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FEP 5 Tier Rx Drug Formulary (607) Standard Option

Effective June 27, 2014

The FEP formulary includes the preferred drug list which is comprised of Tier 1, generics and Tier 2, preferred brand-name drugs. Also included in the formulary are Tier 3, non-preferred brand-name drugs, Tier 4, preferred specialty drugs and Tier 5, non-preferred specialty drugs.

Ask your physician if there is a generic drug available to treat your condition. If there is no generic drug available, ask your physician to prescribe a preferred brand-name drug.

The preferred brand-name drugs within our formulary are listed to identify medicines that are clinically appropriate and cost-effective.

Click on the category name in the Table of Contents below to go directly to that page

INTRODUCTION....................................................................................................................................................................................................... 5 PREFACE ................................................................................................................................................................................................................. 5 PRIOR APPROVAL .................................................................................................................................................................................................. 6 QUANTITY ALLOWANCES ..................................................................................................................................................................................... 6 PHARMACY AND MEDICAL POLICY COMMITTEE .............................................................................................................................................. 6 PRODUCT SELECTION CRITERIA......................................................................................................................................................................... 6 FORMULARY PRODUCT DESCRIPTIONS ............................................................................................................................................................ 6 GENERIC SUBSTITUTION ...................................................................................................................................................................................... 7 DRUG EFFICACY STUDY IMPLEMENTATION DRUGS ........................................................................................................................................ 7 EDITOR ..................................................................................................................................................................................................................... 8 NOTICE ..................................................................................................................................................................................................................... 8 LEGEND ................................................................................................................................................................................................................... 8 ANALGESICS........................................................................................................................................................................................................... 9

ANALGESICS, OTHER .................................................................................................................................................................................. 9 NSAIDs ........................................................................................................................................................................................................... 9 NSAIDs, COMBINATIONS ............................................................................................................................................................................. 9 NSAIDs, TOPICAL ......................................................................................................................................................................................... 9 COX-2 INHIBITORS ....................................................................................................................................................................................... 9 GOUT ............................................................................................................................................................................................................. 9 OPIOID ANALGESICS ................................................................................................................................................................................. 10 NON-OPIOID ANALGESICS ........................................................................................................................................................................ 10 VISCOSUPPLEMENTS ............................................................................................................................................................................... 10

ANTI-INFECTIVES ................................................................................................................................................................................................. 11 ANTIBACTERIALS ....................................................................................................................................................................................... 11 ANTIFUNGALS ............................................................................................................................................................................................ 12 ANTIMALARIALS ......................................................................................................................................................................................... 13 ANTIRETROVIRAL AGENTS ...................................................................................................................................................................... 13 ANTITUBERCULAR AGENTS ..................................................................................................................................................................... 14 ANTIVIRALS................................................................................................................................................................................................. 14 MISCELLANEOUS ....................................................................................................................................................................................... 15

ANTINEOPLASTIC AGENTS ................................................................................................................................................................................ 15 ALKYLATING AGENTS ............................................................................................................................................................................... 15 ANTIMETABOLITES .................................................................................................................................................................................... 16 HORMONAL ANTINEOPLASTIC AGENTS ................................................................................................................................................. 16 IMMUNOMODULATORS ............................................................................................................................................................................. 16 KINASE INHIBITORS ................................................................................................................................................................................... 17 TOPOISOMERASE INHIBITORS ................................................................................................................................................................ 17 MISCELLANEOUS ....................................................................................................................................................................................... 17

CARDIOVASCULAR .............................................................................................................................................................................................. 18 ACE INHIBITORS......................................................................................................................................................................................... 19 ACE INHIBITOR/CALCIUM CHANNEL BLOCKER COMBINATIONS ........................................................................................................ 19 ACE INHIBITOR/DIURETIC COMBINATIONS ............................................................................................................................................ 19 ADRENOLYTICS, CENTRAL ....................................................................................................................................................................... 19

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ALDOSTERONE RECEPTOR ANTAGONISTS .......................................................................................................................................... 19 ALPHA BLOCKERS ..................................................................................................................................................................................... 19 ANGIOTENSIN II RECEPTOR ANTAGONISTS/DIURETIC COMBINATIONS ........................................................................................... 19 ANGIOTENSIN II RECEPTOR ANTAGONIST/CALCIUM CHANNEL BLOCKER COMBINATIONS ......................................................... 20 ANGIOTENSIN II RECEPTOR ANTAGONIST/CALCIUM CHANNEL BLOCKER/DIURETIC COMBINATIONS ....................................... 20 ANTIARRHYTHMICS ................................................................................................................................................................................... 20 ANTILIPEMICS............................................................................................................................................................................................. 20 BETA-BLOCKERS ....................................................................................................................................................................................... 21 BETA-BLOCKER/DIURETIC COMBINATIONS ........................................................................................................................................... 21 CALCIUM CHANNEL BLOCKERS .............................................................................................................................................................. 21 CALCIUM CHANNEL BLOCKER/ANTILIPEMIC COMBINATIONS ............................................................................................................ 22 DIGITALIS GLYCOSIDES ............................................................................................................................................................................ 22 DIRECT RENIN INHIBITORS/DIURETIC COMBINATIONS ....................................................................................................................... 22 DIRECT RENIN INHIBITOR/CALCIUM CHANNEL BLOCKER COMBINATIONS ...................................................................................... 22 DIURETICS .................................................................................................................................................................................................. 22 NITRATES .................................................................................................................................................................................................... 23 NITRATE/VASODILATOR COMBINATIONS .............................................................................................................................................. 23 PULMONARY ARTERIAL HYPERTENSION .............................................................................................................................................. 23 MISCELLANEOUS ....................................................................................................................................................................................... 23

CENTRAL NERVOUS SYSTEM ............................................................................................................................................................................ 23 ANTIANXIETY .............................................................................................................................................................................................. 23 ANTICONVULSANTS .................................................................................................................................................................................. 24 ANTIDEMENTIA ........................................................................................................................................................................................... 24 ANTIDEPRESSANTS .................................................................................................................................................................................. 25 ANTIPARKINSONIAN AGENTS .................................................................................................................................................................. 26 ANTIPSYCHOTICS ...................................................................................................................................................................................... 26 ATTENTION DEFICIT HYPERACTIVITY DISORDER ................................................................................................................................ 27 FIBROMYALGIA........................................................................................................................................................................................... 27 HUNTINGTON'S DISEASE AGENTS .......................................................................................................................................................... 27 HYPNOTICS................................................................................................................................................................................................. 27 MIGRAINE .................................................................................................................................................................................................... 28 MOOD STABILIZERS .................................................................................................................................................................................. 28 MULTIPLE SCLEROSIS .............................................................................................................................................................................. 28 MUSCULOSKELETAL THERAPY AGENTS ............................................................................................................................................... 28 MYASTHENIA GRAVIS ............................................................................................................................................................................... 28 NARCOLEPSY/CATAPLEXY ....................................................................................................................................................................... 29 PSYCHOTHERAPEUTIC-MISCELLANEOUS ............................................................................................................................................. 29 MISCELLANEOUS ....................................................................................................................................................................................... 29

ENDOCRINE AND METABOLIC ........................................................................................................................................................................... 29 ANDROGENS .............................................................................................................................................................................................. 29 ANTIDIABETICS .......................................................................................................................................................................................... 30 CALCIUM RECEPTOR ANTAGONISTS ..................................................................................................................................................... 31 CALCIUM REGULATORS ........................................................................................................................................................................... 32 CONTRACEPTIVES .................................................................................................................................................................................... 32 ENDOMETRIOSIS ....................................................................................................................................................................................... 34 ESTROGENS ............................................................................................................................................................................................... 34 ESTROGEN/PROGESTINS ......................................................................................................................................................................... 34 ESTROGEN/SELECTIVE ESTROGEN RECEPTOR MODULATOR COMBINATIONS ............................................................................. 34 FERTILITY REGULATORS .......................................................................................................................................................................... 34 GLUCOCORTICOIDS .................................................................................................................................................................................. 35 GLUCOSE ELEVATING AGENTS ............................................................................................................................................................... 35 HUMAN GROWTH HORMONES ................................................................................................................................................................. 35 HYPERPARATHYROID TREATMENT, VITAMIN D ANALOGS ................................................................................................................. 35 INSULIN-LIKE GROWTH FACTOR-1 AGENTS .......................................................................................................................................... 35 PHENYLKETONURIA TREATMENT AGENTS ........................................................................................................................................... 35 PHOSPHATE BINDER AGENTS ................................................................................................................................................................. 36 PROGESTINS .............................................................................................................................................................................................. 36 SELECTIVE ESTROGEN RECEPTOR MODULATORS ............................................................................................................................. 36 THYROID AGENTS ..................................................................................................................................................................................... 36 VASOPRESSINS ......................................................................................................................................................................................... 36 MISCELLANEOUS ....................................................................................................................................................................................... 36

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GASTROINTESTINAL ........................................................................................................................................................................................... 37 ANTIDIARRHEALS ...................................................................................................................................................................................... 37 ANTIEMETICS ............................................................................................................................................................................................. 37 ANTISPASMODICS ..................................................................................................................................................................................... 37 CHOLELITHOLYTICS .................................................................................................................................................................................. 37 H2 RECEPTOR ANTAGONISTS .................................................................................................................................................................. 38 INFLAMMATORY BOWEL DISEASE .......................................................................................................................................................... 38 IRRITABLE BOWEL SYNDROME ............................................................................................................................................................... 38 LAXATIVES .................................................................................................................................................................................................. 38 PANCREATIC ENZYMES ............................................................................................................................................................................ 38 PROSTAGLANDINS .................................................................................................................................................................................... 39 PROTON PUMP INHIBITORS ..................................................................................................................................................................... 39 SALIVA STIMULANTS ................................................................................................................................................................................. 39 STEROIDS, RECTAL ................................................................................................................................................................................... 39 ULCER THERAPY COMBINATIONS .......................................................................................................................................................... 39 MISCELLANEOUS ....................................................................................................................................................................................... 39

GENITOURINARY .................................................................................................................................................................................................. 39 BENIGN PROSTATIC HYPERPLASIA ........................................................................................................................................................ 39 URINARY ANTISPASMODICS .................................................................................................................................................................... 39 VAGINAL ANTI-INFECTIVES ...................................................................................................................................................................... 40 MISCELLANEOUS ....................................................................................................................................................................................... 40

HEMATOLOGIC ..................................................................................................................................................................................................... 40 ANTICOAGULANTS .................................................................................................................................................................................... 40 HEMATOPOIETIC GROWTH FACTORS .................................................................................................................................................... 40 HEMOPHILIA, VON WILLEBRAND DISEASE AND RELATED BLEEDING DISORDERS ........................................................................ 41 HEREDITARY ANGIOEDEMA AGENTS ..................................................................................................................................................... 41 IDIOPATHIC THROMBOCYTOPENIC PURPURA AGENTS ...................................................................................................................... 41 PAROXYSMAL NOCTURNAL HEMOGLOBINURIA (PNH) AGENTS ........................................................................................................ 41 PLATELET AGGREGATION INHIBITORS .................................................................................................................................................. 41 PLATELET SYNTHESIS INHIBITORS ........................................................................................................................................................ 41 STEM CELL MOBILIZERS ........................................................................................................................................................................... 41 MISCELLANEOUS ....................................................................................................................................................................................... 42

IMMUNOLOGIC AGENTS ...................................................................................................................................................................................... 42 BIOLOGIC DISEASE-MODIFYING AGENTS .............................................................................................................................................. 42 DISEASE-MODIFYING ANTIRHEUMATIC DRUGS (DMARDs) ................................................................................................................. 42 IMMUNE GLOBULINS ................................................................................................................................................................................. 42 IMMUNOMODULATORS ............................................................................................................................................................................. 43 IMMUNOSUPPRESSANTS ......................................................................................................................................................................... 43

NUTRITIONAL/SUPPLEMENTS ............................................................................................................................................................................ 43 ELECTROLYTES ......................................................................................................................................................................................... 43 VITAMINS AND MINERALS ........................................................................................................................................................................ 43

RESPIRATORY ...................................................................................................................................................................................................... 44 ANAPHYLAXIS TREATMENT AGENTS ..................................................................................................................................................... 44 ANTICHOLINERGICS .................................................................................................................................................................................. 44 ANTICHOLINERGIC/BETA AGONIST COMBINATIONS ............................................................................................................................ 44 ANTIHISTAMINES, LOW SEDATING.......................................................................................................................................................... 44 ANTIHISTAMINES, NONSEDATING ........................................................................................................................................................... 44 ANTIHISTAMINES, SEDATING ................................................................................................................................................................... 45 ANTIHISTAMINE/DECONGESTANT COMBINATIONS .............................................................................................................................. 45 ANTITUSSIVES............................................................................................................................................................................................ 45 ANTITUSSIVE COMBINATIONS ................................................................................................................................................................. 45 BETA AGONISTS ........................................................................................................................................................................................ 45 CYSTIC FIBROSIS ...................................................................................................................................................................................... 45 LEUKOTRIENE RECEPTOR MODIFIERS .................................................................................................................................................. 45 MAST CELL STABILIZERS ......................................................................................................................................................................... 45 NASAL ANTIHISTAMINES .......................................................................................................................................................................... 46 NASAL STEROIDS ...................................................................................................................................................................................... 46 PHOSPHODIESTERASE-4 INHIBITORS .................................................................................................................................................... 46 STEROID/BETA AGONIST COMBINATIONS ............................................................................................................................................. 46 STEROID INHALANTS ................................................................................................................................................................................ 46 XANTHINES ................................................................................................................................................................................................. 46 MISCELLANEOUS ....................................................................................................................................................................................... 46

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TOPICAL ................................................................................................................................................................................................................ 46 DERMATOLOGY.......................................................................................................................................................................................... 46 MOUTH/THROAT/DENTAL AGENTS ......................................................................................................................................................... 50 OPHTHALMIC .............................................................................................................................................................................................. 50 OTIC ............................................................................................................................................................................................................. 53

WEBSITES ............................................................................................................................................................................................................. 54 INDEX ..................................................................................................................................................................................................................... 56

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INTRODUCTION

FEP is pleased to provide the 2014 FEP 5 Tier Rx Drug Formulary as a useful reference for drug product selection. The drugs on the FEP 5 Tier Rx Drug Formulary have been reviewed by the FEP Pharmacy and Medical Policy Committee and FEP physicians and pharmacists and found appropriate for preferred status.

All the information in the FEP 5 Tier Rx Drug Formulary is provided as a reference for drug therapy selection. Specific drug selection for an individual patient rests solely with the prescriber.

National guidelines can be found on the National Guideline Clearinghouse site at http://www.guideline.gov, on the websites listed under each therapeutic class and on the sites listed in the WEBSITES section of this publication.

PREFACE

The formulary is organized by sections, which refer to either a drug class or disease state. Unless exceptions are noted, all dosage forms and strengths of the drug cited are included in the formulary.

The FEP 5 Tier Rx Drug Formulary is an open formulary, but FEP may impose restrictions or not reimburse for specific drug products or types of products. For example, drugs and supplies for weight loss are excluded from the pharmacy benefit. In addition, over-the-counter (OTC) products, with the exception of insulin and diabetes monitoring products, are generally not included in the pharmacy benefit. Some OTC products are listed in the formulary for informational purposes only.

The formulary is separated by Tiers in the following manner:

Tier 1 Tier 2 Tier 3 Tier 4 Tier 5

generic drugs

preferred brand products

non-preferred brand products and all compounded medications

preferred specialty products

non-preferred specialty products

Standard Option Retail Pharmacy Medicare Part B

20% coinsurance 15% coinsurance

30% coinsurance

45% coinsurance 30% coinsurance Limit*: one 30-day supply fill at retail

30% coinsurance Limit*: one 30-day supply fill at retail

Standard Option Mail Pharmacy Medicare Part B

Up to $15 Up to $10

Up to $80 Up to $105

Standard Option Specialty Pharmacy

$35 for up to a 30-day supply $95 for up to a 90-day supply

$55 for up to a 30-day supply $155 for up to a 90-day supply

* First fill of specialty medications is limited to a 30-day supply at retail. All subsequent fills must be through the Specialty Drug Pharmacy Program. A 90-day supply fill of a specialty medication may only be obtained through the Specialty Drug Pharmacy Program once a member has received three 30-day supply fills of that medication. Drug products shown in boldface type in Tier 2, Tier 3, Tier 4 and Tier 5 have generic versions. All generic drug products are Tier 1.

All drugs that are preferred are noted in their respective tiers of the drug lists throughout this formulary. Drugs may be reviewed by the FEP Pharmacy and Medical Policy Committee and designated non-preferred. These drugs are listed in Tier 3. Also, FEP may designate certain drugs as non-preferred, typically if the cost-effectiveness is less than other similar drugs. Generic versions of non-preferred drugs, whether listed or not, are always in Tier 1.

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PRIOR APPROVAL

Prior approval (PA) is required for certain drugs before FEP will cover them. The prescribing physician may request PA by calling toll-free 1-877-727-3784. The list of prior approval medications is subject to change. For a current list of medications that require prior approval please see our Prior Approval web page.

QUANTITY ALLOWANCES

Quantity allowances have been established for some of the medications covered by FEP. Requests for quantities greater than allowed can be submitted to the Prior Approval program by the prescribing physician by calling toll-free 1-877-727-3784. The list of medications that have quantity allowances is subject to change. For a current list of medications with quantity allowances please see our Prior Approval web page.

PHARMACY AND MEDICAL POLICY COMMITTEE

The role of the FEP Pharmacy and Medical Policy Committee includes evaluating new medications, and making recommendations for the designation of preferred or non-preferred status on the FEP 5 Tier Rx Drug Formulary. The FEP Pharmacy and Medical Policy Committee is made up of physicians and pharmacists who are not employees or agents of, nor have financial interest in FEP.

PRODUCT SELECTION CRITERIA

The FEP Pharmacy and Medical Policy Committee will consider U.S. Food and Drug Administration (FDA) approved drugs for preferred status designation. The evaluation includes a literature review; expert opinion may also be sought. Formal reviews are prepared that typically address the following information:

Safety

Efficacy

Comparison studies

Drug interactions

Approved indications

Formulation and administration

Adverse effects

Contraindications

Pharmacokinetics

Patient compliance considerations

Medical outcome and pharmacoeconomic studies

When a new drug is considered for preferred status, an attempt will be made to examine the drug relative to similar drugs currently preferred. In addition, entire therapeutic classes are periodically reviewed. The class review process may result in a designation of non-preferred status to drug(s) in a particular therapeutic class, in an effort to continually promote the most clinically useful and cost-effective agents.

Drugs evaluated by the Pharmacy and Medical Policy Committee and not classified as preferred receive a non-preferred designation in the FEP 5 Tier Rx Drug Formulary. This designation indicates the Pharmacy and Medical Policy Committee's belief that the drug offers no important clinical or cost advantage over comparable preferred drugs, or that there is currently insufficient information to determine its appropriate clinical role, or that questions remain regarding safety and effectiveness. In an open formulary environment, non-preferred drugs are covered under FEP's pharmacy benefit. However, there may be additional costs incurred by the patient to receive a non-preferred medication. Physicians are encouraged to prescribe preferred drugs.

All the information in the FEP 5 Tier Rx Drug Formulary is provided as a reference for drug therapy selection. The final choice of a specific drug selection for an individual patient rests solely with the prescriber.

FORMULARY PRODUCT DESCRIPTIONS

To assist in understanding which specific strengths and dosage forms are preferred, examples are noted below. The general principles shown in the examples can usually be extended to other entries in the book. Any exceptions are noted.

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Preferred products include all strengths and dosage forms of the cited brand-name product.

aripiprazole Abilify Oral tablets, oral disintegrating tablets, solution and all strengths of Abilify would be included in this listing. When a strength or dosage form is specified, only the specified strength and dosage form is preferred. Other strengths/dosage forms of the reference product are not.

acyclovir caps, susp, tabs Zovirax The capsules, suspension and tablets of Zovirax are preferred. From this entry, the cream and ointment cannot be assumed to be on the list unless there is a specific entry.

Extended-release and delayed-release products require their own entry.

sitagliptin/metformin Janumet The immediate-release product listing of Janumet alone would not include the extended-release product Janumet XR. sitagliptin/metformin ext-rel Janumet XR A separate entry for Janumet XR confirms that the extended-release product is on the formulary. Dosage forms will be consistent with the category and use where listed.

neomycin/polymyxin B/hydrocortisone Cortisporin Since Cortisporin is listed only in the OTIC section, it is limited to the otic solution and suspension. From this entry, the topical cream cannot be assumed to be on the list unless there is an entry for this product in the DERMATOLOGY section of the formulary.

GENERIC SUBSTITUTION

Generic substitution is a pharmacy action whereby a generic version is dispensed rather than a prescribed brand-name product. Boldface type indicates generic availability. However, not all strengths or dosage forms of the generic name in boldface type may be generically available. In addition, boldface type may indicate that the brand name cited is a generic. Examples of the latter include Levoxyl and Trivora.

One way to reduce out-of-pocket cost is by requesting a generic drug. Generic drugs are usually priced lower than their brand-name equivalents. Prescription generic drugs are:

Approved by the FDA for safety and effectiveness, and are manufactured under the same strict standards that apply to brand-name drugs.

Tested in humans to assure the generic is absorbed into the bloodstream in a similar rate and to the same extent as the brand-name drug. Generics may be different from the brand in size, color, and inactive ingredients, but this does not alter their effectiveness or ability to be absorbed just like the brand-name drug.

Manufactured in the same strength and dosage form as the brand-name drugs.

When a generic drug is substituted for a brand-name drug, you can expect the generic to produce the same clinical effect and safety profile as the brand-name drug.

DRUG EFFICACY STUDY IMPLEMENTATION DRUGS

Drugs first marketed between 1938 and 1962 were approved as safe but required no showing of effectiveness for FDA approval. Since 1962, all new drugs are required to be both safe and effective before they can be marketed. The legislation that resulted in this change also applies retroactively to all drugs approved as safe from 1938-1962. The Drug Efficacy Study Implementation (DESI) program was established by the FDA to review the effectiveness of these pre-1962 drugs for their labeled indications, and a determination of fully effective was made for most of these products and they remain in the marketplace. A few DESI products remain classified as "less than fully effective" while awaiting final administrative disposition. Also classified as DESI are many products listed as identical, similar, or related to actual DESI products.

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EDITOR

Your comments and suggestions regarding this FEP 5 Tier Rx Drug Formulary are encouraged. Your input is vital to this formulary's continued success. All responses will be reviewed and considered. Please send your comments to:

FEP Rx Drug Formulary - MC 145 P.O. Box 52115 Phoenix, AZ 85072-2115

NOTICE

The information contained in this FEP 5 Tier Rx Drug Formulary and its appendices is provided by FEP, solely for the convenience of medical providers. FEP does not warrant or assure accuracy of such information nor is it intended to be comprehensive in nature. The FEP 5 Tier Rx Drug Formulary is not a complete list of all covered medications. This FEP 5 Tier Rx Drug Formulary is not intended to be a substitute for the knowledge, expertise, skill and judgment of the medical provider in his or her choice of prescription drugs. FEP assumes no responsibility for the actions or omissions of any medical provider based upon reliance, in whole or in part, on the information contained herein. The medical provider should consult the drug manufacturer's product literature or standard references for more detailed information.

The information contained in this document is proprietary. The information may not be copied in whole or in part without the written permission of FEP. ©2014. All rights reserved.

This document contains references to brand-name prescription drugs that are trademarks or registered trademarks of pharmaceutical manufacturers not affiliated with FEP.

If viewing this formulary via Internet, please be advised that the formulary is updated periodically and changes may appear prior to their effective date.

