LEGEND
#
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 sustainedrelease)
PA
Prior Authorization required
QL
Quantity Limits apply
ST
Step Therapy, see pages V-VI for details
SP
Specialty Pharmaceuticals, see pages IV-V for
details
NOTICE
The information contained in this document is proprietary
information. The information may not be copied in whole
or in part without the written permission of
UnitedHealthcare 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.
Doc#: UHC1335a_20110804
vi
Table of Contents
Antineoplastics & Immunosuppressants . . . 4
Antineoplastic Agents . . . . . . . . . . . . . . . . . . . . . . 4
Hormonal Antineoplastic Agents . . . . . . . . . . . . . 5
Immunomodulators . . . . . . . . . . . . . . . . . . . . . . . . 5
Immunosuppressants . . . . . . . . . . . . . . . . . . . . . . 5
Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Seizures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Dermatology . . . . . . . . . . . . . . . . . . . . . . . . . 17
Acne Vulgaris . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Bacterial Infections . . . . . . . . . . . . . . . . . . . . . . . 18
Corticosteroids . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Fungal Infections . . . . . . . . . . . . . . . . . . . . . . . . . 19
Psoriasis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Rosacea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Scabies and Pediculosis . . . . . . . . . . . . . . . . . . 20
Viral Infections . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Blood Modifiers - Anticoagulants . . . . . . . . . 7
Anticoagulants . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Blood Cell Formation . . . . . . . . . . . . . . . . . . . . . . . 7
Platelet Inhibitors . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
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
Ear, Nose & Throat . . . . . . . . . . . . . . . . . . . . 22
Ear . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
Nose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Throat and Mouth . . . . . . . . . . . . . . . . . . . . . . . . 24
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 . . . . . . . . . . . . . . . . 31
Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
Central Nervous System . . . . . . . . . . . . . . . 13
Alzheimer’s Disease . . . . . . . . . . . . . . . . . . . . . . 13
Analgesics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Migraine Acute Therapy . . . . . . . . . . . . . . . . . . . 14
Migraine Prophylactic Therapy . . . . . . . . . . . . . 15
Multiple Sclerosis . . . . . . . . . . . . . . . . . . . . . . . . 15
Myasthenia Gravis . . . . . . . . . . . . . . . . . . . . . . . 15
Parkinson’s Disease . . . . . . . . . . . . . . . . . . . . . . 15
2
Infectious Diseases . . . . . . . . . . . . . . . . . . . 31
Anthelmintics . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
Antibacterials . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
Antifungals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
Antivirals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
Asthma/COPD . . . . . . . . . . . . . . . . . . . . . . . . . . 54
Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
Urological . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
Symptomatic Benign Prostatic Hypertrophy . . 55
Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
Vitamins and Minerals . . . . . . . . . . . . . . . . . 56
Potassium . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
Metabolics . . . . . . . . . . . . . . . . . . . . . . . . . . 36
Musculoskeletal . . . . . . . . . . . . . . . . . . . . . . 38
Arthritis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
Gout . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
Skeletal Muscle Relaxants . . . . . . . . . . . . . . . . . 39
Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . 60
Anaphylaxis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60
Cystic Fibrosis . . . . . . . . . . . . . . . . . . . . . . . . . . . 60
Detoxification Agents . . . . . . . . . . . . . . . . . . . . . 60
Hereditary Angioedema . . . . . . . . . . . . . . . . . . . 60
Hyperphosphatemia . . . . . . . . . . . . . . . . . . . . . . 60
Idiopathic Pulmonary Fibrosis (IPF) . . . . . . . . . 61
Immune Thrombocytopenic Purpura . . . . . . . . 61
Medical Devices . . . . . . . . . . . . . . . . . . . . . . . . . 61
Metabolic Modifiers . . . . . . . . . . . . . . . . . . . . . . 61
Vaccine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
OB-GYN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
Contraceptives . . . . . . . . . . . . . . . . . . . . . . . . . . 39
Endometriosis . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
Hormone Therapy/Menopause . . . . . . . . . . . . 41
Vaginal Infections . . . . . . . . . . . . . . . . . . . . . . . . 42
Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
Ophthalmic . . . . . . . . . . . . . . . . . . . . . . . . . . 42
Allergy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
Anti-Inflammatories . . . . . . . . . . . . . . . . . . . . . . . 43
Glaucoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
Infections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
OTC MEDICATIONS . . . . . . . . . . . . . . . . . . . 63
Acne . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
Antifungals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
Atopic Dermatitis . . . . . . . . . . . . . . . . . . . . . . . . . 63
Cough/Cold Allergy . . . . . . . . . . . . . . . . . . . . . . 63
Psychiatric . . . . . . . . . . . . . . . . . . . . . . . . . . 45 Diabetes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64
Alcohol Deterrents . . . . . . . . . . . . . . . . . . . . . . . 45 Earwax Removal Products . . . . . . . . . . . . . . . . 64
Anxiety . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45 Family Planning . . . . . . . . . . . . . . . . . . . . . . . . . . 64
Attention Deficit Hyperactivity Disorder (ADHD) 46 First Aid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64
Bipolar Disorder . . . . . . . . . . . . . . . . . . . . . . . . . 46 Gastrointestinal . . . . . . . . . . . . . . . . . . . . . . . . . . 65
Depression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46 Lice Products . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
Insomnia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47 Motion Sickness . . . . . . . . . . . . . . . . . . . . . . . . . 65
Narcotic Antagonists . . . . . . . . . . . . . . . . . . . . . 47 Ophthalmics . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
Psychoses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48 Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
Smoking Cessation . . . . . . . . . . . . . . . . . . . . . . 48 Smoking Cessation Products . . . . . . . . . . . . . . 66
Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . 48 Vitamins/Minerals . . . . . . . . . . . . . . . . . . . . . . . . 66
Warts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66
Respiratory Drugs . . . . . . . . . . . . . . . . . . . . 49 Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . 66
Antitussives, Decongestants, Expectorants and
Combinations . . . . . . . . . . . . . . . . . . . . . . . . . . . 49 Index of Covered Drugs . . . . . . . . . . . . . . . . 67
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
thioguanine
trifluridine/tipiracil
XELODA
PURINETHOL
TABLOID
LONSURF
generic
generic
brand
brand
QL
PA, SP
panobinostat
vorinostat
FARYDAK
ZOLINZA
brand
brand
PA, SP
PA, SP
alectinib
axitinib
bosutinib
cabozantinib
ceritinib
cobimetinib
crizotinib
dabrafenib
dasatinib
erlotinib
ALECENSA
INLYTA
BOSULIF
COMETRIQ
ZYKADIA
COTELLIC
XALKORI
TAFINLAR
SPRYCEL
TARCEVA
AFINITOR
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
brand
PA, SP
brand
brand
generic
brand
brand
brand
brand
brand
brand
PA, SP
PA, SP
PA, QL, SP
PA, SP
PA, SP
PA, SP
PA, SP
PA, SP
PA, SP
Antimetabolites
brand
brand
brand
generic
EMCYT
brand
Histone Deacetylase Inhibitors
Kinase Inhibitor
everolimus
gefitinib
ibrutinib
imatinib mesylate
lapatinib ditosylate
lenvatinib
nilotinib
palbociclib
pazopanib
ponatinib
AFINITOR DISPERZ
IRESSA
IMBRUVICA
GLEEVEC
TYKERB
LENVIMA
TASIGNA
IBRANCE
VOTRIENT
ICLUSIG
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
Generic Drug Name
Brand Drug Name
regorafenib
ruxolitinib
sorafenib
sunitinib
trametinib
vandetanib
vemurafenib
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
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
azathioprine
mycophenolate mofetil
mycophenolate sodium
IMURAN
CELLCEPT
MYFORTIC
generic
generic
generic
Immunomodulators
Interferons
Miscellaneous
Immunosuppressants
Antimetabolites
generic
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
ST = Step Therapy
SP = Specialty Pharmacy
5
Generic Drug Name
Calcineurin Inhibitors
cyclosporine
cyclosporine
cyclosporine
cyclosporine, modified
tacrolimus
Rapamycin Derivative
Brand Drug Name
GENGRAF
NEORAL SOLUTION
SANDIMMUNE
SANDIMMUME
SOLUTION
NEORAL
Covered
Drug
Requirements & Limits
generic
modified oral soln 100 mg/ml
generic
brand
generic
GENGRAF
HECORIA
generic
PROGRAF
sirolimus
sirolimus
RAPAMUNE
RAPAMUNE
generic
brand
everolimus
ZORTRESS
brand
alitretinoin 1% gel
bexarotene caps
bexarotene topical gel
cysteamine bitartrate
etoposide
hydroxyurea
hydroxyurea
mesna
mitotane
octreotide
olaparib
pasireotide
procarbazine
sonidegib
tretinoin
vismodegib
PANRETIN
TARGRETIN
TARGRETIN
CYSTAGON
VEPESID
DROXIA
HYDREA
MESNEX
LYSODREN
SANDOSTATIN
LYNPARZA
SIGNIFOR
MATULANE
ODOMZO
VESANOID
ERIVEDGE
Miscellaneous
Miscellaneous
oral soln 100 mg/ml
brand
generic
brand
brand
generic
brand
generic
brand
brand
generic
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
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
pegfilgrastim
plerixafor
sargramostim
TBO-Filgrastim
Platelet Inhibitors
anagrelide
aspirin
cilostazol
clopidogrel
dipyridamole
ticagrelor
Miscellaneous
aminocaproic acid
pentoxifylline
extended-release
PROCRIT
NEUPOGEN
ZARXIO
NEULASTA
MOZOBIL
LEUKINE
GRANIX
AGRYLIN
BAYER
QL
QL
brand
PA, SP
brand
PA, SP
brand
PA, SP
brand
brand
brand
brand
PA, SP
PA, SP
PA, SP
PA, SP
generic
generic
ECOTRIN
PLETAL
PLAVIX
PERSANTINE
BRILINTA
OTC
generic
generic
generic
brand
AMICAR
brand
TRENTAL
generic
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
QL
PA
tabs & syrup only
ST = Step Therapy
SP = Specialty Pharmacy
7
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
Requirements & Limits
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
(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
disopyramide
disopyramide
extended-release
dofetilide
dronedarone
flecainide
mexiletine
propafenone
quinidine gluconate extended-release
quinidine sulfate
quinidine sulfate
extended-release
PACERONE
CORDARONE
NORPACE
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/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
INDERIDE
BETAPACE
BETAPACE AF
generic
generic
generic
generic
generic
generic
brand
generic
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
diltiazem
diltiazem
diltiazem
extended-release
diltiazem
sustained-release
diltiazem
extended-release
verapamil
PROCARDIA XL
NIMOTOP
NYMALIZE
SULAR
generic
QL
generic
brand
generic
QL
sustained release
generic
generic
sustained release coated
beads, QL
sustained release, QL
CARDIZEM CD
generic
QL
CARDIZEM SR
generic
QL
generic
QL
generic
MATXIM LA
CARDIZEM SR
DILACOR XR
TIAZAC
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
DIURIL
DIURIL ORAL
SUSPENSION
CHLORTHALIDONE
LASIX
HYDROCHLOROTHIAZIDE
MICROZIDE
generic
generic
Diuretics
amiloride
amiloride/
hydrochlorothiazide
bumetanide
chlorothiazide
chlorothiazide
chlorthalidone
furosemide
hydrochlorothiazide
hydrochlorothiazide
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
brand
QL
generic
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.
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
INDOCIN
ORUDIS
ORUDIS
TORADOL
MOBIC
RELAFEN
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
Covered
Drug
generic
Brand Drug Name
NAPROSYN
ENTERIC COATEDnaproxen delayed release
NAPROSYN
naproxen sodium
ANAPROX
oxaprozin
DAYPRO
piroxicam
FELDENE
sulindac
CLINORIL
naproxen
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
generic
generic
QL
QL, ST, non-crush resistant
generic
generic
inj, QL
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/aspirin
oxymorphone ER
Migraine Acute Therapy
Ergotamine Derivatives
dihydroergotamine
dihydroergotamine
PERCOCET
PERCODAN
OXYMORPHONE ER
D.H.E. 45
MIGRANAL
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
ST = Step Therapy
SP = Specialty Pharmacy
14
Generic Drug Name
Brand Drug Name
ergotamine/caffeine
ergotamine tartrate/
caffeine
CAFERGOT
MIGERGOT
SUPPOSITORIES
naratriptan
rizatriptan
sumatriptan
Covered
Drug
generic
Requirements & Limits
brand
QL
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
entacapone
pramipexole
pramipexole
dihydrochloride SR
SYMMETREL
COGENTIN
PARLODEL
SINEMET
generic
generic
generic
generic
SINEMET CR
generic
COMTAN
MIRAPEX
generic
generic
Parkinson’s Disease
MIRAPEX ER
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
brand
ST = Step Therapy
SP = Specialty Pharmacy
15
except tabs
24hr tab
Generic Drug Name
Brand Drug Name
ropinirole
ropinirole hydrochloride
SR
selegiline
tolcapone
trihexyphenidyl
REQUIP
Covered
Drug
generic
REQUIP XL
generic
24hr tab
ELDEPRYL
TASMAR
ARTANE
generic
generic
generic
tabs
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
felbamate oral susp
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
oxcarbazepine
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
FELBATOL ORAL SUSP
NEURONTIN
VIMPAT
VIMPAT
LAMICTAL
generic
brand
generic
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
TRILEPTAL
brand
brand
generic
brand
brand
brand
generic
generic
brand
generic
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
Requirements & Limits
PA
ODT tabs
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
QL
Covered
Drug
generic
generic
Generic Drug Name
Brand Drug Name
phenobarbital
phenytoin
phenytoin sodium
extended
pregabalin
pregabalin
primidone
rufinamide
rufinamide suspension
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
benzoyl peroxide gel
BENZIQ
Miscellaneous
PHENYTEK
LYRICA
LYRICA SOLUTION
MYSOLINE
BANZEL
BANZEL SUSPENSION
Requirements & Limits
generic
brand
brand
generic
brand
brand
generic
generic
generic
brand
generic
PA
oral solution, PA
tablets only, QL
PA
ge Limits Apply,
2mg & 4mg
Age Limits Apply,
12mg & 16mg
QL
QL
PA, SP
QL
Dermatology
Acne Vulgaris
Oral
Topical
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
BENZIQ LS
brand
BREVOXYL
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
ST = Step Therapy
SP = Specialty Pharmacy
17
2.75%, 5.25%
Generic Drug Name
benzoyl peroxide wash 4%
& benzoyl peroxide bar
5% kit
clindamycin
clindamycin
clindamycin
erythromycin
erythromycin
Brand Drug Name
Covered
Drug
Requirements & Limits
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%
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
alclometasone
fluocinolone acetonide
fluocinolone acetonide
fluocinolone acetonide
generic
RETIN-A
bacitracin
bacitracin-polymyxinneomycin HC
gentamicin
mupirocin
neomycin/polymyxin B/
bacitracin
silver sulfadiazine
Corticosteroids
Low Potency
generic
generic
OTC
brand
oint 1%
GENTAK
BACTROBAN
generic
generic
ointment, 22 gram tube only
NEOSPORIN
generic
OTC
SILVADENE
generic
ACLOVATE
DERMA-SMOOTHE
OIL/FS
CAPEX SHAMOO
SYNALAR
generic
0.05% crm/oint
generic
oil 0.01%
brand
generic
shampoo 0.01%
soln/crm 0.01%
CORTISPORIN OINTMENT
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
ST = Step Therapy
SP = Specialty Pharmacy
18
Generic Drug Name
Brand Drug Name
hydrocortisone
hydrocortisone
hydrocortisone
hydrocortisone
CORTAID SOLUTION OTC
CORTIZONE
HYTONE
HYTONE
CORTIZONE-10 INTENSIVE
HEALING
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
betamethasone dip
augmented
clobetasol propionate
halobetasol
Fungal Infections
ciclopirox
clotrimazole
clotrimazole
Covered
Drug
generic
generic
generic
generic
Requirements & Limits
soln 1%, OTC
crm, oint, lot OTC
crm 0.5%, 1%, & 2.5%
lotion 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%
DIPROLENE
generic
oint 0.05%
TEMOVATE
ULTRAVATE
generic
generic
crm/gel/oint/soln 0.05%
cream
PENLAC SOLUTION 8%
LOTRIMIN AF
MYCELEX
generic
generic
generic
OTC
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
ST = Step Therapy
SP = Specialty Pharmacy
19
Generic Drug Name
Brand Drug Name
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
CLOTRIMAZOLE
Covered
Drug
brand
LOTRISONE
generic
NIZORAL
EXTINA
XOLEGEL
generic
generic
brand
XOLEGEL KIT
brand
XOLEGEL DUO KIT
brand
Requirements & Limits
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
METROCREAM
brand
PA
metronidazole
METROGEL
miconazole nitrate soln
Psoriasis
Rosacea
2%
2% OTC
liquid 3%
generic
METROLOTION
Scabies and Pediculosis
crotamiton
ivermectin
malathion
permethrin
EURAX
SKLICE
OVIDE
ELIMITE
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
brand
brand
generic
generic
ST = Step Therapy
SP = Specialty Pharmacy
20
lotion 0.5%, PA
5%, QL
Generic Drug Name
Brand Drug Name
permethrin
NIX CREME RINSE
RID SHAMPOO/
BUTOXIDE SHAMPOO
NATROBA
pyrethrins/piperonyl but
spinosad
Viral Infections
podofilox
salicylic acid
17%/collodion
hydrocortisone
hydrocortisone acetate
hydrocortisone acetate
hydrocortisone acetate
w/pramoxine
imiquimod 5% cream
ketoconazole
lidocaine
lidocaine
lidocaine
lidocaine
lidocaine patch
lidocaine/prilocaine
lidocaine-prilocaine
nitroglycerin
Requirements & Limits
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
Covered
Drug
generic
SANTYL
CARAC
EFUDEX
FLUOROPLEX
PHISOHEX
PROCTO-PAK CREAM
PROCTOSOL HC CREAM
2.5%
PROCTOZONE CREAM-HC
2.5%
crm 12%, lotion 5% & 12%
lotion 10%
PA
lotion/ointment, OTC
QL
0.5% cream
1% cream
rectal cream 1%
generic
ANUSOL HC 2.5%
CORTIFOAM AEROSOL
TUCKS OINTMENT OTC
brand
generic
rectal foam 90 mg
rectal ointment
PROCTOFOAM HC FOAM
generic
rectal foam 1-1%
ALDARA
NIZORAL SHAMPOO
LIDAMANTEL
LMX-4
XYLOCAINE
XYLOCAINE
LIDODERM PATCH
EMLA
EMLA
RECTIV
generic
generic
generic
generic
generic
generic
brand
generic
generic
brand
PA
shampoo 2%
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
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
ST = Step Therapy
SP = Specialty Pharmacy
21
Generic Drug Name
Covered
Drug
Brand Drug Name
Requirements & Limits
pimecrolimus
ELIDEL
brand
pimecrolimus
ELIDEL
brand
salicylic acid
CALICYLIC
P & S SHAMPOO
brand
cream QL, ST, Step therapy
is not required for members
ages 2-11; not covered for
members less than 2 years
of age
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%
salicylic acid
SELSUN BLUE
generic
shampoo 2%, 3% OTC
salicylic acid
salicylic acid
salicylic acid
salicylic acid
selenium sulfide
DHS SAL SHAMPOO OTC
SALAC OTC
SALACYN
SALVAX
SALEX
SELSUN
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
foam 6%
shampoo 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
