2014 Rx Preferred Drug Guide (3-Tier) Please bring this guide with you to your next doctor visit.

30692 (Ed. 09/13)

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Do you have questions?

Call Assurant Health Customer Service at the phone number

printed on your ID card.

Dear Member,

To help you know how drugs are covered by your plan, we are

pleased to provide you with a copy of our 2014 Rx Preferred Drug

Guide.

This document provides helpful information on the Assurant Rx

Preferred Drug Guide and your pharmacy benefit plan. You may

want to take this guide with you when you see your doctor to talk

about what is covered under your plan.

Many commonly prescribed drugs are listed in this guide. Please

remember this is not a complete list of drugs covered under your

plan. Because thousands of drugs are included in your pharmacy

benefits plan, we only list the most commonly prescribed ones.

Please note that not all drugs listed in this guide are covered by all

pharmacy benefit programs. Check your benefit materials for the

specific covered drugs and your co-payment program.

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What is the Assurant Rx Preferred Drug Guide?

Our Rx Preferred Drug Guide is meant to give you a general view of drugs covered by your plan. Changes to the list are based on the latest medical findings as well as information from the Food and Drug Administration (FDA) and drug makers.

This list includes both brand-name and generic drugs and is updated regularly. Assurant will generally cover the drugs listed on our Rx Preferred Drug Guide as long as they are medically necessary and plan rules are followed. Coverage is not limited to drugs on the Rx Preferred Drug Guide.

Your plan has different copay or coinsurance tiers for generic, brand-name, preferred and non-preferred drugs. Usually, preferred drugs are covered at a lower copay or coinsurance tier, which means you pay less out of pocket for those drugs.

The Rx Preferred Drug Guide is subject to change. Drugs on the list are based on reliable medical data, safety and cost. When you talk to your doctor about what drug may be right for you, it is important to remember that you and your doctor are responsible for making the final decision on your drug therapy.

Why is the Rx Preferred Drug Guide subject to change?

During the year, we may add or remove drugs from the Rx Preferred Drug Guide. These changes happen for various reasons and may move a drug from one coverage tier to another.

As brand-name drugs lose their patents, generic versions may become available. When this happens, the brand-name drug may move to a higher copayment or coinsurance tier. The generic drug may be added to the list and available at a lower copayment or coinsurance tier.

The FDA approves many new drugs throughout the year. Your plan generally covers new FDA-approved drugs; however, you may pay a higher copayment or coinsurance tier for these drugs. The new drug(s) also may be subject to precertification or step-therapy requirements.

Some drugs may also no longer require a prescription. If your drug becomes available over-the-counter (OTC), the drug will generally no longer be covered under your prescription plan.

If the FDA removes a drug from the market it will also no longer be covered under your prescription plan.

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Why do some drugs have quantity limits?

Your plan may limit the amount of a drug you can receive at one time. These limits help your doctor and pharmacist check that the drugs are used appropriately while promoting patient safety. We use medical guidelines, FDA approval and guidance from drug makers to set these coverage limits. The quantity limits program includes:

Dose Efficiency Edits – Limits coverage of prescriptions to one dose per day for drugs that are approved for once-daily dosing.

Maximum Daily Dose – A message is sent to the pharmacy if a prescription is higher than the maximum allowed dose.

Quantity Limits Over Time – Limits coverage of prescriptions to a specific number of units in a defined amount of time.

To get coverage for amounts over the allowed quantity, you, your doctor or the person you appoint to manage your care must request a coverage override by calling the phone number located on your ID card. The quantity limit list is subject to change.

What is step-therapy?

With step-therapy you must try one or more alternate drugs before your plan will cover a step-therapy drug. These drugs are FDA-approved, treat the same condition(s) and, they may also be available to you at a lower copay or coinsurance tier.

If it is necessary for you to use a drug on the step therapy list, you, your doctor, or the person you appoint to manage your care may request a coverage override by calling the phone number located on your ID card.

What is the Prior Authorization program?

The Prior Authorization program encourages appropriate and cost-effective use of drugs by allowing coverage only when certain conditions are met.

• A physician, a patient, or a person appointed to manage the patient’s care must request prior authorization before drugs on the Prior Authorization List will be covered under a member’s pharmacy benefits plan. If the request is approved, the drug will then be covered at the applicable costs associated with the member’s plan.

• The Prior Authorization program is based upon current medical findings, FDA-approved manufacturer labeling information, and cost.

• To determine if a drug requires prior authorization, refer to the column titled Prior Authorization next to the list of drugs in this guide. You can also call the phone number on the back of the member identification card to obtain more information on the prior authorization review process.

• The list of drugs requiring prior authorization is subject to change.

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What are generic drugs?

Drug manufacturers develop and release new drugs under a brand name. When the patent expires, other manufacturers are then able to make duplicate versions of the same drug. Generic drugs are chemically the same as their branded counterparts. They are also the same in dosage, safety, strength, form and intended use. Plus, generics usually cost less than brand-name drugs.

Generic drugs are only available after the FDA approves them. When filling your prescription, your pharmacist generally can substitute a generic drug for a brand-name drug when the generic is rated by the FDA as equivalent and also where it is permitted by your doctor and state law.

Table of Contents – Preferred Drugs by Therapeutic Class

Therapeutic Class Page(s)

Antineoplastic Agents 6 Blood Products – Modifiers – Volume Expanders 8 Cardiovascular System 9 Central Nervous System 18 Dermatological Agents 30 Endocrine System 36 Gastrointestinal System 45 Genitourinary System 48 Infections and Infestations 50 Musculoskeletal System 56 Ophthalmic Agents 58 Otic Agents 61 Respiratory Tract Agents 62 Miscellaneous 64

THERAPEUTIC CLASS LIST KEY (on following pages)

