Preferred Drug List (PDL) · List of Preferred Drugs. You can read all of the FAQ to learn more, or...

© 2020 United HealthCare Services, Inc. All rights reserved.

Preferred Drug List (PDL)New Jersey Effective Date: 4/1/20

UnitedHealthcare Community Plan does not treat members differently because of sex, age, race, color, disability or national origin.

If you think you were treated unfairly because of your sex, age, race, color, disability or national origin, you can send a complaint to:

Civil Rights Coordinator UnitedHealthcare Civil Rights Grievance P.O. Box 30608 Salt Lake City, UTAH 84130

[email protected]

You must send the complaint within 60 days of when you found out about it. A decision will be sent to you within 30 days. If you disagree with the decision, you have 15 days to ask us to look at it again.

If you need help with your complaint, please call the toll-free member phone number listed on your health plan member ID card, TTY 711, 24 hours a day, 7 days a week.

You can also file a complaint with the U.S. Dept. of Health and Human Services.

Online: https://ocrportal.hhs.gov/ocr/portal/lobby.jsf

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html

Phone: Toll-free 1-800-368-1019, 1-800-537-7697 (TDD)

Mail: U.S. Dept. of Health and Human Services 200 Independence Avenue SW Room 509F, HHH Building Washington, D.C. 20201

If you need help with your complaint, please call the toll-free member phone number listed on your member ID card.

We provide free services to help you communicate with us, such as letters in other languages or large print. You can also ask for an interpreter. To ask for help, please call the toll-free member phone number listed on your health plan member ID card, TTY 711, 24 hours a day, 7 days a week.

CSNJ19MC4421731_000

UnitedHealthcare Community Plan no da un tratamiento diferente a sus miembros en base a su sexo, edad, raza, color, discapacidad u origen nacional.

Si usted piensa que ha sido tratado injustamente por razones como su sexo, edad, raza, color, discapacidad o origen nacional, puede enviar una queja a:

Civil Rights Coordinator UnitedHealthcare Civil Rights Grievance P.O. Box 30608 Salt Lake City, UTAH 84130

[email protected]

Usted tiene que enviar la queja dentro de los 60 días de la fecha cuando se enteró de ella. Se le enviará la decisión en un plazo de 30 días. Si no está de acuerdo con la decisión, tiene 15 días para solicitar que la consideremos de nuevo.

Si usted necesita ayuda con su queja, por favor llame al número de teléfono gratuito para miembros que aparece en su tarjeta de identificación del plan de salud, TTY 711, 24 horas al día, 7 días a la semana.

Usted también puede presentar una queja con el Departamento de Salud y Servicios Humanos de los Estados Unidos.

Internet: https://ocrportal.hhs.gov/ocr/portal/lobby.jsf

Formas para las quejas se encuentran disponibles en: http://www.hhs.gov/ocr/office/file/index.html

Teléfono: Llamada gratuita, 1-800-368-1019, 1-800-537-7697 (TDD)

Correo: U.S. Department of Health and Human Services 200 Independence Avenue SW Room 509F, HHH Building Washington, D.C. 20201

Si necesita ayuda para presentar su queja, por favor llame al número gratuito para miembros anotado en su tarjeta de identificación como miembro.

Ofrecemos servicios gratuitos para ayudarle a comunicarse con nosotros, tales como, cartas en otros idiomas o en letra grande. O bien, puede solicitar un intérprete. Para pedir ayuda, por favor llame al número de teléfono gratuito para miembros que aparece en su tarjeta de identificación del plan de salud, TTY 711, 24 horas al día, 7 días a la semana.

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UnitedHealthcare Community Plan

List of Preferred Drugs

Frequently Asked Questions (FAQ)

Find answers here to questions you have about this UnitedHealthcare Community Plan

List of Preferred Drugs. You can read all of the FAQ to learn more, or look for a question

and answer.

1 What drugs are on the Preferred Drug List? (We call the Preferred Drug List the

“Drug List” for short.)

The drugs on Preferred Drug List that start on page <4> are the drugs covered by

UnitedHealthcare Community Plan. These drugs are available at pharmacies within our

network. A pharmacy is in our network if we have an agreement with them to work with

us and provide you services. We refer to these pharmacies as “network pharmacies.”

UnitedHealthcare will cover all medically necessary drugs if:

· your doctor or other prescriber says you need them to get better or stay healthy,

and

· you fill the prescription at a UnitedHealthcare Community Plan network

pharmacy.

UnitedHealthcare may have additional steps to access certain drugs (see question <#5>

below).

You can also see an up-to-date drug list on our website at

<myuhc.com/CommunityPlan> or call Member Services at < 1-800-941-4647> TTY 711.

2 Does the Drug List ever change?

Yes. UnitedHealthcare Community Plan may add or remove drugs on the Drug List

during the year. Generally, the Drug List will only change if:

· a cheaper drug comes along that works as well as a drug on the Drug List now, or

· we learn that a drug is not safe.

We may also change our rules about drugs. For example, we could:

· Decide to require or not require prior approval for a drug. (Prior approval is permission

from UnitedHealthcare Community Plan before you can get a drug.)

· Add or change the amount of a drug you can get (called “quantity limits”).

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· Add or change step therapy restrictions on a drug. (Step therapy means you must

try one drug before we will cover another drug.)

For more information on these drug rules, see pages <4, 5 and 9>.

Questions 3, 4, and 7 below have more information on what happens

when the Drug List changes.

You can always check the up-to-date Drug List online at <myuhc.com/CommunityPlan>

You can also call Member Services to check the current Drug List at < 1-800-941-4647,

TTY 711>.

3 What happens when another drug comes along that works as well as

a drug on the Drug List now?

If you are taking a drug that is removed because another drug that works just as well is

available, we will tell you. You will get a letter letting you know about the change. We will

also tell you what alternate drugs are available to you. Contact your doctor or other

prescriber to make sure another drug will work for you.

4 What happens when we find out a drug is not safe?

If the Food and Drug Administration (FDA) says a drug you are taking is not safe, we

will take it off the Drug List right away. We will also send you a letter telling you that.

Contact your doctor or other prescriber and ask about your other options.

5 Are there any restrictions or limits on drug coverage? Or are there any

required actions to take in order to get certain drugs?

Yes, some drugs have coverage rules or have limits on the amount you can get. In

some cases your doctor must do something before you can get the drug. For example:

· Prior approval (or prior authorization): For some drugs, your doctor or

other prescriber must get approval from UnitedHealthcare before you

fill your prescription. If you don’t get approval, UnitedHealthcare may

not cover the drug.

· Quantity limits: Sometimes UnitedHealthcare limits the amount of a

drug you can get.

· Step therapy: Sometimes UnitedHealthcare requires you to do step

therapy. This means you will have to try drugs in a certain order for your medical

condition. You might have to try one drug before we will cover another drug. If

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your doctor thinks the first drug doesn’t work for you, then we will cover the

second.

You can find out if your drug has any additional requirements or limits by looking in

the tables on pages <4-68>. You can also get more information by visiting our website at

<myuhc.com/CommunityPlan>. We have posted online documents that explain our prior

authorization and step therapy restrictions. You may also call Member Services and ask

us to send you information about our prior authorization and step therapy restrictions.

6 How will you know if the drug you want has limitations or if there are

required actions to take to get the drug?

The Preferred Drug List on pages <4-68> has a column labeled “Requirements and

Limits.”

7 What happens if we change our rules on how we cover some drugs?

For example, if we add prior authorization (approval), quantity limits,

and/or step therapy restrictions on a drug.

We will tell you if we add prior approval, quantity limits, and/or step therapy restrictions

on a drug. We will tell you before the restriction is added.. This gives you time to talk to

your doctor or other prescriber about what to do next.

8 How can you find a drug on the Drug List?

There are two ways to find a drug:

· You can search by medical condition.

To search by medical condition, find the section labeled “List of drugs by medical

condition” on pages <4-68>. The drugs in this section are grouped into

categories depending on the type of medical conditions they are used to treat.

For example, if you have a heart condition, you should look in the category,

Cardiovascular Agents. That is where you will find drugs that treat heart

conditions.

· You can also search for drugs alphabetically.

To search alphabetically, go to the <Index of Covered Drugs> starting on page <69>

Find the name of your drug. The page number where you can find the drug will be next

to it.

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9 What if the drug you want to take is not on the Drug List?

If you don’t see your drug on the Drug List, call Member Services and ask about it. If you

learn that UnitedHealthcare does not prefer the drug, you can do one of these things:

· Ask Member Services for a list of drugs that are similar to the one you want to take.

Then show the list to your doctor or other prescriber. He or she can prescribe a drug on

the Drug List that is like the one you want to take. Or

· You can ask the health plan to make an exception to cover your drug. Please see

question 11 for more information about exceptions.

10 What if you just joined UnitedHealthcare Community Plan and can’t

find your drug on the Drug List or have a problem getting your drug?

We can help. We may cover a temporary 30-day supply of your drug during the first

90 days you are a member of UnitedHealthcare. This will give you time to talk to your

doctor or other prescriber. He or she can help you decide if there is a similar drug on the

Drug List you can take instead, or whether to request an exception.

11Can you ask for an exception to cover your drug?

Yes. Your doctor can ask UnitedHealthcare Community Plan to make an exception to

cover a drug that is not on the Drug List.

Your doctor can also ask us to change the rules on your drug.

· For example, we may limit the amount of a drug we will cover. If your drug has a limit,

your doctor can ask us to change the limit and cover more.

· Other examples: Your doctor can ask us to drop step therapy restrictions or prior

approval requirements.

12 How long does it take to get an exception?

First, we must receive some information from your doctor supporting your request for an

exception. After we receive the information, we will give you a decision on your

exception request within the timeframes required by the state, generally within 24 hours.

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13 How can you ask for an exception?

To ask for an exception, you can do one of two things:

- Call Member Services. A Member Services representative

will work with you and your doctor to help ask for an exception.

- Call your doctor and ask them to request an exception by calling the Prior

Notification Service at <1-800-310-6826<, or they can fax a request to<866-940-

7328>.

14 What are generic drugs?

Generic drugs are made up of the same active ingredients as brand name drugs.

They usually cost less than the brand name drug and usually don’t have well-known

names. Generic drugs are approved by the Food and Drug Administration (FDA). In

most instances UnitedHealthcare covers generic drugs first. If your doctor feels a brand

name drug is medically necessary, you will need to ask your doctor to submit for prior

approval.

15 What are OTC drugs?

OTC stands for “over-the-counter.” UnitedHealthcare prefers some OTC drugs when

they are written as prescriptions by your provider.

You can read the UnitedHealthcare Community Plan Drug List to see what OTC drugs

are preferred.

16 Does UnitedHealthcare cover OTC non-drug products?

UnitedHealthcare covers some OTC non-drug products when they are written as

prescriptions by your provider.

You can read the UnitedHealthcare Community Plan Drug List to see what OTC non-

drug products are covered.

17 What is a Specialty Pharmacy Medication?

A specialty pharmacy medication is a drug that generally has one or more of the

following characteristics:

It’s used by a small number of people

It treats rare, chronic, and/or potentially life-threatening diseases

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It has special storage or handling requirements such as needing to be

refrigerated

It may need close monitoring, ongoing clinical support and management, and

complete patient education and engagement

It’s a high cost medication

It may not be available at retail pharmacies

It may be oral, injectable, or inhaled

Specialty pharmacy medications are available through our specialty pharmacy network.

If you have questions, call Member Services at <1-800-941-4647, TTY 711>.

List of Preferred Drugs

The List of Preferred Drugs that begins <on the next page> gives you information about

the drugs covered by UnitedHealthcare Community Plan. If you have trouble finding your

drug in the list, turn to the Index that begins on page <69>

.

The first column of the chart lists the generic name of the drug. The second column of

the chart lists brand name drugs. Brand name drugs are capitalized (e.g., CRESTOR).

The third column in the list tells you if the preferred drug covered is the brand or generic

version.

The information in the “Requirements & Limits” column tells you if UnitedHealthcare has

any rules for covering your drug.

Utilization Management Restrictions

PA - Prior approval (or prior authorization)

For some drugs, your doctor or other prescriber must get approval from

UnitedHealthcare Community Plan before you fill your prescription. If you don’t

get approval, UnitedHealthcare may not cover the drug.

QL - Quantity limits

Sometimes UnitedHealthcare Community Plan limits the amount of a drug you

can get.

ST - Step therapy

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Sometimes UnitedHealthcare Community Plan requires you to do step therapy.

This means you will have to try drugs in a certain order for your medical

condition. You might have to try one drug before we will cover another drug. If

your doctor thinks the first drug doesn’t work for you, then your doctor can ask for

approval to cover the second.

Other special requirements for coverage

SP – Specialty Pharmacy

Drug needs to be accessed through a network Specialty Pharmacy.

Specialty Pharmacy Drugs may require extra handling, provider coordination or

patient education that can’t be done at a network retail pharmacy.

Drug Tiers The drugs listed in the PDL have different tiers. The tiers are listed in the grid below.

Tier Name Drug Tier

Tier 1 Generic

Tier 2 Brand

[ABBREVIATIONS] OTC = Over the Counter PA = Prior Authorization required QL = Quantity Limit ST = Step Therapy SP = Specialty Pharmacy * = Available without PA for participating Behavioral Health Prescribers [You can find information on what the symbols and abbreviations in this table mean by going to page <4-68 in the footnotes>]

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2

Table of Contents

Antineoplastics & Immunosuppressants . . . 4Antineoplastic Agents . . . . . . . . . . . . . . . . . . . . . . 4Hormonal Antineoplastic Agents. . . . . . . . . . . . . 5Immunomodulators . . . . . . . . . . . . . . . . . . . . . . . . 6Immunosuppressants . . . . . . . . . . . . . . . . . . . . . . 6Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

Blood Modifiers - Anticoagulants . . . . . . . . . 7Anticoagulants . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7Hematopoietic Agents. . . . . . . . . . . . . . . . . . . . . . 8Platelet Inhibitors . . . . . . . . . . . . . . . . . . . . . . . . . . 8Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

Cardiovascular Agents . . . . . . . . . . . . . . . . . . 8Ace Inhibitors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8Ace Inhibitor/Diuretic Combinations. . . . . . . . . . 9Adrenolytics, Central . . . . . . . . . . . . . . . . . . . . . . . 9Alpha Blockers. . . . . . . . . . . . . . . . . . . . . . . . . . . . 9Angiotensin II Receptor Blockers (Antagonists) 9Angiotensin II Receptor Blocker Combinations. 9Antiarrhythmics and Cardiac Glycosides . . . . . . 9Beta Blockers and Beta Blocker/Diuretic

Combinations . . . . . . . . . . . . . . . . . . . . . . . . . . 10Calcium Channel Blockers. . . . . . . . . . . . . . . . . 10Diuretics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11Lipid Lowering Agents . . . . . . . . . . . . . . . . . . . . 11Nitrates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12Potassium-Removing Agents . . . . . . . . . . . . . . . 12Pulmonary Arterial Hypertension . . . . . . . . . . . 13Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

Central Nervous System. . . . . . . . . . . . . . . . 13Alzheimer’s Disease . . . . . . . . . . . . . . . . . . . . . . 13Amyotrophic Lateral Sclerosis (ALS). . . . . . . . . 13Analeptics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14Analgesics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14Migraine Acute Therapy . . . . . . . . . . . . . . . . . . . 15Migraine Prophylactic Therapy . . . . . . . . . . . . . 16Multiple Sclerosis. . . . . . . . . . . . . . . . . . . . . . . . . 16Myasthenia Gravis . . . . . . . . . . . . . . . . . . . . . . . . 16Parkinson’s Disease . . . . . . . . . . . . . . . . . . . . . . 16Seizures. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

Dermatology . . . . . . . . . . . . . . . . . . . . . . . . . 18Acne Vulgaris . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18Bacterial Infections . . . . . . . . . . . . . . . . . . . . . . . 19Corticosteroids. . . . . . . . . . . . . . . . . . . . . . . . . . . 19Fungal Infections . . . . . . . . . . . . . . . . . . . . . . . . . 20Psoriasis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20Rosacea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21Scabies and Pediculosis. . . . . . . . . . . . . . . . . . . 21Viral Infections . . . . . . . . . . . . . . . . . . . . . . . . . . . 21Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

Ear, Nose & Throat . . . . . . . . . . . . . . . . . . . .22Ear . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22Nose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23Throat and Mouth . . . . . . . . . . . . . . . . . . . . . . . . 24

Endocrinology . . . . . . . . . . . . . . . . . . . . . . . .24Adrenal Corticosteroids . . . . . . . . . . . . . . . . . . . 24Androgens . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25Diabetes Mellitus . . . . . . . . . . . . . . . . . . . . . . . . . 25Growth Stimulating Agents. . . . . . . . . . . . . . . . . 26Lipodystropy Agents . . . . . . . . . . . . . . . . . . . . . . 26Osteoporosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27Thyroid Disease . . . . . . . . . . . . . . . . . . . . . . . . . . 27Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

Gastrointestinal. . . . . . . . . . . . . . . . . . . . . . .27Constipation/Laxatives . . . . . . . . . . . . . . . . . . . . 27Diarrhea. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28Emesis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28Gastroesophageal Reflux Disease (Gerd)/

Peptic Ulcers. . . . . . . . . . . . . . . . . . . . . . . . . . . 28Gastrointestinal Spasm . . . . . . . . . . . . . . . . . . . . 29Inflammatory Bowel Disease . . . . . . . . . . . . . . . 29Pancreatic Enzymes . . . . . . . . . . . . . . . . . . . . . . 30Probiotic Supplementation. . . . . . . . . . . . . . . . . 30Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . 30

Infectious Diseases . . . . . . . . . . . . . . . . . . . 31Anthelmintics . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31Antibacterials . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31Antifungals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32Antiprotozoals. . . . . . . . . . . . . . . . . . . . . . . . . . . . 33Antivirals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . 36

3

Musculoskeletal . . . . . . . . . . . . . . . . . . . . . .36Arthritis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37Gout. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38Skeletal Muscle Relaxants . . . . . . . . . . . . . . . . . 38Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . 38

OB-GYN . . . . . . . . . . . . . . . . . . . . . . . . . . . . .39Contraceptives . . . . . . . . . . . . . . . . . . . . . . . . . . . 39Endometriosis . . . . . . . . . . . . . . . . . . . . . . . . . . . 40Hormone Therapy/Menopause. . . . . . . . . . . . . 40Ovulation Stimulants . . . . . . . . . . . . . . . . . . . . . . 41Vaginal Infections. . . . . . . . . . . . . . . . . . . . . . . . . 41Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . 41

Ophthalmic . . . . . . . . . . . . . . . . . . . . . . . . . .42Allergy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42Anti-Inflammatories . . . . . . . . . . . . . . . . . . . . . . . 42Glaucoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42Immunologic Agents . . . . . . . . . . . . . . . . . . . . . . 43Infections. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . 44

Psychiatric. . . . . . . . . . . . . . . . . . . . . . . . . . .44Alcohol Deterrents . . . . . . . . . . . . . . . . . . . . . . . . 44Anxiety. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44Attention Deficit Hyperactivity Disorder

(ADHD) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45Bipolar Disorder . . . . . . . . . . . . . . . . . . . . . . . . . . 47Depression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47Insomnia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49Narcotic Antagonists . . . . . . . . . . . . . . . . . . . . . . 49Psychoses. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50Smoking Cessation . . . . . . . . . . . . . . . . . . . . . . . 52Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . 52

Respiratory Drugs. . . . . . . . . . . . . . . . . . . . .53Antitussives, Decongestants, Expectorants

and Combinations . . . . . . . . . . . . . . . . . . . . . . 53Asthma/COPD . . . . . . . . . . . . . . . . . . . . . . . . . . . 57

Urological . . . . . . . . . . . . . . . . . . . . . . . . . . .58Symptomatic Benign Prostatic Hypertrophy . . 58Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . 58

Vitamins and Minerals . . . . . . . . . . . . . . . . .59Potassium . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60

Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . 61Anaphylaxis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61Antidotes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61Cystic Fibrosis . . . . . . . . . . . . . . . . . . . . . . . . . . . 61Hereditary Angioedema . . . . . . . . . . . . . . . . . . . 61Hyperphosphatemia . . . . . . . . . . . . . . . . . . . . . . 61Idiopathic Pulmonary Fibrosis (IPF) . . . . . . . . . 61Medical Devices. . . . . . . . . . . . . . . . . . . . . . . . . . 62Metabolic Modifiers . . . . . . . . . . . . . . . . . . . . . . . 62Vaccine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62

OTC MEDICATIONS . . . . . . . . . . . . . . . . . . .64Acne. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64Antifungals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64Antivirals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64Atopic Dermatitis . . . . . . . . . . . . . . . . . . . . . . . . . 64Cough/Cold Allergy. . . . . . . . . . . . . . . . . . . . . . . 64Diabetes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65Earwax Removal Products . . . . . . . . . . . . . . . . . 65Family Planning . . . . . . . . . . . . . . . . . . . . . . . . . . 65First Aid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65Gastrointestinal . . . . . . . . . . . . . . . . . . . . . . . . . . 66Insomnia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66Lice Products . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66Motion Sickness. . . . . . . . . . . . . . . . . . . . . . . . . . 66Ophthalmics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67Urological . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67Smoking Cessation Products . . . . . . . . . . . . . . 67Vitamins/Minerals . . . . . . . . . . . . . . . . . . . . . . . . 67Warts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68Miscellaneous. . . . . . . . . . . . . . . . . . . . . . . . . . . . 68

Index of Covered Drugs . . . . . . . . . . . . . . . .69

4

OTC = Over the CounterPA = Prior Authorization requiredQL = Quantity LimitST = Step TherapySP = Specialty Pharmacy

^ Only available through manual PA process*Available without PA for participating Behavioral Health Prescribers± Medical Office Attestation Needed if Prescribed by Behavioral

Health Provider, Full Prior Authorization Needed if Prescribed by Non-Behavioral Health Provider

Generic Drug Name Brand Drug Name Covered Drug Tier Requirements & Limits

Antineoplastics & Immunosuppressants

Antineoplastic AgentsAlkylating Agentsaltretamine HEXALEN brand 2busulfan MYLERAN brand 2chlorambucil LEUKERAN brand 2cyclophosphamide CYTOXAN generic 1lomustine GLEOSTINE brand 2melphalan ALKERAN brand 2temozolomide TEMODAR generic 1 PA, SPAntimetabolitescapecitabine XELODA generic 1 SPmercaptopurine PURINETHOL generic 1thioguanine TABLOID brand 2 QLtrifluridine/tipiracil LONSURF brand 2 PA, SPHistone Deacetylase Inhibitorspanobinostat FARYDAK brand 2 PA, SPvorinostat ZOLINZA brand 2 PA, SPIsocitrate Dehydrogenase (IDH) Inhibitorsivosidenib TIBSOVO brand 2 PA, QL, SPenasidenib IDHIFA brand 2 PA, QL, SPKinase Inhibitorabemaciclib VERZENIO brand 2 PA, QL, SPacalabrutinib CALQUENCE brand 2 PA, QL, SPafatinib GILOTRIF brand 2 PA, SPalectinib ALECENSA brand 2 PA, SPalpelisib PIQRAY brand 2 PA, QL, SPaxitinib INLYTA brand 2 PA, SPbosutinib BOSULIF brand 2 PA, SPbrigatinib ALUNBRIG brand 2 PA, SP

cabozantinibCOMETRIQCABOMETYX

brand 2 PA, SP

ceritinib ZYKADIA brand 2 PA, SPcobimetinib COTELLIC brand 2 PA, SPcrizotinib XALKORI brand 2 PA, SPdabrafenib TAFINLAR brand 2 PA, SPdasatinib SPRYCEL brand 2 PA, SP

5





entrectinib ROZLYTREK brand 2 PA, QL, SPerdafitinib BALVERSA brand 2 PA, QL, SPerlotinib TARCEVA brand 2 PA, SP

everolimusAFINITORAFINITOR DISPERZ

brand 2 PA, SP

gefitinib IRESSA brand 2 PA, SPibrutinib IMBRUVICA brand 2 PA, SPidelalisib ZYDELIG brand 2 PA, SPimatinib mesylate GLEEVEC generic 1 PA, QL, SPlapatinib ditosylate TYKERB brand 2 PA, SPlarotrectinib VITRAKVI brand 2 PA, QL, SPlenvatinib LENVIMA brand 2 PA, SPmidostaurin RYDAPT brand 2 PA, SPnilotinib TASIGNA brand 2 PA, SPpalbociclib IBRANCE brand 2 PA, SPpazopanib VOTRIENT brand 2 PA, SPpexidartinib TURALIO brand 2 PA, QL, SPponatinib ICLUSIG brand 2 PA, SPregorafenib STIVARGA brand 2 PA, SPruxolitinib JAKAFI brand 2 PA, SPsorafenib NEXAVAR brand 2 PA, SPsunitinib SUTENT brand 2 PA, SPtrametinib MEKINIST brand 2 PA, SPvandetanib CAPRELSA brand 2 PA, SPvemurafenib ZELBORAF brand 2 PA, SPMiscellaneousleucovorin LEUCOVORIN generic 1 QL, tabsmesna MESNEX brand 2 SP, tabsvenetoclax VENCLEXTA brand 2 PA, SPProteasome Inhibitorsixazomib NINLARO generic 1 PA, SPHormonal Antineoplastic AgentsAndrogen Biosynthesis Inhibitors

abiraterone ZYTIGA generic 1 PA, SP, 250 mg tablets only

Antiandrogensapalutamide ERLEADA brand 2 PA, QL, SPbicalutamide CASODEX generic 1

6





darolutamide NUBEQA brand 2 PA, QL, SPflutamide EULEXIN generic 1Antiestrogenstamoxifen NOLVADEX generic 1toremifene FARESTON brand 2Aromatase Inhibitorsanastrozole ARIMIDEX generic 1exemestane AROMASIN generic 1letrozole FEMARA generic 1Gonadotropin Releasing Hormone Analogleuprolide LUPRON generic 1 PA, SP

leuprolideLUPRON DEPOTLUPRON DEPOT 6-MONTHLUPRON DEPOT-PED

brand 2 PA, SP

Progestinmegestrol acetate MEGACE generic 1ImmunomodulatorsInterferonsinterferon alfa-2b INTRON A brand 2 PA, SPinterferon gamma-1b ACTIMMUNE brand 2 PA, SPpeginterferon alfa-2b SYLATRON brand 2 PA, SPMiscellaneouslenalidomide REVLIMID brand 2 PA, SPpomalidomide POMALYST brand 22 PA, SPthalidomide THALOMID brand PA, SP, QLImmunosuppressantsAntimetabolitesazathioprine IMURAN generic 1mycophenolate mofetil CELLCEPT generic 1mycophenolate sodium MYFORTIC generic 1Calcineurin Inhibitorscyclosporine SANDIMMUNE generic 1

cyclosporine, modifiedNEORALGENGRAF

generic 1 caps, QL

tacrolimusHECORIA PROGRAF

generic 1

7





Rapamycin Derivativesirolimus RAPAMUNE generic 1 tabssirolimus RAPAMUNE generic 1 solnMiscellaneouseverolimus ZORTRESS brand 2Miscellaneousalitretinoin 1% gel PANRETIN brand 2 PAbexarotene caps and

topical gel TARGRETIN brand 2 PA, SP

cysteamine bitartrate CYSTAGON brand 2 SPetoposide VEPESID generic 1glasdegib DAURISMO brand 2 PA, QL, SPhydroxyurea DROXIA brand 2hydroxyurea HYDREA generic 1mitotane LYSODREN brand 2niraparib ZEJULA brand 2 PA, SPoctreotide SANDOSTATIN generic 1 SPolaparib LYNPARZA brand 2 PA, SPpasireotide SIGNIFOR brand 2 PA, SPprocarbazine MATULANE brand 2 SPrucaparib RUBRACA brand 2 PA, SPsonidegib ODOMZO brand 2 PA, SPtopotecan HYCAMTIN brand 2 PA, SPtretinoin VESANOID generic 1 caps, SPvismodegib ERIVEDGE brand 2 PA, SP

Blood Modifiers - Anticoagulants

Anticoagulantsapixaban ELIQUIS brand 2 QLbetrixaban BEVYXXA brand 2 QLedoxaban SAVAYSA brand 2 QLenoxaparin LOVENOX generic 1 QL

heparin HEPARIN generic 1INJ 5000 UNIT/ML, PF INJ 5000 UNIT/0.5ML, INJ 10000 UNIT/ML

warfarin COUMADIN generic 1

8





Hematopoietic Agentsdarbepoetin alfa ARANESP brand 2 PA, QL, SPeltrombopag PROMACTA brand 2 PA, SPepoetin alfa-epbx RETACRIT brand 2 PA, SPfilgrastim ZARXIO brand 2 PA, SPlusutrombopag MULPLETA brand 2 PA, QL, SPoprelvekin NEUMEGA brand 2 PA, SPplerixafor MOZOBIL brand 2 PA, SPpegfilgrastim NEULASTA brand 2 PA, SPsargramostim LEUKINE brand 2 PA, SPPlatelet Inhibitorsanagrelide AGRYLIN generic 1

aspirinBAYER

ECOTRINgeneric 1 OTC

cilostazol PLETAL generic 1clopidogrel PLAVIX generic 1 QLdipyridamole PERSANTINE generic 1prasugrel EFFIENT generic 1 Diagnosis Required, QLticagrelor BRILINTA brand 2 Diagnosis Required, QLMiscellaneousaminocaproic acid AMICAR generic 1 tabs, QLaminocaproic acid AMICAR SOLUTION generic 1 oral solution, QLcaplacizumab-yhdp CABLIVI brand 2 PA, QL, SP

deferasiroxEXJADEJADENU

brand 2 PA, SP

emicizumab-kxwh HEMLIBRA brand 2 PA, QL, SPpentoxifylline

extended-release TRENTAL generic 1

Cardiovascular Agents

Ace Inhibitorsbenazepril LOTENSIN generic 1captopril CAPOTEN generic 1enalapril VASOTEC generic 1

enalapril oral soln EPANED brand 2Members ≥ 8 years of age will require prior

authorization

9





fosinopril MONOPRIL generic 1 QLlisinopril ZESTRIL generic 1 QLquinapril ACCUPRIL generic 1 QLramipril ALTACE generic 1trandolapril MAVIK generic 1Ace Inhibitor/Diuretic Combinationsbenazepril/

hydrochlorothiazide LOTENSIN HCT generic 1

captopril/ hydrochlorothiazide CAPOZIDE generic 1

enalapril/ hydrochlorothiazide VASERETIC generic 1

fosinopril/ hydrochlorothiazide MONOPRIL-HCT generic 1 QL

lisinopril/ hydrochlorothiazide ZESTORETIC generic 1 QL

quinapril/ hydrochlorothiazide ACCURETIC generic 1 QL

Adrenolytics, Centralclonidine CATAPRES generic 1 tabletsguanfacine TENEX generic 1Alpha Blockersdoxazosin CARDURA generic 1prazosin MINIPRESS generic 1terazosin HYTRIN generic 1Angiotensin II Receptor Blockers (Antagonists)losartan COZAAR generic 1 QLAngiotensin II Receptor Blocker Combinationslosartan/HCTZ HYZAAR generic 1 QLsacubitril/valsartan ENTRESTO brand 2 PA, QLAntiarrhythmics and Cardiac Glycosidesamiodarone tabs CORDARONE generic 1 200 mg and 400 mgdigoxin LANOXIN generic 1disopyramide NORPACE generic 1disopyramide

extended-release NORPACE CR brand 2

dofetilide TIKOSYN generic 1flecainide TAMBOCOR generic 1

10





mexiletine MEXITIL generic 1propafenone RYTHMOL generic 1 IR onlyquinidine gluconate

extended-releaseQUINIDINE GLUCONATE

EXT-REL generic 1

quinidine sulfate QUINIDINE SULFATE generic 1quinidine sulfate

extended-releaseQUINIDINE SULFATE

EXT-REL generic 1

Beta Blockers and Beta Blocker/Diuretic Combinationsacebutolol SECTRAL generic 1atenolol TENORMIN generic 1atenolol/chlorthalidone TENORETIC generic 1betaxolol KERLONE generic 1bisoprolol ZEBETA generic 1bisoprolol/

hydrochlorothiazide ZIAC generic 1

carvedilol COREG generic 1 QLlabetalol TRANDATE generic 1metoprolol LOPRESSOR generic 1 25, 50, 100mg tabletsmetoprolol succinate TOPROL XL generic 1propranolol INDERAL generic 1 IR onlypropranolol ER 24HR INDERAL LA generic 1 Diagnosis Required, QLpropranolol/HCTZ INDERIDE generic 1sotalol BETAPACE generic 1sotalol AF BETAPACE AF generic 1Calcium Channel BlockersDihydropyridinesamlodipine NORVASC generic 1 QLfelodipine

extended-release PLENDIL generic 1 QL

nifedipine PROCARDIA generic 1nifedipine

extended-releaseADALAT CCPROCARDIA XL

generic 1 QL

nimodipine NIMOTOP generic 1 QLnimodipine oral soln NYMALIZE brand 2

11





Nondihydropyridinesdiltiazem CARDIZEM generic 1diltiazem

extended-release CARDIZEM CD generic 1 QL

diltiazem extended-release

DILACOR XR TIAZAC

generic 1 QL

diltiazem sustained-release CARDIZEM SR generic 1 QL

verapamil CALAN generic 1verapamil

extended-release CALAN SR generic 1 QL

Diureticsamiloride MIDAMOR generic 1amiloride/

hydrochlorothiazide MODURETIC generic 1

bumetanide BUMEX generic 1chlorothiazide DIURIL generic 1

chlorothiazide DIURIL ORAL SUSPENSION brand 2 QL

chlorthalidone CHLORTHALIDONE generic 1furosemide LASIX generic 1hydrochlorothiazide HYDROCHLOROTHIAZIDE generic 1 soln, tabshydrochlorothiazide MICROZIDE generic 1 12.5 mg capsindapamide LOZOL generic 1metolazone ZAROXOLYN generic 1spironolactone ALDACTONE generic 1spironolactone/

hydrochlorothiazide ALDACTAZIDE generic 1

torsemide DEMADEX generic 1triamterene/

hydrochlorothiazideDYAZIDEMAXZIDE

generic 1

Lipid Lowering AgentsBile Acid Resin

cholestyramineQUESTRANQUESTRAN-LIGHT

generic 1

Only the bulk products are covered (cans).