LEGEND

† Generic contraceptives are covered at no charge to the member

‡ Medication is covered at no charge to the member

d DESI drug

OTC Over the counter

PA Prior Approval

boldface Indicates generic availability; boldface may not apply to every strength or dosage form under the listed generic name

delayed-rel Delayed-release (also known as enteric-coated), refer to the reference brand listed for clarification

ext-rel Extended-release (also known as sustained-release), refer to the reference brand listed for clarification

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ANALGESICS

Practice guidelines of pain management are available at: http://www.asahq.org ANALGESICS, OTHER Treatment recommendations for osteoarthritis are available at: http://www.rheumatology.org

acetaminophen inj OFIRMEV Tier 3

NSAIDs

choline magnesium trisalicylate Tier 1

diclofenac sodium delayed-rel Tier 1

diclofenac sodium ext-rel Tier 1 VOLTAREN XR Tier 3

diflunisal Tier 1

etodolac Tier 1

etodolac ext-rel Tier 1

flurbiprofen Tier 1

ibuprofen Tier 1

indomethacin Tier 1

indomethacin ext-rel Tier 1

ketoprofen Tier 1

ketoprofen ext-rel Tier 1

ketorolac Tier 1

meloxicam Tier 1 MOBIC Tier 3

nabumetone Tier 1

naproxen Tier 1 NAPROSYN Tier 3

naproxen sodium Tier 1 ANAPROX Tier 3

oxaprozin Tier 1 DAYPRO Tier 3

piroxicam Tier 1 FELDENE Tier 3

sulindac Tier 1 CLINORIL Tier 3

fenoprofen NALFON Tier 2

ibuprofen inj CALDOLOR Tier 2

indomethacin susp INDOCIN susp Tier 2

ketorolac tromethamine nasal spray SPRIX Tier 3

naproxen sodium ext-rel NAPRELAN Tier 3

NSAIDs, COMBINATIONS

diclofenac sodium delayed-rel/ misoprostol

Tier 1 ARTHROTEC Tier 3

naproxen/esomeprazole delayed-rel VIMOVO Tier 3

NSAIDs, TOPICAL

diclofenac sodium gel VOLTAREN GEL Tier 2

diclofenac sodium soln PENNSAID Tier 3

COX-2 INHIBITORS

PA celecoxib CELEBREX Tier 2

GOUT

allopurinol Tier 1 ZYLOPRIM Tier 3

probenecid Tier 1

colchicine COLCRYS Tier 2

febuxostat ULORIC Tier 2

PA pegloticase KRYSTEXXA Tier 4

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OPIOID ANALGESICS Practice Guidelines for Cancer Pain Management (includes WHO analgesic ladder) are available at: http://www.asahq.org http://www.nccn.org Opioid guidelines in the management of chronic non-malignant pain are available at: http://www.asipp.org/Guidelines.htm

butalbital/acetaminophen/caffeine/ codeine

Tier 1 FIORICET w/CODEINE Tier 3

butalbital/aspirin/caffeine/codeine Tier 1 FIORINAL w/CODEINE Tier 3

butorphanol nasal spray Tier 1

codeine/acetaminophen Tier 1 TYLENOL w/CODEINE Tier 3

fentanyl transdermal Tier 1 DURAGESIC Tier 3

PA fentanyl transmucosal lozenge Tier 1 ACTIQ Tier 3

hydrocodone/acetaminophen Tier 1 LORCET Tier 3

hydrocodone/acetaminophen Tier 1 LORTAB Tier 3

hydrocodone/acetaminophen - Vicodin Tier 1

hydrocodone/acetaminophen - Vicodin ES

Tier 1

hydromorphone Tier 1 DILAUDID Tier 3

morphine Tier 1

morphine ext-rel Tier 1 AVINZA Tier 3

morphine ext-rel Tier 1 KADIAN Tier 2

morphine ext-rel Tier 1 MS CONTIN Tier 3

morphine supp Tier 1

oxycodone Tier 1 ROXICODONE Tier 3

oxycodone concentrate 20 mg/mL Tier 1

oxycodone soln Tier 1

oxycodone/acetaminophen 5/325 Tier 1 PERCOCET Tier 3

oxymorphone Tier 1 OPANA Tier 3

tramadol Tier 1 ULTRAM Tier 3

tramadol ext-rel Tier 1 ULTRAM ER Tier 3

codeine/acetaminophen susp CAPITAL w/CODEINE Tier 2

PA fentanyl citrate buccal FENTORA Tier 2

hydromorphone ext-rel EXALGO Tier 2

oxycodone ext-rel OXYCONTIN Tier 2

oxymorphone ext-rel OPANA ER Tier 2

tapentadol NUCYNTA Tier 2

tapentadol ext-rel NUCYNTA ER Tier 2

buprenorphine transdermal BUTRANS Tier 3

PA fentanyl citrate buccal ONSOLIS Tier 3

PA fentanyl citrate nasal spray LAZANDA Tier 3

PA fentanyl sublingual spray SUBSYS Tier 3

PA fentanyl sublingual tablets ABSTRAL Tier 3

NON-OPIOID ANALGESICS

butalbital/acetaminophen Tier 1

butalbital/acetaminophen/caffeine Tier 1 FIORICET Tier 3

butalbital/aspirin/caffeine Tier 1 FIORINAL Tier 3

butalbital/acetaminophen PHRENILIN FORTE Tier 2

ziconotide PRIALT Tier 4

VISCOSUPPLEMENTS

PA high molecular weight hyaluronan ORTHOVISC Tier 4

PA hylan G-F 20 SYNVISC Tier 4

PA hylan G-F 20 SYNVISC-ONE Tier 4

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PA sodium hyaluronate EUFLEXXA Tier 4

PA sodium hyaluronate GEL-ONE Tier 4

PA sodium hyaluronate HYALGAN Tier 4

PA sodium hyaluronate SUPARTZ Tier 4

ANTI-INFECTIVES

Hepatitis: CDC recommendations on the treatment of hepatitis are available at: http://www.cdc.gov/hepatitis/Resources/ Guidelines for the management of chronic hepatitis by the American Association for the Study of Liver Disease are available at: http://www.aasld.org HIV/AIDS: Guidelines for the treatment of HIV patients by the U.S. Department of Health and Human Services are available at: http://www.aidsinfo.nih.gov Infective Endocarditis: American Heart Association recommendations for the prevention of bacterial endocarditis are available at: http://www.myamericanheart.org Influenza: Recommendations of the Advisory Committee on Immunization Practices are available at: http://www.cdc.gov/ncidod/diseases/flu/fluvirus.htm International Travel: CDC recommendations for international travel are available at: http://www.cdc.gov/travel Sexually Transmitted Diseases: CDC Sexually Transmitted Diseases Guidelines are available at: http://www.cdc.gov/std/treatment/default.htm Respiratory Tract Infection/Antibiotic Use/Community Acquired Pneumonia/Other: Principles of appropriate antibiotic use for treatment of nonspecific upper respiratory tract infection in adults are available at: http://www.cdc.gov/flu/ Practice guidelines and statements developed and endorsed by the Infectious Diseases Society of America are available at: http://www.idsociety.org ANTIBACTERIALS Cephalosporins First Generation

cephalexin Tier 1 KEFLEX Tier 3

Second Generation

cefaclor Tier 1

cefoxitin Tier 1 MEFOXIN Tier 3

cefprozil Tier 1

cefuroxime axetil Tier 1 CEFTIN Tier 3

Third Generation

cefdinir Tier 1

cefditoren Tier 1 SPECTRACEF Tier 3

cefotaxime Tier 1 CLAFORAN Tier 3

cefpodoxime Tier 1

ceftazidime Tier 1 FORTAZ Tier 3

ceftibuten Tier 1 CEDAX Tier 2

ceftriaxone Tier 1 ROCEPHIN Tier 3

cefixime SUPRAX Tier 2

Fourth Generation

cefepime Tier 1

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Fifth Generation

ceftaroline fosamil TEFLARO Tier 2

Erythromycins/Macrolides

azithromycin Tier 1 ZITHROMAX Tier 3

clarithromycin Tier 1 BIAXIN Tier 3

clarithromycin ext-rel Tier 1 BIAXIN XL Tier 3

erythromycin delayed-rel Tier 1

erythromycin ethylsuccinate Tier 1 E.E.S. Tier 3

erythromycin stearate Tier 1

erythromycin/sulfisoxazole Tier 1

azithromycin ext-rel ZMAX Tier 2

erythromycin dispertabs PCE Tier 2

fidaxomicin DIFICID Tier 2

erythromycin delayed-rel ERY-TAB Tier 3

Fluoroquinolones

ciprofloxacin ext-rel Tier 1

ciprofloxacin tabs Tier 1 CIPRO tabs Tier 3

levofloxacin Tier 1 LEVAQUIN Tier 3

moxifloxacin Tier 1 AVELOX Tier 3

ofloxacin Tier 1

ciprofloxacin susp CIPRO susp Tier 2

gemifloxacin FACTIVE Tier 3

Ketolides

telithromycin KETEK Tier 3

Penicillins

amoxicillin, except film-coated tabs Tier 1

amoxicillin/clavulanate Tier 1 AUGMENTIN Tier 3

amoxicillin/clavulanate ext-rel Tier 1 AUGMENTIN XR Tier 3

amoxicillin/clavulanate susp 600 mg Tier 1

ampicillin Tier 1

ampicillin sodium/sulbactam sodium Tier 1 UNASYN Tier 3

dicloxacillin Tier 1

penicillin VK Tier 1

piperacillin/tazobactam Tier 1 ZOSYN Tier 3

amoxicillin ext-rel MOXATAG Tier 3

Tetracyclines

doxycycline hyclate Tier 1 VIBRAMYCIN Tier 3

doxycycline monohydrate Tier 1 ADOXA Tier 3

doxycycline monohydrate Tier 1 MONODOX Tier 3

minocycline Tier 1 MINOCIN Tier 3

minocycline ext-rel Tier 1 SOLODYN Tier 3

tetracycline Tier 1

ANTIFUNGALS

clotrimazole troches Tier 1

fluconazole Tier 1 DIFLUCAN Tier 3

griseofulvin microsize Tier 1 GRIFULVIN V Tier 3

griseofulvin ultramicrosize Tier 1 GRIS-PEG Tier 3

PA itraconazole caps Tier 1 SPORANOX caps Tier 3

ketoconazole tabs Tier 1

nystatin Tier 1

terbinafine tabs Tier 1 LAMISIL Tier 3

13

voriconazole Tier 1 VFEND Tier 3

amphotericin B lipid complex ABELCET Tier 2

amphotericin B lipid complex AMPHOTEC Tier 2

anidulafungin ERAXIS Tier 2

itraconazole oral soln SPORANOX oral soln Tier 2

posaconazole NOXAFIL Tier 2

micafungin MYCAMINE Tier 3

ANTIMALARIALS

atovaquone/proguanil Tier 1 MALARONE Tier 3

chloroquine Tier 1 ARALEN Tier 3

mefloquine Tier 1

primaquine Tier 2

artemether/lumefantrine COARTEM Tier 2

pyrimethamine DARAPRIM Tier 2

ANTIRETROVIRAL AGENTS Antiretroviral Combinations

abacavir/lamivudine/zidovudine Tier 1 TRIZIVIR Tier 2

lamivudine/zidovudine Tier 1 COMBIVIR Tier 2

abacavir/lamivudine EPZICOM Tier 2

efavirenz/emtricitabine/tenofovir ATRIPLA Tier 2

elvitegravir/cobicistat/emtricitabine/ tenofovir

STRIBILD Tier 2

emtricitabine/rilpivirine/tenofovir COMPLERA Tier 2

emtricitabine/tenofovir TRUVADA Tier 2

Chemokine Receptor Antagonists

maraviroc SELZENTRY Tier 2

Fusion Inhibitors

enfuvirtide FUZEON Tier 2

Integrase Inhibitors

dolutegravir TIVICAY Tier 2

raltegravir ISENTRESS Tier 2

Non-nucleoside Reverse Transcriptase Inhibitors

nevirapine Tier 1 VIRAMUNE Tier 2

delavirdine RESCRIPTOR Tier 2

efavirenz SUSTIVA Tier 2

etravirine INTELENCE Tier 2

nevirapine ext-rel VIRAMUNE XR Tier 2

rilpivirine EDURANT Tier 2

Nucleoside Reverse Transcriptase Inhibitors

abacavir Tier 1 ZIAGEN Tier 2

didanosine delayed-rel Tier 1 VIDEX EC Tier 2

lamivudine Tier 1 EPIVIR Tier 2

stavudine Tier 1 ZERIT Tier 2

zidovudine Tier 1 RETROVIR Tier 2

abacavir soln ZIAGEN soln Tier 2

didanosine soln VIDEX soln Tier 2

emtricitabine EMTRIVA Tier 2

Nucleotide Reverse Transcriptase Inhibitors

tenofovir VIREAD Tier 2

14

Protease Inhibitors

atazanavir REYATAZ Tier 2

darunavir PREZISTA Tier 2

fosamprenavir LEXIVA Tier 2

indinavir CRIXIVAN Tier 2

lopinavir/ritonavir KALETRA Tier 2

nelfinavir VIRACEPT Tier 2

ritonavir NORVIR Tier 2

saquinavir mesylate INVIRASE Tier 2

tipranavir APTIVUS Tier 2

ANTITUBERCULAR AGENTS

ethambutol Tier 1 MYAMBUTOL Tier 3

isoniazid Tier 1

pyrazinamide Tier 1

rifabutin Tier 1 MYCOBUTIN Tier 3

rifampin Tier 1 RIFADIN Tier 3

rifampin/isoniazid/pyrazinamide RIFATER Tier 2

rifapentine PRIFTIN Tier 2

bedaquiline SIRTURO Tier 3

ANTIVIRALS Cytomegalovirus Agents

cidofovir Tier 1 VISTIDE Tier 3

foscarnet Tier 1

ganciclovir Tier 1

ganciclovir inj Tier 1 CYTOVENE inj Tier 4

PA valganciclovir VALCYTE Tier 2

cytomegalovirus immune globulin CYTOGAM Tier 4

Hepatitis Agents Hepatitis B

adefovir dipivoxil Tier 1 HEPSERA Tier 4

lamivudine Tier 1 EPIVIR-HBV Tier 2

entecavir BARACLUDE Tier 4

telbivudine TYZEKA Tier 4

Hepatitis C

PA ribavirin caps Tier 1 REBETOL Tier 4

PA ribavirin caps - Ribasphere Tier 1

PA ribavirin tabs Tier 1 COPEGUS Tier 4

PA ribavirin tabs - Ribapak Tier 1

PA ribavirin tabs - Ribatab Tier 1

PA boceprevir VICTRELIS Tier 4

PA ribavirin oral soln REBETOL Tier 4

PA simeprevir OLYSIO Tier 4

PA sofosbuvir SOVALDI Tier 4

PA telaprevir INCIVEK Tier 4

Herpes Agents

acyclovir caps, susp, tabs Tier 1 ZOVIRAX Tier 3

famciclovir Tier 1 FAMVIR Tier 3

valacyclovir Tier 1 VALTREX Tier 3

Influenza Agents

amantadine, except tabs Tier 1

rimantadine Tier 1 FLUMADINE Tier 3

15

oseltamivir TAMIFLU Tier 2

zanamivir RELENZA Tier 2

Respiratory Syncytial Virus Agents

PA palivizumab SYNAGIS Tier 4

MISCELLANEOUS

atovaquone Tier 1 MEPRON Tier 3

aztreonam Tier 1 AZACTAM Tier 3

clindamycin Tier 1 CLEOCIN Tier 3

dapsone Tier 1

meropenem Tier 1 MERREM Tier 3

methenamine hippurate, prophylaxis Tier 1 HIPREX Tier 3

metronidazole tabs Tier 1 FLAGYL Tier 3

nitrofurantoin ext-rel Tier 1 MACROBID Tier 3

nitrofurantoin macrocrystals Tier 1 MACRODANTIN Tier 3

sulfamethoxazole/trimethoprim Tier 1

sulfamethoxazole/trimethoprim DS Tier 1

tinidazole Tier 1 TINDAMAX Tier 3

trimethoprim Tier 1

vancomycin Tier 1 VANCOCIN Tier 3

daptomycin CUBICIN Tier 2

ertapenem INVANZ Tier 2

imipenem/cilastatin PRIMAXIN Tier 2

linezolid ZYVOX Tier 2

nitazoxanide ALINIA Tier 2

rifaximin XIFAXAN Tier 2

doripenem DORIBAX Tier 3

telavancin VIBATIV Tier 3

tigecycline TYGACIL Tier 3

ANTINEOPLASTIC AGENTS

Clinical practice guidelines in oncology are available at: http://www.asco.org http://www.nccn.org ALKYLATING AGENTS

cyclophosphamide Tier 1

ifosfamide/mesna Tier 1

lomustine Tier 1

temozolomide Tier 1 TEMODAR Tier 4

cyclophosphamide inj Tier 4

thiotepa Tier 4

altretamine HEXALEN Tier 2

busulfan MYLERAN Tier 2

chlorambucil LEUKERAN Tier 2

bendamustine TREANDA Tier 4

busulfan BUSULFEX Tier 4

carmustine BICNU Tier 4

carmustine GLIADEL WAFER Tier 4

mechlorethamine MUSTARGEN Tier 4

mechlorethamine gel VALCHLOR Tier 4

melphalan ALKERAN Tier 4

streptozocin ZANOSAR Tier 4

16

ANTIMETABOLITES

capecitabine Tier 1 XELODA Tier 4

cladribine Tier 1

cytarabine Tier 1

floxuridine Tier 1

fludarabine Tier 1 FLUDARA Tier 4

gemcitabine Tier 1 GEMZAR Tier 4

mercaptopurine Tier 1 PURINETHOL Tier 3

thioguanine Tier 1

clofarabine CLOLAR Tier 4

cytarabine liposome DEPOCYT Tier 4

pemetrexed ALIMTA Tier 4

pentostatin NIPENT Tier 4

pralatrexate FOLOTYN Tier 4

rasburicase ELITEK Tier 4

HORMONAL ANTINEOPLASTIC AGENTS Antiandrogens

bicalutamide Tier 1 CASODEX Tier 3

flutamide Tier 1

nilutamide NILANDRON Tier 2

PA abiraterone ZYTIGA Tier 4

PA enzalutamide XTANDI Tier 4

Antiestrogens

tamoxifen Tier 1

toremifene FARESTON Tier 2

fulvestrant FASLODEX Tier 4

Aromatase Inhibitors

anastrozole Tier 1 ARIMIDEX Tier 3

exemestane Tier 1 AROMASIN Tier 3

letrozole Tier 1 FEMARA Tier 3

Gonadotropin-Releasing Hormone (GnRH) Antagonists

degarelix acetate FIRMAGON Tier 4

Luteinizing Hormone-releasing Hormone (LHRH) Agonists

leuprolide acetate Tier 1

goserelin acetate ZOLADEX Tier 4

histrelin acetate VANTAS Tier 4

PA leuprolide acetate ELIGARD Tier 4

PA leuprolide acetate LUPRON DEPOT Tier 4

PA leuprolide acetate LUPRON DEPOT-PED Tier 4

triptorelin pamoate TRELSTAR Tier 4

triptorelin pamoate TRELSTAR DEPOT Tier 4

triptorelin pamoate TRELSTAR LA Tier 4

Progestins

megestrol acetate Tier 1 MEGACE Tier 3

megestrol acetate susp MEGACE ES Tier 2

IMMUNOMODULATORS

lenalidomide REVLIMID Tier 4

PA pomalidomide POMALYST Tier 4

thalidomide THALOMID Tier 4

17

KINASE INHIBITORS

PA vandetanib CAPRELSA Tier 2

PA afatinib GILOTRIF Tier 4

PA axitinib INLYTA Tier 4

PA bosutinib BOSULIF Tier 4

PA cabozantinib COMETRIQ Tier 4

PA crizotinib XALKORI Tier 4

PA dabrafenib TAFINLAR Tier 4

dasatinib SPRYCEL Tier 4

erlotinib TARCEVA Tier 4

everolimus AFINITOR Tier 4

PA ibrutinib IMBRUVICA Tier 4

imatinib mesylate GLEEVEC Tier 4

PA lapatinib TYKERB Tier 4

nilotinib TASIGNA Tier 4

pazopanib VOTRIENT Tier 4

PA ponatinib ICLUSIG Tier 4

PA regorafenib STIVARGA Tier 4

PA ruxolitinib JAKAFI Tier 4

sorafenib NEXAVAR Tier 4

sunitinib SUTENT Tier 4

temsirolimus TORISEL Tier 4

PA trametinib MEKINIST Tier 4

PA vemurafenib ZELBORAF Tier 4

TOPOISOMERASE INHIBITORS

topotecan inj Tier 1 HYCAMTIN inj Tier 4

topotecan HYCAMTIN Tier 4

MISCELLANEOUS

amifostine Tier 1 ETHYOL Tier 4

azacitidine Tier 1 VIDAZA Tier 4

bleomycin sulfate Tier 1

carboplatin Tier 1

cisplatin Tier 1

dactinomycin Tier 1 COSMEGEN Tier 4

daunorubicin Tier 1 CERUBIDINE Tier 4

dexrazoxane Tier 1 TOTECT Tier 4

dexrazoxane Tier 1 ZINECARD Tier 4

etoposide Tier 1

hydroxyurea Tier 1 HYDREA Tier 3

irinotecan Tier 1 CAMPTOSAR Tier 4

leucovorin calcium Tier 1

mesna inj Tier 1 MESNEX inj Tier 3

mitomycin Tier 1

mitoxantrone Tier 1

vincristine Tier 1

vinorelbine Tier 1 NAVELBINE Tier 4

epirubicin Tier 4

vinblastine Tier 4

mitotane LYSODREN Tier 2

procarbazine MATULANE Tier 2

PA ado-trastuzumab emtansine KADCYLA Tier 4

aldesleukin PROLEUKIN Tier 4

PA alemtuzumab CAMPATH Tier 4

arsenic trioxide TRISENOX Tier 4

asparaginase ELSPAR Tier 4

18

PA asparaginase Erwinia chrysanthemi ERWINAZE Tier 4

BCG live vaccine THERACYS Tier 4

BCG live vaccine TICE BCG Tier 4

PA bevacizumab AVASTIN Tier 4

bexarotene caps TARGRETIN caps Tier 4

bortezomib VELCADE Tier 4

PA brentuximab vedotin ADCETRIS Tier 4

PA cabazitaxel JEVTANA Tier 4

PA carfilzomib KYPROLIS Tier 4

cetuximab ERBITUX Tier 4

daunorubicin citrate liposomal DAUNOXOME Tier 4

decitabine DACOGEN Tier 4

docetaxel TAXOTERE Tier 4

doxorubicin liposomal DOXIL Tier 4

epirubicin ELLENCE Tier 4

eribulin HALAVEN Tier 4

etoposide phosphate ETOPOPHOS Tier 4

PA ipilimumab YERVOY Tier 4

ixabepilone IXEMPRA Tier 4

levoleucovorin calcium FUSILEV Tier 4

mesna tabs 400 mg MESNEX Tier 4

methoxsalen inj UVADEX Tier 4

nelarabine ARRANON Tier 4

PA obinutuzumab GAZYVA Tier 4

PA ofatumumab ARZERRA Tier 4

PA omacetaxine mepesuccinate SYNRIBO Tier 4

oxaliplatin ELOXATIN Tier 4

paclitaxel protein-bound particles ABRAXANE Tier 4

panitumumab VECTIBIX Tier 4

pegaspargase ONCASPAR Tier 4

PA pertuzumab PERJETA Tier 4

porfimer sodium PHOTOFRIN Tier 4

PA rituximab RITUXAN Tier 4

romidepsin ISTODAX Tier 4

samarium sm 153 lexidronam QUADRAMET Tier 4

PA sipuleucel-T PROVENGE Tier 4

tositumomab BEXXAR Tier 4

PA trastuzumab HERCEPTIN Tier 4

valrubicin VALSTAR Tier 4

PA vismodegib ERIVEDGE Tier 4

PA vorinostat ZOLINZA Tier 4

PA ziv-aflibercept ZALTRAP Tier 4

CARDIOVASCULAR

The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure is available at: http://www.nhlbi.nih.gov/guidelines/hypertension Guidelines for the evaluation and management of cardiovascular diseases in adults are available at: http://www.acc.org http://www.heartfailureguideline.org http://www.myamericanheart.org

19

ACE INHIBITORS Guidelines for the use of ACE inhibitors are available at: http://professional.diabetes.org http://www.acc.org http://www.myamericanheart.org http://www.nhlbi.nih.gov/guidelines/hypertension

benazepril Tier 1 LOTENSIN Tier 3

enalapril Tier 1 VASOTEC Tier 3

fosinopril Tier 1

lisinopril Tier 1 PRINIVIL Tier 3

lisinopril Tier 1 ZESTRIL Tier 3

perindopril Tier 1 ACEON Tier 3

quinapril Tier 1 ACCUPRIL Tier 3

ramipril Tier 1 ALTACE Tier 3

trandolapril Tier 1 MAVIK Tier 3

ACE INHIBITOR/CALCIUM CHANNEL BLOCKER COMBINATIONS

benazepril/amlodipine Tier 1 LOTREL Tier 3

trandolapril/verapamil ext-rel TARKA Tier 3

ACE INHIBITOR/DIURETIC COMBINATIONS

benazepril/hydrochlorothiazide Tier 1 LOTENSIN HCT Tier 3

captopril/hydrochlorothiazide Tier 1

enalapril/hydrochlorothiazide Tier 1 VASERETIC Tier 3

fosinopril/hydrochlorothiazide Tier 1

lisinopril/hydrochlorothiazide Tier 1 ZESTORETIC Tier 3

quinapril/hydrochlorothiazide Tier 1 ACCURETIC Tier 3

ADRENOLYTICS, CENTRAL

clonidine Tier 1 CATAPRES Tier 3

clonidine transdermal Tier 1 CATAPRES-TTS Tier 3

ALDOSTERONE RECEPTOR ANTAGONISTS

eplerenone Tier 1 INSPRA Tier 3

spironolactone Tier 1 ALDACTONE Tier 3

ALPHA BLOCKERS Guidelines for the use of alpha blockers in various patient populations are available at: http://www.nhlbi.nih.gov/guidelines/hypertension

doxazosin Tier 1 CARDURA Tier 3

prazosin Tier 1 MINIPRESS Tier 3

terazosin Tier 1

ANGIOTENSIN II RECEPTOR ANTAGONISTS/DIURETIC COMBINATIONS Guidelines for the use of angiotensin II receptor antagonists in various patient populations are available at: http://professional.diabetes.org http://www.nhlbi.nih.gov/guidelines/hypertension

candesartan/hydrochlorothiazide Tier 1 ATACAND HCT Tier 3

eprosartan Tier 1 TEVETEN Tier 3

irbesartan Tier 1 AVAPRO Tier 3

irbesartan/hydrochlorothiazide Tier 1 AVALIDE Tier 3

losartan Tier 1 COZAAR Tier 3

losartan/hydrochlorothiazide Tier 1 HYZAAR Tier 3

telmisartan Tier 1 MICARDIS Tier 3

20

telmisartan/hydrochlorothiazide Tier 1 MICARDIS HCT Tier 3

valsartan/hydrochlorothiazide Tier 1 DIOVAN HCT Tier 3

olmesartan BENICAR Tier 2

olmesartan/hydrochlorothiazide BENICAR HCT Tier 2

valsartan DIOVAN Tier 2

azilsartan EDARBI Tier 3

eprosartan/hydrochlorothiazide TEVETEN HCT Tier 3

ANGIOTENSIN II RECEPTOR ANTAGONIST/CALCIUM CHANNEL BLOCKER COMBINATIONS

amlodipine/telmisartan Tier 1 TWYNSTA Tier 3

amlodipine/olmesartan AZOR Tier 2

amlodipine/valsartan EXFORGE Tier 2

ANGIOTENSIN II RECEPTOR ANTAGONIST/CALCIUM CHANNEL BLOCKER/DIURETIC COMBINATIONS

amlodipine/valsartan/hydrochlorothiazide EXFORGE HCT Tier 2

olmesartan/amlodipine/hydrochlorothiazide TRIBENZOR Tier 3

ANTIARRHYTHMICS Guidelines for the use of antiarrhythmics and cardiac glycosides in various patient populations are available at: http://www.acc.org

amiodarone Tier 1 CORDARONE Tier 3

disopyramide Tier 1 NORPACE Tier 3

flecainide Tier 1

mexiletine Tier 1

propafenone ext-rel Tier 1 RYTHMOL SR Tier 3

quinidine gluconate ext-rel Tier 1

quinidine sulfate ext-rel Tier 1

sotalol Tier 1 BETAPACE Tier 3

disopyramide ext-rel NORPACE CR Tier 2

dronedarone MULTAQ Tier 2

dofetilide TIKOSYN Tier 4

ANTILIPEMICS The Third Report of the Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) is available at: http://www.nhlbi.nih.gov/guidelines/cholesterol/index.htm Bile Acid Resins

cholestyramine pkt Tier 1 QUESTRAN/QUESTRAN LIGHT Tier 3

colestipol Tier 1 COLESTID Tier 3

colesevelam WELCHOL Tier 2

Cholesterol Absorption Inhibitors

ezetimibe ZETIA Tier 2

Fibrates

fenofibrate Tier 1 ANTARA Tier 3

fenofibrate Tier 1 TRICOR Tier 3

fenofibric acid delayed-rel Tier 1 TRILIPIX Tier 3

gemfibrozil Tier 1 LOPID Tier 3

fenofibrate LIPOFEN Tier 2

HMG-CoA Reductase Inhibitors/Combinations

atorvastatin Tier 1 LIPITOR Tier 3

fluvastatin Tier 1 LESCOL Tier 3

lovastatin Tier 1 MEVACOR Tier 3

21

pravastatin Tier 1 PRAVACHOL Tier 3

simvastatin Tier 1 ZOCOR Tier 3

rosuvastatin CRESTOR Tier 2

ezetimibe/simvastatin VYTORIN Tier 3

fluvastatin ext-rel LESCOL XL Tier 3

pitavastatin LIVALO Tier 3

Niacins/Combinations

niacin ext-rel Tier 1 NIASPAN Tier 3

niacin ext-rel/simvastatin SIMCOR Tier 2

niacin ext-rel/lovastatin ADVICOR Tier 3

Omega-3 Fatty Acids

icosapent ethyl VASCEPA Tier 3

omega-3 acid ethyl esters LOVAZA Tier 3

Miscellaneous

PA lomitapide JUXTAPID Tier 4

PA mipomersen KYNAMRO Tier 4

BETA-BLOCKERS Guidelines for the use of beta-blockers and beta-blocker combinations in various patient populations are available at: http://www.acc.org http://www.nhlbi.nih.gov/guidelines/hypertension