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
J-TAN PD
RESPA-BR
BROVEX CT
CHLOR-TRIMETON
ALLERGY
CHLOR-TRIMETON
SYRUP
CHLORPHENIRAMINE
CHLORPHENIRAMINE
CHLORPHENIRAMINE
CHLORPHENIRAMINE
CLEMASTINE
CYPROHEPTADINE
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
POLARAMINE
generic
syrup 2 mg/5ml
BENADRYL
BENADRYL
TRIAMINIC
ATARAX
VISTARIL
generic
generic
generic
brand
generic
generic
Nose
Antihistamines - First Generation, Sedating
brompheniramine maleate
brompheniramine maleate
brompheniramine tannate
chlorpheniramine
extended-release
chlorpheniramine maleate
chlorpheniramine maleate
chlorpheniramine maleate
chlorpheniramine tannate
chlorpheniramine tannate
clemastine
cyproheptadine
dexchlorpheniramine
maleate
diphenhydramine
diphenhydramine
diphenhydramine
diphenhydramine
hydroxyzine HCL
hydroxyzine pamoate
Antihistamines - Second Generation, Non-Sedating
cetirizine
cetirizine chew tab
fexofenadine
levocetirizine
loratadine
ZYRTEC
ZYRTEC CHEWABLE TABLET
ALLEGRA
XYZAL
ALAVERT
loratadine
loratadine
CLARITIN
CLARITIN CHEW
CLARITIN RDT
azelastine
ASTELIN
brompheniramine/
pseudoephedrine
LODRANE D
generic
generic
generic
tabs
tabs
generic
OTC
brand
brand
chew tab 5 mg
ODT 5 mg
generic
spray
brand
cap 4-60 mg
Antihistamine/Decongestant Combinations - First Generation
ST = Step Therapy
SP = Specialty Pharmacy
23
OTC
generic
Antihistamines - Others Antihistamine/Decongestant Combinations
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
OTC
tab disp 12.5 mg
oral strips
Generic Drug Name
chlorpheniramine/
phenylephrine/
pyrilamine
chlorpheniramine/
pseudoephedrine
Brand Drug Name
Covered
Drug
TRIOTANN
generic
ACTIFED
generic
Requirements & Limits
OTC
Antihistamine/Decongestant Combinations - Second Generation
cetirizine hydrochloride/
pseudoephedrine
hydrochloride
12 hours
extended-release
fexofenadine/
pseudoephedrine
loratadine/
pseudoephedrine
extended-release
Nasal Steroids
ZYRTEC-D
generic
5 mg-120 mg tablet
ALLEGRA-D
generic
SR tabs
generic
OTC
generic
generic
PA
brand
OTC
ALAVERT-D
ALAVERT ALRG
TAB/SINUS
ALLERGY/CONG
FLONASE
NASACORT AQ
NASACORT ALLERGY 24
triamcinolone nasal spray
HOUR
fluticasone
triamcinolone acetonide
Miscellaneous Nasal
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%
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
DECADRON
FLORINEF
CORTEF
generic
generic
generic
generic
hydrocortisone inj
SOLU-CORTEF
generic
methylprednisolone
methylprednisolone
MEDROL
MEDROL
generic
brand
methylprednisolone inj
SOLU-MEDROL
generic
PRELONE
ORAPRED
generic
prednisolone
prednisolone
prednisolone sodium
phosphate
prednisone
prednisone
prednisone
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
Androgens
syrup
generic
PEDIAPRED
DELTASONE
PREDNISONE
RAYOS
KENALOG-40
triamcinolone inj
SP, Coverable through
Medical Benefit
4mg, 8mg, 16mg, 32mg
2mg
SP, Coverable through
Medical Benefit
conc 5 mg/mL
tabs delayed release
SP, Coverable through
Medical Benefit
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
LEVEMIR
LEVEMIR FLEXPEN
LANTUS
LANTUS SOLOSTAR
brand
brand
brand
brand
PA, QL, vials
PA, QL
QL, vials
PA, QL
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 isophane
insulin isophane/regular
insulin lisopro pro/lispro
insulin lispro prot 50%/lispro 50%
insulin lisopro prot/lispro
insulin lispro
insulin lispro
insulin lispro prot 75%/lispro 25%
insulin regular
HUMULIN N
HUMULIN 70/30
HUMALOG MIX 50/50
HUMALOG MIX 50/50
KWIKPEN
HUMALOG MIX 75/25
HUMALOG
HUMALOG KWIKPEN
HUMALOG MIX 72/25
KWIKPEN
HUMULIN R
HUMULIN R 500 U/ML
KWIKPEN
insulin regular (human)
Covered
Drug
brand
brand
brand
PA, QL
brand
brand
brand
QL, vials
QL, vials
100 U/ml only, PA, QL
brand
PA, QL
brand
OTC, QL, vials
brand
PA
ONE TOUCH SYSTEMS (ULTRA 2, ULTRAMINI,
VERIO, VERIO FLEX, VERIO IQ, VERIO SYNC)
brand
ONE TOUCH TEST STRIPS (ULTRA, VERIO)
brand
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
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
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
OTC, QL, vials
OTC, QL, vials
QL, vials
brand
Monitoring - Strips and Kits/Diabetic Supplies
Oral Agents
Requirements & Limits
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
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
Covered
Drug
brand
brand
brand
generic
generic
Generic Drug Name
Brand Drug Name
sitagliptan
sitagliptan/metformin
sitagliptan/metformin ER
tolazamide
tolbutamide
JANUVIA
JANUMET
JANUMET XR
TOLINASE
TOLBUTAMIDE
exenatide
liraglutide
pramlintide
BYETTA
VICTOZA
SYMLIN
brand
brand
brand
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, ST
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
LEVOXYL
SYNTHROID
CYTOMEL
THYROLAR
TAPAZOLE
PROPYLTHIOURACIL
ARMOUR THYROID
generic
generic
generic
brand
generic
generic
brand
QL
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
VISTOGARD
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
uridine
velaglucerase alfa
PA, SP
QL
PA, SP
PA, SP
PA, SP
PA, SP
brand
PA, SP
brand
brand
brand
PA, SP
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
ZOFRAN ODT
COMPAZINE
PHENERGAN
TIGAN
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
generic
OTC
Gastroesophageal Reflux Disease (Gerd)/Peptic Ulcers
alginic acid/sodium
bicarbonate
alumina/magnesia
MAALOX
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
ST = Step Therapy
SP = Specialty Pharmacy
28
Generic Drug Name
alumina/magnesia/
simethicone
cimetidine
esomeprazole
esomeprazole granules
famotidine
Brand Drug Name
Covered
Drug
Requirements & Limits
MYLANTA
generic
OTC
TAGAMET
NEXIUM 24HR OTC
generic
brand
NEXIUM DELAYED
RELEASE PACKET
brand
PEPCID
generic
PEPCID AC
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
PREVACID SOLUTAB
generic
sulcralfate
Gastrointestinal Spasm
dicyclomine
glycopyrrolate
hyoscyamine sulfate
hyoscyamine sulfate
extended-release
FIRST-LANSOPRAZOLE
PRILOSEC
PRILOSEC POWDER
PROTONIX
orally disintegrating tabs, QL
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
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
COLAZAL
ENTOCORT EC
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
generic
generic
ST = Step Therapy
SP = Specialty Pharmacy
29
PA
Generic Drug Name
Brand Drug Name
hydrocortisone
mesalamine
COLOCORT
ROWASA
APRISO
mesalamine
extended-release
DELZICOL
mesalamine
extended-release
mesalamine supp
olsalazine sodium
sulfasalazine
sulfasalazine
delayed-release
Covered
Drug
generic
generic
Requirements & Limits
enema
enema only
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
TRILYTE
generic
NULYTELY
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
peg 3350/sodium
bicarbonate/sodium
chloride/potassium
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
ZENPEP
PANCREAZE
CREON DR
ZENPEP DR
brand
brand
brand
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
QL
36000-114000-180000 unit
25000-85000-136000 unit
ST = Step Therapy
SP = Specialty Pharmacy
30
Generic Drug Name
Brand Drug Name
sacrosidase
SUCRAID
acidophilus
acidophilus
ACIDOPHILUS XTRA
ACIDOPHILUS
ACIDOPHILUS/BIFIDUS
WAFER
ACIDOPHILUS/CITRUS
PECTIN
ACIDOPHILUS/PECTIN
FLORANEX
PROBIOTIC FORMULA
Probiotic Supplementation
acidophilus/bifidus
acidophilus/citrus pectin
acidophilus/pectin
lactobacillus
probiotic product
Miscellaneous
Covered
Drug
brand
soln 8500 unit/ml, PA, SP
brand
brand
OTC
caps and tabs, OTC
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
Requirements & Limits
URSO FORTE
Infectious Diseases
Anthelmintics
albendazole
ivermectin
praziquantel
Antibacterials
Antituberculosis Agents
aminosalicyclic acid
cycloserine
ethambutol
ethionamide
isoniazid
pyrazinamide
rifabutin
rifampin
rifapentine
ALBENZA
STROMECTOL
BILTRICIDE
brand
brand
brand
PASER
SEROMYCIN
MYAMBUTOL
TRECATOR
ISONIAZID
PYRAZINAMIDE
MYCOBUTIN
RIFADIN
PRIFTIN
brand
generic
generic
brand
generic
generic
generic
generic
brand
Cephalosporins - First Generation
cefadroxil
DURICEF
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
generic
ST = Step Therapy
SP = Specialty Pharmacy
31
PA
PA
PA, SP
Generic Drug Name
Brand Drug Name
cephalexin
KEFLEX
Covered
Drug
generic
cefaclor
cefprozil
cefuroxime axetil
cefuroxime axetil
CECLOR
CEFZIL
CEFTIN
CEFTIN
generic
generic
generic
brand
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
ERYC
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
Tetracyclines
demeclocycline
ERY-TAB
tabs are not covered
tabs
suspension
QL
susp, QL
tablets only
tabs
QL
brand
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
DECLOMYCIN
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
Requirements & Limits
generic
ST = Step Therapy
SP = Specialty Pharmacy
32
PA
Generic Drug Name
doxycycline
delayed-release
doxycycline hyclate
Brand Drug Name
Covered
Drug
VIBRAMYCIN
generic
VIBRAMYCIN
DOXYCYCLINE
doxycycline monohydrate
MONOHYDRATE
minocycline
MINOCIN
minocycline SR
MINOCIN
tetracycline
SUMYCIN
Miscellaneous
Requirements & Limits
generic
generic
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
posaconazole susp
terbinafine
terbinafine
voriconazole
MYCELEX
DIFLUCAN
ANCOBAN
GRIFULVIN V
GRIS-PEG
ONMEL
SPORANOX
SPORANOX
NIZORAL
MICONAZOLE
MYCOSTATIN
NOXAFIL
NOXAFIL
LAMISIL
LAMISIL
VFEND
generic
generic
generic
generic
generic
brand
generic
brand
generic
brand
generic
brand
brand
generic
brand
generic
troches
QL
PA
cidofovir
VISTIDE
foscarnet sodium
FOSCAVIR
generic
ganciclovir
valganciclovir
valganciclovir
CYTOVENE
VALCYTE
VALCYTE
generic
brand
generic
enfuvirtide
FUZEON
adefovir
boceprevir
daclatasvir
elbasvir/grazoprevir
HEPSERA
VICTRELIS
DAKLINZA
ZEPATIER
Antifungals
Antivirals
Cytomegalovirus Treatment
Entry/Fusion Inhibitors
Hepatitis Treatment
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
brand
tab 200 mg, PA
caps, PA, QL
soln, PA, QL
tab 50 mg (mouth-throat)
tabs, PA
PA
QL
oral granules
tabs, PA
Coverable through Medical
Benefit
Coverable through Medical
Benefit
brand
PA
generic
brand
brand
brand
QL, SP
PA, SP
PA, QL, SP
PA
ST = Step Therapy
SP = Specialty Pharmacy
33
soln PA
Generic Drug Name
Brand Drug Name
entecavir
interferon alfa-2b
lamivudine
lamivudine
ombitasvir/paritaprevir/
ritonavir
ombitasvir/paritaprevir/
ritonavir/dasabuvir
ledipasvir/sofosbuvir
peginterferon alfa-2a
peginterferon alfa-2a
peginterferon alfa-2b
BARACLUDE
INTRON A
EPIVIR HBV
EPIVIR HBV
Covered
Drug
brand
brand
brand
generic
Requirements & Limits
QL, SP
PA, SP
SP, solution
QL, SP, tablets
TECHNIVIE
brand
PA
VIEKIRA PAK
brand
PA
HARVONI
PEGASYS
PEGASYS PROCLICK
PEGINTRON
brand
brand
brand
brand
ribavirin
REBETOL/COPEGUS
generic
sofosbuvir
telaprevir
telbivudine
SOVALDI
INCIVEK
TYZEKA
PA, QL, SP
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
docosanol
famciclovir
penciclovir
valacyclovir
ZOVIRAX
ZOVIRAX CREAM
ZOVIRAX OINTMENT
ABREVA OTC
FAMVIR
DENAVIR
VALTREX
generic
brand
generic
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
abacavir
abacavir/lamivudine
abacavir/lamivudine/
zidovudine
didanosine
ZIAGEN
EPZICOM
generic
brand
TRIZIVIR
generic
Herpes Treatment
Influenza Treatment
brand
brand
brand
Non-Nucleoside Reverse Transcriptase Inhibitors
cream 5%
oint 5%
cream 10%, OTC
PA
cream 1%
except tabs
QL
QL
Nucleoside Analogues Nucleoside Reverse - Transcriptase Inhibitors/and Combinations
VIDEX
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
brand
ST = Step Therapy
SP = Specialty Pharmacy
34
Generic Drug Name
didanosine
delayed-release
emtricitabine
emtricitabine/rilpivirine/
tenofovir
lamivudine
lamivudine/zidovudine
stavudine
zidovudine
Brand Drug Name
Covered
Drug
VIDEX EC
generic
EMTRIVA
brand
COMPLERA
brand
EPIVIR
COMBIVIR
ZERIT
RETROVIR
Requirements & Limits
generic
generic
generic
generic
Nucleoside/Nucleotide Reverse - Transcriptase Inhibitor Combination
cobicistat/elvitegravir/ emSTRIBILD
tricitabine/tenofovir
efavirenz/emtricitabine/
ATRIPLA
tenofovir
emtricitabine/tenofovir
TRUVADA
brand
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
Miscellaneous
artemether-lumefantrine
atovaquone
atovaquone/proguanil
bedaquiline
chloroquine phosphate
clindamycin
clindamycin
cobicistat
dapsone
brand
COARTEM
MEPRON
MALARONE
SIRTURO
ARALEN
CLEOCIN
CLEOCIN
TYBOST
DAPSONE
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
brand
generic
generic
brand
generic
generic
generic
brand
brand
ST = Step Therapy
SP = Specialty Pharmacy
35
PA
PA
cap, 75 mg
tabs
Covered
Drug
brand
brand
brand
generic
brand
generic
brand
generic
generic
brand
brand
Generic Drug Name
Brand Drug Name
darunavir/cobicistat
etravirine
etravirine
hydroxychloroquine
interferon gamma-1b
linezolid
maraviroc
mefloquine
metronidazole
neomycin sulfate
neomycin sulfate soln
PREZCOBIX
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
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
Metabolics
arginine
BCAD-1, BCAD-2
betaine
CYSTADANE
biotin
citrulline
cyclinex-1, cyclinex-2
cystine
essential amino acid (EAA)
mix
glutarex-1, glutarex-2
glycine
HCU cooler, express, gel
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
brand
brand
brand
brand
brand
brand
brand
brand
brand
brand
brand
ST = Step Therapy
SP = Specialty Pharmacy
36
chewable tablet
tabs only
Generic Drug Name
Covered
Drug
brand
brand
brand
brand
brand
brand
brand
brand
brand
brand
Brand Drug Name
HCY-1, HCY-2
hominex-1, hominex-2
i-valex-1, i-valex-2
isoleucine
ketonex-1, ketonex-2
kionex
leucine
lipistart
lophlex
MCT procal
milupa PKU-2, milupa
PKU-3
MM/PA express, gel
MSUD analog, complex,
cooler, express
MSUD complex drink mix
MSUD maxamum,
maxamaid
OA-1, OA-2
periflex advance, infant,
junior
PFD-1, PFD-2
phenex-1, phenex-2
phenylade 40, 60, drink
mix
phenylade MTE amino
acid blend
phenylfree-1,
phenylfree-2, HP
phlexy-10
PKU cooler, express, gel
portagen
pro-phree powder
progestimil lipil
propimex-1, propimex-2
provimin
sapropterin
KUVAN
dihydrochloride
sodium benzoate
super soluble duocal
tolerex
TYR cooler, express, gel
tyrex-1, tyrex-2
tyros-1, tyros-2
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
Requirements & Limits
brand
brand
brand
brand
brand
brand
brand
brand
brand
brand
brand
brand
brand
brand
brand
brand
brand
brand
brand
brand
brand
brand
brand
brand
brand
brand
ST = Step Therapy
SP = Specialty Pharmacy
37
PA, SP
Generic Drug Name
Covered
Drug
brand
brand
Brand Drug Name
valine
WND-1, WND-2
XLEU analog, maxamum,
maxamaid
XLYS, XTRYP analog,
maxamum, maxamaid
XMET analog, maxamum,
maxamaid
XMTVI analog, maxamum,
maxamaid
Requirements & Limits
brand
brand
brand
brand
Musculoskeletal
Arthritis
Disease Modifying Anti-Rheumatic Drugs
adalimumab
auranofin
azathioprine
etanercept
hydroxychloroquine
leflunomide
methotrexate
penicillamine
penicillamine
sulfasalazine
sulfasalazine
delayed-release
HUMIRA
RIDAURA
IMURAN
ENBREL
PLAQUENIL
ARAVA
METHOTREXATE
CUPRIMINE
DEPEN TITRATABLE
AZULFIDINE
brand
brand
generic
brand
generic
generic
generic
brand
brand
generic
PA, QL, SP
QL
QL
PA, QL, SP
QL
QL
QL
SP
PA, QL, SP
QL
AZULFIDINE EN-TABS
generic
QL
acetaminophen
TYLENOL
BAYER
generic
OTC
generic
OTC
brand
tablet DR
ASCRIPTIN
brand
tab
BUFFERIN
generic
brand
generic
ca carb-mg carb-mg ox
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
ECOTRIN
HALFPRIN
CELEBREX
VOLTAREN 1% TOPICAL
GEL
CATAFLAM
generic
generic
VOLTAREN
generic
VOLTAREN XR
generic
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
ST = Step Therapy
SP = Specialty Pharmacy
38
Generic Drug Name
Brand Drug Name
diflunisal
etodolac
fenoprofen
DOLOBID
LODINE
NALFON
Covered
Drug
generic
generic
generic
ibuprofen
ADVIL
generic
MOTRIN
INDOCIN
ORUDIS
MOBIC
NAPROSYN
ENTERIC COATEDnaproxen delayed release
NAPROSYN
naproxen sodium
ANAPROX
oxaprozin
DAYPRO
piroxicam
FELDENE
sulindac
CLINORIL
ibuprofen
indomethacin
ketoprofen
meloxicam
naproxen
Gout
generic
generic
generic
generic
generic
Requirements & Limits
IR only
600 mg
tabs, chew tabs
and susp, OTC
tabs, chew tabs and susp
IR only
QL
generic
generic
generic
generic
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
Skeletal Muscle Relaxants
Muscle Spasm
Spasticity
PA
ST
OB-GYN
Contraceptives
Biphasic
Emergency Contraception
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
ST = Step Therapy
SP = Specialty Pharmacy
39
Generic Drug Name
Brand Drug Name
Covered
Drug
Requirements & Limits
DEPO-PROVERA
generic
QL
Injectable
medroxyprogesterone
acetate
Intravaginal
diaphragm
etonogestrel/EE
WIDE-SEAL
NUVARING
ORTHO COIL
brand
brand
wide seal
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
Monophasic - 30 mcg Estrogen
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
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
ST = Step Therapy
SP = Specialty Pharmacy
40
Generic Drug Name
Covered
Drug
Requirements & Limits
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.
Brand Drug Name
CAZIANT
desogestrel/EE
levonorgestrel/EE
norethindrone
acetate/EE/iron
norethindrone/EE
norethindrone/EE
norgestimate/EE
Endometriosis
danazol
CESIA
CYCLESSA
Hormone Therapy/Menopause
Estrogens - Intravaginal
estradiol
estradiol
estradiol
estradiol acetate
estrogens, conjugated
ESTRACE CRM
ESTRING
VAGIFEM
FEMRING
PREMARIN
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
brand
brand
brand
brand
brand
ESTROGEL
ESTRASORB
EVAMIST
MENOSTAR
VIVELLE-DOT
ESTRADIOL TDS
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
vaginal ring
vaginal tablet
vaginal ring, PA
crm
ST = Step Therapy
SP = Specialty Pharmacy
41
Generic Drug Name
Covered
Drug
Brand Drug Name
Requirements & Limits
Estrogen/Progestin
estrogens, conjugated/me- PREMPHASE
droxyprogesterone
PREMPRO
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
generic
brand
OTC
crm
supp
Vaginal Infections
Oral
Vaginal
metronidazole
miconazole
miconazole
miconazole nitrate
sulfanilamide
terconazole
METROGEL 1%
MONISTAT
MONISTAT 3
MICONAZOLE KIT
AVC VAGINAL
TERAZOL 3/7
methylergonovine
tranexamic acid
Miscellaneous
generic
generic
generic
generic
brand
generic
OTC
vaginal supp & cream kit
vaginal cream
crm
METHERGINE
LYSTEDA
generic
generic
PA
OPTIVAR
CROLOM
ALAWAY OTC
generic
generic
brand
brand
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
generic
generic
soln 0.02%
generic
ophth soln 0.027-0.315%
generic
VISINE-AC
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
ST
QL
generic
ST = Step Therapy
SP = Specialty Pharmacy
42
Generic Drug Name
Covered
Drug
Brand Drug Name
Requirements & Limits
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
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
ophth susp technology 0.30.05%
diclofenac sodium
flurbiprofen
ketorolac
VOLTAREN
OCUFEN
ACULAR/ACULAR LS
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
Steroidal
Glaucoma
Beta-Blockers
generic
generic
generic
Carbonic Anhydrase Inhibitors
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
ophth suspension 0.1%
ophthalmic solution
0.3% ophthalmic solution
gel forming solution
ST = Step Therapy
SP = Specialty Pharmacy
43
PA
Generic Drug Name
Covered
Drug
Brand Drug Name
Requirements & Limits
Carbonic Anhydrase Inhibitor/Beta-Blocker Combination
dorzolamide/
timolol maleate
dorzolamide hcl-timolol
maleate
COSOPT
generic
COSOPT PF
brand
ecothiophate
