BCBSRI Large Group 4‐Tier Formulary (Drug List)*
Effective April 1, 2016 to October 1, 2016
A Reference Guide
INTRODUCTION
Below you’ll find the Blue Cross & Blue Shield of Rhode Island (BCBSRI) formulary, which is a list of the prescription drugs covered under your health plan. Our formulary offers a wide range of medications from which to choose and is reviewed periodically by BCBSRI’s Pharmacy and Therapeutics Committee. This committee, which is made up of local, community‐based practicing physicians and pharmacists, evaluates the medications on the formulary for safety and effectiveness and helps to ensure that BCBSRI members have access to medications that support their health.
CONTROLLING COSTS
The BCBSRI formulary divides covered drugs into five “tiers.” Each tier has a corresponding copayment. This allows us to better manage the overall cost of providing prescription drug benefits to our members, while also helping you control what you pay out‐of‐pocket for your medications.
We realize that the BCBSRI formulary may not include every drug from every manufacturer. However, choosing medications from the BCBSRI formulary, when appropriate, can provide you with access to the medications you need—at the most affordable cost.
THE FIVE TIERS
First Tier: Includes generic prescription drugs that have the lowest copayment.
Second Tier: Includes generic prescription drugs that have a higher copayment than the first tier.
Third Tier: Includes high‐cost generic prescription drugs and preferred brand name prescription drugs, which have a higher copayment than the second tier.
Fourth Tier: Includes preferred specialty prescription drugs, which have a higher copayment than the third tier.
HOW TO USE THE FORMULARY REFERENCE GUIDE
This formulary reference guide lists generic drugs first in each drug category. The preferred brand name products are listed next, and non‐preferred brand products are listed last.
PLEASE NOTE: If a generic drug is listed in the “generics” section and its corresponding brand name product is not listed in the “preferred brand name” section, then only the generic drug is on the formulary. If a brand name product is listed in the “preferred brand name” section and its corresponding generic product is not listed in the “generics” section, then a generic version of the medication is not available.
CONSIDERING PREFERRED ALTERNATIVES This formulary reference guide lists possible preferred alternatives for commonly prescribed non‐ preferred medications. However, pharmacists cannot substitute a preferred brand name drug without the prescriber’s approval and will contact the prescriber to obtain authorization to dispense an alternative preferred product when a non‐preferred product has been prescribed.
SAVING ON OUT‐OF‐POCKET COSTS Your health plan’s prescription drug coverage encourages the use of generic and preferred brand name drugs. Choosing non‐preferred drugs may mean paying higher out‐of‐pocket expenses (such as coinsurance, copayments, and deductible amounts) or not receiving coverage at all. You will have lower copayments when you use generic drugs. If you use a brand name drug when there is a generic alternative available, you may be asked to pay the cost difference.
CONSULTING THE PRESCRIBER’S OFFICE WHEN APPROPRIATE BCBSRI’s formulary may provide coverage only for certain medications or for particular uses, time periods, doses, or quantities (for example, the formulary may exclude coverage for medications for unapproved, unproven, or cosmetic indications, as well as over‐the‐counter medications).
When prescription drug coverage is provided based on use or quantity, certain limits may apply. Your prescriber may request an exception based upon your individual circumstances. Contact BCBSRI for additional information to determine whether coverage is available under your plan. Members who are unsure whether these coverage rules apply for a particular medication can consult their BCBSRI subscriber agreement or contact a BCBSRI Customer Service representative to determine specific coverage requirements.
*Formulary Disclaimer: Coverage for some drugs may be limited to specific dosage forms and/or strengths. Your health plan’s benefit design determines what is covered and the applicable copayment. The medications listed on this formulary are subject to change pursuant to the formulary management activities of BCBSRI. The presence of a medication on this formulary list does not guarantee coverage. Certain therapeutic classes are routinely designated as formulary exclusions and are not eligible for coverage. These classes include but are not limited to: Weight Loss, Erectile Dysfunction, Smoking Cessation, OTC status products and drugs with OTC equivalents, Vaccines, products with DESI designations and experimental drugs. Most brand name drugs with generic equivalents are not covered. To see the most up‐to‐date formulary, please visit your member home page on bcbsri.com. You may also call Customer Service at the number listed on the back of your member ID card.
Table of Contents
ANTI-INFECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
PENICILLINS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
CEPHALOSPORIN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
FIRST GENERATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
SECOND GENERATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
THIRD GENERATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
FOURTH GENERATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
MACROLIDES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
TETRACYCLINES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
QUINOLONES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
AMINOGLYCOSIDES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
SULFONAMIDES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
ANTIMYCOBACTERIAL AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
ANTIFUNGALS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
ANTIVIRALS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
ANTIMALARIALS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
AMEBICIDES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
ANTHELMINTICS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
MISC. ANTI-INFECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
ANTINEOPLASTICS, ETC. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
ALKYLATING AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
ANTIMETABOLITES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
HORMONAL AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
IMMUNOMODULATORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
MITOTIC INHIBITORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
ENZYME INHIBITORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
TOPOISOMERASE I INHIBITOR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
ANTINEOPLASTICS MISC. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
CHEMOTHERAPY RESCUE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
ANTINEOPLASTIC COMBO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
CARDIOVASCULAR DRUGS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
CARDIAC GLYCOSIDES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
ANTIANGINAL AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
BETA BLOCKERS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
CALCIUM CHANNEL BLOCKERS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
ANTIARRHYTHMICS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
ACE INHIBITORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
ANGIOTENSIN RCPTR BLOCKER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
DIRECT RENIN INHIBITORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
ANTIHYPERTENSIVES MISC. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
ANTIHYPERTENSIVE COMBO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
DIURETICS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
VASOPRESSORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
ANTIHYPERLIPIDEMICS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
CARDIOVASCULAR - MISC. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
DERMATOLOGICALS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
ACNE PRODUCTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
ROSACEA AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
ANTIBIOTICS - TOPICAL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
ANTIFUNGALS - TOPICAL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
ANTIVIRALS - TOPICAL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
ANTI-INFLAMMATORY AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
ANTIPRURITICS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
ANTIPSORIATICS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
ANTISEBORRHEIC AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
CORTICOSTEROIDS - TOPICAL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
IMMUNOMODULATING AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
DERMATOLOGICALS - MISC. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
ENDOCRINE AND METABOLIC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
CORTICOSTEROIDS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
ANDROGENS-ANABOLIC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
ESTROGENS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
CONTRACEPTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
PROGESTINS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
ANTIDIABETIC AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
INSULIN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
AMYLIN ANALOGS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
INCRETIN MIMETIC AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
SULFONYLUREAS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
BIGUANIDES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
MEGLITINIDE ANALOGUES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
DIABETIC OTHER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
ALPHA-GLUCOSIDASE INHIBIT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
DPP-4 INHIBITORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
INSULIN SENSITIZING AGENT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
ANTIDIABETIC COMBINATIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
BISPHOSPHONATES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
CALCITONINS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
PARATHYROID HORMONE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
RANK LIGAND INHIBITORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
HORMONE RECEPTOR MDLTR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
FERTILITY REGULATORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
LHRH/GNRH AGONIST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
GNRH/LHRH ANTAGONISTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
GROWTH HORMONES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
SOMATOMEDINS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
SOMATOSTATIC AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
GH RECEPTOR ANTAGONISTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
POSTERIOR PITUITARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
CORTICOTROPIN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
PROLACTIN INHIBITORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
VASOPRESSIN ANTAGONISTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
PROGESTERONE ANTAGONISTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
METABOLIC MODIFIERS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
THYROID AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
GASTROINTESTINAL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
LAXATIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
ANTIDIARRHEALS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
ANTACIDS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
ULCER DRUGS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
ANTIEMETICS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
DIGESTIVE AIDS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
GASTROINTESTINAL - MISC. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
GENITOURINARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
URINARY ANTI-INFECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
URINARY ANTISPASMODICS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
VAGINAL PRODUCTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
GENITOURINARY - MISC. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
HEMATOLOGICAL AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
HEMATOPOIETIC AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
ANTICOAGULANTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
HEMOSTATICS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
HEMATOLOGICAL - MISC. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
MOUTH/THROAT/DENTAL AGENT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
NEUROLOGY, CNS, PSYCH . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
ANTIANXIETY AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
ANTIDEPRESSANTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
ANTIPSYCHOTICS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
HYPNOTICS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
ADHD, NARCOLEPSY, ETC. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
ANTICONVULSANTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
ANTIPARKINSON AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
NEUROLOGY, PSYCH - MISC. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
NEUROMUSCULAR AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
MUSCULOSKELETAL AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
ANTIMYASTHENIC AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
OPHTHALMOLOGY AND OTIC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
ANTI-INFECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
ARTIFICIAL TEAR/LUBRICANT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
BETA-BLOCKERS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
OPHTHALMIC STEROIDS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
PROSTAGLANDINS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
CYCLOPLEGIC MYDRIATICS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
DECONGESTANTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
MIOTICS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
ADRENERGIC AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
LOCAL ANESTHETICS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
OPHTHALMICS - MISC. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
OTIC AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
OXYTOCICS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
PAIN MANAGEMENT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
ANALGESICS - NONNARCOTIC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
ANALGESICS - OPIOID . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
ANTI-INFLAMMATORY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
MIGRAINE PRODUCTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
GOUT AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
LOCAL ANESTHETICS-INJ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
RESPIRATORY, ALLERGY, ETC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
ANTIHISTAMINES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
NASAL AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
COUGH/COLD/ALLERGY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
ANTIASTHMATIC/COPD AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
RESPIRATORY AGENTS - MISC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
VITAMINS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
MULTIVITAMINS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
MISCELLANEOUS AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
NON PREFERRED
Maxipime
MACROLIDES
April 2016
TIER 01 GENERIC
azithromycin
ANTI-INFECTIVES
clarithromycin
clarithromycin ER
PENICILLINS
erythromycin
TIER 01 GENERIC
erythromycin base
amoxicillin
erythromycin ethylsuccinate
amoxicillin ER
TIER 03 NON PREFERRED
amoxicillin/clavulanate potassium
DificidST
amoxicillin/clavulanate potassium ER
E.E.S. Granules
ampicillin
Ery-TAB
ampicillin sodium
Eryped 200
ampicillin-sulbactam
Eryped 400
dicloxacillin sodium
Erythrocin Stearate
nafcillin sodium
PCE
oxacillin sodium
Zmax
penicillin v potassium
penicillin G potassium
TETRACYCLINES
penicillin G procaine
TIER 01 GENERIC
penicillin G sodium
demeclocycline HCL
TIER 03 NON PREFERRED
doxycycline
Augmentin
doxycycline hyclate
Bicillin C-R
doxycycline monohydrate
Bicillin L-A
minocycline HCL
Moxatag
tetracycline HCL
TIER 02 FORMULARY
CEPHALOSPORIN
doxycycline hyclate DR
FIRST GENERATION
minocycline HCL ER
TIER 01 GENERIC
TIER 03 NON PREFERRED
cefadroxil
Ocudox
cefazolin sodium
Targadox
cephalexin
Vibramycin
SECOND GENERATION
TIER 01 GENERIC
QUINOLONES
cefaclor
TIER 01 GENERIC
cefaclor ER
ciprofloxacin
cefotetan
ciprofloxacin ER
cefoxitin sodium
ciprofloxacin HCL
cefprozil
levofloxacin
cefuroxime axetil
moxifloxacin HCL
cefuroxime sodium
ofloxacin
TIER 03 NON PREFERRED
TIER 03 NON PREFERRED
Cefotan
Factive
Ceftin
Noroxin
THIRD GENERATION
TIER 01 GENERIC
AMINOGLYCOSIDES
cefdinir
cefditoren pivoxil TIER 01 GENERIC
cefixime amikacin sulfate
cefotaxime sodium gentamicin sulfate
cefpodoxime proxetil gentamicin sulfate pediatric
ceftazidime neomycin sulfate
ceftibuten paromomycin sulfate
ceftriaxone sodium streptomycin sulfate
TIER 02 FORMULARY tobramycin sulfate
Suprax Cap Tab, Chew Tab, 500mg/5 Susp TIER 04 SPECIALTY
tobramycin
TIER 03 NON PREFERRED BethkisPA
Cedax Kitabis PAK
Fortaz Tobi PodhalerPA
Spectracef
FOURTH GENERATION SULFONAMIDES
TIER 01 GENERIC
TIER 01 GENERIC
cefepime
sulfadiazine
TIER 03
Effective April 1, 2016
PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; 1
ANTIMYCOBACTERIAL AGENTS
Norvir
TIER 01 GENERIC
Prezista
cycloserine
Rebetol
ethambutol HCL
Rescriptor
isoniazid
Reyataz
pyrazinamide
Ribasphere Ribapak
rifabutin
Rimantalist
rifampin
Selzentry
TIER 02 FORMULARY
Sustiva
Paser
Truvada
Priftin
Rifater
Viracept
Trecator
Viramune
TIER 03 NON PREFERRED
Virazole
Capastat Sulfate
Viread
Rifamate
Sirturo
TIER 03 NON PREFERRED
Atripla
ANTIFUNGALS
Baraclude
TIER 01 GENERIC
Complera
amphotericin b
Epzicom
fluconazole
Evotaz
flucytosine
Genvoya
griseofulvin microsize
Odefsey
griseofulvin ultramicrosize
Prezcobix
itraconazolePA
Relenza Diskhaler
ketoconazole
SitavigQL,PA
nystatin
Stribild
terbinafine HCL
Tamiflu QL
voriconazole
Tivicay
TIER 03 NON PREFERRED
Triumeq
Cresemba
Tyzeka
LamisilPA
Videx Pediatric
Noxafil
Vitekta
SporanoxPA
Ziagen
Terbinex
TIER 04 SPECIALTY
DaklinzaPA
ANTIVIRALS
Fuzeon
TIER 01 GENERIC
HarvoniPA
abacavir
Peg-intronPA
abacavir sulfate/lamivudine/zidovudine
Peg-intron RedipenPA
acyclovir
Peg-intron Redipen PAK 4PA
adefovir dipivoxil
PegasysPA
didanosine
Pegasys ProclickPA
entecavir
PegintronPA
famciclovir
SovaldiPA
lamivudine
VictrelisQL,PA
lamivudine/zidovudine
nevirapine
ANTIMALARIALS
nevirapine ER
TIER 01 GENERIC
rimantadine HCL
atovaquone/proguanil HCL
stavudine
chloroquine phosphate
valacyclovir HCL
hydroxychloroquine sulfate
valganciclovir
mefloquine HCL
zidovudine
primaquine phosphate
TIER 02 FORMULARY
quinine sulfate
ribavirin
TIER 02 FORMULARY
Aptivus
Daraprim
Crixivan
TIER 03 NON PREFERRED
Edurant
Coartem
Emtriva
Epivir HBV
AMEBICIDES
Intelence
TIER 02 FORMULARY
Invirase
Yodoxin
Isentress
Kaletra
ANTHELMINTICS
Lexiva
TIER 01 GENERIC
ivermectin
Effective April 1, 2016
PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; 2
TIER 02 FORMULARY SPECIALTY
Albenza capecitabinePA
Biltricide
TIER 03 NON PREFERRED HORMONAL AGENTS
Emverm
TIER 01 GENERIC
anastrozole
MISC. ANTI-INFECTIVES
bicalutamide
TIER 01 GENERIC exemestane
atovaquone flutamide
aztreonam letrozole
bacitracin leuprolide acetate
clindamycin palmitate HCL megestrol acetate
clindamycin phosphate tamoxifen citrate
TIER 02 FORMULARY
clindamycin HCL Emcyt
colistimethate sodium Lysodren
dapsone Nilandron
lincomycin HCL Soltamox
lincomycin/lidocaine TIER 03 NON PREFERRED
linezolid Depo-provera
metronidazole Fareston
polymyxin b sulfate TIER 04 SPECIALTY
sulfamethoxazole/trimethoprim EligardPA
sulfamethoxazole/trimethoprim DS Firmagon
tinidazole Lupron DepotPA (7.5, 22.5, 30, 45mg only)
trimethoprim Trelstar
vancomycin HCL Trelstar Mixject
TIER 02 FORMULARY Vantas
Flagyl ER XtandiQL,PA
Nebupent Zoladex
Primsol ZytigaQL,PA
TIER 03 NON PREFERRED
Alinia IMMUNOMODULATORS
Invanz
TIER 01 GENERIC
Ketek
azathioprine
Lincocin
cyclosporine
Pentam 300
cyclosporine modified
Sivextro
mycophenolate mofetil
XifaxanPA
mycophenolic acid DR
TIER 04 SPECIALTY
sirolimus
Cayston
tacrolimus
TIER 02 FORMULARY
ANTINEOPLASTICS, ETC.
Azasan
TIER 03 NON PREFERRED
ALKYLATING AGENTS
Astagraf XL
TIER 01 GENERIC
Cellcept
cyclophosphamide
Imuran
lomustine
Neoral
TIER 02 FORMULARY
Prograf
Alkeran
Rapamune
Hexalen
Sandimmune
Leukeran
Zortress
Myleran
TIER 04 SPECIALTY
TIER 03 NON PREFERRED
PomalystQL,PA
RevlimidQL,PA
TIER 04 SPECIALTY
ThalomidPA
temozolomidePA
ValchlorPA
MITOTIC INHIBITORS
TIER 01 GENERIC
ANTIMETABOLITES
etoposide
TIER 01 GENERIC
mercaptopurine
ENZYME INHIBITORS
methotrexate
TIER 04 SPECIALTY
methotrexate sodium
imatinib mesylatePA
TIER 02 FORMULARY
AfinitorPA
Purixan
Afinitor DisperzPA
Trexall
AlecensaPA
TIER 03 NON PREFERRED
BosulifPA
Tabloid
CaprelsaQL,PA
TIER 04
Effective April 1, 2016
PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; 3
CometriqPA ANTIANGINAL AGENTS
CotellicPA
TIER 01 GENERIC
FarydakPA
isosorbide dinitrate
GilotrifQL,PA
isosorbide dinitrate ER
GleevecPA
isosorbide mononitrate
IbrancePA
isosorbide mononitrate ER
IclusigPA
nitroglycerin lingual
ImbruvicaPA
nitroglycerin transdermal
InlytaPA
nitroglycerin ER
IressaPA
TIER 02 FORMULARY
JakafiPA
Dilatrate SR
Lenvima 10MG Daily DosePA
Nitro-Bid
Lenvima 14MG Daily DosePA
Nitro-Dur
Lenvima 20MG Daily DosePA
Nitrostat
Lenvima 24MG Daily DosePA
TIER 03 NON PREFERRED
LynparzaPA
Nitromist
MekinistPA
Ranexa
NexavarPA
NinlaroPA
BETA BLOCKERS
SprycelPA
TIER 01 GENERIC
StivargaPA
acebutolol HCL
SutentPA
atenolol
TafinlarPA
betaxolol HCL
TagrissoPA
bisoprolol fumarate
TarcevaPA
carvedilol
Tasigna
labetalol HCL
TykerbPA
metoprolol succinate ER
VotrientPA
metoprolol tartrate
XalkoriQL,PA
nadolol
ZelborafQL,PA
pindolol
ZolinzaPA
propranolol HCL
ZydeligPA
propranolol HCL ER
ZykadiaPA
sotalol HCL
sotalol HCL (AF)
TOPOISOMERASE I INHIBITOR
timolol maleate
TIER 03 NON PREFERRED
TIER 03 NON PREFERRED
Hycamtin
Bystolic
Coreg CR
ANTINEOPLASTICS MISC.
Hypertenevide-12.5
TIER 01 GENERIC Inderal XL
hydroxyurea Innopran XL
tretinoin Levatol
TIER 02 FORMULARY Sotylize
Matulane
TIER 04 SPECIALTY CALCIUM CHANNEL BLOCKERS
bexarotenePA
TIER 01 GENERIC
ActimmunePA
amlodipine besylate
Intron A
diltiazem CD
Intron A W/Diluent
diltiazem HCL
SylatronPA
diltiazem HCL ER
felodipine ER
CHEMOTHERAPY RESCUE
isradipine
TIER 01 GENERIC nicardipine HCL
leucovorin calcium nifedipine
TIER 02 FORMULARY nifedipine ER
Mesnex nimodipine
nisoldipine
ANTINEOPLASTIC COMBO nisoldipine ER
verapamil HCL
TIER 04 SPECIALTY
verapamil HCL ER
LonsurfPA
verapamil HCL SR
CARDIOVASCULAR DRUGS
TIER 03 NON PREFERRED
CARDIAC GLYCOSIDES
Cardene SR
TIER 01 GENERIC
digoxin
Hypertenipine-2.5
TIER 03 NON PREFERRED
Nymalize
lanoxin
Lanoxin
Lanoxin Pediatric
Effective April 1, 2016
PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; 4
ANTIARRHYTHMICS TIER 03 NON PREFERRED
Vecamyl
TIER 01 GENERIC
amiodarone HCL
ANTIHYPERTENSIVE COMBO
disopyramide phosphate
flecainide acetate TIER 01 GENERIC
mexiletine HCL amlodipine besylate/benazepril hydrochloride
procainamide HCL amlodipine besylate/benazepril HCL
propafenone HCL amlodipine besylate/valsartan
propafenone HCL ER amlodipine/valsartan/hctz
quinidine gluconate atenolol/chlorthalidone
quinidine gluconate CR benazepril HCL/hydrochlorothiazide
quinidine gluconate ER bisoprolol fumarate/hydrochlorothiazide
quinidine sulfate candesartan cilexetil/hydrochlorothiazide
quinidine sulfate ER captopril/hydrochlorothiazide
TIER 02 FORMULARY enalapril maleate/hydrochlorothiazide
Norpace CR fosinopril sodium/hydrochlorothiazide
Tikosyn irbesartan/hydrochlorothiazideQL
TIER 03 NON PREFERRED lisinopril/hydrochlorothiazide
Multaq losartan potassium/hydrochlorothiazide
methyldopa/hydrochlorothiazide
ACE INHIBITORS metoprolol/hydrochlorothiazide
moexipril/hydrochlorothiazide
TIER 01 GENERIC
nadolol/bendroflumethiazide
benazepril HCL
propranolol/hydrochlorothiazide
captopril
quinapril/hydrochlorothiazide
enalapril maleate
telmisartan/amlodipine
fosinopril sodium
telmisartan/hydrochlorothiazideQL
lisinopril
trandolapril/verapamil HCL
moexipril HCL
trandolapril/verapamil HCL ER
perindopril erbumine
valsartan/hydrochlorothiazide
quinapril HCL
TIER 02 FORMULARY
ramipril
Benicar HCT
trandolapril
TIER 03 NON PREFERRED
TIER 03 NON PREFERRED
AmturnideQL
Epaned
Azor
Clorpres
ANGIOTENSIN RCPTR BLOCKER
Dutoprol
TIER 01 GENERIC
EdarbyclorST
candesartan cilexetilQL
Hypertensolol
eprosartan mesylate
irbesartanQL
losartan potassiumQL
TekamloQL
telmisartanQL
Tekturna HCTST
TIER 02 FORMULARY
Teveten HCTST
valsartanQL
TribenzorQL
BenicarQL
TIER 03 NON PREFERRED
DIURETICS
EdarbiST
TIER 01 GENERIC
acetazolamide
DIRECT RENIN INHIBITORS
acetazolamide sodium
TIER 03 NON PREFERRED
acetazolamide ER
TekturnaST
amiloride HCL
amiloride/hydrochlorothiazide
ANTIHYPERTENSIVES MISC.
