Medicaid Formulary | January 2021 · 2021. 1. 6. · 5 Dosage forms on the document will be...
Transcript of Medicaid Formulary | January 2021 · 2021. 1. 6. · 5 Dosage forms on the document will be...
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2021FORMULARY
SERVING MEDICAID, CHILD HEALTH PLUS, PARTNERSHIP IN CARE (SNP) & ENHANCED (HARP) PLAN
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MetroPlus Health Plan (12/30/2020) INTRODUCTION ...................................................................................................................................................................................................... 4 PREFACE ................................................................................................................................................................................................................. 4 DRUG LIST PRODUCT DESCRIPTIONS ................................................................................................................................................................ 4 GENERIC SUBSTITUTION ...................................................................................................................................................................................... 5 NON-COVERED MEDICATIONS ............................................................................................................................................................................. 5 OVER-THE-COUNTER DRUG COVERAGE ........................................................................................................................................................... 5 SPECIALTY PLAN DESIGN .................................................................................................................................................................................... 5 PLAN DESIGN.......................................................................................................................................................................................................... 6 LEGEND ................................................................................................................................................................................................................... 6 NOTICE ..................................................................................................................................................................................................................... 6 ANALGESICS........................................................................................................................................................................................................... 7
NSAIDs ........................................................................................................................................................................................................... 7 COX-2 INHIBITORS ....................................................................................................................................................................................... 7 GOUT ............................................................................................................................................................................................................. 7 OPIOID ANALGESICS ................................................................................................................................................................................... 7 NON-OPIOID ANALGESICS .......................................................................................................................................................................... 8
ANTI-INFECTIVES ................................................................................................................................................................................................... 8 ANTIBACTERIALS ......................................................................................................................................................................................... 8 ANTIFUNGALS .............................................................................................................................................................................................. 9 ANTIMALARIALS ........................................................................................................................................................................................... 9 ANTIRETROVIRAL AGENTS ........................................................................................................................................................................ 9 ANTITUBERCULAR AGENTS ..................................................................................................................................................................... 10 ANTIVIRALS................................................................................................................................................................................................. 10 MISCELLANEOUS ....................................................................................................................................................................................... 11
ANTINEOPLASTIC AGENTS ................................................................................................................................................................................ 11 ALKYLATING AGENTS ............................................................................................................................................................................... 11 ANTIMETABOLITES .................................................................................................................................................................................... 11 HORMONAL ANTINEOPLASTIC AGENTS ................................................................................................................................................. 12 IMMUNOMODULATORS ............................................................................................................................................................................. 12 KINASE INHIBITORS ................................................................................................................................................................................... 12 MISCELLANEOUS ....................................................................................................................................................................................... 13
CARDIOVASCULAR .............................................................................................................................................................................................. 13 ACE INHIBITORS ........................................................................................................................................................................................ 13 ACE INHIBITOR/CALCIUM CHANNEL BLOCKER COMBINATIONS ........................................................................................................ 13 ACE INHIBITOR/DIURETIC COMBINATIONS ............................................................................................................................................ 13 ADRENOLYTICS, CENTRAL ....................................................................................................................................................................... 13 ALDOSTERONE RECEPTOR ANTAGONISTS .......................................................................................................................................... 14 ALPHA BLOCKERS ..................................................................................................................................................................................... 14 ANGIOTENSIN II RECEPTOR ANTAGONISTS/DIURETIC COMBINATIONS ........................................................................................... 14 ANTIARRHYTHMICS ................................................................................................................................................................................... 14 ANTILIPEMICS............................................................................................................................................................................................. 14 BETA-BLOCKERS ....................................................................................................................................................................................... 15 BETA-BLOCKER/DIURETIC COMBINATIONS ........................................................................................................................................... 15 CALCIUM CHANNEL BLOCKERS .............................................................................................................................................................. 15 DIGITALIS GLYCOSIDES ............................................................................................................................................................................ 16 DIURETICS .................................................................................................................................................................................................. 16 HEART FAILURE ......................................................................................................................................................................................... 16 NITRATES .................................................................................................................................................................................................... 16 PULMONARY ARTERIAL HYPERTENSION .............................................................................................................................................. 16 MISCELLANEOUS ....................................................................................................................................................................................... 17
CENTRAL NERVOUS SYSTEM ............................................................................................................................................................................ 17 ANTIANXIETY .............................................................................................................................................................................................. 17
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ANTICONVULSANTS .................................................................................................................................................................................. 17 ANTIDEMENTIA ........................................................................................................................................................................................... 18 ANTIDEPRESSANTS .................................................................................................................................................................................. 18 ANTIPARKINSONIAN AGENTS .................................................................................................................................................................. 19 ANTIPSYCHOTICS ...................................................................................................................................................................................... 19 ATTENTION DEFICIT HYPERACTIVITY DISORDER ................................................................................................................................ 20 FIBROMYALGIA .......................................................................................................................................................................................... 20 HYPNOTICS ................................................................................................................................................................................................. 20 MIGRAINE .................................................................................................................................................................................................... 20 MOOD STABILIZERS .................................................................................................................................................................................. 20 MULTIPLE SCLEROSIS AGENTS .............................................................................................................................................................. 20 MUSCULOSKELETAL THERAPY AGENTS ............................................................................................................................................... 21 MYASTHENIA GRAVIS ............................................................................................................................................................................... 21 NARCOLEPSY ............................................................................................................................................................................................. 21 PSYCHOTHERAPEUTIC-MISCELLANEOUS ............................................................................................................................................. 21
ENDOCRINE AND METABOLIC ........................................................................................................................................................................... 21 ANDROGENS .............................................................................................................................................................................................. 21 ANTIDIABETICS .......................................................................................................................................................................................... 22 CALCIUM REGULATORS ........................................................................................................................................................................... 23 CONTRACEPTIVES .................................................................................................................................................................................... 23 ENDOMETRIOSIS ....................................................................................................................................................................................... 24 ESTROGENS ............................................................................................................................................................................................... 25 ESTROGEN/PROGESTINS ......................................................................................................................................................................... 25 FERTILITY REGULATORS .......................................................................................................................................................................... 25 GLUCOCORTICOIDS .................................................................................................................................................................................. 25 GLUCOSE ELEVATING AGENTS ............................................................................................................................................................... 25 HUMAN GROWTH HORMONES ................................................................................................................................................................. 25 HYPERPARATHYROID TREATMENT, VITAMIN D ANALOGS ................................................................................................................. 25 PHENYLKETONURIA TREATMENT AGENTS ........................................................................................................................................... 26 PHOSPHATE BINDER AGENTS ................................................................................................................................................................. 26 POTASSIUM-REMOVING AGENTS ............................................................................................................................................................ 26 PROGESTINS .............................................................................................................................................................................................. 26 SELECTIVE ESTROGEN RECEPTOR MODULATORS ............................................................................................................................. 26 THYROID AGENTS ..................................................................................................................................................................................... 26 UREA CYCLE DISORDERS ........................................................................................................................................................................ 26 VASOPRESSIN RECEPTOR ANTAGONISTS ............................................................................................................................................ 26 VASOPRESSINS ......................................................................................................................................................................................... 26 MISCELLANEOUS ....................................................................................................................................................................................... 26