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
XALATAN
TRAVATAN Z
generic
brand
tafluprost
TRAVATAN Z PF
generic
tafluprost
ZIOPTAN
pilocarpine
pilocarpine
PILOPINE HS GEL
ISOPTO CARPINE
brand
generic
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
generic
generic
generic
Cholinesterase Inhibitor
Mydriatics
Oral
Prostaglandins
brand
Topical - Parasympathomimetics
Topical - Sympathomimetics
Infections
Bacterial
bacitracin
ciprofloxacin
erythromycin
gatifloxin
gentamicin
moxifloxacin HCl
neomycin/polymyxin B/
gramicidin
ofloxacin
polymyxin B/bacitracin
polymyxin B/trimethoprim
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
ophth solution preservative
free
QL
ophth soln 0.004%, PA
ophth soln 0.004%
(benzalkonium free), PA
ophth soln 0.0015%. PA
0.1%
0.15%
0.2%
PA
ophth solution 0.5%
ST = Step Therapy
SP = Specialty Pharmacy
44
Generic Drug Name
Brand Drug Name
sulfacetamide
sulfacetamide/
phenylephrine
tobramycin
BLEPH-10
Covered
Drug
generic
VASOSULF
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%
acamprosate
disulfiram
naltrexone
CAMPRAL
ANTABUSE
REVIA
brand
generic
generic
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
Fungal
Viral
Miscellaneous
Requirements & Limits
oint/soln
Psychiatric
Alcohol Deterrents
Anxiety
Benzodiazepines
Miscellaneous
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
ST = Step Therapy
SP = Specialty Pharmacy
45
Generic Drug Name
Covered
Drug
Requirements & Limits
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
QL
Brand Drug Name
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
methylphenidate
extended-release
Bipolar Disorder
divalproex sodium
cap sprinkle
divalproex sodium
delayed-release
lithium carbonate
lithium carbonate
extended-release
ADDERALL
ADDERALL XR
(BRAND ADDERALL XR
IS PREFERRED)
METADATE ER
RITALIN-SR
RITALIN LA
DEPAKOTE SPRINKLE
generic
DEPAKOTE
generic
LITHIUM CARBONATE
ESKALITH CR
generic
LITHOBID
Depression
Monoamine Oxidase Inhibitor (MAOI)
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
Selective Serotonin Reuptake Inhibitor (SSRIs)
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
Minimum age 2
QL
10 mg and 20 mg caps and
20 mg soln only
tablets
oral susp, QL
tablets, QL
tablets, QL
ST = Step Therapy
SP = Specialty Pharmacy
46
Generic Drug Name
Brand Drug Name
Serotonin Norepinephrine Reuptake Inhibitors (SNRIs)
Covered
Drug
Requirements & Limits
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
Tricyclic Antidepressants (TCAs)
NORPRAMIN
SINEQUAN
TOFRANIL
PAMELOR
VIVACTIL
Tricyclic Antidepressant/Phenothiazine combination
amitriptyline/perphenazine TRIAVIL
Miscellaneous Agents
tablets
generic
bupropion
bupropion
extended-release
bupropion
extended-release
bupropion
extended-release
maprotiline
mirtazapine
mirtazapine
trazodone
WELLBUTRIN
generic
FORFIVO XL
generic
450 mg
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
NALOXONE INJ
NARCAN NASAL SPRAY
Insomnia
Benzodiazepines
Non-Benzodiazepines
Narcotic Antagonists
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
brand
generic
brand
2 mg and 8 mg film only,
QL
QL
QL
ST = Step Therapy
SP = Specialty Pharmacy
47
Generic Drug Name
Brand Drug Name
naltrexone
naltrexone IM extended
release susp
REVIA
aripiprazole
aripiprazole ER injection
clozapine
clozapine
(ODT formulation)
olanzapine
olanzapine ODT
paliperidone
quetiapine
quetiapine XR
risperidone
risperidone
risperidone m-tab
risperidone oral soln
ziprasidone
ABILIFY TABLETS
ABILIFY MAINTENA
CLOZARIL
Covered
Drug
generic
VIVITROL
Requirements & Limits
brand
QL
brand
brand
generic
Age Limit Applies, PA, QL
Age Limit Applies, PA, QL
Age Limit Applies, QL
brand
Age Limit Applies, QL
ZYPREXA
ZYPREXA ZYDIS
INVEGA SUSTENNA
SEROQUEL
SEROQUEL XR
RISPERDAL
RISPERDAL CONSTA
RISPERDAL M-TAB
RISPERDAL SOLUTION
GEODON
generic
generic
brand
generic
brand
generic
brand
generic
generic
generic
Age Limit Applies, QL
Age Limit Applies, QL
Age Limit Applies, PA, QL
Age Limit Applies, QL
Age Limit Applies, PA, QL
Age Limit Applies, QL
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
Psychoses
Atypicals
Smoking Cessation
Miscellaneous
FAZACLO
PROLIXIN
PROLIXIN DECANOATE
HALDOL
HALDOL DECANOATE
LOXITANE
TRILAFON
ORAP
MELLARIL
NAVANE
STELAZINE
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
generic
generic
generic
generic
generic
generic
generic
generic
generic
generic
ST = Step Therapy
SP = Specialty Pharmacy
48
PA
Generic Drug Name
Covered
Drug
Brand Drug Name
Requirements & Limits
Respiratory Drugs
Antitussives, Decongestants, Expectorants and Combinations
benzonatate
brompheniramine &
phenylephrine
brompheniramine/
pseudoephedrine
brompheniramine/
pseudoephedrine
brompheniramine/
pseudoephedrine
brompheniramine/
pseudoephedrine
brompheniramine/
pseudoephedrine
brompheniramine/
pseudoephedrine
brompheniramine/
pseudoephedrine/
dextromethorphan
brompheniramine/
pseudoephedrine/
dextromethorphan
brompheniramine/
pseudoephedrine/
dextromethorphan
brompheniramine/
pseudoephedrine/
dextromethorphan/
guaifenesin
carbetapentane/
chlorpheniramine/
ephedrine/
phenylephrine
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
generic
liq 4-20 mg/5 ml
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
BROMFED DM
DALLERGY DM
CARBOFED
NEO DM
ANAPLEX DM
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
ST = Step Therapy
SP = Specialty Pharmacy
49
Generic Drug Name
carbinoxamine/
pseudoephedrine
chlorphen-PEmethscopolamine
chlorphen tan/
carbetapentane tan
chlorphen tan/
pseudoeph tan
chlorphen tan/pyrilamine
tan/PE tan
chlorpheniramine/
dextromethorphan
Brand Drug Name
Covered
Drug
Requirements & Limits
RONDEC DROPS
generic
liquid
generic
syrup
TUSSI-12 S
generic
susp
TANAFED
generic
susp
TRIOTANN PEDIATRIC
SUSP
generic
susp
DURADRYL
QV-ALLERGY
R-TANNAMINE
ROBITUSSIN PED LIQ
CGH/COLD
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
liquid
generic
syrup
generic
generic
MYTUSSIN AC
codeine/guaifenesin/pseuGUIATUSS DAC
doephedrine
PROMETHAZINE
codeine/promethazine
W/CODEINE
susp
generic
generic
M-CLEAR WC
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
generic
QL
generic
generic
ST = Step Therapy
SP = Specialty Pharmacy
50
QL
Generic Drug Name
Brand Drug Name
Covered
Drug
Requirements & Limits
codeine/promethazine/
phenylephrine
dextromethorphan/
brompheniramine/
pseudoephedrine
dextromethorphan/
carbinoxamine/
pseudoephedrine
dextromethorphanguaifenesin
PROMETHAZINE VC
W/CODEINE
generic
QL
BROMETANE DX
generic
CARDEC-DM
generic
drops
DURATUSS DM ELX
generic
soln 25-225 mg/5 ml
dextromethorphan/
guaifenesin
MUCINEX DM
generic
OTC
generic
liq 10-200 mg/ 5 ml
generic
syrup
dextromethorphanguaifenesin
dextromethorphan HBR
dextromethorphan/
promethazine
dextromethorphan
polistirex
extended-release
guaifenesin
guaifenesin
guaifenesin
guaifenesin
guaifenesin
extended-release
guaifenesin/
pseudoephedrine
guaifenesin/
pseudoephedrine/
dextromethorphan
guaifenesin/
pseudoephedrine
extended-release
GG/DM CR
ROBITUSSIN DM
TUSSIN DM
ROBITUSSIN LIQ CGH/
CONG
ROBITUSSIN SYP MAX-ST
ROBITUSSIN PED SYP
PHENERGAN DM
PROMETHAZINE SYP DM
DELSYM
generic
brand
OTC
MUCINEX KIDS
ROBITUSSIN
ROBITUSSIN SYP
CHST CNG
TRIACTIN CHEST
CONGESTION
brand
generic
granules packet
OTC
generic
syrup 100 mg/5 ml
brand
soln 50 mg/5 mL
MUCINEX
generic
OTC
generic
syrup, OTC
ROBITUSSIN PE
PSE/GG
ROBITUSSIN CF
generic
GUAIFED
generic
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
ST = Step Therapy
SP = Specialty Pharmacy
51
Generic Drug Name
Brand Drug Name
guaifenesin/
pseudoephedrine
extended-release
GUAIFEN PSE
hydrocodone/
chlorpheniramine/
phenylephrine
hydrocodone/guaifenesin
hydrocodone/homatropine
loratadine &
pseudoephedrine SR
24hr
phenyleph/bromphen/
dextromethorphan/
guaifenesin
phenylephrine/
brompheniramine-DM
phenylephrine/
brompheniramine-DM
phenylephrine/
brompheniramine-DM
phenylephrine/
brompheniramine-DM
phenylephrine/
brompheniramine/
dextromethorphan
phenylephrine/
chlorpheniramine
phenylephrine/
chlorpheniramine/
dextromethorphan
phenylephrine/
chlorpheniramine/
dextromethorphan
MUCINEX D
Covered
Drug
Requirements & Limits
generic
OTC
GG/PSE CR
HISTUSSIN HC
generic
VITUSSIN
HYDROCODO/GG SYP
HYCODAN
HYDROMET SYP
generic
generic
HYDROCODONE/
TAB HOMATROP
ALLERGY/CONG TAB RELIEF
generic
ALLANHIST SYP PDX
generic
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
generic
OTC
QUAL-TUSSIN SYP DC
tab 10-240 mg
generic
ATUSS DR
DE-CHLOR DM
generic
syrup
generic
syrup
RONDEC DM
STATUSS DM SYP
CARDEC DM SYP
MINUTUSS DR SYP
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
ST = Step Therapy
SP = Specialty Pharmacy
52
Generic Drug Name
phenylephrine/
chlorpheniramine/
dextromethorphan
phenylephrine/
chlorpheniramine/
dihydrocodeine
phenylephrine/
dextromethorphan
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
Brand Drug Name
Covered
Drug
Requirements & Limits
generic
liquid
RONDEC DM DROPS
CARDEC DM DRO
ROBITUSSIN LIQ
CGH/ALRG
DIHYDRO-PE SYP
generic
DIMETAPP DRO
DCON/CGH
generic
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
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
PROMETH VC SYP
6.25-5/5
generic
syrup 6.25-5 mg/ 5 mg
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
ST = Step Therapy
SP = Specialty Pharmacy
53
Generic Drug Name
Brand Drug Name
pseudoephedrine
pseudoephedrine/
acetaminophen/
dextromethorphan
SUDAFED
Covered
Drug
generic
MAPAP COLD TAB
generic
pseudoephedrine/
chlorpheniramine/
dextromethorphan
pseudoephedrine/
dextromethorphan/
guaifenesin
pseudoephedrine/
iburprofen
pseudoephedrine tan/
dexchlorphen tan/
DM tan
pyrilamine tan/phenyleph
tan
tripolidine/
pseudoephedrine
Asthma/COPD
Inhalers - Beta Agonists
PEDIACARE LIQ
MULTI-SY
Requirements & Limits
generic
ROBITUSSIN LIQ PED
NGHT
MULTI SYMPTOM TAB
COLD RLF
generic
CHILD IBUPRO
SUS COLD
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
albuterol
ACCUNEB
generic
albuterol
budesonide
PROVENTIL
PULMICORT RESPULES
generic
brand
Inhalers - Corticosteroids
Inhalers -Corticosteroid/Beta Agonist Combinations
Inhalers for Nebulization
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
QL
PA
0.63 mg/3 ml and
1.25 mg /3 ml
soln 0.083%, 0.5%
susp, QL
ST = Step Therapy
SP = Specialty Pharmacy
54
Covered
Drug
generic
generic
generic
generic
Generic Drug Name
Brand Drug Name
cromolyn
ipratropium
ipratropium/albuterol
levalbuterol HCl
INTAL
ATROVENT
DUONEB
XOPENEX RESPULES
cromolyn
ipratropium/albuterol
ipratropium HFA
nedocromil
omalizumab
tiotropium
INTAL
COMBIVENT RESPIMAT
ATROVENT HFA
TILADE
XOLAIR
SPIRIVA
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
Inhalers - Others
Oral Agents - Beta Agonists
Oral Agents - Leukotriene Modifiers
Oral Agents - Theophylline
THEO-24
soln, QL
soln, QL
soln
QL, ST
brand
brand
brand
brand
brand
brand
Miscellaneous
alpha1-proteinase
inhibitor (human)
alpha1-proteinase
inhibitor (human)
Requirements & Limits
ARALAST NP
brand
PROLASTIN
brand
QL
inhaler
PA, SP
tabs
SP, Coverable through
Medical Benefit
SP, Coverable through
Medical Benefit
Urological
Symptomatic Benign Prostatic Hypertrophy
alfuzosin ER
doxazosin
doxazosin SR
finasteride
tamsulosin
terazosin
UROXATRAL
CARDURA
CARDURA XL
PROSCAR
FLOMAX
HYTRIN
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
generic
generic
brand
generic
generic
generic
ST = Step Therapy
SP = Specialty Pharmacy
55
Generic Drug Name
Covered
Drug
Brand Drug Name
Miscellaneous
bethanechol
URECHOLINE
hyoscyamine,
methenamine,
phenyl salicylate,
UTIRA C
sodium phosphate
monobasic, methylene
blue
HIPREX
methenamine hippurate
UREX
oxybutynin chloride
DITROPAN XL
oxybutynin IR
DITROPAN
pentosan
ELMIRON
potassium citrate
UROCIT-K
propantheline
phenazopyridine
PYRIDIUM
sodium citrate/citric acid BICITRA
tolterodine
DETROL
tolterodine SR
DETROL LA
trospium
SANCTURA
Requirements & Limits
generic
brand
generic
generic
generic
brand
generic
generic
generic
generic
generic
brand
generic
QL, ST
PA
ST
ST
ST
Vitamins and Minerals
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
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
ST = Step Therapy
SP = Specialty Pharmacy
56
Generic Drug Name
ergocalciferol (D2)
ferrous bisglycinate/
polysaccarides iron
ferrous sulfate
Covered
Drug
Requirements & Limits
DRISDOL
generic
Coverage for these
medications will be
determined by the member’s
individual benefits.
Please refer to individual
plan documents for coverage
information.
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.
Brand Drug Name
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
SEA-OMEGA
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
ST = Step Therapy
SP = Specialty Pharmacy
57
capsule
Generic Drug Name
Covered
Drug
Requirements & Limits
HM FISH OIL
generic
delayed release capsule
GNP FISH OIL
MEPHYTON
brand
Brand Drug Name
PRO NUTRIENT
omega-3 fatty acids
phytonadione
polysaccharide iron
complex
prenat w/o A
w/fecbn-fegl-DSS-FA &
DHA
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 bisglyc-FE
prot succ-FA
prenatal vit
w/FE polysac
cmplx-FA
prenatal vit
w/folic acid
NIFEREX
generic
FOLTABS PAK PLUS DHA
RE OB + DHA PAK
brand
GENTEX ADE 28-1 MG
brand
VINATE AZ EX
brand
VITAPHIL
brand
VINATE III
brand
EDGE OB CHW
brand
PRENATAL VITAMINS W/
FOLIC ACID
CENOGEN OB/ULTRA
MATERNA
generic
NATALCARE
NESTABSCBF/FA/RX
prenatal vit w/iron
carbonyl-FA
prenatal vit w/o vit a
w/FE bisglycinate-FA
tab 32-1 mg
prenatal w/o A w/ FE
carbonyl-FE
gluc-DSS-FA
elixir, OTC
NIFEREX-PN FORTE
ATABEX PRENATAL
brand
generic
FOLTABS PRENATAL
brand
TRI RX
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
ST = Step Therapy
SP = Specialty Pharmacy
58
QL
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
renat-FE bis-FE prot succFA-CA & omega DR
vitamin A
Covered
Drug
Brand Drug Name
COMPLETE NATALCARE
PAK DHA
brand
TRUST NATALCARE
PAK DHA
brand
PRUET DHA PAK
SETONET PAK
brand
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
zinc
generic
phosphorus
K-PHOS NEUTRAL
potassium acid phosphate K-PHOS ORIGINAL
generic
brand
Potassium
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
Requirements & Limits
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
ST = Step Therapy
SP = Specialty Pharmacy
59
tabs
Generic Drug Name
potassium bicarbonate/
potassium citrate
effervescent
potassium chloride
potassium chloride
potassium chloride
extended-release
potassium chloride
extended-release
potassium iodide
Brand Drug Name
Covered
Drug
Requirements & Limits
K-LYTE
generic
tabs
K-LOR
POTASSIUM CHLORIDE
K-DUR 10
generic
generic
powder
liquid
generic
tabs
generic
caps
K-DUR 20
KLOR-CON 8
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
brand
brand
PA
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
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
ST = Step Therapy
SP = Specialty Pharmacy
60
Generic Drug Name
Brand Drug Name
sevelamer
sevelamer HCL
RENVELA
RENAGEL
Covered
Drug
generic
brand
nintedanib
pirfenidone capsule
OFEV
ESBRIET
brand
brand
PA, SP
PA, SP
eltrombopag
PROMACTA
brand
PA, SP
Idiopathic Pulmonary Fibrosis (IPF)
Immune Thrombocytopenic Purpura
Medical Devices
Requirements & Limits
ST
tablet, PA
Spacers
Metabolic Modifiers
QL
carglumic acid
glycerol phenylbutyrate
sodium phenylbutyrate
oral powder
sodium phenylbutyrate tab
CARBAGLU
RAVICTI
BUPHENYL ORAL
POWDER
BUPHENYL
diphtheria-tetanus tox adsorbed (dt) im
DIP/TET PED INJ
Vaccine
hepatitis a vaccine susp
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,
CERVARIX
18) 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
FLUZONE HD PF
split high-dose pf
influenza virus vaccine
AFLURIA PF
split pf
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
brand
brand
PA, SP
PA, SP
generic
PA, SP
brand
PA, SP
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
ST = Step Therapy
SP = Specialty Pharmacy
61
Generic Drug Name
influenza virus vaccine
split quadrivalent
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
brand
QL, Age Limits Apply
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
FLUARIX QUAD
FLULAVAL QUAD
FLUZONE QUAD
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
62
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
63
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
64
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
aspirin with buffers tabs
TYLENOL
BAYER
aspirin tabs, EC. tabs
ECOTRIN
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
65
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
66
Index of
of Covered
CoveredDrugs
Drugs
A
abacavir . . . . . . . . . . . . 34
abacavir/lamivudine . . . . . 34
abacavir/lamivudine/
zidovudine . . . . . . . . . 34
ABILIFY MAINTENA . . . . . . 48
ABILIFY TABLETS . . . . . . . 48
abiraterone . . . . . . . . . . . 5
ABREVA OTC . . . . . . . . . 34
acamprosate . . . . . . . . . 45
acarbose . . . . . . . . . . . . 26
ACCOLATE . . . . . . . . . . . 55
ACCUHIST DROPS . . . . . . 49
ACCUHIST PDX DROPS . . . 49
ACCUNEB . . . . . . . . . . . 54
ACCUPRIL . . . . . . . . . . . .8
ACCURETIC . . . . . . . . . . .8
ACCUTANE . . . . . . . . . . 17
acebutalol . . . . . . . . . . . . 9
ACEON . . . . . . . . . . . . . .8
acetaminophen . . . . 13, 38, 65
acetazolamide . . . . . . . . . 44
ACETAZOLAMIDE . . . . . . . 44
acetazolamide
extended-release . . . . . 44
acetic acid . . . . . . . . . . . 22
acetic acid/aluminum acetate22
acetic acid/hydrocortisone . . 22
acetylcysteine . . . . . . . . . 60
acidophilus . . . . . . . . . . 31
ACIDOPHILUS . . . . . . . . . 31
acidophilus/bifidus . . . . . . 31
ACIDOPHILUS/BIFIDUS
WAFER . . . . . . . . . . . 31
acidophilus/citrus pectin . . . 31
ACIDOPHILUS/CITRUS
PECTIN . . . . . . . . . . . 31
acidophilus/pectin . . . . . . 31
ACIDOPHILUS/PECTIN . . . . 31
ACIDOPHILUS XTRA . . . . . 31
acitretin . . . . . . . . . . . . 20
ACLOVATE . . . . . . . . . . . 18
ACTIFED . . . . . . . . . . 24, 64
ACTIGALL . . . . . . . . . . . 31
ACTIMMUNE . . . . . . . . . . 36
ACTOPLUSMET . . . . . . . . 26
ACTOPLUS MET XR . . . . . 26
ACTOS . . . . . . . . . . . . . 26
ACULAR/ACULAR LS . . . . 43
acyclovir . . . . . . . . . . . . 34
ADACEL . . . . . . . . . . . . 62
ADALAT CC . . . . . . . . . . 10
adalimumab . . . . . . . . . . 38
ADCIRCA . . . . . . . . . . . . 12
ADDERALL . . . . . . . . . . . 46
ADDERALL XR . . . . . . . . . 46
adefovir . . . . . . . . . . . . 33
ADEMPAS . . . . . . . . . . . 12
ADVAIR DISKUS . . . . . . . . 54
ADVIL . . . . . . . . . 13, 39, 65
AFINITOR . . . . . . . . . . . . .4
AFINITOR DISPERZ . . . . . . .4
AFLURIA . . . . . . . . . . . . 61
AFLURIA PF . . . . . . . . . . 61
AFRIN . . . . . . . . . . . 24, 64
agalsidase . . . . . . . . . . . 27
AGRYLIN . . . . . . . . . . . . .7
ALAHIST DM . . . . . . . . . . 52
ALAVERT . . . . . . . . . . . . 23
ALAVERT . . . . . . . . . . . . 63
ALAVERT ALRG
TAB/SINUS . . . . . . 24, 64
ALAVERT-D . . . . . . . . 24, 64
ALAWAY . . . . . . . . . . . . 65
ALAWAY OTC . . . . . . . . . 42
albendazole . . . . . . . . . . 31
ALBENZA . . . . . . . . . . . . 31
albuterol . . . . . . . . . . . . 54
albuterol SR tabs . . . . . . . 55
albuterol sulfate . . . . . . . . 54
alclometasone . . . . . . . . 18
