1. No category

Preferred Drug List
 Generics Plus
21NVHPN12912
Generic Plus Drug Benefit Guide
Table of Contents
Introduction .............................................................. i
Drug Benefit Guide .................................................. 1
Section 1
Section 2
Section 3
Section 4
Section 5
Section 6
Section 7
Section 8
Section 9
Section 10
Section 11
Section 12
Section 13
Anti-Infectives
Cancer and Transplant
Cardiovascular
Central Nervous System
Dermatologicals
Endocrine and Hormones
Gastrointestinals
Genitourinary
Musculoskeletal and Pain
Vitamins and Hematologicals
Eye, Ear, and Throat
Respiratory
Self-Injectable/Specialty
Alphabetical Index ................................................... 29
Generic Plus Drug Benefit Guide
Introduction
As a member of a health plan that includes outpatient prescription drug coverage, you have
access to a wide range of effective and affordable medications. The health plan utilizes a
Preferred Drug List (PDL) (also known as a drug formulary) as a tool to guide providers to
prescribe clinically sound yet cost-effective drugs. This list was established to give you access to
the prescription drugs you need at a reasonable cost. Your out-of-pocket prescription cost is
lower when you use preferred medications. Please refer to your Prescription Drug Benefit Rider
or Evidence of Coverage for specific pharmacy benefit information.
The PDL is a list of FDA-approved generic and brand name medications recommended for use
by your health plan. The list is developed and maintained by a Pharmacy and Therapeutics
(P&T) Committee comprised of actively practicing primary care and specialty physicians,
pharmacists and other healthcare professionals. Patient needs, scientific data, drug effectiveness,
availability of drug alternatives currently on the PDL and cost are all considerations in selecting
"preferred" medications. Due to the number of drugs on the market and the continuous
introduction of new drugs, the PDL is a dynamic and routinely updated document screened
regularly to ensure that it remains a clinically sound tool for our providers.
Reading the Drug Benefit Guide
Preferred generic and brand name medications are available for the applicable preferred generic
(tier 1) or preferred brand name (tier 2) copayment. In addition, non-preferred medications, as
well as some medications not listed on the HPN PDL are also covered for a higher (tier 3)
copayment. Certain medications may have quantity, age or therapeutic supply limitations based
on FDA approved dosages, literature documentation or P&T Committee decisions. See your
plan documents for a complete list of covered benefits, limitations and exclusions.
For your convenience, medications are grouped together based on their therapeutic category (i.e.,
Anti-Infectives, Cardiovascular, etc.) and further separated into drug classes (i.e.,
Antidepressants, Contraceptives, etc.). Each drug class has a designated section number (i.e., 1A, 1-B, etc.) and is the reference point noted in the index.
The generic or chemical name is listed to the left of the brand or trade name for each drug.
Drugs with a generic equivalent available are identified by an asterisk (*) before the common
brand name of the product (for example, in the listing for ampicillin.....*PRINCIPEN, indicates
that PRINCIPEN is available as a generic and ampicillin would be dispensed by the pharmacy).
Drugs that are not available generically have the brand-name listed in BOLD print (for example,
the listing for everolimus..... AFINITOR, indicates that there is no generic for AFINITOR and
the brand name product will be dispensed).
Other abbreviations used throughout the PDL are:
• AL
= age limitations
• NTI
= narrow therapeutic index (generic not required)
• PA
= prior authorization
• QL
= quantity limitations
• SIO
= self-injectable/orphan drug
i
•
•
ST
SP
= step therapy
= specialty drug: see www.uhcspecialtyrx.com
Mandatory Generic Substitution Policy
Most of our prescription drug plans include a mandatory generic requirement, therefore, if a
preferred brand name drug is dispensed when a preferred generic equivalent is available, you will
be required to pay the difference between the contracted cost of the generic and brand name drug
in addition to the preferred generic (tier 1) copayment. Please note that not all dosage forms or
strengths may be available in a generic form. The asterisk (*) indicates that at least one form
or strength of the drug is available as a generic at the time of printing. Check with your
pharmacist for more information.
Since this list is to be used in the decision-making process and does not represent standards of
care for an individual, we encourage you to take this reference to all doctor appointments and
verify that the drug he/she prescribes is included on this list. You and your provider should
discuss the best possible treatment plan and medications to meet your needs. Because a drug is
included on our Preferred Drug List does not guarantee that the provider will prescribe that
medication. Your copayment is less if the provider prescribes a preferred medication.
If you have any questions regarding HPN’s Preferred Drug List or to obtain the most current
version, please visit our website or contact our Member Services Department. Our
representatives are available from 8 a.m. to 5 p.m., Monday through Friday. We are proud to be
your healthcare provider of choice. Working together, we can achieve our common goal – to
keep you healthy!
Health Plan of Nevada, Inc.
www.healthplanofnevada.com
(702) 242-7300 or (800) 777-1840
Sierra Health and Life Insurance Company, Inc.
www.sierrahealthandlife.com
(702) 242-7700 or (800) 888-2264
This summary is not an offer of coverage. If there are any differences between the information
contained within this document and a specific plan document, the plan documents will govern.
Participating pharmacies in our retail and/or mail-order network are independent contractors
and are neither employees nor agents of the health plan or its affiliates. This is not meant to
replace the advice of a healthcare provider. This is a proprietary document and may not be
copied or distributed without the express permission the health plan.
ii
Generics Plus Preferred Drug List
This drug benefit guide is applicable for HPN, and SHL
members with generic plus prescription drug benefit
ANTI-INFECTIVES (drugs to treat infections)
1-A Penicillins
Generic Name
amoxicillin
amoxicillin
amoxicillin-clavulanate
ampicillin
dicloxacillin
penicillin V potassium
1-B Cephalosporins
Generic Name
cefaclor
cefadroxil
cefdinir caps
cefdinir susp 125mg/5ml
cefdinir susp 250mg/5ml
cefpodoxime
cefprozil
cefprozil
cefprozil
cefprozil
ceftibuten
cefuroxime
cefuroxime
cephalexin
1-C Macrolides
Generic Name
azithromycin
azithromycin
azithromycin
azithromycin
azithromycin
clarithromycin
clarithromycin SR
QL - Quantity Limits AL - Age Limits
PA - Prior Authorization Required
ST - Step Therapy Required
SIO - Self-Injectable Orphan
Notes
Tier
1
1 QL (10 tablets/50 days)
1
1
1
1
Brand Name
*AMOXIL
*MOXATAG
*AUGMENTIN
*PRINCIPEN
*VEETIDS
Brand Name
*CECLOR
*DURICEF
Notes
*VANTIN 200mg
*CEFZIL 250mg
*CEFZIL 500mg
*CEFZIL 125mg/ml
*CEFZIL 250mg/ml
*CEDAX
*CEFTIN (tablets)
*CEFTIN (suspension)
*KEFLEX
Tier
1
1
1
1
1
1
1
1
1
1
1
1
1
1
QL (24 ml/day)
QL (12 ml/day)
QL (28 tablets/month)
QL (28 tablets/month)
QL (28 tablets/month)
QL (140 mls/month)
QL (140 mls/month)
Brand Name
*ZITHROMAX 250mg
*ZITHROMAX 500mg
*ZITHROMAX 600mg
*ZITHROMAX 100mg/5ml
*ZITHROMAX 200mg/5ml
*BIAXIN
*BIAXIN XL
Tier
1
1
1
1
1
1
1
Notes
QL (6 tablets/fill)
QL (4 tablets/fill)
QL (8 tablets/fill)
QL (30 mls/fill)
QL (30 mls/fill)
QL (28 tablets/month)
QL (28 tablets/month)
QL (28 tablets/month)
Gen Plus PDL
02/01/2015
1
clindamycin *CLEOCIN
erythromycin EC *ERY-TAB
erythromycin ethylsuccinate *EES
erythromycin ethylsuccinate *ERYPED
erythromycin stearate *ERYTHROCIN
1
1
1
1
1
1-D Tetracyclines
Generic Name Brand Name
doxycycline hyclate *PERIOSTAT
doxycycline hyclate 50mg caps *VIBRAMYCIN
doxycycline hyclate 100mg caps *VIBRAMYCIN
doxycycline monohydrate susp *VIBRAMYCIN SUSP
doxycycline hyclate 100mg tabs *VIBRATAB
doxycycline monohydrate 100mg caps *MONODOX 100mg
doxycycline monohydrate 50mg caps *MONODOX 50mg
minocycline tablets *DYNACIN
minocycline capsules *MINOCIN
tetracycline *SUMYCIN
1-E Fluoroquinolones
Generic Name Brand Name
ciprofloxacin *CIPRO
ciprofloxacin SR *CIPRO XR
ciprofloxacin oral susp 250mg/5ml *CIPRO (5%)
levofloxacin *LEVAQUIN
moxifloxacin *AVELOX
ofloxacin *FLOXIN
1-F Antimycobacterial Agents
Generic Name Brand Name
ethambutol *MYAMBUTOL
isoniazid
pyrazinamide
rifabutin *MYCOBUTIN
rifampin *RIFADIN
1-G Antifungals
Generic Name Brand Name
fluconazole *DIFLUCAN 50mg
fluconazole *DIFLUCAN 100mg
fluconazole *DIFLUCAN 150mg
fluconazole *DIFLUCAN 200mg
griseofulvin microsize *GRIFULVIN V
itraconazole *SPORANOX
ketoconazole *NIZORAL
nystatin *MYCOSTATIN susp
terbinafine HCL *LAMISIL
QL - Quantity Limits AL - Age Limits
PA - Prior Authorization Required
ST - Step Therapy Required
SIO - Self-Injectable Orphan
Tier
Notes
3 QL (60 tablets/month)
3
3
3
3
1 QL (28 capsules/month)
1
3
1 QL (60 capsules/month)
3
Notes
Tier
1 QL (60 tablets/month)
1 QL (14 tablets/month)
1
1 QL (14 tablets/month)
1
1
Tier
1
1
1
1
1
Tier
1
1
1
1
1
1
1
1
1
Notes
Notes
QL (30 tablets/month)
QL (30 tablets/month)
QL (1 tablet/fill)
QL (30 tablets/month)
QL (14 capsules/month)
QL (90 tablets/year)
Gen Plus PDL
02/01/2015
2
voriconazole *VFEND 50mg
voriconazole *VFEND 200mg
1-H Miscelleanous Antivirals
Generic Name Brand Name
acyclovir *ZOVIRAX
famciclovir *FAMVIR 125mg
famciclovir *FAMVIR 250mg
famciclovir *FAMVIR 500mg
ribavirin *REBETOL capsules/tablets
rimantadine *FLUMADINE
valacyclovir *VALTREX 500mg
valacyclovir *VALTREX 1gm
valganciclovir HCL *VALCYTE
1-I Antiretrovirals
Generic Name Brand Name
abacavir-lamivudine-zidovudine *TRIZIVIR
didanosine
didanosine *VIDEX EC
entecavir *BARACLUDE
lamivudine *EPIVIR
lamivudine-zidovudine Combivir
nevirapine *VIRAMUNE
nevirapine XR *VIRAMUNE XR 400MG
stavudine *ZERIT
zidovudine *RETROVIR
1-J Antimalarials
Generic Name Brand Name
chloroquine *ARALEN
hydroxychloroquine *PLAQUENIL
mefloquine *LARIAM
primaquine *PRIMAQUINE
quinine sulfate
ivermectin *STROMECTOL
1-L Misc Anti-Infectives
Generic Name Brand Name
atovaquone *MEPRON
EES-sulfisoxazole *PEDIAZOLE
iodoquinol *YODOXIN
metronidazole *FLAGYL tablets
metronidazole *FLAGYL capsule
neomycin *MYCIFRADIN
SMZ-TMP *BACTRIM
SMZ-TMP *SEPTRA
sulfadiazine
QL - Quantity Limits AL - Age Limits
PA - Prior Authorization Required
ST - Step Therapy Required
SIO - Self-Injectable Orphan
1
1
Tier
1
1
1
1
1
1
1
1
1
Tier
1
1
1
1
1
1
1
1
1
1
QL (180 tablets/month)
QL (60 tablets/month)
Notes
QL (60 tablets/month)
QL (60 tablets/month)
QL (21 tablets/month)
QL (180 caps/tabs month) PA SP
QL (14 pills/fill)
QL (60 tablets/month)
QL (30 tablets/month)
QL (60 tablets/month)
Notes
SP
SP
QL (30 tablets/month) SP
SP
SP
SP
SP
SP
SP
Tier
1
1
1
1
1
1
Notes
Tier
1
1
1
1
1
1
1
1
1
Notes
Gen Plus PDL
02/01/2015
3
tobramycin *TOBI
trimethoprim *TRIMPEX
vancomycin *VANCOCIN
1
1
1
PA SP
QL (56 capsules/14 days) PA
CANCER and TRANSPLANT (drugs to treat cancers and prevent organ rejection)
2-A Antineoplastics (cancer drugs)
Tier
Generic Name Brand Name
abiraterone acetate ZYTIGA
2
altretamine HEXALEN
2
bexarotene TARGRETIN
3
busulfan MYLERAN
2
cabozantinib COMETRIQ
3
capecitabine *XELODA
3
ceritinib ZYKADIA
3
chlorambucil LEUKERAN
2
crizotinib XALKORI