GASTROINTESTINAL ........................................................................................................................................................................................... 26 ANTIDIARRHEALS ...................................................................................................................................................................................... 26 ANTIEMETICS ............................................................................................................................................................................................. 27 ANTISPASMODICS ..................................................................................................................................................................................... 27 CHOLELITHOLYTICS .................................................................................................................................................................................. 27 H2 RECEPTOR ANTAGONISTS .................................................................................................................................................................. 27 INFLAMMATORY BOWEL DISEASE .......................................................................................................................................................... 27 LAXATIVES/STOOL SOFTENERS .............................................................................................................................................................. 27 OPIOID-INDUCED CONSTIPATION ........................................................................................................................................................... 27 PANCREATIC ENZYMES ............................................................................................................................................................................ 27 PROSTAGLANDINS .................................................................................................................................................................................... 28 PROTON PUMP INHIBITORS ..................................................................................................................................................................... 28 SALIVA STIMULANTS ................................................................................................................................................................................. 28 STEROIDS, RECTAL ................................................................................................................................................................................... 28 MISCELLANEOUS ....................................................................................................................................................................................... 28
GENITOURINARY .................................................................................................................................................................................................. 28 BENIGN PROSTATIC HYPERPLASIA ........................................................................................................................................................ 28 URINARY ANTISPASMODICS .................................................................................................................................................................... 28 VAGINAL ANTI-INFECTIVES ...................................................................................................................................................................... 28 MISCELLANEOUS ....................................................................................................................................................................................... 28
HEMATOLOGIC ..................................................................................................................................................................................................... 29 ANTICOAGULANTS .................................................................................................................................................................................... 29 HEMATOPOIETIC GROWTH FACTORS .................................................................................................................................................... 29 PAROXYSMAL NOCTURNAL HEMOGLOBINURIA (PNH) AGENTS ........................................................................................................ 29 PLATELET AGGREGATION INHIBITORS .................................................................................................................................................. 29 PLATELET SYNTHESIS INHIBITORS ........................................................................................................................................................ 29 THROMBOCYTOPENIA AGENTS .............................................................................................................................................................. 29
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MISCELLANEOUS ....................................................................................................................................................................................... 29 IMMUNOLOGIC AGENTS ...................................................................................................................................................................................... 30
AUTOIMMUNE AGENTS ............................................................................................................................................................................. 30 DISEASE-MODIFYING ANTIRHEUMATIC DRUGS (DMARDs) ................................................................................................................. 30 HEREDITARY ANGIOEDEMA AGENTS ..................................................................................................................................................... 30 IMMUNOMODULATORS ............................................................................................................................................................................. 30 IMMUNOSUPPRESSANTS ......................................................................................................................................................................... 30
NUTRITIONAL/SUPPLEMENTS ............................................................................................................................................................................ 30 ELECTROLYTES ......................................................................................................................................................................................... 30 VITAMINS AND MINERALS ........................................................................................................................................................................ 31
RESPIRATORY ...................................................................................................................................................................................................... 31 ANAPHYLAXIS TREATMENT AGENTS...................................................................................................................................................... 31 ANTICHOLINERGICS .................................................................................................................................................................................. 31 ANTICHOLINERGIC/BETA AGONIST COMBINATIONS ............................................................................................................................ 31 ANTIHISTAMINES, LOW SEDATING.......................................................................................................................................................... 32 ANTIHISTAMINES, SEDATING ................................................................................................................................................................... 32 ANTIHISTAMINE/DECONGESTANT COMBINATIONS .............................................................................................................................. 32 ANTITUSSIVES............................................................................................................................................................................................ 32 ANTITUSSIVE COMBINATIONS ................................................................................................................................................................. 32 BETA AGONISTS ........................................................................................................................................................................................ 32 CYSTIC FIBROSIS ...................................................................................................................................................................................... 32 LEUKOTRIENE MODULATORS .................................................................................................................................................................. 32 MAST CELL STABILIZERS ......................................................................................................................................................................... 33 MEDICAL SUPPLIES ................................................................................................................................................................................... 33 NASAL ANTIHISTAMINES .......................................................................................................................................................................... 33 NASAL STEROIDS ...................................................................................................................................................................................... 33 PULMONARY FIBROSIS AGENTS ............................................................................................................................................................. 33 RESPIRATORY SYNCYTIAL VIRUS ........................................................................................................................................................... 33 SEVERE ASTHMA AGENTS ....................................................................................................................................................................... 33 STEROID/BETA AGONIST COMBINATIONS ............................................................................................................................................. 33 STEROID INHALANTS ................................................................................................................................................................................ 33 XANTHINES ................................................................................................................................................................................................. 33 MISCELLANEOUS ....................................................................................................................................................................................... 33
TOPICAL ................................................................................................................................................................................................................ 33 DERMATOLOGY ......................................................................................................................................................................................... 33 MOUTH/THROAT/DENTAL AGENTS ......................................................................................................................................................... 35 OPHTHALMIC .............................................................................................................................................................................................. 36 OTIC ............................................................................................................................................................................................................. 37
WEBSITES ............................................................................................................................................................................................................. 38 INDEX ..................................................................................................................................................................................................................... 40
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INTRODUCTION We are pleased to provide the 2020 MetroPlus Health Plan Formulary as a useful reference and informational tool. This document can assist medical providers in selecting clinically appropriate and cost-effective products for their patients. The drugs represented have been reviewed by a National Pharmacy and Therapeutics (P&T) Committee and are approved for inclusion. The document is reflective of current medical practice as of the date of review. The information contained in this document and its appendices is provided solely for the convenience of medical providers. We do not warrant or assure accuracy of such information nor is it intended to be comprehensive in nature. This document 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. All the information in the document is provided as a reference for drug therapy selection. Specific drug selection for an individual patient rests solely with the prescriber. The document is subject to state-specific regulations and rules, including, but not limited to, those regarding generic substitution, controlled substance schedules, preference for brands and mandatory generics whenever applicable. We assume 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. National guidelines can be found on the National Guideline Clearinghouse site at https://www.ahrq.gov/gam/, on the websites listed under each therapeutic class and on the sites listed in the Websites section of this publication.
PREFACE The document is organized by sections. Each section is divided by therapeutic drug class primarily defined by mechanism of action. Products are listed by generic name with brand name for reference only. Unless the cited drug is available as an injectable or an exception is specifically noted, generally, all applicable oral dosage forms and strengths of the drug cited are included in the document. Drugs represented in this document may have varying cost to the plan member based on the plan's benefit structure. Generic medications typically are available at the lower cost, brand-name medications on the document will generally cost more than generics. Generics should be considered the first line of prescribing subject to applicable rules.
DRUG LIST PRODUCT DESCRIPTIONS To assist in understanding which specific strengths and dosage forms on the document are covered, examples are noted below. The general principles shown in the examples can usually be extended to other entries in the document. Any exceptions are noted. Listed products on the document generally include all strengths and dosage forms of the cited brand-name product. pregabalin Lyrica Oral capsules, oral solution and all strengths of Lyrica would be included in this listing. When a strength or dosage form is specified, only the specified strength and dosage form is on the document. Other strengths/dosage forms, including injectable dosage forms of the reference product are not. esomeprazole magnesium delayed-rel suspension 2.5 mg, 5 mg, 10
mg Nexium suspension
The oral suspension dosage form of Nexium is on the document. From this entry, the oral capsule cannot be assumed to be on the list unless there is a separate entry. Extended-release and delayed-release products require their own entry. tofacitinib Xeljanz The immediate-release product listing of Xeljanz alone would not include the extended-release product Xeljanz XR. tofacitinib ext-rel Xeljanz XR A separate entry for Xeljanz XR confirms that the extended-release product is on the document.
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Dosage forms on the document will be consistent with the category and use where listed. nystatin The above nystatin entry listed in the TOPICAL/DERMATOLOGY section is limited to the topical dosage forms. From this entry the oral formulations cannot be assumed to be on the list unless there is an entry for this product in the ANTI-INFECTIVES section of the document.
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 most instances, a brand-name drug for which a generic product becomes available will become non-formulary, with the generic product covered in its place, upon release of the generic product to the market. However, the document is subject to state specific regulations and rules regarding generic substitution and mandatory generic rules apply where appropriate. Generic drugs are usually priced lower than their brand-name equivalents. Prescription generic drugs are:
Approved by the U.S. Food and Drug Administration (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 extent compared to the brand-name drug (bioequivalence). 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 (therapeutic equivalence).
NON-COVERED MEDICATIONS Pharmaceuticals determined by the FDA to be less than effective and identical, related, or similar drugs
(commonly referred to as DESI 5 and 6 drugs). MetroPlus only covers drugs from manufacturers participating in the Federal Medicaid drug rebate program.
OVER-THE-COUNTER DRUG COVERAGE MetroPlus covers over-the-counter (OTC) drugs that obtain fiscal orders that meet Medicaid criteria. These include select medications in the following categories: analgesic and antipyretic, antacid, anti-diarrheal, antihistamine, anti-vertigo, artificial tears and ocular/oral lubricants, chronic renal disease, cough and cold, dermatological, family planning, fecal softener and laxative, hematinic, insulin, pediculicide, smoking cessation agents, and vitamins/minerals. All categories are represented on the formulary. However, not every item made by every manufacturer is covered. Furthermore, not all formulations and/or package sizes are covered. Quantities may also be limited based on acute/episodic vs. chronic/maintenance uses. For the most up-to-date list of covered OTC products, please reference: https://www.emedny.org/info/formfile.aspx
SPECIALTY PLAN DESIGN Specialty Guideline Management (SGM) SGM is our utilization management program that helps ensure appropriate utilization for specialty medication based on currently accepted evidence-based medicine guidelines. SGM is designed to help ensure safety and efficacy while preventing off-guideline utilization. Medications which may be included in the SGM program are identified in the document as “SGM” for your reference. Prescribers may call 1-866-814-5506 to enroll patients in Specialty plan design.
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PLAN DESIGN The document represents a closed formulary plan design. The medications listed on the document are covered by the plan as represented. Certain medications on the list are covered if utilization management criteria are met (i.e., Step Therapy, Prior Authorization, Quantity Limits, etc.); requests for use of such medications outside of their listed criteria will be reviewed for medical necessity. If a medication is not listed on the document, a formulary exception may be requested for coverage. Medical necessity or formulary exception requests will be reviewed based on drug-specific prior authorization criteria or standard non-formulary prescription request criteria.