alcohol swabs . . . . . . . . . 64
ALDACTAZIDE . . . . . . . . . 11
ALDACTONE . . . . . . . . . . 11
ALDARA . . . . . . . . . . . . 21
ALDOMET . . . . . . . . . . . 12
ALDORIL . . . . . . . . . . . . 12
ALDURAZYME . . . . . . . . . 28
ALL CAPS = Brand-name drug
lower case = Generic drug
67
ALECENSA . . . . . . . . . . . .4
alectinib . . . . . . . . . . . . . 4
alendronate . . . . . . . . . . 27
ALESSE . . . . . . . . . . . . . 40
alfuzosin ER . . . . . . . . . . 55
alginic acid/sodium
bicarbonate . . . . . . . . 28
alglucerase . . . . . . . . . . 27
alglucosidase . . . . . . . . . 27
ALINIA . . . . . . . . . . . . . 36
ALINIA SUSPENSION . . . . . 36
alirocumab . . . . . . . . . . 11
alitretinoin 1% gel . . . . . . . 6
ALKERAN . . . . . . . . . . . . 4
ALLANHIST SYP PDX . . . . . 52
ALLEGRA . . . . . . . . . . . . 23
ALLEGRA-D . . . . . . . . . . 24
allergic conjunctivitis . . . . . 65
ALLERGY/CONG . . . . 24, 64
ALLERGY/CONG TAB
RELIEF . . . . . . . . . . . 52
allopurinol . . . . . . . . . . . 39
alpha1-proteinase inhibitor . 55
ALPHAGAN . . . . . . . . . . 44
ALPHAGAN P . . . . . . . . . 44
alprazolam . . . . . . . . . . . 45
ALTACE . . . . . . . . . . . . . .8
altretamine . . . . . . . . . . . 4
alumina/magnesia . . . . . . 28
alumina/magnesia/
simethicone . . . . . . . . 29
aluminum acetate . . . . . . . 21
aluminum chloride . . . . . . 21
aluminum chloride
hexahydrate . . . . . . . . 21
ALUPENT . . . . . . . . . . . . 55
amantadine . . . . . . . . 15, 34
AMARYL . . . . . . . . . . . . 26
AMBIEN . . . . . . . . . . . . 47
ambrisentan . . . . . . . . . . 12
AMERGE . . . . . . . . . . . . 15
AMICAR . . . . . . . . . . . . . 7
amiloride . . . . . . . . . . . . 10
Index of Covered Drugs
amiloride/hydrochlorothiazide10
aminocaproic acid . . . . . . . 7
aminosalicyclic acid . . . . . 31
amiodarone . . . . . . . . . . . 9
amitriptyline . . . . . . . . 15, 47
amitriptyline/perphenazine . 47
amlexanox . . . . . . . . . . . 24
amlodipine . . . . . . . . . . 10
ammonium lactate . . . . . . 21
amoxapine . . . . . . . . . . . 47
amoxicillin . . . . . . . . . . . 32
AMOXICILLIN CAPSULES AND
CHEWABLES . . . . . . . 32
amoxicillin/clavulanate . . . . 32
AMOXIL . . . . . . . . . . . . . 32
AMOXIL SUSP . . . . . . . . . 32
amphetamine/dextroamphetamine mixed salts . . . . 46
amphetamine/dextroamphetamine mixed salts
extended-release . . . . . 46
ampicillin . . . . . . . . . . . 32
ANAFRANIL . . . . . . . . . . 45
anagrelide . . . . . . . . . . . 7
ANAPLEX DM . . . . . . . . . 49
ANAPROX . . . . . . . . . 14, 39
anastrozole . . . . . . . . . . . 5
ANCOBAN . . . . . . . . . . . 33
ANDEHIST . . . . . . . . . . . 49
ANDRODERM . . . . . . . . . 25
ANDROGEL 1% . . . . . . . . 25
ANDROGEL 1.62% . . . . . . 25
ANDROXY . . . . . . . . . . . 25
ANSAID . . . . . . . . . . . . . 13
ANTABUSE . . . . . . . . . . . 45
antacids liquids, chew tabs . 65
ANTARA . . . . . . . . . . . . 11
antidiarrheals . . . . . . . . . 65
antihistamines . . . . . . . . . 63
antipyrine-benzocaine . . . . 22
antitussives. . . . . . . . . . . 64
ANTIVERT . . . . . . . . . . . 28
ANUSOL HC 2.5% . . . . . . 21
ANZEMET . . . . . . . . . . . 28
APHEDRID TAB . . . . . . . . 54
APHTHASOL . . . . . . . . . . 24
apixaban . . . . . . . . . . . . 7
aprepitant . . . . . . . . . . . 28
APRESOLINE . . . . . . . . . 12
APRISO . . . . . . . . . . . . . 30
APTIVUS . . . . . . . . . . . . 35
ARALAST NP . . . . . . . . . 55
ARALEN . . . . . . . . . . . . 35
ARANESP . . . . . . . . . . . . 7
ARAVA . . . . . . . . . . . . . 38
ARCAPTA NEOHALER . . . . 54
arginine . . . . . . . . . . . . 36
ARICEPT . . . . . . . . . . . . 13
ARIMIDEX . . . . . . . . . . . . 5
aripiprazole . . . . . . . . . . 48
aripiprazole ER injection . . . 48
ARMOUR THYROID . . . . . . 27
AROMASIN . . . . . . . . . . . .5
ARTANE . . . . . . . . . . . . 16
artemether-lumefantrine . . . 35
artificial tears . . . . . . . . . 65
ASACOL HD . . . . . . . . . . 30
ASCRIPTIN . . . . . . . . . . . 38
asfotase alfa . . . . . . . . . . 27
ASMANEX TWISTHALER . . . 54
aspirin . . . . . . . . . . . . 7, 38
aspirin/acetaminophen/
caffeine . . . . . . . . . . 13
aspirin-al hydro-mg
hydro-ca carb . . . . . . . 38
aspirin buffered . . . . . . . . 38
aspirin tabs, EC. tabs . . . . . 65
aspirin with buffers tabs . . . 65
ASTELIN . . . . . . . . . . . . 23
ATABEX PRENATAL . . . . . . 58
ATARAX . . . . . . . . . . . . . 23
atazanavir . . . . . . . . . . . 35
atenolol . . . . . . . . . . . . . 9
atenolol/chlorthalidone . . . . 9
ATIVAN . . . . . . . . . . . . . 45
atomoxetine . . . . . . . . . . 46
atorvastatin . . . . . . . . . . 11
atovaquone . . . . . . . . . . 35
ALL CAPS = Brand-name drug
lower case = Generic drug
68
atovaquone/proguanil . . . . 35
ATRALIN . . . . . . . . . . . . 18
ATRIPLA . . . . . . . . . . . . 35
atropine . . . . . . . . . . . . 44
atropine sulfate . . . . . . . . 31
ATROVENT . . . . . . . . . . . 55
ATROVENT HFA . . . . . . . . 55
ATROVENT NS . . . . . . . . . 24
ATUSS DR . . . . . . . . . . . 52
AUBAGIO . . . . . . . . . . . . 15
AUGMENTIN . . . . . . . . . . 32
AUGMENTIN ES-600 . . . . . 32
AURALGAN . . . . . . . . . . 22
auranofin . . . . . . . . . . . 38
AVAPRO . . . . . . . . . . . . . 8
AVC VAGINAL . . . . . . . . . 42
AVEENO CLEAR PADS OTC . 18
AVITA . . . . . . . . . . . . . . 18
AVONEX/AVONEX PEN . . . 15
axitinib . . . . . . . . . . . . . 4
AYGESTIN . . . . . . . . . . . 42
azathioprine . . . . . . . . 5, 38
azelaic acid . . . . . . . . . . 17
azelastine . . . . . . . . . 23, 42
azithromycin . . . . . . . . . . 32
AZOLEN TINCTURE
SOLUTION OTC . . . . . . 20
AZOPT . . . . . . . . . . . . . 43
AZULFIDINE . . . . . . . 30, 38
AZULFIDINE EN-TABS . . 30, 38
B
bacitracin . . . . . . . . . 18, 44
BACITRACIN . . . . . . . 18, 64
bacitracin-polymyxinneomycin HC . . . . . . . 18
baclofen . . . . . . . . . . . . 39
BACLOFEN . . . . . . . . . . . 39
BACTRIM . . . . . . . . . . . . 32
BACTRIM DS . . . . . . . . . . 32
BACTROBAN . . . . . . . . . 18
balsalazide . . . . . . . . . . 29
BALZIVA . . . . . . . . . . . . 40
BANZEL . . . . . . . . . . . . 17
Index of Covered Drugs
BANZEL SUSPENSION . . . . 17
BARACLUDE . . . . . . . . . . 34
BAYER . . . . . . . . . 7, 38, 65
BCAD-1, BCAD-2 . . . . . . . 36
becaplermin gel . . . . . . . . 21
beclomethasone . . . . . . . 54
bedaquiline . . . . . . . . . . 35
BENADRYL . . . . . . . . 23, 63
benazepril . . . . . . . . . . . .8
benazepril/hydrochlorothiazide8
BENTYL . . . . . . . . . . . . 29
BENZAC AC . . . . . . . . . . 17
BENZEFOAM . . . . . . . . . 17
BENZIQ . . . . . . . . . . . . . 17
BENZIQ LS . . . . . . . . . . . 17
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 . . . . . 63
benzoyl peroxide gel . . . . . 17
benzoyl peroxide wash 4% &
benzoyl peroxide bar 5%
kit . . . . . . . . . . . . . 18
benztropine . . . . . . . . . . 15
BERINERT . . . . . . . . . . . 60
BETACARE CREAM AND
LOTION . . . . . . . . . . . 63
BETAGAN . . . . . . . . . . . 43
betaine . . . . . . . . . . . . . 36
betaine powder for oral
solution . . . . . . . . . . 28
betamethasone
augmented dip . . . . . . 19
betamethasone dipropionate 19
betamethasone val. . . . . . . 19
BETAPACE . . . . . . . . . . . .9
BETAPACE AF . . . . . . . . . .9
BETASERON . . . . . . . . . . 15
BETA-VAL . . . . . . . . . . . . 19
betaxolol . . . . . . . . . . . . 43
bethanechol . . . . . . . . . . 56
BETHKIS . . . . . . . . . . . . 60
BETOPTIC -S . . . . . . . . . . 43
bexarotene caps . . . . . . . . 6
bexarotene topical gel . . . . . 6
BIAXIN . . . . . . . . . . . . . 32
BIAXIN XL . . . . . . . . . . . 32
bicalutamide . . . . . . . . . . 5
BICITRA . . . . . . . . . . . . 56
BILTRICIDE . . . . . . . . . . . 31
BIO-D DRO-MULSION . . . . 56
BIO-D-MULSIO DRO FORTE . 56
biotin . . . . . . . . . . . . . . 36
bisoprolol . . . . . . . . . . . . 9
bisoprolol/hydrochlorothiazide 9
BLEPH-10 . . . . . . . . . . . 45
BLEPHAMIDE . . . . . . . . . 43
boceprevir . . . . . . . . . . . 33
BONINE . . . . . . . . . . . . 65
BOOSTRIX . . . . . . . . . . . 62
bosentan . . . . . . . . . . . 12
BOSULIF . . . . . . . . . . . . .4
bosutinib . . . . . . . . . . . . 4
BPO CREAMY KIT . . . . . . 17
BRETHINE . . . . . . . . . . . 55
BREVOXYL . . . . . . . . . . . 17
BREVOXYL-4 . . . . . . . . . . 63
BREVOXYL-4 OTC . . . . . . . 18
BRILINTA . . . . . . . . . . . . .7
brimonidine . . . . . . . . 20, 44
brinzolamide . . . . . . . . . 43
BROMALINE DM . . . . . . . 49
BROMETANE DX . . . . . . . 51
BROMFED DM . . . . . . . . . 49
BROMFENEX PD CAP . . . . 49
bromocriptine . . . . . . 15, 28
brompheniramine maleate . . 23
brompheniramine &
phenylephrine . . . . . . . 49
brompheniramine/
pseudoephedrine 23, 49, 64
ALL CAPS = Brand-name drug
lower case = Generic drug
69
brompheniramine/
pseudoephedrine/
dextromethorphan . . . . 49
brompheniramine/
pseudoephedrine/dextromethorphan/guaifenesin 49
brompheniramine tannate . . 23
BROVEX CT . . . . . . . . . . 23
BROVEX PSB . . . . . . . . . 49
budesonide . . . . . . . . 29, 54
budesonide/formoterol . . . . 54
BUFFERIN . . . . . . . . . . . 38
bumetanide . . . . . . . . . . 10
BUMEX . . . . . . . . . . . . . 10
BUPHENYL . . . . . . . . 27, 61
BUPHENYL ORAL
POWDER . . . . . . . 27, 61
buprenorphine/naloxone . . . 47
bupropion . . . . . . . . . 47, 48
bupropion extended-release 47
Burow’s soln, wet dressings . 64
BUSPAR . . . . . . . . . . . . 45
buspirone . . . . . . . . . . . 45
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 . . . . . 60
cabergoline . . . . . . . . . . 28
cabozantinib . . . . . . . . . . 4
CAFERGOT . . . . . . . . . . 15
calamine . . . . . . . . . . . . 21
CALAN . . . . . . . . . . 10, 15
CALAN SR . . . . . . . . . . . 10
calcipotriene . . . . . . . . . 20
calcitonin-salmon . . . . . . . 27
calcitriol . . . . . . . . . . 20, 56
Index of Covered Drugs
calcium . . . . . . . . . . 56, 66
calcium acetate . . . . . . . . 60
calcium acetate oral solution 60
CALICYLIC . . . . . . . . . . . 22
CALTRATE . . . . . . . . . . . 66
CAMPRAL . . . . . . . . . . . 45
canagliflozin . . . . . . . . . . 26
canagliflozin/metformin . . . 26
CANASA . . . . . . . . . . . . 30
capecitabine . . . . . . . . . . 4
CAPEX SHAMOO . . . . . . . 18
CAPOTEN . . . . . . . . . . . . 8
CAPOZIDE . . . . . . . . . . . .8
CAPRELSA . . . . . . . . . . . .5
capsaicin . . . . . . . . . . . 38
captopril . . . . . . . . . . . . .8
captopril/hydrochlorothiazide . 8
CAPTOPRIL POWDER . . . . . 8
CARAC . . . . . . . . . . . . . 21
CARAFATE . . . . . . . . . . . 29
CARAFATE SUSPENSION . . 29
CARBAGLU . . . . . . . . 27, 61
carbamazepine . . . . . . . . 16
carbamazepine
extended-release . . . . . 16
carbamazepine SR . . . . . . 16
carbamide peroxide . . . 22, 64
CARBATROL . . . . . . . . . 16
carbetapentane/chlorpheniramine/ephedrine/
phenylephrine . . . . . . . 49
carbidopa/levodopa . . . . . 15
carbidopa/levodopa
extended-release . . . . . 15
carbinoxamine/
pseudoephedrine . . . . . 50
CARBOFED . . . . . . . . . . 49
CARDEC-DM . . . . . . . . . . 51
CARDEC DM DRO . . . . . . 53
CARDEC DM SYP . . . . . . . 52
CARDEC DRO . . . . . . . . . 50
CARDEC SYP . . . . . . . 49, 50
CARDENE . . . . . . . . . . . 10
CARDIZEM . . . . . . . . . . . 10
CARDIZEM CD . . . . . . . . . 10
CARDIZEM LA . . . . . . . . . 10
CARDIZEM SR . . . . . . . . . 10
CARDURA . . . . . . . . . 8, 55
CARDURA XL . . . . . . . . . 55
carglumic acid . . . . . . 27, 61
carteolol . . . . . . . . . . . . 43
carvedilol . . . . . . . . . . . . 9
casanthranol-docusate
sodium . . . . . . . . . . 30
CASODEX . . . . . . . . . . . . 5
CATAFLAM . . . . . . . . . . . 38
CATAPRES . . . . . . . . . . . .8
CATAPRES-TTS . . . . . . . . . 8
CAZIANT . . . . . . . . . . . . 41
CECLOR . . . . . . . . . . . . 32
cefaclor . . . . . . . . . . . . 32
cefadroxil . . . . . . . . . . . 31
cefdinir . . . . . . . . . . . . . 32
cefixime . . . . . . . . . . . . 32
cefpodoxime . . . . . . . . . 32
cefprozil . . . . . . . . . . . . 32
CEFTIN . . . . . . . . . . . . . 32
cefuroxime axetil . . . . . . . 32
CEFZIL . . . . . . . . . . . . . 32
CELEBREX . . . . . . . . . . . 38
celecoxib . . . . . . . . . . . 38
CELEXA . . . . . . . . . . . . 46
CELLCEPT . . . . . . . . . . . .5
CELONTIN . . . . . . . . . . . 16
CENESTIN . . . . . . . . . . . 41
CENOGEN OB/ULTRA . . . . 58
CENTRUM . . . . . . . . . . . 57
cephalexin . . . . . . . . . . . 32
CEREDASE . . . . . . . . . . . 27
CEREZYME . . . . . . . . . . 27
ceritinib . . . . . . . . . . . . . 4
CERVARIX . . . . . . . . . . . 61
CESIA . . . . . . . . . . . . . . 41
CETAPHIL CREAM AND
LOTION . . . . . . . . . . . 63
cetirizine . . . . . . . . . . . . 23
ALL CAPS = Brand-name drug
lower case = Generic drug
70
cetirizine hydrochloride/pseudoephedrine hydrochloride
extended-release . . . . . 24
cetirizine/pseudoephedrine
OTC . . . . . . . . . . . . 64
CHANTIX . . . . . . . . . . . . 48
CHERATUSSIN AC . . . . . . 50
CHILD IBUPRO SUS COLD . 54
chloral hydrate . . . . . . . . 47
CHLORAL HYDRATE . . . . . 47
chlorambucil . . . . . . . . . . 4
chlordiazepoxide . . . . . . . 45
chlorhexidine . . . . . . . . . 24
chlorhexidine gluconate . . . 24
chloroquine phosphate . . . . 35
chlorothiazide . . . . . . . . . 10
CHLORPHENIRAMINE . . . . 23
chlorpheniramine/
dextromethorphan . . . . 50
chlorpheniramine
extended-release . . . . . 23
chlorpheniramine maleate . . 23
chlorpheniramine maleate
phenylephrine HCL . . . . 50
chlorpheniramine/
phenylephrine . . . . . . . 50
chlorpheniramine/phenylephrine/pyrilamine . . . . . . 24
chlorpheniramine/
pseudoephedrine 24, 50, 64
chlorpheniramine tannate . . 23
chlorpheniramine tan/
phenylephrine tan . . . . 50
chlorphen-PEmethscopolamine . . . . 50
chlorphen tan/
carbetapentane tan . . . . 50
chlorphen tan/
pseudoeph tan . . . . . . 50
chlorphen tan/pyrilamine tan/
PE tan . . . . . . . . . . . 50
chlorpromazine . . . . . . . . 48
chlorpropamide . . . . . . . . 26
chlorthalidone . . . . . . . . . 10
CHLORTHALIDONE . . . . . . 10
Index of Covered Drugs
CHLOR-TRIMETON . . . . . . 63
CHLOR-TRIMETON
ALLERGY . . . . . . . . . 23
CHLOR-TRIMETON SYRUP . 23
chlorzoxazone . . . . . . . . . 39
CHOLBAM . . . . . . . . . . . 28
cholecalciferol . . . . . . . . . 56
cholestyramine . . . . . . . . 11
cholic acid . . . . . . . . . . . 28
ciclopirox . . . . . . . . . . . 19
cidofovir . . . . . . . . . . . . 33
cilostazol . . . . . . . . . . . . 7
CILOXAN . . . . . . . . . . . . 44
cimetidine . . . . . . . . . . . 29
cinacalcet . . . . . . . . . . . 60
CIPRO . . . . . . . . . . . . . 32
CIPRODEX . . . . . . . . . . . 22
ciprofloxacin . . . . . . . 32, 44
ciprofloxacin/dexamethasone22
citalopram . . . . . . . . . . . 46
citrulline . . . . . . . . . . . . 36
clarithromycin . . . . . . . . . 32
clarithromycin ER . . . . . . . 32
CLARITIN . . . . . . . . . 23, 63
CLARITIN CHEW . . . . . . . 23
CLARITIN RDT . . . . . . . . . 23
CLEAN & CLEAR GEL . . . . 18
CLEARASIL . . . . . . . . . . 63
CLEAR EYES REDNESS
RELIEF . . . . . . . . . . . 42
clemastine . . . . . . . . . . . 23
CLEMASTINE . . . . . . . . . 23
CLEOCIN . . . . . . . . . 35, 42
CLEOCIN T . . . . . . . . . . . 18
CLIMARA . . . . . . . . . . . . 41
clindamycin . . . . . . 18, 35, 42
CLINORIL . . . . . . . . . 14, 39
clobazam . . . . . . . . . . . 16
clobazam suspension . . . . 16
clobetasol propionate . . . . 19
clomipramine . . . . . . . . . 45
clonazepam . . . . . . . 16, 45
clonazepam ODT . . . . . . . 45
clonidine . . . . . . . . . . . . 8
clonidine transdermal . . . . . 8
clopidogrel . . . . . . . . . . . 7
clorazepate . . . . . . . . . . 45
clotrimazole . . . . . . 19, 33, 42
clotrimazole . . . . . . . . . . 63
CLOTRIMAZOLE . . . . . . . . 20
clotrimazole crystals . . . . . 20
clotrimazole with
betamethasone . . . . . . 20
clozapine . . . . . . . . . . . 48
CLOZARIL . . . . . . . . . . . 48
COARTEM . . . . . . . . . . . 35
cobicistat . . . . . . . . . . . 35
cobicistat/elvitegravir/
emtricitabine/tenofovir . . 35
cobimetinib . . . . . . . . . . . 4
CODAL-DM . . . . . . . . . . . 53
codeine/acetaminophen . . . 14
codeine/chlorpheniramine/
pseudoephedrine . . . . . 50
codeine/guaifenesin . . . . . 50
codeine/guaifenesin/
pseudoephedrine . . . . . 50
codeine/promethazine . . . . 50
codeine/promethazine/
phenylephrine . . . . . . . 51
codeine sulfate . . . . . . . . 14
CODIMAL DH . . . . . . . . . 53
COGENTIN . . . . . . . . . . . 15
COLACE . . . . . . . . . 30, 65
COLAZAL . . . . . . . . . . . 29
colchicine . . . . . . . . . . . 39
COLCRYS . . . . . . . . . . . 39
COLESTID . . . . . . . . . . . 11
coliestipol . . . . . . . . . . . 11
collagenase oint . . . . . . . 21
COLLOIDAL OATMEAL
BATHS . . . . . . . . . . . 64
COLOCORT . . . . . . . . . . 30
COLYTE . . . . . . . . . . . . 30
COMBIVENT RESPIMAT . . . 55
COMBIVIR . . . . . . . . . . . 35
COMETRIQ . . . . . . . . . . . 4
COMMIT LOZENGES . . . . . 66
ALL CAPS = Brand-name drug
lower case = Generic drug
71
COMMITT . . . . . . . . . . . 48
COMPAZINE . . . . . . . . . . 28
COMPLERA . . . . . . . . . . 35
COMPLETE NATALCARE
PAK DHA . . . . . . . . . . 59
COMPOUND W STRIPS . . . 66
COMTAN . . . . . . . . . . . . 15
CONCERTA . . . . . . . . . . 46
condoms . . . . . . . . . . . 64
condoms - female . . . . . . . 64
CONDOMS OTC . . . . . . . . 64
CONDYLOX SOL . . . . . . . 21
contraceptive foam . . . . . . 64
contraceptive gel . . . . . . . 64
COPAXONE . . . . . . . . . . 15
CORDARONE . . . . . . . . . .9
CORDRAN . . . . . . . . . . . 19
COREG . . . . . . . . . . . . . .9
CORGARD . . . . . . . . . . . .9
CORICIDIN TAB CGH/CLD . 50
CORN/CALLUS REMOVER
PAD, CLEAR AWAY, ONE
STEP OTC . . . . . . . . . 66
CORTAID . . . . . . . . . . . . 64
CORTAID SOLUTION OTC . . 19
CORTEF . . . . . . . . . . . . 25
CORTIFOAM AEROSOL . . . 21
cortisone acetate . . . . . . . 25
CORTISPORIN . . . . . . . . . 43
CORTISPORIN OINTMENT . 18
CORTISPORIN OTIC . . . . . 23
CORTIZONE . . . . . . . . . . 19
CORTIZONE-10 INTENSIVE
HEALING . . . . . . . . . . 19
COSOPT . . . . . . . . . . . . 44
COSOPT PF . . . . . . . . . . 44
COTELLIC . . . . . . . . . . . . 4
COUMADIN . . . . . . . . . . . 7
COZAAR . . . . . . . . . . . . .8
CPM/PSE . . . . . . . . . . . 50
CREON . . . . . . . . . . . . . 30
CREON DR . . . . . . . . . . . 30
CRIXIVAN . . . . . . . . . . . . 35
crizotinib . . . . . . . . . . . . 4
Index of Covered Drugs
CROLOM . . . . . . . . . . . . 42
cromolyn . . . . . . . . . . . . 55
cromolyn sodium . . . . . 24, 42
crotamiton . . . . . . . . . . . 20
CUPRIMINE . . . . . . . . . . 38
CURITY ALCOHOL PADS . . 64
CUTIVATE . . . . . . . . . . . 19
CUTIVATE LOTION . . . . . . 19
cyanocobalamin . . . . . . . 56
CYCLESSA . . . . . . . . . . . 41
cyclinex-1, cyclinex-2 . . . . . 36
cyclobenzaprine . . . . . . . 39
CYCLOGYL . . . . . . . . . . . 44
cyclopentolate . . . . . . . . . 44
cyclophosphamide . . . . . . . 4
cycloserine . . . . . . . . . . 31
cyclosporine . . . . . . . . 6, 45
cyclosporine, modified . . . . . 6
CYMBALTA . . . . . . . . . . . 47
cyproheptadine . . . . . . . . 23
CYPROHEPTADINE . . . . . . 23
CYSTADANE . . . . . . . 28, 36
CYSTAGON . . . . . . . . . . . 6
CYSTARAN . . . . . . . . . . . 45
cysteamine 0.44%