Individual packets are not covered.

12





Fibratesfenofibrate LOFIBRA generic 1 STgemfibrozil LOPID generic 1HMG-CoA Reductase Inhibitors and Combinationsatorvastatin LIPITOR generic 1 QLlovastatin MEVACOR generic 1 QLsimvastatin ZOCOR generic 1 QLNiacinsniacin NIACOR generic 1niacin extended-release NIASPAN generic 1Miscellaneous

alirocumab PRALUENT brand 2 PA, QL, SP, NDC starting w/72733 pref w/PA

evolocumab REPATHA brand 2 PA, QL, SP, NDC starting w/72511 pref w/PA

ezetimibe ZETIA generic 1 PAomega 3 acid ethyl esters LOVAZA generic 1 PANitratesOralisosorbide dinitrate ISORDIL generic 1isosorbide dinitrate

extended-releaseISOSORBIDE

DINITRATE ER generic 1

isosorbide mononitrate ISMO generic 1isosorbide mononitrate

extended-release IMDUR generic 1

Sublingualisosorbide dinitrate ISORDIL S.L. generic 1nitroglycerin NITROLINGUAL generic 1nitroglycerin NITROSTAT generic 1Transdermal

nitroglycerinNITREK NITRO-DUR

generic 1 transdermal, QL

nitroglycerin NITRO-BID generic 1 ointPotassium-Removing Agentspatiromer VELTASSA brand 2 PA, QLsodium polystyrene

sulfonate KAYEXALATE generic 1 susp only

sodium zirconium cyclosilicate LOKELMA brand 2 PA, QL

13





Pulmonary Arterial Hypertension - Diagnosis Requiredambrisentan LETAIRIS generic 1 QL, SPbosentan TRACLEER brand 2 QL, SPmacitentan OPSUMIT brand 2 QL, SPriociguat ADEMPAS brand 2 QL, SPsildenafil REVATIO generic 1 QL, SP, tabsMiscellaneousguanabenz WYTENSIN generic 1hydralazine APRESOLINE generic 1methyldopa ALDOMET generic 1methyldopa/HCTZ ALDORIL generic 1midodrine PROAMATINE generic 1minoxidil LONITEN generic 1ranolazine RANEXA generic 1 QL, STtafamidis VYNDAMAX brand 2 PA, QL, SPtafamidis meglumine VYNDAQEL brand 2 PA, QL, SP

Central Nervous System

Alzheimer’s Disease

donepezil ARICEPT generic 1

5 mg and 10 mg, QL, Members <18 years of age will require prior

authorization.

donepezil ARICEPT generic 123 mg, ST, Members <18 years of age will require

prior authorization.

galantamine RAZADYNE generic 1QL, Members <18 years of age will require prior

authorization.

memantine NAMENDA generic 1QL, Members <18 years of age will require prior

authorization.

rivastigmine EXELON generic 1QL, Members <18 years of age will require prior

authorization.Amyotrophic Lateral Sclerosis (ALS)riluzole RILUTEK generic 1

14





Analepticsarmodafinil NUVIGIL generic 1 Diagnosis Required, QLAnalgesicsBarbiturate Non-Narcotic Analgesicsbutalbital/acetaminophen PHRENILIN generic 1 QLbutalbital/acetaminophen/

caffeineESGIC ZEBUTAL

generic 1 QL

butalbital/aspirin/caffeine FIORINAL generic 1 QLNon-Narcotic Analgesicsacetaminophen TYLENOL generic 1 OTCaspirin/acetaminophen/

caffeine EXCEDRIN MIGRAINE generic 1 OTC

tramadol ULTRAM generic 1 QLNSAIDSdiclofenac potassium CATAFLAM generic 1diclofenac sodium

delayed-release VOLTAREN generic 1

diclofenac sodium extended-release VOLTAREN XR generic 1

etodolac LODINE generic 1 IR Only

ibuprofen ADVIL generic 1 tabs, chew tabs and susp, OTC

ibuprofen MOTRIN generic 1 tabs, chew tabs and susp

indomethacin INDOCIN generic 1ketoprofen ORUDIS generic 1 IR onlyketorolac tromethamine TORADOL generic 1 QLmeloxicam MOBIC generic 1 QLnabumetone RELAFEN generic 1naproxen NAPROSYN generic 1

naproxen delayed release ENTERIC COATED-NAPROSYN generic 1

oxaprozin DAYPRO generic 1piroxicam FELDENE generic 1sulindac CLINORIL generic 1Opioids - Narcotic Analgesicsbuprenorphine patch BUTRANS generic 1 PA, QLbutalbital/apap/caff/cod FIORICET W/CODEINE generic 1 QL, 50-325-40-30 mgbutalbital/asa/caff/cod FIORINAL W/CODEINE generic 1 QL

15





butorphanol STADOL generic 1 nasal spray, QLcodeine/acetaminophen TYLENOL W/CODEINE generic 1 QLcodeine sulfate generic 1 QLfentanyl transdermal DURAGESIC generic 1 PA, QL

hydrocodone/ acetaminophen

LORCETLORTABLORTAB ELIXIRNORCOVICODINVICODIN ES

generic 1 QL

hydrocodone ER ZOHYDRO ER brand 2 PA, QLhydromorphone DILAUDID generic 1 QL

methadone tab for oral suspension METHADOSE generic 1

40 mg tablet for oral suspension only,

Diagnosis Required, QLmorphine MSIR generic 1 QLmorphine RMS generic 1 QLmorphine

extended-release MS CONTIN generic 1 PA, QL

oxycodone OXYFAST generic 1 soln, QLoxycodone ROXICODONE generic 1 tabs, QLoxycodone/

acetaminophen PERCOCET generic 1 5/325 mg, 7.5/325 mg, 10/325 mg, QL

oxycodone/aspirin PERCODAN generic 1 QL

oxymorphone ER OXYMORPHONE ER generic 1 PA, QL, non-crush resistant

Migraine Acute TherapyErgotamine Derivativesdihydroergotamine D.H.E. 45 generic 1 inj, QLergotamine/caffeine CAFERGOT genericergotamine tartrate/

caffeineMIGERGOT

SUPPOSITORIES brand 2 QL

Selective Serotonin Agonistsnaratriptan AMERGE generic 1 STrizatriptan MAXALT/MAXALT MLT generic 1 QLsumatriptan IMITREX generic 1 QL

sumatriptan IMITREX 4 MG AND 6 MG INJ generic 1 4 mg and 6 mg inj

16





Migraine Prophylactic Therapyamitriptyline ELAVIL generic 1

divalproex sodium cap sprinkle DEPAKOTE SPRINKLE generic 1

Members ≥ 8 years of age will require prior

authorization* divalproex sodium

delayed-release DEPAKOTE generic 1 Minimum age 2

erenumab-aooe AIMOVIG brand 2 PA, QLgalcanezumab-gnim EMGALITY brand 2 PA, QLpropranolol INDERAL generic 1 IR onlyverapamil CALAN generic 1Multiple Sclerosis - Diagnosis Requireddimethyl fumarate TECFIDERA brand 2 QL, SPfingolimod GILENYA brand 2 QL, SPglatiramer acetate COPAXONE generic 1 QL, SPpeginterferon beta-1a PLEGRIDY brand 2 SP, QLsiponimod fumarate MAYZENT brand 2 PA, QL, SPteriflunomide AUBAGIO brand 2 QL, SPMyasthenia Gravispyridostigmine MESTINON generic 1pyridostigmine

extended-release MESTINON TIMESPAN generic 1

Parkinson’s Diseaseamantadine SYMMETREL generic 1 except tabsbenztropine COGENTIN generic 1carbidopa/levodopa SINEMET generic 1carbidopa/levodopa

extended-release SINEMET CR generic 1

entacapone COMTAN generic 1pramipexole MIRAPEX generic 1ropinirole REQUIP generic 1selegiline ELDEPRYL generic 1tolcapone TASMAR generic 1trihexyphenidyl ARTANE generic 1Seizurescarbamazepine TEGRETOL generic 1carbamazepine

extended-releaseCARBATROL TEGRETOL-XR

generic 1

17





clobazam ONFI generic 1 Diagnosis Required, QLclonazepam KLONOPIN generic 1 tabsdiazepam DIASTAT ACUDIAL generic 1 rectal gel, QL

divalproex sodium cap sprinkle DEPAKOTE SPRINKLE generic 1


authorization±divalproex sodium


divalproex sodium SR 24hr DEPAKOTE ER generic 1 QL, Non-preferred*

ethosuximide ZARONTIN generic 1exogabine POTIGA brand 2 Age Limits Applyfelbamate FELBATOL generic 1 QL, tablets

felbamate oral susp FELBATOL ORAL SUSP generic 1QL, suspension, Members ≥ 8 years of age will require

prior authorizationgabapentin NEURONTIN generic 1 caps and tabs onlylacosamide VIMPAT brand 2 Age Limits Apply, PA, QLlamotrigine LAMICTAL generic 1 QL

lamotrigine chew dispersable tab LAMICTAL CD CHEW TAB generic 1


authorization*lamotrigine ODT LAMICTAL ODT generic 1 Non-preferred*lamotrigine SR 24hr LAMICTAL XR generic 1 Non-preferred*lamotrigine starter kit LAMICTAL STARTER KIT generic 1

levetiracetam KEPPRA generic 1 QL, Maximum age of 9 for solution

methsuximide CELONTIN brand 2

oxcarbazepine TRILEPTAL generic 1 QL, Maximum age of 9 for suspension

phenobarbital PHENOBARBITAL generic 1phenytoin DILANTIN INFATABS generic 1phenytoin sodium

extendedDILANTINPHENYTEK

generic 1

pregabalin LYRICA generic 1 QLpregabalin LYRICA SOLUTION generic 1 oral solution, QL

18





primidone MYSOLINE generic 1rufinamide BANZEL brand 2 Diagnosis Required, QL

tiagabine GABITRIL generic 1 Age Limits Apply, PA, QL, 2mg & 4mg

tiagabine GABITRIL brand 2 Age Limits Apply, PA, QL, 12mg & 16mg

topiramate TOPAMAX generic 1 QL

topiramate sprinkle caps TOPAMAX SPRINKLE generic 1QL, Members ≥ 8 years of age will require prior

authorizationvalproic acid DEPAKENE generic 1valproic acid cap

delayed-release STAVZOR brand 2 Non-preferred*

vigabatrin oral solution SABRIL SOLUTION generic 1 PA, SPzonisamide ZONEGRAN generic 1 QLMiscellaneousinotersen inj TEGSEDI brand 2 PA, QL, SPtetrabenazine XENAZINE generic 1 Diagnosis Required, QL, SPvalbenazine INGREZZA brand 2 PA, QL, SP

Dermatology

Acne VulgarisOral

isotretinoin

AMNESTEEMCLARAVISMYORISANZENTANE

generic 1 PA

Topicaladapalene gel DIFFERIN OTC GEL 0.1% brand 2azelaic acid FINACEA generic 1 gelbenzoyl peroxide BENZAC AC generic 1clindamycin CLEOCIN T generic 1 gelclindamycin CLEOCIN T generic 1 lotionclindamycin CLEOCIN T generic 1 solnerythromycin ERYGEL generic 1 gel 2% erythromycin T-STAT generic 1 soln

19





salicylic acid NEUTROGENA OIL FREE ACNE WASH generic 1 liquid 2%, OTC

sulfacetamide/sulfur SULFACET-R generic 1 lotionsulfacetamide/sulfur SUMADAN WASH generic 1

tretinoinAVITA RETIN-A

generic 1 cream, ST

Bacterial Infectionsbacitracin BACITRACIN generic 1 OTCgentamicin GENTAK generic 1

mupirocin BACTROBAN generic 1 ointment, 22 gram tube only

neomycin/polymyxin B/bacitracin NEOSPORIN generic 1 OTC

silver sulfadiazine SILVADENE generic 1CorticosteroidsLow Potencyalclometasone ACLOVATE generic 1 0.05% oint

fluocinolone acetonide DERMA-SMOOTHE OIL/FS generic 1 oil 0.01%

fluocinolone acetonide SYNALAR generic 1 soln 0.01% hydrocortisone CORTIZONE generic 1 crm, oint, lot OTChydrocortisone HYTONE generic 1 crm 0.5%, 1%, & 2.5%hydrocortisone HYTONE generic 1 lotion 1% & 2.5%

hydrocortisone/aloe CORTIZONE-10 INTENSIVE HEALING generic 1 crm 0.5% & 1%, OTC

Medium Potencybetamethasone val BETA-VAL generic 1 crm/oint/lotion 0.1%

fluocinolone acetonide DERMA-SMOOTHE OIL/FS generic 1 oil 0.01%

fluocinolone acetonide SYNALAR generic 1 crm, oint 0.025%fluticasone propionate CUTIVATE generic 1 crm 0.05%, oint 0.005%hydrocortisone butyrate LOCOID generic 1 oint/soln 0.1%mometasone furoate ELOCON generic 1 crm/oint/soln 0.1%prednicarbate DERMATOP generic 1 crm 0.1%triamcinolone acetonide KENALOG generic 1 crm/lot/oint 0.025%triamcinolone acetonide KENALOG generic 1 crm/oint/lotion 0.1%

20





High Potencybetamethasone

augmented dip DIPROLENE generic 1 lotion 0.05%

betamethasone augmented dip DIPROLENE AF generic 1 crm 0.05%

betamethasone dipropionate generic 1 lotion/oint 0.05%

fluocinonide LIDEX generic 1 soln 0.05%fluocinonide emulsified

base LIDEX E generic 1 crm 0.05%

triamcinolone acetonide KENALOG generic 1 crm 0.5%Very High Potencybetamethasone dip

augmented DIPROLENE generic 1 gel 0.05%

betamethasone dip augmented DIPROLENE generic 1 oint 0.05%

clobetasol propionate TEMOVATE generic 1 soln 0.05%clobetasol propionate

emollient base cream TEMOVATE E generic 1 QL

halobetasol ULTRAVATE generic 1 creamFungal Infectionsciclopirox PENLAC SOLUTION 8% generic 1clotrimazole LOTRIMIN AF generic 1 OTCclotrimazole MYCELEX generic 1clotrimazole with

betamethasone LOTRISONE generic 1

ketoconazole NIZORAL generic 1miconazole DESENEX generic 1 2% OTCmiconazole MICATIN generic 1 OTCmiconazole MONISTAT-DERM generic 1nystatin MYCOSTATIN generic 1terbinafine LAMISIL AT generic 1 OTCtolnaftate TINACTIN generic 1 OTCPsoriasisacitretin SORIATANE generic 1 oral caps, PAcalcipotriene DOVONEX generic 1 crm/oint, STcalcipotriene DOVONEX generic 1 solncalcitriol VECTICAL generic 1 ST

21





methoxsalen OXSORALEN-ULTRA generic 1salicylic acid SCALPICIN generic 1 liquid 3%Rosaceabrimonidine MIRVASO brand 2 PA

metronidazoleMETROCREAMMETROGELMETROLOTION

generic 1

Scabies and Pediculosiscrotamiton EURAX brand 2malathion OVIDE generic 1permethrin ELIMITE generic 1 5%, QLpermethrin NIX CREME RINSE generic 1 1%, OTCpyrethrins/piperonyl

butoxide shampoo RID SHAMPOO generic 1 4% OTC

spinosad NATROBA generic 1 QLViral Infectionspodofilox CONDYLOX SOL generic 1 solsalicylic acid 17%/

collodion DUOFILM generic OTC

Miscellaneousaluminum acetate brand 2 soln/cream, OTCaluminum chloride topical

solution HYPERCARE 15% brand 2

ammonium lactate LAC-HYDRIN generic 1 crm 12%, lotion 5% & 12%

ammonium lactate LACTINOL generic 1 lotion 10%becaplermin gel REGRANEX brand 2 Diagnosis Required, QLcalamine brand 2 lotion/ointment, OTCcollagenase SANTYL brand 2 QLcrisaborole EUCRISA brand 2 2% ointment, QL, STfluorouracil EFUDEX generic 1

hydrocortisone

PROCTOSOL HC CREAM 2.5%

PROCTOZONE CREAM-HC 2.5%

ANUSOL HC 2.5%

generic 1

imiquimod 5% cream ALDARA generic 1

22





ketoconazole NIZORAL SHAMPOO generic 1 shampoo 2%lidocaine LIDAMANTEL generic 1 3% cream

lidocaine LMX-4 generic 1 4% cream (15 gm tubes), QL

lidocaine XYLOCAINE generic 1 jelly 2%lidocaine patch LIDODERM generic 1 Diagnosis Required, QLlidocaine/prilocaine EMLA generic 1 2.5% cream

nitroglycerin RECTIV brand 2 Diagnosis Required, QL, 0.4% rectal ointment

pimecrolimus ELIDEL generic 1cream, QL, ST; not covered

for members less than 2 years of age

selenium sulfide SELSUN generic 1 lotion 2.5%

tacrolimus PROTOPIC 0.03% generic 1ointment 0.03%, QL, ST; not covered for members less than 2 years of age

tacrolimus PROTOPIC 0.1% generic 1 ointment 0.1%, ST (minimum age 16)

urea 10%, urea 20%UREA 10% CREAMUREA 20% CREAMUREA 10% LOTION

brand 2

urea 40% UREA generic 1 lotion

Ear, Nose & Throat

Earacetic acid VOSOL OTIC generic 1 oticacetic acid/

aluminum acetate DOMEBORO OTIC generic 1

acetic acid/ hydrocortisone VOSOL HC OTIC generic 1

benzocaine/antipyrine BENZOTIC generic 1carbamide peroxide DEBROX generic 1 6.5%, OTCciprofloxacin/

dexamethasone CIPRODEX brand 2 Diagnosis Required, QL

23





neomycin/polymyxin B/hydrocortisone CORTISPORIN OTIC generic 1 otic

ofloxacin FLOXIN OTIC generic 1NoseAntihistamines - First Generation, Sedating

chlorpheniramine maleate CHLOR-TRIMETON SYRUP generic 1 2 mg/5 ml, OTC

chlorpheniramine extended-release

CHLOR-TRIMETON ALLERGY generic 1 12 mg, OTC

clemastine CLEMASTINE generic 1cyproheptadine CYPROHEPTADINE generic 1diphenhydramine generic 1diphenhydramine BENADRYL generic 1 OTChydroxyzine HCL ATARAX generic 1hydroxyzine pamoate VISTARIL generic 1Antihistamines - Second Generation, Nonsedatingcetirizine ZYRTEC generic 1 OTC

cetirizine chew tab ZYRTEC CHEWABLE TABLET generic 1

OTC, Members ≥ 8 years of age will require prior

authorization.levocetirizine XYZAL generic 1 tabs

loratadineALAVERTCLARITIN

generic 1 OTC

Antihistamines - Others Antihistamine/Decongestant Combinationsazelastine ASTELIN generic 1 sprayAntihistamine/Decongestant Combinations - First Generationchlorpheniramine/

phenylephrine/ pyrilamine

TRIOTANN generic 1

chlorpheniramine/ pseudoephedrine ACTIFED generic 1 OTC

Antihistamine/Decongestant Combinations - Second Generationcetirizine hydrochloride/

pseudoephedrine hydrochloride 12 hours extended-release

ZYRTEC-D generic 1 5 mg-120 mg tablet

24





loratadine/ pseudoephedrine extended-release

ALAVERT DALAVERT ALRG

TAB/SINUSALLERGY/CONG

generic 1 OTC

Nasal Steroidsfluticasone FLONASE generic 1

triamcinolone nasal spray NASACORT ALLERGY 24 HOUR brand 2 OTC

Miscellaneous Nasal Decongestantsoxymetazoline AFRIN generic 1 OTC

phenylephrineNEO-SYNEPHRINE DIMEATAPP DRO

DECONGESgeneric 1 OTC

Miscellaneous Nasalcromolyn sodium NASALCROM generic 1 OTCipratropium nasal ATROVENT NASAL SPRAY generic 1 QLsaline nasal spray 0.65% OCEAN NASAL SPRAY generic 1 OTCThroat and Mouthchlorhexidine gluconate PERIDEX generic 1lidocaine viscous XYLOCAINE generic 1pilocarpine SALAGEN generic 1triamcinolone KENALOG IN ORABASE generic 1 paste

Endocrinology

Adrenal Corticosteroidscortisone acetate generic 1dexamethasone DECADRON generic 1fludrocortisone FLORINEF generic 1hydrocortisone CORTEF generic 1methylprednisolone MEDROL generic 1 4mg, 8mg, 16mg, 32mgmethylprednisolone MEDROL brand 2 2mgprednisoloneprednisolone PRELONE generic 1 syrupprednisolone sodium

phosphateORAPREDPEDIAPRED

generic 1

prednisone DELTASONE generic 1

25





Androgenstestosterone cypionate DEPO-TESTOSTERONE generic 1

testosterone enanthate DELATESTRYL generic 1 Vials only. Disposable syringes not covered.

testosterone gel topical tube, packet, and pump bottle

TESTOSTERONE 1% TOPICAL GEL generic 1 PA

Diabetes Mellitusglucagon hcl for inj GLUCAGON EMERGENCY

KIT brand 2 QL

glucagon nasal powder BAQSIMI brand 2 QLglucagon subcutaneous

soln pref syringe GVOKE PFS brand 2 QL

Glucose Elevating Agentsglucagon, human

recombinant GLUCAGON brand 2 QL

Insulin Combinationsinsulin glargine/lixisenatide SOLIQUA brand 2 QL, STInsulinsinsulin aspart

protamine 70%/ insulin aspart 30%

NOVOLOG MIX 70/30 brand 2 QL, vials

insulin glargine BASAGLAR brand 2insulin human NOVOLIN R brand 2 OTC, QL, vialsinsulin human RELION R brand 2 OTC, QL, vialsinsulin isophane HUMULIN N brand 2 OTC, QL, vialsinsulin isophane human NOVOLIN N brand 2 OTC, QL, vialsinsulin isophane human RELION N brand 2 OTC, QL, vialsinsulin isophane human

70%/regular 30% NOVOLIN 70/30 brand 2 OTC, QL, vials

insulin isophane human 70%/regular 30% RELION 70/30 brand 2 OTC, QL, vials

insulin isophane/regular HUMULIN 70/30 brand 2 OTC, QL, vialsinsulin lisopro pro/lispro HUMALOG MIX 50/50 brand 2 QL, vialsinsulin lisopro prot/lispro HUMALOG MIX 75/25 brand 2 QL, vialsinsulin lispro ADMELOG SOLOSTAR brand 2 PA, QLinsulin lispro ADMELOG VIALS brand 2 QLinsulin regular HUMULIN R brand 2 OTC, QL, U-100 vials

26





Monitoring - Strips and Kits/Diabetic Supplies

ONE TOUCH SYSTEMS (ULTRA 2, ULTRAMINI, VERIO, VERIO FLEX, VERIO IQ, VERIO SYNC) brand 2

QL for insulin dependent or pregnant members:

allow testing up to 6 times per day

ONE TOUCH TEST STRIPS (ULTRA, VERIO) brand 2QL for non-insulin

dependent members: allow twice daily testing

Oral Agentsacarbose PRECOSE generic 1alogliptin NESINA generic 1 STalogliptin/metformin KAZANO generic 1 STalogliptin/pioglitazone OSENI generic 1 STertugliflozin STEGLATRO brand 2 QL, STertugliflozin/metformin SEGLUROMET brand 2 QL, STglimepiride AMARYL generic 1glipizide GLUCOTROL generic 1glipizide extended-release GLUCOTROL XL generic 1glyburide MICRONASE generic 1glyburide, micronized GLYNASE generic 1metformin GLUCOPHAGE generic 1metformin ER FORTAMET generic 1 PA, QLmetformin ER GLUCOPHAGE ER generic 1metformin/glyburide GLUCOVANCE generic 1nateglinide STARLIX generic 1pioglitazone ACTOS generic 1 QLrepaglinide PRANDIN generic 1Miscellaneous Antidiabetic Agentsdulaglutide TRULICITY brand 2 QL, STliraglutide VICTOZA 2 PEN PACK brand 2 QL, STlixisenatide ADLYXIN brand 2 STpramlintide SYMLIN brand 2 PAGrowth Stimulating Agentsmecasermin INCRELEX brand 2 PA, SPsomatropin ZOMACTON brand 2 PA, SPLipodystropy Agentstesamorelin EGRIFTA brand 2 Diagnosis Required, QL, SP

27





Osteoporosisabaloparatide inj TYMLOS brand 2 PA, SPalendronate FOSAMAX generic 1 QLcalcitonin-salmon MIACALCIN generic 1 nasal spray, QLcalcitonin-salmon FORTICAL brand 2 nasal spray, QLetidronate DIDRONEL generic 1raloxifene EVISTA generic 1Thyroid Diseaselevothyroxine LEVOXYL generic 1levothyroxine SYNTHROID generic 1liothyronine CYTOMEL generic 1methimazole TAPAZOLE generic 1propylthiouracil PROPYLTHIOURACIL generic 1Miscellaneousasfotase alfa STRENSIQ brand 2 PA, SPcabergoline DOSTINEX generic 1cholic acid CHOLBAM brand 2 PA, SPcinacalcet SENSIPAR generic 1 PAdesmopressin DDAVP generic 1 QLdesmopressin NOCDURNA brand 2 PA, QLmethylergonovine METHERGINE generic 1mifepristone KORLYM brand 2 PA, SPnitisinone NITYR brand 2 Diagnosis Required, QL, SPpegvisomant SOMAVERT brand 2 PA, SPsapropterin KUVAN brand 2 Diagnosis Required, QL, SP

sapropterin powder KUVAN POWDER FOR SOLUTION brand 2 Diagnosis Required, QL, SP

uridine VISTOGARD brand 2

Gastrointestinal

Constipation/Laxativescasanthranol-docusate

sodium generic 1 OTC

docusate calcium plus generic 1 OTCdocusate potasssium generic 1 OTCdocusate sodium COLACE generic 1 OTCglycerin GLYCERIN SUPPOSITORY generic 1 suppository, OTClactulose ENULOSE generic 1

28





magnesium citrate soln MAGNESIUM CITRATE SOLN generic 1

naloxegol MOVANTIK brand 2 Diagnosis Required, QLpeg 3350/electrolytes COLYTE generic 1peg 3350/sodium

bicarbonate/sodium chloride

TRILYTE generic 1

peg 3350/sodium bicarbonate/sodium chloride/potassium chloride

NULYTELY generic 1

plecanatide TRULANCE brand 2 Diagnosis Required, QLpolyethylene glycol 3350 MIRALAX generic 1 ONLY powder bottleprucalopride MOTEGRITY brand 2 Diagnosis Required, QLsennosides SENOKOT generic 1 8.6 mg tab, OTCDiarrheacrofelemer MYTESI brand 2 Diagnosis Required, QLdiphenoxylate/atropine LOMOTIL generic 1loperamide IMODIUM A-D generic 1 OTCloperamide LOPERAMIDE generic 1Emesisaprepitant EMEND generic 1 QL applies to 40 mg, 80

mg and 80-125 mgdronabinol MARINOL generic 1 PAmeclizine ANTIVERT generic 1metoclopramide REGLAN generic 1

ondansetronZOFRANZOFRAN ODT

generic 1 QL

prochlorperazine COMPAZINE generic 1promethazine PHENERGAN generic 1rolapitant VARUBI brand 2trimethobenzamide TIGAN generic 1 300 mg capsGastroesophageal Reflux Disease (Gerd)/Peptic Ulcersalginic acid/sodium

bicarbonate brand 2 OTC

alumina/magnesia MAALOX generic 1 OTCalumina/magnesia/

simethicone MYLANTA generic 1 OTC

29





cimetidine TAGAMET generic 1

esomeprazole NEXIUM 24HR OTC generic/brand 1/2 PA, QL, OTC

esomeprazole granules NEXIUM DELAYED RELEASE PACKET brand 2

Members ≥ 2 yearsof age will require prior

authorization.

famotidinePEPCIDPEPCID AC

generic 1

OTC Pepcid AC 10 mg and 20 mg also covered/encouraged with written

prescription.lansoprazole PREVACID generic 1

lansoprazole delayed-release PREVACID SOLUTAB generic 1

orally disintegrating tabs, Members ≥ 2 years

of age will require priorauthorization. QL

omeprazole delayed-release PRILOSEC generic 1 Capsules only, QL

pantoprazole PROTONIX generic 1ranitidine ZANTAC generic 1 150 mg tabsranitidine syrup ZANTAC generic 1sodium bicarbonate generic 1 tabletssucralfate CARAFATE generic 1

sulcralfate CARAFATE SUSPENSION brand 2

suspension, Members 10 years of age up to 65 years of age will require

prior authorization.Gastrointestinal Spasmdicyclomine BENTYL generic 1 tablets onlyglycopyrrolate ROBINUL generic 1hyoscyamine sulfate LEVSIN generic 1hyoscyamine sulfate

extended-release LEVSINEX generic 1

Inflammatory Bowel Diseasebalsalazide COLAZAL generic 1budesonide ENTOCORT EC generic 1 Diagnosis Required, QLhydrocortisone COLOCORT generic 1 enemamesalamine ROWASA generic 1 enema only

30





mesalamine extended-release DELZICOL generic 1

mesalamine supp CANASA generic 1sulfasalazine AZULFIDINE generic 1sulfasalazine

delayed-release AZULFIDINE EN-TABS generic 1

Pancreatic Enzymes

pancrelipaseCREONCREON 3000 UNIT

brand 2

Probiotic Supplementationacidophilus ACIDOPHILUS XTRA brand 2 OTCacidophilus ACIDOPHILUS brand 2 caps and tabs, OTC

acidophilus/bifidus ACIDOPHILUS/BIFIDUS WAFER generic 1 OTC

acidophilus/citrus pectin ACIDOPHILUS/CITRUS PECTIN generic 1 tabs, OTC

acidophilus/pectin ACIDOPHILUS/PECTIN generic 1 caps, OTC

probiotics

ALIGNBACIDBIOGAIACULTURELLEDIGESTIVE PROBIOTICFLORAJENFLORANEX FLORASTORLACTINEXPHILLIPS COLON HEALTHRISA-BIDRISAQUAD

brand 2 OTC

Miscellaneousatropine sulfate SAL-TROPINE brand 2misoprostol CYTOTEC generic 1teduglutide GATTEX brand 2 PA, SP

ursodiolACTIGALL URSO URSO FORTE

generic 1

31





Infectious Diseases

Anthelminticsalbendazole ALBENZA generic 1 Diagnosis Required, QLivermectin STROMECTOL generic 1praziquantel BILTRICIDE brand 2 Diagnosis Required, QL

pyrantel pamoate PIN-X brand 2 chewable tablets, suspension

pyrantel pamoate REESE’S PINWORM MEDICINE brand 2 tablets, suspension

AntibacterialsAntituberculosis Agentsaminosalicyclic acid PASER brand 2cycloserine SEROMYCIN generic 1ethambutol MYAMBUTOL generic 1ethionamide TRECATOR brand 2isoniazid ISONIAZID generic 1pyrazinamide PYRAZINAMIDE generic 1rifabutin MYCOBUTIN generic 1rifampin RIFADIN generic 1rifapentine PRIFTIN brand 2Cephalosporins - First Generationcefadroxil DURICEF generic 1cephalexin KEFLEX generic 1 tabs are not coveredCephalosporins - Second Generationcefaclor CECLOR generic 1cefprozil CEFZIL generic 1cefuroxime axetil CEFTIN generic 1 tabscefuroxime axetil CEFTIN brand 2 suspensionCephalosporins - Third Generationcefdinir OMNICEF generic 1cefixime SUPRAX brand 2 400 mg caps only, QLFluoroquinolonesciprofloxacin CIPRO generic 1levofloxacin LEVAQUIN generic 1 tablets onlyofloxacin FLOXIN generic 1 tabs

32





Macrolidesazithromycin ZITHROMAX generic 1 QLclarithromycin BIAXIN generic 1clarithromycin ER BIAXIN XL generic 1erythromycin

delayed-release ERYC generic 1

erythromycin delayed-release ERY-TAB brand 2

erythromycin ethylsuccinate

E.E.S. ERYPED

generic 1

erythromycin stearate ERYTHROCIN generic 1erythromycin/sulfisoxazole PEDIAZOLE generic 1fidaxomicin DIFICID brand 2 PAPenicillinsamoxicillin AMOXICILLIN CAPSULES

AND CHEWABLES generic 1 Except 500 mg and 875 mg film-coated tabs.