bumetanide
TIER 01 GENERIC
chlorothiazide
clonidine HCL
chlorthalidone
doxazosin
furosemide
doxazosin mesylate
hydrochlorothiazide
eplerenone
indapamide
guanfacine HCL
methazolamide
hydralazine HCL
methyclothiazide
methyldopa
metolazone
minoxidil
spironolactone
phenoxybenzamine hydrochloride
spironolactone/hydrochlorothiazide
phentolamine mesylate
torsemide
prazosin HCL
triamterene/hydrochlorothiazide
reserpine
TIER 02 FORMULARY
terazosin HCL
Aldactazide
TIER 02 FORMULARY
Diuril
Demser
Effective April 1, 2016
PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; 5
Edecrin
TIER 03 NON PREFERRED AdcircaQL,PA
Demadex AdempasPA
Dyrenium LetairisQL,PA
Opsumit
VASOPRESSORS OrenitramPA
RemodulinPA
TIER 01 GENERIC
TracleerQL,PA
ephedrine sulfate
TyvasoPA
epinephrine
Tyvaso RefillPA
midodrine HCL
Tyvaso StarterPA
phenylephrine HCL
VentavisPA
TIER 02 FORMULARY
Epipen 2-PAKQL
DERMATOLOGICALS
Epipen-JR 2-PAKQL
TIER 03 NON PREFERRED
ACNE PRODUCTS
AdrenaclickQL
TIER 01 GENERIC
Adrenalin
clindamycin phosphate
TIER 04 SPECIALTY
erythromycin
NortheraPA
tretinoin
TIER 02 FORMULARY
ANTIHYPERLIPIDEMICS
adapalene
TIER 01 GENERIC
adapalene P.M.
atorvastatin calcium
benzoyl peroxide
cholestyramine
benzoyl peroxide SHORT contact
cholestyramine light
clindamycin/benzoyl peroxide
colestipol HCL
erythromycin/benzoyl peroxide
fenofibrate
sodium sulfacetamide
fenofibrate micronized
sodium sulfacetamide/sulfur
fenofibric acid DR
sodium sulfacetamide/sulfur cleanser
fluvastatin
sodium sulfacetamide/sulfur cleanser IN urea
fluvastatin sodium ER
sodium sulfacetamide/sulfur cleansing cloths
gemfibrozil
sodium sulfacetamide/sulfur green
lovastatin
sodium sulfacetamide/sulfur wash
omega-3-acid ethyl esters
sodium sulfacetamide/sulfur IN urea
pravastatin sodium
sulfacetamide sodium
simvastatin
sulfacetamide sodium/sulfur
TIER 02 FORMULARY
sulfacetamide sodium/sulfur cleanser
niacin ER
tretinoin microsphere
Crestor
tretinoin microsphere P.M.
Welchol
TIER 03 NON PREFERRED
Zetia
Avar
TIER 03 NON PREFERRED
Avar LS
Advicor
Clinoin
Altoprev
Epiduo Forte
Fenoglide
Fabior
Livalo
Tretin-X
Simcor
Vascepa
ROSACEA AGENTS
Vytorin
TIER 01 GENERIC
TIER 04 SPECIALTY
doxycycline
JuxtapidQL,PA
metronidazole
KynamroQL,PA
TIER 03 NON PREFERRED
Finacea
CARDIOVASCULAR - MISC.
TIER 01 GENERIC
ANTIBIOTICS - TOPICAL
papaverine HCL
TIER 01 GENERIC
TIER 02 FORMULARY
gentamicin sulfate
amlodipine besylate/atorvastatin calcium
mupirocin
mupirocin calcium
TIER 03 NON PREFERRED
TIER 02 FORMULARY
CialisRR
Cortisporin
CorlanorPA
TIER 03 NON PREFERRED
EntrestoPA
centany
LevitraRR
Altabax
Muse RR
Centany AT
Staxyn RR
Neo-Synalar
ViagraRR
TIER 04 SPECIALTY
ANTIFUNGALS - TOPICAL
sildenafilQL,PA (for use in pulmonary hypertension only)
TIER 01
Effective April 1, 2016
PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; RR = Rider Required 6
GENERIC Zithranol
ciclopirox Zithranol-RR
TIER 04 SPECIALTY
CosentyxPA
Cosentyx Sensoready PenPA
clotrimazole/betamethasone dipropionate StelaraQL,PA
econazole nitrate
ketoconazole ANTISEBORRHEIC AGENTS
naftifine hydrochloride
TIER 01 GENERIC
naftifine HCL
glycolic acid
nystatin
glycolic acid 70% high purity
nystatin/triamcinolone
selenium sulfide
oxiconazole nitrate
sodium sulfacetamide
TIER 02 FORMULARY
sodium sulfacetamide wash
Exelderm
TIER 03 NON PREFERRED
Halotin
Ovace Plus
Lamisil Spray
Promiseb
Oxistat
Promiseb Complete
Xolegel
Selrx
TIER 03 NON PREFERRED
Tersi Foam
TL Triseb
Ecoza
CORTICOSTEROIDS - TOPICAL
Luzu
TIER 01 GENERIC
Mentax
alclometasone dipropionate
Naftin
amcinonide
augmented betamethasone dipropionate
Recura
betamethasone dipropionate
Vusion
betamethasone valerate
Xolegel Corepak
clobetasol propionate
Xolegel Duo/Head & Shoulders
clobetasol propionate emollient
Xolegel Duo/Xolex
clocortolone pivalate
clocortolone pivalate P.M.
ANTIVIRALS - TOPICAL
desonide
TIER 01 GENERIC
desoximetasone
acyclovir
diflorasone diacetate
TIER 03 NON PREFERRED
fluocinolone acetonide
DenavirQL
fluocinonide
fluocinonide-e
ANTI-INFLAMMATORY AGENTS
fluticasone propionate
TIER 01 GENERIC halobetasol propionate
diclofenac sodium
TIER 02 FORMULARY hydrocortisone acetate/aloe
Voltaren hydrocortisone butyrate
TIER 03 NON PREFERRED hydrocortisone valerate
FlectorST hydrocortisone IN absorbase
PennsaidPA mometasone furoate
Xrylix prednicarbate
triamcinolone acetonide
ANTIPRURITICS TIER 02 FORMULARY
calcipotriene/betamethasone dipropionate
TIER 01 GENERIC
hydrocortisone butyrate (lipid)
doxepin hydrochloride
hydrocortisone butyrate (lipophilic)
TIER 03 NON PREFERRED
TIER 03 NON PREFERRED
Prudoxin
Capex
Zonalon
Cloderm
Cloderm P.M.
ANTIPSORIATICS
Cordran
TIER 01 GENERIC
Cordran Tape
acitretin
Dermasorb HC
calcipotriene
Dermasorb Ta
calcitriol
Desonate
methoxsalen
Desowen Cream/Cetaphil Lotion
TIER 02 FORMULARY
Desowen Lotion/Cetaphil Cream
8-mop
Desowen Ointment/Cetaphil Lotion
TIER 03 NON PREFERRED
Enstilar
Sorilux
Epifoam
Taltz
Halog
Tazorac
Halonate
Vectical
Effective April 1, 2016
PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; 7
Locoid Eurax
Pandel
Pediaderm HC
Pediaderm TA Gordofilm
Pramosone Gordons Urea
Scalacort DK Kerafoam
Kerafoam 42
Xerac AC
Synalar TS TIER 03 NON PREFERRED
Taclonex Susp
Texacort Alevicyn Antipruritic SG
Topicort Atopiclair
Trianex
Verdeso Avenova
IMMUNOMODULATING AGENTS Copasil
Eletone
TIER 01 GENERIC
tacrolimus
Elimite
TIER 02 FORMULARY
Emulsion SB
imiquimod
Epiceram
Elidel
Hylatopic
TIER 03 NON PREFERRED
Hylatopic Plus
Zyclara
Zyclara P.M.
DERMATOLOGICALS - MISC.