acebutolol Tier 1 SECTRAL Tier 3

atenolol Tier 1 TENORMIN Tier 3

carvedilol Tier 1 COREG Tier 3

metoprolol Tier 1 LOPRESSOR Tier 3

metoprolol ext-rel Tier 1 TOPROL-XL Tier 3

pindolol Tier 1

propranolol Tier 1

propranolol ext-rel Tier 1 INDERAL LA Tier 3

carvedilol phosphate ext-rel COREG CR Tier 2

esmolol BREVIBLOC Tier 2

nebivolol BYSTOLIC Tier 2

penbutolol LEVATOL Tier 2

propranolol ext-rel INNOPRAN XL Tier 3

BETA-BLOCKER/DIURETIC COMBINATIONS Guidelines for the use of beta-blockers and diuretic combinations in various patient populations are available at: http://www.acc.org http://www.nhlbi.nih.gov/guidelines/hypertension

atenolol/chlorthalidone Tier 1 TENORETIC Tier 3

bisoprolol/hydrochlorothiazide Tier 1 ZIAC Tier 3

metoprolol/hydrochlorothiazide Tier 1 LOPRESSOR HCT Tier 3

metoprolol succinate ext-rel/hydrochlorothiazide

DUTOPROL Tier 3

CALCIUM CHANNEL BLOCKERS Dihydropyridines

amlodipine Tier 1 NORVASC Tier 3

felodipine ext-rel Tier 1

nicardipine Tier 1

nifedipine ext-rel Tier 1 ADALAT CC Tier 3

nifedipine ext-rel Tier 1 PROCARDIA XL Tier 3

22

nimodipine Tier 1 NIMOTOP Tier 3

nisoldipine ext-rel Tier 1 SULAR Tier 2

nicardipine ext-rel CARDENE SR Tier 3

Nondihydropyridines

diltiazem Tier 1 CARDIZEM Tier 3

diltiazem ext-rel Tier 1 DILACOR XR Tier 3

diltiazem ext-rel Tier 1 TIAZAC Tier 3

diltiazem ext-rel 360 mg Tier 1 CARDIZEM CD Tier 2

diltiazem ext-rel, except 360 mg Tier 1 CARDIZEM CD Tier 3

verapamil Tier 1 CALAN Tier 3

verapamil ext-rel Tier 1 CALAN SR Tier 3

CALCIUM CHANNEL BLOCKER/ANTILIPEMIC COMBINATIONS

amlodipine/atorvastatin Tier 1 CADUET Tier 3

DIGITALIS GLYCOSIDES

digoxin Tier 1 LANOXIN Tier 2

DIRECT RENIN INHIBITORS/DIURETIC COMBINATIONS

aliskiren TEKTURNA Tier 2

aliskiren/hydrochlorothiazide TEKTURNA HCT Tier 2

DIRECT RENIN INHIBITOR/CALCIUM CHANNEL BLOCKER COMBINATIONS

aliskiren/amlodipine TEKAMLO Tier 3

DIURETICS Carbonic Anhydrase Inhibitors

acetazolamide Tier 1

acetazolamide ext-rel Tier 1 DIAMOX SEQUELS Tier 3

methazolamide Tier 1

Loop Diuretics

bumetanide Tier 1

furosemide Tier 1 LASIX Tier 3

torsemide Tier 1 DEMADEX Tier 3

ethacrynic acid EDECRIN Tier 3

Potassium-sparing Diuretics

amiloride Tier 1

Thiazides and Thiazide-like Diuretics

chlorthalidone Tier 1

hydrochlorothiazide Tier 1

indapamide Tier 1

metolazone Tier 1 ZAROXOLYN Tier 3

Diuretic Combinations

amiloride/hydrochlorothiazide Tier 1

spironolactone/hydrochlorothiazide Tier 1 ALDACTAZIDE Tier 3

triamterene/hydrochlorothiazide Tier 1 DYAZIDE Tier 3

triamterene/hydrochlorothiazide Tier 1 MAXZIDE Tier 3

triamterene/hydrochlorothiazide 37.5/25

Tier 1 MAXZIDE-25 Tier 3

triamterene/hydrochlorothiazide 50/25 Tier 1

23

NITRATES Oral

isosorbide dinitrate oral Tier 1 ISORDIL Tier 3

isosorbide mononitrate Tier 1

isosorbide mononitrate ext-rel Tier 1 IMDUR Tier 3

Sublingual

nitroglycerin sublingual spray Tier 1 NITROLINGUAL Tier 3

nitroglycerin sublingual NITROSTAT Tier 2

nitroglycerin sublingual aerosol NITROMIST Tier 2

Transdermal

nitroglycerin transdermal Tier 1

nitroglycerin transdermal Tier 1 NITRO-DUR Tier 3

NITRATE/VASODILATOR COMBINATIONS

isosorbide dinitrate/hydralazine BIDIL Tier 2

PULMONARY ARTERIAL HYPERTENSION Endothelin Receptor Antagonists

PA ambrisentan LETAIRIS Tier 4

PA bosentan TRACLEER Tier 4

PA macitentan OPSUMIT Tier 4

Phosphodiesterase Inhibitors

PA sildenafil Tier 1 REVATIO Tier 4

PA tadalafil ADCIRCA Tier 4

Prostaglandin Vasodilators

PA epoprostenol VELETRI Tier 4

PA epoprostenol sodium FLOLAN Tier 4

PA iloprost VENTAVIS Tier 4

PA treprostinil REMODULIN Tier 4

PA treprostinil TYVASO Tier 4

PA treprostinil ext-rel ORENITRAM Tier 4

Soluble Guanylate Cyclase Stimulators

PA riociguat ADEMPAS Tier 4

MISCELLANEOUS

hydralazine Tier 1

midodrine Tier 1

minoxidil Tier 1

ranolazine ext-rel RANEXA Tier 2

CENTRAL NERVOUS SYSTEM

Practice guidelines for psychiatric disorders are available at: http://www.psych.org ANTIANXIETY Benzodiazepines

alprazolam Tier 1 XANAX Tier 3

alprazolam ext-rel Tier 1 XANAX XR Tier 3

chlordiazepoxide Tier 1

clonazepam tabs Tier 1 KLONOPIN Tier 3

clorazepate Tier 1 TRANXENE T-TAB Tier 3

diazepam Tier 1 VALIUM Tier 3

24

lorazepam Tier 1 ATIVAN Tier 3

oxazepam Tier 1

Miscellaneous

buspirone Tier 1

clomipramine Tier 1 ANAFRANIL Tier 3

fluvoxamine Tier 1

fluvoxamine ext-rel Tier 1 LUVOX CR Tier 3

hydroxyzine HCl Tier 1

hydroxyzine pamoate Tier 1 VISTARIL Tier 3

ANTICONVULSANTS Practice guidelines for the treatment of epilepsy are available at: http://www.aan.com

carbamazepine Tier 1 TEGRETOL Tier 3

carbamazepine ext-rel Tier 1 TEGRETOL-XR Tier 3

diazepam rectal gel Tier 1 DIASTAT Tier 3

divalproex sodium delayed-rel Tier 1 DEPAKOTE Tier 3

ethosuximide Tier 1 ZARONTIN Tier 3

felbamate Tier 1 FELBATOL Tier 3

gabapentin Tier 1 NEURONTIN Tier 3

lamotrigine Tier 1 LAMICTAL Tier 3

lamotrigine ext-rel Tier 1 LAMICTAL XR Tier 3

levetiracetam Tier 1 KEPPRA Tier 3

levetiracetam ext-rel Tier 1 KEPPRA XR Tier 3

oxcarbazepine Tier 1 TRILEPTAL Tier 3

oxcarbazepine susp Tier 1 TRILEPTAL susp Tier 2

phenobarbital Tier 1

phenytoin Tier 1 DILANTIN INFATABS Tier 3

phenytoin sodium extended Tier 1 DILANTIN Tier 3

primidone Tier 1 MYSOLINE Tier 3

tiagabine Tier 1 GABITRIL Tier 3

topiramate Tier 1 TOPAMAX Tier 3

valproic acid Tier 1 DEPAKENE Tier 3

zonisamide Tier 1 ZONEGRAN Tier 3

clobazam ONFI Tier 2

ezogabine POTIGA Tier 2

lacosamide VIMPAT Tier 2

lamotrigine orally disintegrating tablets LAMICTAL ODT Tier 2

rufinamide BANZEL Tier 2

valproic acid delayed-rel STAVZOR Tier 2

eslicarbazepine APTIOM Tier 3

perampanel FYCOMPA Tier 3

vigabatrin SABRIL Tier 4

ANTIDEMENTIA Practice guidelines for the management of dementia are available at: http://www.aan.com

donepezil Tier 1 ARICEPT Tier 3

donepezil orally disintegrating tabs Tier 1 ARICEPT ODT Tier 3

galantamine Tier 1 RAZADYNE Tier 3

galantamine ext-rel Tier 1 RAZADYNE ER Tier 3

rivastigmine Tier 1 EXELON Tier 3

memantine NAMENDA Tier 2

rivastigmine transdermal EXELON PATCH Tier 2

25

ANTIDEPRESSANTS Although these agents are primarily indicated for depression, some of these are also approved for other indications, including bipolar disorder, obsessive-compulsive disorder, panic disorder and premenstrual dysphoric disorder. Guidelines for the evaluation and management of bipolar and depressive disorders are available at: http://www.psych.org Monoamine Oxidase Inhibitors (MAOIs)

phenelzine Tier 1 NARDIL Tier 3

tranylcypromine Tier 1 PARNATE Tier 3

selegiline transdermal EMSAM Tier 2

isocarboxazid MARPLAN Tier 3

Selective Serotonin Reuptake Inhibitors (SSRIs)

citalopram Tier 1 CELEXA Tier 3

escitalopram Tier 1 LEXAPRO Tier 3

fluoxetine Tier 1 PROZAC Tier 3

fluoxetine delayed-rel Tier 1 PROZAC WEEKLY Tier 3

paroxetine HCl Tier 1 PAXIL Tier 3

paroxetine HCl ext-rel Tier 1 PAXIL CR Tier 3

sertraline Tier 1 ZOLOFT Tier 3

fluoxetine SARAFEM Tier 3

paroxetine mesylate PEXEVA Tier 3

vilazodone VIIBRYD Tier 3

Serotonin Norepinephrine Reuptake Inhibitors (SNRIs)

duloxetine delayed-rel Tier 1 CYMBALTA Tier 3

venlafaxine Tier 1

venlafaxine ext-rel Tier 1 EFFEXOR XR Tier 3

venlafaxine ext-rel tabs Tier 1

desvenlafaxine ext-rel KHEDEZLA Tier 3

desvenlafaxine ext-rel PRISTIQ Tier 3

levomilnacipran ext-rel FETZIMA Tier 3

Tricyclic Antidepressants (TCAs)

amitriptyline Tier 1

desipramine Tier 1 NORPRAMIN Tier 3

doxepin Tier 1

imipramine HCl Tier 1 TOFRANIL Tier 3

imipramine pamoate Tier 1 TOFRANIL-PM Tier 3

nortriptyline Tier 1 PAMELOR Tier 3

protriptyline Tier 1 VIVACTIL Tier 3

Miscellaneous Agents

amitriptyline/perphenazine Tier 1

bupropion Tier 1 WELLBUTRIN Tier 3

bupropion ext-rel Tier 1 WELLBUTRIN SR Tier 3

bupropion ext-rel Tier 1 WELLBUTRIN XL Tier 3

mirtazapine Tier 1 REMERON Tier 3

nefazodone Tier 1

trazodone Tier 1

bupropion ext-rel APLENZIN Tier 3

bupropion ext-rel FORFIVO XL Tier 3

26

ANTIPARKINSONIAN AGENTS Practice guidelines for the diagnosis and treatment of Parkinson's disease are available at: http://www.aan.com

amantadine, except tabs Tier 1

benztropine Tier 1

bromocriptine Tier 1 PARLODEL Tier 3

carbidopa/levodopa Tier 1 PARCOPA Tier 3

carbidopa/levodopa Tier 1 SINEMET Tier 3

carbidopa/levodopa ext-rel Tier 1 SINEMET CR Tier 3

carbidopa/levodopa/entacapone Tier 1 STALEVO Tier 3

diphenhydramine Tier 1

entacapone Tier 1 COMTAN Tier 3

pramipexole Tier 1 MIRAPEX Tier 3

ropinirole Tier 1 REQUIP Tier 3

ropinirole ext-rel Tier 1 REQUIP XL Tier 3

selegiline caps Tier 1 ELDEPRYL Tier 3

trihexyphenidyl Tier 1

pramipexole ext-rel MIRAPEX ER Tier 2

rasagiline mesylate AZILECT Tier 2

selegiline orally disintegrating tabs ZELAPAR Tier 2

tolcapone TASMAR Tier 2

rotigotine transdermal NEUPRO Tier 3

apomorphine APOKYN Tier 4

ANTIPSYCHOTICS Atypicals

clozapine Tier 1 CLOZARIL Tier 3

clozapine orally disintegrating tablets Tier 1 FAZACLO Tier 2

olanzapine Tier 1 ZYPREXA/ZYPREXA ZYDIS Tier 3

olanzapine/fluoxetine Tier 1 SYMBYAX Tier 3

quetiapine Tier 1 SEROQUEL Tier 3

risperidone Tier 1 RISPERDAL Tier 3

ziprasidone Tier 1 GEODON Tier 3

aripiprazole ABILIFY Tier 2

paliperidone palmitate INVEGA SUSTENNA Tier 2

quetiapine ext-rel SEROQUEL XR Tier 2

risperidone long-acting inj RISPERDAL CONSTA Tier 2

asenapine SAPHRIS Tier 3

iloperidone FANAPT Tier 3

lurasidone LATUDA Tier 3

olanzapine pamoate ZYPREXA RELPREVV Tier 3

paliperidone ext-rel INVEGA Tier 3

Miscellaneous

fluphenazine Tier 1

haloperidol Tier 1

loxapine Tier 1 LOXITANE Tier 3

perphenazine Tier 1

thioridazine Tier 1

thiothixene Tier 1

trifluoperazine Tier 1

27

ATTENTION DEFICIT HYPERACTIVITY DISORDER Guidelines for the evaluation and management of attention deficit disorder are available at: http://www.aacap.org http://www.aap.org

PA amphetamine/dextroamphetamine mixed salts

Tier 1 ADDERALL Tier 3

PA amphetamine/dextroamphetamine mixed salts ext-rel

Tier 1 ADDERALL XR Tier 3

clonidine ext-rel Tier 1 KAPVAY Tier 3

PA dexmethylphenidate Tier 1 FOCALIN Tier 3

PA dexmethylphenidate ext-rel Tier 1 FOCALIN XR Tier 2

PA dextroamphetamine Tier 1

PA dextroamphetamine ext-rel Tier 1 DEXEDRINE SPANSULE Tier 3

PA methylphenidate Tier 1 RITALIN Tier 3

PA methylphenidate ext-rel Tier 1 CONCERTA Tier 3

PA methylphenidate ext-rel Tier 1 METADATE CD Tier 2

PA methylphenidate ext-rel Tier 1 RITALIN LA Tier 3

PA methylphenidate ext-rel Tier 1 RITALIN-SR Tier 3

atomoxetine STRATTERA Tier 2

guanfacine ext-rel INTUNIV Tier 2

PA lisdexamfetamine VYVANSE Tier 2

PA methylphenidate ext-rel 10 mg RITALIN LA 10 mg Tier 2

PA methylphenidate transdermal DAYTRANA Tier 2

FIBROMYALGIA

pregabalin LYRICA Tier 2

milnacipran SAVELLA Tier 3

HUNTINGTON'S DISEASE AGENTS

PA tetrabenazine XENAZINE Tier 4

HYPNOTICS Practice parameters for the treatment of sleep disorders and clinical guidelines for the evaluation and management of chronic insomnia in adults are available at: http://www.aasmnet.org Benzodiazepines

estazolam Tier 1

flurazepam Tier 1

temazepam Tier 1 RESTORIL Tier 3

quazepam DORAL Tier 3

Nonbenzodiazepines

zaleplon Tier 1 SONATA Tier 3

zolpidem Tier 1 AMBIEN Tier 3

zolpidem ext-rel Tier 1 AMBIEN CR Tier 3

butabarbital BUTISOL SODIUM Tier 3

eszopiclone LUNESTA Tier 3

ramelteon ROZEREM Tier 3

secobarbital SECONAL Tier 3

zolpidem sublingual EDLUAR Tier 3

tasimelteon HETLIOZ Tier 4

Tricyclics

doxepin SILENOR Tier 3

28

MIGRAINE Guidelines for prevention and management of migraine headaches are available at: http://www.aan.com Ergotamine Derivatives

dihydroergotamine inj Tier 1 D.H.E. 45 Tier 3

ergotamine/caffeine supp Tier 1 MIGERGOT Tier 2

ergotamine/caffeine CAFERGOT Tier 3

Selective Serotonin Agonists

naratriptan Tier 1 AMERGE Tier 3

rizatriptan Tier 1 MAXALT/MAXALT-MLT Tier 3

sumatriptan Tier 1 IMITREX Tier 3

zolmitriptan Tier 1 ZOMIG/ZOMIG-ZMT Tier 3

frovatriptan FROVA Tier 3

sumatriptan inj ALSUMA Tier 3

Selective Serotonin Agonist/Nonsteroidal Anti-inflammatory Drug (NSAID) Combinations

sumatriptan/naproxen sodium TREXIMET Tier 3

Miscellaneous

d acetaminophen/dichloralphenazone/ isometheptene

Tier 1

diclofenac potassium packets CAMBIA Tier 3

MOOD STABILIZERS

lithium carbonate Tier 1

lithium carbonate ext-rel tabs 300 mg Tier 1 LITHOBID Tier 3

lithium carbonate ext-rel tabs 450 mg Tier 1

carbamazepine EQUETRO Tier 2

MULTIPLE SCLEROSIS Practice guidelines for multiple sclerosis are available at: http://www.aan.com

PA dalfampridine ext-rel AMPYRA Tier 4

PA dimethyl fumarate delayed-rel TECFIDERA Tier 4

PA fingolimod GILENYA Tier 4

glatiramer COPAXONE Tier 4

interferon beta-1a AVONEX Tier 4

interferon beta-1a REBIF Tier 4

interferon beta-1b BETASERON Tier 4

interferon beta-1b EXTAVIA Tier 4

PA natalizumab TYSABRI Tier 4

PA teriflunomide AUBAGIO Tier 4

MUSCULOSKELETAL THERAPY AGENTS

baclofen Tier 1

cyclobenzaprine Tier 1

dantrolene Tier 1 DANTRIUM Tier 3

baclofen intrathecal LIORESAL INTRATHECAL Tier 2

cyclobenzaprine ext-rel AMRIX Tier 3

MYASTHENIA GRAVIS

pyridostigmine tabs 60 mg Tier 1 MESTINON Tier 3

pyridostigmine ext-rel tabs 180 mg MESTINON TIMESPAN Tier 2

pyridostigmine syrup MESTINON syrup Tier 2

29

NARCOLEPSY/CATAPLEXY

PA modafinil Tier 1 PROVIGIL Tier 3

sodium oxybate XYREM Tier 2

PA armodafinil NUVIGIL Tier 3

PSYCHOTHERAPEUTIC-MISCELLANEOUS Alcohol Deterrents

acamprosate calcium Tier 1 CAMPRAL Tier 3

disulfiram Tier 1 ANTABUSE Tier 3

naltrexone Tier 1 REVIA Tier 3

naltrexone microspheres VIVITROL Tier 4

Opioid Antagonists

naloxone inj Tier 1

Partial Opioid Agonist/Opioid Antagonist Combinations

buprenorphine Tier 1

buprenorphine/naloxone sublingual tabs

Tier 1

buprenorphine/naloxone sublingual film SUBOXONE FILM Tier 2

buprenorphine/naloxone sublingual tabs ZUBSOLV Tier 2

Pseudobulbar Affect

dextromethorphan/quinidine NUEDEXTA Tier 2

Smoking Deterrents

bupropion ext-rel Tier 1 ZYBAN Tier 3

OTC nicotine transdermal Tier 1

varenicline CHANTIX Tier 2

MISCELLANEOUS Amyotrophic Lateral Sclerosis

riluzole Tier 1 RILUTEK Tier 3

Botulinum Toxins

PA abobotulinumtoxinA DYSPORT Tier 4

PA incobotulinumtoxinA XEOMIN Tier 4

PA onabotulinumtoxinA BOTOX Tier 4

PA rimabotulinumtoxinB MYOBLOC Tier 4

Restless Legs Syndrome

gabapentin enacarbil ext-rel HORIZANT Tier 3

ENDOCRINE AND METABOLIC

ANDROGENS Clinical practice guidelines for the treatment of hypogonadism are available at: http://www.aace.com

testosterone cypionate Tier 1

testosterone enanthate Tier 1

testosterone gel ANDROGEL Tier 2

testosterone transdermal ANDRODERM Tier 2

testosterone gel FORTESTA Tier 3

testosterone soln AXIRON Tier 3

30

ANTIDIABETICS Guidelines of treatment and management of diabetes are available at: http://professionals.diabetes.org Alpha-glucosidase Inhibitors

acarbose Tier 1 PRECOSE Tier 3

miglitol GLYSET Tier 2

Amylin Analogs

pramlintide SYMLINPEN Tier 2

Biguanides

metformin Tier 1 GLUCOPHAGE Tier 3

metformin ext-rel Tier 1 FORTAMET Tier 3

metformin ext-rel Tier 1 GLUCOPHAGE XR Tier 3

metformin soln RIOMET Tier 2

Biguanide/Sulfonylurea Combinations

glipizide/metformin Tier 1 METAGLIP Tier 3

glyburide/metformin Tier 1 GLUCOVANCE Tier 3

Dipeptidyl Peptidase-4 (DPP-4) Inhibitors

saxagliptin ONGLYZA Tier 2

sitagliptin phosphate JANUVIA Tier 2

alogliptin NESINA Tier 3

linagliptin TRADJENTA Tier 3

Dipeptidyl Peptidase-4 (DPP-4) Inhibitor/Biguanide Combinations

saxagliptin/metformin ext-rel KOMBIGLYZE XR Tier 2

sitagliptin/metformin JANUMET Tier 2

sitagliptin/metformin ext-rel JANUMET XR Tier 2

alogliptin/metformin KAZANO Tier 3

linagliptin/metformin JENTADUETO Tier 3

Dipeptidyl Peptidase-4 (DPP-4) Inhibitor/Insulin Sensitizer Combinations

alogliptin/pioglitazone OSENI Tier 3

Incretin Mimetic Agents

exenatide BYETTA Tier 2

exenatide ext-rel BYDUREON Tier 2

liraglutide VICTOZA Tier 2

Insulins

insulin aspart NOVOLOG Tier 2

insulin aspart protamine 70%/ insulin aspart 30%

NOVOLOG MIX 70/30 Tier 2

insulin detemir LEVEMIR Tier 2

insulin glargine LANTUS Tier 2

insulin glulisine APIDRA Tier 2

OTC insulin human HUMULIN R Tier 2

OTC insulin human NOVOLIN R Tier 2

OTC insulin isophane human HUMULIN N Tier 2

OTC insulin isophane human NOVOLIN N Tier 2

OTC insulin isophane human 70%/regular 30% HUMULIN 70/30 Tier 2

OTC insulin isophane human 70%/regular 30% NOVOLIN 70/30 Tier 2

insulin lispro HUMALOG Tier 2

insulin lispro protamine/insulin lispro HUMALOG MIX Tier 2

31

Insulin Sensitizers

pioglitazone Tier 1 ACTOS Tier 3

rosiglitazone AVANDIA Tier 3

Insulin Sensitizer/Biguanide Combinations

pioglitazone/metformin Tier 1 ACTOPLUS MET Tier 3

pioglitazone/metformin ext-rel ACTOPLUS MET XR Tier 2

rosiglitazone/metformin AVANDAMET Tier 3

Insulin Sensitizer/Sulfonylurea Combinations

pioglitazone/glimepiride Tier 1 DUETACT Tier 3

rosiglitazone/glimepiride AVANDARYL Tier 3

Meglitinides

nateglinide Tier 1 STARLIX Tier 3

repaglinide Tier 1 PRANDIN Tier 3

Meglitinide/Biguanide Combinations

repaglinide/metformin PRANDIMET Tier 2

Sodium-Glucose Co-transporter 2 (SGLT2) Inhibitors

canagliflozin INVOKANA Tier 3

Sulfonylureas

glimepiride Tier 1 AMARYL Tier 3

glipizide Tier 1 GLUCOTROL Tier 3

glipizide ext-rel Tier 1 GLUCOTROL XL Tier 3

glyburide Tier 1 DIABETA Tier 3

glyburide, micronized Tier 1 GLYNASE Tier 3

Supplies

OTC blood glucose meters and kits ACCU-CHEK METERS AND KITS Tier 2

OTC blood glucose meters and kits ONETOUCH METERS AND KITS Tier 2

OTC blood glucose test strips ACCU-CHEK TEST STRIPS Tier 2

OTC blood glucose test strips ONETOUCH TEST STRIPS Tier 2

OTC insulin syringes BD INSULIN SYRINGES Tier 2

OTC lancet device ACCU-CHEK FASTCLIX LANCET DEVICE

Tier 2

OTC lancet device SOFTCLIX LANCET DEVICE Tier 2

OTC lancet device SOFTTOUCH LANCET DEVICE Tier 2

OTC lancets ACCU-CHEK FASTCLIX LANCETS Tier 2

OTC lancets ONETOUCH LANCETS Tier 2

OTC lancets SOFTCLIX LANCETS Tier 2

OTC lancets SOFTTOUCH LANCETS Tier 2

OTC urine test strips CHEMSTRIP K URINE KETONE STRIPS Tier 2

OTC urine test strips CHEMSTRIP UGK URINE GLUCOSE/ KETONE STRIPS

Tier 2

OTC urine test strips CHEMSTRIP UG URINE GLUCOSE STRIPS

Tier 2

Miscellaneous

bromocriptine CYCLOSET Tier 3

CALCIUM RECEPTOR ANTAGONISTS

cinacalcet SENSIPAR Tier 4

32

CALCIUM REGULATORS Guidelines of treatment and management of osteoporosis are available at: http://www.aace.com http://www.nof.org Bisphosphonates