amoxicillin AMOXIL SUSP generic 1 suspensionamoxicillin/clavulanate AUGMENTIN generic 1ampicillin PRINCIPEN generic 1dicloxacillin DICLOXACILLIN generic 1penicillin VK VEETIDS generic 1Sulfonamidessulfamethoxazole/

trimethoprim, DSBACTRIMBACTRIM DS

generic 1

Tetracyclines

doxycycline monohydrate DOXYCYCLINE MONOHYDRATE generic 1 50mg & 100mg caps

minocycline MINOCIN generic 1 capsules, except 75 mgomadacycline NUZYRA brand 2 PA, QLMiscellaneousvancomycin powder for

oral solution FIRVANQ brand 2 Diagnosis Required, QL

Antifungalsclotrimazole MYCELEX generic 1 trochesfluconazole DIFLUCAN generic 1 QLgriseofulvin microsize GRIFULVIN V generic 1griseofulvin ultramicrosize GRIS-PEG generic 1itraconazole SPORANOX generic 1 caps, PA, QL

33





itraconazole SPORANOX brand 2 soln, PA, QLketoconazole NIZORAL generic 1nystatin MYCOSTATIN generic 1terbinafine LAMISIL generic 1 QLvoriconazole VFEND generic 1 PA, tabletsAntiprotozoalsatovaquone MEPRON generic 1 PAbenznidazole BENZNIDAZOLE brand 2 Diagnosis Required, QLmiltefosine IMPAVIDO brand 2 PA

nitazoxanide suspension ALINIA SUSPENSION brand 2Members ≥ 8 years of age will require prior

authorization.nitazoxanide tablet ALINIA brand 2 Diagnosis Required, QLpentamidine isethionate

for nebulization NEBUPENT brand 2

AntiviralsCytomegalovirus Treatmentganciclovir CYTOVENE generic 1valganciclovir VALCYTE generic 1 tabs onlyHepatitis Treatmentelbasvir/grazoprevir ZEPATIER brand 2 PA, QL, SPentecavir BARACLUDE generic 1 SP

glecaprevir/pibrentasvir MAVYRET brand 2PA, SP, preferred for

Genotypes 1, 2, 3, 4, 5, & 6

interferon alfa-2b INTRON A brand 2 PA, SPlamivudine EPIVIR HBV generic 1 tabs, SPlamivudine EPIVIR HBV brand 2 solution, SPpeginterferon alfa-2a PEGASYS brand 2 PA, SPpeginterferon alfa-2a PEGASYS PROCLICK brand 2 PA, SP

ribavirin REBETOL/COPEGUS generic 1 200 mg caps and tabs only, SP

sofosbuvir/velpatasvir EPCLUSA generic 1 PA, QL, SPHerpes Treatmentacyclovir ZOVIRAX generic 1 caps, tabs, suspensiondocosanol ABREVA OTC CREAM brand 2valacyclovir VALTREX generic 1

34





Influenza Treatmentamantadine SYMMETREL generic 1 except tabsoseltamivir TAMIFLU generic 1 capsules, QLrimantadine FLUMADINE generic 1zanamivir RELENZA brand 2 QLIntegrase Inhibitors:dolutegravir TIVICAY brand 2 Diagnosis Requiredraltegravir ISENTRESS brand 2 Diagnosis Required

raltegravir ISENTRESS CHEWABLE brand 2 chewable tablet, Diagnosis Required

raltegravir ISENTRESS HD brand 2 Diagnosis Required

raltegravir susp ISENTRESS SUSP brand 2

Members ≥ 2 years of age will require prior authorization. Diagnosis Required

Non-Nucleoside Reverse Transcriptase Inhibitors - Diagnosis Requireddelavirdine RESCRIPTOR brand 2efavirenz SUSTIVA brand 2etravirine INTELENCE brand 2nevirapine VIRAMUNE generic 1nevirapine ER VIRAMUNE XR generic 1rilpivirine EDURANT brand 2Nucleoside Analogues Nucleoside Reverse - Transcriptase Inhibitors/and Combinations

-Diagnosis Requiredabacavir ZIAGEN generic 1abacavir/lamivudine EPZICOM generic 1abacavir/lamivudine/

zidovudine TRIZIVIR generic 1

didanosine VIDEX brand 2didanosine

delayed-release VIDEX EC generic 1

doravirine/lamivudine/ tenofovir disoproxil DELSTRIGO brand 2 QL

efavirenz/lamivudine/tenofovir disoproxil fumarate

SYMFISYMFI LO

brand 2 QL

emtricitabine EMTRIVA brand 2

35





emtricitabine/rilpivirine/tenofovir COMPLERA brand 2 PA

lamivudine EPIVIR generic 1lamivudine/tenofovir

disoproxil fumarate CIMDUO brand 2 QL

lamivudine/zidovudine COMBIVIR generic 1stavudine ZERIT generic 1zidovudine RETROVIR generic 1Nucleoside/Nucleotide Reverse - Transcriptase Inhibitor Combination - Diagnosis Requiredemtricitabine/rilpivirine/

tenofovir ODEFSEY brand 2

emtricitabine/tenofovir alafenamide DESCOVY brand 2 QL

emtricitabine/tenofovir disoproxil TRUVADA brand 2

Nucleotide Analogues Nucleotide Reverse Transcriptase Inhibitor - Diagnosis Requiredtenofovir VIREAD generic 1Protease Inhibitors - Diagnosis Requiredatazanavir REYATAZ generic 1

atazanavir REYATAZ POWDER PACKET brand 2


authorizationdarunavir PREZISTA brand 2fosamprenavir LEXIVA brand 2indinavir CRIXIVAN brand 2lopinavir/ritonavir KALETRA brand 2 tabletslopinavir/ritonavir KALETRA generic 1 solutionnelfinavir VIRACEPT brand 2ritonavir NORVIR brand 2saquinavir mesylate INVIRASE brand 2tipranavir APTIVUS brand 2Miscellaneousabacavir/dolutegravir/

lamivudine TRIUMEQ brand 2 Diagnosis Required, QL

atazanavir/cobicistat EVOTAZ brand 2 Diagnosis Required, QLbictegravir/emtricitabine/

tenofovir alafenamide BIKTARVY brand 2 PA, QL

36





cobicistat TYBOST brand 2 Diagnosis Required, QLcobicistat/elvitegravir/

emtricitabine/tenofovir STRIBILD brand 2 PA, QL

darunavir/cobicistat PREZCOBIX brand 2 Diagnosis Required, QLdolutegravir/lamivudine DOVATO brand 2 Diagnosis Required, QLdolutegravir/rilpivirine JULUCA brand 2 Diagnosis Required, QLelvitegravir/cobicistat/

emtricitabine/tenofovir alafenamide fumarate

GENVOYA brand 2 PA, QL

enfuvirtide FUZEON brand 2 Diagnosis Required, QLmaraviroc SELZENTRY brand 2 Diagnosis Required, QLMiscellaneousbedaquiline SIRTURO brand 2chloroquine phosphate ARALEN generic 1clindamycin CLEOCIN generic 1 150 mg and 300 mg onlydapsone DAPSONE brand 2hydroxychloroquine PLAQUENIL generic 1linezolid ZYVOX generic 1 PAmefloquine LARIAM generic 1metronidazole FLAGYL generic 1 tabs onlyneomycin sulfate brand 2nitrofurantoin

extended-release MACROBID generic 1

nitrofurantoin macrocrystals MACRODANTIN generic 1

nitrofurantoin susp FURADANTIN SUSP 25 MG/5 ML generic 1


authorization.palivizumab SYNAGIS brand 2 PA, SPparomomycin HUMATIN generic 1povidone-iodine generic 1 OTCprimaquine generic 1pyrimethamine DARAPRIM brand 2 PA, SPtafenoquine KRINTAFEL brand 2 QLtrimethoprim TRIMETHOPRIM generic 1 tabs only

37





Musculoskeletal

ArthritisDisease Modifying Anti-Rheumatic Drugsadalimumab HUMIRA brand 2 PA, SPanakinra KINERET brand 2 PA, SPapremilast OTEZLA brand 2 PA, SPazathioprine IMURAN generic 1baricitinib OLUMIANT brand 2 PA, QL, SPcanakinumab ILARIS brand 2 PA, SPcertolizumab pegol CIMZIA brand 2 PA, SPetanercept ENBREL brand 2 PA, SPhydroxychloroquine PLAQUENIL generic 1leflunomide ARAVA generic 1methotrexate generic 1penicillamine DEPEN TITRATABLE brand 2 Diagnosis Required, QL, SPsarilumab KEVZARA brand 2 PA, QL, SPsecukinumab COSENTYX brand 2 PA, SPsulfasalazine AZULFIDINE generic 1sulfasalazine

delayed-release AZULFIDINE EN-TABS generic 1

tildrakizumab-asmn injection ILUMYA brand 2 PA, QL, SP

NSAIDs and Other Analgesicsacetaminophen TYLENOL generic 1 OTC

aspirinBAYERECOTRIN

generic 1 OTC

capsaicinCAPSAGELCAPZASIN-PCASTIVA

brand 2 OTC, gel, lotion, 0.035% cream

capsaicin generic 1 OTC, 0.025%, 0.075%, & 0.1% cream

celecoxib CELEBREX generic 1 PA, QL

diclofenac 1% gel VOLTAREN 1% TOPICAL GEL generic 1 PA

diclofenac potassium CATAFLAM generic 1

38





diclofenac sodium delayed-release VOLTAREN generic 1

diclofenac sodium extended-release VOLTAREN XR generic 1

etodolac LODINE generic 1 IR only

ibuprofen ADVIL generic 1 tabs, chew tabs and susp, OTC

ibuprofen MOTRIN generic 1 tabs, chew tabs and suspindomethacin INDOCIN generic 1ketoprofen ORUDIS generic 1 IR onlymeloxicam MOBIC generic 1 QLnaproxen NAPROSYN generic 1

naproxen delayed release ENTERIC COATED-NAPROSYN generic

oxaprozin DAYPRO generic 1piroxicam FELDENE generic 1salsalate DISALCID generic 1 QLsulindac CLINORIL generic 1Goutallopurinol ZYLOPRIM generic 1colchicine MITIGARE brand 2 QLfebuxostat ULORIC generic 1 STprobenecid PROBENECID generic 1Skeletal Muscle RelaxantsMuscle Spasmchlorzoxazone PARAFON FORTE DSC generic 1cyclobenzaprine FLEXERIL generic 1 5mg & 10mgmethocarbamol ROBAXIN generic 1orphenadrine

extended-release NORFLEX generic 1

Spasticitybaclofen BACLOFEN generic 1dantrolene DANTRIUM generic 1diazepam VALIUM generic 1 QLtizanidine ZANAFLEX generic 1 tabs only, QLMiscellaneousamifampridine RUZURGI brand 2 PA, QL, SP

39





OB-GYN

ContraceptivesBiphasicdesogestrel/EE MIRCETTE generic 1 QLnorethindrone/EE ORTHO-NOVUM 10/11 generic 1 QLEmergency Contraceptionlevonorgestrel PLAN B ONE STEP generic 1Extended Cyclelevonorgestrel/EE SEASONALE generic 1 QLInjectablemedroxyprogesterone

acetate DEPO-PROVERA generic 1 QL

Intravaginaletonogestrel/EE NUVARING generic 1 ring, QL

ortho diaphragmORTHO COILORTHO FLATORTHO FLEX

brand 2 QL

Monophasic - 20 mcg Estrogenlevonorgestrel/EE ALESSE generic 1 0.1/20, QLnorethindrone acetate/EE LOESTRIN 1/20 generic 1 1/20, QLnorethindrone acetate/EE/

iron LOESTRIN FE 1/20 generic 1 1/20, QL

Monophasic - 30 mcg Estrogendesogestrel/EE ORTHO-CEPT generic 1 0.15/30, QLlevonorgestrel/EE NORDETTE generic 1 0.15/30, QLnorethindrone acetate/EE LOESTRIN 1.5/30 generic 1 1.5/30, QLnorethindrone acetate/EE/

iron LOESTRIN FE 1.5/30 generic 1 1.5/30, QL

norgestrel/EE LO/OVRAL generic 1 0.3/30, QLMonophasic - 35 mcg Estrogenethynodiol diacetate/EE ZOVIA 1/35 generic 1 1/35, QLnorethindrone/EE BALZIVA generic 1 0.4/35, QLnorethindrone/EE MODICON generic 1 0.5/35, QLnorethindrone/EE ORTHO-NOVUM 1/35 generic 1 1/35, QLnorgestimate/EE ORTHO-CYCLEN generic 1 0.25/35, QL

40





Monophasic - 50 mcg Estrogenethynodiol diacetate/EE ZOVIA 1/50 generic 1 1/50, QLnorethindrone/EE OVCON 50 generic 1 1/50, QLnorethindrone/ME ORTHO-NOVUM 1/50 generic 1 1/50, QLnorgestrel/EE OVRAL generic 1 0.5/50, QLProgestinnorethindrone ORTHO MICRONOR generic 1Transdermal

norelgestromin/EEORTHO EVRAXULANE

generic 1

Triphasicdesogestrel/EE CYCLESSA generic 1 QLlevonorgestrel/EE TRIVORA generic 1 QLnorethindrone

acetate/EE/iron ESTROSTEP FE generic 1 QL

norethindrone/EE ORTHO-NOVUM 7/7/7 generic 1 QLnorethindrone/EE TRI-NORINYL generic QLnorgestimate/EE ORTHO TRI-CYCLEN generic 1 QLEndometriosisdanazol DANOCRINE generic 1Hormone Therapy/MenopauseEstrogens - Intravaginalestradiol ESTRACE CRM generic 1 QLyuvafem or estradiol

vaginal tablet VAGIFEM generic 1 QL

Estrogens - Oralestradiol ESTRACE generic 1estrogens, conjugated PREMARIN brand 2estropipate OGEN generic 1Estrogens - Transdermalestradiol CLIMARA generic 1 QLEstrogen/Progestinestrogens, conjugated/

medroxyprogesteronePREMPHASEPREMPRO

brand 2

41





Progestinsmedroxyprogesterone

acetate PROVERA generic 1

norethindrone acetate AYGESTIN generic 1progesterone micronized

cap PROMETRIUM generic 1 Diagnosis Required, QL

Ovulation Stimulants

choriogonadotropin alfa OVIDREL brand 2

Diagnosis Required for Hypogonadism or

Cryptorchidism; Infertility diagnosis is a plan

exclusion, QL

chorionic gonadotropin NOVAREL brand 2

Diagnosis Required for Hypogonadism or

Cryptorchidism; Infertility diagnosis is a plan

exclusion, QLVaginal InfectionsOralfluconazole DIFLUCAN generic 1 QLmetronidazole FLAGYL generic 1 tabsVaginalclotrimazole GYNE-LOTRIMIN generic 1 OTCclindamycin CLEOCIN generic 1 crm

metronidazoleMETROGEL-VAGINAL METROGEL 1%

generic 1

miconazole MONISTAT generic 1 OTCmiconazole MONISTAT 3 generic 1terconazole TERAZOL 3/7 generic 1 crmMiscellaneousconjugated estrogen/

bazedoxifene DUAVEE brand 2

elagolix ORILISSA brand 2 PA, QLmethylergonovine METHERGINE generic 1tranexamic acid LYSTEDA generic 1 Diagnosis Required, QL

42





Ophthalmic

Allergyazelastine OPTIVAR generic 1 STcromolyn sodium CROLOM generic 1 QLketotifen ALAWAY OTC generic 1ketotifen ZADITOR generic 1 OTC, QL

naphazoline/glycerin CLEAR EYES REDNESS RELIEF generic 1

naphazoline HCL VASOCLEAR generic 1 soln 0.02%naphazoline/zinc sulfate VASOCLEAR A brand 2 OTCtetrahydrozoline/

zinc sulfate VISINE-AC generic 1

Anti-InflammatoriesAnti-Infective/Anti-Inflammatory Combinationsbacitracin/polymyxin/

neomycin/hc CORTISPORIN generic 1 ointment

neomycin/polymyxin B/dexamethasone MAXITROL generic 1

sulfacetamide/pred phos VASOCIDIN generic 1 10%/0.25%tobramycin/

dexamethasone TOBRADEX generic 1

Nonsteroidaldiclofenac sodium VOLTAREN generic 1flurbiprofen OCUFEN generic 1ketorolac ACULAR/ACULAR LS generic 1Steroidaldexamethasone sodium

phosphate DEXASOL generic 1 soln 0.1%

fluorometholone FML LIQUIFILM generic 1 susp 0.1%prednisolone acetate PRED FORTE generic 1 1%prednisolone phosphate INFLAMASE FORTE generic 1 1%GlaucomaBeta-Blockerscarteolol generic 1levobunolol BETAGAN generic 1 ophthalmic solutionmetipranolol OPTIPRANOLOL generic 1 0.3% ophthalmic solutiontimolol maleate TIMOPTIC generic 1

43





Carbonic Anhydrase Inhibitorsdorzolamide TRUSOPT generic 1Carbonic Anhydrase Inhibitor/Beta-Blocker Combinationdorzolamide/

timolol maleate COSOPT generic 1

Cholinesterase Inhibitorecothiophate PHOSPHOLINE IODINE brand 2Mydriaticsatropine ISOPTO ATROPINE generic 1cyclopentolate CYCLOGYL generic 1 1%homatropine ISOPTO HOMATROPINE brand 2 2%scopolamine ISOPTO HYOSCINE brand 2Oralacetazolamide ACETAZOLAMIDE generic 1acetazolamide

extended-release DIAMOX SEQUELS generic 1

methazolamide NEPTAZANE generic 1Prostaglandinslatanoprost XALATAN generic 1 QLTopical - Parasympathomimeticspilocarpine ISOPTO CARPINE generic 1pilocarpine PILOPINE HS GEL brand 2Topical - Sympathomimeticsbrimonidine ALPHAGAN P generic 1 0.15%brimonidine ALPHAGAN generic 1 0.2%Immunologic Agentslifitegrast XIIDRA brand 2 PAInfectionsBacterialbacitracin generic 1ciprofloxacin CILOXAN generic 1 solutionerythromycin ERYTHROMYCIN generic 1gentamicin GENTAK generic 1neomycin/bacitracin/

polymyxin NEOSPORIN generic 1 ointment

neomycin/polymyxin B/gramicidin NEOSPORIN generic 1 solution

ofloxacin OCUFLOX generic 1

44





polymyxin B/bacitracin POLYSPORIN generic 1polymyxin B/trimethoprim POLYTRIM generic 1sulfacetamide BLEPH-10 generic 1 oint/solntobramycin TOBREX generic 1 solutionViral trifluridine VIROPTIC generic 1Miscellaneousapraclonidin ophthalmic

solution LOPIDINE generic 1 QL

cysteamine 0.44% ophthalmic solution CYSTARAN brand 2 Diagnosis Required,

QL, SPsodium chloride

hypertonic MURO 128 generic 1

Psychiatric

Alcohol Deterrentsacamprosate CAMPRAL brand 2disulfiram ANTABUSE generic 1naltrexone REVIA generic 1AnxietyBenzodiazepinesalprazolam XANAX generic 1 QL, IR onlyalprazolam ODT NIRAVAM generic 1 Non-preferred±alprazolam tab SR 24HR XANAX XR generic 1 Non-preferred±chlordiazepoxide LIBRIUM generic 1clonazepam KLONOPIN generic 1 not wafersclonazepam ODT KLONOPIN WAFER generic 1 Non-preferred*clorazepate TRANXENE generic 1diazepam VALIUM generic 1 QLdiazepam concentrate

solution DIAZEPAM INTENSOL generic 1 Non-preferred±

lorazepam ATIVAN generic 1 QLlorazepam concentrate

solution LORAZEPAM INTENSOL generic 1 Non-preferred±

oxazepam SERAX generic 1 QLMiscellaeousbuspirone BUSPAR generic 1fluvoxamine LUVOX generic 1meprobamate tablet EQUANIL generic 1 Non-preferred±

45





Attention Deficit Hyperactivity Disorder (ADHD) - Diagnosis Required amphetamine/

dextroamphetamine mixed salts

ADDERALL generic 1 Age Limits Apply, QL

amphetamine/ dextroamphetamine mixed salts extended-release

ADDERALL XR generic/brand 1/2 Age Limits Apply, QL

amphetamine extended-release ADZENYS ER brand 2 Diagnosis Required,

Non-preferred±

amphetamine sulfate EVEKEO brand 2Age Limits Apply,

Diagnosis Required, Non-preferred±

amphetamine susp extended release DYANAVEL XR brand 2 Diagnosis Required,

Non-preferred±amphetamine tab

extended release dispersible

ADZENYS XR-ODT brand 2 Diagnosis Required, Non-preferred±

amphetamine/dextroamphetamine 3-bead cap ER 24hr

MYDAYIS brand 2 Diagnosis Required, QL, Non-preferred±

atomoxetine STRATTERA generic 1 Age Limits Apply, QL

clonidine HCL tab SR 12HR KAPVAY generic 1

Age Limits Apply, Diagnosis Required,

Non-preferred±

dexmethylphenidate FOCALIN generic 1Age Limits Apply,


dexmethylphenidate HCL cap SR 24 HR FOCALIN XR generic 1


Non-preferred±

dextroamphetamineDEXEDRINEDEXTROSTAT

generic 1Age Limits Apply,

Diagnosis Required, QL, Non-preferred±

dextroamphetamine ZENZEDI brand 2Age Limits Apply,


46





dextroamphetamine extended-release DEXEDRINE SPANSULE generic 1

Age Limits Apply, Diagnosis Required, QL,

Non-preferred±

dextroamphetamine sulfate oral solution PROCENTRA generic 1


Non-preferred±guanfacine ER INTUNIV generic 1 Age Limits Apply, QLlisdexamfetamine VYVANSE brand 2 Age Limits Apply, QLlisdexamfetamine

chewable tab VYVANSE CHEWABLE brand 2 Age Limits Apply, QL

methamphetamine DESOXYN generic 1Age Limits Apply,


methylphenidate RITALIN generic 1 Age Limits Apply, tabs only, QL

methylphenidate chew tabs METHYLIN generic 1


Non-preferred±

methylphenidate extended-release APTENSIO XR brand 2


Non-preferred±methylphenidate

extended-release CONCERTA generic 1 Age Limits Apply, Diagnosis Required, QL

methylphenidate extended-release

METADATE CD METADATE ER

generic 1 Age Limits Apply, QL

methylphenidate extended-release RITALIN LA generic 1 Age Limits Apply, QL,

20 mg, 30 mg, 40 mgmethylphenidate

extended-release disintegrating

COTEMPLA XR-ODT brand 2Age Limits Apply,


methylphenidate extended-release suspension

QUILLIVANT XR brand 2Age Limits Apply,


methylphenidate HCL cap CR METADATE CD generic 1


Non-preferred±methylphenidate HCL

chew tab extended-release

QUILLICHEW ER brand 2 Diagnosis Required, Non-preferred±

47





methylphenidate HCL ER 24hr generic 1

Age Limits Apply, QL, 18 mg, 27 mg, 36 mg,

54 mg tablets, Mallinckrodt and Kremers

Urban labelers

methylphenidate patch DAYTRANA brand 2Age Limits Apply,


Bipolar Disorderdivalproex sodium

cap sprinkle DEPAKOTE SPRINKLE generic 1Members ≥ 8 years of age will require prior

authorization±divalproex sodium


lithium carbonate LITHIUM CARBONATE generic 1lithium carbonate

extended-releaseESKALITH CR LITHOBID

generic 1

DepressionMonoamine Oxidase Inhibitor (MAOI)isocarboxazid MARPLAN brand 2 Non-preferred±phenelzine NARDIL generic 1 Non-preferred±tranylcypromine PARNATE generic 1Selective Serotonin Reuptake Inhibitor (SSRIs)citalopram CELEXA generic 1 QLescitalopram LEXAPRO generic 1 tablets, QLescitalopram 10mg &

methylfolate-B12-B6-D thpk

PRAMLYTE brand 2 Non-preferred±

escitalopram oxalate soln LEXAPRO ORAL SOLUTION generic 1 oral solution,

Non-preferred±

fluoxetine PROZAC generic 1 10 mg and 20 mg caps and 20 mg soln only

fluoxetine capsule PROZAC generic 1 40mg, Non-preferred±fluoxetine HCL (PMDD)

tabs SARAFEM brand 2 Non-preferred±

fluoxetine HCL cap delayed-release 90 mg PROZAC WEEKLY generic 1 Non-preferred±

fluoxetine tablet FLUOXETINE generic 1 Non-preferred±

48





fluvoxamine maleate cap SR 24HR LUVOX CR generic 1 Non-preferred±

paroxetine PAXIL generic 1 tabletsparoxetine HCL oral susp PAXIL brand 2 Non-preferred±paroxetine HCL tab SR

24HR PAXIL CR generic 1 Non-preferred±

paroxetine mesylate tab PEXEVA brand 2 Non-preferred±sertraline ZOLOFT generic 1 QLSerotonin Norepinephrine Reuptake Inhibitors (SNRIs)

desvenlafaxine fumarate tab SR 24HR

DESVENLAFAXINE FUMARATE TAB SR 24HR

generic 1 Non-preferred±

desvenlafaxine succinate tab SR 24HR PRISTIQ generic 1 Non-preferred±

desvenlafaxine tab SR 24HR KHEDEZLA generic 1 Non-preferred±

duloxetine CYMBALTA generic 1 QLduloxetine IRENKA generic 1 Non-preferred±levomilnacipran FETZIMA brand 2 Non-preferred±venlafaxine EFFEXOR generic 1 QLvenlafaxine HCL tab

SR 24HRVENLAFAXINE HCL TAB SR

24HR generic 1 Non-preferred±

venlafaxine XR EFFEXOR XR generic 1 QLTricyclic Antidepressants (TCAs)amitriptyline ELAVIL generic 1 tabletsamoxapine generic 1chlordiazepoxide-

amitriptyline LIMBITROL DS generic 1 Non-preferred±

clomipramine ANAFRANIL generic 1 Non-preferred±desipramine NORPRAMIN generic 1doxepin SINEQUAN generic 1imipramine HCL TOFRANIL generic 1 tabletsimipramine pamoate TOFRANIL-PM generic 1 Non-preferred±nortriptyline PAMELOR generic 1protriptyline VIVACTIL generic 1 Non-preferred±trimipramine SURMONTIL brand 2 Non-preferred±Tricyclic Antidepressant/Phenothiazine Combinationamitriptyline/perphenazine TRIAVIL generic 1

49





Miscellaneous Agentsbupropion WELLBUTRIN generic 1bupropion

extended-release WELLBUTRIN SR generic 1 QL

bupropion extended-release WELLBUTRIN XL generic 1 150 mg and 300 mg

bupropion HCL tab SR 24HR FORFIVO XL brand 2 Non-preferred±

bupropion hydrobromide APLENZIN brand 2 Non-preferred±maprotiline LUDIOMIL generic 1mirtazapine REMERON generic 1 tabs (not soltabs)mirtazapine ODT REMERON SOLTAB generic 1 Non-preferred±nefazodone SERZONE generic 1 Non-preferred±selegiline td patch EMSAM brand 2 Non-preferred±trazodone DESYREL generic 1 50, 100, & 150 mg onlytrazodone DESYREL generic 1 300 mg, Non-preferred±vilazodone VIIBRYD brand 2 Non-preferred±vortioxetine TRINTELLIX brand 2 Non-preferred±InsomniaBenzodiazepines

temazepam RESTORIL generic 1 15 mg and 30 mg only, QL

triazolam HALCION generic 1 QLNon-Benzodiazepineschloral hydrate CHLORAL HYDRATE generic 1diphenhydramine NYTOL QUICK CAPS generic 1 OTCdoxylamine succinate UNISOM generic 1 25mg, OTC, QLzaleplon SONATA generic 1 QLzolpidem AMBIEN generic 1 QLNarcotic Antagonistsbuprenorphine SUBUTEX generic 1 Diagnosis Required, QLbuprenorphine

hclnaloxone hcl SL film SUBOXONE brand 2 2 mg and 8 mg film only, Diagnosis Required, QL

buprenorphine hcl-naloxone hcl SL ZUBSOLV brand 2 QL, Non-preferred±

buprenorphine hcl-naloxone hcl SL film SUBOXONE brand 2 QL, 4 & 12mg,

Non-preferred±

50





buprenorphine hcl-naloxone hcl SL tab SUBOXONE generic 1 Diagnosis Required, QL

buprenorphine-naloxone buccal film BUNAVAIL brand 2 QL, Non-preferred±

lofexidine LUCEMYRA brand 2 QL, Non-preferred±naloxone NALOXONE INJ generic 1 QLnaloxone NARCAN NASAL SPRAY brand 2naloxone hcl solution auto-

injector EVZIO brand 2 Non-preferred±

naltrexone REVIA generic 1PsychosesAtypicals - Diagnosis Required

aripiprazole ABILIFY TABLETS generic 1 Age Limit Applies, tablets, QL

aripiprazole ER injection ABILIFY MAINTENA brand 2 Age Limit Applies, PA, QL, ±

aripiprazole lauroxil IM ER susp ARISTADA brand 2 PA, QL, ±

aripiprazole ODT ABILIFY DISCMELT brand 2Age Limits Apply,


aripiprazole oral solution ABILIFY SOLUTION brand 2Age Limits Apply,


asenapine maleate sublingual SAPHRIS brand 2 Diagnosis Required, QL,

Non-preferred±

brexpiprazole REXULTI brand 2 Diagnosis Required , QL, Non-preferred±

cariprazine VRAYLAR brand 2 Diagnosis Required, Non-preferred±

clozapine CLOZARIL generic 1 Age Limit Applies, 25mg, 50mg & 100mg only

clozapine CLOZARIL generic 1200 mg, Age Limits

Apply, Diagnosis Required, Non-preferred±

clozapine ODT FAZACLO generic 1 Diagnosis Required, Non-preferred±

51





clozapine susp VERSACLOZ brand 2 Diagnosis Required, Non-preferred±

iloperidone FANAPT brand 2 Diagnosis Required, QL, Non-preferred±

lurasidone LATUDA brand 2Age Limit Applies,


olanzapine ZYPREXA generic 1 Age Limit Applies, tablets, QL

olanzapine-fluoxetine SYMBYAX generic 1 Diagnosis Required, Non-preferred±

olanzapine INJ ZYPREXA generic 1 Diagnosis Required, Non-preferred±

olanzapine ODT ZYPREXA ZYDIS generic 1Age Limits Apply,


olanzapine pamoate for extended-release IM sus

ZYPREXA RELPREVV brand 2 Diagnosis Required, QL, Non-preferred±

paliperidone INVEGA SUSTENNA brand 2 Age Limit Applies, PA, QL, ±

paliperidone INVEGA TRINZA brand 2 Age Limit Applies, PA, QL, ±

paliperidone tab SR 24HR INVEGA generic 1Age Limits Apply,


pimavanserin NUPLAZID brand 2 Non-preferred±quetiapine SEROQUEL generic 1 Age Limit Applies, QL

quetiapine fumarate tab SR 24HR SEROQUEL XR generic 1


Non-preferred±

risperidone RISPERDAL generic 1 Age Limit Applies, QL, (Not M-Tabs)

risperidone RISPERDAL CONSTA brand 2 Age Limit Applies, PA, QL±

risperidone ODT RISPERDAL M-TAB generic 1Age Limits Apply,


52





risperidone oral soln RISPERDAL SOLUTION generic 1QL, Members ≥ 8 years of age will require prior

authorization, ±risperidone subcutaneous

for ER PERSERIS brand 2 Age Limits Apply, PA, QL±

ziprasidone GEODON generic 1 Age Limit Applies, QLTypicalshaloperidol lactate oral

conc HALDOL CONCENTRATE generic 1 Diagnosis Required, QL, Non-preferred±

loxapine aerosol powder breath activated ADASUVE brand 2 Non-preferred±

molindone MOBAN brand 2 Diagnosis Required, QL, Non-preferred±

Miscellaneouscarbamazepine

(antipsychotic) cap SR 12HR

EQUETRO brand 2 Non-preferred±

Smoking Cessationbupropion hcl (smoking

deterrent) tab SR 12hr ZYBAN generic 1

nicotine NICODERM CQ generic 1 patches, QLnicotine inhaler system NICOTROL INHALER brand 2 QLnicotine nasal spray NICOTROL NS brand 2 QLnicotine polacrilex gum NICORETTE OTC generic 1 QLnicotine polacrilex lozenge COMMITT OTC generic 1 QLnicotine TD patch

24 HR kitNICOTINE TD PATCH

24 HR KIT brand 2

varenicline CHANTIX brand 2 QLMiscellaneouschlorpromazine THORAZINE generic 1 Diagnosis Requireddextromethorphan/

quinidine NUEDEXTA brand 2 Diagnosis Required, QL

fluphenazine PROLIXIN generic 1 Diagnosis Requiredfluphenazine decanoate PROLIXIN DECANOATE generic 1 Diagnosis Required

haloperidol HALDOL generic 1 Diagnosis Required, tablets only

haloperidol decanoate HALDOL DECANOATE generic 1 Diagnosis Required

53





loxapine LOXITANE generic 1 Diagnosis Requiredperphenazine TRILAFON generic 1 Diagnosis Requiredpimozide ORAP generic 1 Diagnosis Requiredthioridazine MELLARIL generic 1 Diagnosis Requiredthiothixene NAVANE generic 1 Diagnosis Requiredtrifluoperazine STELAZINE generic 1 Diagnosis Required