TIER 01 GENERIC
arnica flower
Keralyt Scalp
benzoin compound tincture
benzoin tincture
Lycelle
boric acid
Mb Hydrogel
capsaicin
Medi-derm/L-RX
coal TAR
Megrix
cocaine HCL
Neosalus
ethyl chloride
Neosalus CP
ethyl chloride/fine pinpoint
Neuvaxin
ethyl chloride/fine stream
Nivatopic Plus
ethyl chloride/medium jet stream
Nuvail
ethyl chloride/medium stream
Pliaglis
ethyl chloride/mist
Pr Cream
lactic acid
Presera
lactic acid e
Pruclair
lactic acid w/vitamin e
Prumyx
lidocaine
Qutenza
lidocaine and tetracaine cream
Relyyt
lidocaine HCL
Salvax Duo Plus
lidocaine HCL jelly
Sinelee
lidocaine-prilocaine-cream base
Sklice
lidocaine/prilocaine
Solaice
lindane
Synera
malathion
Tetrix
permethrin
Tropazone
podofilox
Ulesfia
pyrogallic acid
salicylic acid
Umecta
salicylic acid cream
Umecta PD
salicylic acid lotion
Veregen
sodium hyaluronate
ENDOCRINE AND METABOLIC
spinosad
sulfurated lime CORTICOSTEROIDS
urea
TIER 01 GENERIC
urea topical
betamethasone sodium phosphate/betamethasone acetate
cortisone acetate
dexamethasone
TIER 02 FORMULARY
dexamethasone sodium phosphate
Anacaine
fludrocortisone acetate
Condylox
Effective April 1, 2016
PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; 8
hydrocortisone tabs norethindrone acetate/ethinyl estradiol
methylprednisolone TIER 02 FORMULARY
methylprednisolone acetate Alora
methylprednisolone dose pack Cenestin
methylprednisolone sodiumsuccinate Climara Pro
methylprednisolone PF Combipatch
prednisolone Depo-estradiol
prednisolone sodium phosphate Enjuvia
prednisone Menest
triamcinolone Premarin
TIER 02 FORMULARY Premphase
budesonide Prempro
prednisolone sodium phosphate ODT TIER 03 NON PREFERRED
Dexamethasone Intensol Angeliq
Orapred ODT Delestrogen
Prednisone Intensol Divigel
TIER 03 NON PREFERRED Duavee
Elestrin
Estrasorb
Depo-medrol Estrogel
Dexpak 10 Day Evamist
Dexpak 13 Day Menostar
Dexpak 6 Day Minivelle
Dyural-l
FLO-pred
Medrol CONTRACEPTIVES
Millipred
TIER 01 GENERIC
Millipred DP
desogestrel/ethinyl estradiol
drospirenone/ethinyl estradiol
levonorgestrel
levonorgestrel and ethinyl estradiol
levonorgestrel/ethinyl estradiol
norethindrone
norethindrone & ethinyl estradiol ferrous fumarate
norethindrone acetate/ethinyl estradiol
norethindrone acetate/ethinyl estradiol/ferrous fumarate
Solu-medrol
norgestimate/ethinyl estradiol
Uceris
TIER 03 NON PREFERRED
Veripred 20
Beyaz
Ella
ANDROGENS-ANABOLIC (PA required for use less than 40 yo)
Falessa
TIER 01 GENERIC LO Loestrin FE
danazolPA Minastrin 24 FE
methyltestosteronePA Natazia
oxandrolonePA Norinyl 1+50
testosteronePA Quartette
testosterone cypionatePA Safyral
testosterone enanthatePA
testosterone P.M. PA PROGESTINS
TIER 02 FORMULARY
TIER 01 GENERIC
AndrogelPA
medroxyprogesterone acetate
Androgel P.M. PA
medroxyprogesterone/lidocaine
AndroxyPA
megestrol acetate
AxironPA
norethindrone acetate
TIER 03 NON PREFERRED
progesterone
Anadrol-50PA
TIER 04 SPECIALTY
AndrodermSTPA
MakenaPA
FortestaPA
StriantSTPA
ANTIDIABETIC AGENTS
TestimPA
INSULIN
VogelxoPA
TIER 02 FORMULARY (All Lilly Insulin preferred)
Vogelxo P.M. PA
Humalog
Humalog Kwikpen
ESTROGENS
Humalog Mix 50/50
TIER 01 GENERIC
Humalog Mix 50/50 Kwikpen
estradiol
Humalog Mix 75/25 and Kwikpen
estradiol valerate
Humulin N, Humulin R, Humulin 70/30
estradiol/norethindrone acetate
Humulin R U-500 (concentrated) Humulin R U-500 Kwikpen
estropipate
Lantus
Lantus Solostar
Effective April 1, 2016
PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; 9
Levemir GENERIC
Levemir Flexpen alogliptin/metformin HCL
Levemir Flextouch alogliptin/pioglitazone
TIER 03 NON PREFERRED glipizide/metformin HCL
glyburide/metformin HCL
AMYLIN ANALOGS pioglitazone HCL/metformin HCL
TIER 03 NON PREFERRED repaglinide/metformin hydrochloride
Symlinpen 120 TIER 02 FORMULARY
Symlinpen 60 pioglitazone HCL-glimepiride
INCRETIN MIMETIC AGENTS Actoplus Met XR
TIER 02 FORMULARY Janumet
Byetta Janumet XR
Tanzeum Jentadueto
TIER 03 NON PREFERRED TIER 03 NON PREFERRED
BydureonPA
VictozaPA
Trulicity PA
SULFONYLUREAS Avandamet
TIER 01 GENERIC Avandaryl
chlorpropamide InvokametQL,ST
glimepiride KazanoST
glipizide Kombiglyze XRST
glipizide ER OseniST
glyburide Xigduo XRST
glyburide micronized
tolazamide BISPHOSPHONATES
tolbutamide
TIER 01 GENERIC
TIER 03 NON PREFERRED
alendronate sodium
Diabeta
etidronate disodium
BIGUANIDES
ibandronate sodium
TIER 01 GENERIC
risedronate sodium
metformin HCL
risedronate sodium DR
metformin HCL ER
TIER 03 NON PREFERRED
TIER 03 NON PREFERRED
Binosto
Riomet
Fosamax Plus DST
MEGLITINIDE ANALOGUES
TIER 01 GENERIC
CALCITONINS
nateglinide
TIER 01 GENERIC
repaglinide
calcitonin salmon
DIABETIC OTHER
calcitonin-salmon
TIER 01 FORMULARY – LIFESCAN PRODUCTS PREFERRED
TIER 03 NON PREFERRED
ONE Touch Test Strips – Ultra, Ultra Mini, UltraSmart,Verio IQ, Verios Sync
fortical
TIER 03 NON PREFERRED
Miacalcin
FarxigaQL,ST
Glucagen Hypokit
PARATHYROID HORMONE
Glucagon Emergency Kit
TIER 04 SPECIALTY
InvokanaQL,ST
ForteoPA
JardianceQL,ST
TIER 04 SPECIALTY
RANK LIGAND INHIBITORS
KorlymPA
TIER 04 SPECIALTY
ALPHA-GLUCOSIDASE INHIBIT
ProliaPA
TIER 01 GENERIC
XgevaPA
acarbose
TIER 02 FORMULARY
HORMONE RECEPTOR MDLTR
Glyset
TIER 01 GENERIC
DPP-4 INHIBITORS
raloxifene hydrochloride
TIER 01 GENERIC
TIER 03 NON PREFERRED
alogliptin
Osphena
TIER 02 FORMULARY
Januvia
FERTILITY REGULATORS
Tradjenta
TIER 01 GENERIC
TIER 03 NON PREFERRED
clomiphene citrate
NesinaST
TIER 04 SPECIALTY
OnglyzaST
chorionic gonadotropin
INSULIN SENSITIZING AGENT
Bravelle PA
TIER 01 GENERIC
Follistim AQ
pioglitazone HCL
Gonal-fST
TIER 03 NON PREFERRED
Gonal-f RFFST
Avandia
Gonal-f RFF PenPA
ANTIDIABETIC COMBINATIONS
Gonal-f RFF RedijectPA
TIER 01
Effective April 1, 2016
PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; 10
Menopur GENERIC
Ovidrel cabergoline
Repronex
VASOPRESSIN ANTAGONISTS
LHRH/GNRH AGONIST
TIER 03 NON PREFERRED
TIER 02 FORMULARY Samsca
Synarel
TIER 04 SPECIALTY PROGESTERONE ANTAGONISTS
Lupaneta Pack
TIER 02 FORMULARY
Lupron Depot-PED
Mifeprex
Supprelin LA
METABOLIC MODIFIERS
GNRH/LHRH ANTAGONISTS
TIER 01 GENERIC
TIER 04 SPECIALTY
calcitriol
ganirelix acetate
doxercalciferol
Cetrotide
levocarnitine
paricalcitol
GROWTH HORMONES
sodium phenylbutyrate
TIER 04 SPECIALTY TIER 02 FORMULARY
GenotropinPA Buphenyl
Genotropin MiniquickPA Orfadin
HumatropePA Sensipar
Humatrope Combo PackPA TIER 03 NON PREFERRED
Norditropin CartridgePA Cystadane
Norditropin FlexproPA Xuriden
Norditropin Nordiflex PenPA TIER 04 SPECIALTY
Nutropin AQ Nuspin 10PA CarbagluPA
Nutropin AQ Nuspin 20PA Kuvan
Nutropin AQ Nuspin 5PA RavictiPA
Nutropin AQ PenPA
OmnitropePA THYROID AGENTS
SaizenPA
TIER 01 GENERIC
Saizen Click.easyPA
levothyroxine sodium
SerostimPA
levothyroxine sodium TAB 0.075MG
Tev-tropinPA
liothyronine sodium
ZomactonPA
methimazole
ZorbtivePA
propylthiouracil
TIER 02 FORMULARY
SOMATOMEDINS
Thyrolar-1
TIER 04 SPECIALTY Thyrolar-1/2
IncrelexPA Thyrolar-1/4
Thyrolar-2
SOMATOSTATIC AGENTS Thyrolar-3
TIER 03 NON PREFERRED
TIER 01 GENERIC
Armour Thyroid
octreotide acetate
Cytomel
TIER 04 SPECIALTY
Nature-throid
Sandostatin Lar Depot
Nature-throid NT-2.5
SigniforQL,PA
Synthroid
Signifor LarPA
Tirosint
Somatuline Depot
Westhroid
Wp Thyroid
GH RECEPTOR ANTAGONISTS
TIER 04 SPECIALTY
GASTROINTESTINAL
Somavert
LAXATIVES
POSTERIOR PITUITARY
TIER 01 GENERIC
TIER 01 GENERIC cascara sagrada
desmopressin acetate lactulose
vasopressin mineral oil heavy
TIER 02 FORMULARY peg 3350/electrolytes
Stimate peg-3350/electrolytes
peg-3350/NACL/NA bicarbonate/KCL
CORTICOTROPIN polyethylene glycol 3350
senna plus
TIER 04 SPECIALTY
TIER 02 FORMULARY
Golytely
Moviprep
PROLACTIN INHIBITORS
Osmoprep
TIER 01
Suclear
Effective April 1, 2016
PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; 11
TIER 03 NON PREFERRED
Colyte-flavor Packs Symax Duotab
Kristalose
Prepopik ANTIEMETICS
Suprep Bowel Prep
TIER 01 GENERIC
dimenhydrinate
ANTIDIARRHEALS
dronabinol
TIER 01 GENERIC granisetron HCLQL
diphenoxylate/atropine ondansetron ODT
paregoric ondansetron HCL
TIER 02 FORMULARY trimethobenzamide HCL
opium TIER 02 FORMULARY
opium tincture Transderm-scop
Motofen TIER 03 NON PREFERRED
VSL#3 DS Akynzeo
TIER 03 NON PREFERRED Anzemet
FulyzaqPA Cesamet
Restora RX Emend
Rezyst IM Granisol
Rezyst SB Sancuso
Zuplenz
ANTACIDS
DIGESTIVE AIDS
TIER 01 GENERIC
sodium bicarbonate TIER 01 GENERIC
pancrelipase
ULCER DRUGS TIER 02 FORMULARY
Creon
TIER 01 GENERIC
Pancreaze
atropine sulfate
Ultresa
belladonna & opium
Viokace
belladonna alkaloids & opium
Zenpep
chlordiazepoxide HCL/clidinium bromide
TIER 03 NON PREFERRED
cimetidine
Pertzye
cimetidine HCL
TIER 04 SPECIALTY
dicyclomine hci
SucraidPA
dicyclomine HCL
famotidine
GASTROINTESTINAL - MISC.
