2019 Controlled Access Formulary List
Transcript of 2019 Controlled Access Formulary List
2019 Controlled Access Formulary List
The 2019 Controlled Access Formulary drug list is shown below. The formulary is the list of drugs included in your prescription plan. Inclusion on the list does not guarantee coverage.
The following list is not a complete list of products that are on the formulary.
PLEASE NOTE: Brand-name drugs may move to non-preferred status if a generic version becomes available during the year. Not all the drugs listed are covered by all prescription plans; check your benefit materials for the specific drugs covered and the copayments for your prescription plan. For specific questions about your coverage, please call the phone number printed on your member ID card.
KEY [INJ] – Injectable Drug [SP] – Specialty Drug CR – Controlled Release ER, XR, XL – Extended Release FA – Folic Acid FE – Ferrous (Iron) HCL – Hydrochloride HCTZ – Hydrochlorothiazide LA – Long Acting ODT – Oral Dissolving Tablet Brand-name drugs are listed in CAPITAL letters. Example: ABILIFY MAINTENA Generic drugs are listed in lower-case letters. Example: ibuprofen
For the member: FDA-approved generic medications meet strict standards and contain the same active ingredients as their corresponding brand-name medications, although they may have a different appearance.
For the physician: Please prescribe preferred products and allow generic substitutions when medically appropriate.
Costs for covered alternatives may vary. THIS DOCUMENT LIST IS EFFECTIVE JANUARY 1, 2019 THROUGH JUNE 30, 2019. THIS LIST IS SUBJECT TO CHANGE.
Addiction ............................... 6 Alcohol Deterrents/ Anti-craving .................................. 6 Opioid Dependence Treatments .............................................. 6 Smoking Cessation Agents ..... 6
ADHD Drugs .......................... 6 Analeptics .............................. 6 Attention Deficit Hyperactivity Disorder Agents, Amphetamines ...................... 6 Attention Deficit Hyperactivity Disorder Agents, Non-amphetamines ....................... 6
Allergy Drugs ......................... 6 Allergenic Extracts ................. 6 Antihistamines ....................... 6 Ophthalmic Anti-Allergy Agents .............................................. 6
Ophthalmic Anti-Inflammatories ...................... 6
Alzheimer's Disease and Dementia Drugs ..................... 6
Cholinesterase Inhibitors ....... 6 N-methyl-D-aspartate (NMDA) Receptor Antagonist .............. 6
Amebicides ............................ 6 All Agents .............................. 6
Antibiotics ............................. 6 Aminoglycosides .................... 6 Antibacterials, Other ............. 6 Beta-Lactam, Cephalosporins . 6 Beta-Lactam, Other ............... 6 Beta-Lactam, Penicillins ......... 7 Macrolides ............................. 7 Quinolones ............................ 7 Sulfonamides ......................... 7
Tetracyclines .......................... 7 Anticonvulsants ..................... 7
All Agents .............................. 7 GABA Modulators .................. 7 Valproic Acid ......................... 7
Antidepressants ..................... 7 All Agents .............................. 7 Antidepressants, Other .......... 7 Monoamine Oxidase Inhibitors .............................................. 7 SSRIs/ SNRIs (Selective Serotonin Reuptake Inhibitors/ Serotonin and Norepinephrine Reuptake Inhibitor) ................ 7 Tricyclics ................................ 7
Antidiarrheal/ Probiotic Agents ................................... 7
Antidiarrheal/ Probiotic Agents .............................................. 7
Gastrointestinal Adsorbents .. 7 Antidotes And Specific Antagonists ............................ 7
All Agents .............................. 7 Benzodiazepine Antagonists .. 7
Antiemetics ............................ 7 5-HT3 Receptor Antagonists .. 7
Antifungals ............................ 7 All Agents .............................. 7 Imidazole-Related Antifungals 7
Antihistamines ....................... 7 Antihistamines - Alkylamines . 7 Antihistamines - Ethanolamines .............................................. 7 Antihistamines - Ethylenediamines .................. 7
Antihyperlipidemics ............... 7 Bile Acid Sequestrants............ 7
Costs for covered alternatives may vary. THIS DOCUMENT LIST IS EFFECTIVE JANUARY 1, 2019 THROUGH JUNE 30, 2019. THIS LIST IS SUBJECT TO CHANGE.
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Antihypertensives ................. 7 ACE Inhibitors ........................ 7 Antiadrenergic Antihypertensives .................. 7 Vasodilators .......................... 7
Anti-infective Agents ............. 7 All Agents .............................. 7 Anti-infective Misc. - Combinations ........................ 7 Carbapenems ......................... 7 Glycopeptides ........................ 7 Lincosamides ......................... 7 Monobactams ....................... 8 Streptogramins ...................... 8
Antimalarials ......................... 8 All Agents .............................. 8
Antimyasthenic/ Cholinergic Agents ................................... 8
Antimyasthenic/ Cholinergic Agents ................................... 8
Antimycobacterial Agents ..... 8 All Agents .............................. 8
Antineoplastics And Adjunctive Therapies ............. 8
Antineoplastic - Hormonal and Related Agents ...................... 8 Antineoplastic - Immunomodulators ............... 8 Antineoplastic Antibiotics ...... 8 Antineoplastic Enzyme Inhibitors ............................... 8 Antineoplastic Radiopharmaceuticals ........... 8 Antineoplastics Misc. ............. 8 Chemotherapy Adjuncts ......... 8
Antiparkinson And Related Therapy Agents ..................... 8
Antiparkinson Dopaminergics 8 Antipsychotics/ Antimanic Agents ................................... 8
Phenothiazines ...................... 8 Quinolinone Derivatives ......... 8
Antiseptics & Disinfectants .... 8 All Agents .............................. 8 Silver Antiseptics .................... 8
Antivirals ............................... 8
Antiretrovirals ....................... 8 CMV Agents ........................... 8 Herpes Agents ....................... 8 Influenza Agents .................... 8
Anxiety Drugs ........................ 8 Antianxiety Agents ................ 8 Anxiolytics, Other .................. 8 Benzodiazepines .................... 8
Asthma/ Lung Drugs .............. 8 Antiasthmatic - Monoclonal Antibodies ............................. 8 Anti-Inflammatories, Inhaled Corticosteroids ....................... 8 Antileukotrienes .................... 8 Bronchodilators, Anticholinergic....................... 8 Bronchodilators, Sympathomimetic .................. 8 Pulmonary Antihypertensives 8 Respiratory Tract Agents, Other .............................................. 8 Sympathomimetics ................ 9 Xanthines .............................. 9
Beta Blockers ......................... 9 Beta Blockers Cardio-Selective 9 Beta Blockers Non-Selective ... 9
Bladder Control Drugs ........... 9 Antispasmodics, Urinary ........ 9
Bladder, Genital, and Kidney Conditions Drugs ................... 9
Genitourinary Agents, Other .. 9 Blood Clotting Drugs .............. 9
Coagulants ............................ 9 Blood Formation Drugs .......... 9
Blood Formation Modifiers .... 9 Blood Pressure Drugs............. 9
Alpha-Adrenergic Agonists .... 9 Alpha-Adrenergic Blocking Agents ................................... 9 Angiotensin II Receptor Antagonists ........................... 9 Angiotensin-converting Enzyme (ACE) Inhibitors ...................... 9 Beta-Adrenergic Blocking Agents ................................... 9
Calcium Channel Blocking Agents ................................... 9
Blood Thinners ....................... 9 Anticoagulants ...................... 9 Heparins And Heparinoid-Like Agents ................................... 9 In Vitro/ Lock Anticoagulants. 9 Thrombin Inhibitors ............... 9
Bowel Treatment Drugs ......... 9 Antispasmodics, Gastrointestinal ..................... 9 Gastrointestinal Agents, Other .............................................10 Irritable Bowel Syndrome Agents ..................................10 Laxatives ..............................10
Cardiac Drugs ....................... 10 Cardiovascular Agents, Other10 Diuretics, Carbonic Anhydrase Inhibitors ..............................10 Diuretics, Loop ......................10 Diuretics, Potassium-sparing.10 Diuretics, Thiazide ................10
Cardiotonics ......................... 10 Cardiac Glycosides ................10
Cardiovascular Agents ......... 10 Cardioplegic Solutions ..........10 Peripheral Vasodilators ........10 Pulmonary Hypertension - Phosphodiesterase Inhibitors 10
Central Nervous System Drugs ............................................ 10
Central Nervous System, Other .............................................10
Cephalosporins .................... 10 Cephalosporin Combinations 10
Chemotherapy Agents ......... 10 Alkylating Agents .................10 Antiangiogenic Agents ..........10 Antiestrogens/ Modifiers ......10 Antimetabolites ....................11 Antineoplastics, Other ..........11 Aromatase Inhibitors, 3rd Generation ...........................11 Enzyme Inhibitors .................11 Molecular Target Inhibitors ..11
Monoclonal Antibodies .........11 Retinoids ..............................11
Chest Pain Drugs .................. 11 Nitrates ................................11 Vasodilators, Direct-acting Arterial .................................11 Vasodilators, Direct-acting Arterial/ Venous ...................11
Cholesterol Control Drugs .... 11 Dyslipidemics, Fibric Acid Derivatives ...........................11 Dyslipidemics, HMG CoA Reductase Inhibitors .............11 Dyslipidemics, Other .............11
Contraceptives ..................... 11 Implants ...............................11 Injectable ..............................12 IUD .......................................12 Oral ......................................12 Transdermal .........................12 Vaginal .................................12
Corticosteroids ..................... 12 Glucocorticosteroids .............12
Cough/ Cold/ Allergy ............ 12 Antitussives ..........................12 Expectorants .........................12
Cystic Fibrosis Agents ........... 12 All Agents .............................12
Dental and Oral Agents ........ 12 All Agents .............................12
Dermatologicals ................... 12 Acne Products .......................12 Antifungals - Topical .............12 Antipruritics - Topical ............12 Antipsoriatics ........................12 Antiseborrheic Products ........12 Burn Products .......................12 Cauterizing Agents ................13 Keratolytic/ Antimitotic Agents .............................................13 Local Anesthetics - Topical ....13 Misc. Topical .........................13 Scabicides & Pediculicides .....13 Scar Treatment Products .......13
Costs for covered alternatives may vary. THIS DOCUMENT LIST IS EFFECTIVE JANUARY 1, 2019 THROUGH JUNE 30, 2019. THIS LIST IS SUBJECT TO CHANGE.
