PHARMACY BENEFIT DIMENSIONS DRUG FORMULARY · 2014-05-27 · Liptruzet® Lopid® Onmel® Tricor®...

Pharmacy Benefit Dimensions – May 2014 1

PHARMACY BENEFIT DIMENSIONS DRUG FORMULARY This Drug Formulary represents the list of drugs and their appropriate copayment tiers for most members enrolled in an Pharmacy Benefit Dimensions pharmacy plan.

Introduction to The Drug Formulary Generic drugs appear in lower case, brand name drugs start with a capital letter. This formulary lists all covered Tier 1 and Tier 2 drugs but only lists representative products in Tier 3.

Formulary/preferred generic drugs and select Over the Counter (OTC) and select Brand Name drugs listed on the Formulary are assigned to copay Tier 1. The formulary follows a “Mandatory Generic” policy which means that in most instances, once a generic product is available for which there are no bioequivalence concerns, the branded product is assigned to Copay Tier 3, and the generic product is assigned to Copay Tier 1. Certain non‐preferred generic drugs may also be covered in the 3rd tier when efficacy, safety or cost factors suggest that better alternatives exist on the formulary. Generic substitution is used only as required by state pharmacy laws. Not all tier 3 non‐preferred drugs are listed in the formulary. For members with a 3 tier plan, most drugs not listed may be obtained, but the member will be responsible for their third tier copayment. Therapeutic interchange is not utilized.

Pharmacy Benefit Dimensions reserves the right to modify the copay tier of a particular drug as necessary. For example, the copay tier of a brand drug will be raised from Tier 2 to Tier 3 when a generic drug becomes available (the generic drug will be placed in copay Tier 1). The copay of a brand drug may be lowered from Tier 3 to Tier 2 if the generic equivalents are discontinued or no longer available.

Compounded prescriptions (medications that are not commercially manufactured) must be prepared by a participating pharmacy and contain at least one prescription component. The dispensing pharmacy is required to submit for prior approval and when covered, will take a Tier 2 copayment. Coverage is provided in accordance with our Compounding Drug Products Policy. Bulk products and powders are excluded from coverage because they are not prescription drug products that are approved under sections 505, 505(j) or 507 of the Federal Food Drug and Cosmetic Act.

Most self‐administered injectable drugs require prior authorization. Some exceptions are: insulin, glucagon, epinephrine emergency kits, etc. Drugs not intended for self administration are not covered under the pharmacy benefit and should be obtained and administered by an appropriate healthcare professional.

Certain drugs which are either self‐injectable, require special distribution, handling and/or are at limited supply are restricted to designated pharmacies that specialize in biotech injectables. These drugs are listed in the formulary under their therapeutic category as well as in the Specialty Drug section of the formulary (Chapter 23).

Over the Counter (OTC) drugs listed on the formulary must have a prescription (written or verbal) from a licensed health care provider.

Certain self‐funded employer groups may not follow this base formulary. Members in these pharmacy benefit management groups should refer to their summary plan description and/or their benefit administrator.

Specific drugs may be Preferred Brand or Non‐Preferred Brand based on individual employer requests.

Certain self‐funded employer groups may not follow this base formulary. Members in these pharmacy benefit management groups should refer to their summary plan description and/or their benefit administrator.

Drugs not listed in the fomulary which are covered under the Affordable Care Act (ACA) as preventative services may be covered. Certain restrictions may apply.


Benefit Exclusions (please note that benefit exclusions may vary by employer group):

Appetite suppressants/weight loss medications are excluded from coverage unless otherwise specified in a participants’s SPD.

Smoking cessation products may not be covered by all employer groups, benefits vary by plan.

Addiction maintenance/detox drugs may be excluded from coverage if specified in a participant’s SPD.

Medical devices (which may or may not require a prescription)

Medical foods other than PKU supplements (which may or may not require a prescription)

The following Drugs are excluded from the Formulary (not covered):

Antara®

fenofibrate 48mg, 145mg (Generic Tricor®)

fenofibric cap

Fenoglide®

Fibricor®

Karbinal® ER

Lipofen®

Liptruzet®

Lopid®

Onmel®

Tricor®

Triglide®

Trilipix®

Please note that some drugs and/or drug classes, even though not listed on the Formulary, may require prior authorization. The prescriber completes a prior authorization request form and faxes it to Pharmacy Benefit Dimensions. This form can also be used by physicians to submit information to support a request for an exception to the formulary. This list does not guarantee coverage. For questions, or to obtain Prior Authorization/Non‐Formulary Request Forms, a representative may be contacted at (716) 631‐2934 or (800) 247‐1466 ext. 5311. Prior Authorization Forms are also available to be printed from our website: www.pbdrx.com. Replacement of lost, stolen or damaged medications is the responsibility of the member. Emergency Room scripts are limited to a 10 day supply.


TABLE OF CONTENTS

CHAPTER 1 ‐ ALLERGY/COUGH & COLD ......................................................................................................................... 4

CHAPTER 2 – ASTHMA/RESPIRATORY ........................................................................................................................... 5

CHAPTER 3 – BLADDER/KIDNEY .................................................................................................................................... 6

CHAPTER 4 – BLOOD .................................................................................................................................................... 7

CHAPTER 5 – CANCER ................................................................................................................................................... 8

CHAPTER 6 – CARDIOVASCULAR – HYPERTENSION ....................................................................................................... 9

CHAPTER 7 – CARDIOVASCULAR – LIPID LOWERING ................................................................................................... 12

CHAPTER 8 – CARDIOVASCULAR/HEART ..................................................................................................................... 13

CHAPTER 9 – DERMATOLOGICAL MEDICATIONS ......................................................................................................... 14

CHAPTER 10 – DIABETES ............................................................................................................................................. 16

CHAPTER 11 – EAR/THROAT MEDICATIONS ................................................................................................................ 17

CHAPTER 12 – EYE ...................................................................................................................................................... 18

CHAPTER 13 – HORMONES/STEROIDS ........................................................................................................................ 20

CHAPTER 14 – INFECTION ........................................................................................................................................... 21

CHAPTER 15 – MEN’S HEALTH .................................................................................................................................... 23

CHAPTER 16 – MENTAL HEALTH ................................................................................................................................. 23

CHAPTER 17 – NERVOUS SYSTEM ............................................................................................................................... 25

CHAPTER 18 – PAIN .................................................................................................................................................... 27

CHAPTER 19 – SMOKING CESSATION .......................................................................................................................... 29

CHAPTER 20 – STOMACH/INTESTINAL ........................................................................................................................ 29

CHAPTER 21 – VITAMINS/MINERALS .......................................................................................................................... 31

CHAPTER 22 – WOMEN’S HEALTH .............................................................................................................................. 31

CHAPTER 23 – DENTAL FORMULARY ........................................................................................................................... 33

ADDITIONAL FORMULARY INFORMATION .................................................................................................................. 34

AFFORDABLE CARE ACT PREVENTATIVE SERVICES ...................................................................................................... 34

SPECIALTY PHARMACY INFORMATION ....................................................................................................................... 35

STEP THERAPY INFORMATION .................................................................................................................................... 36

KEY: PA – Prior Authorization QL – Quantity Limit ST – Step Therapy AL – Age Limit/Restriction RM – Restricted to MalesRF – Restricted to Females HT – Tablet Splitting ♦ ‐ Sedative/Hypnotic Drug ‡ ‐ Specialty Pharmacy + ‐ 90 day supplyLast Updated 05.08.2014

Please note: Medications listed on the drug formulary as covered without restriction may require prior authorization or may not be covered if it is determined that they are being used in conjunction with a procedure or treatment not covered under the members Health Contract.


CHAPTER 1 ‐ ALLERGY/COUGH & COLD

1.A. Sedating Antihistamines

TIER 1 TIER 2 TIER 3

clemastine fumarate syrup cyproheptadine + diphenhydramine 50mg + hydroxyzine HCl + AL hydroxyzine pamoate + AL promethazine + PA

clemastine fumarate tabs Tavist® Vistaril®

1.B. Non‐Sedating Antihistamines


Clarinex® PA Clarinex® Reditab PA desloratadine PA desloratadine odt PA levocetirizine dihydrochloride PA Xyzal® PA

1.C. Sedating Antihistamine/Decongestant Combinations


promethazine AL phenyleprine

chlorphen/DM/PE AL Rescon® JR Rescon‐MX® AL Rynatan® susp

1.D. Nasal Steroids/Other Nasal Products


azelastine nasal spray flunisolide nasal fluticasone propionate nasal ipratropium

Nasonex®

Astelin® ST Astepro® ST

Atrovent® 0.06% nasal spray Atrovent® 0.03% spray Atrovent® nasal solution 0.06% Beconase

® AQ ST AL Dymista

® ST QL

Flonase® ST

Nasarel® Omnaris® ST Patanase® ST Qnasl

® ST QL

Rhinocort® Aqua ST

Veramyst® ST

ZetonnaTM ST

1.E. Narcotic‐containing Cough Products


codeine‐guaifenesin‐pseudoephedrine codeine‐guaifenesin hydrocodone‐homatropine hydrocodone‐guaifenesin‐phenylephrine hydrocodone polistirex‐chlorpheniramine polistirex

hydrocodone‐phenylephrine syruppromethazine with codeine promethazine/phenylephrine/codiene syrup

Allfen® CDX liquid Tussionex

®


1.F. Non‐Narcotic‐containing Cough Products


benzonatate promethazine/dextromethorphan PA SSKI

Tessalon®

1.G. Other Allergy


Auvi‐QTM Epipen®

CHAPTER 2 – ASTHMA/RESPIRATORY

2.A. Sympathomimetics


albuterol sulfate tabs +, syrup albuterol nebs metaproterenol tabs + syrup terbutaline tabs +

Arcapta® Neohaler + AL

Foradil® + ST

Maxair® Autohaler Proair

® HFA Proventil HFA

® Serevent® Diskus + ST Ventolin HFA®

Accuneb® Alupent

® Brethine® Isuprel

® Perforomist

® PA Proventil® Xopenex®

2.B. Xanthine Derivatives


aminophylline + theophylline SR + theophylline ER +

Dyphylline‐GG®

Lufyllin®

Quibron® Uniphyl

® 400mg, 600mg

2.C. Inhaled Corticosteroids and Combinations


Alvesco® Asmanex® + budesonide respules 0.25mg, 0.5mg AL + Flovent® Diskus 50mcg, 100mcg, 250mg Flovent

® HFA + Pulmicort® Flexhaler Pulmicort

® Respules 1mg AL + QVar® +

Advair® +

Advair® HFA + Dulera

® AL + Symbicort® +

Aerobid® Aerobid‐M® Daliresp

® PA

Pulmicort Respules® 0.25mg, 0.5mg AL Zetonna

® PA


2.D. Mast Cell Stabilizers


cromolyn sodium 10mg/ml nebs + Intal® nebs

2.E. Leukotriene Modifiers


montelukast sodium chews (ages 1‐5 only) + montelukast sodium tabs +

Accolate® Singulair® chews AL Singulair® zafirlukast Zyflo

® CR PA

2.F. Other Respiratory Drugs


acetylcysteine ipratropium 200mcg/ml nebs + sodium chloride for inhalation

Anoro Ellipta®AL Atrovent

® HFA + Combivent® Kalydeco® PA ‡ Pulmozyme

® Spiriva® + AL

albuterol‐ipratropium neb soln Atrovent

® Neb Breo Ellipta® AL Duoneb®

TudorzaTM Pressair AL

CHAPTER 3 – BLADDER/KIDNEY

3.A. Antispasmodics


flavoxate hcl + hyoscyamine + AL oxybutynin + oxybutynin chloride SR + tolterodine er ST QL + tolterodine tartrate ST QL + trospium ST + trospium er ST +

Enablex® + ST

Anturol® ST Detrol

® ST QL Detrol LA® ST QL Ditropan® Ditropan

® XL Levsin®/SL MyrbetriqTM

ST

Sanctura® ST Sanctura XR

® ST Toviaz® ST trospium ST

Urispas® Vesicare

® ST


3.B. Cholinergic Stimulants


bethanechol chloride + Urecholine®

3.C. Urinary Anesthetics


phenazopyridine Pyridium®

3.D. Other Urinary Products


citric acid/sodium citrate potassium citrate + potassium citrate/citric acid +

Elmiron® PA QL Renacidin®

Bicitra® Polycitra® Urocit‐K

®

CHAPTER 4 – BLOOD

4.A. Anticoagulants


enoxaparin sodium PA fondaparinox PA heparin sodium jantoven + warfarin sodium +

Eliquis® Fragmin® PA Mephyton® + Pradaxa

TM +

Xarelto®+

Arixtra® PA Coumadin® Lovenox® PA

4.B. Antiplatelets


aspirin/dipyridamole + clopidogrel bisulfate + dipyridamole + sulfinpyrazone +

Aggrenox® PA Brilinta

® +

Effient® + AL

Persantine® Plavix

® Ticlid® ticlopidine

4.C. Hematopoietic Agents

TIER 1 TIER 2 TIER 3 Aranesp® PA ‡

Epogen® PA ‡ Granix® PA ‡Neulasta® PA ‡ Neupogen® PA ‡ Procrit® PA ‡ Promacta® PA ‡

Leukine® PA Neumega® PA

4.D. Other Blood Modifiers


aminocaproic acid anagrelide + PA cilostazol + pentoxifylline +

Arcalyst® PA ‡

Exjade® PA ‡ Revlimid® PA ‡

Agrylin® PA Ferriprox® PA ‡ Firazyr® PA ‡ Pletal® Trental®


CHAPTER 5 – CANCER

5.A. Cancer Drugs


anastrozole + ‡ PA RF bicalutamide ‡ RM capecitabine PA cyclophosphamide etoposide (caps only) ‡ exemestane ‡ + + ‡ PA RF flutamide ‡ RM hydroxyurea 500mg ‡ letrozole ‡ + PA RF (QL AL for Fertility) leucovorin calcium tabs megestrol acetate ‡ mercaptopurine methotrexate tabs + octreotide PA tamoxifen + temozolomide ‡ tretinoin ‡

Actimmune® PA ‡

Afinitor® PA ‡ Alkeran® ‡ Caprelsa® PA ‡

CeeNu® Emcyt® ‡ ErivedgeTM PA ‡ Fareston® + RF ‡ Gleevec® PA ‡ Hexalen® ‡ Hycamtin® cap PA ‡ Jakafi® PA ‡ Leukeran® ‡ Lysodren

® ‡ Matulane® ‡ Mesnex® PA ‡ Myleran

® ‡

Nilandron® PA

Oforta® PA ‡

Proleukin® PA Sprycel

® ST ‡ Sutent® PA ‡ Tabloid® Tarceva

® PA ‡ Tasigna® ST ‡ Teslac® Thalomid

® ‡ Tykerb

® PA ‡ Votrient® PA ‡ Zolinza® PA ‡ Zortress® PA Zytiga® PA ‡

Arimidex® + ‡ PA RF Aromasin® + ‡ PA RF Bosulif® PA ‡ Casodex® ‡ RM Cometriq

® PA ‡ Cytoxan® ‡ Droxia® ‡ Femara® ‡ + PA RF (QL AL for Fertility) Gilotrif

TM PA ‡ Hydrea® ‡ Iclusig® PA ‡ Imbruvica® PA ‡ Inlyta® PA ‡ Iressa

® ‡ Megace® ES ‡ Mekinist TM

PA ‡ Nexavar

® PA ‡

Pomalyst® PA ‡ Sandostatin® PA Signifor® PA Stivarga

® PA

SylatronTM PA ‡

Tafinlar TM PA ‡

Temodar® ‡ Vesanoid® ‡ Xalkori® PA ‡ Xeloda

® PA Xtandi

® PA ‡ ZelborafTM

PA ‡

5.B. Immunosuppressant Drugs


azathioprine + cyclosporine capsules cyclosporine modified + cyclosporine oral solution mycophenolate + mycophenolate sodium dr + PA prednisolone prednisone sirolimus 0.5mg PA tacrolimus

Azasan® + Rapamune

® 1mg, 2mg, soln PA

AstagrafTM XL PA CellCept

® Imuran® Myfortic® PA Neoral® Orapred

® Prograf® Rapamune

® 0.5mg PA Rayos® ST Sandimmune

®


CHAPTER 6 – Cardiovascular – Hypertension

6.A. ACE Inhibitors


benazepril + captopril + enalapril + HT fosinopril + HT lisinopril + HT moexipril + HT quinapril + HT perindopril + HT ramipril + trandolapril + HT

Accupril® Aceon® Altace® caps Capoten® Epaned

® soln PA Lotensin® Mavik®

Prinivil® Univasc

® Vasotec® Zestril®

6.B. Angiotensin II Receptor Blockers


candesartan ST + eprosartan ST + irbesartan + HT losartan + telmisartan ST +

Diovan® + ST HT Atacand® ST Avapro® ST HT Benicar® ST Cozaar

® ST Edarbi® ST Micardis® ST Teveten

® ST

6.C. Beta Blockers


acebutolol hcl + atenolol + bisoprolol fumerate + HT carvedilol + Dutoprol® + labetalol + metoprolol + metoprolol succinate SR + nadolol + pindolol+ propranolol + propranolol ER + timolol +

Betaxolol® Bystolic® Coreg® Corgard® Inderal® LA Innopran XL

® Kerlone® Levatol® Lopressor

® Sectral® Tenormin® Toprol

® XL Trandate® Zebeta®


6.D. Calcium Channel Blockers


amlodipine + amlodipine besylate‐benazepril hcl + diltiazem cd + Cartia XT + dilatiazem xr + diltiazem ER bead caps + diltiazem hcl + diltiazem SR + felodipine er + Nifediac CC Nifedical XL nifedipine ER + nimodipine PA verapamil + verapamil ER caps + verapamil SR tablets +

Adalat® CC

Calan® Calan® SR Cardene® SR Cardizem® Cardizem

® LA Cardizem

® CD Dilacor® XR DynaCirc® CR Isoptin® SR Kerlone® Lotrel® Nicardipine® Nimotop® PA nisoldipine Norvasc® Nymalize

® PA QL Plendil

® Procardia® XL Sular® Tiazac® Verelan® PM

6.E. Diuretics /Loop Diuretic


bumetanide + furosemide + torsemide +

Demadex® Edecrin

® Lasix®

6.E.ii. Thiazide and Related Drugs


chlorothiazide tabs + chlorthalidone + hydrochlorothiazide + indapamide + methyclothiazide + metolazone +

Diuril® susp Zaroxolyn®

6.E.iii. Potassium Sparing Diuretics


amiloride hcl + hctz/spironolactone + spironolactone + triamterene/hctz

Aldactazide® 50/50 + Aldactazide 25/25® Aldactone

®

Dyazide®

Dyrenium® Maxzide

®


6.F. Vasodilators


doxazosin + hydralazine hcl + minoxidil tabs + prazosin hcl + terazosin +

Cardura® Cardura® XL Minipress®

6.G. Centrally Acting Hypertensives


clonidine hcl + clonidine hcl TD patch guanfacine hcl + methyldopa +

Catapres®

Catapres®‐TTS Tenex®

6.H. Hypertensive Combinations


amlodipine besylate/benazepril hcl + atenolol/chlorthalidone + benazepril/hctz + bisoprolol/hctz + candesartan/hctz + ST captopril/hctz + enalapril/hctz + HT irbesartan/hctz + HT lisinopril/hctz + HT losartan/hctz + metoprolol/hctz + moexipril/hctz + HT propranolol/hctz + quinapril/hctz + HT telmisartan/hctz + ST valsartan/hctz + HT

Accuretic® Atacand HCT® ST Avalide

® ST HT Azor® ST Benicar HCT® ST Corzide

® Diovan® HCT ST HT Edarbyclor® ST Exforge

® ST Exforge® HCT ST Hyzaar® ST Lopressor HCT

® Lotensin HCT® Lotrel® methyldopa/hctz Micardis

® HCT ST Prinzide

® Tarka® telmisartan/amlodipine ST trandolapril/verapamil hcl Tenoretic

® Tribenzor

TM ST

Twynsta® ST Uniretic® Vaseretic

® Zestoretic® Ziac®

6.I. Renin‐Angiotensin Inhibitor


AmturnideTM ST Tekamlo

® ST Tekturna® ST Tekturna

® HCT ST


CHAPTER 7 – Cardiovascular – Lipid Lowering

7.A. Bile Acid Sequestrants

TIER 1 TIER 2 TIER 3 cholestyramine/cholestyramine light (bulk) + colestipol granules(bulk) + colestipol tab 1gm +

Welchol® + Colestid® (bulk) Colestid

® tab Questran

® Questran Light®

7.B. HMG‐CoA Reductase Inhibitors


atorvastatin calcium + HT lovastatin + HT pravastatin + HT simvastatin + HT

Crestor® + HT

fluvastatin Juxtapid® PA ‡ Kynamro® PA ‡ QL Lescol® Lipitor

® Livalo® Mevacor® Pravachol

® Zocor

®

7.C. Fibric Acid Derivatives


fenofibrate tabs 54mg, 160mg + fenofibrate caps 67mg, 134mg, 200mg + gemfibrozil + Lofibra +

7.D. Other Antihyperlipidemic


niacin er + Lovaza® + Zetia

® +

Niaspan® VascepaTM


7.E. Antihyperlipidemic Combination Products


Simcor® +

Advicor® atorvastatin/amlodipine Caduet® Vytorin® ST

CHAPTER 8 – Cardiovascular/Heart

8.A. Antiarrhythmics


amiodarone + digoxin + disopyramide + flecainide acetate + mexiletine hcl + propafenone hcl + propafenone hcl sr + quinidine gluconate SR + quinidine sulfate + quinidine sulfate SR + sotalol +

Norpace CR® + Tikosyn®+

Lanoxin® Multaq® Norpace

® Rythmol® SR Tambocor®

8.B. Nitrates


isosorbide dinitrate + isosorbide mononitrate + isosorbide mononitrate SR + nitroglycerin long‐acting + nitroglycerin ointment nitroglycerin patch + nitroglycerin sublingual +

