BCBSRI 5-Tier Formulary (Drug List)*However, pharmacists cannot substitute a preferred brand‐name...

A Reference Guide

INTRODUCTION

Below you’ll find the BCBSRI formulary, which is a list of all the prescription drugs covered under your health plan. Our formulary offers a wide range of medications from which to choose and is reviewed periodically by BCBSRI’s Pharmacy and Therapeutics Committee. This committee, which is made up of local, community‐based practicing physicians and pharmacists, evaluates the medications on the formulary for safety and effectiveness and helps to ensure that BCBSRI members have access to medications that support their health.

CONTROLLING COSTS

The BCBSRI formulary divides covered drugs into five “tiers.” Each tier has a corresponding copayment. This allows us to better manage the overall cost of providing prescription drug benefits to our members, while also helping you control what you pay out of pocket for your medications.

We realize that the BCBSRI formulary may not include every drug from every manufacturer. However, choosing medications from the BCBSRI formulary, when appropriate, can provide you with access to the medications you need—at the most affordable cost.

THE FIVE TIERS

• First Tier: Includes generic prescription drugs that have the lowest copayment.

• Second Tier: Includes generic prescription drugs that have a higher copayment than the first tier.

• Third Tier: Includes high‐cost generic prescription drugs and preferred brand‐name prescription drugs, which have a higher copayment than the second tier.

• Fourth Tier: Includes highest cost generic drugs and non‐preferred brand name drugs that have a higher copayment than the third tier.

• Fifth Tier: Includes specialty prescription drugs that have the highest copayment.

HOW TO USE THE FORMULARY REFERENCE GUIDE

This formulary reference guide lists generic drugs first in each drug category. The preferred brand name products are listed next, and non‐preferred brand products are listed last.

PLEASE NOTE: If a generic drug is listed in the “generics” section and its corresponding brand‐name product is not listed in the “preferred brand‐name” section, then only the generic drug is on the formulary. If a brand name

BCBSRI 5-Tier Formulary (Drug List)* Effective October 1, 2016 to December 31, 2016

product is listed in the “preferred brand‐name” section and its corresponding generic product is not listed in the “generics” section, then a generic version of the medication is not available.

CONSIDERING PREFERRED ALTERNATIVES This formulary reference guide lists possible preferred alternatives for commonly prescribed non‐ preferred medications. However, pharmacists cannot substitute a preferred brand‐name drug without the prescriber’s approval and will contact the prescriber to obtain authorization to dispense an alternative preferred product when a non‐preferred product has been prescribed.

SAVING ON OUT‐OF‐POCKET COSTS Your health plan’s prescription drug coverage encourages the use of generic and preferred brand‐ name drugs. Choosing non‐preferred drugs may mean paying higher out‐of‐pocket expenses (such as coinsurance, copayments, and deductible amounts) or not receiving coverage at all. You will have lower copayments when you use generic drugs. If you use a brand‐name drug when there is a generic alternative available, you may be asked to pay the cost difference.

CONSULTING THE PRESCRIBER’S OFFICE WHEN APPROPRIATE BCBSRI’s formulary may provide coverage only for certain medications or for particular uses, time periods, doses, or quantities (e.g., the formulary may exclude coverage for medications for unapproved, unproven, or cosmetic indications, as well as over‐the‐counter medications).

When prescription drug coverage is provided based on use or quantity, certain limits may apply. Your prescriber may request an exception based upon your individual circumstances. Contact BCBSRI for additional information to determine whether coverage is available under your plan. Patients who are unsure whether these coverage rules apply for a particular medication can consult their BCBSRI subscriber agreement or contact a BCBSRI member services representative to determine specific coverage requirements.

*Formulary Disclaimer: Coverage for some drugs may be limited to specific dosage forms and/or strengths. Your health plan’s benefit design determines what is covered and the applicable copayment. The medications listed on this formulary are subject to change pursuant to the formulary management activities of BCBSRI. The presence of a medication on this formulary list does not guarantee coverage. Certain therapeutic classes are routinely designated as formulary exclusions and are not eligible for coverage, these classes include Weight Loss, Erectile Dysfunction, Smoking Cessation, OTC status products and drugs with OTC equivalents, Vaccines, products with DESI designations and experimental drugs. Most brand name drugs with generic equivalents are not covered. To see the most up‐to‐date formulary, please visit your member home page on BCBSRI.com. You may also call Member Services at the number listed on the back of your member ID card.

Table of Contents

ANTI-INFECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

PENICILLINS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

CEPHALOSPORIN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

FIRST GENERATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

SECOND GENERATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

THIRD GENERATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

FOURTH GENERATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

MACROLIDES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

TETRACYCLINES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

QUINOLONES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

AMINOGLYCOSIDES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

SULFONAMIDES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

ANTIMYCOBACTERIAL AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

ANTIFUNGALS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

ANTIVIRALS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

ANTIMALARIALS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

AMEBICIDES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

ANTHELMINTICS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

MISC. ANTI-INFECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

ANTINEOPLASTICS, ETC. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

ALKYLATING AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

ANTIMETABOLITES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

HORMONAL AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

IMMUNOMODULATORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

MITOTIC INHIBITORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

ENZYME INHIBITORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

TOPOISOMERASE I INHIBITOR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

ANTINEOPLASTICS MISC. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

CHEMOTHERAPY RESCUE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

ANTINEOPLASTIC COMBO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

CARDIOVASCULAR DRUGS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

CARDIAC GLYCOSIDES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

ANTIANGINAL AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

BETA BLOCKERS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

CALCIUM CHANNEL BLOCKERS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

ANTIARRHYTHMICS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

ACE INHIBITORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

ANGIOTENSIN RCPTR BLOCKER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

DIRECT RENIN INHIBITORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

ANTIHYPERTENSIVES MISC. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

ANTIHYPERTENSIVE COMBO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

DIURETICS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

VASOPRESSORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

ANTIHYPERLIPIDEMICS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

CARDIOVASCULAR - MISC. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

DERMATOLOGICALS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

ACNE PRODUCTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

ROSACEA AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

ANTIBIOTICS - TOPICAL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

ANTIFUNGALS - TOPICAL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

ANTIVIRALS - TOPICAL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

ANTI-INFLAMMATORY AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

ANTIPRURITICS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

ANTIPSORIATICS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

ANTISEBORRHEIC AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

CORTICOSTEROIDS - TOPICAL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

IMMUNOMODULATING AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

DERMATOLOGICALS - MISC. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

ENDOCRINE AND METABOLIC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

CORTICOSTEROIDS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

ANDROGENS-ANABOLIC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

ESTROGENS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

CONTRACEPTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

PROGESTINS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

ANTIDIABETIC AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

INSULIN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

AMYLIN ANALOGS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

INCRETIN MIMETIC AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

SULFONYLUREAS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

BIGUANIDES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

MEGLITINIDE ANALOGUES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

DIABETIC OTHER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

ALPHA-GLUCOSIDASE INHIBIT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

DPP-4 INHIBITORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

INSULIN SENSITIZING AGENT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

ANTIDIABETIC COMBINATIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

BISPHOSPHONATES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

CALCITONINS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

PARATHYROID HORMONE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

RANK LIGAND INHIBITORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

HORMONE RECEPTOR MDLTR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

FERTILITY REGULATORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

LHRH/GNRH AGONIST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

GNRH/LHRH ANTAGONISTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

GROWTH HORMONES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

SOMATOMEDINS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

SOMATOSTATIC AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

GH RECEPTOR ANTAGONISTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

POSTERIOR PITUITARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

CORTICOTROPIN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

PROLACTIN INHIBITORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

VASOPRESSIN ANTAGONISTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

PROGESTERONE ANTAGONISTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

METABOLIC MODIFIERS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

THYROID AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

GASTROINTESTINAL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

LAXATIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

ANTIDIARRHEALS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

ANTACIDS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

ULCER DRUGS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

ANTIEMETICS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

DIGESTIVE AIDS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

GASTROINTESTINAL - MISC. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

GENITOURINARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

URINARY ANTI-INFECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

URINARY ANTISPASMODICS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

VAGINAL PRODUCTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

GENITOURINARY - MISC. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

HEMATOLOGICAL AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

HEMATOPOIETIC AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

ANTICOAGULANTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

HEMOSTATICS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

HEMATOLOGICAL - MISC. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

MOUTH/THROAT/DENTAL AGENT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

NEUROLOGY, CNS, PSYCH . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

ANTIANXIETY AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

ANTIDEPRESSANTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

ANTIPSYCHOTICS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

HYPNOTICS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

ADHD, NARCOLEPSY, ETC. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

ANTICONVULSANTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

ANTIPARKINSON AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

NEUROLOGY, PSYCH - MISC. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

NEUROMUSCULAR AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

MUSCULOSKELETAL AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

ANTIMYASTHENIC AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

OPHTHALMOLOGY AND OTIC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

ANTI-INFECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

ARTIFICIAL TEAR/LUBRICANT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

BETA-BLOCKERS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

OPHTHALMIC STEROIDS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

PROSTAGLANDINS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

CYCLOPLEGIC MYDRIATICS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

DECONGESTANTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

MIOTICS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

ADRENERGIC AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

LOCAL ANESTHETICS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

OPHTHALMICS - MISC. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

OTIC AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

OXYTOCICS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

PAIN MANAGEMENT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

ANALGESICS - NONNARCOTIC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

ANALGESICS - OPIOID . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

ANTI-INFLAMMATORY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

MIGRAINE PRODUCTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

GOUT AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

LOCAL ANESTHETICS-INJ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

RESPIRATORY, ALLERGY, ETC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

ANTIHISTAMINES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

NASAL AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

COUGH/COLD/ALLERGY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

ANTIASTHMATIC/COPD AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

RESPIRATORY AGENTS - MISC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

VITAMINS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

MULTIVITAMINS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

MISCELLANEOUS AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

FOURTH GENERATION

TIER 01 GENERIC

cefepime

TIER 04 NON PREFERRED

April 2016

ANTI-INFECTIVES MACROLIDES

TIER 02 GENERIC

PENICILLINS

azithromycin

TIER 01 GENERIC

clarithromycin

amoxicillin

clarithromycin ER

amoxicillin ER

erythromycin

ampicillin

erythromycin base

ampicillin sodium

erythromycin ethylsuccinate

ampicillin-sulbactam


dicloxacillin sodium

DificidST

nafcillin sodium

E.E.S. Granules

oxacillin sodium

Ery-TAB

penicillin v potassium

Eryped 200

penicillin G procaine

Eryped 400

penicillin G sodium

Erythrocin Stearate

TIER 02 GENERIC

PCE

amoxicillin/clavulanate potassium

Zmax

amoxicillin/clavulanate potassium ER

penicillin G potassium

TETRACYCLINES


TIER 01 GENERIC

Augmentin

demeclocycline HCL

Bicillin C-R

doxycycline hyclate

Bicillin L-A

minocycline HCL

Moxatag

tetracycline HCL

TIER 02 GENERIC

CEPHALOSPORIN

doxycycline

FIRST GENERATION

doxycycline hyclate DR

TIER 01 GENERIC

doxycycline monohydrate

cefadroxil

minocycline HCL ER

cefazolin sodium


cephalexin

Ocudox

SECOND GENERATION

Targadox

TIER 01 GENERIC

Vibramycin

cefaclor ER

cefotetan

QUINOLONES

cefoxitin sodium

TIER 01 GENERIC

cefprozil

ciprofloxacin

cefuroxime axetil

ciprofloxacin HCL

cefuroxime sodium

levofloxacin

TIER 02 GENERIC

moxifloxacin HCL

cefaclor

TIER 02 GENERIC


ciprofloxacin ER

Cefotan

ofloxacin

Ceftin


THIRD GENERATION

Factive

TIER 01 GENERIC

Noroxin

cefditoren pivoxil

cefixime

AMINOGLYCOSIDES

cefotaxime sodium

ceftibuten TIER 01 GENERIC

ceftriaxone sodium gentamicin sulfate pediatric

TIER 02 GENERIC neomycin sulfate

cefdinir streptomycin sulfate

cefpodoxime proxetil tobramycin sulfate

ceftazidime TIER 02 GENERIC

TIER 03 FORMULARY amikacin sulfate

Suprax gentamicin sulfate

paromomycin sulfate

TIER 04 NON PREFERRED TIER 05 SPECIALTY

Cedax tobramycin

Fortaz BethkisPA

Spectracef

Tobi PodhalerPA

Effective April 1, 2016

PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; 1

SULFONAMIDES Epivir HBV

Intelence

TIER 02 GENERIC

Invirase

sulfadiazine

Isentress

Kaletra

ANTIMYCOBACTERIAL AGENTS

Lexiva

TIER 01 GENERIC

Norvir

cycloserine

Prezista

isoniazid

Rebetol

pyrazinamide

Rescriptor

rifabutin

Reyataz

TIER 02 GENERIC

Rimantalist

ethambutol HCL

Selzentry

rifampin

Sustiva

TIER 03 FORMULARY

Truvada

Paser

Priftin

Viracept

Rifater

Viramune

Trecator

Virazole


Viread

Capastat Sulfate


Rifamate

Atripla

Sirturo

Baraclude

Complera

ANTIFUNGALS

Epzicom

TIER 01 GENERIC

Evotaz

amphotericin b

Genvoya

flucytosine

Moderiba

ketoconazole

terbinafine HCL

TIER 02 GENERIC

Odefsey

fluconazole

Prezcobix

griseofulvin microsize

Relenza Diskhaler

griseofulvin ultramicrosize

Ribasphere Ribapak

itraconazolePA

SitavigQL,PA

nystatin

Stribild

voriconazole

Tamiflu


Tivicay

Cresemba

Triumeq

LamisilPA

Tyzeka

Noxafil

Videx Pediatric

SporanoxPA

Vitekta

Terbinex

Ziagen

TIER 05 SPECIALTY

ANTIVIRALS

DaklinzaPA

TIER 01 GENERIC

Fuzeon

acyclovir

HarvoniPA

didanosine

Peg-intronPA

entecavir

Peg-intron RedipenPA

lamivudine

nevirapine

PegasysPA

nevirapine ER

Pegasys ProclickPA

rimantadine HCL

PegintronPA

stavudine

SovaldiPA

valacyclovir HCL

VictrelisQL,PA

valganciclovir

TIER 02 GENERIC

ANTIMALARIALS

abacavir

TIER 01 GENERIC

abacavir sulfate/lamivudine/zidovudine

chloroquine phosphate

adefovir dipivoxil

hydroxychloroquine sulfate

famciclovir

TIER 02 GENERIC

lamivudine/zidovudine

atovaquone/proguanil HCL

ribavirin

mefloquine HCL

zidovudine

primaquine phosphate

quinine sulfate

TIER 03 FORMULARY

TIER 03 FORMULARY

Aptivus

Daraprim

Crixivan


Edurant

Coartem

Emtriva



AMEBICIDES GENERIC

mercaptopurine

TIER 03 FORMULARY

methotrexate

Yodoxin

methotrexate sodium

TIER 03 FORMULARY

ANTHELMINTICS

Trexall

TIER 01 GENERIC


ivermectin

Purixan

TIER 03 FORMULARY

Tabloid

Albenza

TIER 05 SPECIALTY

Biltricide

capecitabinePA


Emverm

HORMONAL AGENTS

TIER 01 GENERIC

MISC. ANTI-INFECTIVES

anastrozole

TIER 01 GENERIC

letrozole

atovaquone

tamoxifen citrate

aztreonam

TIER 02 GENERIC

bacitracin

bicalutamide

clindamycin phosphate

exemestane

flutamide

clindamycin HCL

leuprolide acetate

lincomycin HCL

megestrol acetate

lincomycin/lidocaine

TIER 03 FORMULARY

linezolid

Emcyt

metronidazole

Lysodren

polymyxin b sulfate

Nilandron

sulfamethoxazole/trimethoprim

Soltamox

sulfamethoxazole/trimethoprim DS


trimethoprim

Depo-provera

TIER 02 GENERIC

Fareston

clindamycin palmitate HCL

TIER 05 SPECIALTY

colistimethate sodium

EligardPA

dapsone

Firmagon

tinidazole

Lupron DepotPA

vancomycin HCL

Trelstar

TIER 03 FORMULARY

Trelstar Mixject

Flagyl ER

Vantas

Nebupent

XtandiQL,PA

Primsol

Zoladex


ZytigaQL,PA

Alinia

Invanz

IMMUNOMODULATORS

Ketek

TIER 01 GENERIC

azathioprine

Pentam 300

mycophenolic acid DR

Sivextro

sirolimus

XifaxanPA

TIER 02 GENERIC

TIER 05 SPECIALTY

cyclosporine

Cayston

cyclosporine modified

mycophenolate mofetil

ANTINEOPLASTICS, ETC.