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Wound Care Products ...........13 Diabetic Drugs ..................... 13
Antidiabetic Agents ..............13 Antidiabetic Combinations ....13 DPP-4....................................13 Glycemic Agents ...................13 Incretin Mimetic Agents (GLP-1 Receptor Agonists) ................13 Insulins .................................13 SGLT2 Inhibitors ....................13
Diabetic Supplies ................. 13 Monitoring Devices & Supplies .............................................13
Diagnostic Products ............. 13 Diagnostic Biologicals ...........13 Diagnostic Drugs...................13 Miscellaneous Contrast Media .............................................13 Radiographic Contrast Media .............................................13
Dietary Products/ Dietary Management Products ........ 13
Nutritional Substitutes ..........13 Nutritional Supplements .......13
Digestive Aids ...................... 13 Digestive Enzymes ................13 Gastric Acidifiers ...................13
Diuretics .............................. 13 Carbonic Anhydrase Inhibitors .............................................13 Loop Diuretics .......................13 Osmotic Diuretics ..................13 Potassium Sparing Diuretics..14
Drugs to Regulate Hormones14 Hormonal Agents, Stimulant/ Replacement/ Modifying (Adrenal) ..............................14
Drugs to Treat Airway Disease ............................................ 14
Phosphodiesterase Inhibitors, Airways Disease ....................14
Drugs to Treat Allergies, Cough, Cold and Lung Conditions ........................... 14
Respiratory Tract/ Pulmonary Agents ..................................14
Drugs to Treat Angioedema . 14
Angioedema (HAE) Agents ....14 Drugs to Treat Viral Infections ............................................ 14
Anti-Cytomegalovirus (CMV) Agents ..................................14 Antivirals ..............................14
Ear Drugs ............................. 14 Otic Agents ...........................14
Endocrine And Metabolic Agents ................................. 14
Metabolic Modifiers .............14 Posterior Pituitary Hormones 14
Enzyme Replacement/ Modifying Drugs .................. 14
Enzyme Replacement/ Modifiers ..............................14
EnzymeReplacement/ Modifying Drugs .................. 14
Enzyme Replacements/ Modifiers ..............................14
Estrogens ............................. 14 All Agents .............................14
Eye Drugs ............................. 14 Ophthalmic Agents, Other ....14
Fibromyalgia Drugs .............. 14 Fibromyalgia Agents .............14
Flu Drugs ............................. 14 Anti-Influenza Agents ...........14
Fluoroquinolones ................ 14 All Agents .............................14
Fungal Infection Drugs ......... 15 Antifungals ...........................15
Gastrointestinal Agents ....... 15 Inflammatory Bowel Agents .15
General Anesthetics ............ 15 Anesthetics ...........................15 Barbiturate Anesthetics ........15
Genitourinary Agents .......... 15 Alkalinizers ...........................15 Genitourinary Irrigants .........15
Glaucoma Drugs .................. 15 Ophthalmic Antiglaucoma Agents ..................................15 Ophthalmic Prostaglandin and Prostamide Analogs ..............15
Gout Agents ......................... 15 All Agents .............................15
Gout Drugs........................... 15 Antigout Agents....................15
Heart Regulation Drugs ........ 15 Antiarrhythmics ....................15 Antiarrhythmics Type I-B ......15 Antiarrhythmics Type III ........15
Hematological Agents .......... 15 Antihemophilic Products .......15 Plasma Expanders .................15 Plasma Proteins ....................15 Platelet Aggregation Inhibitors .............................................15 Protamine .............................15
Hematopoietic Agents ......... 15 Agents for Gaucher Disease ..15 Cobalamins ...........................15 Hematopoietic Growth Factors .............................................15
Hemostatics ......................... 15 Hemostatics - Systemic .........15
Hepatitis Drugs .................... 15 Anti-hepatitis B (HBV) Agents .............................................15 Anti-hepatitis C (HCV) Agents15
Herpes Drugs ....................... 15 Antiherpetic Agents ..............15
HIV Drugs ............................. 15 Anti-HIV Agents, Integrase Inhibitors (INSTI) ...................15 Anti-HIV Agents, Non-nucleoside Reverse Transcriptase Inhibitors (NNRTI) .................................15 Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors (NRTI) .............................................15 Anti-HIV Agents, Other .........16 Anti-HIV Agents, Protease Inhibitors ..............................16
Hormone Replacement/ Modifying Drugs .................. 16
Androgens ............................16 Bulk Chemicals - C's...............16
Bulk Chemicals - D's ..............16 Estrogens ..............................16 Fertility Regulators ...............16 Growth Hormones ................16 Insulin-Like Growth Factors (Somatomedins) ...................16 LHRH/ GnRH Agonist Analog Pituitary Suppressants ..........16 Posterior Pituitary Hormones 16 Progestins .............................16 Selective Estrogen Receptor Modifying Agents .................16
Hormone Suppressants ........ 16 Antiandrogens ......................16 Antineoplastic - Hormonal and Related Agents .....................16 Bulk Chemicals - L's ...............16 GnRH/ LHRH Antagonists ......16 Growth Hormone Receptor Antagonists ..........................16 Growth Hormone Releasing Hormones (GHRH) .................16 Hormonal Agents, Suppressant (Adrenal) ..............................16 Hormonal Agents, Suppressant (Parathyroid) ........................16 LHRH/ GnRH Agonist Analog Pituitary Suppressants ..........16 Prolactin Inhibitors ...............16 Somatostatic Agents .............16
Hypnotics/ Sedatives/ Sleep Disorder Agents ................... 16
Barbiturate Hypnotics ...........16 Non-Barbiturate Hypnotics ...16
Immune System Drugs ......... 16 Immune Suppressants ...........16 Immunizing Agents, Passive ..16 Immunomodulators ..............17
Inflammatory Bowel Disease Drugs ................................... 17
Aminosalicylates ...................17 Glucocorticoids .....................17
Laxatives .............................. 17 Laxative Combinations..........17 Lubricant Laxatives ...............17
Local Anesthetics ................. 17
Costs for covered alternatives may vary. THIS DOCUMENT LIST IS EFFECTIVE JANUARY 1, 2019 THROUGH JUNE 30, 2019. THIS LIST IS SUBJECT TO CHANGE.
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All Agents .............................17 Local Anesthetics-parenteral 17
Local Anesthetic Combinations .............................................17 Local Anesthetics - Amides ....17 Local Anesthetics - Esters ......17
Macrolides .......................... 17 Erythromycins .......................17
Migraine Drugs .................... 17 Ergot Alkaloids .....................17 Serotonin (5-HT) 1b/ 1d Receptor Agonists .................17
Migraine Products ............... 17 All Agents .............................17 Migraine Products - Monoclonal Antibodies .........17
Minerals & Electrolytes ....... 17 Bicarbonates.........................17 Calcium .................................17 Magnesium ..........................17 Manganese ...........................17 Phosphate ............................17 Potassium .............................17 Sodium .................................17 Trace Minerals ......................17 Zinc .......................................17
Miscellaneous Anti-Infectives ............................................ 17
Antimycobacterials, Other ....17 Miscellaneous Therapeutic Classes ................................. 17
Chelating Agents ..................17 Enzymes................................17 Irrigation Solutions ...............17 Peritoneal Dialysis Solutions .17 Sclerosing Agents..................17
Mood Disorder Drugs .......... 17 1st Generation/ Typical ........17 2nd Generation/ Atypical......17 Mood Stabilizers ...................18 Treatment-Resistant .............18
Mouth/ Throat/ Dental Agents ............................................ 18
Dental Products ....................18
Multiple Sclerosis Drugs ...... 18 Multiple Sclerosis Agents ......18
Musculoskeletal Therapy Agents ................................. 18
Direct Muscle Relaxants ........18 Myasthenia Gravis Drugs ..... 18
Parasympathomimetics ........18 Nausea and Vomiting Drugs 18
Antiemetics, Other ................18 Emetogenic Therapy Adjuncts .............................................18
Neuromuscular Agents ........ 18 Depolarizing Muscle Relaxants .............................................18 Nondepolarizing Muscle Relaxants ..............................18
Neurotoxins ......................... 18 Neuromuscular Blocking Agent - Neurotoxins ........................18
Nutrients ............................. 18 Carbohydrates ......................18 Lipids ....................................18 Lipotropics ............................18 Proteins ................................18
Ophthalmic Agents .............. 18 Miotics..................................18 Ophthalmic Anti-infectives ....18 Ophthalmic Gene Therapy ....18 Ophthalmic Kinase Inhibitors 18 Ophthalmic Surgical Aids ......18 Ophthalmics .........................18
Opioid Pain Relievers ........... 18 Opioid Agonists ....................18 Opioid Analgesics, Long-acting .............................................18 Opioid Analgesics, Short-acting .............................................18 Opioid Combinations ............19 Opioid Partial Agonists .........19
Osteoarthritis ...................... 19 Viscosupplements .................19
Osteoporosis (Bone Loss) Drugs ................................... 19
Metabolic Bone Disease Agents .............................................19
Otic Agents .......................... 19 Otic Combinations ................19
Oxytocics ............................. 19 Abortifacients/ Agents for Cervical Ripening ..................19 All Agents .............................19
Pain/ Anti-Inflammatory Drugs ............................................ 19
Analgesics.............................19 Analgesics Other ...................19 Nonsteroidal Anti-inflammatory Agents (NSAIDs) .............................................19 Nonsteroidal Anti-Inflammatory Drugs..............19 Salicylates.............................19
Pain/ Swelling Management Drugs ................................... 19
Skeletal Muscle Relaxants.....19 Parkinson's Disease Drugs ... 19
Anticholinergics ....................19 Antiparkinson Agents, Other .19 Dopamine Agonists ...............19 Dopamine Precursors/ L-Amino Acid Decarboxylase Inhibitors .............................................19 Monoamine Oxidase B (MAO-B) Inhibitors ..........................19
Passive Immunizing And Treatment Agents ................ 19
Immune Serums ....................19 Penicillins............................. 19
Aminopenicillins ...................19 Natural Penicillins .................19 Penicillin Combinations .........19 Penicillinase-Resistant Penicillins..............................19
Phosphate-Removing Agents ............................................ 19
Phosphate Binders ................19 Platelet Modifying Drugs ..... 19
Platelet Modifying Agents ....19 Prostate Enlargement Drugs 19
Benign Prostatic Hypertrophy Agents ..................................19
Protozoal Infection Drugs .... 19
Antiprotozoals ......................19 Psychotherapeutic And Neurological Agents ............. 20
Antidementia Agents ............20 Postherpetic Neuralgia (PHN)/ Neuropathic Pain Agents ......20
Respiratory Agents .............. 20 Cystic Fibrosis Agents ............20
Scabies and Lice Drugs ......... 20 Pediculicides/ Scabicides .......20
Sedation and Sleep Drugs .... 20 GABA Receptor Modulators ..20 Sleep Disorders, Other ..........20
Seizure Control Drugs........... 20 Anticonvulsants, Other .........20 Calcium Channel Modifying Agents ..................................20 Gamma-Aminobutyric Acid (GABA) Augmenting Agents ..20 Glutamate Reducing Agents .20 Sodium Channel Agents ........20
Skin Agents .......................... 20 Acne Products .......................20 Agents for Wrinkles/ Lipoatrophy/ Other Aesthetic Uses ......................................20 Antifungals - Topical .............20 Anti-inflammatory Agents - Topical ..................................20 Antimetabolites ....................20 Antineoplastic or Premalignant Lesion Agents - Topical .........20 Antipruritics - Topical ............20 Antipsoriatics ........................20 Antiseborrheic Products ........20 Corticosteroids - Topical ........20 Eczema Agents......................20 Emollient/ Keratolytic Agents .............................................20 Emollients .............................20 Enzymes - Topical..................20 Immunomodulating Agents - Topical ..................................21 Immunosuppressive Agents ..21 Immunosuppressive Agents - Topical ..................................21
Costs for covered alternatives may vary. THIS DOCUMENT LIST IS EFFECTIVE JANUARY 1, 2019 THROUGH JUNE 30, 2019. THIS LIST IS SUBJECT TO CHANGE.
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Inflammatory Bowel Agents .21 Keratolytic/ Antimitotic Agents .............................................21 Leprostatics ..........................21 Local Anesthetics - Topical ....21 Metabolic Modifiers .............21 Nonsteroidal Anti-inflammatory Agents (NSAIDs) .............................................21 Otic Combinations ................21 Rosacea Agents ....................21 Tricyclic Agents .....................21 Wound Care Products ...........21
Sulfonamides....................... 21 All Agents .............................21
Tetracyclines ....................... 21 All Agents .............................21
Thyroid Agents .................... 21 Thyroid Hormones ................21
Thyroid Replacement Drugs 21 Hormonal Agents, Stimulant/ Replacement/ Modifying (Thyroid) ...............................21
Thyroid Suppressing Drugs .. 21 Antithyroid Agents................21
Toxoids ................................ 21 Toxoid Combinations ............21
Tuberculosis Drugs .............. 21 Antituberculars .....................21
Ulcer and Stomach Acid Drugs ............................................ 21
Histamine2 (H2) receptor Antagonists ..........................21 Protectants ...........................21 Proton Pump Inhibitors .........21
Ulcer Drugs/ Antispasmodics/ Anticholinergics ................... 21
Antispasmodics .....................21 Proton Pump Inhibitors .........21
Urinary Anti-infectives ........ 21 All Agents .............................21
Vaccines .............................. 21 All Agents .............................21 Viral Vaccines .......................21
Vaginal Products ................. 21
Miscellaneous Vaginal Products .............................................21
Vasopressors ....................... 21 All Agents .............................21
Vitamins .............................. 21 Water Soluble Vitamins ........21
Vitamins, Minerals, Electrolytes .......................... 21
Electrolyte/ Mineral Modifiers .............................................21 Electrolyte/ Mineral Replacement .........................22 Prenatal Vitamins .................22 Therapeutic Nutrients/ Minerals/ Electrolytes ...........22 Vitamins ...............................22
Worm Infection Drugs ......... 22 Anthelmintics .......................22
Costs for covered alternatives may vary. THIS DOCUMENT LIST IS EFFECTIVE JANUARY 1, 2019 THROUGH JUNE 30, 2019. THIS LIST IS SUBJECT TO CHANGE.