3
cyclophosphamide CYTOXAN
2
dabrafenib mesylat TAFINLAR
3
dasatinib SPRYCEL
3
erlotinib TARCEVA
3
estramustine EMCYT
2
etoposide *VEPESID
1
everolimus AFINITOR
3
fludarabine OFORTA
3
flutamide *EULEXIN
1
gefitinib IRESSA
3
hydroxyurea *HYDREA
1
ibrutinib IMBRUVICA
3
idelalisib ZYDELIG
3
imatinib mesylate GLEEVEC
2
lapatinib ditosylate TYKERB
3
lenalidomide REVLIMID
3
lomustine *CEENU
1
mechlorethamine hcl VALCHLOR
3
megestrol *MEGACE ES
1
melphalan ALKERAN
2
mercaptopurine *PURINETHOL
1
mercaptopurine PURIXAN
3
mitotane LYSODREN
2
nilotinib TASIGNA
3
nilutamide NILANDRON
3
olaparib LYNPARZA
3
pazopanib VOTRIENT
3
3
pomalidomide POMALYST
ponatinib hcl ICLUSIG
3
Iclusig ST = requires trial of Tasigna
QL - Quantity Limits AL - Age Limits
PA - Prior Authorization Required
ST - Step Therapy Required
SIO - Self-Injectable Orphan
Notes
PA
SP
PA
PA SP
PA SP
PA
PA SP
PA SP
PA SP
PA SP
PA
QL (30 tablets/month)
PA SP
PA SP
PA SP
PA SP
PA SP
PA SP
PA
PA SP
PA SP
PA SP
PA SP
PA ST
Gen Plus PDL
02/01/2015
4
procarbazine HCL MATULANE
2
sorafenib tosylate NEXAVAR
3 PA SP
sunitinib SUTENT
3 PA SP
temozolomide *TEMODAR
1 PA SP
thioguanine THIOGUANINE
2
topotecan HYCAMTIM
3 PA
toremifene citrate FARESTON
3 QL (30 tablets/month)
tretinoin *VESANOID
1 SP
vemurafenib ZELBORAF
3 PA SP
3 PA SP
vorinostat ZOLINZA
abiraterone acetate ZYTIGA
3 PA
altretamine HEXALEN
2
anastrozole *ARIMIDEX
1 QL (30 tablets/month)
axitinib INLYTA
3 QL PA SP
bexarotene TARGRETIN
3 SP
bicalutamide *CASODEX
1
bosutinib BOSULIF
3 PA ST SP
Bosulif ST = requires failure to Tasigna and Gleevec
busulfan MYLERAN
2
capecitabine XELODA
3 PA SP
chlorambucil LEUKERAN
2
crizotinib XALKORI
3 PA
cyclophosphamide CYCLOPHOSPH
3
cyclophosphamide CYTOXAN
2
dasatinib SPRYCEL
3 PA SP SP
Sprycel ST = requires trial of Tasigna
degarelix acetate FIRMAGON
3 SP (80MG - 1 vial/mo and 120MG vial enzalutamide XTANDI
3 PA ST SP
Xtandi ST = requires trial of Zytiga
erlotinib TARCEVA
3 PA SP
estramustine EMCYT
2
etoposide *VEPESID
1
everolimus AFINITOR
3 PA SP
exemestane *AROMASIN
1 QL (30 tablets/month)
fludarabine OFORTA
3 PA
flutamide *EULEXIN
1
gefitinib IRESSA
3 QL (30 tablets/month)
hydroxyurea *HYDREA
1
hydroxyurea DROXIA
3
imatinib mesylate GLEEVEC
3 PA SP
lapatinib ditosylate TYKERB
3 PA SP
lenalidomide REVLIMID
3 PA SP
letrozole *FEMARA
1 QL (30 tablets/month)
leucovorin calcium *LEUCOVORIN CALCIUM
1 SIO
leucovorin calcium *WELLCOVORIN
1
lomustine CEENU
2
QL - Quantity Limits AL - Age Limits
PA - Prior Authorization Required
ST - Step Therapy Required
SIO - Self-Injectable Orphan
vials/year
Gen Plus PDL
02/01/2015
5
megestrol *MEGACE
megestrol MEGACE ES
melphalan ALKERAN
mercaptopurine *PURINETHOL
mesna MESNEX
methotrexate
methotrexate TREXALL
mitotane LYSODREN
nilotinib TASIGNA
nilutamide NILANDRON
pazopanib VOTRIENT
procarbazine HCL MATULANE
regorafenib STIVARGA
ruxolitinib phosphate JAKAFI
sorafenib tosylate NEXAVAR
sunitinib SUTENT
tamoxifen *NOLVADEX
tamoxifen SOLTAMOX
temozolomide TEMODAR
testolactone TESLAC
thalidomide THALOMID
thioguanine THIOGUANINE
topotecan HYCAMTIM
toremifene citrate FARESTON
trametinib dimethyl sulfoxide MEKINIST
tretinoin *VESANOID
vandetanib CAPRELSA
vemurafenib ZELBORAF
vismodegib ERIVEDGE
vorinostat ZOLINZA
2-B Immunosuppressives
Generic Name Brand Name
azathioprine *IMURAN
cyclosporine *SANDIMMUNE (NTI)
cyclosporine modified *GENGRAF
cyclosporine modified *NEORAL (NTI)
mycophenlate *MYFORTIC
mycophenolate mofetil *CELLCEPT
sirolimus *RAPAMUNE
tacrolimus *PROGRAF
1
3
2
1
2
1
3
2
3
3
3
2
3
3
3
3
1
3
3
2
3
2
3
3
3
1
3
3
3
3
Tier
1
2
1
2
1
1
1
1
PA
PA SP
PA SP
PA SP
PA
PA SP
PA SP
PA SP
PA SP
PA
QL (30 tablets/month)
PA SP
SP
PA SP
PA SP
QL PA SP
PA SP
Notes
SP
SP
SP
QL (120 tablets/month) SP
SP
SP
SP
CARDIOVASCULAR (drugs to treat heart conditions)
digoxin *LANOXIN (NTI)
2
3-B Antianginals
Generic Name Brand Name
isosorbide dinitrate *ISORDIL
QL - Quantity Limits AL - Age Limits
PA - Prior Authorization Required
ST - Step Therapy Required
SIO - Self-Injectable Orphan
Tier
1
Notes
Gen Plus PDL
02/01/2015
6
isosorbide mononitrate *IMDUR
1
nitroglycerin ointment *NITROBID
1
nitroglycerin patch *MINITRAN
1
nitroglycerin patch *NITRO-DUR
1
nitroglycerin spray *NITROLINGUAL PUMPSPRAY 1
3-C Beta Blockers
Notes
Generic Name Brand Name
Tier
acebutolol *SECTRAL
1
atenolol *TENORMIN
1
betaxolol *KERLONE
1
bisoprolol *ZEBETA
1
carvedilol *COREG 3.125mg
1 QL (60 tablets/month)
carvedilol *COREG 6.25mg
1 QL (60 tablets/month)
carvedilol *COREG 12.5mg
1 QL (60 tablets/month)
carvedilol *COREG 25mg
1 QL (120 tablets/month)
labetalol *NORMODYNE
1
labetalol *TRANDATE
1
metoprolol *LOPRESSOR
1
metoprolol succinate SR *TOPROL XL
1 QL (45 tablets/month)
nadolol *CORGARD 20mg
1 QL (90 tablets/month)
nadolol *CORGARD 40mg
1 QL (60 tablets/month)
nadolol *CORGARD 80mg
1 QL (90 tablets/month)
nadolol *CORGARD 120mg
1 QL (60 tablets/month)
pindolol *VISKEN
1
propranolol *INDERAL
1
propranolol HCL CR *INDERAL LA
1
sotalol *BETAPACE
1
sotalol AF *BETAPACE AF
1
timolol maleate *BLOCADREN
1
3-D Calcium Channel Blockers
Generic Name Brand Name
Tier
Notes
amlodipine *NORVASC
1
cartia XT
2 QL (60 capsules/month)
diltiazem *CARDIZEM
1
diltiazem SR *TIAZAC
1
diltiazem SR 12HR *CARDIZEM SR
1
felodipine *PLENDIL
1 QL (60 tablets/month)
isradipine *DYNACIRC
1 QL (60 tablets/month)
nicardipine *CARDENE
1
nifedipine CR *ADALAT CC
1
nifedipine CR *PROCARDIA XL
1
nifedipine IR *ADALAT CC
1
nifedipine IR *PROCARDIA
1
nisoldipine SR *SULAR 8.5mg
1 QL (30 tablets/month)
nisoldipine SR *SULAR 10mg
1 QL (30 tablets/month)
nisoldipine SR *SULAR 17mg
1 QL (30 tablets/month)
QL - Quantity Limits AL - Age Limits
PA - Prior Authorization Required
ST - Step Therapy Required
SIO - Self-Injectable Orphan
Gen Plus PDL
02/01/2015
7
nisoldipine SR *SULAR 20mg
nisoldipine SR *SULAR 25.5mg
nisoldipine SR *SULAR 30mg
nisoldipine SR *SULAR 34mg
nisoldipine SR *SULAR 40mg
verapamil *CALAN
verapamil SR *CALAN SR
verapamil SR *VERELAN PM
3-E Antiarrhythmics
Generic Name Brand Name
amiodarone *CORDARONE
disopyramide *NORPACE
flecainide *TAMBOCOR
mexiletine *MEXITIL
propafenone *RYTHMOL
propafenone *RYTHMOL SR
quinidine gluconate
quinidine sulfate
3-F Angiotensin Converting Enzyme (ACE) Inhibitors
Generic Name Brand Name
benazepril *LOTENSIN
captopril *CAPOTEN
enalapril *VASOTEC
fosinopril *MONOPRIL
lisinopril *PRINIVIL
lisinopril *ZESTRIL
moexipril *UNIVASC
perindopril *ACEON
quinapril *ACCUPRIL
ramipril *ALTACE
trandolapril *MAVIK
3-G Angiotensin II Receptor Blockers (ARB's)
Generic Name Brand Name
candesartan *ATACAND
eprosartan *Teveten 600mg
irbesartan *AVAPRO
losartan *COZAAR 25mg
losartan *COZAAR 50mg
losartan *COZAAR 100mg
valsartan *DIOVAN 40mg
valsartan *DIOVAN 80mg
valsartan *DIOVAN 160mg
valsartan *DIOVAN 320mg
3-H Miscellaneous Antihypertensives
Generic Name Brand Name
clonidine *CATAPRES
QL - Quantity Limits AL - Age Limits
PA - Prior Authorization Required
ST - Step Therapy Required
SIO - Self-Injectable Orphan
1
1
1
1
1
1
1
1
Tier
1
1
1
1
1
1
1
1
QL (30 tablets/month)
QL (60 tablets/month)
QL (60 tablets/month)
QL (30 tablets/month)
QL (30 tablets/month)
Notes
Tier
1
1
1
1
1
1
1
1
1
1
1
Notes
QL (60 tablets/month)
Tier
1
1
1
1
1
1
1
1
1
1
Notes
QL (60 tablets/month)
QL (30 tablets/month)
QL (30 tablets/month)
QL (60 tablets/month)
QL (60 tablets/month)
QL (30 tablets/month)
QL (30 tablets/month)
QL (30 tablets/month)
QL (60 tablets/month)
QL (30 tablets/month)
Tier
1
QL (60 tablets/month)
QL (60 tablets/month)
QL (60 tablets/month)
QL (60 tablets/month)
QL (60 tablets/month)
QL (60 tablets/month)
QL (60 tablets/month)
QL (60 capsules/month)
QL (60 tablets/month)
Notes
Gen Plus PDL
02/01/2015
8
clonidine patch *CATAPRES-TTS
1 QL (8 patches/month)
doxazosin *CARDURA
1 QL (60 tablets/month)
guanfacine *TENEX
1
1
hydralazine *APRESOLINE
methyldopa *ALDOMET
1
minoxidil *LONITEN
1
prazosin *MINIPRESS
1
reserpine
1
sildenafil *REVATIO
1 PA SP
1 QL (60 capsules/month)
terazosin *HYTRIN
3-I Antihypertensive Combinations
Generic Name Brand Name
Tier
Notes
amlodipine-benazepril *LOTREL
1 QL (30 capsules/month)
atenolol-chlorthalidone *TENORETIC
1
benazepril-HCTZ *LOTENSIN HCT
1 QL (60 tablets/month)
bisoprolol-HCTZ *ZIAC
1
candesartan-HCTZ *ATACAND HCT
1 QL (60 tablets/month)
captopril-HCTZ *CAPOZIDE
1
enalapril-HCTZ *VASERETIC
1
fosinopril-HCTZ *MONOPRIL HCT
1 QL (60 tablets/month)
irbesartan-HCTZ *AVALIDE
1 QL (30 tablets/month)
lisinopril-HCTZ *PRINZIDE
1
lisinopril-HCTZ *ZESTORETIC
1
losartan-HCTZ *HYZAAR
1 QL (30 tablets/month)
methyldopa-HCTZ *ALDORIL
1
moexipril-HCTZ *UNIRETIC
1 QL (60 tablets/month)
nadolol-bendroflumethiazide *CORZIDE
1 QL (60 tablets/month)
propranolol-HCTZ *INDERIDE
1
quinapril-HCTZ *ACCURETIC
1 QL (60 tablets/month)
telmisartan-HCTZ *MICARDIS HCT
1 QL (30 tablets/month)
trandolapril-verapamil *TARKA
1 QL (60 tablets/month)
valsartan-HCTZ *DIOVAN-HCT 80-12.5mg & 160-12.5mg 1 QL (60 tablets/month)
valsartan-HCTZ *DIOVAN-HCT 160-25mg, 320-12.5mg, & 320-25mg 1 QL (30 tablets/month)
3-J Diuretics
Generic Name Brand Name
Tier
Notes
acetazolamide *DIAMOX
1
amiloride
1
amiloride-HCTZ *MODURETIC
1
bumetanide *BUMEX
1
chlorothiazide *DIURIL
1
chlorthalidone *HYGROTON
1
eplerenone *INSPRA
1 QL (30 tablets/month)
furosemide *LASIX
1
hydrochlorothiazide *HYDRODIURIL
1
hydrochlorothiazide *MICROZIDE
1
indapamide *LOZOL
1
QL - Quantity Limits AL - Age Limits
PA - Prior Authorization Required
ST - Step Therapy Required
SIO - Self-Injectable Orphan
Gen Plus PDL
02/01/2015
9
methazolamide *NEPTAZANE
methyclothiazide *AQUATENSEN
metolazone *ZAROXOLYN
spironolactone *ALDACTONE
spironolactone-HCTZ *ALDACTAZIDE
torsemide *DEMADEX
triamterene-HCTZ *DYAZIDE
triamterene-HCTZ *MAXZIDE
3-K Pressors
Generic Name Brand Name
midodrine *PROAMATINE
3-L Antihyperlipidemics
Generic Name Brand Name
atorvastatin *LIPITOR
cholestyramine *QUESTRAN
colestipol *COLESTID
fenofibrate *LIPOFEN
fenofibrate *LOFIBRA
fenofibrate *ANTARA
fenofibrate *TRICOR
gemfibrozil *LOPID
lovastatin *MEVACOR 10mg
lovastatin *MEVACOR 20mg
lovastatin *MEVACOR 40mg
niacin SR *NIASPAN
omega-3-acid ethyl esters *LOVAZA
pravastatin *PRAVACHOL
simvastatin *ZOCOR
1
1
1
1
1
1
1
1
Tier
1
Tier
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
Notes
Notes
QL (30 tablets/month)
QL (30 tablets/month)
QL (30 capsules/month)
QL (30 capsules/month)
QL (30 tablets/month)
QL (30 tablets/month)
QL (30 tablets/month)
QL (60 tablets/month)
PA QL (120 capsules/month)
QL (30 tablets/month)
QL (30 tablets/month)
CENTRAL NERVOUS SYSTEM (drugs that affect the brain)
4-A Antianxiety Agents
Generic Name Brand Name
alprazolam *XANAX
alprazolam SR *XANAX XR 0.5mg
alprazolam SR *XANAX XR 1mg
alprazolam SR *XANAX XR 2mg
alprazolam SR *XANAX XR 3mg
alprazolam *NIRAVAM
buspirone *BUSPAR 10mg
buspirone *BUSPAR 15mg
chlordiazepoxide *LIBRIUM
clorazepate *TRANXENE
diazepam *VALIUM
hydroxyzine HCL *ATARAX
hydroxyzine pamoate *VISTARIL
lorazepam *ATIVAN
QL - Quantity Limits AL - Age Limits
PA - Prior Authorization Required
ST - Step Therapy Required
SIO - Self-Injectable Orphan
Tier
1
1
1
1
1
1
1
1
1
1
1
1
1
1
Notes
QL (30 tablets/month)
QL (30 tablets/month)
QL (30 tablets/month)
QL (60 tablets/month)
QL (60 tablets/month)
QL (120 tablets/month)
Gen Plus PDL
02/01/2015
10
meprobamate
oxazepam
4-B Antidepressants
Generic Name
amitriptyline
amoxapine
bupropion
bupropion
bupropion SR
bupropion SR
bupropion SR
bupropion XL
citalopram
clomipramine
desipramine
doxepin
duloxetine
duloxetine
duloxetine
escitalopram
escitalopram
escitalopram
fluoxetine
fluoxetine
fluoxetine
fluoxetine
fluoxetine