tacrolimus

ALKYLATING AGENTS

TIER 03 FORMULARY

TIER 01 GENERIC

Azasan

cyclophosphamide


TIER 02 GENERIC

Astagraf XL

lomustine

Cellcept

TIER 03 FORMULARY

Imuran

Alkeran

Neoral

Hexalen

Prograf

Leukeran

Rapamune

Myleran

Sandimmune


Zortress

Gleostine

TIER 05 SPECIALTY

TIER 05 SPECIALTY

PomalystQL,PA

temozolomidePA

RevlimidQL,PA

ValchlorPA

ThalomidPA

ANTIMETABOLITES

TIER 02



MITOTIC INHIBITORS ANTINEOPLASTIC COMBO

TIER 02 GENERIC TIER 05 SPECIALTY

etoposide LonsurfPA

ENZYME INHIBITORS CARDIOVASCULAR DRUGS

TIER 05 SPECIALTY

CARDIAC GLYCOSIDES

imatinib mesylatePA

TIER 02 GENERIC

AfinitorPA

digoxin

Afinitor DisperzPA


AlecensaPA

BosulifPA

CaprelsaQL,PA

CometriqPA

CotellicPA

ANTIANGINAL AGENTS

FarydakPA

TIER 01 GENERIC

GilotrifQL,PA

isosorbide dinitrate

isosorbide mononitrate

IbrancePA

isosorbide mononitrate ER

IclusigPA

nitroglycerin ER

ImbruvicaPA

TIER 02 GENERIC

InlytaPA

isosorbide dinitrate ER

IressaPA

nitroglycerin lingual

JakafiPA

nitroglycerin transdermal

Lenvima 10MG Daily DosePA

TIER 03 FORMULARY


Dilatrate SR


Nitro-bid


Nitro-Dur

LynparzaPA

Nitrostat

MekinistPA


NexavarPA

Nitromist

NinlaroPA

Ranexa

SprycelPA

StivargaPA

BETA BLOCKERS

SutentPA

TIER 01 GENERIC

TafinlarPA

acebutolol HCL

TagrissoPA

atenolol

TarcevaPA

carvedilol

Tasigna

labetalol HCL

TykerbPA

metoprolol tartrate

VotrientPA

pindolol

XalkoriQL,PA

propranolol HCL

ZelborafQL,PA

sotalol HCL

ZolinzaPA

sotalol HCL (AF)

ZydeligPA

TIER 02 GENERIC

ZykadiaPA

betaxolol HCL

bisoprolol fumarate

TOPOISOMERASE I INHIBITOR

metoprolol succinate ER


nadolol

Hycamtin

propranolol HCL ER

timolol maleate

ANTINEOPLASTICS MISC.


TIER 02 GENERIC

Bystolic

hydroxyurea

Coreg CR

tretinoin

Hypertenevide-12.5

TIER 03 FORMULARY

Inderal XL

Matulane

Innopran XL

TIER 05 SPECIALTY

Levatol

bexarotenePA

Sotylize

ActimmunePA

Intron A

CALCIUM CHANNEL BLOCKERS

Intron A W/Diluent

TIER 01 GENERIC

SylatronPA

amlodipine besylate

diltiazem HCL

CHEMOTHERAPY RESCUE

nicardipine HCL

TIER 01 GENERIC

verapamil HCL

leucovorin calcium

verapamil HCL ER

TIER 03 FORMULARY

Mesnex

TIER 02 GENERIC

diltiazem CD



diltiazem HCL ER ANTIHYPERTENSIVES MISC.

felodipine ER

TIER 01 GENERIC

isradipine

clonidine HCL

nifedipine

doxazosin

nifedipine ER

doxazosin mesylate

nimodipine

guanfacine HCL

nisoldipine

hydralazine HCL

nisoldipine ER

methyldopa

verapamil HCL SR

minoxidil


phenoxybenzamine hydrochloride

Cardene SR

phentolamine mesylate

prazosin HCL

Hypertenipine-2.5

reserpine

Nymalize

terazosin HCL

TIER 02 GENERIC

ANTIARRHYTHMICS

eplerenone

TIER 01 GENERIC TIER 03 FORMULARY

amiodarone HCL Demser

flecainide acetate TIER 04 NON PREFERRED

procainamide HCL Vecamyl

quinidine gluconate

quinidine sulfate ANTIHYPERTENSIVE COMBO

quinidine sulfate ER

TIER 01 GENERIC

TIER 02 GENERIC

amlodipine besylate/valsartan

disopyramide phosphate

amlodipine/valsartan/hctz

mexiletine HCL

atenolol/chlorthalidone

propafenone HCL

benazepril HCL/hydrochlorothiazide

propafenone HCL ER

bisoprolol fumarate/hydrochlorothiazide

quinidine gluconate CR

captopril/hydrochlorothiazide

quinidine gluconate ER

enalapril maleate/hydrochlorothiazide

TIER 03 FORMULARY

lisinopril/hydrochlorothiazide

Norpace CR

losartan potassium/hydrochlorothiazide

Tikosyn

methyldopa/hydrochlorothiazide


propranolol/hydrochlorothiazide

Multaq

telmisartan/amlodipine

telmisartan/hydrochlorothiazideQL

ACE INHIBITORS

trandolapril/verapamil HCL

TIER 01 GENERIC trandolapril/verapamil HCL ER

benazepril HCL TIER 02 GENERIC

captopril amlodipine besylate/benazepril hydrochloride

enalapril maleate amlodipine besylate/benazepril HCL

fosinopril sodium candesartan cilexetil/hydrochlorothiazide

lisinopril fosinopril sodium/hydrochlorothiazide

quinapril HCL irbesartan/hydrochlorothiazideQL

ramipril metoprolol/hydrochlorothiazide

trandolapril moexipril/hydrochlorothiazide

TIER 02 GENERIC nadolol/bendroflumethiazide

moexipril HCL quinapril/hydrochlorothiazide

perindopril erbumine valsartan/hydrochlorothiazide

TIER 04 NON PREFERRED TIER 03 FORMULARY

Epaned Benicar HCT


ANGIOTENSIN RCPTR BLOCKER AmturnideQL

Azor

TIER 01 GENERIC

Clorpres

losartan potassiumQL

Dutoprol

telmisartanQL

EdarbyclorST

TIER 02 GENERIC

Hypertensolol

candesartan cilexetilQL

eprosartan mesylate

irbesartanQL

TekamloQL

valsartanQL

Tekturna HCTST

TIER 03 FORMULARY

Teveten HCTST

BenicarQL

TribenzorQL


EdarbiST

DIURETICS

DIRECT RENIN INHIBITORS TIER 01 GENERIC

acetazolamide


acetazolamide sodium

TekturnaST



amiloride/hydrochlorothiazide Vascepa

bumetanide Vytorin

chlorothiazide TIER 05 SPECIALTY

furosemide JuxtapidQL,PA

hydrochlorothiazide KynamroQL,PA

indapamide

metolazone CARDIOVASCULAR - MISC.

spironolactone

TIER 01 GENERIC

spironolactone/hydrochlorothiazide

papaverine HCL

torsemide

TIER 02 GENERIC

triamterene/hydrochlorothiazide

amlodipine besylate/atorvastatin calcium

TIER 02 GENERIC

TIER 03 FORMULARY

acetazolamide ER

amiloride HCL


chlorthalidone

Cialis RR

methazolamide

CorlanorPA

methyclothiazide

EntrestoPA

TIER 03 FORMULARY

Levitra RR

Aldactazide

Muse

Diuril

StaxynRR

Edecrin

ViagraRR


TIER 05 SPECIALTY

sildenafilQL,PA (for pulmonary hypertension only)

Dyrenium

sildenafil citrateQL,PA (for pulmonary hypertension only)

AdcircaQL,PA

VASOPRESSORS

AdempasPA

TIER 01 GENERIC LetairisQL,PA

ephedrine sulfate

epinephrine OrenitramPA

phenylephrine HCL RemodulinPA

TIER 02 GENERIC TracleerQL,PA

midodrine HCL TyvasoPA

TIER 03 FORMULARY

Epipen 2-PAKQL

Epipen-JR 2-PAKQL VentavisPA


AdrenaclickQL DERMATOLOGICALS

Adrenalin

ACNE PRODUCTS

TIER 05 SPECIALTY

TIER 01 GENERIC

NortheraPA


sulfacetamide sodium/sulfur

ANTIHYPERLIPIDEMICS

tretinoin microsphere

TIER 01 GENERIC

TIER 02 GENERIC

atorvastatin calcium

adapalene

fluvastatin sodium ER

adapalene P.M.

gemfibrozil

benzoyl peroxide

lovastatin

omega-3-acid ethyl esters

clindamycin/benzoyl peroxide

pravastatin sodium rosuvastatin

erythromycin

simvastatin

erythromycin/benzoyl peroxide

TIER 02 GENERIC

sodium sulfacetamide

cholestyramine

sodium sulfacetamide/sulfur

cholestyramine light

sodium sulfacetamide/sulfur cleanser

colestipol HCL

sodium sulfacetamide/sulfur cleanser IN urea

fenofibrate

sodium sulfacetamide/sulfur cleansing cloths

fenofibrate micronized

sodium sulfacetamide/sulfur green

fenofibric acid DR

sodium sulfacetamide/sulfur wash

fluvastatin

sodium sulfacetamide/sulfur IN urea

niacin ER

sulfacetamide sodium

TIER 03 FORMULARY

sulfacetamide sodium/sulfur cleanser

tretinoin

Welchol

tretinoin microsphere P.M.

Zetia



Avar

Advicor

Avar LS

Altoprev

Clinoin

Fenoglide

Epiduo Forte

Livalo

Fabior

Simcor

Tretin-X


PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; RR= Requires Rider for coverage 6

ROSACEA AGENTS PennsaidPA

Xrylix

TIER 01 GENERIC

doxycycline

ANTIPRURITICS

TIER 02 GENERIC

metronidazole TIER 02 GENERIC

TIER 04 NON PREFERRED doxepin hydrochloride

Finacea TIER 04 NON PREFERRED

Prudoxin

ANTIBIOTICS - TOPICAL Zonalon

TIER 02 GENERIC

ANTIPSORIATICS

gentamicin sulfate

mupirocin TIER 01 GENERIC

mupirocin calcium methoxsalen

TIER 03 FORMULARY TIER 02 GENERIC

Cortisporin acitretin

TIER 04 NON PREFERRED calcipotriene

centany calcitriol

Altabax TIER 03 FORMULARY

Centany AT 8-mop

Neo-synalar TIER 04 NON PREFERRED

Sorilux

ANTIFUNGALS - TOPICAL Taltz

Tazorac

TIER 01 GENERIC

Vectical

ciclopirox nail lacquer

Zithranol

ciclopirox olamine

Zithranol-rr

TIER 05 SPECIALTY

econazole nitrate

CosentyxPA

ketoconazole

Cosentyx Sensoready PenPA

naftifine hydrochloride

StelaraQL,PA

naftifine HCL

nystatin

ANTISEBORRHEIC AGENTS

oxiconazole nitrate

TIER 02 GENERIC TIER 01 GENERIC

ciclopirox glycolic acid

clotrimazole/betamethasone dipropionate glycolic acid 70% high purity

nystatin/triamcinolone sodium sulfacetamide

TIER 03 FORMULARY TIER 02 GENERIC

Exelderm selenium sulfide

Halotin sodium sulfacetamide wash

Lamisil Spray TIER 04 NON PREFERRED

Ovace Plus

Xolegel Promiseb

TIER 04 NON PREFERRED Promiseb Complete

Selrx

Ecoza Tersi Foam

TL Triseb

Luzu

Mentax CORTICOSTEROIDS - TOPICAL

TIER 01 GENERIC

alclometasone dipropionate

Recura

augmented betamethasone dipropionate

Vusion

calcipotriene/betamethasone dipropionate

clobetasol propionate

Xolegel Duo/Head & Shoulders

clobetasol propionate emollient

Xolegel Duo/Xolex

clocortolone pivalate

clocortolone pivalate P.M.

ANTIVIRALS - TOPICAL

desonide

TIER 02 GENERIC fluocinonide

acyclovir fluocinonide-e

TIER 04 NON PREFERRED fluticasone propionate

DenavirQL halobetasol propionate

ANTI-INFLAMMATORY AGENTS hydrocortisone IN absorbase

mometasone furoate

TIER 01 GENERIC

TIER 02 GENERIC

diclofenac sodium gel

amcinonide

TIER 03 FORMULARY

betamethasone dipropionate

betamethasone valerate


desoximetasone

FlectorST



diflorasone diacetate sulfurated lime

fluocinolone acetonide TIER 02 GENERIC

hydrocortisone acetate/aloe coal TAR

hydrocortisone butyrate ethyl chloride

hydrocortisone butyrate (lipid) ethyl chloride/fine pinpoint

hydrocortisone butyrate (lipophilic) ethyl chloride/fine stream

hydrocortisone valerate ethyl chloride/medium jet stream

prednicarbate ethyl chloride/medium stream

triamcinolone acetonide ethyl chloride/mist

TIER 04 NON PREFERRED lidocaine

Capex lidocaine HCL

Cloderm lindane

Cloderm P.M. malathion

permethrin

Cordran Tape podofilox

Dermasorb HC salicylic acid

Dermasorb TA salicylic acid cream

Desonate salicylic acid lotion

Desowen Cream/Cetaphil Lotion

Desowen Lotion/Cetaphil Cream spinosad

Desowen Ointment/Cetaphil Lotion urea

Enstilar urea topical

Epifoam

Halog

Halonate TIER 03 FORMULARY

Locoid Anacaine

Pandel Atopiclair

Pediaderm HC Condylox

Pediaderm TA Eurax

Scalacort DK

Gordofilm

Gordons Urea

Synalar Ts Kerafoam

Taclonex Kerafoam 42

Texacort Xerac Ac

Topicort TIER 04 NON PREFERRED

Trianex

Alevicyn Antipruritic SG

Verdeso

IMMUNOMODULATING AGENTS Avenova

Clever Choice Comfort EZ Patch

TIER 01 GENERIC

Copasil

tacrolimus

Eletone

TIER 02 GENERIC

Eletone Twinpack

imiquimod

TIER 03 FORMULARY

Emulsion SB

Elidel

Epiceram


Hylatopic

Zyclara

Hylatopic Plus

Zyclara P.M.

DERMATOLOGICALS - MISC.

TIER 01 GENERIC

arnica flower

IV Infusion Cpi

benzoin compound tincture

Keralyt Scalp

benzoin tincture

Lido-RX 4.1

boric acid

Lycelle

capsaicin

Mb Hydrogel

cocaine HCL

Medi-derm/L-RX

lactic acid

Megrix

lactic acid e

Neosalus

lactic acid w/vitamin e

Neosalus CP

lidocaine and tetracaine cream

Neuvaxin

lidocaine HCL jelly

Nivatopic Plus

lidocaine-prilocaine-cream base

Nuvail

lidocaine/prilocaine

Pliaglis

pyrogallic acid

Pr Cream

sodium hyaluronate

Presera



Pruclair GENERIC

Prumyx methyltestosterone

Qutenza oxandrolone

Relyyt testosterone 1% gel

Salvax Duo Plus testosterone P.M.