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Addiction Alcohol Deterrents/ Anti-craving
acamprosate calcium disulfiram naltrexone hydrochloride VIVITROL [SP]
Opioid Dependence Treatments
BELBUCA buprenorphine
hydrochloride buprenorphine
hydrochloride [INJ] buprenorphine-naloxone naloxone hcl naloxone hcl [INJ] naltrexone hydrochloride NARCAN SUBOXONE ZUBSOLV
Smoking Cessation Agents
bupropion sr CHANTIX
ADHD Drugs Analeptics
caffeine caffeine & sodium
benzoate [INJ]
Attention Deficit Hyperactivity Disorder Agents, Amphetamines
dextroamphetamine sulfate
dextroamphetamine sulfate er
dextroamphetamine-amphet er
dextroamphetamine-amphetamine
EVEKEO methamphetamine hcl MYDAYIS PROCENTRA VYVANSE zenzedi
Attention Deficit Hyperactivity Disorder Agents, Non-amphetamines
atomoxetine hcl clonidine hcl er DAYTRANA dexmethylphenidate hcl dexmethylphenidate hcl er guanfacine hcl er
metadate er methylphenidate er methylphenidate hcl methylphenidate hcl cd methylphenidate la QUILLICHEW ER QUILLIVANT XR
Allergy Drugs Allergenic Extracts
ODACTRA
Antihistamines
azelastine hcl carbinoxamine cetirizine hcl chlorpheniramine maleate clemastine fumarate cyproheptadine hcl desloratadine diphenhydramine hcl diphenhydramine hcl [INJ] levocetirizine
dihydrochloride olopatadine hcl pharbedryl phenadoz promethazine hcl promethazine hcl [INJ] promethegan
Ophthalmic Anti-Allergy Agents
azelastine hcl BEPREVE cromolyn sodium epinastine hcl olopatadine hcl PAZEO
Ophthalmic Anti-Inflammatories
ALREX bromfenac sodium dexamethasone sodium
phosphate dexamethasone sodium
phosphate [INJ] diclofenac sodium fluorometholone flurbiprofen sodium ILEVRO ketorolac tromethamine ketorolac tromethamine
[INJ] LOTEMAX OZURDEX [SP] prednisolone acetate prednisolone sodium
phosphate
PROLENSA
Alzheimer's Disease and Dementia Drugs Cholinesterase Inhibitors
donepezil hcl galantamine galantamine er rivastigmine
N-methyl-D-aspartate (NMDA) Receptor Antagonist
memantine hcl
Amebicides All Agents
iodoquinol
Antibiotics Aminoglycosides
amikacin sulfate amikacin sulfate [INJ] BETHKIS [SP] GENTAK gentamicin sulfate gentamicin sulfate [INJ] gentamicin sulfate in ns KITABIS PAK [SP] neomycin sulfate paromomycin sulfate streptomycin sulfate TOBI PODHALER [SP] TOBRADEX tobramycin sulfate [SP] tobramycin sulfate [SP]
[INJ]
Antibacterials, Other
bacitracin benzalkonium chloride chloramphenicol sod
succinate CLEOCIN PHOSPHATE clindacin etz clindacin p clindamycin hcl clindamycin palmitate hcl clindamycin pediatric clindamycin phosphate clindamycin phosphate
[INJ] colistimethate sodium colistimethate sodium [INJ] daptomycin FEM PH iodine iodoquinol-hydrocortisone-
aloe
lincomycin hcl lincomycin hcl [INJ] linezolid lugol's mafenide acetate methenamine hippurate methenamine mandelate metronidazole mupirocin neomycin-polymyxin b nitrofurantoin nitrofurantoin
macrocrystal phenol polymyxin b sulfate polymyxin b sulfate [INJ] rosadan silver nitrate SILVER NITRATE
APPLICATOR SULFAMYLON tigecycline tinidazole trimethoprim vancomycin hcl vancomycin-ns vandazole VIBATIV XIFAXAN
Beta-Lactam, Cephalosporins
cefaclor cefaclor er cefadroxil cefazolin sodium cefazolin sodium [INJ] cefdinir cefditoren pivoxil cefepime hcl cefepime hcl [INJ] cefixime cefotaxime sodium [INJ] cefotetan cefotetan [INJ] cefoxitin cefpodoxime proxetil cefprozil ceftazidime ceftazidime [INJ] ceftriaxone ceftriaxone [INJ] cefuroxime axetil cefuroxime sodium cefuroxime sodium [INJ] cephalexin TEFLARO
Beta-Lactam, Other
Costs for covered alternatives may vary. THIS DOCUMENT LIST IS EFFECTIVE JANUARY 1, 2019 THROUGH JUNE 30, 2019. THIS LIST IS SUBJECT TO CHANGE.
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imipenem-cilastatin sodium
INVANZ INVANZ [INJ] meropenem meropenem-0.9% nacl
Beta-Lactam, Penicillins
amoxicillin amoxicillin-clavulanate pot
er amoxicillin-clavulanate
potass ampicillin trihydrate ampicillin/sulbactam ampicillin/sulbactam [INJ] AUGMENTIN dicloxacillin sodium nafcillin sodium nafcillin sodium [INJ] OXACILLIN SODIUM oxacillin sodium [INJ] penicillin g potassium [INJ] penicillin g procaine penicillin g sodium [INJ] penicillin v potassium PFIZERPEN [INJ] piperacillin-tazobactam ZOSYN
Macrolides
AZASITE azithromycin clarithromycin clarithromycin er E.E.S. ery ERYGEL ERY-TAB ERYTHROCIN STEARATE erythromycin erythromycin
ethylsuccinate
Quinolones
ciprofloxacin ciprofloxacin er ciprofloxacin hcl FLOXIN gatifloxacin levofloxacin hemihydrate MOXEZA moxifloxacin hcl ofloxacin
Sulfonamides
silver sulfadiazine ssd
sulfacetamide sodium sulfadiazine sulfamethoxazole/trimetho
prim sulfasalazine sulfasalazine dr sulfatrim
Tetracyclines
avidoxy demeclocycline hcl doxy 100 doxycycline hyclate doxycycline monohydrate MINOCIN minocycline hcl mondoxyne nl morgidox okebo ORACEA SOLODYN tetracycline hcl
Anticonvulsants All Agents
levetiracetam-nacl roweepra xr subvenite
GABA Modulators
vigadrone [SP]
Valproic Acid
valproate sodium
Antidepressants All Agents
bupropion hcl er
Antidepressants, Other
amitriptyline/chlordiazepoxide
amitriptyline-perphenazine bupropion hcl bupropion hcl xl bupropion sr mirtazapine olanzapine-fluoxetine hcl
Monoamine Oxidase Inhibitors
phenelzine sulfate tranylcypromine sulfate
SSRIs/ SNRIs (Selective Serotonin Reuptake Inhibitors/ Serotonin and Norepinephrine Reuptake Inhibitor)
citalopram hbr
desvenlafaxine succinate er duloxetine hcl escitalopram oxalate FETZIMA fluoxetine dr fluoxetine hcl fluvoxamine maleate maprotiline hcl paroxetine er paroxetine hcl paroxetine mesylate sertraline hcl trazodone hcl venlafaxine hcl venlafaxine hcl er VIIBRYD
Tricyclics
amitriptyline hcl amoxapine clomipramine hcl desipramine hcl doxepin hcl imipramine hcl imipramine pamoate nortriptyline hcl protriptyline hcl trimipramine maleate
Antidiarrheal/ Probiotic Agents Antidiarrheal/ Probiotic Agents
bismuth subgallate
Gastrointestinal Adsorbents
kaolin pectin
Antidotes And Specific Antagonists All Agents
activated charcoal BAL IN OIL calcium disodium
versenate [INJ] edetate calcium disodium fomepizole methylene blue physostigmine salicylate
[INJ] PROTOPAM CHLORIDE
[INJ] sodium thiosulfate
Benzodiazepine Antagonists
flumazenil
Antiemetics
5-HT3 Receptor Antagonists palonosetron hcl
Antifungals All Agents
ABELCET AMBISOME
Imidazole-Related Antifungals
fluconazole in dextrose fluconazole in saline miconazole
Antihistamines Antihistamines - Alkylamines
brompheniramine maleate
Antihistamines - Ethanolamines
doxylamine succinate
Antihistamines - Ethylenediamines
pyrilamine maleate tripelennamine hcl
Antihyperlipidemics Bile Acid Sequestrants
colesevelam hcl
Antihypertensives ACE Inhibitors
enalaprilat
Antiadrenergic Antihypertensives
reserpine
Vasodilators
sodium nitroprusside
Anti-infective Agents All Agents
baci-im metro iv
Anti-infective Misc. - Combinations
smz-tmp ds
Carbapenems
ertapenem [INJ]
Glycopeptides
DALVANCE ORBACTIV vancomycin-d5w
Lincosamides
Costs for covered alternatives may vary. THIS DOCUMENT LIST IS EFFECTIVE JANUARY 1, 2019 THROUGH JUNE 30, 2019. THIS LIST IS SUBJECT TO CHANGE.
Page 8 of 22
clindamycin phosphate-d5w
Monobactams
AZACTAM-ISO-OSMOTIC DEXTROSE
aztreonam [INJ]
Streptogramins
SYNERCID
Antimalarials All Agents
quinacrine hcl
Antimyasthenic/ Cholinergic Agents Antimyasthenic/ Cholinergic Agents
ENLON [INJ] REGONOL [INJ]
Antimycobacterial Agents All Agents
aminosalicylic acid
Antineoplastics And Adjunctive Therapies Antineoplastic - Hormonal and Related Agents
ERLEADA [SP] YONSA
Antineoplastic - Immunomodulators
levamisole hcl
Antineoplastic Antibiotics
dactinomycin
Antineoplastic Enzyme Inhibitors
temsirolimus
Antineoplastic Radiopharmaceuticals
LUTATHERA [SP] XOFIGO [SP]
Antineoplastics Misc.
BCG (TICE STRAIN)
Chemotherapy Adjuncts
ELITEK
Antiparkinson And Related Therapy Agents Antiparkinson Dopaminergics
levodopa
Antipsychotics/ Antimanic Agents Phenothiazines
prochlorperazine edisylate [INJ]
Quinolinone Derivatives
ARISTADA INITIO
Antiseptics & Disinfectants All Agents
hydrogen peroxide
Silver Antiseptics
silver protein
Antivirals Antiretrovirals
atazanavir sulfate BIKTARVY CIMDUO efavirenz ritonavir SYMFI SYMFI LO tenofovir disoproxil
fumarate TROGARZO [SP]
CMV Agents
ganciclovir sodium [SP] PREVYMIS
Herpes Agents
acyclovir sodium
Influenza Agents
RAPIVAB
Anxiety Drugs Antianxiety Agents
droperidol droperidol [INJ]
Anxiolytics, Other
buspirone hcl hydroxyzine hcl hydroxyzine pamoate
Benzodiazepines
alprazolam alprazolam er ALPRAZOLAM INTENSOL alprazolam odt alprazolam xr chlordiazepoxide hcl clonazepam
clorazepate dipotassium diazepam diazepam [INJ] estazolam lorazepam lorazepam [INJ] lorazepam intensol midazolam hcl midazolam hcl [INJ] midazolam hcl-nacl triazolam
Asthma/ Lung Drugs Antiasthmatic - Monoclonal Antibodies
FASENRA [SP]
Anti-Inflammatories, Inhaled Corticosteroids
ARNUITY ELLIPTA ASMANEX ASMANEX HFA budesonide FLOVENT DISKUS FLOVENT HFA flunisolide fluticasone propionate mometasone furoate QNASL QVAR QVAR REDIHALER triamcinolone acetonide triamcinolone acetonide
[INJ]
Antileukotrienes
montelukast sodium zafirlukast zileuton
Bronchodilators, Anticholinergic
ATROVENT HFA INCRUSE ELLIPTA ipratropium bromide SPIRIVA SPIRIVA RESPIMAT
Bronchodilators, Sympathomimetic
ADRENALIN CHLORIDE [INJ] albuterol sulfate ARCAPTA NEOHALER epinephrine epinephrine [INJ] EPIPEN [INJ] EPIPEN JR. [INJ] levalbuterol hcl
metaproterenol sulfate PERFOROMIST PROAIR HFA PROAIR RESPICLICK SEREVENT DISKUS STRIVERDI RESPIMAT terbutaline sulfate VENTOLIN HFA
Pulmonary Antihypertensives
ADEMPAS [SP] epoprostenol sodium [SP] FLOLAN [SP] LETAIRIS [SP] OPSUMIT [SP] REMODULIN [SP] [INJ] sildenafil citrate [SP] TRACLEER [SP] TYVASO [SP] UPTRAVI [SP] VELETRI [SP]
Respiratory Tract Agents, Other
acetylcysteine ADVAIR DISKUS ADVAIR HFA ANORO ELLIPTA ARALAST NP [SP] BREO ELLIPTA bromipheniramin-
pseudoephed-dm brompheniramine
w/pseudoephed CAYSTON [SP] cromolyn sodium DULERA ESBRIET [SP] EXACTUSS fluticasone-salmeterol GILTUSS GRASTEK hydrocod-cpm-
pseudoephedrine hydrocodone-
chlorpheniramine iodine KALYDECO [SP] lugol's NEOTUSS PLUS OFEV [SP] ORKAMBI [SP] PROLASTIN C [SP] promethazine vc
w/codeine promethazine w/codeine promethazine w/dm pseudoephedrine hcl RAGWITEK SYMBICORT
Costs for covered alternatives may vary. THIS DOCUMENT LIST IS EFFECTIVE JANUARY 1, 2019 THROUGH JUNE 30, 2019. THIS LIST IS SUBJECT TO CHANGE.