glycopyrrolate
hyoscyamine sulfate TIER 01 GENERIC
hyoscyamine sulfate ODT alosetron hydrochloride
hyoscyamine sulfate ER balsalazide disodium
hyoscyamine sulfate SR calcium acetate
lansoprazole dexpanthenol
lansoprazole/amoxicillin/clarithromycin hydrocortisone tabs
methscopolamine bromide hydrocortisone acetate/lidocaine HCL
misoprostol hydrocortisone acetate/pramoxine
nizatidine lactulose
omeprazole lidocaine HCL-hydrocortisone acetate with aloe
omeprazole/sodium bicarbonate lidocaine HCL/hydrocortisone acetate
pantoprazole sodium mesalamine
propantheline bromide metoclopramide ODT
rabeprazole sodium metoclopramide HCL
ranitidine HCL sevelamer carbonate
scopolamine hydrobromide sulfasalazine
sucralfate ursodiol
TIER 02 FORMULARY
TIER 02 FORMULARY cromolyn sodium
Carafate Apriso
TIER 03 NON PREFERRED Asacol HD
Aciphex SprinklePA Canasa
Atropen Fosrenol
Cantil Lialda
Cuvposa Pentasa
Gabitidine Proctofoam HC
Levsin Renagel
Renvela
Pamine FQ TIER 03 NON PREFERRED
Prevacid SolutabPA auryxia
ProtonixPA Amitiza
Pylera
Effective April 1, 2016
PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; 12
TIER 03 NON PREFERRED
Chenodal AVC
Cortifoam Clindesse
Delzicol Crinone
Dipentum Endometrin
Entereg Estrace
Giazo Femring
Linzess Gynazole-1
MovantikQL,PA Relagard
Phoslyra
Procort GENITOURINARY - MISC.
Rectiv
TIER 01 GENERIC
Relistor
alfuzosin HCL ER
Sfrowasa
citric acid/sodium citrate
Uceris
dutasteride
Velphoro
dutasteride/tamsulosin hydrochloride
TIER 04 SPECIALTY
finasteride
CimziaQL,PA
phenazopyridine HCL
Cimzia Starter KitQL,PA
potassium citrate ER
GattexPA
potassium citrate-citric acid crystals
potassium citrate/citric acid
GENITOURINARY
potassium citrate/sodium citrate/citric acid
sodium citrate/citric acid
URINARY ANTI-INFECTIVES
tamsulosin HCL
TIER 01 GENERIC
tricitrates
methenamine hippurate
TIER 02 FORMULARY
methenamine mandelate
Cystagon
nitrofurantoin
Elmiron
nitrofurantoin macrocrystals
K-phos NO 2
nitrofurantoin monohydrate
Lithostat
nitrofurantoin monohydrate/macrocrystals
Oracit
TIER 03 NON PREFERRED
TIER 03 NON PREFERRED
Monurol
Cardura XL
Uretron D/S
Rapaflo
Uroqid #2
TIER 04 SPECIALTY
Procysbi
URINARY ANTISPASMODICS
ThiolaPA
TIER 01 GENERIC
bethanechol chloride
HEMATOLOGICAL AGENTS
darifenacin hydrobromide ER
HEMATOPOIETIC AGENTS
darifenacin ER
flavoxate HCL TIER 01 GENERIC
oxybutynin chloride
oxybutynin chloride ER cyanocobalamin
tolterodine tartrate folic acid
tolterodine tartrate ER hydroxocobalamin
trospium chloride TIER 02 FORMULARY
trospium chloride ER Droxia
TIER 02 FORMULARY TIER 03 NON PREFERRED
Vesicare Ciferex
TIER 03 NON PREFERRED Feriva 21/7
Gelnique Mozobil
Myrbetriq Nascobal
Toviaz Omontys
TIER 04 SPECIALTY
VAGINAL PRODUCTS Aranesp Albumin FreePA
Cerdelga
TIER 01 GENERIC
EpogenPA
clindamycin phosphate
Granix
metronidazole vaginal
Mircera
terconazole
NeulastaPA
TIER 02 FORMULARY
Cleocin
NeumegaPA
Estring
NeupogenPA,ST
NplatePA
ProcritPA
PromactaPA
ZavescaPA
Premarin
Vagifem
Effective April 1, 2016
PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; 13
ANTICOAGULANTS Xyntha
TIER 01 GENERIC
MOUTH/THROAT/DENTAL AGENT
fondaparinux sodium
heparin sodium
heparin sodium dcu
TIER 01 GENERIC
heparin sodium/sodium chloride 0.9% premix
cevimeline HCL
heparin sodium/NACL 0.45%
chlorhexidine gluconate
heparin sodium/NACL 0.9%
chlorhexidine gluconate oral rinse
warfarin sodium
clotrimazole
TIER 02 FORMULARY
lidocaine viscous
enoxaparin sodium
lidocaine HCL
Xarelto
lidocaine HCL viscous
TIER 03 NON PREFERRED
nystatin
Arixtra
pilocarpine hydrochloride
Eliquis
pilocarpine HCL
Fragmin
stannous fluoride oral rinse
Iprivask
triamcinolone acetonide
Pradaxa
triamcinolone IN orabase
SavaysaQL
TIER 02 FORMULARY
Caphosol
HEMOSTATICS
Debacterol
TIER 01 GENERIC TIER 03 NON PREFERRED
aminocaproic acid Aquoral
tranexamic acid
TIER 02 FORMULARY Gelclair
Artiss Nafrinse Daily/Acidulated
Astringyn Nafrinse Daily/Neutral
Nafrinse Weekly
Neutrasal
Oravig
Salivamax
Thrombogen
TIER 03 NON PREFERRED NEUROLOGY, CNS, PSYCH
Evicel
ANTIANXIETY AGENTS
Evithrom
TIER 01 GENERIC
Recothrom
alprazolam
alprazolam ODT
Tisseel
alprazolam ER
Tisseel VH
buspirone HCL
chlordiazepoxide HCL
HEMATOLOGICAL - MISC.
clorazepate dipotassium
TIER 01 GENERIC
diazepam
anagrelide hydrochloride
droperidol
aspirin/dipyridamole
hydroxyzine pamoate
cilostazol
hydroxyzine HCL
clopidogrel
lorazepam
dipyridamole
meprobamate
pentoxifylline ER
oxazepam
ticlopidine HCL
TIER 02 FORMULARY
TIER 02 FORMULARY
Alprazolam Intensol
Aggrenox
TIER 03 NON PREFERRED
TIER 03 NON PREFERRED
Gabavale-5
Brilinta
Gabazolamine
Cathflo Activase
Gabazolamine-0.5
Effient
Kalbitor
Kinlytic
ANTIDEPRESSANTS
Kovaltry
TIER 01 GENERIC
Novoeight
amitriptyline HCL
Nuwiq
amoxapine
Xyntha Solofuse
bupropion HCL
TIER 04 SPECIALTY
bupropion HCL ER
Benefix
bupropion HCL SR
FirazyrPA
bupropion HCL XL
Helixate FS
citalopram hydrobromideQL
Ixinity
clomipramine HCL
Kogenate FS
desipramine HCL
Kogenate FS Bio-set
desvenlafaxine ER
Recombinate
doxepin HCL
Effective April 1, 2016
PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; 14
escitalopram oxalateQL quetiapine fumarate
fluoxetine DR risperidone
fluoxetine HCL risperidone ODT
fluvoxamine maleate thioridazine HCL
fluvoxamine maleate ERPA thiothixene
imipramine pamoate trifluoperazine HCL
imipramine HCL ziprasidone HCL
maprotiline HCL
mirtazapine TIER 02 FORMULARY
mirtazapine ODT aripiprazolePA
nefazodone HCL lithium
nortriptyline HCL Equetro
paroxetine HCL Risperdal Consta
paroxetine HCL ERQL Seroquel XRST
phenelzine sulfate Zyprexa Relprevv
protriptyline HCL TIER 03 NON PREFERRED
sertraline HCLQL AbilifyPA
tranylcypromine sulfate Abilify DiscmeltPA
trazodone HCL Abilify Maintena
trimipramine maleate FanaptST
venlafaxine HCL
venlafaxine HCL ERQL FazacloST
TIER 02 FORMULARY Geodon
duloxetine HCLPA Invega Sustenna
Appbutamone Invega TrinzaPA
Gaboxetine LatudaST
Marplan SaphrisST
Sentroxatine VersaclozST
TIER 03 NON PREFERRED Vraylar
Emsam HYPNOTICS
FetzimaST
TIER 01 GENERIC
estazolam
Khedezla
eszopiclone
Oleptro
flurazepam HCL
Parnate
phenobarbital
PaxilPA
phenobarbital sodium
PexevaQL,ST
quazepam
PristiqST
temazepam
triazolam
zaleplon
zolpidem tartrate
Trazamine
TIER 02 FORMULARY
ViibrydST
zolpidem tartrate ER
Butisol Sodium
TIER 03 NON PREFERRED
ANTIPSYCHOTICS
Amytal Sodium
TIER 01 GENERIC Doral
aripiprazole ODTPA Gabazolpidem-5
chlorpromazine HCL Nembutal Sodium
clozapine Rozerem
clozapine ODT
fluphenazine decanoate Strazepam
fluphenazine HCL Zolpimist
haloperidol
haloperidol decanoate ADHD, NARCOLEPSY, ETC.