ophthalmic solution . . . . 45
cysteamine bitartrate . . . . . . 6
cystine . . . . . . . . . . . . . 36
CYSTOSPAZ . . . . . . . . . . 29
CYTOMEL . . . . . . . . . . . 27
CYTOTEC . . . . . . . . . . . 31
CYTOVENE . . . . . . . . . . . 33
CYTOXAN . . . . . . . . . . . . 4
D
D3-50 CAP . . . . . . . . . . . 56
dabigatran etexilate mesylate . 7
dabrafenib . . . . . . . . . . . 4
daclatasvir . . . . . . . . . . . 33
DAKLINZA . . . . . . . . . . . 33
DALLERGY DM . . . . . . . . 49
DALMANE . . . . . . . . . . . 47
danazol . . . . . . . . . . . . 41
DANOCRINE . . . . . . . . . . 41
DANTRIUM . . . . . . . . . . . 39
dantrolene . . . . . . . . . . . 39
dapsone . . . . . . . . . . . . 35
DAPSONE . . . . . . . . . . . 35
DARAPRIM . . . . . . . . . . . 36
darbepoetin alfa . . . . . . . . 7
darunavir . . . . . . . . . . . 35
darunavir/cobicistat . . . . . 36
dasatinib . . . . . . . . . . . . 4
DAYPRO . . . . . . . . . . 14, 39
DDAVP . . . . . . . . . . . . . 28
DEBROX . . . . . . . . . 22, 64
DECADRON . . . . . . . . . . 25
DE-CHLOR DM . . . . . . . . 52
DECLOMYCIN . . . . . . . . . 32
DECONEX . . . . . . . . . . . 53
DECONEX IR . . . . . . . . . . 53
decongestants . . . . . . . . 65
deferasirox . . . . . . . . . . . 60
deferiprone . . . . . . . . . . 60
DELATESTRYL . . . . . . . . . 25
delavirdine . . . . . . . . . . . 34
DELFEN . . . . . . . . . . . . 64
DELOS . . . . . . . . . . . . . 17
DELOS . . . . . . . . . . . . . 63
DELSYM . . . . . . . . . . 51, 64
DELTASONE . . . . . . . . . . 25
DELZICOL . . . . . . . . . . . 30
DEMADEX . . . . . . . . . . . 11
demeclocycline . . . . . . . . 32
DEMEROL . . . . . . . . . . . 14
DENAVIR . . . . . . . . . . . . 34
DEPAKENE . . . . . . . . . . . 17
DEPAKOTE . . . . . . 15, 16, 46
DEPAKOTE
SPRINKLE . . . . 15, 16, 46
DEPEN TITRATABLE . . . . . 38
DEPO-PROVERA . . . . . . . 40
DEPO-TESTOSTERONE . . . 25
DERMAPHOR OINTMENT . . 63
DERMA-SMOOTHE OIL/FS . 18
dermatological baths . . . . . 64
DERMATOP . . . . . . . . . . 19
DESENEX . . . . . . . . . . . 20
ALL CAPS = Brand-name drug
lower case = Generic drug
72
desipramine . . . . . . . . . . 47
desmopressin . . . . . . . . . 28
desogestrel/EE . . . . 39, 40, 41
DESYREL . . . . . . . . . . . . 47
DETROL . . . . . . . . . . . . 56
DETROL LA . . . . . . . . . . 56
dexamethasone . . . . . 25, 43
dexamethasone sodium
phosphate . . . . . . . . . 43
DEXASOL . . . . . . . . . . . 43
dexchlorpheniramine maleate23
DEXEDRINE . . . . . . . . . . 46
DEXEDRINE SPANSULE . . . 46
dextroamphetamine . . . . . 46
dextroamphetamine
extended-release . . . . . 46
dextromethorphan/
brompheniramine/
pseudoephedrine . . . . . 51
dextromethorphan/
carbinoxamine/
pseudoephedrine . . . . . 51
dextromethorphanguaifenesin . . . . . . . . 51
dextromethorphan/
guaifenesin . . . . . . . . 51
dextromethorphan HBR . . . 51
dextromethorphan polistirex
extended-release . . . . . 51
dextromethorphan/
promethazine . . . . . . . 51
dextromethorphan/
quinidine . . . . . . . . . 48
DEXTROSTAT . . . . . . . . . 46
D.H.E. 45 . . . . . . . . . . . . 14
DHS SAL SHAMPOO OTC . . 22
DIABINESE . . . . . . . . . . . 26
DIAMOX SEQUELS . . . . . . 44
diaphragm . . . . . . . . . . . 40
DIASTAT ACUDIAL . . . . . . . 16
DIASTAT PEDIATRIC . . . . . 16
diazepam . . . . . . . 16, 39, 45
DIAZEPAM INTENSOL . . . . 45
diclofenac 1% gel . . . . . . . 38
Index of Covered Drugs
diclofenac potassium . . . . . 38
diclofenac sodium . . . . . . 43
diclofenac sodium
delayed-release . . . . 13, 38
diclofenac sodium
extended-release . . . . . 38
diclofenac sodium SR . . . . 13
dicloxacillin . . . . . . . . . . 32
DICLOXACILLIN . . . . . . . . 32
dicyclomine . . . . . . . . . . 29
didanosine . . . . . . . . . . 34
didanosine delayed-release . 35
DIDRONEL . . . . . . . . . . . 27
diflorasone diacetate . . . . . 19
DIFLUCAN . . . . . . . . 33, 42
diflunisal . . . . . . . . . . . . 39
DIHISTINE DH . . . . . . . . . 50
dihydroergotamine . . . . . . 14
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 . . . . . . . . 65
DIMETAPP . . . . . . . . . . . 64
DIMETAPP CLD ELX/
ALLERGY . . . . . . . . . 49
DIMETAPP DM . . . . . . . . . 52
DIMETAPP DRO DCON/CGH53
DIMETAPP DRO DECONGES 64
DIMETAPP ELX CLD/ALLE . . 49
DIMETAPP SYP CGH/CLD . . 50
dimethyl fumarate . . . . . . . 15
DIOVAN . . . . . . . . . . . . . .8
DIOVAN HCT . . . . . . . . . . .9
DIPENTUM . . . . . . . . . . . 30
diphenhydramine . . . . 23, 47
diphenoxylate/atropine . . . . 28
diphtheria-tetanus tox
adsorbed (dt) im . . . . . 61
DIPROLENE . . . . . . . . . . 19
DIPROLENE AF . . . . . . . . 19
DIPROSONE . . . . . . . . . . 19
DIP/TET PED INJ . . . . . . . 61
dipyridamole . . . . . . . . . . 7
disopyramide . . . . . . . . . . 9
disopyramide extended-release9
disulfiram . . . . . . . . . . . 45
DITROPAN . . . . . . . . . . . 56
DITROPAN XL . . . . . . . . . 56
DIURIL . . . . . . . . . . . . . 10
DIURIL ORAL SUSPENSION . 10
divalproex sodium
cap sprinkle . . . 15, 16, 46
divalproex sodium
delayed-release . . 15, 16, 46
DIVIGEL . . . . . . . . . . . . . 41
docosanol . . . . . . . . . . . 34
docusate calcium plus . . . . 30
docusate potasssium . . . . . 30
docusate sodium . . . . . . . 30
dofetilide . . . . . . . . . . . . 9
dolasetron . . . . . . . . . . . 28
DOLOBID . . . . . . . . . . . . 39
DOLOPHINE . . . . . . . . . . 14
DOMEBORO . . . . . . . . . . 64
DOMEBORO OTIC . . . . . . 22
donepezil . . . . . . . . . . . 13
dornase alfa . . . . . . . . . . 60
dorzolamide . . . . . . . . . . 43
dorzolamide hcl-timolol
maleate . . . . . . . . . . 44
dorzolamide/timolol maleate 44
DOSTINEX . . . . . . . . . . . 28
DOVONEX . . . . . . . . . . . 20
doxazosin . . . . . . . . . . 8, 55
doxazosin SR . . . . . . . . . 55
doxepin . . . . . . . . . . . . 47
doxycycline delayed-release . 33
doxycycline hyclate . . . . . . 33
doxycycline monohydrate . . 33
ALL CAPS = Brand-name drug
lower case = Generic drug
73
DOXYCYCLINE
MONOHYDRATE . . . . . 33
DRAMAMINE . . . . . . . . . 65
DRISDOL . . . . . . . . . . . . 57
dronabinol . . . . . . . . . . . 28
dronedarone . . . . . . . . . . 9
DROXIA . . . . . . . . . . . . . .6
DRYSOL OTC . . . . . . . . . 21
DUETACT . . . . . . . . . . . . 26
DULCOLAX . . . . . . . . . . 65
DULERA . . . . . . . . . . . . 54
duloxetine . . . . . . . . . . . 47
DUOFILM . . . . . . . . . 21, 66
DUONEB . . . . . . . . . . . . 55
DUOPLANT GEL, COMPOUND
W, SAL-PLANT OTC . . . . 66
DURADRYL . . . . . . . . . . 50
DURAGESIC . . . . . . . . . . 14
DURATUSS DM ELX . . . . . 51
DURICEF . . . . . . . . . . . . 31
DYAZIDE . . . . . . . . . . . . 11
DYNACIRC . . . . . . . . . . . 10
E
ecothiophate . . . . . . . . . 44
ECOTRIN . . . . . . . . 7, 38, 65
ED A-HIST TABLETS AND
LIQUID . . . . . . . . . . . 50
EDGE OB CHW . . . . . . . . 58
edoxaban . . . . . . . . . . . . 7
EDURANT . . . . . . . . . . . 34
E.E.S. . . . . . . . . . . . . . . 32
efavirenz . . . . . . . . . . . . 34
efavirenz/emtricitabine/
tenofovir . . . . . . . . . . 35
EFFEXOR . . . . . . . . . . . . 47
EFFEXOR XR . . . . . . . . . . 47
EFUDEX . . . . . . . . . . . . 21
ELAPRASE . . . . . . . . . . . 27
ELAVIL . . . . . . . . . . . 15, 47
elbasvir/grazoprevir . . . . . . 33
ELDEPRYL . . . . . . . . . . . 16
electrolyte . . . . . . . . . . . 56
electrolyte rehydrating soln . . 65
Index of Covered Drugs
ELELYSO . . . . . . . . . . . . 28
ELESTRIN . . . . . . . . . . . 41
ELIDEL . . . . . . . . . . . . . 22
ELIMITE . . . . . . . . . . . . . 20
ELIQUIS . . . . . . . . . . . . . .7
ELMIRON . . . . . . . . . . . . 56
ELOCON . . . . . . . . . . . . 19
eltrombopag . . . . . . . . . . 61
elvitegravir/cobicistat/emtricitabine/tenofovir alafenamide fumarate . . . . . . 35
EMCYT . . . . . . . . . . . . . .4
EMEND . . . . . . . . . . . . . 28
EMETROL . . . . . . . . . . . 65
EMLA . . . . . . . . . . . . . . 21
emollients . . . . . . . . . . . 63
empagliflozin . . . . . . . . . 26
empagliflozin/metformin . . . 26
emtricitabine . . . . . . . . . 35
emtricitabine/rilpivirine/
tenofovir . . . . . . . . . . 35
emtricitabine/tenofovir . . . . 35
EMTRIVA . . . . . . . . . . . . 35
enalapril . . . . . . . . . . . . . 8
enalapril/hydrochlorothiazide . 8
ENBREL . . . . . . . . . . . . 38
enfuvirtide . . . . . . . . . . . 33
ENGERIX-B . . . . . . . . . . . 61
ENJUVIA . . . . . . . . . . . . 41
enoxaparin . . . . . . . . . . . 7
entacapone . . . . . . . . . . 15
entecavir . . . . . . . . . . . . 34
ENTERIC COATEDNAPROSYN . . . . . . 14, 39
ENTEX LQ LIQ . . . . . . . . . 53
ENTOCORT EC . . . . . . . . 29
ENTRESTO . . . . . . . . . . . .9
ENULOSE . . . . . . . . . . . 30
E-OINTMENT . . . . . . . . . 63
EPANED . . . . . . . . . . . . . 8
epinephrine . . . . . . . . . . 60
EPINEPHRINE AUTO-INJECT
BY IMPAX LABS . . . . . 60
EPIPEN . . . . . . . . . . . . . 60
EPIPEN JR. . . . . . . . . . . . 60
EPITOL . . . . . . . . . . . . . 16
EPIVIR . . . . . . . . . . . . . . 35
EPIVIR HBV . . . . . . . . . . . 34
eplerenone . . . . . . . . . . 12
epoetin alfa . . . . . . . . . . . 7
EPOGEN . . . . . . . . . . . . .7
epoprostenol . . . . . . . . . 12
EPZICOM . . . . . . . . . . . . 34
EQUATRO . . . . . . . . . . . 16
ergocalciferol . . . . . . . . . 57
ergotamine/caffeine . . . . . 15
ergotamine tartrate/caffeine . 15
ERIVEDGE . . . . . . . . . . . .6
erlotinib . . . . . . . . . . . . . 4
ERYC . . . . . . . . . . . . . . 32
ERYGEL . . . . . . . . . . . . 18
ERY-TAB . . . . . . . . . . . . 32
ERYTHROCIN . . . . . . . . . 32
erythromycin . . . . . . . 18, 44
ERYTHROMYCIN . . . . . . . 44
erythromycin delayed-release 32
erythromycin ethylsuccinate . 32
erythromycin stearate . . . . . 32
erythromycin/sulfisoxazole . . 32
ESBRIET . . . . . . . . . . . . 61
escitalopram . . . . . . . . . 46
ESGIC . . . . . . . . . . . . . 13
ESKALITH CR . . . . . . . . . 46
ESKIMO-3 . . . . . . . . . . . 57
esomeprazole . . . . . . . . . 29
essential amino acid mix . . . 36
estazolam . . . . . . . . . . . 47
esterified estrogens . . . . . . 41
ESTRACE . . . . . . . . . . . . 41
estradiol . . . . . . . . . . . . 41
estradiol acetate . . . . . . . 41
ESTRADIOL TDS . . . . . . . 41
estramustine
phosphate sodium . . . . . 4
ESTRASORB . . . . . . . . . . 41
ESTRING . . . . . . . . . . . . 41
ESTROGEL . . . . . . . . . . . 41
estrogen patch . . . . . . . . 41
ALL CAPS = Brand-name drug
lower case = Generic drug
74
estrogens, conjugated . . . . 41
estrogens, conjugated/
medroxyprogesterone . . 42
estrogens, conjugated,
synthetic A . . . . . . . . . 41
estrogens, conjugated,
synthetic B . . . . . . . . 41
estropipate . . . . . . . . . . 41
ESTROSTEP FE . . . . . . . . 41
etanercept . . . . . . . . . . . 38
ethambutol . . . . . . . . . . 31
ethionamide . . . . . . . . . . 31
ethosuximide . . . . . . . . . 16
ethynodiol diacetate/EE . . . 40
etidronate . . . . . . . . . . . 27
etodolac . . . . . . . . . . 13, 39
etonogestrel/EE . . . . . . . . 40
etoposide . . . . . . . . . . . . 6
etravirine . . . . . . . . . . . . 36
EULEXIN . . . . . . . . . . . . .5
EURAX . . . . . . . . . . . . . 20
EVAMIST . . . . . . . . . . . . 41
everolimus . . . . . . . . . . 4, 6
EVISTA . . . . . . . . . . . . . 27
EXCEDRIN MIGRAINE . . . . 13
EXELON . . . . . . . . . . . . 13
exemestane . . . . . . . . . . . 5
exenatide . . . . . . . . . . . 27
EXJADE . . . . . . . . . . . . . 60
exogabine . . . . . . . . . . . 16
EXTAVIA . . . . . . . . . . . . 15
EXTINA . . . . . . . . . . . . . 20
EXUVIANCE . . . . . . . . . . 18
ezetimibe . . . . . . . . . . . 11
F
FABRAZYME . . . . . . . . . . 27
famciclovir . . . . . . . . . . . 34
famotidine . . . . . . . . 29, 65
FAMVIR . . . . . . . . . . . . . 34
FARESTON . . . . . . . . . . . .5
FARYDAK . . . . . . . . . . . . .4
FAZACLO . . . . . . . . . . . . 48
febuxostat . . . . . . . . . . . 39
Index of Covered Drugs
felbamate . . . . . . . . . . . 16
FELBATOL . . . . . . . . . . . 16
FELDENE . . . . . . . . . 14, 39
felodipine extended-release . 10
FEMARA . . . . . . . . . . . . .5
FEMRING . . . . . . . . . . . . 41
fenofibrate . . . . . . . . . . . 11
fenoprofen . . . . . . . . 13, 39
fentanyl transdermal . . . . . 14
FEOSOL . . . . . . . . . . 57, 66
FERGON . . . . . . . . . . . . 66
FERRIPROX . . . . . . . . . . 60
ferrous bisglycinate/
polysaccarides iron . . . . 57
ferrous sulfate . . . . . . . . . 57
fexofenadine . . . . . . . . . . 23
fexofenadine/
pseudoephedrine . . . . . 24
filgrastim . . . . . . . . . . . . 7
FINACEA . . . . . . . . . . . . 17
finasteride . . . . . . . . . . . 55
fingolimod . . . . . . . . . . . 15
FIORICET . . . . . . . . . . . . 13
FIORICET W/CODEINE . . . . 14
FIORINAL . . . . . . . . . . . . 13
FIORINAL W/CODEINE . . . . 14
FIRAZYR . . . . . . . . . . . . 60
FIRST-LANSOPRAZOLE . . . 29
FLAGYL . . . . . . . . . . 36, 42
flecainide . . . . . . . . . . . . 9
FLEET ENEMA . . . . . . . . . 65
FLEET PHOSPHO-SODA . . . 65
FLEXERIL . . . . . . . . . . . . 39
FLOLAN . . . . . . . . . . . . 12
FLOMAX . . . . . . . . . . . . 55
FLONASE . . . . . . . . . . . . 24
FLORANEX . . . . . . . . . . . 31
FLORINEF . . . . . . . . . . . 25
FLOVENT HFA . . . . . . . . . 54
FLOXIN . . . . . . . . . . . . . 32
FLOXIN OTIC . . . . . . . . . . 23
FLUARIX QUAD . . . . . . . . 62
FLUBLOK . . . . . . . . . . . . 61
FLUCELVAX . . . . . . . . . . 62
fluconazole . . . . . . . . 33, 42
flucytosine . . . . . . . . . . . 33
fludrocortisone . . . . . . . . 25
FLULAVAL QUAD . . . . . . . 62
FLUMADINE . . . . . . . . . . 34
fluocinolone acetonide . 18, 19
fluocinonide . . . . . . . . . . 19
fluocinonide emulsified base 19
fluoride . . . . . . . . . . . . . 57
fluoride dental rinse . . . . . 66
fluorometholone . . . . . . . 43
FLUOROPLEX . . . . . . . . . 21
fluorouracil . . . . . . . . . . 21
fluoxetine . . . . . . . . . . . 46
fluoxymesterone . . . . . . . 25
fluphenazine . . . . . . . . . 48
fluphenazine decanoate . . . 48
flurandrenolide . . . . . . . . 19
flurazepam . . . . . . . . . . 47
flurbiprofen . . . . . . . . 13, 43
flutamide . . . . . . . . . . . . 5
fluticasone . . . . . . . . . . . 24
fluticasone HFA . . . . . . . . 54
fluticasone propionate . . . . 19
fluticasone/salmeterol . . . . 54
FLUVIRIN . . . . . . . . . . . . 62
fluvoxamine . . . . . . . . . . 45
fluvoxamine SR . . . . . . . . 45
FLUZONE HD PF . . . . . . . 61
FLUZONE QUAD . . . . . . . 62
FLUZONE SPLT . . . . . . . . 61
FML . . . . . . . . . . . . . . 43
FML FORTE . . . . . . . . . . 43
FML LIQUIFILM . . . . . . . . 43
folic acid . . . . . . . . . . . . 57
FOLIC ACID . . . . . . . . . . 57
FOLTABS PAK PLUS DHA RE
OB + DHA PAK . . . . . . 58
FOLTABS PRENATAL . . . . . 58
FORADIL AEROLIZER . . . . 54
FORFIVO XL . . . . . . . . . . 47
formoterol . . . . . . . . . . . 54
FORTEO . . . . . . . . . . . . 27
FORTICAL . . . . . . . . . . . 27
ALL CAPS = Brand-name drug
lower case = Generic drug
75
FOSAMAX . . . . . . . . . . . 27
fosamprenavir . . . . . . . . . 35
foscarnet sodium . . . . . . . 33
FOSCAVIR . . . . . . . . . . . 33
fosinopril . . . . . . . . . . . . 8
fosinopril/hydrochlorothiazide 8
FOSRENOL . . . . . . . . . . 60
FUNGOID TINCTURE KIT . . 20
FURADANTIN SUSP . . . . . 36
furosemide . . . . . . . . . . 10
FUZEON . . . . . . . . . . . . 33
G
gabapentin . . . . . . . . . . 16
GABITRIL . . . . . . . . . . . . 17
galantamine . . . . . . . . . . 13
ganciclovir . . . . . . . . . . . 33
GARDASIL . . . . . . . . . . . 61
GARDASIL 9 . . . . . . . . . . 61
gatifloxin . . . . . . . . . . . . 44
GATTEX . . . . . . . . . . . . 31
gefitinib . . . . . . . . . . . . . 4
GEL-KAM . . . . . . . . . . . . 57
gemfibrozil . . . . . . . . . . . 11
GENGRAF . . . . . . . . . . . .6
GENOTROPIN . . . . . . . . . 27
GENTAK . . . . . . . . . . 18, 44
gentamicin . . . . . . . . 18, 44
gentamicin/prednisolone
acetate . . . . . . . . . . . 43
GENTEX ADE . . . . . . . . . 58
GENVOYA . . . . . . . . . . . 35
GEODON . . . . . . . . . . . . 48
GG/DM CR . . . . . . . . . . . 51
GG/PSE CR . . . . . . . . . . 52
GILENYA . . . . . . . . . . . . 15
GILPHEX TR . . . . . . . . . . 53
glatiramer acetate . . . . . . . 15
GLATOPA . . . . . . . . . . . . 15
GLEEVEC . . . . . . . . . . . . 4
GLEOSTINE . . . . . . . . . . . 4
glimepiride . . . . . . . . . . 26
glipizide . . . . . . . . . . . . 26
glipizide extended-release . . 26
Index of Covered Drugs
glipizide/metformin . . . . . . 26
GLUCAGON . . . . . . . . . . 25
glucagon, human
recombinant . . . . . . . . 25
GLUCOPHAGE . . . . . . . . 26
GLUCOPHAGE ER . . . . . . 26
glucose oral tablets . . . . . . 64
GLUCOTROL . . . . . . . . . 26
GLUCOTROL XL . . . . . . . . 26
GLUCOVANCE . . . . . . . . 26
glutarex-1, glutarex-2 . . . . . 36
glyburide . . . . . . . . . . . . 26
glyburide, micronized . . . . . 26
glycerin . . . . . . . . . . . . 30
GLYCERIN SUPPOSITORY . . 30
GLYCERIN TOPICAL . . . . . 63
glycerol phenylbutyrate . 27, 61
glycine . . . . . . . . . . . . . 36
glycopyrrolate . . . . . . . . . 29
GLYNASE . . . . . . . . . . . . 26
GNP FISH OIL . . . . . . . . . 58
granisetron . . . . . . . . . . 28
granisetron . . . . . . . . . . 28
GRANIX . . . . . . . . . . . . . .7
GRIFULVIN V . . . . . . . . . . 33
griseofulvin microsize . . . . . 33
griseofulvin ultramicrosize . . 33
GRIS-PEG . . . . . . . . . . . 33
GUAIFED . . . . . . . . . . . . 51
guaifenesin . . . . . . . . . . 51
guaifenesin extended-release 51
guaifenesin/
pseudoephedrine . . . . . 51
guaifenesin/
pseudoephedrine/
dextromethorphan . . . . 51
guaifenesin/
pseudoephedrine
extended-release . . . 51, 52
GUAIFEN PSE . . . . . . . . . 52
guanabenz . . . . . . . . . . 12
guanfacine . . . . . . . . . . . 8
guanfacine ER . . . . . . . . 46
GUIATUSS/AC . . . . . . . . . 50
GUIATUSS DAC . . . . . . . . 50
GYNE-LOTRIMIN . . . . . 42, 63
GYNOL II . . . . . . . . . . . . 64
H
HALCION . . . . . . . . . . . . 47
HALDOL . . . . . . . . . . . . 48
HALDOL DECANOATE . . . . 48
HALFPRIN . . . . . . . . . . . 38
halobetasol . . . . . . . . . . 19
haloperidol . . . . . . . . . . 48
haloperidol decanoate . . . . 48
HARVONI . . . . . . . . . . . . 34
HAVRIX . . . . . . . . . . . . . 61
HCU cooler, express, gel . . . 36
HCY-1, HCY-2 . . . . . . . . . 37
HECORIA . . . . . . . . . . . . 6
HEMANGEOL . . . . . . . . . .9
heparin . . . . . . . . . . . . . 7
HEPARIN . . . . . . . . . . . . .7
hepatitis a vaccine susp . . . 61
hepatitis b vaccine . . . . . . 61
HEPSERA . . . . . . . . . . . 33
hexachlorophene . . . . . . . 21
HEXALEN . . . . . . . . . . . . 4
HIPREX . . . . . . . . . . . . . 56
HISTACOL DM . . . . . . . . . 49
HISTEX . . . . . . . . . . . . . 50
HISTUSSIN HC . . . . . . . . 52
HM FISH OIL . . . . . . . . . . 58
homatropine . . . . . . . . . . 44
hominex-1, hominex-2 . . . . 37
HUMALOG . . . . . . . . . . . 26
HUMALOG KWIKPEN . . . . 26
HUMALOG MIX 50/50 . . . . 26
HUMALOG MIX 50/50
KWIKPEN . . . . . . . . . 26
HUMALOG MIX 72/25
KWIKPEN . . . . . . . . . 26
HUMALOG MIX 75/25 . . . . 26
human papillomavirus (hpv)
9-valent recomb vac . . . 61
ALL CAPS = Brand-name drug
lower case = Generic drug
76
human papillomavirus (hpv)
bival (type 16, 18)
recmb vac . . . . . . . . . 61
human papillomavirus (hpv)
quadrivalent
recombinant vac . . . . . 61
HUMATIN . . . . . . . . . . . . 36