lower case– Generic medication – lowest co-payment

UPPERCASE – Brand-name medication – Higher co-payment

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Medication Name

3-Tier G = Generic

P = Preferred Brand

NP = Non Preferred

Brand Prior

Authorization Quantity

Limit Step

Therapy

Antineoplastic Agents

Alkylating Agents

ALKERAN P

CEENU P

lomustine G

cyclophosphamide G

HEXALEN P

LEUKERAN P

MYLERAN P

TEMODAR capsule P √

temozolomide G √

Antimetabolites

mercaptopurine G

methotrexate G

PURINETHOL NP

TABLOID P

TREXALL NP

XELODA NP √

Antineoplastic – Enzyme Inhibitors

AFINITOR NP √

BOSULIF NP √

CAPRELSA NP √

COMETRIQ NP √

GILOTRIF NP √

GLEEVEC P √

ICLUSIG NP √

INLYTA NP √

IRESSA NP

JAKAFI NP √

MEKINIST NP √

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NEXAVAR NP √

POMALYST NP √

SPRYCEL NP √

STIVARGA NP √

SUTENT P √

TAFINLAR NP √

TARCEVA P √

TASIGNA P √

TYKERB NP √

VOTRIENT NP √

XALKORI NP √

ZELBORAF NP √

ZOLINZA NP √

Antineoplastic – Hormonal Agents

anastrozole G

ARIMIDEX NP

AROMASIN NP

bicalutamide G

CASODEX NP

EMCYT P

exemestane G

FARESTON NP

FEMARA NP

flutamide G

letrozole G

LYSODREN NP

MEGACE NP

MEGACE ES NP

megestrol G

NILANDRON P

tamoxifen G

XTANDI NP √

ZYTIGA P √

Antineoplastics – Miscellaneous

ERIVEDGE NP √

HYDREA NP

hydroxyurea G

MATULANE P

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TARGRETIN P

tretinoin 10 mg G √

Chemotherapy Rescue/Antidote Agents

leucovorin calcium G

MESNEX NP

Immunomodulators

REVLIMID NP

THALOMID NP

Topoisomerase I Inhibitor

HYCAMTIN NP √

Blood Products – Modifiers – Volume Expanders

Anticoagulants – Coumarin

COUMADIN NP

jantoven G

warfarin G

Anticoagulants – Direct Thrombin Inhibitors/Factor Xa Inhibitor

ELIQUIS NP √ √

IPRIVASK NP

PRADAXA P √

XARELTO P √

Anticoagulants – Heparins

ARIXTRA NP

fondaparinux G

FRAGMIN NP

heparin sodium G

LOVENOX NP

enoxaparin G

Hemostatics – Systemic

AMICAR NP

aminocaproic acid G

LYSTEDA NP √

tranexamic acid G √

Platelet Aggregation Inhibitors

AGGRENOX P

AGRYLIN NP

anagrelide G

BRILINTA NP √

cilostazol G

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clopidogrel G

dipyridamole G

EFFIENT P √

PERSANTINE NP

PLAVIX NP

PLETAL NP

ticlopidine G

Cardiovascular System

Alpha-Beta Blockers

carvedilol G

COREG NP

COREG CR P

labetalol G

TRANDATE NP

Anaphylaxis Therapy Agents

ADRENACLICK NP

AUVI-Q NP √

epinephrine G

EPIPEN P

EPIPEN-JR P

TWINJECT NP

Angiotensin Converting Enzyme (ACE) Inhibitors and Combinations

ACCUPRIL NP

ACCURETIC NP

ACEON NP

ALTACE NP

benazepril G

benazepril/hydrochlorothiazide G

captopril G

captopril/hydrochlorothiazide G

enalapril G

enalapril/hydrochlorothiazide G

EPANED NP √

fosinopril G

fosinopril/hydrochlorothiazide G

lisinopril G

lisinopril/hydrochlorothiazide G

moexipril G

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moexipril/hydrochlorothiazide G

LOTENSIN NP

LOTENSIN HCT NP

MAVIK NP

perindopril G

PRINIVIL NP

PRINZIDE NP

quinapril G

quinapril/hydrochlorothiazide G

ramipril G

trandolapril G

UNIRETIC NP

UNIVASC NP

VASERETIC NP

VASOTEC NP

ZESTORETIC NP

ZESTRIL NP

Angiotensin II Receptor Antagonists and Combinations

ATACAND NP √

candesartan G √

ATACAND HCT NP √

candesartan/hydrochlorothiazide G √

AVALIDE NP √

AVAPRO NP √

AZOR NP √ √

BENICAR NP √ √

BENICAR HCT NP √ √

COZAAR NP √

DIOVAN NP √ √

DIOVAN HCT NP √ √

EDARBI NP √ √

EDARBYCLOR NP √ √

eprosartan G √

EXFORGE P √

EXFORGE HCT P √

HYZAAR NP √

irbesartan G √

irbesartan/hydrochlorothiazide G √

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losartan G √

losartan/hydrochlorothiazide G √

MICARDIS P √

MICARDIS HCT P √

TEVETEN NP √

TEVETEN HCT NP

TRIBENZOR NP √ √

TWYNSTA NP √ √

valsartan/hydrochlorothiazide G √

Antiadrenergic Antihypertensives

CARDURA NP

CATAPRES NP

CATAPRES-TTS NP

clonidine G

doxazosin G

guanabenz G

guanfacine G

methyldopa G

MINIPRESS NP

NEXICLON NP √

prazosin G

reserpine G

TENEX NP

terazosin G

Antianginals – Nitrates

amyl nitrite G

DILATRATE SR NP

IMDUR NP

ISORDIL NP

isosorbide dinitrate G

isosorbide mononitrate G

MONOKET NP

NITRO-BID NP

NITRO-DUR NP

nitroglycerin G

nitroglycerin CR G

nitroglycerin SL G

NITROLINGUAL NP

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NITROMIST NP

NITROSTAT P

Antianginals – Other

RANEXA P √

Antiarrhythmics Type I-A

disopyramide G

NORPACE NP

procainamide G

quinidine gluconate G

quinidine sulfate G

Antiarrhythmics Type I-B

mexiletine G

Antiarrhythmics Type I-C

flecainide G

propafenone G

RYTHMOL NP

RYTHMOL SR NP

TAMBOCOR NP

Antiarrhythmics Type III

amiodarone G

CORDARONE NP

MULTAQ P

PACERONE NP

TIKOSYN NP

Antihyperlipidemics – Bile Sequestrants

cholestyramine G

cholestyramine light G

COLESTID NP

colestipol G

prevalite G

QUESTRAN NP

QUESTRAN LITE NP

WELCHOL P

Antihyperlipidemics – Fibric Acid Derivatives

ANTARA NP √

fenofibrate G

fenofibrate choline G

fenofibrate micronized G

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fenofibric acid G

FENOGLIDE NP √

FIBRICOR NP √

gemfibrozil G

LOFIBRA NP √

LOPID NP √

LIPOFEN NP √

TRICOR NP √

TRIGLIDE NP √

TRILIPIX NP √

fenofibrate delayed-release G

Antihyperlipidemics – HMG CoA Reductase Inhibitors

ADVICOR NP √

ALTOPREV NP √ √

amlodipine/atorvastatin G √

atorvastatin G √

CADUET NP √ √

CRESTOR P √

fluvastatin G √

LESCOL NP √

LESCOL XL NP √ √

LIPITOR NP √ √

LIPTRUZET P √

LIVALO NP √

lovastatin G √

MEVACOR NP √

PRAVACHOL NP √

pravastatin G √

SIMCOR P √

simvastatin G √

VYTORIN NP √

ZOCOR NP √

Antihyperlipidemics – Intestinal Cholesterol Absorption Inhibitor

ZETIA P √

Antihyperlipidemics – Miscellaneous

JUXTAPID NP √ √

LOVAZA P

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VASCEPA P

Antihyperlipidemics – Nicotinic Acid Derivatives

niacin ER tablet G

NIASPAN NP

Antihypertensives-Miscellaneous

VECAMYL NP √ √

Beta Blockers Cardioselective and Combinations

acebutolol G

atenolol G

atenolol/chlorthalidone G

betaxolol G

bisoprolol G

bisoprolol/hydrochlorothiazide G

BYSTOLIC P

DUTOPROL P

KERLONE NP

LOPRESS HCT NP

LOPRESSOR NP

metoprolol G

metoprolol ER G

metoprolol/hydrochlorothiazide G

SECTRAL NP

TENORETIC NP

TENORMIN NP

TOPROL XL NP

ZEBETA NP

ZIAC NP

Beta Blockers Non-Selective and Combinations

BETAPACE NP

BETAPACE AF NP

CORGARD NP

CORZIDE NP

INDERAL LA NP

INNOPRAN XL NP

LEVATOL NP

nadolol G

nadolol/bendroflumethiazide G

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pindolol G

propranolol G

propranolol SR G

propranolol/hydrochlorothiazide G

sorine G

sotalol G

sotalol AF G

timolol G

Calcium Blockers

ADALAT CC NP

afeditab G

amlodipine G

CALAN NP

CALAN SR NP

CARDENE SR NP

CARDIZEM NP

CARDIZEM CD NP

CARDIZEM LA NP

cartia XT G

COVERA-HS NP

DILACOR XR NP

dilt-CD G

dilt-XR G

diltiazem G

diltiazem CD/ER/CR/XT G

diltiazem SR extended release beads G

DYNACIRC CR NP

felodipine G

ISOPTIN SR NP

isradipine G

matzim LA G

nicardipine G

nifediac CC G

nifedical XL G

nifedipine G

nifedipine CR/ER/SR G

nimodipine G

nisoldipine G

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NIMOTOP NP

NORVASC NP

NYMALIZE NP √

PROCARDIA NP

PROCARDIA XL NP

SULAR NP

taztia XT G

TIAZAC NP

verapamil G

verapamil CR/ER/SR G

VERELAN NP

VERELAN PM NP

VERELAN SR NP

Cardiac Glycosides

digoxin G

LANOXIN NP

Cardiovascular Combinations – Miscellaneous

amlodipine/benazepril G

BIDIL NP

CLORPRES NP

hydralazine/hydrochlorothiazide G

LOTREL NP

methyldopa/hydrochlorothiazide G

rauwolfia/bendroflumethiazide G

TARKA NP

Direct Renin Inhibitor and Combinations

AMTURNIDE NP √

TEKAMLO NP √

TEKTURNA NP √

TEKTURNA HCT NP √

Diuretics – Carbonic Anhydrase Inhibitors

acetazolamide G

DIAMOX NP

methazolamide G

Diuretics – Loop

bumetanide G

DEMADEX NP

EDECRIN NP

17

furosemide G

LASIX NP

torsemide G

Diuretics – Potassium Sparing and Combinations

ALDACTAZIDE NP

ALDACTONE NP

amiloride G

amiloride/hydrochlorothiazide G

DYAZIDE NP

DYRENIUM NP

MAXZIDE NP

MIDAMOR NP

spironolactone G

spironolactone/hydrochlorothiazide G

triamterene/hydrochlorothiazide G

Diuretics – Selective Aldosterone Receptor Antagonists (SARAs)