haloperidol lactate
TIER 01 GENERIC
lithium carbonate
caffeine citrate
lithium carbonate ER
caffeine/sodium benzoate
loxapine
dexmethylphenidate HCL
loxapine succinate
dexmethylphenidate HCL ER
molindone hydrochloride
dextroamphetamine sulfate
olanzapine
guanfacine ER
olanzapine ODT
methamphetamine HCL
paliperidone ER
methylphenidate hydrochloride
perphenazine
methylphenidate HCL
prochlorperazine
TIER 02 FORMULARY
prochlorperazine edisylate
dextroamphetamine sulfate ER
prochlorperazine maleate
methylphenidate HCL CD
Effective April 1, 2016
PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; 15
methylphenidate HCL ER Depakene
modafinil Depakote
Adderall XR Depakote ER
Concerta Depakote Sprinkles
NuvigilPA Dilantin
Dilantin Infatabs
Strattera Dilantin-125
Vyvanse Felbatol
TIER 03 NON PREFERRED Fycompa
amphetamine/dextroamphetamineST Keppra
methylphenidate HCL SRST Keppra XR
Adderall Lamictal
Lamictal Chewable Dispersible
Daytrana
Dexedrine
Dyanavel XR Lamictal XR
Focalin LyricaPA
Focalin XR Mysoline
Metadate CD OnfiST
Methylin Oxtellar XR
Procentra Peganone
Quillivant XR Phenytek
Ritalin Potiga
Ritalin LA Spritam
Tegretol
Zenzedi Topamax
Topamax Sprinkle
ANTICONVULSANTS Trileptal
Trokendi XR
TIER 01 GENERIC
Vimpat
carbamazepine
Zarontin
carbamazepine ER
TIER 04 SPECIALTY
clonazepam
SabrilPA
clonazepam ODT
diazepam
ANTIPARKINSON AGENTS
divalproex sodium
divalproex sodium DR TIER 01 GENERIC
divalproex sodium ER amantadine HCL
ethosuximide benztropine mesylate
felbamate bromocriptine mesylate
gabapentin carbidopa
lamotrigine carbidopa/levodopa
lamotrigine ODT carbidopa/levodopa ODT
lamotrigine titrationQL carbidopa/levodopa ER
lamotrigine ER carbidopa/levodopa/entacapone
levetiracetam entacapone
levetiracetam ER pramipexole dihydrochloride
oxcarbazepine pramipexole dihydrochloride ER
phenytoin ropinirole ER
phenytoin sodium ropinirole HCL
phenytoin sodium extended selegiline HCL
primidone tolcapone
tiagabine hydrochloride trihexyphenidyl HCL
topiramate TIER 03 NON PREFERRED
valproic acid Apokyn
zonisamide Azilect
TIER 02 FORMULARY Mirapex ER
Gabitril Neupro
Lamictal ODT Rytary
Stalevo 100
Stalevo 125
Stavzor
Stalevo 150
Tegretol-XR
Stalevo 200
Stalevo 50
Stalevo 75
TIER 03 NON PREFERRED
Zelapar
Aptiom
Banzel
NEUROLOGY, PSYCH - MISC.
Carbatrol
TIER 01 GENERIC
Celontin
acamprosate calcium DR
Effective April 1, 2016
PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; 16
chlordiazepoxide/amitriptyline FORMULARY
disulfiram metaxalone
donepezil HCL Prazolamine
ergoloid mesylates
fluoxetine
galantamine hydrobromide TIER 03 NON PREFERRED
memantine hydrochloride
memantine HCL
memantine HCL titration PAK Lorzone
olanzapine/fluoxetine
perphenazine/amitriptyline
pimozide
rivastigmine tartrate ANTIMYASTHENIC AGENTS
rivastigmine transdermal system
TIER 01 GENERIC
TIER 02 FORMULARY
guanidine HCL
Namenda XR
neostigmine methylsulfate
pyridostigmine bromide
TIER 02 FORMULARY
TIER 03 NON PREFERRED
TIER 03 NON PREFERRED
NamzaricPA
Enlon
Sarafem
SavellaPA
OPHTHALMOLOGY AND OTIC
ANTI-INFECTIVES
TIER 01 GENERIC
TIER 04 SPECIALTY
bacitracin
tetrabenazinePA
bacitracin/polymyxin b
AmpyraQL,PA
ciprofloxacin HCL
AubagioPA,ST
erythromycin
Avonex
gentamicin sulfate
Avonex Pen
levofloxacin
Betaseron
neomycin/bacitracin/polymyxin
Glatiramir acetate 20mg QL
neomycin/polymyxin/bacitracin zinc
ExtaviaPA,ST
neomycin/polymyxin/gramicidin
GilenyaST
ofloxacin
NuedextaPA
polymyxin b sulfate/trimethoprim sulfate
Plegridy
sodium sulfacetamide
sulfacetamide sodium
RebifPA,ST
tobramycin sulfate
Rebif RebidosePA,ST
trifluridine
trimethoprim sulfate/polymyxin b sulfate
TIER 02 FORMULARY
TecfideraQL,ST
gatifloxacin
Betadine Ophthalmic Prep
XyremPA
Ciloxan
Natacyn
NEUROMUSCULAR AGENTS
Tobrex
TIER 01 GENERIC
Vigamox
riluzole
TIER 03 NON PREFERRED
TIER 03 NON PREFERRED
Azasite
Quelicin 1000
Besivance
TIER 04 SPECIALTY
Mitosol
BotoxPA
Moxeza
DysportPA
Zirgan
MyoblocPA
XeominPA
ARTIFICIAL TEAR/LUBRICANT
TIER 03 NON PREFERRED
MUSCULOSKELETAL AGENTS
Lacrisert
TIER 01 GENERIC
baclofen
BETA-BLOCKERS
chlorzoxazone
TIER 01 GENERIC
cyclobenzaprine HCL
betaxolol HCL
dantrolene sodium
carteolol HCL
methocarbamol
dorzolamide HCL/timolol maleate
orphenadrine citrate
levobunolol HCL
orphenadrine citrate ER
timolol maleate
orphenadrine/asa/caffeine
timolol maleate ophthalmic gel forming
tizanidine HCL
TIER 02 FORMULARY
TIER 02
Betoptic-s
Effective April 1, 2016
PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; 17
TIER 03 NON PREFERRED TIER 03 NON PREFERRED
metipranolol Isopto Carbachol
Betimol Phospholine Iodide
Combigan
Cosopt PF ADRENERGIC AGENTS
TIER 01 GENERIC
apraclonidine
OPHTHALMIC STEROIDS
brimonidine tartrate
TIER 01 GENERIC TIER 02 FORMULARY
dexamethasone sodium phosphate Iopidine
fluorometholone TIER 03 NON PREFERRED
neomycin/polymyxin/bacitracin/hydrocortisone
neomycin/polymyxin/dexamethasone Simbrinza
neomycin/polymyxin/hydrocortisone
prednisolone acetate LOCAL ANESTHETICS
prednisolone sodium phosphate
TIER 01 GENERIC
sulfacetamide sodium/prednisolone sodium phosphate
proparacaine HCL
tobramycin/dexamethasone
TIER 02 FORMULARY
TIER 03 NON PREFERRED
Alrex
Akten
Blephamide
Blephamide S.o.p.
OPHTHALMICS - MISC.
FML
TIER 01 GENERIC
FML Forte
azelastine HCL
Lotemax
bromfenac
Maxidex
cromolyn sodium
Pred Mild
diclofenac sodium
Pred-G
dorzolamide HCL
Pred-G S.o.p.
epinastine HCL
Tobradex
flurbiprofen sodium
TIER 03 NON PREFERRED
ketorolac tromethamine
Durezol
olopatadine HCL
Flarex
TIER 02 FORMULARY
Tobradex ST
Azopt
Vexol
Nevanac
Zylet
TIER 03 NON PREFERRED
Acuvail
PROSTAGLANDINS
Alocril
TIER 01 GENERIC
Alomide
latanoprost
Bepreve
travoprost
Emadine
TIER 02 FORMULARY
Ilevro
Travatan Z
Lastacaft
TIER 03 NON PREFERRED
Pataday
Lumigan
Prolensa
Rescula
TIER 04 SPECIALTY
Zioptan
CystaranQL,PA
CYCLOPLEGIC MYDRIATICS
OTIC AGENTS
TIER 01 GENERIC
TIER 01 GENERIC
atropine sulfate
acetic acid
cyclopentolate hydrochloride
acetic acid/aluminum acetate
cyclopentolate HCL
antipyrine/benzocaine
homatropine HBR
ciprofloxacin
TIER 02 FORMULARY
fluocinolone acetonide
Cyclomydril
fluocinolone acetonide ear drops
Isopto Homatropine
hydrocortisone/acetic acid
Isopto Hyoscine
neomycin/polymyxin/hydrocortisone
TIER 03 NON PREFERRED
neomycin/polymyxin/HC
Cyclogyl
ofloxacin
TIER 02 FORMULARY
DECONGESTANTS
Ciprodex
TIER 01 GENERIC Coly-mycin S
naphazoline HCL TIER 03 NON PREFERRED
phenylephrine HCL Cetraxal
Cipro HC
MIOTICS Cortisporin-tc
Otiprio
TIER 01 GENERIC
pilocarpine HCL
Effective April 1, 2016
PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; 18
OXYTOCICS fentanyl citrate oral transmucosalQL,PA
Capital/Codeine
Suboxone Film QL,PA
TIER 01 GENERIC
TIER 03 NON PREFERRED
methylergonovine maleate
AbstralPA
oxytocin
Conzip
TIER 02 FORMULARY
Dilaudid-HP
Cervidil
Embeda
Prostin E2
ExalgoPA
TIER 03 NON PREFERRED
FentoraPA
Hemabate
Prepidil
LazandaPA
Lortab
PAIN MANAGEMENT
Morphine Sulfate Powder
ANALGESICS - NONNARCOTIC
Nucynta
TIER 01 GENERIC
Nucynta ERPA
butalbital/acetaminophen
Opana ER (crush Resistant)PA
butalbital/acetaminophen/caffeine
Oxaydo
butalbital/aspirin/caffeine
Oxecta
choline magnesium trisalicylate
OxycontinQL,PA
diflunisal
Primlev
salsalate
Roxicet
TIER 03 NON PREFERRED
SubsysPA
Allzital
Synalgos-DC
Bupap
Trezix
Equagesic
Zamicet
Levacet
ANTI-INFLAMMATORY
ANALGESICS – OPIOID (PA may be required for new starts)
TIER 01 GENERIC
TIER 01 GENERIC
diclofenac potassium
acetaminophen/caffeine/dihydrocodeine
diclofenac sodium DR
acetaminophen/codeine
diclofenac sodium ER
acetaminophen/codeine #2
diclofenac sodium/misoprostol
acetaminophen/codeine #3
etodolac
acetaminophen/codeine #4
etodolac ER
acetaminophen/codeine phosphate
fenoprofen calcium
alfentanil
flurbiprofen
aspirin-caffeine-dihydrocodeine
ibuprofen
buprenorphine HCLPA