LEGEND
AL Age Limit OTC Over the counter PA Prior Authorization PA, QL Quantity Limit is applied after Prior Authorization approval QL Quantity Limit SGM Specialty Guideline Management ST Step Therapy 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
NOTICE The information contained in this document is proprietary. The information may not be copied in whole or in part without written permission. ©2020. All rights reserved. This document contains references to brand-name prescription drugs that are trademarks or registered trademarks of pharmaceutical manufacturers. MetroPlus Health Plan does not operate the websites/organizations listed here, nor is it responsible for the availability or reliability of the websites' content. These listings do not imply or constitute an endorsement, sponsorship or recommendation by MetroPlus Health Plan. Please be advised that this document is updated periodically and changes may appear prior to their effective date to allow for client notification.
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ANALGESICS Practice guidelines of pain management are available at: https://www.asahq.org Treatment recommendations for osteoarthritis are available at: https://www.rheumatology.org NSAIDs
diclofenac sodium delayed-rel diclofenac sodium ext-rel diflunisal etodolac etodolac ext-rel flurbiprofen ibuprofen QL ketorolac meloxicam MOBIC nabumetone naproxen NAPROSYN naproxen sodium oxaprozin DAYPRO sulindac
COX-2 INHIBITORS
PA celecoxib CELEBREX GOUT
allopurinol ZYLOPRIM QL colchicine tabs COLCRYS probenecid
OPIOID ANALGESICS Practice Guidelines for Cancer Pain Management (includes WHO analgesic ladder) are available at: https://www.asahq.org https://www.nccn.org Opioid guidelines in the management of chronic non-malignant pain are available at: https://www.asipp.org/ASIPP-Guidelines.html The quantity of opioid products covered (including those that are combined with acetaminophen, aspirin or ibuprofen) will be limited to up to 90 morphine milligram equivalents (MMEs) per day based on a 30-day supply. Members may be subject to additional quantity limit restrictions, including a first-fill limit of 7 days (for members who are opioid-naïve) and 90 days of treatment per 365 days.
QL codeine/acetaminophen PA, QL fentanyl transdermal DURAGESIC QL hydrocodone/acetaminophen NORCO PA, QL hydromorphone ext-rel QL hydromorphone tabs DILAUDID PA, QL methadone tabs 5 mg, 10 mg DOLOPHINE QL morphine PA, QL morphine ext-rel MS CONTIN QL oxycodone QL oxycodone ROXICODONE QL oxycodone/acetaminophen PERCOCET QL oxycodone/aspirin PERCODAN QL tramadol 50 mg ULTRAM PA, QL tramadol ext-rel tabs
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QL tramadol/acetaminophen ULTRACET NON-OPIOID ANALGESICS
QL butalbital/acetaminophen/caffeine ESGIC QL butalbital/aspirin/caffeine FIORINAL
ANTI-INFECTIVES Practice guidelines and statements developed and endorsed by the Infectious Diseases Society of America are available at: https://www.idsociety.org Hepatitis: CDC recommendations on the treatment of hepatitis are available at: https://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: https://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: https://www.aidsinfo.nih.gov Infective Endocarditis: American Heart Association recommendations for the prevention of bacterial endocarditis are available at: https://professional.heart.org Influenza: Recommendations of the Advisory Committee on Immunization Practices are available at: https://www.cdc.gov/vaccines/hcp/acip-recs/vacc-specific/flu.html International Travel: CDC recommendations for international travel are available at: https://wwwnc.cdc.gov/travel 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: https://www.cdc.gov/pneumonia/management-prevention-guidelines.html Sexually Transmitted Diseases: CDC Sexually Transmitted Diseases Guidelines are available at: https://www.cdc.gov/std/treatment/default.htm ANTIBACTERIALS Aminoglycosides
neomycin Cephalosporins Cephalosporin Combinations
PA ceftolozane/tazobactam ZERBAXA First Generation
cefadroxil cephalexin KEFLEX
Second Generation
cefprozil cefuroxime axetil
Third Generation
cefdinir Erythromycins/Macrolides
azithromycin ZITHROMAX clarithromycin clarithromycin ext-rel
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erythromycin base erythromycin delayed-rel erythromycin ethylsuccinate erythromycin stearate
Fluoroquinolones
ciprofloxacin tabs CIPRO levofloxacin
Penicillins
amoxicillin amoxicillin/clavulanate AUGMENTIN ampicillin dicloxacillin penicillin G BICILLIN L-A penicillin VK
Sulfonamides
sulfadiazine sulfamethoxazole/trimethoprim sulfamethoxazole/trimethoprim DS
Tetracyclines
doxycycline monohydrate caps 50 mg, 100 mg doxycycline monohydrate suspension VIBRAMYCIN doxycycline monohydrate tabs 50 mg, 75 mg, 100 mg minocycline MINOCIN tetracycline
ANTIFUNGALS
clotrimazole troches fluconazole DIFLUCAN griseofulvin microsize suspension griseofulvin ultramicrosize PA, QL itraconazole caps SPORANOX nystatin QL terbinafine tabs PA voriconazole VFEND
ANTIMALARIALS
QL atovaquone/proguanil MALARONE QL chloroquine QL mefloquine
ANTIRETROVIRAL AGENTS Antiretroviral Adjuvants
QL cobicistat TYBOST Antiretroviral Combinations
QL abacavir/dolutegravir/lamivudine TRIUMEQ QL abacavir/lamivudine EPZICOM QL abacavir/lamivudine/zidovudine TRIZIVIR QL atazanavir/cobicistat EVOTAZ QL bictegravir/emtricitabine/tenofovir alafenamide BIKTARVY QL darunavir/cobicistat PREZCOBIX QL darunavir/cobicistat/emtricitabine/tenofovir alafenamide SYMTUZA QL dolutegravir/lamivudine DOVATO QL dolutegravir/rilpivirine JULUCA
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QL efavirenz/emtricitabine/tenofovir disoproxil fumarate ATRIPLA QL efavirenz/lamivudine/tenofovir disoproxil fumarate SYMFI QL efavirenz/lamivudine/tenofovir disoproxil fumarate SYMFI LO QL elvitegravir/cobicistat/emtricitabine/tenofovir alafenamide GENVOYA QL elvitegravir/cobicistat/emtricitabine/tenofovir disoproxil fumarate STRIBILD QL emtricitabine/rilpivirine/tenofovir alafenamide ODEFSEY QL emtricitabine/rilpivirine/tenofovir disoproxil fumarate COMPLERA QL, * emtricitabine/tenofovir alafenamide DESCOVY QL, * emtricitabine/tenofovir disoproxil fumarate TRUVADA QL lamivudine/tenofovir disoproxil fumarate CIMDUO QL lamivudine/zidovudine COMBIVIR
* Documentation may be required for select instances in which product labeling dictates monitoring Chemokine Receptor Antagonists
QL maraviroc SELZENTRY Integrase Inhibitors
QL dolutegravir TIVICAY QL raltegravir ISENTRESS
Non-nucleoside Reverse Transcriptase Inhibitors
QL efavirenz SUSTIVA QL etravirine INTELENCE QL nevirapine VIRAMUNE QL nevirapine ext-rel VIRAMUNE XR QL rilpivirine EDURANT
Nucleoside Reverse Transcriptase Inhibitors
QL abacavir ZIAGEN QL didanosine delayed-rel QL emtricitabine EMTRIVA QL lamivudine EPIVIR QL stavudine QL zidovudine RETROVIR
Nucleotide Reverse Transcriptase Inhibitors
QL tenofovir disoproxil fumarate VIREAD Protease Inhibitors
QL atazanavir REYATAZ QL darunavir PREZISTA QL fosamprenavir LEXIVA QL indinavir CRIXIVAN QL lopinavir/ritonavir KALETRA QL nelfinavir VIRACEPT QL ritonavir NORVIR QL tipranavir APTIVUS
ANTITUBERCULAR AGENTS
ethambutol MYAMBUTOL isoniazid pyrazinamide rifampin RIFADIN
ANTIVIRALS Cytomegalovirus Agents
QL valganciclovir VALCYTE
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Hepatitis Agents Hepatitis B
adefovir dipivoxil HEPSERA entecavir solution BARACLUDE entecavir tabs BARACLUDE lamivudine tabs EPIVIR-HBV
Hepatitis C
#, SGM glecaprevir/pibrentasvir MAVYRET SGM ribavirin caps, tabs 200mg SGM sofosbuvir/velpatasvir