alendronate Tier 1 FOSAMAX Tier 3

etidronate Tier 1

ibandronate Tier 1 BONIVA Tier 3

pamidronate Tier 1

zoledronic acid Tier 1 RECLAST Tier 4

zoledronic acid Tier 1 ZOMETA Tier 4

risedronate ACTONEL Tier 2

tiludronate SKELID Tier 2

alendronate/vitamin D3 FOSAMAX PLUS D Tier 3

risedronate delayed-rel ATELVIA Tier 3

Calcitonins

calcitonin-salmon spray Tier 1 MIACALCIN Tier 3

calcitonin-salmon inj MIACALCIN inj Tier 3

Parathyroid Hormones

teriparatide FORTEO Tier 4

Miscellaneous

denosumab PROLIA Tier 4

denosumab XGEVA Tier 4

CONTRACEPTIVES EE = ethinyl estradiol ME = mestranol Monophasic 20 mcg Estrogen

† drospirenone/EE 3/20 - Gianvi Tier 1 YAZ Tier 3

† levonorgestrel/EE 0.1/20 Tier 1

† norethindrone acetate/EE 1/20 Tier 1 LOESTRIN 1/20 Tier 3

† norethindrone acetate/EE 1/20 and iron Tier 1 LOESTRIN FE 1/20 Tier 3

† norethindrone acetate/EE 1/20 and iron - Lomedia 24 FE

Tier 1

30 mcg Estrogen

† desogestrel/EE 0.15/30 Tier 1 DESOGEN Tier 3

† desogestrel/EE 0.15/30 Tier 1 ORTHO-CEPT Tier 3

† drospirenone/EE 3/30 Tier 1 YASMIN Tier 3

† levonorgestrel/EE 0.15/30 Tier 1

† levonorgestrel/EE 0.15/30 - Levora Tier 1

† norethindrone acetate/EE 1.5/30 Tier 1 LOESTRIN 1.5/30 Tier 3

† norethindrone acetate/EE 1.5/30 and iron

Tier 1 LOESTRIN FE 1.5/30 Tier 3

† norgestrel/EE 0.3/30 - Cryselle Tier 1

† norgestrel/EE 0.3/30 - Low-Ogestrel Tier 1

35 mcg Estrogen

† ethynodiol diacetate/EE 1/35 - Zovia 1/35

Tier 1

† norethindrone/EE 0.4/35 Tier 1 OVCON 35 Tier 3

33

† norethindrone/EE 0.5/35 Tier 1 BREVICON Tier 3

† norethindrone/EE 0.5/35 Tier 1 MODICON Tier 3

† norethindrone/EE 1/35 Tier 1 NORINYL 1+35 Tier 3

† norethindrone/EE 1/35 Tier 1 ORTHO-NOVUM 1/35 Tier 3

† norgestimate/EE 0.25/35 Tier 1 ORTHO-CYCLEN Tier 3

50 mcg Estrogen

† ethynodiol diacetate/EE 1/50 - Zovia 1/50

Tier 1

† norethindrone/ME 1/50 Tier 1 NORINYL 1+50 Tier 3

† norgestrel/EE 0.5/50 Tier 1

Biphasic

† desogestrel/EE Tier 1 MIRCETTE Tier 3

norethindrone/EE NECON 10/11 Tier 3

Triphasic

† desogestrel/EE Tier 1 CYCLESSA Tier 3

† levonorgestrel/EE - Trivora Tier 1

† norethindrone acetate/EE and iron Tier 1 ESTROSTEP FE Tier 3

† norethindrone/EE Tier 1 ORTHO-NOVUM 7/7/7 Tier 3

† norethindrone/EE Tier 1 TRI-NORINYL Tier 3

† norgestimate/EE Tier 1 ORTHO TRI-CYCLEN Tier 3

norgestimate/EE ORTHO TRI-CYCLEN LO Tier 3

Four Phase

estradiol valerate and dienogest/ estradiol valerate

NATAZIA Tier 3

Extended Cycle

† levonorgestrel/EE 0.1/20 and EE 10 Tier 1 LOSEASONIQUE Tier 3

† levonorgestrel/EE 0.15/30 - Jolessa Tier 1

† levonorgestrel/EE 0.15/30 and EE 10 Tier 1 SEASONIQUE Tier 3

Continuous

† levonorgestrel/EE 0.09/20 - Amethyst Tier 1

Progestin Only

† norethindrone Tier 1 NOR-QD Tier 3

† norethindrone Tier 1 ORTHO MICRONOR Tier 3

Implant

‡ etonogestrel implant IMPLANON Tier 4

‡ etonogestrel implant NEXPLANON Tier 4

Injectable

† medroxyprogesterone acetate 150 mg/mL

Tier 1 DEPO-PROVERA Tier 3

Progestin Intrauterine Device

‡ levonorgestrel releasing IUD MIRENA Tier 4

‡ levonorgestrel releasing IUD SKYLA Tier 4

Transdermal

‡ norelgestromin/EE ORTHO EVRA Tier 2

34

Vaginal

‡ etonogestrel/EE ring NUVARING Tier 2

ENDOMETRIOSIS

danazol Tier 1

PA nafarelin SYNAREL Tier 2

leuprolide acetate/norethindrone acetate LUPANETA PACK Tier 4

ESTROGENS Guidelines of treatment and management of hormone therapy and menopause are available at: http://www.menopause.org Injectable

estradiol valerate Tier 1 DELESTROGEN Tier 2

Oral

estradiol Tier 1 ESTRACE Tier 3

estrogens, esterified/methyltestosterone

Tier 1

estropipate Tier 1

estrogens, conjugated PREMARIN Tier 2

estrogens, conjugated, synthetic B ENJUVIA Tier 2

Transdermal

estradiol Tier 1 CLIMARA Tier 3

estradiol VIVELLE-DOT Tier 2

estradiol transdermal spray EVAMIST Tier 2

estradiol ALORA Tier 3

estradiol transdermal gel ESTROGEL Tier 3

Vaginal

estradiol vaginal crm ESTRACE Tier 2

estradiol vaginal tabs VAGIFEM Tier 2

estrogens, conjugated crm PREMARIN crm Tier 2

estradiol vaginal ring FEMRING Tier 3

ESTROGEN/PROGESTINS Oral

EE/norethindrone acetate Tier 1 FEMHRT Tier 3

estradiol/norethindrone acetate Tier 1 ACTIVELLA Tier 3

estradiol/norgestimate PREFEST Tier 2

estrogens, conjugated/medroxyprogesterone

PREMPHASE Tier 2

estrogens, conjugated/medroxyprogesterone

PREMPRO Tier 2

Transdermal

estradiol/levonorgestrel CLIMARA PRO Tier 2

estradiol/norethindrone acetate COMBIPATCH Tier 3

ESTROGEN/SELECTIVE ESTROGEN RECEPTOR MODULATOR COMBINATIONS

conjugated estrogens/bazedoxifene DUAVEE Tier 3

FERTILITY REGULATORS

PA chorionic gonadotropin Tier 1

PA clomiphene Tier 1 CLOMID Tier 3

PA gonadorelin LUTREPULSE Tier 2

35

PA cetrorelix CETROTIDE Tier 4

PA choriogonadotropin alfa OVIDREL Tier 4

PA follitropin beta FOLLISTIM AQ Tier 4

PA ganirelix acetate GANIRELIX Tier 4

PA menotropins MENOPUR Tier 4

PA menotropins REPRONEX Tier 4

PA urofollitropin BRAVELLE Tier 4

GLUCOCORTICOIDS

cortisone acetate Tier 1

dexamethasone Tier 1

fludrocortisone Tier 1

hydrocortisone Tier 1 CORTEF Tier 3

methylprednisolone Tier 1 MEDROL Tier 3

prednisolone Tier 1

prednisolone sodium phosphate Tier 1 ORAPRED Tier 3

prednisolone sodium phosphate 5 mg/5 mL

Tier 1

prednisolone syrup Tier 1 PRELONE Tier 3

prednisone Tier 1

prednisolone sodium phosphate MILLIPRED Tier 2

prednisolone sodium phosphate orally disintegrating tablet

ORAPRED ODT Tier 2

prednisone delayed-rel RAYOS Tier 3

GLUCOSE ELEVATING AGENTS

diazoxide PROGLYCEM Tier 2

glucagon, human recombinant GLUCAGON EMERGENCY KIT Tier 2

HUMAN GROWTH HORMONES Guidelines for use of growth hormone are available at: http://www.aace.com/publications/guidelines

PA somatropin HUMATROPE Tier 4

PA somatropin NORDITROPIN Tier 4

PA, * somatropin SEROSTIM Tier 4

PA somatropin ZORBTIVE Tier 4

PA somatropin GENOTROPIN Tier 5

PA somatropin NUTROPIN AQ Tier 5

PA somatropin NUTROPIN AQ NUSPIN Tier 5

PA somatropin OMNITROPE Tier 5

PA somatropin SAIZEN Tier 5

PA somatropin TEV-TROPIN Tier 5

* Indicated for AIDS wasting only HYPERPARATHYROID TREATMENT, VITAMIN D ANALOGS

calcitriol (1,25-D3) Tier 1 ROCALTROL Tier 3

doxercalciferol Tier 1 HECTOROL Tier 3

paricalcitol Tier 1 ZEMPLAR Tier 3

INSULIN-LIKE GROWTH FACTOR-1 AGENTS

PA mecasermin INCRELEX Tier 4

PHENYLKETONURIA TREATMENT AGENTS

PA sapropterin KUVAN Tier 4

36

PHOSPHATE BINDER AGENTS

calcium acetate Tier 1 PHOSLO Tier 3

lanthanum FOSRENOL Tier 2

sevelamer carbonate RENVELA Tier 2

sevelamer RENAGEL Tier 3

PROGESTINS Injectable

hydroxyprogesterone caproate MAKENA Tier 4

Oral

medroxyprogesterone acetate Tier 1 PROVERA Tier 3

norethindrone acetate Tier 1 AYGESTIN Tier 3

PA progesterone, micronized Tier 1 PROMETRIUM Tier 3

Vaginal

PA progesterone supp ENDOMETRIN Tier 2

SELECTIVE ESTROGEN RECEPTOR MODULATORS

raloxifene Tier 1 EVISTA Tier 3

ospemifene OSPHENA Tier 3

THYROID AGENTS Antithyroid Agents

methimazole Tier 1 TAPAZOLE Tier 3

propylthiouracil Tier 1

Thyroid Supplements

levothyroxine Tier 1 SYNTHROID Tier 2

levothyroxine - Levoxyl Tier 1

liothyronine Tier 1 CYTOMEL Tier 3

liotrix THYROLAR Tier 3

thyroid ARMOUR THYROID Tier 3

VASOPRESSINS

desmopressin Tier 1 DDAVP Tier 3

MISCELLANEOUS

acetylcysteine Tier 1 ACETADOTE Tier 3

levocarnitine Tier 1 CARNITOR Tier 3

methylergonovine Tier 1

octreotide acetate Tier 1 SANDOSTATIN Tier 4

corticotropin powder Tier 4

hydroxocobalamin CYANOKIT Tier 2

miglustat ZAVESCA Tier 2

nitisinone ORFADIN Tier 2

pegademase, bovine ADAGEN Tier 2

trientine SYPRINE Tier 2

gallium nitrate GANITE Tier 3

PA mifepristone KORLYM Tier 3

PA agalsidase beta FABRAZYME Tier 4

PA alglucosidase alfa LUMIZYME Tier 4

PA alglucosidase alfa MYOZYME Tier 4

PA corticotropin ACTHAR H.P. Tier 4

cysteamine CYSTAGON Tier 4

PA cysteamine delayed-rel PROCYSBI Tier 4

PA elosulfase alfa VIMIZIM Tier 4

37

PA galsulfase NAGLAZYME Tier 4

PA glycerol phenylbutyrate RAVICTI Tier 4

histrelin acetate SUPPRELIN LA Tier 4

PA idursulfase ELAPRASE Tier 4

PA imiglucerase CEREZYME Tier 4

lanreotide acetate SOMATULINE DEPOT Tier 4

PA laronidase ALDURAZYME Tier 4

octreotide acetate SANDOSTATIN LAR Tier 4

PA pasireotide SIGNIFOR Tier 4

pegvisomant SOMAVERT Tier 4

PA taliglucerase alfa ELELYSO Tier 4

PA tesamorelin EGRIFTA Tier 4

thyrotropin alfa THYROGEN Tier 4

tolvaptan SAMSCA Tier 4

PA velaglucerase alfa VPRIV Tier 4

GASTROINTESTINAL

Guidelines for the treatment and management of various gastrointestinal diseases/conditions are available at: http://www.acg.gi.org http://www.gastro.org ANTIDIARRHEALS

diphenoxylate/atropine Tier 1 LOMOTIL Tier 3

loperamide Tier 1

opium tincture Tier 1

crofelemer delayed-rel FULYZAQ Tier 3

ANTIEMETICS

dronabinol Tier 1 MARINOL Tier 3

granisetron Tier 1

meclizine Tier 1 ANTIVERT Tier 3

metoclopramide Tier 1 REGLAN Tier 3

ondansetron Tier 1 ZOFRAN Tier 3

prochlorperazine Tier 1

promethazine Tier 1

trimethobenzamide Tier 1 TIGAN Tier 3

aprepitant EMEND Tier 2

dolasetron ANZEMET Tier 2

granisetron transdermal SANCUSO Tier 2

ondansetron oral soluble film ZUPLENZ Tier 2

palonosetron ALOXI Tier 2

scopolamine transdermal TRANSDERM SCOP Tier 2

doxylamine/pyridoxine delayed-rel DICLEGIS Tier 3

ANTISPASMODICS

dicyclomine Tier 1 BENTYL Tier 3

d hyoscyamine sulfate Tier 1 LEVSIN Tier 3

d hyoscyamine sulfate ext-rel Tier 1 LEVBID Tier 3

propantheline 15 mg Tier 1

d atropine/hyoscyamine/scopolamine/ phenobarbital

DONNATAL Tier 3

CHOLELITHOLYTICS

ursodiol Tier 1 ACTIGALL Tier 3

ursodiol Tier 1 URSO Tier 3

ursodiol Tier 1 URSO FORTE Tier 3

38

H2 RECEPTOR ANTAGONISTS

cimetidine Tier 1

* famotidine Tier 1 PEPCID Tier 3

famotidine susp Tier 1 PEPCID susp Tier 3

nizatidine Tier 1 AXID Tier 3

ranitidine Tier 1 ZANTAC Tier 3

* Except 20 mg INFLAMMATORY BOWEL DISEASE Oral Agents

balsalazide Tier 1 COLAZAL Tier 3

budesonide delayed-rel caps Tier 1 ENTOCORT EC Tier 3

sulfasalazine Tier 1 AZULFIDINE Tier 3

sulfasalazine delayed-rel Tier 1 AZULFIDINE EN-TABS Tier 3

mesalamine delayed-rel caps DELZICOL Tier 2

mesalamine delayed-rel tabs ASACOL HD Tier 2

mesalamine delayed-rel tabs LIALDA Tier 2

mesalamine ext-rel caps APRISO Tier 2

mesalamine ext-rel caps PENTASA Tier 2

olsalazine DIPENTUM Tier 3

Rectal Agents

hydrocortisone enema Tier 1

mesalamine rectal susp Tier 1 ROWASA Tier 2

hydrocortisone acetate foam CORTIFOAM Tier 2

mesalamine supp CANASA Tier 2

IRRITABLE BOWEL SYNDROME Irritable Bowel Syndrome with Constipation

lubiprostone AMITIZA Tier 2

linaclotide LINZESS Tier 3

Irritable Bowel Syndrome with Diarrhea

alosetron LOTRONEX Tier 3

LAXATIVES

lactulose Tier 1

peg 3350/electrolytes Tier 1 COLYTE Tier 3

peg 3350/electrolytes Tier 1 GOLYTELY Tier 2

peg 3350/electrolytes Tier 1 NULYTELY Tier 3

peg 3350/electrolytes MOVIPREP Tier 2

sodium phosphates OSMOPREP Tier 2

sodium phosphates VISICOL Tier 2

sodium sulfate/potassium sulfate/ magnesium sulfate

SUPREP Tier 2

peg 3350/electrolytes + bisacodyl HALFLYTELY Tier 3

sodium picosulfate/magnesium oxide/ citric acid

PREPOPIK Tier 3

PANCREATIC ENZYMES

pancrelipase VIOKACE Tier 2

pancrelipase delayed-rel CREON Tier 2

pancrelipase delayed-rel PANCREAZE Tier 2

pancrelipase delayed-rel ZENPEP Tier 2

39

PROSTAGLANDINS

misoprostol Tier 1 CYTOTEC Tier 3

PROTON PUMP INHIBITORS

lansoprazole delayed-rel Tier 1

omeprazole delayed-rel Tier 1 PRILOSEC Tier 3

omeprazole/sodium bicarbonate Tier 1 ZEGERID Tier 3

pantoprazole delayed-rel Tier 1 PROTONIX Tier 3

rabeprazole delayed-rel Tier 1 ACIPHEX Tier 3

esomeprazole delayed-rel NEXIUM Tier 2

dexlansoprazole delayed-rel DEXILANT Tier 3

SALIVA STIMULANTS

cevimeline Tier 1 EVOXAC Tier 3

pilocarpine tabs Tier 1 SALAGEN Tier 3

STEROIDS, RECTAL

d hydrocortisone acetate/pramoxine foam EPIFOAM Tier 2

d hydrocortisone acetate/pramoxine foam PROCTOFOAM-HC Tier 2

ULCER THERAPY COMBINATIONS

lansoprazole + amoxicillin + clarithromycin

Tier 1 PREVPAC Tier 3

bismuth subsalicylate + metronidazole + tetracycline

PYLERA Tier 2

MISCELLANEOUS

cromolyn sodium Tier 1 GASTROCROM Tier 3

PA sodium phenylbutyrate Tier 1 BUPHENYL Tier 4

sucralfate Tier 1 CARAFATE Tier 3

methylnaltrexone RELISTOR Tier 2

sacrosidase SUCRAID Tier 2

sucralfate susp CARAFATE susp Tier 2

alvimopan ENTEREG Tier 3

glycopyrrolate CUVPOSA Tier 3

nitroglycerin rectal oint 0.4% RECTIV Tier 3

dextranomer/sodium hyaluronate SOLESTA Tier 4

PA palifermin KEPIVANCE Tier 4

PA teduglutide GATTEX Tier 4

GENITOURINARY

BENIGN PROSTATIC HYPERPLASIA Guidelines for the management of BPH are available at: http://www.auanet.org/guidelines

alfuzosin ext-rel Tier 1

finasteride Tier 1 PROSCAR Tier 3

tamsulosin Tier 1 FLOMAX Tier 3

dutasteride AVODART Tier 2

dutasteride/tamsulosin JALYN Tier 2

silodosin RAPAFLO Tier 2

PA tadalafil 2.5 mg, 5 mg CIALIS Tier 3

URINARY ANTISPASMODICS

oxybutynin Tier 1

oxybutynin ext-rel Tier 1 DITROPAN XL Tier 3

tolterodine Tier 1 DETROL Tier 3

40

tolterodine ext-rel Tier 1 DETROL LA Tier 3

trospium Tier 1 SANCTURA Tier 3

trospium ext-rel Tier 1 SANCTURA XR Tier 3

fesoterodine ext-rel TOVIAZ Tier 2

oxybutynin transdermal OXYTROL Tier 2

solifenacin succinate VESICARE Tier 2

darifenacin ext-rel ENABLEX Tier 3

mirabegron ext-rel MYRBETRIQ Tier 3

oxybutynin gel GELNIQUE Tier 3

VAGINAL ANTI-INFECTIVES

metronidazole Tier 1 METROGEL-VAGINAL Tier 3

terconazole Tier 1 TERAZOL 3 Tier 3

terconazole Tier 1 TERAZOL 7 Tier 3

clindamycin supp CLEOCIN vaginal supp Tier 2

MISCELLANEOUS

bethanechol Tier 1 URECHOLINE Tier 3

phenazopyridine Tier 1 PYRIDIUM Tier 3

potassium citrate ext-rel Tier 1 UROCIT-K Tier 3

potassium citrate ext-rel 15 mEq Tier 1 UROCIT-K 15 mEq Tier 2

pentosan polysulfate sodium ELMIRON Tier 2

HEMATOLOGIC

ANTICOAGULANTS Injectable

enoxaparin Tier 1 LOVENOX Tier 3

dalteparin FRAGMIN Tier 2

desirudin IPRIVASK Tier 2

Oral

warfarin Tier 1 COUMADIN Tier 2

dabigatran etexilate PRADAXA Tier 2

rivaroxaban XARELTO Tier 2

apixaban ELIQUIS Tier 3

Synthetic Heparinoid-like Agents

fondaparinux Tier 1 ARIXTRA Tier 2

Miscellaneous

betaine anhydrous CYSTADANE Tier 2

HEMATOPOIETIC GROWTH FACTORS Guidelines for the management of neutropenia are available at: http://www.asco.org Guidelines for the management of anemia associated with chronic kidney disease are available at: http://www.kidney.org/professionals/kdoqi/guidelines_commentaries.cfm#guidelines

PA darbepoetin alfa ARANESP Tier 4

PA epoetin alfa EPOGEN Tier 4

PA epoetin alfa PROCRIT Tier 4

PA filgrastim NEUPOGEN Tier 4

oprelvekin NEUMEGA Tier 4

PA pegfilgrastim NEULASTA Tier 4

PA sargramostim LEUKINE Tier 4

PA tbo-filgrastim GRANIX Tier 4

41

HEMOPHILIA, VON WILLEBRAND DISEASE AND RELATED BLEEDING DISORDERS Guidelines of treatment and management of hemophilia are available at: http://www.hemophilia.org

factor IX concentrate BEBULIN VH Tier 3

AHF, human/VWF, human HUMATE-P Tier 4

antihemophilic factor ALPHANATE Tier 4

antihemophilic factor HEMOFIL M Tier 4

antihemophilic factor KOATE-DVI Tier 4

antihemophilic factor MONOCLATE-P Tier 4

antihemophilic factor, recombinant ADVATE Tier 4

antihemophilic factor, recombinant HELIXATE FS Tier 4

antihemophilic factor, recombinant KOGENATE FS Tier 4

antihemophilic factor, recombinant RECOMBINATE Tier 4

antihemophilic factor, recombinant REFACTO Tier 4

antihemophilic factor, recombinant XYNTHA Tier 4

anti-inhibitor coagulant complex FEIBA VH IMMUNO Tier 4

coagulation factor VIIa NOVOSEVEN RT Tier 4

desmopressin spray STIMATE Tier 4

factor IX concentrate ALPHANINE SD Tier 4

factor IX concentrate BEBULIN Tier 4

factor IX concentrate BENEFIX Tier 4

factor IX concentrate MONONINE Tier 4

factor IX concentrate PROFILNINE SD Tier 4

factor IX concentrate RIXUBIS Tier 4

factor XIII concentrate CORIFACT Tier 4

fibrinogen RIASTAP Tier 4

VWF, human/factor VIII complex WILATE Tier 4

HEREDITARY ANGIOEDEMA AGENTS

PA ecallantide KALBITOR Tier 4

PA C1 esterase inhibitor BERINERT Tier 4

PA C1 esterase inhibitor CINRYZE Tier 4

PA icatibant FIRAZYR Tier 4

IDIOPATHIC THROMBOCYTOPENIC PURPURA AGENTS

PA eltrombopag PROMACTA Tier 4

romiplostim NPLATE Tier 4

PAROXYSMAL NOCTURNAL HEMOGLOBINURIA (PNH) AGENTS

PA eculizumab SOLIRIS Tier 4

PLATELET AGGREGATION INHIBITORS

clopidogrel Tier 1 PLAVIX Tier 3

dipyridamole Tier 1 PERSANTINE Tier 3

ticlopidine Tier 1

dipyridamole ext-rel/aspirin AGGRENOX Tier 2

prasugrel EFFIENT Tier 2

ticagrelor BRILINTA Tier 3

PLATELET SYNTHESIS INHIBITORS

anagrelide Tier 1 AGRYLIN Tier 3

STEM CELL MOBILIZERS

plerixafor MOZOBIL Tier 4

42

MISCELLANEOUS

cilostazol Tier 1 PLETAL Tier 3

deferoxamine Tier 1 DESFERAL Tier 4

pentoxifylline ext-rel Tier 1

tranexamic acid Tier 1 CYKLOKAPRON inj Tier 2

tranexamic acid Tier 1 LYSTEDA Tier 3

alteplase CATHFLO ACTIVASE Tier 2

PA deferiprone FERRIPROX Tier 2

PA protein C concentrate, human CEPROTIN Tier 2

PA deferasirox EXJADE Tier 4

IMMUNOLOGIC AGENTS

Guidelines for the management of rheumatic diseases are available at: http://www.rheumatology.org BIOLOGIC DISEASE-MODIFYING AGENTS

PA adalimumab HUMIRA Tier 4

PA etanercept ENBREL Tier 4

PA infliximab REMICADE Tier 4

PA abatacept ORENCIA Tier 5

PA anakinra KINERET Tier 5

PA certolizumab pegol CIMZIA Tier 5

PA golimumab SIMPONI Tier 5

DISEASE-MODIFYING ANTIRHEUMATIC DRUGS (DMARDs)

hydroxychloroquine Tier 1 PLAQUENIL Tier 3

leflunomide Tier 1 ARAVA Tier 3

methotrexate Tier 1

methotrexate RHEUMATREX Tier 2

penicillamine CUPRIMINE Tier 2

auranofin RIDAURA Tier 3

methotrexate inj OTREXUP Tier 4

PA tofacitinib XELJANZ Tier 5

IMMUNE GLOBULINS

hepatitis B immune globulin HEPAGAM B Tier 4

hepatitis B immune globulin HYPERHEP B S-D Tier 4

PA immune globulin, gamma GAMASTAN S-D Tier 4

PA immune globulin, gamma GAMUNEX-C Tier 4

PA immune globulin, gamma (IGG) GAMMAKED Tier 4

PA immune globulin, gamma (IGG) GAMMAPLEX Tier 4

PA immune globulin, intravenous BIVIGAM Tier 4

PA immune globulin, intravenous CARIMUNE NF Tier 4

PA immune globulin, intravenous FLEBOGAMMA Tier 4

PA immune globulin, intravenous GAMMAGARD LIQUID Tier 4

PA immune globulin, intravenous GAMMAGARD S-D Tier 4

PA immune globulin, intravenous GAMUNEX Tier 4

PA immune globulin, intravenous OCTAGAM Tier 4

PA immune globulin, intravenous PRIVIGEN Tier 4

PA immune globulin, subcutaneous HIZENTRA Tier 4

Rho (D) immune globulin HYPERRHO S-D Tier 4

Rho (D) immune globulin MICRHOGAM Tier 4

Rho (D) immune globulin MICRHOGAM PLUS Tier 4

Rho (D) immune globulin RHOGAM Tier 4

Rho (D) immune globulin RHOGAM PLUS Tier 4

Rho (D) immune globulin RHOPHYLAC Tier 4

43

Rho (D) immune globulin WINRHO SDF Tier 4

PA varicella zoster immune globulin VARIZIG Tier 4

IMMUNOMODULATORS CDC recommendations on the treatment of hepatitis are available at: http://www.cdc.gov/hepatitis/Resources/ Guidelines for the management of hepatitis are available at: http://www.aasld.org Interferons