Nitrostat® QL Imdur®

Isordil®

Minitran® Nitro‐Bid

®

Nitro‐Dur® Nitrolingual aerosol spray

8.C. Other Cardiovascular Drugs


eplerenone + PA midodrine hcl phentolamine inj PA sildenafil AL PA

Adcirca® PA Dibenzyline

® Letairis® PA ‡ Tracleer® PA ‡

AdempasTM PA ‡

Inspra® PA

Opsumit® PA ‡ OrenitramTM

PA ‡ ProAmatine

® Ranexa® Revatio® AL PA VecamylTM PA ‡


CHAPTER 9 – Dermatological Medications

9.A. Topical Corticosteroid Drugs


alclometasone diproprionate augmented betamethasone diproprionate (and AF)

augmented betamethasone betamethasone diproprionate bethamethasone valerate cream, lotion, oint clobetasol proprionate oint; cream desonide 0.05% cream; oint; lotion desoximetasone diflorasone diacetate fluticasone cr; oint fluocinonide fluocinolone acetonide fluticasone propionate lotion 0.05% halobetasol propionate hydrocortisone rectal cream 2.5% hydrocortisone 25mg rectal hydrocortisone 2.5% cream; oint; lotion hydrocortisone valerate mometasone furoate + prednicarbate cr, oint triamcinolone acetonide

Capex®

Cordran® Tape only Halog®

Aclovate® Apexicon E® betamethasone valerate foam Carmol‐HC® clobetasol propionate foam Clobex® Clobex® Spray Cordran® lotion Cutivate

® cream; oint Cutivate® 0.05% lotion DermAtop®

Desowen® lotion Diprolene® (and AF) Diprolene

® 0.05% lotion Elocon® Halonate® Lidex

®

Luxiq® foam

Novacort®

Olux® foam Pediderm

® HC Pramosone® E Temovate® Topicort

® Ultravate® Verdeso® Westcort

®

9.B. Antiacne Drugs


adapalene generic Avita

® benzoyl peroxide cr,gel,lot OTC clindamax clindamycin phosphate gel 1% clindamycin phosphate‐benzoyl peroxide gel clindamycintopical erythromycin gel erythromycin pads erythromycin/benzoyl peroxide gel isotretinoin PA metronidazole cream, lotion, gel Myorisan® PA generic Retin‐A® generic Sulfacet‐R

® rosadan sulfacetamide sodium lotion sulfacetamide sodium w/sulfur emulsion/cleanser

tretinoin microsphere gel Zenatane

® PA

Azelex® Derma‐Smoothe/FS

® Finacea® Finacea® Plus Kit Noritate

® Ziana®

Absorbica® PA Accutane

® PA Avar‐E® LS Avita® BenzaClin

® ST Benzefoam® Brevoxyl

® benzoyl peroxide (rx only), cloths, foam 5.3% Cleocin‐T

® Clindagel® Differin

® cream, gel Duac

® Klaron® Metrocream® Metrogel

® 0.75%, 1% Metrolotion® minocycline hcl er PA minocycline hcl tabs PA Plexion

® cleanser Retin‐A® Retin‐A

® Micro Rosadan® Kit Rosula

® Emulsion Cleanser Solodyn® PA sulfacetamide sodium w/sulfer cream, liquid Sumadan

TM Sumaxin® Wash Tretin® X QL Triaz

® Cloths 3% Veltin

TM


9.C. Antipsoriasis and Antieczema Drugs


acitretin PA calcipotriene soln, oint, cream PA methotrexate tabs + selenium sulfide sulfacetamide sodium lotion

Elidel® AL PA FabiorTM

QL PA Protopic® AL PA Tazorac® PA

8‐Mop® Dovonex® PA Keralyt® scalp Salvax® Duo Kit PA Soriatane® PA SoriluxTM PA Taclonex

® PA Zithranol‐RR

® PA QL

9.D. Antifungal Drugs


ciclopirox 0.77% clotrimazole cream, lotion, soln OTC econazole nitrate cream 1% ketoconazole 2% shampoo ketoconazole cream Lamisil AT

® cream OTC miconazole cream, lotion, aerosol, soln OTC Nizoral A‐D® shampoo OTC nystatin 100,000u/1g cream; oint nystatin pwd nystatin‐triamcinolone Nystop

®

ciclopirox soln ciclopirox shampoo ciclopirox kit Extina®

ketoconazole foam 2% Ketodan

® Loprox® Loprox® Shampoo Mentax

® Micatin® Naftin® Nizoral

® shampoo Oxistat® Penlac® Vusion

®

9.E. Other Dermatological Products


aluminum chloride 20% ammonium lactate cr, lotion calcitriol ointment PA clotrimazole w/ betamethasone cream 1‐0.05%

diclofenac gel PA fluorouracil imiquimod cream PA lidocaine cr lidocaine hc cr lidocaine viscous soln lidocaine‐prilocaine cream lindane normal saline for irrigation permethrin cream podofilox solution

Carac®

Eurax® Oxsoralen‐Ultra

® (oral only) Veregen

®

Aldara® PA Analpram® E Drysol® Efudex

® Epiduo

® PA Evoclin® Foam lidocaine patch Lidoderm

® Medrox‐RX® PA Mirvaso® Gel PA Momexin® Natroba

® ST QL Panretin® Gel PA Picato® Gel PA Regranex

® PA Solaraze® PA spinosad suspension 0.9% ST QL Sklice

® ST QL

Targretin® Gel PA Ulesfia® Uramaxin® urea ValchlorTM

PA ‡ Vectical

® PA Vytone® Zyclara

® PA QL Zypram® 2.35‐1% cream and kit


9.F. Antibiotics


acyclovir ointment gentamicin silver sulfadiazine mupirocin acyclovir oint

Aczone® PA Altabax® ST Bactroban® Sitavig® XereseTM Zovirax

®

CHAPTER 10 – Diabetes NOTE: Insulin, oral anti‐diabetic agents and diabetic suppplies that are not listed on the formulary require prior authorization and if authorized, will be covered in accordance with the member’s contract. Copayments vary by plan.

10.A. Insulin

TIER 1 TIER 2 TIER 3 Humulin® Insulins +

Humalog® +

Lantus® +

Levemir® + Novolin

® insulins + Novolog

® insulins +

Apidra® PA QL Apidra

® Solostar PA

10.B. Oral Hypoglycemic Drugs


acarbose + glimepiride + glimepiride/pioglitaone + glipizide + glipizide‐metformin glipizide CR tablets + glyburide + glyburide‐metformin + glyburide micronized + metformin hcl (500mg, 850mg, 1,000mg) + metformin tb24 + metformin SR + nateglinide + PA pioglitazone hcl + pioglitazone hcl/metformin hcl + repaglinide +

Actoplus Met® XR

Invokana® PA Janumet® + Janumet

® XR + Januvia

® + HT Jentadueto® + Kombiglyze

® XR Onglyza® + HT Proglycem

® PA

Prandin® +

Prandimet® +

Riomet®

Tradjenta® +

Actos® Actoplus Met® Amaryl® Avandamet

® PA Avandaryl® PA Avandia® PA Cycloset

® Diabeta® PA Duetact

®

Farxiga® PA Fortamet

® PA

Glucophage/Glucophage XR® PA Glucotrol® PA Glucotrol XL

® PA Glucovance

® PA Glumetza® ST Glyset

® PA Glynase® PA Juvisync® Kazano® Metaglip

® Nesina® Oseni® Prandin

® Precose

® Starlix® PA


10.B.i Other Drugs Affecting Glucose


glucagon

Bydureon® ST Byetta® ST Symlin® PA Victoza® ST Welchol® +

10.C. Diabetic Supplies


NovoFine® Needles

Blood Glucose Monitors The manufacturers listed below will provide a glucose meter to you with no copayment. Quantities are limited by each manufacturer to one meter per member. Please have your ID number available when you contact the manufacturer. Accu‐Chek glucose meters can be obtained by calling Roche Diagnostics at 1‐888‐744‐3671.

One Touch glucose meters can be obtained by calling Lifescan, Inc. at 1‐888‐377‐5227, please reference offer code 289IHA001.

Accu‐Chek® Glucose Meters OneTouch® Glucose Meters

Accu‐Chek® Active Accu‐Chek® Advantage Accu‐Chek® Aviva Plus Accu‐Chek

® Compact Accu‐Chek® Nano SmartView

OneTouch® Ultra® OneTouch® Ultra® 2 OneTouch® UltraMiniTM

OneTouch® UltraSmart® OneTouch® Verio® IQ OneTouc® Verio® Sync Meter

Diabetic Test Strips

Products listed in this section are a covered benefit based on your plan. Products not listed require prior authorization. Copayments vary by plan.

Accu‐Chek® Diabetic Test Strips OneTouch® Diabetic Test Strips

Accu‐Chek® Active Accu‐Chek

® Aviva Plus Accu‐Chek® Aviva Accu‐Chek® Comfort Curve Accu‐Chek

® Compact Accu‐Chek® SmartView

OneTouch® Basic® OneTouch

® Profile® OneTouch® SureStep® OneTouch® Ultra® OneTouch

® Verio®

CHAPTER 11 – Ear/Throat Medications

11.A. Drugs Affecting the Ear


acetic acid otic soln antyipyrine/benzocaine otic soln ciprofloxacin otic PA AL generic Cortisporin® Otic sol, susp generic Domeboro® Otic hydrocortisone w/acetic acid otic soln ofloxacin otic PA AL

Ciprodex® PA AL Chloromycetin® Otic

Auralgan® Otic Soln

Cipro HC® Otic PA AL colistimethate Cortane B

® Otic Cortisporin® otic sol, susp Cortisporin® Otic‐TC Cresylate

® Otic Domeboro® Otic Floxin® Otic PA AL Neotic

® Trioxin® Otic susp Zinotic®/Zinotic® ES


11.B. Drugs Affecting the Throat and Mouth


cevimeline QL chlorhexidine oral rinse triamcinolone in Orabase lidocaine viscous pilocarpine tab +

Evoxac® QL Kenalog® in Orabase Peridex® Salagen®

CHAPTER 12 – Eye

12.A. Ophthalmic Antiinfective drugs


bacitracin ophthalmic chloramphenicol ciprofloxacin ophth soln erythromycin ophthalmic gentamicin ophthalmic generic Neosporin® ophthalmic levofloxacin opth soln ofloxacin ophth soln generic Polytrim

® generic Polysporin® ophthalmic sulfacetamide sodium 10% tobramycin trifluridine

Natacyn® PA

Zirgan®

Azasite® PA QL

Besivance® Ciloxan® gatifloxacin soln PA Moxeza

® PA Ocuflox® QL Quixin® Vigamox

® PA Viroptic® Zymaxid® PA

12.B. Ophthalmic Corticosteroid Drugs


dexamethasone ophthalmic hydrocortisone w/acetic acid otic soln fluorometholone ophthalmic prednisolone ophthalmic

Acuvail® PA

Alrex® 5ml only PA Flarex

® FML‐Forte

® ophthalmic Lotemax

® 5ml only Lotemax® ointment, gel Pred Mild® Vexol

® 5ml only

Acetasol® HC otic soln HMS® Pred Forte

®

12.C. Ophthalmic Antiinfective/Steroid Combination Drugs


dexamethasone/tobramycin generic Cortisporin® ophthalmic generic Maxitrol® ophthalmic generic Metimyd

® generic NeoDecadron

®

Blephamide® Liquifilm

Poly‐Pred® Tobradex® ointment

Pred‐G®

Pred‐G S.O.P. ® Tobradex® susp. Tobradex

® ST Zylet

®


12.D. Glaucoma Drugs


acetazolamide tab + apraclonidine brimonidine tartrate 0.2% brimonidine solution carteolol dipivefrin dorzolamide hcl soln dorzolamide/timolol ophth soln + latanoprost ophth soln PA levobunolol HCl methazolamide + metipranolol pilocarpine soln timolol maleate timolol ophthalmic gel

Alphagan P® 0.1% Azopt® Betimol® 5ml only Betoptic® S Combigan® 5ml only Isopto Carbachol

® Lumigan

® PA Phospholine® iodide Pilopine® H.S. Simbrinza® Travatan® PA

Travatan® Z PA

Alphagan P® 0.15% Betagan® Cosopt® Cosopt® PF Diamox® Iopidine

® Optipranolol

® Rescula® PA Timoptic® Timolol® XE Trusopt® Xalatan® PA Zioptan® PA

12.E. Other Ophthalmic Drugs


Alaway® OTC atropine azelastine ST bromfenac cromolyn sodium + PA diclofenac sodium ophth soln + PA epinastine ST homatropine ketorolac tromethamine ophth soln 0.4% and 0.5% PA

naphazoline OTC QL phenylephrine ophthalmic 2.5% tropicamide Zaditor® OTC

Alomide® PA BromdayTM ® PA Max. 2 fills per year

Cystaran® PA Ilevro® PA Max. 2 fills per year Lacrisert® Nevanac

® PA Max. 2 fills per year Restasis® PA

Acular® PA Acular® LS PA Akten

® Alamast® Alocril® ST Bepreve

® opth ST Durezol® Elestat® ST

Emadine®

flurbiprofen ophth soln ketotifen fumerate ophth soln (rx only) LastacaftTM ST Mydfrin

® Ocufen® ophth soln Pataday

® ST

Patanol® ST Prolensa® ST PA Max 2 fills per year

Optivar® ST Voltaren

®ophth soln PA


CHAPTER 13 – Hormones/Steroids

13.A. Oral Steroids


dexamethasone cortisone acetate + fludrocortisone acetate + hydrocortisone tab + methylprednisolone prednisolone oral syrup prednisone

Celestone® Cortef® Decadron® Medrol® Orapred

® Pediapred® Prelone®

13.B. Thyroid and Antithyroid Drugs


levothroid + levothyroxine + levoxyl + liothyronine + methimazole + propylthiouracil + thyroid + unithroid +

Armour Thyroid® + Synthroid

® + Cytomel® Tapazole

® TirosintTM

13.C. Growth Hormone Products


Norditropin® PA ‡ Somavert® PA ‡

Genotropin® PA ‡ Humatrope® PA ‡ Nutropin®/Nutropin® AQ PA ‡ Saizen

® PA ‡ Serostim® PA

13.D. Osteoporosis


alendronate tabs + calcitonin‐salmon Fortical

®

Actonel® + Atelvia

TM Forteo

® PA ‡ (limited to 26 fills/lifetime) Fosamax® plus D + Miacalcin® inj. PA

Binosto® ST Boniva

® tabs QL Fosamax

® tabs ibandronate sodium tabs QL Miacalcin® nasal spray

13.E. Other Endocrine Drugs


cabergoline PA QL desmopressin + sodium phenylbutyrate PA

Buphenyl® PA CarbagluTM

PA

Chemet® Cystagon® PA Didronel

® Increlex

® PA ‡ Korlym® PA ‡ Menostar

® + RF AL Orfadin® PA ‡ Sensipar® + Stimate

® Syprine® + Zavesca® PA ‡

DDAVP® MyaleptTM PA ‡ Oxandrin

® Procysbi® PA ‡ Ravicti

® PA ‡ Samsca

® PA


CHAPTER 14 – Infection

14.A. Antibiotics (Antibiotics are generally limited to a 10 day supply with one refill within 15 days of original fill.)


amoxicillin caps, susp amoxicillin clavulanate ampicillin caps, susp azithromycin QL, 600mg QL PA azithromycin

® susp QL cefaclor caps, susp cefadroxil cefdinir cefprozil cefuroxime 250mg & 500mg tabs cephalexin caps, susp cephradine capsules ciprofloxacin tabs clarithromycin clarithromycin SR QL clindamycin 75mg, 150mg, 300mg clindamycin granules dicloxacillin caps doxycycline hyclate caps, tabs doxycycline hyclate TBEC dr QL erythromycin base enteric pellets erythromycin estolate caps, susp erythromycin ethylsuccinate tabs, susp erythromycin stearate erythromycin/sulfisoxazole susp levofloxacin minocycline caps (50mg & 100mg only) moxifloxacin hcl nitrofurantoin macrocrystals PA penicillin VK tabs, soln sulfamethoxazole/trimethoprim sulfisoxazole tabs tetracycline caps, susp trimethoprim tabs

Ery‐Tab®

Suprax® tabs, susp Vibramycin® susp

amoxicillin/clavulanate er Augmentin® XR Avelox® Biaxin® Biaxin XL

® tabs QL Ceftin® 125mg tabs, susp Cefzil® Cetraxal® PA QL Max. 7 day supply Cipro

® ciprofloxacin hcl SR 24 hr tabs Cleocin® pediatric granules Doryx® QL doxycycline DR QL doxycycline monohydrate Furadantin® susp PA Keflex® Ketek

®

Noroxin®

Levaquin®

Macrobid®

Minocin® Minocin Pac® PA Monodox® 75mg Moxatag

® Proquin® XR Zithromax® QL, 600mg QL PA Zithromax

® susp QL ZMax

® Zyvox® PA

14.B. Antifungals


clotrimazole troche fluconazole 150mg tab (QL, females only) fluconazole tabs/oral suspension griseofulvin 125mg, 250mg griseofulvin suspension itraconazole caps PA ketoconazole tabs PA nystatin oral suspension nystatin tabs terbinafine hcl PA voriconazole PA

Lamisil® oral granules PA Noxafil

® PA Noxafil DR® PA

Ancobon® Diflucan

® 150mg (QL, females only) Diflucan® tabs/oral suspension Ertaczo

® QL flucytosine Grifulvin

® V Gris‐Peg® griseofulvin 500mg Lamisil

® PA Mycelex® Troche Nizoral® PA Oravig

® ST AL Sporanox® PA Terbinex

® PA QL Vfend® PA


14.C. HIV Drugs


abacavir sulfate tabs + abacavir sulfate/lamivudine/zidovudine PA didanosine dr lamivudine + lamivudine/zidovudine nevirapine nevirapine sr stavudine zidovudine

Aptivus® Atripla® CompleraTM Crixivan® Emtriva® Epzicom

® Fuzeon

® PA ‡ Intelence® Invirase® Isentress® Kaletra® Lexiva® Norvir® Prezista® ST Rescriptor® Reyataz® Selzentry

® Stribild

TM Sustiva® Trivicay® Truvada® Videx® Viramune

® XR 100mgViread® Viracept® Ziagen® soln

Combivir®

EdurantTM Epivir® Retrovir® Trizivir® PA Videx

® EC Viramune

® Viramune® XR Zerit® Ziagen® tabs

14.D. Other Antiviral Drugs


acyclovir adefovir dipivoxil tabs PA amantadine + famciclovir QL ganciclovir PA lamivudine tab PA ribavirin ‡ PA valacyclovir QL

Alferon N® PA

Baraclude® PA Relenza

® QL AL Tamiflu® QL Tyzeka® PA Valcyte

® PA

Copegus®‡ PA Epivir‐HBV® PA Famvir

® QL

flumadine Hepsera® PA Rebetol

® ‡ PA Valtrex® QL Zovirax®

14.E. Antituberculosis Drugs


ethambutol isoniazid + pyrazinamide rifabutin PA rifampin

Rifater®

Myambutol®

Mycobutin® PA Rifadin

® Seromycin

® Sirturo® PA Trecator

®

14.F. Other Specialized Antiinfective Drugs


chloroquine phosphate dapsone hydroxychloroquine sulfate + mebendazole QL metronidazole mefloquine hcl QL neomycin sulfate paromomycin primaquine phosphate quinine sulfate caps PA QL AL tinidazole tabs tobramycin neb PA QL ‡ vancomycin caps PA

Alinia® tabs PA, soln PA AL Cayston® PA QL AL Must be obtained from Cystic Fibrosis Services

Coartem® QL Daraprim® Mepron® PA Nebupent

® PA Stromectol® Yodoxin

®

Aralen® phosphate atovaquone/proguanil Bethkis

® PA QL ‡ Dificid® PA Flagyl® Malarone

® metronidazole 375mg caps Qualaquin

® PA QL AL Tindamax® Tobi® PA QL ‡ Vancocin

® capsules PA Xifaxan® 200mg QL, 550mg PA


CHAPTER 15 – Men’s Health

15.A. Drugs for Benign Prostatic Dysplasia


alfuzosin + RM doxazosin + finasteride + RM tamsulosin hcl sr + terazosin (capsules only) +

Avodart® + RM Cardura® Cardura® XL Cialis® 2.5mg & 5mg RM Duplicate therapy with ED drugs is not allowed.