# MAVYRET for genotypes 1, 2, 3, 4, 5, 6 Herpes Agents
acyclovir caps, suspension, tabs ZOVIRAX famciclovir valacyclovir VALTREX
Influenza Agents
QL oseltamivir TAMIFLU MISCELLANEOUS
ST atovaquone MEPRON clindamycin CLEOCIN dapsone ivermectin STROMECTOL PA linezolid ZYVOX PA linezolid injection ZYVOX QL mebendazole EMVERM metronidazole FLAGYL nitrofurantoin ext-rel MACROBID nitrofurantoin macrocrystals MACRODANTIN nitrofurantoin suspension PA pyrimethamine DARAPRIM rifabutin MYCOBUTIN trimethoprim QL vancomycin VANCOCIN
ANTINEOPLASTIC AGENTS Clinical practice guidelines in oncology are available at: https://www.asco.org https://www.nccn.org ALKYLATING AGENTS
busulfan MYLERAN chlorambucil LEUKERAN cyclophosphamide caps lomustine GLEOSTINE melphalan ALKERAN SGM temozolomide TEMODAR
ANTIMETABOLITES
SGM capecitabine XELODA mercaptopurine methotrexate TREXALL
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HORMONAL ANTINEOPLASTIC AGENTS Antiandrogens
bicalutamide CASODEX SGM enzalutamide XTANDI flutamide
Antiestrogens
SGM fulvestrant FASLODEX tamoxifen toremifene FARESTON
Aromatase Inhibitors
anastrozole ARIMIDEX exemestane AROMASIN letrozole FEMARA
Luteinizing Hormone-Releasing Hormone (LHRH) Agonists
SGM goserelin acetate ZOLADEX SGM leuprolide acetate SGM leuprolide acetate LUPRON DEPOT SGM triptorelin pamoate TRELSTAR
Gonadotropin Releasing Hormone (GnRH) Antagonists
SGM degarelix acetate FIRMAGON Progestins
megestrol acetate MEGACE IMMUNOMODULATORS
SGM lenalidomide REVLIMID KINASE INHIBITORS
SGM afatinib GILOTRIF SGM axitinib INLYTA SGM bosutinib BOSULIF SGM, QL cabozantinib CABOMETYX SGM cabozantinib COMETRIQ SGM ceritinib ZYKADIA SGM dabrafenib TAFINLAR SGM dasatinib SPRYCEL SGM erlotinib TARCEVA SGM everolimus AFINITOR SGM ibrutinib IMBRUVICA SGM idelalisib ZYDELIG SGM imatinib mesylate GLEEVEC SGM lapatinib TYKERB SGM lenvatinib LENVIMA SGM midostaurin RYDAPT SGM nilotinib TASIGNA SGM palbociclib IBRANCE SGM pazopanib VOTRIENT SGM ponatinib ICLUSIG SGM regorafenib STIVARGA SGM ruxolitinib JAKAFI SGM sorafenib NEXAVAR SGM sunitinib SUTENT SGM trametinib MEKINIST SGM vandetanib CAPRELSA
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SGM vemurafenib ZELBORAF MISCELLANEOUS
SGM bexarotene caps TARGRETIN etoposide hydroxyurea HYDREA leucovorin mitotane LYSODREN SGM niraparib ZEJULA SGM olaparib LYNPARZA SGM panobinostat FARYDAK procarbazine MATULANE SGM rucaparib RUBRACA tretinoin caps QL uridine triacetate VISTOGARD SGM venetoclax VENCLEXTA SGM vismodegib ERIVEDGE SGM vorinostat ZOLINZA
CARDIOVASCULAR The Eighth Report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure is available at: https://jamanetwork.com/journals/jama/fullarticle/1791497 Guidelines for the evaluation and management of cardiovascular diseases in adults are available at: https://www.acc.org https://professional.heart.org ACE INHIBITORS Guidelines for the use of ACE inhibitors are available at: https://jamanetwork.com/journals/jama/fullarticle/1791497 https://professional.diabetes.org https://www.acc.org https://professional.heart.org
benazepril LOTENSIN captopril enalapril VASOTEC fosinopril lisinopril ZESTRIL quinapril ACCUPRIL ramipril ALTACE trandolapril
ACE INHIBITOR/CALCIUM CHANNEL BLOCKER COMBINATIONS
amlodipine/benazepril LOTREL ACE INHIBITOR/DIURETIC COMBINATIONS
benazepril/hydrochlorothiazide LOTENSIN HCT captopril/hydrochlorothiazide enalapril/hydrochlorothiazide VASERETIC fosinopril/hydrochlorothiazide lisinopril/hydrochlorothiazide ZESTORETIC quinapril/hydrochlorothiazide ACCURETIC
ADRENOLYTICS, CENTRAL
clonidine CATAPRES clonidine transdermal CATAPRES-TTS
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guanfacine ALDOSTERONE RECEPTOR ANTAGONISTS
eplerenone INSPRA spironolactone ALDACTONE
ALPHA BLOCKERS Guidelines for the use of alpha blockers in various patient populations are available at: https://jamanetwork.com/journals/jama/fullarticle/1791497
doxazosin CARDURA prazosin MINIPRESS terazosin
ANGIOTENSIN II RECEPTOR ANTAGONISTS/DIURETIC COMBINATIONS Guidelines for the use of angiotensin II receptor antagonists in various patient populations are available at: https://jamanetwork.com/journals/jama/fullarticle/1791497 https://professional.diabetes.org
irbesartan AVAPRO irbesartan/hydrochlorothiazide AVALIDE losartan COZAAR losartan/hydrochlorothiazide HYZAAR valsartan DIOVAN valsartan/hydrochlorothiazide DIOVAN HCT
ANTIARRHYTHMICS Guidelines for the use of antiarrhythmics and cardiac glycosides in various patient populations are available at: https://www.acc.org
amiodarone disopyramide NORPACE disopyramide ext-rel NORPACE CR SGM dofetilide TIKOSYN flecainide propafenone propafenone ext-rel RYTHMOL SR sotalol BETAPACE sotalol BETAPACE AF
ANTILIPEMICS The 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the Management of Blood Cholesterol is available at: https://www.ahajournals.org/doi/10.1161/CIR.0000000000000625 Bile Acid Resins
cholestyramine QUESTRAN/QUESTRAN LIGHT colestipol COLESTID
Cholesterol Absorption Inhibitors
ezetimibe ZETIA Fibrates
fenofibrate fenofibrate TRICOR gemfibrozil LOPID
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15
HMG-CoA Reductase Inhibitors atorvastatin LIPITOR lovastatin pravastatin PRAVACHOL ST rosuvastatin CRESTOR simvastatin ZOCOR
Niacins
niacin ext-rel NIASPAN Omega-3 Fatty Acids
PA icosapent ethyl VASCEPA PCSK9 Inhibitors
SGM evolocumab REPATHA BETA-BLOCKERS Guidelines for the use of beta-blockers and beta-blocker combinations in various patient populations are available at: https://jamanetwork.com/journals/jama/fullarticle/1791497 https://www.acc.org
atenolol TENORMIN bisoprolol carvedilol COREG labetalol metoprolol succinate ext-rel TOPROL-XL metoprolol tartrate 25 mg, 50 mg, 100 mg LOPRESSOR nadolol CORGARD pindolol propranolol propranolol ext-rel INDERAL LA timolol
BETA-BLOCKER/DIURETIC COMBINATIONS Guidelines for the use of beta-blockers and diuretic combinations in various patient populations are available at: https://jamanetwork.com/journals/jama/fullarticle/1791497 https://www.acc.org
atenolol/chlorthalidone TENORETIC bisoprolol/hydrochlorothiazide ZIAC metoprolol/hydrochlorothiazide LOPRESSOR HCT
CALCIUM CHANNEL BLOCKERS Dihydropyridines
amlodipine NORVASC felodipine ext-rel nifedipine ext-rel nifedipine ext-rel PROCARDIA XL
Nondihydropyridines
diltiazem CARDIZEM diltiazem ext-rel diltiazem ext-rel CARDIZEM CD diltiazem ext-rel TIAZAC diltiazem ext-rel, except 120 mg CARDIZEM LA verapamil ext-rel CALAN SR verapamil ext-rel VERELAN PM
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16
DIGITALIS GLYCOSIDES digoxin LANOXIN digoxin pediatric elixir
DIURETICS Carbonic Anhydrase Inhibitors
acetazolamide acetazolamide ext-rel methazolamide
Loop Diuretics
bumetanide furosemide LASIX torsemide
Potassium-sparing Diuretics
amiloride Thiazides and Thiazide-like Diuretics
chlorthalidone hydrochlorothiazide indapamide metolazone
Diuretic Combinations
amiloride/hydrochlorothiazide spironolactone/hydrochlorothiazide ALDACTAZIDE triamterene/hydrochlorothiazide DYAZIDE triamterene/hydrochlorothiazide MAXZIDE
HEART FAILURE
ivabradine CORLANOR sacubitril/valsartan ENTRESTO
NITRATES Oral
isosorbide dinitrate 5 mg, 10 mg, 20 mg, 30 mg ISORDIL isosorbide mononitrate isosorbide mononitrate ext-rel nitroglycerin ext-rel
Sublingual
nitroglycerin sublingual NITROSTAT Transdermal
nitroglycerin ointment NITRO-BID nitroglycerin transdermal nitroglycerin transdermal NITRO-DUR
PULMONARY ARTERIAL HYPERTENSION Endothelin Receptor Antagonists