Sinelee TIER 02 GENERIC

Sklice danazol

Solaice testosterone cypionate

Synera testosterone enanthate

Tetrix TIER 03 FORMULARY

Tropazone Androgel 1.62%

Ulesfia

Androxy

Umecta Axiron

Umecta PD TIER 04 NON PREFERRED

Veregen Anadrol-50

AndrodermST

ENDOCRINE AND METABOLIC Fortesta

StriantST

CORTICOSTEROIDS

Testim

TIER 01 GENERIC

Vogelxo

dexamethasone

Vogelxo P.M.

dexamethasone sodium phosphate

hydrocortisone tabs

ESTROGENS

methylprednisolone acetate

TIER 01 GENERIC

methylprednisolone sodiumsuccinate

estradiol

methylprednisolone PF

estropipate

prednisolone

norethindrone acetate/ethinyl estradiol

prednisolone sodium phosphate

TIER 02 GENERIC

prednisolone sodium phosphate ODT

estradiol valerate

prednisone

estradiol/norethindrone acetate

triamcinolone

TIER 03 FORMULARY

TIER 02 GENERIC

Alora

betamethasone sodium phosphate/betamethasone acetate

Cenestin

budesonide Climara Pro

cortisone acetate Combipatch

fludrocortisone acetate Depo-estradiol

methylprednisolone Enjuvia

methylprednisolone dose pack Menest

TIER 03 FORMULARY Prefest

Dexamethasone Intensol Premphase

Orapred ODT Prempro

Prednisone Intensol TIER 04 NON PREFERRED

TIER 04 NON PREFERRED Angeliq

Delestrogen

Divigel

Depo-medrol Duavee

Elestrin

Estrasorb

Estrogel

Dyural-l Evamist

FLO-pred Menostar

Medrol Minivelle

Millipred Premarin

Millipred DP

CONTRACEPTIVES

TIER 01 GENERIC

norethindrone & ethinyl estradiol ferrous fumarate

norgestimate/ethinyl estradiol

TIER 02 GENERIC

desogestrel/ethinyl estradiol

drospirenone/ethinyl estradiol

levonorgestrel

Solu-medrol

levonorgestrel and ethinyl estradiol

Uceris

levonorgestrel/ethinyl estradiol

Veripred 20

norethindrone

norethindrone acetate/ethinyl estradiol

ANDROGENS-ANABOLIC (May require PA for < 40 yo use )

norethindrone acetate/ethinyl estradiol/ferrous fumarate

TIER 01

TIER 04



NON PREFERRED GENERIC

Beyaz nateglinide

Ella repaglinide

Falessa DIABETIC OTHER

LO Loestrin FE TIER 01 FORMULARY- LIFESCAN PRODUCTS PREFERRED

Minastrin 24 FE ONE Touch Test Strips – Ultra, Ultra Mini, UltraSmart,Verio IQ, Verios Sync

Natazia TIER 04 NON PREFERRED

Norinyl 1+50 FarxigaQL,ST

Quartette Glucagen Hypokit

Safyral Glucagon Emergency Kit

InvokanaQL,ST

PROGESTINS JardianceQL,ST

TIER 05 SPECIALTY

TIER 01 GENERIC

KorlymPA

medroxyprogesterone acetate

ALPHA-GLUCOSIDASE INHIBIT

medroxyprogesterone/lidocaine

TIER 01 GENERIC

megestrol acetate

acarbose

TIER 02 GENERIC

TIER 03 FORMULARY

norethindrone acetate

progesterone

DPP-4 INHIBITORS

TIER 05 SPECIALTY

TIER 01 GENERIC

MakenaPA

alogliptin

TIER 03 FORMULARY

ANTIDIABETIC AGENTS

Januvia

INSULIN

Tradjenta

TIER 03 FORMULARY (Lilly Products preferred)


Humulin N, R, all forms preferred

NesinaST

Humalog Kwikpen

OnglyzaST

Humalog Mix 50/50

INSULIN SENSITIZING AGENT

Humalog Mix 50/50 Kwikpen

TIER 02 GENERIC

Humalog Mix 75/25

pioglitazone HCL

Humalog Mix 75/25 Kwikpen


Humulin R U-500 (concentrated)

Avandia

Lantus

ANTIDIABETIC COMBINATIONS

Lantus Solostar

TIER 01 GENERIC

Levemir

alogliptin/metformin HCL

Levemir Flexpen

alogliptin/pioglitazone

Levemir Flextouch

glyburide/metformin HCL


repaglinide/metformin hydrochloride

TIER 02 GENERIC

AMYLIN ANALOGS

glipizide/metformin HCL


pioglitazone HCL-glimepiride

Symlinpen 120

pioglitazone HCL/metformin HCL

Symlinpen 60

TIER 03 FORMULARY

INCRETIN MIMETIC AGENTS

Actoplus Met XR

TIER 03 FORMULARY

Janumet

Byetta

Janumet XR

Tanzeum

Jentadueto



Bydureon

Appformin

VictozaPA

Appformin-d

SULFONYLUREAS

Avandamet

TIER 01 GENERIC

Avandaryl

chlorpropamide

InvokametQL,ST

glimepiride

KazanoST

glipizide

Kombiglyze XRST

glipizide ER

OseniST

glyburide

Xigduo XRST

glyburide micronized

tolazamide

BISPHOSPHONATES

tolbutamide

TIER 01 GENERIC


alendronate sodium

Diabeta

risedronate sodium

BIGUANIDES

risedronate sodium DR

TIER 01 GENERIC

TIER 02 GENERIC

metformin HCL

etidronate disodium

metformin HCL ER

ibandronate sodium



Riomet

Binosto

MEGLITINIDE ANALOGUES

TIER 02



Fosamax Plus DST SerostimPA

Tev-tropinPA

CALCITONINS ZomactonPA

ZorbtivePA

TIER 02 GENERIC

calcitonin salmon

SOMATOMEDINS

calcitonin-salmon

TIER 04 NON PREFERRED TIER 05 SPECIALTY

fortical IncrelexPA

Miacalcin

SOMATOSTATIC AGENTS

PARATHYROID HORMONE

TIER 02 GENERIC

TIER 05 SPECIALTY octreotide acetate

ForteoPA TIER 05 SPECIALTY

Sandostatin Lar Depot

RANK LIGAND INHIBITORS SigniforQL,PA

Signifor LARPA

TIER 05 SPECIALTY

Somatuline Depot

ProliaPA

XgevaPA

GH RECEPTOR ANTAGONISTS

HORMONE RECEPTOR MDLTR TIER 05 SPECIALTY

Somavert

TIER 01 GENERIC

raloxifene hydrochloride

POSTERIOR PITUITARY


Osphena TIER 01 GENERIC

vasopressin

FERTILITY REGULATORS TIER 02 GENERIC

desmopressin acetate

TIER 01 GENERIC

TIER 03 FORMULARY

clomiphene citrate

Stimate

TIER 05 SPECIALTY

chorionic gonadotropin

Bravelle

Follistim AQ

Gonal-fST

Gonal-f RFFST

Gonal-f RFF PenPA PROLACTIN INHIBITORS

Gonal-f RFF RedijectPA

TIER 02 GENERIC

Menopur

cabergoline

Ovidrel

Repronex

VASOPRESSIN ANTAGONISTS


LHRH/GNRH AGONIST

Samsca

TIER 03 FORMULARY

Synarel

PROGESTERONE ANTAGONISTS

TIER 05 SPECIALTY

TIER 03 FORMULARY

Lupaneta Pack

Mifeprex

Lupron Depot-PED

Supprelin LA

METABOLIC MODIFIERS

TIER 01 GENERIC

GNRH/LHRH ANTAGONISTS

calcitriol

TIER 05 SPECIALTY

doxercalciferol

ganirelix acetate

sodium phenylbutyrate

Cetrotide

TIER 02 GENERIC

levocarnitine

GROWTH HORMONES

paricalcitol

TIER 05 SPECIALTY

TIER 03 FORMULARY

GenotropinPA

Buphenyl

Genotropin MiniquickPA

Orfadin

HumatropePA

Sensipar


Norditropin CartridgePA

Cystadane

Norditropin FlexproPA

Xuriden

Norditropin Nordiflex PenPA

TIER 05 SPECIALTY

Nutropin AQ Nuspin 10PA

CarbagluPA


Kuvan


RavictiPA

Nutropin AQ PenPA

OmnitropePA

THYROID AGENTS

SaizenPA

TIER 01

Saizen Click.easyPA



GENERIC belladonna alkaloids & opium

levothyroxine sodium chlordiazepoxide HCL/clidinium bromide

levothyroxine sodium TAB 0.075MG cimetidine

methimazole dicyclomine hci

TIER 02 GENERIC dicyclomine HCL

liothyronine sodium famotidine

propylthiouracil glycopyrrolate

TIER 03 FORMULARY hyoscyamine sulfate ODT

Thyrolar-1 omeprazole

Thyrolar-1/2 omeprazole/sodium bicarbonate

Thyrolar-1/4 pantoprazole sodium

Thyrolar-2 scopolamine hydrobromide

Thyrolar-3 TIER 02 GENERIC

TIER 04 NON PREFERRED belladonna & opium

Armour Thyroid cimetidine HCL

Cytomel hyoscyamine sulfate

Nature-throid hyoscyamine sulfate ER

Nature-throid NT-2.5 hyoscyamine sulfate SR

Synthroid lansoprazole

Tirosint lansoprazole/amoxicillin/clarithromycin

Westhroid methscopolamine bromide

Wp Thyroid misoprostol

nizatidine

GASTROINTESTINAL propantheline bromide

rabeprazole sodium

LAXATIVES

ranitidine HCL

TIER 01 GENERIC

sucralfate

cascara sagrada

lactulose

TIER 03 FORMULARY

mineral oil heavy

Carafate

polyethylene glycol 3350


senna plus

Aciphex SprinklePA

TIER 02 GENERIC

Atropen

peg 3350/electrolytes

Cantil

peg-3350/electrolytes

Cuvposa

peg-3350/NACL/NA bicarbonate/KCL

Gabitidine

TIER 03 FORMULARY

Levsin

Golytely

Moviprep

Pamine FQ

Osmoprep

Prevacid SolutabPA

Suclear

ProtonixPA


Pylera

Colyte-flavor Packs

Kristalose

Symax Duotab

Prepopik

Suprep Bowel Prep

ANTIEMETICS

TIER 01 GENERIC

ANTIDIARRHEALS

dimenhydrinate

TIER 01 GENERIC

ondansetron ODT

paregoric

trimethobenzamide HCL

TIER 02 GENERIC

TIER 02 GENERIC

diphenoxylate/atropine

dronabinol

opium

granisetron HCLQL

opium tincture

ondansetron HCL

TIER 03 FORMULARY

TIER 03 FORMULARY

Motofen

Transderm-scop

VSL#3 DS



Akynzeo

FulyzaqPA

Anzemet

Restora RX

Cesamet

Rezyst IM

Emend

Rezyst SB

Granisol

Sancuso

ANTACIDS

Zuplenz

TIER 01 GENERIC

sodium bicarbonate

DIGESTIVE AIDS

TIER 02 GENERIC

ULCER DRUGS

pancrelipase

TIER 01 GENERIC

TIER 03

atropine sulfate



FORMULARY methenamine mandelate

Creon nitrofurantoin

Pancreaze nitrofurantoin macrocrystals

SucraidPA nitrofurantoin monohydrate

Ultresa nitrofurantoin monohydrate/macrocrystals

Viokace TIER 04 NON PREFERRED

Zenpep Monurol

TIER 04 NON PREFERRED Uretron D/S

Pertzye Uroqid #2

GASTROINTESTINAL - MISC. URINARY ANTISPASMODICS


alosetron hydrochloride bethanechol chloride

dexpanthenol darifenacin hydrobromide ER

lactulose darifenacin ER

metoclopramide ODT oxybutynin chloride

metoclopramide HCL tolterodine tartrate ER

sevelamer carbonate TIER 02 GENERIC

TIER 02 GENERIC flavoxate HCL

balsalazide disodium oxybutynin chloride ER

calcium acetate tolterodine tartrate

cromolyn sodium trospium chloride

hydrocortisone tabs trospium chloride ER

hydrocortisone acetate/lidocaine HCL TIER 03 FORMULARY

hydrocortisone acetate/pramoxine Vesicare

lidocaine HCL-hydrocortisone acetate with aloe TIER 04 NON PREFERRED

lidocaine HCL/hydrocortisone acetate Gelnique

mesalamine Myrbetriq

sulfasalazine Toviaz

ursodiol

TIER 03 FORMULARY VAGINAL PRODUCTS

Apriso

TIER 01 GENERIC

Asacol HD

terconazole

Canasa

TIER 02 GENERIC

Fosrenol


Lialda

metronidazole vaginal

Pentasa

TIER 03 FORMULARY

Cleocin

Renagel

Estring

Renvela


auryxia

Amitiza

Premarin

Chenodal

Vagifem

Cortifoam


Delzicol

AVC

Dipentum

Clindesse

Entereg

Crinone

Giazo

Endometrin

Linzess

Estrace

MovantikQL,PA

Femring

Phoslyra

Gynazole-1

Procort

Relagard

Rectiv

Relistor

GENITOURINARY - MISC.

Sfrowasa

TIER 01 GENERIC

Uceris

alfuzosin HCL ER

Velphoro

dutasteride

TIER 05 SPECIALTY

dutasteride/tamsulosin hydrochloride

CimziaQL,PA

finasteride

Cimzia Starter KitQL,PA

phenazopyridine HCL

GattexPA

potassium citrate/sodium citrate/citric acid

tamsulosin HCL

GENITOURINARY

tricitrates

URINARY ANTI-INFECTIVES TIER 02 GENERIC

citric acid/sodium citrate

TIER 02 GENERIC

potassium citrate ER

methenamine hippurate



potassium citrate-citric acid crystals HEMOSTATICS

potassium citrate/citric acid

TIER 02 GENERIC

sodium citrate/citric acid

aminocaproic acid

TIER 03 FORMULARY

tranexamic acid

Cystagon

TIER 03 FORMULARY

Elmiron

Artiss

K-phos NO 2

Astringyn

Lithostat

Oracit


Cardura XL

Rapaflo

Thrombogen

TIER 05 SPECIALTY


Procysbi

Evicel

ThiolaPA

Evithrom

Recothrom

HEMATOLOGICAL AGENTS

Tisseel

HEMATOPOIETIC AGENTS

Tisseel VH

TIER 01 GENERIC

HEMATOLOGICAL - MISC.