Flomax® Hytrin® Proscar

® RM

Rapaflo® RM Uroxatral® RM

15.B. Erectile Dysfunction

Drugs in this category are limited to male patients only. Duplicate therapy with other ED medications is not allowed.


yohimbine

Caverject® PA QL = 6 per fill/48 per year Edex

® PA QL = 6 per fill/48 per year

Muse® PA QL = 6 per fill/48 per year Viagra® QL = 6 per fill/72 per year

Cialis® 10mg & 20mg QL = 4 tabs mth/48 per year Levitra

® QL = 4 tabs mth/48 per year Staxyn® QL = 4 tabs mth/48 per year/12 fills year Stendra® QL = 4 tabs mth/48 per year/12 fills year

15.C. Male Hormones


testosterone cypionate PA Androderm® RM PA Androgel® RM PA Android

® + Androxy® + Methitest

® + Testim

® RM PA Testred® +

AxironTM RM PA

Bio‐T‐Gel® RM PA Depo‐Testosterone

® PA FortestaTM

RM PA

Striant® PA

CHAPTER 16 – Mental Health

16.A. Antianxiety Drugs


alprazolam buspirone clorazepate chlordiazepoxide diazepam AL lorazepam oxazepam

alprazolam xr Ativan® Tranxene

®

Valium® Xanax®

Xanax® XR

16.B. Sedative/Hypnotic Drugs


diphenhydramine 50mg only + flurazepam ♦ AL hydroxyzine hcl + AL hydroxyzine AL pamoate + temazepam ♦ triazolam ♦ zaleplon ♦ zolpidem tartrate ♦

Rozerem® ♦

Ambien® ♦ Ambien® CR ♦ ST Edular® SL ST QL ♦ Halcion

® ♦ HetliozTM

PA Intermezzo

® ST QL Lunesta

® PA meprobamate AL Restoril

® ♦

Sonata® ♦

Vistaril®

zolpidem er ♦ ST


16.C. Depression/Mania


amitriptyline amitriptyline/perphenazine bupropion + bupropion hcl SR 12 hr + bupropion hcl SR 24hr + citalopram + HT clomipramine desipramine doxepin duloxetine escitalopram oxalate + HT fluoxetine hcl 10mg & 20mg tabs/capsules + fluoxetine liquid fluvoxamine imipramine HCl (PM non‐form) lithium carbonate + lithium carbonate CR tab maprotiline PA mirtazapine + mirtazapine ODT + nefazodone hcl + PA nortriptyline paroxetine tabs + HT paroxetine er + ST paroxetine hcl sr + ST phenelzine tab protriptyline sertraline + HT tranylcypromine trazodone + trimipramine venlafaxine + venlafaxine er +

Savella® +

Amoxapine® Anafranil® BrintellixTM

ST BrisdelleTM Celexa® Cymbalta

® desvenlafaxine ST Effexor® XR Emsam® PA Fetzima® ST fluoxetine 40mg capsules, 60mg tabs, PMDD, 90mg

fluvoxamine er Forfivo® XL Lexapro® + HT Nardil® Oleptro

® ST Pamelor

® Parnate® Paxil® Paxil® CR ST Prozac® Prozac

® Weekly Niravam® PA Norpramin® Pristiq

® ST Remeron® Remeron Sol‐Tab® Sarafem

® Silenor® QL Surmontil

® Tofranil® Tofranil® PM Viibryd

TM Vivactil® Wellbutrin

® Wellbutrin SR

® Wellbutrin XL® Zoloft®

16.D. Antipsychotic drugs


chlorpromazine + clozapine QL fluphenazine haloperidol + loxapine + olanzapine + olanzapine odt PA perphenazine + risperidone + risperidone odt PA risperidone solution AL thioridazine + AL thiothixene + trifluoperazine + quetiapine fumarate ziprasidone +

Abilify® 5mg & 15mg PA

Abilify® 10mg, 20mg & 30mg HT PA Abilify® oral solution PA Orap®

Abilify® Discmelt PA

Fanapt® PA Fazaclo® QL Geodon® Haldol

® LatudaTM Navane® olanzapine‐fluoxetine PA Risperdal® Risperdal® M PA Risperdal® solution AL Saphris® Seroquel

® Seroquel® XR ST Symbyax

® PA Thorazine

® Zyprexa® Zyprexa®/Zydis® PA


16.E. CNS Stimulant Drugs

(Generally for Hyperkinesis or Narcolepsy only. Not covered as appetite suppressant.)


amphetamine mixture + AL amphetamine‐dextroamphetamine sr + AL dexmethylphenidate hcl cp24 AL dextroamphetamine tabs & SR + AL methamphetamine + AL methylphenidate + AL methylphenidate cd AL methylphenidate er AL methylphenidate SR tabs + AL

Nuvigil® + AL PAStrattera® + AL

Adderall® AL Adderall XR® AL clonidine hcl er Concerta

® AL Daytrana

® AL Dexedrine®/Spansules AL

dexmethylphenidate hcl sr AL Dextrostat® AL Focalin® XR AL KapvayTM Metadate CD

® AL Methylin

® AL modafinil PA AL Provigil

® PA AL Quillivant® XR ST AL Ritalin® AL /Ritalin LA® AL Vyvanse

® AL

Zenzedi® AL

CHAPTER 17 – Nervous System

17.A. Anticonvulsants


carbamazepine + carbamazepine er + clonazepam tabs clonazepam odt ST divalproex sodium tabs + divalproex sodium sr + divalproex sodium sprinkles + ethosuximide 250mg/5ml syrup ethosuximide capsules + felbamate gabapentin + lamotrigine tablets + lamotrigine chewable tablets + levetiracetam + oxcarbazepine + phenobarbital + phenytoin chew tab + phenytoin sodium + phenytoin sodium extended + phenytoin sodium susp + primidone + tiagabine + PA topiramate + topiramate sprinkle + PA AL valproic acid + zonisamide + PA

Banzel® PA AL

Celontin® + Diastat® PA Lyrica

® Peganone

® + Phenytek® + Sabril

® PA Vimpat® PA AL

Aptiom® PA Carbatrol® Depakene® Depakote

® Depakote ER

® Depakote® Sprinkles Dilantin

® Dilantin® Infatab Dilantin® 125 suspension Felbatol

® FycompaTM PA AL Gabitril

® PA Gralise® ST Horizant

® PA Keppra® Keppra

® XR Klonopin

®/Klonopin® Wafers Lamictal® tabs Lamictal® chewable tablets Lamictal

® ODT PA, Titration Kit PA QL Lamictal® Starter Kit QL Lamictal® XR AL, Starter Kit PA QL AL lamotrigine er AL levetiracetam xr Mebaral

® Mysoline® Neurontin

® Oxtellar® XR Phenytek® Potiga® Tegretol

®/Tegretol® XR Topamax® Topamax

® Sprinkles PA AL Trileptal

® TrokendiTM XR PA Zarontin® Zonegran

® PA


17.B. Antiparkinson Drugs


amantadine hcl + benztropine + bromocriptine mesylate + carbidopa/levodopa + carbidopa/levodopa CR + carbidopa/levodopa/entacapone tabs + carbidopa/levodopa odt ST diphenhydramine 50mg + entacapone + ST pramipexole dihydrochloride + PA ropinirole hydrochloride tabs + PA selegiline + trihexyphenidyl +

Apokyn® PA ‡ Azilect® + PA Zelapar® + PA

carbidopa Cogentin® Comtan® ST Eldepryl® Kemadrin® Lodosyn

® Mirapex

®/ Mirapex® ER PA Neupro® PA Parlodel® Parcopa® ST Requip® PA Requip® XL PA ropinirole hcl tabs 24 hour PA Sinemet® Sinemet CR® Stalevo

® Tasmar

® ST

17.C. Alzheimer’s Drugs


donepezil + donepezil 23mg + ST galantamine + galantamine SR + galantamine oral solution

Namenda® tabs, soln + Aricept®

Aricept® ODT Aricept® 23mg ST Cognex

® Exelon® Namenda® XR Razadyne

®

Razadyne® ER

rivastigmine

17.D. Multiple Sclerosis Drugs


AmpyraTM ER PA ‡ Avonex® PA ‡ Copaxone

® PA ‡ Gilenya

TM PA ‡ Tecfidera® PA ‡

Aubagio® PA ‡ Extavia® PA ‡ Rebif® PA ‡

17.E. Other CNS/Autonomic Drugs


acamprosate calcium tab dr PA buprenorphine hcl PA buprenorphine hcl/naloxone hcl sublingual disulfiram naltrexone pyridostigmine bromide 60mg tab

Mestinon® 60mg syrup, 180mg CR tab Nuedexta

TM XR PA OnfiTM PA Prostigmin® Suboxone® Filmtab Xenazine® PA QL Xyrem

® PA Zubsolv®

Antabuse® PA

ButransTM

PA

Campral® PA Intuniv® AL NortheraTM PA ‡ Revia® Subutex

® PA Suboxone® SL


CHAPTER 18 – Pain

18.A. Narcotic Pain Relieving


acetaminophen w/codeine aspirin w/codeine belladonna/opium supp codeine sulfate fentanyl TD patch 12mcg, 25mcg fentanyl TD patch 50mcg, 75mg, 100mcg ST hydrocodone w/acetaminophen hydrocodone/APAP soln 7.5/500 mg per 15ml hydrocodone w/ibuprofen hydromorphone hcl PA methadone hcl 5mg,10mg morphine sulfate ir morphine sulfate cap sr 24hr 10mg, 20mg, 30mg, 50mg, 60mg, 80mg morphine sulfate cap sr 24hr 100mg, 200mgST morphine sulfate supp morphine sulfate tablets oral solution morphine sulfate ER oxycodone 5mg tablets/soln oxycodone w/acetaminophen tramadol tramadol er tablets ST

Nucynta®

Nucynta® ER Oxycontin® 10mg, 15mg, 20mg, 30mg, 40mg Oxycontin® 60mg, 80mg ST

AbstralTM PA AL

Limited distribution via REMS program. Actiq® PA Avinza® 30mg Avinza® 45mg, 60mg, 75mg, 90mg, 120mg ST B&O Supprettes® AL Combunox

® QL Conzip® ST Dilaudid® PA Duragesic® ST Exalgo® ST Fentora

® PA Kadian®

10mg, 20mg, 30mg, 50mg, 60mg, 80mg Kadian® 100mg, 200mg ST Lazanda® PA Lortab

®

Magnacet® morphine sulfate beads sr 24hr ST MS Contin

® Norco® Onsolis

® PA ‡ AL Opana

® PA Opana ER® Oramorph

®

Oxecta® PA

oxycodone w/ibuprofen QL oxymorphone PA Percocet® Percodan® Reprexain

® PA

Roxicodone® Rybix® ODT PA Ryzolt

® ST

Subsys® PA Talwin NX® PA tramadol/apap PA Tylenol w/Codeine

® Tylox® Ultracet® PA Ultram

® ER ST Vicodin® Vicoprofen® 7.5mg/200mg Xodol

®


18.B. Antiinflammatory, i.e. NSAIDs

TIER 1 TIER 2 TIER 3 aspirin CR 800mg + diclofenac sodium enteric coated tablets + diclofenac sodium SR 24‐hr 100 mg + diflunisal + etodolac + flurbiprofen tabs + ibuprofen + (prescription strengths only, OTC not covered)

indomethacin + indomethacin SR + ketoprofen + ketorolac PA QL AL meclofenamate + meloxicam + nabumetone + naproxen + naproxen sodium + oxaprozin + piroxicam + salsalate + sulindac + tolmetin sodium +, 200mg PA

Celebrex® + ST fenoprofen +

Anaprox® Daypro® Duexis® PA EC Naprosyn

® Flector® patch Indocin

® ketoprofen extended release mefenamic acid Motrin® Mobic® Nalfon® Naprelan

® QL Naprelan

® SR Naprosyn®

Pennsaid® QL Ponstel® Meloxicam® Comfort PacKit QL Sprix

TM PA QL

Vimovo® PA Voltaren‐XR®

Voltaren® gel QL Zipsor

®

18.C. Migraine Drugs


butalbital/apap/caffeine/codeine butorphanol tartrate NS PA divalproex sodium sr ergotamine w/caffeine acetaminophen; butalbital; caffeineaspirin; butalbital; caffeine

aspirin; butalbital; caffeine; codeine isometheptene mucate/dichloralphenazone/acetaminophen acetaminophen; butalbital sumatriptan inj QL sumatriptan nasal spray QL sumatriptan tabs QL zolmitriptan QL

Cafergot®

Ergomar®

Migranal® PA QL Relpax

® tablets QL Zomig® Nasal Spray QL

Alsuma® QL Amerge

® QL Axert® QL Cambia

® PA QL AL Depakote ER® DHE® 45 QL PA Esgic

® Esgic Plus® Fiorinal® Fioricet

® Frova® QL Imitrex

® QL Maxalt

® QL Maxalt‐MLT® QL Midrin® naratriptan QL Phrenilin® Forte rizatriptan benzoate QL rizatriptan benzoate odt QL Stadol NS® PA Sumavel

® QL Treximet

® ST QL Zelrix® QL ZecuityTM

QL

Zomig® QL

18.D. Antirheumatics


diclofenac w/misoprostol QL hydroxychloroquine sulfate + leflunomide + PA methotrexate tabs + methotrexate inj PA

Cuprimine® Depen® Titratabs Enbrel

® ‡ PA Humira® ‡ PA Ridaura® Thiola

TM Trexall®

Arava® 10mg, 20mg PA

Arthrotec® QL Cimzia

® ‡ PA Kineret® ‡ PA Orencia® SQ ‡ PA Otrexup

TM PA

Simponi® ‡ PA Xeljanz® ‡ PA


18.E. Gout


allopurinol + colchicine w/probenicid + probenicid + sulfinpyrazone +

Colcrys® + Uloric® ST

Zyloprim®

18.F. Muscle Relaxants


baclofen + carisoprodol AL chlorzoxazone AL cyclobenzaprine 5mg, 10mg tabs AL dantrolene caps diazepam AL methocarbamol riluzole + tizanidine tablets +

Amrix® PA cyclobenzaprine er PA Dantrium® Equagesic

® AL Flexeril® Lioresal® PA meprobamate/aspirin metaxalone AL Norflex

® Rilutek® + Robaxin® Skelaxin

® AL tizanidine caps Zanaflex®

CHAPTER 19 – Smoking Cessation

19.A. Smoking Cessation


bupropion SR QL Chantix® QL Nicotrol® Inhaler QL Nicotrol® NS QL Zyban

® QL

CHAPTER 20 – Stomach/Intestinal

20.A. Antiulcer/Reflux Drugs


cimetidine + famotidine 10mg, 20mg, 40mg + QL lansoprazole misoprostol 100mcg, 200mcg + omeprazole 10mg, 20mg caps omeprazole 40mg caps + PA pantoprazole ranitidine tabs + ranitidine syrup rabeprazole sucralfate +

Aciphex® PA Dexilant® PA esomeprazole strontium PA Nexium

® PA omeprazole sodium bicarbonate PA Prevacid

® PA

Prevacid Solutab PA Prilosec

® Protonix® PA ranitidine hcl capsules Zantac

® tabs, syrup Zantac® capsules Zegerid

® PA

20.B. Drugs affecting GI Motility


bethanechol chloride + chlordiazepoxide/clidinium dicyclomine hyoscyamine sulfate + AL atropine sulfate; diphenoxylate hcl metoclopramide propantheline

Donnatal® Amitiza® ST Bentyl® Fulyzaq

® PA

Levsin® Librax

® Linzess® ST Metozolv® ODT PA ProBanthine

® Reglan®


20.C. Antiemetics


meclizine 12.5mg, 25mg + ondansetron 24mg QL ondansetron 4mg, 8mg QL ondansetron odt QL (no QL for hematology/oncology providers)

ondansetron susp QL promethazine hcl supp PA prochlorperazine tab + AL prochlorperazine supp trimethobenzamide PA

Emend® (Therapy pack only) ST QL Emend® 40mg capsules Emend® 80mg, 125mg capsules ST QL

Antivert® Anzemet® ST QL Compazine® Diclegis® PA granisetron ST QL Kytril

® ST QL Marinol

® Phenergan® suppositories Sancuso® Patch ST QL Tigan® PA Transderm‐Scop® QL Zofran® 4mg, 8mg QL Zofran® ODT QL Zofran® susp QL ZuplenzTM ST QL (no QL for hematology/oncology providers, ST applies to

all providers)

20.D. Other GI Drugs


balsalazide AL budesonide PA Colocort

® cromolyn sodium oral generic Colyte® generic Golytely® QL glycopyrrolate hydrocortisone cream, supp, enema lactulose syrup mesalamine enema Procto‐Pak

® 1% Proctocream‐HC

® 2.5% Proctosol‐HC

® 2.5% Proctosone® 2.5% sulfasalazine + sulfasalazine DR + ursodiol

AprisoTM

Asacol® HD + Canasa

® suppositories Creon® + Cystadane® ‡ PA Delzicol® Kuvan

® ‡ PA QL Pancreaze® + Pentasa® + Pertzye

® + Relistor® Sucraid

® PA Ultresa

® Viokace® Zenpep

® +

Actigall®

Anusol HC® 2.5% Azulfidine

® Azulfidine EN® ChenodalTM PA Colazal® AL Colyte

® Cortenema® Cortifoam®

CuvposaTM ST Dipentum® Entocort

® EC PA Gastrocrom

® Gattex® ‡ PA Giazo

® RM

Golytely® QL Glycate® ST Halflytely

® Bowel Prep Kit Lialda

® Omeclamox‐Pak

® OsmoPrep® Prepopik

® Proctocort

® 1%

Proctofoam HC® Robinul® Rowasa® Enema Suclear

TM Uceris® PA Urso® Urso® Forte Zorbtive

® ‡ PA

20.E. Hepatitis


adefovir dipivoxil tabs PA lamivudine tab PA ribavirin ‡ PA

Incivek® PA ‡ Infergen® PA ‡ Intron A

® PA ‡ Pegasys® PA ‡ Peg‐Intron® PA ‡ Victrelis

® PA ‡

Copegus® PA ‡ Epivir‐HBV® PA Hepsera

® PA

Moderiba® PA ‡ OlysioTM

PA ‡ Rebetol

® PA ‡ SovaldiTM

PA ‡


CHAPTER 21 – Vitamins/Minerals

21.A. Vitamins/Minerals

Prenatal vitamins classified as medical foods are not covered. Multivitamins are NOT included in the Formulary as various OTC products are available.


calcitriol + calcium acetate caps + Dailyvite® + PA ergocalciferol + fe‐fumarate vit C/vit B12/folic acid + folic acid + iron poly complex/folic acid/vit b12 + Ferrex

® 150 Forte + ferrogels + generic prenatal vitamins + AL RF hematogen + iFerex® 150 Forte + Klor‐Con® levocarnitine 330mg PA Myferon® 150 Forte + Nephronex® + PA paricalcitrol + ST Pol‐iron

® 150 Forte polysaccharide iron forte + poly‐vitamin w/fluoride + potassium bicarbonate/chloride + potassium chloride tab, cap, liquid + potassium chloride er + Rena‐Vite Rx

®+ PA sodium fluoride + sodium fluoride gel, paste, cream sodium polystyrene sulfonate trigels + tri‐vitamin w/fluoride + vitamin B12 inj. Vol‐Care

® + PA

Brand Name Prenatal Vitamins + AL RF Fosrenol® + Galzin® + QL PhoslyraTM Renagel® + Renvela® +

doxercalciferol ST Hectorol® ST Nascobal® Velphoro® Zemplar® ST

CHAPTER 22 – Women’s Health

22.A. Estrogen Related Products


danazol estradiol + estradiol weekly patch + estropipate + raloxifene +

Alora® + Estrace® cream Estraderm® + Estring® Minivelle

® Premarin® + AL Premarin® cream Vagifem

® Vivelle‐Dot® +

Cenestin® Climara® Duavee® AL Estrace® Estrogel

® Evista® + Femring® Menest

® Osphena®

22.B. Estrogen Combinations


estradiol/norethindrone acetate + norethindrone acetate‐ethinyl estradiol + (Restricted to females)

Combipatch® + Femhrt Low Dose® + Premphase

® + Prempro

® + AL progesterone suppositories

Activella® Femhrt® + RF Angeliq® Prefest

®


22.C. Progestins


medroxyprogesterone + norethindrone acetate + progesterone micronized caps +

Aygestin® Crinone® PA AL QL = 3 fills per year Endometrin® PA AL QL = 3 fills per year Prochieve® PA Prometrium® Provera

®

22.D. Contraceptives ‐ (For members with contraceptive coverage)

For plans that follow the Women’s Wellness Mandate: All tier 1 generic drugs are covered at a $0 copayment. Brand name drugs without a generic equivalent are covered at a $0 copayment. Brand name drugs with a generic equivalent are covered at the copayment based on your plan design. Cervical caps, diaphragms, female condoms, and spermicides are covered at a $0 copayment. Both prescription and over‐the‐counter (OTC) products are covered only when prescribed by a licensed healthcare provider and require a valid prescription.


Apri® + Altavera

® + Amethyst

® Aranelle® + Aviane® + Balziva

® + Camila® + Cesia® + Cryselle® + Daysee

® drospirenone/ estradiol

Enpresse® +

Errin® + estradiol/ norethindrone +

Gianvi® +

Jolessa® + Jolivette

® + Junel®/Junel FE® + Kariva

® + Kelnor

® + Leena® + Lessina® + levonorgestrel QL Levora® + Loryna

® + Low‐Ogestrel

® +

Lutera® + medoxyprogesterone PA

Microgestin® + Microgestin FE

® + Mononessa

® + Necon® + Next Choice® QL Nora‐Be

® + Nortrel® + Ocella

® + Ogestrel® + Portia® + Previfem

® + Quasense

® + Reclipsen® + Solia

® + Sprintec® + Sronyx® + Tilia FE

® + Tri‐Legest FE®+ Trinessa® + Tri‐Previfem

® + Tri‐Sprintec

® + Trivora® + Velivet

® + Zenchent

® + Zovia® +

Cervical caps Diaphragms Ella

TM QL NuvaRing® + QL OrthoEvra® + Ortho Tri‐Cyclen

® Lo +

BeyazTM Brevicon

® Camrese

® Lo Cyclessa® Depo‐Provera® PA Desogen

® estradiol/levonorgesterel Estrostep FE® Femcon FE® Generess

® FE Loestrin

® Loestrin FE® Loestrin

® 24 Fe Lo/Ovral® Loseasonique® QL Minastrin

® 24 FE Mircette® Modicon® Natazia

® PA Nordette® Nor‐QD

® Ortho‐Cept

® Norinyl® Ortho‐Cyclen® Ortho Micronor

® Ortho‐Novum® Ortho Tri‐Cyclen

® Ovcon

® Plan B® QL = 6 fills per year Plan B

® One Step QL SafyralTM Seasonale

® Seasonique® Tri‐Norinyl® Yasmin

® Yaz®

Zeosa®

22.E. Fertility

(Other coverage restrictions may apply)


chorionic gonadotropin ST clomiphene citrate QL RF

Bravelle® PA Menopur

® PA Repronex

® PA

Follistim®/AQ PA Ganirelix

® PA Gonal‐F

® PA Gonal‐F RFF® PA Luveris® PA Ovidrel

® ST Pregnyl® PA


22.F. Vaginal Antiinfectives


clindamycin phosphate vaginal cream clotrimazole vaginal cream OTC metronidazole vaginal gel miconazole vaginal cream OTC

AVC® Cream Cleocin® vaginal suppositories

Cleocin® Vaginal Gyne‐Lotrimin® Metrogel® Vaginal Monistat® Terazol® QL

22.G. Other Women’s Health Drugs


nifedipine PA terbutaline

Alferon N® PA Lupron® Methergine

® Synarel® PA

Lysteda® PA AL tranexamic acid PA AL

CHAPTER 23 – Dental Formulary

Note: Drugs in this category are reserved for dental providers only. Unless otherwise specified, all products are limited to a 10 day supply with 1 refill. Drugs not on the list below will not be covered.