SGM ambrisentan LETAIRIS SGM bosentan TRACLEER
Phosphodiesterase Inhibitors
SGM sildenafil REVATIO
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17
Prostaglandin Vasodilators SGM epoprostenol sodium FLOLAN SGM iloprost VENTAVIS SGM treprostinil REMODULIN SGM treprostinil TYVASO
MISCELLANEOUS
hydralazine methyldopa midodrine
CENTRAL NERVOUS SYSTEM Practice guidelines for psychiatric disorders are available at: https://www.psychiatry.org ANTIANXIETY Benzodiazepines
QL alprazolam XANAX QL chlordiazepoxide QL clonazepam tabs KLONOPIN QL diazepam VALIUM QL lorazepam ATIVAN QL oxazepam
Miscellaneous
buspirone QL* clomipramine ANAFRANIL fluvoxamine
QL* Only applies to members of age 65 and older ANTICONVULSANTS Practice guidelines for the treatment of epilepsy are available at: https://www.aan.com
carbamazepine TEGRETOL carbamazepine ext-rel CARBATROL carbamazepine ext-rel TEGRETOL-XR diazepam rectal gel DIASTAT divalproex sodium delayed-rel DEPAKOTE divalproex sodium ext-rel DEPAKOTE ER ethosuximide ZARONTIN QL gabapentin NEURONTIN lamotrigine LAMICTAL levetiracetam KEPPRA levetiracetam injection KEPPRA oxcarbazepine TRILEPTAL phenobarbital phenytoin DILANTIN INFATABS phenytoin sodium extended DILANTIN phenytoin sodium extended PHENYTEK primidone MYSOLINE tiagabine GABITRIL topiramate sprinkle caps, tabs TOPAMAX valproic acid SGM vigabatrin SABRIL zonisamide ZONEGRAN
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18
ANTIDEMENTIA Practice guidelines for the management of dementia are available at: https://www.aan.com
donepezil ARICEPT galantamine RAZADYNE galantamine ext-rel RAZADYNE ER PA* memantine NAMENDA PA rivastigmine caps, solution PA rivastigmine transdermal EXELON PATCH
PA* Only applies to members < 30 years of age 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: https://www.psychiatry.org Monoamine Oxidase Inhibitors (MAOIs)
isocarboxazid MARPLAN phenelzine NARDIL tranylcypromine PARNATE
Selective Serotonin Reuptake Inhibitors (SSRIs)
citalopram CELEXA escitalopram LEXAPRO fluoxetine caps PROZAC paroxetine HCl ext-rel PAXIL CR paroxetine HCl tabs PAXIL sertraline ZOLOFT
Serotonin Norepinephrine Reuptake Inhibitors (SNRIs)
PA duloxetine delayed-rel CYMBALTA venlafaxine venlafaxine ext-rel EFFEXOR XR
Tricyclic Antidepressants (TCAs)
QL* amitriptyline QL* desipramine NORPRAMIN QL* doxepin QL* imipramine HCl QL* nortriptyline PAMELOR
QL* Only applies to members of age 65 and older Miscellaneous Agents
bupropion bupropion ext-rel WELLBUTRIN SR bupropion ext-rel WELLBUTRIN XL mirtazapine REMERON trazodone
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19
ANTIPARKINSONIAN AGENTS Practice guidelines for the diagnosis and treatment of Parkinson's disease are available at: https://www.aan.com
amantadine benztropine PA bromocriptine PARLODEL carbidopa/levodopa SINEMET carbidopa/levodopa ext-rel carbidopa/levodopa orally disintegrating tabs carbidopa/levodopa/entacapone STALEVO entacapone COMTAN pramipexole MIRAPEX ropinirole selegiline trihexyphenidyl
ANTIPSYCHOTICS Atypicals
aripiprazole ABILIFY aripiprazole ext-rel injection ABILIFY MAINTENA aripiprazole lauroxil ext-rel injection ARISTADA aripiprazole lauroxil ext-rel injection ARISTADA INITIO aripiprazole orally disintegrating tabs PA asenapine SAPHRIS clozapine CLOZARIL clozapine orally disintegrating tabs PA iloperidone FANAPT PA lurasidone LATUDA olanzapine ZYPREXA PA paliperidone ext-rel INVEGA paliperidone palmitate ext-rel injection INVEGA SUSTENNA paliperidone palmitate ext-rel injection INVEGA TRINZA quetiapine SEROQUEL PA quetiapine ext-rel SEROQUEL XR risperidone RISPERDAL risperidone long-acting injection RISPERDAL CONSTA ziprasidone GEODON
Miscellaneous
chlorpromazine fluphenazine fluphenazine decanoate injection fluphenazine injection haloperidol haloperidol decanoate injection HALDOL DECANOATE haloperidol lactate injection HALDOL perphenazine SGM pimavanserin NUPLAZID thiothixene trifluoperazine
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20
ATTENTION DEFICIT HYPERACTIVITY DISORDER Guidelines for the evaluation and management of attention deficit disorder are available at: https://www.aacap.org https://www.aap.org
QL amphetamine/dextroamphetamine mixed salts ADDERALL QL amphetamine/dextroamphetamine mixed salts ext-rel ADDERALL XR ST, QL atomoxetine STRATTERA QL dexmethylphenidate FOCALIN QL dextroamphetamine ext-rel DEXEDRINE SPANSULE QL dextroamphetamine tabs 5 mg, 10 mg QL methylphenidate RITALIN QL methylphenidate ext-rel QL methylphenidate ext-rel CONCERTA ST, QL methylphenidate ext-rel 20 mg, 30 mg, 40 mg RITALIN LA QL methylphenidate ext-rel tabs 20 mg - Metadate ER QL methylphenidate solution, tabs METHYLIN
FIBROMYALGIA
PA milnacipran SAVELLA PA, QL pregabalin LYRICA
HYPNOTICS Practice parameters for the treatment of sleep disorders and clinical guidelines for the evaluation and management of chronic insomnia are available at: https://aasm.org Benzodiazepines
QL temazepam RESTORIL Nonbenzodiazepines
QL zolpidem AMBIEN MIGRAINE Guidelines for prevention and management of migraine headaches are available at: https://www.aan.com Acute Migraine Agents Triptans
ST, QL naratriptan AMERGE ST, QL rizatriptan MAXALT QL sumatriptan IMITREX QL sumatriptan injection IMITREX QL sumatriptan nasal spray IMITREX ST, QL zolmitriptan ZOMIG
MOOD STABILIZERS
lithium carbonate lithium carbonate ext-rel tabs 300 mg LITHOBID lithium carbonate ext-rel tabs 450 mg lithium citrate
MULTIPLE SCLEROSIS AGENTS Practice guidelines for multiple sclerosis are available at: https://www.aan.com
SGM dimethyl fumarate delayed-rel TECFIDERA SGM fingolimod GILENYA
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21
SGM glatiramer COPAXONE SGM interferon beta-1a REBIF SGM interferon beta-1b EXTAVIA SGM teriflunomide AUBAGIO
MUSCULOSKELETAL THERAPY AGENTS
baclofen 10 mg, 20 mg QL carisoprodol SOMA chlorzoxazone 500 mg cyclobenzaprine 5 mg, 10 mg dantrolene DANTRIUM methocarbamol ROBAXIN orphenadrine ext-rel tizanidine tabs ZANAFLEX
MYASTHENIA GRAVIS
pyridostigmine MESTINON pyridostigmine ext-rel MESTINON TIMESPAN
NARCOLEPSY
PA armodafinil NUVIGIL PSYCHOTHERAPEUTIC-MISCELLANEOUS Alcohol Deterrents
acamprosate calcium disulfiram ANTABUSE naltrexone microspheres VIVITROL
Opioid Antagonists
naloxone injection QL naloxone nasal spray NARCAN naltrexone
Partial Opioid Agonists
buprenorphine sublingual Partial Opioid Agonist/Opioid Antagonist Combinations
QL buprenorphine/naloxone sublingual Pseudobulbar Affect
PA dextromethorphan/quinidine NUEDEXTA Smoking Deterrents Treating Tobacco Use and Dependence: 2008 Update-Clinical Practice Guideline is available at: https://www.ahrq.gov/professionals/clinicians-providers/guidelines-recommendations/tobacco/index.html
bupropion ext-rel nicotine inhaler NICOTROL nicotine nasal spray NICOTROL NS varenicline CHANTIX
ENDOCRINE AND METABOLIC ANDROGENS Clinical practice guidelines for the treatment of hypogonadism are available at: https://www.aace.com
PA testosterone cypionate DEPO-TESTOSTERONE PA testosterone enanthate DELATESTRYL
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22
PA testosterone gel FORTESTA PA testosterone gel 25 mg/2.5 g ANDROGEL
ANTIDIABETICS Guidelines of treatment and management of diabetes are available at: https://professional.diabetes.org Alpha-glucosidase Inhibitors
acarbose PRECOSE Biguanides
metformin metformin ext-rel
Biguanide/Sulfonylurea Combinations
glipizide/metformin METAGLIP Dipeptidyl Peptidase-4 (DPP-4) Inhibitors
ST alogliptin Dipeptidyl Peptidase-4 (DPP-4) Inhibitor/Biguanide Combinations