Page 9 of 22
TRELEGY ELLIPTA ZEMAIRA [SP]
Sympathomimetics
ephedrine hcl isoproterenol hcl [INJ]
Xanthines
aminophylline theophylline in 5%
dextrose
Beta Blockers Beta Blockers Cardio-Selective
esmolol hcl
Beta Blockers Non-Selective
sorine sotalol hcl
Bladder Control Drugs Antispasmodics, Urinary
darifenacin er flavoxate hcl GELNIQUE HYOPHEN me-naphos-mb-hyo 1 MYRBETRIQ oxybutynin chloride oxybutynin chloride er tolterodine tartrate tolterodine tartrate er TOVIAZ trospium chloride UROGESIC uryl VESICARE
Bladder, Genital, and Kidney Conditions Drugs Genitourinary Agents, Other
aminoacetic acid bethanechol chloride CAVERJECT CIALIS DEPEN ELMIRON glycine MUSE phenazopyridine hcl phosphasal RENACIDIN uretron d-s URIMAR-T urin d.s. uro-458 uroav-81 uroav-b
uro-mp ustell utira-c vilamit mb vilevev mb
Blood Clotting Drugs Coagulants
ADVATE [SP] ADYNOVATE [SP] AFSTYLA [SP] ALPHANATE [SP] ALPHANINE SD [SP] ALPROLIX [SP] AMICAR BEBULIN [SP] BENEFIX [SP] COAGADEX [SP] CORIFACT [SP] FEIBA NF [SP] HELIXATE FS [SP] HEMOFIL-M [SP] HUMATE-P [SP] IXINITY [SP] KOGENATE FS [SP] KOVALTRY [SP] MONOCLATE-P [SP] MONONINE [SP] MONSEL'S NOVOEIGHT [SP] NOVOSEVEN RT [SP] NUWIQ [SP] OBIZUR [SP] PROFILNINE SD [SP] RIASTAP [SP] tranexamic acid TRETTEN [SP] VONVENDI [SP] WILATE [SP]
Blood Formation Drugs Blood Formation Modifiers
anagrelide hydrochloride CEPROTIN [SP] GRANIX [SP] LEUKINE [SP] [INJ] MOZOBIL [SP] NEULASTA [SP] NPLATE [SP] PROCRIT [SP] [INJ] PROMACTA [SP] SOLIRIS [SP] ZARXIO [SP] [INJ]
Blood Pressure Drugs Alpha-Adrenergic Agonists
clonidine hcl guanfacine hcl
methyldopa methyldopate hcl midodrine hcl phenylephrine hcl-ns
Alpha-Adrenergic Blocking Agents
doxazosin mesylate phenoxybenzamine hcl phentolamine mesylate phentolamine mesylate
[INJ] prazosin hcl
Angiotensin II Receptor Antagonists
candesartan cilexetil EDARBI eprosartan mesylate irbesartan losartan potassium olmesartan medoxomil telmisartan valsartan
Angiotensin-converting Enzyme (ACE) Inhibitors
benazepril hcl captopril enalapril maleate fosinopril sodium lisinopril moexipril hcl perindopril erbumine quinapril ramipril trandolapril
Beta-Adrenergic Blocking Agents
acebutolol hcl atenolol betaxolol hcl bisoprolol fumarate BYSTOLIC carvedilol carvedilol er labetalol hcl metoprolol succinate metoprolol tartrate nadolol pindolol propranolol hcl propranolol hcl er timolol maleate
Calcium Channel Blocking Agents
afeditab cr
amlodipine besylate cartia xt diltiazem 24hr cd diltiazem cd diltiazem er diltiazem hcl dilt-xr felodipine er isradipine matzim la nicardipine hcl nifedipine nifedipine er nimodipine nisoldipine taztia xt verapamil er verapamil er pm verapamil hcl
Blood Thinners Anticoagulants
acd ACD-A ACTIVASE CATHFLO ACTIVASE [INJ] ELIQUIS enoxaparin sodium [SP] fondaparinux sodium [SP] FRAGMIN [SP] heparin sodium heparin sodium [INJ] heparin sodium in 0.9%
nacl jantoven sodium citrate THROMBATE III TRICITRASOL [INJ] warfarin sodium XARELTO
Heparins And Heparinoid-Like Agents
heparin sodium in 0.45% nacl
heparin sodium in 5% dextrose
In Vitro/ Lock Anticoagulants
CITRATE PHOSPHATE DEXTROSE
Thrombin Inhibitors
bivalirudin
Bowel Treatment Drugs Antispasmodics, Gastrointestinal
ANASPAZ
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Page 10 of 22
atropine sulfate atropine sulfate [INJ] belladonna & opium belladonna-phenobarbital clidinium
w/chlordiazepoxide dicyclomine hcl ed-spaz glycopyrrolate glycopyrrolate [INJ] hyoscyamine sulfate hyosyne LEVSIN [INJ] methscopolamine bromide oscimin oscimin sl oscimin sr phenohytro propantheline bromide symax-sl symax-sr
Gastrointestinal Agents, Other
CHENODAL [SP] CHOLBAM [SP] cromolyn sodium diphenoxylate w/atropine lansoprazol-amoxicil-
clarithro loperamide hcl magnesium oxide opium paregoric PYLERA SEROSTIM [SP] simethicone sodium bicarbonate ursodiol XERMELO [SP]
Irritable Bowel Syndrome Agents
alosetron hcl AMITIZA LINZESS VIBERZI
Laxatives
bisacodyl constulose docusate sodium enulose gavilyte-c gavilyte-g gavilyte-h and bisacodyl gavilyte-n generlac glycerin
glycerol formal glycolax lactulose mineral oil peg 3350-electrolyte peg-prep polyethylene glycol PREPOPIK sorbitol SUPREP trilyte with flavor packets
Cardiac Drugs Cardiovascular Agents, Other
ADRENALIN CHLORIDE [INJ] amiloride hcl w/hctz amlodipine besylate-
benazepril amlodipine-atorvastatin amlodipine-olmesartan amlodipine-valsartan amlodipine-valsartan-hctz atenolol w/chlorthalidone benazepril hcl-hctz bisoprolol fumarate/hctz BYVALSON candesartan-
hydrochlorothiazid captopril/hydrochlorothiazi
de CORLANOR DEMSER digitek digox digoxin digoxin [INJ] EDARBYCLOR enalapril maleate/hctz ENTRESTO ephedrine sulfate ephedrine sulfate [INJ] fosinopril-
hydrochlorothiazide irbesartan-
hydrochlorothiazide isoxsuprine hcl lisinopril-hctz losartan-
hydrochlorothiazide methyldopa/hydrochloroth
iazide metoprolol-
hydrochlorothiazide milrinone in 5% dextrose milrinone lactate moexipril-
hydrochlorothiazide nadolol-
bendroflumethiazide
NATRECOR olmesartan-amlodipine-
hctz olmesartan-
hydrochlorothiazide pentoxifylline propranolol hcl-hctz quinapril-
hydrochlorothiazide RANEXA spironolactone w/hctz TEKTURNA TEKTURNA HCT telmisartan-amlodipine telmisartan-
hydrochlorothiazid trandolapril-verapamil triamterene w/hctz valsartan-
hydrochlorothiazide
Diuretics, Carbonic Anhydrase Inhibitors
acetazolamide
Diuretics, Loop
bumetanide bumetanide [INJ] ethacrynic acid furosemide furosemide [INJ] torsemide
Diuretics, Potassium-sparing
amiloride hcl eplerenone spironolactone
Diuretics, Thiazide
chlorothiazide chlorthalidone hydrochlorothiazide indapamide methyclothiazide metolazone
Cardiotonics Cardiac Glycosides
LANOXIN PEDIATRIC [INJ]
Cardiovascular Agents Cardioplegic Solutions
cardioplegic
Peripheral Vasodilators
nylidrin hcl
Pulmonary Hypertension - Phosphodiesterase Inhibitors
tadalafil
Central Nervous System Drugs Central Nervous System, Other
benzphetamine hcl caffeine citrated diethylpropion hcl diethylpropion hcl er NAMZARIC NUEDEXTA phendimetrazine tartrate phentermine hcl RADICAVA [SP] riluzole serotonin hcl succinylcholine chloride succinylcholine chloride
[INJ] tetrabenazine [SP]
Cephalosporins Cephalosporin Combinations
AVYCAZ ZERBAXA
Chemotherapy Agents Alkylating Agents
BENDEKA [SP] BICNU busulfan cyclophosphamide dacarbazine GLEOSTINE HEXALEN ifosfamide LEUKERAN MATULANE [SP] melphalan hcl MUSTARGEN [INJ] MYLERAN TEMODAR [SP] temozolomide [SP] thiotepa thiotepa [INJ] TREANDA [SP] VALCHLOR [SP] YONDELIS [SP] ZANOSAR
Antiangiogenic Agents
POMALYST [SP] REVLIMID [SP] THALOMID [SP]
Antiestrogens/ Modifiers
EMCYT FARESTON
Costs for covered alternatives may vary. THIS DOCUMENT LIST IS EFFECTIVE JANUARY 1, 2019 THROUGH JUNE 30, 2019. THIS LIST IS SUBJECT TO CHANGE.