23.A. Antiinfectives


amoxicillin amoxicillin susp azithromycin 500mg QL cephalexin clarithromycin 500mg QL clindamycin 75mg, 150mg, 300mg clotrimazole troche doxycycline hyclate doxycycline hyclate 20mg QL erythromycin erythromycin susp nystatin oral suspension penicillin VK tetracycline capsules

23.B. Analgesics


acetaminophen w/codeine acetaminophen w/codeine susp apap/codeine tabs hydrocodone w/acetaminophen hydrocodone‐ibuprofen tab 7.5‐200mg ibuprofen (Rx strengths only) ibuprofen suspension (Rx strengths only) naproxen naproxen sodium

23.C. Fluoride Products


poly‐vitamin w/fluoride sodium fluoride QL tri‐vitamin w/fluoride

23.D. Glucocorticoid Drugs


dexamethasone triamcinolone in orabase methylprednisolone prednisone


23.E. Other Drugs Affecting the Throat and Mouth


chlorhexidine QL lidocaine viscous

ADDITIONAL FORMULARY INFORMATION

AFFORDABLE CARE ACT PREVENTATIVE SERVICES Prescription and OTC versions (where applicable) will be covered only with a prescription written by a licensed healthcare provider.

Aspirin for Cardiovascular Disease Prevention Aspirin will be covered for men (ages 45 to 79) and women (ages 55 to 79) when the benefits outweigh the potential bleeding risks for cardiovascular disease prevention.

Contraceptive Coverage All formulary generic and preferred brand name drugs (without a generic equivalent) will have a zero dollar ($0) copayment. Cervical caps, diaphragms, female condoms and spermicides will have a zero ($0) copayment. Both prescription and over‐the‐counter (OTC) products will be covered only when prescribed by a licensed healthcare provider.

Fluoride Oral fluoride products (chewable tablets and solutions) will be covered for children 6 months of age and older who do not receive the recommended amount of fluoride in their water supply.

Folic Acid supplements Supplements containing 0.4mg to 0.8mg of folic acid will be covered for women who are planning or are capable of pregnancy.

Iron Supplementation for Children Iron supplements will be covered for children aged 6 months to 12 months who are at high risk for iron deficiency anemia.

Tobacco Cessation Products (FDA Approved) Prescription and OTC products will be covered for adults 18 years of age and older and for pregnant women with no age limit. The following products are covered: patches, gums, nasal sprays, inhalers, lozenges, Chantix and bupropion sr (generic version of Zyban).

Vaccines Flu, Pneumonia vaccinations will be covered when administered at a network pharmacy.

Vitamin D Prescription and OTC products will be covered for adults aged 65 years and older who are at an increased risk for falls.


SPECIALTY PHARMACY INFORMATION

The specialty medications below are obtained at Reliance Rx: 1‐800‐809‐4763

AdempasTM Afinitor® Alkeran

® anastrozole Aranesp® Arimidex® Aromasin® Avonex® bicalutamide Bosulif® Casodex® Cimzia® Comtriq

® Copaxone

® Copegus® Cystadane® Cytoxan

® Droxia® Emcyt

® Enbrel® Epogen®

etoposide exemestane Extavia

® Fareston® Femara® Firazyr® flutamide Forteo® Fuzeon® Gattex® Genotropin® GilenyaTM Gleevec

® Hexalen

® Humatrope® Humira® Hydrea

® hydroxyurea Iclusig

® Imbruvica® Incivek®

Increlex®

Infergen® Inlyta

® Intron‐A® Juxtapid® Kalydeco® Kineret® Korlym® Leukeran® letrozole Lysodren® Megace® ES megestrol acetate Mekinist

TM Mesnex® MyaleptTM Myleran

® Neulasta® Neupogen

® NortheraTM Nutropin®

Nutropin® AQ

Oforta® Olysio

TM Opsumit® Orencia®SQ OrenitramTM Orfadin® Pegasys® Peg‐Intron® Pomalyst® Procrit® Procysbi® Ravicti

® Rebetol

® Rebif® ribavirin Saizen® Simponi® Sovaldi

TM Sprycel® Sutent®

SylatronTM

TafinlarTM Tarceva

® Tasigna® Tecfidera® Temodar® temozolomide tretinoin ValchlorTM VecamylTM Vesanoid® Victrelis® Xeljanz

® Xtandi

® ZelborafTM Zolinza® Zorbtiv

® Zytiga®

The medications below are limited distribution and available Walgreens Specialty Pharmacy:

Actimmune® Ampyra

TM ER

Aubagio® Erivedge

®

Exjade® Hycamtin

® Jakafi® Kuvan

®

Kynamro®

Letairis® Nexavar®

Promacta®

Revlimid® Stivarga

®

Thalomid® Tracleer

®

Tykerb® Votrient

® Xalkori®

The medications below are limited distribution and available Accredo® Pharmacy: 1‐866‐489‐1875

Apokyn®

Arcalyst® GilotrifTM

Iressa® Matulane® Sabril

® Somavert® Sucraid

® Xenazine® Zavesca

®

The medications below are limited distribution and available at the specialty pharmacy listed: Caprelsa

® ‐ Biologics Inc. (1‐800‐850‐4306) Cayston

® ‐ Available through Cystic Fibrosis Services

Chenodal® ‐ Centric Specialty Pharmacy (1‐866‐849‐4481) Ferriprox® ‐ Centric Specialty Pharmacy (1‐866‐849‐4481) Onsolis® ‐ Express Scripts (1‐877‐536‐4340) Xyrem® ‐ Express Scripts (1‐877‐536‐4340)


MEDICATIONS REQUIRING STEP THERAPY Medication Step Therapy Requirement(s)

Alocril® Prior use of Zaditor® or Alaway® OTC.

Altabax® Prior use of generic mupirocin.

Ambien® CR Prior use of Ambien® (zolpidem).

Amitiza® Prior use of lactulose.

Anturol® Prior use of oxybutynin, no step therapy required for patients over the age of 64.

Anzemet® Prior use of ondansetron.

Aricept® 23mg Prior use of donepezil 10mg once daily for three months.

Astelin® Prior use of generic azelastine.

Astepro® Prior use of generic azelastine.

Avinza® Prior use of narcotic medications.

Azor® Prior use of an Angiotensin Converting Enzyme, Angiotensin Receptor Blocker or a Calcium Channel Blocker.

Beconase® AQ Prior use of flunisolide, fluticasone propionate, triamcinolone acetonide or Nasonex.

Benicar® Prior use of generic Angiotensin Receptor Blockers.

Benzaclin®/Benzaclin® Pump Prior use of clindamycin phosphate‐benzoyl peroxide gel.

Bepreve® Prior use of Zaditor® or Alaway® OTC.

Binosto® Prior use of alendronate.

BrintellixTM Prior use of generic SSRI.

Bydureon® Concurrent use of metformin, a sulfonylurea or a thiazolodonedione (TZD).

Byetta® Concurrent use of metformin, a sulfonylurea or a thiazolodonedione (TZD).

candesartan/ candesartan/hctz Prior use of irbesartan and losartan.

carbidopa/levodopa odt Prior use of carbidopa/levodopa or carbidopa/levodopa sr.

Celebrex® Previous trial/failure of two non‐steroidal anti‐inflammatories (NSAIDs).

chorionic gonadotropin Prior use of clomiphene, menotropin, urofollitropin within previous 20 days.

clonazepam odt Prior use of immediate release clonazepam.

Comtan® Concurrent use of levodopa/carbidopa.

Conzip® Prior use of immediate release tramadol.

CuvposaTM/Glycate® Prior use of glycopyrrolate.

Detrol®/Detrol® LA Prior use of oxybutynin, no step therapy required for patients over the age of 64.

Duragesic® Prior use of narcotic medications.

Dymista® Prior use of azelastine or fluticasone propionate.

Edarbi® Prior use of generic Angiotensin Receptor Blockers.

Edular® Prior use of zolpidem.

Elestat® Prior use of Zaditor® or Alaway® OTC.

Emend®, Emend® Therapy Pack Concurrent use of dexamethasone.

Enablex® Prior use of oxybutynin, no step therapy required for patients over the age of 64.

entacapone Concurrent use of levodopa/carbidopa.

eprosartan Prior use of irbesartan and losartan.

Exalgo® Prior use of narcotic medications.

Exforge®/Exforge® HCT Prior use of an Angiotensin Converting Enzyme, Angiotensin Receptor Blocker or a Calcium Channel Blocker.

fentanyl Prior use of narcotic medications.

Fentora® Prior use of narcotic medications.

Fetzima® Prior use of venlafaxine er.

Flonase® Prior use of flunisolide, fluticasone propionate, triamcinolone acetonide or Nasonex.

Foradil® Concurrent use of an inhaled corticosteroid.

Gelnique® Prior use of oxybutynin, no step therapy required for patients over the age of 64.

Glumetza® Prior use of extended release metformin.

Gralise® Prior use of gabapentin.

granisetron Prior use of ondansetron.

Hectorol® Prior use of calcitriol.

Intermezzo® Prior use of zolpidem.

Kadian® Prior use of narcotic medications.

Kytril® Prior use of ondansetron.

LastacaftTM Prior use of Zaditor® or Alaway® OTC

Linzess® Prior use of lactulose.

metformin er Prior use of extended release metformin.

Micardis®/Micardis® HCT Prior use of a generic angiotensin II receptor blocker.

Myrbetriq® Prior use of oxybutynin, no step therapy required for patients over the age of 64.

Natroba® Prior use of generic permethrin or Lindane.

Oleptro® Prior use of generic trazodone.

Omnaris® Prior use of flunisolide, fluticasone propionate, triamcinolone acetonide or Nasonex.


MEDICATIONS REQUIRING STEP THERAPY Medication Step Therapy Requirement(s)

Opana® ER (crush resistant) Prior use of narcotic medications.

Optivar® Prior use of Zaditor® or Alaway® OTC.

Oravig® Prior use of clotrimazole troche, fluconazole or nystatin.

Oxycontin® Prior use of narcotic medications.

Ovidrel® Prior use of clomiphene, menotropin, urofollitropin within previous 20 days.

paricalcitrol Prior use of calcitriol.

paroxetine hcl er Prior use of paroxetine.

Pataday® Prior use of Zaditor® or Alaway® OTC

Patanase® Prior use of flunisolide, fluticasone propionate, triamcinolone acetonide or Nasonex.

Patanol® Prior use of Zaditor® or Alaway® OTC

Paxil® CR Prior use of paroxetine.

Prezista® Concurrent use of Norvir®.

Prolensa® Prior use of generic bromfenac.

Pristiq® Prior use of venlafaxine er.

Qnasl® Prior use of flunisolide, fluticasone propionate, triamcinolone acetonide or Nasonex.

Quillivant® XR Prior use of generic methylphenidate sr.

Rayos® Prior use of immediate release prednisone.

Rhinocort® Aqua Prior use of flunisolide, fluticasone propionate, triamcinolone acetonide or Nasonex.

Sanctura®/Sanctura® XR Prior use of oxybutynin, no step therapy required for patients over the age of 64.

Sancuso® Prior use of ondansetron.

Serevent® Diskus Concurrent use of an inhaled corticosteroid.

Seroquel® XR Prior use of immediate release Seroquel®.

Sklice® Prior use of generic permethrin or Lindane.

Sprycel® Prior use of Gleevec® within a 90 day period.

Tasigna® Prior use of Gleevec® within a 90 day period.

Tasmar® Concurrent use of levodopa/carbidopa.

Tekamlo® Prior use of an Angiotensin Converting Enzyme, Angiotensin Receptor Blocker or a Calcium Channel Blocker.

Tekturna®/Tekturna® HCT Prior use of an Angiotensin Converting Enzyme Inhibitor and an Angiotensin Receptor Blocker.

telmisartan/telmisartan/hctz Prior use of irbesartan and losartan.

Teveten®/Teveten® HCT Prior use of an Angiotensin Converting Enzyme (ACE) Inhibitor.

tolterodine tartrate Prior use of oxybutynin, no step therapy required for patients over the age of 64.

Toviaz® Prior use of oxybutynin, no step therapy required for patients over the age of 64.

tramadol er Prior use of immediate release tramadol.

Treximet® Prior use of Imitrex® within previous 90 day period.

TribenzorTM Prior use of an Angiotensin Converting Enzyme, Angiotensin Receptor Blocker or a Calcium Channel Blocker.

trospium chloride er Prior use of oxybutynin, no step therapy required for patients over the age of 64.

Twynsta® Prior use of an Angiotensin Converting Enzyme, Angiotensin Receptor Blocker or a Calcium Channel Blocker.

Ulroic® Prior use of allopurinol.

Ultram® ER Prior use of immediate release tramadol.

Veramyst® Prior use of flunisolide, fluticasone propionate, triamcinolone acetonide or Nasonex.

Vesicare® Prior use of oxybutynin, no step therapy required for patients over the age of 64.

Victoza® Concurrent use of metformin, a sulfonylurea or a thiazolodonedione (TZD).

Vytorin® Prior use of simvastatin.

Zemplar® Prior use of calcitriol.

ZetonnaTM Prior use of flunisolide, fluticasone propionate, triamcinolone acetonide or Nasonex.

zolpidem er Prior use of zolpidem.

Zuplenz® Prior use of ondansetron.


INDEX

8

8‐Mop® .............................................................................................. 15

A

abacavir sulfate ................................................................................ 22 abacavir sulfate/lamivudine/zidovudine .......................................... 22 Abilify® .............................................................................................. 24 Abilify® Discmelt ................................................................................ 24 Abilify® oral solution ......................................................................... 24 Absorbica® ........................................................................................ 14 AbstralTM ........................................................................................... 27 acamprosate calcium tab dr ............................................................. 26 acarbose ........................................................................................... 16 Accolate

® ............................................................................................. 6 Accu‐Chek® Diabetic Test Strips ....................................................... 17 Accu‐Chek® Glucose Meters ............................................................. 17 Accuneb® ............................................................................................. 5 Accupril® ............................................................................................. 9 Accuretic

® ......................................................................................... 11 Accutane® ......................................................................................... 14 acebutolol HCl .................................................................................... 9 Aceon

® ................................................................................................ 9 acetaminophen w/codeine ......................................................... 27, 33 acetaminophen w/codeine susp ...................................................... 33 acetaminophen w/hydrocodone ...................................................... 33 acetaminophen; butalbital ............................................................... 28 acetaminophen; butalbital; caffeine ................................................ 28 Acetasol

® HC otic soln ....................................................................... 18 acetazolamide tab ............................................................................ 19 acetic acid otic soln........................................................................... 17 acetylcysteine ..................................................................................... 6 Aciphex

® ............................................................................................ 29 acitretin ............................................................................................ 15 Aclovate

® .......................................................................................... 14 Actigall® ............................................................................................. 30 Actimmune

® ................................................................................. 8, 35 Actiq

® ................................................................................................ 27 Actonel® ............................................................................................ 20 Actoplus Met

® ................................................................................... 16 Actoplus Met® XR .............................................................................. 16 Actos® ............................................................................................... 16 Acular

® .............................................................................................. 19 Acular® LS .......................................................................................... 19 Acuvail® ............................................................................................. 18 acyclovir ............................................................................................ 22 acyclovir oint .................................................................................... 16 acyclovir ointment ............................................................................ 16 Aczone® ............................................................................................. 16 Adalat

® CC ......................................................................................... 10 adapalene ......................................................................................... 14 Adcirca

®............................................................................................. 13 Adderall XR® ...................................................................................... 25 Adderall® ........................................................................................... 25 adefovir dipivoxil tabs ................................................................ 22, 30 Adempas

TM ................................................................................. 13, 35 Advair® ................................................................................................ 5 Advair

® HFA ......................................................................................... 5 Advicor® ............................................................................................ 13 Aerobid® .............................................................................................. 5

Aerobid‐M® ......................................................................................... 5 Afinitor® ........................................................................................ 8, 35 Aggrenox® ........................................................................................... 7 Agrylin® ............................................................................................... 7 Akten® ............................................................................................... 19 Alamast® ........................................................................................... 19 Alaway® ............................................................................................ 19 albuterol nebs .................................................................................... 5 albuterol sulfate tabs ......................................................................... 5 albuterol‐ipratropium neb soln .......................................................... 6 alclometasone .................................................................................. 14 Aldactazide 25/25

® ........................................................................... 10 Aldactazide® 50/50 ........................................................................... 10 Aldactone® ........................................................................................ 10 Aldara® .............................................................................................. 15 alendronate tabs .............................................................................. 20 Alferon N® ................................................................................... 22, 33 alfuzosin ........................................................................................... 23 Alinia® tabs, soln ............................................................................... 22 Alkeran

® ........................................................................................ 8, 35 Allfen

® CDX ......................................................................................... 4 allopurinol ........................................................................................ 29 Alocril® .............................................................................................. 36 Alomide

® ........................................................................................... 19 Alora® ................................................................................................ 31 Alphagan P

® 0.1% ............................................................................. 19 Alphagan P® 0.15% ........................................................................... 19 alprazolam ........................................................................................ 23 alprazolam xr .................................................................................... 23 Alrex

® ................................................................................................ 18 Altabax® ...................................................................................... 16, 36 Altace

® caps ........................................................................................ 9 Altavera® ........................................................................................... 32 aluminum chloride 20%.................................................................... 15 Alupent

® ............................................................................................. 5 Alvesco® .............................................................................................. 5 alwin NX® .......................................................................................... 27 amantadine ...................................................................................... 22 amantadine hcl ................................................................................. 26 Amaryl

® ............................................................................................. 16 Ambien

® ............................................................................................ 23 Ambien

® CR ................................................................................ 23, 36 Amerge

® ........................................................................................... 28 Amethia® .......................................................................................... 32 Amethyst

® ......................................................................................... 32 amiloride hcl ..................................................................................... 10 aminocaproic acid .............................................................................. 7 aminophylline ..................................................................................... 5 amiodarone ...................................................................................... 13 Amitiza

® ...................................................................................... 29, 36 amitriptyline ..................................................................................... 24 amitriptyline/ perphenazine ............................................................ 24 amlodipine besylate‐ ........................................................................ 10 amlodipine besylate/benazepril hcl ................................................. 11 ammonium lactate cr ....................................................................... 15 Amoxapine

® ...................................................................................... 24 amoxicillin ........................................................................................ 33 amoxicillin caps, susp ....................................................................... 21 amoxicillin clavulanate ..................................................................... 21 amoxicillin susp ................................................................................ 33 amoxicillin/ ....................................................................................... 21 amphetamine mixture ...................................................................... 25 amphetamine‐dextroamphetamine sr ............................................. 25


ampicillin caps, susp ......................................................................... 21 AmpyraTM ER ..................................................................................... 26 Amrix® ............................................................................................... 29 AmturnideTM ..................................................................................... 11 Anafranil® .......................................................................................... 24 anagrelide ........................................................................................... 7 Analpram

® E ...................................................................................... 15 Anaprox® ........................................................................................... 28 anastrozole ................................................................................... 8, 35 Ancobon® .......................................................................................... 21 Androderm

® ...................................................................................... 23 Androgel® .......................................................................................... 23 Android®............................................................................................ 23 Androxy® ........................................................................................... 23 Anoro Ellipta® ...................................................................................... 6 Antabuse

® ......................................................................................... 26 Antara® ................................................................................................ 2 Antivert® ........................................................................................... 30 Anturol® ........................................................................................ 6, 36 antyipyrine/benzocaine otic soln ..................................................... 17 Anusol HC® 2.5% ............................................................................... 30 Anzemet® .................................................................................... 30, 36 apap/codeine tabs ............................................................................ 33 Apexicon E

® ....................................................................................... 14 Apidra

® .............................................................................................. 16 Apidra

® Solostar ................................................................................ 16 Apokyn® ............................................................................................ 26 apraclonidine .................................................................................... 19 Apri® .................................................................................................. 32 Apriso

TM ............................................................................................ 30 Aptiom® ............................................................................................. 25 Aptivus® ............................................................................................ 22 Aralen

® phosphate ............................................................................ 22 Aranelle® ........................................................................................... 32 Aranesp

® ....................................................................................... 7, 35 Arava

® ............................................................................................... 28 Arcalyst® ........................................................................................ 7, 35 Arcapta

® Neohaler .............................................................................. 5 Aricept® ............................................................................................. 26 Aricept® 23mg ................................................................................... 36 Aricept

® ODT ..................................................................................... 26 Arimidex® ...................................................................................... 8, 35 Arixtra

®................................................................................................ 7 Armour Thyroid

® ............................................................................... 20 Aromasin

® ..................................................................................... 8, 35 Arthrotec

® ........................................................................................ 28

Asacol® HD ........................................................................................ 30 Asmanex® ............................................................................................ 5 aspirin CR 800mg .............................................................................. 28 aspirin w/codeine ............................................................................. 27 aspirin/dipyridamole .......................................................................... 7 aspirin; butalbital; caffeine ............................................................... 28 aspirin; butalbital; caffeine; codeine ................................................ 28 Astagraf

TM XL ...................................................................................... 8 Astelin® ......................................................................................... 4, 36 Astepro® ........................................................................................ 4, 36 Atacand HCT

® .................................................................................... 11 Atacand® ............................................................................................. 9 Atelvia

TM ........................................................................................... 20 atenolol .............................................................................................. 9 atenolol/chlorthalidone .................................................................... 11 Ativan® .............................................................................................. 23 atorvastatin calcium ......................................................................... 12 atorvastatin/amlodipine ................................................................... 13 atovaquone/proguanil ...................................................................... 22

Atripla® ............................................................................................. 22 atropine sulfate; diphenoxylate hcl .................................................. 29 Atrovent® 0.03% ................................................................................. 4 Atrovent® 0.06% ................................................................................. 4 Atrovent® HFA .................................................................................... 6 Atrovent

® nasal ................................................................................... 4 Atrovent® Neb .................................................................................... 6 Aubagio® ..................................................................................... 26, 35 augmented betamethasone ............................................................. 14 Augmentin® XR ................................................................................. 21 Auralgan

® Otic Soln ........................................................................... 17 Auvi‐QTM ............................................................................................. 5 Avalide® ............................................................................................ 11 Avandamet® ...................................................................................... 16 Avandaryl® ........................................................................................ 16 Avandia

® ........................................................................................... 16 Avapro® ............................................................................................... 9 Avar‐E® LS ......................................................................................... 14 AVC® Cream ...................................................................................... 33 Avelox

® ............................................................................................. 21 Aviane® ............................................................................................. 32 Avinza® ........................................................................................ 27, 36 Avita

® ................................................................................................ 14 Avodart® ........................................................................................... 23 Avonex

® ...................................................................................... 26, 35 Axert

® ............................................................................................... 28 AxironTM ........................................................................................... 23 Aygestin® .......................................................................................... 32 Azasan® ............................................................................................... 8 Azasite