ST alogliptin/metformin Incretin Mimetic Agents
ST dulaglutide TRULICITY ST liraglutide VICTOZA ST semaglutide OZEMPIC
Insulins
insulin human HUMULIN R insulin human NOVOLIN R insulin isophane human HUMULIN N insulin isophane human NOVOLIN N insulin isophane human 70%/regular 30% HUMULIN 70/30 insulin isophane human 70%/regular 30% NOVOLIN 70/30 insulin aspart protamine 70%/insulin aspart 30% NOVOLOG MIX 70/30 insulin glargine BASAGLAR insulin glargine SEMGLEE insulin lispro ADMELOG insulin lispro protamine/insulin lispro HUMALOG MIX
Insulin Sensitizers
pioglitazone ACTOS Insulin Sensitizer/Biguanide Combinations
pioglitazone/metformin ACTOPLUS MET Insulin Sensitizer/Sulfonylurea Combinations
pioglitazone/glimepiride DUETACT Meglitinides
nateglinide STARLIX repaglinide
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23
Sodium-Glucose Co-Transporter 2 (SGLT2) Inhibitors PA* empagliflozin JARDIANCE ST ertugliflozin STEGLATRO
PA* Covered for cardiovascular indication Sulfonylureas
glimepiride AMARYL glipizide GLUCOTROL glipizide ext-rel GLUCOTROL XL
Supplies
OTC, QL alcohol swabs OTC blood glucose monitoring kits, test strips FREESTYLE FREEDOM LITE kits and
test strips OTC blood glucose monitoring kits, test strips FREESTYLE INSULINX kits and test
strips OTC blood glucose monitoring kits, test strips FREESTYLE LITE kits and test strips OTC blood glucose monitoring kits, test strips PRECISION XTRA kits and test strips OTC insulin syringes, needles BD ULTRAFINE insulin syringes and
needles OTC lancets OTC, QL multiple urine test products KETO-DIASTIX OTC, QL multiple urine test products MULTISTIX
CALCIUM REGULATORS Guidelines of treatment and management of osteoporosis are available at: https://www.aace.com https://www.nof.org Bisphosphonates
alendronate tabs FOSAMAX Calcitonins
calcitonin-salmon MIACALCIN CONTRACEPTIVES EE = ethinyl estradiol In accordance with the Comprehensive Contraception Coverage Act (CCCA), contraceptives may be dispensed as a 12-month supply at one time. Monophasic † † Products in this category may be dispensed as a 12-month supply at one time. 20 mcg Estrogen
drospirenone/EE 3/20 YAZ levonorgestrel/EE 0.1/20 norethindrone acetate/EE 1/20 LOESTRIN 1/20 norethindrone acetate/EE 1/20 and iron LOESTRIN FE 1/20
30 mcg Estrogen
desogestrel/EE 0.15/30 - Apri drospirenone/EE 3/30 YASMIN levonorgestrel/EE 0.15/30 norethindrone acetate/EE 1.5/30 LOESTRIN 1.5/30 norethindrone acetate/EE 1.5/30 and iron LOESTRIN FE 1.5/30 norgestrel/EE 0.3/30
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24
35 mcg Estrogen ethynodiol diacetate/EE 1/35 norethindrone/EE 0.4/35 norethindrone/EE 0.5/35 norethindrone/EE 1/35 norgestimate/EE 0.25/35
50 mcg Estrogen
ethynodiol diacetate/EE 1/50 Biphasic † † Products in this category may be dispensed as a 12-month supply at one time.
desogestrel/EE MIRCETTE Triphasic † † Products in this category may be dispensed as a 12-month supply at one time.
desogestrel/EE levonorgestrel/EE norethindrone/EE norgestimate/EE
Progestin Only † † Products in this category may be dispensed as a 12-month supply at one time.
norethindrone ORTHO MICRONOR Emergency Contraception
QL ulipristal ELLA Injectable † † Products in this category may be dispensed as a 12-month supply at one time.
QL medroxyprogesterone acetate 104 mg/0.65 mL DEPO-SUBQ PROVERA 104 QL medroxyprogesterone acetate 150 mg/mL DEPO-PROVERA
Transdermal † † Products in this category may be dispensed as a 12-month supply at one time.
norelgestromin/EE Vaginal † † Products in this category may be dispensed as a 12-month supply at one time.
etonogestrel/EE ring NUVARING Miscellaneous
QL diaphragm ENDOMETRIOSIS
danazol nafarelin SYNAREL
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25
ESTROGENS Guidelines of treatment and management of hormone therapy and menopause are available at: https://www.menopause.org https://www.aace.com/files/menopause.pdf Oral
estradiol ESTRACE Transdermal
estradiol CLIMARA Vaginal
estradiol vaginal tabs VAGIFEM estrogens, conjugated cream PREMARIN
ESTROGEN/PROGESTINS Oral
EE/norethindrone acetate FEMHRT EE/norethindrone acetate - Jinteli estradiol/norethindrone acetate ACTIVELLA
Transdermal
estradiol/norethindrone acetate COMBIPATCH FERTILITY REGULATORS Ovulation Stimulants, Synthetic
PA, QL clomiphene GLUCOCORTICOIDS
dexamethasone fludrocortisone hydrocortisone CORTEF methylprednisolone MEDROL methylprednisolone 2 mg MEDROL methylprednisolone injection SOLU-MEDROL prednisolone sodium phosphate orally disintegrating tabs ORAPRED ODT prednisolone sodium phosphate solution 5 mg/5 mL, 15 mg/5
mL, 25 mg/5 mL
prednisolone syrup PRELONE prednisone
GLUCOSE ELEVATING AGENTS
QL glucagon, human recombinant GLUCAGEN HYPOKIT QL glucagon, human recombinant GLUCAGON EMERGENCY KIT
HUMAN GROWTH HORMONES Guidelines for use of growth hormone are available at: https://www.aace.com/publications/guidelines
SGM somatropin NORDITROPIN SGM somatropin SEROSTIM SGM somatropin ZORBTIVE
HYPERPARATHYROID TREATMENT, VITAMIN D ANALOGS
calcitriol (1,25-D3) ROCALTROL doxercalciferol HECTOROL paricalcitol ZEMPLAR
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26
PHENYLKETONURIA TREATMENT AGENTS SGM sapropterin KUVAN
PHOSPHATE BINDER AGENTS
calcium acetate sevelamer carbonate tabs ST sucroferric oxyhydroxide VELPHORO
POTASSIUM-REMOVING AGENTS
sodium polystyrene sulfonate PROGESTINS Injectable
SGM hydroxyprogesterone caproate MAKENA Oral
medroxyprogesterone acetate PROVERA norethindrone acetate AYGESTIN progesterone, micronized PROMETRIUM
SELECTIVE ESTROGEN RECEPTOR MODULATORS
raloxifene EVISTA THYROID AGENTS Antithyroid Agents
methimazole TAPAZOLE propylthiouracil
Thyroid Supplements
levothyroxine levothyroxine SYNTHROID levothyroxine - Levoxyl liothyronine CYTOMEL
UREA CYCLE DISORDERS
SGM sodium phenylbutyrate BUPHENYL VASOPRESSIN RECEPTOR ANTAGONISTS
SGM tolvaptan SAMSCA VASOPRESSINS
PA desmopressin spray PA desmopressin spray, tabs DDAVP
MISCELLANEOUS
cabergoline SGM cysteamine CYSTAGON
GASTROINTESTINAL Guidelines for the treatment and management of various gastrointestinal diseases/conditions are available at: https://gi.org https://www.gastro.org ANTIDIARRHEALS
diphenoxylate/atropine LOMOTIL loperamide
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27
ANTIEMETICS PA, QL aprepitant caps EMEND QL dronabinol QL granisetron tabs meclizine metoclopramide REGLAN QL ondansetron ZOFRAN prochlorperazine promethazine promethazine suppository trimethobenzamide TIGAN
ANTISPASMODICS
chlordiazepoxide/clidinium dicyclomine glycopyrrolate tabs 1 mg, 2 mg hyoscyamine sulfate LEVSIN hyoscyamine sulfate ext-rel LEVBID hyoscyamine sulfate ext-rel caps hyoscyamine sulfate orally disintegrating tabs
CHOLELITHOLYTICS
ursodiol ACTIGALL ursodiol URSO
H2 RECEPTOR ANTAGONISTS
cimetidine famotidine PEPCID nizatidine
INFLAMMATORY BOWEL DISEASE Oral Agents
balsalazide budesonide delayed-rel caps ENTOCORT EC mesalamine ext-rel caps APRISO sulfasalazine AZULFIDINE sulfasalazine delayed-rel AZULFIDINE EN-TABS
Rectal Agents
hydrocortisone enema mesalamine rectal suspension ROWASA mesalamine suppository CANASA
LAXATIVES/STOOL SOFTENERS
lactulose solution peg 3350/electrolytes peg 3350/electrolytes GOLYTELY peg 3350/electrolytes NULYTELY
OPIOID-INDUCED CONSTIPATION
naloxegol MOVANTIK PANCREATIC ENZYMES
PA pancrelipase VIOKACE PA pancrelipase delayed-rel CREON PA pancrelipase delayed-rel ZENPEP
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28
PROSTAGLANDINS misoprostol CYTOTEC
PROTON PUMP INHIBITORS
AL*, QL esomeprazole magnesium delayed-rel suspension 2.5 mg, 5 mg, 10 mg
NEXIUM