fluvoxamine
fluvoxamine
fluvoxamine
imipramine
maprotiline
mirtazapine
mirtazapine soltabs
nefazodone HCL
nortriptyline
paroxetine HCL
paroxetine HCL
paroxetine HCL
paroxetine HCL
paroxetine HCL SR
paroxetine HCL SR
paroxetine HCL SR
phenelzine sulfate
protriptyline
sertraline HCL
QL - Quantity Limits AL - Age Limits
PA - Prior Authorization Required
ST - Step Therapy Required
SIO - Self-Injectable Orphan
1
1
*SERAX
Brand Name
*ELAVIL
*ASENDIN
*WELLBUTRIN 75mg
*WELLBUTRIN 100mg
*WELLBUTRIN SR 100mg
*WELLBUTRIN SR 150mg
*WELLBUTRIN SR 200mg
*WELLBUTRIN XL
*CELEXA
*ANAFRANIL
*NORPRAMIN
*SINEQUAN
*CYMBALTA 20mg
*CYMBALTA 30mg
*CYMBALTA 60mg
*LEXAPRO 5mg
*LEXAPRO 10mg
*LEXAPRO 20mg
*PROZAC 10mg
*PROZAC 20mg
*PROZAC 40mg
*PROZAC 60mg
*PROZAC WEEKLY
*LUVOX
*LUVOX CR 100mg
*LUVOX CR 150mg
*TOFRANIL
*LUDIOMIL
*REMERON
*REMERON SOLTABS
*SERZONE
*PAMELOR
*PAXIL 10mg
*PAXIL 20mg
*PAXIL 30mg
*PAXIL 40mg
*PAXIL CR 12.5mg
*PAXIL CR 25mg
*PAXIL CR 37.5mg
*NARDIL
*VIVACTIL
*ZOLOFT 25mg
Tier
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
Notes
QL (180 tablets/month)
QL (120 tablets/month)
QL (60 tablets/month)
QL (60 tablets/month)
QL (60 tablets/month)
QL (30 tablets/month)
QL (45 tablets/month)
M
QL (60 capsules/month)
QL (60 capsules/month)
QL (30 capsules/month)
QL (45 tablets/month)
QL (45 tablets/month)
QL (30 tablets/month)
QL (30 capsules/month)
QL (120 capsules/month)
QL (60 capsules/month)
QL (30 capsules/month)
QL (4 capsules/month)
QL (90 tablets/month)
QL (30 capsules/month)
QL (60 capsules/month)
QL (30 tablets/month)
QL (30 tablets/month)
QL (30 tablets/month)
QL (30 tablets/month)
QL (60 tablets/month)
QL (45 tablets/month)
QL (30 tablets/month)
QL (60 tablets/month)
QL (60 tablets/month)
QL (45 tablets/month)
Gen Plus PDL
02/01/2015
11
sertraline HCL *ZOLOFT 50mg
1 QL (45 tablets/month)
sertraline HCL *ZOLOFT 100mg
1 QL (60 tablets/month)
trazodone *DESYREL
1
trimipramine maleate *SURMONTIL
1
venlafaxine *EFFEXOR
1 QL (90 tablets/month)
venlafaxine SR *EFFEXOR XR (cap) 37.5mg
1 QL (90 capsules/month)
venlafaxine SR *EFFEXOR XR (cap) 75mg
1 QL (90 capsules/month)
venlafaxine SR *EFFEXOR XR (cap) 150mg
1 QL (60 capsules/month)
venlafaxine SR *EFFEXOR XR (cap) 225mg
1 QL (30 capsules/month)
venlafaxine SR *VENLAFAXINE XR (tab) 37.5mg 1 QL (90 tablets/month)
venlafaxine SR *VENLAFAXINE XR (tab) 75mg 1 QL (90 tablets/month)
venlafaxine SR *VENLAFAXINE XR (tab) 150mg 1 QL (60 tablets/month)
venlafaxine SR *VENLAFAXINE XR (tab) 225mg 1 QL (30 tablets/month)
4-C Hypnotics (Sleep Aids)
Tier
Generic Name Brand Name
Notes
estazolam *PROSOM
1
eszopiclone *LUNESTA
1 QL (30 tablets/month) ST
Lunesta ST = requires 30 day fill of zolpidem in the past 2 years
flurazepam *DALMANE
1
phenobarbital
1
temazepam *RESTORIL
1 QL (30 capsules/month)
triazolam *HALCION
1 QL (15 tablets/fill; 2 fills/month)
zaleplon *SONATA 5mg
1 QL (30 capsules/month)
zaleplon *SONATA 10mg
1 QL (60 capsules/month)
zolpidem *AMBIEN
1 QL (30 tablets/month)
zolpidem CR *AMBIEN CR
1 QL (30 tablets/month)
1
chlorpromazine *THORAZINE
clozapine *FAZACLO
1 PA
clozapine *CLOZARIL (NTI)
2 PA
fluphenazine *PROLIXIN
1
1
haloperidol *HALDOL
lithium carbonate *ESKALITH
1
lithium carbonate CR *ESKALITH CR
1
lithium carbonate CR *LITHOBID
1
1
loxapine *LOXITANE
olanzapine *ZYPREXA
1 QL (30 tablets/month)
olanzapine *ZYPREXA ZYDIS
1 QL (30 tablets/month)
perphenazine *TRILAFONE
1
prochlorperazine *COMPAZINE
1
quetiapine fumarate *SEROQUEL 25mg
1 QL (90 tablets/month)
quetiapine fumarate *SEROQUEL 100mg
1 QL (90 tablets/month)
quetiapine fumarate *SEROQUEL 200mg
1 QL (120 tablets/month)
quetiapine fumarate *SEROQUEL 300mg
1 QL (90 tablets/month)
risperidone *RISPERDAL
1
risperidone *RISPERDAL M
1
thioridazine
1
QL - Quantity Limits AL - Age Limits
PA - Prior Authorization Required
ST - Step Therapy Required
SIO - Self-Injectable Orphan
Gen Plus PDL
02/01/2015
12
thiothixene *NAVANE
trifluoperazine *STELAZINE
ziprasidone HCL *GEODON
1
1
1
QL (60 capsules/month)
4-E Stimulants
Notes
Generic Name Brand Name
Tier
amphetamine-d-amphetamine *ADDERALL
1
amphetamine-d-amphetamine SR ADDERALL XR 5mg
2 QL (30 capsules/month)
amphetamine-d-amphetamine SR ADDERALL XR 10mg
2 QL (30 capsules/month)
amphetamine-d-amphetamine SR ADDERALL XR 15mg
2 QL (30 capsules/month)
amphetamine-d-amphetamine SR ADDERALL XR 20mg
2 QL (60 capsules/month)
amphetamine-d-amphetamine SR ADDERALL XR 25mg
2 QL (30 capsules/month)
amphetamine-d-amphetamine SR ADDERALL XR 30mg
2 QL (30 capsules/month)
amphetamine-d-amphetamine SR AMPHETAMINE-D-AMPHETAMINE SR 1 ST
Amphetamine-D-Amphetamine SR ST = requires 90 day trial of brand Adderall XR in past 2 years
dexmethylphenidate *FOCALIN
1 QL (60 tablets/month)
1 QL (30 capsules/month)
dexmethylphenidate SR *FOCALIN XR
dextroamphetamine *DEXEDRINE
1
dextroamphetamine *DEXEDRINE SPANSULES
1
dextroamphetamine sulfate oral soln *PROCENTRA
1
methamphetamine *DESOXYN
1 QL (150 tablets/month)
methylphenidate *METHYLIN (tablets) 5mg
1 QL (180 tablets/month)
methylphenidate *METHYLIN (tablets) 10mg
1 QL (180 tablets/month)
methylphenidate *METHYLIN (tablets) 20mg
1 QL (60 tablets/month)
methylphenidate *METHYLIN ER
1 QL (90 tablets/month)
methylphenidate *RITALIN 5mg
1 QL (180 tablets/month)
methylphenidate *RITALIN 10mg
1 QL (180 tablets/month)
methylphenidate *RITALIN 20mg
1 QL (90 tablets/month)
methylphenidate CR *RITALIN SR
1 QL (90 tablets/month)
methylphenidate SR Ritalin LA 10mg
1 QL (30 capsules/month)
methylphenidate SR Ritalin LA 20mg
1 QL (30 capsules/month)
methylphenidate SR Ritalin LA 30mg
1 QL (60 capsules/month)
methylphenidate SR Ritalin LA 40mg
1 QL (30 capsules/month)
modafinil *PROVIGIL 100mg
1 PA QL (30 tablets/month)
modafinil *PROVIGIL 200mg
1 PA QL (60 tablets/month)
4-F Misc Psychotherapeutic and Neurological Agents
Notes
Tier
Generic Name Brand Name
disulfiram *ANTABUSE
1
donepezil *ARICEPT
1 QL (30 tablets/month)
ergoloid mesylates *HYDERGINE
1
galantamine *RAZADYNE
1 QL (60 tablets/month)
galantamine *RAZADYNE ER
1 QL (30 capsules/month)
guanfacine *INTUNIV
1 QL (30 tablets/month)
olanzapine-fluoxetine *SYMBYAX
1
perphenazine-amitriptyline *ETRAFON
1
rivastigmine *EXELON
1 QL (60 capsules/month)
4-G Anticonvulsants
QL - Quantity Limits AL - Age Limits
PA - Prior Authorization Required
ST - Step Therapy Required
SIO - Self-Injectable Orphan
Gen Plus PDL
02/01/2015
13
Generic Name Brand Name
carbamazepine *TEGRETOL (NTI)
carbamazepine SR *CARBATROL
carbamazepine SR *TEGRETOL XR
clonazepam *KLONOPIN
diazepam rectal *DIASTAT
divalproex sodium EC *DEPAKOTE
ethosuximide *ZARONTIN
gabapentin *GABARONE
gabapentin *NEURONTIN 100mg
gabapentin *NEURONTIN 300mg
gabapentin *NEURONTIN 400mg
gabapentin *NEURONTIN 600mg
gabapentin *NEURONTIN 800mg
lamotrigine *LAMICTAL
lamotrigine *LAMICTAL STARTER KIT
lamotrigine *LAMICTAL XR
lamotrigine *LAMICTAL XR KIT
levetiracetam *KEPPRA
levetiracetam *KEPPRA XR
oxcarbazepine *TRILEPTAL 100mg
oxcarbazepine *TRILEPTAL 300mg
oxcarbazepine *TRILEPTAL 600mg
phenytoin *DILANTIN (NTI)
phenytoin *PHENYTEK (NTI)
primidone *MYSOLINE
tiagabine *GABITRIL
topiramate *TOPAMAX SPRINKLES
topiramate *TOPAMAX
valproic acid *DEPAKENE
zonisamide *ZONEGRAN 50mg
zonisamide *ZONEGRAN 100mg
4-H Antiparkinsonian Agents
Generic Name Brand Name
benztropine *COGENTIN
bromocriptine (tablets) *PARLODEL
carbidopa *LODOSYN
carbidopa-levodopa *SINEMET
carbidopa-levodopa *PARCOPA
carbidopa-levodopa CR *SINEMET CR
entacapone *COMTAN
pramipexole *MIRAPEX
ropinirole *REQUIP
trihexyphenidyl *ARTANE
*SELEGILINE
4-I Smoking Deterrents
QL - Quantity Limits AL - Age Limits
PA - Prior Authorization Required
ST - Step Therapy Required
SIO - Self-Injectable Orphan
Tier
2
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
2
2
1
1
1
1
1
1
1
Notes
QL (1 kit/month)
QL (240 capsules/month)
QL (360 capsules/month)
QL (270 capsules/month)
QL (180 tablets/month)
QL (120 tablets/month)
QL (1 kit/month)
QL (1 kit/month)
QL (60 tablets/month)
QL (90 tablets/month)
QL (120 tablets/month)
QL (120 capsules/month)
QL (90 tablets/month)
QL (120 capsules/month)
QL (180 capsules/month)
Notes
Tier
1
1
1
1
1
1
1 QL (240 tablets/month)
1 QL (90 tablets/month)
1 QL (90 tablets/month)
1
1
Gen Plus PDL
02/01/2015
14
bupropion SR *ZYBAN
1
PA QL (60 tablets/month)
DERMATOLOGICALS (drugs to treat skin disorders or conditions)
5-A Anorectal
Notes
Generic Name Brand Name
Tier
hydrocortisone rectal *ANUSOL-HC
1
hydrocortisone-pramoxine rectal *ANALPRAM-HC
1
5-B Acne Products
Notes
Generic Name Brand Name
Tier
adapalene *DIFFERIN 0.1% cream/gel
1 ST AL
Differin 0.1% generic ST = requires trial of BRAND Differin cream/gel the past 120 days
adapalene *DIFFERIN 0.3%
3 ST AL
Differin 0.3% generic ST = requires trial of BRAND Differin cream/gel the past 120 days
benzoyl peroxide-erythromycin gel *BENZAMYCIN
1 QL (60 gm/month)
clindamycin topical *CLEOCIN-T
1
1 QL (50 gm/month)
clindamycin-benzoyl peroxide gel *BENZACLIN
clindamycin-benzoyl peroxide gel *DUAC
1 AL
erythromycin topical *ERYGEL
1
isotretinoin *ACCUTANE
1 QL (60 capsules/month) PA
isotretinoin *AMNESTEEM
1 QL (60 capsules/month) PA
isotretinoin *CLARAVIS
1 QL (60 capsules/month) PA
isotretinoin *SOTRET
1 QL (60 capsules/month) PA
metronidazole cream *METROCREAM
1 QL (60 gm/month)
metronidazole gel *METROGEL**
1 QL (60 gm/month)
metronidazole lotion *METROLOTION
1
sulfacetamide lotion (acne) *KLARON
1
sulfacetamide-sulfur emulsion *PLEXION
1
tretinoin *RETIN-A **
1 AL
** Larger tube sizes (60 grams or above) will be subject to a 60-day supply limit and 2 copays will apply
5-C Topical Antibiotics
Generic Name
gentamicin topical
mupirocin
mupirocin
silver sulfadiazine
5-D Topical Antifungals
Generic Name
ciclopirox
ciclopirox solution
clotrimazole-betamethasone
econazole
ketoconazole shampoo
ketoconazole topical
nystatin topical
QL - Quantity Limits AL - Age Limits
PA - Prior Authorization Required
ST - Step Therapy Required
SIO - Self-Injectable Orphan
Brand Name
*GARAMYCIN
*BACTROBAN
*BACTROBAN CREAM
*SILVADENE
Tier
1
1
2
1
Brand Name
*LOPROX
*PENLAC
*LOTRISONE
*SPECTAZOLE
*NIZORAL SHAMPOO
Tier
Notes
1
1 QL (7 ml/month)
1 QL (30 ml/month)
1
1
1
1
*MYCOSTATIN topical
Notes
Gen Plus PDL
02/01/2015
15
nystatin-triamcinolone *MYCOLOG II
1
acyclovir topical *ZOVIRAX topical
1
5-F Antipsoriatics
Notes
Generic Name Brand Name
Tier
anthralin *PSORIATEC
1
acitretin *SORIATANE
1
acitretin *SORIATANE CK kit
1 QL (1 kit/month)
calcipotriene *DOVONEX
1 QL (1 tube/month)
calcipotriene-betamethasone *TACLONEX
1 QL (1 tube/month)
1 QL (100 gm/month)
calcitriol ointment *VECTICAL
** Larger tube sizes (60 grams or above) will be subject to a 60-day supply limit and 2 copays will apply
5-G Scabicides and Pediculicides
Generic Name Brand Name
Notes
Tier
lindane shampoo *KWELL
1
permethrin *ELIMITE
1
1
spinosad *NATROBA
5-H Topical Corticosteroids
Generic Name Brand Name
Tier
Notes
alclometasone *ACLOVATE
1
amcinonide *CYCLOCORT
1
augmented betamethasone *DIPROLENE
1
augmented betamethasone *DIPROLENE AF
1
betamethasone dipropionate *DIPROSONE
1
betamethasone foam *LUXIQ
1
betamethasone valerate *VALISONE
1
clobetasol foam *OLUX
1
clobetasol propionate *TEMOVATE
1
clocortolone *CLODERM
1
desonide *DESOWEN
1
desoximetasone *TOPICORT
1
diclofenac sodium *SOLARAZE 3% GEL
1
flucinolone oil *DERMA-SMOOTH FS
1
fluocinolone acetonide *SYNALAR
1
fluocinonide *LIDEX
1
fluocinonide *VANOS
1 QL (1 tube/month)
fluticasone *CUTIVATE **
1
1
halobetasol *ULTRAVATE
hydrocortisone butyrate *LOCOID
1 QL (45 gm/month)
hydrocortisone valerate *WESTCORT
1
mometasone *ELOCON
1