Respiratory Drugs

Antitussives, Decongestants, Expectorants and Combinationsbenzonatate TESSALON generic 1brompheniramine &

phenylephrineDIMETAPP CLD ELX/

ALLERGY generic 1

brompheniramine/ pseudoephedrine

UNI-HIST DROPSACCUHIST DROPS

generic 1

brompheniramine/ pseudoephedrine/ dextromethorphan

BROMFED DM generic 1 syrup

chlorphen tan/ carbetapentane tan TUSSI-12 S generic 1 susp

chlorphen tan/pyrilamine tan/PE tan

TRIOTANN PEDIATRIC SUSP

R-TANNAMINEgeneric 1 susp

chlorpheniramine/ dextromethorphan

ROBITUSSIN PED LIQ CGH/COLD

ROBITUSSIN LIQ CGH/CLD

DIMETAPP SYP CGH/CLDCORICIDIN TAB

CGH/CLD

generic 1

chlorpheniramine maleate phenylephrine HCL

ED A-HIST TABLETS AND LIQUID generic 1

chlorpheniramine/ phenylephrine

RONDEC DROPSCARDEC DRO

generic 1 liquid

chlorpheniramine/ phenylephrine

RONDEC SYRUPCARDEC SYP

generic 1 syrup

54





chlorpheniramine tan/ phenylephrine tan RYNATAN PEDIATRIC SUSP generic 1 susp

chlorpheniramine/ pseudoephedrine LOHIST-D generic 1

codeine/ chlorpheniramine/pseudoephedrine

DIHISTINE DH PHENYLHIST LIQ DH

generic 1

codeine/guaifenesinGUIATUSS AC GG/CODEINE M-CLEAR WC

generic 1 QL

codeine/guaifenesin/pseudoephedrine GUIATUSS DAC generic 1

codeine/promethazine PROMETHAZINE W/CODEINE generic 1 QL

codeine/promethazine/phenylephrine

PROMETHAZINE VC W/CODEINE generic 1 QL

dextromethorphan/ brompheniramine/pseudoephedrine

BROMETANE DX generic 1

dextromethorphan- guaifenesin DURATUSS DM ELX generic 1 soln 25-225 mg/5 ml

dextromethorphan/ guaifenesin

GG/DM CRMUCINEX DMROBITUSSIN DMTUSSIN DM

generic 1 OTC

dextromethorphan- guaifenesin

ROBITUSSIN LIQ CGH/CONG generic 1 liq 10-200 mg/ 5 ml

dextromethorphan hbrROBITUSSIN SYP MAX-STROBITUSSIN PED SYP

generic 1 syrup

dextromethorphan polistirex extended-release

DELSYM brand 2 OTC

dextromethorphan/ promethazine

PHENERGAN DMPROMETHAZINE SYP DM

generic 1

guaifenesin ROBITUSSIN generic 1 OTC

55





guaifenesin ROBITUSSIN SYP CHST CNG generic 1 syrup 100 mg/5 ml

guaifenesin extended-release MUCINEX generic 1 OTC

guaifenesin/ pseudoephedrine

ROBITUSSIN PE PSE/GG

generic 1 syrup, OTC

guaifenesin/ pseudoephedrine/ dextromethorphan

ROBITUSSIN CF generic 1

guaifenesin/ pseudoephedrine extended-release

MUCINEX D generic 1 OTC

hydrocodone/homatropine

HYCODANHYDROMET SYPHYDROCODONE/

TAB HOMATROP

generic 1

loratadine & pseudoephedrine SR 24hr

CLARITIN-D generic 1

phenylephrine/ brompheniramine/ dextromethorphan

generic 1 OTC

phenylephrine/ chlorpheniramine/ dextromethorphan

RONDEC DMSTATUSS DM SYPCARDEC DM SYPMINUTUSS DR SYP

generic 1 syrup

phenylephrine/ chlorpheniramine/ dextromethorphan

RONDEC DM DROPSCARDEC DM DROROBITUSSIN LIQ

CGH/ALRG

generic 1 liquid

phenylephrine/ chlorpheniramine/ dihydrocodeine

DIHYDRO-PE SYP generic 1

phenylephrine/ dextromethorphan

DIMETAPP DRO DCON/CGH generic 1

56





phenylephrine/ dextromethorphan/guaifenesin

ROBITUSSIN LIQ CGH/CLD generic 1

phenylephrine/ephed/CPM w/carbetapentane

RYNATUSS PEDIATRIC SUSP generic 1 susp

phenylephrine/guaifenesin ROBITUSSIN LIQ HD/CHST generic 1

phenylephrine/ pyrilamine w/hydrocodone

CODIMAL DH generic 1 syrup

promethazine & phenylephrine

PROMETH VC SYP 6.25-5/5 generic 1 syrup 6.25-5 mg/ 5 mg

pseudoephedrine/ acetaminophen/ dextromethorphan

MAPAP COLD TAB generic 1

pseudoephedrine/ chlorpheniramine/ dextromethorphan

PEDIACARE LIQ MULTI-SY

ROBITUSSIN LIQ PED NGHT

generic 1

pseudoephedrine/ dextromethorphan/guaifenesin

MULTI SYMPTOM TAB COLD RLF generic 1

pseudoephedrine/ iburprofen

CHILD IBUPRO SUS COLD

IBUOROFEN TAB COLD/SIN

generic 1

pseudoephedrine tan/ dexchlorphen tan/ DM tan

TANAFED DMX SUSPENSION

TRI-FED Xgeneric 1 susp

pyrilamine tan/ phenyleph tan RYNA-12 S generic 1 susp

tripolidine/ pseudoephedrine

TRIPROL/PSE SYPAPHEDRID TAB

generic 1

57





Asthma/COPDInhalers - Beta Agonistsalbuterol sulfate VENTOLIN HFA generic 1 QLindacaterol ARCAPTA NEOHALER brand 2olodaterol STRIVERDI RESPIMAT brand 2Inhalers - Corticosteroidsbeclomethasone QVAR REDIHALER brand 2 QLfluticasone furoate ARNUITY ELLIPTA brand 2 QL

mometasone ASMANEX HFA brand 2Patients 8 years and

older will require prior authorization

Inhalers -Corticosteroid/Beta Agonist Combinationsfluticasone/salmeterol ADVAIR generic 1 PA, QLfluticasone/salmeterol AIRDUO RESPICLICK generic 1 QLfluticasone/salmeterol WIXELA INHUB brand 2 PA, QLInhalers - Othersipratropium/albuterol COMBIVENT RESPIMAT brand 2 inhaleripratropium HFA ATROVENT HFA brand 2omalizumab XOLAIR brand 2 PA, SPtiotropium/olodaterol STIOLTO brand 2 QLumeclidinium inhalation INCRUSE ELLIPTA brand 2Inhalers for Nebulization

albuterol ACCUNEB generic 1

0.63 mg/3 ml and 1.25 mg /3 ml, Covered for members less than 8

years of age. Members ≥ 8 years of age will require

prior authorization.albuterol PROVENTIL generic 1 soln 0.083%, 0.5%

budesonide PULMICORT RESPULES generic 1susp, Members ≥ 5 yearsof age will require prior

authorization, QLcromolyn INTAL generic 1 soln, QLipratropium ATROVENT generic 1 soln, QLipratropium/albuterol DUONEB generic 1 solnlevalbuterol HCl XOPENEX RESPULES generic 1 QL, ST

58





Oral Agents - Leukotriene Modifiersmontelukast SINGULAIR generic 1 QLOral Agents - Theophyllinetheophylline THEOPHYLLINE generic 1 liquidtheophylline

extended-release THEO-24 brand 2 caps

theophylline extended-release

THEOCHRONUNIPHYL

generic 1 tabs

Miscellaneousbenralizumab injection FASENRA brand 2 PA, QL, SPmepolizumab injection NUCALA brand 2 PA, SP

Urological

Symptomatic Benign Prostatic Hypertrophyalfuzosin ER UROXATRAL generic 1doxazosin CARDURA generic 1finasteride PROSCAR generic 1tamsulosin FLOMAX generic 1terazosin HYTRIN generic 1Miscellaneousbethanechol URECHOLINE generic 1hyoscyamine,

methenamine, phenyl salicylate, sodium phosphate monobasic, methylene blue

UTIRA C brand 2

methenamine hippurateHIPREXUREX

generic 1

oxybutynin chloride DITROPAN XL generic 1 QLoxybutynin IR DITROPAN generic 1

oxybutynin patch OXYTROL FOR WOMEN OTC PATCH brand 2

pentosan polysulfate ELMIRON brand 2 Diagnosis Required, QLpotassium citrate UROCIT-K generic 1phenazopyridine PYRIDIUM generic 1sodium citrate/citric acid BICITRA generic 1tolterodine DETROL generic 1 STtrospium SANCTURA generic 1 ST

59





Vitamins and Mineralsb-complex B-COMPLEX VITAMIN TAB generic 1 OTC, QLcalcitriol ROCALTROL generic

calcitriol oral soln ROCALTROL SOLUTION generic 1Members ≥ 8 years of age will require prior

authorization.calcium OS-CAL generic 1 OTCcalcium carb-vit D w/

minerals CALTRATE W/D generic 1 OTC, QL

cholecalciferol VITAMIN D 400 UNIT generic 1 caps & tabs 400 unit, OTC



cholecalciferol D3-50 CAP brand 2 cap 50000 unit, OTC

cholecalciferol generic 1 drops 400 unit/0.03 ml, OTC

cholecalciferol generic 1 drops 2000 unit/0.03 ml, OTC

cyanocobalamin VITAMIN B-12 generic 1 injelectrolyte PEDIALYTE generic 1 soln, oral, OTCergocalciferol (D2) DRISDOL generic 1ferrous sulfate FEOSOL generic 1 OTC

fluoride

GEL-KAMLURIDE LURIDE LOZI-TABSPREVIDENTPHOS-FLUR

generic 1

folic acid FOLIC ACID generic 1magnesium oxide MAG-OX generic 1 OTCmultiple vitamin chewable

tablet and drops AQUADEKS brand 2 Diagnosis Required, QL

multivitamins/fluoride/±iron POLY-VI-FLOR generic 1

60





multivitamins/minerals CENTRUM generic 1 OTCphytonadione MEPHYTON brand 2

prenatal vitamins

ALIVE PRENATAL MULTIVITAMIN/PLANT DHA

GNP DAILY PRENATALHM ONE DAILY PRENATALONE-A-DAY WOMENS

PRENATAL SM ONE DAILY PRENATALTHERANATAL ONE

generic/brand 1/2 OTC, QL

vitamin A generic 1 OTCvitamin ADC/fluoride/±iron

drops TRI-VI-FLOR generic 1

vitamin B complex/ vitamin C/folic acid NEPHROCAPS generic 1

vitamin B-1 generic 1 OTCvitamin C generic 1 OTCvitamin B-6 generic 1 OTC

vitamins pediatric TRI-VI-SOL generic 1 members <3 years old, OTC

zinc generic 1 OTCPotassiumphosphorus K-PHOS NEUTRAL generic 1 tabspotassium acid phosphate K-PHOS ORIGINAL brand 2potassium bicarbonate/

potassium citrate effervescent

K-LYTE generic 1 tabs

potassium chloride K-LOR generic 1 powderpotassium chloride POTASSIUM CHLORIDE generic 1 liquid

potassium chloride extended-release

K-DUR 10K-DUR 20K-TAB M20 KLOR-CON 8 KLOR-CON 10

generic 1 tabs

61





potassium chloride extended-release MICRO-K 10 generic 1 caps

Miscellaneous

Anaphylaxis

epinephrineEPIPEN EPIPEN JR.

generic 1 QL

epinephrine SYMJEPI brand 2 QLAntidotesacetylcysteine CETYLEV brand 2succimer CHEMET brand 2 QLCystic Fibrosisacetylcysteine MUCOMYST generic 1

aztreonam CAYSTON brand 2 Diagnosis Required, QL, SP

dornase alfa PULMOZYME brand 2 Diagnosis Required, QL, SP

ivacaftorKALYDECOKALYDECO GRANULES

brand 2 PA, SP

lumacaftor/ivacaftor ORKAMBI brand 2 PA, SPsodium chloride for

nebulizer HYPERSALNEBUSAL

generic 1

tezacaftor/ivcaftor SYMDEKO brand 2 PA, SP

tobramycin neb soln BETHKIS brand 2 Diagnosis Required, QL, SP

Hereditary Angioedemac1 esterase inhibitor,

human BERINERT brand 2 PA, SP

c1 esterase inhibitor, human HAEGARDA brand 2 PA, QL, SP

icatibant FIRAZYR generic 1 PA, SPHyperphosphatemiacalcium acetate PHOSLO generic 1 667 mg tablet onlysevelamer RENVELA generic 1 ST, tabletsIdiopathic Pulmonary Fibrosis (IPF)nintedanib OFEV brand 2 PA, SPpirfenidone capsule ESBRIET brand 2 PA, SP

62





Medical Devicesinsulin pen needle QL, BD brand onlyinsulin syringes QL, BD brand onlylancets QLspacers QLMetabolic Modifierscarglumic acid CARBAGLU brand 2 PA, SPglycerol phenylbutyrate RAVICTI brand 2 PA, SP

sodium phenylbutyrate BUPHENYL ORAL POWDER generic 1 Diagnosis Required,

QL, SPVaccine diphtheria-tetanus tox

adsorbed (dt) im DIP/TET PED INJ brand 2 QL

hepatitis a vaccine suspHAVRIXVAQTA

brand 2 QL

hepatitis b vaccine (recombinant)

ENGERIX-BRECOMBIVAX HB

brand 2 QL

hepatitis b vaccine recombinant adjuvanted

HEPLISAV-B brand 2 QL

human papillomavirus (hpv) 9-valent recomb vac

GARDASIL 9 brand 2 QL

human papillomavirus (hpv) quadrivalent recombinant vac

GARDASIL brand 2 QL

influenza virus vaccine live quadrivalent intranasal FLUMIST QUAD brand 2 QL

influenza virus vaccine recombinant hemagglutinin (ha) quadrivalent

FLUBLOK QUAD brand 2 QL

influenza virus vaccine split AFLURIA brand 2 QL

influenza virus vaccine split high-dose pf FLUZONE HD PF brand 2 QL

influenza virus vaccine split pf AFLURIA PF brand 2 QL

63





influenza virus vaccine split quadrivalent

AFLURIA QUAD FLUARIX QUADFLULAVAL QUADFLUZONE QUAD

brand 2 QL

influenza virus vaccine split quadrivalent pf AFLURIA QUAD PF brand 2 QL

influenza virus vaccine tiss-cult subunit quadrivalent

FLUCELVAX QUAD brand 2 QL

influenza virus vaccine types a&b surface antigen

FLUAD brand 2 QL

measles, mumps & rubella virus vaccines for inj M-M-R II brand 2 QL

meningococcal (a, c, y, and w-135) MENOMUNE brand 2 QL

meningococcal (a, c, y, and w-135) conjugate vaccine

MENACTRA brand 2 QL

meningococcal (a, c, y, and w-135) oligo conj vac for inj

MENVEO brand 2 QL

pneumococcal 13-valent conjugate PREVNAR 13 brand 2 QL

pneumococcal vaccine polyvalent

PNEUMOVAXPNEUMOVAX 23

brand 2 QL

tet tox-diph-acell pertuss ad

ADACELBOOSTRIX

brand 2 QL

tetanus-diphtheria toxoids (td)

TENIVACTET/DIP TOX INJ

brand 2 QL

tetanus immune globulin (human) HYPERTET S/D brand 2 QL

typhoid vaccine VIVOTIF BERNA brand 2 capsulesvaricella virus vac live for

subcutaneous VARIVAX brand 2 QL

zoster vaccine live ZOSTAVAX brand 2 Age Limits Apply, QLzoster vaccine

recombinant adjuvanted

SHINGRIX brand 2 Age Limits Apply, QL

64




Generic Drug Name Brand Drug Name Examples

OTC MEDICATIONS

The following is a list of OTC products on the PDL. Some OTC products are listed on the druglist. OTC products covered are restricted to generics when available. Brand names are providedas reference only.

Acneadapalene gel DIFFERIN OTC GEL 0.1%benzoyl peroxide crm, gel, lotion CLEARASILAntifungalsclotrimazole

miconazole crm

tolnaftate

MICATINLOTRIMIN AFTINACTIN

vaginal productsMONISTATGYNE-LOTRIMIN

Antiviralsdocosanol ABREVA OTC CREAMAtopic Dermatitis

emollients

BETACARE CREAM AND LOTIONCETAPHIL CREAM AND LOTIONDERMAPHOR OINTMENTE-OINTMENTGLYCERIN TOPICAL

Cough/Cold Allergy

antihistamines

CHLOR-TRIMETONBENADRYLCLARITINALAVERTZYRTEC

Antihistamine/Decongestant Combinationsbrompheniramine/pseudoephedrine DIMETAPPcetirizine/pseudoephedrine OTC ZYRTEC Dchlorpheniramine/pseudoephedrine ACTIFED

loratadine/pseudoephedrineALAVERT ALRG TAB/SINUSALAVERT D ALLERGY/CONG

65





Cough/Cold

antitussives Age edit applied. Not covered for members under the age 2.

ROBITUSSINROBITUSSIN DMROBITUSSIN PEROBITUSSIN CFDELSYM

nasal spraysNEO-SYNEPHRINEAFRINDIMETAPP DRO DECONGES

Diabetesalcohol swabs CURITY ALCOHOL PADSglucose oral tablets

insulin (vials only) HUMULINNOVOLIN

Earwax Removal Productscarbamide peroxide DEBROXFamily Planning

condoms-male

TROJANKIMONOLIFESTYLESTRUSTEXDUREXFANTASY

contraceptive foam DELFENcontraceptive gel GYNOL IIFirst AidBurow’s soln, wet dressings DOMEBOROdermatological baths COLLOIDAL OATMEAL BATHShydrocortisone crm, oint CORTAID

topical antibacterialsNEOSPORINBACITRACIN

66





Gastrointestinal

antacids liquids, chew tabsMYLANTA LIQUIDMAALOX LIQUIDTUMS

antidiarrhealsIMODIUM A-DKAOPECTATE

electrolyte rehydrating soln PEDIALYTEfamotidine PEPCID AClaxative enemas FLEET ENEMA

laxativesDULCOLAXFLEET PHOSPHO-SODA

probiotics

ALIGNBACIDBIOGAIACULTURELLEDIGESTIVE PROBIOTICFLORAJENFLORANEX FLORASTORLACTINEXPHILLIPS COLON HEALTHRISA-BIDRISAQUAD

psyllium METAMUCILrectal hydrocortisone crm, suppositories PREPARATION Hsimethicone MYLICONstool softeners COLACEsugar+orthophosphoric acid EMETROLInsomniadoxylamine succinate UNISOMLice Productspermethrin NIXpyrethrins/piperonyl butoxide liquid shampoo RID SHAMPOOMotion Sicknessdimenhydrinate DRAMAMINEmeclizine BONINE

67





Ophthalmics

allergic conjunctivitisALAWAYZADITOR

artificial tears HYPOTEARS

decongestantsVISINEMURINENAPHCON A

Pain acetaminophen tabs, liquid,

drops, suppositories, chew tabs TYLENOL

aspirin tabs, EC tabs, chew tabsBAYERECOTRIN

aspirin with buffers tabs

ibuprofen tabs, chew tabs, drops, suspADVILMOTRIN IB

Urologicaloxybutynin patch OXYTROL FOR WOMEN OTC PATCHSmoking Cessation Products

nicotineCOMMIT LOZENGES (QUANTITY LIMIT)NICODERM CQ (QUANTITY LIMIT)NICOTINE GUM (QUANTITY LIMIT)

Vitamins/Mineralsb-complex B-COMPLEX VITAMIN TAB

calcium

CALTRATECALTRATE W/D OS-CALTUMS

iron ferrous fumarate, ferrous gluconate, ferrous sulfate, ferrous bis-glycinate chelate and polysaccharide iron caps

FERGONFEOSOL

magnesium oxide MAG-OXvitamin D 400 IU VITAMIN D 400 IU

vitamins pediatric members <3 years oldVI-DAYLINPOLY-VI-SOLTRI-VI-SOL

68





vitamins prenatal

ALIVE PRENATAL MULTIVITAMIN/PLANT DHA

ONE-A-DAY WOMENS PRENATAL STUART PRENATAL

Wartssalicylic acid 17%/collodion DUOFILMMiscellaneousfluoride dental rinse PHOS-FLUR

69

Index of Covered Drugs

ALL CAPS = Brand-name drug Lower case = Generic drugALL CAPS = Brand-name drug Lower case = Generic drug

Aabacavir . . . . . . . . . . . . . . .34, 35abacavir/dolutegravir/

lamivudine . . . . . . . . . . . . . 35abacavir/lamivudine . . . . . . . . 34abacavir/lamivudine/

zidovudine . . . . . . . . . . . . . 34abaloparatide inj . . . . . . . . . . . 27abemaciclib . . . . . . . . . . . . . . . . 4ABILIFY DISCMELT . . . . . . . . 50ABILIFY MAINTENA . . . . . . . . 50ABILIFY SOLUTION . . . . . . . . 50ABILIFY TABLETS . . . . . . . . . 50abiraterone . . . . . . . . . . . . . . . . . 5ABREVA OTC CREAM . . .33, 64acalabrutinib . . . . . . . . . . . . . . . 4acamprosate . . . . . . . . . . . . . . 44acarbose . . . . . . . . . . . . . . . . . 26ACCUHIST DROPS . . . . . . . . 53ACCUNEB . . . . . . . . . . . . . . . . 57ACCUPRIL . . . . . . . . . . . . . . . . . 9ACCURETIC . . . . . . . . . . . . . . . 9acebutolol . . . . . . . . . . . . . . . . 10acetaminophen

. . . . . . . . 14, 15, 37, 56, 67acetaminophen tabs, liquid,

drops, suppositories, chew tabs . . . . . . . . . . . . . . . . . . . 67

acetazolamide . . . . . . . . . . . . . 43acetazolamide

extended-release . . . . . . . 43acetic acid . . . . . . . . . . . . . . . . 22acetic acid/aluminum

acetate . . . . . . . . . . . . . . . . 22acetic acid/hydrocortisone . . 22acetylcysteine . . . . . . . . . . . . . 61acidophilus . . . . . . . . . . . . . . . 30ACIDOPHILUS XTRA . . . . . . . 30acidophilus/bifidus . . . . . . . . . 30ACIDOPHILUS/BIFIDUS

WAFER . . . . . . . . . . . . . . . . 30acidophilus/citrus pectin . . . . 30acidophilus/pectin . . . . . . . . . 30acitretin . . . . . . . . . . . . . . . . . . . 20ACLOVATE . . . . . . . . . . . . . . . . 19

ACTIFED . . . . . . . . . . . . . .23, 64ACTIGALL . . . . . . . . . . . . . . . . 30ACTIMMUNE . . . . . . . . . . . . . . . 6ACTOS . . . . . . . . . . . . . . . . . . . 26ACULAR/ACULAR LS . . . . . . 42acyclovir . . . . . . . . . . . . . . . . . . 33ADACEL . . . . . . . . . . . . . . . . . . 63ADALAT CC . . . . . . . . . . . . . . . 10adalimumab . . . . . . . . . . . . . . . 37adapalene gel . . . . . . . . . .18, 64ADASUVE . . . . . . . . . . . . . . . . 52ADDERALL . . . . . . . . . . . . . . . 45ADDERALL XR . . . . . . . . . . . . 45ADEMPAS . . . . . . . . . . . . . . . . 13ADLYXIN . . . . . . . . . . . . . . . . . 26ADMELOG SOLOSTAR . . . . . 25ADMELOG VIALS . . . . . . . . . . 25ADVAIR . . . . . . . . . . . . . . . . . . . 57ADVIL . . . . . . . . . . . . . 14, 38, 67ADZENYS ER . . . . . . . . . . . . . 45ADZENYS XR-ODT . . . . . . . . . 45afatinib . . . . . . . . . . . . . . . . . . . . 4AFINITOR . . . . . . . . . . . . . . . . . . 5AFINITOR DISPERZ . . . . . . . . . 5AFLURIA . . . . . . . . . . . . . .62, 63AFLURIA PF . . . . . . . . . . . . . . . 62AFLURIA QUAD . . . . . . . . . . . 63AFLURIA QUAD PF . . . . . . . . 63AFRIN . . . . . . . . . . . . . . . . .24, 65AGRYLIN . . . . . . . . . . . . . . . . . . 8AIMOVIG . . . . . . . . . . . . . . . . . 16AIRDUO RESPICLICK . . . . . . 57ALAVERT . . . . . . . . . . 23, 24, 64ALAVERT ALRG TAB/

SINUS . . . . . . . . . . . . . .24, 64ALAVERT D . . . . . . . . . . . .24, 64ALAWAY . . . . . . . . . . . . . . .42, 67ALAWAY OTC . . . . . . . . . . . . . 42albendazole . . . . . . . . . . . . . . . 31ALBENZA . . . . . . . . . . . . . . . . 31albuterol . . . . . . . . . . . . . . . . . . 57albuterol sulfate . . . . . . . . . . . . 57alclometasone . . . . . . . . . . . . . 19alcohol swabs . . . . . . . . . . . . . 65ALDACTAZIDE . . . . . . . . . . . . 11ALDACTONE . . . . . . . . . . . . . . 11

ALDARA . . . . . . . . . . . . . . . . . . 21ALDOMET . . . . . . . . . . . . . . . . 13ALDORIL . . . . . . . . . . . . . . . . . 13ALECENSA . . . . . . . . . . . . . . . . 4alectinib . . . . . . . . . . . . . . . . . . . 4alendronate . . . . . . . . . . . . . . . 27ALESSE . . . . . . . . . . . . . . . . . . 39alfuzosin ER . . . . . . . . . . . . . . . 58alginic acid/sodium

bicarbonate . . . . . . . . . . . . 28ALIGN . . . . . . . . . . . . . . . . .30, 66ALINIA . . . . . . . . . . . . . . . . . . . 33ALINIA SUSPENSION . . . . . . 33alirocumab . . . . . . . . . . . . . . . . 12alitretinoin 1% gel . . . . . . . . . . . 7Alive Prenatal Multivitamin/

Plant DHA . . . . . . . . . .60, 68ALKERAN . . . . . . . . . . . . . . . . . 4allergic conjunctivitis . . . . . . . 67ALLERGY/CONG . . . . . . .24, 64allopurinol . . . . . . . . . . . . . . . . 38alogliptin . . . . . . . . . . . . . . . . . . 26alogliptin/metformin . . . . . . . . 26alogliptin/pioglitazone . . . . . . 26alpelisib . . . . . . . . . . . . . . . . . . . 4ALPHAGAN . . . . . . . . . . . . . . . 43ALPHAGAN P . . . . . . . . . . . . . 43alprazolam . . . . . . . . . . . . . . . . 44alprazolam ODT . . . . . . . . . . . 44alprazolam tab SR 24HR . . . . 44ALTACE . . . . . . . . . . . . . . . . . . . 9altretamine . . . . . . . . . . . . . . . . . 4alumina/magnesia . . . . . . . . . 28alumina/magnesia/

simethicone . . . . . . . . . . . . 28aluminum acetate . . . . . . .21, 22aluminum chloride topical

solution . . . . . . . . . . . . . . . 21ALUNBRIG . . . . . . . . . . . . . . . . . 4amantadine . . . . . . . . . . . .16, 34AMARYL . . . . . . . . . . . . . . . . . 26AMBIEN . . . . . . . . . . . . . . . . . . 49ambrisentan . . . . . . . . . . . . . . . 13AMERGE . . . . . . . . . . . . . . . . . 15AMICAR . . . . . . . . . . . . . . . . . . . 8


70

ALL CAPS = Brand-name drug Lower case = Generic drug

Index of Covered DrugsIndex of Covered Drugs


AMICAR SOLUTION . . . . . . . . . 8amifampridine . . . . . . . . . . . . . 38amiloride . . . . . . . . . . . . . . . . . 11amiloride/

hydrochlorothiazide . . . . . 11aminocaproic acid . . . . . . . . . . 8aminosalicyclic acid . . . . . . . . 31amiodarone tabs . . . . . . . . . . . . 9amitriptyline . . . . . . . . . . . .16, 48amitriptyline/perphenazine . . 48amlodipine . . . . . . . . . . . . . . . . 10ammonium lactate . . . . . . . . . 21AMNESTEEM . . . . . . . . . . . . . 18amoxapine . . . . . . . . . . . . . . . . 48amoxicillin . . . . . . . . . . . . . . . . 32AMOXICILLIN CAPSULES AND

CHEWABLES . . . . . . . . . . 32amoxicillin/clavulanate . . . . . . 32AMOXIL SUSP. . . . . . . . . . . . . 32amphetamine

extended-release . . . . . . . 45amphetamine sulfate . . . . . . . 45amphetamine susp extended

release . . . . . . . . . . . . . . . . 45amphetamine tab extended

release dispersible . . . . . . 45amphetamine/

dextroamphetamine 3-bead cap ER 24hr . . . . . . . . . . . 45

amphetamine/dextroamphetamine mixed salts . . . . . . . . . . . . . . . . . . 45

amphetamine/dextroamphetamine mixed salts extended-release . . . 45

ampicillin . . . . . . . . . . . . . . . . . 32ANAFRANIL . . . . . . . . . . . . . . . 48anagrelide . . . . . . . . . . . . . . . . . 8anakinra . . . . . . . . . . . . . . . . . . 37anastrozole. . . . . . . . . . . . . . . . . 6ANTABUSE . . . . . . . . . . . . . . . 44antacids liquids, chew tabs . . 66antidiarrheals . . . . . . . . . . . . . . 66antihistamines . . . . . . . . . .23, 64antitussives . . . . . . . . . . . .53, 65ANTIVERT . . . . . . . . . . . . . . . . 28

ANUSOL HC 2.5% . . . . . . . . . 21apalutamide . . . . . . . . . . . . . . . . 5APHEDRID TAB . . . . . . . . . . . 56apixaban . . . . . . . . . . . . . . . . . . 7APLENZIN . . . . . . . . . . . . . . . . 49apraclonidin ophthalmic

solution . . . . . . . . . . . . . . . 44apremilast . . . . . . . . . . . . . . . . 37aprepitant . . . . . . . . . . . . . . . . . 28APRESOLINE . . . . . . . . . . . . . 13APTENSIO XR . . . . . . . . . . . . . 46APTIVUS . . . . . . . . . . . . . . . . . 35AQUADEKS . . . . . . . . . . . . . . . 59ARALEN . . . . . . . . . . . . . . . . . . 36ARANESP . . . . . . . . . . . . . . . . . 8ARAVA . . . . . . . . . . . . . . . . . . . 37ARCAPTA NEOHALER . . . . . 57ARICEPT . . . . . . . . . . . . . . . . . 13ARIMIDEX . . . . . . . . . . . . . . . . . 6aripiprazole . . . . . . . . . . . . . . . 50aripiprazole ER injection . . . . 50aripiprazole lauroxil IM

ER susp . . . . . . . . . . . . . . . 50aripiprazole ODT . . . . . . . . . . . 50aripiprazole oral solution . . . . 50ARISTADA . . . . . . . . . . . . . . . . 50armodafinil . . . . . . . . . . . . . . . . 14ARNUITY ELLIPTA . . . . . . . . . 57AROMASIN . . . . . . . . . . . . . . . . 6ARTANE . . . . . . . . . . . . . . . . . . 16artificial tears . . . . . . . . . . . . . . 67asenapine maleate

sublingual . . . . . . . . . . . . . 50asfotase alfa . . . . . . . . . . . . . . . 27ASMANEX HFA . . . . . . . . . . . . 57aspirin . . . . . . . .8, 14, 15, 37, 67aspirin tabs, EC tabs,

chew tabs . . . . . . . . . . . . . 67aspirin with buffers tabs . . . . . 67aspirin/acetaminophen/

caffeine . . . . . . . . . . . . . . . 14ASTELIN. . . . . . . . . . . . . . . . . . 23ATARAX . . . . . . . . . . . . . . . . . . 23atazanavir . . . . . . . . . . . . . . . . . 35atazanavir/cobicistat . . . . . . . 35atenolol . . . . . . . . . . . . . . . . . . . 10

atenolol/chlorthalidone . . . . . 10ATIVAN . . . . . . . . . . . . . . . . . . . 44atomoxetine . . . . . . . . . . . . . . . 45atorvastatin . . . . . . . . . . . . . . . 12atovaquone . . . . . . . . . . . . . . . 33atropine . . . . . . . . . . . 28, 30, 43atropine sulfate . . . . . . . . . . . . 30ATROVENT . . . . . . . . . . . .24, 57ATROVENT HFA . . . . . . . . . . . 57ATROVENT NASAL SPRAY . 24AUBAGIO . . . . . . . . . . . . . . . . . 16AUGMENTIN . . . . . . . . . . . . . . 32AVITA . . . . . . . . . . . . . . . . . . . . 19axitinib . . . . . . . . . . . . . . . . . . . . 4AYGESTIN . . . . . . . . . . . . . . . . 41azathioprine . . . . . . . . . . . . . 6, 37azelaic acid . . . . . . . . . . . . . . . 18azelastine . . . . . . . . . . . . . .23, 42azithromycin . . . . . . . . . . . . . . 32aztreonam . . . . . . . . . . . . . . . . 61AZULFIDINE . . . . . . . . . . .30, 37AZULFIDINE EN-TABS . . .30, 37

Bb-complex . . . . . . . . . . . . .59, 67B-complex vitamin tab . . .59, 67BACID . . . . . . . . . . . . . . . . .30, 66bacitracin . . . . . . . 19, 42-44, 65bacitracin/polymyxin/

neomycin/hc . . . . . . . . . . . 42baclofen . . . . . . . . . . . . . . . . . . 38BACTRIM . . . . . . . . . . . . . . . . . 32BACTRIM DS . . . . . . . . . . . . . . 32BACTROBAN . . . . . . . . . . . . . 19balsalazide . . . . . . . . . . . . . . . . 29BALVERSA . . . . . . . . . . . . . . . . 5BALZIVA . . . . . . . . . . . . . . . . . . 39BANZEL . . . . . . . . . . . . . . . . . . 18BAQSIMI. . . . . . . . . . . . . . . . . . 25BARACLUDE . . . . . . . . . . . . . . 33baricitinib . . . . . . . . . . . . . . . . . 37BASAGLAR . . . . . . . . . . . . . . . 25BAYER . . . . . . . . . . . . . 8, 37, 67becaplermin gel . . . . . . . . . . . 21beclomethasone . . . . . . . . . . . 57bedaquiline . . . . . . . . . . . . . . . 36