® ............................................................................................. 18 azathioprine ....................................................................................... 8 azelastine ......................................................................................... 19 azelastine nasal spray ......................................................................... 4 Azelex

® .............................................................................................. 14 Azilect

® ............................................................................................. 26 azithromycin ............................................................................... 21, 33 azithromycin® susp .......................................................................... 21 Azopt

® ............................................................................................... 19 Azor® ........................................................................................... 11, 36 Azulfidine EN® ................................................................................... 30 Azulfidine

® ........................................................................................ 30

B

B&O Supprettes® .............................................................................. 27 bacitracin ophthalmic ....................................................................... 18 baclofen ............................................................................................ 29 Bactroban® ........................................................................................ 16 balsalazide ........................................................................................ 30 Balziva

® ............................................................................................. 32 Banzel® .............................................................................................. 25 Baraclude

® ........................................................................................ 22 Beconase® AQ ............................................................................... 4, 36 belladonna/opium supp ................................................................... 27 benazepril ........................................................................................... 9 benazepril/hctz ................................................................................ 11 Benicar HCT

® ..................................................................................... 11 Benicar® ........................................................................................ 9, 36 Bentyl® .............................................................................................. 29 Benzaclin

® ......................................................................................... 36 BenzaClin® ........................................................................................ 14 Benzaclin

® Pump ............................................................................... 36 Benzefoam

® ...................................................................................... 14 benzoyl peroxide .............................................................................. 14 benzoyl peroxide cr,gel,lot ............................................................... 14


benztropine ...................................................................................... 26 Bepreve® ........................................................................................... 36 Bepreve® opth ................................................................................... 19 Besivance® ........................................................................................ 18 Betagan® ........................................................................................... 19 betamethasone ................................................................................ 14 betamethasone valerate foam ......................................................... 14 Betaxolol

® ........................................................................................... 9 bethamethasone valerate crem, lotion, oint .................................... 14 bethanechol chloride .................................................................... 7, 29 Bethkis

® ............................................................................................. 22 Betimol® ............................................................................................ 19 Betoptic® S ........................................................................................ 19 BeyazTM ............................................................................................. 32 Biaxin XL® tabs .................................................................................. 21 Biaxin

® ............................................................................................... 21 bicalutamide ................................................................................. 8, 35 Bicitra® ................................................................................................ 7 Binosto® ...................................................................................... 20, 36 Bio‐T‐Gel

® .......................................................................................... 23 bisoprolol fumerate ............................................................................ 9 Blephamide® Liquifilm ....................................................................... 18 Boniva

® tabs ...................................................................................... 20 Bosulif® .......................................................................................... 8, 35 brand and generic prenatal .............................................................. 31 Brand Name Prenatal Vitamins ........................................................ 31 Bravelle

® ........................................................................................... 32 Breo Ellipta® ........................................................................................ 6 Brethine® ............................................................................................. 5 Brevicon

® .......................................................................................... 32 Brevoxyl® ........................................................................................... 14 Brilinta® ............................................................................................... 7 brimonidine solution ........................................................................ 19 brimonidine tartrate 0.2% ................................................................ 19 Brintellix

TM .................................................................................. 24, 36 Brisdelle

TM ........................................................................................ 24 BromdayTM ........................................................................................ 19 bromfenac ........................................................................................ 19 bromocriptine mesylate ................................................................... 26 budesonide ....................................................................................... 30 budesonide respules 0.25mg, 0.5mg .................................................. 5 bumetanide ...................................................................................... 10 Buphenyl

® ......................................................................................... 20 buprenorphine hcl ............................................................................ 26 buprenorphine hcl/naloxone hcl sublingual ..................................... 26 bupropion ......................................................................................... 24 bupropion hcl SR 12 hr ..................................................................... 24 bupropion hcl SR 24hr ...................................................................... 24 bupropion SR .................................................................................... 29 buspirone .......................................................................................... 23 butalbital/apap/caffeine/codeine .................................................... 28 butorphanol tartrate NS ................................................................... 28 Butrans

TM .......................................................................................... 26 Bydureon

® ................................................................................... 17, 36 Byetta® ........................................................................................ 17, 36 Bystolic® .............................................................................................. 9

C

cabergoline ....................................................................................... 20 Caduet® ............................................................................................. 13 Cafergot

® ........................................................................................... 28 Calan

®................................................................................................ 10 Calan® SR ........................................................................................... 10 calciprotiene soln, oint, cream ......................................................... 15

calcitonin‐salmon ............................................................................. 20 calcitriol ............................................................................................ 31 calcitriol ointment ............................................................................ 15 calcium acetate caps ........................................................................ 31 Cambia® ............................................................................................ 28 Camila

® ............................................................................................. 32 Campral® ........................................................................................... 26 Camrese® Lo ..................................................................................... 32 Canasa® suppositories ...................................................................... 30 candesartan .................................................................................. 9, 36 candesartan/hctz ....................................................................... 11, 36 capecitabine ....................................................................................... 8 Capex® .............................................................................................. 14 Capoten® ............................................................................................. 9 Caprelsa® ...................................................................................... 8, 35 captopril ............................................................................................. 9 captopril/hctz ................................................................................... 11 Carac

® ............................................................................................... 15 CarbagluTM ........................................................................................ 20 carbamazepine ................................................................................. 25 carbamazepine er ............................................................................. 25 Carbatrol® ......................................................................................... 25 carbidopa ......................................................................................... 26 carbidopa/levodopa ......................................................................... 26 carbidopa/levodopa CR .................................................................... 26 carbidopa/levodopa odt ............................................................. 26, 36 carbidopa/levodopa/entacapone tabs ............................................. 26 Cardene

® SR ...................................................................................... 10 Cardizem® ......................................................................................... 10 Cardizem

® LA .................................................................................... 10 Cardizem®CD..................................................................................... 10 Cardura® ..................................................................................... 11, 23 Cardura

® XL ................................................................................. 11, 23 carisoprodol ..................................................................................... 29 Carmol‐HC

® ....................................................................................... 14 carteolol ........................................................................................... 19 Cartia XT ........................................................................................... 10 carvedilol ............................................................................................ 9 Casodex

® ....................................................................................... 8, 35 Catapres® .......................................................................................... 11 Catapres

®‐TTS ................................................................................... 11 Caverject® ......................................................................................... 23 Cayston

® ..................................................................................... 22, 35 CeeNu

® ............................................................................................... 8 cefaclor caps, susp ........................................................................... 21 cefadroxil .......................................................................................... 21 cefdinir ............................................................................................. 21 cefprozil ............................................................................................ 21 cefuroxime ....................................................................................... 21 Cefzil

® ............................................................................................... 21 Celebrex® .................................................................................... 28, 36 Celestone® ........................................................................................ 20 Celexa® .............................................................................................. 24 CellCept

® ............................................................................................. 8 Celontin® ........................................................................................... 25 Cenestin® .......................................................................................... 31 cephalexin ........................................................................................ 33 cephalexin caps, susp ....................................................................... 21 cephradine capsules ......................................................................... 21 Cervical caps ..................................................................................... 32 Cesia® ................................................................................................ 32 Cetraxal

® ........................................................................................... 21 cevimeline ........................................................................................ 18 Chantix

® ............................................................................................ 29 Chemet

® ........................................................................................... 20


Chenodal® ........................................................................................ 35 ChenodalTM ....................................................................................... 30 chloramphenicol ............................................................................... 18 chlordiazepoxide .............................................................................. 23 chlordiazepoxide/clidinium .............................................................. 29 chlorhexidine .................................................................................... 34 chlorhexidine oral rinse .................................................................... 18 Chloromycetin

® Otic ......................................................................... 17 chloroquine phosphate .................................................................... 22 chlorothiazide tabs ........................................................................... 10 chlorphen/DM/PE ............................................................................... 4 chlorpromazine ................................................................................. 24 chlorthalidone .................................................................................. 10 chlorzoxazone ................................................................................... 29 cholestyramine/cholestyramine light (bulk) ..................................... 12 chorionic gonadotropin .............................................................. 32, 36 Cialis

® 10mg &20mg .......................................................................... 23 Cialis® 2.5mg & 5mg .......................................................................... 23 ciclopirox kit ..................................................................................... 15 ciclopirox shampoo ........................................................................... 15 ciclopirox soln ................................................................................... 15 cilostazol ............................................................................................. 7 Ciloxan

® ............................................................................................. 18 cimetidine ......................................................................................... 29 Cimzia

® ........................................................................................ 28, 35 Cipro HC

® Otic ................................................................................... 17 Cipro® ................................................................................................ 21 Cipro® XR ........................................................................................... 21 Ciprodex® .......................................................................................... 17 ciprofloxacin hcl SR ........................................................................... 21 ciprofloxacin ophth soln ................................................................... 18 ciprofloxacin otic .............................................................................. 17 ciprofloxacin tabs ............................................................................. 21 citalopram ........................................................................................ 24 citric acid/sodium citrate .................................................................... 7 Clarinex

® ............................................................................................. 4 Clarinex® Reditab ................................................................................ 4 clarithromycin ................................................................................... 21 clarithromycin 500mg ....................................................................... 33 clarithromycin SR .............................................................................. 21 clemastine .......................................................................................... 4 clemastine fumarate tabs ................................................................... 4 Cleocin

® 75mg ................................................................................... 33 Cleocin

® pediatric granules ............................................................... 21 Cleocin

® Vaginal ................................................................................ 33 Cleocin

® vaginal suppositories .......................................................... 33

Cleocin‐T® .......................................................................................... 14 Climara® ............................................................................................ 31 Clindagel® .......................................................................................... 14 clindamax ......................................................................................... 14 clindamycin ................................................................................. 21, 33 clindamycin granules ........................................................................ 21 clindamycin phosphate gel 1% ......................................................... 14 clindamycin phosphate vaginal cream ............................................. 33 clindamycin phosphate‐benzoyl peroxide gel .................................. 14 clindamycintopical ............................................................................ 14 clobetasol propionate foam ............................................................. 14 clobetasol proprionate ..................................................................... 14 Clobex

® .............................................................................................. 14 Clobex® Spray .................................................................................... 14 clomipramine .................................................................................... 24 clonazepam odt .......................................................................... 25, 36 clonazepam tabs ............................................................................... 25 clonidine HCl ..................................................................................... 11 clonidine HCl TD patch ...................................................................... 11

clopidogrel bisulfate ........................................................................... 7 clorazepate ....................................................................................... 23 clotrimazole cream, lotion, soln ....................................................... 15 clotrimazole troche .................................................................... 21, 33 clotrimazole vaginal cream .............................................................. 33 clotrimazole w/ betamethasone cream 1‐0.05% ............................. 15 clozapine .......................................................................................... 24 Coartem® .......................................................................................... 22 codeine sulfate ................................................................................. 27 codeine‐guaifenesin ........................................................................... 4 codeine‐guaifenesin‐pseudoephedrine.............................................. 4 Cogentin® .......................................................................................... 26 Cognex® ............................................................................................ 26 Colazal® ............................................................................................. 30 colchicine w/probenicid ................................................................... 29 Colcrys

® ............................................................................................. 29 Colestid® (bulk) ................................................................................. 12 Colestid® tab ..................................................................................... 12 colestipol granules(bulk) .................................................................. 12 colestipol tab 1gm ............................................................................ 12 colistimethate .................................................................................. 17 Colocort® .......................................................................................... 30 Colyte

® .............................................................................................. 30 Combigan® ........................................................................................ 19 Combipatch

® ..................................................................................... 31 Combivent

® ......................................................................................... 6 Combivir® .......................................................................................... 22 Combunox® ....................................................................................... 27 Cometriq® ........................................................................................... 8 Compazine

® ...................................................................................... 30 CompleraTM ...................................................................................... 22 Comtan® ..................................................................................... 26, 36 Comtriq

® ........................................................................................... 35 Concerta® .......................................................................................... 25 Conzip

® ....................................................................................... 27, 36 Copaxone

® .................................................................................. 26, 35 Copegus® .............................................................................. 22, 30, 35 Cordran

® lotion ................................................................................. 14 Cordran® Tape only ........................................................................... 14 Coreg® ................................................................................................. 9 Corgard

® ............................................................................................. 9 Cortane B® Otic ................................................................................. 17 Cortef

® .............................................................................................. 20 Cortenema

® ...................................................................................... 30 Cortifoam

® ........................................................................................ 30 cortisone acetate ............................................................................. 20 Cortisporin® otic sol, susp ................................................................ 17 Cortisporin® Otic‐TC .......................................................................... 17 Corzide® ............................................................................................ 11 Cosopt

® ............................................................................................. 19 Coumadin® .......................................................................................... 7 Cozaar® ............................................................................................... 9 Creon® .............................................................................................. 30 Crestor

® ............................................................................................ 12 Cresylate® Otic .................................................................................. 17 Crinone® ........................................................................................... 32 Crixivan

® ........................................................................................... 22 cromolyn sodium .............................................................................. 19 cromolyn sodium 10mg/ml nebs ....................................................... 6 cromolyn sodium oral ...................................................................... 30 Cryselle®............................................................................................ 32 Cuprimine

® ....................................................................................... 28 Cutivate

® 0.05% lotion ...................................................................... 14 Cutivate® cream; oint ....................................................................... 14 Cuvposa

TM ........................................................................................ 36


Cyclessa® ........................................................................................... 32 cyclobenzaprine er ........................................................................... 29 cyclophosphamide .............................................................................. 8 Cycloset® ........................................................................................... 16 cyclosporine capsules ......................................................................... 8 cyclosporine modified ........................................................................ 8 cyclosporine oral solution ................................................................... 8 Cymbalta

® ......................................................................................... 24 cyproheptadine .................................................................................. 4 Cystadane® .................................................................................. 30, 35 Cystagon

® .......................................................................................... 20 Cystaran® .......................................................................................... 19 Cytomel® ........................................................................................... 20 Cytoxan® ....................................................................................... 8, 35

D

Dailyvite® .......................................................................................... 31 Daliresp® ............................................................................................. 5 danazol ............................................................................................. 31 Dantrium® ......................................................................................... 29 dantrolene caps ................................................................................ 29 Dapsone ............................................................................................ 22 Daraprim

® ......................................................................................... 22 Daypro

® ............................................................................................. 28 Daytrana® .......................................................................................... 25 DDAVP® ............................................................................................. 20 Decadron

® ......................................................................................... 20 Delzicol® ............................................................................................ 30 Demadex

® ......................................................................................... 10 Depakene® ........................................................................................ 25 Depakote ER® .............................................................................. 25, 28 Depakote

® ......................................................................................... 25 Depakote® Sprinkles.......................................................................... 25 Depen® Titratabs ............................................................................... 28 Depo‐Provera

® .................................................................................. 32 Depo‐Testosterone® ......................................................................... 23 Derma‐Smoothe/FS® ......................................................................... 14 desipramine ...................................................................................... 24 desloratadine odt ............................................................................... 4 desloratidine ....................................................................................... 4 desmopressin ................................................................................... 20 Desogen

® .......................................................................................... 32 desonide0.05% ................................................................................. 14 Desowen® lotion ............................................................................... 14 desoximetasone ............................................................................... 14 desvenlafaxine .................................................................................. 24 Detrol LA® ........................................................................................... 6 Detrol

® .......................................................................................... 6, 36 Detrol® LA ......................................................................................... 36 dexamethasone .......................................................................... 20, 33 dexamethasone ophthalmic ............................................................. 18 dexamethasone/tobramycin ............................................................ 18 Dexedrine

® ........................................................................................ 25 Dexilant

® ........................................................................................... 29 dexmethylphenidate hcl cp24 .......................................................... 25 dexmethylphenidate hcl sr ............................................................... 25 dextroamphetamine tabs & SR ......................................................... 25 Dextrostat® ....................................................................................... 25 DHE

® 45 ............................................................................................ 28 Diabeta® ............................................................................................ 16 Diamox

® ............................................................................................ 19 Diaphragms ....................................................................................... 32 Diastat® ............................................................................................. 25 diazepam .......................................................................................... 23

Dibenzyline® ..................................................................................... 13 Diclegis® ............................................................................................ 30 diclofenac gel ................................................................................... 15 diclofenac sodium enteric coated tablets ........................................ 28 diclofenac sodium ophth soln .......................................................... 19 diclofenac sodium SR 24‐hr 100 mg ................................................. 28 diclofenac w/misoprostol ................................................................. 28 dicloxacillin caps ............................................................................... 21 dicyclomine ...................................................................................... 29 didanosine DR .................................................................................. 22 Didronel

® .......................................................................................... 20 Differin® cream, gel .......................................................................... 14 Dificid® .............................................................................................. 22 diflorasone diacetate ....................................................................... 14 Diflucan tabs/oral suspension .......................................................... 21 Diflucan

® 150mg ............................................................................... 21 diflunisal ........................................................................................... 28 digoxin .............................................................................................. 13 Dilacor® XR ........................................................................................ 10 Dilantin

® ............................................................................................ 25 Dilantin® Infatab ............................................................................... 25 Dilantin®125 suspension ................................................................... 25 dilatiazem xr ..................................................................................... 10 Dilaudid

® ........................................................................................... 27 diltiazem cd ...................................................................................... 10 diltiazem ER bead ............................................................................. 10 diltiazem HCl .................................................................................... 10 diltiazem SR ...................................................................................... 10 Diovan

® ............................................................................................... 9 Diovan

® HCT ...................................................................................... 11 Dipentum® ........................................................................................ 30 diphenhydramine ............................................................................. 23 diphenhydramine 50mg .............................................................. 4, 26 dipivefrin .......................................................................................... 19 Diprolene

® ........................................................................................ 14 Diprolene

® (and AF) .......................................................................... 14 dipyridamole ...................................................................................... 7 disopyramide .................................................................................... 13 disulfiram ......................................................................................... 26 Ditropan

® ............................................................................................ 6 Ditropan

® XL ....................................................................................... 6 Diuril® susp ....................................................................................... 10 divalproex sodium sprinkles ............................................................. 25 divalproex sodium sr .................................................................. 25, 28 divalproex sodium tabs .................................................................... 25 Domeboro

® Otic ............................................................................... 17

donepezil .......................................................................................... 26 donepezil 23mg ................................................................................ 26 Donnatal® ......................................................................................... 29 Doryx

® ............................................................................................... 21 dorzolamide hcl soln ........................................................................ 19 dorzolamide/timolol ophth soln ...................................................... 19 Dovonex® soln .................................................................................. 15 doxazosin ......................................................................................... 23 doxepin............................................................................................. 24 doxercalciferol .................................................................................. 31 doxycycline hyclate caps, tabs ......................................................... 21 doxycycline DR ................................................................................. 21 doxycycline hyclate .......................................................................... 33 doxycycline hyclate 20mg ................................................................ 33 doxycycline hyclate TBEC dr ............................................................. 21 doxycycline monohydrate ................................................................ 21 drospirenone/estradiol .................................................................... 32 Droxia

® .......................................................................................... 8, 35 Drysol

® .............................................................................................. 15


Duac® ................................................................................................ 14 Duavee® ............................................................................................ 31 Duetact® ............................................................................................ 16 Duexis® .............................................................................................. 28 Dulera® ................................................................................................ 5 duloxetine ......................................................................................... 24 Duoneb

® .............................................................................................. 6 Duragesic® ................................................................................... 27, 36 Durezol® ............................................................................................ 19 Dutoprol® ............................................................................................ 9 Dyazide

® ............................................................................................ 10 Dymista® ....................................................................................... 4, 36 DynaCirc® CR ..................................................................................... 10 Dyphylline‐GG® ................................................................................... 5 Dyrenium® ......................................................................................... 10

E

EC Naprosyn® .................................................................................... 28 econazole nitrate cream 1% ............................................................. 15 Edarbi® .......................................................................................... 9, 36 Edarbyclor

® ....................................................................................... 11 Edecrin® ............................................................................................ 10 Edex

® ................................................................................................. 23 Edular

® .............................................................................................. 36 EdurantTM ......................................................................................... 22 Effexor® XR ........................................................................................ 24 Effient

® ................................................................................................ 7 Efudex® ............................................................................................. 15 Eldepryl

® ........................................................................................... 26 Elestat®........................................................................................ 19, 36 Elidel® ................................................................................................ 15 Eliquis

® ................................................................................................ 7 EllaTM ................................................................................................. 32 Elmiron® .............................................................................................. 7 Elocon

® .............................................................................................. 14 Emadine® .......................................................................................... 19 Emcyt® ........................................................................................... 8, 35 Emend

® ....................................................................................... 30, 36 Emsam® ............................................................................................. 24 Emtriva® ............................................................................................ 22 Enablex

® ........................................................................................ 6, 36 enalapril .............................................................................................. 9 Enbrel

® ........................................................................................ 28, 35 Endometrin® ..................................................................................... 32 enoxaparin sodium ............................................................................. 7 Enpresse® .......................................................................................... 32 entacapone ....................................................................................... 36 Entocort

® EC ...................................................................................... 30 Epaned® soln ....................................................................................... 9 Epiduo® ............................................................................................. 15 epinastine ......................................................................................... 19 Epipen

® ............................................................................................... 5 Epivir® ............................................................................................... 22 Epivir‐HBV

® ................................................................................. 22, 30 eplerenone ....................................................................................... 13 Epogen® ........................................................................................ 7, 35 eprosartan .................................................................................... 9, 36 Epzicom® ........................................................................................... 22 Equagesic

® ........................................................................................ 29 ergocalciferol .................................................................................... 31 Ergomar

® ........................................................................................... 28 ergotamine w/caffeine ..................................................................... 28 Erivedge® .......................................................................................... 35 ErivedgeTM .......................................................................................... 8

Errin® ................................................................................................ 32 Ertaczo® ............................................................................................ 21 Ery‐Tab® ............................................................................................ 21 erythromycin .................................................................................... 33 erythromycin base enteric pellets .................................................... 21 erythromycin estolate caps, susp ..................................................... 21 erythromycin ethylsuccinate tabs, susp ........................................... 21 erythromycin gel .............................................................................. 14 erythromycin ophthalmic ................................................................. 18 erythromycin pads ........................................................................... 14 erythromycin stearate ...................................................................... 21 erythromycin susp ............................................................................ 33 erythromycin/benzoyl peroxide gel ................................................. 14 erythromycin/sulfisoxazole susp ...................................................... 21 escitalopram oxalate ........................................................................ 24 Esgic Plus