pramoxine-HC cream *PRAMOSONE
1
prednicarbate *DERMATOP
1
sodium hyaluronate *HYLIRA
1
triamcinolone acetonide *KENALOG
1
** Larger tube sizes will be subject to a 60-day supply limit and 2 copays will apply
5-I Miscellaneous Topicals
QL - Quantity Limits AL - Age Limits
PA - Prior Authorization Required
ST - Step Therapy Required
SIO - Self-Injectable Orphan
Gen Plus PDL
02/01/2015
16
Notes
Generic Name Brand Name
Tier
aluminum chloride *DRYSOL
1
fluorouracil *EFUDEX
1
imiquimod *ALDARA
1 QL (12 packets/month)
1
lidocaine (topical) *XYLOCAINE
lidocaine patch *LIDODERM
1 PA
lidocaine/hydrocortisone *ANAMANTLE
1
lidocaine-prilocaine *EMLA cream
1 QL (30 gm/month)
podofilox *CONDYLOX
1
selenium sulfide shampoo *SELSUN
1
sulfacetamide *OVACE
1
sulfacetamide *OVACE PLUS SHAMPOO 1% 1
sulfacetamide-urea lotion *CARMOL SCALP
1
1 QL (1 tube/month)
tacrolimus topical *PROTOPIC OINT
trypsin-castor oil-peruvian balsam *XENADERM
1
1
urea *VANAMIDE
urea (carbamide) *CARMOL 40
1
ENDOCRINE AND HORMONES (drugs to treat metabolic or hormone conditions, ie diabetes)
6-A Corticosteroids
Generic Name Brand Name
cortisone acetate *CORTONE
dexamethasone *DECADRON
fludrocortisone *FLORINEF
hydrocortisone acetate *CORTEF
methylprednisolone *MEDROL
prednisolone *PRELONE
prednisolone sodium *ORAPRED
prednisolone sodium *PEDIAPRED
prednisone
6-B Androgens
Generic Name Brand Name
danazol *DANOCRINE
testosterone *TESTIM
6-C Estrogens
Generic Name Brand Name
esterified estrogens
estradiol *ESTRACE
estradiol patch *CLIMARA
estradiol-norethindrone *ACTIVELLA
estrogens-methyltestosterone *ESTRATEST
estrogens-methyltestosterone *ESTRATEST HS
estropipate *OGEN
6-D Contraceptives
Generic Name Brand Name
QL - Quantity Limits AL - Age Limits
PA - Prior Authorization Required
ST - Step Therapy Required
SIO - Self-Injectable Orphan
Tier
1
1
1
1
1
1
1
1
1
Notes
Tier
1
1 PA
Notes
Notes
Tier
1
1
1 QL (4 patches/month)
1 QL (1 dialpak/month)
1
1
1
Tier
Notes
Gen Plus PDL
02/01/2015
17
MONOPHASIC PRODUCTS
ethinyl estradiol (EE) /desogestrel products
Apri, Emoquette, Reclipsen, Solia *ORTHO CEPT
1 QL (28 tablets/21 days)
mestranol/norethindrone
*NORINYL
1 QL (28 tablets/21 days)
Necon 1/150
DESOGEN
3 QL (28 tablets/21 days)
EE/norgestimate products
ORTHO CYCLEN
1 QL (28 tablets/21 days)
Sprintec, Previfem, Mononessa
3 QL (28 tablets/21 days) ST
Sprintec, Previfem, Mononessa ST = requires trial of brand Ortho Cyclen within the last 120 days
EE/norethindrone products
el,Cyclafem,Necon,Norinyl,Alyacen *ORTHO NOVUM 1/35
1 QL (28 tablets/21 days)
Lomedia 24 FE *LOESTRIN 24 FE
1 QL (28 tablets/month)
1 QL (28 tablets/21 days)
Junel Fe, Gildess Fe, Microgestin Fe *LOESTRIN FE
Microgestin, Junel, Gildess *LOESTRIN
3 QL (28 tablets/21 days)
Balziva, Zenchent FE, Briellyn *OVCON-35
3 QL (28 tablets/21 days)
Nortrel, Necon, Brevicon *MODICON
1 QL (28 tablets/21 days)
EE/drospirenone products
YAZ
2 QL (28 tablets/21 days)
Gianvi, Loryna,
3 QL (28 tablets/21 days) ST
Gianvi, Loryna, ST = requires trial of brand Yaz within the last 120 days
YASMIN
1 QL (28 tablets/21 days)
Ocella, Zarah, Syeda
3 QL (28 tablets/21 days) ST
Ocella , Zarah, Syeda ST = requires trial of brand Yasmin in past 120 days
EE/norgestrel products
Low-ogestrel, Cryselle *LO/OVRAL
1 QL (28 tablets/21 days)
EE/ethynodiol products
Kelnor
1 QL (28 tablets/21 days)
Zovia 1/35
1 QL (28 tablets/21 days)
EE/levonorgestrel products
Altavera, Levora, Marlissa, Portia *NORDETTE
1 QL (28 tablets/21 days)
Aviane,Lessina,Lutera,Sronyx,Orsythia *ALESSE
1 QL (28 tablets/21 days)
Jolessa, Introvale, Quasense *SEASONALE
1 QL (91 tablets/3 months)
Amethyst *LYBREL
1 QL (28 tablets/21 days)
BIPHASIC PRODUCTS
EE-desogestrel/EE
Kariva, Azurette, Viorele *MIRCETTE
EE-levonorgestrel/EE
Camrese Lo, Amethia Lo *LOSEASONIQUE
Camrese, Amethia, *SEASONIQUE
EE/norethindrone-EE/norethindrone
Necon 10/11 *ORTHO NOVUM 10/11
LO LOESTRIN FE
TRIPHASIC PRODUCTS
QL - Quantity Limits AL - Age Limits
PA - Prior Authorization Required
ST - Step Therapy Required
SIO - Self-Injectable Orphan
3
QL (28 tablets/month)
1
1
QL (28 tablets/21 days)
QL (91 tablets/3 months)
1
3
QL (28 tablets/21 days)
QL (28 tablets/month)
Gen Plus PDL
02/01/2015
18
EE/norethindrone-EE/norethindrone-EE/norethindrone
Aranelle, Leena *TRI-NORINYL
1 QL (28 tablets/21 days)
ORTHO-NOVUM 7/7/7
1 QL (28 tablets/21 days)
econ 7/7/7, Nortrel 7/7/7, Cyclafem
3 QL (28 tablets/21 days) ST
Alyacen, Necon 7/7/7, Nortrel 7/7/7, Cyclafem ST = requires failure of brand Ortho Novum 7/7/7
Tilia FE, Tri Legest FE *ESTROSTEP (FE)
1 QL (28 tablets/21 days)
EE/levonogestrel-EE/Levonorgestrel-EE/Levonorgestrel
Trivora, Myzilra *ENPRESSE
1 QL (28 tablets/21 days)
EE/desogestrel-EE/desogestrel-EE/desogestrel
Cesia, Velivet, Caziant *CYCLESSA
1 QL (28 tablets/21 days)
EE/norgestimate-EE/norgestimate-EE/norgestimate
ORTHO TRI CYCLEN
1 QL (28 tablets/21 days)
Tri-Sprintec,Tri-Previfem,Trinessa
3 QL (28 tablets/21 days) ST
Tri-Sprintec, Tri-Previfem, Trinessa ST= requires trial of brand Ortho Tri Cyclen
within the last 120 days
ORTHO TRI CYCLEN LO
2 QL (28 tablets/21 days)
4-PHASIC PRODUCTS
estradiol-estradiol/dienogest-estradiol/dienogest-estradiol
NATAZIA
1 QL (28 tablets/21 days)
PROGESTIN ONLY-PRODUCTS
Norethindrone
ORTHO MICRONOR
1 QL (28 tablets/month)
Camila, Errin, Heather, Jolivette, Nora Be
3 QL (28 tablets/month) ST
Camila, Errin, Heather, Jolivette, Nora Be requires failure to brand Ortho Micronor
MISCELLANEOUS
Levonorgestrel
mifepristone KORLYM
3 PA SP
Next choice *PLAN B
1
PLAN B ONE-STEP
1
Ulipristal
ELLA
1 QL (28 tablets/21 days)
Etonogestrel/EE
NUVARING
2 QL (1 ring/month)
Norelgestromin/EE
*ORTHO EVRA
1 QL (3 patches/month)
DIAPHRAMS
1
FEMCAP
3 QL (1 cap/year)
6-E Progestins
Generic Name Brand Name
Tier
Notes
medroxyprogesterone *PROVERA
1
norethindrone *AYGESTIN
1
progesterone micronized *PROMETRIUM
1
6-F Oral Antidiabetics (diabetes)
Generic Name Brand Name
Tier
Notes
acarbose *PRECOSE
1 QL (90 tablets/month)
QL - Quantity Limits AL - Age Limits
PA - Prior Authorization Required
ST - Step Therapy Required
SIO - Self-Injectable Orphan
Gen Plus PDL
02/01/2015
19
albiglutide TANZEUM INJ
2
alogliptin benzoate NESINA
2
alogliptin-metformin KAZANO
2
alogliptin-pioglitazone OSENI
2
bromocriptine CYCLOSET
3
canagliflozin INVOKANA
2 ST
Invokana ST= requires a 30-day trial of metformin, glimepiride, glipizide, glyburide or pioglitazone
canagliflozin-metformin INVOKAMET
2 ST
Invokamet ST= requires a 30-day trial of metformin, glimepiride, glipizide, glyburide or Actoplus Met
chlorpropamide *DIABINESE
1
empagliflozin JARDIANCE
2
glimepiride *AMARYL
1 QL (60 tablets/month)
glipizide *GLUCOTROL 5mg
1 QL (90 tablets/month)
glipizide *GLUCOTROL 10mg
1 QL (60 tablets/month)
glipizide CR *GLUCOTROL XL 2.5mg
1 QL (90 tablets/month)
glipizide CR *GLUCOTROL XL 5mg
1 QL (60 tablets/month)
glipizide CR *GLUCOTROL XL 10mg
1 QL (60 tablets/month)
glipizide-metformin *METAGLIP
1 QL (120 tablets/month)
glyburide *DIABETA
1
glyburide-metformin *GLUCOVANCE
1 QL (120 tablets/month)
glyburide micronized *GLYNASE
1 QL (60 tablets/month)
linagliptin TRADJENTA
2
linagliptin-metformin JENTADUETO
2
metformin *GLUCOPHAGE 500mg
1 QL (150 tablets/month)
metformin *GLUCOPHAGE 850mg
1 QL (90 tablets/month)
metformin *GLUCOPHAGE 1000mg
1 QL (75 tablets/month)
metformin GLUMETZA 500mg
3 QL (120 tablets/month)
metformin GLUMETZA 1000mg
3 QL (60 tablets/month)
metformin RIOMET
3 QL (750 mls/month)
metformin SR *GLUCOPHAGE XR 500mg
1 QL (120 tablets/month)
metformin SR *GLUCOPHAGE XR 750mg
1 QL (90 tablets/month)
metformin SR *FORTAMET 500mg
3 QL (120 tablets/month)
metformin SR *FORTAMET 1000mg
3 QL (75 tablets/month)
miglitol GLYSET
3 QL (120 tablets/month)
nateglinide *STARLIX
1 QL (90 tablets/month)
piolitazone *ACTOS
1 QL (30 tablets/month)
piolitazone-glimepiride *DUETACT
1 QL (30 tablets/month)
piolitazone-metformin *ACTOPLUS MET
2 QL (90 tablets/month)
piolitazone-metformin ACTOPLUS MET XR
3 QL (30 tablets/month)
repaglinide *PRANDIN
2 QL (120 tablets/month)
repaglinide-metformin PRANDIMET
2
rosiglitazone AVANDIA
3 QL (30 tablets/month)
rosiglitazone maleate-glimepiride AVANDARYL 4/1mg
3 QL (60 tablets/month)
rosiglitazone maleate-glimepiride AVANDARYL 4/2mg
3 QL (60 tablets/month)
rosiglitazone maleate-glimepiride AVANDARYL 4/4mg
3 QL (30 tablets/month)
rosiglitazone-metformin AVANDAMET 1/500mg
3 QL (120 tablets/month)
QL - Quantity Limits AL - Age Limits
PA - Prior Authorization Required
ST - Step Therapy Required
SIO - Self-Injectable Orphan
Gen Plus PDL
02/01/2015
20
rosiglitazone-metformin AVANDAMET 2/500mg
3 QL (120 tablets/month)
rosiglitazone-metformin AVANDAMET 4/500mg
3 QL (120 tablets/month)
rosiglitazone-metformin AVANDAMET 2/1000mg
3 QL (60 tablets/month)
rosiglitazone-metformin AVANDAMET 4/1000mg
3 QL (60 tablets/month)
saxagliptin ONGLYZA
2 QL (30 tablets/month)
saxagliptin-metformin KOMBIGLYZE XR
2 QL (30 tablets/month)
sitaglipin JANUVIA
3 QL (30 tablets/month) ST
Januvia ST = requires a trial of THREE of the following in the past 2 years: Nesina, Tradjenta, Onglyza
sitaglipin-metformin JANUMET
3 QL (60 tablets/month) ST
Janumet ST = requires trial/failure to all of the following: Kazano, Jentadueto, Kombiglyze XR
sitaglipin-metformin JANUMET XR
3 QL (30 tablets/month) ST
Janumet XR ST = requires trial/failure to all of the following: Kazano, Jentadueto, Kombiglyze XR
sitagliptin-simvastatin JUVISYNC
3 ST
Juvisync ST = requires fill of metformin within the past 2 years
tolazamide *TOLINASE
1
tolbutamide *TOLBUTAMIDE
1
6-G Insulins
Generic Name Brand Name
Tier
Notes
insulin (human) NOVOLIN
3 ST
NOVOLIN ST = requires failure of a Lilly product within the last 2 years
insulin (human) HUMULIN
1
insulin (human) HUMULIN PEN
2
insulin (human) RELION
3
insulin aspart NOVOLOG
3 ST
NOVOLOG ST = requires failure of a Lilly product within the last 2 years
insulin aspart mix NOVOLOG MIX
3 ST
NOVOLOG MIX ST = requires failure of a Lilly product within the last 2 years
insulin detemir LEVEMIR
1
insulin glargine LANTUS (vials/pen/solostar)
3
insulin glulisine APIDRA
3
insulin glulisine APIDRA SOLOSTAR
3
insulin lispro HUMALOG
1
insulin lispro HUMALOG PEN
2
insulin lispro mix HUMALOG MIX
1
2
insulin lispro mix HUMALOG MIX PEN
DEX4 GLUCOSE
1
DEX4 GLUCOSE BITS
3
GLUCAGEN
2 QL (2 kits/month)
GLUCAGON
2 QL (2 kits/month)
GLUCO SHOT
3
GLUCOSE BITS
3
GLUCOSE CHEW
1 QL (30 tablets/month)
GLUCOSE GEL
1
GLUTOSE
3
diazoxide PROGLYCEM
3
mifepristone KORLYM
3
QL - Quantity Limits AL - Age Limits
PA - Prior Authorization Required
ST - Step Therapy Required
SIO - Self-Injectable Orphan
Gen Plus PDL
02/01/2015
21
6-I Thyroid Agents
Notes
Generic Name Brand Name
Tier
levothroid
1 QL (60 tablets/month)
levothyroxine
1 QL (60 tablets/month)
levothyroxine *SYNTHROID (NTI)
2 QL (60 tablets/month)
levoxyl
1 QL (60 tablets/month)
liothyronine *CYTOMEL
1
liotrix THYROLAR
1
methimazole *TAPAZOLE
1 QL (90 tablets/month)
propylthiouracil *PTU
1
unithroid
1 QL (60 tablets/month)
6-J Miscellaneous Endocrine
Generic Name Brand Name
Tier
Notes
alendronate * FOSAMAX 5mg
1 QL (30 tablets/month)
alendronate * FOSAMAX 10mg
1 QL (30 tablets/month)
alendronate * FOSAMAX 35mg
1 QL (4 tablets/month)
alendronate * FOSAMAX 40mg
1 QL (4 tablets/month)
alendronate * FOSAMAX 70mg
1 QL (4 tablets/month)
cabergoline *DOSTINEX
1
calcitonin (salmon) nasal *FORTICAL
1 QL (2 bottles/month)
desmopressin (nasal) *DDAVP
1 QL (1 bottle/month)
desmopressin (oral) *DDAVP 0.1mg
1 QL (30 tablets/month)
desmopressin (oral) *DDAVP 0.2mg
1 QL (90 tablets/month)
etidronate *DIDRONEL
1