71



BENADRYL . . . . . . . . . . . .23, 64benazepril . . . . . . . . . . . . . . . 8, 9benazepril/

hydrochlorothiazide . . . . . . 9benralizumab injection . . . . . . 58BENTYL . . . . . . . . . . . . . . . . . . 29BENZAC AC . . . . . . . . . . . . . . 18benznidazole . . . . . . . . . . . . . . 33benzocaine/antipyrine . . . . . . 22benzonatate . . . . . . . . . . . . . . . 53BENZOTIC . . . . . . . . . . . . . . . . 22benzoyl peroxide . . . . . . . .18, 64benzoyl peroxide crm, gel,

lotion . . . . . . . . . . . . . . . . . . 64benztropine . . . . . . . . . . . . . . . 16BERINERT . . . . . . . . . . . . . . . . 61BETA-VAL . . . . . . . . . . . . . . . . 19BETACARE CREAM AND

LOTION . . . . . . . . . . . . . . . 64BETAGAN . . . . . . . . . . . . . . . . 42betamethasone augmented

dip . . . . . . . . . . . . . . . . . . . . 20betamethasone dip

augmented . . . . . . . . . . . . 20betamethasone dipropionate 20betamethasone val . . . . . . . . . 19BETAPACE . . . . . . . . . . . . . . . 10BETAPACE AF . . . . . . . . . . . . . 10betaxolol . . . . . . . . . . . . . . . . . . 10bethanechol . . . . . . . . . . . . . . . 58BETHKIS . . . . . . . . . . . . . . . . . 61betrixaban . . . . . . . . . . . . . . . . . 7BEVYXXA . . . . . . . . . . . . . . . . . 7bexarotene caps and topical

gel . . . . . . . . . . . . . . . . . . . . . 7BIAXIN . . . . . . . . . . . . . . . . . . . 32BIAXIN XL . . . . . . . . . . . . . . . . 32bicalutamide . . . . . . . . . . . . . . . 5BICITRA . . . . . . . . . . . . . . . . . . 58bictegravir/emtricitabine/

tenofovir alafenamide . . . . 35BIKTARVY . . . . . . . . . . . . . . . . 35BILTRICIDE . . . . . . . . . . . . . . . 31BIOGAIA . . . . . . . . . . . . . . .30, 66bisoprolol . . . . . . . . . . . . . . . . . 10

bisoprolol/ hydrochlorothiazide . . . . . 10

BLEPH-10 . . . . . . . . . . . . . . . . 44BONINE . . . . . . . . . . . . . . . . . . 66BOOSTRIX . . . . . . . . . . . . . . . . 63bosentan . . . . . . . . . . . . . . . . . 13BOSULIF . . . . . . . . . . . . . . . . . . 4bosutinib . . . . . . . . . . . . . . . . . . 4brexpiprazole . . . . . . . . . . . . . . 50brigatinib . . . . . . . . . . . . . . . . . . 4BRILINTA . . . . . . . . . . . . . . . . . . 8brimonidine . . . . . . . . . . . .21, 43BROMETANE DX . . . . . . . . . . 54BROMFED DM . . . . . . . . . . . . 53brompheniramine &

phenylephrine . . . . . . . . . . 53brompheniramine/

pseudoephedrine 53, 54, 64brompheniramine/

pseudoephedrine/dextromethorphan . . . . . . 53

budesonide . . . . . . . . . . . .29, 57bumetanide . . . . . . . . . . . . . . . 11BUMEX . . . . . . . . . . . . . . . . . . . 11BUNAVAIL . . . . . . . . . . . . . . . . 50BUPHENYL ORAL

POWDER . . . . . . . . . . . . . . 62buprenorphine . . . . . 14, 49, 50buprenorphine hcl-naloxone

hcl SL . . . . . . . . . . . . . .49, 50buprenorphine hcl-naloxone

hcl SL film . . . . . . . . . . . . . 49buprenorphine hcl-naloxone

hcl SL tab. . . . . . . . . . . . . . 50buprenorphine hclnaloxone

hcl SL film . . . . . . . . . . . . . 49buprenorphine patch . . . . . . . 14buprenorphine-naloxone

buccal film . . . . . . . . . . . . . 50bupropion . . . . . . . . . . . . .49, 52bupropion extended-release . 49bupropion hcl (smoking

deterrent) tab SR 12hr . . . 52bupropion HCL tab SR 24HR 49bupropion hydrobromide . . . 49Burow’s soln, wet dressings . 65

BUSPAR . . . . . . . . . . . . . . . . . . 44buspirone . . . . . . . . . . . . . . . . . 44busulfan . . . . . . . . . . . . . . . . . . . 4butalbital/acetaminophen . . . 14butalbital/acetaminophen/

caffeine . . . . . . . . . . . . . . . 14butalbital/apap/caff/cod . . . . 14butalbital/asa/caff/cod . . . . . 14butalbital/aspirin/caffeine . . . 14butorphanol . . . . . . . . . . . . . . . 15BUTRANS . . . . . . . . . . . . . . . . 14

Cc1 esterase inhibitor, human . 61cabergoline . . . . . . . . . . . . . . . 27CABLIVI . . . . . . . . . . . . . . . . . . . 8CABOMETYX . . . . . . . . . . . . . . 4cabozantinib . . . . . . . . . . . . . . . 4CAFERGOT . . . . . . . . . . . . . . . 15calamine . . . . . . . . . . . . . . . . . . 21CALAN . . . . . . . . . . . . . . . .11, 16CALAN SR . . . . . . . . . . . . . . . . 11calcipotriene . . . . . . . . . . . . . . 20calcitonin-salmon . . . . . . . . . . 27calcitriol . . . . . . . . . . . . . . .20, 59calcitriol oral soln . . . . . . . . . . 59calcium . . . . . 10, 27, 59, 61, 67calcium acetate . . . . . . . . . . . . 61calcium carb-vit D

w/ minerals . . . . . . . . . . . . 59CALQUENCE . . . . . . . . . . . . . . 4CALTRATE . . . . . . . . . . . . .59, 67CALTRATE W/D . . . . . . . .59, 67CAMPRAL . . . . . . . . . . . . . . . . 44canakinumab . . . . . . . . . . . . . 37CANASA. . . . . . . . . . . . . . . . . . 30capecitabine . . . . . . . . . . . . . . . 4caplacizumab-yhdp . . . . . . . . . 8CAPOTEN . . . . . . . . . . . . . . . . . 8CAPOZIDE . . . . . . . . . . . . . . . . . 9CAPRELSA . . . . . . . . . . . . . . . . 5CAPSAGEL . . . . . . . . . . . . . . . 37capsaicin . . . . . . . . . . . . . . . . . 37captopril . . . . . . . . . . . . . . . . . 8, 9captopril/

hydrochlorothiazide . . . . . . 9

72


Index of Covered DrugsCAPZASIN-P . . . . . . . . . . . . . . 37CARAFATE . . . . . . . . . . . . . . . . 29CARAFATE SUSPENSION . . 29CARBAGLU . . . . . . . . . . . . . . . 62carbamazepine . . . . . . . . .16, 52carbamazepine (antipsychotic)

cap SR 12HR . . . . . . . . . . 52carbamazepine extended-

release . . . . . . . . . . . . . . . . 16carbamide peroxide . . . . .22, 65CARBATROL . . . . . . . . . . . . . . 16carbidopa/levodopa . . . . . . . . 16carbidopa/levodopa

extended-release . . . . . . . 16CARDEC DM DRO . . . . . . . . . 55CARDEC DM SYP . . . . . . . . . 55CARDEC DRO . . . . . . . . . . . . . 53CARDEC SYP . . . . . . . . . . . . . 53CARDIZEM . . . . . . . . . . . . . . . 11CARDIZEM CD . . . . . . . . . . . . 11CARDIZEM SR . . . . . . . . . . . . 11CARDURA . . . . . . . . . . . . . . 9, 58carglumic acid . . . . . . . . . . . . . 62cariprazine . . . . . . . . . . . . . . . . 50carteolol . . . . . . . . . . . . . . . . . . 42carvedilol . . . . . . . . . . . . . . . . . 10casanthranol-docusate

sodium . . . . . . . . . . . . . . . . 27CASODEX . . . . . . . . . . . . . . . . . 5CASTIVA . . . . . . . . . . . . . . . . . 37CATAFLAM . . . . . . . . . . . .14, 37CATAPRES . . . . . . . . . . . . . . . . . 9CAYSTON . . . . . . . . . . . . . . . . 61CECLOR . . . . . . . . . . . . . . . . . 31cefaclor . . . . . . . . . . . . . . . . . . . 31cefadroxil . . . . . . . . . . . . . . . . . 31cefdinir . . . . . . . . . . . . . . . . . . . 31cefixime . . . . . . . . . . . . . . . . . . 31cefprozil . . . . . . . . . . . . . . . . . . 31CEFTIN . . . . . . . . . . . . . . . . . . . 31cefuroxime axetil . . . . . . . . . . . 31CEFZIL . . . . . . . . . . . . . . . . . . . 31CELEBREX . . . . . . . . . . . . . . . 37celecoxib . . . . . . . . . . . . . . . . . 37CELEXA . . . . . . . . . . . . . . . . . . 47CELLCEPT . . . . . . . . . . . . . . . . . 6

CELONTIN . . . . . . . . . . . . . . . . 17CENTRUM . . . . . . . . . . . . . . . . 60cephalexin . . . . . . . . . . . . . . . . 31ceritinib . . . . . . . . . . . . . . . . . . . . 4certolizumab pegol . . . . . . . . . 37CETAPHIL CREAM AND

LOTION . . . . . . . . . . . . . . . 64cetirizine . . . . . . . . . . . . . . .23, 64cetirizine chew tab . . . . . . . . . 23cetirizine hydrochloride/

pseudoephedrine hydrochloride 12 hours extended-release . . . . . . . 23

cetirizine/pseudoephedrine OTC . . . . . . . . . . . . . . . . . . 64

CETYLEV . . . . . . . . . . . . . . . . . 61CHANTIX . . . . . . . . . . . . . . . . . 52CHEMET . . . . . . . . . . . . . . . . . 61CHILD IBUPRO SUS COLD . 56CHLOR-TRIMETON . . . . .23, 64CHLOR-TRIMETON

ALLERGY . . . . . . . . . . . . . 23CHLOR-TRIMETON SYRUP . 23chloral hydrate . . . . . . . . . . . . . 49chlorambucil . . . . . . . . . . . . . . . 4chlordiazepoxide. . . . . . . . . . . 44chlordiazepoxide-

amitriptyline . . . . . . . . . . . 48chlorhexidine gluconate. . . . . 24chloroquine phosphate . . . . . 36chlorothiazide . . . . . . . . . . . . . 11chlorphen tan/carbetapentane

tan . . . . . . . . . . . . . . . . . . . . 53chlorphen tan/pyrilamine tan/

PE tan . . . . . . . . . . . . . . . . . 53chlorpheniramine extended-

release . . . . . . . . . . . . . . . . 23chlorpheniramine

maleate . . . . . . . . . . . .23, 53chlorpheniramine maleate

phenylephrine HCL . . . . . 53chlorpheniramine tan/

phenylephrine tan. . . . . . . 54chlorpheniramine/

dextromethorphan . . . . . . . . . . . . . . . 53, 55, 56

chlorpheniramine/phenylephrine . . . . . . .23, 53

chlorpheniramine/phenylephrine/ pyrilamine . . . . . . . . . . . . . 23

chlorpheniramine/pseudoephedrine . . . . . . . . . . . . . . . 23, 54, 64

chlorpromazine . . . . . . . . . . . . 52chlorthalidone . . . . . . . . . .10, 11chlorzoxazone . . . . . . . . . . . . . 38cholbam . . . . . . . . . . . . . . . . . . 27cholecalciferol . . . . . . . . . . . . . 59cholestyramine . . . . . . . . . . . . 11cholic acid . . . . . . . . . . . . . . . . 27choriogonadotropin alfa . . . . . 41chorionic gonadotropin . . . . . 41ciclopirox . . . . . . . . . . . . . . . . . 20cilostazol . . . . . . . . . . . . . . . . . . 8CILOXAN . . . . . . . . . . . . . . . . . 43CIMDUO . . . . . . . . . . . . . . . . . . 35cimetidine . . . . . . . . . . . . . . . . 29CIMZIA . . . . . . . . . . . . . . . . . . . 37cinacalcet . . . . . . . . . . . . . . . . . 27CIPRO . . . . . . . . . . . . . . . . . . . 31CIPRODEX . . . . . . . . . . . . . . . . 22ciprofloxacin . . . . . . . 22, 31, 43ciprofloxacin/

dexamethasone . . . . . . . . 22citalopram . . . . . . . . . . . . . . . . 47CLARAVIS . . . . . . . . . . . . . . . . 18clarithromycin . . . . . . . . . . . . . 32clarithromycin ER . . . . . . . . . . 32CLARITIN . . . . . . . . . . . . . .23, 64CLARITIN-D . . . . . . . . . . . . . . . 55CLEAR EYES REDNESS

RELIEF . . . . . . . . . . . . . . . . 42CLEARASIL . . . . . . . . . . . . . . . 64clemastine . . . . . . . . . . . . . . . . 23CLEOCIN . . . . . . . . . . 18, 36, 41CLEOCIN T . . . . . . . . . . . . . . . 18CLIMARA . . . . . . . . . . . . . . . . . 40clindamycin . . . . . . . . 18, 36, 41CLINORIL . . . . . . . . . . . . . .14, 38clobazam . . . . . . . . . . . . . . . . . 17clobetasol propionate. . . . . . . 20

73



clobetasol propionate emollient base cream . . . . . . . . . . . . 20

clomipramine. . . . . . . . . . . . . . 48clonazepam . . . . . . . . . . . .17, 44clonazepam ODT . . . . . . . . . . 44clonidine. . . . . . . . . . . . . . . . 9, 45clonidine HCL tab SR 12HR . 45clopidogrel . . . . . . . . . . . . . . . . . 8clorazepate . . . . . . . . . . . . . . . 44clotrimazole . . . . . 20, 32, 41, 64clotrimazole with

betamethasone . . . . . . . . . 20clozapine . . . . . . . . . . . . . .50, 51clozapine ODT . . . . . . . . . . . . . 50clozapine susp . . . . . . . . . . . . 51CLOZARIL . . . . . . . . . . . . . . . . 50cobicistat . . . . . . . . . . . . . .35, 36cobicistat/elvitegravir/

emtricitabine/tenofovir . . . 36cobimetinib . . . . . . . . . . . . . . . . 4codeine sulfate . . . . . . . . . . . . 15codeine/acetaminophen . . . . 15codeine/chlorpheniramine/

pseudoephedrine . . . . . . . 54codeine/guaifenesin. . . . . . . . 54codeine/guaifenesin/

pseudoephedrine . . . . . . . 54codeine/promethazine. . . . . . 54codeine/promethazine/

phenylephrine . . . . . . . . . . 54CODIMAL DH . . . . . . . . . . . . . 56COGENTIN . . . . . . . . . . . . . . . 16COLACE . . . . . . . . . . . . . .27, 66COLAZAL . . . . . . . . . . . . . . . . 29colchicine . . . . . . . . . . . . . . . . . 38collagenase . . . . . . . . . . . . . . . 21COLLOIDAL OATMEAL

BATHS . . . . . . . . . . . . . . . . 65COLOCORT. . . . . . . . . . . . . . . 29COLYTE . . . . . . . . . . . . . . . . . . 28COMBIVENT RESPIMAT . . . . 57COMBIVIR . . . . . . . . . . . . . . . . 35COMETRIQ . . . . . . . . . . . . . . . . 4COMMIT LOZENGES . . . . . . . 67COMMITT OTC . . . . . . . . . . . . 52COMPAZINE . . . . . . . . . . . . . . 28

COMPLERA . . . . . . . . . . . . . . 35COMTAN . . . . . . . . . . . . . . . . . 16CONCERTA . . . . . . . . . . . . . . . 46condoms-male . . . . . . . . . . . . 65CONDYLOX SOL . . . . . . . . . . 21conjugated estrogen/

bazedoxifene . . . . . . . . . . . 41contraceptive foam . . . . . . . . . 65contraceptive gel . . . . . . . . . . . 65COPAXONE . . . . . . . . . . . . . . . 16CORDARONE . . . . . . . . . . . . . . 9COREG . . . . . . . . . . . . . . . . . . 10CORICIDIN TAB CGH/CLD . . 53CORTAID . . . . . . . . . . . . . . . . . 65CORTEF . . . . . . . . . . . . . . . . . . 24cortisone acetate . . . . . . . . . . 24CORTISPORIN . . . . . . . . .23, 42CORTISPORIN OTIC . . . . . . . 23CORTIZONE . . . . . . . . . . . . . . 19CORTIZONE-10 INTENSIVE

HEALING . . . . . . . . . . . . . . 19COSENTYX . . . . . . . . . . . . . . . 37COSOPT . . . . . . . . . . . . . . . . . 43COTELLIC . . . . . . . . . . . . . . . . . 4COTEMPLA XR-ODT . . . . . . . 46COUMADIN . . . . . . . . . . . . . . . . 7COZAAR . . . . . . . . . . . . . . . . . . 9CREON . . . . . . . . . . . . . . . . . . . 30CREON 3000 UNIT . . . . . . . . 30crisaborole . . . . . . . . . . . . . . . . 21CRIXIVAN . . . . . . . . . . . . . . . . . 35crizotinib . . . . . . . . . . . . . . . . . . . 4crofelemer . . . . . . . . . . . . . . . . 28CROLOM . . . . . . . . . . . . . . . . . 42cromolyn . . . . . . . . . . 24, 42, 57cromolyn sodium . . . . . . .24, 42crotamiton . . . . . . . . . . . . . . . . 21CULTURELLE . . . . . . . . . .30, 66CURITY ALCOHOL PADS . . . 65CUTIVATE . . . . . . . . . . . . . . . . 19cyanocobalamin . . . . . . . . . . . 59CYCLESSA . . . . . . . . . . . . . . . 40cyclobenzaprine . . . . . . . . . . . 38CYCLOGYL . . . . . . . . . . . . . . . 43cyclopentolate . . . . . . . . . . . . . 43cyclophosphamide . . . . . . . . . . 4

cycloserine . . . . . . . . . . . . . . . . 31cyclosporine . . . . . . . . . . . . . . . 6cyclosporine, modified . . . . . . . 6CYMBALTA . . . . . . . . . . . . . . . 48cyproheptadine . . . . . . . . . . . . 23CYSTAGON . . . . . . . . . . . . . . . . 7CYSTARAN . . . . . . . . . . . . . . . 44cysteamine 0.44% ophthalmic

solution . . . . . . . . . . . . . . . 44cysteamine bitartrate . . . . . . . . 7CYTOMEL . . . . . . . . . . . . . . . . 27CYTOTEC . . . . . . . . . . . . . . . . 30CYTOVENE . . . . . . . . . . . . . . . 33CYTOXAN . . . . . . . . . . . . . . . . . 4

DD3-50 CAP . . . . . . . . . . . . . . . . 59D.H.E. 45 . . . . . . . . . . . . . . . . . 15dabrafenib . . . . . . . . . . . . . . . . . 4danazol . . . . . . . . . . . . . . . . . . . 40DANOCRINE . . . . . . . . . . . . . . 40DANTRIUM . . . . . . . . . . . . . . . 38dantrolene . . . . . . . . . . . . . . . . 38dapsone . . . . . . . . . . . . . . . . . . 36DARAPRIM . . . . . . . . . . . . . . . 36darbepoetin alfa . . . . . . . . . . . . 8darolutamide . . . . . . . . . . . . . . . 6darunavir . . . . . . . . . . . . . .35, 36darunavir/cobicistat . . . . . . . . 36dasatinib . . . . . . . . . . . . . . . . . . . 4DAURISMO . . . . . . . . . . . . . . . . 7DAYPRO . . . . . . . . . . . . . . .14, 38DAYTRANA . . . . . . . . . . . . . . . 47DDAVP . . . . . . . . . . . . . . . . . . . 27DEBROX . . . . . . . . . . . . . .22, 65DECADRON . . . . . . . . . . . . . . 24decongestants . . . . . 24, 53, 67deferasirox . . . . . . . . . . . . . . . . . 8DELATESTRYL . . . . . . . . . . . . 25delavirdine . . . . . . . . . . . . . . . . 34DELFEN . . . . . . . . . . . . . . . . . . 65DELSTRIGO . . . . . . . . . . . . . . 34DELSYM . . . . . . . . . . . . . . .54, 65DELTASONE . . . . . . . . . . . . . . 24DELZICOL . . . . . . . . . . . . . . . . 30DEMADEX . . . . . . . . . . . . . . . . 11

74


Index of Covered DrugsDEPAKENE . . . . . . . . . . . . . . . 18DEPAKOTE . . . . . . . . 16, 17, 47DEPAKOTE ER . . . . . . . . . . . . 17DEPAKOTE

SPRINKLE . . . . . . 16, 17, 47DEPEN TITRATABLE . . . . . . . 37DEPO-PROVERA . . . . . . . . . . 39DEPO-TESTOSTERONE . . . . 25DERMA-SMOOTHE OIL/FS . 19DERMAPHOR OINTMENT . . 64dermatological baths . . . . . . . 65DERMATOP . . . . . . . . . . . . . . . 19DESCOVY . . . . . . . . . . . . . . . . 35DESENEX . . . . . . . . . . . . . . . . 20desipramine . . . . . . . . . . . . . . . 48desmopressin . . . . . . . . . . . . . 27desogestrel/EE . . . . . . . . .39, 40DESOXYN . . . . . . . . . . . . . . . . 46desvenlafaxine fumarate tab

SR 24HR . . . . . . . . . . . . . . 48desvenlafaxine succinate tab

SR 24HR . . . . . . . . . . . . . . 48desvenlafaxine tab SR

24HR . . . . . . . . . . . . . . . . . 48DESYREL . . . . . . . . . . . . . . . . . 49DETROL . . . . . . . . . . . . . . . . . . 58dexamethasone . . . . 22, 24, 42dexamethasone sodium

phosphate . . . . . . . . . . . . . 42DEXASOL . . . . . . . . . . . . . . . . 42DEXEDRINE . . . . . . . . . . .45, 46DEXEDRINE SPANSULE . . . . 46dexmethylphenidate . . . . . . . . 45dexmethylphenidate HCL cap

SR 24 HR . . . . . . . . . . . . . 45dextroamphetamine . . . . .45, 46dextroamphetamine

extended-release . . . . . . . 46dextroamphetamine sulfate

oral solution . . . . . . . . . . . . 46dextromethorphan hbr . . . . . . 54dextromethorphan polistirex

extended-release . . . . . . . 54dextromethorphan-

guaifenesin . . . . . . . . . . . . 54

dextromethorphan/brompheniramine/pseudoephedrine . . . . . . . 54

dextromethorphan/ guaifenesin . . . . . . . . .54, 56

dextromethorphan/promethazine . . . . . . . . . . 54

dextromethorphan/ quinidine . . . . . . . . . . . . . . 52

DEXTROSTAT . . . . . . . . . . . . . 45DIAMOX SEQUELS . . . . . . . . 43DIASTAT ACUDIAL . . . . . . . . . 17diazepam . . . . . . . . . . 17, 38, 44diazepam concentrate

solution . . . . . . . . . . . . . . . 44DIAZEPAM INTENSOL . . . . . 44diclofenac 1% gel . . . . . . . . . . 37diclofenac potassium . . . .14, 37diclofenac sodium . . 14, 38, 42diclofenac sodium delayed-

release . . . . . . . . . . . . .14, 38diclofenac sodium extended-

release . . . . . . . . . . . . .14, 38dicloxacillin . . . . . . . . . . . . . . . 32dicyclomine . . . . . . . . . . . . . . . 29didanosine . . . . . . . . . . . . . . . . 34didanosine delayed-release . . 34DIDRONEL. . . . . . . . . . . . . . . . 27DIFFERIN OTC GEL

0.1% . . . . . . . . . . . . . . .18, 64DIFICID . . . . . . . . . . . . . . . . . . . 32DIFLUCAN . . . . . . . . . . . . .32, 41DIGESTIVE PROBIOTIC .30, 66digoxin . . . . . . . . . . . . . . . . . . . . 9DIHISTINE DH . . . . . . . . . . . . . 54DIHYDRO-PE SYP . . . . . . . . . 55dihydroergotamine . . . . . . . . . 15DILACOR XR . . . . . . . . . . . . . . 11DILANTIN . . . . . . . . . . . . . . . . . 17DILANTIN INFATABS . . . . . . . 17DILAUDID . . . . . . . . . . . . . . . . 15diltiazem . . . . . . . . . . . . . . . . . . 11diltiazem extended-release . . 11diltiazem sustained-release . . 11DIMEATAPP DRO

DECONGES . . . . . . . . . . . 24

dimenhydrinate . . . . . . . . . . . . 66DIMETAPP . . . . . . 53, 55, 64, 65DIMETAPP CLD ELX/

ALLERGY . . . . . . . . . . . . . 53DIMETAPP DRO DCON/

CGH . . . . . . . . . . . . . . . . . . 55DIMETAPP DRO

DECONGES . . . . . . . . . . . 65DIMETAPP SYP CGH/CLD . . 53dimethyl fumarate . . . . . . . . . . 16DIP/TET PED INJ . . . . . . . . . . 62diphenhydramine . . . . . . .23, 49diphenoxylate/atropine . . . . . 28diphtheria-tetanus tox

adsorbed (dt) im . . . . . . . . 62DIPROLENE . . . . . . . . . . . . . . 20DIPROLENE AF . . . . . . . . . . . 20dipyridamole . . . . . . . . . . . . . . . 8DISALCID . . . . . . . . . . . . . . . . . 38disopyramide . . . . . . . . . . . . . . . 9disopyramide

extended-release . . . . . . . . 9disulfiram . . . . . . . . . . . . . . . . . 44DITROPAN . . . . . . . . . . . . . . . . 58DITROPAN XL . . . . . . . . . . . . . 58DIURIL . . . . . . . . . . . . . . . . . . . 11DIURIL ORAL SUSPENSION 11divalproex sodium cap

sprinkle . . . . . . . . 16, 17, 47divalproex sodium delayed-

release . . . . . . . . . 16, 17, 47divalproex sodium SR 24hr . . 17docosanol . . . . . . . . . . . . .33, 64docusate calcium plus . . . . . . 27docusate potasssium . . . . . . . 27docusate sodium . . . . . . . . . . 27dofetilide. . . . . . . . . . . . . . . . . . . 9dolutegravir . . . . . . . . . . . . 34-36dolutegravir/lamivudine . .35, 36dolutegravir/rilpivirine . . . . . . . 36DOMEBORO . . . . . . . . . . .22, 65DOMEBORO OTIC . . . . . . . . . 22donepezil . . . . . . . . . . . . . . . . . 13doravirine/lamivudine/

tenofovir disoproxil . . . . . . 34dornase alfa . . . . . . . . . . . . . . . 61

75



dorzolamide . . . . . . . . . . . . . . . 43dorzolamide/timolol maleate 43DOSTINEX . . . . . . . . . . . . . . . . 27DOVATO . . . . . . . . . . . . . . . . . . 36DOVONEX . . . . . . . . . . . . . . . . 20doxazosin . . . . . . . . . . . . . . . 9, 58doxepin . . . . . . . . . . . . . . . . . . 48doxycycline monohydrate . . . 32doxylamine succinate . . . .49, 66DRAMAMINE . . . . . . . . . . . . . 66DRISDOL . . . . . . . . . . . . . . . . . 59dronabinol . . . . . . . . . . . . . . . . 28DROXIA . . . . . . . . . . . . . . . . . . . 7DUAVEE . . . . . . . . . . . . . . . . . . 41dulaglutide . . . . . . . . . . . . . . . . 26DULCOLAX . . . . . . . . . . . . . . . 66duloxetine . . . . . . . . . . . . . . . . 48DUOFILM . . . . . . . . . . . . . .21, 68DUONEB . . . . . . . . . . . . . . . . . 57DURAGESIC . . . . . . . . . . . . . . 15DURATUSS DM ELX . . . . . . . 54DUREX . . . . . . . . . . . . . . . . . . . 65DURICEF . . . . . . . . . . . . . . . . . 31DYANAVEL XR . . . . . . . . . . . . 45DYAZIDE . . . . . . . . . . . . . . . . . 11

EE-OINTMENT . . . . . . . . . . . . . 64E.E.S. . . . . . . . . . . . . . . . . . . . . 32ecothiophate . . . . . . . . . . . . . . 43ECOTRIN . . . . . . . . . . . 8, 37, 67ED A-HIST TABLETS AND

LIQUID . . . . . . . . . . . . . . . . 53edoxaban . . . . . . . . . . . . . . . . . . 7EDURANT . . . . . . . . . . . . . . . . 34efavirenz . . . . . . . . . . . . . . . . . . 34efavirenz/lamivudine/tenofovir

disoproxil fumarate . . . . . . 34EFFEXOR . . . . . . . . . . . . . . . . . 48EFFEXOR XR . . . . . . . . . . . . . . 48EFFIENT . . . . . . . . . . . . . . . . . . . 8EFUDEX . . . . . . . . . . . . . . . . . . 21EGRIFTA . . . . . . . . . . . . . . . . . 26elagolix . . . . . . . . . . . . . . . . . . . 41ELAVIL . . . . . . . . . . . . . . . .16, 48elbasvir/grazoprevir . . . . . . . . 33

ELDEPRYL . . . . . . . . . . . . . . . . 16electrolyte . . . . . . . . . . . . . .59, 66electrolyte rehydrating soln . . 66ELIDEL . . . . . . . . . . . . . . . . . . . 22ELIMITE . . . . . . . . . . . . . . . . . . 21ELIQUIS . . . . . . . . . . . . . . . . . . . 7ELMIRON . . . . . . . . . . . . . . . . . 58ELOCON . . . . . . . . . . . . . . . . . 19eltrombopag . . . . . . . . . . . . . . . 8elvitegravir/cobicistat/

emtricitabine/tenofovir alafenamide fumarate . . . 36

EMEND . . . . . . . . . . . . . . . . . . 28EMETROL . . . . . . . . . . . . . . . . 66EMGALITY . . . . . . . . . . . . . . . . 16emicizumab-kxwh . . . . . . . . . . . 8EMLA . . . . . . . . . . . . . . . . . . . . 22emollients . . . . . . . . . . . . . . . . . 64EMSAM . . . . . . . . . . . . . . . . . . 49emtricitabine . . . . . . . . . . . 34-36emtricitabine/rilpivirine/

tenofovir . . . . . . . . . . . . . . . 35emtricitabine/tenofovir

alafenamide . . . . . . . . .35, 36emtricitabine/tenofovir

disoproxil . . . . . . . . . . . . . . 35EMTRIVA . . . . . . . . . . . . . . . . . 34enalapril . . . . . . . . . . . . . . . . . 8, 9enalapril oral soln . . . . . . . . . . . 8enalapril/hydrochlorothiazide . 9enasidenib . . . . . . . . . . . . . . . . . 4ENBREL . . . . . . . . . . . . . . . . . . 37enfuvirtide . . . . . . . . . . . . . . . . 36ENGERIX-B . . . . . . . . . . . . . . . 62enoxaparin . . . . . . . . . . . . . . . . . 7entacapone . . . . . . . . . . . . . . . 16entecavir . . . . . . . . . . . . . . . . . . 33ENTERIC COATED-

NAPROSYN . . . . . . . . .14, 38ENTOCORT EC . . . . . . . . . . . . 29entrectinib . . . . . . . . . . . . . . . . . 5ENTRESTO . . . . . . . . . . . . . . . . 9ENULOSE . . . . . . . . . . . . . . . . 27EPANED . . . . . . . . . . . . . . . . . . . 8EPCLUSA . . . . . . . . . . . . . . . . . 33epinephrine . . . . . . . . . . . . . . . 61