cyanocobalamin

TIER 01 GENERIC

folic acid

aspirin/dipyridamole

TIER 02 GENERIC

clopidogrel

hydroxocobalamin

dipyridamole

TIER 03 FORMULARY

TIER 02 GENERIC

Droxia

anagrelide hydrochloride


cilostazol

Ciferex

pentoxifylline ER

Feriva 21/7

ticlopidine HCL

Mozobil

TIER 03 FORMULARY

Nascobal

Aggrenox

Omontys


TIER 05 SPECIALTY

Brilinta

Aranesp Albumin FreePA

Cathflo Activase

Cerdelga

Effient

EpogenPA

Kalbitor

Granix

Kinlytic

Mircera

Kovaltry

NeulastaPA

Novoeight

Nuwiq

NeumegaPA

Xyntha Solofuse

NeupogenPA,ST

TIER 05 SPECIALTY

NplatePA

Benefix

ProcritPA

FirazyrPA

PromactaPA

Helixate FS

ZavescaPA

Ixinity

Kogenate FS

ANTICOAGULANTS

Kogenate FS Bio-set

TIER 01 GENERIC

Recombinate

Xyntha

MOUTH/THROAT/DENTAL AGENT

warfarin sodium

TIER 02 GENERIC

enoxaparin sodium TIER 01 GENERIC

fondaparinux sodium chlorhexidine gluconate

heparin sodium chlorhexidine gluconate oral rinse

heparin sodium dcu lidocaine viscous

TIER 03 FORMULARY Eliquis

lidocaine HCL

Xarelto lidocaine HCL viscous

TIER 04 NON PREFERRED TIER 02 GENERIC

Arixtra cevimeline HCL

clotrimazole

Fragmin nystatin

Iprivask pilocarpine hydrochloride

Pradaxa pilocarpine HCL

SavaysaQL stannous fluoride oral rinse

triamcinolone acetonide

triamcinolone IN orabase



TIER 03 FORMULARY mirtazapine ODT

Caphosol nefazodone HCL

Debacterol paroxetine HCL ERQL

TIER 04 NON PREFERRED phenelzine sulfate

Aquoral protriptyline HCL

tranylcypromine sulfate

Gelclair TIER 03 FORMULARY

Nafrinse Daily/Acidulated duloxetine HCLPA

Nafrinse Daily/Neutral Appbutamone

Nafrinse Weekly Gaboxetine

Neutrasal Marplan

Oravig Sentroxatine

Salivamax TIER 04 NON PREFERRED

NEUROLOGY, CNS, PSYCH Emsam

FetzimaST

ANTIANXIETY AGENTS

TIER 01 GENERIC

Khedezla

alprazolam

Oleptro

buspirone HCL

chlordiazepoxide HCL

Paxil Susp PA

clorazepate dipotassium

PexevaQL,ST

droperidol

PristiqST

hydroxyzine pamoate

hydroxyzine HCL

lorazepam

meprobamate

Trazamine

TIER 02 GENERIC

ViibrydST

alprazolam ODT

alprazolam ER

diazepam

ANTIPSYCHOTICS

oxazepam

TIER 01 GENERIC

TIER 03 FORMULARY

aripiprazole ODTPA

Alprazolam Intensol

chlorpromazine HCL


clozapine ODT

fluphenazine HCL

haloperidol

haloperidol lactate

lithium carbonate

loxapine

ANTIDEPRESSANTS

loxapine succinate

TIER 01 GENERIC

molindone hydrochloride

amitriptyline HCL

paliperidone ER

amoxapine

prochlorperazine edisylate

doxepin HCL

prochlorperazine maleate

escitalopram oxalateQL

quetiapine fumarate

fluoxetine HCL

thiothixene

fluvoxamine maleate

mirtazapine

TIER 02 GENERIC

nortriptyline HCL

clozapine

paroxetine HCL

fluphenazine decanoate

sertraline HCLQL

haloperidol decanoate

trazodone HCL

lithium

trimipramine maleate

lithium carbonate ER

venlafaxine HCL

olanzapine

venlafaxine HCL ERQL

olanzapine ODT

TIER 02 GENERIC

perphenazine

bupropion HCL

prochlorperazine

bupropion HCL ER

risperidone

bupropion HCL SR

risperidone ODT

bupropion HCL XL

thioridazine HCL

citalopram hydrobromideQL

trifluoperazine HCL

clomipramine HCL

ziprasidone HCL

desipramine HCL

TIER 03 FORMULARY

desvenlafaxine ER

Equetro

fluoxetine DR

Risperdal Consta

fluvoxamine maleate ERPA

Seroquel XRST

imipramine pamoate

Zyprexa Relprevv

imipramine HCL

TIER 04

maprotiline HCL



NON PREFERRED Adzenys XR-ODT

aripiprazolePA Daytrana

AbilifyPA Dexedrine

Abilify DiscmeltPA Dyanavel XR

Abilify Maintena Focalin

FanaptST Focalin XR

Metadate CD

FazacloST Methylin

Geodon Procentra

Invega Sustenna Quillivant XR

Invega TrinzaPA Ritalin

LatudaST Ritalin LA

SaphrisST

VersaclozST Zenzedi

Vraylar

ANTICONVULSANTS

HYPNOTICS

TIER 01 GENERIC

TIER 01 GENERIC carbamazepine

estazolam clonazepam

eszopiclone divalproex sodium DR

flurazepam HCL divalproex sodium ER

phenobarbital sodium lamotrigine

quazepam lamotrigine ODT

temazepam lamotrigine titrationQL

triazolam oxcarbazepine

zolpidem tartrate phenytoin sodium

TIER 02 GENERIC primidone

phenobarbital topiramate

zaleplon valproic acid

zolpidem tartrate ER TIER 02 GENERIC

TIER 03 FORMULARY carbamazepine ER

Butisol Sodium clonazepam ODT

TIER 04 NON PREFERRED diazepam

Amytal Sodium divalproex sodium

Doral ethosuximide

felbamate

Nembutal Sodium gabapentin

Rozerem lamotrigine ER

levetiracetam

Strazepam levetiracetam ER

Zolpimist phenytoin

phenytoin sodium extended

ADHD, NARCOLEPSY, ETC. tiagabine hydrochloride

zonisamide

TIER 01 GENERIC

TIER 03 FORMULARY

caffeine/sodium benzoate

Gabitril

dexmethylphenidate HCL ER

Lamictal ODT

guanfacine ER

methylphenidate HCL

TIER 02 GENERIC

Stavzor

caffeine citrate

Tegretol-XR

dexmethylphenidate HCL

dextroamphetamine sulfate

dextroamphetamine sulfate ER


methamphetamine HCL

Aptiom

methylphenidate hydrochloride

Banzel

methylphenidate HCL CD

Carbatrol

methylphenidate HCL ER

Celontin

Depakene

TIER 03 FORMULARY

Depakote

armodafinil PA Adderall XR

Depakote ER

Concerta

Depakote Sprinkles

modafinil PA

Dilantin

Ritalin SR

Dilantin Infatabs

Strattera

Dilantin-125

Vyvanse

Felbatol


Fycompa

amphetamine/dextroamphetamineST

Keppra

methylphenidate HCL SRST

Keppra XR

Adderall



Lamictal GENERIC

Lamictal Chewable Dispersible acamprosate calcium DR

chlordiazepoxide/amitriptyline

disulfiram

Lamictal XR olanzapine/fluoxetine

LyricaPA rivastigmine tartrate

Mysoline TIER 03 FORMULARY

OnfiST Namenda XR

Oxtellar XR

Peganone

Phenytek TIER 04 NON PREFERRED

Potiga

Spritam NamzaricPA

Tegretol Sarafem

Topamax SavellaPA

Topamax Sprinkle

Trileptal

Trokendi XR TIER 05 SPECIALTY

Vimpat tetrabenazinePA

Zarontin AmpyraQL,PA

TIER 05 SPECIALTY AubagioPA,ST

SabrilPA Avonex

Avonex Pen

ANTIPARKINSON AGENTS Betaseron

ExtaviaPA,ST

TIER 01 GENERIC

benztropine mesylate

glatiramer acetate 20mg/ml

carbidopa

NuedextaPA

carbidopa/levodopa

Plegridy

carbidopa/levodopa ODT

carbidopa/levodopa/entacapone

RebifPA,ST

pramipexole dihydrochloride

Rebif RebidosePA,ST

pramipexole dihydrochloride ER

ropinirole HCL

selegiline HCL

TecfideraQL,ST

tolcapone

TIER 02 GENERIC

XyremPA

amantadine HCL

bromocriptine mesylate

NEUROMUSCULAR AGENTS

carbidopa/levodopa ER

entacapone TIER 02 GENERIC

ropinirole ER riluzole

trihexyphenidyl HCL TIER 04 NON PREFERRED

TIER 04 NON PREFERRED Quelicin 1000

Apokyn TIER 05 SPECIALTY

Azilect BotoxPA

Mirapex ER DysportPA

Neupro MyoblocPA

Rytary XeominPA

Stalevo 100

Stalevo 125 MUSCULOSKELETAL AGENTS

Stalevo 150

TIER 01 GENERIC

Stalevo 200

baclofen

Stalevo 50

chlorzoxazone

Stalevo 75

cyclobenzaprine HCL

Zelapar

methocarbamol

orphenadrine/asa/caffeine

NEUROLOGY, PSYCH - MISC.

tizanidine HCL


donepezil HCL dantrolene sodium

ergoloid mesylates metaxalone

fluoxetine orphenadrine citrate

galantamine hydrobromide orphenadrine citrate ER

memantine hydrochloride TIER 03 FORMULARY

memantine HCL Prazolamine

perphenazine/amitriptyline

pimozide TIER 04 NON PREFERRED

rivastigmine transdermal system

TIER 02



Lorzone OPHTHALMIC STEROIDS

TIER 01 GENERIC

dexamethasone sodium phosphate

fluorometholone

ANTIMYASTHENIC AGENTS

neomycin/polymyxin/dexamethasone

TIER 01 GENERIC prednisolone acetate

guanidine HCL sulfacetamide sodium/prednisolone sodium phosphate

neostigmine methylsulfate TIER 02 GENERIC

pyridostigmine bromide neomycin/polymyxin/bacitracin/hydrocortisone

TIER 03 FORMULARY neomycin/polymyxin/hydrocortisone

prednisolone sodium phosphate

TIER 04 NON PREFERRED tobramycin/dexamethasone

Enlon TIER 03 FORMULARY

Alrex

OPHTHALMOLOGY AND OTIC Blephamide

Blephamide S.O.P.

ANTI-INFECTIVES

FML

TIER 01 GENERIC

FML Forte

ciprofloxacin HCL

Lotemax

ofloxacin

Maxidex

sodium sulfacetamide

Pred Mild

tobramycin sulfate

Pred-G

TIER 02 GENERIC

Pred-G S.O.P.

bacitracin

Tobradex

bacitracin/polymyxin b


erythromycin

Durezol

gatifloxacin

Flarex

gentamicin sulfate

Tobradex ST

levofloxacin

Vexol

neomycin/bacitracin/polymyxin

Zylet

neomycin/polymyxin/bacitracin zinc

neomycin/polymyxin/gramicidin

PROSTAGLANDINS

polymyxin b sulfate/trimethoprim sulfate

TIER 02 GENERIC

sulfacetamide sodium

latanoprost

trifluridine

travoprost

trimethoprim sulfate/polymyxin b sulfate

TIER 03 FORMULARY

TIER 03 FORMULARY

Travatan Z

Betadine Ophthalmic Prep


Ciloxan

Lumigan

Natacyn

Rescula

Tobrex

Zioptan

Vigamox


CYCLOPLEGIC MYDRIATICS

Azasite

TIER 01 GENERIC

Besivance

cyclopentolate hydrochloride

Mitosol

TIER 02 GENERIC

Moxeza

atropine sulfate

Zirgan

cyclopentolate HCL

homatropine HBR

ARTIFICIAL TEAR/LUBRICANT

TIER 03 FORMULARY


Cyclomydril

Lacrisert

Isopto Homatropine

Isopto Hyoscine

BETA-BLOCKERS


TIER 01 GENERIC

timolol maleate

TIER 02 GENERIC

DECONGESTANTS

betaxolol HCL

TIER 01 GENERIC

carteolol HCL

naphazoline HCL

dorzolamide HCL/timolol maleate

TIER 02 GENERIC

levobunolol HCL

phenylephrine HCL

metipranolol

timolol maleate ophthalmic gel forming

MIOTICS

TIER 03 FORMULARY

TIER 02 GENERIC

Betoptic-S

pilocarpine HCL



Betimol

Isopto Carbachol

Combigan

Phospholine Iodide

Cosopt PF



ADRENERGIC AGENTS

TIER 01 GENERIC

TIER 01 GENERIC

methylergonovine maleate

brimonidine tartrate

TIER 02 GENERIC

TIER 02 GENERIC

oxytocin

apraclonidine

TIER 03 FORMULARY

TIER 03 FORMULARY

Cervidil

Iopidine

Prostin E2



Alphagan P

Hemabate

Simbrinza

Prepidil

LOCAL ANESTHETICS

PAIN MANAGEMENT

TIER 01 GENERIC

proparacaine HCL ANALGESICS - NONNARCOTIC

tetracaine HCL

TIER 01 GENERIC


butalbital/acetaminophen/caffeine

Akten

choline magnesium trisalicylate

TIER 02 GENERIC

OPHTHALMICS - MISC.

butalbital/acetaminophen

TIER 01 GENERIC butalbital/aspirin/caffeine

cromolyn sodium diflunisal

flurbiprofen sodium salsalate

olopatadine HCL TIER 04 NON PREFERRED

TIER 02 GENERIC Allzital

azelastine HCL Bupap

bromfenac Equagesic

diclofenac sodium Levacet

dorzolamide HCL

epinastine HCL ANALGESICS – OPIOID (May require Prior Authorization for New Starts )

ketorolac tromethamine

TIER 01 GENERIC

TIER 03 FORMULARY

acetaminophen/caffeine/dihydrocodeine

Azopt

acetaminophen/codeine

Nevanac

acetaminophen/codeine #2



Acuvail


Alocril

acetaminophen/codeine phosphate

Alomide

alfentanil

Bepreve

aspirin-caffeine-dihydrocodeine

Emadine

butalbital/acetaminophen/caffeine/codeine

Ilevro

hydrocodone/acetaminophen

Lastacaft

hydromorphone HCL ERPA

Pataday

morphine sulfate

Prolensa

morphine sulfate ERQL,PA

TIER 05 SPECIALTY

nalbuphine HCL

CystaranQL,PA

oxycodone HCL

oxycodone HCL ERQL,PA

OTIC AGENTS

oxycodone/acetaminophen

TIER 01 GENERIC oxycodone/ibuprofen

acetic acid/aluminum acetate tramadol hydrochloride/acetaminophen

antipyrine/benzocaine tramadol HCL

TIER 02 GENERIC

acetic acid TIER 02 GENERIC

ciprofloxacin buprenorphine HCLPA

fluocinolone acetonide buprenorphine HCL/naloxone HCLQL

fluocinolone acetonide ear drops butalbital/aspirin/caffeine/codeine

hydrocortisone/acetic acid butorphanol tartrate

neomycin/polymyxin/hydrocortisone codeine sulfate

neomycin/polymyxin/HC fentanylPA

ofloxacin fentanyl citrate oral transmucosalQL,PA

TIER 03 FORMULARY hydrocodone bitartrate/acetaminophen

Ciprodex hydrocodone/ibuprofen

Coly-mycin S hydromorphone HCL

TIER 04 NON PREFERRED hydromorphone HCL dosette

Cetraxal levorphanol tartrate

Cipro HC meperidine HCL

Cortisporin-tc methadone HCLPA

Otiprio oxycodone/aspirin

oxymorphone hydrochloride

OXYTOCICS oxymorphone hydrochloride ERPA



pentazocine/naloxone HCL

tramadol HCL ER Mobic

TIER 03 FORMULARY Nalfon

Capital/Codeine

SuboxoneQL,PA

TIER 04 NON PREFERRED Rasuvo

AbstralPA Rheumatrex

Conzip SprixPA

Dilaudid-HP

Embeda

ExalgoPA

FentoraPA

KadianQL,PA

LazandaPA

Lortab

Nucynta

Nucynta ERPA TIER 05 SPECIALTY

Opana ER (crush Resistant)PA ActemraPA

Oxaydo Arcalyst

Oxecta EnbrelPA

OxycontinQL,PA Enbrel SureclickPA

Primlev HumiraQL,PA

Roxicet Humira Pediatric Crohns Disease Starter Pack

SubsysPA Humira PenQL,PA

Synalgos-dc Humira Pen-Crohns DiseasestarterQL,PA

Trezix Humira Pen-Psoriasis StarterQL,PA

Zamicet Ilaris

KineretPA

ANTI-INFLAMMATORY OrenciaQL,PA

OtezlaQL,PA

TIER 01 GENERIC

SimponiPA

diclofenac potassium

XeljanzQL,PA

etodolac

Xeljanz XR

etodolac ER

fenoprofen calcium

MIGRAINE PRODUCTS

flurbiprofen

ibuprofen TIER 01 GENERIC

indomethacin almotriptan malate

ketoprofen frovatriptan succinate

ketorolac tromethamine TIER 02 GENERIC

meclofenamate sodium dihydroergotamine mesylate

nabumetone naratriptan HCL

naproxen rizatriptan benzoate

naproxen sodium rizatriptan benzoate ODT

naproxen sodium ER sumatriptan

sulindac sumatriptan succinate

TIER 02 GENERIC sumatriptan succinate refill

diclofenac sodium DR zolmitriptan

diclofenac sodium ER zolmitriptan ODT

diclofenac sodium/misoprostol TIER 03 FORMULARY

indomethacin ER Migral

ketoprofen ER Relpax

leflunomide TIER 04 NON PREFERRED

mefenamic acid AlsumaST

meloxicam Cafergot

oxaprozin Ergomar

piroxicam

tolmetin sodium Imitrex

TIER 03 FORMULARY Migergot

Indocin Sumavel DoseproST

Ridaura TreximetST

TIER 04 NON PREFERRED Zembrace Symtouch

celecoxib Zomig

Zomig Nasal Spray

GOUT AGENTS

TIER 01 GENERIC

IC 400

allopurinol

IC 800

colchicine



TIER 02 GENERIC flunisolide

probenecid fluticasone propionate

probenecid/colchicine ipratropium bromide

TIER 03 FORMULARY triamcinolone acetonide

Colcrys TIER 03 FORMULARY

TIER 04 NON PREFERRED Adrenalin

Mitigare Bactroban Nasal

Uloric

Tyzine

Tyzine Pediatric Nasal Drops


Beconase AQ

Dymista

Omnaris

Qnasl

Qnasl Childrens

Veramyst

Zetonna

COUGH/COLD/ALLERGY

TIER 01 GENERIC

benzonatate

dextromethorphan HBR/chlorpheniramine/phenylephrine HCL

guaifenesin/codeine

hydrocodone bitartrate/chlorpheniramine maleate/PSE

phenylephrine/guaifenesin

promethazine-DM

promethazine/codeine

promethazine/dextromethorphan

promethazine/phenylephrine

TIER 02 GENERIC

acetylcysteine

bromphen/pseudoephedrine HCL/dextromethorphan HBR

hydrocodone bitartrate/homatropine methylbromide

hydrocodone polistirex/chlorpheniramine polistirex

hydrocodone/homatropine

promethazine/phenylephrine/codeine

sodium chloride

TIER 03 FORMULARY

Vituz

RESPIRATORY, ALLERGY, ETC


ANTIHISTAMINES Carbaphen 12

Carbaphen 12 PED

TIER 01 GENERIC

Codar AR

brompheniramine

Codar D

brompheniramine tannate

Cpb Wc

carbinoxamine maleate

Decon-a

cetirizine HCL

Gilphex TR

cyproheptadine HCL

Giltuss PED-c

desloratadine ODT

Giltuss TR

dexchlorpheniramine maleate

Hypersal

diphenhydramine HCL

Lortuss EX

levocetirizine dihydrochloride

M-end PE

promethazine HCL

Mar-cof Bp

promethazine HCL plain

Nebusal

TIER 02 GENERIC

Neotuss Plus

clemastine fumarate

Panatuss Dxp

desloratadine

Pediatex TDM


Pro-clear Ac

Karbinal ER

Relhist

Phenergan Fortis

Rescon-JR

Rescon-MX

NASAL AGENTS

Rezira

TIER 01 GENERIC

Semprex-d

budesonide

Statuss Green

Tricode AR

olopatadine HCL

Tricode GF

TIER 02 GENERIC

azelastine HCL mometasone furoate nasal



Tuzistra XR Zyflo CR

Vanacof CD TIER 05 SPECIALTY

Z-tuss AC XolairPA

ANTIASTHMATIC/COPD AGENTS RESPIRATORY AGENTS - MISC

TIER 01 GENERIC TIER 04 NON PREFERRED

albuterol Curosurf

albuterol sulfate Infasurf

epinephrine HCL

ipratropium bromide TIER 05 SPECIALTY

metaproterenol sulfate EsbrietPA

theophylline CR KalydecoQL,PA

theophylline ER OfevPA

TIER 02 GENERIC OrkambiPA

albuterol sulfate ER Pulmozyme

budesonide

cromolyn sodium VITAMINS

ipratropium bromide/albuterol sulfate

MULTIVITAMINS (Coverage limited to Rx Legend status)