® ......................................................................................... 28 Esgic® ................................................................................................ 28 esomeprazole strontium .................................................................. 29 Estrace® ............................................................................................ 31 Estrace

® cream ................................................................................. 31 Estraderm® ....................................................................................... 31 estradiol ........................................................................................... 31 estradiol weekly patch ..................................................................... 31 estradiol/levonorgesterel ................................................................. 32 estradiol/norethindrone .................................................................. 32 Estring

® ............................................................................................. 31 Estrogel® ........................................................................................... 31 estropipate ....................................................................................... 31 Estrostep FE® .................................................................................... 32 ethambutol ....................................................................................... 22 ethosuximide 250mg/5ml syrup ...................................................... 25 ethosuximide capsules ..................................................................... 25 etodolac ........................................................................................... 28 etoposide ......................................................................................... 35 etoposide (caps only) ......................................................................... 8 Eurax

® ............................................................................................... 15 evetiracetam .................................................................................... 25 Evista

® ............................................................................................... 31 Evoclin® Foam ................................................................................... 15 Evoxac® ............................................................................................. 18 Exalgo

® ........................................................................................ 27, 36 Exelon® ............................................................................................. 26 exemestane .................................................................................. 8, 35 Exforge

® ...................................................................................... 11, 36 Exforge

® HCT ............................................................................... 11, 36 Exjade

® .......................................................................................... 7, 35

Extavia® ....................................................................................... 26, 35 Extina® .............................................................................................. 15

F

FabiorTM ............................................................................................ 15 famciclovir ........................................................................................ 22 famotidine ........................................................................................ 29 Famvir® ............................................................................................. 22 Fanapt® ............................................................................................. 24 Fareston® ...................................................................................... 8, 35 Farxiga® ............................................................................................. 16 Fazaclo® ............................................................................................ 24 fe‐fumarate vitamin C/vitamin B12/folic acid .................................. 31 felbamate ......................................................................................... 25 Felbatol

® ........................................................................................... 25 felodipine er ..................................................................................... 10 Femara® ........................................................................................ 8, 35 Femcon FE® ....................................................................................... 32


Femhrt Low Dose® ............................................................................ 31 Femhrt® ............................................................................................. 31 Femring® ........................................................................................... 31 fenofibrate 48mg, 145mg ................................................................... 2 fenofibrate tabs,caps ........................................................................ 12 fenofibric cap ...................................................................................... 2 Fenoglide

® ........................................................................................... 2 fentanyl............................................................................................. 36 fentanyl TD patch ............................................................................. 27 Fentora® ...................................................................................... 27, 36 Ferrex® 150 Forte ............................................................................. 31 Ferriprox® ............................................................................................ 7 ferrogels ........................................................................................... 31 Fetzima® ...................................................................................... 24, 36 Fibricor® .............................................................................................. 2 Finacea

® ............................................................................................ 14 Finacea® Plus Kit ................................................................................ 14 finasteride ........................................................................................ 23 Fioricet® ............................................................................................ 28 Fiorinal

® ............................................................................................ 28 Firazyr® .......................................................................................... 7, 35 Flagyl® ............................................................................................... 22 Flarex

® ............................................................................................... 18 flavoxate hcl ....................................................................................... 6 flecainide acetate ............................................................................. 13 Flector

® patch ................................................................................... 28 Flexeril® ............................................................................................. 29 Flomax® ............................................................................................. 23 Flonase® ........................................................................................ 4, 36 Flovent® Diskus 50mcg, 100mcg, 250mg ............................................ 5 Flovent

® HFA ....................................................................................... 5 Floxin® Otic ....................................................................................... 17 fluconazole 150mg tab ..................................................................... 21 fluconazole tabs/oral suspension ..................................................... 21 flucytosine ........................................................................................ 21 fludrocortisone acetate .................................................................... 20 flumadine ......................................................................................... 22 flunisolide nasal .................................................................................. 4 fluocinolone acetonide ..................................................................... 14 fluocinonide ...................................................................................... 14 fluorometholone ophthalmic ........................................................... 18 fluorouracil ....................................................................................... 15 fluoxetine.......................................................................................... 24 fluoxetine hcl .................................................................................... 24 fluoxetine liquid ................................................................................ 24 fluphenazine ..................................................................................... 24 flurazepam ........................................................................................ 23 flurbiprofen ophth soln .................................................................... 19 flurbiprofen tabs ............................................................................... 28 flutamide ...................................................................................... 8, 35 fluticasone cr; oint ............................................................................ 14 fluticasone propionate lotion 0.05% ................................................ 14 fluticasone propionate nasal .............................................................. 4 fluvastatin ......................................................................................... 12 fluvoxamine ...................................................................................... 24 fluvoxamine er .................................................................................. 24 FML‐Forte

® ophthalmic ..................................................................... 18 Focalin XR ......................................................................................... 25 folic acid............................................................................................ 31 Follistim®/AQ .................................................................................... 32 fondaparinox ...................................................................................... 7 Foradil® ......................................................................................... 5, 36 Forfivo

® XL ......................................................................................... 24 Fortamet® ......................................................................................... 16 Forteo

® ........................................................................................ 20, 35

FortestaTM ......................................................................................... 23 Fortical ............................................................................................. 14 Fortical® ............................................................................................ 20 Fosamax® tabs ................................................................................. 20 Fosamax® plus D ............................................................................... 20 fosinopril ............................................................................................ 9 Fosrenol

® .......................................................................................... 31 Fragmin® ............................................................................................. 7 Frova® ............................................................................................... 28 Fulyzaq® ............................................................................................ 29 Furadantin

® susp .............................................................................. 21 furosemide ....................................................................................... 10 Fuzeon® ............................................................................................ 35 FycompaTM ....................................................................................... 25

G

gabapentin ....................................................................................... 25 Gabitril® ............................................................................................ 25 galantamine ..................................................................................... 26 galantamine oral solution ................................................................ 26 galantamine SR ................................................................................. 26 Galzin® .............................................................................................. 31 ganciclovir ........................................................................................ 22 Ganirelix

® .......................................................................................... 32 Gastrocrom® ..................................................................................... 30 gatifloxacin soln ............................................................................... 18 Gattex

® ....................................................................................... 30, 35 Gelnique® .......................................................................................... 36 gemfibrozil ....................................................................................... 12 Generess

® FE ..................................................................................... 32 generic Avita® ................................................................................... 14 generic benzonatate .......................................................................... 5 generic Colyte

® ................................................................................. 30 generic Cortisporin® ophthalmic ...................................................... 18 generic Cortisporin

® Otic sol, susp .................................................... 17 generic Domeboro® Otic ................................................................... 17 generic Golytely® .............................................................................. 30 generic Maxitrol

® ophthalmic ........................................................... 18 generic Metimyd® ............................................................................. 18 generic NeoDecadron® ..................................................................... 18 generic Neosporin

® ........................................................................... 18 generic Polysporin

®........................................................................... 18 generic Polytrim® .............................................................................. 18 generic Retin‐A® ............................................................................... 14 generic Sulfacet‐R

® ........................................................................... 14 generic Tylox® ................................................................................... 27 Genotropin® ................................................................................ 20, 35 gentamicin ........................................................................................ 16 gentamicin ophthalmic ..................................................................... 18 Geodon® ........................................................................................... 24 Gianvi

® .............................................................................................. 32 Giazo® ............................................................................................... 30 GilenyaTM .................................................................................... 26, 35 Gilotrif

TM ............................................................................................. 8 Gleevec® ....................................................................................... 8, 35 glimepiride ....................................................................................... 16 glimepiride/pioglitaone .................................................................... 16 glipizide ............................................................................................ 16 glipizide CR tablets ........................................................................... 16 glipizide‐metformin .......................................................................... 16 glucagon ........................................................................................... 17 Glucophage ...................................................................................... 16 Glucophage XR

® ................................................................................ 16 Glucotrol XL® ..................................................................................... 16


Glucotrol® ......................................................................................... 16 Glucovance® ...................................................................................... 16 Glumetza® ......................................................................................... 36 glyburide ........................................................................................... 16 glyburide micronized ........................................................................ 16 glyburide‐metformin ........................................................................ 16 Glycate

® ...................................................................................... 30, 36 glycopyrrolate ................................................................................... 30 Glynase® ............................................................................................ 16 Glyset® .............................................................................................. 16 Golytely

® ........................................................................................... 30 Gonal‐F RFF® ..................................................................................... 32 Gonal‐F® ............................................................................................ 32 Gralise® ....................................................................................... 25, 36 granisetron ................................................................................. 30, 36 Granix

® ................................................................................................ 7 Grifulvin® V ........................................................................................ 21 griseofulvin 125mg, 250mg .............................................................. 21 griseofulvin 500mg ........................................................................... 21 griseofulvin suspension .................................................................... 21 Gris‐Peg® 125 mg .............................................................................. 21 guanfacine HCl .................................................................................. 11 Gyne‐Lotrimin

® ................................................................................. 33

H

Halcion® ............................................................................................ 23 Haldol

® .............................................................................................. 24 Halflytely® Bowel Prep Kit ................................................................. 30 halobetasol propionate .................................................................... 14 Halog

® ............................................................................................... 14 Halonate® .......................................................................................... 14 haloperidol ....................................................................................... 24 hctz/spironolactone.......................................................................... 10 Hectorol

® ..................................................................................... 31, 36 hematogen ....................................................................................... 31 heparin sodium ................................................................................... 7 Hepsera

® ..................................................................................... 22, 30 Hexalen

® ....................................................................................... 8, 35 HMS® ................................................................................................. 18 homatropine ..................................................................................... 19 Horizant

® ........................................................................................... 25 Humalog

® .......................................................................................... 16 Humatrope® ................................................................................ 20, 35 Humira® ....................................................................................... 28, 35 Humulin

® Insulins .............................................................................. 16 Hycamtin® ......................................................................................... 35 Hycamtin® cap ..................................................................................... 8 hydralazine HCl ................................................................................. 11 Hydrea

® ......................................................................................... 8, 35 hydrochlorothiazide ......................................................................... 10 hydrocodone polistirex‐chlorpheniramine ......................................... 4 hydrocodone w/acetaminophen ................................................ 27, 33 hydrocodone w/ibuprofen ............................................................... 27 hydrocodone/APAP soln ................................................................... 27 hydrocodone‐guaifenesin‐phenylephrine .......................................... 4 hydrocodone‐homatropine ................................................................ 4 hydrocodone‐ibuprofen tab 7.5‐200mg ........................................... 33 hydrocodone‐phenylephrine syrup .................................................... 4 hydrocortisone 2.5% ......................................................................... 14 hydrocortisone 25mg rectal ............................................................. 14 hydrocortisone cream, supp ............................................................. 30 hydrocortisone rectal ....................................................................... 14 hydrocortisone tab ........................................................................... 20 hydrocortisone valerate ................................................................... 14

hydrocortisone w/acetic acid otic soln ....................................... 17, 18 hydromorphone hcl .......................................................................... 27 hydroxychloroquine sulfate ....................................................... 22, 28 hydroxyurea ..................................................................................... 35 hydroxyurea 500mg ........................................................................... 8 hydroxyzine hcl ................................................................................ 23 hydroxyzine HCl ................................................................................. 4 hydroxyzine pamoate ................................................................... 4, 23 hyoscyamine ...................................................................................... 6 hyoscyamine sulfate ......................................................................... 29 Hytrin

® .............................................................................................. 23 Hyzaar® ............................................................................................. 11

I

ibandronate sodium tabs ................................................................. 20 ibuprofen .................................................................................... 28, 33 ibuprofen suspension ....................................................................... 33 Iclusig® .......................................................................................... 8, 35 iFerex® 150 Forte .............................................................................. 31 Ilevro® ............................................................................................... 19 Imbruvica

® .................................................................................... 8, 35 Imdur® .............................................................................................. 13 imipramine HCl ................................................................................. 24 imiquimod cream ............................................................................. 15 Imitrex

® ............................................................................................. 28 Imuran®............................................................................................... 8 Incivek

® ....................................................................................... 30, 35 Increlex® ........................................................................................... 35 indapamide ...................................................................................... 10 Inderal

® LA .......................................................................................... 9 Indocin® ............................................................................................ 28 indomethacin ................................................................................... 28 indomethacin SR .............................................................................. 28 Infergen

® ..................................................................................... 30, 35 Inlyta

® ........................................................................................... 8, 35 Innopran XL® ....................................................................................... 9 Inspra® .............................................................................................. 13 Inta

® nebs ........................................................................................... 6 Intelence® ......................................................................................... 22 Intermezzo® ................................................................................ 23, 36 Intron A

® ........................................................................................... 30 Intron‐A

® .......................................................................................... 35 Intuniv® ............................................................................................. 26 Invirase® ............................................................................................ 22 Invokana

® ......................................................................................... 16 Iopidine® ........................................................................................... 19 ipratropium ........................................................................................ 4 ipratropium 200mcg/ml nebs ............................................................ 6 irbesartan ........................................................................................... 9 irbesartan/hctz ................................................................................. 11 Iressa

® ........................................................................................... 8, 35 iron poly complex/folic acid/vit b12 ................................................. 31 Isentress® .......................................................................................... 22 Ismo

® ................................................................................................ 13 isometheptene ................................................................................. 28 isoniazid ........................................................................................... 22 Isoptin®SR ......................................................................................... 10 Isopto Carbachol® ............................................................................. 19 Isordil

® .............................................................................................. 13 isosorbide dinitrate .......................................................................... 13 isosorbide mononitrate .................................................................... 13 isotretinoin ....................................................................................... 14 Isuprel

® ............................................................................................... 5 itraconazole caps .............................................................................. 21


J

Jakafi® ........................................................................................... 8, 35 jantoven .............................................................................................. 7 Janumet

® ........................................................................................... 16 Janumet® XR ...................................................................................... 16 Januvia®............................................................................................. 16 Jentadueto® ...................................................................................... 16 Jolessa® ............................................................................................. 32 Junel FE® ........................................................................................... 32 Junel

® ................................................................................................ 32 Juvisync® ........................................................................................... 16 Juxtapid

® ..................................................................................... 12, 35

K

Kadian®.............................................................................................. 36 Kadian® 100mg, 200mg ..................................................................... 27 Kadian® 10mg, 20mg, 30mg, 50mg, 60mg, 80mg ............................. 27 Kaletra® ............................................................................................. 22 Kalydeco

® ...................................................................................... 6, 35 KapvayTM ........................................................................................... 25 Karbinal® ER ........................................................................................ 2 Kariva

® .............................................................................................. 32 Kazano® ............................................................................................. 16 Keflex® ............................................................................................... 21 Kelnor

® .............................................................................................. 32 Kemadrin® ......................................................................................... 26 Kenalog® in Orabase ......................................................................... 18 Keppra

® ............................................................................................. 25 Keppra® XR ........................................................................................ 25 Keralyt® scalp .................................................................................... 15 Kerlone

® ........................................................................................ 9, 10 Ketek® ............................................................................................... 21 ketoconazole 2% shampoo ............................................................... 15 ketoconazole cream ......................................................................... 15 ketoconazole foam 2% ..................................................................... 15 ketoconazole tabs ............................................................................. 21 Ketodan

® ........................................................................................... 15 ketoprofen ........................................................................................ 28 ketoprofen extended release ........................................................... 28 ketorolac ........................................................................................... 28 ketorolac tromethamine ophth soln 0.4% and 0.5% ........................ 19 ketotifen fumerate ophth soln ......................................................... 19 Kineret

® ....................................................................................... 28, 35 Klaron

® .............................................................................................. 14 Klonopin® .......................................................................................... 25 Klonopin® Wafers .............................................................................. 25 Klor‐Con® .......................................................................................... 31 Kombiglyze

® XR ................................................................................. 16 Korlym® ....................................................................................... 20, 35 Kuvan®......................................................................................... 30, 35 Kynamro

® .......................................................................................... 12 Kytril® .......................................................................................... 30, 36

L

labetalol .............................................................................................. 9 Lacrisert® ........................................................................................... 19 lactulose syrup .................................................................................. 30 Lamictal

® chewable tablets ............................................................... 25 Lamictal® ODT ................................................................................... 25 Lamictal

® ODT Titration Kit ............................................................... 25 Lamictal® Starter Kit .......................................................................... 25 Lamictal® tabs ................................................................................... 25

Lamictal® XR ...................................................................................... 25

Lamictal® XR Starter Kit .................................................................... 25 Lamisil AT® cream ............................................................................. 15 Lamisil® ............................................................................................. 21 Lamisil® oral granules....................................................................... 21 lamivudine ........................................................................................ 22 lamivudine tab ........................................................................... 22, 30 lamivudine/zidovudine ..................................................................... 22 lamotrigine chewable tablets ........................................................... 25 lamotrigine er ................................................................................... 25 lamotrigine tablets ........................................................................... 25 Lanoxin

® ............................................................................................ 13 lansoprazole ..................................................................................... 29 Lantus®.............................................................................................. 16 Lasix® ................................................................................................ 10 Lastacaft

TM ................................................................................. 19, 36 latanoprost ophth soln ..................................................................... 19 LatudaTM ........................................................................................... 24 Lazanda® ........................................................................................... 27 Leena

®............................................................................................... 32 leflunomide ...................................................................................... 28 Lescol® .............................................................................................. 12 Lessina

® ............................................................................................ 32 Letairis®....................................................................................... 13, 35 letrozole ....................................................................................... 8, 35 leucovorin calcium tabs ...................................................................... 8 Leukeran

® ..................................................................................... 8, 35 Leukine® .............................................................................................. 7 Levaquin® .......................................................................................... 21 Levatol

® .............................................................................................. 9 Levemir® ........................................................................................... 16 levetiracetam xr ............................................................................... 25 Levitra

® ............................................................................................. 23 levobunolol HCl ................................................................................ 19 levocarnitine 330mg ......................................................................... 31 levocetirizine dihydrochloride ............................................................ 4 levofloxacin ...................................................................................... 21 levofloxacin opth soln ...................................................................... 18 levonorgestrel .................................................................................. 32 Levora

® ............................................................................................. 32 levothroid ......................................................................................... 20 levothyroxine ................................................................................... 20 levoxyl .............................................................................................. 20 Levsin

® .............................................................................................. 29 Levsin

®/SL ........................................................................................... 6 Lexapro

® ........................................................................................... 24

Lexiva® .............................................................................................. 22 Lialda® ............................................................................................... 30 Librax® .............................................................................................. 29 Lidex

® ................................................................................................ 14 lidocaine cr ....................................................................................... 15 lidocaine HC cr .................................................................................. 15 lidocaine patch ................................................................................. 15 lidocaine viscous ........................................................................ 18, 34 lidocaine viscous soln ....................................................................... 15 lidocaine‐prilocaine cream ............................................................... 15 Lidoderm

® ......................................................................................... 15 lindane.............................................................................................. 15 Linzess® ....................................................................................... 29, 36 Lioresal® ............................................................................................ 29 liothyronine ...................................................................................... 20 Lipitor® .............................................................................................. 12 Lipofen

® .............................................................................................. 2 lisinopril .............................................................................................. 9 lisinopril/hctz .................................................................................... 11


lithium carbonate ............................................................................. 24 lithium carbonate CR tab .................................................................. 24 Livalo® ............................................................................................... 12 Lo/Ovral® ........................................................................................... 32 Lodosyn® ........................................................................................... 26 Loestrin FE

® ....................................................................................... 32 Loestrin® ........................................................................................... 32 Loestrin® 24 Fe .................................................................................. 32 Lofibra ............................................................................................... 12 Lopid® .................................................................................................. 2 Lopressor HCT

® ................................................................................. 11 Lopressor® ........................................................................................... 9 Loprox® ............................................................................................. 15 Loprox® Shampoo ............................................................................. 15 lorazepam ......................................................................................... 23 Lortab

® .............................................................................................. 27 Loryna®.............................................................................................. 32 losartan ............................................................................................... 9 losartan/hctz .................................................................................... 11 Loseasonique

® ................................................................................... 32 Lotemax® ........................................................................................... 18 Lotensin® ............................................................................................. 9 LotensinHCT

® .................................................................................... 11 Lotrel® ......................................................................................... 10, 11 lovastatin .......................................................................................... 12 Lovaza

®.............................................................................................. 12 Lovenox® ............................................................................................. 7 Low‐Ogestrel® ................................................................................... 32 loxapine ............................................................................................ 24 Lufyllin

® ............................................................................................... 5 Lumigan® ........................................................................................... 19 Lunesta® ............................................................................................ 23 Lupron

® ............................................................................................. 33 Lutera® .............................................................................................. 32 Luveris

® ............................................................................................. 32 Luxiq

® foam ....................................................................................... 14 Lyrica® ............................................................................................... 25 Lysodren

® ...................................................................................... 8, 35 Lysteda® ............................................................................................ 33

M

Macrobid® ......................................................................................... 21 Magnacet® ........................................................................................ 27 Malarone® ......................................................................................... 22 maprotiline ....................................................................................... 24 Marinol® ............................................................................................ 30 Matulane® ..................................................................................... 8, 35 Mavik

® ................................................................................................. 9 Maxair® Autohaler .............................................................................. 5 Maxalt® ............................................................................................. 28 Maxalt‐MLT

® ..................................................................................... 28 Maxzide® ........................................................................................... 10 Mebaral® ........................................................................................... 25 mebendazole .................................................................................... 22 meclizine ........................................................................................... 30 meclofenamate ................................................................................ 28 medoxyprogesterone ....................................................................... 32 Medrol® ............................................................................................. 20 Medrox

‐RX® ....................................................................................... 15 medroxyprogesterone ...................................................................... 32 mefenamic acid ................................................................................ 28 mefloquine hcl .................................................................................. 22 Megace

® ES ................................................................................... 8, 35 megestrol acetate ......................................................................... 8, 35

Mekinist TM ......................................................................................... 8 MekinistTM ....................................................................................... 35 meloxicam ........................................................................................ 28 Meloxicam® Comfort PacKit ............................................................. 28 Menest® ............................................................................................ 31 Menopur

® ......................................................................................... 32 Menostar® ........................................................................................ 20 Mentax® ............................................................................................ 15 Mephyton® ......................................................................................... 7 meprobamate .................................................................................. 23 meprobamate/aspirin ...................................................................... 29 Mepron® ........................................................................................... 22 mercaptopurine ................................................................................. 8 mesalamine enema .......................................................................... 30 Mesnex® ....................................................................................... 8, 35 Mestinon