exenatide BYDUREON
3
exenatide BYETTA
2
ibandronate *BONIVA
1 QL (1 tablet/month)
levocarnitine *CARNITOR
1
liraglutide VICTOZA
3 QL (2 pens/month)
pramlintide SYMLIN AMYLIN ANALOG
2 ST
Symlin ST = requires concurrent mealtime insulin therapy (rapid or fast acting)
raloxifene *EVISTA
1 QL (30 tablets/month)
3 QL (1 tablet/month)
risedronate *ACTONEL 150mg
6-K Diabetic Supplies
ACCU-CHEK ACTIVE CARE KIT 1
ACCU-CHEK ACTIVE TEST STRIPS 1
ACCU-CHEK ADVANTAGE CARE KIT
1
ACCU-CHEK AVIVA CARE KIT 1
ACCU-CHEK AVIVA TEST STRIPS 1
ACCU-CHEK COMFORT CURVE TEST STRIPS
1
ACCU-CHEK COMPACT CARE KIT 1
ACCU-CHEK COMPACT TEST STRIPS
1
ACCU-CHEK METER
1
ASCENSIA AUTODISC TEST STRIPS
3
ASCENSIA BREEZE 2 TEST STRIPS 3
ASCENSIA ELITE TEST STRIPS 3
QL - Quantity Limits AL - Age Limits
PA - Prior Authorization Required
ST - Step Therapy Required
SIO - Self-Injectable Orphan
Gen Plus PDL
02/01/2015
22
CONTOUR TEST STRIPS
FREESTYLE FLASH SYSTEM
FREESTYLE FREEDOM LITE METER
FREESTYLE FREEDOM METER
FREESTYLE LITE METER
FREESTYLE SYSTEM
FREESTYLE TEST STRIPS
GLUCOMETER DEX TEST STRIPS
ONE TOUCH SYSTEM
ONE TOUCH TEST STRIPS
ONE TOUCH ULTRA 2 SYSTEM
ONE TOUCH ULTRA MINI SYSTEM
ONE TOUCH ULTRA SYSTEM
ONE TOUCH ULTRA TEST STRIPS
PRECISION XTRA METER
PRECISION XTRA TEST STRIPS
RELION TEST STRIPS
SMARTVIEW TEST STRIPS
SURESTEP SYSTEM
SURESTEP TEST STRIPS
VERIO TEST STRIPS
3
3
3
3
3
3
3
3
1
1
1
1
1
1
3
3
3
1
1
1
1
GASTROINTESTINAL (drugs to treat stomach or intestinal conditions, ie reflux, constipation, etc)
7-A Laxatives
Generic Name Brand Name
lactulose
PEG electrolyte *COLYTE
peg(high)-electrolyte *NULYTELY
7-B Antidiarrheals
Generic Name Brand Name
diphenoxylate-atropine *LOMOTIL
opium tincture *OPIUM TINCTURE
paregoric
7-C Miscelleanous Ulcer Drugs
Generic Name Brand Name
dicyclomine *BENTYL
amoxicillin-clarithro-lansopraz CR *PREVPAC
glycopyrrolate *ROBINUL
glycopyrrolate *ROBINUL FORTE
hyoscyamine *LEVSIN
hyoscyamine *LEVBID
hyoscyamine *NULEV
misoprostol *CYTOTEC
phenobarbital-belladonna *DONNATAL
7-D H2 Blockers
Generic Name Brand Name
QL - Quantity Limits AL - Age Limits
PA - Prior Authorization Required
ST - Step Therapy Required
SIO - Self-Injectable Orphan
Tier
1
1
1
Notes
Tier
Notes
1
1 QL (72 mls/month)
1
Tier
Notes
1
3 QL (1 pak/year)
1
1
1
1
1
1 QL (120 tablets/month)
1
Tier
Notes
Gen Plus PDL
02/01/2015
23
cimetidine *TAGAMET
famotidine *PEPCID
nizatadine *AXID
ranitidine *ZANTAC
7-E Proton Pump Inhibitors (PPI)
Generic Name Brand Name
lansoprazole *PREVACID
lansoprazole *PREVACID SOLUTAB
omeprazole *PRILOSEC 20mg capsules
omeprazole *PRILOSEC 20mg tablets
omeprazole *PRILOSEC 40mg
omeprazole-sodium bicarb *ZEGERID
pantoprazole *PROTONIX
rabeprazole *ACIPHEX
7-F Antiemetics
Generic Name Brand Name
dronabinol *MARINOL
granisetron *KYTRIL
ondansetron *ZOFRAN 4mg
ondansetron *ZOFRAN 8mg
ondansetron *ZOFRAN 24mg
ondansetron *ZOFRAN ODT 4mg
ondansetron *ZOFRAN ODT 8mg
trimethobenzamide *TIGAN
7-H Miscelleanous Gastrointestinal
Generic Name Brand Name
balsalazide *COLAZAL
adefovir *HEPSERA
budesonide SR *ENTOCORT EC
calcium acetate (phosphate binder) *PHOSLO
mesalamine enema *ROWASA
metoclopramide *REGLAN
sevelamer RENVELA
sulfasalazine *AZULFIDINE
sulfasalazine EC *AZULFIDINE EN
ursodiol *ACTIGALL
ursodiol *URSO
ursodiol *URSO FORTE
1
1
1
1
Tier
1
1
1
1
1
1
1
1
Tier
1
1
1
1
1
1
1
1
Notes
QL (30 capsules/month)
QL (30 tablets/month) PA
QL (60 capsules/month)
QL (60 tablets/month)
QL (60 capsules/month)
QL (30 capsules/month)
QL (60 tablets/month)
QL (30 tablets/month)
Notes
PA
QL (2 tablets/fill; 2 fills/month)
QL (90 tablets/month)
QL (90 tablets/month)
QL (90 tablets/month)
QL (90 tablets/month)
QL (90 tablets/month)
Notes
Tier
1 QL (270 capsules/month)
1 QL (30 tablets/month) SP
1 QL (90 capsules/month)
1
1
1
1
1
1
1
1
1
GENITOURINARY (drugs to treat genital and bladder or kidney conditions)
8-A Urinary Anti-Infectives
Generic Name Brand Name
methenamine-NA biphosphate *UROQID
nitrofurantoin macro *MACROBID
nitrofurantoin macrocrystals *MACRODANTIN
8-B Urinary Antispasmodics
QL - Quantity Limits AL - Age Limits
PA - Prior Authorization Required
ST - Step Therapy Required
SIO - Self-Injectable Orphan
Tier
1
1
1
Notes
Gen Plus PDL
02/01/2015
24
Generic Name Brand Name
bethanechol *URECHOLINE
flavoxate *URISPAS
oxybutynin *DITROPAN
oxybutynin CR *DITROPAN XL 5mg
oxybutynin CR *DITROPAN XL 10mg
oxybutynin CR *DITROPAN XL 15mg
trospium *SANCTURA
8-C Vaginal Products
Generic Name Brand Name
clindamycin vaginal *CLEOCIN vaginal cream
metronidazole vaginal *METROGEL vaginal
metronidazole vaginal *VANDAZOLE
nystatin vaginal
triple sulfas vaginal
8-D Miscelleanous Genitourinary Agents
Generic Name Brand Name
citric acid-sodium citrate *BICITRA
finasteride *PROSCAR
phenazopyridine *PYRIDIUM
potassium citrate CR *UROCIT-K
tamsulosin *FLOMAX
Tier
1
1
1
1
1
1
1
Tier
1
1
1
1
1
Notes
QL (240 tablets/month)
QL (240 tablets/month)
QL (30 tablets/month)
QL (60 tablets/month)
QL (60 tablets/month)
QL (60 tablets/month)
Notes
Tier
Notes
1
1 QL (30 tablets/month)
1
1
1 QL (60 capsules/month)
MUSCULOSKELETAL AND PAIN (drugs to treat pain and muscle conditions)
9-A Analgesics-Non-Narcotic
Generic Name Brand Name
APAP-butalbital *PHRENILIN
APAP-caffeine-butalbital *ESGIC PLUS
APAP-caffeine-butalbital *FIORICET
ASA-caffeine-butalbital *FIORINAL
choline-mag salicylates *TRILISATE
salsalate *DISALCID
9-B Analgesics-Narcotic
Generic Name Brand Name
APAP-codeine *TYLENOL w/CODEINE
APAP-hydrocodone *LORCET 10/650mg
APAP-hydrocodone *LORTAB
APAP-hydrocodone *NORCO
APAP-hydrocodone *VICODIN
APAP-hydrocodone *VICODIN ES
APAP-hydrocodone *VICODIN HP
ASA-caffeine-but-codeine *FIORINAL w/CODEINE
ASA-codeine *EMPIRIN w/CODEINE
buprenorphine *SUBUTEX
buprenorphine naloxone *SUBOXONE TABLETS
butorphanol *STADOL NS
QL - Quantity Limits AL - Age Limits
PA - Prior Authorization Required
ST - Step Therapy Required
SIO - Self-Injectable Orphan
Notes
Tier
1 QL (360 tablets/month)
1 QL (360 tablets/month)
1 QL (360 tablets/month)
1
1
1
Tier
1
1
1
1
1
1
1
1
1
1
1
1
Notes
QL (390 tablets/month)
QL (180 tablets/month)
QL (240 tablets/month)
QL (360 tablets/month)
QL (240 tablets/month)
QL (150 tablets/month)
QL (180 tablets/month)
PA
PA
QL (1 bottle/month)
Gen Plus PDL
02/01/2015
25
fentanyl lollipop *ACTIQ
1 QL (120 lozenges/month) PA
fentanyl patch *DURAGESIC
1 QL (10 patches/month) ST
Duragesic ST = requires 30 day trial fill of MSSR in past 2 years
hydromorphone *DILAUDID 2mg
1 QL (360 tablets/month)
hydromorphone *DILAUDID 4mg
1 QL (360 tablets/month)
hydromorphone *DILAUDID 8mg
1 QL (360 tablets/month)
hydromorphone ER *EXALGO
ibuprofen-hydrocodone *VICOPROFEN
1 QL (480 tablets/month)
ibuprofen-hydrocodone *REPREXAIN
1 QL (480 tablets/month)
meperidine *DEMEROL
1 QL (360 tablets/month)
morphine *AVINZA 30mg
1 QL (30 capsules/month) ST
morphine *AVINZA 60mg
1 QL (30 capsules/month) ST
morphine *AVINZA 90mg
1 QL (60 capsules/month) ST
morphine *AVINZA 120mg
1 QL (90 capsules/month) ST
*Avinza ST = requires 30 day trial fill of BOTH MSSR and Opana ER in the past 2 year
morphine sulfate *ROXANOL
1
morphine sulfate SR *MS CONTIN
1
naloxone
1
naltrexone *REVIA
1
oxycodone *OXYIR
1
oxycodone *ROXICODONE
1 QL (360 tablets/month)
oxycodone SR *OXYCONTIN
1 QL (60 tablets/month) ST
Oxycontin ST = requires 30 day trial fill of BOTH MSSR and Opana ER in the past 2 year
oxycodone-APAP *PERCOCET 2.5-325mg
1 QL (360 tablets/month)
oxycodone-APAP *PERCOCET 5-325mg
1 QL (360 tablets/month)
oxycodone-APAP *PERCOCET 7.5-325mg
1 QL (360 tablets/month)
oxycodone-APAP *PERCOCET 10-325mg
1 QL (360 tablets/month)
oxycodone-APAP *PERCOCET 7.5-500mg
1 QL (240 tablets/month)
oxycodone-APAP *PERCOCET 10-650mg
1 QL (180 tablets/month)
oxycodone-ASA *PERCODAN
1 QL (360 tablets/month)
oxymorphone *OPANA
1 QL (180 tablets/month)
1 QL (60 tablets/month)
oxymorphone ER *OPANA ER
pentazocine-naloxone *TALWIN NX
1
tramadol *ULTRAM
1 QL (240 tablets/month)
tramadol ER *ULTRAM ER 200mg
1 QL (30 tablets/month)
tramadol ER *ULTRAM ER 300mg
1 QL (30 tablets/month)
tramadol-APAP ULTRACET
2 QL (240 tablets/month)
9-C Non-Steroidal Anti-Inflammatory Drugs (NSAIDS)
Generic Name Brand Name
Tier
Notes
celecoxib *CELEBREX 50mg
1 QL (60 capsules/month)
celecoxib *CELEBREX 100mg
1 QL (60 capsules/month)
celecoxib *CELEBREX 200mg
1 QL (60 capsules/month)
celecoxib *CELEBREX 400mg
1 QL (30 capsules/month)
diclofenac *VOLTAREN 25mg
1 QL (240 tablets/month)
diclofenac *VOLTAREN 50mg
1 QL (120 tablets/month)
diclofenac *VOLTAREN 75mg
1 QL (90 tablets/month)
QL - Quantity Limits AL - Age Limits
PA - Prior Authorization Required
ST - Step Therapy Required
SIO - Self-Injectable Orphan
Gen Plus PDL
02/01/2015
26
diclofenac potassium *CATAFLAM
diclofenac SR *VOLTAREN XR
diclofenac-misoprostol *ARTHROTEC
etodolac *LODINE 200mg
etodolac *LODINE 300mg
etodolac *LODINE 400mg
etodolac *LODINE 500mg
etodolac SR *LODINE XL 600mg
fenoprofen *NALFON
flurbiprofen *ANSAID
ibuprofen *MOTRIN
indomethacin *INDOCIN
indomethacin CR *INDOCIN SR
ketorolac *TORADOL
meclofenamate *MECLOMEN
mefenamic acid *PONSTEL
meloxicam *MOBIC 7.5mg
meloxicam *MOBIC 15mg
nabumetone *RELAFEN
naproxen *NAPROSYN
naproxen sodium *ANAPROX
oxaprozin *DAYPRO
piroxicam *FELDENE
sulindac *CLINORIL
tolmetin sodium *TOLECTIN
9-D Anti-Rheumatic Agents
Generic Name Brand Name
leflunomide *ARAVA
methotrexate
9-E Migraine Products
Generic Name Brand Name
dihydroergotamine (nasal) *MIGRANAL
divalproex sodium (migraine) *DEPAKOTE ER
ergotamine-phenobarb-belladona
naratriptan *AMERGE
rizatriptan *MAXALT
rizatriptan *MAXALT MLT
sumatriptan *IMITREX
sumatriptan *IMITREX NASAL
sumatriptan *SUMATRIPTAN INJ
zolmitriptan *ZOMIG
zolmitriptan *ZOMIG ZMT
9-F Gout
Generic Name Brand Name
allopurinol *ZYLOPRIM
colchicine-probenecid *COLBENEMID
QL - Quantity Limits AL - Age Limits
PA - Prior Authorization Required
ST - Step Therapy Required
SIO - Self-Injectable Orphan
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
QL (120 tablets/month)
QL (120 tablets/month)
QL (90 capsules/month)
QL (90 capsules/month)
QL (90 tablets/month)
QL (90 tablets/month)
QL (60 tablets/month)
QL (20 tablets/month)
QL (60 tablets/month)
QL (30 tablets/month)
QL (90 tablets/month)
Tier
Notes
1 QL (30 tablets/month)
1
Tier
1
1
1
1
1
1
1
1
1
1
1
Tier
1
1
Notes
QL (6 tablets/fill; 2 fills/month)
QL (6 tablets/fill; 2 fills/month)
QL (6 tablets/fill; 2 fills/month)
QL (9 tablets/fill; 2 fills/month)
QL (6 vials/month)
QL (2 kits/fill, 2 fills/month)
QL (6 tablets/fill; 2 fills/month)
QL (6 tablets/fill; 2 fills/month)
Notes
Gen Plus PDL
02/01/2015
27
probenecid *BENEMID
1
9-G Musculoskeletal Therapy Agents
Notes
Generic Name Brand Name
Tier
baclofen *LIORESAL
1
carisoprodol *SOMA
1 QL (120 tablets/month)
carisoprodol-ASA *SOMA COMPOUND
1 QL (120 tablets/month)
carisoprodol-ASA-codeine *SOMA CPD w/CODEINE
1 QL (120 tablets/month)
chlorzoxazone *PARAFON FORTE
1
cyclobenzaprine *FLEXERIL 5mg
1 QL (90 tablets/month)
cyclobenzaprine *FLEXERIL 10mg
1
cyclobenzaprine *FEXMID
1 QL (90 tablets/month) ST
Fexmid ST = requires 2 fills of generic cyclobenzaprine in past 2 years
dantrolene *DANTRIUM
1
methocarbamol *ROBAXIN
1
orphenadrine citrate *NORFLEX
1
tizanidine *ZANAFLEX
1
9-H Miscelleanous Neuromuscular Agents
Notes
Generic Name Brand Name
Tier
pyridostigmine *MESTINON
1
riluzole *RILUTEK
1 QL (60 tablets/month)
VITAMINS & HEMATOLOGICALS (drugs to treat vitamin deficiencies and other blood
disorders)
10-A Vitamins
Generic Name Brand Name
Tier
Notes
calcitriol *ROCALTROL
1
1
docercalciferol *HECTOROL
ergocalciferol [vitamin D] *CALCIFEROL
1