indomethacin
buprenorphine HCL/naloxone HCLQL
indomethacin ER
butalbital/acetaminophen/caffeine/codeine
ketoprofen
butalbital/aspirin/caffeine/codeine
ketoprofen ER
butorphanol tartrate
ketorolac tromethamine
codeine sulfate
leflunomide
hydrocodone bitartrate/acetaminophen
meclofenamate sodium
hydrocodone/acetaminophen
mefenamic acid
hydrocodone/ibuprofen
meloxicam
hydromorphone HCL
nabumetone
hydromorphone HCL dosette
naproxen
hydromorphone HCL ERPA
naproxen sodium
levorphanol tartrate
oxaprozin
meperidine HCL
piroxicam
methadone HCLPA
sulindac
morphine sulfate
tolmetin sodium
morphine sulfate ERQL,PA
TIER 02 FORMULARY
nalbuphine HCL
celecoxib
oxycodone HCL
naproxen sodium ER
oxycodone HCL ERQL,PA
Indocin
oxycodone/acetaminophen
Ridaura
oxycodone/aspirin
TIER 03 NON PREFERRED
oxycodone/ibuprofen
oxymorphone hydrochloride
oxymorphone hydrochloride ERPA
pentazocine/naloxone HCL
tramadol hydrochloride/acetaminophen
IC 400
tramadol HCL
IC 800
tramadol HCL ER
Mobic
TIER 02 FORMULARY
Nalfon
fentanylPA
Effective April 1, 2016
PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; 19
TIER 03 NON PREFERRED
Mitigare
Rasuvo Uloric
Rheumatrex
SprixPA
TIER 04 SPECIALTY
ActemraPA
Arcalyst
EnbrelPA
Enbrel SureclickPA
HumiraQL,PA
Humira Pediatric Crohns Disease Starter Pack
Humira PenQL,PA
Humira Pen-crohns DiseasestarterQL,PA
Humira Pen-psoriasis StarterQL,PA
Ilaris
KineretPA
OrenciaQL,PA
OtezlaQL,PA
SimponiPA
XeljanzQL,PA
Xeljanz XR
MIGRAINE PRODUCTS
TIER 01 GENERIC
almotriptan malate
dihydroergotamine mesylate
RESPIRATORY, ALLERGY, ETC
frovatriptan succinate
ANTIHISTAMINES
naratriptan HCL
TIER 01 GENERIC
rizatriptan benzoate
brompheniramine
sumatriptan
brompheniramine tannate
sumatriptan succinate
carbinoxamine maleate
sumatriptan succinate refill
cetirizine HCL
zolmitriptan
clemastine fumarate
TIER 02 FORMULARY
cyproheptadine HCL
rizatriptan benzoate ODT
desloratadine
zolmitriptan ODT
desloratadine ODT
Migral
dexchlorpheniramine maleate
Relpax
diphenhydramine HCL
TIER 03 NON PREFERRED
levocetirizine dihydrochloride
AlsumaST
promethazine HCL
Cafergot
promethazine HCL plain
Ergomar
TIER 03 NON PREFERRED
FrovaST
Karbinal ER
Imitrex
Phenergan Fortis
Migergot
Sumavel DoseproST
NASAL AGENTS
TreximetST
TIER 01 GENERIC
Zomig azelastine HCL
Zomig Nasal Spray budesonide
flunisolide
GOUT AGENTS fluticasone propionate
ipratropium bromide
TIER 01 GENERIC
mometasone furoate
allopurinol
olopatadine HCL
colchicine
triamcinolone acetonide
probenecid
TIER 02 FORMULARY
probenecid/colchicine
Adrenalin
TIER 02 FORMULARY
Bactroban Nasal
Colcrys
Effective April 1, 2016
PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; 20
Nasonex theophylline CR
Tyzine theophylline ER
Tyzine Pediatric Nasal Drops zafirlukast
TIER 03 NON PREFERRED TIER 02 FORMULARY
Beconase AQ budesonide
Dymista Asmanex HFA
Omnaris Asmanex Twisthaler 120 Metered Doses
Qnasl Asmanex Twisthaler 14 Metered Doses
Qnasl Childrens Asmanex Twisthaler 30 Metered Doses
Veramyst Asmanex Twisthaler 60 Metered Doses
Zetonna Asmanex Twisthaler 7 Metered Doses
Atrovent HFA
COUGH/COLD/ALLERGY Combivent Respimat
Dulera
TIER 01 GENERIC
Elixophyllin
acetylcysteine
Foradil Aerolizer
benzonatate
Incruse Ellipta
bromphen/pseudoephedrine HCL/dextromethorphan HBR
Lufyllin
dextromethorphan HBR/chlorpheniramine/phenylephrine HCL
Proair HFA
hydrocodone bitartrate/chlorpheniramine maleate/PSE
Qvar
hydrocodone bitartrate/homatropine methylbromide
Serevent Diskus
hydrocodone polistirex/chlorpheniramine polistirex
Spiriva Handihaler
hydrocodone/homatropine
Symbicort
phenylephrine/guaifenesin
Theo-24
promethazine-DM
Ventolin HFA
promethazine/codeine
TIER 03 NON PREFERRED
promethazine/dextromethorphan
Advair DiskusST
promethazine/phenylephrine
Advair HFAST
promethazine/phenylephrine/codeine
Alvesco
sodium chloride
Anoro Ellipta
TIER 02 FORMULARY
Arcapta Neohaler
Vituz
Arnuity ElliptaST
TIER 03 NON PREFERRED
Breo ElliptaQL,ST
Carbaphen 12
Brovana
Carbaphen 12 PED
DalirespPA
Codar AR
Flovent DiskusST
Cpb Wc
Flovent HFAST
Decon-a
Isuprel
Gilphex TR
Perforomist
Giltuss PED-c
Proair Respiclick
Giltuss TR
Proventil HFAST
Hypersal
Pulmicort FlexhalerST
Nebusal
Pulmophylline
Neotuss Plus
Spiriva Respimat
Panatuss Dxp
Stiolto Respimat
Pediatex TDM
Tudorza Pressair
Relhist
Xopenex
Rescon-JR
Xopenex HFAST
Rescon-MX
Zyflo
Rezira
Zyflo CR
Semprex-D
TIER 04 SPECIALTY
XolairPA
Tuzistra XR
RESPIRATORY AGENTS - MISC
ANTIASTHMATIC/COPD AGENTS
TIER 03 NON PREFERRED
TIER 01 GENERIC
Curosurf
albuterol
Infasurf
albuterol sulfate
Survanta Intratracheal
albuterol sulfate ER
TIER 04 SPECIALTY
cromolyn sodium
EsbrietPA
epinephrine HCL
KalydecoQL,PA
ipratropium bromide
OfevPA
ipratropium bromide/albuterol sulfate
OrkambiPA
levalbuterol
Pulmozyme
levalbuterol HCL
metaproterenol sulfate
VITAMINS
montelukast sodium
MULTIVITAMINS
terbutaline sulfate
TIER 01 GENERIC
theophylline
b-complex 100
Effective April 1, 2016
PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; 21
TIER 02 FORMULARY Prenate Pixie
Mykidz Iron Fl Prenate Restore
TIER 03 NON PREFERRED Prenate Star
Atabex EC Preque 10
Bal-care DHA Provida OB
Citranatal Assure R-natal OB
Citranatal B-calm Select-ob+dha
Citranatal DHA Select-OB
Citranatal Harmony Taron-bc
Citranatal RX Taron-c DHA
Citranatal 90 DHA Texavite LQ
Concept DHA Tri-VI-flor
Concept OB Tricare Prenatal Compleat
Crnatal Tricare Prenatal DHA One
Duet DHA Balanced Triveen-duo DHA
Duet DHA 400 Triveen-prx RNF
Duet DHA 400EC Vemavite-prx 2
Duet DHA 430 Vinacal B
Duet DHA 430EC Vinate AZ Extra
Escavite Vinate Calcium
Escavite D Vinate DHA RF
Floriva Vita-pren
Focalgin CA Vitafol Ultra
Focalgin 90 DHA Vitafol-nano
Folcaps Omega 3 Vitafol-ob+dha
Folet DHA Vitafol-one
Folivane-prx DHA NF Vitamedmd One RX/Quatrefolic
Folivane-OB Vitamedmd Plus RX/Quatre Folic
Gesticare DHA Vitamedmd Redichew RX
Marnatal-f Vitamedmd Redichew RX/Quatrefolic
Mynatal Vitapearl
Natachew Viva DHA
Natalvirt CA Zatean-pn
Natalvirt 90 DHA Zatean-pn DHA
Natalvit Zatean-pn Plus
Natelle One Zatean-CH
Neevo DHA
Nestabs MISCELLANEOUS AGENTS
Nestabs Abc
Nestabs DHA
TIER 01 GENERIC
Newgen
pentetate calcium trisodium
Nexa Plus
pentetate zinc trisodium
Nicomide
TIER 03 NON PREFERRED
Niva-plus
Chemet
O-CAL Fa
TIER 04 SPECIALTY
O-CAL Prenatal
Exjade
Obstetrix DHA
FerriproxPA
Ocuvel
OB Complete
OB Complete One
OB Complete Petite
OB Complete Premier
OB Complete 400
OB Complete/DHA
Paire OB
Poly-VI-flor
Poly-VI-flor/Iron
Prefera OB
Prefera OB + DHA
Preferaob +dha
Preferaob One
Prefol-DHA
Prenata
Prenate
Prenate AM
Prenate DHA
Prenate Elite
Prenate Enhance
Prenate Essential
Prenate Mini
Effective April 1, 2016
PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; 22
Index
A
almotriptan malate, 20
Alocril, 18
abacavir, 2
alogliptin, 10 apraclonidine, 18
abacavir sulfate/lamivudine/zidovudine, 2
alogliptin/metformin HCL, 10 Apriso, 12
Abilify, 15
alogliptin/pioglitazone, 10 Aptiom, 16
Abilify Discmelt, 15
Alomide, 18 Aptivus, 2
Abilify Maintena, 15
Alora, 9 Aquoral, 14
Abstral, 19
alosetron hydrochloride, 12 Aranesp Albumin Free, 13
acamprosate calcium DR, 16
Arcalyst, 20
acarbose, 10
alprazolam, 14 Arcapta Neohaler, 21
acebutolol HCL, 4
alprazolam ER, 14 aripiprazole, 15
acetaminophen/caffeine/dihydrocodeine, 19
Alprazolam Intensol, 14 aripiprazole ODT, 15
alprazolam ODT, 14
acetaminophen/codeine, 19
Alrex, 18
acetaminophen/codeine #2, 19
Alsuma, 20 Arixtra, 14
acetaminophen/codeine #3, 19
Altabax, 6 Armour Thyroid, 11
acetaminophen/codeine #4, 19
Altoprev, 6 arnica flower, 8
acetaminophen/codeine phosphate, 19
Alvesco, 21 Arnuity Ellipta, 21
acetazolamide, 5
amantadine HCL, 16 Artiss, 14
acetazolamide ER, 5
amcinonide, 7 Asacol HD, 12
acetazolamide sodium, 5
amikacin sulfate, 1 Asmanex HFA, 21
acetic acid, 18