levalbuterol

TIER 02 GENERIC

levalbuterol HCL

b-complex 100

montelukast sodium

TIER 03 FORMULARY

terbutaline sulfate

Mykidz Iron Fl

theophylline


zafirlukast

Atabex EC

TIER 03 FORMULARY

Bal-care DHA

Asmanex HFA

Citranatal Assure

Asmanex Twisthaler 120 Metered Doses

Citranatal B-calm


Citranatal DHA


Citranatal Harmony


Citranatal RX


Citranatal 90 DHA

Atrovent HFA

Concept DHA

Breo ElliptaQL,ST

Concept OB

Combivent Respimat

Crnatal

Dulera

Duet DHA Balanced

Elixophyllin

Duet DHA 400

Foradil Aerolizer

Duet DHA 400EC

Incruse Ellipta

Duet DHA 430

Lufyllin

Duet DHA 430EC

Proair HFA

Escavite

Qvar

Escavite D

Serevent Diskus

Floriva

Spiriva Handihaler

Focalgin CA

Symbicort

Focalgin 90 DHA

Theo-24

Folcaps Omega 3

Ventolin HFA

Folet DHA


Folivane-prx DHA NF

Advair DiskusST

Folivane-OB

Advair HFAST

Gesticare DHA

Alvesco

Marnatal-f

Anoro Ellipta

Mynatal

Arcapta Neohaler

Natachew

Arnuity ElliptaST

Natalvirt CA

Brovana

Natalvirt 90 DHA

DalirespPA

Natalvit

Flovent DiskusST

Natelle One

Flovent HFAST

Neevo DHA

Isuprel

Nestabs

Perforomist

Nestabs Abc

Proair Respiclick

Nestabs DHA

Proventil HFAST

Newgen

Pulmicort FlexhalerST

Nexa Plus

Pulmophylline

Nicomide

Spiriva Respimat

Niva-plus

Stiolto Respimat

O-CAL Fa

Tudorza Pressair

O-CAL Prenatal

Obstetrix DHA

Xopenex HFAST

Ocuvel

Zyflo

OB Complete



OB Complete One

OB Complete Petite

OB Complete Premier

OB Complete 400

OB Complete/DHA

Paire OB

Poly-VI-flor

Poly-VI-flor/Iron

Prefera OB

Prefera OB + DHA

Preferaob +dha

Preferaob One

Prefol-DHA

Prenata

Prenate

Prenate AM

Prenate DHA

Prenate Elite

Prenate Enhance

Prenate Essential

Prenate Mini

Prenate Pixie

Prenate Restore

Prenate Star

Preque 10

Provida OB

R-natal OB

Select-ob+dha

Select-OB

Taron-bc

Taron-c DHA

Texavite LQ

Tri-VI-flor

Tricare Prenatal Compleat

Tricare Prenatal DHA One

Triveen-duo DHA

Triveen-prx RNF

Vemavite-prx 2

Vinacal B

Vinate AZ Extra

Vinate Calcium

Vinate DHA RF

Vita-pren

Vitafol Ultra

Vitafol-nano

Vitafol-ob+dha

Vitafol-one

Vitamedmd One RX/Quatrefolic

Vitamedmd Plus RX/Quatre Folic

Vitamedmd Redichew RX

Vitamedmd Redichew RX/Quatrefolic

Vitapearl

Viva DHA

Zatean-pn

Zatean-pn DHA

Zatean-pn Plus

Zatean-CH

MISCELLANEOUS AGENTS

TIER 01 GENERIC

pentetate calcium trisodium

pentetate zinc trisodium


Chemet

TIER 05 SPECIALTY

Exjade

FerriproxPA



Index

A

almotriptan malate, 20 Appformin, 10

Alocril, 19 Appformin-d, 10

abacavir, 2

alogliptin, 10 apraclonidine, 19

abacavir sulfate/lamivudine/zidovudine, 2

alogliptin/metformin HCL, 10 Apriso, 13

Abilify, 16

alogliptin/pioglitazone, 10 Aptiom, 16

Abilify Discmelt, 16

Alomide, 19 Aptivus, 2

Abilify Maintena, 16

Alora, 9 Aquoral, 15

Abstral, 20

alosetron hydrochloride, 13 Aranesp Albumin Free, 14

acamprosate calcium DR, 17

Alphagan P, 19 Arcalyst, 20

acarbose, 10

alprazolam, 15 Arcapta Neohaler, 22

acebutolol HCL, 4

alprazolam ER, 15 aripiprazole, 16

acetaminophen/caffeine/dihydrocodeine, 19

Alprazolam Intensol, 15 aripiprazole ODT, 15

alprazolam ODT, 15 armodafinil, 16

acetaminophen/codeine, 19

Alrex, 18

acetaminophen/codeine #2, 19

Alsuma, 20 Arixtra, 14


Altabax, 7 Armour Thyroid, 12


Altoprev, 6 arnica flower, 8

acetaminophen/codeine phosphate, 19

Alvesco, 22 Arnuity Ellipta, 22

acetazolamide, 5

amantadine HCL, 17 Artiss, 14

acetazolamide ER, 6

amcinonide, 7 Asacol HD, 13

acetazolamide sodium, 5

amikacin sulfate, 1 Asmanex HFA, 22

acetic acid, 19

amiloride HCL, 6 Asmanex Twisthaler 120 Metered Doses, 22

acetic acid/aluminum acetate, 19

amiloride/hydrochlorothiazide, 6

acetylcysteine, 21

aminocaproic acid, 14 Asmanex Twisthaler 14 Metered Doses, 22

Aciphex Sprinkle, 12

amiodarone HCL, 5

acitretin, 7

Amitiza, 13 Asmanex Twisthaler 30 Metered Doses, 22

Actemra, 20

amitriptyline HCL, 15

Actimmune, 4

amlodipine besylate, 4 Asmanex Twisthaler 60 Metered Doses, 22

Actoplus Met XR, 10

amlodipine besylate/atorvastatin calcium, 6

Asmanex Twisthaler 7 Metered Doses, 22

amlodipine besylate/benazepril HCL, 5

Acuvail, 19

amlodipine besylate/benazepril hydrochloride, 5

aspirin-caffeine-dihydrocodeine, 19

acyclovir, 2, 7

aspirin/dipyridamole, 14

adapalene, 6

amlodipine besylate/valsartan, 5 Astagraf XL, 3

adapalene P.M., 6

amlodipine/valsartan/hctz, 5 Astringyn, 14

Adcirca, 6

amoxapine, 15 Atabex EC, 22

Adderall, 16

amoxicillin, 1 atenolol, 4

Adderall XR, 16

amoxicillin ER, 1 atenolol/chlorthalidone, 5

adefovir dipivoxil, 2

amoxicillin/clavulanate potassium, 1 Atopiclair, 8

Adempas, 6

amoxicillin/clavulanate potassium ER, 1 atorvastatin calcium, 6

Adrenaclick, 6

amphetamine/dextroamphetamine, 16 atovaquone, 3

Adrenalin, 6, 21

amphotericin b, 2 atovaquone/proguanil HCL, 2

Advair Diskus, 22

ampicillin, 1 Atripla, 2

Advair HFA, 22

ampicillin sodium, 1 Atropen, 12

Advicor, 6

ampicillin-sulbactam, 1 atropine sulfate, 12, 18

Adzenys XR-ODT, 16

Ampyra, 17 Atrovent HFA, 22

Afinitor, 4

Amturnide, 5 Aubagio, 17

Afinitor Disperz, 4

Amytal Sodium, 16 augmented betamethasone dipropionate, 7

Aggrenox, 14

Anacaine, 8

Akten, 19

Anadrol-50, 9 Augmentin, 1

Akynzeo, 12

anagrelide hydrochloride, 14

Albenza, 3

albuterol, 22

auryxia, 13

albuterol sulfate, 22

anastrozole, 3 Avandamet, 10

albuterol sulfate ER, 22

Androderm, 9 Avandaryl, 10

alclometasone dipropionate, 7

Androgel 1.62%, 9 Avandia, 10

Aldactazide, 6

Avar, 6

Alecensa, 4

Androxy, 9 Avar LS, 6

alendronate sodium, 10

Angeliq, 9 Avc, 13

Alevicyn Antipruritic SG, 8

Anoro Ellipta, 22 Avenova, 8

alfentanil, 19

antipyrine/benzocaine, 19 Avonex, 17

alfuzosin HCL ER, 13

Anzemet, 12 Avonex Pen, 17

Alinia, 3

Axiron, 9

Alkeran, 3

Apokyn, 17 Azasan, 3

allopurinol, 20

Appbutamone, 15 Azasite, 18

Allzital, 19

azathioprine, 3

HCL/dextromethorphan HBR, 21

azelastine HCL, 19, 21

brompheniramine, 21 Cardura XL, 14

Azilect, 17

brompheniramine tannate, 21 carteolol HCL, 18

azithromycin, 1

Brovana, 22 carvedilol, 4

Azopt, 19

budesonide, 9, 21, 22 cascara sagrada, 12

Azor, 5

bumetanide, 6 Cathflo Activase, 14

aztreonam, 3

Bupap, 19 Cayston, 3

B

Buphenyl, 11 Cedax, 1

bupivacaine HCL, 21 cefaclor, 1

bupivacaine/epinephrine, 21 cefaclor ER, 1

b-complex 100, 22

buprenorphine HCL, 19 cefadroxil, 1

bacitracin, 3, 18

buprenorphine HCL/naloxone HCL, 19 cefazolin sodium, 1

bacitracin/polymyxin b, 18

bupropion HCL, 15 cefdinir, 1

baclofen, 17

bupropion HCL ER, 15 cefditoren pivoxil, 1

Bactroban Nasal, 21

bupropion HCL SR, 15 cefepime, 1

Bal-care DHA, 22

bupropion HCL XL, 15 cefixime, 1

balsalazide disodium, 13

buspirone HCL, 15

Banzel, 16

butalbital/acetaminophen, 19 cefotaxime sodium, 1

Baraclude, 2

butalbital/acetaminophen/caffeine, 19 cefotetan, 1

Beconase AQ, 21

butalbital/acetaminophen/caffeine/codeine, 19

cefoxitin sodium, 1

belladonna & opium, 12

cefpodoxime proxetil, 1

belladonna alkaloids & opium, 12

butalbital/aspirin/caffeine, 19 cefprozil, 1

benazepril HCL, 5

butalbital/aspirin/caffeine/codeine, 19 ceftazidime, 1

benazepril HCL/hydrochlorothiazide, 5

Butisol Sodium, 16 ceftibuten, 1

Benefix, 14

butorphanol tartrate, 19 Ceftin, 1

Benicar, 5

Bydureon, 10 ceftriaxone sodium, 1

Benicar HCT, 5

Byetta, 10 cefuroxime axetil, 1

benzoin compound tincture, 8

Bystolic, 4 cefuroxime sodium, 1

benzoin tincture, 8

C celecoxib, 20

benzonatate, 21

Cellcept, 3

benzoyl peroxide, 6

cabergoline, 11

Celontin, 16

Cafergot, 20

Cenestin, 9

benztropine mesylate, 17

caffeine citrate, 16

centany, 7

Bepreve, 19

caffeine/sodium benzoate, 16

Centany AT, 7

Besivance, 18

calcipotriene, 7

cephalexin, 1

Betadine Ophthalmic Prep, 18

calcipotriene/betamethasone dipropionate, 7

Cerdelga, 14

betamethasone dipropionate, 7

Cervidil, 19

betamethasone sodium phosphate/betamethasone acetate, 9

calcitonin salmon, 11

Cesamet, 12

calcitonin-salmon, 11

cetirizine HCL, 21

betamethasone valerate, 7

calcitriol, 7, 11

Cetraxal, 19

Betaseron, 17

calcium acetate, 13

Cetrotide, 11

betaxolol HCL, 4, 18

Canasa, 13

cevimeline HCL, 14

bethanechol chloride, 13

candesartan cilexetil, 5

Chemet, 23

Bethkis, 1

candesartan cilexetil/hydrochlorothiazide, 5

Chenodal, 13

Betimol, 18

chlordiazepoxide HCL, 15

Betoptic-s, 18

Cantil, 12

chlordiazepoxide HCL/clidinium bromide, 12

bexarotene, 4

Capastat Sulfate, 2

Beyaz, 10

capecitabine, 3

chlordiazepoxide/amitriptyline, 17

bicalutamide, 3

Capex, 8

chlorhexidine gluconate, 14

Bicillin C-R, 1

Caphosol, 15

chlorhexidine gluconate oral rinse, 14

Bicillin L-a, 1

Capital/Codeine, 20

chloroprocaine HCL, 21

Caprelsa, 4

chloroquine phosphate, 2

Biltricide, 3

capsaicin, 8

chlorothiazide, 6

Binosto, 10

captopril, 5

chlorpromazine HCL, 15

bisoprolol fumarate, 4

captopril/hydrochlorothiazide, 5

chlorpropamide, 10

bisoprolol fumarate/hydrochlorothiazide, 5

Carafate, 12

chlorthalidone, 6

Carbaglu, 11

chlorzoxazone, 17

Blephamide, 18

carbamazepine, 16

cholestyramine, 6

Blephamide S.o.p., 18

carbamazepine ER, 16

cholestyramine light, 6

boric acid, 8

Carbaphen 12, 21

choline magnesium trisalicylate, 19

Bosulif, 4

Carbaphen 12 PED, 21

chorionic gonadotropin, 11

Botox, 17

Carbatrol, 16

Cialis, 6

Bravelle, 11

carbidopa, 17

Breo Ellipta, 22

carbidopa/levodopa, 17

ciclopirox, 7

Brilinta, 14

carbidopa/levodopa ER, 17

ciclopirox nail lacquer, 7

brimonidine tartrate, 19

carbidopa/levodopa ODT, 17

ciclopirox olamine, 7

bromfenac, 19

carbidopa/levodopa/entacapone, 17

bromocriptine mesylate, 17

carbinoxamine maleate, 21

Ciferex, 14

bromphen/pseudoephedrine

Cardene SR, 5

cilostazol, 14

Combivent Respimat, 22 Depakote, 16

Ciloxan, 18

Cometriq, 4 Depakote ER, 16

cimetidine, 12

Complera, 2 Depakote Sprinkles, 16

cimetidine HCL, 12

Concept DHA, 22 Depo-estradiol, 9

Cimzia, 13

Concept OB, 22 Depo-medrol, 9

Cimzia Starter Kit, 13

Concerta, 16 Depo-provera, 3

Cipro HC, 19

Condylox, 8

Ciprodex, 19

ciprofloxacin, 1, 19