QL omeprazole delayed-rel caps PRILOSEC QL pantoprazole delayed-rel tabs PROTONIX
AL* Covered for < 1 year only SALIVA STIMULANTS
pilocarpine tabs SALAGEN STEROIDS, RECTAL
hydrocortisone cream ANUSOL-HC 2.5% hydrocortisone cream PROCTOCORT 1%
MISCELLANEOUS
PA* glycopyrrolate CUVPOSA sucralfate tabs
PA* Covered for 3-16 years of age GENITOURINARY BENIGN PROSTATIC HYPERPLASIA Guidelines for the management of BPH are available at: https://www.auanet.org/guidelines
alfuzosin ext-rel UROXATRAL doxazosin CARDURA finasteride PROSCAR tamsulosin FLOMAX terazosin
URINARY ANTISPASMODICS
oxybutynin oxybutynin ext-rel DITROPAN XL trospium
* Gender restriction - Coverage for females VAGINAL ANTI-INFECTIVES
clindamycin cream CLEOCIN clotrimazole metronidazole miconazole terconazole
MISCELLANEOUS
bethanechol pentosan polysulfate sodium ELMIRON phenazopyridine PYRIDIUM potassium citrate ext-rel UROCIT-K
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HEMATOLOGIC Guidelines of treatment and management of hemophilia are available at: https://www.hemophilia.org ANTICOAGULANTS CHEST guidelines are available at: https://www.chestnet.org/Guidelines-and-Resources/CHEST-Guideline-Topic-Areas/Pulmonary-Vascular Injectable
enoxaparin LOVENOX Oral
apixaban ELIQUIS rivaroxaban XARELTO * warfarin COUMADIN
* Both Coumadin and warfarin are covered. Synthetic Heparinoid-like Agents
fondaparinux ARIXTRA HEMATOPOIETIC GROWTH FACTORS Guidelines for the management of neutropenia are available at: https://www.asco.org Guidelines for the management of anemia associated with chronic kidney disease are available at: https://www.kidney.org/professionals/guidelines#guidelines
SGM darbepoetin alfa ARANESP SGM filgrastim-sndz ZARXIO SGM pegfilgrastim-cbqv UDENYCA
PAROXYSMAL NOCTURNAL HEMOGLOBINURIA (PNH) AGENTS
SGM eculizumab SOLIRIS PLATELET AGGREGATION INHIBITORS
clopidogrel PLAVIX dipyridamole prasugrel EFFIENT ticagrelor BRILINTA
PLATELET SYNTHESIS INHIBITORS
anagrelide AGRYLIN THROMBOCYTOPENIA AGENTS
SGM eltrombopag tabs PROMACTA MISCELLANEOUS
cilostazol SGM deferasirox EXJADE SGM deferasirox JADENU
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IMMUNOLOGIC AGENTS Guidelines for the management of rheumatic diseases are available at: https://www.rheumatology.org AUTOIMMUNE AGENTS
SGM adalimumab HUMIRA SGM brodalumab SILIQ SGM etanercept ENBREL SGM sarilumab KEVZARA SGM, QL secukinumab COSENTYX SGM tofacitinib XELJANZ SGM tofacitinib ext-rel XELJANZ XR
DISEASE-MODIFYING ANTIRHEUMATIC DRUGS (DMARDs)
hydroxychloroquine PLAQUENIL leflunomide ARAVA methotrexate SGM methotrexate injection RASUVO
HEREDITARY ANGIOEDEMA AGENTS
SGM C1 esterase inhibitor CINRYZE SGM C1 esterase inhibitor, recombinant RUCONEST
IMMUNOMODULATORS CDC recommendations on the treatment of hepatitis are available at: https://www.cdc.gov/hepatitis/Resources/ Guidelines for the management of hepatitis are available at: https://www.aasld.org Interferons
SGM interferon alfa-2b INTRON A SGM peginterferon alfa-2a PEGASYS
Miscellaneous
SGM canakinumab ILARIS IMMUNOSUPPRESSANTS Antimetabolites
azathioprine AZASAN azathioprine IMURAN mycophenolate mofetil CELLCEPT
Calcineurin Inhibitors
cyclosporine SANDIMMUNE cyclosporine, modified NEORAL tacrolimus PROGRAF
Rapamycin Derivatives
sirolimus RAPAMUNE NUTRITIONAL/SUPPLEMENTS ELECTROLYTES Potassium
potassium bicarbonate effervescent tabs 25 mEq potassium chloride ext-rel potassium chloride ext-rel K-TAB
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31
potassium chloride liquid Miscellaneous
potassium phosphate K-PHOS VITAMINS AND MINERALS Folic Acid/Combinations
folic acid folic acid/vitamin B6/vitamin B12
Prenatal Vitamins
prenatal vitamins/carbonyl iron/docusate/folic acid - Prenatal AD
prenatal vitamins/carbonyl iron/ferrous fumarate/folic acid + DHA CITRANATAL MEDLEY prenatal vitamins/carbonyl iron/folic acid - Prenatabs Rx prenatal vitamins/DHA/docusate/folic acid CITRANATAL 90 DHA prenatal vitamins/DHA/docusate/folic acid CITRANATAL DHA prenatal vitamins/DHA/docusate/folic acid CITRANATAL HARMONY prenatal vitamins/docusate/folic acid CITRANATAL RX prenatal vitamins/docusate/folic acid + DHA CITRANATAL ASSURE prenatal vitamins/ferrous fumarate/docusate/folic acid -
Prenatal 19
prenatal vitamins/folic acid + pyridoxine CITRANATAL B-CALM Miscellaneous
cyanocobalamin injection ergocalciferol (D2) VITAMIN D fluoride drops, tabs multivitamins/fluoride drops, tabs multivitamins/fluoride/iron drops, tabs phytonadione MEPHYTON vitamin ADC/fluoride drops vitamin ADC/fluoride/iron drops vitamin B complex/vitamin C/folic acid NEPHROCAPS
RESPIRATORY Guidelines to the management, prevention, or treatment of COPD and asthma are available at: https://www.aaaai.org https://ginasthma.org https://goldcopd.org https://www.nhlbi.nih.gov The Allergy Report and guidelines for allergy-related conditions are available at: https://www.aaaai.org ANAPHYLAXIS TREATMENT AGENTS
QL epinephrine EPIPEN QL epinephrine EPIPEN JR. QL epinephrine auto-injector
ANTICHOLINERGICS
QL ipratropium inhalation solution QL tiotropium SPIRIVA RESPIMAT QL umeclidinium INCRUSE ELLIPTA
ANTICHOLINERGIC/BETA AGONIST COMBINATIONS Short Acting
QL ipratropium/albuterol inhalation solution
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ANTIHISTAMINES, LOW SEDATING cetirizine
ANTIHISTAMINES, SEDATING
clemastine cyproheptadine diphenhydramine hydroxyzine HCl hydroxyzine pamoate VISTARIL
ANTIHISTAMINE/DECONGESTANT COMBINATIONS
promethazine/phenylephrine ANTITUSSIVES Clinical practice guidelines are available at: https://journal.chestnet.org/article/S0012-3692(15)52856-0/pdf
benzonatate TESSALON ANTITUSSIVE COMBINATIONS Opioid
codeine/chlorpheniramine/pseudoephedrine codeine/guaifenesin liquid codeine/guaifenesin/pseudoephedrine codeine/promethazine codeine/promethazine/phenylephrine hydrocodone/homatropine
Non-opioid
dextromethorphan/brompheniramine/pseudoephedrine dextromethorphan/promethazine
BETA AGONISTS Inhalants Short Acting
QL albuterol inhalation solution QL albuterol sulfate, CFC-free aerosol
Long Acting Hand-held Active Inhalation
QL olodaterol, CFC-free aerosol STRIVERDI RESPIMAT Oral Agents
albuterol albuterol ext-rel terbutaline
CYSTIC FIBROSIS
SGM dornase alfa PULMOZYME SGM elexacaftor/tezacaftor/ivacaftor + ivacaftor TRIKAFTA SGM ivacaftor KALYDECO SGM lumacaftor/ivacaftor ORKAMBI SGM tobramycin inhalation solution KITABIS PAK SGM tobramycin inhalation solution TOBI
LEUKOTRIENE MODULATORS
montelukast SINGULAIR
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MAST CELL STABILIZERS QL cromolyn inhalation solution
MEDICAL SUPPLIES
OTC, QL mask OTC, QL nebulizer OTC sodium chloride inhalation solution OTC, QL spacer AEROCHAMBER OTC, QL vaporizer sodium chloride inhalation solution
NASAL ANTIHISTAMINES
QL azelastine spray NASAL STEROIDS
QL flunisolide spray PULMONARY FIBROSIS AGENTS
SGM, QL pirfenidone ESBRIET RESPIRATORY SYNCYTIAL VIRUS
SGM palivizumab SYNAGIS SEVERE ASTHMA AGENTS
SGM omalizumab XOLAIR STEROID/BETA AGONIST COMBINATIONS
QL budesonide/formoterol SYMBICORT AL*, QL fluticasone/salmeterol 100/50 ADVAIR DISKUS ST, QL mometasone/formoterol DULERA
AL* Covered for ages 4-11 years only STEROID INHALANTS
QL budesonide inhalation suspension PULMICORT RESPULES QL fluticasone FLOVENT DISKUS QL fluticasone, CFC-free aerosol FLOVENT HFA QL mometasone ASMANEX QL mometasone, CFC-free aerosol ASMANEX HFA
XANTHINES
theophylline ext-rel caps THEO-24 theophylline ext-rel tabs theophylline liquid theophylline liquid ELIXOPHYLLIN
MISCELLANEOUS