EPIPEN . . . . . . . . . . . . . . . . . . . 61EPIPEN JR. . . . . . . . . . . . . . . . 61EPIVIR . . . . . . . . . . . . . . . .33, 35EPIVIR HBV . . . . . . . . . . . . . . . 33epoetin alfa-epbx . . . . . . . . . . . 8EPZICOM . . . . . . . . . . . . . . . . . 34EQUANIL . . . . . . . . . . . . . . . . . 44EQUETRO . . . . . . . . . . . . . . . . 52erdafitinib . . . . . . . . . . . . . . . . . . 5erenumab-aooe . . . . . . . . . . . . 16ergocalciferol (D2) . . . . . . . . . 59ergotamine tartrate/caffeine . 15ergotamine/caffeine . . . . . . . . 15ERIVEDGE . . . . . . . . . . . . . . . . . 7ERLEADA . . . . . . . . . . . . . . . . . 5erlotinib . . . . . . . . . . . . . . . . . . . 5ertugliflozin . . . . . . . . . . . . . . . 26ertugliflozin/metformin . . . . . . 26ERY-TAB . . . . . . . . . . . . . . . . . . 32ERYC . . . . . . . . . . . . . . . . . . . . 32ERYGEL . . . . . . . . . . . . . . . . . . 18ERYPED . . . . . . . . . . . . . . . . . . 32ERYTHROCIN . . . . . . . . . . . . . 32erythromycin . . . . . . . 18, 32, 43erythromycin

delayed-release . . . . . . . . . 32erythromycin ethylsuccinate . 32erythromycin stearate . . . . . . . 32erythromycin/sulfisoxazole . . 32ESBRIET . . . . . . . . . . . . . . . . . 61escitalopram . . . . . . . . . . . . . . 47escitalopram 10mg &

methylfolate-B12-B6-D thpk . . . . . . . . . . . . . . . . . . 47

escitalopram oxalate soln . . . 47ESGIC . . . . . . . . . . . . . . . . . . . . 14ESKALITH CR . . . . . . . . . . . . . 47esomeprazole . . . . . . . . . . . . . 29esomeprazole granules . . . . . 29ESTRACE . . . . . . . . . . . . . . . . . 40ESTRACE CRM. . . . . . . . . . . . 40estradiol . . . . . . . . . . . . . . . . . . 40estrogens, conjugated . . . . . . 40estrogens, conjugated/

medroxyprogesterone . . . 40estropipate . . . . . . . . . . . . . . . . 40

76


Index of Covered DrugsESTROSTEP FE . . . . . . . . . . . 40etanercept . . . . . . . . . . . . . . . . 37ethambutol . . . . . . . . . . . . . . . . 31ethionamide . . . . . . . . . . . . . . . 31ethosuximide . . . . . . . . . . . . . . 17ethynodiol diacetate/EE . .39, 40etidronate . . . . . . . . . . . . . . . . . 27etodolac . . . . . . . . . . . . . . .14, 38etonogestrel/EE . . . . . . . . . . . 39etoposide . . . . . . . . . . . . . . . . . . 7etravirine . . . . . . . . . . . . . . . . . . 34EUCRISA . . . . . . . . . . . . . . . . . 21EULEXIN . . . . . . . . . . . . . . . . . . 6EURAX . . . . . . . . . . . . . . . . . . . 21EVEKEO . . . . . . . . . . . . . . . . . . 45everolimus . . . . . . . . . . . . . . . 5, 7EVISTA . . . . . . . . . . . . . . . . . . . 27evolocumab . . . . . . . . . . . . . . . 12EVOTAZ . . . . . . . . . . . . . . . . . . 35EVZIO . . . . . . . . . . . . . . . . . . . . 50EXCEDRIN MIGRAINE . . . . . . 14EXELON . . . . . . . . . . . . . . . . . . 13exemestane . . . . . . . . . . . . . . . . 6EXJADE . . . . . . . . . . . . . . . . . . . 8exogabine . . . . . . . . . . . . . . . . 17ezetimibe . . . . . . . . . . . . . . . . . 12

Ffamotidine . . . . . . . . . . . . .29, 66FANAPT . . . . . . . . . . . . . . . . . . 51FANTASY . . . . . . . . . . . . . . . . . 65FARESTON . . . . . . . . . . . . . . . . 6FARYDAK . . . . . . . . . . . . . . . . . . 4FASENRA . . . . . . . . . . . . . . . . . 58FAZACLO . . . . . . . . . . . . . . . . . 50febuxostat . . . . . . . . . . . . . . . . 38felbamate . . . . . . . . . . . . . . . . . 17felbamate oral susp . . . . . . . . 17FELBATOL . . . . . . . . . . . . . . . . 17FELBATOL ORAL SUSP . . . . 17FELDENE . . . . . . . . . . . . . .14, 38felodipine extended-release . 10FEMARA . . . . . . . . . . . . . . . . . . 6fenofibrate . . . . . . . . . . . . . . . . 12fentanyl transdermal . . . . . . . . 15FEOSOL . . . . . . . . . . . . . . .59, 67

FERGON . . . . . . . . . . . . . . . . . 67ferrous fumarate, ferrous

gluconate, ferrous sulfate, ferrous bis-glycinate chelate . . . . . . . . . . . . . . . . 67

ferrous sulfate . . . . . . . . . .59, 67FETZIMA . . . . . . . . . . . . . . . . . 48fidaxomicin . . . . . . . . . . . . . . . 32filgrastim . . . . . . . . . . . . . . . . . . . 8FINACEA . . . . . . . . . . . . . . . . . 18finasteride . . . . . . . . . . . . . . . . 58fingolimod . . . . . . . . . . . . . . . . 16FIORICET W/CODEINE . . . . . 14FIORINAL . . . . . . . . . . . . . . . . . 14FIORINAL W/CODEINE . . . . . 14FIRAZYR . . . . . . . . . . . . . . . . . 61FIRVANQ . . . . . . . . . . . . . . . . . 32FLAGYL . . . . . . . . . . . . . . .36, 41flecainide . . . . . . . . . . . . . . . . . . 9FLEET ENEMA . . . . . . . . . . . . 66FLEET PHOSPHO-SODA . . . 66FLEXERIL . . . . . . . . . . . . . . . . . 38FLOMAX. . . . . . . . . . . . . . . . . . 58FLONASE . . . . . . . . . . . . . . . . . 24FLORAJEN . . . . . . . . . . . .30, 66FLORANEX . . . . . . . . . . . .30, 66FLORASTOR . . . . . . . . . . .30, 66FLORINEF . . . . . . . . . . . . . . . . 24FLOXIN . . . . . . . . . . . . . . . .23, 31FLOXIN OTIC . . . . . . . . . . . . . . 23FLUAD . . . . . . . . . . . . . . . . . . . 63FLUARIX QUAD . . . . . . . . . . . 63FLUBLOK QUAD . . . . . . . . . . . 62FLUCELVAX QUAD . . . . . . . . 63fluconazole . . . . . . . . . . . .32, 41fludrocortisone . . . . . . . . . . . . 24FLULAVAL QUAD . . . . . . . . . . 63FLUMADINE . . . . . . . . . . . . . . 34FLUMIST QUAD . . . . . . . . . . . 62fluocinolone acetonide . . . . . . 19fluocinonide . . . . . . . . . . . . . . . 20fluocinonide emulsified

base . . . . . . . . . . . . . . . . . . 20fluoride . . . . . . . . . . . . 59, 60, 68fluoride dental rinse . . . . . . . . 68fluorometholone . . . . . . . . . . . 42

fluorouracil . . . . . . . . . . . . . . . . 21fluoxetine . . . . . . . . . . . . . . . . . 47fluoxetine capsule . . . . . . . . . . 47fluoxetine HCL (PMDD) tabs . 47fluoxetine HCL cap delayed-

release 90 mg . . . . . . . . . . 47fluoxetine tablet . . . . . . . . . . . . 47fluphenazine . . . . . . . . . . . . . . 52fluphenazine decanoate . . . . 52flurbiprofen . . . . . . . . . . . . . . . 42flutamide . . . . . . . . . . . . . . . . . . 6fluticasone . . . . . . . . . 19, 24, 57fluticasone furoate . . . . . . . . . 57fluticasone propionate . . . . . . 19fluticasone/salmeterol . . . . . . 57fluvoxamine . . . . . . . . . . . .44, 48fluvoxamine maleate cap SR

24HR . . . . . . . . . . . . . . . . . 48FLUZONE HD PF . . . . . . . . . . 62FLUZONE QUAD. . . . . . . . . . . 63FML LIQUIFILM . . . . . . . . . . . . 42FOCALIN . . . . . . . . . . . . . . . . . 45FOCALIN XR . . . . . . . . . . . . . . 45folic acid . . . . . . . . . . . . . . .59, 60FORFIVO XL . . . . . . . . . . . . . . 49FORTAMET . . . . . . . . . . . . . . . 26FORTICAL . . . . . . . . . . . . . . . . 27FOSAMAX . . . . . . . . . . . . . . . . 27fosamprenavir . . . . . . . . . . . . . 35fosinopril. . . . . . . . . . . . . . . . . . . 9fosinopril/

hydrochlorothiazide . . . . . . 9FURADANTIN SUSP

25 MG/5 ML . . . . . . . . . . . 36furosemide . . . . . . . . . . . . . . . . 11FUZEON . . . . . . . . . . . . . . . . . . 36

Ggabapentin . . . . . . . . . . . . . . . . 17GABITRIL . . . . . . . . . . . . . . . . . 18galantamine . . . . . . . . . . . . . . . 13galcanezumab-gnim . . . . . . . . 16ganciclovir . . . . . . . . . . . . . . . . 33GARDASIL . . . . . . . . . . . . . . . . 62GARDASIL 9 . . . . . . . . . . . . . . 62

77



GATTEX . . . . . . . . . . . . . . . . . . 30gefitinib . . . . . . . . . . . . . . . . . . . . 5GEL-KAM . . . . . . . . . . . . . . . . . 59gemfibrozil . . . . . . . . . . . . . . . . 12GENGRAF . . . . . . . . . . . . . . . . . 6GENTAK . . . . . . . . . . . . . . .19, 43gentamicin . . . . . . . . . . . . .19, 43GENVOYA . . . . . . . . . . . . . . . . 36GEODON . . . . . . . . . . . . . . . . . 52GG/CODEINE . . . . . . . . . . . . . 54GG/DM CR . . . . . . . . . . . . . . . 54GILENYA . . . . . . . . . . . . . . . . . 16GILOTRIF . . . . . . . . . . . . . . . . . . 4glasdegib . . . . . . . . . . . . . . . . . . 7glatiramer acetate . . . . . . . . . . 16glecaprevir/pibrentasvir . . . . . 33GLEEVEC . . . . . . . . . . . . . . . . . 5GLEOSTINE . . . . . . . . . . . . . . . . 4glimepiride . . . . . . . . . . . . . . . . 26glipizide . . . . . . . . . . . . . . . . . . 26glipizide extended-release . . . 26GLUCAGON . . . . . . . . . . . . . . 25GLUCAGON EMERGENCY

KIT . . . . . . . . . . . . . . . . . . . 25glucagon hcl for inj . . . . . . . . . 25glucagon nasal powder . . . . . 25glucagon subcutaneous soln

pref syringe . . . . . . . . . . . . 25glucagon, human

recombinant . . . . . . . . . . . 25GLUCOPHAGE . . . . . . . . . . . . 26GLUCOPHAGE ER . . . . . . . . . 26glucose oral tablets . . . . . . . . 65GLUCOTROL . . . . . . . . . . . . . 26GLUCOTROL XL . . . . . . . . . . . 26GLUCOVANCE . . . . . . . . . . . . 26glyburide . . . . . . . . . . . . . . . . . 26glyburide, micronized . . . . . . . 26glycerin . . . . . . . . . . . . 27, 42, 64GLYCERIN SUPPOSITORY . . 27GLYCERIN TOPICAL . . . . . . . 64glycerol phenylbutyrate . . . . . 62glycopyrrolate . . . . . . . . . . . . . 29GLYNASE . . . . . . . . . . . . . . . . . 26GNP Daily Prenatal . . . . . . . . . 60GRIFULVIN V . . . . . . . . . . . . . . 32

GRIS-PEG . . . . . . . . . . . . . . . . 32griseofulvin microsize . . . . . . . 32griseofulvin ultramicrosize . . . 32guaifenesin . . . . . . . . . . . . 54-56guaifenesin extended-release 55guaifenesin/

pseudoephedrine . . . .54, 55guaifenesin/pseudoephedrine

extended-release . . . . . . . 55guaifenesin/pseudoephedrine/

dextromethorphan . . . . . . 55guanabenz . . . . . . . . . . . . . . . . 13guanfacine . . . . . . . . . . . . . . 9, 46guanfacine ER . . . . . . . . . . . . . 46GUIATUSS AC . . . . . . . . . . . . . 54GUIATUSS DAC . . . . . . . . . . . 54GVOKE PFS . . . . . . . . . . . . . . . 25GYNE-LOTRIMIN . . . . . . .41, 64GYNOL II . . . . . . . . . . . . . . . . . 65

HHAEGARDA . . . . . . . . . . . . . . . 61HALCION . . . . . . . . . . . . . . . . . 49HALDOL . . . . . . . . . . . . . . . . . . 52HALDOL CONCENTRATE . . 52HALDOL DECANOATE . . . . . 52halobetasol . . . . . . . . . . . . . . . 20haloperidol . . . . . . . . . . . . . . . . 52haloperidol decanoate . . . . . . 52haloperidol lactate oral conc . 52HAVRIX . . . . . . . . . . . . . . . . . . . 62HECORIA . . . . . . . . . . . . . . . . . . 6HEMLIBRA . . . . . . . . . . . . . . . . 8heparin . . . . . . . . . . . . . . . . . . . . 7hepatitis a vaccine susp . . . . . 62hepatitis b vaccine

(recombinant) . . . . . . . . . . 62hepatitis b vaccine recombinant

adjuvanted . . . . . . . . . . . . . 62HEPLISAV-B . . . . . . . . . . . . . . 62HEXALEN . . . . . . . . . . . . . . . . . 4HIPREX . . . . . . . . . . . . . . . . . . 58HM One Daily Prenatal . . . . . . 60homatropine . . . . . . . . . . .43, 55HUMALOG MIX 50/50. . . . . . 25HUMALOG MIX 75/25. . . . . . 25

human papillomavirus (hpv) 9-valent recomb vac . . . . . 62

human papillomavirus (hpv) quadrivalent recombinant vac . . . . . . . . . . . . . . . . . . . 62

HUMATIN . . . . . . . . . . . . . . . . . 36HUMIRA . . . . . . . . . . . . . . . . . . 37HUMULIN. . . . . . . . . . . . . .25, 65HUMULIN 70/30 . . . . . . . . . . 25HUMULIN N . . . . . . . . . . . . . . . 25HUMULIN R . . . . . . . . . . . . . . . 25HYCAMTIN . . . . . . . . . . . . . . . . 7HYCODAN . . . . . . . . . . . . . . . . 55hydralazine. . . . . . . . . . . . . . . . 13HYDREA . . . . . . . . . . . . . . . . . . 7hydrochlorothiazide . . . . . . 9-11hydrocodone ER . . . . . . . . . . . 15hydrocodone/

acetaminophen . . . . . . . . . 15hydrocodone/homatropine . . 55HYDROCODONE/TAB

HOMATROP . . . . . . . . . . . 55hydrocortisone

. . . . . .19, 21-24, 29, 65, 66hydrocortisone butyrate . . . . . 19hydrocortisone crm, oint . . . . 65hydrocortisone/aloe . . . . . . . . 19HYDROMET SYP . . . . . . . . . . 55hydromorphone . . . . . . . . . . . 15hydroxychloroquine . . . . .36, 37hydroxyurea . . . . . . . . . . . . . . . . 7hydroxyzine HCL . . . . . . . . . . . 23hydroxyzine pamoate . . . . . . . 23hyoscyamine . . . . . . . . . . .29, 58hyoscyamine sulfate . . . . . . . . 29hyoscyamine sulfate

extended-release . . . . . . . 29HYPERCARE 15% . . . . . . . . . 21HYPERSAL . . . . . . . . . . . . . . . 61HYPERTET S/D . . . . . . . . . . . 63HYPOTEARS . . . . . . . . . . . . . . 67HYTONE . . . . . . . . . . . . . . . . . 19HYTRIN . . . . . . . . . . . . . . . . 9, 58HYZAAR . . . . . . . . . . . . . . . . . . 9

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Index of Covered DrugsI

IBRANCE . . . . . . . . . . . . . . . . . . 5ibrutinib . . . . . . . . . . . . . . . . . . . 5IBUOROFEN TAB

COLD/SIN . . . . . . . . . . . . . 56ibuprofen . . . . . . . . . . 14, 38, 67ibuprofen tabs, chew tabs,

drops, susp . . . . . . . . . . . . 67icatibant . . . . . . . . . . . . . . . . . . 61ICLUSIG . . . . . . . . . . . . . . . . . . . 5idelalisib . . . . . . . . . . . . . . . . . . . 5IDHIFA . . . . . . . . . . . . . . . . . . . . 4ILARIS . . . . . . . . . . . . . . . . . . . 37iloperidone . . . . . . . . . . . . . . . . 51ILUMYA . . . . . . . . . . . . . . . . . . 37imatinib mesylate . . . . . . . . . . . 5IMBRUVICA . . . . . . . . . . . . . . . . 5IMDUR . . . . . . . . . . . . . . . . . . . 12imipramine HCL . . . . . . . . . . . 48imipramine pamoate . . . . . . . 48imiquimod 5% cream . . . . . . . 21IMITREX . . . . . . . . . . . . . . . . . . 15IMITREX 4 MG AND

6 MG INJ . . . . . . . . . . . . . . 15IMODIUM A-D . . . . . . . . . .28, 66IMPAVIDO . . . . . . . . . . . . . . . . 33IMURAN . . . . . . . . . . . . . . . . 6, 37INCRELEX . . . . . . . . . . . . . . . . 26INCRUSE ELLIPTA . . . . . . . . . 57indacaterol . . . . . . . . . . . . . . . . 57indapamide . . . . . . . . . . . . . . . 11INDERAL . . . . . . . . . . . . . .10, 16INDERAL LA . . . . . . . . . . . . . . 10INDERIDE . . . . . . . . . . . . . . . . 10indinavir . . . . . . . . . . . . . . . . . . 35INDOCIN . . . . . . . . . . . . . .14, 38indomethacin . . . . . . . . . .14, 38INFLAMASE FORTE . . . . . . . . 42influenza virus vaccine live

quadrivalent intranasal . . . 62influenza virus vaccine

recombinant hemagglutinin (ha) quadrivalent . . . . . . . . 62

influenza virus vaccine split . . . . . . . . . . . . . . . .62, 63

influenza virus vaccine split high-dose pf . . . . . . . . . . . 62

influenza virus vaccine split pf . . . . . . . . . . . . . . . . . 62

influenza virus vaccine split quadrivalent . . . . . . . . . . . . 63

influenza virus vaccine split quadrivalent pf . . . . . . . . . 63

influenza virus vaccine tiss-cult subunit quadrivalent. . . . . 63

influenza virus vaccine types a&b surface antigen . . . . . 63

INGREZZA . . . . . . . . . . . . . . . . 18INLYTA . . . . . . . . . . . . . . . . . . . . 4inotersen inj . . . . . . . . . . . . . . . 18insulin (vials only) . . . . . . . . . . 65insulin aspart protamine 70%/

insulin aspart 30% . . . . . . 25insulin glargine . . . . . . . . . . . . 25insulin glargine/lixisenatide . . 25insulin human . . . . . . . . . . . . . 25insulin isophane . . . . . . . . . . . 25insulin isophane human . . . . . 25insulin isophane human 70%/

regular 30% . . . . . . . . . . . . 25insulin isophane/regular . . . . 25insulin lisopro pro/lispro . . . . 25insulin lisopro prot/lispro . . . . 25insulin lispro . . . . . . . . . . . . . . . 25insulin pen needle . . . . . . . . . 62insulin regular . . . . . . . . . . . . . 25insulin syringes . . . . . . . . . . . . 62INTAL . . . . . . . . . . . . . . . . . . . . 57INTELENCE . . . . . . . . . . . . . . . 34interferon alfa-2b . . . . . . . . . 6, 33interferon gamma-1b . . . . . . . . 6INTRON A . . . . . . . . . . . . . . 6, 33INTUNIV . . . . . . . . . . . . . . . . . . 46INVEGA . . . . . . . . . . . . . . . . . . 51INVEGA SUSTENNA . . . . . . . 51INVEGA TRINZA . . . . . . . . . . . 51INVIRASE . . . . . . . . . . . . . . . . . 35ipratropium . . . . . . . . . . . .24, 57ipratropium HFA . . . . . . . . . . . 57ipratropium nasal . . . . . . . . . . 24ipratropium/albuterol . . . . . . . 57

IRENKA . . . . . . . . . . . . . . . . . . 48IRESSA . . . . . . . . . . . . . . . . . . . . 5iron . . . . . . . . 39, 40, 59, 60, 67ISENTRESS . . . . . . . . . . . . . . . 34ISENTRESS CHEWABLE . . . 34ISENTRESS HD . . . . . . . . . . . 34ISENTRESS SUSP . . . . . . . . . 34ISMO . . . . . . . . . . . . . . . . . . . . . 12isocarboxazid . . . . . . . . . . . . . 47isoniazid . . . . . . . . . . . . . . . . . . 31ISOPTO ATROPINE . . . . . . . . 43ISOPTO CARPINE . . . . . . . . . 43ISOPTO HOMATROPINE. . . . 43ISOPTO HYOSCINE . . . . . . . . 43ISORDIL . . . . . . . . . . . . . . . . . . 12ISORDIL S.L. . . . . . . . . . . . . . . 12isosorbide dinitrate . . . . . . . . . 12ISOSORBIDE

DINITRATE ER . . . . . . . . . 12isosorbide dinitrate extended-

release . . . . . . . . . . . . . . . . 12isosorbide mononitrate . . . . . 12isosorbide mononitrate

extended-release . . . . . . . 12isotretinoin . . . . . . . . . . . . . . . . 18itraconazole . . . . . . . . . . . .32, 33ivacaftor . . . . . . . . . . . . . . . . . . 61ivermectin . . . . . . . . . . . . . . . . 31ivosidenib . . . . . . . . . . . . . . . . . . 4ixazomib . . . . . . . . . . . . . . . . . . . 5

JJADENU . . . . . . . . . . . . . . . . . . . 8JAKAFI . . . . . . . . . . . . . . . . . . . . 5JULUCA . . . . . . . . . . . . . . . . . . 36

KK-DUR 10 . . . . . . . . . . . . . . . . . 60K-DUR 20 . . . . . . . . . . . . . . . . . 60K-LOR . . . . . . . . . . . . . . . . . . . . 60K-LYTE . . . . . . . . . . . . . . . . . . . 60K-PHOS NEUTRAL . . . . . . . . . 60K-PHOS ORIGINAL . . . . . . . . 60K-TAB M20. . . . . . . . . . . . . . . . 60KALETRA . . . . . . . . . . . . . . . . 35KALYDECO . . . . . . . . . . . . . . . 61

79



KALYDECO GRANULES . . . . 61KAOPECTATE . . . . . . . . . . . . . 66KAPVAY . . . . . . . . . . . . . . . . . . 45KAYEXALATE . . . . . . . . . . . . . 12KAZANO . . . . . . . . . . . . . . . . . 26KEFLEX . . . . . . . . . . . . . . . . . . 31KENALOG . . . . . . . . . 19, 20, 24KENALOG IN ORABASE . . . . 24KEPPRA . . . . . . . . . . . . . . . . . . 17KERLONE . . . . . . . . . . . . . . . . 10ketoconazole . . . . . . . 20, 22, 33ketoprofen . . . . . . . . . . . . .14, 38ketorolac . . . . . . . . . . . . . .14, 42ketorolac tromethamine . . . . . 14ketotifen . . . . . . . . . . . . . . . . . . 42KEVZARA . . . . . . . . . . . . . . . . 37KHEDEZLA . . . . . . . . . . . . . . . 48KIMONO. . . . . . . . . . . . . . . . . . 65KINERET . . . . . . . . . . . . . . . . . 37KLONOPIN . . . . . . . . . . . .17, 44KLONOPIN WAFER . . . . . . . . 44KLOR-CON 10 . . . . . . . . . . . . 60KLOR-CON 8 . . . . . . . . . . . . . 60KORLYM . . . . . . . . . . . . . . . . . 27KRINTAFEL . . . . . . . . . . . . . . . 36KUVAN . . . . . . . . . . . . . . . . . . . 27KUVAN POWDER FOR

SOLUTION . . . . . . . . . . . . 27

Llabetalol . . . . . . . . . . . . . . . . . . 10LAC-HYDRIN . . . . . . . . . . . . . . 21lacosamide . . . . . . . . . . . . . . . 17LACTINEX . . . . . . . . . . . . .30, 66LACTINOL . . . . . . . . . . . . . . . . 21lactulose . . . . . . . . . . . . . . . . . . 27LAMICTAL . . . . . . . . . . . . . . . . 17LAMICTAL CD CHEW TAB . . 17LAMICTAL ODT . . . . . . . . . . . 17LAMICTAL STARTER KIT . . . 17LAMICTAL XR . . . . . . . . . . . . . 17LAMISIL . . . . . . . . . . . . . . .20, 33LAMISIL AT . . . . . . . . . . . . . . . 20lamivudine . . . . . . . . . . . . . 33-36lamivudine/tenofovir disoproxil

fumarate . . . . . . . . . . . .34, 35

lamivudine/zidovudine . . .34, 35lamotrigine . . . . . . . . . . . . . . . . 17lamotrigine chew dispersable

tab . . . . . . . . . . . . . . . . . . . . 17lamotrigine ODT . . . . . . . . . . . 17lamotrigine SR 24hr . . . . . . . . 17lamotrigine starter kit . . . . . . . 17lancets . . . . . . . . . . . . . . . . . . . 62LANOXIN . . . . . . . . . . . . . . . . . . 9lansoprazole . . . . . . . . . . . . . . 29lansoprazole delayed-release 29lapatinib ditosylate . . . . . . . . . . 5LARIAM . . . . . . . . . . . . . . . . . . 36larotrectinib . . . . . . . . . . . . . . . . 5LASIX . . . . . . . . . . . . . . . . . . . . 11latanoprost . . . . . . . . . . . . . . . . 43LATUDA . . . . . . . . . . . . . . . . . . 51laxative enemas . . . . . . . . . . . 66laxatives . . . . . . . . . . . . . . .27, 66leflunomide . . . . . . . . . . . . . . . 37lenalidomide . . . . . . . . . . . . . . . 6lenvatinib . . . . . . . . . . . . . . . . . . 5LENVIMA . . . . . . . . . . . . . . . . . . 5LETAIRIS . . . . . . . . . . . . . . . . . 13letrozole . . . . . . . . . . . . . . . . . . . 6leucovorin . . . . . . . . . . . . . . . . . 5LEUKERAN . . . . . . . . . . . . . . . . 4LEUKINE . . . . . . . . . . . . . . . . . . 8leuprolide . . . . . . . . . . . . . . . . . . 6levalbuterol HCl . . . . . . . . . . . . 57LEVAQUIN . . . . . . . . . . . . . . . . 31levetiracetam . . . . . . . . . . . . . . 17levobunolol . . . . . . . . . . . . . . . 42levocetirizine . . . . . . . . . . . . . . 23levofloxacin . . . . . . . . . . . . . . . 31levomilnacipran . . . . . . . . . . . . 48levonorgestrel . . . . . . . . . .39, 40levonorgestrel/EE . . . . . . .39, 40levothyroxine . . . . . . . . . . . . . . 27LEVOXYL . . . . . . . . . . . . . . . . . 27LEVSIN . . . . . . . . . . . . . . . . . . . 29LEVSINEX . . . . . . . . . . . . . . . . 29LEXAPRO . . . . . . . . . . . . . . . . 47LEXAPRO ORAL

SOLUTION . . . . . . . . . . . . 47LEXIVA . . . . . . . . . . . . . . . . . . . 35

LIBRIUM . . . . . . . . . . . . . . . . . . 44LIDAMANTEL . . . . . . . . . . . . . 22LIDEX . . . . . . . . . . . . . . . . . . . . 20LIDEX E . . . . . . . . . . . . . . . . . . 20lidocaine . . . . . . . . . . . . . . .22, 24lidocaine patch . . . . . . . . . . . . 22lidocaine viscous . . . . . . . . . . 24lidocaine/prilocaine . . . . . . . . 22LIDODERM . . . . . . . . . . . . . . . 22LIFESTYLES . . . . . . . . . . . . . . 65lifitegrast . . . . . . . . . . . . . . . . . . 43LIMBITROL DS . . . . . . . . . . . . 48linezolid . . . . . . . . . . . . . . . . . . 36liothyronine . . . . . . . . . . . . . . . 27LIPITOR . . . . . . . . . . . . . . . . . . 12liraglutide . . . . . . . . . . . . . . . . . 26lisdexamfetamine . . . . . . . . . . 46lisdexamfetamine chewable

tab . . . . . . . . . . . . . . . . . . . . 46lisinopril . . . . . . . . . . . . . . . . 9, 92lisinopril/hydrochlorothiazide . 9lithium carbonate . . . . . . . . . . 47lithium carbonate extended-

release . . . . . . . . . . . . . . . . 47LITHOBID . . . . . . . . . . . . . . . . . 47lixisenatide . . . . . . . . . . . . .25, 26LMX-4 . . . . . . . . . . . . . . . . . . . . 22LO/OVRAL . . . . . . . . . . . . . . . . 39LOCOID . . . . . . . . . . . . . . . . . . 19LODINE . . . . . . . . . . . . . . .14, 38LOESTRIN 1/20 . . . . . . . . . . . 39LOESTRIN 1.5/30 . . . . . . . . . 39LOESTRIN FE 1/20 . . . . . . . . 39LOESTRIN FE 1.5/30 . . . . . . . 39lofexidine . . . . . . . . . . . . . . . . . 50LOFIBRA . . . . . . . . . . . . . . . . . 12LOHIST-D . . . . . . . . . . . . . . . . . 54LOKELMA . . . . . . . . . . . . . . . . 12LOMOTIL . . . . . . . . . . . . . . . . . 28lomustine . . . . . . . . . . . . . . . . . . 4LONITEN . . . . . . . . . . . . . . . . . 13LONSURF . . . . . . . . . . . . . . . . . 4loperamide . . . . . . . . . . . . . . . . 28LOPID . . . . . . . . . . . . . . . . . . . . 12LOPIDINE . . . . . . . . . . . . . . . . . 44lopinavir/ritonavir . . . . . . . . . . 35

80


Index of Covered DrugsLOPRESSOR . . . . . . . . . . . . . . 10loratadine . . . . . . . 23, 24, 55, 64loratadine & pseudoephedrine

SR 24hr . . . . . . . . . . . . . . . 55loratadine/

pseudoephedrine 24, 55, 64loratadine/pseudoephedrine

extended-release . . . . . . . 24lorazepam . . . . . . . . . . . . . . . . 44lorazepam concentrate

solution . . . . . . . . . . . . . . . 44LORAZEPAM INTENSOL . . . 44LORCET . . . . . . . . . . . . . . . . . . 15LORTAB . . . . . . . . . . . . . . . . . . 15LORTAB ELIXIR . . . . . . . . . . . 15losartan . . . . . . . . . . . . . . . . . . . 9losartan/HCTZ . . . . . . . . . . . . . 9LOTENSIN . . . . . . . . . . . . . . . 8, 9LOTENSIN HCT . . . . . . . . . . . . 9LOTRIMIN AF . . . . . . . . . .20, 64LOTRISONE . . . . . . . . . . . . . . . 20lovastatin . . . . . . . . . . . . . . . . . 12LOVAZA . . . . . . . . . . . . . . . . . . 12LOVENOX . . . . . . . . . . . . . . . . . 7loxapine . . . . . . . . . . . . . . .52, 53loxapine aerosol powder

breath activated . . . . . . . . 52LOXITANE . . . . . . . . . . . . . . . . 53LOZOL . . . . . . . . . . . . . . . . . . . 11LUCEMYRA . . . . . . . . . . . . . . . 50LUDIOMIL . . . . . . . . . . . . . . . . 49lumacaftor/ivacaftor . . . . . . . . 61LUPRON . . . . . . . . . . . . . . . . . . 6LUPRON DEPOT . . . . . . . . . . . 6LUPRON DEPOT 6-MONTH . . 6LUPRON DEPOT-PED . . . . . . . 6lurasidone . . . . . . . . . . . . . . . . 51LURIDE . . . . . . . . . . . . . . . . . . . 59LURIDE LOZI-TABS. . . . . . . . . 59lusutrombopag . . . . . . . . . . . . . 8LUVOX . . . . . . . . . . . . . . . .44, 48LUVOX CR . . . . . . . . . . . . . . . . 48LYNPARZA . . . . . . . . . . . . . . . . 7LYRICA . . . . . . . . . . . . . . . . . . . 17LYRICA SOLUTION . . . . . . . . 17

LYSODREN . . . . . . . . . . . . . . . . 7LYSTEDA . . . . . . . . . . . . . . . . . 41

MM-CLEAR WC . . . . . . . . . . . . . 54M-M-R II . . . . . . . . . . . . . . . . . . 63MAALOX . . . . . . . . . . . . . .28, 66MAALOX LIQUID . . . . . . . . . . 66macitentan . . . . . . . . . . . . . . . . 13MACROBID . . . . . . . . . . . . . . . 36MACRODANTIN . . . . . . . . . . . 36MAG-OX . . . . . . . . . . . . . . .59, 67magnesium citrate soln . . . . . 28magnesium oxide . . . . . . .59, 67malathion . . . . . . . . . . . . . . . . . 21MAPAP COLD TAB . . . . . . . . 56maprotiline . . . . . . . . . . . . . . . . 49maraviroc . . . . . . . . . . . . . . . . . 36MARINOL . . . . . . . . . . . . . . . . . 28MARPLAN . . . . . . . . . . . . . . . . 47MATULANE . . . . . . . . . . . . . . . . 7MAVIK . . . . . . . . . . . . . . . . . . . . . 9MAVYRET . . . . . . . . . . . . . . . . 33MAXALT/MAXALT MLT . . . . . 15MAXITROL. . . . . . . . . . . . . . . . 42MAXZIDE . . . . . . . . . . . . . . . . . 11MAYZENT . . . . . . . . . . . . . . . . 16measles, mumps & rubella

virus vaccines for inj . . . . . 63mecasermin . . . . . . . . . . . . . . . 26meclizine . . . . . . . . . . . . . .28, 66MEDROL . . . . . . . . . . . . . . . . . 24medroxyprogesterone

acetate . . . . . . . . . . . . .39, 41mefloquine . . . . . . . . . . . . . . . . 36MEGACE . . . . . . . . . . . . . . . . . . 6megestrol acetate . . . . . . . . . . . 6MEKINIST . . . . . . . . . . . . . . . . . 5MELLARIL . . . . . . . . . . . . . . . . 53meloxicam . . . . . . . . . . . . .14, 38melphalan . . . . . . . . . . . . . . . . . 4memantine . . . . . . . . . . . . . . . . 13MENACTRA . . . . . . . . . . . . . . . 63meningococcal (a, c, y, and

w-135) . . . . . . . . . . . . . . . . 63

meningococcal (a, c, y, and w-135) conjugate vaccine . . . . . . . . . . . . . . . . 63

meningococcal (a, c, y, and w-135) oligo conj vac for inj . . . . . . . . . . . . . . . . . . 63