eplerenone G

INSPRA NP

Diuretics – Thiazide and Thiazide-Like

chlorothiazide G

chlorthalidone G

DIURIL NP

hydrochlorothiazide G

indapamide G

methychlothiazide G

metolazone G

MICROZIDE NP

THALITONE NP

ZAROXOLYN NP

Pheochromocytoma Agents

DEMSER NP

DIBENZYLINE P

Pulmonary Hypertension Agents

ADCIRCA NP √

LETAIRIS P

REVATIO NP √

sildenafil G √

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TRACLEER P

TYVASO NP

VENTAVIS NP

Vasodilators

hydralazine G

isoxsuprine G

minoxidil G

papaverine ER G

Central Nervous System

ALS Agents

RILUTEK NP

riluzole G

Alzheimer's Disease – Antidementia

ARICEPT 5 and 10 mg NP

ARICEPT 23 mg NP

ARICEPT ODT NP

donepezil G

donepezil ODT G

EXELON capsule NP

EXELON patch P

EXELON solution P

galantamine G

galantamine SR G

NAMENDA P

NAMENDA XR P

RAZADYNE NP

RAZADYNE ER NP

rivastigmine G

Antianxiety – Benzodiazepines

alprazolam G

alprazolam ER G

alprazolam ODT G

chlordiazepoxide G

clorazepate G

diazepam G

lorazepam G

NIRAVAM NP

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oxazepam G

XANAX XR NP

Antianxiety – Miscellaneous

buspirone G

hydroxyzine hydrochloride G

hydroxyzine pamoate G

meprobamate G

Anticonvulsants – Benzodiazepines

clonazepam G

clonazepam orally disintegrating tablet G

DIASTAT NP

diazepam rectal gel G

KLONOPIN NP

ONFI NP

Anticonvulsants – Carbamates

felbamate G

FELBATOL NP

Anticonvulsants – GABA Modulators

GABITRIL NP

SABRIL powder NP

SABRIL tablet NP

tiagabine G

Anticonvulsants – Hydantoins

DILANTIN NP

phenytoin extended G

phenytoin sodium G

Anticonvulsants – Miscellaneous

BANZEL NP

carbamazepine G

carbamazepine SR G

carbamazepine XR G

CARBATROL NP

gabapentin G √

KEPPRA NP

KEPPRA XR NP

LAMICTAL NP

LAMICTAL ODT NP

LAMICTAL ER NP

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lamotrigine G

lamotrigine ER G

levetiracetam G

levetiracetam ER G

LYRICA NP √ √

NEURONTIN NP √

oxcarbazepine G

OXTELLAR XR NP

POTIGA NP √

primidone G

TEGRETOL NP

TEGRETOL XR NP

TOPAMAX NP

topiramate G

TRILEPTAL NP

TROKENDI XR NP √ √

VIMPAT NP √

ZONEGRAN NP

zonisamide G

Anticonvulsants – Succinimides

CELONTIN NP

ethosuximide G

ZARONTIN NP

Anticonvulsants – Valproic Acid

DEPAKENE NP

DEPAKOTE NP

DEPAKOTE ER NP

DEPAKOTE SPRINKLE NP

divalproex sodium delayed-release G

divalproex sodium sprinkle G

divalproex sodium SR G

STAVZOR NP

valproic acid G

Antidepressants – Alpha-2 Receptor Antagonists

mirtazapine G √

mirtazapine ODT G √

REMERON NP √

REMERON SOLUTAB NP √

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Antidepressants – MAO Inhibitors