Page 11 of 22
FASLODEX tamoxifen citrate
Antimetabolites
adrucil ALIMTA cladribine clofarabine cytarabine [INJ] DROXIA fluorouracil FOLOTYN [SP] gemcitabine hcl hydroxyurea mercaptopurine PURIXAN [SP] TABLOID thioguanine
Antineoplastics, Other
ABRAXANE [SP] ADRIAMYCIN ARRANON [SP] azacitidine [SP] [INJ] bleomycin sulfate [INJ] calcium folinate capecitabine [SP] carboplatin cisplatin daunorubicin hcl decitabine [SP] dexrazoxane docetaxel doxorubicin hcl doxorubicin hcl liposomal epirubicin hcl floxuridine floxuridine [INJ] fludarabine phosphate HALAVEN [SP] idarubicin hcl irinotecan hcl ISTODAX [SP] IXEMPRA [SP] JEVTANA [SP] KYMRIAH [SP] KYPROLIS leucovorin calcium leucovorin calcium [INJ] levoleucovorin calcium lipodox LONSURF [SP] MARQIBO mesna MESNEX mitomycin mitoxantrone [SP] NINLARO [SP]
ONCASPAR [INJ] oxaliplatin paclitaxel PHOTOFRIN PROLEUKIN [SP] SIPULEUCEL-T PROVENGE SYNRIBO [SP] teniposide THERACYS TICE BCG tice bcg [INJ] TRISENOX VALSTAR VELCADE [SP] [INJ] VERZENIO [SP] vinblastine sulfate vincasar pfs vincristine sulfate vinorelbine tartrate VORAXAZE VYXEOS LIPOSOME [SP] YESCARTA [SP] ZALTRAP [SP] ZOLINZA [SP] ZYKADIA [SP]
Aromatase Inhibitors, 3rd Generation
anastrozole exemestane letrozole
Enzyme Inhibitors
ALIQOPA [SP] ETOPOPHOS etoposide HYCAMTIN [SP] LYNPARZA [SP] ONIVYDE [SP] RUBRACA [SP] toposar topotecan hcl ZEJULA [SP] ZYDELIG [SP]
Molecular Target Inhibitors
AFINITOR [SP] AFINITOR DISPERZ [SP] ALECENSA [SP] BOSULIF [SP] CABOMETYX [SP] CAPRELSA [SP] COTELLIC [SP] ERIVEDGE [SP] GILOTRIF [SP] IBRANCE [SP] ICLUSIG [SP] IDHIFA [SP]
imatinib mesylate [SP] IMBRUVICA [SP] INLYTA [SP] IRESSA [SP] JAKAFI [SP] LENVIMA [SP] MEKINIST [SP] NERLYNX [SP] NEXAVAR [SP] RYDAPT [SP] SPRYCEL [SP] STIVARGA [SP] SUTENT [SP] TAFINLAR [SP] TAGRISSO [SP] TARCEVA [SP] TASIGNA [SP] TYKERB [SP] VENCLEXTA [SP] VENCLEXTA STARTING
PACK [SP] VOTRIENT [SP] XALKORI [SP] ZELBORAF [SP]
Monoclonal Antibodies
ADCETRIS [SP] ARZERRA [SP] AVASTIN [SP] BAVENCIO [SP] BESPONSA [SP] BLINCYTO [SP] CYRAMZA [SP] DARZALEX [SP] ERBITUX [SP] GAZYVA [SP] HERCEPTIN [SP] IMFINZI [SP] KADCYLA [SP] KEYTRUDA [SP] LARTRUVO [SP] OPDIVO [SP] PERJETA [SP] RITUXAN HYCELA [SP] SYLVANT [SP] TECENTRIQ [SP] UNITUXIN [SP] VECTIBIX [SP] YERVOY [SP] ZEVALIN
Retinoids
bexarotene TARGRETIN
Chest Pain Drugs Nitrates
nitroglycerin in d5w
Vasodilators, Direct-acting Arterial
hydralazine hcl hydralazine hcl [INJ] minoxidil papaverine hcl papaverine hcl [INJ]
Vasodilators, Direct-acting Arterial/ Venous
DILATRATE-SR isosorbide dinitrate isosorbide mononitrate NITRO-BID nitroglycerin nitro-time RECTIV
Cholesterol Control Drugs Dyslipidemics, Fibric Acid Derivatives
fenofibrate fenofibric acid gemfibrozil LIPOFEN
Dyslipidemics, HMG CoA Reductase Inhibitors
atorvastatin calcium fluvastatin er fluvastatin sodium LIVALO lovastatin pravastatin sodium rosuvastatin calcium simvastatin
Dyslipidemics, Other
cholestyramine cholestyramine light colestipol hcl ezetimibe ezetimibe-simvastatin JUXTAPID [SP] niacin er omega-3 acid ethyl esters PRALUENT PEN [SP] prevalite REPATHA PUSHTRONEX
[SP] REPATHA SURECLICK [SP] REPATHA SYRINGE [SP] VASCEPA
Contraceptives Implants
NEXPLANON
Costs for covered alternatives may vary. THIS DOCUMENT LIST IS EFFECTIVE JANUARY 1, 2019 THROUGH JUNE 30, 2019. THIS LIST IS SUBJECT TO CHANGE.
Page 12 of 22
Injectable
medroxyprogesterone acetate
IUD
KYLEENA [SP] MIRENA SKYLA
Oral
altavera alyacen amethia amethia lo amethyst apri aranelle ashlyna aubra aubra eq aviane azurette balziva bekyree blisovi 24 fe blisovi fe briellyn camila camrese camrese lo caziant chateal chateal eq cryselle cyclafem cyred dasetta daysee deblitane delyla desogestrel-ethinyl
estradiol desogestr-eth estrad eth
estra drospirenone-eth estra-
levomef drospirenone-ethinyl
estradiol elinest emoquette enpresse enskyce errin estarylla ethynodiol-ethinyl
estradiol falmina fayosim
femynor gianvi gildess fe heather incassia introvale isibloom jencycla jolessa jolivette juleber junel junel fe kaitlib fe kariva kelnor 1-35 kelnor 1-50 kurvelo larin larin fe larissia layolis fe leena lessina levonest levonorgestrel-eth
estradiol levonorg-eth estrad eth
estrad levora lillow LO LOESTRIN FE loryna low-ogestrel lutera lyza marlissa melodetta 24 fe mibelas 24 fe microgestin microgestin fe mili mono-linyah mononessa myzilra necon nikki nora-be norethindrone acetate norethindrone-ethin
estradiol norethin-eth estra ferrous
fum norgestimate-ethinyl
estradiol NORGESTREL-ETHINY
ESTRA norlyda norlyroc
nortrel ocella OGESTREL orsythia philith pimtrea pirmella portia previfem quasense rajani reclipsen rivelsa setlakin sharobel sprintec sronyx syeda tarina fe TAYTULLA tilia fe tri femynor tri-estarylla tri-legest fe tri-linyah tri-lo-estarylla tri-lo-marzia tri-lo-sprintec tri-mili trinessa trinessa lo tri-previfem tri-sprintec trivora tri-vylibra tulana tydemy velivet vienva viorele vyfemla vylibra wera wymzya fe zarah zovia
Transdermal
XULANE
Vaginal
NUVARING
Corticosteroids Glucocorticosteroids
budesonide er decadron dexamethasone-0.9% nacl
methylprednisolone sod succ [INJ]
prednisolone acetate micronize
Cough/ Cold/ Allergy Antitussives
hydrocodone compound
Expectorants
bromhexine hydrochloride terpin hydrate
Cystic Fibrosis Agents All Agents
KALYDECO [SP]
Dental and Oral Agents All Agents
cevimeline hcl chlorhexidine gluconate denta 5000 plus dentagel FIRST-MOUTHWASH BLM KEPIVANCE oralone pilocarpine hcl sf sf 5000 plus sodium fluoride triamcinolone acetonide triamcinolone acetonide
[INJ]
Dermatologicals Acne Products
isotretinoin metronidazole benzoate
Antifungals - Topical
benzoic acid ciclopirox olamine clioquinol gentian violet iodochlorohydroxyquinolin
e
Antipruritics - Topical
camphor
Antipsoriatics
anthralin
Antiseborrheic Products
glycolic acid
Burn Products
nitrofurazone
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Cauterizing Agents
chloroacetic acid
Keratolytic/ Antimitotic Agents
cantharidin podophyllum resin
Local Anesthetics - Topical
glydo lidozion pramoxine hcl
Misc. Topical
ACUICYN aluminum chloride arnica flower ichthammol tannic acid
Scabicides & Pediculicides
crotan
Scar Treatment Products
celacyn
Wound Care Products
ACTICOAT KENDALL MEDIHONEY RESTORE SILVASORB SP ANTIPRURITIC XEROFORM XEROFORM PETROLATUM
DRESSING
Diabetic Drugs Antidiabetic Agents
acarbose BYDUREON BYDUREON BCISE BYDUREON PEN BYETTA glimepiride glipizide glipizide er glipizide xl glyburide glyburide micronized metformin hcl metformin hcl er miglitol nateglinide pioglitazone hcl repaglinide SYMLINPEN 120 SYMLINPEN 60
tolazamide tolbutamide TRULICITY VICTOZA
Antidiabetic Combinations
glipizide-metformin glyburide-metformin hcl GLYXAMBI INVOKAMET INVOKAMET XR JANUMET JANUMET XR JENTADUETO JENTADUETO XR pioglitazone-glimepiride pioglitazone-metformin repaglinide-metformin hcl SEGLUROMET SOLIQUA 100-33 SYNJARDY SYNJARDY XR XIGDUO XR XULTOPHY 100-3.6
DPP-4
JANUVIA TRADJENTA
Glycemic Agents
GLUCAGEN [INJ] GLUCAGON EMERGENCY
KIT [INJ] PROGLYCEM
Incretin Mimetic Agents (GLP-1 Receptor Agonists)
OZEMPIC
Insulins
HUMALOG HUMALOG JUNIOR
KWIKPEN HUMALOG MIX 50-50 HUMALOG MIX 75-25 HUMULIN R HUMULIN R U-500
KWIKPEN LANTUS LANTUS SOLOSTAR LEVEMIR LEVEMIR FLEXTOUCH NOVOLOG NOVOLOG FLEXPEN NOVOLOG MIX 70-30 TOUJEO MAX SOLOSTAR TOUJEO SOLOSTAR TRESIBA FLEXTOUCH U-100
TRESIBA FLEXTOUCH U-200
SGLT2 Inhibitors
FARXIGA INVOKANA JARDIANCE STEGLATRO
Diabetic Supplies Monitoring Devices & Supplies
ACCU-CHEK RAPID D ACCU-CHEK SPIRIT ACCU-CHEK TENDER ACCU-CHEK ULTRAFLEX AUTOSOFT 30 AUTOSOFT 90 AUTOSOFT XC cartridge pump cartridge stamped CLEO 90 INFUSION SET COMFORT COMFORT SHORT CONTACT DETACH
INFUSION SET DELTEC COZMO CLEO
INFUSION SET INFUSION SET INSET 30 INFUSION SET INSET 30 TUBING INSET INFUSION SET insulin cartridge MINIMED MINIMED RESERVOIR MIO INFUSION SET OMNIPOD OMNIPOD DASH ONE TOUCH PING PARADIGM PARADIGM INFUSION PARADIGM SILHOUETTE POLYFIN QR QUICK RELEASE SOFT
TEFLON QUICK-SET PARADIGM REVEL PROGRAMMABLE
PUMP SILHOUETTE SOF-SET SOF-SET MICRO SURE-T PARADIGM T:30 INFUSION SET T:90 T:FLEX T:SLIM T:SLIM G4 TRUE METRIX TEST STRIPS
AND METERS TRUSTEEL INFUSION SET
VARISOFT INFUSION SET VGO 20 VGO 30 VGO 40
Diagnostic Products Diagnostic Biologicals
APLISOL CANDIN TUBERSOL
Diagnostic Drugs
d-xylose HISTATROL INTRADERMAL IC GREEN [INJ] INDIGO CARMINE [INJ] indocyanine green [INJ] isosulfan blue KINEVAC [INJ] LEXISCAN R-GENE 10 xylose
Miscellaneous Contrast Media
EOVIST
Radiographic Contrast Media
barium sulfate OMNIPAQUE
Dietary Products/ Dietary Management Products Nutritional Substitutes
sodium saccharin
Nutritional Supplements
FIBERSOURCE HN NOURISH
Digestive Aids Digestive Enzymes
pepsin 3;000 digestion
Gastric Acidifiers
l-glutamic acid
Diuretics Carbonic Anhydrase Inhibitors
acetazolamide sodium [INJ]
Loop Diuretics
ethacrynate sodium
Osmotic Diuretics
mannitol OSMITROL
Costs for covered alternatives may vary. THIS DOCUMENT LIST IS EFFECTIVE JANUARY 1, 2019 THROUGH JUNE 30, 2019. THIS LIST IS SUBJECT TO CHANGE.