PA interferon alfa-2b INTRON A Tier 4

PA interferon alfacon-1 INFERGEN Tier 4

PA interferon gamma-1b, recombinant ACTIMMUNE Tier 4

PA peginterferon alfa-2a PEGASYS Tier 4

PA peginterferon alfa-2b PEGINTRON Tier 4

PA peginterferon alfa-2b PEGINTRON REDIPEN Tier 4

PA peginterferon alfa-2b SYLATRON Tier 4

Miscellaneous

PA canakinumab ILARIS Tier 4

PA rilonacept ARCALYST Tier 4

PA apremilast OTEZLA Tier 5

PA tocilizumab ACTEMRA Tier 5

IMMUNOSUPPRESSANTS Antimetabolites

azathioprine Tier 1 IMURAN Tier 3

mycophenolate mofetil Tier 1 CELLCEPT Tier 4

mycophenolate sodium delayed-rel Tier 1 MYFORTIC Tier 4

mycophenolate mofetil CELLCEPT suspension Tier 4

Calcineurin Inhibitors

cyclosporine Tier 1 SANDIMMUNE Tier 4

cyclosporine, modified Tier 1 NEORAL Tier 4

tacrolimus Tier 1 PROGRAF Tier 4

tacrolimus ext-rel ASTAGRAF XL Tier 4

Rapamycin Derivatives

sirolimus Tier 1 RAPAMUNE Tier 4

everolimus ZORTRESS Tier 4

Miscellaneous

belatacept NULOJIX Tier 4

PA belimumab BENLYSTA Tier 4

NUTRITIONAL/SUPPLEMENTS

ELECTROLYTES Potassium

potassium chloride ext-rel Tier 1

potassium chloride liquid Tier 1

potassium chloride powder Tier 1

VITAMINS AND MINERALS Folic Acid Agents

folic acid Tier 1

44

Prenatal Vitamins

prenatal vitamins/folic acid DUET DHA Tier 2

prenatal vitamins/folic acid PRENATE ELITE Tier 2

prenatal vitamins/docusate/folic acid CITRANATAL RX Tier 3

prenatal vitamins/folic acid VITAFOL-OB Tier 3

prenatal vitamins/folic acid VITAFOL-PN Tier 3

Miscellaneous

cyanocobalamin inj Tier 1

ergocalciferol (D2) Tier 1 DRISDOL Tier 3

fluoride drops Tier 1 LURIDE Tier 3

fluoride tabs Tier 1 LURIDE LOZI-TABS Tier 3

multivitamins/fluoride drops, tabs Tier 1

multivitamins/fluoride/iron drops, tabs Tier 1

sodium ferric gluconate inj Tier 1 FERRLECIT Tier 3

vitamin ADC/fluoride drops Tier 1

vitamin ADC/fluoride/iron drops Tier 1

cyanocobalamin spray NASCOBAL Tier 2

ferumoxytol inj FERAHEME Tier 2

iron sucrose inj VENOFER Tier 2

phytonadione MEPHYTON Tier 2

zinc acetate GALZIN Tier 2

RESPIRATORY

Guidelines to the management, prevention, or treatment of COPD and asthma are available at: http://www.aaaai.org http://www.ginasthma.com http://www.goldcopd.com http://www.nhlbi.nih.gov The Allergy Report and guidelines for allergy-related conditions are available at: http://www.aaaai.org ANAPHYLAXIS TREATMENT AGENTS

epinephrine AUVI-Q Tier 2

epinephrine EPIPEN Tier 2

epinephrine EPIPEN JR. Tier 2

ANTICHOLINERGICS

ipratropium soln Tier 1

tiotropium SPIRIVA Tier 2

aclidinium bromide TUDORZA PRESSAIR Tier 3

ANTICHOLINERGIC/BETA AGONIST COMBINATIONS

ipratropium/albuterol soln Tier 1 DUONEB Tier 3

ipratropium/albuterol, CFC-free aerosol COMBIVENT RESPIMAT Tier 2

umeclidinium/vilanterol ANORO ELLIPTA Tier 3

ANTIHISTAMINES, LOW SEDATING

levocetirizine Tier 1 XYZAL Tier 3

ANTIHISTAMINES, NONSEDATING

desloratadine Tier 1 CLARINEX Tier 3

desloratadine syrup CLARINEX syrup Tier 3

45

ANTIHISTAMINES, SEDATING

cyproheptadine Tier 1

diphenhydramine Tier 1

hydroxyzine HCl Tier 1

hydroxyzine pamoate Tier 1 VISTARIL Tier 3

promethazine Tier 1

ANTIHISTAMINE/DECONGESTANT COMBINATIONS

desloratadine/pseudoephedrine ext-rel CLARINEX-D Tier 3

ANTITUSSIVES

benzonatate Tier 1 TESSALON Tier 3

ANTITUSSIVE COMBINATIONS Opioid

codeine/promethazine Tier 1

codeine/promethazine/phenylephrine Tier 1

hydrocodone/chlorpheniramine/ pseudoephedrine

Tier 1 ZUTRIPRO Tier 3

hydrocodone/homatropine Tier 1

hydrocodone/pseudoephedrine REZIRA Tier 3

BETA AGONISTS Inhalants Short Acting

albuterol soln Tier 1 ACCUNEB Tier 3

albuterol soln Tier 1 VENTOLIN Tier 3

albuterol sulfate, CFC-free aerosol PROAIR HFA Tier 2

albuterol sulfate, CFC-free aerosol PROVENTIL HFA Tier 2

albuterol sulfate, CFC-free aerosol VENTOLIN HFA Tier 2

Long Acting

formoterol inhalation caps FORADIL Tier 2

salmeterol xinafoate SEREVENT DISKUS Tier 2

arformoterol soln BROVANA Tier 3

indacaterol ARCAPTA NEOHALER Tier 3

Oral Agents

albuterol Tier 1

albuterol ext-rel Tier 1 VOSPIRE ER Tier 3

metaproterenol Tier 1

terbutaline Tier 1

CYSTIC FIBROSIS

tobramycin inhalation soln Tier 1 TOBI Tier 4

aztreonam lysine inhalation soln CAYSTON Tier 4

PA dornase alfa PULMOZYME Tier 4

PA ivacaftor KALYDECO Tier 4

tobramycin inhalation soln BETHKIS Tier 4

LEUKOTRIENE RECEPTOR MODIFIERS

montelukast Tier 1 SINGULAIR Tier 3

zafirlukast Tier 1 ACCOLATE Tier 3

zileuton ext-rel ZYFLO CR Tier 3

MAST CELL STABILIZERS

cromolyn soln Tier 1

46

NASAL ANTIHISTAMINES

azelastine spray Tier 1 ASTELIN Tier 3

azelastine spray Tier 1 ASTEPRO Tier 3

olopatadine PATANASE Tier 3

NASAL STEROIDS

budesonide spray Tier 1 RHINOCORT AQUA Tier 3

flunisolide spray Tier 1

fluticasone spray Tier 1 FLONASE Tier 3

triamcinolone acetonide spray Tier 1 NASACORT AQ Tier 3

fluticasone furoate spray VERAMYST Tier 2

mometasone spray NASONEX Tier 2

beclomethasone spray BECONASE AQ Tier 3

PHOSPHODIESTERASE-4 INHIBITORS

roflumilast DALIRESP Tier 3

STEROID/BETA AGONIST COMBINATIONS

budesonide/formoterol SYMBICORT Tier 2

fluticasone/salmeterol ADVAIR Tier 2

fluticasone/salmeterol, CFC-free aerosol ADVAIR HFA Tier 2

mometasone/formoterol DULERA Tier 2

fluticasone/vilanterol BREO ELLIPTA Tier 3

STEROID INHALANTS

budesonide inhalation suspension Tier 1 PULMICORT RESPULES Tier 3

beclomethasone, CFC-free aerosol QVAR Tier 2

budesonide PULMICORT FLEXHALER Tier 2

fluticasone FLOVENT Tier 2

fluticasone, CFC-free aerosol FLOVENT HFA Tier 2

mometasone ASMANEX Tier 2

ciclesonide ALVESCO Tier 3

XANTHINES

caffeine citrate Tier 1 CAFCIT Tier 3

theophylline ext-rel tabs Tier 1

theophylline ext-rel caps THEO-24 Tier 2

theophylline liquid ELIXOPHYLLIN Tier 2

MISCELLANEOUS

ipratropium spray Tier 1 ATROVENT spray Tier 3

alpha-1 proteinase inhibitor ARALAST NP Tier 4

alpha-1 proteinase inhibitor GLASSIA Tier 4

alpha-1 proteinase inhibitor ZEMAIRA Tier 4

PA omalizumab XOLAIR Tier 4

TOPICAL

DERMATOLOGY Acne Guidelines for the care and treatment of acne vulgaris are available at: http://www.aad.org/education-and-quality-care/clinical-guidelines Oral

isotretinoin Tier 1

isotretinoin ABSORICA Tier 3

47

Topical

PA adapalene Tier 1 DIFFERIN Tier 3

benzoyl peroxide Tier 1 BENZAC AC Tier 3

clindamycin gel, lotion, soln Tier 1 CLEOCIN T Tier 3

clindamycin swabs Tier 1

clindamycin/benzoyl peroxide Tier 1 BENZACLIN Tier 2

clindamycin/benzoyl peroxide Tier 1 DUAC Tier 3

erythromycin gel 2% Tier 1

erythromycin soln Tier 1

erythromycin/benzoyl peroxide Tier 1 BENZAMYCIN Tier 3

PA tretinoin Tier 1 RETIN-A Tier 3

PA tretinoin gel microsphere Tier 1 RETIN-A MICRO Tier 3

PA adapalene/benzoyl peroxide EPIDUO Tier 2

PA tazarotene TAZORAC Tier 2

PA tretinoin ATRALIN Tier 2

azelaic acid AZELEX Tier 3

clindamycin/benzoyl peroxide ACANYA Tier 3

PA clindamycin/tretinoin ZIANA Tier 3

Actinic Keratosis

diclofenac sodium Tier 1 SOLARAZE Tier 3

fluorouracil Tier 1 EFUDEX Tier 3

fluorouracil CARAC Tier 3

fluorouracil FLUOROPLEX Tier 3

Antibiotics

gentamicin Tier 1

mupirocin Tier 1 BACTROBAN Tier 3

silver sulfadiazine Tier 1 SILVADENE Tier 3

retapamulin ALTABAX Tier 2

mafenide SULFAMYLON Tier 3

Antifungals

ciclopirox Tier 1 LOPROX Tier 3

clotrimazole Tier 1

clotrimazole/betamethasone Tier 1

econazole Tier 1

ketoconazole Tier 1

nystatin Tier 1

ketoconazole 2% XOLEGEL Tier 2

miconazole nitrate/zinc oxide VUSION Tier 2

naftifine NAFTIN Tier 2

oxiconazole OXISTAT Tier 2

sertaconazole ERTACZO Tier 2

sulconazole EXELDERM Tier 2

terbinafine LAMISIL Tier 2

Antipsoriatics Guidelines of care for the management and treatment of psoriasis with topical therapies are available at: http://www.aad.org Injectable

PA ustekinumab STELARA Tier 5

Oral

acitretin Tier 1 SORIATANE Tier 3

methoxsalen oral OXSORALEN-ULTRA Tier 2

48

Topical

betamethasone dipropionate/ calcipotriene

Tier 1 TACLONEX Tier 3

calcipotriene Tier 1 DOVONEX Tier 3

calcitriol oint Tier 1 VECTICAL Tier 3

anthralin DRITHOCREME HP Tier 2

Antiseborrheics

ketoconazole shampoo 2% Tier 1 NIZORAL SHAMPOO Tier 3

selenium sulfide shampoo 2.5% Tier 1

Corticosteroids Low Potency

alclometasone crm, oint 0.05% Tier 1 ACLOVATE Tier 3

desonide crm, lotion, oint 0.05% Tier 1 DESOWEN Tier 3

fluocinolone acetonide soln 0.01% Tier 1

hydrocortisone crm 2.5% Tier 1

hydrocortisone lotion 1% Tier 1

desonide foam 0.05% VERDESO Tier 2

desonide gel 0.05% DESONATE Tier 2

fluocinolone shampoo 0.01% CAPEX Tier 3

pramoxine/hydrocortisone PRAMOSONE Tier 3

pramoxine/hydrocortisone/emollient PRAMOSONE E Tier 3

Medium Potency

betamethasone valerate crm, lotion, oint 0.1%

Tier 1

clocortolone pivalate crm 0.1% Tier 1 CLODERM Tier 3

desoximetasone crm, oint 0.05% Tier 1 TOPICORT LP Tier 3

fluocinolone acetonide crm, oint 0.025%

Tier 1

fluocinolone acetonide oil 0.01% Tier 1 DERMA-SMOOTHE/FS Tier 2

fluticasone propionate crm, lotion 0.05%, oint 0.005%

Tier 1 CUTIVATE Tier 3

hydrocortisone butyrate crm 0.1% Tier 1 LOCOID LIPOCREAM Tier 3

hydrocortisone butyrate crm, oint, soln 0.1%

Tier 1 LOCOID Tier 3

hydrocortisone valerate crm, oint 0.2% Tier 1 WESTCORT Tier 3

mometasone crm, lotion, oint 0.1% Tier 1 ELOCON Tier 3

triamcinolone acetonide crm, lotion 0.025%

Tier 1

triamcinolone acetonide crm, lotion, oint 0.1%

Tier 1

flurandrenolide crm 0.05% CORDRAN SP Tier 2

flurandrenolide lotion 0.05% CORDRAN Tier 2

flurandrenolide tape CORDRAN Tier 2

hydrocortisone probutate crm 0.1% PANDEL Tier 2

hydrocortisone butyrate lotion 0.1% LOCOID LOTION Tier 3

High Potency

amcinonide crm, lotion, oint 0.1% Tier 1

betamethasone dipropionate augmented crm 0.05%

Tier 1 DIPROLENE AF Tier 3

betamethasone dipropionate augmented lotion 0.05%

Tier 1 DIPROLENE Tier 3

betamethasone dipropionate crm, lotion, oint 0.05%

Tier 1

49

desoximetasone crm, oint 0.25%, gel 0.05%

Tier 1 TOPICORT Tier 3

diflorasone diacetate crm 0.05% Tier 1

fluocinonide crm, gel, oint, soln 0.05% Tier 1

triamcinolone acetonide crm 0.5% Tier 1

diflorasone diacetate emollient crm 0.05% APEXICON E Tier 2

halcinonide crm, oint 0.1% HALOG Tier 3

Very High Potency

betamethasone dipropionate augmented gel, oint 0.05%

Tier 1 DIPROLENE Tier 3

clobetasol propionate crm, gel, oint, soln 0.05%

Tier 1 TEMOVATE Tier 3

clobetasol propionate lotion, shampoo 0.05%

Tier 1 CLOBEX Tier 3

diflorasone diacetate oint 0.05% Tier 1

fluocinonide crm 0.1% Tier 1 VANOS Tier 3

halobetasol propionate crm, oint 0.05%

Tier 1 ULTRAVATE Tier 3

clobetasol propionate spray 0.05% CLOBEX Tier 3

Emollients

ammonium lactate 12% Tier 1 LAC-HYDRIN Tier 3

urea URAMAXIN Tier 2

urea 45% URAMAXIN GT Tier 2

Immunomodulators Guidelines for the treatment of atopic dermatitis are available at: http://www.aad.org

pimecrolimus ELIDEL Tier 2

tacrolimus PROTOPIC Tier 2

Local Analgesics

lidocaine patch Tier 1 LIDODERM Tier 3

capsaicin 8% patch QUTENZA Tier 3

Local Anesthetics

lidocaine Tier 1 XYLOCAINE Tier 3

lidocaine/prilocaine Tier 1

Rosacea

metronidazole crm 0.75% Tier 1 METROCREAM Tier 3

metronidazole gel 0.75% Tier 1

metronidazole gel 1% Tier 1 METROGEL Tier 3

metronidazole lotion 0.75% Tier 1 METROLOTION Tier 3

sulfacetamide/sulfur Tier 1

doxycycline monohydrate ORACEA Tier 2

azelaic acid gel FINACEA Tier 3

brimonidine topical gel MIRVASO Tier 3

metronidazole crm NORITATE Tier 3

Scabicides and Pediculicides

lindane Tier 1

permethrin 5% Tier 1

spinosad Tier 1 NATROBA Tier 3

crotamiton EURAX Tier 2

50

ivermectin SKLICE Tier 2

benzyl alcohol ULESFIA Tier 3

Miscellaneous Skin and Mucous Membrane

acyclovir oint Tier 1 ZOVIRAX oint Tier 3

doxepin crm Tier 1 ZONALON Tier 3

imiquimod Tier 1 ALDARA Tier 3

podofilox Tier 1 CONDYLOX Tier 3

acyclovir ZOVIRAX crm Tier 2

alitretinoin PANRETIN Tier 2

becaplermin REGRANEX Tier 2

d hydrocortisone/aloe polysaccharide/ iodoquinol

ALCORTIN A Tier 2

imiquimod ZYCLARA Tier 2

absorbable fibrin sealant TACHOSIL Tier 3

acyclovir/hydrocortisone XERESE Tier 3

sinecatechins VEREGEN Tier 3

PA tretinoin emollient RENOVA Tier 3

PA collagenase clostridium histolyticum XIAFLEX Tier 4

PA interferon alfa-n3 ALFERON N Tier 4

MOUTH/THROAT/DENTAL AGENTS Anesthetics - Topical Oral

lidocaine viscous Tier 1

Steroids - Mouth/Throat

triamcinolone paste Tier 1

Miscellaneous

sodium fluoride Tier 1 PREVIDENT Tier 3

OPHTHALMIC Preferred Practice Pattern Guidelines for the treatment of various ophthalmic conditions are available at: http://one.aao.org Antiallergics

cromolyn sodium Tier 1

epinastine Tier 1 ELESTAT Tier 3

phenylephrine Tier 1

lodoxamide ALOMIDE Tier 2

alcaftadine LASTACAFT Tier 3

bepotastine BEPREVE Tier 3

olopatadine PATADAY Tier 3

olopatadine PATANOL Tier 3

Antifungals

natamycin NATACYN Tier 2

Anti-infectives

bacitracin Tier 1

ciprofloxacin Tier 1 CILOXAN Tier 3

erythromycin Tier 1

gentamicin Tier 1

levofloxacin Tier 1

neomycin/polymyxin B/gramicidin Tier 1 NEOSPORIN Tier 3

ofloxacin Tier 1 OCUFLOX Tier 3

polymyxin B/bacitracin Tier 1

51

polymyxin B/trimethoprim Tier 1 POLYTRIM Tier 3

sulfacetamide soln 10% Tier 1 BLEPH-10 Tier 3

tobramycin Tier 1 TOBREX Tier 3

azithromycin AZASITE Tier 2

besifloxacin BESIVANCE Tier 2

moxifloxacin MOXEZA Tier 2

moxifloxacin VIGAMOX Tier 2

Anti-infective/Anti-inflammatory Combinations

neomycin/dexamethasone Tier 1

neomycin/polymyxin B/ dexamethasone

Tier 1 MAXITROL Tier 3

neomycin/polymyxin B/hydrocortisone susp

Tier 1

sulfacetamide/prednisolone phosphate 10%/0.25%

Tier 1

tobramycin/dexamethasone susp 0.3%/0.1%

Tier 1 TOBRADEX SUSPENSION Tier 3

gentamicin/prednisolone acetate PRED-G Tier 2

sulfacetamide/prednisolone acetate oint 10%/0.2%

BLEPHAMIDE SOP Tier 2

tobramycin/dexamethasone oint 0.3%/0.1%

TOBRADEX OINTMENT Tier 2

tobramycin/loteprednol ZYLET Tier 2

Anti-inflammatories Nonsteroidal

bromfenac sodium Tier 1

diclofenac sodium Tier 1

flurbiprofen Tier 1 OCUFEN Tier 3

ketorolac 0.5% Tier 1 ACULAR Tier 3

nepafenac NEVANAC Tier 3

Steroidal

dexamethasone sodium phosphate Tier 1

fluorometholone Tier 1 FML Tier 3

prednisolone acetate 1% Tier 1 PRED FORTE Tier 3

prednisolone phosphate 1% Tier 1

dexamethasone MAXIDEX Tier 2

dexamethasone OZURDEX Tier 2

difluprednate DUREZOL Tier 2

fluorometholone acetate FLAREX Tier 2

loteprednol 0.2% ALREX Tier 2

loteprednol 0.5% LOTEMAX Tier 2

prednisolone acetate 0.12% PRED MILD Tier 2

rimexolone VEXOL Tier 2

Antivirals

trifluridine Tier 1 VIROPTIC Tier 3

ganciclovir ZIRGAN Tier 2

Beta-blockers Nonselective

carteolol Tier 1

levobunolol Tier 1 BETAGAN Tier 3

metipranolol Tier 1 OPTIPRANOLOL Tier 3

timolol maleate Tier 1 TIMOPTIC Tier 3

52

timolol maleate gel Tier 1 TIMOPTIC-XE Tier 3

timolol hemihydrate BETIMOL Tier 2

timolol maleate ISTALOL Tier 3

Selective

betaxolol BETOPTIC S Tier 3

Carbonic Anhydrase Inhibitors Topical

dorzolamide Tier 1 TRUSOPT Tier 3

brinzolamide AZOPT Tier 2

Carbonic Anhydrase Inhibitor/Beta-blocker Combinations

dorzolamide/timolol maleate Tier 1 COSOPT Tier 3

Immunomodulators

cyclosporine, emulsion RESTASIS Tier 2

Mydriatics

atropine Tier 1

cyclopentolate Tier 1 CYCLOGYL Tier 3

homatropine Tier 1 ISOPTO HOMATROPINE Tier 3

scopolamine ISOPTO HYOSCINE Tier 2

Parasympathomimetics

pilocarpine PILOPINE HS GEL Tier 3

Prostaglandins

latanoprost Tier 1 XALATAN Tier 3

travoprost Tier 1

bimatoprost LUMIGAN Tier 2

tafluprost ZIOPTAN Tier 2

travoprost TRAVATAN Z Tier 2

Sympathomimetics

brimonidine 0.15% Tier 1 ALPHAGAN P 0.15% Tier 3

brimonidine 0.2% Tier 1

brimonidine 0.1% ALPHAGAN P 0.1% Tier 2

Sympathomimetic/Beta-blocker Combinations

brimonidine/timolol COMBIGAN Tier 2

Miscellaneous

naphazoline Tier 1

aflibercept EYLEA Tier 4

cysteamine CYSTARAN Tier 4

PA ocriplasmin JETREA Tier 4

pegaptanib sodium MACUGEN Tier 4

ranibizumab LUCENTIS Tier 4

verteporfin VISUDYNE Tier 4

53

OTIC Clinical practice guidelines for the treatment of otitis media are available at: http://www.aap.org Anti-infectives

acetic acid Tier 1

acetic acid/aluminum acetate Tier 1

ciprofloxacin otic Tier 1 CETRAXAL Tier 2

ofloxacin otic Tier 1

Anti-infective/Anti-inflammatory Combinations

acetic acid/hydrocortisone Tier 1

neomycin/polymyxin B/hydrocortisone Tier 1 CORTISPORIN OTIC Tier 3

ciprofloxacin/dexamethasone CIPRODEX Tier 2

ciprofloxacin/hydrocortisone CIPRO HC OTIC Tier 2

Miscellaneous

fluocinolone acetonide Tier 1 DERMOTIC Tier 2

hydrocortisone/neomycin/colistin/ thonzonium

CORTISPORIN-TC OTIC Tier 3

hydrocortisone/pramoxine/chloroxylenol CORTANE-B Tier 3

54

WEBSITES

Agency for Healthcare Research and Quality http://www.ahrq.gov Alzheimer's Association http://www.alz.org American Academy of Allergy, Asthma and Immunology http://www.aaaai.org American Academy of Child & Adolescent Psychiatry http://www.aacap.org American Academy of Dermatology http://www.aad.org American Academy of Neurology http://www.aan.com American Academy of Ophthalmology http://www.aao.org American Academy of Pediatrics http://www.aap.org American Association for the Study of Liver Disease http://www.aasld.org American Association of Clinical Endocrinologists http://www.aace.com American Association of Diabetes Educators http://www.diabeteseducator.org American Cancer Society http://www.cancer.org American College of Allergy, Asthma and Immunology http://www.acaai.org American College of Cardiology http://www.acc.org American College of Chest Physicians http://www.chestnet.org American College of Gastroenterology http://www.acg.gi.org American College of Physicians http://www.acponline.org American College of Rheumatology http://www.rheumatology.org

American Congress of Obstetricians and Gynecologists http://www.acog.org American Diabetes Association http://www.diabetes.org American Gastroenterological Association http://www.gastro.org American Headache Society Committee for Headache Education http://www.achenet.org American Heart Association http://www.myamericanheart.org American Lung Association http://www.lungusa.org American Medical Association http://www.ama-assn.org American Psychiatric Association http://www.psych.org American Society of Anesthesiologists http://www.asahq.org American Society of Clinical Oncology http://www.asco.org American Society of Interventional Pain Physicians http://www.asipp.org American Urological Association http://www.auanet.org Centers for Disease Control and Prevention http://www.cdc.gov Centers for Disease Control and Prevention Guideline topics: AIDS http://www.cdc.gov/hiv/resources/guidelines/index.htm Centers for Disease Control and Prevention Guideline topics: Sexually Transmitted Diseases http://www.cdc.gov/std/treatment/default.htm CVS Caremark http://www.caremark.com The Food and Drug Administration http://www.fda.gov

55

Global Initiative for Asthma http://www.ginasthma.com Infectious Diseases Society of America http://www.idsociety.org Institute for Safe Medication Practices http://www.ismp.org Johns Hopkins AIDS Service http://www.thebody.com/content/art12096.html Juvenile Diabetes Research Foundation International http://www.jdf.org MedWatch http://www.fda.gov/medwatch National Agricultural Library http://www.nal.usda.gov National Cancer Institute http://www.cancer.gov/cancerinformation National Comprehensive Cancer Network http://www.nccn.org