® ......................................................................................... 26 Metadate CD® ................................................................................... 25 Metaglip® .......................................................................................... 16 metaproterenol tabs .......................................................................... 5 metaxalone ...................................................................................... 29 metformin er .................................................................................... 36 metformin hcl ................................................................................... 16 metformin SR ................................................................................... 16 metformin tb24 ................................................................................ 16 methadone hcl ................................................................................. 27 methamphetamine .......................................................................... 25 methazolamide ................................................................................ 19 Methergine

® ..................................................................................... 33 methimazole .................................................................................... 20 Methitest

® ........................................................................................ 23 methocarbamol ................................................................................ 29 methotrexate inj .............................................................................. 28 methotrexate tabs .................................................................. 8, 15, 28 methyclothiazide .............................................................................. 10 methyldopa ...................................................................................... 11 methyldopa/hctz .............................................................................. 11 Methylin

® .......................................................................................... 25 methylphenidate .............................................................................. 25 methylphenidate cd ......................................................................... 25 methylphenidate SR tabs ................................................................. 25 methylprednisolone ......................................................................... 33 metipranolol ..................................................................................... 19 metoclopramide ............................................................................... 29 metolazone ...................................................................................... 10 metoprolol ......................................................................................... 9 metoprolol succinate SR ..................................................................... 9 metoprolol/hctz ............................................................................... 11 Metozolv

® ODT ................................................................................. 29 Metrocream® .................................................................................... 14 Metrogel

® 0.75%, 1% ........................................................................ 14 Metrogel® Vaginal ............................................................................. 33 Metrolotion® ..................................................................................... 14 metronidazole .................................................................................. 22 metronidazole 375mg caps .............................................................. 22 metronidazole cream, lotion, gel ..................................................... 14 metronidazole vaginal gel ................................................................ 33 Mevacor

® .......................................................................................... 12 mexiletine HCl .................................................................................. 13 Miacalcin® inj. ................................................................................... 20 Miacalcin® nasal spray ...................................................................... 20 Micardis® ...................................................................................... 9, 36 Micardis

® HCT ............................................................................. 11, 36 Micatin

® ............................................................................................ 15 miconazole cream, lotion, aerosol, soln ........................................... 15 miconazole vaginal cream ................................................................ 33


Microgestin FE® ................................................................................. 32 Microgestin® ..................................................................................... 32 Midamor® .......................................................................................... 10 midodrine hcl .................................................................................... 13 Midrin® .............................................................................................. 28 Migranal

® .......................................................................................... 28 Minastrin® ......................................................................................... 32 Minipress® ......................................................................................... 11 Minitran® .......................................................................................... 13 Minivelle® .......................................................................................... 31 Minocin Pac

® ..................................................................................... 21 Minocin® ........................................................................................... 21 minocycline caps (50mg & 100mg only) ........................................... 21 minocycline hcl er ............................................................................. 14 minocycline hcl tabs ......................................................................... 14 minoxidil tabs ................................................................................... 11 Mirapex

® ........................................................................................... 26 Mirapex® ER ...................................................................................... 26 Mircette® .......................................................................................... 32 mirtazapine ODT ............................................................................... 24 Mirvaso® Gel ..................................................................................... 15 misoprostol ....................................................................................... 29 Mobic

® .............................................................................................. 28 modafinil ........................................................................................... 25 Moderiba

® ......................................................................................... 30 Modicon

® .......................................................................................... 32 moexipril/hctz .................................................................................. 11 mometasone furoate ........................................................................ 14 Momexin® ......................................................................................... 15 Monistat

® .......................................................................................... 33 Monodox® ......................................................................................... 21 Mononessa® ...................................................................................... 32 montelukast sodium chews ................................................................ 6 montelukast sodium tabs ................................................................... 6 morphine sulfate beads sr ................................................................ 27 morphine sulfate cap sr 24hr 100mg, 200mg ................................... 27 morphine sulfate cap sr 24hr 10mg, 20mg, ...................................... 27 morphine sulfate ER ......................................................................... 27 morphine sulfate ir ........................................................................... 27 morphine sulfate supp ...................................................................... 27 morphine sulfate tablets, oral solution ............................................ 27 Motrin

® ............................................................................................. 28 Moxatag

® .......................................................................................... 21 Moxeza

® ............................................................................................ 18 moxifloxacin hcl ................................................................................ 21 MS Contin

® ........................................................................................ 27

mucate/dichloralphenazone/acetaminophen .................................. 28 Multaq® ............................................................................................. 13 mupirocin ......................................................................................... 16 Muse® ............................................................................................... 23 MyaleptTM ........................................................................................ 35 Myambutol® ...................................................................................... 22 Mycelex® Troche ............................................................................... 21 Mycobutin

® ....................................................................................... 22 mycophenolate ................................................................................... 8 mycophenolate sodium dr .................................................................. 8 Mydfrin® ............................................................................................ 19 Myferon® 150 Forte .......................................................................... 31 Myfortic

® ............................................................................................. 8 Myleran® ....................................................................................... 8, 35 Myorisan® ......................................................................................... 14 Myrbetriq

® ........................................................................................ 36 Myrbetriq

TM ........................................................................................ 6 Mysoline® .......................................................................................... 25

N

nabumetone ..................................................................................... 28 nadolol ............................................................................................... 9 Naftin

® .............................................................................................. 15 Nalfon® ............................................................................................. 28 naltrexone ........................................................................................ 26 Namenda® soln ................................................................................. 26 Namenda® XR .................................................................................... 26 naphazoline ...................................................................................... 19 Naprelan

® ......................................................................................... 28 Naprelan® SR..................................................................................... 28 Naprosyn

® ......................................................................................... 28 naproxen .................................................................................... 28, 33 naproxen sodium ....................................................................... 28, 33 naratriptan ....................................................................................... 28 Nardil® .............................................................................................. 24 Nasarel® .............................................................................................. 4 Nascobal® ......................................................................................... 31 Nasonex® ............................................................................................ 4 Natacyn

® ........................................................................................... 18 Natazia® ............................................................................................ 32 nateglinide ....................................................................................... 16 Natroba

® ..................................................................................... 15, 36 Navane® ............................................................................................ 24 Nebupent® ........................................................................................ 22 Necon

® .............................................................................................. 32 nefazodone hcl ................................................................................. 24 neomycin sulfate .............................................................................. 22 Neoral

® ............................................................................................... 8 Neotic® .............................................................................................. 17 Nesina

® ............................................................................................. 16 Neulasta® ...................................................................................... 7, 35 Neumega® ........................................................................................... 7 Neupogen

® ................................................................................... 7, 35 Neupro® ............................................................................................ 26 Neurontin® ........................................................................................ 25 Nevanac

® .......................................................................................... 19 nevirapine ........................................................................................ 22 nevirapine sr ..................................................................................... 22 Nexavar

® ............................................................................................. 8 Nexium

® ............................................................................................ 29 Next Choice® ..................................................................................... 32 niacin er ............................................................................................ 12 Niaspan

® ........................................................................................... 12 Nicardipine

® ...................................................................................... 10 Nicotrol® Inhaler ............................................................................... 29 Nicotrol

® NS ...................................................................................... 29 Nifediac CC ....................................................................................... 10 Nifedical XL ....................................................................................... 10 nifedipine ......................................................................................... 33 nifedipine ER .................................................................................... 10 nimodipine ....................................................................................... 10 Nimotop

® .......................................................................................... 10 Niravam® ........................................................................................... 24 nisoldipine ........................................................................................ 10 Nitro‐Bid®.......................................................................................... 13 Nitro‐Dur® ......................................................................................... 13 nitrofurantoin macrocrystals ............................................................ 21 nitroglycerin ointment ..................................................................... 13 nitroglycerin patch ........................................................................... 13 nitroglycerin sublingual .................................................................... 13 Nitrolingual aerosol spray ................................................................ 13 Nitrostat

® .......................................................................................... 13 Nizoral A‐D

® shampoo ...................................................................... 15


Nizoral® ............................................................................................. 21 Nizoral® shampoo ............................................................................. 15 Nora‐Be® ........................................................................................... 32 Norco® ............................................................................................... 27 Nordette® .......................................................................................... 32 Norditropin

® ...................................................................................... 20 norethindrone acetate ..................................................................... 32 norethindrone acetate‐ethinyl estradiol .......................................... 31 Norflex® ............................................................................................. 29 Norinyl® ............................................................................................. 32 Noritate

® ........................................................................................... 14 Noroxin® ............................................................................................ 21 Norpace CR® ...................................................................................... 13 Norpace® ........................................................................................... 13 Norpramin® ....................................................................................... 24 Nor‐QD

® ............................................................................................ 32 NortheraTM .................................................................................. 26, 35 Nortrel® ............................................................................................. 32 nortriptyline ...................................................................................... 24 Norvasc

® ........................................................................................... 10 Norvir® .............................................................................................. 22 Novacort® .......................................................................................... 14 NovoFine

® Needles ........................................................................... 17 Novolin® insulins ............................................................................... 16 Novolog

® insulins .............................................................................. 16 Noxafil DR

® ........................................................................................ 21 Noxafil® ............................................................................................. 21 Nucynta® ........................................................................................... 27 Nucynta® ER ...................................................................................... 27 Nuedexta

TM XR .................................................................................. 26 Nutropin® .................................................................................... 20, 35 Nutropin® AQ .............................................................................. 20, 35 NuvaRing

® ......................................................................................... 32 Nuvigil® ............................................................................................. 25 Nymalize

® .......................................................................................... 10 nystatin 100,000u/1g cream; oint .................................................... 15 nystatin oral suspension ............................................................. 21, 33 nystatin pwd ..................................................................................... 15 nystatin tabs ..................................................................................... 21 nystatin‐triamcinolone ..................................................................... 15 Nystop

® ............................................................................................. 15

O

Ocella® .............................................................................................. 32 octreotide ........................................................................................... 8 Ocufen® ophth soln ........................................................................... 19 Ocuflox® ............................................................................................ 18 ofloxacin ophth soln ......................................................................... 18 ofloxacin otic .................................................................................... 17 Oforta® .......................................................................................... 8, 35 Ogestrel

® ........................................................................................... 32 olanzapine ........................................................................................ 24 olanzapine odt .................................................................................. 24 olanzapine‐fluoxetine ....................................................................... 24 Oleptro® ...................................................................................... 24, 36 Olux® foam ........................................................................................ 14 OlysioTM ...................................................................................... 30, 35 Omeclamox‐Pak® .............................................................................. 30 omeprazole ....................................................................................... 29 omeprazole sodium bicarbonate ...................................................... 29 Omnaris

® ....................................................................................... 4, 36 ondansetron ..................................................................................... 30 ondansetron odt ............................................................................... 30 ondansetron susp ............................................................................. 30

OneTouch® Diabetic Test Strips ....................................................... 17 OneTouch® Glucose Meters ............................................................. 17 OnfiTM ............................................................................................... 26 Onglyza® ........................................................................................... 16 Onmel® ............................................................................................... 2 Onsolis

® ...................................................................................... 27, 35 Opana ER® ......................................................................................... 27 Opana® .............................................................................................. 27 Opana® ER (crush resistant) .............................................................. 37 Opsumit® .................................................................................... 13, 35 Optipranolol

® .................................................................................... 19 Optivar® ...................................................................................... 19, 37 Oramorph® ....................................................................................... 27 Orap® ................................................................................................ 24 Orapred® ....................................................................................... 8, 20 Oravig

® ........................................................................................ 21, 37 Orencia® SQ ...................................................................................... 28 Orencia®SQ ....................................................................................... 35 OrenitramTM ............................................................................... 13, 35 Orfadin

® ...................................................................................... 20, 35 Ortho Micronor® ............................................................................... 32 Ortho Tri‐Cyclen® .............................................................................. 32 Ortho Tri‐Cyclen

® Lo ......................................................................... 32 Ortho‐Cept® ...................................................................................... 32 Ortho‐Cyclen

® ................................................................................... 32 OrthoEvra

® ........................................................................................ 32 Ortho‐Novum® .................................................................................. 32 Oseni® ............................................................................................... 16 OsmoPrep® ....................................................................................... 30 Osphena

® .......................................................................................... 31 Ovcon® .............................................................................................. 32 Ovidrel® ...................................................................................... 32, 37 Oxandrin

® ..................................................................................... 8, 20 oxaprozin .......................................................................................... 28 oxazepam ......................................................................................... 23 oxcarbazepine .................................................................................. 25 Oxecta

® ............................................................................................. 27 Oxistat

® ............................................................................................. 15 Oxsoralen‐Ultra® ............................................................................... 15 Oxtellar® XR ...................................................................................... 25 oxybutynin.......................................................................................... 6 oxybutynin chloride SR ....................................................................... 6 oxycodone 5mg tablets/soln ............................................................ 27 oxycodone w/acetaminophen 5/325mg .......................................... 27 oxycodone w/ibuprofen ................................................................... 27 Oxycontin

® .................................................................................. 27, 37

oxymorphone ................................................................................... 27

P

Pamelor® ........................................................................................... 24 Pancreaze

® ........................................................................................ 30 Panretin® Gel .................................................................................... 15 pantoprazole .................................................................................... 29 Parcopa

® ........................................................................................... 26 paricalcitrol ...................................................................................... 31 Parlodel® ........................................................................................... 26 Parnate®............................................................................................ 24 paromomycin ................................................................................... 22 paroxetine hcl er .............................................................................. 37 paroxetine hcl sr ............................................................................... 24 paroxetine tabs ................................................................................ 24 Pataday

® ........................................................................................... 37 Patanase® ..................................................................................... 4, 37 Patanol® ...................................................................................... 19, 37


Paxil CR® ............................................................................................ 24 Paxil® ................................................................................................. 24 Paxil® CR ............................................................................................ 37 Pediapred® ........................................................................................ 20 Pediderm® HC ................................................................................... 14 Peganone

® ........................................................................................ 25 Pegasys® ...................................................................................... 30, 35 Peg‐Intron® ................................................................................. 30, 35 penicillin VK ...................................................................................... 33 penicillin VK tabs, soln ...................................................................... 21 Penlac

® .............................................................................................. 15 Pennsaid® .......................................................................................... 28 Pentasa® ............................................................................................ 30 pentoxifylline ...................................................................................... 7 Percocet® .......................................................................................... 27 Percodan

® ......................................................................................... 27 Perforomist® ....................................................................................... 5 Peridex® ............................................................................................ 18 perindopril .......................................................................................... 9 permethrin cream ............................................................................ 15 perphenazine .................................................................................... 24 Persantine® ......................................................................................... 7 Pertzye

® ............................................................................................ 30 phenazopyridine ................................................................................. 7 phenelzine tab .................................................................................. 24 Phenergan suppositories

® ................................................................. 30 phenobarbital ................................................................................... 25 phentolamine inj .............................................................................. 13 phenylephrine ophthalmic 2.5% ....................................................... 19 Phenytek® ......................................................................................... 25 phenytoin ......................................................................................... 25 phenytoin chew tab .......................................................................... 25 phenytoin sodium ............................................................................. 25 phenytoin sodium susp..................................................................... 25 Phoslyra

TM ........................................................................................ 31 Phospholine

® iodide .......................................................................... 19 Phrenilin® Forte ................................................................................. 28 Picato

® Gel ........................................................................................ 15 pilocarpine soln ................................................................................ 19 pilocarpine tab .................................................................................. 18 Pilopine

® H.S. .................................................................................... 19 pioglitazone hcl ................................................................................. 16 pioglitazone hcl/metformin hcl ........................................................ 16 piroxicam .......................................................................................... 28 Plan B

® .............................................................................................. 32 Plan B

® One Step ............................................................................... 32

Plavix® ................................................................................................. 7 Plendil®.............................................................................................. 10 Pletal® ................................................................................................. 7 Plexion

® cleanser .............................................................................. 14 podofilox solution ............................................................................. 15 Pol‐iron® 150 Forte ........................................................................... 31 Polycitra® ............................................................................................ 7 Poly‐Pred

® ......................................................................................... 18 polysaccharide iron forte .................................................................. 31 poly‐vitamin w/fluoride .............................................................. 31, 33 Pomalyst® ...................................................................................... 8, 35 Ponstel® ............................................................................................ 28 Portia

® ............................................................................................... 32 potassium bicarbonate/chloride ...................................................... 31 potassium chloride er ....................................................................... 31 potassium chloride tab, cap, liquid ................................................... 31 potassium citrate ................................................................................ 7 potassium citrate/citric acid ............................................................... 7 Potiga

® .............................................................................................. 25

PradaxaTM ........................................................................................... 7 pramipexole dihydrochloride ........................................................... 26 Pramosone® E ................................................................................... 14 Prandimet® ....................................................................................... 16 Prandin® ............................................................................................ 16 Pravachol

® ........................................................................................ 12 pravastatin ....................................................................................... 12 prazosin HCl ...................................................................................... 11 Precose® ........................................................................................... 16 Pred Forte® ....................................................................................... 18 Pred Mild

® ........................................................................................ 18 Pred‐G S.O.P. ® .................................................................................. 18 Pred‐G® ............................................................................................. 18 prednicarbate cr,oint ....................................................................... 14 prednisolone ...................................................................................... 8 prednisolone ophthalmic ................................................................. 18 prednisolone oral syrup ................................................................... 20 prednisone ............................................................................. 8, 20, 33 Prefest

® ............................................................................................. 31 Pregnyl

® ............................................................................................ 32 Prelone® ............................................................................................ 20 Premarin® ......................................................................................... 31 Premarin

® cream .............................................................................. 31 Premphase® ...................................................................................... 31 Prempro

® .......................................................................................... 31 Prepopik

® .......................................................................................... 30 Prevacid Solutab ............................................................................... 29 Prevacid® .......................................................................................... 29 Previfem® .......................................................................................... 32 Prezista

® ..................................................................................... 22, 37 Prilosec® ............................................................................................ 29 primaquine phosphate ..................................................................... 22 primidone ......................................................................................... 25 Prinivil

® ............................................................................................... 9 Prinzide

® ........................................................................................... 11 Pristiq

® ........................................................................................ 24, 37 Proair® HFA ......................................................................................... 5 ProAmatine

® ..................................................................................... 13 ProBanthine® .................................................................................... 29 probenicid ........................................................................................ 29 Procardia

® XL .................................................................................... 10 Prochieve® ........................................................................................ 32 prochlorperazine tab, supp .............................................................. 30 Procrit

® ......................................................................................... 7, 35 Proctocort

® 1% ................................................................................. 30 Proctocream‐HC

®2.5% ...................................................................... 30

Proctofoam HC® ................................................................................ 30 Procto‐Pak® 1% ................................................................................. 30 Proctosol‐HC® 2.5% .......................................................................... 30 Proctosone

® 2.5% ............................................................................. 30 Procysbi® ..................................................................................... 20, 35 progesterone suppositories ............................................................. 31 Proglycem® ....................................................................................... 16 Prograf

® .............................................................................................. 8 Prolensa® .................................................................................... 19, 37 Proleukin® ........................................................................................... 8 Promacta

® ..................................................................................... 7, 35 promethazine ..................................................................................... 4 promethazine hcl supp ..................................................................... 30 promethazine VC ................................................................................ 4 promethazine/ ................................................................................... 4 promethazine/dextromethorphan ..................................................... 5 Prometrium

® ..................................................................................... 32 propafenone hcl ............................................................................... 13 propafenone hcl sr ........................................................................... 13


propantheline ................................................................................... 29 propranolol ......................................................................................... 9 propranolol ER .................................................................................... 9 propranolol/hctz ............................................................................... 11 propylthiouracil ................................................................................ 20 Proquin

® XR ....................................................................................... 21 Proscar® ............................................................................................ 23 Prostigmin® ....................................................................................... 26 Protonix® ........................................................................................... 29 Protopic® ........................................................................................... 15 protriptyline ...................................................................................... 24 Proventil HFA® .................................................................................... 5 Proventil® ............................................................................................ 5 Provera® ............................................................................................ 32 Provigil® ............................................................................................. 25 Prozac

® .............................................................................................. 24 Prozac® Weekly ................................................................................. 24 Pulmicort Respules® 0.25mg, 0.5mg ................................................... 5 Pulmicort® Flexhaler ........................................................................... 5 Pulmicort

® Respules 1mg .................................................................... 5 Pulmozyme® ........................................................................................ 6 pyrazinamide .................................................................................... 22 Pyridium

® ............................................................................................ 7 pyridostigmine bromide 60mg tab ................................................... 26

Q

Qnasl® ........................................................................................... 4, 37 Qualaquin® ........................................................................................ 22 Quasense

® ......................................................................................... 32 Questran Light® ................................................................................. 12 Questran® ......................................................................................... 12 quetiapine fumarate ......................................................................... 24 Quibron

® ............................................................................................. 5 Quillivant® XR .............................................................................. 25, 37 quinapril ............................................................................................. 9 quinapril/hctz ................................................................................... 11 quinidine gluconate SR ..................................................................... 13 quinidine sulfate ............................................................................... 13 quinidine sulfate SR .......................................................................... 13 quinine sulfate caps .......................................................................... 22 Quixin

® .............................................................................................. 18 QVar

® .................................................................................................. 5

R

rabeprazole ....................................................................................... 29 raloxifene .......................................................................................... 31 ramipril ............................................................................................... 9 Ranexa

® ............................................................................................. 13 ranitidine hcl capsules ...................................................................... 29 ranitidine syrup ................................................................................ 29 ranitidine tabs................................................................................... 29 Rapaflo® ...................................................................................... 11, 23 Rapamune® ......................................................................................... 8 Ravicti® ........................................................................................ 20, 35 Rayos® ............................................................................................... 37 Razadyne

® ......................................................................................... 26 Razadyne® ER .................................................................................... 26 Rebetol

® ................................................................................ 22, 30, 35 Rebif

® .......................................................................................... 26, 35 Reclipsen® ......................................................................................... 32 Reglan® .............................................................................................. 29 Regranex

® ......................................................................................... 15 Relenza® ............................................................................................ 22

Relistor® ............................................................................................ 30 Relpax® tablets ................................................................................. 28 Remeron Sol‐Tab® ............................................................................. 24 Remeron® ......................................................................................... 24 Renacidin® .......................................................................................... 7 Renagel