EMSAM NP √

MARPLAN NP

NARDIL NP

PARNATE NP

phenelzine G

tranylcypromine sulfate G

Antidepressants – Miscellaneous

APLENZIN NP √ √

budeprion G √

budeprion XL G √

bupropion G √

bupropion SR G √

FORFIVO XL NP √ √

maprotiline G √

WELLBUTRIN NP √

WELLBUTRIN SR NP √

WELLBUTRIN XL P √

Antidepressants – Modified Cyclics

nefazodone G

OLEPTRO NP √ √

trazodone G

VIIBRYD NP √ √

VIIBRYD KIT NP √ √

Antidepressants – Serotonin-Norepinephrine Reuptake Inhibitors

CYMBALTA NP √ √

DESVENLAFAXINE ER NP √ √

EFFEXOR XR NP √

PRISTIQ NP √ √

venlafaxine G √

venlafaxine ER capsule G √

VENLAFAXINE ER tablet NP √ √

venlafaxine ER tablet G √

Antidepressants – Selective Serotonin Reuptake Inhibitors

CELEXA NP √

citalopram G √

escitalopram G √

fluoxetine G √

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FLUOXETINE 60 MG NP √ √

fluoxetine delayed-release G √

fluvoxamine G √

LEXAPRO NP √

LUVOX CR NP √

paroxetine G √

paroxetine ER G √

PAXIL NP √

PAXIL CR NP √

PEXEVA NP √ √

PROZAC NP √

PROZAC WEEKLY NP √

sertraline G √

ZOLOFT NP √

Antidepressants – Tricyclic Agents

ANAFRANIL NP

amitriptyline G

amoxapine G

clomipramine G

desipramine G

doxepin G

imipramine G

NORPRAMIN NP

nortriptyline G

PAMELOR NP

protriptyline G

SURMONTIL NP

TOFRANIL NP

TOFRANIL-PM NP

trimipramine G

VIVACTIL NP

Antiparkinsonian Adjuvant

LODOSYN NP

Antiparkinsonian Anticholinergic

benztropine G

trihexyphenidyl G

Antiparkinsonian COMT Inhibitors

COMTAN NP

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entacapone G

TASMAR NP

Antiparkinsonian Dopaminergic

amantadine G

bromocriptine G

carbidopa/levodopa G

carbidopa/levodopa ODT G

carbidopa/levodopa SR G

carbidopa/levodopa/entacapone G

MIRAPEX NP

MIRAPEX ER P √

NEUPRO NP

PARCOPA NP

PARLODEL NP

pramipexole G

REQUIP NP

REQUIP XL NP

ropinirole G

ropinirole ER G

SINEMET NP

SINEMET CR NP

STALEVO NP

Antiparkinsonian Monoamine Oxidase Inhibitor

AZILECT P

ELDEPRYL NP

selegiline G

Antipsychotics – Atypical

ABILIFY NP √

ABILIFY DISC NP √

clozapine G √

CLOZARIL NP √

FANAPT NP √ √

FAZACLO NP √

GEODON NP √

INVEGA NP √ √

LATUDA NP √

olanzapine G √

olanzapine ODT G √

24

quetiapine G √

RISPERDAL NP √

RISPERDAL M NP √

risperidone G √

risperidone ODT G √

SAPHRIS NP √

SEROQUEL NP √

SEROQUEL XR P √

ZYPREXA NP √

ZYPREXA ZYDIS NP √

ziprasidone G √

Antipsychotics – Combinations

chlordiazepoxide/amitriptyline G

olanzapine/fluoxetine G √

perphenazine/amitriptyline G

SYMBYAX NP √

Antipsychotics – First Generation

chlorpromazine G

compro G

fluphenazine G

haloperidol G

loxapine G

perphenazine G

prochlorperazine G

thioridazine G

thiothixene G

trifluoperazine G

Antipsychotics – Miscellaneous

EQUETRO NP

Attention Deficit Disorder

ADDERALL NP √ √

ADDERALL XR NP √ √

amphetamine/dextroamphetamine G √

amphetamine/dextroamphetamine SR G √

CONCERTA NP √ √

DAYTRANA P √

DESOXYN NP √ √

DEXEDRINE NP √ √

25

DEXEDRINE CR NP √ √

dexmethylphenidate G √

dextroamphetamine G √

dextroamphetamine CR G √

dextroamphetamine sulfate solution G √

FOCALIN NP √ √

FOCALIN XR NP √ √

INTUNIV NP √ √

KAPVAY NP √ √

KAPVAY DOSE PACK NP √ √

METADATE CD NP √ √

metadate ER G √

methamphetamine G √

methylin G √

METHYLIN chew/soln NP √ √

methylin ER G √

methylphenidate G √

methylphenidate SR G √

PROCENTRA NP √ √

QUILLIVANT XR NP √ √

RITALIN NP √ √

RITALIN LA NP √ √

RITALIN SR NP √ √

STRATTERA P √

VYVANSE P √

ZENZEDI 2.5MG and 7.5MG NP √ √

zenzedi 5MG and 10MG G √

Chemical Dependency

acampro cal G

ANTABUSE NP

CAMPRAL NP

naltrexone G

Fibromyalgia

CYMBALTA NP √ √

LYRICA NP √ √

SAVELLA P √

Huntington's Disease – Chorea

XENAZINE P √

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Lithium

lithium carbonate G

lithium carbonate CR G

lithium citrate G

LITHOBID NP

Migraine Products

ALSUMA NP √

AMERGE NP √

AXERT NP √ √

CAMBIA NP √

dihydroergotamine nasal G √

FROVA NP √ √

IMITREX NP √

MAXALT NP √

rizatriptan G √

MAXALT MLT NP √

rizatriptan MLT G √

MIGRANAL NP √

naratriptan G √

RELPAX NP √ √

sumatriptan G √

SUMAVEL NP √ √

TREXIMET NP √ √

ZOMIG NP √

zolmitriptan G √

ZOMIG ZMT NP √

zolmitriptan ZMT G √

Multiple Sclerosis Agents

AMPYRA P √

AUBAGIO NP √

GILENYA NP √

TECFIDERA NP √

Narcotic Agonists

ABSTRAL NP √ √

ACTIQ NP √ √

AVINZA NP √

codeine phosphate G

codeine sulfate G

27

CONZIP NP √

DEMEROL NP

DILAUDID NP

DURAGESIC NP √

EXALGO NP √ √

fentanyl lozenge G √ √

fentanyl patch G √

FENTORA NP √ √

hydromorphone G

KADIAN NP √

LAZANDA NP √ √

levorphanol G

meperidine G

methadone G √

methadose G √

morphine sulfate G

morphine sulfate CR G √

MS CONTIN NP √

NUCYNTA P √

NUCYNTA ER P √

ONSOLIS NP √ √

OPANA NP

OPANA ER NP √

ORAMORPH SR NP √

OXECTA NP

oxycodone G

OXYCONTIN CR P √

oxymorphone ER G √

RYBIX ODT NP

SUBSYS SPRAY NP √ √

tramadol G

tramadol ER G √

ULTRAM NP

ULTRAM ER NP √

XOLOX NP

Narcotic Combinations

acetaminophen/codeine G

butalbital/acetaminophen/caffeine/codeine G

28

butalbital/aspirin/caffeine/codeine G

BUPAP NP

CAPITAL/CODEINE NP

COCET NP

COCET PLUS NP

FIORICET/CODEINE NP

FIORINAL/CODEINE NP

hydrocodone/acetaminophen G

hydrocodone/ibuprofen G

IBUDONE NP

LIQUICET NP

LORCET NP

LORCET PLUS NP

LORTAB NP

MAGNACET NP

MAXIDONE NP

NORCO NP

oxycodone/acetaminophen G

oxycodone/aspirin G

oxycodone/ibuprofen G √

ORBIVAN NP

ORBIVAN CF NP

pentazocine/acetaminophen G

PERCOCET NP

PERCODAN NP

PHRENILIN NP

REPREXAIN NP

ROXICET NP

stagesic G

STAFLEX NP

SYNALGOS DC NP

dihydrocodeine compound cap G

TYLENOL/CODEINE NP

TYLOX NP

ULTRACET NP

VICODIN NP

VICODIN ES NP

29

vicodin HP G

VICOPROFEN NP

XODOL NP

ZOLVIT NP

ZYDONE NP

Narcotic Partial Agonists

buprenorphine G √

butorphanol G √

buprenorphine/naloxone sublingual tablet G √

BUTRANS P √

pentazocine/naloxone G

SUBOXONE film NP √ √

SUBOXONE sublingual tablet NP √

SUBUTEX NP √

ZUBSOLV NP √ √

Postherpetic Neuralgia (PHN) Agents

GRALISE NP √

Premenstrual Dysphoric Disorder

SARAFEM NP √

fluoxetine (PMDD) G √