National Foundation for Infectious Diseases http://www.nfid.org National Guideline Clearinghouse http://www.guideline.gov National Heart, Lung and Blood Institute http://www.nhlbi.nih.gov National Institutes of Health http://www.nih.gov National Kidney Foundation http://www.kidney.org National Osteoporosis Foundation http://www.nof.org North American Menopause Society http://www.menopause.org United States Department of Health and Human Services http://www.hhs.gov World Health Organization http://www.who.int

56

INDEX

A abacavir, 13 abacavir soln, 13 abacavir/lamivudine, 13 abacavir/lamivudine/zidovudine, 13 abatacept, 42 ABELCET, 13 ABILIFY, 26 abiraterone, 16 abobotulinumtoxinA, 29 ABRAXANE, 18 absorbable fibrin sealant, 50 ABSORICA, 46 ABSTRAL, 10 acamprosate calcium, 29 ACANYA, 47 acarbose, 30 ACCOLATE, 45 ACCU-CHEK FASTCLIX LANCET DEVICE, 31 ACCU-CHEK FASTCLIX LANCETS, 31 ACCU-CHEK METERS AND KITS, 31 ACCU-CHEK TEST STRIPS, 31 ACCUNEB, 45 ACCUPRIL, 19 ACCURETIC, 19 acebutolol, 21 ACEON, 19 ACETADOTE, 36 acetaminophen inj, 9 acetaminophen/dichloralphenazone/isometheptene, 28 acetazolamide, 22 acetazolamide ext-rel, 22 acetic acid, 53 acetic acid/aluminum acetate, 53 acetic acid/hydrocortisone, 53 acetylcysteine, 36 ACIPHEX, 39 acitretin, 47 aclidinium bromide, 44 ACLOVATE, 48 ACTEMRA, 43 ACTHAR H.P., 36 ACTIGALL, 37 ACTIMMUNE, 43 ACTIQ, 10 ACTIVELLA, 34 ACTONEL, 32 ACTOPLUS MET, 31 ACTOPLUS MET XR, 31 ACTOS, 31 ACULAR, 51 acyclovir, 50 acyclovir caps, susp, tabs, 14 acyclovir oint, 50 acyclovir/hydrocortisone, 50 ADAGEN, 36 ADALAT CC, 21 adalimumab, 42 adapalene, 47 adapalene/benzoyl peroxide, 47 ADCETRIS, 18 ADCIRCA, 23 ADDERALL, 27

ADDERALL XR, 27 adefovir dipivoxil, 14 ADEMPAS, 23 ado-trastuzumab emtansine, 17 ADOXA, 12 ADVAIR, 46 ADVAIR HFA, 46 ADVATE, 41 ADVICOR, 21 afatinib, 17 AFINITOR, 17 aflibercept, 52 agalsidase beta, 36 AGGRENOX, 41 AGRYLIN, 41 AHF, human/VWF, human, 41 albuterol, 45 albuterol ext-rel, 45 albuterol soln, 45 albuterol sulfate, CFC-free aerosol, 45 alcaftadine, 50 alclometasone crm, oint 0.05%, 48 ALCORTIN A, 50 ALDACTAZIDE, 22 ALDACTONE, 19 ALDARA, 50 aldesleukin, 17 ALDURAZYME, 37 alemtuzumab, 17 alendronate, 32 alendronate/vitamin D3, 32 ALFERON N, 50 alfuzosin ext-rel, 39 alglucosidase alfa, 36 ALIMTA, 16 ALINIA, 15 aliskiren, 22 aliskiren/amlodipine, 22 aliskiren/hydrochlorothiazide, 22 alitretinoin, 50 ALKERAN, 15 allopurinol, 9 alogliptin, 30 alogliptin/metformin, 30 alogliptin/pioglitazone, 30 ALOMIDE, 50 ALORA, 34 alosetron, 38 ALOXI, 37 alpha-1 proteinase inhibitor, 46 ALPHAGAN P 0.1%, 52 ALPHAGAN P 0.15%, 52 ALPHANATE, 41 ALPHANINE SD, 41 alprazolam, 23 alprazolam ext-rel, 23 ALREX, 51 ALSUMA, 28 ALTABAX, 47 ALTACE, 19 alteplase, 42 altretamine, 15 ALVESCO, 46 alvimopan, 39

57

amantadine, except tabs, 14, 26 AMARYL, 31 AMBIEN, 27 AMBIEN CR, 27 ambrisentan, 23 amcinonide crm, lotion, oint 0.1%, 48 AMERGE, 28 amifostine, 17 amiloride, 22 amiloride/hydrochlorothiazide, 22 amiodarone, 20 AMITIZA, 38 amitriptyline, 25 amitriptyline/perphenazine, 25 amlodipine, 21 amlodipine/atorvastatin, 22 amlodipine/olmesartan, 20 amlodipine/telmisartan, 20 amlodipine/valsartan, 20 amlodipine/valsartan/hydrochlorothiazide, 20 ammonium lactate 12%, 49 amoxicillin ext-rel, 12 amoxicillin, except film-coated tabs, 12 amoxicillin/clavulanate, 12 amoxicillin/clavulanate ext-rel, 12 amoxicillin/clavulanate susp 600 mg, 12 amphetamine/dextroamphetamine mixed salts, 27 amphetamine/dextroamphetamine mixed salts ext-rel, 27 AMPHOTEC, 13 amphotericin B lipid complex, 13 ampicillin, 12 ampicillin sodium/sulbactam sodium, 12 AMPYRA, 28 AMRIX, 28 ANAFRANIL, 24 anagrelide, 41 anakinra, 42 ANAPROX, 9 anastrozole, 16 ANDRODERM, 29 ANDROGEL, 29 anidulafungin, 13 ANORO ELLIPTA, 44 ANTABUSE, 29 ANTARA, 20 anthralin, 48 antihemophilic factor, 41 antihemophilic factor, recombinant, 41 anti-inhibitor coagulant complex, 41 ANTIVERT, 37 ANZEMET, 37 APEXICON E, 49 APIDRA, 30 apixaban, 40 APLENZIN, 25 APOKYN, 26 apomorphine, 26 apremilast, 43 aprepitant, 37 APRISO, 38 APTIOM, 24 APTIVUS, 14 ARALAST NP, 46 ARALEN, 13 ARANESP, 40 ARAVA, 42

ARCALYST, 43 ARCAPTA NEOHALER, 45 arformoterol soln, 45 ARICEPT, 24 ARICEPT ODT, 24 ARIMIDEX, 16 aripiprazole, 26 ARIXTRA, 40 armodafinil, 29 ARMOUR THYROID, 36 AROMASIN, 16 ARRANON, 18 arsenic trioxide, 17 artemether/lumefantrine, 13 ARTHROTEC, 9 ARZERRA, 18 ASACOL HD, 38 asenapine, 26 ASMANEX, 46 asparaginase, 17 asparaginase Erwinia chrysanthemi, 18 ASTAGRAF XL, 43 ASTELIN, 46 ASTEPRO, 46 ATACAND HCT, 19 atazanavir, 14 ATELVIA, 32 atenolol, 21 atenolol/chlorthalidone, 21 ATIVAN, 24 atomoxetine, 27 atorvastatin, 20 atovaquone, 15 atovaquone/proguanil, 13 ATRALIN, 47 ATRIPLA, 13 atropine, 52 atropine/hyoscyamine/scopolamine/phenobarbital, 37 ATROVENT spray, 46 AUBAGIO, 28 AUGMENTIN, 12 AUGMENTIN XR, 12 auranofin, 42 AUVI-Q, 44 AVALIDE, 19 AVANDAMET, 31 AVANDARYL, 31 AVANDIA, 31 AVAPRO, 19 AVASTIN, 18 AVELOX, 12 AVINZA, 10 AVODART, 39 AVONEX, 28 AXID, 38 AXIRON, 29 axitinib, 17 AYGESTIN, 36 azacitidine, 17 AZACTAM, 15 AZASITE, 51 azathioprine, 43 azelaic acid, 47 azelaic acid gel, 49 azelastine spray, 46 AZELEX, 47

58

AZILECT, 26 azilsartan, 20 azithromycin, 12, 51 azithromycin ext-rel, 12 AZOPT, 52 AZOR, 20 aztreonam, 15 aztreonam lysine inhalation soln, 45 AZULFIDINE, 38 AZULFIDINE EN-TABS, 38

B bacitracin, 50 baclofen, 28 baclofen intrathecal, 28 BACTROBAN, 47 balsalazide, 38 BANZEL, 24 BARACLUDE, 14 BCG live vaccine, 18 BD INSULIN SYRINGES, 31 BEBULIN, 41 BEBULIN VH, 41 becaplermin, 50 beclomethasone spray, 46 beclomethasone, CFC-free aerosol, 46 BECONASE AQ, 46 bedaquiline, 14 belatacept, 43 belimumab, 43 benazepril, 19 benazepril/amlodipine, 19 benazepril/hydrochlorothiazide, 19 bendamustine, 15 BENEFIX, 41 BENICAR, 20 BENICAR HCT, 20 BENLYSTA, 43 BENTYL, 37 BENZAC AC, 47 BENZACLIN, 47 BENZAMYCIN, 47 benzonatate, 45 benzoyl peroxide, 47 benztropine, 26 benzyl alcohol, 50 bepotastine, 50 BEPREVE, 50 BERINERT, 41 besifloxacin, 51 BESIVANCE, 51 BETAGAN, 51 betaine anhydrous, 40 betamethasone dipropionate augmented crm 0.05%, 48 betamethasone dipropionate augmented gel, oint 0.05%, 49 betamethasone dipropionate augmented lotion 0.05%, 48 betamethasone dipropionate crm, lotion, oint 0.05%, 48 betamethasone dipropionate/calcipotriene, 48 betamethasone valerate crm, lotion, oint 0.1%, 48 BETAPACE, 20 BETASERON, 28 betaxolol, 52 bethanechol, 40 BETHKIS, 45 BETIMOL, 52 BETOPTIC S, 52

bevacizumab, 18 bexarotene caps, 18 BEXXAR, 18 BIAXIN, 12 BIAXIN XL, 12 bicalutamide, 16 BICNU, 15 BIDIL, 23 bimatoprost, 52 bismuth subsalicylate + metronidazole + tetracycline, 39 bisoprolol/hydrochlorothiazide, 21 BIVIGAM, 42 bleomycin sulfate, 17 BLEPH-10, 51 BLEPHAMIDE SOP, 51 blood glucose meters and kits, 31 blood glucose test strips, 31 boceprevir, 14 BONIVA, 32 bortezomib, 18 bosentan, 23 BOSULIF, 17 bosutinib, 17 BOTOX, 29 BRAVELLE, 35 brentuximab vedotin, 18 BREO ELLIPTA, 46 BREVIBLOC, 21 BREVICON, 33 BRILINTA, 41 brimonidine 0.1%, 52 brimonidine 0.15%, 52 brimonidine 0.2%, 52 brimonidine topical gel, 49 brimonidine/timolol, 52 brinzolamide, 52 bromfenac sodium, 51 bromocriptine, 26, 31 BROVANA, 45 budesonide, 46 budesonide delayed-rel caps, 38 budesonide inhalation suspension, 46 budesonide spray, 46 budesonide/formoterol, 46 bumetanide, 22 BUPHENYL, 39 buprenorphine, 29 buprenorphine transdermal, 10 buprenorphine/naloxone sublingual film, 29 buprenorphine/naloxone sublingual tabs, 29 bupropion, 25 bupropion ext-rel, 25, 29 buspirone, 24 busulfan, 15 BUSULFEX, 15 butabarbital, 27 butalbital/acetaminophen, 10 butalbital/acetaminophen/caffeine, 10 butalbital/acetaminophen/caffeine/codeine, 10 butalbital/aspirin/caffeine, 10 butalbital/aspirin/caffeine/codeine, 10 BUTISOL SODIUM, 27 butorphanol nasal spray, 10 BUTRANS, 10 BYDUREON, 30 BYETTA, 30

59

BYSTOLIC, 21

C C1 esterase inhibitor, 41 cabazitaxel, 18 cabozantinib, 17 CADUET, 22 CAFCIT, 46 CAFERGOT, 28 caffeine citrate, 46 CALAN, 22 CALAN SR, 22 calcipotriene, 48 calcitonin-salmon inj, 32 calcitonin-salmon spray, 32 calcitriol (1,25-D3), 35 calcitriol oint, 48 calcium acetate, 36 CALDOLOR, 9 CAMBIA, 28 CAMPATH, 17 CAMPRAL, 29 CAMPTOSAR, 17 canagliflozin, 31 canakinumab, 43 CANASA, 38 candesartan/hydrochlorothiazide, 19 capecitabine, 16 CAPEX, 48 CAPITAL w/CODEINE, 10 CAPRELSA, 17 capsaicin 8% patch, 49 captopril/hydrochlorothiazide, 19 CARAC, 47 CARAFATE, 39 CARAFATE susp, 39 carbamazepine, 24, 28 carbamazepine ext-rel, 24 carbidopa/levodopa, 26 carbidopa/levodopa ext-rel, 26 carbidopa/levodopa/entacapone, 26 carboplatin, 17 CARDENE SR, 22 CARDIZEM, 22 CARDIZEM CD, 22 CARDURA, 19 carfilzomib, 18 CARIMUNE NF, 42 carmustine, 15 CARNITOR, 36 carteolol, 51 carvedilol, 21 carvedilol phosphate ext-rel, 21 CASODEX, 16 CATAPRES, 19 CATAPRES-TTS, 19 CATHFLO ACTIVASE, 42 CAYSTON, 45 CEDAX, 11 cefaclor, 11 cefdinir, 11 cefditoren, 11 cefepime, 11 cefixime, 11 cefotaxime, 11 cefoxitin, 11

cefpodoxime, 11 cefprozil, 11 ceftaroline fosamil, 12 ceftazidime, 11 ceftibuten, 11 CEFTIN, 11 ceftriaxone, 11 cefuroxime axetil, 11 CELEBREX, 9 celecoxib, 9 CELEXA, 25 CELLCEPT, 43 CELLCEPT suspension, 43 cephalexin, 11 CEPROTIN, 42 CEREZYME, 37 certolizumab pegol, 42 CERUBIDINE, 17 CETRAXAL, 53 cetrorelix, 35 CETROTIDE, 35 cetuximab, 18 cevimeline, 39 CHANTIX, 29 CHEMSTRIP K URINE KETONE STRIPS, 31 CHEMSTRIP UG URINE GLUCOSE STRIPS, 31 CHEMSTRIP UGK URINE GLUCOSE/KETONE STRIPS, 31 chlorambucil, 15 chlordiazepoxide, 23 chloroquine, 13 chlorthalidone, 22 cholestyramine pkt, 20 choline magnesium trisalicylate, 9 choriogonadotropin alfa, 35 chorionic gonadotropin, 34 CIALIS, 39 ciclesonide, 46 ciclopirox, 47 cidofovir, 14 cilostazol, 42 CILOXAN, 50 cimetidine, 38 CIMZIA, 42 cinacalcet, 31 CINRYZE, 41 CIPRO HC OTIC, 53 CIPRO susp, 12 CIPRO tabs, 12 CIPRODEX, 53 ciprofloxacin, 50 ciprofloxacin ext-rel, 12 ciprofloxacin otic, 53 ciprofloxacin susp, 12 ciprofloxacin tabs, 12 ciprofloxacin/dexamethasone, 53 ciprofloxacin/hydrocortisone, 53 cisplatin, 17 citalopram, 25 CITRANATAL RX, 44 cladribine, 16 CLAFORAN, 11 CLARINEX, 44 CLARINEX syrup, 44 CLARINEX-D, 45 clarithromycin, 12 clarithromycin ext-rel, 12

60

CLEOCIN, 15 CLEOCIN T, 47 CLEOCIN vaginal supp, 40 CLIMARA, 34 CLIMARA PRO, 34 clindamycin, 15 clindamycin gel, lotion, soln, 47 clindamycin supp, 40 clindamycin swabs, 47 clindamycin/benzoyl peroxide, 47 clindamycin/tretinoin, 47 CLINORIL, 9 clobazam, 24 clobetasol propionate crm, gel, oint, soln 0.05%, 49 clobetasol propionate lotion, shampoo 0.05%, 49 clobetasol propionate spray 0.05%, 49 CLOBEX, 49 clocortolone pivalate crm 0.1%, 48 CLODERM, 48 clofarabine, 16 CLOLAR, 16 CLOMID, 34 clomiphene, 34 clomipramine, 24 clonazepam tabs, 23 clonidine, 19 clonidine ext-rel, 27 clonidine transdermal, 19 clopidogrel, 41 clorazepate, 23 clotrimazole, 47 clotrimazole troches, 12 clotrimazole/betamethasone, 47 clozapine, 26 clozapine orally disintegrating tablets, 26 CLOZARIL, 26 coagulation factor VIIa, 41 COARTEM, 13 codeine/acetaminophen, 10 codeine/acetaminophen susp, 10 codeine/promethazine, 45 codeine/promethazine/phenylephrine, 45 COLAZAL, 38 colchicine, 9 COLCRYS, 9 colesevelam, 20 COLESTID, 20 colestipol, 20 collagenase clostridium histolyticum, 50 COLYTE, 38 COMBIGAN, 52 COMBIPATCH, 34 COMBIVENT RESPIMAT, 44 COMBIVIR, 13 COMETRIQ, 17 COMPLERA, 13 COMTAN, 26 CONCERTA, 27 CONDYLOX, 50 conjugated estrogens/bazedoxifene, 34 COPAXONE, 28 COPEGUS, 14 CORDARONE, 20 CORDRAN, 48 CORDRAN SP, 48 COREG, 21

COREG CR, 21 CORIFACT, 41 CORTANE-B, 53 CORTEF, 35 corticotropin, 36 corticotropin powder, 36 CORTIFOAM, 38 cortisone acetate, 35 CORTISPORIN OTIC, 53 CORTISPORIN-TC OTIC, 53 COSMEGEN, 17 COSOPT, 52 COUMADIN, 40 COZAAR, 19 CREON, 38 CRESTOR, 21 CRIXIVAN, 14 crizotinib, 17 crofelemer delayed-rel, 37 cromolyn sodium, 39, 50 cromolyn soln, 45 crotamiton, 49 CUBICIN, 15 CUPRIMINE, 42 CUTIVATE, 48 CUVPOSA, 39 cyanocobalamin inj, 44 cyanocobalamin spray, 44 CYANOKIT, 36 CYCLESSA, 33 cyclobenzaprine, 28 cyclobenzaprine ext-rel, 28 CYCLOGYL, 52 cyclopentolate, 52 cyclophosphamide, 15 cyclophosphamide inj, 15 CYCLOSET, 31 cyclosporine, 43 cyclosporine, emulsion, 52 cyclosporine, modified, 43 CYKLOKAPRON inj, 42 CYMBALTA, 25 cyproheptadine, 45 CYSTADANE, 40 CYSTAGON, 36 CYSTARAN, 52 cysteamine, 36, 52 cysteamine delayed-rel, 36 cytarabine, 16 cytarabine liposome, 16 CYTOGAM, 14 cytomegalovirus immune globulin, 14 CYTOMEL, 36 CYTOTEC, 39 CYTOVENE inj, 14

D D.H.E. 45, 28 dabigatran etexilate, 40 dabrafenib, 17 DACOGEN, 18 dactinomycin, 17 dalfampridine ext-rel, 28 DALIRESP, 46 dalteparin, 40 danazol, 34

61

DANTRIUM, 28 dantrolene, 28 dapsone, 15 daptomycin, 15 DARAPRIM, 13 darbepoetin alfa, 40 darifenacin ext-rel, 40 darunavir, 14 dasatinib, 17 daunorubicin, 17 daunorubicin citrate liposomal, 18 DAUNOXOME, 18 DAYPRO, 9 DAYTRANA, 27 DDAVP, 36 decitabine, 18 deferasirox, 42 deferiprone, 42 deferoxamine, 42 degarelix acetate, 16 delavirdine, 13 DELESTROGEN, 34 DELZICOL, 38 DEMADEX, 22 denosumab, 32 DEPAKENE, 24 DEPAKOTE, 24 DEPOCYT, 16 DEPO-PROVERA, 33 DERMA-SMOOTHE/FS, 48 DERMOTIC, 53 DESFERAL, 42 desipramine, 25 desirudin, 40 desloratadine, 44 desloratadine syrup, 44 desloratadine/pseudoephedrine ext-rel, 45 desmopressin, 36 desmopressin spray, 41 DESOGEN, 32 desogestrel/EE, 33 desogestrel/EE 0.15/30, 32 DESONATE, 48 desonide crm, lotion, oint 0.05%, 48 desonide foam 0.05%, 48 desonide gel 0.05%, 48 DESOWEN, 48 desoximetasone crm, oint 0.05%, 48 desoximetasone crm, oint 0.25%, gel 0.05%, 49 desvenlafaxine ext-rel, 25 DETROL, 39 DETROL LA, 40 dexamethasone, 35, 51 dexamethasone sodium phosphate, 51 DEXEDRINE SPANSULE, 27 DEXILANT, 39 dexlansoprazole delayed-rel, 39 dexmethylphenidate, 27 dexmethylphenidate ext-rel, 27 dexrazoxane, 17 dextranomer/sodium hyaluronate, 39 dextroamphetamine, 27 dextroamphetamine ext-rel, 27 dextromethorphan/quinidine, 29 DIABETA, 31 DIAMOX SEQUELS, 22

DIASTAT, 24 diazepam, 23 diazepam rectal gel, 24 diazoxide, 35 DICLEGIS, 37 diclofenac potassium packets, 28 diclofenac sodium, 47, 51 diclofenac sodium delayed-rel, 9 diclofenac sodium delayed-rel/misoprostol, 9 diclofenac sodium ext-rel, 9 diclofenac sodium gel, 9 diclofenac sodium soln, 9 dicloxacillin, 12 dicyclomine, 37 didanosine delayed-rel, 13 didanosine soln, 13 DIFFERIN, 47 DIFICID, 12 diflorasone diacetate crm 0.05%, 49 diflorasone diacetate emollient crm 0.05%, 49 diflorasone diacetate oint 0.05%, 49 DIFLUCAN, 12 diflunisal, 9 difluprednate, 51 digoxin, 22 dihydroergotamine inj, 28 DILACOR XR, 22 DILANTIN, 24 DILANTIN INFATABS, 24 DILAUDID, 10 diltiazem, 22 diltiazem ext-rel, 22 diltiazem ext-rel 360 mg, 22 diltiazem ext-rel, except 360 mg, 22 dimethyl fumarate delayed-rel, 28 DIOVAN, 20 DIOVAN HCT, 20 DIPENTUM, 38 diphenhydramine, 26, 45 diphenoxylate/atropine, 37 DIPROLENE, 48, 49 DIPROLENE AF, 48 dipyridamole, 41 dipyridamole ext-rel/aspirin, 41 disopyramide, 20 disopyramide ext-rel, 20 disulfiram, 29 DITROPAN XL, 39 divalproex sodium delayed-rel, 24 docetaxel, 18 dofetilide, 20 dolasetron, 37 dolutegravir, 13 donepezil, 24 donepezil orally disintegrating tabs, 24 DONNATAL, 37 DORAL, 27 DORIBAX, 15 doripenem, 15 dornase alfa, 45 dorzolamide, 52 dorzolamide/timolol maleate, 52 DOVONEX, 48 doxazosin, 19 doxepin, 25, 27 doxepin crm, 50

62

doxercalciferol, 35 DOXIL, 18 doxorubicin liposomal, 18 doxycycline hyclate, 12 doxycycline monohydrate, 12, 49 doxylamine/pyridoxine delayed-rel, 37 DRISDOL, 44 DRITHOCREME HP, 48 dronabinol, 37 dronedarone, 20 drospirenone/EE 3/20 - Gianvi, 32 drospirenone/EE 3/30, 32 DUAC, 47 DUAVEE, 34 DUET DHA, 44 DUETACT, 31 DULERA, 46 duloxetine delayed-rel, 25 DUONEB, 44 DURAGESIC, 10 DUREZOL, 51 dutasteride, 39 dutasteride/tamsulosin, 39 DUTOPROL, 21 DYAZIDE, 22 DYSPORT, 29

E E.E.S., 12 ecallantide, 41 econazole, 47 eculizumab, 41 EDARBI, 20 EDECRIN, 22 EDLUAR, 27 EDURANT, 13 EE/norethindrone acetate, 34 efavirenz, 13 efavirenz/emtricitabine/tenofovir, 13 EFFEXOR XR, 25 EFFIENT, 41 EFUDEX, 47 EGRIFTA, 37 ELAPRASE, 37 ELDEPRYL, 26 ELELYSO, 37 ELESTAT, 50 ELIDEL, 49 ELIGARD, 16 ELIQUIS, 40 ELITEK, 16 ELIXOPHYLLIN, 46 ELLENCE, 18 ELMIRON, 40 ELOCON, 48 elosulfase alfa, 36 ELOXATIN, 18 ELSPAR, 17 eltrombopag, 41 elvitegravir/cobicistat/emtricitabine/tenofovir, 13 EMEND, 37 EMSAM, 25 emtricitabine, 13 emtricitabine/rilpivirine/tenofovir, 13 emtricitabine/tenofovir, 13 EMTRIVA, 13

ENABLEX, 40 enalapril, 19 enalapril/hydrochlorothiazide, 19 ENBREL, 42 ENDOMETRIN, 36 enfuvirtide, 13 ENJUVIA, 34 enoxaparin, 40 entacapone, 26 entecavir, 14 ENTEREG, 39 ENTOCORT EC, 38 enzalutamide, 16 EPIDUO, 47 EPIFOAM, 39 epinastine, 50 epinephrine, 44 EPIPEN, 44 EPIPEN JR., 44 epirubicin, 17, 18 EPIVIR, 13 EPIVIR-HBV, 14 eplerenone, 19 epoetin alfa, 40 EPOGEN, 40 epoprostenol, 23 epoprostenol sodium, 23 eprosartan, 19 eprosartan/hydrochlorothiazide, 20 EPZICOM, 13 EQUETRO, 28 ERAXIS, 13 ERBITUX, 18 ergocalciferol (D2), 44 ergotamine/caffeine, 28 ergotamine/caffeine supp, 28 eribulin, 18 ERIVEDGE, 18 erlotinib, 17 ERTACZO, 47 ertapenem, 15 ERWINAZE, 18 ERY-TAB, 12 erythromycin, 50 erythromycin delayed-rel, 12 erythromycin dispertabs, 12 erythromycin ethylsuccinate, 12 erythromycin gel 2%, 47 erythromycin soln, 47 erythromycin stearate, 12 erythromycin/benzoyl peroxide, 47 erythromycin/sulfisoxazole, 12 escitalopram, 25 eslicarbazepine, 24 esmolol, 21 esomeprazole delayed-rel, 39 estazolam, 27 ESTRACE, 34 estradiol, 34 estradiol transdermal gel, 34 estradiol transdermal spray, 34 estradiol vaginal crm, 34 estradiol vaginal ring, 34 estradiol vaginal tabs, 34 estradiol valerate, 34 estradiol valerate and dienogest/estradiol valerate, 33