HUMIRA . . . . . . . . . . . . 38
HUMULIN . . . . . . . . . . . 64
HUMULIN 70/30 . . . . . . . 26
HUMULIN N . . . . . . . . . . 26
HUMULIN R . . . . . . . . . . 26
HUMULIN R 500 U/ML
KWIKPEN . . . . . . . . . 26
HYCODAN . . . . . . . . . . . 52
hydralazine . . . . . . . . . . 12
HYDREA . . . . . . . . . . . . . 6
hydrochlorothiazide . . . . . . 10
HYDROCHLOROTHIAZIDE . 10
HYDROCODO/GG SYP . . . 52
hydrocodone/
acetaminophen . . . . . . 14
hydrocodone/chlorpheniramine/phenylephrine . . . 52
hydrocodone ER . . . . . . . 14
hydrocodone/guaifenesin . . 52
hydrocodone/homatropine . 52
HYDROCODONE/
TAB HOMATROP . . . . . 52
hydrocortisone . .19, 21, 25, 30
hydrocortisone acetate . . . . 21
hydrocortisone acetate
w/pramoxine . . . . . . . 21
hydrocortisone/aloe . . . . . 19
hydrocortisone butyrate . . . 19
hydrocortisone crm, oint . . . 64
hydrocortisone inj . . . . . . . 25
hydrocortisone valerate . . . 19
HYDROMET SYP . . . . . . . 52
hydromorphone . . . . . . . . 14
hydroxychloroquine . . . 36, 38
hydroxyurea . . . . . . . . . . 6
hydroxyzine HCL . . . . . . . 23
hydroxyzine pamoate . . . . . 23
Index of Covered Drugs
hyoscyamine, methenamine,
phenyl salicylate, sodium
phosphate monobasic,
methylene blue . . . . . . 56
hyoscyamine sulfate . . . . . 29
hyoscyamine sulfate
extended-release . . . . . 29
HYPERCARE 20% . . . . . . . 21
HYPERTET S/D . . . . . . . . 62
HYPOTEARS . . . . . . . . . . 65
HYTONE . . . . . . . . . . . . 19
HYTRIN . . . . . . . . . . . 8, 55
HYZAAR . . . . . . . . . . . . . 9
I
IBRANCE . . . . . . . . . . . . .4
ibrutinib . . . . . . . . . . . . . 4
IBUOROFEN TAB COLD/SIN 54
ibuprofen . . . . . . . 13, 39, 65
icatibant . . . . . . . . . . . . 60
ICLUSIG . . . . . . . . . . . . . 4
idursulfase . . . . . . . . . . . 27
iloprost . . . . . . . . . . . . . 12
imatinib mesylate . . . . . . . . 4
IMBRUVICA . . . . . . . . . . . 4
IMDUR . . . . . . . . . . . . . 12
imiglucerase . . . . . . . . . . 27
imipramine HCL . . . . . . . 47
imiquimod 5% cream . . . . . 21
IMITREX . . . . . . . . . . . . 15
IMODIUM A-D . . . . . . . 28, 65
IMODIUM A-D CHW . . . . . . 28
IMODIUM A-D LIQ . . . . . . . 28
IMURAN . . . . . . . . . . . 5, 38
INCIVEK . . . . . . . . . . . . 34
INCRELEX . . . . . . . . . . . 27
indacaterol . . . . . . . . . . . 54
indapamide . . . . . . . . . . 11
INDERAL . . . . . . . . . . 9, 15
INDERIDE . . . . . . . . . . . . 9
indinavir . . . . . . . . . . . . 35
INDOCIN . . . . . . . . . 13, 39
indomethacin . . . . . . . 13, 39
INFLAMASE FORTE . . . . . . 43
influenza virus vaccine recombinant hemagglutinin . . . . 61
influenza virus vaccine split . 61
influenza virus vaccine split
high-dose pf . . . . . . . . 61
influenza virus vaccine split pf61
influenza virus vaccine split
quadrivalent . . . . . . . . 62
influenza virus vaccine
tiss-cult subunit . . . . . . 62
influenza virus vaccine types
a&b surface antigen . . . 62
INLYTA . . . . . . . . . . . . . . 4
INSPRA . . . . . . . . . . . . . 12
insulin detemir . . . . . . . . 25
insulin glargine . . . . . . . . 25
insulin isophane . . . . . . . . 26
insulin isophane/regular . . . 26
insulin lisopro pro/lispro . . . 26
insulin lisopro prot/lispro . . . 26
insulin lispro . . . . . . . . . . 26
insulin lispro prot 50%/lispro
50% . . . . . . . . . . . . 26
insulin lispro prot 75%/lispro
25% . . . . . . . . . . . . 26
insulin regular . . . . . . . . . 26
insulin . . . . . . . . . . . . . 64
INTAL . . . . . . . . . . . . . . 55
INTELENCE . . . . . . . . . . 36
interferon alfa-2b . . . . . . 5, 34
interferon beta-1a . . . . . . . 15
interferon beta-1b . . . . . . . 15
interferon gamma-1b . . . . . 36
INTRON A . . . . . . . . . . 5, 34
INTUNIV . . . . . . . . . . . . 46
INVEGA SUSTENNA . . . . . 48
INVIRASE . . . . . . . . . . . . 35
INVOKAMET . . . . . . . . . . 26
INVOKANA . . . . . . . . . . . 26
ipratropium . . . . . . . . . . 55
ipratropium/albuterol . . . . . 55
ipratropium bromide . . . . . 24
ipratropium HFA . . . . . . . 55
irbesartan . . . . . . . . . . . . 8
IRESSA . . . . . . . . . . . . . .4
ALL CAPS = Brand-name drug
lower case = Generic drug
77
iron . . . . . . . . . . . . . . . 66
iron polysaccharides . . . . . 66
ISENTRESS . . . . . . . . . . 36
ISMO . . . . . . . . . . . . . . 11
ISOCHRON . . . . . . . . . . 11
isoleucine . . . . . . . . . . . 37
isoniazid . . . . . . . . . . . . 31
ISONIAZID . . . . . . . . . . . 31
ISOPTO ATROPINE . . . . . . 44
ISOPTO CARPINE . . . . . . . 44
ISOPTO HOMATROPINE . . . 44
ISOPTO HYOSCINE . . . . . . 44
ISORDIL . . . . . . . . . . . . 11
ISORDIL S.L. . . . . . . . . . . 12
isosorbide dinitrate . . . . 11, 12
ISOSORBIDE
DINITRATE ER . . . . . . . 11
isosorbide dinitrate
extended-release . . . . . 11
isosorbide mononitrate . . . . 11
isosorbide mononitrate
extended-release . . . . . 12
isotretinoin . . . . . . . . . . . 17
isradipine . . . . . . . . . . . 10
itraconazole . . . . . . . . . . 33
ivacaftor . . . . . . . . . . . . 60
ivacaftor . . . . . . . . . . . . 60
i-valex-1, i-valex-2 . . . . . . . 37
ivermectin . . . . . . . . . 20, 31
ixazomib . . . . . . . . . . . . 5
J
JADENU . . . . . . . . . . . . 60
JAKAFI . . . . . . . . . . . . . . 5
JANUMET . . . . . . . . . . . 27
JANUMET XR . . . . . . . . . 27
JANUVIA . . . . . . . . . . . . 27
JARDIANCE . . . . . . . . . . 26
JENTADUETO . . . . . . . . . 26
J-TAN D PD . . . . . . . . . . . 49
J-TAN PD . . . . . . . . . . . . 23
K
KALETRA . . . . . . . . . . . . 35
Index of Covered Drugs
KALYDECO . . . . . . . . . . . 60
KAOPECTATE . . . . . . . . . 65
KAYEXALATE . . . . . . . . . 12
K-DUR 10 . . . . . . . . . . . . 60
K-DUR 20 . . . . . . . . . . . . 60
KEFLEX . . . . . . . . . . . . . 32
KENALOG . . . . . . . . . . . 19
KENALOG-40 . . . . . . . . . 25
KENALOG IN ORABASE . . . 24
KEPPRA . . . . . . . . . . . . 16
KEPPRA XR . . . . . . . . . . 16
KERALYT . . . . . . . . . . . . 18
ketoconazole . . . . . 20, 21, 33
ketoconazole foam . . . . . . 20
ketoconazole gel . . . . . . . 20
ketoconazole gel 2% & hydrocortisone gel 1% kit . . . 20
ketoconazole gel 2% & pyrithione zinc shampoo 1% kit 20
ketoconazole shampoo . . . 20
ketonex-1, ketonex-2 . . . . . 37
ketoprofen . . . . . . . . 13, 39
ketoprofen SR . . . . . . . . . 13
ketorolac . . . . . . . . . . . . 43
ketorolac tromethamine . . . 13
ketotifen . . . . . . . . . . . . 42
kionex . . . . . . . . . . . . . 37
KITABIS . . . . . . . . . . . . . 60
KLARON LOTION . . . . . . . 18
KLONOPIN . . . . . . . . 16, 45
KLONOPIN WAFERS . . . . . 45
K-LOR . . . . . . . . . . . . . . 60
KLOR-CON 8 . . . . . . . . . 60
KLOR-CON 10 . . . . . . . . . 60
K-LYTE . . . . . . . . . . . . . 60
KORLYM . . . . . . . . . . . . 28
K-PHOS NEUTRAL . . . . . . 59
K-PHOS ORIGINAL . . . . . . 59
KRISTALOSE . . . . . . . . . . 30
KUVAN . . . . . . . . . . 28, 37
KYTRIL . . . . . . . . . . . . . 28
L
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 . . . . . . . . . . . . . 33
LAMISIL AT . . . . . . . . . . . 20
LAMISIL GEL . . . . . . . . . . 20
LAMISIL SOLUTION . . . . . . 20
lamivudine . . . . . . . . 34, 35
lamivudine/zidovudine . . . . 35
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
lansoprazole . . . . . . . . . . 29
lansoprazole delayed-release 29
lansoprazole susp . . . . . . 29
lanthanum carbonate . . . . . 60
LANTUS . . . . . . . . . . . . 25
LANTUS SOLOSTAR . . . . . 25
lapatinib ditosylate . . . . . . . 4
LARIAM . . . . . . . . . . . . . 36
laronidase . . . . . . . . . . . 28
LASIX . . . . . . . . . . . . . . 10
latanoprost . . . . . . . . . . 44
laxative enemas . . . . . . . . 65
laxatives . . . . . . . . . . . . 65
ledipasvir/sofosbuvir . . . . . 34
leflunomide . . . . . . . . . . 38
lenalidomide . . . . . . . . . . 5
ALL CAPS = Brand-name drug
lower case = Generic drug
78
lenvatinib . . . . . . . . . . . . 4
LENVIMA . . . . . . . . . . . . .4
LETAIRIS . . . . . . . . . . . . 12
letrozole . . . . . . . . . . . . . 5
leucine . . . . . . . . . . . . . 37
LEUKERAN . . . . . . . . . . . .4
LEUKINE . . . . . . . . . . . . .7
leuprolide . . . . . . . . . . . . 5
levalbuterol HCl . . . . . . . . 55
LEVAQUIN . . . . . . . . . . . 32
LEVBID . . . . . . . . . . . . . 29
LEVEMIR . . . . . . . . . . . . 25
LEVEMIR FLEXPEN . . . . . . 25
levetiracetam . . . . . . . . . 16
levetiracetam SR . . . . . . . 16
levobunolol . . . . . . . . . . 43
levocetirizine . . . . . . . . . 23
levofloxacin . . . . . . . . . . 32
levonorgestrel . . . . . . . . . 39
levonorgestrel/EE . . . . 40, 41
levothyroxine . . . . . . . . . 27
LEVOXYL . . . . . . . . . . . . 27
LEVSIN . . . . . . . . . . . . . 29
LEVSINEX . . . . . . . . . . . 29
LEXAPRO . . . . . . . . . . . 46
LEXIVA . . . . . . . . . . . . . 35
LIALDA . . . . . . . . . . . . . 30
LIBRIUM . . . . . . . . . . . . 45
LIDAMANTEL . . . . . . . . . 21
LIDEX . . . . . . . . . . . . . . 19
LIDEX E . . . . . . . . . . . . . 19
lidocaine . . . . . . . . . . . . 21
lidocaine patch . . . . . . . . 21
lidocaine-prilocaine . . . . . . 21
lidocaine/prilocaine . . . . . 21
lidocaine viscous . . . . . . . 24
LIDODERM PATCH . . . . . . 21
linaclotide . . . . . . . . . . . 31
linagliptin . . . . . . . . . . . 26
linagliptin/metformin . . . . . 26
linezolid . . . . . . . . . . . . 36
LINZESS . . . . . . . . . . . . 31
liothyronine . . . . . . . . . . 27
liotrix . . . . . . . . . . . . . . 27
Index of Covered Drugs
lipistart . . . . . . . . . . . . . 37
LIPITOR . . . . . . . . . . . . . 11
LIPOFEN . . . . . . . . . . . . 11
LIQUIBID PD . . . . . . . . . . 53
liraglutide . . . . . . . . . . . 27
lisdexamfetamine . . . . . . . 46
lisinopril . . . . . . . . . . . . . 8
lisinopril/hydrochlorothiazide . 8
lithium carbonate . . . . . . . 46
LITHIUM CARBONATE . . . . 46
lithium carbonate
extended-release . . . . . 46
LITHOBID . . . . . . . . . . . . 46
LMX-4 . . . . . . . . . . . . . . 21
LOCOID . . . . . . . . . . . . . 19
LODINE . . . . . . . . . . 13, 39
LODRANE D . . . . . . . . . . 23
LOESTRIN 1.5/30 . . . . . . . 40
LOESTRIN 1/20 . . . . . . . . 40
LOESTRIN FE 1.5/30 . . . . . 40
LOESTRIN FE 1/20 . . . . . . 40
LOFIBRA . . . . . . . . . . . . 11
LOHIST-DM . . . . . . . . . . . 52
LOMOTIL . . . . . . . . . . . . 28
lomustine . . . . . . . . . . . . 4
LONITEN . . . . . . . . . . . . 12
LONSURF . . . . . . . . . . . . 4
LO/OVRAL . . . . . . . . . . . 40
loperamide . . . . . . . . . . 28
LOPERAMIDE . . . . . . . . . 28
lophlex . . . . . . . . . . . . . 37
LOPID . . . . . . . . . . . . . . 11
lopinavir/ritonavir . . . . . . . 35
LOPRESSOR . . . . . . . . . . .9
loratadine . . . . . . . . . . . 23
loratadine/pseudoephedrine 64
loratadine/pseudoephedrine
extended-release . . . . . 24
loratadine &
pseudoephedrine SR . . 52
lorazepam . . . . . . . . . . . 45
LORAZEPAM INTENSOL . . . 45
LORCET . . . . . . . . . . . . 14
LORTAB . . . . . . . . . . . . 14
LORTAB ELIXIR . . . . . . . . 14
losartan . . . . . . . . . . . . . 8
losartan/HCTZ . . . . . . . . . 9
LOTENSIN . . . . . . . . . . . . 8
LOTENSIN HCT . . . . . . . . . 8
LOTRIMIN AF . . . . . . . 19, 63
LOTRISONE . . . . . . . . . . 20
lovastatin . . . . . . . . . . . . 11
LOVENOX . . . . . . . . . . . . 7
loxapine . . . . . . . . . . . . 48
LOXITANE . . . . . . . . . . . 48
LOZOL . . . . . . . . . . . . . 11
LUDIOMIL . . . . . . . . . . . 47
lumacaftor/ivacaftor . . . . . 60
LUMIZYME . . . . . . . . . . . 27
LUPRON . . . . . . . . . . . . .5
LUPRON DEPOT . . . . . . . . 5
LUPRON DEPOT 6-MONTH . .5
LUPRON DEPOT-PED . . . . . .5
LURIDE . . . . . . . . . . . . . 57
LURIDE LOZI-TABS . . . . . . 57
LUVOX . . . . . . . . . . . . . 45
LUVOX CR . . . . . . . . . . . 45
LYNPARZA . . . . . . . . . . . .6
LYRICA . . . . . . . . . . . . . 17
LYSODREN . . . . . . . . . . . .6
LYSTEDA . . . . . . . . . . . . 42
M
MAALOX . . . . . . . . . 28, 65
macitentan . . . . . . . . . . 12
MACROBID . . . . . . . . . . 36
MACRODANTIN . . . . . . . . 36
MAGNACET . . . . . . . . . . 14
magnesium oxide . . . . 57, 66
MAG-OX . . . . . . . . . . 57, 66
MALARONE . . . . . . . . . . 35
malathion . . . . . . . . . . . 20
MAPAP COLD TAB . . . . . . 54
maprotiline . . . . . . . . . . 47
maraviroc . . . . . . . . . . . 36
MARINOL . . . . . . . . . . . . 28
MATERNA . . . . . . . . . . . 58
MATULANE . . . . . . . . . . . 6
ALL CAPS = Brand-name drug
lower case = Generic drug
79
MATXIM LA . . . . . . . . . . . 10
MAVIK . . . . . . . . . . . . . . .8
MAXALT/MAXALT MLT . . . . 15
MAXIDEX . . . . . . . . . . . . 43
MAXITROL . . . . . . . . . . . 43
MAXZIDE . . . . . . . . . . . . 11
M-CLEAR WC . . . . . . . . . 50
MCT procal . . . . . . . . . . 37
measles, mumps & rubella virus
vaccines for inj . . . . . . 62
mecasermin . . . . . . . . . . 27
meclizine . . . . . . . . . 28, 65
MEDIFIN PE . . . . . . . . . . 53
MEDIPLAST . . . . . . . . . . 66
MEDROL . . . . . . . . . . . . 25
medroxyprogesterone
acetate . . . . . . . . 40, 42
mefloquine . . . . . . . . . . 36
MEGACE . . . . . . . . . . . . .5
megestrol acetate . . . . . . . 5
MEKINIST . . . . . . . . . . . . 5
MELLARIL . . . . . . . . . . . 48
meloxicam . . . . . . . . 13, 39
melphalan . . . . . . . . . . . 4
memantine . . . . . . . . . . 13
memantine SR . . . . . . . . 13
MENACTRA . . . . . . . . . . 62
MENEST . . . . . . . . . . . . 41
meningococcal
(a, c, y, and w-135) . . . . 62
meningococcal (a, c, y, and
w-135) conjugate vaccine 62
meningococcal (a, c, y, and
w-135) oligo conj
vac for inj . . . . . . . . . 62
MENOMUNE . . . . . . . . . . 62
MENOSTAR . . . . . . . . . . 41
MENVEO . . . . . . . . . . . . 62
meperidine . . . . . . . . . . 14
MEPHYTON . . . . . . . . . . 58
MEPRON . . . . . . . . . . . . 35
mercaptopurine . . . . . . . . 4
mesalamine . . . . . . . . . . 30
Index of Covered Drugs
mesalamine
extended-release . . . . . 30
mesalamine supp . . . . . . . 30
mesna . . . . . . . . . . . . . . 6
MESNEX . . . . . . . . . . . . .6
MESTINON . . . . . . . . . . . 15
MESTINON TIMESPAN . . . . 15
METADATE ER . . . . . . . . . 46
METAGLIP . . . . . . . . . . . 26
METAMUCIL . . . . . . . . . . 65
metaproterenol . . . . . . . . 55
METAPROTERENOL SYRUP 55
metformin . . . . . . . . . . . 26
metformin ER . . . . . . . . . 26
metformin/glyburide . . . . . 26
methadone . . . . . . . . . . 14
methazolamide . . . . . . . . 44
methenamine hippurate . . . 56
METHERGINE . . . . . . 28, 42
methimazole . . . . . . . . . . 27
methocarbamol . . . . . . . . 39
methotrexate . . . . . . . . . 38
METHOTREXATE . . . . . . . 38
methoxsalen . . . . . . . . . . 20
methsuximide . . . . . . . . . 16
methyldopa . . . . . . . . . . 12
methyldopa/HCTZ . . . . . . 12
methylergonovine . . . . 28, 42
METHYLIN SOLUTION . . . . 46
methylphenidate . . . . . . . 46
methylphenidate
extended-release . . . . . 46
methylprednisolone . . . . . . 25
metipranolol . . . . . . . . . . 43
metoclopramide . . . . . . . 28
metolazone . . . . . . . . . . 11
metoprolol . . . . . . . . . . . 9
metoprolol succinate . . . . . . 9
METROCREAM . . . . . . . . 20
METROGEL . . . . . . . . . . 20
METROGEL 1% . . . . . . . . 42
METROGEL-VAGINAL . . . . 42
METROLOTION . . . . . . . . 20
metronidazole . . . . 20, 36, 42
MEVACOR . . . . . . . . . . . 11
mexiletine . . . . . . . . . . . . 9
MEXITIL . . . . . . . . . . . . . .9
MIACALCIN . . . . . . . . . . 27
MICATIN . . . . . . . . . . 20, 63
miconazole . . . . . . . . 20, 42
MICONAZOLE . . . . . . . . . 33
miconazole buccal . . . . . . 33
miconazole crm, soln . . . . . 63
MICONAZOLE KIT . . . . . . . 42
miconazole nitrate . . . . . . 42
miconazole nitrate kit . . . . . 20
miconazole nitrate lotion . . . 20
miconazole nitrate soln . . . . 20
MICRO-K 10 . . . . . . . . . . 60
MICRONASE . . . . . . . . . . 26
MICROZIDE . . . . . . . . . . 10
MIDAMOR . . . . . . . . . . . 10
midodrine . . . . . . . . . . . 12
mifepristone . . . . . . . . . . 28
MIGERGOT SUPPOSITORIES15
MIGRANAL . . . . . . . . . . . 14
milupa PKU-2, milupa PKU-3 37
MINIPRESS . . . . . . . . . . . .8
MINOCIN . . . . . . . . . . . . 33
minocycline . . . . . . . . . . 33
minocycline SR . . . . . . . . 33
minoxidil . . . . . . . . . . . . 12
MINUTUSS DR SYP . . . . . . 52
MIRALAX . . . . . . . . . . . . 30
MIRAPEX . . . . . . . . . . . . 15
MIRAPEX ER . . . . . . . . . . 15
MIRCETTE . . . . . . . . . . . 39
mirtazapine . . . . . . . . . . 47
MIRVASO . . . . . . . . . . . . 20
misoprostol . . . . . . . . . . 31
MITIGARE . . . . . . . . . . . 39
mitotane . . . . . . . . . . . . . 6
MM/PA express, gel . . . . . 37
M-M-R II . . . . . . . . . . . . . 62
MOBIC . . . . . . . . . . 13, 39
MODICON . . . . . . . . . . . 40
MODURETIC . . . . . . . . . . 10
moexipril . . . . . . . . . . . . 8
ALL CAPS = Brand-name drug
lower case = Generic drug
80
moexipril/ hydrochlorothiazide 8
mometasone . . . . . . . . . 54
mometasone/formoterol . . . 54
mometasone furoate . . . . . 19
MONISTAT . . . . . . . . 42, 63
MONISTAT 3 . . . . . . . . . . 42
MONISTAT-DERM . . . . . . . 20
MONOPRIL . . . . . . . . . . . 8
MONOPRIL-HCT . . . . . . . . .8
montelukast . . . . . . . . . . 55
morphine . . . . . . . . . . . 14
morphine extended-release . 14
MOSCO CALLUS/CORN
LIQUID REMOVER OTC . 66
MOSCO CALLUS/CORN
REMOVER OTC . . . . . . 66
MOTRIN . . . . . . . . . . 13, 39
MOTRIN IB . . . . . . . . . . . 65
MOVANTIK . . . . . . . . . . . 31
moxifloxacin HCl . . . . . . . 44
MOZOBIL . . . . . . . . . . . . .7
MS CONTIN . . . . . . . . . . 14
MSIR . . . . . . . . . . . . . . 14
MSUD analog, complex, cooler,
express . . . . . . . . . . 37
MSUD complex drink mix . . 37
MSUD maxamum, maxamaid 37
MUCINEX . . . . . . . . . . . 51
MUCINEX COLD LIQ /KIDS . 53
MUCINEX D . . . . . . . . . . 52
MUCINEX DM . . . . . . . . . 51
MUCINEX KIDS . . . . . . . . 51
MUCOMYST . . . . . . . . . . 60
MULTAQ . . . . . . . . . . . . . 9
MULTI SYMPTOM TAB
COLD RLF . . . . . . . . . 54
multivitamins/fluoride/±iron . 57
multivitamins/minerals . . . . 57
mupirocin . . . . . . . . . . . 18
MURINE . . . . . . . . . . . . 65
MURO 128 . . . . . . . . . . . 45
MYAMBUTOL . . . . . . . . . 31
MYCELEX . . . . . . . . . 19, 33
MYCITRACIN . . . . . . . . . . 64
Index of Covered Drugs
MYCOBUTIN . . . . . . . . . . 31
mycophenolate mofetil . . . . .5
mycophenolate sodium . . . . 5
MYCOSTATIN . . . . . . . 20, 33
MYFORTIC . . . . . . . . . . . .5
MYLANTA . . . . . . . . . 29, 65
MYLERAN . . . . . . . . . . . . 4
MYLICON . . . . . . . . . . . 65
MYSOLINE . . . . . . . . . . . 17
MYTUSSIN AC . . . . . . . . . 50
N
nabumetone . . . . . . . . . . 13
nadolol . . . . . . . . . . . . . 9
NALFON . . . . . . . . . . 13, 39
naloxegol . . . . . . . . . . . 31
naloxone . . . . . . . . . . . . 47
NALOXONE INJ . . . . . . . . 47
naltrexone . . . . . . . . . 45, 48
naltrexone IM extended
release susp . . . . . . . . 48
NAMENDA . . . . . . . . . . . 13
NAMENDA XR . . . . . . . . . 13
naphazoline/antazoline . . . 42
naphazoline/glycerin . . . . . 42
naphazoline HCL . . . . . . . 42
naphazoline w/pheniramine 42
naphazoline/zinc sulfate . . . 42
NAPHCON A . . . . . . . 42, 65
NAPROSYN . . . . . . . . 14, 39
naproxen . . . . . . . . . 14, 39
naproxen delayed release 14, 39
naproxen sodium . . . . 14, 39
naratriptan . . . . . . . . . . . 15