paricalcitol [vitamin D] *ZEMPLAR
1 QL (30 capsules/month) SP
10-B Multivitamins
Generic Name Brand Name
Tier
Notes
B complex-vit C-FA *NEPHROCAPS
1
ped multi vitamin-fluoride *POLY-VI-FLOR
1
ped multi vitamin-fluoride-FE *POLY-VI-FLOR-FE
1
ped vitamins ACD-fluoride *TRI-VI-FLOR
1
ped vitamins ACD-fluoride-FE *TRI-VI-FLOR-FE
1
pnv-select
1
prenatal low iron
1
10-C Minerals
Generic Name Brand Name
Tier
Notes
cyanocobalamin inj
1
FA-vit B6-vit B12 *FOLBEE
1 QL (30 tablets/month)
FA-vit B6-vit B12 *FOLGARD RX
1 QL (30 tablets/month)
FA-vit B6-vit B12 *FOLTX TABLETS
1 QL (60 tablets/month)
FE fum-vit C-vit B12-FA *CHROMAGEN FORTE
1
1
folic acid
L-methylfolate B12 B6 *METANX TABLETS
1 QL (60 tablets/month)
QL - Quantity Limits AL - Age Limits
PA - Prior Authorization Required
ST - Step Therapy Required
SIO - Self-Injectable Orphan
Gen Plus PDL
02/01/2015
28
10-D Anticoagulants
Generic Name Brand Name
warfarin *COUMADIN (NTI)
10-E Miscelleanous Hematologicals
Generic Name Brand Name
aminocaproic acid *AMICAR
anagrelide *AGRYLIN
cilostazol *PLETAL
clopidogrel *PLAVIX
dipyridamole *PERSANTINE
pentoxifylline *TRENTAL
sodium polystyrene sulfonate *KAYEXALATE
ticlopidine *TICLID
tranexamic acid *LYSTEDA
Tier
2
Notes
Tier
1
1
1
1
1
1
1
1
1
Notes
QL (60 tablets/month)
QL (90 tablets/month)
QL (60 tablets/month)
QL (5 days therapy/28 days)
EYE, EAR AND THROAT (drugs to treat eye, ear and throat conditions)
11-A Ophthalmic Anti-infectives
Generic Name Brand Name
bacitracin ophth
bacitracin-polymyxin B ophth *POLYSPORIN ophth
ciprofloxacin ophth *CILOXAN
gatifloxacin ophth *ZYMAXID
gentamycin sulfate ophth *GENTAMICIN OINT 3%
levofloxacin ophth *QUIXIN
moxifloxacin ophth *VIGAMOX
neomycin-polymyxin B-gramacidin ophth *NEOSPORIN ophth
ofloxacin ophth *OCUFLOX
sulfacetamide sodium ophth *BLEPH-10
tobramycin ophth *TOBREX
trifluridine ophth *VIROPTIC
trimethoprim-polymy B ophth *POLYTRIM ophth
11-B Ophthalmics Beta-Blocker
Generic Name Brand Name
carteolol ophth *OCUPRESS
dorzolamide-timolol ophth *COSOPT
levobunolol ophth *BETAGAN
metipranolol ophth *OPTIPRANOLOL
timolol maleate ophth *TIMOPTIC
timolol maleate ophth *TIMOPTIC XE
11-C Ophthalmic Steroids
Generic Name Brand Name
dexamethasone phosphate ophth *DECADRON ophth
fluorometholone ophth *FML LIQUIFILM
neomycin-polymyxin-HC ophth *CORTISPORIN OPHTH
QL - Quantity Limits AL - Age Limits
PA - Prior Authorization Required
ST - Step Therapy Required
SIO - Self-Injectable Orphan
Tier
Notes
1
1
1
1 QL (2.5 ml/month)
1
1
1 QL (3 ml/month)
1
1 QL (10 ml/month)
1
1
1
1
Tier
1
1
1
1
1
1
Notes
Tier
1
1
1
Notes
Gen Plus PDL
02/01/2015
29
prednisolone ophth *PRED FORTE
sulfacetamide-prednisolone ophth *BLEPHAMIDE
tobramycin-dexamethasone ophth *TOBRADEX
11-D Ophthalmic Prostaglandin
Generic Name Brand Name
latanoprost ophth *XALATAN
travaprost ophth *TRAVATAN Z 2.5ml
travaprost ophth *TRAVATAN Z 5ml
11-E Ophthalmic Cycloplegics
Generic Name Brand Name
atropine ophth *ISOPTO ATROPINE
cyclopentolate ophth *CYCLOGYL
homatropine ophth *ISOPTO HOMATROPINE
tropicamide ophth *MYDRIACYL
11-F Ophthalmics Miotics
Generic Name Brand Name
pilocarpine ophth *ISOPTO CARPINE
11-G Ophthalmics Adrenergic Agents
Generic Name Brand Name
apraclonidine ophth *IOPIDINE
brimonidine ophth *ALPHAGAN P 0.2%
brimonidine ophth *ALPHAGAN P 0.15%
11-H Ophthalmics Miscelleanous
Generic Name Brand Name
bromfenac ophth *XIBROM
cromolyn sodium ophth *CROLOM ophth
diclofenac ophth *VOLTAREN ophth
dorzolamide ophth *TRUSOPT
flurbiprofen ophth *OCUFEN
ketorolac ophth *ACULAR
ketorolac ophth *ACULAR LS
11-I Otic (Ear) Medications
Generic Name Brand Name
hydrocortisone-acetic acid otic *VOSOL-HC
neomycin-polymyxin-HC otic *CORTISPORIN otic
ofloxacin otic *FLOXIN OTIC
11-J Mouth and Throat
Generic Name Brand Name
cevimeline *EVOXAC
chlorhexidine *PERIDEX
clotrimazole troche *MYCELEX TROCHE
lidocaine *VISCOUS LIDOCAINE
pilocarpine *SALAGEN 5mg
pilocarpine *SALAGEN 7.5mg
sodium fluoride *KARIGEL
sodium fluoride *KARIGEL-N
QL - Quantity Limits AL - Age Limits
PA - Prior Authorization Required
ST - Step Therapy Required
SIO - Self-Injectable Orphan
1
1
1
QL (5 ml/month)
Notes
Tier
1 QL (5 ml/month)
1 QL (3 ml/month)
1 QL (10 ml/month)
Tier
1
1
1
1
Notes
Tier
1
Notes
Tier
1
1
1
Notes
Tier
1
1
1
1
1
1
1
Notes
Notes
Tier
1
1
1 QL (10 ml/month)
Tier
Notes
1 QL (90 capsules/month)
1
1
1
1 QL (180 tablets/month)
1 QL (120 tablets/month)
1
1
Gen Plus PDL
02/01/2015
30
triamcinolone/orabase *KENALOG-ORABASE
1
RESPIRATORY (drugs to treat breathing conditions, ie asthma and allergies)
12-A Antihistamines
Generic Name Brand Name
cyproheptadine *PERIACTIN
promethazine *PHENERGAN
12-B Topical Nasal Products
Generic Name Brand Name
azelastine nasal *ASTELIN
flunisolide nasal
fluticasone nasal *FLONASE
ipratropium nasal *ATROVENT 0.03% NASAL
ipratropium nasal *ATROVENT 0.06% NASAL
triamcinolone nasal *NASACORT
12-C Cough/Cold/Allergy
Generic Name Brand Name
acetylcysteine *MUCOMYST
benzonatate *TESSALON
cardec DM *RONDEC DM
chlorpheniramine *ED CHLORPED
chlorpheniramine-PSE *DECONAMINE
hydrocodone-homatropine *HYCODAN
promethazine VC PHENERGAN VC
promethazine VC- codeine PHENERGAN VC w/CODEINE
promethazine-codeine *PHENERGAN w/CODEINE
PSE-guaifenesin-codeine *NOVAHISTINE
PSE-methscopolamine *ALLERX-D
pseudoeph-chlorphen w/hydroco soln *ZUTRIPRO
12-D Asthma/COPD
Generic Name Brand Name
albuterol nebulizer *PROVENTIL (nebulizer)
albuterol tablets *PROVENTIL (tablets)
albuterol SR tablets *VOSPIRE ER 4mg
albuterol SR tablets *VOSPIRE ER 8mg
albuterol-ipratropium nebulizer *DUONEB
aminophylline
cromolyn sodium nebulizer *INTAL (nebulizer)
ipratropium nebulizer *ATROVENT (nebulizer)
levalbuterol nebulizer *XOPENEX 0.31mg/3ml
levalbuterol nebulizer *XOPENEX 0.63mg/3ml
levalbuterol nebulizer *XOPENEX 1.25mg/3ml
levalbuterol nebulizer *XOPENEX 1.25 mg/0.5 ml
metaproterenol nebulizer *ALUPENT (nebulizer)
metaproterenol tablets *ALUPENT (tablets)
montelukast *SINGULAIR 4mg
QL - Quantity Limits AL - Age Limits
PA - Prior Authorization Required
ST - Step Therapy Required
SIO - Self-Injectable Orphan
Tier
1
1
Tier
1
1
1
1
1
1
Notes
Notes
QL (1 inhaler/month)
QL (3 inhalers/month)
QL (1 inhaler/month)
QL (2 inhalers/month)
QL (1 inhaler/month)
Tier
1
1
1
1
1
1
1
1
1
1
1
1
Notes
Tier
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
Notes
QL (60 tablets/month)
QL (120 tablets/month)
QL (540 mls/month)
QL (120 vials/month)
QL (450 mls/month)
QL (270 mls/month (1 vial = 3 ml)
QL (270 mls/month (1 vial = 3 ml)
QL (270 mls/month (1 vial = 3 ml)
QL (90 mls/month (1 vial = 3 ml)
QL (120 vials/month (300 ml/month)
QL (30 tablets/month)
Gen Plus PDL
02/01/2015
31
montelukast
montelukast
montelukast
terbutaline
theophylline
theophylline CR
zafirlukast
beclomethasone HFA inhaler
beclomethasone HFA inhaler
budesonide nebulizer
budesonide nebulizer
ciclesonide inhaler
mometasone inhaler
mometasone inhaler
*SINGULAIR 5mg
*SINGULAIR 10mg
*SINGULAIR 4mg Granules
*BRETHINE
*UNIPHYL
*ACCOLATE
QVAR 40mcg
QVAR 80mcg
*PULMICORT RESPULES 0.25mg
*PULMICORT RESPULES 0.5mg
ALVESCO
ASMANEX
ASMANEX HFA
1
1
1
1
1
1
1
1
1
1
1
1
1
1
QL (30 tablets/month)
QL (30 tablets/month)
QL (30 packets/month)
QL (30 tablets/month)
QL (60 tablets/month)
QL (1 inhaler/month)
QL (2 inhaler/month)
QL (120 respules/month)
QL (60 respules/month)
QL (1 inhaler/month)
QL (1 inhaler/month)
SELF-INJECTABLE/SPECIALTY (injectable drugs)
13-A Anticoagulants
Generic Name
enoxaparin sodium
fondaparinux sodium
13-G Somatostatin Analogs
Generic Name
octreotide acetate
QL - Quantity Limits AL - Age Limits
PA - Prior Authorization Required
ST - Step Therapy Required
SIO - Self-Injectable Orphan
Brand Name
*LOVENOX
*ARIXTRA
Tier
Notes
1 SIO (covered up to 21 days without prior auth
1 SIO (covered up to 21 days without prior auth
Brand Name
*OCTREOTIDE
Tier
1 PA SIO
Notes
Gen Plus PDL
02/01/2015
32
AlphabeticalIndex
Drug Name PDL Section Drug Name PDL Section abiraterone acetate
acarbose
ACCOLATE
ACCU‐CHEK ACTIVE CARE KIT
ACCU‐CHEK ACTIVE TEST STRIPS
ACCU‐CHEK ADVANTAGE CARE KIT
ACCU‐CHEK AVIVA CARE KIT
ACCU‐CHEK AVIVA TEST STRIPS
ACCU‐CHEK COMFORT CURVE TEST STRIPS
ACCU‐CHEK COMPACT CARE KIT
ACCU‐CHEK COMPACT TEST STRIPS
ACCUPRIL
ACCURETIC
ACCUTANE
ACCUZYME
Acebutolol
ACEON acetazolamide
acetylcysteine
ACLOVATE
ACTIGALL
ACTIQ
ACTOPLUS MET ACTOPLUS MET XR
ACTOS ACULAR
ACULAR LS
acyclovir
ADALAT CC adapalene
ADDERALL
AFINITOR
AGRYLIN
albuterol nebulizer
albuterol SR tablets
2‐A
6‐F
12‐D
6‐K
6‐K
6‐K
albuterol tablets
albuterol‐ipratropium nebulizer
alclometasone
ALDACTAZIDE
ALDACTONE
ALDARA
ALDOMET
ALDORIL
alendronate
ALESSE
ALKERAN
ALLERX‐D
allopurinol
ALPHAGAN P alprazolam
alprazolam SR
ALTACE altretamine
aluminum chloride
AMARYL
AMBIEN AMBIEN CR amcinonide
AMERGE AMICAR
amiloride
amiloride‐HCTZ
aminocaproic acid
aminophylline
amiodarone
amitriptyline
amlodipine
amlodipine‐benazepril
AMNESTEEM
amoxapine
amoxicillin
amoxicillin‐clavulanate
AMOXIL
6‐K
6‐K
6‐K
6‐K
6‐K
3‐F
3‐I
5‐B
5‐I
3‐C
3‐F
3‐J
12‐C
5‐H
7‐H
9‐B
6‐F
6‐F
6‐F
11‐H
11‐H
1‐H
3‐D
5‐B
4‐E
2‐A
10‐E
12‐D
12‐D
29 12‐D
12‐D
5‐H
3‐J
3‐J
5‐I
3‐H
3‐I
6‐J
6‐D
2‐A
12‐C
9‐F
11‐G
4‐A
4‐A
3‐F
2‐A
5‐I
6‐F
4‐C
4‐C
5‐H
9‐E
10‐E
3‐J
3‐J
10‐E
12‐D
3‐E
4‐B
3‐D
3‐I
5‐B
4‐B
1‐A
1‐A
1‐A
AlphabeticalIndex
Drug Name PDL Section Drug Name PDL Section amphetamine‐d‐amphetamine
ampicillin
AMRIX ANAFRANIL
anagrelide
ANALPRAM‐HC
ANAMANTLE
ANAPROX
anastrozole
ANSAID
ANTABUSE
anthralin
ANUSOL‐HC
APAP‐butalbital
APAP‐caffeine‐butalbital
APAP‐codeine
APAP‐hydrocodone
APAP‐isometh‐dichlor hydrate
APIDRA
apraclonidine ophth
APRESOLINE
Apri
AQUATENSEN
ARALEN
ARAVA
ARICEPT ARIMIDEX ARIXTRA
AROMASIN ARTANE
ASA‐caffeine‐butalbital
ASA‐caffeine‐but‐codeine
ASA‐codeine
ASCENSIA AUTODISC TEST STRIPS
ASCENSIA BREEZE 2 TEST STRIPS
ASCENSIA ELITE TEST STRIPS
ASENDIN
ASTELIN 4‐E
1‐A
9‐G
4‐B
10‐E
5‐A
5‐I
9‐C
2‐A
9‐C
4‐F
5‐F
5‐A
9‐A
9‐A
9‐B
9‐B
9‐E
6‐G
11‐G
3‐H
6‐D
3‐J
1‐J
9‐D
4‐F
2‐A
13‐A
2‐A
4‐H
9‐A
9‐B
9‐B
6‐K
6‐K
6‐K
4‐B
12‐B
ATARAX
atenolol
atenolol‐chlorthalidone
ATIVAN
atorvastatin
atropine ophth
ATROVENT NASAL
augmented betamethasone
AUGMENTIN
AVALIDE AVANDAMET AVANDARYL AVANDIA AVAPRO Aviane
AXID
AYGESTIN
azathioprine
azelastine nasal
azithromycin
AZULFIDINE
AZULFIDINE EN
B complex‐vit C‐FA
bacitracin ophth
bacitracin‐polymyxin B ophth
baclofen
BACTRIM
BACTROBAN
balsalazide
benazepril
benazepril‐HCTZ
BENEMID
BENTYL
BENZACLIN BENZAMYCIN
benzonatate
benzoyl peroxide‐erythromycin gel
30 4‐A
3‐C
3‐I
4‐A
3‐L
11‐E
12‐B
5‐H
1‐A
3‐I
6‐F
6‐F
6‐F
3‐G
6‐D
7‐D
6‐E
2‐B
12‐B
1‐C
7‐H
7‐H
10‐B
11‐A
11‐A
9‐G
1‐L
5‐C
7‐H
3‐F
3‐I
9‐F
7‐C
5‐B
5‐B
12‐C
5‐B
AlphabeticalIndex
Drug Name PDL Section Drug Name PDL Section benztropine
BETAGAN
betamethasone dipropionate
betamethasone valerate
BETAPACE
BETAPACE AF
betaxolol
bethanechol
bexarotene
BIAXIN
BIAXIN XL
bicalutamide
BICITRA
bisoprolol
bisoprolol‐HCTZ
BLEPH‐10
BLEPHAMIDE
BLOCADREN
BONIVA BOSULIF bosutinib BRETHINE
Brevicon
brimonidine ophth
bromocriptine
bromocriptine (tablets)
budesonide SR
bumetanide
BUMEX
buprenorphine
bupropion
bupropion SR
bupropion XL
BUSPAR buspirone
busulfan
butorphanol
BYDUREON
4‐H
11‐B
5‐H
5‐H
3‐C
3‐C
3‐C
8‐B
2‐A
1‐C
1‐C
2‐A
8‐D
3‐C
3‐I
11‐A
11‐C
3‐C
6‐J
2‐A 2‐A 12‐D
6‐D
11‐G
6‐F
4‐H
7‐H
3‐J
3‐J
9‐B
4‐B
4‐B
4‐B
4‐A
4‐A
2‐A
9‐B
6‐J
BYETTA
caberoline
CAFERGOT
CALAN
CALAN SR
CALCIFEROL
calcipotriene
calcitonin (salmon) nasal
calcitriol
calcium acetate (phosphate binder)
calcium acetate (phosphate binder)
Camila
capecitabine
CAPOTEN
CAPOZIDE
captopril
captopril‐HCTZ
carbamazepine
carbamazepine SR
CARBATROL
carbidopa‐levodopa
carbidopa‐levodopa CR
carbinoxamine‐PSE