Psychotherapeutic and Neurological Agents

ergoloid mesylate G

ORAP NP

modafinil G √

NUVIGIL NP √

PROVIGIL NP √

XYREM NP √

Restless Leg Syndrome

HORIZANT NP √

Sedative/Hypnotics – Barbiturate

BUTISOL SODIUM NP

MEBARAL NP

phenobarbital G

SECONAL NP

Sedative/Hypnotics – Nonbarbiturates

AMBIEN NP √

AMBIEN CR NP √

chloral hydrate G

30

DORAL NP

quazepam G

EDLUAR NP √ √

estazolam G

flurazepam G

HALCION NP

INTERMEZZO NP √ √

LUNESTA NP √

midazolam G

ROZEREM NP √ √

SILENOR NP √ √

SONATA NP √ √

temazepam G

triazolam G

zaleplon G √

zolpidem G √

zolpidem ER G √

ZOLPIMIST NP √ √

Miscellaneous

CUVPOSA NP

NUEDEXTA NP √

Dermatological Agents

Acne Products

ABSORICA NP

ACANYA NP √

ACZONE NP

adapalene G

AKNE-MYCIN NP

amnesteem G

ATRALIN NP √

avita G

AZELEX NP

BENZACLIN NP √

BENZAMYCIN NP √

BENZEFOAM NP

BENZEFOAM ULTRA NP √

BENZIQ NP

BENZIQ LS NP

31

BENZIQ wash NP

benzoyl peroxide G

claravis G

CLARIFOAM EF NP

clindamax G

clindamycin G

clindamycin/benzoyl peroxide G

DIFFERIN 0.1% cream/gel/lotion NP √

DIFFERIN 0.3% gel P

DUAC NP √

clindamycin/benzoyl peroxide 1.2-5% gel G

EPIDUO P

erythromycin G

erythromycin/benzoyl peroxide G

EVOCLIN NP

FABIOR NP √ √

isotretinoin G

KLARON NP

lavoclen G

METROCREAM NP

METROGEL 1% only NP

metronidazole gel 1% G

METROLOTION NP

metronidazole G

myorisan G

NEOBENZ NP

NORITATE NP

NUOX NP

pacnex wash G

PACNEX HP NP

PACNEX LP NP

PACNEX MX NP

PLEXION cloth NP

PLEXION emulsion NP

PLEXION SCT NP

RETIN-A NP √

RETIN-A MICRO P

RIAX NP √

32

sodium sulfacetamide/sulfur G

SODIUM SULFA LIQ 10% WASH NP

sotret G

SSS 10-4 NP

SUMADAN WASH NP

SUMAXIN NP

SUMAXIN TS NP

tretinoin G

TRETIN-X NP √

TRIAZ NP

VANOXIDE NP

VELTIN NP √

ZACARE NP

Z-CLINZ NP

ZIANA P

Antibiotics – Topical

ALTABAX NP

BACTROBAN NP

CENTANY NP

gentamicin G

mupirocin G

Antifungals – Topical

ALOQUIN NP

ciclopirox G

clotrimazole/betamethasone G

econazole G

ERTACZO NP

EXELDERM NP

HALOTIN NP

hydrocortisone/iodoquinol G

ketoconazole G

LOPROX NP

LOTRISONE NP

NAFTIN NP

nystatin G

nystatin/triamcinolone G

OXISTAT NP

PENLAC NP

33

VUSION NP

XOLEGEL NP

Antineoplastics and Keratolytics – Topical

CARAC NP

EFUDEX NP

FLUOROPLEX NP

fluorouracil G

LEVULAN KERA NP

METVIXIA NP

PANRETIN P

PICATO NP √

SOLARAZE NP

TARGRETIN P

UTOPIC NP

Antipruritics and Topical Anesthetics

cocaine hydrochloride G

lidocaine G

lidocaine pad G √

lidocaine/prilocaine G

LIDODERM NP √

PLIAGLIS NP

prudoxin G

QUTENZA NP

SYNERA NP

ZONALON NP

Antipsoriatics

8-MOP NP

acitretin G

calcipotriene G

CALCITRENE NP

calcitriol G

DOVONEX NP

DRITHO-SCALP NP

OXSORALEN-UL NP

SORIATANE P

SORILUX NP

TACLONEX NP

TAZORAC P

34

VECTICAL NP

Antiseborrheic Products

EXTINA NP

ketoconazole foam G

SCALACORT DK NP

selenium sulfide G

SELRIX NP

sulfacetamide sodium G

Antiviral – Topical

acyclovir G

DENAVIR NP

XERESE NP

ZOVIRAX NP

Corticosteroids – Topical

alclometasone G

amcinonide G

augmented betamethasone dipropionate G

betamethasone valerate G

clobetasol G

CLOBEX spray P

CLOBEX lotion/shampoo NP

CLODERM NP

CORDRAN NP

CUTIVATE NP

DERMATOP NP

DESONATE NP

desonide G

desoximetasone G

diflorasone G

DIPROLENE AF NP

ELOCON NP

fluocinolone acetonide G

fluocinonide G

fluticasone G

HALOG NP

hydrocortisone G

hydrocortisone butyrate G

35

hydrocortisone valerate G

hydrocortisone/pramoxine G

lidocaine/hydrocortisone G

LOCOID NP

LOCOID LIPOCREAM NP

LUXIQ NP

mometasone G

NUZON NP

OLUX NP

OLUX-E NP

prednicarbate G

TACLONEX NP

triamcinolone G

ULTRAVATE NP

VANOS NP

VERDESO NP

VYTONE NP

Keratolytic/Antimitotic Agents

CONDYLOX NP

podofilox G

Immunomodulating Agents – Topical

ALDARA NP √

ELIDEL P

imiquimod G √

PROTOPIC P

ZYCLARA NP √

Rosacea Agents

FINACEA NP

metronidazole G

MIRVASO NP √

ORACEA P √

Scabicides & Pediculicides

EURAX NP

lindane G

NATROBA NP

permethrin G

SKLICE NP

spinosad G

36

ULESFIA NP

Sinecatechin

VEREGEN NP

Endocrine System

Antidiuretic Agents

DDAVP NP

desmopressin G

minirin G

STIMATE NP

Contraceptives – Emergency-(Applies only to plans with contraceptive coverage)

ELLA NP

next choice G

PLAN B NP

levonorgesterol tablet 0.75 mg G

Contraceptives – Oral-(Applies only to plans with contraceptive coverage)

altavera G

amethia lo G

amethyst G

apri G

aranelle G

aviane G

BEYAZ NP

BREVICON NP

briellyn G

camrese G

camrese lo G

cesia G

cryselle G

CYCLESSA NP

DESOGEN NP

ELLA NP

emoquette G

enpresse G

ESTROSTEP FE NP

FEMCON NP

GENERESS FE NP

gianvi G

gildess FE G

37

jolessa G

junel 1.5/30 G

junel 1/20 G

junel FE 1.5/30 G

junel FE 1/20 G

kariva G

kelnor G

leena G

lessina G

levora G

LO LOESTRIN FE NP

LO/OVRAL NP

LOESTRIN 1.5/30 NP

LOESTRIN 1/20 NP

LOESTRIN FE NP

LOESTRIN FE 1.5/30 NP

LOESTRIN-24 NP

LOMINISTRIN PAK FE NP

loryna G

LOSEASONIQUE NP

low-ogestrel G

lutera G

LYBREL NP

microgestin 1.5/30 G

microgestin 1/20 G

microgestin FE 1.5/30 G

microgestin FE 1/20 G

MINASTRIN 24 FE NP

MIRCETTE NP

MODICON 0.5/35 NP

mononessa G

NATAZIA NP

necon 0.5/35 G

necon 1/35 G

necon 1/50 G

necon 10/11 G

necon 7/7/7 G

NORDETTE NP

38

NORINYL 1+35 NP

NORINYL 1+50 NP

nortrel 0.5/35 G

nortrel 1/35 G

nortrel 7/7/7 G

ocella G

ogestrel G

ORTHO TRI-CYCLEN NP

ORTHO TRI-CYCLEN LO NP

ORTHO-CEPT NP

ORTHO-CYCLEN NP

ORTHO-NOVUM 1/35 NP

ORTHO-NOVUM 7/7/7 NP

OVCON 35 NP

OVCON 50 NP

portia G

previfem G

QUARTETTE NP

quasense G

reclipsen G

SEASONALE NP

SEASONIQUE NP

amethia G

solia G

sprintec G

sronyx G

syedah G

trinessa G

TRI-NORINYL NP

tri-previfem G

tri-sprintec G

trivora G

velivet G

YASMIN NP

YAZ NP

zarah G

zenchent FE G

zeosa G

39

zovia 1/35E G

zovia 1/50E G

Contraceptives – Oral Progestins-(Applies only to plans with contraceptive coverage)

camila G

errin G

jolivette G

nora-be G

NOR-QD NP

ORTHO MICRONOR NP

Contraceptives – Transdermal-(Applies only to plans with contraceptive coverage)

ORTHO EVRA NP

Contraceptives – Vaginal-(Applies only to plans with contraceptive coverage)