Page 14 of 22
Potassium Sparing Diuretics triamterene
Drugs to Regulate Hormones Hormonal Agents, Stimulant/ Replacement/ Modifying (Adrenal)
anucort-hc betamethasone acetate betamethasone acetate-
sod phos [INJ] betamethasone sodium
phosphate cortisone acetate deltasone desoximetasone DEXAMETHASONE dexamethasone acetate dexamethasone
micronized dexamethasone sodium
phosphate dexamethasone sodium
phosphate [INJ] fludrocortisone acetate fluticasone propionate fluticasone propionate
micro hemmorex-hc hydrocortisone hydrocortisone acetate mercaptopurine methylprednisolone methylprednisolone [INJ] methylprednisolone ac
micro methylprednisolone
acetate [INJ] MILLIPRED mometasone furoate prednisolone prednisolone sodium phos
odt prednisolone sodium
phosphate prednisone SOLU-CORTEF [INJ] triamcinolone triamcinolone acetonide triamcinolone acetonide
[INJ] triamcinolone diacetate VERIPRED 20
Drugs to Treat Airway Disease Phosphodiesterase Inhibitors, Airways Disease
DALIRESP
ELIXOPHYLLIN theochron theophylline anhydrous
Drugs to Treat Allergies, Cough, Cold and Lung Conditions Respiratory Tract/ Pulmonary Agents
COMBIVENT RESPIMAT dextromethorphan hbr DYMISTA guaifenesin hydrocodone/homatropine hydromet ipratropium-albuterol nebusal NUCALA [SP] promethazine vc pulmosal PULMOZYME [SP] sodium chloride sodium chloride [INJ] STIOLTO RESPIMAT XOLAIR [SP]
Drugs to Treat Angioedema Angioedema (HAE) Agents
CINRYZE [SP] FIRAZYR [SP]
Drugs to Treat Viral Infections Anti-Cytomegalovirus (CMV) Agents
cidofovir valganciclovir hcl
Antivirals
ribavirin [SP]
Ear Drugs Otic Agents
acetasol hc acetic acid acetic acid/hydrocortisone CIPRODEX ciprofloxacin hcl CORTANE-B exotic-hc fluocinolone acetonide oil neomycin/polymyxin/hc otomax-hc OTOVEL
Endocrine And Metabolic Agents Metabolic Modifiers
CRYSVITA [SP] MEPSEVII [SP] PALYNZIQ [SP] sodium phenylacet-sod
benzoate
Posterior Pituitary Hormones
vasopressin-ns
Enzyme Replacement/ Modifying Drugs Enzyme Replacement/ Modifiers
ADAGEN [SP] ALDURAZYME [SP] CERDELGA [SP] CEREZYME [SP] CREON CYSTADANE [SP] CYSTAGON [SP] ELAPRASE [SP] FABRAZYME [SP] KANUMA [SP] KUVAN [SP] LUMIZYME [SP] NAGLAZYME [SP] NITYR [SP] OCALIVA [SP] ORFADIN [SP] RAVICTI [SP] sodium phenylbutyrate STRENSIQ [SP] SUCRAID [SP] VIMIZIM [SP] VIOKACE ZENPEP
EnzymeReplacement/ Modifying Drugs Enzyme Replacements/ Modifiers
BRINEURA [SP] [INJ]
Estrogens All Agents
ethinyl estradiol
Eye Drugs Ophthalmic Agents, Other
altacaine altafluor atropine sulfate atropine sulfate [INJ] bacitracin/polymyxin bio glo cyclopentolate hcl CYSTARAN [SP] EYLEA [SP]
flucaine ful-glo green glo homatropaire homatropine
hydrobromide JETREA [SP] neo/polymyxin/dexametha
sone neomycin/bacitracin/poly/
hc neomycin/bacitracin/poly
myxin neomycin/polymyxin/gram
icidin neomycin/polymyxin/hc neomycin-polymyxin-
dexamethaso neo-polycin neo-polycin hc phenylephrine hcl phenylephrine hcl [INJ] polycin polymyxin b sul-
trimethoprim proparacaine hcl proparacaine-fluorescein RESTASIS RESTASIS MULTIDOSE sulfacetamide
w/prednisolone tetcaine tetracaine hcl tetracaine hcl [INJ] TOBRADEX TOBRADEX ST tobramycin-
dexamethasone tropicamide VISUDYNE [SP] XIIDRA ZYLET
Fibromyalgia Drugs Fibromyalgia Agents
duloxetine hcl LYRICA SAVELLA
Flu Drugs Anti-Influenza Agents
oseltamivir phosphate RELENZA rimantadine hcl
Fluoroquinolones All Agents
ciprofloxacin-d5w levofloxacin-d5w
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Fungal Infection Drugs Antifungals
amphotericin b amphotericin b [INJ] caspofungin acetate ciclodan ciclopirox clotrimazole CRESEMBA econazole nitrate ERAXIS(WATER DILUENT) fluconazole flucytosine griseofulvin griseofulvin ultramicrosize itraconazole ketoconazole MICONAZOLE 3 miconazole nitrate MYCAMINE naftifine hcl NATACYN NOXAFIL nyamyc nystatin nystatin w/triamcinolone nystatin/triamcinolone nystop oxiconazole nitrate SPORANOX terbinafine terconazole tolnaftate voriconazole
Gastrointestinal Agents Inflammatory Bowel Agents
aminosalicylic acid sulfazine
General Anesthetics Anesthetics
etomidate ketamine hcl ketamine hcl [INJ] propofol
Barbiturate Anesthetics
BREVITAL SODIUM [INJ]
Genitourinary Agents Alkalinizers
potassium citrate
Genitourinary Irrigants
aqua care sodium chloride
curity
Glaucoma Drugs Ophthalmic Antiglaucoma Agents
ALPHAGAN P apraclonidine hcl betaxolol hcl bimatoprost brimonidine tartrate carteolol hcl COMBIGAN dorzolamide hcl dorzolamide-timolol levobunolol hcl methazolamide metipranolol PHOSPHOLINE IODIDE pilocarpine hcl timolol maleate
Ophthalmic Prostaglandin and Prostamide Analogs
bimatoprost latanoprost LUMIGAN TRAVATAN Z
Gout Agents All Agents
allopurinol sodium ALOPRIM
Gout Drugs Antigout Agents
allopurinol colchicine COLCRYS KRYSTEXXA [SP] MITIGARE probenecid probenecid w/colchicine ULORIC
Heart Regulation Drugs Antiarrhythmics
adenosine amiodarone hcl dofetilide flecainide acetate mexiletine hcl pacerone procainamide hcl procainamide hcl [INJ] propafenone hcl propafenone hcl er quinidine gluconate quinidine gluconate [INJ]
quinidine sulfate sotalol sotalol af SOTYLIZE
Antiarrhythmics Type I-B
lidocaine hcl in dextrose
Antiarrhythmics Type III
ibutilide fumarate NEXTERONE
Hematological Agents Antihemophilic Products
HEMLIBRA [SP]
Plasma Expanders
hetastarch w/sodium chloride
HEXTEND LACTATED ELECTROLYTE
LMD 10% WITH 0.9% SODCHLORIDE
LMD 10% WITH 5% DEXTROSE
VOLUVEN
Plasma Proteins
albumin alburx albutein buminate plasbumin PLASMANATE
Platelet Aggregation Inhibitors
eptifibatide REOPRO
Protamine
protamine sulfate
Hematopoietic Agents Agents for Gaucher Disease
miglustat [SP]
Cobalamins
hydroxocobalamin
Hematopoietic Growth Factors
DOPTELET [SP]
Hemostatics Hemostatics - Systemic
aminocaproic acid
Hepatitis Drugs Anti-hepatitis B (HBV) Agents
adefovir dipivoxil BARACLUDE entecavir EPIVIR HBV lamivudine VEMLIDY
Anti-hepatitis C (HCV) Agents
EPCLUSA [SP] HARVONI [SP] INTRON A [SP] [INJ] MAVYRET [SP] moderiba [SP] RIBAPAK [SP] ribasphere [SP] ribavirin [SP] SOVALDI [SP] SYLATRON [SP] TECHNIVIE [SP] VIEKIRA PAK [SP] VIEKIRA XR [SP] VOSEVI [SP]
Herpes Drugs Antiherpetic Agents
acyclovir famciclovir trifluridine valacyclovir ZOVIRAX
HIV Drugs Anti-HIV Agents, Integrase Inhibitors (INSTI)
DESCOVY ISENTRESS ISENTRESS HD STRIBILD TIVICAY
Anti-HIV Agents, Non-nucleoside Reverse Transcriptase Inhibitors (NNRTI)
COMPLERA EDURANT GENVOYA INTELENCE nevirapine nevirapine er ODEFSEY RESCRIPTOR
Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors (NRTI)
abacavir abacavir-lamivudine
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abacavir-lamivudine-zidovudine
didanosine EMTRIVA lamivudine lamivudine-zidovudine RETROVIR stavudine TRIUMEQ TRUVADA VIDEX VIREAD zidovudine
Anti-HIV Agents, Other
FUZEON [SP] SELZENTRY
Anti-HIV Agents, Protease Inhibitors
APTIVUS CRIXIVAN fosamprenavir calcium INVIRASE KALETRA LEXIVA lopinavir-ritonavir NORVIR PREZISTA REYATAZ VIRACEPT
Hormone Replacement/ Modifying Drugs Androgens
ANDRODERM ANDROGEL danazol METHITEST methyltestosterone methyltestosterone
micronized oxandrolone testosterone testosterone cypionate testosterone enanthate testosterone micronized
Bulk Chemicals - C's
chorionic gonadotropin [SP]
Bulk Chemicals - D's
desmopressin acetate
Estrogens
amabelz COMBIPATCH
covaryx covaryx h.s. DEPO-ESTRADIOL DIVIGEL DUAVEE eemt eemt hs estradiol estradiol valerate estradiol-norethindrone
acetat ESTRING estrogen &
methyltestosterone fyavolv jevantique lo jinteli lopreeza mimvey mimvey lo MINIVELLE norethindrone-ethin
estradiol PREMARIN PREMARIN [INJ] PREMPHASE PREMPRO yuvafem
Fertility Regulators
FOLLISTIM AQ [SP] MENOPUR [SP] NOVAREL [SP] OVIDREL [SP]
Growth Hormones
GENOTROPIN [SP]
Insulin-Like Growth Factors (Somatomedins)
INCRELEX [SP]
LHRH/ GnRH Agonist Analog Pituitary Suppressants
TRIPTODUR [SP]
Posterior Pituitary Hormones
desmopressin acetate desmopressin acetate [INJ] STIMATE [SP]
Progestins
CRINONE DEPO-PROVERA hydroxyprogesterone
caproate [SP] MAKENA [SP] medroxyprogesterone
acetate
megestrol acetate norethindrone acetate progesterone
Selective Estrogen Receptor Modifying Agents
clomiphene citrate raloxifene hcl
Hormone Suppressants Antiandrogens
bicalutamide flutamide nilutamide XTANDI [SP] ZYTIGA [SP]
Antineoplastic - Hormonal and Related Agents
ELIGARD [SP] FIRMAGON [SP] leuprolide acetate [SP] LUPRON DEPOT [SP] VANTAS [SP] ZOLADEX [SP]
Bulk Chemicals - L's
leuprolide acetate [SP]
GnRH/ LHRH Antagonists
CETROTIDE [SP]
Growth Hormone Receptor Antagonists
SOMAVERT [SP]
Growth Hormone Releasing Hormones (GHRH)
EGRIFTA [SP]
Hormonal Agents, Suppressant (Adrenal)
LYSODREN
Hormonal Agents, Suppressant (Parathyroid)
SENSIPAR
LHRH/ GnRH Agonist Analog Pituitary Suppressants
SYNAREL
Prolactin Inhibitors
cabergoline
Somatostatic Agents
octreotide acetate [SP] [INJ]
SIGNIFOR [SP]
SOMATULINE DEPOT [SP]
Hypnotics/ Sedatives/ Sleep Disorder Agents Barbiturate Hypnotics
AMYTAL SODIUM [INJ] pentobarbital sodium pentobarbital sodium [INJ] phenobarbital sodium [INJ]
Non-Barbiturate Hypnotics
chloral hydrate
Immune System Drugs Immune Suppressants
azathioprine azathioprine sodium [INJ] cyclosporine ENBREL [SP] gengraf HUMIRA [SP] HUMIRA PEDIATRIC [SP] methotrexate methotrexate [INJ] methotrexate sodium methotrexate sodium [INJ] mycophenolate mofetil mycophenolic acid NULOJIX [SP] OTREXUP PROGRAF RAPAMUNE RASUVO REMICADE [SP] SANDIMMUNE sirolimus tacrolimus TORISEL [SP] ZORTRESS