carbinoxamine‐PSE‐DM
cardec DM
CARDENE
CARDIZEM
CARDIZEM SR
CARDURA
carisoprodol
carisoprodol‐ASA
carisoprodol‐ASA‐codeine
CARMOL 40
CARMOL SCALP
CARNITOR
carteolol ophth
31 6‐J
6‐J
9‐E
3‐D
3‐D
10‐A
5‐F
6‐J
10‐A
7‐H
7‐H
6‐D
2‐A
3‐F
3‐I
3‐F
3‐I
4‐G
4‐G
4‐G
4‐H
4‐H
12‐C
12‐C
12‐C
3‐D
3‐D
3‐D
3‐H
9‐G
9‐G
9‐G
5‐I
5‐I
6‐J
11‐B
AlphabeticalIndex
Drug Name PDL Section Drug Name PDL Section cartia XT
carvedilol
CASODEX
CATAFLAM
CATAPRES
CATAPRES‐TTS
CECLOR
CEENU
cefaclor
cefadroxil
cefdinir
cefpodoxime
cefprozil
cefuroxime
CEFZIL CELEXA
CELLCEPT
cephalexin
chlorambucil
chlordiazepoxide
chlorhexidine
chloroquine
chlorothiazide
chlorpheniramine
chlorpheniramine‐PSE
chlorphen‐pyrilamine‐PE
chlorpromazine
chlorpropamide
chlorthalidone
chlorzoxazone
cholestyramine
choline‐mag salicylates
CHROMAGEN FORTE
ciclesonide nasal
ciclopirox
ciclopirox solution
cilostazol
CILOXAN
3‐D
3‐C
2‐A
9‐C
3‐H
3‐H
1‐B
2‐A
1‐B
1‐B
1‐B
1‐B
1‐B
1‐B
1‐B
4‐B
2‐B
1‐B
2‐A
4‐A
11‐J
1‐J
3‐J
12‐C
12‐C
12‐C
4‐D
6‐F
3‐J
9‐G
3‐L
9‐A
10‐C
12‐B
5‐D
5‐D
10‐E
11‐A
cimetidine
CIPRO
CIPRO XR
ciprofloxacin
ciprofloxacin ophth
ciprofloxacin SR
citalopram
citric acid‐sodium citrate
CLARAVIS
clarithromycin
clarithromycin SR
CLEOCIN
CLEOCIN vaginal cream
CLEOCIN‐T
CLIMARA
clindamycin
clindamycin topical
clindamycin vaginal
clindamycin‐benzoyl peroxide gel
CLINORIL
clobetasol foam
clobetasol propionate
clonazepam
clonidine
clonidine patch
clopidogrel
clorazepate
clotrimazole troche
clotrimazole‐betamethasone
CODIMAL DH
COGENTIN
COLAZAL
COLBENEMID
colchicine‐probenecid
COLESTID
colestipol
COLYTE
Combivir
32 7‐D
1‐E
1‐E
1‐E
11‐A
1‐E
4‐B
8‐D
5‐B
1‐C
1‐C
1‐C
8‐C
5‐B
6‐C
1‐C
5‐B
8‐C
5‐B
9‐C
5‐H
5‐H
4‐G
3‐H
3‐H
10‐E
4‐A
11‐J
5‐D
12‐C
4‐H
7‐H
9‐F
9‐F
3‐L
3‐L
7‐A
1‐I
AlphabeticalIndex
Drug Name PDL Section Drug Name PDL Section COMPAZINE
CONCERTA CONDYLOX
CONTOUR TEST STRIPS
CORDARONE
COREG CORGARD CORTEF
cortisone acetate
CORTISPORIN OPHTH
CORTISPORIN otic
CORTONE
CORZIDE
COSOPT
COZAAR crizotinib
CROLOM ophth
cromolyn sodium nebulizer
cromolyn sodium ophth
cyanocobalamin inj
CYCLESSA
cyclobenzaprine
CYCLOCORT
CYCLOGYL
cyclopentolate ophth
cyclophosphamide
CYCLOSET
cyclosporine modified
CYLERT
cyproheptadine
CYTOMEL
CYTOTEC
CYTOXAN
dabrafenib mesylate DALMANE
danazol
DANOCRINE
DANTRIUM
4‐D
4‐E
5‐I
6‐K
3‐E
3‐C
3‐C
6‐A
6‐A
11‐C
11‐I
6‐A
3‐I
11‐B
3‐G
2‐A
11‐H
12‐D
11‐H
10‐C
6‐D
9‐G
5‐H
11‐E
11‐E
2‐A
6‐F
2‐B
4‐F
12‐A
6‐I
7‐C
2‐A
2‐A 4‐C
6‐B
6‐B
9‐G
dantrolene
DARVOCET N DARVON
dasatinib
DAYPRO
DDAVP
DECADRON
DECADRON ophth
DECONAMINE
DEMADEX
DEMEROL
DEPAKENE
DEPAKOTE
DEPAKOTE ER
DERMATOP
desipramine
desmopressin (nasal)
desmopressin (oral)
DESOGEN
desonide
DESOWEN
desoximetasone
DESOXYN
DESYREL
dexamethasone
dexamethasone phosphate ophth
DEXEDRINE
DEXEDRINE SPANSULES
dexmethylphenidate
dextroamphetamine
dextroamphetamine solution
DIABETA
DIABINESE
DIAMOX
DIASTAT
diazepam
diazepam rectal
diclofenac
33 9‐G
9‐B
9‐B
2‐A
9‐C
6‐J
6‐A
11‐C
12‐C
3‐J
9‐B
4‐G
4‐G
9‐E
5‐H
4‐B
6‐J
6‐J
6‐D
5‐H
5‐H
5‐H
4‐E
4‐B
6‐A
11‐C
4‐E
4‐E
4‐E
4‐E
4‐E
6‐F
6‐F
3‐J
4‐G
4‐A
4‐G
9‐C
AlphabeticalIndex
Drug Name PDL Section Drug Name PDL Section diclofenac ophth
diclofenac potassium
diclofenac SR
dicloxacillin
dicyclomine
didanosine
DIDRONEL
DIFFERIN DIFLUCAN DILANTIN DILAUDID diltiazem
diltiazem SR
diltiazem SR 12HR
diphenoxylate‐atropine
DIPROLENE
DIPROLENE AF
DIPROSONE
dipyridamole
DISALCID
disopyramide
disulfiram
DITROPAN
DITROPAN XL DIURIL
divalproex sodium (migraine)
divalproex sodium EC
donepezil
DONNATAL
dorzolamide ophth
dorzolamide‐timolol ophth
DOSTINEX
DOVONEX
doxazosin
doxepin
doxycycline
doxycycline hyclate
doxycycline monohyclate
11‐H
9‐C
9‐C
1‐A
7‐C
1‐I
6‐J
5‐B
1‐G
4‐G
9‐B
3‐D
3‐D
3‐D
7‐B
5‐H
5‐H
5‐H
10‐E
9‐A
3‐E
4‐F
8‐B
8‐B
3‐J
9‐E
4‐G
4‐F
7‐C
11‐H
11‐B
6‐J
5‐F
3‐H
4‐B
1‐D
1‐D
1‐D
dronabinol
7‐F
drospirenone‐ethyinyl
6‐D
DRYSOL
5‐I
DUET DHA EC
10‐B
DUETACT 6‐F
DUONEB
12‐D
DURAGESIC
9‐B
DURICEF
1‐B
DYAZIDE
3‐J
DYNACIRC
3‐D
DYNAPEN
1‐A
econazole
5‐D
ED CHLORPED
12‐C
EES
1‐C
EES‐sulfisoxazole
1‐L
EFFEXOR
4‐B
EFFEXOR XR 4‐B
EFUDEX
5‐I
ELAVIL
4‐B
ELIMITE
5‐G
ELLA
6‐J
ELOCON
5‐H
EMCYT
2‐A
EMLA cream
5‐I
EMPIRIN w/CODEINE
9‐B
enalapril
3‐F
enalapril‐HCTZ
3‐I
enoxaparin sodium
13‐A
ENPRESSE
6‐D
ENTOCORT EC
7‐H
ENTUSS
12‐C
eplerenone
3‐J
eprosartan
3‐G
ergocalciferol [vitamin D]
10‐A
ergoloid mesylates
4‐F
ergotamine‐caffeine
9‐E
ergotamine‐phenobarb‐belladona 9‐E
erlotinib
2‐A
34 AlphabeticalIndex
Drug Name PDL Section Drug Name PDL Section ERYGEL
ERYPED
erythromycin estolate
erythromycin ethylsuccinate
erythromycin topical
escitalopram
ESGIC PLUS
ESKALITH
ESKALITH CR
estazolam
esterified estrogens
ESTRACE
estradiol
estradiol patch
estramustine
ESTRATEST
ESTRATEST HS
estrogens‐methyltestosterone
estropipate
ethambutol
ethosuximide
etidronate
etodolac
etodolac SR
etoposide
ETRAFON
EULEXIN
everolimus
EXELON
exemestane
exenatide
famciclovir
famotidine
FAMVIR FARESTON
FA‐vit B6‐vit B12
FE fum‐vit C‐vit B12‐FA
FELDENE
5‐B
1‐C
1‐C
1‐C
5‐B
4‐B
9‐A
4‐D
4‐D
4‐C
6‐C
6‐C
6‐C
6‐C
2‐A
6‐C
6‐C
6‐C
6‐C
1‐F
4‐G
6‐J
9‐C
9‐C
2‐A
4‐F
2‐A
2‐A
4‐F
2‐A
6‐J
1‐H
7‐D
1‐H
2‐A
10‐C
10‐C
9‐C
felodipine
FEMARA
FEMCAP
fenofibrate
fenoprofen
fentanyl lollipop
fentanyl patch
finasteride
FIORICET
FIORINAL
FIORINAL w/CODEINE
flavoxate
flecainide
FLEXERIL FLOMAX
FLONASE
FLORINEF
FLOXIN
FLOXIN OTIC
fluconazole
fludarabine
fludrocortisone
FLUMADINE
flunisolide nasal
fluocinolone acetonide
fluocinonide
fluorometholone ophth
fluorouracil
fluoxetine
fluphenazine
flurazepam
flurbiprofen
flurbiprofen ophth
flutamide
fluticasone
fluticasone nasal
fluvoxamine
FML LIQUIFILM
35 3‐D
2‐A
6‐D
3‐L
9‐C
9‐B
9‐B
8‐D
9‐A
9‐A
9‐B
8‐B
3‐E
9‐G
8‐D
12‐B
6‐A
1‐E
11‐I
1‐G
2‐A
6‐A
1‐H
12‐B
5‐H
5‐H
11‐C
5‐I
4‐B
4‐D
4‐C
9‐C
11‐H
2‐A
5‐H
12‐B
4‐B
11‐C
AlphabeticalIndex
Drug Name PDL Section Drug Name PDL Section FOCALIN
FOLBEE
FOLGARD RX
folic acid
FOLTX
fondaparinux sodium
FORTAMET FORTICAL
fosinopril
fosinopril‐HCTZ
FREESTYLE FLASH SYSTEM
FREESTYLE FREEDOM LITE METER
FREESTYLE FREEDOM METER
FREESTYLE LITE METER
FREESTYLE SYSTEM
FREESTYLE TEST STRIPS
furosemide
gabapentin
GABARONE
Gabitril galantamine
ganciclovir
GANTANOL
GANTRISIN
GARAMYCIN
gefitinib
gemfibrozil
GENGRAF
gentamicin topical
gentamycin sulfate ophth
GEODON
Gianvi
GLEEVEC glimepiride
glipizide
glipizide CR
glipizide‐metformin
GLUCAGON
4‐E
10‐C
10‐C
10‐C
10‐C
13‐A
6‐F
6‐J
3‐F
3‐I
6‐K
6‐K
6‐K
6‐K
6‐K
6‐K
3‐J
4‐G
4‐G
4‐G 4‐F
1‐H
1‐L
1‐L
5‐C
2‐A
3‐L
2‐B
5‐C
11‐A
4‐D
6‐D
2‐A
6‐F
6‐F
6‐F
6‐F
6‐H
GLUCOMETER DEX TEST STRIPS
GLUCOPHAGE GLUCOPHAGE XR GLUCOTROL GLUCOTROL XL GLUCOVANCE
GLUMETZA glyburide
glyburide micronized
glyburide‐metformin
glycerol phenylbutyrate glycopyrrolate
GLYNASE
GLYSET granisetron
GRIFULVIN V
griseofulvin microsize
guanfacine
guanfacine
HALCION
HALDOL
halobetasol
haloperidol
HEXALEN
homatropine ophth
HUMALOG HUMALOG MIX
HUMALOG MIX PEN
HUMALOG PEN
HUMULIN HUMULIN PEN
HYCAMTIM HYCODAN
HYDERGINE
hydralazine
HYDREA
hydrochlorothiazide
hydrocodone‐guaifenesin
36 6‐K
6‐F
6‐F
6‐F
6‐F
6‐F
6‐F
6‐F
6‐F
6‐F
9‐F 7‐C
6‐F
6‐F
7‐F
1‐G
1‐G
3‐H
4‐F
4‐C
4‐D
5‐H
4‐D
2‐A
11‐E
6‐G
6‐G
6‐G
6‐G
6‐G
6‐G
2‐A
12‐C
4‐F
3‐H
2‐A
3‐J
12‐C
AlphabeticalIndex
Drug Name PDL Section Drug Name PDL Section hydrocodone‐homatropine
hydrocortisone acetate
hydrocortisone butyrate
hydrocortisone rectal
hydrocortisone valerate
hydrocortisone‐acetic acid otic
hydrocortisone‐pramoxine rectal
HYDRODIURIL
hydromorphone
hydroxychloroquine
hydroxyurea
hydroxyzine HCL
hydroxyzine pamoate
HYGROTON
HYLIRA
hyoscyamine
hyoscyamine SR
HYTRIN
HYZAAR
ibandronate
ibuprofen
ibuprofen‐hydrocodone
ICLUSIG ILOSONE
imatinib mesylate
IMBRUVICA IMDUR
imipramine
imiquimod
IMITREX
IMITREX NASAL
IMURAN
indapamide
INDERAL
INDERAL LA
INDERIDE
INDOCIN
INDOCIN SR
12‐C
6‐A
5‐H
5‐A
5‐H
11‐I
5‐A
3‐J
9‐B
1‐J
2‐A
4‐A
4‐A
3‐J
5‐H
7‐C
7‐C
3‐H
3‐I
6‐J
9‐C
9‐B
2‐A 1‐C
2‐A
2‐A 3‐B
4‐B
5‐I
9‐E
9‐E
2‐B
3‐J
3‐C
3‐C
3‐I
9‐C
9‐C
indomethacin
indomethacin CR
INSPRA
insulin (human)
insulin aspart
insulin aspart mix
insulin detemir
insulin glargine
insulin glulisine
insulin lispro
insulin lispro mix
interferon beta‐1B
INVOKANA iodoquinol
IOPIDINE
ipratropium nasal
ipratropium nebulizer
irbesartan
irbesartan‐HCTZ
IRESSA isoniazid
ISOPTO ATROPINE
ISOPTO CARPINE
ISOPTO HOMATROPINE
ISORDIL
isosorbide dinitrate
isosorbide mononitrate
isotretinoin
isradipine
itraconazole
JANUMET JANUVIA
Jolivette
Junel Fe
KARIGEL
KARIGEL‐N
Kariva
KAYEXALATE
37 9‐C
9‐C
3‐J
6‐G
6‐G
6‐G
6‐G
6‐G
6‐G
6‐G
6‐G
13‐E
6‐F 1‐L
11‐G
12‐B
12‐D
3‐G
3‐I
2‐A
1‐F
11‐E
11‐F
11‐E
3‐B
3‐B
3‐B
5‐B
3‐D
1‐G
6‐F
6‐F
6‐D
6‐D
11‐J
11‐J
6‐D
10‐E
AlphabeticalIndex
Drug Name PDL Section Drug Name PDL Section KEFLEX
KENALOG
KENALOG‐ORABASE
KEPPRA
KERALAC
KERLONE
ketoconazole
ketoconazole shampoo
ketoconazole topical
ketorolac
ketorolac ophth
KLARON
KLONOPIN
KOMBIGLYZE XR
KWELL
KYTRIL
labetalol
lactulose
LAMICTAL
LAMICTAL STARTER KIT
LAMISIL
lamivudine‐zidovudine
lamotrigine
LANOXIN lansoprazole
LANTUS lapatinib ditosylate
LARIAM
LASIX
latanoprost ophth
leflunomide
lenalidomide
Lessina
letrozole
leucovorin calcium
leucovorin calcium
LEUKERAN
levalbuterol nebulizer
1‐B
5‐H
11‐J
4‐G
5‐I
3‐C
1‐G
5‐D
5‐D
9‐C
11‐H
5‐B
4‐G
6‐F
5‐G
7‐F
3‐C
7‐A
4‐G
4‐G
1‐G
1‐I
4‐G
3‐A
7‐E
6‐G
2‐A
1‐J
3‐J
11‐D
9‐D
2‐A
6‐D
2‐A
2‐A
2‐A
2‐A
12‐D
LEVAQUIN
LEVBID
LEVEMIR levetiracetam
levobunolol ophth
levocarnitine
levofloxacin
levofloxacin ophth
Levora
levothroid
levothyroxine
levothyroxine
levoxyl
LEVSIN
LEVSINEX
LEXAPRO LIBRIUM
LIDEX
lidocaine
lidocaine (topical)
lidocaine‐prilocaine
linagliptin
lindane shampoo
LIORESAL
liothyronine
liotrix
LIPITOR
LIPOFEN LIQUADD
liraglutide
lisinopril
lisinopril‐HCTZ
lithium carbonate
lithium carbonate CR
LITHOBID
L‐methylfolate B12 B6
LO LOESTRIN FE
LOCOID
38 1‐E
7‐C
6‐G
4‐G
11‐B
6‐J
1‐E
11‐A
6‐D
6‐I
6‐I
6‐I
6‐I
7‐C
7‐C
4‐B
4‐A
5‐H
11‐J
5‐I
5‐I
6‐F
5‐G
9‐G
6‐I
6‐I
3‐L
3‐L 4‐E
6‐J
3‐F
3‐I
4‐D
4‐D
4‐D
10‐C
6‐D
5‐H
AlphabeticalIndex
Drug Name PDL Section Drug Name PDL Section LOESTRIN
LOESTRIN FE
LOFIBRA
LOMOTIL
lomustine
LONITEN
LOPID
LOPRESSOR
LOPROX
lorazepam
LORTAB
loryna
losartan
losartan‐HCTZ
LOSEASONIQUE
LOTENSIN
LOTENSIN HCT
LOTREL
LOTRISONE
lovastatin
LOVENOX
loxapine
LOXITANE
LOZOL
LUDIOMIL
Lutera
LUVOX
LYBREL
LYSODREN
MACROBID
MACRODANTIN
maprotiline
MARINOL
MATULANE
MAVIK
MAXZIDE
MEBARAL
meclofenamate
6‐D
6‐D
3‐L
7‐B
2‐A
3‐H
3‐L
3‐C
5‐D
4‐A
9‐B
6‐D
3‐G
3‐I
6‐D
3‐F
3‐I
3‐I
5‐D
3‐L
13‐A
4‐D
4‐D
3‐J
4‐B
6‐D
4‐B
6‐D
2‐A
8‐A
8‐A
4‐B
7‐F
2‐A
3‐F
3‐J
4‐C
9‐C
MECLOMEN
MEDROL
medroxyprogesterone
mefenamic acid
mefloquine
MEGACE
MEGACE ES MEKINIST
meloxicam melphalan
meperidine
mephobarbital
meprobamate
mercaptopurine
mesalamine enema
mesna
MESNEX
MESTINON
METAGLIP
METANX
metaproterenol nebulizer
metaproterenol tablets
metformin
metformin SR
methamphetamine
methazolamide
methenamine‐NA biphosphate
methimazole
methocarbamol
methocarbamol‐ASA
methotrexate
methotrexate
methyclothiazide
methyldopa
methyldopa‐HCTZ
METHYLIN
METHYLIN ER
methylphenidate
39 9‐C
6‐A
6‐E
9‐C
1‐J
2‐A
2‐A
2‐A
9‐C 2‐A
9‐B
4‐C
4‐A
2‐A
7‐H
2‐A
2‐A
9‐H
6‐F
10‐C
12‐D
12‐D
6‐F
6‐F
4‐E
3‐J
8‐A
6‐I
9‐G
9‐G
2‐A
9‐D
3‐J
3‐H
3‐I
4‐E
4‐E
4‐E
AlphabeticalIndex
Drug Name PDL Section Drug Name PDL Section methylphenidate CR
methylphenidate SA
methylphenidate SR
methylprednisolone
metipranolol ophth
metoclopramide
metolazone
metoprolol
metoprolol succinate SR
METROCREAM
METROGEL vaginal
METROLOTION
metronidazole
metronidazole cream
metronidazole lotion
metronidazole vaginal
MEVACOR
mexiletine
MEXITIL
Microgestin
Microgestin Fe
MICROZIDE
midodrine
MIDRIN
miglitol
MINIPRESS
MINITRAN
MINOCIN
minocycline
minoxidil
MIRAPEX
MIRCETTE
mirtazapine
mirtazapine soltabs
misoprostol
mitotane