Conzip, 20 Dermasorb HC, 8

ciprofloxacin ER, 1

Copasil, 8 Dermasorb Ta, 8

ciprofloxacin HCL, 1, 18

desipramine HCL, 15

citalopram hydrobromide, 15

desloratadine, 21

Cordran Tape, 8 desloratadine ODT, 21

Coreg CR, 4 desmopressin acetate, 11

Citranatal 90 DHA, 22

Corlanor, 6 desogestrel/ethinyl estradiol, 9

Citranatal Assure, 22

Cortifoam, 13 Desonate, 8

Citranatal B-calm, 22

cortisone acetate, 9 desonide, 7

Citranatal DHA, 22

Cortisporin, 7 Desowen Cream/Cetaphil Lotion, 8

Citranatal Harmony, 22

Cortisporin-tc, 19 Desowen Lotion/Cetaphil Cream, 8

Citranatal RX, 22

Cosentyx, 7 Desowen Ointment/Cetaphil Lotion, 8

citric acid/sodium citrate, 13

Cosentyx Sensoready Pen, 7 desoximetasone, 7

clarithromycin, 1

Cosopt PF, 18 desvenlafaxine ER, 15

clarithromycin ER, 1

Cotellic, 4 dexamethasone, 9

clemastine fumarate, 21

Cpb Wc, 21 Dexamethasone Intensol, 9

Cleocin, 13

Creon, 13 dexamethasone sodium phosphate, 9, 18

Clever Choice Comfort EZ Patch, 8

Cresemba, 2

Climara Pro, 9

dexchlorpheniramine maleate, 21

clindamycin HCL, 3

Crinone, 13 Dexedrine, 16

clindamycin palmitate HCL, 3

Crixivan, 2 dexmethylphenidate HCL, 16

clindamycin phosphate, 3, 6, 13

Crnatal, 22 dexmethylphenidate HCL ER, 16

cromolyn sodium, 13, 19, 22

Curosurf, 22

clindamycin/benzoyl peroxide, 6

Cuvposa, 12

Clindesse, 13

cyanocobalamin, 14 dexpanthenol, 13

Clinoin, 6

dextroamphetamine sulfate, 16

clobetasol propionate, 7

cyclobenzaprine HCL, 17 dextroamphetamine sulfate ER, 16

clobetasol propionate emollient, 7

dextromethorphan HBR/chlorpheniramine/phenylephrine HCL, 21

clocortolone pivalate, 7

Cyclomydril, 18

clocortolone pivalate P.M., 7

cyclopentolate HCL, 18

Cloderm, 8

cyclopentolate hydrochloride, 18

Diabeta, 10

Cloderm P.M., 8

cyclophosphamide, 3

diazepam, 15, 16

clomiphene citrate, 11

cycloserine, 2

diclofenac potassium, 20 diclofenac sodium, 19

clomipramine HCL, 15

cyclosporine, 3

diclofenac sodium gel, 7

clonazepam, 16

cyclosporine modified, 3

diclofenac sodium DR, 20

clonazepam ODT, 16

cyproheptadine HCL, 21

diclofenac sodium ER, 20

clonidine HCL, 5

Cystadane, 11

diclofenac sodium/misoprostol, 20

clopidogrel, 14

Cystagon, 14

dicloxacillin sodium, 1

clorazepate dipotassium, 15

Cystaran, 19

dicyclomine hci, 12

Clorpres, 5

Cytomel, 12

dicyclomine HCL, 12

clotrimazole, 14

D

didanosine, 2

clotrimazole/betamethasone dipropionate, 7

Dificid, 1

Daklinza, 2

diflorasone diacetate, 8

Daliresp, 22

clozapine, 15

diflunisal, 19

danazol, 9

clozapine ODT, 15

digoxin, 4

dantrolene sodium, 17

coal TAR, 8

dihydroergotamine mesylate, 20

dapsone, 3

Coartem, 2

Dilantin, 16

Daraprim, 2

cocaine HCL, 8

Dilantin Infatabs, 16

darifenacin ER, 13

Codar AR, 21

Dilantin-125, 16

darifenacin hydrobromide ER, 13

Codar D, 21

Dilatrate SR, 4

Daytrana, 16

codeine sulfate, 19

Dilaudid-HP, 20

Debacterol, 15

colchicine, 20

diltiazem CD, 4

Decon-a, 21

Colcrys, 21

diltiazem HCL, 4

Delestrogen, 9

colestipol HCL, 6

diltiazem HCL ER, 5

Delzicol, 13

colistimethate sodium, 3

dimenhydrinate, 12

Coly-mycin S, 19

Dipentum, 13

demeclocycline HCL, 1

Colyte-flavor Packs, 12

diphenhydramine HCL, 21

Demser, 5

Combigan, 18

diphenoxylate/atropine, 12

Denavir, 7

Combipatch, 9

dipyridamole, 14

Depakene, 16

disopyramide phosphate, 5

Emadine, 19 ethyl chloride/medium stream, 8

disulfiram, 17

Embeda, 20 ethyl chloride/mist, 8

Diuril, 6

Emcyt, 3 etidronate disodium, 10

divalproex sodium, 16

Emend, 12 etodolac, 20

divalproex sodium DR, 16

Emsam, 15 etodolac ER, 20

divalproex sodium ER, 16

Emtriva, 2 etoposide, 4

Divigel, 9

Emulsion SB, 8 Eurax, 8

donepezil HCL, 17

Emverm, 3 Evamist, 9

Doral, 16

enalapril maleate, 5 Evicel, 14

dorzolamide HCL, 19

enalapril maleate/hydrochlorothiazide, 5 Evithrom, 14

dorzolamide HCL/timolol maleate, 18

Enbrel, 20 Evotaz, 2

doxazosin, 5

Enbrel Sureclick, 20 Exalgo, 20

doxazosin mesylate, 5

Endometrin, 13 Exelderm, 7

doxepin HCL, 15

Enjuvia, 9 exemestane, 3

doxepin hydrochloride, 7

Enlon, 18 Exjade, 23

doxercalciferol, 11

enoxaparin sodium, 14

doxycycline, 1, 7

Enstilar, 8 Extavia, 17

doxycycline hyclate, 1

entacapone, 17 F

doxycycline hyclate DR, 1

entecavir, 2

Fabior, 6

doxycycline monohydrate, 1

Entereg, 13

Factive, 1

dronabinol, 12

Entresto, 6

Falessa, 10

droperidol, 15

Epaned, 5

famciclovir, 2

drospirenone/ethinyl estradiol, 9

ephedrine sulfate, 6

famotidine, 12

Droxia, 14

Epiceram, 8

Fanapt, 16

Duavee, 9

Epiduo Forte, 6

Duet DHA 400, 22

Epifoam, 8

Fareston, 3

Duet DHA 400EC, 22

epinastine HCL, 19

Farxiga, 10

Duet DHA 430, 22

epinephrine, 6

Farydak, 4

Duet DHA 430EC, 22

epinephrine HCL, 22

Fazaclo, 16

Duet DHA Balanced, 22

Epipen 2-PAK, 6

felbamate, 16

Dulera, 22

Epipen-JR 2-PAK, 6

Felbatol, 16

duloxetine HCL, 15

Epivir HBV, 2

felodipine ER, 5

eplerenone, 5

Femring, 13

Epogen, 14

fenofibrate, 6

eprosartan mesylate, 5

fenofibrate micronized, 6

Epzicom, 2

fenofibric acid DR, 6

Equagesic, 19

Fenoglide, 6

Equetro, 15

fenoprofen calcium, 20

ergoloid mesylates, 17

fentanyl, 19

Ergomar, 20

fentanyl citrate oral transmucosal, 19

Durezol, 18

Ery-TAB, 1

Fentora, 20

dutasteride, 13

Eryped 200, 1

Feriva 21/7, 14

dutasteride/tamsulosin hydrochloride, 13

Eryped 400, 1

Ferriprox, 23

Dutoprol, 5

Erythrocin Stearate, 1

Fetzima, 15

Dyanavel XR, 16

erythromycin, 1, 6, 18

Finacea, 7

Dymista, 21

erythromycin base, 1

finasteride, 13

Dyrenium, 6

erythromycin ethylsuccinate, 1

Firazyr, 14

Dysport, 17

erythromycin/benzoyl peroxide, 6

Firmagon, 3

Dyural-l, 9

Esbriet, 22

E

Escavite, 22

Escavite D, 22

E.E.S. Granules, 1

escitalopram oxalate, 15

econazole nitrate, 7

estazolam, 16

Ecoza, 7

Estrace, 13

Edarbi, 5

estradiol, 9

Edarbyclor, 5

estradiol valerate, 9

Edecrin, 6

estradiol/norethindrone acetate, 9

Edurant, 2

Estrasorb, 9

Effient, 14

Estring, 13

Elestrin, 9

Estrogel, 9

Eletone, 8

Flagyl ER, 3

estropipate, 9

Eletone Twinpack, 8

eszopiclone, 16

Elidel, 8

Flarex, 18

ethambutol HCL, 2

Eligard, 3

flavoxate HCL, 13

ethosuximide, 16

flecainide acetate, 5

ethyl chloride, 8

Eliquis, 14

Flector, 7

ethyl chloride/fine pinpoint, 8

Elixophyllin, 22

FLO-pred, 9

ethyl chloride/fine stream, 8

Ella, 10

Floriva, 22

ethyl chloride/medium jet stream, 8

Elmiron, 14

Flovent Diskus, 22

Flovent HFA, 22

homatropine HBR, 18

fluconazole, 2

Gelclair, 15

flucytosine, 2

Gelnique, 13

fludrocortisone acetate, 9

gemfibrozil, 6

flunisolide, 21

Genotropin, 11 Humulin N, R all forms, 10

fluocinolone acetonide, 8, 19

Genotropin Miniquick, 11 Humalog, 10

fluocinolone acetonide ear drops, 19

gentamicin sulfate, 1, 7, 18 Humalog Kwikpen, 10

fluocinonide, 7

gentamicin sulfate pediatric, 1 Humalog Mix 50/50, 10

fluocinonide-e, 7

Genvoya, 2 Humalog Mix 50/50 Kwikpen, 10

fluorometholone, 18

Geodon, 16 Humalog Mix 75/25, 10

fluoxetine, 17

Gesticare DHA, 22 Humalog Mix 75/25 Kwikpen, 10

fluoxetine DR, 15

Giazo, 13 Humatrope, 11

fluoxetine HCL, 15

Gilenya, 17 Humatrope Combo Pack, 11

fluphenazine decanoate, 15

Gilotrif, 4 Humira, 20

fluphenazine HCL, 15

Gilphex TR, 21 Humira Pediatric Crohns Disease Starter Pack, 20

flurazepam HCL, 16

Giltuss PED-c, 21

flurbiprofen, 20

Giltuss TR, 21 Humira Pen, 20

flurbiprofen sodium, 19

glatiramer acetate 20mg/ml, 17 Humira Pen-crohns Diseasestarter, 20

flutamide, 3

Gleostine, 3 Humira Pen-psoriasis Starter, 20

fluticasone propionate, 7, 21

glimepiride, 10 Humulin R U-500 (concentrated), 10

fluvastatin, 6

glipizide, 10 Humulin R U-500 Kwikpen, 10

fluvastatin sodium ER, 6

glipizide ER, 10 Hycamtin, 4

fluvoxamine maleate, 15

glipizide/metformin HCL, 10 hydralazine HCL, 5

fluvoxamine maleate ER, 15

Glucagen Hypokit, 10 hydrochlorothiazide, 6

FML, 18

Glucagon Emergency Kit, 10 hydrocodone bitartrate/acetaminophen, 19

FML Forte, 18

glyburide, 10

Focalgin 90 DHA, 22

glyburide micronized, 10 hydrocodone bitartrate/chlorpheniramine maleate/PSE, 21

Focalgin CA, 22

glyburide/metformin HCL, 10

Focalin, 16

glycolic acid, 7 hydrocodone bitartrate/homatropine methylbromide, 21

Focalin XR, 16

glycolic acid 70% high purity, 7

Folcaps Omega 3, 22

glycopyrrolate, 12 hydrocodone polistirex/chlorpheniramine polistirex, 21

Folet DHA, 22

folic acid, 14

Golytely, 12 hydrocodone/acetaminophen, 19

Folivane-OB, 22

Gonal-f, 11 hydrocodone/homatropine, 21

Folivane-PRX DHA NF, 22

Gonal-f RFF, 11 hydrocodone/ibuprofen, 19

Follistim AQ, 11

Gonal-f RFF Pen, 11 hydrocortisone tabs, 7, 9, 13

fondaparinux sodium, 14

Gonal-f RFF Rediject, 11 hydrocortisone acetate/aloe, 8

Foradil Aerolizer, 22

Gordofilm, 8 hydrocortisone acetate/lidocaine HCL, 13

Gordons Urea, 8 hydrocortisone acetate/pramoxine, 13

Fortaz, 1

granisetron HCL, 12 hydrocortisone butyrate, 8

Forteo, 11

Granisol, 12 hydrocortisone butyrate (lipid), 8

Fortesta, 9

Granix, 14 hydrocortisone butyrate (lipophilic), 8

fortical, 11

griseofulvin microsize, 2 hydrocortisone IN absorbase, 7

Fosamax Plus D, 11

griseofulvin ultramicrosize, 2 hydrocortisone valerate, 8

fosinopril sodium, 5

guaifenesin/codeine, 21 hydrocortisone/acetic acid, 19

fosinopril sodium/hydrochlorothiazide, 5

guanfacine ER, 16 hydromorphone HCL, 19

Fosrenol, 13

guanfacine HCL, 5 hydromorphone HCL dosette, 19

Fragmin, 14

guanidine HCL, 18 hydromorphone HCL ER, 19

Gynazole-1, 13 hydroxocobalamin, 14

frovatriptan succinate, 20

H hydroxychloroquine sulfate, 2

Fulyzaq, 12

hydroxyurea, 4

furosemide, 6

hydroxyzine HCL, 15

halobetasol propionate, 7

Fuzeon, 2

hydroxyzine pamoate, 15

Halog, 8

Fycompa, 16

Hylatopic, 8

Halonate, 8

G

Hylatopic Plus, 8

haloperidol, 15

hyoscyamine sulfate, 12

gabapentin, 16

haloperidol decanoate, 15

hyoscyamine sulfate ER, 12

haloperidol lactate, 15

hyoscyamine sulfate ODT, 12

Halotin, 7

hyoscyamine sulfate SR, 12

Harvoni, 2

Hypersal, 21

Helixate FS, 14

Hypertenevide-12.5, 4

Gabitidine, 12

Hemabate, 19

Hypertenipine-2.5, 5

Gabitril, 16

heparin sodium, 14