Immunizing Agents, Passive
ATGAM CYTOGAM [SP] GAMASTAN S-D [SP] GAMMAGARD LIQUID [SP]
[INJ] GAMMAGARD S-D [SP] GAMUNEX-C [SP] [INJ] HEPAGAM B [INJ] HIZENTRA [SP] HYPERHEP B S-D HYPERRAB S-D HYPERRHO S-D [SP] HYPERTET S-D IMOGAM RABIES-HT PRIVIGEN [SP] THYMOGLOBULIN VARIZIG
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Immunomodulators
ACTIMMUNE [SP] ALFERON N [INJ] BENLYSTA [SP] ILARIS [SP] leflunomide OTEZLA [SP] RIDAURA SIMULECT SYNAGIS [SP]
Inflammatory Bowel Disease Drugs Aminosalicylates
APRISO balsalazide disodium CANASA mesalamine PENTASA
Glucocorticoids
budesonide ec colocort hc pramoxine hydrocortisone pramcort procto-med hc procto-pak proctosol-hc proctozone-hc UCERIS
Laxatives Laxative Combinations
CLENPIQ
Lubricant Laxatives
mineral oil heavy mineral oil light MURI-LUBE MINERAL OIL
Local Anesthetics All Agents
bupivacaine hcl bupivacaine hcl [INJ] cocaine hcl dermacinrx prizopak ethyl chloride lidocaine lidocaine hcl lidocaine hcl [INJ] lidocaine-prilocaine lido-k lidopin lidopril lorenza MARCAINE [INJ]
relador pak relador pak plus SCAR sensorcaine [INJ] sensorcaine-mpf [INJ] zeruvia
Local Anesthetics-parenteral Local Anesthetic Combinations
bupivacaine hcl-epinephrine [INJ]
lidocaine hcl w/epinephrine [INJ]
SENSORCAINE WITH EPINEPHRINE [INJ]
xylocaine dental-epinephrine [INJ]
Local Anesthetics - Amides
bupivacaine w/dextrose [INJ]
CARBOCAINE [INJ] lidocaine hcl in 7.5%
dextrose polocaine [INJ] ropivacaine hcl/pf [INJ] ropivacaine hcl-ns [INJ]
Local Anesthetics - Esters
chloroprocaine hcl [INJ] procaine hcl
Macrolides Erythromycins
ERYTHROCIN LACTOBIONATE
erythromycin stearate
Migraine Drugs Ergot Alkaloids
dihydroergotamine mesylate
dihydroergotamine mesylate [INJ]
ergotamine-caffeine MIGERGOT
Serotonin (5-HT) 1b/ 1d Receptor Agonists
almotriptan malate eletriptan hbr frovatriptan succinate naratriptan hcl rizatriptan sumatriptan succinate sumatriptan succ-naproxen
sod zolmitriptan zolmitriptan odt
ZOMIG
Migraine Products All Agents
ergotamine tartrate
Migraine Products - Monoclonal Antibodies
AIMOVIG AUTOINJECTOR AIMOVIG AUTOINJECTOR
(2 PACK)
Minerals & Electrolytes Bicarbonates
NEUT sodium acetate sodium bicarbonate-water sodium lactate
Calcium
calcium chloride calcium lactate calcium phosphate calcium phosphate tribasic
Magnesium
magnesium carbonate magnesium chloride magnesium chloride [INJ] magnesium sulfate in
dextrose
Manganese
manganese
Phosphate
GLYCOPHOS sodium phosphate
Potassium
potassium acetate
Sodium
monoject 0.9% nacl [INJ] monoject prefill advanced
[INJ] normal saline [INJ] saline flush [INJ] sodium chloride-water syrex [INJ]
Trace Minerals
chromium copper chloride cupric sulfate MULTITRACE-4 multitrace-5 selenium
TRACE ELEMENTS-4
Zinc
zinc chloride
Miscellaneous Anti-Infectives Antimycobacterials, Other
dapsone rifabutin
Miscellaneous Therapeutic Classes Chelating Agents
penicillamine(d-) trientine hcl
Enzymes
bromelain chymotrypsin
Irrigation Solutions
aqua care sterile water irrig curity lactated ringers
Peritoneal Dialysis Solutions
DELFLEX W/DEXTROSE EXTRANEAL ICODEXTRIN
DIALYSIS
Sclerosing Agents
ETHAMOLIN SOTRADECOL
Mood Disorder Drugs 1st Generation/ Typical
chlorpromazine hcl chlorpromazine hcl [INJ] fluphenazine decanoate fluphenazine decanoate
[INJ] fluphenazine hcl fluphenazine hcl [INJ] haloperidol haloperidol [INJ] haloperidol decanoate haloperidol lactate haloperidol lactate [INJ] loxapine succinate pimozide thioridazine hcl thiothixene trifluoperazine hcl
2nd Generation/ Atypical
ABILIFY MAINTENA aripiprazole
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aripiprazole odt ARISTADA clozapine odt LATUDA olanzapine olanzapine odt paliperidone er quetiapine fumarate quetiapine fumarate er RISPERDAL CONSTA risperidone risperidone odt ziprasidone hcl
Mood Stabilizers
lithium carbonate lithium citrate
Treatment-Resistant
clozapine
Mouth/ Throat/ Dental Agents Dental Products
zinc acetate
Multiple Sclerosis Drugs Multiple Sclerosis Agents
AMPYRA [SP] AVONEX ADMINISTRATION
PACK [SP] AVONEX PEN [SP] COPAXONE [SP] GILENYA [SP] glatiramer acetate [SP] glatopa [SP] OCREVUS [SP] PLEGRIDY [SP] TECFIDERA [SP]
Musculoskeletal Therapy Agents Direct Muscle Relaxants
revonto
Myasthenia Gravis Drugs Parasympathomimetics
guanidine hcl MESTINON neostigmine methylsulfate pyridostigmine bromide pyridostigmine bromide er
Nausea and Vomiting Drugs Antiemetics, Other
AKYNZEO compro dimenhydrinate
dimenhydrinate [INJ] meclizine hcl metoclopramide hcl metoclopramide hcl [INJ] metoclopramide hcl odt perphenazine prochlorperazine maleate trimethobenzamide hcl
Emetogenic Therapy Adjuncts
aprepitant dronabinol granisetron hcl ondansetron hcl ondansetron hcl [INJ] ondansetron odt SANCUSO VARUBI
Neuromuscular Agents Depolarizing Muscle Relaxants
ANECTINE [INJ]
Nondepolarizing Muscle Relaxants
atracurium besylate cisatracurium besylate pancuronium bromide rocuronium bromide vecuronium bromide
Neurotoxins Neuromuscular Blocking Agent - Neurotoxins
BOTOX [SP] [INJ] MYOBLOC [SP]
Nutrients Carbohydrates
dextrose dextrose in water fructose
Lipids
intralipid
Lipotropics
choline bitartrate
Proteins
alanine AMINOSYN AMINOSYN II AMINOSYN M AMINOSYN WITH
ELECTROLYTES AMINOSYN-RF CLINIMIX
CLINIMIX E FREAMINE HBC FREAMINE III HEPATAMINE histidine hcl l-alanine l-arginine base l-cysteine l-glutamic acid l-leucine l-proline l-threonine l-valine NEPHRAMINE phenylalanine (dl) plenamine PREMASOL PROCALAMINE PROSOL taurine threonine TRAVASOL TROPHAMINE tryptophan (l)
Ophthalmic Agents Miotics
MIOSTAT
Ophthalmic Anti-infectives
ak-poly-bac
Ophthalmic Gene Therapy
LUXTURNA [SP]
Ophthalmic Kinase Inhibitors
RHOPRESSA
Ophthalmic Surgical Aids
ocucoat
Ophthalmics
balanced salt BSS FLUORESCITE
Opioid Pain Relievers Opioid Agonists
alfentanil hydrochloride [INJ]
codeine phosphate duramorph [INJ] morphine sulfate cr morphine sulfate in
dextrose remifentanil hcl sufentanil citrate ULTIVA
Opioid Analgesics, Long-acting
diskets fentanyl hydromorphone er HYSINGLA ER INFUMORPH [INJ] levorphanol tartrate methadone hcl methadone hcl [INJ] METHADOSE morphine sulfate er NUCYNTA ER OXYCONTIN oxymorphone hcl oxymorphone hcl er tramadol hcl er
Opioid Analgesics, Short-acting
acetaminophen w/codeine apap-caffeine-
dihydrocodeine asa-butalb-caff-cod ascomp with codeine butalbital compound
w/codeine butalbital/caff/apap/codei
ne butorphanol tartrate butorphanol tartrate [INJ] codeine sulfate endocet fentanyl citrate fentanyl citrate [INJ] fentanyl citrate/ns hydrocodone bitartrate hydrocodone bit-ibuprofen hydrocodone
w/acetaminophen hydromorphone hcl hydromorphone hcl [INJ] hydromorphone hcl/ns lorcet lorcet hd lorcet plus meperidine hcl morphine sulfate morphine sulfate [INJ] morphine sulfate/ns nalbuphine hcl nalbuphine hcl [INJ] NUCYNTA oxycodone hcl oxycodone hcl-ibuprofen oxycodone
w/acetaminophen oxycodone w/aspirin oxymorphone hcl tramadol hcl
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tramadol hcl-acetaminophen
verdrocet vicodin vicodin es vicodin hp
Opioid Combinations
panlor
Opioid Partial Agonists
SUBLOCADE [SP]
Osteoarthritis Viscosupplements
EUFLEXXA [SP] MONOVISC [SP] ORTHOVISC [SP]
Osteoporosis (Bone Loss) Drugs Metabolic Bone Disease Agents
alendronate sodium calcitonin-salmon calcitriol doxercalciferol etidronate disodium FORTEO [SP] ibandronate sodium MIACALCIN [INJ] NATPARA [SP] pamidronate disodium paricalcitol risedronate sodium risedronate sodium dr TYMLOS [SP] XGEVA [SP] zoledronic acid ZOMETA
Otic Agents Otic Combinations
antibiotic ear solution
Oxytocics Abortifacients/ Agents for Cervical Ripening
HEMABATE
All Agents
oxytocin [INJ]
Pain/ Anti-Inflammatory Drugs Analgesics
acetaminophen acetaminophen
w/butalbital
butalbital compound butalbital
w/acetaminophen butalbital/apap/caffeine butalbital-asp-caffeine phrenilin forte PRIALT [SP] TENCON zebutal
Analgesics Other
OFIRMEV
Nonsteroidal Anti-inflammatory Agents (NSAIDs)
ibuprofen lysine phenylbutazone
Nonsteroidal Anti-Inflammatory Drugs
aspirin CALDOLOR celecoxib choline mag trisalicylate diclofenac potassium diclofenac sodium diclofenac sodium-
misoprostol diflunisal etodolac etodolac er fenoprofen calcium FLECTOR flurbiprofen ibu ibuprofen indomethacin ketoprofen ketorolac tromethamine ketorolac tromethamine
[INJ] klofensaid ii meclofenamate sodium mefenamic acid meloxicam nabumetone nabumetone micronized naproxen naproxen sodium naproxen sodium ds naproxen sodium er oxaprozin piroxicam profeno salsalate sulindac tolmetin sodium
Salicylates
acetyl salicylic acid sodium salicylate
Pain/ Swelling Management Drugs Skeletal Muscle Relaxants
baclofen carisoprodol chlorzoxazone cyclobenzaprine hcl dantrolene sodium GABLOFEN LIORESAL metaxall metaxalone methocarbamol methocarbamol [INJ] orphenadrine citrate orphenadrine citrate [INJ] tizanidine hcl
Parkinson's Disease Drugs Anticholinergics
benztropine mesylate benztropine mesylate [INJ] trihexyphenidyl hcl
Antiparkinson Agents, Other
amantadine hcl entacapone tolcapone
Dopamine Agonists
APOKYN [SP] apomorphine hcl bromocriptine mesylate pramipexole di-hcl pramipexole er ropinirole hcl
Dopamine Precursors/ L-Amino Acid Decarboxylase Inhibitors
carbidopa carbidopa/levodopa carbidopa-levodopa er carbidopa-levodopa-
entacapone