MOBIC modafinil
4‐E
4‐E
4‐E
6‐A
11‐B
7‐H
3‐J
3‐C
3‐C
5‐B
8‐C
5‐B
1‐L
5‐B
5‐B
8‐C
3‐L
3‐E
3‐E
6‐D
6‐D
3‐J
3‐K
9‐E
6‐F
3‐H
3‐B
1‐D
1‐D
3‐H
4‐H
6‐D
4‐B
4‐B
7‐C
2‐A
9‐C
4‐E
MODICON
MODURETIC
moexipril
moexipril‐HCTZ
mometasone
MONODOX Mononessa
MONOPRIL
MONOPRIL HCT
montelukast
morphine
morphine sulfate
morphine sulfate SR
MOTRIN
MS CONTIN
MUCOMYST
mupirocin
MYAMBUTOL
MYCELEX TROCHE
MYCIFRADIN
MYCOLOG II
mycophenolate mofetil
MYCOSTATIN topical
MYDRIACYL
MYLERAN
MYSOLINE
nabumetone
nadolol
nadolol‐bendroflumethiazide
NALFON
naltrexone
NAPROSYN
naproxen
naproxen sodium
naratriptan
NARDIL
NASALIDE
NASAREL
40 6‐D
3‐J
3‐F
3‐I
5‐H
1‐D
6‐D
3‐F
3‐I
12‐D
9‐B
9‐B
9‐B
9‐C
9‐B
12‐C
5‐C
1‐F
11‐J
1‐L
5‐D
2‐B
5‐D
11‐E
2‐A
4‐G
9‐C
3‐C
3‐I
9‐C
9‐B
9‐C
9‐C
9‐C
9‐E
4‐B
12‐B
12‐B
AlphabeticalIndex
Drug Name PDL Section Drug Name PDL Section NATALCARE
NATAZIA
nateglinide
NATELLE C
NAVANE
Necon
Necon nefazodone HCL
neomycin
neomycin‐polymyxin B‐
gramacidin ophth
neomycin‐polymyxin‐HC ophth
neomycin‐polymyxin‐HC otic
NEOSPORIN ophth
NEPHROCAPS
NEPTAZANE
NESTABS
NEURONTIN
nevirapine
NEXAVAR
nicardipine nifedipine CR
nifedipine IR
NILANDRON
nilotinib
nilutamide
NIRAVAM
nisoldipine SR
NITROBID
NITRO‐DUR
nitrofurantoin macro
nitrofurantoin macrocrystals
nitroglycerin ointment
nitroglycerin patch
nitroglycerin spray
NITROLINGUAL PUMPSPRAY
nizatadine
NIZORAL
10‐B
6‐D
6‐F
10‐B
4‐D
6‐D
6‐D
4‐B
1‐L
11‐A
NIZORAL SHAMPOO
NOLVADEX
NORCO
NORDETTE
norethindrone
NORFLEX
Norinyl
NORMODYNE
NORPACE
NORPRAMIN
Nortrel
nortriptyline
NORVASC
NOVAHISTINE
NOVOLIN
NOVOLOG NOVOLOG MIX NULEV
NULYTELY
NUVARING
nystatin
nystatin topical
nystatin vaginal
nystatin‐triamcinolone
Ocella
OCTREOTIDE
octreotide acetate
OCUFEN
OCUFLOX
OCUPRESS
ofloxacin
ofloxacin ophth
ofloxacin otic
OFORTA
OGEN
olanzapine
omeprazole
omeprazole‐sodium bicarb
11‐C
11‐I
11‐A
10‐B
3‐J
10‐B
4‐G
1‐I
2‐A
3‐D 3‐D
3‐D
2‐A
2‐A
2‐A
4‐A
3‐D
3‐B
3‐B
8‐A
8‐A
3‐B
3‐B
3‐B
3‐B
7‐D
1‐G
41 5‐D
2‐A
9‐B
6‐D
6‐E
9‐G
6‐D
3‐C
3‐E
4‐B
6‐D
4‐B
3‐D
12‐C
6‐G
6‐G
6‐G
7‐C
7‐A
6‐D
1‐G
5‐D
8‐C
5‐D
6‐D
13‐G
13‐G
11‐H
11‐A
11‐B
1‐E
11‐A
11‐I
2‐A
6‐C
4‐D
7‐E
7‐E
AlphabeticalIndex
Drug Name PDL Section Drug Name PDL Section ondansetron
ONE TOUCH SYSTEM
ONE TOUCH TEST STRIPS
ONE TOUCH ULTRA 2 SYSTEM
ONE TOUCH ULTRA MINI SYSTEM
ONE TOUCH ULTRA SYSTEM
ONE TOUCH ULTRA TEST STRIPS
ONGLYZA
OPANA
OPIUM TINCTURE
OPIUM TINCTURE
OPTIPRANOLOL
ORAPRED
orphenadrine citrate
ORTHO CEPT ORTHO CYCLEN
ORTHO EVRA
ORTHO MICRONOR
OVACE
OVACE PLUS SHAMPOO 1%
oxaprozin
oxazepam
oxcarbazepine
oxybutynin
oxybutynin CR
oxycodone
oxycodone‐APAP
oxycodone‐ASA
OXYIR
oxymorphone
PAMELOR
pancrelipase
pantoprazole
papain‐urea
PARAFON FORTE
PARCOPA
paregoric
PARLODEL
7‐F
6‐K
6‐K
6‐K
6‐K
6‐K
6‐K
6‐F
9‐B
7‐B
7‐B
11‐B
6‐A
9‐G
6‐D
6‐D
6‐D
6‐D
5‐I
5‐I
9‐C
4‐A
4‐G
8‐B
8‐B
9‐B
9‐B
9‐B
9‐B
9‐B
4‐B
7‐G
7‐E
5‐I
9‐G
4‐H
7‐B
4‐H
paroxetine HCL
paroxetine HCL SR
PAXIL PAXIL CR pazopanib
ped multi vitamin‐fluoride
ped multi vitamin‐fluoride‐FE
ped vitamins ACD‐fluoride
ped vitamins ACD‐fluoride‐FE
PEDIAPRED
PEDIATEX D
PEDIATEX DM
PEDIAZOLE
PEG electrolyte
peg(high)‐electrolyte
pemoline
penicillin V potassium
PENLAC
pentazocine‐naloxone
pentoxifylline
PEPCID
PE‐pyrilamine‐hydrocodone
PERCOCET PERCODAN
pergolide
PERIACTIN
PERIDEX
perindopril
PERIOSTAT
PERMAX
permethrin
perphenazine
perphenazine‐amitriptyline
PERSANTINE
phenazopyridine
phenelzine sulfate
PHENERGAN
PHENERGAN VC
42 4‐B
4‐B
4‐B
4‐B
2‐A
10‐B
10‐B
10‐B
10‐B
6‐A
12‐C
12‐C
1‐L
7‐A
7‐A
4‐F
1‐A
5‐D
9‐B
10‐E
7‐D
12‐C
9‐B
9‐B
4‐H
12‐A
11‐J
3‐F
1‐D
4‐H
5‐G
4‐D
4‐F
10‐E
8‐D
4‐B
12‐A
12‐C
AlphabeticalIndex
Drug Name PDL Section Drug Name PDL Section PHENERGAN VC w/CODEINE
PHENERGAN w/CODEINE
phenobarbital
phenobarbital‐belladonna
phenytoin
PHOSLO
PHRENILIN
pilocarpine
pilocarpine ophth
PILOPTIC‐1/2
PILOPTIC‐3
pindolol
piolitazone
piolitazone‐glimepiride
piolitazone‐metformin
piroxicam
PLAQUENIL
PLAVIX
PLENDIL
PLETAL
PLEXION
podofilox
POLYSPORIN ophth
POLYTRIM ophth
POLY‐VI‐FLOR
POLY‐VI‐FLOR‐FE
pomalidomide
POMALYST ponatinib hcl PONSTEL Portia
potassium citrate CR
pramipexole
pramlintide
PRAMOSONE
pramoxine‐HC cream
PRANDIMET PRANDIN 12‐C
12‐C
4‐C
7‐C
4‐G
7‐H
9‐A
11‐J
11‐F
11‐F
11‐F
3‐C
6‐F
6‐F
6‐F
9‐C
1‐J
10‐E
3‐D
10‐E
5‐B
5‐I
11‐A
11‐A
10‐B
10‐B
2‐A
2‐A 2‐A 9‐C 6‐D
8‐D
4‐H
6‐J
5‐H
5‐H
6‐F
6‐F
PRAVACHOL
pravastatin
prazosin
PRECARE
PRECISION XTRA METER
PRECISION XTRA TEST STRIPS
PRECOSE
PRED FORTE
prednicarbate
prednisolone
prednisolone
prednisolone ophth
prednisolone sodium
prednisolone sodium phosphate
prednisone
PRELONE
prenatal FE‐CBN‐DSS‐Methylfol‐
FA
prenatal vitamins‐FE‐FA
prenatal vitamins‐iron carbonyl‐
FA
PRENATE DHA
PRENATE ELITE
PREVACID
PREVACID SOLUTAB
Previfem
PRILOSEC
PRIMACARE
primaquine
primaquine
primidone
PRINCIPEN
PRINIVIL
PRINZIDE
PROAMATINE
probenecid
procainamide
procarbazine HCL
43 3‐L
3‐L
3‐H
10‐B
6‐K
6‐K
6‐F
11‐C
5‐H
6‐A
6‐A
11‐C
6‐A
6‐A
6‐A
6‐A
10‐B
10‐B
10‐B
10‐B
10‐B
7‐E
7‐E
6‐D
7‐E
10‐B
1‐J
1‐J
4‐G
1‐A
3‐F
3‐I
3‐K
9‐F
3‐E
2‐A
AlphabeticalIndex
Drug Name PDL Section Drug Name PDL Section PROCARDIA
PROCARDIA XL
prochlorperazine
progesterone micronized
PROGRAF
PROLIXIN
promethazine
promethazine VC
promethazine VC‐ codeine
promethazine‐codeine
PROMETRIUM
PRONESTYL
propafenone
propoxyphene
propoxyphene nap‐APAP
propoxyphene‐APAP
propranolol
propranolol HCL CR
propranolol‐HCTZ
propylthiouracil
PROSCAR
PROSOM
PROTONIX
protriptyline
PROVERA
PROVIGIL PROZAC PROZAC WEEKLY
PSE‐guaifenesin‐codeine
PSE‐methscopolamine
PSORIATEC
PTU
PURINETHOL
pyrazinamide
PYRIDIUM
pyridostigmine
pyrilamine‐phenyleph
QUESTRAN
3‐D
3‐D
4‐D
6‐E
2‐B
4‐D
12‐A
12‐C
12‐C
12‐C
6‐E
3‐E
3‐E
9‐B
9‐B
9‐B
3‐C
3‐C
3‐I
6‐I
8‐D
4‐C
7‐E
4‐B
6‐E
4‐E
4‐B
4‐B
12‐C
12‐C
5‐F
6‐I
2‐A
1‐F
8‐D
9‐H
12‐C
3‐L
quetiapine fumarate
quinapril
quinapril‐HCTZ
quinidine gluconate
quinidine sulfate
quinine sulfate
QUIXIN
ramipril
ranitidine
RAVICTI
RAZADYNE RAZADYNE ER
REBETOL Reclipsen
REGLAN
regorafenib
RELAFEN RELION
REMERON
REMERON SOLTABS
repaglinide
repaglinide‐metformin
REPREXAIN
REQUIP
reserpine
RESTORIL RETROVIR
REVIA
REVLIMID
ribavirin
RIFADIN
rifampin
rimantadine
RIOMET
risedronate
RISPERDAL
RISPERDAL M
risperidone
44 4‐D
3‐F
3‐I
3‐E
3‐E
1‐J
11‐A
3‐F
7‐D
9‐F
4‐F 4‐F
1‐H
6‐D
7‐H
2‐A
9‐C 6‐G
4‐B
4‐B
6‐F
6‐F
9‐B
4‐H
3‐H
4‐C
1‐I
9‐B
2‐A
1‐H
1‐F
1‐F
1‐H
6‐F
6‐J
4‐D
4‐D
4‐D
AlphabeticalIndex
Drug Name PDL Section Drug Name PDL Section RITALIN Ritalin LA RITALIN SR
rivastigmine
ROBAXIN
ROBAXISAL
ROBINUL
ROBINUL FORTE
ROCALTROL
RONDEC
RONDEC DM
ropinirole
rosiglitazone
rosiglitazone maleate‐glimepiride
rosiglitazone‐metformin
ROWASA
ROXANOL
ROXICODONE
RYNA‐12
RYNATAN‐S
RYTHMOL
RYTHMOL SR
salsalate
SANCTURA
saxagliptin
saxagliptin‐metformin
SEASONALE
SEASONIQUE
SECTRAL
SELEGILINE
selenium sulfide shampoo
SELSUN
SEPTRA
SERAX
SEROQUEL sertraline HCL
SERZONE
SILVADENE
4‐E
4‐E
4‐E
4‐F
9‐G
9‐G
7‐C
7‐C
10‐A
12‐C
12‐C
4‐H
6‐F
6‐F
6‐F
7‐H
9‐B
9‐B
12‐C
12‐C
3‐E
3‐E
9‐A
8‐B
6‐F
6‐F
6‐D
6‐D
3‐C
4‐H
5‐I
5‐I
1‐L
4‐A
4‐D
4‐B
4‐B
5‐C
silver sulfadiazine
simvastatin
SINEMET
SINEMET CR
SINEQUAN
SINGULAIR sitaglipin
sitaglipin‐metformin
SMZ‐TMP
sodium fluoride
sodium hyaluronate
sodium polystyrene sulfonate
Solia
SOLTAMOX
SOMA
SOMA COMPOUND
SOMA CPD w/CODEINE
somatropin
SONATA
sorafenib tosylate
sotalol sotalol AF
SOTRET
SPECTAZOLE
spironolactone
spironolactone‐HCTZ
SPORANOX
Sprintec
SPRYCEL STADOL NS
STARLIX
stavudine
STELAZINE
STIVARGA
STUARTNATAL SUBUTEX
SULAR sulfacetamide
45 5‐C
3‐L
4‐H
4‐H
4‐B
12‐D
6‐F
6‐F
1‐L
11‐J
5‐H
10‐E
6‐D
2‐A
9‐G
9‐G
9‐G
13‐B
4‐C
2‐A
3‐C 3‐C
5‐B
5‐D
3‐J
3‐J
1‐G
6‐D
2‐A
9‐B
6‐F
1‐I
4‐D
2‐A
10‐B
9‐B
3‐D
5‐I
AlphabeticalIndex
Drug Name PDL Section Drug Name PDL Section sulfacetamide lotion (acne)
sulfacetamide sodium ophth
sulfacetamide‐prednisolone ophth
sulfacetamide‐sulfur emulsion
sulfacetamide‐urea lotion
sulfadiazine
sulfamethoxazole
sulfasalazine
sulfasalazine EC
sulfisoxazole
sulindac
sumatriptan
SUMYCIN
sunitinib
SURESTEP SYSTEM
SURESTEP TEST STRIPS
SURMONTIL
SUTENT
SYMLIN AMYLIN ANALOG SYNALAR
tacrolimus
TAFINLAR
TAGAMET TALWIN NX
TAMBOCOR
tamoxifen
tamsulosin
TANZEUM TAPAZOLE
TARCEVA TARGRETIN
TARKA
TASIGNA
TEBAMIDE
TEGRETOL XR
temazepam
TEMODAR 5‐B
11‐A
11‐C
TEMOVATE
temozolomide
TENEX
TENORETIC
TENORMIN
terazosin
terbinafine HCL
terbutaline
TESLAC
TESSALON
testolactone
testosterone
tetracycline
thalidomide
THALOMID theophylline theophylline CR
thioguanine
thioguanine
thioridazine
thiothixene
THORAZINE
THYROLAR
tiagabine
TIAZAC TICLID
ticlopidine
TIGAN
Tilia FE
timolol maleate
timolol maleate ophth
TIMOPTIC
TIMOPTIC XE
tizanidine
TOBRADEX
tobramycin ophth
tobramycin‐dexamethasone ophth
5‐B
5‐I
1‐L
1‐L
7‐H
7‐H
1‐L
9‐C
9‐E
1‐D
2‐A
6‐K
6‐K
4‐B
2‐A
6‐J
5‐H
2‐B
2‐A
7‐D 9‐B
3‐E
2‐A
8‐D
6‐F 6‐I
2‐A
2‐A
3‐I
2‐A
7‐F
4‐G
4‐C
2‐A
46 5‐H
2‐A
3‐H
3‐I
3‐C
3‐H
1‐G
12‐D
2‐A
12‐C
2‐A
6‐B
1‐D
2‐A
2‐A 12‐D
12‐D
2‐A
2‐A
4‐D
4‐D
4‐D
6‐I
4‐G
3‐D 10‐E
10‐E
7‐F
6‐D
3‐C
11‐B
11‐B
11‐B
9‐G
11‐C
11‐A
11‐C
AlphabeticalIndex
Drug Name PDL Section Drug Name PDL Section TOBREX
TOFRANIL
tolazamide
tolbutamide
tolbutamide
TOLECTIN
TOLINASE
tolmetin sodium
TOPAMAX
TOPAMAX SPRINKLES
TOPICORT
topiramate
topotecan
TOPROL XL
TORADOL
toremifene citrate
torsemide
TRADJENTA
tramadol
tramadol ER
TRANDATE
trandolapril
trandolapril‐verapamil
TRANXENE
trazodone
TRENTAL
tretinoin
tretinoin
TREXALL
triamcinolone acetonide
triamcinolone/orabase
triamterene‐HCTZ
triazolam
trifluoperazine
trifluridine ophth
trihexyphenidyl
TRILAFONE
TRILEPTAL 11‐A
4‐B
6‐F
6‐F
6‐F
9‐C
6‐F
9‐C
4‐G
4‐G
5‐H
4‐G
2‐A
3‐C
9‐C
2‐A
3‐J
6‐F
9‐B
9‐B
3‐C
3‐F
3‐I
4‐A
4‐B
10‐E
2‐A
5‐B
2‐A
5‐H
11‐J
3‐J
4‐C
4‐D
11‐A
4‐H
4‐D
4‐G
TRILISATE
9‐A
trimethobenzamide
7‐F
trimethobenzamide‐benzocaine 7‐F
trimethoprim
1‐L
trimethoprim‐polymy B ophth
11‐A
trimipramine maleate
4‐B
TRIMPEX
1‐L
Trinessa
6‐D
TRI‐NORINYL
6‐D
triple sulfas vaginal
8‐C
Tri‐Previfem
6‐D
Tri‐Sprintec
6‐D
TRI‐VI‐FLOR
10‐B
TRI‐VI‐FLOR‐FE
10‐B
Trivora
6‐D
tropicamide ophth
11‐E
trospium
8‐B
TRUSOPT
11‐H
TRYCET
9‐B
trypsin‐castor oil‐peruvian balsam 5‐I
TYKERB
2‐A
TYLENOL w/CODEINE
9‐B
ULTRAM
9‐B
ULTRAVATE
5‐H
UNIPHYL
12‐D
UNIRETIC
3‐I
unithroid
6‐I
UNIVASC
3‐F
urea
5‐I
urea (carbamide)
5‐I
URECHOLINE
8‐B
URISPAS
8‐B
UROCIT‐K
8‐D
UROQID
8‐A
URSO
7‐H
URSO FORTE
7‐H
ursodiol
7‐H
valacyclovir
1‐H
47 AlphabeticalIndex
Drug Name PDL Section Drug Name PDL Section VALCHLOR
VALISONE VALIUM
valproic acid
VALTREX VANAMIDE
VANCOCIN
vancomycin
VANDAZOLE
VASERETIC
VASOTEC
VEETIDS
VELOSEF
vemurafenib
venlafaxine
venlafaxine SR
VENLAFAXINE XR VEPESID
verapamil
verapamil SR
VERELAN PM
VESANOID
VFEND VIBRAMYCIN
VIBRATABS
VICODIN
VICODIN ES
VICODIN HP
VICOPROFEN
VICTOZA
VIDEX EC
VIRAMUNE
VIROPTIC
VISCOUS LIDOCAINE
VISKEN
VISTARIL
VIVACTIL
VOLTAREN 2‐A
5‐H 4‐A
4‐G
1‐H
5‐I
2‐A
1‐L
8‐C
3‐I
3‐F
1‐A
1‐B
2‐A
4‐B
4‐B
4‐B
2‐A
3‐D
3‐D
3‐D
2‐A
1‐G
1‐D
1‐D
9‐B
9‐B
9‐B
9‐B
6‐J
1‐I
1‐I
11‐A
11‐J
3‐C
4‐A
4‐B
9‐C
VOLTAREN ophth
VOLTAREN XR
voriconazole
vorinostat
VOSOL‐HC
VOSPIRE ER VOTRIENT
warfarin
WELLBUTRIN WELLBUTRIN SR
WELLBUTRIN XL
WELLCOVORIN
WESTCORT
XALATAN
XALKORI
XANAX
XANAX XR XELODA
XENADERM
XOPENEX XYLOCAINE
YASMIN
YAZ YODOXIN
zafirlukast
zaleplon
ZANAFLEX
ZANTAC
Zarah
ZARONTIN
ZAROXOLYN
ZEBETA
ZEGERID
ZERIT
ZESTORETIC
ZESTRIL
ZIAC
zidovudine
48 11‐H
9‐C
1‐G
2‐A
11‐I
12‐D
2‐A
10‐D
4‐B
4‐B
4‐B
2‐A
5‐H
11‐D
2‐A
4‐A
4‐A
2‐A
5‐I
12‐D
5‐I
6‐D
6‐D
1‐L
12‐D
4‐C
9‐G
7‐D
6‐D
4‐G
3‐J
3‐C
7‐E
1‐I
3‐I
3‐F
3‐I
1‐I
AlphabeticalIndex
Drug Name PDL Section Drug Name PDL Section ziprasidone HCL
ZITHROMAX ZOCOR
ZOFRAN ZOFRAN ODT ZOLINZA ZOLOFT zolpidem
zolpidem CR
ZONEGRAN zonisamide
ZOVIRAX
ZYKADIA
ZYLOPRIM ZYPREXA
ZYPREXA ZYDIS
ZYTIGA
4‐D
1‐C
3‐L
7‐F
7‐F
2‐A
4‐B
4‐C
4‐C
4‐G
4‐G
1‐H
2‐A
9‐F 4‐D
4‐D
2‐A
49