® ........................................................................................... 31 Renvela® ........................................................................................... 31 Repronex® ......................................................................................... 32 Requip® ............................................................................................. 26 Requip® XL ........................................................................................ 26 Rescon

® JR .......................................................................................... 4 Rescon‐MX® ........................................................................................ 4 Rescriptor® ........................................................................................ 22 Rescula® ............................................................................................ 19 Restasis® ........................................................................................... 19 Restoril

® ............................................................................................ 23 Retin‐A® ............................................................................................ 14 Retin‐A® Micro .................................................................................. 14 Retrovir® ........................................................................................... 22 Revatio

® ............................................................................................ 13 Revia® ............................................................................................... 26 Revlimid® ...................................................................................... 7, 35 Reyataz

®............................................................................................ 22 Rhinocort® Aqua ........................................................................... 4, 37 ribavirin ................................................................................ 22, 30, 35 Ridaura

® ............................................................................................ 28 rifabutin ............................................................................................ 22 Rifadin® ............................................................................................. 22 rifampin ............................................................................................ 22 Rifater

® ............................................................................................. 22 Rilutek® ............................................................................................. 29 Riomet®............................................................................................. 16 Risperdal

® ......................................................................................... 24 Risperdal® M ..................................................................................... 24 Risperdal

® solution ........................................................................... 24 risperidone ....................................................................................... 24 risperidone odt ................................................................................ 24 Ritalin LA

® ......................................................................................... 25 Ritalin® .............................................................................................. 25 rivastigmine ...................................................................................... 26 rizatriptan benzoate ......................................................................... 28 rizatriptan benzoate odt................................................................... 28 Robaxin

® ........................................................................................... 29 Robinul

® ............................................................................................ 30 ropinirole hcl tabs 24 hour ............................................................... 26 ropinirole hydrochloride .................................................................. 26 rosadan ............................................................................................ 14 Rosadan

® Kit...................................................................................... 14 Rosula® Emulsion Cleanser ............................................................... 14 Rowasa

® Enema ................................................................................ 30 Roxicodone® ..................................................................................... 27 Rozerem® .......................................................................................... 23 Rybix® ODT ........................................................................................ 27 Rynatan

® susp ..................................................................................... 4 Rythmol® SR ...................................................................................... 13 Ryzolt® .............................................................................................. 27

S

Sabril® ......................................................................................... 25, 35 Saizen® ........................................................................................ 20, 35 Salagen

® ............................................................................................ 18 salsalate ............................................................................................ 28 Salvax® Duo Kit ................................................................................. 15 Samsca® ............................................................................................ 20


Sanctura XR® ....................................................................................... 6 Sanctura® .......................................................................................... 37 Sanctura® XR ..................................................................................... 37 Sancuso® ........................................................................................... 37 Sancuso® Patch ................................................................................. 30 Sandimmune

® ..................................................................................... 8 Sandostatin® ....................................................................................... 8 Saphris® ............................................................................................. 24 Sarafem® ........................................................................................... 24 Savella® ............................................................................................. 24 Seasonale

® ........................................................................................ 32 Seasonique® ...................................................................................... 32 Sectral® ............................................................................................... 9 selegiline ........................................................................................... 26 selenium sulfide ................................................................................ 15 Selzentry

® .......................................................................................... 22 Sensipar® ........................................................................................... 20 Serevent® Diskus ........................................................................... 5, 37 Seromycin® ........................................................................................ 22 Seroquel

® .......................................................................................... 24 Seroquel® XR ............................................................................... 24, 37 Serostim® .......................................................................................... 20 sertraline .......................................................................................... 24 Signifor

® .............................................................................................. 8 sildenafil ........................................................................................... 13 Silenor

® ............................................................................................. 24 silver sulfadiazine ............................................................................. 16 Simcor® ............................................................................................. 13 Simponi® ..................................................................................... 28, 35 simvastatin ....................................................................................... 12 Sinemet CR

® ...................................................................................... 26 Sinemet® ........................................................................................... 26 Singulair

® ............................................................................................. 6 Singulair® chews .................................................................................. 6 sirolimus 0.5mg .................................................................................. 8 Sirturo

® ............................................................................................. 22 Sitavig® .............................................................................................. 16 Skelaxin

® ........................................................................................... 29 Sklice® ............................................................................................... 37 sodium chloride for inhalation ........................................................... 6 sodium fluoride .......................................................................... 31, 33 sodium fluoride gel, paste, cream .................................................... 31 sodium phenylbutyrate .................................................................... 20 sodium polystyrene sulfonate .......................................................... 31 Solaraze

® ........................................................................................... 15 Solia

® ................................................................................................. 32

Solodyn® ............................................................................................ 14 Somavert® ................................................................................... 20, 35 Sonata® ............................................................................................. 23 Soriatane

® ......................................................................................... 15 SoriluxTM ........................................................................................... 15 sotalol ............................................................................................... 13 SovaldiTM ..................................................................................... 30, 35 spinosad suspension 0.9% ................................................................ 15 Spiriva

® ................................................................................................ 6 spironolactone .................................................................................. 10 Sporanox

® ......................................................................................... 21 Sprintec® ........................................................................................... 32 Sprix

TM .............................................................................................. 28 Sprycel® ................................................................................... 8, 35, 37 Sronyx® .............................................................................................. 32 SSKI ..................................................................................................... 5 Stadol NS

® ......................................................................................... 28 Stalevo® ............................................................................................. 26 Starlix

® .............................................................................................. 16

stavudine .......................................................................................... 22 Staxyn® ............................................................................................. 23 Stendra® ............................................................................................ 23 Stimate® ............................................................................................ 20 Stivarga® ............................................................................................. 8 Strattera

® .......................................................................................... 25 Striant® ............................................................................................. 23 StribildTM .......................................................................................... 22 Stromectol® ...................................................................................... 22 Suboxone® Filmtab ........................................................................... 26 Suboxone® SL ................................................................................... 26 Subsys® ............................................................................................. 27 Subutex® ........................................................................................... 26 Sucraid® ...................................................................................... 30, 35 sucralfate .......................................................................................... 29 Sular

® ................................................................................................ 10 sulfacetamide sodium 10% .............................................................. 18 sulfacetamide sodium lotion ...................................................... 14, 15 sulfacetamide sodium w/sulfer cream, liquid .................................. 14 sulfacetamide sodium w/sulfur emulsion/cleanser ......................... 14 sulfamethoxazole/ ............................................................................ 21 sulfamethoxazole/trimethoprim ...................................................... 21 sulfasalazine ..................................................................................... 30 sulfasalazine DR ................................................................................ 30 sulfinpyrazone .............................................................................. 7, 29 sulfisoxazole tabs ............................................................................. 21 sulindac ............................................................................................ 28 SumadanTM ....................................................................................... 14 sumatriptan inj ................................................................................. 28 sumatriptan nasal spray ................................................................... 28 sumatriptan tabs .............................................................................. 28 Sumavel

® .......................................................................................... 28 Sumaxin

® .......................................................................................... 14 Suprax® tabs, susp ............................................................................ 21 Surmontil

® ........................................................................................ 24 Sustiva

® ............................................................................................. 22 Sutent®.......................................................................................... 8, 35 Sylatron

TM ..................................................................................... 8, 35 Symbicort® .......................................................................................... 5 Symbyax® .......................................................................................... 24 Symlin

® ............................................................................................. 17 Synarel® ............................................................................................ 33 Synthroid

® ......................................................................................... 20 Syprine

® ............................................................................................ 20

T

Tabloid® .............................................................................................. 8 Taclonex

® .......................................................................................... 15 tacrolimus .......................................................................................... 8 Tafinlar TM ........................................................................................... 8 Tafinlar

TM ......................................................................................... 35 Tambocor® ........................................................................................ 13 Tamiflu® ............................................................................................ 22 tamoxifen ........................................................................................... 8 tamsulosin hcl sr ............................................................................... 23 Tapazole

® .......................................................................................... 20 Tarceva® ........................................................................................ 8, 35 Targretin® Gel ................................................................................... 15 Tarka

® ............................................................................................... 11 Tasigna® .................................................................................. 8, 35, 37 Tasmar

® ...................................................................................... 26, 37 Tavist

® ................................................................................................. 4 Tazorac® ............................................................................................ 15 Tecfidera® ................................................................................... 26, 35


Tegretol® ........................................................................................... 25 Tegretol® XR ...................................................................................... 25 Tekamlo® ..................................................................................... 11, 37 Tekturna® .................................................................................... 11, 37 Tekturna® HCT ............................................................................. 11, 37 telmisartan ................................................................................... 9, 37 telmisartan/amlodipine .................................................................... 11 telmisartan/hctz ......................................................................... 11, 37 temazepam ....................................................................................... 23 Temodar

® ...................................................................................... 8, 35 Temovate

® ........................................................................................ 14 temozolomide .............................................................................. 8, 35 Tenex® ............................................................................................... 11 Tenoretic® ......................................................................................... 11 Tenormin® ........................................................................................... 9 Terazol

® ............................................................................................. 33 terazosin ........................................................................................... 23 terbinafine hcl .................................................................................. 21 Terbinex® .......................................................................................... 21 terbutaline ........................................................................................ 33 terbutaline tabs .................................................................................. 5 Teslac® ................................................................................................ 8 Tessalon

® ............................................................................................ 5 Testim® .............................................................................................. 23 testosterone cypionate..................................................................... 23 Testred

® ............................................................................................ 23 tetracycline caps, susp ...................................................................... 21 tetracycline capsules ........................................................................ 33 Teveten® ....................................................................................... 9, 37 Teveten

® HCT .................................................................................... 37 Thalomid® ..................................................................................... 8, 35 theophylline ER ................................................................................... 5 theophylline SR ................................................................................... 5 thioguanine......................................................................................... 8 Thiola

TM ............................................................................................ 28 thioridazine ....................................................................................... 24 thiothixene ....................................................................................... 24 Thorazine

® ......................................................................................... 24 thyroid .............................................................................................. 20 tiagabine ........................................................................................... 25 Tiazac

® ............................................................................................... 10 Ticlid® .................................................................................................. 7 ticlopidine ........................................................................................... 7 Tigan

® ................................................................................................ 30 Tikosyn

® ............................................................................................ 13 Tilia FE

® ............................................................................................. 32

timolol ................................................................................................ 9 timolol maleate ................................................................................ 19 timolol ophthalmic gel ...................................................................... 19 Timolol® XE ........................................................................................ 19 Timoptic® .......................................................................................... 19 Tindamax® ......................................................................................... 22 tinidazole tabs .................................................................................. 22 Tirosint

TM .......................................................................................... 20 tizanidine caps .................................................................................. 29 tizanidine tablets .............................................................................. 29 Tobi® ................................................................................................. 22 Tobradex® ointment ......................................................................... 18 Tobradex

® ST ..................................................................................... 18 Tobradex® susp ................................................................................. 18 tobramycin ....................................................................................... 18 tobramycin neb ................................................................................ 22 Tofranil

® ............................................................................................ 24 Tofranil® PM ...................................................................................... 24 tolmetin sodium ............................................................................... 28

tolterodine er ..................................................................................... 6 tolterodine tartrate ...................................................................... 6, 37 Topamax® ......................................................................................... 25 Topamax® Sprinkles .......................................................................... 25 Topicort® ........................................................................................... 14 topiramate ....................................................................................... 25 topiramate sprinkle .......................................................................... 25 Toprol

® XL ........................................................................................... 9 torsemide ......................................................................................... 10 Toviaz® .......................................................................................... 6, 37 Tracleer

® ..................................................................................... 13, 35 Tradjenta® ......................................................................................... 16 tramadol ........................................................................................... 27 tramadol er ................................................................................ 27, 37 Trandate® ............................................................................................ 9 trandolapril ......................................................................................... 9 trandolapril/ ..................................................................................... 11 tranexamic acid ................................................................................ 33 Transderm‐Scop

® .............................................................................. 30 Tranxene

® ......................................................................................... 23 tranylcypromine ............................................................................... 24 trazodone ......................................................................................... 24 Trecator® .......................................................................................... 22 Trental® ............................................................................................... 7 Tretin

® X ............................................................................................ 14 tretinoin ....................................................................................... 8, 35 tretinoin microsphere gel ................................................................. 14 Trexall

® ............................................................................................. 28 Treximet® .................................................................................... 28, 37 triamcinolone in orabase................................................................. 18 triamcinolone acetonide .............................................................. 4, 14 triamcinolone in orabase ................................................................. 33 triamterene/hctz .............................................................................. 10 Triaz

® Cloths 3% ................................................................................ 14 triazolam .......................................................................................... 23 Tribenzor

TM ................................................................................. 11, 37 Tricor® ................................................................................................. 2 trifluoperazine .................................................................................. 24 trifluridine ........................................................................................ 18 trigels ................................................................................................ 31 Triglide

® .............................................................................................. 2 trihexyphenidyl ................................................................................ 26 Tri‐Legest FE

® .................................................................................... 32 Trileptal

® ........................................................................................... 25 Trilipix

® ............................................................................................... 2 trimethobenzamide .......................................................................... 30 trimethoprim tabs ............................................................................ 21 trimipramine .................................................................................... 24 Trinessa® ........................................................................................... 32 Tri‐Norinyl

® ....................................................................................... 32 Trioxin® Otic susp .............................................................................. 17 Tri‐Previfem® .................................................................................... 32 Tri‐Sprintec® ..................................................................................... 32 Trivicay

® ............................................................................................ 22 tri‐vitamin w/fluoride ................................................................. 31, 33 Trivora® ............................................................................................. 32 Trizivir

® ............................................................................................. 22 TrokendiTM XR ................................................................................... 25 tropicamide ...................................................................................... 19 trospium ............................................................................................. 6 trospium chloride er ......................................................................... 37 trospium er ......................................................................................... 6 Trusopt

® ............................................................................................ 19 Truvada® ........................................................................................... 22 Tudorza

TM Pressair ............................................................................. 6


Tussionex® ........................................................................................... 4 Twinject® ............................................................................................. 5 Twynsta® ..................................................................................... 11, 37 Tykerb® ......................................................................................... 8, 35 Tylenol w/Codeine® .......................................................................... 27 Tylox

® ................................................................................................ 27 Tyzeka® ............................................................................................. 22

U

Uceris® .............................................................................................. 30 Ulesfia

® ............................................................................................. 15 Uloric® ............................................................................................... 29 Ulroic

® ............................................................................................... 37 Ultracet

® ........................................................................................... 27 Ultram® ER .................................................................................. 27, 37 Ultravate® ......................................................................................... 14 Ultresa® ............................................................................................. 30 Uniphyl® .............................................................................................. 5 Uniretic® ............................................................................................ 11 unithroid ........................................................................................... 20 Univasc

® .............................................................................................. 9 Uramaxin® ......................................................................................... 15 urea .................................................................................................. 15 Urecholine

® ......................................................................................... 7 Urispas®............................................................................................... 6 Urocit‐K® ............................................................................................. 7 Uroxatral

® ......................................................................................... 23 Urso® ................................................................................................. 30 Urso

® Forte ....................................................................................... 30 ursodiol ............................................................................................. 30

V

Vagifem® ........................................................................................... 31 valacyclovir ....................................................................................... 22 Valchlor

TM ................................................................................... 15, 35 Valcyte® ............................................................................................. 22 Valium

® ............................................................................................. 23 valproic acid ...................................................................................... 25 valsartan/hctz ................................................................................... 11 Valtrex

® ............................................................................................. 22 Vancocin

® capsules ........................................................................... 22 vancomycin caps ............................................................................... 22 VascepaTM ......................................................................................... 12 Vaseretic®.......................................................................................... 11 Vasotec

® .............................................................................................. 9 VecamylTM ................................................................................... 13, 35 Vectical® ............................................................................................ 15 Velivet

® ............................................................................................. 32 Velphoro® .......................................................................................... 31 VeltinTM ............................................................................................. 14 venlafaxine ....................................................................................... 24 venlafaxine er ................................................................................... 24 Ventolin HFA® ..................................................................................... 5 Veramyst® ..................................................................................... 4, 37 verapamil .......................................................................................... 10 verapamil ER caps ............................................................................. 10 Verdeso® ........................................................................................... 14 Veregen

® ........................................................................................... 15 Verelan

® PM ...................................................................................... 10 Vesanoid® ...................................................................................... 8, 35 Vesicare® ....................................................................................... 6, 37 Vexol

® ............................................................................................... 18 Vfend® ............................................................................................... 21

Viagra® .............................................................................................. 23 Vibramycin® susp .............................................................................. 21 Vicodin® ............................................................................................ 27 Vicoprofen® ...................................................................................... 27 Victoza® ...................................................................................... 17, 37 Victrelis

® ..................................................................................... 30, 35 Videx® ............................................................................................... 22 Videx® EC .......................................................................................... 22 Vigamox® .......................................................................................... 18 ViibrydTM........................................................................................... 24 Vimovo

® ............................................................................................ 28 Vimpat® ............................................................................................ 25 Viokace® ............................................................................................ 30 Viracept® ........................................................................................... 22 Viramune® ........................................................................................ 22 Viramune

® XR ................................................................................... 22 Viread® .............................................................................................. 22 Viroptic®............................................................................................ 18 Vistaril® ......................................................................................... 4, 23 vitamin B12 inj.................................................................................. 31 Vivactil® ............................................................................................ 24 Vivelle‐Dot® ...................................................................................... 31 Vol‐Care

® .......................................................................................... 31 Voltaren® gel ..................................................................................... 28 Voltaren

® ophth soln ........................................................................ 19 Voltaren‐XR

® ..................................................................................... 28 voriconazole ..................................................................................... 21 Votrient® ....................................................................................... 8, 35 Vusion® ............................................................................................. 15 Vytone

® ............................................................................................. 15 Vytorin® ...................................................................................... 13, 37 Vyvanse® ........................................................................................... 25

W

warfarin sodium ................................................................................. 7 Welchol® ..................................................................................... 12, 17 Wellbutrin SR® .................................................................................. 24 Wellbutrin XL

® .................................................................................. 24 Wellbutrin® ....................................................................................... 24 Westcort® ......................................................................................... 14

X

Xalatan® ............................................................................................ 19 Xalkori® ......................................................................................... 8, 35 Xanax

® .............................................................................................. 23 Xanax® XR .......................................................................................... 23 Xarelto® .............................................................................................. 7 Xeljanz

® ....................................................................................... 28, 35 Xeloda® ............................................................................................... 8 Xenazine® .................................................................................... 26, 35 XereseTM ........................................................................................... 16 Xifaxan

® ............................................................................................ 22 Xodol® ............................................................................................... 27 Xopenex® ............................................................................................ 5 Xtandi® .......................................................................................... 8, 35 Xylocaine Viscous

® ............................................................................ 18 Xyrem® ........................................................................................ 26, 35 Xyzal

® .................................................................................................. 4

Y

Yasmin® ............................................................................................. 32 Yaz® ................................................................................................... 32


Yodoxin® ............................................................................................ 22 yohimbine ......................................................................................... 23

Z

Zaditor® ............................................................................................. 19 zafirlukast ........................................................................................... 6 zaleplon ............................................................................................ 23 Zanaflex® ........................................................................................... 29 Zantac® capsules ............................................................................... 29 Zantac® tabs/syrup ............................................................................ 29 Zarontin

® ........................................................................................... 25 Zaroxolyn® ......................................................................................... 10 Zavesca

® ...................................................................................... 20, 35 Zebeta

® ............................................................................................... 9 ZecuityTM ........................................................................................... 28 Zegerid® ............................................................................................ 29 Zelapar® ............................................................................................ 26 ZelborafTM ..................................................................................... 8, 35 Zelrix® ................................................................................................ 28 Zemplar® ..................................................................................... 31, 37 Zenatane

® ......................................................................................... 14 Zenchent® ......................................................................................... 32 Zenpep

® ............................................................................................ 30 Zenzedi

® ............................................................................................ 25 Zeosa® ............................................................................................... 32 Zerit® ................................................................................................. 22 Zestoretic

® ........................................................................................ 11 Zestril®................................................................................................. 9 Zetia

® ................................................................................................ 12 Zetonna® ............................................................................................. 5 ZetonnaTM ..................................................................................... 4, 37 Ziac

® .................................................................................................. 11 Ziagen® soln ....................................................................................... 22 Ziagen® tabs ...................................................................................... 22 Ziana

® ................................................................................................ 14 zidovudine ........................................................................................ 22 Zinotic® .............................................................................................. 17

Zinotic® ES ......................................................................................... 17 Zioptan® ............................................................................................ 19 ziprasidone ....................................................................................... 24 Zipsor® .............................................................................................. 28 Zirgan® .............................................................................................. 18 Zithromax

® ........................................................................................ 21 ZMax® ............................................................................................... 21 Zocor® ............................................................................................... 12 Zofran® .............................................................................................. 30 Zofran® ODT ...................................................................................... 30 Zofran

® susp ..................................................................................... 30 Zolinza® ......................................................................................... 8, 35 zolmitriptan ..................................................................................... 28 Zoloft® ............................................................................................... 24 zolpidem er ................................................................................ 23, 37 zolpidem tartrate ............................................................................. 23 Zomig

® .............................................................................................. 28 Zomig® Nasal Spray ........................................................................... 28 Zonegran® ......................................................................................... 25 zonisamide ....................................................................................... 25 Zorbtiv® ............................................................................................ 35 Zorbtive® ........................................................................................... 30 Zortress

® ............................................................................................. 8 Zovia® ................................................................................................ 32 Zovirax

® ...................................................................................... 16, 22 Zovirax

® ointment ............................................................................. 16 Zuplenz® ............................................................................................ 37 ZuplenzTM ......................................................................................... 30 Zyban® .............................................................................................. 29 Zyclara

® ............................................................................................. 15 Zyflo® CR ............................................................................................. 6 Zylet® ................................................................................................ 18 Zyloprim

® .......................................................................................... 29 Zymaxid® ........................................................................................... 18 Zypram

® 2.35‐1% cream and kit ....................................................... 15 Zyprexa

® ........................................................................................... 24 Zytiga® ................................................................................................ 8 Zyvox

® ............................................................................................... 21

PHARMACY BENEFIT DIMENSIONS DRUG FORMULARY · 2014-05-27 · Liptruzet® Lopid® Onmel® Tricor®...

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Transcript of PHARMACY BENEFIT DIMENSIONS DRUG FORMULARY · 2014-05-27 · Liptruzet® Lopid® Onmel® Tricor®...