Hypertensolol, 5

Gaboxetine, 15

I

galantamine hydrobromide, 17

ganirelix acetate, 11

ibandronate sodium, 10

gatifloxacin, 18

Ibrance, 4

Gattex, 13

ibuprofen, 20

Hexalen, 3

IC 400, 20

Karbinal ER, 21 letrozole, 3

IC 800, 20

Kazano, 10 leucovorin calcium, 4

Iclusig, 4

Keppra, 16 Leukeran, 3

Ilaris, 20

Keppra XR, 16 leuprolide acetate, 3

Ilevro, 19

Kerafoam, 8 Levacet, 19

imatinib mesylate, 4

Kerafoam 42, 8 levalbuterol, 22

Imbruvica, 4

Keralyt Scalp, 8 levalbuterol HCL, 22

imipramine HCL, 15

Ketek, 3 Levatol, 4

imipramine pamoate, 15

ketoconazole, 2, 7 Levemir, 10

imiquimod, 8

Levemir Flexpen, 10

Imitrex, 20

ketoprofen, 20 Levemir Flextouch, 10

Imuran, 3

ketoprofen ER, 20 levetiracetam, 16

Increlex, 11

ketorolac tromethamine, 19, 20 levetiracetam ER, 16

Incruse Ellipta, 22

Khedezla, 15 Levitra, 6

indapamide, 6

Kineret, 20 levobunolol HCL, 18

Inderal XL, 4

Kinlytic, 14 levocarnitine, 11

Indocin, 20

levocetirizine dihydrochloride, 21

indomethacin, 20

Kogenate FS, 14 levofloxacin, 1, 18

indomethacin ER, 20

Kogenate FS Bio-set, 14 levonorgestrel, 9

Infasurf, 22

Kombiglyze XR, 10 levonorgestrel and ethinyl estradiol, 9

Inlyta, 4

Korlym, 10 levonorgestrel/ethinyl estradiol, 9

Innopran XL, 4

Kovaltry, 14 levorphanol tartrate, 19

Intelence, 2

Kristalose, 12 levothyroxine sodium, 12

Intron A, 4

Kuvan, 11 levothyroxine sodium TAB 0.075MG, 12

Intron A W/Diluent, 4

Kynamro, 6 Levsin, 12

Invanz, 3

L Lexiva, 2

Invega Sustenna, 16

Lialda, 13

labetalol HCL, 4

Invega Trinza, 16

Lido-RX 4.1, 8

Lacrisert, 18

Invirase, 2

lidocaine, 8

lactic acid, 8

Invokamet, 10

lidocaine and tetracaine cream, 8

lactic acid e, 8

Invokana, 10

lidocaine HCL, 8, 14, 21

lactic acid w/vitamin e, 8

Iopidine, 19

lidocaine HCL jelly, 8

lactulose, 12, 13

ipratropium bromide, 21, 22

lidocaine HCL viscous, 14

Lamictal, 17

ipratropium bromide/albuterol sulfate, 22

lidocaine HCL-hydrocortisone acetate with aloe, 13

Lamictal Chewable Dispersible, 17

Iprivask, 14

Lamictal ODT, 16

irbesartan, 5

lidocaine HCL/hydrocortisone acetate, 13

irbesartan/hydrochlorothiazide, 5

lidocaine viscous, 14

Iressa, 4

lidocaine-prilocaine-cream base, 8

Isentress, 2

lidocaine/epinephrine, 21

isoniazid, 2

lidocaine/prilocaine, 8

Isopto Carbachol, 18

Isopto Homatropine, 18

lincomycin HCL, 3

Lamictal XR, 17

Isopto Hyoscine, 18

lincomycin/lidocaine, 3

Lamisil, 2

isosorbide dinitrate, 4

lindane, 8

Lamisil Spray, 7

isosorbide dinitrate ER, 4

linezolid, 3

lamivudine, 2

isosorbide mononitrate, 4

Linzess, 13

lamivudine/zidovudine, 2

isosorbide mononitrate ER, 4

liothyronine sodium, 12

lamotrigine, 16

isradipine, 5

lisinopril, 5

lamotrigine ER, 16

Isuprel, 22

lisinopril/hydrochlorothiazide, 5

lamotrigine ODT, 16

itraconazole, 2

lithium, 15

lamotrigine titration, 16

IV Infusion Cpi, 8

lithium carbonate, 15

ivermectin, 3

lithium carbonate ER, 15

Ixinity, 14

Lithostat, 14

J

Livalo, 6

lansoprazole, 12

LO Loestrin FE, 10

Jakafi, 4

lansoprazole/amoxicillin/clarithromycin, 12

Locoid, 8

Janumet, 10

lomustine, 3

Janumet XR, 10

Lantus, 10

Lonsurf, 4

Januvia, 10

Lantus Solostar, 10

lorazepam, 15

Jardiance, 10

Lastacaft, 19

Lortab, 20

Jentadueto, 10

latanoprost, 18

Lortuss EX, 21

Juxtapid, 6

Latuda, 16

K

Lazanda, 20

Lorzone, 18

leflunomide, 20

losartan potassium, 5

K-phos NO 2, 14

Lenvima 10MG Daily Dose, 4

losartan potassium/hydrochlorothiazide, 5

Kadian, 20


Kalbitor, 14


Lotemax, 18

Kaletra, 2


lovastatin, 6

Kalydeco, 22

Letairis, 6

loxapine, 15

methyldopa, 5 Motofen, 12

loxapine succinate, 15

methyldopa/hydrochlorothiazide, 5 Movantik, 13

Lufyllin, 22

methylergonovine maleate, 19 Moviprep, 12

Lumigan, 18

Methylin, 16 Moxatag, 1

Lupaneta Pack, 11

methylphenidate HCL, 16 Moxeza, 18

Lupron Depot, 3

methylphenidate HCL CD, 16 moxifloxacin HCL, 1

Lupron Depot-PED, 11

methylphenidate HCL ER, 16 Mozobil, 14

Luzu, 7

methylphenidate HCL SR, 16 Multaq, 5

Lycelle, 8

methylphenidate hydrochloride, 16 mupirocin, 7

Lynparza, 4

methylprednisolone, 9 mupirocin calcium, 7

Lyrica, 17

methylprednisolone acetate, 9 Muse, 6

Lysodren, 3

methylprednisolone dose pack, 9 mycophenolate mofetil, 3

methylprednisolone PF, 9 mycophenolic acid DR, 3

methylprednisolone sodiumsuccinate, 9 Mykidz Iron Fl, 22

M

methyltestosterone, 9 Myleran, 3

metipranolol, 18 Mynatal, 22

M-end PE, 21

metoclopramide HCL, 13 Myobloc, 17

Makena, 10

metoclopramide ODT, 13 Myrbetriq, 13

malathion, 8

metolazone, 6 Mysoline, 17

maprotiline HCL, 15

metoprolol succinate ER, 4 N

Mar-cof Bp, 21

metoprolol tartrate, 4

Marnatal-f, 22

nabumetone, 20

metoprolol/hydrochlorothiazide, 5

Marplan, 15

nadolol, 4

metronidazole, 3, 7

Matulane, 4

nadolol/bendroflumethiazide, 5

metronidazole vaginal, 13

Maxidex, 18

nafcillin sodium, 1

mexiletine HCL, 5

Nafrinse Daily/Acidulated, 15

Miacalcin, 11

Mb Hydrogel, 8

Nafrinse Daily/Neutral, 15

midodrine HCL, 6

meclofenamate sodium, 20

Nafrinse Weekly, 15

Mifeprex, 11

Medi-derm/L-RX, 8

naftifine HCL, 7

Migergot, 20

Medrol, 9

naftifine hydrochloride, 7

Migral, 20

medroxyprogesterone acetate, 10

Millipred, 9

medroxyprogesterone/lidocaine, 10

nalbuphine HCL, 19

Millipred DP, 9

mefenamic acid, 20

Nalfon, 20

Minastrin 24 FE, 10

mefloquine HCL, 2

Namenda XR, 17

mineral oil heavy, 12

megestrol acetate, 3, 10

Minivelle, 9

Megrix, 8

Namzaric, 17

minocycline HCL, 1

Mekinist, 4

naphazoline HCL, 18

minocycline HCL ER, 1

meloxicam, 20

naproxen, 20

minoxidil, 5

Mirapex ER, 17

memantine HCL, 17

naproxen sodium, 20

Mircera, 14

naproxen sodium ER, 20

mirtazapine, 15

memantine hydrochloride, 17

naratriptan HCL, 20

mirtazapine ODT, 15

Menest, 9

Nascobal, 14

misoprostol, 12

Menopur, 11

Mitigare, 21

Menostar, 9

Natachew, 22

Mitosol, 18

Mentax, 7

Natacyn, 18

meperidine HCL, 19

Natalvirt 90 DHA, 22

Mobic, 20

meprobamate, 15

Natalvirt CA, 22

modafinil, 16

mercaptopurine, 3

Natalvit, 22

Moderiba, 2

mesalamine, 13

Natazia, 10

Mesnex, 4

nateglinide, 10

Natelle One, 22

moexipril HCL, 5

Metadate CD, 16

Nature-throid, 12

moexipril/hydrochlorothiazide, 5

metaproterenol sulfate, 22

Nature-throid Nt-2.5, 12

molindone hydrochloride, 15

metaxalone, 17

Nebupent, 3

mometasone furoate, 7, 21

metformin HCL, 10

Nebusal, 21

metformin HCL ER, 10

Neevo DHA, 22

methadone HCL, 19

nefazodone HCL, 15

methamphetamine HCL, 16

Nembutal Sodium, 16

methazolamide, 6

Neo-synalar, 7

methenamine hippurate, 13

neomycin sulfate, 1

methenamine mandelate, 13

neomycin/bacitracin/polymyxin, 18

methimazole, 12

neomycin/polymyxin/bacitracin zinc, 18

methocarbamol, 17

neomycin/polymyxin/bacitracin/hydrocortisone, 18

montelukast sodium, 22

methotrexate, 3

Monurol, 13

methotrexate sodium, 3

neomycin/polymyxin/dexamethasone, 18

morphine sulfate, 19

methoxsalen, 7

neomycin/polymyxin/gramicidin, 18

morphine sulfate ER, 19

methscopolamine bromide, 12

neomycin/polymyxin/HC, 19

methyclothiazide, 6

neomycin/polymyxin/hydrocortisone, 18,

19

Noxafil, 2 oxacillin sodium, 1

Neoral, 3

Nplate, 14 oxandrolone, 9

Neosalus, 8

Nucynta, 20 oxaprozin, 20

Neosalus CP, 8

Nucynta ER, 20 Oxaydo, 20

neostigmine methylsulfate, 18

Nuedexta, 17 oxazepam, 15

Neotuss Plus, 21

Nutropin AQ Nuspin 10, 11 oxcarbazepine, 16

Nesacaine, 21

Nutropin AQ Nuspin 20, 11 Oxecta, 20

Nesina, 10

Nutropin AQ Nuspin 5, 11 oxiconazole nitrate, 7

Nestabs, 22

Nutropin AQ Pen, 11

Nestabs Abc, 22

Nuvail, 8 Oxtellar XR, 17

Nestabs DHA, 22

oxybutynin chloride, 13

Neulasta, 14

Nuwiq, 14 oxybutynin chloride ER, 13

Nymalize, 5 oxycodone HCL, 19

Neumega, 14

nystatin, 2, 7, 14 oxycodone HCL ER, 19

Neupogen, 14

nystatin/triamcinolone, 7 oxycodone/acetaminophen, 19

Neupro, 17

O oxycodone/aspirin, 19

Neutrasal, 15

oxycodone/ibuprofen, 19

O-CAL Fa, 22

Neuvaxin, 8

Oxycontin, 20

O-CAL Prenatal, 22

Nevanac, 19

oxymorphone hydrochloride, 19

OB Complete, 22

nevirapine, 2

oxymorphone hydrochloride ER, 19

OB Complete 400, 23

nevirapine ER, 2

oxytocin, 19

OB Complete One, 23

Newgen, 22

P

OB Complete Petite, 23

Nexa Plus, 22

OB Complete Premier, 23 Paire OB, 23

Nexavar, 4

OB Complete/DHA, 23 paliperidone ER, 15

niacin ER, 6

Obstetrix DHA, 22 Pamine FQ, 12

nicardipine HCL, 4

octreotide acetate, 11 Panatuss Dxp, 21

Nicomide, 22

Ocudox, 1 Pancreaze, 13

nifedipine, 5

Ocuvel, 22 pancrelipase, 12

nifedipine ER, 5

Odefsey, 2 Pandel, 8

Nilandron, 3

Ofev, 22 pantoprazole sodium, 12

nimodipine, 5

ofloxacin, 1, 18, 19 papaverine HCL, 6

Ninlaro, 4

olanzapine, 15 paregoric, 12

nisoldipine, 5

olanzapine ODT, 15 paricalcitol, 11

nisoldipine ER, 5

olanzapine/fluoxetine, 17

Nitro-bid, 4

Oleptro, 15 paromomycin sulfate, 1

Nitro-dur, 4

olopatadine HCL, 19, 21 paroxetine HCL, 15

nitrofurantoin, 13

paroxetine HCL ER, 15

nitrofurantoin macrocrystals, 13

omega-3-acid ethyl esters, 6 Paser, 2

nitrofurantoin monohydrate, 13

omeprazole, 12 Pataday, 19

nitrofurantoin monohydrate/macrocrystals, 13

omeprazole/sodium bicarbonate, 12 Paxil Susp, 15

Omnaris, 21 PCE, 1

nitroglycerin ER, 4

Omnitrope, 11

nitroglycerin lingual, 4

Omontys, 14 Pediaderm HC, 8

nitroglycerin transdermal, 4

ondansetron HCL, 12 Pediaderm TA, 8

Nitromist, 4

ondansetron ODT, 12 Pediatex TDM, 21

Nitrostat, 4

One Touch Test Strips, 10 peg 3350/electrolytes, 12

Niva-plus, 22

Onfi, 17 peg-3350/electrolytes, 12

Nivatopic Plus, 8

Onglyza, 10 peg-3350/NACL/NA bicarbonate/KCL, 12

nizatidine, 12

Opana ER (crush Resistant), 20 Peg-intron, 2

Norditropin Cartridge, 11

opium, 12 Peg-intron Redipen, 2

Norditropin Flexpro, 11

opium tincture, 12

Norditropin Nordiflex Pen, 11

Oracit, 14 Peganone, 17

norethindrone, 9

Orapred ODT, 9 Pegasys, 2

norethindrone & ethinyl estradiol ferrous fumarate, 9

Oravig, 15 Pegasys Proclick, 2

Orencia, 20 Pegintron, 2

norethindrone acetate, 10

Orenitram, 6 penicillin G potassium, 1

norethindrone acetate/ethinyl estradiol, 9(2)