Monoamine Oxidase B (MAO-B) Inhibitors
rasagiline mesylate selegiline hcl
Passive Immunizing And Treatment Agents Immune Serums
HYPERRAB
Penicillins Aminopenicillins
ampicillin sodium ampicillin sodium [INJ]
Natural Penicillins
BICILLIN L-A penicillin gk-iso-osm
dextrose
Penicillin Combinations
BICILLIN C-R
Penicillinase-Resistant Penicillins
nafcill in dextrose
Phosphate-Removing Agents Phosphate Binders
calcium acetate lanthanum carbonate PHOSLYRA sevelamer carbonate VELPHORO
Platelet Modifying Drugs Platelet Modifying Agents
aspirin-dipyridamole er BRILINTA cilostazol clopidogrel dipyridamole prasugrel hcl ZONTIVITY
Prostate Enlargement Drugs Benign Prostatic Hypertrophy Agents
alfuzosin hcl er CIALIS dutasteride dutasteride-tamsulosin finasteride RAPAFLO tamsulosin hcl terazosin hcl
Protozoal Infection Drugs Antiprotozoals
ALINIA atovaquone atovaquone-proguanil hcl chloroquine phosphate COARTEM DARAPRIM [SP] hydroxychloroquine sulfate mefloquine hcl
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NEBUPENT primaquine quinine sulfate
Psychotherapeutic And Neurological Agents Antidementia Agents
memantine hcl er
Postherpetic Neuralgia (PHN)/ Neuropathic Pain Agents
LYRICA CR
Respiratory Agents Cystic Fibrosis Agents
SYMDEKO [SP]
Scabies and Lice Drugs Pediculicides/ Scabicides
lindane malathion permethrin spinosad
Sedation and Sleep Drugs GABA Receptor Modulators
eszopiclone flurazepam hcl zaleplon zolpidem tartrate zolpidem tartrate er
Sleep Disorders, Other
armodafinil modafinil ROZEREM SECONAL SODIUM XYREM
Seizure Control Drugs Anticonvulsants, Other
BRIVIACT levetiracetam roweepra
Calcium Channel Modifying Agents
CELONTIN ethosuximide zonisamide
Gamma-Aminobutyric Acid (GABA) Augmenting Agents
diazepam diazepam [INJ] divalproex sodium divalproex sodium er gabapentin
GRALISE ONFI phenobarbital primidone SABRIL [SP] tiagabine hcl valproic acid vigabatrin [SP]
Glutamate Reducing Agents
felbamate lamotrigine lamotrigine (blue) lamotrigine (green) lamotrigine (orange) lamotrigine odt QUDEXY XR
Sodium Channel Agents
carbamazepine carbamazepine er epitol fosphenytoin sodium [INJ] oxcarbazepine PEGANONE phenytoin phenytoin sodium VIMPAT
Skin Agents Acne Products
10-1 ABSORICA ACANYA adapalene adapalene-benzoyl
peroxide amnesteem avar avita benzepro benzoyl peroxide bp foam BPO claravis CLEANSING WASH clindacin etz clindamycin phos-tretinoin clindamycin-benzoyl
peroxide dapsone EPIDUO FORTE erythromycin-benzoyl
peroxide myorisan neuac ONEXTON retinoic acid
sodium sulfacetamide/sulfur
ss 10-2 sss 10-5 sulfacetamide sodium sulfacetamide sodium-
sulfur sulfacleanse 8/4 tretinoin tretinoin acid tretinoin microsphere zenatane
Agents for Wrinkles/ Lipoatrophy/ Other Aesthetic Uses
REFISSA
Antifungals - Topical
clotrimazole/betamethasone
dermazene cream hydrocortisone
w/iodoquinol hydrocortisone-iodoquinol-
aloe
Anti-inflammatory Agents - Topical
diclofenac sodium
Antimetabolites
fluorouracil
Antineoplastic or Premalignant Lesion Agents - Topical
CARAC diclofenac sodium fluorouracil PICATO
Antipruritics - Topical
doxepin hcl PRUDOXIN
Antipsoriatics
acitretin calcipotriene calcitrene calcitriol COSENTYX 150MG [SP] COSENTYX 300MG [SP] DRITHOCREME HP methoxsalen STELARA [SP] tazarotene TAZORAC
Antiseborrheic Products
seb-prev selenium sulfide sodium sulfacetamide sulfacetamide sodium
Corticosteroids - Topical
ala-cort alclometasone
dipropionate amcinonide APEXICON E betamethasone
dipropionate betamethasone valerate calcipotriene-
betamethasone dp clobetasol e clobetasol emulsion clobetasol propionate clodan desonide desoximetasone diflorasone diacetate ENSTILAR fluocinolone acetonide fluocinonide fluocinonide-e flurandrenolide fluticasone propionate halobetasol propionate hc pramoxine hydrocortisone hydrocortisone acetate hydrocortisone butyrate hydrocortisone valerate mometasone furoate nolix prednicarbate TACLONEX triamcinolone acetonide TRIANEX triderm
Eczema Agents
DUPIXENT [SP]
Emollient/ Keratolytic Agents
CEM-UREA k50 rea-lo umecta urea ure-k
Emollients
ammonium lactate
Enzymes - Topical
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collagenase SANTYL
Immunomodulating Agents - Topical
imiquimod
Immunosuppressive Agents
tacrolimus
Immunosuppressive Agents - Topical
ELIDEL tacrolimus
Inflammatory Bowel Agents
STELARA [SP]
Keratolytic/ Antimitotic Agents
podofilox salicylic acid salicylic acid er salimez SALVAX
Leprostatics
dapsone
Local Anesthetics - Topical
capsaicin
Metabolic Modifiers
calcitriol
Nonsteroidal Anti-inflammatory Agents (NSAIDs)
diclofenac sodium
Otic Combinations
CORTANE-B
Rosacea Agents
FINACEA MIRVASO SOOLANTRA
Tricyclic Agents
doxepin hcl
Wound Care Products
REGRANEX
Sulfonamides All Agents
sulfamethoxazole sulfapyridine sulfathiazole sulfisoxazole
Tetracyclines All Agents
coremino minocycline hcl er oxytetracycline hcl
Thyroid Agents Thyroid Hormones
PCCA T3 SODIUM DILUTION
Thyroid Replacement Drugs Hormonal Agents, Stimulant/ Replacement/ Modifying (Thyroid)
ARMOUR THYROID levothyroxine sodium levoxyl liothyronine sodium NATURE-THROID np thyroid thyroid unithroid WESTHROID
Thyroid Suppressing Drugs Antithyroid Agents
methimazole propylthiouracil
Toxoids Toxoid Combinations
PEDIARIX PENTACEL QUADRACEL DTAP-IPV
Tuberculosis Drugs Antituberculars
CAPASTAT SULFATE [INJ] cycloserine ethambutol hcl isoniazid isoniazid [INJ] PRIFTIN pyrazinamide rifampin SIRTURO
Ulcer and Stomach Acid Drugs Histamine2 (H2) receptor Antagonists
cimetidine famotidine nizatidine ranitidine hcl ranitidine hcl [INJ]
Protectants
CARAFATE misoprostol sucralfate
Proton Pump Inhibitors
DEXILANT esomeprazole magnesium FIRST-LANSOPRAZOLE FIRST-OMEPRAZOLE lansoprazole omeppi omeprazole omeprazole-sodium
bicarbonate pantoprazole sodium rabeprazole sodium
Ulcer Drugs/ Antispasmodics/ Anticholinergics Antispasmodics
isopropamide iodide scopolamine
hydrobromide
Proton Pump Inhibitors
esomeprazole sodium
Urinary Anti-infectives All Agents
nalidixic acid
Vaccines All Agents
ACTHIB ADACEL AFLURIA BEXSERO BIOTHRAX BOOSTRIX DAPTACEL diphtheria-tetanus toxoids-
ped ENGERIX-B FLUARIX FLULAVAL FLUZONE FLUZONE HIGH-DOSE GARDASIL 9 HAVRIX HIBERIX IMOVAX RABIES VACCINE INFANRIX IPOL [INJ] IXIARO MENACTRA
M-M-R II VACCINE W/DILUENT
PEDVAXHIB PNEUMOVAX 23 [INJ] PREVNAR 13 RABAVERT RECOMBIVAX HB ROTATEQ SHINGRIX STAMARIL tetanus diphtheria toxoids TICE BCG tice bcg [INJ] TRUMENBA TWINRIX TYPHIM VI VARIVAX VACCINE VAXCHORA VACCINE VIVOTIF YF-VAX
Viral Vaccines
AFLURIA QUAD 2018-2019 FLUAD 2018-2019 FLUBLOK QUAD 2018-2019 PROQUAD
Vaginal Products Miscellaneous Vaginal Products
TRIMO-SAN
Vasopressors All Agents
dobutamine hcl dobutamine hcl in dextrose dopamine hcl dopamine hcl in 5%
dextrose epinephrine hcl epinephrine-d5w norepinephrine bitar-0.9%
nacl norepinephrine bitartrate norepinephrine bitartrate-
d5w phenylephrine hcl-d5w
Vitamins Water Soluble Vitamins
aminobenzoic acid calcium pantothenate sodium ascorbate
Vitamins, Minerals, Electrolytes Electrolyte/ Mineral Modifiers
CHEMET EXJADE [SP]
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FERRIPROX [SP] JADENU [SP] JADENU SPRINKLE [SP] kionex SAMSCA [SP] sodium polystyrene
sulfonate sps
Electrolyte/ Mineral Replacement
calcium carbonate calcium gluconate CARBAGLU [SP] cytra-k effer-k FERAHEME ferrous sulfate ISOLYTE S k effervescent klor-con klor-con m klor-con sprinkle klor-con-ef K-PHOS ORIGINAL K-TAB magnesium sulfate magnesium sulfate [INJ] MULTIGEN phospho-trin 250 neutral PLASMA-LYTE 148 PLASMA-LYTE A PH 7.4 potassium bicarbonate potassium chl-normal
saline potassium chloride potassium citrate er potassium phosphate sod ferric gluconate
complex sodium chloride sodium chloride [INJ] sodium fluoride VELTASSA VENOFER zinc sulfate
Prenatal Vitamins
BAL-CARE DHA C-NATE DHA COMPLETE NATAL DHA COMPLETENATE DOTHELLE DHA ELITE-OB FOLIVANE-OB HEMENATAL OB HEMENATAL OB + DHA MYNATAL
MYNATAL ADVANCE MYNATAL PLUS MYNATAL-Z MYNATE 90 PLUS NEWGEN OBSTETRIX DHA PNV 29-1 PNV OB+DHA PNV-DHA PNV-DHA + DOCUSATE PNV-OMEGA PNV-SELECT PR NATAL 400 PR NATAL 400 EC PR NATAL 430 PR NATAL 430 EC PRENA1 CHEW PRENA1 PEARL PRENA1 TRUE PRENAISSANCE PRENAISSANCE PLUS PRENATABS RX PRENATAL 19 PRENATAL LOW IRON PRENATAL PLUS PRENATAL VITAMIN PLUS
LOW IRON PRENATAL-U PREPLUS PRETAB SE-NATAL 19 TARON PRENATAL TARON-BC TARON-C DHA TRINATAL RX 1 TRINATE TRI-TABS DHA TRIVEEN-DUO DHA ULTIMATECARE ONE VINATE II VINATE ONE VINATE-M VIRT-C DHA VIRT-NATE DHA VIRT-PN VIRT-PN DHA VIRT-PN PLUS VP-HEME OB + DHA ZATEAN-PN DHA ZATEAN-PN PLUS
Therapeutic Nutrients/ Minerals/ Electrolytes
levocarnitine ringers tis-u-sol
Vitamins
AQUASOL A ascorbic acid ascorbic acid [INJ] b-complex [INJ] biotin calcium ascorbate cod liver oil cyanocobalamin cyanocobalamin [INJ] d-biotin ergocalciferol fabb folic acid folic acid [INJ] FOLTANX INFUVITE l-methyl-b6-b12 L-METHYLFOLATE-
MECOBALAMIN-NAC L-METHYL-MC NAC M.V.I. ADULT M.V.I. PEDIATRIC METAFOLBIC METAFOLBIC PLUS n-acetyl-l-cysteine NASCOBAL nephronex-sl niacin niacinamide NUTRIVIT phytonadione phytonadione [INJ] pyridoxine hcl pyridoxine hcl [INJ] SUPPORT thiamine hcl thiamine hcl [INJ] TL G-FOL OS vitacel vitamin a vitamin d2 vitamin e vitamin k [INJ] wheat germ oil
Worm Infection Drugs Anthelmintics
ALBENZA benznidazole EMVERM ivermectin mebendazole praziquantel thiabendazole