MENOMUNE . . . . . . . . . . . . . . 63MENVEO . . . . . . . . . . . . . . . . . 63MEPHYTON . . . . . . . . . . . . . . 60mepolizumab injection . . . . . . 58meprobamate tablet . . . . . . . . 44MEPRON . . . . . . . . . . . . . . . . . 33mercaptopurine . . . . . . . . . . . . . 4mesalamine . . . . . . . . . . . .29, 30mesalamine

extended-release . . . . . . . 30mesalamine supp . . . . . . . . . . 30mesna . . . . . . . . . . . . . . . . . . . . . 5MESNEX . . . . . . . . . . . . . . . . . . 5MESTINON . . . . . . . . . . . . . . . 16MESTINON TIMESPAN . . . . . 16METADATE CD . . . . . . . . . . . . 46METADATE ER . . . . . . . . . . . . 46METAMUCIL . . . . . . . . . . . . . . 66metformin . . . . . . . . . . . . . . . . . 26metformin ER . . . . . . . . . . . . . 26metformin/glyburide . . . . . . . . 26methadone tab for oral

suspension . . . . . . . . . . . . 15METHADOSE . . . . . . . . . . . . . 15methamphetamine . . . . . . . . . 46methazolamide . . . . . . . . . . . . 43methenamine . . . . . . . . . . . . . 58methenamine hippurate . . . . . 58METHERGINE . . . . . . . . . .27, 41methimazole . . . . . . . . . . . . . . 27methocarbamol . . . . . . . . . . . . 38methotrexate . . . . . . . . . . . . . . 37methoxsalen . . . . . . . . . . . . . . 21methsuximide . . . . . . . . . . . . . 17methyldopa . . . . . . . . . . . . . . . 13methyldopa/HCTZ . . . . . . . . . 13methylene blue . . . . . . . . . . . . 58methylergonovine . . . . . . .27, 41METHYLIN . . . . . . . . . . . . . . . . 46methylphenidate . . . . . . . .46, 47

81



methylphenidate chew tabs . 46methylphenidate extended-

release . . . . . . . . . . . . . . . . 46methylphenidate extended-

release disintegrating . . . . 46methylphenidate extended-

release suspension . . . . . 46methylphenidate HCL

cap CR . . . . . . . . . . . . . . . . 46methylphenidate HCL chew tab

extended-release . . . . . . . 46methylphenidate HCL ER

24hr . . . . . . . . . . . . . . . . . . 47methylphenidate patch. . . . . . 47methylprednisolone . . . . . . . . 24metipranolol . . . . . . . . . . . . . . . 42metoclopramide . . . . . . . . . . . 28metolazone . . . . . . . . . . . . . . . 11metoprolol . . . . . . . . . . . . . . . . 10metoprolol succinate . . . . . . . 10METROCREAM . . . . . . . . . . . 21METROGEL . . . . . . . . . . . .21, 41METROGEL 1% . . . . . . . . . . . 41METROGEL-VAGINAL . . . . . . 41METROLOTION . . . . . . . . . . . 21metronidazole . . . . . . 21, 36, 41MEVACOR . . . . . . . . . . . . . . . . 12mexiletine . . . . . . . . . . . . . . . . . 10MEXITIL . . . . . . . . . . . . . . . . . . 10MIACALCIN . . . . . . . . . . . . . . . 27MICATIN . . . . . . . . . . . . . . .20, 64miconazole . . . . . . . . 20, 41, 64miconazole crm . . . . . . . . . . . 64MICRO-K 10 . . . . . . . . . . . . . . 61MICRONASE . . . . . . . . . . . . . . 26MICROZIDE . . . . . . . . . . . . . . . 11MIDAMOR . . . . . . . . . . . . . . . . 11midodrine . . . . . . . . . . . . . . . . . 13midostaurin . . . . . . . . . . . . . . . . 5mifepristone . . . . . . . . . . . . . . . 27MIGERGOT

SUPPOSITORIES . . . . . . . 15miltefosine . . . . . . . . . . . . . . . . 33MINIPRESS . . . . . . . . . . . . . . . . 9MINOCIN . . . . . . . . . . . . . . . . . 32

minocycline . . . . . . . . . . . . . . . 32minoxidil . . . . . . . . . . . . . . . . . . 13MINUTUSS DR SYP . . . . . . . . 55MIRALAX . . . . . . . . . . . . . . . . . 28MIRAPEX . . . . . . . . . . . . . . . . . 16MIRCETTE . . . . . . . . . . . . . . . . 39mirtazapine . . . . . . . . . . . . . . . 49mirtazapine ODT . . . . . . . . . . . 49MIRVASO . . . . . . . . . . . . . . . . . 21misoprostol . . . . . . . . . . . . . . . 30MITIGARE . . . . . . . . . . . . . . . . 38mitotane . . . . . . . . . . . . . . . . . . . 7MOBAN . . . . . . . . . . . . . . . . . . 52MOBIC . . . . . . . . . . . . . . . .14, 38MODICON . . . . . . . . . . . . . . . . 39MODURETIC . . . . . . . . . . . . . . 11molindone . . . . . . . . . . . . . . . . 52mometasone . . . . . . . . . . .19, 57mometasone furoate . . . . . . . 19MONISTAT . . . . . . . . . . . . .41, 64MONISTAT 3 . . . . . . . . . . . . . . 41MONISTAT-DERM . . . . . . . . . . 20MONOPRIL . . . . . . . . . . . . . . . . 9MONOPRIL-HCT . . . . . . . . . . . . 9montelukast . . . . . . . . . . . . . . . 58morphine . . . . . . . . . . . . . . . . . 15morphine extended-release . . 15MOTEGRITY . . . . . . . . . . . . . . 28MOTRIN . . . . . . . . . . . 14, 38, 67MOTRIN IB . . . . . . . . . . . . . . . 67MOVANTIK . . . . . . . . . . . . . . . 28MOZOBIL . . . . . . . . . . . . . . . . . . 8MS CONTIN . . . . . . . . . . . . . . . 15MSIR . . . . . . . . . . . . . . . . . . . . . 15MUCINEX . . . . . . . . . . . . . .54, 55MUCINEX D . . . . . . . . . . . . . . . 55MUCINEX DM . . . . . . . . . . . . . 54MUCOMYST . . . . . . . . . . . . . . 61MULPLETA . . . . . . . . . . . . . . . . 8MULTI SYMPTOM TAB COLD

RLF . . . . . . . . . . . . . . . . . . . 56multiple vitamin chewable tablet

and drops . . . . . . . . . . . . . 59multivitamins/fluoride/±iron . 59multivitamins/minerals . . . . . . 60mupirocin . . . . . . . . . . . . . . . . . 19

MURINE . . . . . . . . . . . . . . . . . . 67MURO 128 . . . . . . . . . . . . . . . 44MYAMBUTOL . . . . . . . . . . . . . 31MYCELEX . . . . . . . . . . . . .20, 32MYCOBUTIN . . . . . . . . . . . . . . 31mycophenolate mofetil . . . . . . . 6mycophenolate sodium . . . . . . 6MYCOSTATIN . . . . . . . . . .20, 33MYDAYIS . . . . . . . . . . . . . . . . . 45MYFORTIC. . . . . . . . . . . . . . . . . 6MYLANTA . . . . . . . . . . . . .28, 66MYLANTA LIQUID . . . . . . . . . 66MYLERAN . . . . . . . . . . . . . . . . . 4MYLICON . . . . . . . . . . . . . . . . . 66MYORISAN . . . . . . . . . . . . . . . 18MYSOLINE . . . . . . . . . . . . . . . . 18MYTESI . . . . . . . . . . . . . . . . . . 28

Nnabumetone . . . . . . . . . . . . . . 14naloxegol . . . . . . . . . . . . . . . . . 28naloxone . . . . . . . . . . . . . . . . . . 50naloxone hcl solution auto-

injector . . . . . . . . . . . . . . . . 50NALOXONE INJ . . . . . . . . . . . 50naltrexone . . . . . . . . . . . . .44, 50NAMENDA . . . . . . . . . . . . . . . . 13naphazoline HCL . . . . . . . . . . 42naphazoline/glycerin . . . . . . . 42naphazoline/zinc sulfate . . . . 42NAPHCON A . . . . . . . . . . . . . . 67NAPROSYN . . . . . . . . . . . .14, 38naproxen . . . . . . . . . . . . . .14, 38naproxen delayed

release . . . . . . . . . . . . .14, 38naratriptan . . . . . . . . . . . . . . . . 15NARCAN NASAL SPRAY . . . 50NARDIL . . . . . . . . . . . . . . . . . . 47NASACORT ALLERGY 24

HOUR . . . . . . . . . . . . . . . . . 24nasal sprays . . . . . . . . . . . . . . . 65NASALCROM . . . . . . . . . . . . . 24nateglinide . . . . . . . . . . . . . . . . 26NATROBA . . . . . . . . . . . . . . . . 21NAVANE . . . . . . . . . . . . . . . . . . 53NEBUPENT . . . . . . . . . . . . . . . 33

82


Index of Covered DrugsNEBUSAL . . . . . . . . . . . . . . . . 61nefazodone . . . . . . . . . . . . . . . 49nelfinavir . . . . . . . . . . . . . . . . . . 35NEO-SYNEPHRINE . . . . .24, 65neomycin sulfate . . . . . . . . . . . 36neomycin/bacitracin/

polymyxin . . . . . . . . . . . . . . 43neomycin/polymyxin B/

bacitracin . . . . . . . . . . . . . . 19neomycin/polymyxin B/

dexamethasone . . . . . . . . 42neomycin/polymyxin B/

gramicidin . . . . . . . . . . . . . 43neomycin/polymyxin B/

hydrocortisone . . . . . . . . . 23NEORAL . . . . . . . . . . . . . . . . . . 6NEOSPORIN . . . . . . . 19, 43, 65NEPHROCAPS . . . . . . . . . . . . 60NEPTAZANE . . . . . . . . . . . . . . 43NESINA . . . . . . . . . . . . . . . . . . 26NEULASTA . . . . . . . . . . . . . . . . 8NEUMEGA . . . . . . . . . . . . . . . . . 8NEURONTIN . . . . . . . . . . . . . . 17NEUTROGENA OIL FREE

ACNE WASH . . . . . . . . . . . 19nevirapine . . . . . . . . . . . . . . . . 34nevirapine ER . . . . . . . . . . . . . 34NEXAVAR . . . . . . . . . . . . . . . . . 5NEXIUM 24HR OTC . . . . . . . . 29NEXIUM DELAYED RELEASE

PACKET . . . . . . . . . . . . . . . 29niacin . . . . . . . . . . . . . . . . . . . . 12niacin extended-release . . . . . 12NIACOR . . . . . . . . . . . . . . . . . . 12NIASPAN . . . . . . . . . . . . . . . . . 12NICODERM CQ . . . . . . . .52, 67NICODERM CQ . . . . . . . . . . . 67NICORETTE OTC . . . . . . . . . . 52nicotine . . . . . . . . . . . . . . . .52, 67NICOTINE GUM . . . . . . . . . . . 67nicotine inhaler system . . . . . 52nicotine nasal spray . . . . . . . . 52nicotine polacrilex gum . . . . . 52nicotine polacrilex lozenge . . 52nicotine TD patch 24 HR kit . 52NICOTROL INHALER. . . . . . . 52

NICOTROL NS . . . . . . . . . . . . 52nifedipine . . . . . . . . . . . . . . . . . 10nifedipine extended-release . 10nilotinib . . . . . . . . . . . . . . . . . . . . 5nimodipine . . . . . . . . . . . . . . . . 10nimodipine oral soln . . . . . . . . 10NIMOTOP. . . . . . . . . . . . . . . . . 10NINLARO . . . . . . . . . . . . . . . . . . 5nintedanib . . . . . . . . . . . . . . . . 61niraparib . . . . . . . . . . . . . . . . . . . 7NIRAVAM . . . . . . . . . . . . . . . . . 44nitazoxanide suspension . . . . 33nitazoxanide tablet . . . . . . . . . 33nitisinone . . . . . . . . . . . . . . . . . 27NITREK . . . . . . . . . . . . . . . . . . 12NITRO-BID . . . . . . . . . . . . . . . . 12NITRO-DUR . . . . . . . . . . . . . . . 12nitrofurantoin

extended-release . . . . . . . 36nitrofurantoin macrocrystals . 36nitrofurantoin susp . . . . . . . . . 36nitroglycerin . . . . . . . . . . . .12, 22NITROLINGUAL . . . . . . . . . . . 12NITROSTAT . . . . . . . . . . . . . . . 12NITYR . . . . . . . . . . . . . . . . . . . . 27NIX . . . . . . . . . . . . . . . . . . .21, 66NIX CREME RINSE . . . . . . . . . 21NIZORAL . . . . . . . . . . 20, 22, 33NIZORAL SHAMPOO. . . . . . . 22NOCDURNA . . . . . . . . . . . . . . 27NOLVADEX . . . . . . . . . . . . . . . . 6NORCO . . . . . . . . . . . . . . . . . . 15NORDETTE . . . . . . . . . . . . . . . 39norelgestromin/EE . . . . . . . . . 40norethindrone . . . . . . . . . . 39-41norethindrone acetate . . . 39-41norethindrone acetate/

EE . . . . . . . . . . . . . . . . .39, 40norethindrone acetate/

EE/iron . . . . . . . . . . . . .39, 40norethindrone/EE . . . . . . .39, 40norethindrone/ME . . . . . . . . . 40NORFLEX . . . . . . . . . . . . . . . . 38norgestimate/EE . . . . . . . .39, 40norgestrel/EE . . . . . . . . . .39, 40NORPACE . . . . . . . . . . . . . . . . . 9

NORPACE CR . . . . . . . . . . . . . . 9NORPRAMIN . . . . . . . . . . . . . . 48nortriptyline . . . . . . . . . . . . . . . 48NORVASC . . . . . . . . . . . . . . . . 10NORVIR . . . . . . . . . . . . . . . . . . 35NOVAREL . . . . . . . . . . . . . . . . 41NOVOLIN . . . . . . . . . . . . . .25, 65NOVOLIN 70/30 . . . . . . . . . . . 25NOVOLIN N . . . . . . . . . . . . . . . 25NOVOLIN R . . . . . . . . . . . . . . . 25NOVOLOG MIX 70/30 . . . . . . 25NUBEQA . . . . . . . . . . . . . . . . . . 6NUCALA . . . . . . . . . . . . . . . . . 58NUEDEXTA . . . . . . . . . . . . . . . 52NULYTELY . . . . . . . . . . . . . . . . 28NUPLAZID . . . . . . . . . . . . . . . . 51NUVARING . . . . . . . . . . . . . . . 39NUVIGIL . . . . . . . . . . . . . . . . . . 14NUZYRA . . . . . . . . . . . . . . . . . 32NYMALIZE . . . . . . . . . . . . . . . . 10nystatin . . . . . . . . . . . . . . . .20, 33NYTOL QUICK CAPS . . . . . . . 49

OOCEAN NASAL SPRAY . . . . . 24octreotide . . . . . . . . . . . . . . . . . . 7OCUFEN . . . . . . . . . . . . . . . . . 42OCUFLOX . . . . . . . . . . . . . . . . 43ODEFSEY. . . . . . . . . . . . . . . . . 35ODOMZO . . . . . . . . . . . . . . . . . . 7OFEV . . . . . . . . . . . . . . . . . . . . 61ofloxacin . . . . . . . . . . . 23, 31, 43OGEN . . . . . . . . . . . . . . . . . . . . 40olanzapine . . . . . . . . . . . . . . . . 51olanzapine INJ. . . . . . . . . . . . . 51olanzapine ODT . . . . . . . . . . . 51olanzapine pamoate for

extended-release IM sus . 51olanzapine-fluoxetine . . . . . . . 51olaparib . . . . . . . . . . . . . . . . . . . 7olodaterol . . . . . . . . . . . . . . . . . 57OLUMIANT . . . . . . . . . . . . . . . 37omadacycline . . . . . . . . . . . . . 32omalizumab . . . . . . . . . . . . . . . 57omega 3 acid ethyl esters . . . 12omeprazole delayed-release . 29

83



OMNICEF . . . . . . . . . . . . . . . . . 31ondansetron . . . . . . . . . . . . . . 28One Touch Systems . . . . . . . . 26One Touch Test Strips . . . . . . 26One-A-Day Womens

Prenatal . . . . . . . . . . . .60, 68ONFI . . . . . . . . . . . . . . . . . . . . . 17oprelvekin . . . . . . . . . . . . . . . . . 8OPSUMIT . . . . . . . . . . . . . . . . . 13OPTIPRANOLOL . . . . . . . . . . 42OPTIVAR . . . . . . . . . . . . . . . . . 42ORAP . . . . . . . . . . . . . . . . . . . . 53ORAPRED . . . . . . . . . . . . . . . . 24ORILISSA . . . . . . . . . . . . . . . . . 41ORKAMBI . . . . . . . . . . . . . . . . 61orphenadrine

extended-release . . . . . . . 38ORTHO COIL . . . . . . . . . . . . . 39ortho diaphragm . . . . . . . . . . . 39ORTHO EVRA . . . . . . . . . . . . . 40ORTHO FLAT . . . . . . . . . . . . . 39ORTHO FLEX . . . . . . . . . . . . . 39ORTHO MICRONOR . . . . . . . 40ORTHO TRI-CYCLEN . . . . . . . 40ORTHO-CEPT . . . . . . . . . . . . . 39ORTHO-CYCLEN . . . . . . . . . . 39ORTHO-NOVUM 1/35 . . . . . . 39ORTHO-NOVUM 1/50 . . . . . . 40ORTHO-NOVUM 10/11 . . . . 39ORTHO-NOVUM 7/7/7 . . . . . 40ORUDIS . . . . . . . . . . . . . . .14, 38OS-CAL . . . . . . . . . . . . . . .59, 67oseltamivir . . . . . . . . . . . . . . . . 34OSENI . . . . . . . . . . . . . . . . . . . . 26OTEZLA . . . . . . . . . . . . . . . . . . 37OVCON 50 . . . . . . . . . . . . . . . . 40OVIDE . . . . . . . . . . . . . . . . . . . . 21OVIDREL . . . . . . . . . . . . . . . . . 41OVRAL . . . . . . . . . . . . . . . .39, 40oxaprozin . . . . . . . . . . . . . .14, 38oxazepam . . . . . . . . . . . . . . . . 44oxcarbazepine . . . . . . . . . . . . . 17OXSORALEN-ULTRA . . . . . . . 21oxybutynin chloride . . . . . . . . 58oxybutynin IR . . . . . . . . . . . . . . 58oxybutynin patch. . . . . . . .58, 67

oxycodone . . . . . . . . . . . . . . . . 15oxycodone/acetaminophen . 15oxycodone/aspirin . . . . . . . . . 15OXYFAST . . . . . . . . . . . . . . . . . 15oxymetazoline . . . . . . . . . . . . . 24oxymorphone ER . . . . . . . . . . 15OXYTROL FOR WOMEN OTC

PATCH . . . . . . . . . . . . .58, 67

Ppalbociclib . . . . . . . . . . . . . . . . . 5paliperidone . . . . . . . . . . . . . . . 51paliperidone tab SR 24HR . . 51palivizumab . . . . . . . . . . . . . . . 36PAMELOR . . . . . . . . . . . . . . . . 48pancrelipase . . . . . . . . . . . . . . 30panobinostat . . . . . . . . . . . . . . . 4PANRETIN . . . . . . . . . . . . . . . . . 7pantoprazole . . . . . . . . . . . . . . 29PARAFON FORTE DSC . . . . . 38PARNATE . . . . . . . . . . . . . . . . . 47paromomycin . . . . . . . . . . . . . 36paroxetine . . . . . . . . . . . . . . . . 48paroxetine HCL oral susp . . . 48paroxetine HCL tab SR 24HR 48paroxetine mesylate tab . . . . . 48PASER . . . . . . . . . . . . . . . . . . . 31pasireotide . . . . . . . . . . . . . . . . . 7patiromer . . . . . . . . . . . . . . . . . 12PAXIL . . . . . . . . . . . . . . . . . . . . 48PAXIL CR . . . . . . . . . . . . . . . . . 48pazopanib . . . . . . . . . . . . . . . . . 5PEDIACARE LIQ MULTI-SY . . 56PEDIALYTE . . . . . . . . . . . .59, 66PEDIAPRED . . . . . . . . . . . . . . . 24PEDIAZOLE . . . . . . . . . . . . . . . 32peg 3350/electrolytes . . . . . . 28peg 3350/sodium bicarbonate/

sodium chloride . . . . . . . . 28peg 3350/sodium bicarbonate/

sodium chloride/potassium chloride . . . . . . . . . . . . . . . 28

PEGASYS . . . . . . . . . . . . . . . . . 33PEGASYS PROCLICK . . . . . . 33pegfilgrastim . . . . . . . . . . . . . . . 8peginterferon alfa-2a . . . . . . . 33

peginterferon alfa-2b . . . . . . . . 6peginterferon beta-1a . . . . . . . 16pegvisomant . . . . . . . . . . . . . . 27penicillamine . . . . . . . . . . . . . . 37penicillin VK . . . . . . . . . . . . . . . 32PENLAC SOLUTION 8% . . . . 20pentamidine isethionate for

nebulization . . . . . . . . . . . . 33pentosan polysulfate . . . . . . . 58pentoxifylline

extended-release . . . . . . . . 8PEPCID . . . . . . . . . . . . . . .29, 66PEPCID AC . . . . . . . . . . . .29, 66PERCOCET . . . . . . . . . . . . . . . 15PERCODAN . . . . . . . . . . . . . . . 15PERIDEX . . . . . . . . . . . . . . . . . 24permethrin . . . . . . . . . . . . .21, 66perphenazine . . . . . . . . . .48, 53PERSANTINE . . . . . . . . . . . . . . 8PERSERIS . . . . . . . . . . . . . . . . 52PEXEVA . . . . . . . . . . . . . . . . . . 48pexidartinib . . . . . . . . . . . . . . . . 5phenazopyridine . . . . . . . . . . . 58phenelzine . . . . . . . . . . . . . . . . 47PHENERGAN . . . . . . . . . .28, 54PHENERGAN DM . . . . . . . . . . 54phenobarbital . . . . . . . . . . . . . 17phenyl salicylate . . . . . . . . . . . 58phenylephrine . . . 23, 24, 53-56phenylephrine/

brompheniramine/dextromethorphan . . . . . . 55

phenylephrine/chlorpheniramine/ dextromethorphan . . . . . . 55

phenylephrine/chlorpheniramine/dihydrocodeine . . . . . . . . . 55

phenylephrine/dextromethorphan . . .55, 56

phenylephrine/dextromethorphan/guaifenesin . . . . . . . . . . . . 56

phenylephrine/ephed/CPM w/carbetapentane . . . . . . 56

phenylephrine/guaifenesin . . 56

84


Index of Covered Drugsphenylephrine/pyrilamine

w/hydrocodone . . . . . . . . 56PHENYLHIST LIQ DH . . . . . . 54PHENYTEK . . . . . . . . . . . . . . . 17phenytoin . . . . . . . . . . . . . . . . . 17phenytoin sodium extended . 17PHILLIPS COLON

HEALTH . . . . . . . . . . . .30, 66PHOS-FLUR . . . . . . . . . . .59, 68PHOSLO . . . . . . . . . . . . . . . . . 61PHOSPHOLINE IODINE . . . . 43phosphorus . . . . . . . . . . . . . . . 60PHRENILIN . . . . . . . . . . . . . . . 14phytonadione. . . . . . . . . . . . . . 60pilocarpine . . . . . . . . . . . . .24, 43PILOPINE HS GEL . . . . . . . . . 43pimavanserin . . . . . . . . . . . . . . 51pimecrolimus . . . . . . . . . . . . . . 22pimozide . . . . . . . . . . . . . . . . . 53PIN-X . . . . . . . . . . . . . . . . . . . . . 31pioglitazone . . . . . . . . . . . . . . . 26PIQRAY . . . . . . . . . . . . . . . . . . . 4pirfenidone capsule . . . . . . . . 61piroxicam . . . . . . . . . . . . . .14, 38PLAN B ONE STEP . . . . . . . . 39PLAQUENIL . . . . . . . . . . . .36, 37PLAVIX . . . . . . . . . . . . . . . . . . . . 8plecanatide . . . . . . . . . . . . . . . 28PLEGRIDY . . . . . . . . . . . . . . . . 16PLENDIL . . . . . . . . . . . . . . . . . 10plerixafor . . . . . . . . . . . . . . . . . . 8PLETAL . . . . . . . . . . . . . . . . . . . 8pneumococcal 13-valent

conjugate . . . . . . . . . . . . . . 63pneumococcal vaccine

polyvalent. . . . . . . . . . . . . . 63PNEUMOVAX . . . . . . . . . . . . . 63PNEUMOVAX 23 . . . . . . . . . . 63podofilox . . . . . . . . . . . . . . . . . 21POLY-VI-FLOR . . . . . . . . . . . . . 59POLY-VI-SOL . . . . . . . . . . . . . . 67polyethylene glycol 3350 . . . . 28polymyxin B/bacitracin . .19, 44polymyxin B/trimethoprim . . . 44polysaccharide iron caps . . . . 67POLYSPORIN . . . . . . . . . . . . . 44

POLYTRIM . . . . . . . . . . . . . . . . 44pomalidomide . . . . . . . . . . . . . . 6POMALYST . . . . . . . . . . . . . . . . 6ponatinib . . . . . . . . . . . . . . . . . . 5potassium acid phosphate . . 60potassium bicarbonate/

potassium citrate effervescent . . . . . . . . . . . . 60

potassium chloride . . 28, 60, 61potassium chloride

extended-release . . . .60, 61potassium citrate . . . . . . . .58, 60POTIGA . . . . . . . . . . . . . . . . . . 17povidone-iodine . . . . . . . . . . . 36PRALUENT . . . . . . . . . . . . . . . 12pramipexole . . . . . . . . . . . . . . . 16pramlintide . . . . . . . . . . . . . . . . 26PRAMLYTE . . . . . . . . . . . . . . . 47PRANDIN . . . . . . . . . . . . . . . . . 26prasugrel . . . . . . . . . . . . . . . . . . 8praziquantel . . . . . . . . . . . . . . . 31prazosin . . . . . . . . . . . . . . . . . . . 9PRECOSE . . . . . . . . . . . . . . . . 26PRED FORTE . . . . . . . . . . . . . 42prednicarbate . . . . . . . . . . . . . 19prednisolone . . . . . . . . . . .24, 42prednisolone acetate . . . . . . . 42prednisolone phosphate . . . . 42prednisolone sodium

phosphate . . . . . . . . . . . . . 24prednisone . . . . . . . . . . . . . . . . 24pregabalin . . . . . . . . . . . . . . . . 17PRELONE . . . . . . . . . . . . . . . . 24PREMARIN . . . . . . . . . . . . . . . 40PREMPHASE . . . . . . . . . . . . . 40PREMPRO . . . . . . . . . . . . . . . . 40prenatal vitamins . . . . . . . . . . . 60PREPARATION H . . . . . . . . . . 66PREVACID . . . . . . . . . . . . . . . . 29PREVACID SOLUTAB . . . . . . 29PREVIDENT . . . . . . . . . . . . . . . 59PREVNAR 13 . . . . . . . . . . . . . 63PREZCOBIX . . . . . . . . . . . . . . 36PREZISTA . . . . . . . . . . . . . . . . 35PRIFTIN . . . . . . . . . . . . . . . . . . 31PRILOSEC . . . . . . . . . . . . . . . . 29

primaquine. . . . . . . . . . . . . . . . 36primidone . . . . . . . . . . . . . . . . . 18PRINCIPEN . . . . . . . . . . . . . . . 32PRISTIQ . . . . . . . . . . . . . . . . . . 48PROAMATINE . . . . . . . . . . . . . 13probenecid . . . . . . . . . . . . . . . 38probiotics . . . . . . . . . . . . . .30, 66procarbazine . . . . . . . . . . . . . . . 7PROCARDIA . . . . . . . . . . . . . . 10PROCARDIA XL . . . . . . . . . . . 10PROCENTRA . . . . . . . . . . . . . 46prochlorperazine . . . . . . . . . . . 28PROCTOSOL HC CREAM

2.5% . . . . . . . . . . . . . . . . . . 21PROCTOZONE CREAM-HC

2.5% . . . . . . . . . . . . . . . . . . 21progesterone micronized

cap . . . . . . . . . . . . . . . . . . . 41PROGRAF . . . . . . . . . . . . . . . . . 6PROLIXIN . . . . . . . . . . . . . . . . . 52PROLIXIN DECANOATE . . . . 52PROMACTA . . . . . . . . . . . . . . . . 8PROMETH VC SYP

6.25-5/5 . . . . . . . . . . . . . . . 56promethazine . . . . . . 28, 54, 56promethazine &

phenylephrine . . . . . . .54, 56PROMETHAZINE SYP DM . . 54PROMETHAZINE VC

W/CODEINE . . . . . . . . . . . 54PROMETHAZINE

W/CODEINE . . . . . . . . . . . 54PROMETRIUM . . . . . . . . . . . . 41propafenone . . . . . . . . . . . . . . 10propranolol . . . . . . . . . . . .10, 16propranolol ER 24HR . . . . . . 10propranolol/HCTZ . . . . . . . . . 10propylthiouracil . . . . . . . . . . . . 27PROSCAR . . . . . . . . . . . . . . . . 58PROTONIX . . . . . . . . . . . . . . . . 29PROTOPIC 0.03% . . . . . . . . . 22PROTOPIC 0.1% . . . . . . . . . . . 22protriptyline . . . . . . . . . . . . . . . 48PROVENTIL . . . . . . . . . . . . . . . 57PROVERA . . . . . . . . . . . . . . . . 41PROZAC . . . . . . . . . . . . . . . . . 47

85



PROZAC WEEKLY . . . . . . . . . 47prucalopride . . . . . . . . . . . . . . 28PSE/GG . . . . . . . . . . . . . . . . . . 55pseudoephedrine tan/

dexchlorphen tan/ DM tan . . . . . . . . . . . . . . . . 56

pseudoephedrine/acetaminophen/dextromethorphan . . . . . . 56

pseudoephedrine/chlorpheniramine/dextromethorphan . . . . . . 56

pseudoephedrine/dextromethorphan/guaifenesin . . . . . . . . . . . . 56

pseudoephedrine/ iburprofen . . . . . . . . . . . . . 56

psyllium . . . . . . . . . . . . . . . . . . 66PULMICORT RESPULES . . . 57PULMOZYME . . . . . . . . . . . . . 61PURINETHOL . . . . . . . . . . . . . . 4pyrantel pamoate . . . . . . . . . . 31pyrazinamide . . . . . . . . . . . . . . 31pyrethrins/piperonyl butoxide

liquid shampoo . . . . . . . . . 66pyrethrins/piperonyl butoxide

shampoo . . . . . . . . . . . . . . 21PYRIDIUM . . . . . . . . . . . . . . . . 58pyridostigmine . . . . . . . . . . . . . 16pyridostigmine

extended-release . . . . . . . 16pyrilamine tan/phenyleph tan 56pyrimethamine . . . . . . . . . . . . 36

QQUESTRAN . . . . . . . . . . . . . . . 11QUESTRAN-LIGHT . . . . . . . . . 11quetiapine . . . . . . . . . . . . . . . . 51quetiapine fumarate tab SR

24HR . . . . . . . . . . . . . . . . . 51QUILLICHEW ER . . . . . . . . . . 46QUILLIVANT XR . . . . . . . . . . . 46quinapril . . . . . . . . . . . . . . . . . . . 9quinapril/hydrochlorothiazide . 9QUINIDINE GLUCONATE

EXT-REL . . . . . . . . . . . . . . 10

quinidine gluconate extended-release . . . . . . . . . . . . . . . . 10

quinidine sulfate . . . . . . . . . . . 10QUINIDINE SULFATE

EXT-REL . . . . . . . . . . . . . . 10quinidine sulfate

extended-release . . . . . . . 10QVAR REDIHALER . . . . . . . . . 57

RR-TANNAMINE . . . . . . . . . . . . 53raloxifene . . . . . . . . . . . . . . . . . 27raltegravir . . . . . . . . . . . . . . . . . 34raltegravir susp . . . . . . . . . . . . 34ramipril . . . . . . . . . . . . . . . . . . . . 9RANEXA . . . . . . . . . . . . . . . . . 13ranitidine . . . . . . . . . . . . . . . . . 29ranitidine syrup . . . . . . . . . . . . 29ranolazine . . . . . . . . . . . . . . . . 13RAPAMUNE. . . . . . . . . . . . . . . . 7RAVICTI . . . . . . . . . . . . . . . . . . 62RAZADYNE . . . . . . . . . . . . . . . 13REBETOL/COPEGUS . . . . . . 33RECOMBIVAX HB . . . . . . . . . 62rectal hydrocortisone crm,

suppositories . . . . . . . . . . . 66RECTIV . . . . . . . . . . . . . . . . . . . 22REESE’S PINWORM