NUVARING NP

Diabetes – Alpha-Glucosidase Inhibitors

acarbose G

GLYSET NP

PRECOSE NP

Diabetes – Amylin Analogs

SYMLIN P

SYMLINPEN P

Diabetes – Biguanides and Combinations

FORTAMET NP

glipizide/metformin G

GLUCOPHAGE NP

GLUCOPHAGE XR NP

GLUCOVANCE NP

GLUMETZA NP

glyburide/metformin G

METAGLIP NP

metformin G

metformin ER G

RIOMET NP

Diabetes – Dopamine Receptor Agonists

CYCLOSET P

Diabetes – DPP-IV Inhibitors and Combinations

JANUMET P

JANUMET XR P

JANUVIA P

40

JENTADUETO P

KOMBIGLYZE XR P

KAZANO NP √ √

NESINA NP √ √

ONGLYZA P

OSENI NP √ √

TRADJENTA P

Diabetes – Glucocorticoid Receptor Antagonist

KORLYM NP √

Diabetes – Incretin Mimetic Agents

BYDUREON P √

BYETTA NP √

VICTOZA P √

Diabetes – Insulin

APIDRA NP

HUMALOG products P

HUMULIN products P

LANTUS P

LANTUS SOLOSTAR P

LEVEMIR P

LEVEMIR FLEXPEN P

NOVOLIN products NP √

NOVOLOG products P

RELION products NP √

Diabetes – Meglitinides and Combinations

nateglinide G

PRANDIMET NP

PRANDIN NP

repaglinide G

STARLIX NP

Diabetes - Sodium-glucose co-transporter 2 (SGLT2) inhibitor

INVOKANA NP √ √

Diabetes – Sulfonylureas

AMARYL NP

chlorpropamide G

DIABETA NP

glimepiride G

glipizide G

41

glipizide ER G

glipizide XL G

GLUCOTROL NP

GLUCOTROL XL NP

glyburide G

glyburide micronized G

GLYNASE NP

tolazamide G

tolbutamide G

Diabetic Supplies

BD insulin syringes P

BD lancets P

BD pen needles P

FREESTYLE glucose test strips P √

FREESTYLE LITE glucose test strips P √

FREESTYLE INSULINX P √

glucose test strips (any other brand name) NP √ √

All Brand insulin syringes NP

insulin syringes (any generic) G

All Brand lancets NP

lancets (any generic) G

ONE TOUCH FAST TAKE glucose test strips P √

ONE TOUCH ULTRA glucose test strips P √

ONE TOUCH VERIO IQ glucose test strips P √

All Brand pen needles NP

pen needles (any generic) G

PRECISION QID glucose test strips P √

PRECISION SOF-TACT glucose test strips P √

PRECISION XTRA glucose test strips P √

PRECISION XTRA ketone test strips P √

Diabetes – Thiazolidinediones (TZDs) and Combinations

ACTOPLUS MET NP

pioglitazone/metformin G

ACTOPLUS MET XR NP

ACTOS NP

pioglitazone G

AVANDAMET NP

AVANDARYL NP

42

AVANDIA NP

DUETACT NP

pioglitazone/glimepiride G

JUVISYNC P

Gaucher Disease

ZAVESCA NP

Glucose Elevating Agent

PROGLYCEM P

Gout Agents

allopurinol G

COLCRYS P

probenecid G

probenecid/colchicine G

ULORIC NP √

ZYLOPRIM NP

Hereditary Tyrosinemia

ORFADIN P

Homocystinuria

CYSTADANE P

Hormone Replacement – Androgens

ANDRODERM NP √ √

ANDROGEL P √

AXIRON NP √ √

danazol G

FORTESTA NP √ √

STRIANT NP √ √

TESTIM P √

Hormone Replacement – Estrogens

ALORA NP √

CENESTIN P

CLIMARA NP √

DIVIGEL P

ELESTRIN NP

ENJUVIA P

ESTRACE NP

ESTRADERM NP √

estradiol patch G √

estradiol tablet G

43

ESTRASORB NP

ESTROGEL NP

estropipate G

EVAMIST P

MENEST NP

MENOSTAR NP √

MINIVELLE NP √

ortho-est G

PREMARIN NP

VIVELLE-DOT NP √

Hormone Replacement – Estrogen Combinations

ACTIVELLA NP

ANGELIQ NP

CLIMARA PRO NP √

COMBIPATCH NP √

estradiol/norethindrone acetate G

FEMHRT NP

FEMHRT LOW DOSE NP

FEMTRACE NP

jinteli G

PREFEST NP

PREMPHASE NP

PREMPRO NP

Hormone Replacement – Progestins

medroxyprogesterone acetate G

norethindrone acetate G

progesterone micronized capsule G

PROMETRIUM NP

Hyperammonemia

RAVICTI NP √

sodium phenylbutyrate G

Hyperparathyroidism

HECTOROL NP

SENSIPAR NP

ZEMPLAR P

LHRH/GnRH Agonist Analog Pituitary Suppressants

SYNAREL NP

44

Metabolic Modifiers

CARNITOR NP

SUCRAID NP

Phenylketonuria

KUVAN P

Steroids – Glucocorticosteroids

budesonide SR G √

cortisone AC G

dexamethasone G

ENTOCORT EC NP √

FLO-PRED NP

hydrocortisone G

methylprednisolone G

MILLIPRED NP

ORAPRED NP

prednisolone G

prednisone G

RAYOS NP √

VERIPRED NP

Steroids – Mineralocorticoid

fludrocort G

Thyroid Hormones

ARMOUR THYROID NP

CYTOMEL NP

levothroid G

levothyroxine G

levoxyl G

liothyronine sodium G

SYNTHROID NP

THYROLAR NP

TIROSINT NP

unithroid G

Thyroid – Antithyroid Agents

methimazole G

propylthiouracil G

TAPAZOLE NP

Vasopressin Receptor Antagonist

SAMSCA P

45

Gastrointestinal System

Acid Suppressants – H-2 Antagonists

AXID NP

cimetidine G

famotidine G

nizatidine G

PEPCID NP

ranitidine G

ZANTAC NP

Acid Suppressants – Proton Pump Inhibitors

ACIPHEX NP √ √

DEXILANT P √

ESOMEPRAZOLE STRONTIUM NP √ √

lansoprazole G √

lansoprazole ODT G √

NEXIUM P √

omeprazole G √

omeprazole/bicarbonate G √

pantoprazole G √

PREVACID NP √ √

PREVACID SOLUTAB NP √ √

PRILOSEC NP √ √

PROTONIX NP √ √

ZEGERID NP √ √

Anal Fissure

RECTIVE NP

HIV-Related Antidiarrheal

FULYZAQ NP √

Antiemetics – 5-HT3 Receptor Antagonists

ANZEMET tablet NP √

DICLEGIS NP √

granisetron G √

GRANISOL NP √

ondansetron G √

ondansetron ODT G √

SANCUSO PAD NP √

ZOFRAN NP √

ZOFRAN ODT NP √

46

ZUPLENZ NP √

Antiemetics – Anticholinergic

TRANSDERM-SCOP NP

trimethobenzamide G

Antiemetics – Miscellaneous

CESAMET NP √

dronabinol G

EMEND capsule P √

MARINOL NP

Anti-Ulcer Drugs

misoprostol G

sucralfate G

Bowel Evacuants

COLYTE NP

gavilyte-g G

GOLYTELY NP

HALFLYTELY NP

MOVIPREP P

NULYTELY NP

OSMOPREP NP

peg 3350 G

polyethylene glycol G

PREPOPIK NP

trilyte G

SUCLEAR KIT NP

SUPREP NP

VISICOL NP

Chronic Constipation Agents

AMITIZA P

LINZESS NP √

Gallstone Solubilizing Agents

CHENODAL NP

URSO 250 NP

URSO FORTE NP

ursodiol G

GI Antiallergy Agents

cromolyn sodium concentrate G

47

GASTROCROM NP

GI Stimulants

metoclopramide G

METOZOLV ODT NP

H. pylori Agents

HELIDAC NP

lansoprazole/amoxicillin/clarithromycin P

OMECLAMOX-PAK P

PREVPAC NP

PYLERA P

Inflammatory Bowel Agents

APRISO P √

ASACOL P √

ASACOL HD P √

AZULFIDINE NP √

AZULFIDINE ENTAB NP √

balsalazide G √

CANASA P √

COLAZAL NP √

DELZICOL P √

DIPENTUM NP √

GIAZO NP √

LIALDA P √

mesalamine G

PENTASA NP √

sulfasalazine G √

sulfasalazine ER G √

sulfazine G √

sulfazine EC G √

UCERIS NP √

Irritable Bowel Syndrome (IBS) Agent

LOTRONEX NP

Laxatives

KRISTALOSE NP

lactulose G

Pancreatic Enzymes

CREON P

DIGEX NP

48

PANCRELIPASE NP

PANCREAZE NP

PERTZYE NP √

ULTRESA NP √

VIOKACE NP √

ZENPEP P

Rectal Steroids

colocort G

CORTIFOAM NP

Genitourinary System

Cystinosis Agents

CYSTAGON NP

PROCYSBI NP √ √

Interstitial Cystitis Agent

ELMIRON P √

Phosphate Binders

calcium acetate G

ELIPHOS NP

FOSRENOL P

PHOSLO NP

PHOSLYRA P