63

estradiol/levonorgestrel, 34 estradiol/norethindrone acetate, 34 estradiol/norgestimate, 34 ESTROGEL, 34 estrogens, conjugated, 34 estrogens, conjugated crm, 34 estrogens, conjugated, synthetic B, 34 estrogens, conjugated/medroxyprogesterone, 34 estrogens, esterified/methyltestosterone, 34 estropipate, 34 ESTROSTEP FE, 33 eszopiclone, 27 etanercept, 42 ethacrynic acid, 22 ethambutol, 14 ethosuximide, 24 ethynodiol diacetate/EE 1/35 - Zovia 1/35, 32 ethynodiol diacetate/EE 1/50 - Zovia 1/50, 33 ETHYOL, 17 etidronate, 32 etodolac, 9 etodolac ext-rel, 9 etonogestrel implant, 33 etonogestrel/EE ring, 34 ETOPOPHOS, 18 etoposide, 17 etoposide phosphate, 18 etravirine, 13 EUFLEXXA, 11 EURAX, 49 EVAMIST, 34 everolimus, 17, 43 EVISTA, 36 EVOXAC, 39 EXALGO, 10 EXELDERM, 47 EXELON, 24 EXELON PATCH, 24 exemestane, 16 exenatide, 30 exenatide ext-rel, 30 EXFORGE, 20 EXFORGE HCT, 20 EXJADE, 42 EXTAVIA, 28 EYLEA, 52 ezetimibe, 20 ezetimibe/simvastatin, 21 ezogabine, 24

F FABRAZYME, 36 FACTIVE, 12 factor IX concentrate, 41 factor XIII concentrate, 41 famciclovir, 14 famotidine, 38 famotidine susp, 38 FAMVIR, 14 FANAPT, 26 FARESTON, 16 FASLODEX, 16 FAZACLO, 26 febuxostat, 9 FEIBA VH IMMUNO, 41 felbamate, 24

FELBATOL, 24 FELDENE, 9 felodipine ext-rel, 21 FEMARA, 16 FEMHRT, 34 FEMRING, 34 fenofibrate, 20 fenofibric acid delayed-rel, 20 fenoprofen, 9 fentanyl citrate buccal, 10 fentanyl citrate nasal spray, 10 fentanyl sublingual spray, 10 fentanyl sublingual tablets, 10 fentanyl transdermal, 10 fentanyl transmucosal lozenge, 10 FENTORA, 10 FERAHEME, 44 FERRIPROX, 42 FERRLECIT, 44 ferumoxytol inj, 44 fesoterodine ext-rel, 40 FETZIMA, 25 fibrinogen, 41 fidaxomicin, 12 filgrastim, 40 FINACEA, 49 finasteride, 39 fingolimod, 28 FIORICET, 10 FIORICET w/CODEINE, 10 FIORINAL, 10 FIORINAL w/CODEINE, 10 FIRAZYR, 41 FIRMAGON, 16 FLAGYL, 15 FLAREX, 51 FLEBOGAMMA, 42 flecainide, 20 FLOLAN, 23 FLOMAX, 39 FLONASE, 46 FLOVENT, 46 FLOVENT HFA, 46 floxuridine, 16 fluconazole, 12 FLUDARA, 16 fludarabine, 16 fludrocortisone, 35 FLUMADINE, 14 flunisolide spray, 46 fluocinolone acetonide, 53 fluocinolone acetonide crm, oint 0.025%, 48 fluocinolone acetonide oil 0.01%, 48 fluocinolone acetonide soln 0.01%, 48 fluocinolone shampoo 0.01%, 48 fluocinonide crm 0.1%, 49 fluocinonide crm, gel, oint, soln 0.05%, 49 fluoride drops, 44 fluoride tabs, 44 fluorometholone, 51 fluorometholone acetate, 51 FLUOROPLEX, 47 fluorouracil, 47 fluoxetine, 25 fluoxetine delayed-rel, 25 fluphenazine, 26

64

flurandrenolide crm 0.05%, 48 flurandrenolide lotion 0.05%, 48 flurandrenolide tape, 48 flurazepam, 27 flurbiprofen, 9, 51 flutamide, 16 fluticasone, 46 fluticasone furoate spray, 46 fluticasone propionate crm, lotion 0.05%, oint 0.005%, 48 fluticasone spray, 46 fluticasone, CFC-free aerosol, 46 fluticasone/salmeterol, 46 fluticasone/salmeterol, CFC-free aerosol, 46 fluticasone/vilanterol, 46 fluvastatin, 20 fluvastatin ext-rel, 21 fluvoxamine, 24 fluvoxamine ext-rel, 24 FML, 51 FOCALIN, 27 FOCALIN XR, 27 folic acid, 43 FOLLISTIM AQ, 35 follitropin beta, 35 FOLOTYN, 16 fondaparinux, 40 FORADIL, 45 FORFIVO XL, 25 formoterol inhalation caps, 45 FORTAMET, 30 FORTAZ, 11 FORTEO, 32 FORTESTA, 29 FOSAMAX, 32 FOSAMAX PLUS D, 32 fosamprenavir, 14 foscarnet, 14 fosinopril, 19 fosinopril/hydrochlorothiazide, 19 FOSRENOL, 36 FRAGMIN, 40 FROVA, 28 frovatriptan, 28 fulvestrant, 16 FULYZAQ, 37 furosemide, 22 FUSILEV, 18 FUZEON, 13 FYCOMPA, 24

G gabapentin, 24 gabapentin enacarbil ext-rel, 29 GABITRIL, 24 galantamine, 24 galantamine ext-rel, 24 gallium nitrate, 36 galsulfase, 37 GALZIN, 44 GAMASTAN S-D, 42 GAMMAGARD LIQUID, 42 GAMMAGARD S-D, 42 GAMMAKED, 42 GAMMAPLEX, 42 GAMUNEX, 42 GAMUNEX-C, 42

ganciclovir, 14, 51 ganciclovir inj, 14 GANIRELIX, 35 ganirelix acetate, 35 GANITE, 36 GASTROCROM, 39 GATTEX, 39 GAZYVA, 18 GELNIQUE, 40 GEL-ONE, 11 gemcitabine, 16 gemfibrozil, 20 gemifloxacin, 12 GEMZAR, 16 GENOTROPIN, 35 gentamicin, 47, 50 gentamicin/prednisolone acetate, 51 GEODON, 26 GILENYA, 28 GILOTRIF, 17 GLASSIA, 46 glatiramer, 28 GLEEVEC, 17 GLIADEL WAFER, 15 glimepiride, 31 glipizide, 31 glipizide ext-rel, 31 glipizide/metformin, 30 GLUCAGON EMERGENCY KIT, 35 glucagon, human recombinant, 35 GLUCOPHAGE, 30 GLUCOPHAGE XR, 30 GLUCOTROL, 31 GLUCOTROL XL, 31 GLUCOVANCE, 30 glyburide, 31 glyburide, micronized, 31 glyburide/metformin, 30 glycerol phenylbutyrate, 37 glycopyrrolate, 39 GLYNASE, 31 GLYSET, 30 golimumab, 42 GOLYTELY, 38 gonadorelin, 34 goserelin acetate, 16 granisetron, 37 granisetron transdermal, 37 GRANIX, 40 GRIFULVIN V, 12 griseofulvin microsize, 12 griseofulvin ultramicrosize, 12 GRIS-PEG, 12 guanfacine ext-rel, 27

H HALAVEN, 18 halcinonide crm, oint 0.1%, 49 HALFLYTELY, 38 halobetasol propionate crm, oint 0.05%, 49 HALOG, 49 haloperidol, 26 HECTOROL, 35 HELIXATE FS, 41 HEMOFIL M, 41 HEPAGAM B, 42

65

hepatitis B immune globulin, 42 HEPSERA, 14 HERCEPTIN, 18 HETLIOZ, 27 HEXALEN, 15 high molecular weight hyaluronan, 10 HIPREX, 15 histrelin acetate, 16, 37 HIZENTRA, 42 homatropine, 52 HORIZANT, 29 HUMALOG, 30 HUMALOG MIX, 30 HUMATE-P, 41 HUMATROPE, 35 HUMIRA, 42 HUMULIN 70/30, 30 HUMULIN N, 30 HUMULIN R, 30 HYALGAN, 11 HYCAMTIN, 17 HYCAMTIN inj, 17 hydralazine, 23 HYDREA, 17 hydrochlorothiazide, 22 hydrocodone/acetaminophen, 10 hydrocodone/acetaminophen - Vicodin, 10 hydrocodone/acetaminophen - Vicodin ES, 10 hydrocodone/chlorpheniramine/pseudoephedrine, 45 hydrocodone/homatropine, 45 hydrocodone/pseudoephedrine, 45 hydrocortisone, 35 hydrocortisone acetate foam, 38 hydrocortisone acetate/pramoxine foam, 39 hydrocortisone butyrate crm 0.1%, 48 hydrocortisone butyrate crm, oint, soln 0.1%, 48 hydrocortisone butyrate lotion 0.1%, 48 hydrocortisone crm 2.5%, 48 hydrocortisone enema, 38 hydrocortisone lotion 1%, 48 hydrocortisone probutate crm 0.1%, 48 hydrocortisone valerate crm, oint 0.2%, 48 hydrocortisone/aloe polysaccharide/iodoquinol, 50 hydrocortisone/neomycin/colistin/thonzonium, 53 hydrocortisone/pramoxine/chloroxylenol, 53 hydromorphone, 10 hydromorphone ext-rel, 10 hydroxocobalamin, 36 hydroxychloroquine, 42 hydroxyprogesterone caproate, 36 hydroxyurea, 17 hydroxyzine HCl, 24, 45 hydroxyzine pamoate, 24, 45 hylan G-F 20, 10 hyoscyamine sulfate, 37 hyoscyamine sulfate ext-rel, 37 HYPERHEP B S-D, 42 HYPERRHO S-D, 42 HYZAAR, 19

I ibandronate, 32 ibrutinib, 17 ibuprofen, 9 ibuprofen inj, 9 icatibant, 41

ICLUSIG, 17 icosapent ethyl, 21 idursulfase, 37 ifosfamide/mesna, 15 ILARIS, 43 iloperidone, 26 iloprost, 23 imatinib mesylate, 17 IMBRUVICA, 17 IMDUR, 23 imiglucerase, 37 imipenem/cilastatin, 15 imipramine HCl, 25 imipramine pamoate, 25 imiquimod, 50 IMITREX, 28 immune globulin, gamma, 42 immune globulin, gamma (IGG), 42 immune globulin, intravenous, 42 immune globulin, subcutaneous, 42 IMPLANON, 33 IMURAN, 43 INCIVEK, 14 incobotulinumtoxinA, 29 INCRELEX, 35 indacaterol, 45 indapamide, 22 INDERAL LA, 21 indinavir, 14 INDOCIN susp, 9 indomethacin, 9 indomethacin ext-rel, 9 indomethacin susp, 9 INFERGEN, 43 infliximab, 42 INLYTA, 17 INNOPRAN XL, 21 INSPRA, 19 insulin aspart, 30 insulin aspart protamine 70%/insulin aspart 30%, 30 insulin detemir, 30 insulin glargine, 30 insulin glulisine, 30 insulin human, 30 insulin isophane human, 30 insulin isophane human 70%/regular 30%, 30 insulin lispro, 30 insulin lispro protamine/insulin lispro, 30 insulin syringes, 31 INTELENCE, 13 interferon alfa-2b, 43 interferon alfacon-1, 43 interferon alfa-n3, 50 interferon beta-1a, 28 interferon beta-1b, 28 interferon gamma-1b, recombinant, 43 INTRON A, 43 INTUNIV, 27 INVANZ, 15 INVEGA, 26 INVEGA SUSTENNA, 26 INVIRASE, 14 INVOKANA, 31 ipilimumab, 18 ipratropium soln, 44 ipratropium spray, 46

66

ipratropium/albuterol soln, 44 ipratropium/albuterol, CFC-free aerosol, 44 IPRIVASK, 40 irbesartan, 19 irbesartan/hydrochlorothiazide, 19 irinotecan, 17 iron sucrose inj, 44 ISENTRESS, 13 isocarboxazid, 25 isoniazid, 14 ISOPTO HOMATROPINE, 52 ISOPTO HYOSCINE, 52 ISORDIL, 23 isosorbide dinitrate oral, 23 isosorbide dinitrate/hydralazine, 23 isosorbide mononitrate, 23 isosorbide mononitrate ext-rel, 23 isotretinoin, 46 ISTALOL, 52 ISTODAX, 18 itraconazole caps, 12 itraconazole oral soln, 13 ivacaftor, 45 ivermectin, 50 ixabepilone, 18 IXEMPRA, 18

J JAKAFI, 17 JALYN, 39 JANUMET, 30 JANUMET XR, 30 JANUVIA, 30 JENTADUETO, 30 JETREA, 52 JEVTANA, 18 JUXTAPID, 21

K KADCYLA, 17 KADIAN, 10 KALBITOR, 41 KALETRA, 14 KALYDECO, 45 KAPVAY, 27 KAZANO, 30 KEFLEX, 11 KEPIVANCE, 39 KEPPRA, 24 KEPPRA XR, 24 KETEK, 12 ketoconazole, 47 ketoconazole 2%, 47 ketoconazole shampoo 2%, 48 ketoconazole tabs, 12 ketoprofen, 9 ketoprofen ext-rel, 9 ketorolac, 9 ketorolac 0.5%, 51 ketorolac tromethamine nasal spray, 9 KHEDEZLA, 25 KINERET, 42 KLONOPIN, 23 KOATE-DVI, 41 KOGENATE FS, 41 KOMBIGLYZE XR, 30 KORLYM, 36

KRYSTEXXA, 9 KUVAN, 35 KYNAMRO, 21 KYPROLIS, 18

L LAC-HYDRIN, 49 lacosamide, 24 lactulose, 38 LAMICTAL, 24 LAMICTAL ODT, 24 LAMICTAL XR, 24 LAMISIL, 12, 47 lamivudine, 13, 14 lamivudine/zidovudine, 13 lamotrigine, 24 lamotrigine ext-rel, 24 lamotrigine orally disintegrating tablets, 24 lancet device, 31 lancets, 31 LANOXIN, 22 lanreotide acetate, 37 lansoprazole + amoxicillin + clarithromycin, 39 lansoprazole delayed-rel, 39 lanthanum, 36 LANTUS, 30 lapatinib, 17 laronidase, 37 LASIX, 22 LASTACAFT, 50 latanoprost, 52 LATUDA, 26 LAZANDA, 10 leflunomide, 42 lenalidomide, 16 LESCOL, 20 LESCOL XL, 21 LETAIRIS, 23 letrozole, 16 leucovorin calcium, 17 LEUKERAN, 15 LEUKINE, 40 leuprolide acetate, 16 leuprolide acetate/norethindrone acetate, 34 LEVAQUIN, 12 LEVATOL, 21 LEVBID, 37 LEVEMIR, 30 levetiracetam, 24 levetiracetam ext-rel, 24 levobunolol, 51 levocarnitine, 36 levocetirizine, 44 levofloxacin, 12, 50 levoleucovorin calcium, 18 levomilnacipran ext-rel, 25 levonorgestrel releasing IUD, 33 levonorgestrel/EE - Trivora, 33 levonorgestrel/EE 0.09/20 - Amethyst, 33 levonorgestrel/EE 0.1/20, 32 levonorgestrel/EE 0.1/20 and EE 10, 33 levonorgestrel/EE 0.15/30, 32 levonorgestrel/EE 0.15/30 - Jolessa, 33 levonorgestrel/EE 0.15/30 - Levora, 32 levonorgestrel/EE 0.15/30 and EE 10, 33 levothyroxine, 36

67

levothyroxine - Levoxyl, 36 LEVSIN, 37 LEXAPRO, 25 LEXIVA, 14 LIALDA, 38 lidocaine, 49 lidocaine patch, 49 lidocaine viscous, 50 lidocaine/prilocaine, 49 LIDODERM, 49 linaclotide, 38 linagliptin, 30 linagliptin/metformin, 30 lindane, 49 linezolid, 15 LINZESS, 38 LIORESAL INTRATHECAL, 28 liothyronine, 36 liotrix, 36 LIPITOR, 20 LIPOFEN, 20 liraglutide, 30 lisdexamfetamine, 27 lisinopril, 19 lisinopril/hydrochlorothiazide, 19 lithium carbonate, 28 lithium carbonate ext-rel tabs 300 mg, 28 lithium carbonate ext-rel tabs 450 mg, 28 LITHOBID, 28 LIVALO, 21 LOCOID, 48 LOCOID LIPOCREAM, 48 LOCOID LOTION, 48 lodoxamide, 50 LOESTRIN 1.5/30, 32 LOESTRIN 1/20, 32 LOESTRIN FE 1.5/30, 32 LOESTRIN FE 1/20, 32 lomitapide, 21 LOMOTIL, 37 lomustine, 15 loperamide, 37 LOPID, 20 lopinavir/ritonavir, 14 LOPRESSOR, 21 LOPRESSOR HCT, 21 LOPROX, 47 lorazepam, 24 LORCET, 10 LORTAB, 10 losartan, 19 losartan/hydrochlorothiazide, 19 LOSEASONIQUE, 33 LOTEMAX, 51 LOTENSIN, 19 LOTENSIN HCT, 19 loteprednol 0.2%, 51 loteprednol 0.5%, 51 LOTREL, 19 LOTRONEX, 38 lovastatin, 20 LOVAZA, 21 LOVENOX, 40 loxapine, 26 LOXITANE, 26 lubiprostone, 38

LUCENTIS, 52 LUMIGAN, 52 LUMIZYME, 36 LUNESTA, 27 LUPANETA PACK, 34 LUPRON DEPOT, 16 LUPRON DEPOT-PED, 16 lurasidone, 26 LURIDE, 44 LURIDE LOZI-TABS, 44 LUTREPULSE, 34 LUVOX CR, 24 LYRICA, 27 LYSODREN, 17 LYSTEDA, 42

M macitentan, 23 MACROBID, 15 MACRODANTIN, 15 MACUGEN, 52 mafenide, 47 MAKENA, 36 MALARONE, 13 maraviroc, 13 MARINOL, 37 MARPLAN, 25 MATULANE, 17 MAVIK, 19 MAXALT/MAXALT-MLT, 28 MAXIDEX, 51 MAXITROL, 51 MAXZIDE, 22 MAXZIDE-25, 22 mecasermin, 35 mechlorethamine, 15 mechlorethamine gel, 15 meclizine, 37 MEDROL, 35 medroxyprogesterone acetate, 36 medroxyprogesterone acetate 150 mg/mL, 33 mefloquine, 13 MEFOXIN, 11 MEGACE, 16 MEGACE ES, 16 megestrol acetate, 16 megestrol acetate susp, 16 MEKINIST, 17 meloxicam, 9 melphalan, 15 memantine, 24 MENOPUR, 35 menotropins, 35 MEPHYTON, 44 MEPRON, 15 mercaptopurine, 16 meropenem, 15 MERREM, 15 mesalamine delayed-rel caps, 38 mesalamine delayed-rel tabs, 38 mesalamine ext-rel caps, 38 mesalamine rectal susp, 38 mesalamine supp, 38 mesna inj, 17 mesna tabs 400 mg, 18 MESNEX, 18

68

MESNEX inj, 17 MESTINON, 28 MESTINON syrup, 28 MESTINON TIMESPAN, 28 METADATE CD, 27 METAGLIP, 30 metaproterenol, 45 metformin, 30 metformin ext-rel, 30 metformin soln, 30 methazolamide, 22 methenamine hippurate, prophylaxis, 15 methimazole, 36 methotrexate, 42 methotrexate inj, 42 methoxsalen inj, 18 methoxsalen oral, 47 methylergonovine, 36 methylnaltrexone, 39 methylphenidate, 27 methylphenidate ext-rel, 27 methylphenidate ext-rel 10 mg, 27 methylphenidate transdermal, 27 methylprednisolone, 35 metipranolol, 51 metoclopramide, 37 metolazone, 22 metoprolol, 21 metoprolol ext-rel, 21 metoprolol succinate ext-rel/hydrochlorothiazide, 21 metoprolol/hydrochlorothiazide, 21 METROCREAM, 49 METROGEL, 49 METROGEL-VAGINAL, 40 METROLOTION, 49 metronidazole, 40 metronidazole crm, 49 metronidazole crm 0.75%, 49 metronidazole gel 0.75%, 49 metronidazole gel 1%, 49 metronidazole lotion 0.75%, 49 metronidazole tabs, 15 MEVACOR, 20 mexiletine, 20 MIACALCIN, 32 MIACALCIN inj, 32 micafungin, 13 MICARDIS, 19 MICARDIS HCT, 20 miconazole nitrate/zinc oxide, 47 MICRHOGAM, 42 MICRHOGAM PLUS, 42 midodrine, 23 mifepristone, 36 MIGERGOT, 28 miglitol, 30 miglustat, 36 MILLIPRED, 35 milnacipran, 27 MINIPRESS, 19 MINOCIN, 12 minocycline, 12 minocycline ext-rel, 12 minoxidil, 23 mipomersen, 21 mirabegron ext-rel, 40

MIRAPEX, 26 MIRAPEX ER, 26 MIRCETTE, 33 MIRENA, 33 mirtazapine, 25 MIRVASO, 49 misoprostol, 39 mitomycin, 17 mitotane, 17 mitoxantrone, 17 MOBIC, 9 modafinil, 29 MODICON, 33 mometasone, 46 mometasone crm, lotion, oint 0.1%, 48 mometasone spray, 46 mometasone/formoterol, 46 MONOCLATE-P, 41 MONODOX, 12 MONONINE, 41 montelukast, 45 morphine, 10 morphine ext-rel, 10 morphine supp, 10 MOVIPREP, 38 MOXATAG, 12 MOXEZA, 51 moxifloxacin, 12, 51 MOZOBIL, 41 MS CONTIN, 10 MULTAQ, 20 multivitamins/fluoride drops, tabs, 44 multivitamins/fluoride/iron drops, tabs, 44 mupirocin, 47 MUSTARGEN, 15 MYAMBUTOL, 14 MYCAMINE, 13 MYCOBUTIN, 14 mycophenolate mofetil, 43 mycophenolate sodium delayed-rel, 43 MYFORTIC, 43 MYLERAN, 15 MYOBLOC, 29 MYOZYME, 36 MYRBETRIQ, 40 MYSOLINE, 24

N nabumetone, 9 nafarelin, 34 naftifine, 47 NAFTIN, 47 NAGLAZYME, 37 NALFON, 9 naloxone inj, 29 naltrexone, 29 naltrexone microspheres, 29 NAMENDA, 24 naphazoline, 52 NAPRELAN, 9 NAPROSYN, 9 naproxen, 9 naproxen sodium, 9 naproxen sodium ext-rel, 9 naproxen/esomeprazole delayed-rel, 9 naratriptan, 28

69

NARDIL, 25 NASACORT AQ, 46 NASCOBAL, 44 NASONEX, 46 NATACYN, 50 natalizumab, 28 natamycin, 50 NATAZIA, 33 nateglinide, 31 NATROBA, 49 NAVELBINE, 17 nebivolol, 21 NECON 10/11, 33 nefazodone, 25 nelarabine, 18 nelfinavir, 14 neomycin/dexamethasone, 51 neomycin/polymyxin B/dexamethasone, 51 neomycin/polymyxin B/gramicidin, 50 neomycin/polymyxin B/hydrocortisone, 53 neomycin/polymyxin B/hydrocortisone susp, 51 NEORAL, 43 NEOSPORIN, 50 nepafenac, 51 NESINA, 30 NEULASTA, 40 NEUMEGA, 40 NEUPOGEN, 40 NEUPRO, 26 NEURONTIN, 24 NEVANAC, 51 nevirapine, 13 nevirapine ext-rel, 13 NEXAVAR, 17 NEXIUM, 39 NEXPLANON, 33 niacin ext-rel, 21 niacin ext-rel/lovastatin, 21 niacin ext-rel/simvastatin, 21 NIASPAN, 21 nicardipine, 21 nicardipine ext-rel, 22 nicotine transdermal, 29 nifedipine ext-rel, 21 NILANDRON, 16 nilotinib, 17 nilutamide, 16 nimodipine, 22 NIMOTOP, 22 NIPENT, 16 nisoldipine ext-rel, 22 nitazoxanide, 15 nitisinone, 36 NITRO-DUR, 23 nitrofurantoin ext-rel, 15 nitrofurantoin macrocrystals, 15 nitroglycerin rectal oint 0.4%, 39 nitroglycerin sublingual, 23 nitroglycerin sublingual aerosol, 23 nitroglycerin sublingual spray, 23 nitroglycerin transdermal, 23 NITROLINGUAL, 23 NITROMIST, 23 NITROSTAT, 23 nizatidine, 38 NIZORAL SHAMPOO, 48

NORDITROPIN, 35 norelgestromin/EE, 33 norethindrone, 33 norethindrone acetate, 36 norethindrone acetate/EE 1.5/30, 32 norethindrone acetate/EE 1.5/30 and iron, 32 norethindrone acetate/EE 1/20, 32 norethindrone acetate/EE 1/20 and iron, 32 norethindrone acetate/EE 1/20 and iron - Lomedia 24 FE, 32 norethindrone acetate/EE and iron, 33 norethindrone/EE, 33 norethindrone/EE 0.4/35, 32 norethindrone/EE 0.5/35, 33 norethindrone/EE 1/35, 33 norethindrone/ME 1/50, 33 norgestimate/EE, 33 norgestimate/EE 0.25/35, 33 norgestrel/EE 0.3/30 - Cryselle, 32 norgestrel/EE 0.3/30 - Low-Ogestrel, 32 norgestrel/EE 0.5/50, 33 NORINYL 1+35, 33 NORINYL 1+50, 33 NORITATE, 49 NORPACE, 20 NORPACE CR, 20 NORPRAMIN, 25 NOR-QD, 33 nortriptyline, 25 NORVASC, 21 NORVIR, 14 NOVOLIN 70/30, 30 NOVOLIN N, 30 NOVOLIN R, 30 NOVOLOG, 30 NOVOLOG MIX 70/30, 30 NOVOSEVEN RT, 41 NOXAFIL, 13 NPLATE, 41 NUCYNTA, 10 NUCYNTA ER, 10 NUEDEXTA, 29 NULOJIX, 43 NULYTELY, 38 NUTROPIN AQ, 35 NUTROPIN AQ NUSPIN, 35 NUVARING, 34 NUVIGIL, 29 nystatin, 12, 47