MEDICINE . . . . . . . . . . . . . 31REGLAN . . . . . . . . . . . . . . . . . 28regorafenib . . . . . . . . . . . . . . . . 5REGRANEX . . . . . . . . . . . . . . . 21RELAFEN . . . . . . . . . . . . . . . . . 14RELENZA. . . . . . . . . . . . . . . . . 34RELION 70/30 . . . . . . . . . . . . 25RELION N . . . . . . . . . . . . . . . . 25RELION R . . . . . . . . . . . . . . . . 25REMERON . . . . . . . . . . . . . . . . 49REMERON SOLTAB . . . . . . . . 49RENVELA . . . . . . . . . . . . . . . . 61repaglinide . . . . . . . . . . . . . . . . 26REPATHA . . . . . . . . . . . . . . . . . 12REQUIP . . . . . . . . . . . . . . . . . . 16RESCRIPTOR . . . . . . . . . . . . . 34RESTORIL . . . . . . . . . . . . . . . . 49RETACRIT . . . . . . . . . . . . . . . . . 8

RETIN-A . . . . . . . . . . . . . . . . . . 19RETROVIR . . . . . . . . . . . . . . . . 35REVATIO . . . . . . . . . . . . . . . . . 13REVIA . . . . . . . . . . . . . . . . .44, 50REVLIMID . . . . . . . . . . . . . . . . . 6REXULTI . . . . . . . . . . . . . . . . . . 50REYATAZ . . . . . . . . . . . . . . . . . 35REYATAZ POWDER

PACKET . . . . . . . . . . . . . . . 35ribavirin . . . . . . . . . . . . . . . . . . . 33RID SHAMPOO . . . . . . . . .21, 66rifabutin . . . . . . . . . . . . . . . . . . 31RIFADIN . . . . . . . . . . . . . . . . . . 31rifampin . . . . . . . . . . . . . . . . . . 31rifapentine . . . . . . . . . . . . . . . . 31rilpivirine . . . . . . . . . . . . . . . 34-36RILUTEK . . . . . . . . . . . . . . . . . 13riluzole . . . . . . . . . . . . . . . . . . . 13rimantadine . . . . . . . . . . . . . . . 34riociguat . . . . . . . . . . . . . . . . . . 13RISA-BID . . . . . . . . . . . . . .30, 66RISAQUAD . . . . . . . . . . . . .30, 66RISPERDAL . . . . . . . . . . . .51, 52RISPERDAL CONSTA . . . . . . 51RISPERDAL M-TAB . . . . . . . . 51RISPERDAL SOLUTION . . . . 52risperidone . . . . . . . . . . . . .51, 52risperidone ODT . . . . . . . . . . . 51risperidone oral soln . . . . . . . . 52risperidone subcutaneous for

ER . . . . . . . . . . . . . . . . . . . . 52RITALIN . . . . . . . . . . . . . . . . . . 46RITALIN LA . . . . . . . . . . . . . . . 46ritonavir . . . . . . . . . . . . . . . . . . . 35rivastigmine . . . . . . . . . . . . . . . 13rizatriptan . . . . . . . . . . . . . . . . . 15RMS . . . . . . . . . . . . . . . . . . . . . 15ROBAXIN . . . . . . . . . . . . . . . . . 38ROBINUL . . . . . . . . . . . . . . . . . 29ROBITUSSIN . . . . . . . . 53-56, 65ROBITUSSIN CF . . . . . . . .55, 65ROBITUSSIN DM . . . . . . .54, 65ROBITUSSIN LIQ

CGH/ALRG . . . . . . . . . . . . 55ROBITUSSIN LIQ

CGH/CLD . . . . . . . . . .53, 56

86


Index of Covered DrugsROBITUSSIN LIQ CGH/

CONG . . . . . . . . . . . . . . . . 54ROBITUSSIN LIQ HD/

CHST . . . . . . . . . . . . . . . . . 56ROBITUSSIN LIQ PED

NGHT . . . . . . . . . . . . . . . . . 56ROBITUSSIN PE . . . . . . . .55, 65ROBITUSSIN PED LIQ

CGH/COLD . . . . . . . . . . . . 53ROBITUSSIN PED SYP . . . . . 54ROBITUSSIN SYP CHST

CNG . . . . . . . . . . . . . . . . . . 55ROBITUSSIN SYP MAX-ST . . 54ROCALTROL . . . . . . . . . . . . . . 59ROCALTROL SOLUTION . . . 59rolapitant . . . . . . . . . . . . . . . . . 28RONDEC DM . . . . . . . . . . . . . 55RONDEC DM DROPS . . . . . . 55RONDEC DROPS . . . . . . . . . . 53RONDEC SYRUP . . . . . . . . . . 53ropinirole . . . . . . . . . . . . . . . . . 16ROWASA . . . . . . . . . . . . . . . . . 29ROXICODONE . . . . . . . . . . . . 15ROZLYTREK . . . . . . . . . . . . . . . 5RUBRACA . . . . . . . . . . . . . . . . . 7rucaparib . . . . . . . . . . . . . . . . . . 7rufinamide . . . . . . . . . . . . . . . . 18ruxolitinib . . . . . . . . . . . . . . . . . . 5RUZURGI . . . . . . . . . . . . . . . . . 38RYDAPT . . . . . . . . . . . . . . . . . . . 5RYNA-12 S . . . . . . . . . . . . . . . 56RYNATAN PEDIATRIC

SUSP . . . . . . . . . . . . . . . . . 54RYNATUSS PEDIATRIC

SUSP . . . . . . . . . . . . . . . . . 56RYTHMOL . . . . . . . . . . . . . . . . 10

SSABRIL SOLUTION . . . . . . . . 18sacubitril/valsartan . . . . . . . . . . 9SAL-TROPINE . . . . . . . . . . . . . 30SALAGEN . . . . . . . . . . . . . . . . 24salicylic acid . . . . . . . 19, 21, 68salicylic acid 17%/

collodion . . . . . . . . . . .21, 68saline nasal spray 0.65% . . . . 24

salsalate . . . . . . . . . . . . . . . . . . 38SANCTURA . . . . . . . . . . . . . . . 58SANDIMMUNE . . . . . . . . . . . . . 6SANDOSTATIN . . . . . . . . . . . . . 7SANTYL . . . . . . . . . . . . . . . . . . 21SAPHRIS . . . . . . . . . . . . . . . . . 50sapropterin . . . . . . . . . . . . . . . . 27sapropterin powder . . . . . . . . 27saquinavir mesylate . . . . . . . . 35SARAFEM . . . . . . . . . . . . . . . . 47sargramostim. . . . . . . . . . . . . . . 8sarilumab . . . . . . . . . . . . . . . . . 37savaysa . . . . . . . . . . . . . . . . . . . . 7SCALPICIN . . . . . . . . . . . . . . . 21scopolamine . . . . . . . . . . . . . . 43SEASONALE . . . . . . . . . . . . . . 39SECTRAL . . . . . . . . . . . . . . . . . 10secukinumab . . . . . . . . . . . . . . 37SEGLUROMET . . . . . . . . . . . . 26selegiline . . . . . . . . . . . . . .16, 49selegiline td patch . . . . . . . . . . 49selenium sulfide . . . . . . . . . . . 22SELSUN . . . . . . . . . . . . . . . . . . 22SELZENTRY . . . . . . . . . . . . . . 36sennosides . . . . . . . . . . . . . . . 28SENOKOT . . . . . . . . . . . . . . . . 28SENSIPAR . . . . . . . . . . . . . . . . 27SERAX . . . . . . . . . . . . . . . . . . . 44SEROMYCIN . . . . . . . . . . . . . . 31SEROQUEL . . . . . . . . . . . . . . . 51SEROQUEL XR . . . . . . . . . . . . 51sertraline . . . . . . . . . . . . . . . . . 48SERZONE . . . . . . . . . . . . . . . . 49sevelamer . . . . . . . . . . . . . . . . . 61SHINGRIX . . . . . . . . . . . . . . . . 63SIGNIFOR . . . . . . . . . . . . . . . . . 7sildenafil . . . . . . . . . . . . . . . . . . 13SILVADENE . . . . . . . . . . . . . . . 19silver sulfadiazine . . . . . . . . . . 19simethicone . . . . . . . . . . . .28, 66simvastatin . . . . . . . . . . . . . . . . 12SINEMET . . . . . . . . . . . . . . . . . 16SINEMET CR . . . . . . . . . . . . . . 16SINEQUAN . . . . . . . . . . . . . . . 48SINGULAIR . . . . . . . . . . . . . . . 58siponimod fumarate . . . . . . . . 16

sirolimus . . . . . . . . . . . . . . . . . . . 7SIRTURO . . . . . . . . . . . . . . . . . 36SM One Daily Prenatal . . . . . . 60sodium bicarbonate . . . . .28, 29sodium chloride for

nebulizer . . . . . . . . . . . . . . 61sodium chloride hypertonic . 44sodium citrate/citric acid . . . . 58sodium phenylbutyrate . . . . . 62sodium phosphate

monobasic . . . . . . . . . . . . . 58sodium polystyrene

sulfonate . . . . . . . . . . . . . . 12sodium zirconium

cyclosilicate . . . . . . . . . . . . 12sofosbuvir/velpatasvir. . . . . . . 33SOLIQUA . . . . . . . . . . . . . . . . . 25somatropin . . . . . . . . . . . . . . . . 26SOMAVERT . . . . . . . . . . . . . . . 27SONATA . . . . . . . . . . . . . . . . . . 49sonidegib . . . . . . . . . . . . . . . . . . 7sorafenib . . . . . . . . . . . . . . . . . . 5SORIATANE . . . . . . . . . . . . . . . 20sotalol . . . . . . . . . . . . . . . . . . . . 10sotalol AF . . . . . . . . . . . . . . . . . 10spacers . . . . . . . . . . . . . . . . . . . 62spinosad . . . . . . . . . . . . . . . . . 21spironolactone. . . . . . . . . . . . . 11spironolactone/

hydrochlorothiazide . . . . . 11SPORANOX . . . . . . . . . . . .32, 33SPRYCEL . . . . . . . . . . . . . . . . . . 4STADOL . . . . . . . . . . . . . . . . . . 15STARLIX . . . . . . . . . . . . . . . . . . 26STATUSS DM SYP . . . . . . . . . 55stavudine . . . . . . . . . . . . . . . . . 35STAVZOR . . . . . . . . . . . . . . . . . 18STEGLATRO . . . . . . . . . . . . . . 26STELAZINE . . . . . . . . . . . . . . . 53STIOLTO . . . . . . . . . . . . . . . . . . 57STIVARGA . . . . . . . . . . . . . . . . . 5stool softeners . . . . . . . . . . . . . 66STRATTERA . . . . . . . . . . . . . . 45STRENSIQ . . . . . . . . . . . . . . . . 27STRIBILD . . . . . . . . . . . . . . . . . 36STRIVERDI RESPIMAT . . . . . 57

87



STROMECTOL . . . . . . . . . . . . 31STUART PRENATAL . . . . . . . 68SUBOXONE . . . . . . . . . . . .49, 50SUBUTEX . . . . . . . . . . . . . . . . 49succimer . . . . . . . . . . . . . . . . . 61sucralfate . . . . . . . . . . . . . . . . . 29sugar+orthophosphoric acid 66sulcralfate . . . . . . . . . . . . . . . . . 29SULFACET-R . . . . . . . . . . . . . . 19sulfacetamide . . . . . . 19, 42, 44sulfacetamide/pred phos . . . 42sulfacetamide/sulfur . . . . . . . . 19sulfamethoxazole/

trimethoprim, DS . . . . . . . 32sulfasalazine . . . . . . . . . . .30, 37sulfasalazine

delayed-release . . . . . .30, 37sulindac . . . . . . . . . . . . . . .14, 38SUMADAN WASH . . . . . . . . . 19sumatriptan . . . . . . . . . . . . . . . 15sunitinib . . . . . . . . . . . . . . . . . . . 5SUPRAX . . . . . . . . . . . . . . . . . . 31SURMONTIL . . . . . . . . . . . . . . 48SUSTIVA . . . . . . . . . . . . . . . . . . 34SUTENT . . . . . . . . . . . . . . . . . . . 5SYLATRON . . . . . . . . . . . . . . . . 6SYMBYAX . . . . . . . . . . . . . . . . 51SYMDEKO . . . . . . . . . . . . . . . . 61SYMFI . . . . . . . . . . . . . . . . . . . . 34SYMFI LO . . . . . . . . . . . . . . . . . 34SYMJEPI . . . . . . . . . . . . . . . . . 61SYMLIN . . . . . . . . . . . . . . . . . . 26SYMMETREL . . . . . . . . . .16, 34SYNAGIS . . . . . . . . . . . . . . . . . 36SYNALAR . . . . . . . . . . . . . . . . 19SYNTHROID . . . . . . . . . . . . . . 27

TT-STAT . . . . . . . . . . . . . . . . . . . 18TABLOID . . . . . . . . . . . . . . . . . . 4tacrolimus . . . . . . . . . . . . . . 6, 22tafamidis . . . . . . . . . . . . . . . . . . 13tafamidis meglumine . . . . . . . 13tafenoquine . . . . . . . . . . . . . . . 36TAFINLAR . . . . . . . . . . . . . . . . . 4TAGAMET . . . . . . . . . . . . . . . . 29

TAMBOCOR . . . . . . . . . . . . . . . 9TAMIFLU . . . . . . . . . . . . . . . . . 34tamoxifen . . . . . . . . . . . . . . . . . . 6tamsulosin . . . . . . . . . . . . . . . . 58TANAFED DMX

SUSPENSION . . . . . . . . . . 56TAPAZOLE . . . . . . . . . . . . . . . . 27TARCEVA . . . . . . . . . . . . . . . . . . 5TARGRETIN . . . . . . . . . . . . . . . . 7TASIGNA . . . . . . . . . . . . . . . . . . 5TASMAR . . . . . . . . . . . . . . . . . . 16TECFIDERA . . . . . . . . . . . . . . . 16teduglutide . . . . . . . . . . . . . . . . 30TEGRETOL . . . . . . . . . . . . . . . 16TEGRETOL-XR . . . . . . . . . . . . 16TEGSEDI . . . . . . . . . . . . . . . . . 18temazepam . . . . . . . . . . . . . . . 49TEMODAR . . . . . . . . . . . . . . . . . 4TEMOVATE . . . . . . . . . . . . . . . 20TEMOVATE E . . . . . . . . . . . . . 20temozolomide . . . . . . . . . . . . . . 4TENEX . . . . . . . . . . . . . . . . . . . . 9TENIVAC . . . . . . . . . . . . . . . . . 63tenofovir . . . . . . . . . . . . . . . 34-36TENORETIC . . . . . . . . . . . . . . 10TENORMIN . . . . . . . . . . . . . . . 10TERAZOL 3/7 . . . . . . . . . . . . . 41terazosin . . . . . . . . . . . . . . . . 9, 58terbinafine . . . . . . . . . . . . .20, 33terconazole . . . . . . . . . . . . . . . 41teriflunomide . . . . . . . . . . . . . . 16tesamorelin . . . . . . . . . . . . . . . 26TESSALON . . . . . . . . . . . . . . . 53TESTOSTERONE 1%

TOPICAL GEL . . . . . . . . . . 25testosterone cypionate . . . . . . 25testosterone enanthate . . . . . . 25testosterone gel topical tube,

packet, and pump bottle . 25tet tox-diph-acell pertuss ad . 63TET/DIP TOX INJ . . . . . . . . . . 63tetanus immune globulin

(human) . . . . . . . . . . . . . . . 63tetanus-diphtheria toxoids

(td) . . . . . . . . . . . . . . . . . . . 63tetrabenazine . . . . . . . . . . . . . . 18

tetrahydrozoline/zinc sulfate . 42tezacaftor/ivcaftor . . . . . . . . . . 61thalidomide . . . . . . . . . . . . . . . . 6THALOMID . . . . . . . . . . . . . . . . 6THEO-24 . . . . . . . . . . . . . . . . . 58THEOCHRON . . . . . . . . . . . . . 58theophylline . . . . . . . . . . . . . . . 58theophylline

extended-release . . . . . . . 58Theranatal One . . . . . . . . . . . . 60thioguanine . . . . . . . . . . . . . . . . 4thioridazine . . . . . . . . . . . . . . . 53thiothixene . . . . . . . . . . . . . . . . 53THORAZINE . . . . . . . . . . . . . . 52tiagabine . . . . . . . . . . . . . . . . . 18TIAZAC . . . . . . . . . . . . . . . . . . . 11TIBSOVO . . . . . . . . . . . . . . . . . . 4ticagrelor . . . . . . . . . . . . . . . . . . 8TIGAN . . . . . . . . . . . . . . . . . . . . 28TIKOSYN . . . . . . . . . . . . . . . . . . 9tildrakizumab-asmn

injection . . . . . . . . . . . . . . . 37timolol maleate . . . . . . . . .42, 43TIMOPTIC . . . . . . . . . . . . . . . . 42TINACTIN . . . . . . . . . . . . . .20, 64tiotropium/olodaterol . . . . . . . 57tipranavir . . . . . . . . . . . . . . . . . 35TIVICAY . . . . . . . . . . . . . . . . . . 34tizanidine . . . . . . . . . . . . . . . . . 38TOBRADEX . . . . . . . . . . . . . . . 42tobramycin . . . . . . . . . 42, 44, 61tobramycin neb soln . . . . . . . . 61tobramycin/

dexamethasone . . . . . . . . 42TOBREX . . . . . . . . . . . . . . . . . . 44TOFRANIL . . . . . . . . . . . . . . . . 48TOFRANIL-PM . . . . . . . . . . . . . 48tolcapone . . . . . . . . . . . . . . . . . 16tolnaftate . . . . . . . . . . . . . .20, 64tolterodine . . . . . . . . . . . . . . . . 58TOPAMAX . . . . . . . . . . . . . . . . 18TOPAMAX SPRINKLE . . . . . . 18topical antibacterials . . . . . . . . 65topiramate . . . . . . . . . . . . . . . . 18topiramate sprinkle caps . . . . 18topotecan . . . . . . . . . . . . . . . . . . 7

88


Index of Covered DrugsTOPROL XL . . . . . . . . . . . . . . . 10TORADOL . . . . . . . . . . . . . . . . 14toremifene . . . . . . . . . . . . . . . . . 6torsemide . . . . . . . . . . . . . . . . . 11TRACLEER . . . . . . . . . . . . . . . 13tramadol . . . . . . . . . . . . . . . . . . 14trametinib . . . . . . . . . . . . . . . . . . 5TRANDATE . . . . . . . . . . . . . . . 10trandolapril . . . . . . . . . . . . . . . . . 9tranexamic acid . . . . . . . . . . . . 41TRANXENE . . . . . . . . . . . . . . . 44tranylcypromine . . . . . . . . . . . . 47trazodone . . . . . . . . . . . . . . . . . 49TRECATOR . . . . . . . . . . . . . . . 31TRENTAL . . . . . . . . . . . . . . . . . . 8tretinoin . . . . . . . . . . . . . . . . 7, 19TRI-FED X. . . . . . . . . . . . . . . . . 56TRI-NORINYL . . . . . . . . . . . . . 40TRI-VI-FLOR . . . . . . . . . . . . . . . 60TRI-VI-SOL . . . . . . . . . . . . .60, 67triamcinolone . . . . . . . 19, 20, 24triamcinolone acetonide .19, 20triamcinolone nasal spray . . . 24triamterene/

hydrochlorothiazide . . . . . 11TRIAVIL . . . . . . . . . . . . . . . . . . 48triazolam . . . . . . . . . . . . . . . . . . 49trifluoperazine . . . . . . . . . . . . . 53trifluridine . . . . . . . . . . . . . . . 4, 44trifluridine/tipiracil . . . . . . . . . . . 4trihexyphenidyl . . . . . . . . . . . . 16TRILAFON . . . . . . . . . . . . . . . . 53TRILEPTAL . . . . . . . . . . . . . . . 17TRILYTE . . . . . . . . . . . . . . . . . . 28trimethobenzamide . . . . . . . . 28trimethoprim . . . . . . . 32, 36, 44trimipramine . . . . . . . . . . . . . . 48TRINTELLIX . . . . . . . . . . . . . . . 49TRIOTANN . . . . . . . . . . . . .23, 53TRIOTANN PEDIATRIC

SUSP . . . . . . . . . . . . . . . . . 53tripolidine/pseudoephedrine 56TRIPROL/PSE SYP . . . . . . . . 56TRIUMEQ . . . . . . . . . . . . . . . . . 35TRIVORA . . . . . . . . . . . . . . . . . 40

TRIZIVIR . . . . . . . . . . . . . . . . . . 34TROJAN . . . . . . . . . . . . . . . . . . 65trospium . . . . . . . . . . . . . . . . . . 58TRULANCE . . . . . . . . . . . . . . . 28TRULICITY . . . . . . . . . . . . . . . . 26TRUSOPT . . . . . . . . . . . . . . . . 43TRUSTEX . . . . . . . . . . . . . . . . . 65TRUVADA . . . . . . . . . . . . . . . . 35TUMS . . . . . . . . . . . . . . . . .66, 67TURALIO . . . . . . . . . . . . . . . . . . 5TUSSI-12 S . . . . . . . . . . . . . . . 53TUSSIN DM . . . . . . . . . . . . . . . 54TYBOST . . . . . . . . . . . . . . . . . . 36TYKERB . . . . . . . . . . . . . . . . . . . 5TYLENOL . . . . . . . 14, 15, 37, 67TYLENOL W/CODEINE . . . . . 15TYMLOS . . . . . . . . . . . . . . . . . 27typhoid vaccine . . . . . . . . . . . . 63

UULORIC . . . . . . . . . . . . . . . . . . 38ULTRA . . . . . . . . . . . . . . . . . . . 26ULTRA 2, ULTRAMINI . . . . . . 26ULTRAM . . . . . . . . . . . . . . . . . . 14ULTRAVATE . . . . . . . . . . . . . . . 20umeclidinium inhalation . . . . . 57UNI-HIST DROps . . . . . . . . . . 53UNIPHYL . . . . . . . . . . . . . . . . . 58UNISOM . . . . . . . . . . . . . . .49, 66UREA . . . . . . . . . . . . . . . . . . . . 22UREA 10% CREAM . . . . . . . . 22UREA 10% LOTION . . . . . . . . 22urea 10%, urea 20% . . . . . . . . 22UREA 20% CREAM . . . . . . . . 22urea 40% . . . . . . . . . . . . . . . . . 22URECHOLINE . . . . . . . . . . . . . 58UREX . . . . . . . . . . . . . . . . . . . . 58uridine . . . . . . . . . . . . . . . . . . . 27UROCIT-K . . . . . . . . . . . . . . . . 58UROXATRAL . . . . . . . . . . . . . . 58URSO . . . . . . . . . . . . . . . . . . . . 30URSO FORTE . . . . . . . . . . . . . 30ursodiol . . . . . . . . . . . . . . . . . . 30UTIRA C . . . . . . . . . . . . . . . . . . 58

VVAGIFEM . . . . . . . . . . . . . . . . . 40vaginal products . . . . . . . . . . . 64valacyclovir . . . . . . . . . . . . . . . . 33valbenazine . . . . . . . . . . . . . . . 18VALCYTE . . . . . . . . . . . . . . . . . 33valganciclovir . . . . . . . . . . . . . . 33VALIUM . . . . . . . . . . . . . . .38, 44valproic acid . . . . . . . . . . . . . . 18valproic acid cap delayed-

release . . . . . . . . . . . . . . . . 18VALTREX . . . . . . . . . . . . . . . . . 33vancomycin powder for oral

solution . . . . . . . . . . . . . . . 32vandetanib . . . . . . . . . . . . . . . . . 5VAQTA . . . . . . . . . . . . . . . . . . . 62varenicline . . . . . . . . . . . . . . . . 52varicella virus vac live for

subcutaneous . . . . . . . . . . 63VARIVAX . . . . . . . . . . . . . . . . . 63VARUBI . . . . . . . . . . . . . . . . . . 28VASERETIC . . . . . . . . . . . . . . . . 9VASOCIDIN . . . . . . . . . . . . . . . 42VASOCLEAR . . . . . . . . . . . . . . 42VASOCLEAR A . . . . . . . . . . . . 42VASOTEC . . . . . . . . . . . . . . . . . . 8VECTICAL . . . . . . . . . . . . . . . . 20VEETIDS . . . . . . . . . . . . . . . . . 32VELTASSA . . . . . . . . . . . . . . . . 12vemurafenib . . . . . . . . . . . . . . . . 5VENCLEXTA . . . . . . . . . . . . . . . 5venetoclax . . . . . . . . . . . . . . . . . 5venlafaxine . . . . . . . . . . . . . . . . 48venlafaxine HCL tab SR

24HR . . . . . . . . . . . . . . . . . 48venlafaxine XR . . . . . . . . . . . . . 48VENTOLIN HFA . . . . . . . . . . . . 57VEPESID . . . . . . . . . . . . . . . . . . 7verapamil . . . . . . . . . . . . . .11, 16verapamil extended-release . . 11VERIO . . . . . . . . . . . . . . . . . . . . 26VERIO, VERIO FLEX, VERIO IQ,

VERIO SYNC . . . . . . . . . . . 26VERSACLOZ . . . . . . . . . . . . . . 51

89



VERZENIO . . . . . . . . . . . . . . . . . 4VESANOID . . . . . . . . . . . . . . . . . 7vfend . . . . . . . . . . . . . . . . . . . . . 33VI-DAYLIN . . . . . . . . . . . . . . . . . 67VICODIN . . . . . . . . . . . . . . . . . . 15VICODIN ES . . . . . . . . . . . . . . . 15VICTOZA 2 PEN PACK . . . . . 26VIDEX . . . . . . . . . . . . . . . . . . . . 34VIDEX EC . . . . . . . . . . . . . . . . . 34vigabatrin oral solution . . . . . . 18VIIBRYD . . . . . . . . . . . . . . . . . . 49vilazodone . . . . . . . . . . . . . . . . 49VIMPAT . . . . . . . . . . . . . . . . . . . 17VIRACEPT . . . . . . . . . . . . . . . . 35VIRAMUNE . . . . . . . . . . . . . . . 34VIRAMUNE XR . . . . . . . . . . . . 34VIREAD . . . . . . . . . . . . . . . . . . 35VIROPTIC . . . . . . . . . . . . . . . . . 44VISINE . . . . . . . . . . . . . . . . . . . 67VISINE-AC . . . . . . . . . . . . . . . . 42vismodegib . . . . . . . . . . . . . . . . 7VISTARIL . . . . . . . . . . . . . . . . . 23VISTOGARD . . . . . . . . . . . . . . 27vitamin A . . . . . . . . . . . . . . . . . 60vitamin ADC/fluoride/±iron

drops . . . . . . . . . . . . . . . . . 60vitamin B complex/vitamin C/

folic acid . . . . . . . . . . . . . . . 60vitamin B-1 . . . . . . . . . . . . . . . . 60VITAMIN B-12 . . . . . . . . . . . . . 59vitamin B-6 . . . . . . . . . . . . . . . . 60vitamin C . . . . . . . . . . . . . . . . . 60VITAMIN D 1000 UNIT . . . . . . 59VITAMIN D 2000 UNIT . . . . . . 59vitamin D 400 IU . . . . . . . . . . . 67VITAMIN D 400 UNIT . . . . . . . 59vitamins pediatric . . . . . . .60, 67vitamins pediatric members

<3 years old . . . . . . . . . . . . 67vitamins prenatal . . . . . . . . . . . 68VITRAKVI . . . . . . . . . . . . . . . . . . 5VIVACTIL . . . . . . . . . . . . . . . . . 48VIVOTIF BERNA . . . . . . . . . . . 63VOLTAREN . . . . . 14, 37, 38, 42VOLTAREN 1% TOPICAL GEL 37

VOLTAREN XR . . . . . . . . .14, 38voriconazole . . . . . . . . . . . . . . 33vorinostat . . . . . . . . . . . . . . . . . . 4vortioxetine. . . . . . . . . . . . . . . . 49VOSOL HC OTIC . . . . . . . . . . 22VOSOL OTIC . . . . . . . . . . . . . . 22VOTRIENT . . . . . . . . . . . . . . . . . 5VRAYLAR . . . . . . . . . . . . . . . . . 50VYNDAMAX . . . . . . . . . . . . . . . 13VYNDAQEL . . . . . . . . . . . . . . . 13VYVANSE . . . . . . . . . . . . . . . . 46VYVANSE CHEWABLE . . . . . 46

Wwarfarin . . . . . . . . . . . . . . . . . . . 7WELLBUTRIN . . . . . . . . . . . . . 49WELLBUTRIN SR . . . . . . . . . . 49WELLBUTRIN XL . . . . . . . . . . 49WIXELA INHUB . . . . . . . . . . . . 57WYTENSIN . . . . . . . . . . . . . . . 13

XXALATAN . . . . . . . . . . . . . . . . . 43XALKORI . . . . . . . . . . . . . . . . . . 4XANAX . . . . . . . . . . . . . . . . . . . 44XANAX XR . . . . . . . . . . . . . . . . 44XELODA . . . . . . . . . . . . . . . . . . . 4XENAZINE . . . . . . . . . . . . . . . . 18XIIDRA . . . . . . . . . . . . . . . . . . . 43XOLAIR . . . . . . . . . . . . . . . . . . 57XOPENEX RESPULES . . . . . . 57XULANE . . . . . . . . . . . . . . . . . . 40XYLOCAINE . . . . . . . . . . . .22, 24XYZAL . . . . . . . . . . . . . . . . . . . 23

Yyuvafem or estradiol vaginal

tablet . . . . . . . . . . . . . . . . . 40

ZZADITOR . . . . . . . . . . . . . .42, 67zaleplon . . . . . . . . . . . . . . . . . . 49ZANAFLEX . . . . . . . . . . . . . . . 38zanamivir . . . . . . . . . . . . . . . . . 34ZANTAC . . . . . . . . . . . . . . . . . . 29

ZARONTIN . . . . . . . . . . . . . . . 17ZAROXOLYN . . . . . . . . . . . . . . 11ZARXIO . . . . . . . . . . . . . . . . . . . 8ZEBETA . . . . . . . . . . . . . . . . . . 10ZEBUTAL . . . . . . . . . . . . . . . . . 14ZEJULA . . . . . . . . . . . . . . . . . . . 7ZELBORAF . . . . . . . . . . . . . . . . 5ZENTANE . . . . . . . . . . . . . . . . . 18ZENZEDI . . . . . . . . . . . . . . . . . 45ZEPATIER . . . . . . . . . . . . . . . . 33ZERIT . . . . . . . . . . . . . . . . . . . . 35ZESTORETIC . . . . . . . . . . . . . . 9ZESTRIL . . . . . . . . . . . . . . . . . . . 9ZETIA . . . . . . . . . . . . . . . . . . . . 12ZIAC . . . . . . . . . . . . . . . . . . . . . 10ZIAGEN . . . . . . . . . . . . . . . . . . 34zidovudine . . . . . . . . . . . . .34, 35zinc . . . . . . . . . . . . . . . . . . .42, 60ziprasidone . . . . . . . . . . . . . . . 52ZITHROMAX . . . . . . . . . . . . . . 32ZOCOR. . . . . . . . . . . . . . . . . . . 12ZOFRAN . . . . . . . . . . . . . . . . . . 28ZOFRAN ODT . . . . . . . . . . . . . 28ZOHYDRO ER . . . . . . . . . . . . . 15ZOLINZA . . . . . . . . . . . . . . . . . . 4ZOLOFT . . . . . . . . . . . . . . . . . . 48zolpidem . . . . . . . . . . . . . . . . . 49ZOMACTON . . . . . . . . . . . . . . 26ZONEGRAN . . . . . . . . . . . . . . 18zonisamide . . . . . . . . . . . . . . . 18ZORTRESS . . . . . . . . . . . . . . . . 7ZOSTAVAX . . . . . . . . . . . . . . . . 63zoster vaccine live . . . . . . . . . . 63zoster vaccine recombinant

adjuvanted . . . . . . . . . . . . . 63ZOVIA 1/35 . . . . . . . . . . . . . . . 39ZOVIA 1/50 . . . . . . . . . . . . . . . 40ZOVIRAX . . . . . . . . . . . . . . . . . 33ZUBSOLV . . . . . . . . . . . . . . . . . 49ZYBAN . . . . . . . . . . . . . . . . . . . 52ZYDELIG . . . . . . . . . . . . . . . . . . 5ZYKADIA . . . . . . . . . . . . . . . . . . 4ZYLOPRIM . . . . . . . . . . . . . . . . 38ZYPREXA . . . . . . . . . . . . . . . . 51ZYPREXA RELPREVV . . . . . . 51

90


Index of Covered DrugsZYPREXA ZYDIS . . . . . . . . . . 51ZYRTEC . . . . . . . . . . . . . . .23, 64ZYRTEC CHEWABLE

TABLET . . . . . . . . . . . . . . . 23ZYRTEC D . . . . . . . . . . . . . . . . 64ZYRTEC-D . . . . . . . . . . . . . . . . 23ZYTIGA . . . . . . . . . . . . . . . . . . . 5ZYVOX . . . . . . . . . . . . . . . . . . . 36

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92

“My Medications” worksheetTake this worksheet with you each time you visit a doctor. Each of your doctors should be aware of every drug you take and you should have a list as well.

Name of Medicineand Strength

DrugTier

I Take ThisMedicine For Directions Doctor

Example: Lisinopril, 20mg Tier 1 High blood pressure One tablet daily Dr. Johnson

Preferred Drug List (PDL) · List of Preferred Drugs. You can read all of the FAQ to learn more, or...

Documents

Transcript of Preferred Drug List (PDL) · List of Preferred Drugs. You can read all of the FAQ to learn more, or...