ipratropium nasal spray TOPICAL DERMATOLOGY Acne Guidelines for the care and treatment of acne vulgaris are available at: https://www.aad.org/practicecenter/quality/clinical-guidelines Oral
PA isotretinoin PA isotretinoin - Amnesteem
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PA isotretinoin - Claravis PA isotretinoin - Myorisan PA isotretinoin - Zenatane
Topical
benzoyl peroxide, except foam QL clindamycin gel, lotion, solution CLEOCIN T QL erythromycin gel 2% QL erythromycin solution sulfacetamide lotion 10% KLARON PA tretinoin RETIN-A
Actinic Keratosis
fluorouracil cream 4% TOLAK fluorouracil cream 5% EFUDEX
Antibiotics
gentamicin mupirocin ointment silver sulfadiazine SILVADENE
Antifungals
QL ciclopirox LOPROX QL clotrimazole QL ketoconazole cream 2% QL nystatin
Antipsoriatics Guidelines of care for the management and treatment of psoriasis with topical therapies are available at: https://www.aad.org Topical
ST, QL calcipotriene ointment, solution 0.005% Antiseborrheics
ketoconazole shampoo 2% selenium sulfide lotion 2.5%
Atopic Dermatitis Guidelines for the treatment of atopic dermatitis are available at: https://www.aad.org/practicecenter/quality/clinical-guidelines
ST* tacrolimus PROTOPIC ST* tacrolimus 0.1%: In addition to clinical criteria, the member must be at least 16 years of age. Corticosteroids Low Potency
alclometasone cream, ointment 0.05% fluocinolone acetonide solution 0.01% QL hydrocortisone cream, lotion, ointment 2.5%
Medium Potency
QL betamethasone valerate cream, lotion, ointment 0.1% fluocinolone acetonide cream, ointment 0.025% QL fluticasone propionate cream 0.05%, ointment 0.005% CUTIVATE hydrocortisone butyrate solution 0.1% QL mometasone cream, lotion, ointment 0.1%
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QL triamcinolone acetonide cream, lotion, ointment 0.025% QL triamcinolone acetonide cream, lotion, ointment 0.1%
High Potency
QL betamethasone dipropionate augmented cream 0.05% DIPROLENE AF QL betamethasone dipropionate cream, lotion, ointment 0.05% desoximetasone cream 0.25% TOPICORT QL fluocinonide cream, gel, ointment 0.05% fluocinonide solution 0.05% QL triamcinolone acetonide cream, ointment 0.5%
Very High Potency
QL betamethasone dipropionate augmented ointment 0.05% DIPROLENE clobetasol propionate solution 0.05% QL halobetasol propionate cream, ointment 0.05%
Emollients
ammonium lactate 12% Local Analgesics
PA lidocaine patch LIDODERM Local Anesthetics
QL lidocaine/prilocaine cream lidocaine/prilocaine kit
Rosacea
metronidazole cream 0.75% METROCREAM metronidazole gel 0.75% ST metronidazole gel 1% METROGEL metronidazole lotion 0.75% METROLOTION
Scabicides and Pediculicides
ST malathion OVIDE permethrin ST spinosad NATROBA
Miscellaneous Skin and Mucous Membrane
imiquimod ALDARA podofilox solution
MOUTH/THROAT/DENTAL AGENTS Anesthetics - Topical Oral
lidocaine viscous Steroids - Mouth/Throat
triamcinolone paste Miscellaneous
chlorhexidine PERIDEX AL sodium fluoride PREVIDENT
AL Covered to maximum patient age of 21
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OPHTHALMIC Preferred Practice Pattern Guidelines for the treatment of various ophthalmic conditions are available at: https://one.aao.org Antiallergics
cromolyn sodium Antifungals
natamycin NATACYN Anti-infectives
bacitracin ciprofloxacin solution CILOXAN erythromycin gentamicin levofloxacin moxifloxacin VIGAMOX neomycin/polymyxin B/gramicidin ofloxacin OCUFLOX polymyxin B/bacitracin polymyxin B/trimethoprim POLYTRIM sulfacetamide solution 10% BLEPH-10 tobramycin solution TOBREX
Anti-infective/Anti-inflammatory Combinations
neomycin/polymyxin B/bacitracin/hydrocortisone ointment neomycin/polymyxin B/dexamethasone MAXITROL neomycin/polymyxin B/hydrocortisone suspension sulfacetamide/prednisolone phosphate 10%/0.25% tobramycin/dexamethasone suspension 0.3%/0.1% TOBRADEX
Anti-inflammatories Nonsteroidal
diclofenac sodium ketorolac 0.4% ACULAR LS ketorolac 0.5% ACULAR
Steroidal
dexamethasone sodium phosphate fluorometholone 0.1% suspension FML LIQUIFILM prednisolone acetate 1% PRED FORTE prednisolone phosphate 1%
Antivirals
trifluridine Beta-blockers Nonselective
levobunolol timolol hemihydrate BETIMOL timolol maleate TIMOPTIC timolol maleate gel TIMOPTIC-XE
Selective
betaxolol 0.5%
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Carbonic Anhydrase Inhibitors Topical
dorzolamide TRUSOPT Carbonic Anhydrase Inhibitor/Beta-blocker Combinations
dorzolamide/timolol maleate COSOPT Carbonic Anhydrase Inhibitor/Sympathomimetic Combinations
brinzolamide/brimonidine SIMBRINZA Prostaglandins
latanoprost XALATAN Sympathomimetics
brimonidine 0.15% ALPHAGAN P brimonidine 0.2%
OTIC Clinical practice guidelines for the treatment of otitis media are available at: https://www.aap.org Anti-infectives
acetic acid ofloxacin otic
Anti-infective/Anti-inflammatory Combinations
ciprofloxacin/dexamethasone CIPRODEX neomycin/polymyxin B/hydrocortisone
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WEBSITES Agency for Healthcare Research and Quality https://www.ahrq.gov Alzheimer's Association https://www.alz.org American Academy of Allergy, Asthma and Immunology https://www.aaaai.org American Academy of Child & Adolescent Psychiatry https://www.aacap.org American Academy of Dermatology https://www.aad.org American Academy of Neurology https://www.aan.com American Academy of Ophthalmology https://www.aao.org American Academy of Pediatrics https://www.aap.org American Association for the Study of Liver Disease https://www.aasld.org American Association of Clinical Endocrinologists https://www.aace.com American Association of Diabetes Educators https://www.diabeteseducator.org American Cancer Society https://www.cancer.org American College of Allergy, Asthma and Immunology https://www.acaai.org American College of Cardiology https://www.acc.org American College of Chest Physicians https://www.chestnet.org American College of Gastroenterology https://gi.org American College of Physicians https://www.acponline.org American College of Rheumatology https://www.rheumatology.org
American Congress of Obstetricians and Gynecologists https://www.acog.org American Diabetes Association http://www.diabetes.org American Gastroenterological Association https://www.gastro.org American Headache Society Committee for Headache Education https://americanheadachesociety.org American Heart Association https://professional.heart.org American Lung Association https://www.lung.org American Medical Association https://www.ama-assn.org American Psychiatric Association https://www.psychiatry.org American Society of Anesthesiologists https://www.asahq.org American Society of Clinical Oncology https://www.asco.org American Society of Interventional Pain Physicians https://www.asipp.org American Urological Association https://www.auanet.org Centers for Disease Control and Prevention https://www.cdc.gov Centers for Disease Control and Prevention Guideline topics: AIDS https://www.cdc.gov/hiv/default.html Centers for Disease Control and Prevention Guideline topics: Sexually Transmitted Diseases https://www.cdc.gov/std/treatment/default.htm CVS Caremark https://www.caremark.com The Food and Drug Administration https://www.fda.gov
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Global Initiative for Asthma https://ginasthma.org Infectious Diseases Society of America https://www.idsociety.org Institute for Safe Medication Practices https://www.ismp.org Johns Hopkins AIDS Service https://www.thebody.com/content/art12096.html Juvenile Diabetes Research Foundation International https://www.jdrf.org MedWatch https://www