NARCAN NASAL SPRAY . . . 47
NARIZ . . . . . . . . . . . . . . 53
NASACORT ALLERGY . . . . 24
NASACORT AQ . . . . . . . . 24
NASALCROM . . . . . . . . . 24
nasal sprays . . . . . . . . . . 64
NATACYN . . . . . . . . . . . . 45
NATALCARE . . . . . . . . . . 58
natamycin . . . . . . . . . . . 45
nateglinide . . . . . . . . . . . 26
NATROBA . . . . . . . . . . . 21
NAVANE . . . . . . . . . . . . 48
nedocromil . . . . . . . . . . 55
nelfinavir . . . . . . . . . . . . 35
NEOBENZ MICR LIQ . . . . . 17
NEO DM . . . . . . . . . . . . 49
NEO-FRADIN . . . . . . . . . . 36
neomycin/polymyxin B/
bacitracin . . . . . . . . . 18
neomycin/polymyxin B/
dexamethasone . . . . . . 43
neomycin/polymyxin B/
gramicidin . . . . . . . . . 44
neomycin/polymyxin B/
hydrocortisone . . . . 23, 43
neomycin sulfate . . . . . . . 36
NEORAL . . . . . . . . . . . . . 6
NEOSPORIN . . . . . 18, 44, 64
NEO-SYNEPHRINE . . . 24, 64
NEPHROCAPS . . . . . . . . 59
NEPTAZANE . . . . . . . . . . 44
NESTABSCBF/FA/RX . . . . . 58
NEULASTA . . . . . . . . . . . .7
NEUPOGEN . . . . . . . . . . .7
NEURONTIN . . . . . . . . . . 16
NEUTROGENA OIL FREE
ACNE WASH . . . . . . . . 18
NEUTROGENA RAPID
CLEAR GEL . . . . . . . . 18
nevirapine . . . . . . . . . . . 34
nevirapine ER . . . . . . . . . 34
NEXAVAR . . . . . . . . . . . . .5
NEXIUM 24HR OTC . . . . . . 29
NEXIUM DELAYED
RELEASE PACKET . . . . 29
niacin . . . . . . . . . . . . . 11
niacin extended-release . . . 11
NIACOR . . . . . . . . . . . . 11
NIASPAN . . . . . . . . . . . . 11
nicardipine . . . . . . . . . . 10
NICODERM . . . . . . . . . . 48
NICODERM CQ . . . . . . . . 66
NICORETTE . . . . . . . . . . 48
nicotine . . . . . . . . . . 48, 66
ALL CAPS = Brand-name drug
lower case = Generic drug
81
NICOTINE GUM . . . . . . . . 66
nicotine inhaler system . . . . 48
nicotine polacrilex gum . . . . 48
nicotine polacrilex lozenge . . 48
NICOTROL . . . . . . . . 48, 66
nifedipine . . . . . . . . . . . 10
nifedipine extended-release . 10
NIFEREX . . . . . . . 57, 58, 66
NIFEREX-PN FORTE . . . . . 58
nilotinib . . . . . . . . . . . . . 4
nimodipine . . . . . . . . . . 10
NIMOTOP . . . . . . . . . . . 10
NINLARO . . . . . . . . . . . . .5
nintedanib . . . . . . . . . . . 61
nisoldipine . . . . . . . . . . . 10
nitazoxanide suspension . . . 36
nitazoxanide tablet . . . . . . 36
NITREK . . . . . . . . . . . . 12
NITRO-BID . . . . . . . . . . . 12
NITRO-DUR . . . . . . . . . . 12
nitrofurantoin
extended-release . . . . . 36
nitrofurantoin macrocrystals . 36
nitrofurantoin susp . . . . . . 36
nitroglycerin . . . . . . . .12, 21
nitroglycerin extended-release12
NITROLINGUAL . . . . . . . . 12
NITROSTAT . . . . . . . . . . . 12
NIX . . . . . . . . . . . . . . . 65
NIX CREME RINSE . . . . . . 21
NIZORAL . . . . . . . . . 20, 33
NIZORAL A-D OTC . . . . . . 20
NIZORAL SHAMPOO . . . . . 21
NOLVADEX . . . . . . . . . . . .5
NORCO . . . . . . . . . . . . . 14
NORDETTE . . . . . . . . . . 40
NORDITROPIN . . . . . . . . . 27
norelgestromin/EE . . . . . . 40
norethindrone . . . . . . . . . 40
norethindrone acetate . . . . 42
norethindrone acetate/EE . . 40
norethindrone
acetate/EE/iron . . . 40, 41
norethindrone/EE . . 39, 40, 41
Index of Covered Drugs
norethindrone/ME . . . . . . 40
NORFLEX . . . . . . . . . . . 39
norgestimate/EE . . . . . 40, 41
norgestrel . . . . . . . . . . . 40
norgestrel/EE . . . . . . . . . 40
NORPACE . . . . . . . . . . . . 9
NORPACE CR . . . . . . . . . .9
NORPRAMIN . . . . . . . . . . 47
nortriptyline . . . . . . . . . . 47
NORVASC . . . . . . . . . . . 10
NORVIR . . . . . . . . . . . . . 35
NOXAFIL . . . . . . . . . . . . 33
NUEDEXTA . . . . . . . . . . . 48
NULYTELY . . . . . . . . . . . 30
NUTROPIN AQ NUSPIN . . . 27
NUVARING . . . . . . . . . . . 40
NYMALIZE . . . . . . . . . . . 10
nystatin . . . . . . . . . . 20, 33
NYTOL QUICK CAPS . . . . . 47
O
OA-1, OA-2 . . . . . . . . . . 37
OC8 . . . . . . . . . . . . 17, 63
OCEAN NASAL SPRAY . . . . 24
octreotide . . . . . . . . . . . . 6
OCUFEN . . . . . . . . . . . . 43
OCUFLOX . . . . . . . . . . . 44
ODOMZO . . . . . . . . . . . . .6
OFEV . . . . . . . . . . . . . . 61
ofloxacin . . . . . . . 23, 32, 44
OGEN . . . . . . . . . . . . . . 41
olanzapine . . . . . . . . . . . 48
olanzapine ODT . . . . . . . . 48
olaparib . . . . . . . . . . . . . 6
olodaterol . . . . . . . . . . . 54
olsalazine sodium . . . . . . . 30
omalizumab . . . . . . . . . . 55
ombitasvir/paritaprevir/
ritonavir . . . . . . . . . . 34
ombitasvir/paritaprevir/
ritonavir/dasabuvir . . . . 34
omega-3 fatty acids . . . 57, 58
omeprazole delayed-release 29
OMNICEF . . . . . . . . . . . . 32
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
ONMEL . . . . . . . . . . . . . 33
OPCON A . . . . . . . . . . . 42
OPSUMIT . . . . . . . . . . . . 12
OPTIPRANOLOL . . . . . . . 43
OPTIVAR . . . . . . . . . . . . 42
ORAP . . . . . . . . . . . . . . 48
ORAPRED . . . . . . . . . . . 25
ORKAMBI . . . . . . . . . . . 60
orphenadrine
extended-release . . . . . 39
ORTHO-CEPT . . . . . . . . . 40
ORTHO COIL . . . . . . . . . 40
ORTHO-CYCLEN . . . . . . . 40
ortho diaphragm . . . . . . . 40
ORTHO EVRA . . . . . . . . . 40
ORTHO FLAT . . . . . . . . . 40
ORTHO FLEX . . . . . . . . . 40
ORTHO MICRONOR . . . . . 40
ORTHO-NOVUM 1/35 . . . . 40
ORTHO-NOVUM 1/50 . . . . 40
ORTHO-NOVUM 7/7/7 . . . . 41
ORTHO-NOVUM 10/11 . . . 39
ORTHO TRI-CYCLEN . . . . . 41
ORUDIS . . . . . . . . . . 13, 39
OS-CAL . . . . . . . . . . 56, 66
oseltamivir . . . . . . . . . . . 34
OVCON 50 . . . . . . . . . . . 40
OVIDE . . . . . . . . . . . . . . 20
OVRAL . . . . . . . . . . . . . 40
OVRETTE . . . . . . . . . . . . 40
oxaprozin . . . . . . . . . 14, 39
oxazepam . . . . . . . . . . . 45
oxcarbazepine . . . . . . . . 16
OXSORALEN-ULTRA . . . . . 20
oxybutynin chloride . . . . . . 56
oxybutynin IR . . . . . . . . . 56
ALL CAPS = Brand-name drug
lower case = Generic drug
82
oxycodone . . . . . . . . . . 14
oxycodone/acetaminophen . 14
oxycodone/aspirin . . . . . . 14
oxycodone ER . . . . . . . . 14
OXYCONTIN . . . . . . . . . . 14
OXYFAST . . . . . . . . . . . . 14
oxymetazoline . . . . . . . . . 24
oxymorphone ER . . . . . . . 14
OXYMORPHONE ER . . . . . 14
P
PACERONE . . . . . . . . . . . 9
palbociclib . . . . . . . . . . . 4
paliperidone . . . . . . . . . . 48
palivizumab . . . . . . . . . . 36
PAMELOR . . . . . . . . . . . 47
pancrealipase DR . . . . . . . 30
PANCREAZE . . . . . . . . . . 30
pancrelipase . . . . . . . . . 30
panobinostat . . . . . . . . . . 4
PANOXYL BAR . . . . . . . . 63
PANOXYL BAR OTC . . . . . 17
PANOXYL CREAM . . . . . . 63
PANOXYL CREAM OTC . . . 17
PANRETIN . . . . . . . . . . . .6
pantoprazole . . . . . . . . . 29
pantoprazole delayed-release 29
PARAFON FORTE DSC . . . . 39
PARLODEL . . . . . . . . 15, 28
PARNATE . . . . . . . . . . . . 46
paromomycin . . . . . . . . . 36
paroxetine . . . . . . . . . . . 46
paroxetine SR . . . . . . . . . 46
PASER . . . . . . . . . . . . . 31
pasireotide . . . . . . . . . . . 6
PAXIL . . . . . . . . . . . . . . 46
PAXIL CR . . . . . . . . . . . . 46
pazopanib . . . . . . . . . . . 4
PEDIACARE LIQ MULTI-SY . . 54
PEDIALYTE . . . . . . . . 56, 65
PEDIAPRED . . . . . . . . . . 25
PEDIAZOLE . . . . . . . . . . 32
peg 3350/electrolytes . . . . 30
Index of Covered Drugs
peg 3350/sodium bicarbonate/
sodium chloride . . . . . 30
peg 3350/sodium
bicarbonate/sodium chloride/potassium chloride . 30
PEGASYS . . . . . . . . . . . . 34
PEGASYS PROCLICK . . . . 34
pegfilgrastim . . . . . . . . . . 7
peginterferon alfa-2a . . . . . 34
peginterferon alfa-2b . . . . 5, 34
PEGINTRON . . . . . . . . . . 34
pegvisomant . . . . . . . . . 28
penciclovir . . . . . . . . . . . 34
penicillamine . . . . . . . . . 38
penicillin VK . . . . . . . . . . 32
PENLAC SOLUTION 8% . . . 19
PENTASA . . . . . . . . . . . . 30
pentosan . . . . . . . . . . . . 56
pentoxifylline extended-release 7
PEPCID . . . . . . . . . . . . . 29
PEPCID AC . . . . . . . . 65, 29
PEPCID AZ CHW . . . . . . . 29
PERCOCET . . . . . . . . . . 14
PERCODAN . . . . . . . . . . 14
PERIDEX . . . . . . . . . . . . 24
periflex advance, infant, junior37
perindopril . . . . . . . . . . . 8
PERIOGARD . . . . . . . . . . 24
permethrin . . . . . . 20, 21, 65
perphenazine . . . . . . . . . 48
PERSANTINE . . . . . . . . . . 7
PFD-1, PFD-2 . . . . . . . . . 37
phenazopyridine . . . . . . . 56
PHENERGAN . . . . . . . . . 28
PHENERGAN DM . . . . . . . 51
phenex-1, phenex-2 . . . . . . 37
phenobarbital . . . . . . . . . 17
PHENOBARBITAL . . . . . . . 17
phenylade 40, 60, drink mix 37
phenylade MTE amino
acid blend . . . . . . . . . 37
phenyleph/bromphen/dextromethorphan/guaifenesin 52
phenylephrine . . . . . . . . . 24
phenylephrine/
brompheniramine/
dextromethorphan . . . . 52
phenylephrine/
brompheniramine-DM . . 52
phenylephrine/
chlorpheniramine . . . . . 52
phenylephrine/
chlorpheniramine/
dextromethorphan . . 52, 53
phenylephrine/chlorpheniramine/dihydrocodeine . . 53
phenylephrine/
dextromethorphan . . . . 53
phenylephrine/dextromethorphan/guaifenesin . . . . 53
phenylephrine/ephed/CPM
w/carbetapentane . . . . 53
phenylephrine/guaifenesin . . 53
phenylephrine/hydrocodone/
guaifenesin . . . . . . . . 53
phenylephrine/pyrilamine/
dextromethorphan . . . . 53
phenylephrine/pyrilamine
w/hydrocodone . . . . . . 53
phenylephrine tan/pyrilamine
tan/carbeta tan . . . . . . 53
phenylfree-1,
phenylfree-2, HP . . . . . 37
PHENYLHIST LIQ DH . . . . . 50
PHENYTEK . . . . . . . . . . . 17
phenytoin . . . . . . . . . . . 17
phenytoin sodium extended . 17
PHISOHEX . . . . . . . . . . . 21
phlexy-10 . . . . . . . . . . . 37
PHOS-FLUR . . . . . . . . 57, 66
PHOSLYRA . . . . . . . . . . . 60
PHOSPHOLINE IODINE . . . 44
phosphorus . . . . . . . . . . 59
PHRENILIN . . . . . . . . . . . 13
phytonadione . . . . . . . . . 58
pilocarpine . . . . . . . . 24, 44
PILOPINE HS GEL . . . . . . . 44
PIMA . . . . . . . . . . . . . . 60
ALL CAPS = Brand-name drug
lower case = Generic drug
83
pimecrolimus . . . . . . . . . 22
pimozide . . . . . . . . . . . . 48
pindolol . . . . . . . . . . . . . 9
PINDOLOL . . . . . . . . . . . .9
pioglitazone . . . . . . . . . . 26
pioglitazone/glimepiride . . . 26
pioglitazone/metformin . . . 26
pioglitazone/metformin ER . 26
PIPERONYL BUTOXIDE . . . 65
piperonyl butoxide gel, liquid
shampoo . . . . . . . . . 65
pirfenidone capsule . . . . . 61
piroxicam . . . . . . . . . 14, 39
PKU cooler, express, gel . . . 37
PLAN B . . . . . . . . . . . . . 39
PLAQUENIL . . . . . . . . 36, 38
PLAVIX . . . . . . . . . . . . . . 7
PLENDIL . . . . . . . . . . . . 10
plerixafor . . . . . . . . . . . . 7
PLETAL . . . . . . . . . . . . . .7
PLEXION . . . . . . . . . . . . 18
pneumococcal 13-valent
conjugate . . . . . . . . . 62
pneumococcal vaccine
polyvalent . . . . . . . . . 62
PNEUMOVAX . . . . . . . . . 62
PNEUMOVAX 23 . . . . . . . 62
podofilox . . . . . . . . . . . . 21
POLARAMINE . . . . . . . . . 23
polyethylene glycol 3350 . . . 30
polymyxin B/bacitracin . . . . 44
polymyxin B/trimethoprim . . 44
polysaccharide iron complex 58
POLYSPORIN . . . . . . . . . 44
POLYTRIM . . . . . . . . . . . 44
POLY-VI-FLOR . . . . . . . . . 57
POLY-VI-SOL . . . . . . . . . . 66
pomalidomide . . . . . . . . . 5
POMALYST . . . . . . . . . . . .5
ponatinib . . . . . . . . . . . . 4
portagen . . . . . . . . . . . . 37
posaconazole . . . . . . . . . 33
potassium acid phosphate . . 59
Index of Covered Drugs
potassium bicarbonate/potassium citrate effervescent 60
potassium chloride . . . . . . 60
potassium chloride . . . . . . 60
POTASSIUM CHLORIDE . . . 60
potassium chloride
extended-release . . . . . 60
potassium citrate . . . . . . . 56
potassium iodide . . . . . . . 60
POTIGA . . . . . . . . . . . . . 16
povidone-iodine . . . . . . . . 36
PRADAXA . . . . . . . . . . . . 7
PRALUENT . . . . . . . . . . . 11
pramipexole . . . . . . . . . . 15
pramipexole
dihydrochloride SR . . . . 15
pramlintide . . . . . . . . . . 27
PRANDIN . . . . . . . . . . . . 26
PRAVACHOL . . . . . . . . . . 11
pravastatin . . . . . . . . . . . 11
praziquantel . . . . . . . . . . 31
prazosin . . . . . . . . . . . . . 8
PRECOSE . . . . . . . . . . . 26
PRED FORTE . . . . . . . . . 43
PRED-G . . . . . . . . . . . . . 43
PRED MILD . . . . . . . . . . 43
prednicarbate . . . . . . . . . 19
prednisolone . . . . . . . . . 25
prednisolone acetate . . . . . 43
prednisolone phosphate . . . 43
prednisolone sodium
phosphate . . . . . . . . . 25
prednisone . . . . . . . . . . 25
PREDNISONE . . . . . . . . . 25
pregabalin . . . . . . . . . . . 17
PRELONE . . . . . . . . . . . 25
PREMARIN . . . . . . . . . . . 41
PREMPHASE . . . . . . . . . 42
PREMPRO . . . . . . . . . . . 42
PRENATAL VITAMINS W/
FOLIC ACID . . . . . . . . 58
prenatal vit w/FE bisglyc-FE
prot succ-FA . . . . . . . . 58
prenatal vit w/FE bisglycinate
chelate-FA . . . . . . . . . 58
prenatal vit w/FE polysac
cmplx-FA . . . . . . . . . 58
prenatal vit w/folic acid . . . . 58
prenatal vit w/iron
carbonyl-FA . . . . . . . . 58
prenatal vit w/o vit a w/FE
bisglycinate-FA tab . . . . 58
prenatal w/o A w/ FE carbonylFE gluc-DSS-FA . . . . . . 58
prenat-FE Bis-FE prot succ-FACA & omega 3 . . . . . . 59
prenat w/o A w/fecbn-fegl-DSSFA & DHA . . . . . . . . . 58
PREPARATION H . . . . . . . 65
PRESGEN B . . . . . . . . . . 52
PREVACID . . . . . . . . . . . 29
PREVIDENT . . . . . . . . . . 57
PREVNAR 13 . . . . . . . . . 62
PREZCOBIX . . . . . . . . . . 36
PREZISTA . . . . . . . . . . . . 35
PRIFTIN . . . . . . . . . . . . . 31
PRILOSEC . . . . . . . . . . . 29
primaquine . . . . . . . . . . 36
primidone . . . . . . . . . . . 17
PRINCIPEN . . . . . . . . . . . 32
PROAMATINE . . . . . . . . . 12
probenecid . . . . . . . . . . 39
PROBENECID . . . . . . . . . 39
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
ALL CAPS = Brand-name drug
lower case = Generic drug
84
progestimil lipil . . . . . . . . 37
PROGRAF . . . . . . . . . . . . 6
PROLASTIN . . . . . . . . . . 55
PROLIXIN . . . . . . . . . . . . 48
PROLIXIN DECANOATE . . . 48
PROMACTA . . . . . . . . . . 61
promethazine . . . . . . . . . 28
promethazine &
phenylephrine . . . . . . . 53
PROMETHAZINE SYP DM . . 51
PROMETHAZINE VC
W/CODEINE . . . . . . . . 51
PROMETHAZINE
W/CODEINE . . . . . . . . 50
PROMETH VC SYP . . . . . . 53
PROMETRIUM . . . . . . . . . 42
PRO NUTRIENT . . . . . . . . 58
propafenone . . . . . . . . . . 9
propantheline . . . . . . . . . 56
pro-phree powder . . . . . . . 37
propimex-1, propimex-2 . . . 37
propranolol . . . . . . . . . 9, 15
propranolol/HCTZ . . . . . . . 9
propylthiouracil . . . . . . . . 27
PROPYLTHIOURACIL . . . . . 27
PROSCAR . . . . . . . . . . . 55
PROSOM . . . . . . . . . . . . 47
PROTONIX . . . . . . . . . . . 29
PROTONIX PAK . . . . . . . . 29
PROTOPIC 0.1% . . . . . . . . 22
PROTOPIC 0.03% . . . . . . . 22
protriptyline . . . . . . . . . . 47
PROVENTIL . . . . . . . . . . 54
PROVERA . . . . . . . . . . . 42
provimin . . . . . . . . . . . . 37
PROZAC . . . . . . . . . . . . 46
PRUET DHAEC PAK . . . . . 59
PRUET DHA PAK
SETONET PAK . . . . . . 59
PSE/GG . . . . . . . . . . . . 51
pseudoephedrine . . . . . . . 54
pseudoephedrine/
acetaminophen/
dextromethorphan . . . . 54
Index of Covered Drugs
pseudoephedrine/chlorpheniramine/dextromethorphan 54
pseudoephedrine/dextromethorphan/guaifenesin . . . . 54
pseudoephedrine/iburprofen 54
pseudoephedrine tan/ dexchlorphen tan/DM tan . . . . . 54
PSORCON CREAM . . . . . . 19
PSORCON OINTMENT . . . . 19
P & S SHAMPOO . . . . . . . 22
psyllium . . . . . . . . . . . . 65
PULMICORT RESPULES . . . 54
PULMOZYME . . . . . . . . . 60
PURINETHOL . . . . . . . . . . 4
pyrazinamide . . . . . . . . . 31
PYRAZINAMIDE . . . . . . . . 31
pyrethrins/piperonyl but . . . 21
PYRIDIUM . . . . . . . . . . . 56
pyridostigmine . . . . . . . . 15
pyridostigmine
extended-release . . . . . 15
pyrilamine tan/phenyleph tan 54
pyrimethamine . . . . . . . . 36
Q
QUALAQUIN . . . . . . . . . . 36
QUAL-TUSSIN SYP DC . 52, 53
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 . . . . . . . . . 36
QV-ALLERGY . . . . . . . . . 50
QVAR . . . . . . . . . . . . . . 54
R
raloxifene . . . . . . . . . . . 27
raltegravir . . . . . . . . . . . 36
ramelteon . . . . . . . . . . . 47
ramipril . . . . . . . . . . . . . 8
RANEXA . . . . . . . . . . . . 12
ranitidine . . . . . . . . . . . . 29
ranitidine effer . . . . . . . . . 29
ranitidine syrup . . . . . . . . 29
ranolazine . . . . . . . . . . . 12
RAPAMUNE . . . . . . . . . . . 6
RAVICTI . . . . . . . . . . 27, 61
RAYOS . . . . . . . . . . . . . 25
RAZADYNE . . . . . . . . . . 13
REBETOL/COPEGUS . . . . 34
REBIF . . . . . . . . . . . . . . 15
RECOMBIVAX HB . . . . . . . 61
rectal crm, suppositories . . . 65
RECTIV . . . . . . . . . . . . . 21
REGLAN . . . . . . . . . . . . 28
regorafenib . . . . . . . . . . . 5
REGRANEX . . . . . . . . . . 21
RELAFEN . . . . . . . . . . . . 13
RELENZA . . . . . . . . . . . . 34
REMERON . . . . . . . . . . . 47
REMERON ODT . . . . . . . . 47
REMODULIN . . . . . . . . . . 12
RENAGEL . . . . . . . . . . . 61
renat-FE bis-FE prot succ-FACA & omega DR . . . . . 59
RENVELA . . . . . . . . . . . . 61
repaglinide . . . . . . . . . . 26
REQUIP . . . . . . . . . . . . . 16
REQUIP XL . . . . . . . . . . . 16
RESCRIPTOR . . . . . . . . . 34
RESPA-BR . . . . . . . . . . . 23
RESPERAL-DM . . . . . . . . . 49
RESTASIS . . . . . . . . . . . . 45
RESTORIL . . . . . . . . . . . 47
RETIN-A . . . . . . . . . . . . 18
RETROVIR . . . . . . . . . . . 35
REVATIO . . . . . . . . . . . . 12
ALL CAPS = Brand-name drug
lower case = Generic drug
85
REVIA . . . . . . . . . . . 45, 48
REVLIMID . . . . . . . . . . . . 5
REYATAZ . . . . . . . . . . . . 35
ribavirin . . . . . . . . . . . . 34
RIDAURA . . . . . . . . . . . . 38
RID SHAMPOO/
BUTOXIDE SHAMPOO . . 21
rifabutin . . . . . . . . . . . . 31
RIFADIN . . . . . . . . . . . . . 31
rifampin . . . . . . . . . . . . 31
rifapentine . . . . . . . . . . . 31
rilpivirine . . . . . . . . . . . . 34
rimantadine . . . . . . . . . . 34
rimexolone . . . . . . . . . . . 43
riociguat . . . . . . . . . . . . 12
RISPERDAL . . . . . . . . . . 48
RISPERDAL CONSTA . . . . . 48
RISPERDAL M-TAB . . . . . . 48
RISPERDAL SOLUTION . . . 48
risperidone . . . . . . . . . . 48
risperidone m-tab . . . . . . . 48
RITALIN . . . . . . . . . . . . . 46
RITALIN LA . . . . . . . . . . . 46
RITALIN-SR . . . . . . . . . . . 46
ritonavir . . . . . . . . . . . . 35
rivaroxaban . . . . . . . . . . . 7
rivastigmine . . . . . . . . . . 13
rizatriptan . . . . . . . . . . . 15
RMS . . . . . . . . . . . . . . . 14
ROBAXIN . . . . . . . . . . . . 39
ROBINUL . . . . . . . . . . . . 29
ROBINUL FORTE . . . . . . . 29
ROBITUSSIN . . . . . . . 51, 64
ROBITUSSIN CF . . . . . 51, 64
ROBITUSSIN DM . . . . . 51, 64
ROBITUSSIN LIQ CGH/ALRG53
ROBITUSSIN LIQ CGH/CLD . 50
ROBITUSSIN LIQ
CGH/CONG . . . . . . . . 51
ROBITUSSIN LIQ HD/CHST . 53
ROBITUSSIN LIQ PED NGHT 54
ROBITUSSIN PE . . . 51, 53, 64
ROBITUSSIN PED LIQ CGH/
COLD . . . . . . . . . . . . 50
Index of Covered Drugs
ROBITUSSIN PED SYP . . . . 51
ROBITUSSIN SYP
CHST CNG . . . . . . . . . 51