RENAGEL NP √

RENVELA P

Prostatic Hypertrophy Agents

alfuzosin G

AVODART P

CARDURA XL NP

CIALIS 2.5 mg, 5 mg P √

finasteride G

FLOMAX NP

JALYN P

PROSCAR NP

RAPAFLO P

tamsulosin G

UROXATRAL NP

Urinary Antispasmodics

bethanechol G

DETROL NP √

49

DETROL LA NP √

DITROPAN XL NP √

ENABLEX P

flavoxate G

hyoscyamine G

oxybutynin G

oxybutynin ER G

GELNIQUE NP

MYRBETRIQ NP √

OXYTROL NP √

SANCTURA NP √

SANCTURA XR NP √

tolterodine G

TOVIAZ NP √

trospium G

trospium ER

URECHOLINE NP

VESICARE P

Urinary Anti-infectives and Combinations

MACROBID NP

methenamine hippurate G

methenamine mandelate G

MONUROL NP

nitrofurantoin G

nitrofurantoin monohydrate macrocrystal G

UREX NP

URIBEL NP

URIMAR-T NP

UTA NP

Vaginal Anti-infectives

CLEOCIN VAGINAL NP

clindamax G

METROGEL VAGINAL NP

nystatin vaginal G

TERAZOL NP

terconazole G

tioconazole G

vandazole G

50

zazole G

Vaginal Estrogens

ESTRACE VAGINAL NP

ESTRING NP

FEMRING P

PREMARIN VAGINAL NP

VAGIFEM NP

Vaginal Progestins

CRINONE P

ENDOMETRIN P

PROGESTERONE VAGINAL NP

Infections and Infestations

Antibacterials – Aminoglycosides

neomycin G

paromomycin G

Antibacterials – Ampicillins and Combinations

amoxicillin G

amoxicillin/K clavulanate G

amoxicillin/K clavulanate SR G

ampicillin G

AUGMENTIN NP

AUGMENTIN ES NP

AUGMENTIN XR NP

MOXATAG NP

Antibacterials – Cephalosporins, 1st Generation

cefadroxil G

cephalexin G

Antibacterials – Cephalosporins, 2nd Generation

cefaclor G

cefaclor ER G

cefprozil G

CEFTIN NP

cefuroxime G

Antibacterials – Cephalosporins, 3rd Generation

CEDAX NP

cefdinir G

cefditoren G

51

cefpodoxime G

SPECTRACEF NP

SUPRAX NP

Antibacterials – Fluoroquinolones

AVELOX P

AVELOX ABC P

CIPRO NP

ciprofloxacin G

ciprofloxacin ER G

FACTIVE NP

LEVAQUIN NP

levofloxacin G

NOROXIN NP

ofloxacin G

Antibacterials – Ketolide

KETEK NP

Antibacterials – Macrolides

azithromycin G

BIAXIN NP

BIAXIN XL NP

clarithromycin G

clarithromycin SR G

DIFICID NP √

e.e.s. G

erythrocin G

erythromycin G

erythromycin delayed-release particles G

erythromycin ethylsuccinate G

PCE NP

ZITHROMAX NP

ZMAX NP

Antibacterials – Miscellaneous

clindamycin G

metronidazole G

NEBUPENT P

tinidazole G

TINDAMAX NP

trimethoprim G

52

XIFAXAN NP √

ZYVOX P

Antibacterials – Penicillins

dicloxacillin sodium G

penicillin VK G

Antibacterials – Sulfonamide

sulfadiazine G

Antibacterials – Tetracyclines

ADOXA NP

avidoxy G

demeclocycline G

DORYX NP

doxycycline hyclate G

doxycycline monohydrate G

DYNACIN NP

MINOCIN NP

minocycline G

MONODOX NP

NUTRIDOX NP

ORAXYL NP

SOLODYN NP

tetracycline G

VIBRAMYCIN NP

Antifungals

ANCOBON NP

BIO-STATIN NP

clotrimazole troche G

DIFLUCAN (all other strengths) NP

DIFLUCAN 150 mg NP √

fluconazole (all other strengths) G

fluconazole 150 mg G √

flucytosine G

GRIFULVIN V NP

GRIS-PEG NP

itraconazole G

ketoconazole G

LAMISIL NP

NOXAFIL NP

53

nystatin G

ONMEL NP

ORAVIG NP √

SPORANOX NP

terbinafine G

VFEND NP

voriconazole G

Anti-infective Agents – Miscellaneous

colistimethate sodium G

COLY-MYCIN M NP

Antimalarials and Combinations

ARALEN NP √

atovaquone/proguanil G

chloroquine G √

COARTEM NP

DARAPRIM NP

hydroxychloroquine G √

MALARONE NP

mefloquine G

PLAQUENIL NP √

primaquine G

QUALAQUIN NP √

quinine sulfate G √

Antimycobacterial Agents

dapsone G

ethambutol G

isonarif G

isoniazid G

MYAMBUTOL P

pyrazinamide G

RIFAMATE NP

rifampin G

RIFATER NP

Antiprotozoal Agents

ALINIA NP

MEPRON P

Antiretrovirals – Chemokine Receptor Antagonist

SELZENTRY NP

54

Antiretrovirals – Integrase Inhibitors

ISENTRESS NP

TIVICAY NP

Antiretrovirals – NRTI/NNRTI Combination

ATRIPLA NP

Antiretrovirals – NRTI/NNRTI/HIV integrase Combination

STRIBILD NP

Antiretrovirals – Non-Nucleoside Reverse Transcriptase Inhibitors (NNRTIs)

EDURANT NP

INTELENCE NP

nevirapine G

RESCRIPTOR NP

SUSTIVA P

VIRAMUNE NP

VIRAMUNE XR NP

Antiretrovirals – Nucleoside (NRTI) and Nucleotide (NtRTI) Analogs

abacavir G

COMBIVIR NP

COMPLERA NP

didanosine delayed-release G

EMTRIVA P

EPIVIR NP

EPZICOM NP

lamivudine G

lamivudine/zidovudine G

RETROVIR NP

stavudine G

TRIZIVIR NP

TRUVADA P

VIDEX P

VIDEX EC NP

VIREAD P

ZERIT NP

ZIAGEN NP

zidovudine G

Antiretrovirals – Protease Inhibitors

APTIVUS P

CRIXIVAN NP

55

INVIRASE NP

KALETRA P

LEXIVA P

NORVIR P

PREZISTA P

REYATAZ P

VIRACEPT NP

Antituberculin

SIRTURO NP √

Antivirals – CMV Agent

VALCYTE P √

Antivirals – Hepatitis Agents

adefovir dipivoxil P

BARACLUDE NP

COPEGUS NP

EPIVIR HBV NP

HEPSERA NP

INCIVEK NP √

REBETOL NP

ribatab G

ribapak G

ribasphere G

ribavirin G

TYZEKA NP

VICTRELIS NP √

Antivirals – Herpes Agents

acyclovir G

FAMVIR NP √

famciclovir G √

valacyclovir G

VALTREX NP

ZOVIRAX NP

Antivirals – Influenza Agents

FLUMADINE NP

RELENZA NP √

rimantadine G

TAMIFLU NP √

56

Antivirals – Respiratory Syncytial Virus (RSV) Agent

VIRAZOLE NP

Musculoskeletal System

Antimyasthenic Agents

MESTINON P

MESTINON TIMESPAN P

pyridostigmine G

Antirheumatic Agents

ARAVA NP

leflunomide G

RHEUMATREX NP

RIDAURA NP

Muscle Relaxants and Combinations

AMRIX NP √

baclofen G

carisoprodol G

carisoprodol/aspirin G

carisoprodol/aspirin/codeine G

chlorzoxazone G

cyclobenzaprine G

cyclobenzaprine ER G

DANTRIUM NP

dantrolene G

FEXMID NP √

LORZONE NP

metaxalone G

methocarbamol G

orphenadrine ER G

orphenadrine/aspirin/caffeine G

SKELAXIN NP

tizanidine G

ZANAFLEX NP

NSAIDs

ARTHROTEC NP

CELEBREX NP √

DAYPRO NP

DUEXIS NP √ √

diclofenac G

57

diclofenac potassium G

diclofenac sodium XR G

etodolac G

etodolac ER G

fenoprofen G

FLECTOR patch P √

flurbiprofen G

ibuprofen G

indomethacin G

indomethacin ER G

ketoprofen G

ketoprofen ER G

ketorolac G √

meclofenamate sodium G

mefenamic acid G √

meloxicam G

MOBIC NP

nabumetone G

NAPRELAN NP

naproxen G

oxaprozin G

piroxicam G

PENNSAID NP √ √

PONSTEL NP √

SPRIX NP √

sulindac G

tolmetin sodium G

VIMOVO P √ √

VOLTAREN NP

VOLTAREN GEL P √ √

VOLTAREN XR NP

ZIPSOR NP

Osteoporosis/Bone Modifying Agents

ACTONEL P √

alendronate G √

ATELVIA P √

BINOSTO NP √ √

BONIVA tablet NP √ √

58

calcitonin salmon nasal G

DIDRONEL NP

etidronate G

fortical G

FOSAMAX NP √

FOSAMAX PLUS D NP √ √

ibandronate tablet G √

MIACALCIN NASAL NP

SKELID NP

Rheumatoid Arthritis

XELJANZ NP √

Selective Estrogen Receptor Modulator (SERM)