Orfadin, 11 penicillin G procaine, 1

Orkambi, 22 penicillin G sodium, 1

norethindrone acetate/ethinyl estradiol/ferrous fumarate, 9

orphenadrine citrate, 17 penicillin v potassium, 1

orphenadrine citrate ER, 17 Pennsaid, 7

norgestimate/ethinyl estradiol, 9

orphenadrine/asa/caffeine, 17 Pentam 300, 3

Norinyl 1+50, 10

Oseni, 10 Pentasa, 13

Noroxin, 1

Osmoprep, 12 pentazocine/naloxone HCL, 20

Norpace CR, 5

Osphena, 11 pentetate calcium trisodium, 23

Northera, 6

Otezla, 20 pentetate zinc trisodium, 23

nortriptyline HCL, 15

Otiprio, 19 pentoxifylline ER, 14

Norvir, 2

Ovace Plus, 7 Perforomist, 22

Novoeight, 14

Ovidrel, 11 perindopril erbumine, 5

permethrin, 8

Prefol-DHA, 23 propranolol/hydrochlorothiazide, 5

perphenazine, 15

Premarin, 9, 13 propylthiouracil, 12

perphenazine/amitriptyline, 17

Premphase, 9 Prostin E2, 19

Pertzye, 13

Prempro, 9 Protonix, 12

Pexeva, 15

Prenata, 23 protriptyline HCL, 15

phenazopyridine HCL, 13

Prenate, 23 Proventil HFA, 22

phenelzine sulfate, 15

Prenate AM, 23 Provida OB, 23

Phenergan Fortis, 21

Prenate DHA, 23 Pruclair, 9

phenobarbital, 16

Prenate Elite, 23 Prudoxin, 7

phenobarbital sodium, 16

Prenate Enhance, 23 Prumyx, 9

phenoxybenzamine hydrochloride, 5

Prenate Essential, 23 Pulmicort Flexhaler, 22

phentolamine mesylate, 5

Prenate Mini, 23 Pulmophylline, 22

phenylephrine HCL, 6, 18

Prenate Pixie, 23 Pulmozyme, 22

phenylephrine/guaifenesin, 21

Prenate Restore, 23 Purixan, 3

Phenytek, 17

Prenate Star, 23 Pylera, 12

phenytoin, 16

Prepidil, 19 pyrazinamide, 2

phenytoin sodium, 16

Prepopik, 12 pyridostigmine bromide, 18

phenytoin sodium extended, 16

Preque 10, 23 pyrogallic acid, 8

Phoslyra, 13

Presera, 8 Q

Phospholine Iodide, 18

Prevacid Solutab, 12

Qnasl, 21

pilocarpine HCL, 14, 18

Qnasl Childrens, 21

pilocarpine hydrochloride, 14

Prezcobix, 2

Quartette, 10

pimozide, 17

Prezista, 2

quazepam, 16

pindolol, 4

Priftin, 2

Quelicin 1000, 17

pioglitazone HCL, 10

primaquine phosphate, 2

quetiapine fumarate, 15

pioglitazone HCL-glimepiride, 10

primidone, 16

Quillivant XR, 16

pioglitazone HCL/metformin HCL, 10

Primlev, 20

quinapril HCL, 5

piroxicam, 20

Primsol, 3

quinapril/hydrochlorothiazide, 5

Plegridy, 17

Pristiq, 15

quinidine gluconate, 5

quinidine gluconate CR, 5

Pliaglis, 8

quinidine gluconate ER, 5

podofilox, 8

quinidine sulfate, 5

Poly-VI-flor, 23

quinidine sulfate ER, 5

Poly-VI-flor/Iron, 23

Pro-clear Ac, 21

quinine sulfate, 2

polyethylene glycol 3350, 12

Proair HFA, 22

Qutenza, 9

polymyxin b sulfate, 3

Proair Respiclick, 22

Qvar, 22

polymyxin b sulfate/trimethoprim sulfate, 18

probenecid, 21

R

probenecid/colchicine, 21

Pomalyst, 3

procainamide HCL, 5

R-natal OB, 23

potassium citrate ER, 13

Procentra, 16

rabeprazole sodium, 12

potassium citrate-citric acid crystals, 14

prochlorperazine, 15

raloxifene hydrochloride, 11

potassium citrate/citric acid, 14

prochlorperazine edisylate, 15

ramipril, 5

potassium citrate/sodium citrate/citric acid, 13

prochlorperazine maleate, 15

Ranexa, 4

Procort, 13

ranitidine HCL, 12

Potiga, 17

Procrit, 14

Rapaflo, 14

PR Cream, 8

Rapamune, 3

Pradaxa, 14

Procysbi, 14

Rasuvo, 20

pramipexole dihydrochloride, 17

progesterone, 10

Ravicti, 11

pramipexole dihydrochloride ER, 17

Prograf, 3

pravastatin sodium, 6

Prolensa, 19

Prazolamine, 17

Prolia, 11

prazosin HCL, 5

Promacta, 14

Rebetol, 2

Pred Mild, 18

promethazine HCL, 21

Rebif, 17

Pred-G, 18

promethazine HCL plain, 21

Rebif Rebidose, 17

Pred-G S.o.p., 18

promethazine-DM, 21

prednicarbate, 8

promethazine/codeine, 21

prednisolone, 9

promethazine/dextromethorphan, 21

Recombinate, 14

prednisolone acetate, 18

promethazine/phenylephrine, 21

Recothrom, 14

prednisolone sodium phosphate, 9, 18

promethazine/phenylephrine/codeine, 21

prednisolone sodium phosphate ODT, 9

Promiseb, 7

Rectiv, 13

prednisone, 9

Promiseb Complete, 7

Recura, 7

Prednisone Intensol, 9

propafenone HCL, 5

Relagard, 13

Prefera OB, 23

propafenone HCL ER, 5

Relenza Diskhaler, 2

Prefera OB + DHA, 23

propantheline bromide, 12

Relhist, 21

Preferaob +dha, 23

proparacaine HCL, 19

Relistor, 13

Preferaob One, 23

propranolol HCL, 4

Relpax, 20

Prefest, 9

propranolol HCL ER, 4

Relyyt, 9

Remodulin, 6

Scalacort DK, 8 spinosad, 8

Renagel, 13

scopolamine hydrobromide, 12 Spiriva Handihaler, 22

Renvela, 13

Select-OB, 23 Spiriva Respimat, 22

repaglinide, 10

Select-ob+dha, 23 spironolactone, 6

repaglinide/metformin hydrochloride, 10

selegiline HCL, 17 spironolactone/hydrochlorothiazide, 6

Repronex, 11

selenium sulfide, 7 Sporanox, 2

Rescon-JR, 21

Selrx, 7 Spritam, 17

Rescon-MX, 21

Selzentry, 2 Sprix, 20

Rescriptor, 2

Semprex-d, 21 Sprycel, 4

Rescula, 18

senna plus, 12 Stalevo 100, 17

reserpine, 5

Sensipar, 11 Stalevo 125, 17

Restora RX, 12

Sensorcaine-mpf/Epinephrine, 21 Stalevo 150, 17

Revlimid, 3

Stalevo 200, 17

Reyataz, 2

Stalevo 50, 17

Rezira, 21

Stalevo 75, 17

Rezyst IM, 12

stannous fluoride oral rinse, 14

Rezyst SB, 12

Statuss Green, 21

Rheumatrex, 20

stavudine, 2

Ribasphere Ribapak, 2

Stavzor, 16

ribavirin, 2

Sentroxatine, 15 Staxyn, 6

Ridaura, 20

Serevent Diskus, 22 Stelara, 7

rifabutin, 2

Seroquel XR, 15 Stimate, 11

Rifamate, 2

Serostim, 11 Stiolto Respimat, 22

rifampin, 2

sertraline HCL, 15 Stivarga, 4

Rifater, 2

sevelamer carbonate, 13 Strattera, 16

riluzole, 17

Sfrowasa, 13 Strazepam, 16

rimantadine HCL, 2

Signifor, 11 streptomycin sulfate, 1

Rimantalist, 2

Signifor LAR, 11 Striant, 9

Riomet, 10

sildenafil, 6 Stribild, 2

risedronate sodium, 10

sildenafil citrate, 6 Suboxone, 20

risedronate sodium DR, 10

Simbrinza, 19 Subsys, 20

Risperdal Consta, 15

Simcor, 6 Suclear, 12

risperidone, 15

Simponi, 20 Sucraid, 13

risperidone ODT, 15

simvastatin, 6 sucralfate, 12

Ritalin, 16

Sinelee, 9 sulfacetamide sodium, 6, 18

Ritalin LA, 16

sirolimus, 3 sulfacetamide sodium/prednisolone sodium phosphate, 18

Ritalin SR, 16

Sirturo, 2

rivastigmine tartrate, 17

Sitavig, 2 sulfacetamide sodium/sulfur, 6

rivastigmine transdermal system, 17

Sivextro, 3 sulfacetamide sodium/sulfur cleanser, 6

rizatriptan benzoate, 20

Sklice, 9 sulfadiazine, 2

rizatriptan benzoate ODT, 20

sulfamethoxazole/trimethoprim, 3

ropinirole ER, 17

sodium bicarbonate, 12 sulfamethoxazole/trimethoprim DS, 3

ropinirole HCL, 17 rosuvastatin, 6

sodium chloride, 21 sulfasalazine, 13

Roxicet, 20

sodium citrate/citric acid, 14 sulfurated lime, 8

Rozerem, 16

sodium hyaluronate, 8 sulindac, 20

Rytary, 17

sodium phenylbutyrate, 11 sumatriptan, 20

S

sodium sulfacetamide, 6, 7, 18 sumatriptan succinate, 20

sodium sulfacetamide wash, 7 sumatriptan succinate refill, 20

Sabril, 17

sodium sulfacetamide/sulfur, 6 Sumavel Dosepro, 20

Safyral, 10

sodium sulfacetamide/sulfur cleanser, 6 Supprelin LA, 11

Saizen, 11

sodium sulfacetamide/sulfur cleanser IN urea, 6

Suprax, 1

Saizen Click.easy, 11

Suprep Bowel Prep, 12

salicylic acid, 8

sodium sulfacetamide/sulfur cleansing cloths, 6

salicylic acid cream, 8

Sustiva, 2

sodium sulfacetamide/sulfur green, 6 Sutent, 4

sodium sulfacetamide/sulfur IN urea, 6 Sylatron, 4

salicylic acid lotion, 8

sodium sulfacetamide/sulfur wash, 6 Symax Duotab, 12

Salivamax, 15

Solaice, 9 Symbicort, 22

salsalate, 19

Soltamox, 3 Symlinpen 120, 10

Salvax Duo Plus, 9

Solu-medrol, 9 Symlinpen 60, 10

Samsca, 11

Somatuline Depot, 11

Sancuso, 12

Somavert, 11

Sandimmune, 3

Sorilux, 7 Synalar Ts, 8

Sandostatin Lar Depot, 11

sotalol HCL, 4 Synalgos-dc, 20

Saphris, 16

sotalol HCL (AF), 4 Synarel, 11

Sarafem, 17

Sotylize, 4 Synera, 9

Savaysa, 14

Sovaldi, 2 Synthroid, 12

Savella, 17

Spectracef, 1

T

tretinoin microsphere, 6

tretinoin microsphere P.M., 6

Tabloid, 3

Trexall, 3

Taclonex, 8

Treximet, 20

tacrolimus, 3, 8

Trezix, 20

Tafinlar, 4

Thrombogen, 14 Tri-VI-flor, 23

Tagrisso, 4

Thyrolar-1, 12 triamcinolone, 9

Taltz, 7

Thyrolar-1/2, 12 triamcinolone acetonide, 8, 14, 21

Tamiflu, 2

Thyrolar-1/4, 12 triamcinolone IN orabase, 14

tamoxifen citrate, 3

Thyrolar-2, 12 triamterene/hydrochlorothiazide, 6

tamsulosin HCL, 13

Thyrolar-3, 12 Trianex, 8

Tanzeum, 10

tiagabine hydrochloride, 16 triazolam, 16

Tarceva, 4

ticlopidine HCL, 14 Tribenzor, 5

Targadox, 1

Tikosyn, 5 Tricare Prenatal Compleat, 23

Taron-bc, 23

timolol maleate, 4, 18 Tricare Prenatal DHA One, 23

Taron-c DHA, 23

timolol maleate ophthalmic gel forming, 18

tricitrates, 13

Tasigna, 4

Tricode AR, 21

Tazorac, 7

Tricode GF, 21

Tecfidera, 17

tinidazole, 3 trifluoperazine HCL, 15

Tirosint, 12 trifluridine, 18

Tegretol, 17

Tisseel, 14 trihexyphenidyl HCL, 17

Tegretol-XR, 16

Tisseel VH, 14 Trileptal, 17

Tekamlo, 5

Tivicay, 2 trimethobenzamide HCL, 12

Tekturna, 5

trimethoprim, 3

Tekturna HCT, 5

tizanidine HCL, 17 trimethoprim sulfate/polymyxin b sulfate, 18

telmisartan, 5

TL Triseb, 7

telmisartan/amlodipine, 5

Tobi Podhaler, 1 trimipramine maleate, 15

telmisartan/hydrochlorothiazide, 5

Tobradex, 18 Triumeq, 2

temazepam, 16

Tobradex ST, 18 Triveen-duo DHA, 23

temozolomide, 3

tobramycin, 1 Triveen-prx RNF, 23

terazosin HCL, 5

tobramycin sulfate, 1, 18 Trokendi XR, 17

terbinafine HCL, 2

tobramycin/dexamethasone, 18 Tropazone, 9

Terbinex, 2

Tobrex, 18 trospium chloride, 13

terbutaline sulfate, 22

tolazamide, 10 trospium chloride ER, 13

terconazole, 13

tolbutamide, 10 Truvada, 2

Tersi Foam, 7

tolcapone, 17 Tudorza Pressair, 22

Testim, 9

tolmetin sodium, 20

testosterone 1% gel, 9

tolterodine tartrate, 13

testosterone cypionate, 9

tolterodine tartrate ER, 13

testosterone enanthate, 9

Topamax, 17 Tuzistra XR, 22

testosterone P.M., 9

Topamax Sprinkle, 17 Tykerb, 4

tetrabenazine, 17

Topicort, 8 Tyvaso, 6

topiramate, 16

tetracycline HCL, 1

torsemide, 6

Tetrix, 9

Toviaz, 13 Tyzeka, 2

Tev-tropin, 11

Tracleer, 6 Tyzine, 21

Teveten HCT, 5

Tradjenta, 10 Tyzine Pediatric Nasal Drops, 21

Texacort, 8

tramadol HCL, 19 U

Texavite LQ, 23

tramadol HCL ER, 20

Thalomid, 3

Uceris, 9, 13

tramadol hydrochloride/acetaminophen, 19

Theo-24, 22

Ulesfia, 9

theophylline, 22

Uloric, 21

trandolapril, 5

theophylline CR, 22

trandolapril/verapamil HCL, 5

theophylline ER, 22

trandolapril/verapamil HCL ER, 5

Ultresa, 13

tranexamic acid, 14

Umecta, 9

Transderm-scop, 12

Umecta PD, 9

tranylcypromine sulfate, 15

urea, 8

Travatan Z, 18

travoprost, 18

Trazamine, 15

trazodone HCL, 15

urea topical, 8

Trecator, 2

Uretron D/S, 13

Trelstar, 3

Uroqid #2, 13

Trelstar Mixject, 3

ursodiol, 13

Trepadiclofen-25, 20

V

Trepoxicam-7.5, 20

Thiola, 14

Tretin-X, 6

Vagifem, 13

thioridazine HCL, 15

tretinoin, 4, 6

valacyclovir HCL, 2

thiothixene, 15

Valchlor, 3

Vytorin, 6 Zomacton, 11

Vyvanse, 16 Zomig, 20

valganciclovir, 2

W Zomig Nasal Spray, 20

valproic acid, 16

Zonalon, 7

warfarin sodium, 14

valsartan, 5

zonisamide, 16

Welchol, 6

valsartan/hydrochlorothiazide, 5

Zorbtive, 11

Westhroid, 12

Vanacof CD, 22

Zortress, 3

Wp Thyroid, 12

vancomycin HCL, 3

Zuplenz, 12

X

Vantas, 3

Zyclara, 8

Vascepa, 6

Zyclara P.M., 8

Xalkori, 4

vasopressin, 11

Zydelig, 4

Xarelto, 14

Vecamyl, 5

Zyflo, 22

Xeljanz, 20

Vectical, 7

Zyflo CR, 22

Xeljanz XR, 20

Velphoro, 13

Zykadia, 4

Xeomin, 17

Vemavite-prx 2, 23

Zylet, 18

Xerac Ac, 8

venlafaxine HCL, 15

Zyprexa Relprevv, 15

Xgeva, 11

venlafaxine HCL ER, 15

Zytiga, 3

Xifaxan, 3

Ventavis, 6

8

Xigduo XR, 10

Ventolin HFA, 22

Xolair, 22

8-mop, 7

Veramyst, 21

Xolegel, 7

verapamil HCL, 4

verapamil HCL ER, 4

Xolegel Duo/Head & Shoulders, 7

verapamil HCL SR, 5

Xolegel Duo/Xolex, 7

Verdeso, 8

Veregen, 9

Xopenex HFA, 22

Veripred 20, 9

Xrylix, 7

Versacloz, 16

Xtandi, 3

Vesicare, 13

Xuriden, 11

Vexol, 18

Viagra, 6

Xyntha, 14

Vibramycin, 1

Xyntha Solofuse, 14

Victoza, 10

Xyrem, 17

Victrelis, 2

Y

Videx Pediatric, 2

Yodoxin, 3

Vigamox, 18

Viibryd, 15

Z

Z-tuss Ac, 22

Vimpat, 17

zafirlukast, 22

Vinacal B, 23

zaleplon, 16

Vinate AZ Extra, 23

Zamicet, 20

Vinate Calcium, 23

Zarontin, 17

Vinate DHA RF, 23

Zatean-CH, 23

Viokace, 13

Zatean-pn, 23

Viracept, 2

Zatean-pn DHA, 23

Viramune, 2

Zatean-pn Plus, 23

Virazole, 2

Zavesca, 14

Viread, 2

Zelapar, 17

Vita-pren, 23

Zelboraf, 4

Vitafol Ultra, 23

Zembrace Symtouch, 20

Vitafol-nano, 23

Zenpep, 13

Vitafol-ob+dha, 23

Zenzedi, 16

Vitafol-one, 23

Zetia, 6

Vitamedmd One RX/Quatrefolic, 23

Zetonna, 21

Vitamedmd Plus RX/Quatre Folic, 23

Ziagen, 2

Vitamedmd Redichew RX, 23

zidovudine, 2

Vitamedmd Redichew RX/Quatrefolic, 23

Zioptan, 18

Vitapearl, 23

ziprasidone HCL, 15

Vitekta, 2

Zirgan, 18

Vituz, 21

Zithranol, 7

Viva DHA, 23

Zithranol-RR, 7

Vogelxo, 9

Zmax, 1

Vogelxo P.M., 9

Zoladex, 3

Zolinza, 4

voriconazole, 2

zolmitriptan, 20

Votrient, 4

zolmitriptan ODT, 20

Vraylar, 16

zolpidem tartrate, 16

Vsl#3 DS, 12

zolpidem tartrate ER, 16

Vusion, 7

Zolpimist, 16

RX-114513 10/2016

BCBSRI 5-Tier Formulary (Drug List)*However, pharmacists cannot substitute a preferred brand‐name...

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Transcript of BCBSRI 5-Tier Formulary (Drug List)*However, pharmacists cannot substitute a preferred brand‐name...