ROBITUSSIN SYP MAX-ST . . 51
ROCALTROL . . . . . . . . . . 56
RONDEC DM . . . . . . . 52, 53
RONDEC DROPS . . . . . . . 50
RONDEC SYRUP . . . . . 49, 50
ropinirole . . . . . . . . . . . 16
ropinirole hydrochloride SR . 16
ROWASA . . . . . . . . . . . . 30
ROXICODONE . . . . . . . . . 14
ROZEREM . . . . . . . . . . . 47
R-TANNAMINE . . . . . . . . . 50
rufinamide . . . . . . . . . . . 17
rufinamide suspension . . . . 17
ruxolitinib . . . . . . . . . . . . 5
RYNA-12 S . . . . . . . . . . . 54
RYNATAN PEDIATRIC SUSP . 50
RYNATUSS . . . . . . . . . . . 49
RYNATUSS PEDIATRIC SUSP53
RYTHMOL . . . . . . . . . . . .9
S
SABRIL SOLUTION . . . . . . 17
sacrosidase . . . . . . . . . . 31
sacubitril/valsartan . . . . . . . 9
SALAC OTC . . . . . . . . . . 22
SALACYN . . . . . . . . . . . 22
SALAGEN . . . . . . . . . . . 24
SALEX . . . . . . . . . . . 18, 22
salicylic acid . . . . . 18, 20, 22
salicylic acid
17%/collodion . . . . 21, 66
salicylic acid film forming liquid
27.5% OTC . . . . . . . . 66
salicylic acid gel 17% OTC . . 66
salicylic acid pad 40% OTC . 66
salicylic acid plaster 40% . . 66
salicylic acid soln OTC . . . . 66
salicylic acid strip 40% . . . . 66
salicylic acid topical patch
15% OTC . . . . . . . . . 66
saline nasal spray 0.65% . . . 24
salmeterol xinafoate . . . . . 54
SAL-TROPINE . . . . . . . . . 31
SALVAX . . . . . . . . . . . . . 22
SANCTURA . . . . . . . . . . 56
SANDIMMUNE . . . . . . . . . .6
SANDOSTATIN . . . . . . . . . .6
SANTYL . . . . . . . . . . . . 21
sapropterin . . . . . . . . . . 28
sapropterin dihydrochloride . 37
sapropterin powder . . . . . . 28
saquinavir mesylate . . . . . . 35
sargramostim . . . . . . . . . . 7
SAVAYSA . . . . . . . . . . . . .7
SCALPICIN . . . . . . . . . . . 20
scopolamine . . . . . . . . . 44
SEA-OMEGA . . . . . . . . . . 57
SEBIZON . . . . . . . . . . . . 18
SECTRAL . . . . . . . . . . . . .9
SEDAPAP . . . . . . . . . . . . 13
selegiline . . . . . . . . . . . 16
selenium sulfide . . . . . . . . 22
SELSUN . . . . . . . . . . . . 22
SELSUN BLUE . . . . . . . . . 22
SELZENTRY . . . . . . . . . . 36
sennosides . . . . . . . . . . 30
SENOKOT . . . . . . . . . . . 30
SENSIPAR . . . . . . . . . . . 60
SERAX . . . . . . . . . . . . . 45
SEREVENT DISKUS . . . . . . 54
SEROMYCIN . . . . . . . . . . 31
SEROQUEL . . . . . . . . . . 48
SEROQUEL XR . . . . . . . . 48
sertraline . . . . . . . . . . . . 46
sevelamer . . . . . . . . . . . 61
sevelamer HCL . . . . . . . . 61
SIGNIFOR . . . . . . . . . . . . 6
sildenafil . . . . . . . . . . . . 12
SILVADENE . . . . . . . . . . . 18
silver sulfadiazine . . . . . . . 18
simethicone . . . . . . . . . . 65
simvastatin . . . . . . . . . . . 11
SINEMET . . . . . . . . . . . . 15
SINEMET CR . . . . . . . . . . 15
SINEQUAN . . . . . . . . . . . 47
ALL CAPS = Brand-name drug
lower case = Generic drug
86
SINGULAIR . . . . . . . . . . . 55
sirolimus . . . . . . . . . . . . 6
SIRTURO . . . . . . . . . . . . 35
sitagliptan . . . . . . . . . . . 27
sitagliptan/metformin . . . . . 27
sitagliptan/metformin ER . . . 27
SKLICE . . . . . . . . . . . . . 20
sodium benzoate . . . . . . . 37
sodium chloride hypertonic . 45
sodium citrate/citric acid . . . 56
sodium phenylbutyrate oral
powder . . . . . . . . 27, 61
sodium phenylbutyrate tab . . 27
sodium phenylbutyrate tab . . 61
sodium polysterene sulfonate 12
sofosbuvir . . . . . . . . . . . 34
SOLU-CORTEF . . . . . . . . 25
SOLU-MEDROL . . . . . . . . 25
somatropin . . . . . . . . . . 27
SOMAVERT . . . . . . . . . . 28
SONATA . . . . . . . . . . . . 47
sonidegib . . . . . . . . . . . . 6
sorafenib . . . . . . . . . . . . 5
SORIATANE . . . . . . . . . . 20
sotalol . . . . . . . . . . . . . . 9
SOVALDI . . . . . . . . . . . . 34
Spacers . . . . . . . . . . . . 61
spinosad . . . . . . . . . . . . 21
SPIRIVA . . . . . . . . . . . . . 55
spironolactone . . . . . . . . 11
SPIRONOLACTONE . . . . . 11
spironolactone/
hydrochlorothiazide . . . 11
SPORANOX . . . . . . . . . . 33
SPRYCEL . . . . . . . . . . . . .4
STADOL . . . . . . . . . . . . 14
STARLIX . . . . . . . . . . . . 26
STATUSS DM SYP . . . . . . . 52
stavudine . . . . . . . . . . . 35
STELAZINE . . . . . . . . . . . 48
STIVARGA . . . . . . . . . . . . 5
stool softeners . . . . . . . . 65
STRATTERA . . . . . . . . . . 46
STRENSIQ . . . . . . . . . . . 27
Index of Covered Drugs
STRIBILD . . . . . . . . . . . . 35
STRI-DEX . . . . . . . . . . . . 18
STRIVERDI RESPIMAT . . . . 54
STROMECTOL . . . . . . . . . 31
STUART PRENATAL . . . . . . 66
SUBOXONE . . . . . . . . . . 47
SUCRAID . . . . . . . . . . . . 31
sucralfate . . . . . . . . . . . 29
SUDAFED . . . . . . . . . . . 54
sugar+orthophosphoric acid 65
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 . . . . . . . . . . 32
sulfamethoxazole/
trimethoprim, DS . . . . . 32
sulfanilamide . . . . . . . . . 42
sulfasalazine . . . . . . . 30, 38
sulfasalazine
delayed-release . . . . 30, 38
sulindac . . . . . . . . . . 14, 39
sumatriptan . . . . . . . . . . 15
SUMYCIN . . . . . . . . . . . . 33
sunitinib . . . . . . . . . . . . . 5
SUPER OMEGA . . . . . . . . 57
super soluble duocal . . . . . 37
SUPRAX . . . . . . . . . . . . 32
SUPRAX . . . . . . . . . . . . 32
SUPRESS-PE PEDIATRIC
DROPS . . . . . . . . . . . 53
SUSTIVA . . . . . . . . . . . . 34
SUTENT . . . . . . . . . . . . . 5
SYLATRON . . . . . . . . . . . .5
SYMBICORT . . . . . . . . . . 54
SYMLIN . . . . . . . . . . . . . 27
SYMMETREL . . . . . . . 15, 34
SYNAGIS . . . . . . . . . . . . 36
SYNALAR . . . . . . . . . 18, 19
SYNJARDY . . . . . . . . . . . 26
SYNTHROID . . . . . . . . . . 27
T
TABLOID . . . . . . . . . . . . . 4
tacrolimus . . . . . . . . . . 6, 22
tadalafil . . . . . . . . . . . . 12
TAFINLAR . . . . . . . . . . . . 4
tafluprost . . . . . . . . . . . . 44
TAGAMET . . . . . . . . . . . 29
taliglucerase . . . . . . . . . . 28
TAMBOCOR . . . . . . . . . . .9
TAMIFLU . . . . . . . . . . . . 34
tamoxifen . . . . . . . . . . . . 5
tamsulosin . . . . . . . . . . . 55
TANAFED . . . . . . . . . . . . 50
TANAFED DMX
SUSPENSION . . . . . . . 54
TAPAZOLE . . . . . . . . . . . 27
TARCEVA . . . . . . . . . . . . .4
TARGRETIN . . . . . . . . . . . 6
TASIGNA . . . . . . . . . . . . .4
TASMAR . . . . . . . . . . . . 16
TBO-Filgrastim . . . . . . . . . 7
TECFIDERA . . . . . . . . . . 15
TECHNIVIE . . . . . . . . . . . 34
teduglutide . . . . . . . . . . 31
TEGRETOL . . . . . . . . . . . 16
TEGRETOL-XR . . . . . . . . . 16
telaprevir . . . . . . . . . . . . 34
telbivudine . . . . . . . . . . . 34
temazepam . . . . . . . . . . 47
TEMODAR . . . . . . . . . . . .4
TEMOVATE . . . . . . . . . . . 19
temozolomide . . . . . . . . . 4
TENEX . . . . . . . . . . . . . . 8
TENIVAC . . . . . . . . . . . . 62
tenofovir . . . . . . . . . . . . 35
TENORETIC . . . . . . . . . . .9
TENORMIN . . . . . . . . . . . .9
TERAZOL 3/7 . . . . . . . . . 42
terazosin . . . . . . . . . . 8, 55
terbinafine . . . . . . . . 20, 33
ALL CAPS = Brand-name drug
lower case = Generic drug
87
terbinafine gel . . . . . . . . . 20
terbinafine HCL . . . . . . . . 20
terbutaline . . . . . . . . . . . 55
terconazole . . . . . . . . . . 42
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 (td)62
tetanus immune globulin . . . 62
TET/DIP TOX INJ . . . . . . . 62
tetrabenazine . . . . . . . . . 17
tetracycline . . . . . . . . . . 33
tetrahydrozoline/zinc sulfate . 42
tet tox-diph-acell pertuss ad . 62
thalidomide . . . . . . . . . . . 5
THALOMID . . . . . . . . . . . .5
THEO-24 . . . . . . . . . . . . 55
THEOCHRON . . . . . . . . . 55
theophylline . . . . . . . . . . 55
THEOPHYLLINE . . . . . . . . 55
theophylline extended-release55
THEOPHYLLINE EXT-REL . . 55
thioguanine . . . . . . . . . . . 4
thioridazine . . . . . . . . . . 48
thiothixene . . . . . . . . . . . 48
THORAZINE . . . . . . . . . . 48
thyroid tab . . . . . . . . . . . 27
THYROLAR . . . . . . . . . . 27
tiagabine . . . . . . . . . . . . 17
TIAZAC . . . . . . . . . . . . . 10
ticagrelor . . . . . . . . . . . . 7
TIGAN . . . . . . . . . . . . . . 28
TIKOSYN . . . . . . . . . . . . .9
TILADE . . . . . . . . . . . . . 55
Index of Covered Drugs
timolol . . . . . . . . . . . . . 43
timolol maleate . . . . . . . 9, 43
TIMOPTIC . . . . . . . . . . . 43
TIMOPTIC XE . . . . . . . . . 43
TINACTIN . . . . . . . . . 20, 63
tiotropium . . . . . . . . . . . 55
tipranavir . . . . . . . . . . . . 35
tizanidine . . . . . . . . . . . 39
TOBRADEX . . . . . . . . . . 43
TOBRADEX ST . . . . . . . . . 43
tobramycin . . . . . . . . . . 45
tobramycin-dexamethasone . 43
tobramycin/dexamethasone 43
tobramycin neb soln . . . . . 60
TOBREX . . . . . . . . . . . . 45
TOFRANIL . . . . . . . . . . . 47
tolazamide . . . . . . . . . . . 27
tolbutamide . . . . . . . . . . 27
TOLBUTAMIDE . . . . . . . . 27
tolcapone . . . . . . . . . . . 16
tolerex . . . . . . . . . . . . . 37
TOLINASE . . . . . . . . . . . 27
tolnaftate . . . . . . . . . 20, 63
tolterodine . . . . . . . . . . . 56
tolterodine SR . . . . . . . . . 56
TOPAMAX . . . . . . . . . . . 17
TOPAMAX SPRINKLE . . . . . 17
topical antibacterials . . . . . 64
topiramate . . . . . . . . . . . 17
topiramate sprinkle caps . . . 17
TOPROL XL . . . . . . . . . . . 9
TORADOL . . . . . . . . . . . 13
toremifene . . . . . . . . . . . 5
torsemide . . . . . . . . . . . 11
TRACLEER . . . . . . . . . . . 12
TRADJENTA . . . . . . . . . . 26
tramadol . . . . . . . . . . . . 13
trametinib . . . . . . . . . . . . 5
TRANDATE . . . . . . . . . . . .9
trandolapril . . . . . . . . . . . 8
tranexamic acid . . . . . . . . 42
TRANS-VER-SAL PATCH . . . 66
TRANXENE . . . . . . . . . . . 45
tranylcypromine . . . . . . . . 46
TRAVATAN Z . . . . . . . . . . 44
TRAVATAN Z PF . . . . . . . . 44
trazodone . . . . . . . . . . . 47
TRECATOR . . . . . . . . . . . 31
TRENTAL . . . . . . . . . . . . .7
treprostinil . . . . . . . . . . . 12
tretinoin . . . . . . . . . . . 6, 18
TRIACTIN CHEST
CONGESTION . . . . . . . 51
triamcinolone . . . . . . . . . 24
triamcinolone acetonide . 19, 24
triamcinolone inj . . . . . . . 25
triamcinolone nasal spray . . 24
TRIAMINIC . . . . . . . . . . . 23
TRIAMINIC LIQ CHST/NAS . 53
TRIAMINIC SYR CHST/NAS . 53
triamterene/
hydrochlorothiazide . . . 11
TRIANEX . . . . . . . . . . . . 19
TRIAVIL . . . . . . . . . . . . . 47
TRIAZ CLOTHS . . . . . . . . 17
triazolam . . . . . . . . . . . . 47
TRICOR . . . . . . . . . . . . . 11
TRI-FED X . . . . . . . . . . . . 54
trifluoperazine . . . . . . . . . 48
trifluridine . . . . . . . . . . . 45
trifluridine/tipiracil . . . . . . . 4
TRIGLIDE . . . . . . . . . . . . 11
trihexyphenidyl . . . . . . . . 16
TRILAFON . . . . . . . . . . . 48
TRILEPTAL . . . . . . . . . . . 16
TRILYTE . . . . . . . . . . . . 30
trimethobenzamide . . . . . . 28
trimethoprim . . . . . . . . . . 36
TRIMETHOPRIM . . . . . . . . 36
TRI-NORINYL . . . . . . . . . 41
TRIOTANN . . . . . . . . . . . 24
TRIOTANN PEDIATRIC SUSP 50
tripolidine/pseudoephedrine 54
TRIPROL/PSE SYP . . . . . . 54
TRI RX . . . . . . . . . . . . . 58
TRI-VI-FLOR . . . . . . . . . . 59
TRI-VI-SOL . . . . . . . . 59, 66
TRIVORA . . . . . . . . . . . . 41
ALL CAPS = Brand-name drug
lower case = Generic drug
88
TRIZIVIR . . . . . . . . . . . . 34
TROJAN . . . . . . . . . . . . 64
trospium . . . . . . . . . . . . 56
TRUSOPT . . . . . . . . . . . 43
TRUST NATALCARE
PAK DHA . . . . . . . . . . 59
TRUVADA . . . . . . . . . . . . 35
T-STAT . . . . . . . . . . . . . 18
TUCKS OINTMENT OTC . . . 21
TUMS . . . . . . . . . . . 65, 66
TUSSI 12D S . . . . . . . . . . 53
TUSSI-12 S . . . . . . . . . . . 50
TUSSIN DM . . . . . . . . . . 51
TYBOST . . . . . . . . . . . . 35
TYKERB . . . . . . . . . . . . . 4
TYLENOL . . . . . . . 13, 38, 65
TYLENOL W/CODEINE . . . 14
typhoid vaccine . . . . . . . . 62
TYR cooler, express, gel . . . 37
tyrex-1, tyrex-2 . . . . . . . . . 37
tyros-1, tyros-2 . . . . . . . . 37
TYVASO . . . . . . . . . . . . 12
TYZEKA . . . . . . . . . . . . 34
U
ULORIC . . . . . . . . . . . . . 39
ULTRAM . . . . . . . . . . . . 13
ULTRAVATE . . . . . . . . . . 19
UNI-HIST DRO . . . . . . . . . 49
UNIPHYL . . . . . . . . . . . . 55
UNIRETIC . . . . . . . . . . . . 8
UNIVASC . . . . . . . . . . . . .8
urea 40% . . . . . . . . . . . 22
UREA 40% LOTION . . . . . . 22
URECHOLINE . . . . . . . . . 56
UREX . . . . . . . . . . . . . . 56
uridine . . . . . . . . . . . . . 28
UROCIT-K . . . . . . . . . . . 56
UROXATRAL . . . . . . . . . . 55
URSO . . . . . . . . . . . . . 31
ursodiol . . . . . . . . . . . . 31
URSO FORTE . . . . . . . . . 31
Index of Covered Drugs
UTIRA C . . . . . . . . . . . . 56
V
VAGIFEM . . . . . . . . . . . . 41
vaginal products . . . . . . . 63
valacyclovir . . . . . . . . . . 34
VALCYTE . . . . . . . . . . . . 33
valganciclovir . . . . . . . . . 33
valine . . . . . . . . . . . . . . 38
VALIUM . . . . . . . . . . 39, 45
valproic acid . . . . . . . . . . 17
valsartan . . . . . . . . . . . . 8
valsartan/hydrochlorothiazide 9
VALTREX . . . . . . . . . . . . 34
VANCOCIN HCL . . . . . . . . 33
vancomycin HCl . . . . . . . 33
vandetanib . . . . . . . . . . . 5
VANTIN . . . . . . . . . . . . . 32
VAQTA . . . . . . . . . . . . . 61
varenicline . . . . . . . . . . . 48
varicella virus vac live for subcutaneous . . . . . . . . . . 62
VARIVAX . . . . . . . . . . . . 62
VASERETIC . . . . . . . . . . . 8
VASOCIDIN . . . . . . . . . . . 43
VASOCLEAR . . . . . . . . . . 42
VASOCLEAR A . . . . . . . . 42
VASOSULF . . . . . . . . . . . 45
VASOTEC . . . . . . . . . . . . .8
VECTICAL . . . . . . . . . . . 20
VEETIDS . . . . . . . . . . . . 32
velaglucerase alfa . . . . . . . 28
VELIVET . . . . . . . . . . . . 41
vemurafenib . . . . . . . . . . 5
venlafaxine . . . . . . . . . . 47
venlafaxine XR . . . . . . . . 47
VENTAVIS . . . . . . . . . . . . 12
VENTOLIN HFA . . . . . . . . 54
VEPESID . . . . . . . . . . . . . 6
VERALAN PM . . . . . . . . . 10
verapamil . . . . . . . . . 10, 15
verapamil extended-release . 10
VESANOID . . . . . . . . . . . .6
VEXOL . . . . . . . . . . . . . 43
VFEND . . . . . . . . . . . . . 33
VIBRAMYCIN . . . . . . . . . . 33
VICODIN . . . . . . . . . . . . 14
VICODIN ES . . . . . . . . . . 14
VICOPROFEN . . . . . . . . . 14
VICTOZA . . . . . . . . . . . . 27
VICTRELIS . . . . . . . . . . . 33
VI-DAYLIN . . . . . . . . . . . . 66
VIDEX . . . . . . . . . . . . . . 34
VIDEX EC . . . . . . . . . . . . 35
VIEKIRA PAK . . . . . . . . . . 34
vigabatrin oral solution . . . . 17
VIGAMOX . . . . . . . . . . . . 44
VIMPAT . . . . . . . . . . . . . 16
VINATE AZ EX . . . . . . . . . 58
VINATE III . . . . . . . . . . . . 58
VIRACEPT . . . . . . . . . . . 35
VIRAMUNE . . . . . . . . . . . 34
VIRAMUNE XR . . . . . . . . . 34
VIREAD . . . . . . . . . . . . . 35
VIROPTIC . . . . . . . . . . . . 45
VISINE . . . . . . . . . . . . . 65
VISINE-AC . . . . . . . . . . . 42
vismodegib . . . . . . . . . . . 6
VISTARIL . . . . . . . . . . . . 23
VISTIDE . . . . . . . . . . . . . 33
VISTOGARD . . . . . . . . . . 28
vitamin A . . . . . . . . . . . . 59
vitamin ADC/fluoride/±iron
drops . . . . . . . . . . . 59
vitamin B-1 . . . . . . . . . . 59
vitamin B-6 . . . . . . . . . . 59
VITAMIN B-12 . . . . . . . . . 56
vitamin B complex/
vitamin C/folic acid . . . . 59
vitamin C . . . . . . . . . . . 59
vitamin D . . . . . . . . . . . . 66
VITAMIN D . . . . . . . . . 56, 66
vitamins pediatric . . . . 59, 66
vitamins prenatal . . . . . . . 66
VITAPHIL . . . . . . . . . . . . 58
VITUSSIN . . . . . . . . . . . . 52
VIVACTIL . . . . . . . . . . . . 47
VIVELLE-DOT . . . . . . . . . 41
ALL CAPS = Brand-name drug
lower case = Generic drug
89
VIVITROL . . . . . . . . . . . . 48
VIVOTIF BERNA . . . . . . . . 62
VOLTAREN . . . . . . 13, 38, 43
VOLTAREN 1% TOPICAL GEL38
VOLTAREN XR . . . . . . 13, 38
voriconazole . . . . . . . . . . 33
vorinostat . . . . . . . . . . . . 4
VOSOL HC OTIC . . . . . . . 22
VOSOL OTIC . . . . . . . . . . 22
VOSPIRE ER . . . . . . . . . . 55
VOTRIENT . . . . . . . . . . . . 4
VPRIV . . . . . . . . . . . . . . 28
VYVANSE . . . . . . . . . . . . 46
W
warfarin . . . . . . . . . . . . . 7
WELLBUTRIN . . . . . . . . . 47
WELLBUTRIN SR . . . . . . . 47
WELLBUTRIN XL . . . . . . . 47
WESTCORT . . . . . . . . . . 19
WIDE-SEAL . . . . . . . . . . . 40
WND-1, WND-2 . . . . . . . . 38
WYTENSIN . . . . . . . . . . . 12
X
XALATAN . . . . . . . . . . . . 44
XALKORI . . . . . . . . . . . . .4
XANAX . . . . . . . . . . . . . 45
XANAX XR . . . . . . . . . . . 45
XARELTO . . . . . . . . . . . . .7
XELODA . . . . . . . . . . . . . 4
XENAZINE . . . . . . . . . . . 17
XLEU analog, maxamum,
maxamaid . . . . . . . . . 38
XLYS, XTRYP analog, maxamum, maxamaid . . . . . 38
XMET analog, maxamum,
maxamaid . . . . . . . . . 38
XMTVI analog, maxamum,
maxamaid . . . . . . . . . 38
XOLAIR . . . . . . . . . . . . . 55
XOLEGEL . . . . . . . . . . . . 20
XOLEGEL DUO KIT . . . . . . 20
XOLEGEL KIT . . . . . . . . . 20
Index of Covered Drugs
XOPENEX RESPULES . . . . 55
XYLOCAINE . . . . . . . . 21, 24
XYZAL . . . . . . . . . . . . . 23
Z
zafirlukast . . . . . . . . . . . 55
zaleplon . . . . . . . . . . . . 47
ZANAFLEX . . . . . . . . . . . 39
zanamivir . . . . . . . . . . . 34
ZANTAC . . . . . . . . . . . . 29
ZARONTIN . . . . . . . . . . . 16
ZAROXOLYN . . . . . . . . . . 11
ZARXIO . . . . . . . . . . . . . .7
ZEASORB-AF . . . . . . . . . 20
ZEBETA . . . . . . . . . . . . . .9
ZEBUTAL . . . . . . . . . . . . 13
ZELBORAF . . . . . . . . . . . .5
ZENPEP . . . . . . . . . . . . 30
ZENPEP DR . . . . . . . . . . 30
ZEPATIER . . . . . . . . . . . . 33
ZERIT . . . . . . . . . . . . . . 35
ZESTORETIC . . . . . . . . . . .8
ZESTRIL . . . . . . . . . . . . . 8
ZETIA . . . . . . . . . . . . . . 11
ZIAC . . . . . . . . . . . . . . . .9
ZIAGEN . . . . . . . . . . . . . 34
zidovudine . . . . . . . . . . . 35
zinc . . . . . . . . . . . . . . . 59
ZIOPTAN . . . . . . . . . . . . 44
ziprasidone . . . . . . . . . . 48
ZITHROMAX . . . . . . . . . . 32
ZOCOR . . . . . . . . . . . . . 11
ZOFRAN . . . . . . . . . . . . 28
ZOFRAN ODT . . . . . . . . . 28
ZOHYDRO ER . . . . . . . . . 14
ZOLINZA . . . . . . . . . . . . .4
ZOLOFT . . . . . . . . . . . . 46
zolpidem . . . . . . . . . . . . 47
ZONEGRAN . . . . . . . . . . 17
zonisamide . . . . . . . . . . 17
ZORTRESS . . . . . . . . . . . .6
ZOSTAVAX . . . . . . . . . . . 62
zoster vaccine live . . . . . . . 62
ZOVIA 1/35 . . . . . . . . . . 40
ZOVIA 1/50 . . . . . . . . . . 40
ZOVIRAX . . . . . . . . . . . . 34
ZOVIRAX CREAM . . . . . . . 34
ZOVIRAX OINTMENT . . . . . 34
ZYBAN . . . . . . . . . . . . . 48
ZYKADIA . . . . . . . . . . . . .4
ZYLOPRIM . . . . . . . . . . . 39
ZYMAR . . . . . . . . . . . . . 44
ZYPREXA . . . . . . . . . . . . 48
ZYPREXA ZYDIS . . . . . . . 48
ZYRTEC . . . . . . . . . . 23, 63
ZYRTEC D . . . . . . . . 24, 64
ZYTIGA . . . . . . . . . . . . . .5
ZYVOX . . . . . . . . . . . . . 36
ALL CAPS = Brand-name drug
lower case = Generic drug
90
Notes
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91
“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, 20mg
Tier 1
High blood pressure
One tablet daily
Dr. Johnson
92
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10/16