O obinutuzumab, 18 ocriplasmin, 52 OCTAGAM, 42 octreotide acetate, 36, 37 OCUFEN, 51 OCUFLOX, 50 ofatumumab, 18 OFIRMEV, 9 ofloxacin, 12, 50 ofloxacin otic, 53 olanzapine, 26 olanzapine pamoate, 26 olanzapine/fluoxetine, 26 olmesartan, 20 olmesartan/amlodipine/hydrochlorothiazide, 20 olmesartan/hydrochlorothiazide, 20

70

olopatadine, 46, 50 olsalazine, 38 OLYSIO, 14 omacetaxine mepesuccinate, 18 omalizumab, 46 omega-3 acid ethyl esters, 21 omeprazole delayed-rel, 39 omeprazole/sodium bicarbonate, 39 OMNITROPE, 35 onabotulinumtoxinA, 29 ONCASPAR, 18 ondansetron, 37 ondansetron oral soluble film, 37 ONETOUCH LANCETS, 31 ONETOUCH METERS AND KITS, 31 ONETOUCH TEST STRIPS, 31 ONFI, 24 ONGLYZA, 30 ONSOLIS, 10 OPANA, 10 OPANA ER, 10 opium tincture, 37 oprelvekin, 40 OPSUMIT, 23 OPTIPRANOLOL, 51 ORACEA, 49 ORAPRED, 35 ORAPRED ODT, 35 ORENCIA, 42 ORENITRAM, 23 ORFADIN, 36 ORTHO EVRA, 33 ORTHO MICRONOR, 33 ORTHO TRI-CYCLEN, 33 ORTHO TRI-CYCLEN LO, 33 ORTHO-CEPT, 32 ORTHO-CYCLEN, 33 ORTHO-NOVUM 1/35, 33 ORTHO-NOVUM 7/7/7, 33 ORTHOVISC, 10 oseltamivir, 15 OSENI, 30 OSMOPREP, 38 ospemifene, 36 OSPHENA, 36 OTEZLA, 43 OTREXUP, 42 OVCON 35, 32 OVIDREL, 35 oxaliplatin, 18 oxaprozin, 9 oxazepam, 24 oxcarbazepine, 24 oxcarbazepine susp, 24 oxiconazole, 47 OXISTAT, 47 OXSORALEN-ULTRA, 47 oxybutynin, 39 oxybutynin ext-rel, 39 oxybutynin gel, 40 oxybutynin transdermal, 40 oxycodone, 10 oxycodone concentrate 20 mg/mL, 10 oxycodone ext-rel, 10 oxycodone soln, 10 oxycodone/acetaminophen 5/325, 10

OXYCONTIN, 10 oxymorphone, 10 oxymorphone ext-rel, 10 OXYTROL, 40 OZURDEX, 51

P paclitaxel protein-bound particles, 18 palifermin, 39 paliperidone ext-rel, 26 paliperidone palmitate, 26 palivizumab, 15 palonosetron, 37 PAMELOR, 25 pamidronate, 32 PANCREAZE, 38 pancrelipase, 38 pancrelipase delayed-rel, 38 PANDEL, 48 panitumumab, 18 PANRETIN, 50 pantoprazole delayed-rel, 39 PARCOPA, 26 paricalcitol, 35 PARLODEL, 26 PARNATE, 25 paroxetine HCl, 25 paroxetine HCl ext-rel, 25 paroxetine mesylate, 25 pasireotide, 37 PATADAY, 50 PATANASE, 46 PATANOL, 50 PAXIL, 25 PAXIL CR, 25 pazopanib, 17 PCE, 12 peg 3350/electrolytes, 38 peg 3350/electrolytes + bisacodyl, 38 pegademase, bovine, 36 pegaptanib sodium, 52 pegaspargase, 18 PEGASYS, 43 pegfilgrastim, 40 peginterferon alfa-2a, 43 peginterferon alfa-2b, 43 PEGINTRON, 43 PEGINTRON REDIPEN, 43 pegloticase, 9 pegvisomant, 37 pemetrexed, 16 penbutolol, 21 penicillamine, 42 penicillin VK, 12 PENNSAID, 9 PENTASA, 38 pentosan polysulfate sodium, 40 pentostatin, 16 pentoxifylline ext-rel, 42 PEPCID, 38 PEPCID susp, 38 perampanel, 24 PERCOCET, 10 perindopril, 19 PERJETA, 18 permethrin 5%, 49

71

perphenazine, 26 PERSANTINE, 41 pertuzumab, 18 PEXEVA, 25 phenazopyridine, 40 phenelzine, 25 phenobarbital, 24 phenylephrine, 50 phenytoin, 24 phenytoin sodium extended, 24 PHOSLO, 36 PHOTOFRIN, 18 PHRENILIN FORTE, 10 phytonadione, 44 pilocarpine, 52 pilocarpine tabs, 39 PILOPINE HS GEL, 52 pimecrolimus, 49 pindolol, 21 pioglitazone, 31 pioglitazone/glimepiride, 31 pioglitazone/metformin, 31 pioglitazone/metformin ext-rel, 31 piperacillin/tazobactam, 12 piroxicam, 9 pitavastatin, 21 PLAQUENIL, 42 PLAVIX, 41 plerixafor, 41 PLETAL, 42 podofilox, 50 polymyxin B/bacitracin, 50 polymyxin B/trimethoprim, 51 POLYTRIM, 51 pomalidomide, 16 POMALYST, 16 ponatinib, 17 porfimer sodium, 18 posaconazole, 13 potassium chloride ext-rel, 43 potassium chloride liquid, 43 potassium chloride powder, 43 potassium citrate ext-rel, 40 potassium citrate ext-rel 15 mEq, 40 POTIGA, 24 PRADAXA, 40 pralatrexate, 16 pramipexole, 26 pramipexole ext-rel, 26 pramlintide, 30 PRAMOSONE, 48 PRAMOSONE E, 48 pramoxine/hydrocortisone, 48 pramoxine/hydrocortisone/emollient, 48 PRANDIMET, 31 PRANDIN, 31 prasugrel, 41 PRAVACHOL, 21 pravastatin, 21 prazosin, 19 PRECOSE, 30 PRED FORTE, 51 PRED MILD, 51 PRED-G, 51 prednisolone, 35 prednisolone acetate 0.12%, 51

prednisolone acetate 1%, 51 prednisolone phosphate 1%, 51 prednisolone sodium phosphate, 35 prednisolone sodium phosphate 5 mg/5 mL, 35 prednisolone sodium phosphate orally disintegrating tablet, 35 prednisolone syrup, 35 prednisone, 35 prednisone delayed-rel, 35 PREFEST, 34 pregabalin, 27 PRELONE, 35 PREMARIN, 34 PREMARIN crm, 34 PREMPHASE, 34 PREMPRO, 34 prenatal vitamins/docusate/folic acid, 44 prenatal vitamins/folic acid, 44 PRENATE ELITE, 44 PREPOPIK, 38 PREVIDENT, 50 PREVPAC, 39 PREZISTA, 14 PRIALT, 10 PRIFTIN, 14 PRILOSEC, 39 primaquine, 13 PRIMAXIN, 15 primidone, 24 PRINIVIL, 19 PRISTIQ, 25 PRIVIGEN, 42 PROAIR HFA, 45 probenecid, 9 procarbazine, 17 PROCARDIA XL, 21 prochlorperazine, 37 PROCRIT, 40 PROCTOFOAM-HC, 39 PROCYSBI, 36 PROFILNINE SD, 41 progesterone supp, 36 progesterone, micronized, 36 PROGLYCEM, 35 PROGRAF, 43 PROLEUKIN, 17 PROLIA, 32 PROMACTA, 41 promethazine, 37, 45 PROMETRIUM, 36 propafenone ext-rel, 20 propantheline 15 mg, 37 propranolol, 21 propranolol ext-rel, 21 propylthiouracil, 36 PROSCAR, 39 protein C concentrate, human, 42 PROTONIX, 39 PROTOPIC, 49 protriptyline, 25 PROVENGE, 18 PROVENTIL HFA, 45 PROVERA, 36 PROVIGIL, 29 PROZAC, 25 PROZAC WEEKLY, 25 PULMICORT FLEXHALER, 46

72

PULMICORT RESPULES, 46 PULMOZYME, 45 PURINETHOL, 16 PYLERA, 39 pyrazinamide, 14 PYRIDIUM, 40 pyridostigmine ext-rel tabs 180 mg, 28 pyridostigmine syrup, 28 pyridostigmine tabs 60 mg, 28 pyrimethamine, 13

Q QUADRAMET, 18 quazepam, 27 QUESTRAN/QUESTRAN LIGHT, 20 quetiapine, 26 quetiapine ext-rel, 26 quinapril, 19 quinapril/hydrochlorothiazide, 19 quinidine gluconate ext-rel, 20 quinidine sulfate ext-rel, 20 QUTENZA, 49 QVAR, 46

R rabeprazole delayed-rel, 39 raloxifene, 36 raltegravir, 13 ramelteon, 27 ramipril, 19 RANEXA, 23 ranibizumab, 52 ranitidine, 38 ranolazine ext-rel, 23 RAPAFLO, 39 RAPAMUNE, 43 rasagiline mesylate, 26 rasburicase, 16 RAVICTI, 37 RAYOS, 35 RAZADYNE, 24 RAZADYNE ER, 24 REBETOL, 14 REBIF, 28 RECLAST, 32 RECOMBINATE, 41 RECTIV, 39 REFACTO, 41 REGLAN, 37 regorafenib, 17 REGRANEX, 50 RELENZA, 15 RELISTOR, 39 REMERON, 25 REMICADE, 42 REMODULIN, 23 RENAGEL, 36 RENOVA, 50 RENVELA, 36 repaglinide, 31 repaglinide/metformin, 31 REPRONEX, 35 REQUIP, 26 REQUIP XL, 26 RESCRIPTOR, 13 RESTASIS, 52 RESTORIL, 27

retapamulin, 47 RETIN-A, 47 RETIN-A MICRO, 47 RETROVIR, 13 REVATIO, 23 REVIA, 29 REVLIMID, 16 REYATAZ, 14 REZIRA, 45 RHEUMATREX, 42 RHINOCORT AQUA, 46 Rho (D) immune globulin, 42, 43 RHOGAM, 42 RHOGAM PLUS, 42 RHOPHYLAC, 42 RIASTAP, 41 ribavirin caps, 14 ribavirin caps - Ribasphere, 14 ribavirin oral soln, 14 ribavirin tabs, 14 ribavirin tabs - Ribapak, 14 ribavirin tabs - Ribatab, 14 RIDAURA, 42 rifabutin, 14 RIFADIN, 14 rifampin, 14 rifampin/isoniazid/pyrazinamide, 14 rifapentine, 14 RIFATER, 14 rifaximin, 15 rilonacept, 43 rilpivirine, 13 RILUTEK, 29 riluzole, 29 rimabotulinumtoxinB, 29 rimantadine, 14 rimexolone, 51 riociguat, 23 RIOMET, 30 risedronate, 32 risedronate delayed-rel, 32 RISPERDAL, 26 RISPERDAL CONSTA, 26 risperidone, 26 risperidone long-acting inj, 26 RITALIN, 27 RITALIN LA, 27 RITALIN LA 10 mg, 27 RITALIN-SR, 27 ritonavir, 14 RITUXAN, 18 rituximab, 18 rivaroxaban, 40 rivastigmine, 24 rivastigmine transdermal, 24 RIXUBIS, 41 rizatriptan, 28 ROCALTROL, 35 ROCEPHIN, 11 roflumilast, 46 romidepsin, 18 romiplostim, 41 ropinirole, 26 ropinirole ext-rel, 26 rosiglitazone, 31 rosiglitazone/glimepiride, 31

73

rosiglitazone/metformin, 31 rosuvastatin, 21 rotigotine transdermal, 26 ROWASA, 38 ROXICODONE, 10 ROZEREM, 27 rufinamide, 24 ruxolitinib, 17 RYTHMOL SR, 20

S SABRIL, 24 sacrosidase, 39 SAIZEN, 35 SALAGEN, 39 salmeterol xinafoate, 45 samarium sm 153 lexidronam, 18 SAMSCA, 37 SANCTURA, 40 SANCTURA XR, 40 SANCUSO, 37 SANDIMMUNE, 43 SANDOSTATIN, 36 SANDOSTATIN LAR, 37 SAPHRIS, 26 sapropterin, 35 saquinavir mesylate, 14 SARAFEM, 25 sargramostim, 40 SAVELLA, 27 saxagliptin, 30 saxagliptin/metformin ext-rel, 30 scopolamine, 52 scopolamine transdermal, 37 SEASONIQUE, 33 secobarbital, 27 SECONAL, 27 SECTRAL, 21 selegiline caps, 26 selegiline orally disintegrating tabs, 26 selegiline transdermal, 25 selenium sulfide shampoo 2.5%, 48 SELZENTRY, 13 SENSIPAR, 31 SEREVENT DISKUS, 45 SEROQUEL, 26 SEROQUEL XR, 26 SEROSTIM, 35 sertaconazole, 47 sertraline, 25 sevelamer, 36 sevelamer carbonate, 36 SIGNIFOR, 37 sildenafil, 23 SILENOR, 27 silodosin, 39 SILVADENE, 47 silver sulfadiazine, 47 SIMCOR, 21 simeprevir, 14 SIMPONI, 42 simvastatin, 21 sinecatechins, 50 SINEMET, 26 SINEMET CR, 26 SINGULAIR, 45

sipuleucel-T, 18 sirolimus, 43 SIRTURO, 14 sitagliptin phosphate, 30 sitagliptin/metformin, 30 sitagliptin/metformin ext-rel, 30 SKELID, 32 SKLICE, 50 SKYLA, 33 sodium ferric gluconate inj, 44 sodium fluoride, 50 sodium hyaluronate, 11 sodium oxybate, 29 sodium phenylbutyrate, 39 sodium phosphates, 38 sodium picosulfate/magnesium oxide/citric acid, 38 sodium sulfate/potassium sulfate/magnesium sulfate, 38 sofosbuvir, 14 SOFTCLIX LANCET DEVICE, 31 SOFTCLIX LANCETS, 31 SOFTTOUCH LANCET DEVICE, 31 SOFTTOUCH LANCETS, 31 SOLARAZE, 47 SOLESTA, 39 solifenacin succinate, 40 SOLIRIS, 41 SOLODYN, 12 somatropin, 35 SOMATULINE DEPOT, 37 SOMAVERT, 37 SONATA, 27 sorafenib, 17 SORIATANE, 47 sotalol, 20 SOVALDI, 14 SPECTRACEF, 11 spinosad, 49 SPIRIVA, 44 spironolactone, 19 spironolactone/hydrochlorothiazide, 22 SPORANOX caps, 12 SPORANOX oral soln, 13 SPRIX, 9 SPRYCEL, 17 STALEVO, 26 STARLIX, 31 stavudine, 13 STAVZOR, 24 STELARA, 47 STIMATE, 41 STIVARGA, 17 STRATTERA, 27 streptozocin, 15 STRIBILD, 13 SUBOXONE FILM, 29 SUBSYS, 10 SUCRAID, 39 sucralfate, 39 sucralfate susp, 39 SULAR, 22 sulconazole, 47 sulfacetamide soln 10%, 51 sulfacetamide/prednisolone acetate oint 10%/0.2%, 51 sulfacetamide/prednisolone phosphate 10%/0.25%, 51 sulfacetamide/sulfur, 49 sulfamethoxazole/trimethoprim, 15

74

sulfamethoxazole/trimethoprim DS, 15 SULFAMYLON, 47 sulfasalazine, 38 sulfasalazine delayed-rel, 38 sulindac, 9 sumatriptan, 28 sumatriptan inj, 28 sumatriptan/naproxen sodium, 28 sunitinib, 17 SUPARTZ, 11 SUPPRELIN LA, 37 SUPRAX, 11 SUPREP, 38 SUSTIVA, 13 SUTENT, 17 SYLATRON, 43 SYMBICORT, 46 SYMBYAX, 26 SYMLINPEN, 30 SYNAGIS, 15 SYNAREL, 34 SYNRIBO, 18 SYNTHROID, 36 SYNVISC, 10 SYNVISC-ONE, 10 SYPRINE, 36

T TACHOSIL, 50 TACLONEX, 48 tacrolimus, 43, 49 tacrolimus ext-rel, 43 tadalafil, 23 tadalafil 2.5 mg, 5 mg, 39 TAFINLAR, 17 tafluprost, 52 taliglucerase alfa, 37 TAMIFLU, 15 tamoxifen, 16 tamsulosin, 39 TAPAZOLE, 36 tapentadol, 10 tapentadol ext-rel, 10 TARCEVA, 17 TARGRETIN caps, 18 TARKA, 19 TASIGNA, 17 tasimelteon, 27 TASMAR, 26 TAXOTERE, 18 tazarotene, 47 TAZORAC, 47 tbo-filgrastim, 40 TECFIDERA, 28 teduglutide, 39 TEFLARO, 12 TEGRETOL, 24 TEGRETOL-XR, 24 TEKAMLO, 22 TEKTURNA, 22 TEKTURNA HCT, 22 telaprevir, 14 telavancin, 15 telbivudine, 14 telithromycin, 12 telmisartan, 19

telmisartan/hydrochlorothiazide, 20 temazepam, 27 TEMODAR, 15 TEMOVATE, 49 temozolomide, 15 temsirolimus, 17 tenofovir, 13 TENORETIC, 21 TENORMIN, 21 TERAZOL 3, 40 TERAZOL 7, 40 terazosin, 19 terbinafine, 47 terbinafine tabs, 12 terbutaline, 45 terconazole, 40 teriflunomide, 28 teriparatide, 32 tesamorelin, 37 TESSALON, 45 testosterone cypionate, 29 testosterone enanthate, 29 testosterone gel, 29 testosterone soln, 29 testosterone transdermal, 29 tetrabenazine, 27 tetracycline, 12 TEVETEN, 19 TEVETEN HCT, 20 TEV-TROPIN, 35 thalidomide, 16 THALOMID, 16 THEO-24, 46 theophylline ext-rel caps, 46 theophylline ext-rel tabs, 46 theophylline liquid, 46 THERACYS, 18 thioguanine, 16 thioridazine, 26 thiotepa, 15 thiothixene, 26 THYROGEN, 37 thyroid, 36 THYROLAR, 36 thyrotropin alfa, 37 tiagabine, 24 TIAZAC, 22 ticagrelor, 41 TICE BCG, 18 ticlopidine, 41 TIGAN, 37 tigecycline, 15 TIKOSYN, 20 tiludronate, 32 timolol hemihydrate, 52 timolol maleate, 51, 52 timolol maleate gel, 52 TIMOPTIC, 51 TIMOPTIC-XE, 52 TINDAMAX, 15 tinidazole, 15 tiotropium, 44 tipranavir, 14 TIVICAY, 13 TOBI, 45 TOBRADEX OINTMENT, 51

75

TOBRADEX SUSPENSION, 51 tobramycin, 51 tobramycin inhalation soln, 45 tobramycin/dexamethasone oint 0.3%/0.1%, 51 tobramycin/dexamethasone susp 0.3%/0.1%, 51 tobramycin/loteprednol, 51 TOBREX, 51 tocilizumab, 43 tofacitinib, 42 TOFRANIL, 25 TOFRANIL-PM, 25 tolcapone, 26 tolterodine, 39 tolterodine ext-rel, 40 tolvaptan, 37 TOPAMAX, 24 TOPICORT, 49 TOPICORT LP, 48 topiramate, 24 topotecan, 17 topotecan inj, 17 TOPROL-XL, 21 toremifene, 16 TORISEL, 17 torsemide, 22 tositumomab, 18 TOTECT, 17 TOVIAZ, 40 TRACLEER, 23 TRADJENTA, 30 tramadol, 10 tramadol ext-rel, 10 trametinib, 17 trandolapril, 19 trandolapril/verapamil ext-rel, 19 tranexamic acid, 42 TRANSDERM SCOP, 37 TRANXENE T-TAB, 23 tranylcypromine, 25 trastuzumab, 18 TRAVATAN Z, 52 travoprost, 52 trazodone, 25 TREANDA, 15 TRELSTAR, 16 TRELSTAR DEPOT, 16 TRELSTAR LA, 16 treprostinil, 23 treprostinil ext-rel, 23 tretinoin, 47 tretinoin emollient, 50 tretinoin gel microsphere, 47 TREXIMET, 28 triamcinolone acetonide crm 0.5%, 49 triamcinolone acetonide crm, lotion 0.025%, 48 triamcinolone acetonide crm, lotion, oint 0.1%, 48 triamcinolone acetonide spray, 46 triamcinolone paste, 50 triamterene/hydrochlorothiazide, 22 triamterene/hydrochlorothiazide 37.5/25, 22 triamterene/hydrochlorothiazide 50/25, 22 TRIBENZOR, 20 TRICOR, 20 trientine, 36 trifluoperazine, 26 trifluridine, 51

trihexyphenidyl, 26 TRILEPTAL, 24 TRILEPTAL susp, 24 TRILIPIX, 20 trimethobenzamide, 37 trimethoprim, 15 TRI-NORINYL, 33 triptorelin pamoate, 16 TRISENOX, 17 TRIZIVIR, 13 trospium, 40 trospium ext-rel, 40 TRUSOPT, 52 TRUVADA, 13 TUDORZA PRESSAIR, 44 TWYNSTA, 20 TYGACIL, 15 TYKERB, 17 TYLENOL w/CODEINE, 10 TYSABRI, 28 TYVASO, 23 TYZEKA, 14

U ULESFIA, 50 ULORIC, 9 ULTRAM, 10 ULTRAM ER, 10 ULTRAVATE, 49 umeclidinium/vilanterol, 44 UNASYN, 12 URAMAXIN, 49 URAMAXIN GT, 49 urea, 49 urea 45%, 49 URECHOLINE, 40 urine test strips, 31 UROCIT-K, 40 UROCIT-K 15 mEq, 40 urofollitropin, 35 URSO, 37 URSO FORTE, 37 ursodiol, 37 ustekinumab, 47 UVADEX, 18

V VAGIFEM, 34 valacyclovir, 14 VALCHLOR, 15 VALCYTE, 14 valganciclovir, 14 VALIUM, 23 valproic acid, 24 valproic acid delayed-rel, 24 valrubicin, 18 valsartan, 20 valsartan/hydrochlorothiazide, 20 VALSTAR, 18 VALTREX, 14 VANCOCIN, 15 vancomycin, 15 vandetanib, 17 VANOS, 49 VANTAS, 16 varenicline, 29 varicella zoster immune globulin, 43

76

VARIZIG, 43 VASCEPA, 21 VASERETIC, 19 VASOTEC, 19 VECTIBIX, 18 VECTICAL, 48 velaglucerase alfa, 37 VELCADE, 18 VELETRI, 23 vemurafenib, 17 venlafaxine, 25 venlafaxine ext-rel, 25 venlafaxine ext-rel tabs, 25 VENOFER, 44 VENTAVIS, 23 VENTOLIN, 45 VENTOLIN HFA, 45 VERAMYST, 46 verapamil, 22 verapamil ext-rel, 22 VERDESO, 48 VEREGEN, 50 verteporfin, 52 VESICARE, 40 VEXOL, 51 VFEND, 13 VIBATIV, 15 VIBRAMYCIN, 12 VICTOZA, 30 VICTRELIS, 14 VIDAZA, 17 VIDEX EC, 13 VIDEX soln, 13 vigabatrin, 24 VIGAMOX, 51 VIIBRYD, 25 vilazodone, 25 VIMIZIM, 36 VIMOVO, 9 VIMPAT, 24 vinblastine, 17 vincristine, 17 vinorelbine, 17 VIOKACE, 38 VIRACEPT, 14 VIRAMUNE, 13 VIRAMUNE XR, 13 VIREAD, 13 VIROPTIC, 51 VISICOL, 38 vismodegib, 18 VISTARIL, 24, 45 VISTIDE, 14 VISUDYNE, 52 VITAFOL-OB, 44 VITAFOL-PN, 44 vitamin ADC/fluoride drops, 44 vitamin ADC/fluoride/iron drops, 44 VIVACTIL, 25 VIVELLE-DOT, 34 VIVITROL, 29 VOLTAREN GEL, 9 VOLTAREN XR, 9 voriconazole, 13 vorinostat, 18 VOSPIRE ER, 45

VOTRIENT, 17 VPRIV, 37 VUSION, 47 VWF, human/factor VIII complex, 41 VYTORIN, 21 VYVANSE, 27

W warfarin, 40 WELCHOL, 20 WELLBUTRIN, 25 WELLBUTRIN SR, 25 WELLBUTRIN XL, 25 WESTCORT, 48 WILATE, 41 WINRHO SDF, 43

X XALATAN, 52 XALKORI, 17 XANAX, 23 XANAX XR, 23 XARELTO, 40 XELJANZ, 42 XELODA, 16 XENAZINE, 27 XEOMIN, 29 XERESE, 50 XGEVA, 32 XIAFLEX, 50 XIFAXAN, 15 XOLAIR, 46 XOLEGEL, 47 XTANDI, 16 XYLOCAINE, 49 XYNTHA, 41 XYREM, 29 XYZAL, 44

Y YASMIN, 32 YAZ, 32 YERVOY, 18

Z zafirlukast, 45 zaleplon, 27 ZALTRAP, 18 zanamivir, 15 ZANOSAR, 15 ZANTAC, 38 ZARONTIN, 24 ZAROXOLYN, 22 ZAVESCA, 36 ZEGERID, 39 ZELAPAR, 26 ZELBORAF, 17 ZEMAIRA, 46 ZEMPLAR, 35 ZENPEP, 38 ZERIT, 13 ZESTORETIC, 19 ZESTRIL, 19 ZETIA, 20 ZIAC, 21 ZIAGEN, 13 ZIAGEN soln, 13 ZIANA, 47

77

ziconotide, 10 zidovudine, 13 zileuton ext-rel, 45 zinc acetate, 44 ZINECARD, 17 ZIOPTAN, 52 ziprasidone, 26 ZIRGAN, 51 ZITHROMAX, 12 ziv-aflibercept, 18 ZMAX, 12 ZOCOR, 21 ZOFRAN, 37 ZOLADEX, 16 zoledronic acid, 32 ZOLINZA, 18 zolmitriptan, 28 ZOLOFT, 25 zolpidem, 27 zolpidem ext-rel, 27 zolpidem sublingual, 27 ZOMETA, 32

ZOMIG/ZOMIG-ZMT, 28 ZONALON, 50 ZONEGRAN, 24 zonisamide, 24 ZORBTIVE, 35 ZORTRESS, 43 ZOSYN, 12 ZOVIRAX, 14 ZOVIRAX crm, 50 ZOVIRAX oint, 50 ZUBSOLV, 29 ZUPLENZ, 37 ZUTRIPRO, 45 ZYBAN, 29 ZYCLARA, 50 ZYFLO CR, 45 ZYLET, 51 ZYLOPRIM, 9 ZYPREXA RELPREVV, 26 ZYPREXA/ZYPREXA ZYDIS, 26 ZYTIGA, 16 ZYVOX, 15