EVISTA P

Ophthalmic Agents

Glaucoma – Adrenergic Agents

ALPHAGAN P P

apraclonidine G

brimonidine G

IOPIDINE NP

Glaucoma – Beta-blockers

betaxolol ophthalmic G

BETIMOL NP

BETOPTIC-S NP

carteolol G

ISTALOL NP

levobunolol G

metipranolol G

OPTIPRANOLOL NP

timolol ophthalmic G

Glaucoma – Carbonic Anhydrase Inhibitors

AZOPT P

dorzolamide G

dorzolamide/timolol G

COSOPT NP

COSOPT PF NP

COMBIGAN P

SIMBRINZA NP

TRUSOPT NP

59

Glaucoma – Miotics

ISO CARBACHOL NP

ISOPTO CARPINE NP

PHOSPHOLINE NP

pilocarpine G

PILOPINE HS NP

Glaucoma – Prostaglandins

latanoprost G

LUMIGAN 0.01% P

LUMIGAN 0.03% P

TRAVATAN Z P

XALATAN NP

ZIOPTAN NP √

Ophthalmic Miscellaneous

CYSTARAN NP √

Ophthalmic Antihistamines and NSAIDs

ACULAR NP

ACULAR LS NP

ACUVAIL NP

ALAMAST NP

ALOCRIL NP

ALOMIDE NP

azelastine ophthalmic G

BEPREVE NP

BROMDAY NP

bromfenac G

cromolyn sodium ophthalmic G

diclofenac ophthalmic G

ELESTAT NP

EMADINE NP

epinastine G

flurbiprofen ophthalmic G

ILEVRO NP

ketorolac tromethamine ophthalmic G

LASTACAFT NP

NEVANAC NP

OPTIVAR NP

PATADAY P

60

PATANOL NP √

PROLENSA NP

VOLTAREN NP

Ophthalmic Anti-infectives

AZASITE P

bacitracin G

bacitracin/neomycin/polymyxin G

bacitracin/polymyxin G

BESIVANCE NP

ciprofloxacin G

erythromycin G

gentamicin G

IQUIX NP

levofloxacin G

neomycin/polymyxin/gramicidin G

ofloxacin G

polymyxin B/trimethoprim G

QUIXIN NP

sulfacetamide sodium G

tobramycin G

trifluridine G

triple antibiotic G

VIGAMOX NP

ZIRGAN NP

ZYMAXID NP

Ophthalmic Immunomodulator

RESTASIS P

Ophthalmic Steroidal Anti-inflammatory Drugs

ALREX P

bacitracin/polymyxin/neomycin/hydrocortisone

G

BLEPHAMIDE S.O.P. NP

dexamethasone phosphate G

dexamethasone/neomycin/polymyxin G

DUREZOL NP

fluorometholone G

fluor-op G

FML FORTE NP

61

FML LIQUIFILM NP

FML S.O.P. NP

LOTEMAX OINTMENT NP

LOTEMAX SUSPENSION NP

neomycin/polymyxin/hydrocortisone G

poly-dex G

PRED-G NP

PRED-G S.O.P NP

prednisolone G

sulfacetamide sodium/prednisolone G

tobramycin/dexamethasone G

TOBRADEX NP

TOBRADEX ST NP

VEXOL NP

ZYLET NP

Otic Agents

Otic Analgesics

PINNACAINE NP

Otic Anti-infectives

ciprofloxacin otic G

ofloxacin otic G

Otic Combinations

acetic acid/antipyrine/benzocaine/polycosanol

G

antipyrine/benzocaine G

CETRAXAL NP

CIPRO HC NP

CIPRODEX P

COLY-MYCIN S NP

cortomycin G

myoxin G

neomycin/polymyxin/hydrocortisone G

NEOTIC NP

otozin G

TREAGAN NP

TRIOXIN NP

ZINOTIC NP

ZINOTIC ES NP

62

Respiratory Tract Agents

Antiasthmatics – Anticholinergics

ATROVENT HFA NP

ipratropium inhaler G

SPIRIVA P

TUDORZA NP

Anti-Inflammatory Agents (nebulizer)

cromolyn sodium nebulizer G

Bronchodilators – Sympathomimetics

ACCUNEB NP

ADVAIR DISKUS NP √

ADVAIR HFA NP √

albuterol G

ARCAPTA NP

BREO ELLIPTA NP √ √

BROVANA NP

COMBIVENT RESPIMAT P

COMBIVENT NP

DULERA P

DUONEB NP

FORADIL P

ipratropium/albuterol G

levalbuterol G

MAXAIR AUTOHALER NP √

metaproterenol G

PERFOROMIST P

PROAIR HFA P

PROVENTIL HFA P

SEREVENT DISKUS P

SYMBICORT P

terbutaline G

VENTOLIN HFA NP √

VOSPIRE ER NP

XOPENEX NP √

XOPENEX HFA NP √

Bronchodilators – Xanthines

aminophylline G

THEO-24 NP

63

theochron G

theophylline ER G

Cystic Fibrosis Agents

CAYSTON NP

KALYDECO NP √

PULMOZYME P

TOBI NP

TOBI PODHALER NP √

Inhaled Corticosteroids

ALVESCO NP

ASMANEX P

budesonide inhalation suspension G

FLOVENT DISKUS P

FLOVENT HFA P

PULMICORT FLEXHALER NP

PULMICORT RESPULES NP

QVAR P

Leukotriene Modulators

ACCOLATE NP √

zafirlukast G √

SINGULAIR NP √

montelukast G √

ZYFLO NP √

ZYFLO CR NP √

Mouth and Throat Products

cevimeline G

EVOXAC NP

pilocarpine G

SALAGEN NP

Nasal Antiallergy

ASTELIN NASAL NP

ASTEPRO P

azelastine nasal G

DYMISTA NP

PATANASE NP

Nasal Anti-infective

BACTROBAN NASAL NP

Nasal Anticholinergics

64

ATROVENT NASAL NP

ipratropium nasal G

Nasal Steroids

BECONASE AQ NP

FLONASE NP

flunisolide G

fluticasone nasal G

NASACORT AQ NP √

NASONEX P

QNASL NP

OMNARIS NP

RHINOCORT AQ NP √

triamcinolone nasal G

VERAMYST P

ZETONNA NP √

Non-Sedating Antihistamines and Combinations

CLARINEX NP √

CLARINEX-D NP √

CLARINEX REDITAB NP √

desloratadine G √

desloratadine ODT G √

levocetirizine G √

XYZAL NP √

Selective Phosphodiesterase 4 (PDE4) Inhibitors

DALIRESP NP √

Upper Respiratory – Cough/Cold/Allergy Combinations

hydrocodone/chlorpheniramine polistirex G

SEMPREX-D NP √

TUSSICAPS NP

TUSSIONEX NP

VITUZ NP

Miscellaneous

Immunosuppressive Agents

ASTAGRAF XL NP

AZASAN NP

azathioprine G

CELLCEPT NP

65

cyclosporine G

cyclosporine modified G

gengraf G

IMURAN NP

MYFORTIC NP

mycophenolate G

NEORAL NP

PROGRAF NP

RAPAMUNE NP

SANDIMMUNE NP

tacrolimus G

ZORTRESS NP

Vasomotor Associated with Menopause

BRISDELLE NP √ √

Wilson's Disease

DEPEN TITRATABS P

SYPRINE NP

CUPRIMINE NP