amiloride HCL, 5 Asmanex Twisthaler 120 Metered Doses, 21
acetic acid/aluminum acetate, 18
amiloride/hydrochlorothiazide, 5
acetylcysteine, 21
aminocaproic acid, 14 Asmanex Twisthaler 14 Metered Doses, 21
Aciphex Sprinkle, 12
amiodarone HCL, 5
acitretin, 7
Amitiza, 12 Asmanex Twisthaler 30 Metered Doses, 21
Actemra, 20
amitriptyline HCL, 14
Actimmune, 4
amlodipine besylate, 4 Asmanex Twisthaler 60 Metered Doses, 21
Actoplus Met XR, 10
amlodipine besylate/atorvastatin calcium, 6
Asmanex Twisthaler 7 Metered Doses, 21
amlodipine besylate/benazepril HCL, 5
Acuvail, 18
amlodipine besylate/benazepril hydrochloride, 5
aspirin-caffeine-dihydrocodeine, 19
acyclovir, 2, 7
aspirin/dipyridamole, 14
adapalene, 6
amlodipine besylate/valsartan, 5 Astagraf XL, 3
adapalene P.M., 6
amlodipine/valsartan/hctz, 5 Astringyn, 14
Adcirca, 6
amoxapine, 14 Atabex EC, 22
Adderall, 16
amoxicillin, 1 atenolol, 4
Adderall XR, 16
amoxicillin ER, 1 atenolol/chlorthalidone, 5
adefovir dipivoxil, 2
amoxicillin/clavulanate potassium, 1 Atopiclair, 8
Adempas, 6
amoxicillin/clavulanate potassium ER, 1 atorvastatin calcium, 6
Adrenaclick, 6
amphetamine/dextroamphetamine, 16 atovaquone, 3
Adrenalin, 6, 20
amphotericin b, 2 atovaquone/proguanil HCL, 2
Advair Diskus, 21
ampicillin, 1 Atripla, 2
Advair HFA, 21
ampicillin sodium, 1 Atropen, 12
Advicor, 6
ampicillin-sulbactam, 1 atropine sulfate, 12, 18
Ampyra, 17 Atrovent HFA, 21
Afinitor, 3
Amturnide, 5 Aubagio, 17
Afinitor Disperz, 3
Amytal Sodium, 15 augmented betamethasone dipropionate, 7
Aggrenox, 14
Anacaine, 8
Akten, 18
Anadrol-50, 9 Augmentin, 1
Akynzeo, 12
anagrelide hydrochloride, 14
Albenza, 3
albuterol, 21
auryxia, 12
albuterol sulfate, 21
anastrozole, 3 Avandamet, 10
albuterol sulfate ER, 21
Androderm, 9 Avandaryl, 10
alclometasone dipropionate, 7
Androgel, 9 Avandia, 10
Aldactazide, 5
Androgel P.M., 9 Avar, 6
Alecensa, 3
Androxy, 9 Avar LS, 6
alendronate sodium, 10
Angeliq, 9 Avc, 13
Alevicyn Antipruritic SG, 8
Anoro Ellipta, 21 Avenova, 8
alfentanil, 19
antipyrine/benzocaine, 18 Avonex, 17
alfuzosin HCL ER, 13
Anzemet, 12 Avonex Pen, 17
Alinia, 3
Axiron, 9
Alkeran, 3
Apokyn, 16 Azasan, 3
allopurinol, 20
Appbutamone, 15 Azasite, 17
Allzital, 19
azathioprine, 3
HCL/dextromethorphan HBR, 21
azelastine HCL, 18, 20
brompheniramine, 20 Cardura XL, 13
Azilect, 16
brompheniramine tannate, 20 carteolol HCL, 17
azithromycin, 1
Brovana, 21 carvedilol, 4
Azopt, 18
budesonide, 9, 20, 21 cascara sagrada, 11
Azor, 5
bumetanide, 5 Cathflo Activase, 14
aztreonam, 3
Bupap, 19 Cayston, 3
B
Buphenyl, 11 Cedax, 1
cefaclor, 1
cefaclor ER, 1
b-complex 100, 21
buprenorphine HCL, 19 cefadroxil, 1
bacitracin, 3, 17
buprenorphine HCL/naloxone HCL, 19 cefazolin sodium, 1
bacitracin/polymyxin b, 17
bupropion HCL, 14 cefdinir, 1
baclofen, 17
bupropion HCL ER, 14 cefditoren pivoxil, 1
Bactroban Nasal, 20
bupropion HCL SR, 14 cefepime, 1
Bal-care DHA, 22
bupropion HCL XL, 14 cefixime, 1
balsalazide disodium, 12
buspirone HCL, 14 Cefotan, 1
Banzel, 16
butalbital/acetaminophen, 19 cefotaxime sodium, 1
Baraclude, 2
butalbital/acetaminophen/caffeine, 19 cefotetan, 1
Beconase AQ, 21
butalbital/acetaminophen/caffeine/codeine, 19
cefoxitin sodium, 1
belladonna & opium, 12
cefpodoxime proxetil, 1
belladonna alkaloids & opium, 12
butalbital/aspirin/caffeine, 19 cefprozil, 1
benazepril HCL, 5
butalbital/aspirin/caffeine/codeine, 19 ceftazidime, 1
benazepril HCL/hydrochlorothiazide, 5
Butisol Sodium, 15 ceftibuten, 1
Benefix, 14
butorphanol tartrate, 19 Ceftin, 1
Benicar, 5
Bydureon, 10 ceftriaxone sodium, 1
Benicar HCT, 5
Byetta, 10 cefuroxime axetil, 1
benzoin compound tincture, 8
Bystolic, 4 cefuroxime sodium, 1
benzoin tincture, 8
C celecoxib, 19
benzonatate, 21
Cellcept, 3
benzoyl peroxide, 6
cabergoline, 11
Celontin, 16
benzoyl peroxide SHORT contact, 6
Cafergot, 20
Cenestin, 9
benztropine mesylate, 16
caffeine citrate, 15
centany, 6
Bepreve, 18
caffeine/sodium benzoate, 15
Centany AT, 6
Besivance, 17
calcipotriene, 7
cephalexin, 1
Betadine Ophthalmic Prep, 17
calcipotriene/betamethasone dipropionate, 7
Cerdelga, 13
betamethasone dipropionate, 7
Cervidil, 19
betamethasone sodium phosphate/betamethasone acetate, 8
calcitonin salmon, 10
Cesamet, 12
calcitonin-salmon, 10
cetirizine HCL, 20
betamethasone valerate, 7
calcitriol, 7, 11
Cetraxal, 18
Betaseron, 17
calcium acetate, 12
Cetrotide, 11
betaxolol HCL, 4, 17
Canasa, 12
cevimeline HCL, 14
bethanechol chloride, 13
candesartan cilexetil, 5
Chemet, 22
Bethkis, 1
candesartan cilexetil/hydrochlorothiazide, 5
Chenodal, 13
Betimol, 18
chlordiazepoxide HCL, 14
Betoptic-s, 17
Cantil, 12
chlordiazepoxide HCL/clidinium bromide, 12
bexarotene, 4
Capastat Sulfate, 2
Beyaz, 9
capecitabine, 3
chlordiazepoxide/amitriptyline, 17
bicalutamide, 3
Capex, 7
chlorhexidine gluconate, 14
Bicillin C-R, 1
Caphosol, 14
chlorhexidine gluconate oral rinse, 14
Bicillin L-A, 1
Capital/Codeine, 19
Bidil, 6
Caprelsa, 3
chloroquine phosphate, 2
Biltricide, 3
capsaicin, 8
chlorothiazide, 5
Binosto, 10
captopril, 5
chlorpromazine HCL, 15
bisoprolol fumarate, 4
captopril/hydrochlorothiazide, 5
chlorpropamide, 10
bisoprolol fumarate/hydrochlorothiazide, 5
Carafate, 12
chlorthalidone, 5
Carbaglu, 11
chlorzoxazone, 17
Blephamide, 18
carbamazepine, 16
cholestyramine, 6
Blephamide S.o.p., 18
carbamazepine ER, 16
cholestyramine light, 6
boric acid, 8
Carbaphen 12, 21
choline magnesium trisalicylate, 19
Bosulif, 3
Carbaphen 12 PED, 21
chorionic gonadotropin, 10
Botox, 17
Carbatrol, 16
Cialis, 6
Bravelle, 10
carbidopa, 16
Breo Ellipta, 21
carbidopa/levodopa, 16
ciclopirox, 7
Brilinta, 14
carbidopa/levodopa ER, 16
brimonidine tartrate, 18
carbidopa/levodopa ODT, 16
bromfenac, 18
carbidopa/levodopa/entacapone, 16
bromocriptine mesylate, 16
carbinoxamine maleate, 20
Ciferex, 13
bromphen/pseudoephedrine
Cardene SR, 4
cilostazol, 14
Cometriq, 4 Depakote ER, 16
Ciloxan, 17
Complera, 2 Depakote Sprinkles, 16
cimetidine, 12
Concept DHA, 22 Depo-estradiol, 9
cimetidine HCL, 12
Concept OB, 22 Depo-medrol, 9
Cimzia, 13
Concerta, 16 Depo-provera, 3
Cimzia Starter Kit, 13
Condylox, 8
Cipro HC, 18
Ciprodex, 18
Conzip, 19 Dermasorb HC, 7
ciprofloxacin, 1, 18
Copasil, 8 Dermasorb Ta, 7
ciprofloxacin ER, 1
desipramine HCL, 14
ciprofloxacin HCL, 1, 17
Cordran, 7 desloratadine, 20
citalopram hydrobromide, 14
Cordran Tape, 7 desloratadine ODT, 20
Coreg CR, 4 desmopressin acetate, 11
Corlanor, 6 desogestrel/ethinyl estradiol, 9
Citranatal 90 DHA, 22
Cortifoam, 13 Desonate, 7
Citranatal Assure, 22
cortisone acetate, 8 desonide, 7
Citranatal B-calm, 22
Cortisporin, 6 Desowen Cream/Cetaphil Lotion, 7
Citranatal DHA, 22
Cortisporin-tc, 18 Desowen Lotion/Cetaphil Cream, 7
Citranatal Harmony, 22
Cosentyx, 7 Desowen Ointment/Cetaphil Lotion, 7
Citranatal RX, 22
Cosentyx Sensoready Pen, 7 desoximetasone, 7
citric acid/sodium citrate, 13
Cosopt PF, 18 desvenlafaxine ER, 14
clarithromycin, 1
Cotellic, 4 dexamethasone, 8
clarithromycin ER, 1
Cpb Wc, 21 Dexamethasone Intensol, 9
clemastine fumarate, 20
Creon, 12 dexamethasone sodium phosphate, 8, 18
Cleocin, 13
Cresemba, 2
Crestor, 6 dexchlorpheniramine maleate, 20
Climara Pro, 9
Crinone, 13 Dexedrine, 16
clindamycin HCL, 3
Crixivan, 2 dexmethylphenidate HCL, 15
clindamycin palmitate HCL, 3
Crnatal, 22 dexmethylphenidate HCL ER, 15
clindamycin phosphate, 3, 6, 13
cromolyn sodium, 12, 18, 21 Dexpak 10 Day, 9
Curosurf, 21 Dexpak 13 Day, 9
Cuvposa, 12 Dexpak 6 Day, 9
clindamycin/benzoyl peroxide, 6
cyanocobalamin, 13 dexpanthenol, 12
Clindesse, 13
dextroamphetamine sulfate, 15
Clinoin, 6
cyclobenzaprine HCL, 17 dextroamphetamine sulfate ER, 15
clobetasol propionate, 7
Cyclogyl, 18 dextromethorphan HBR/chlorpheniramine/phenylephrine HCL, 21
clobetasol propionate emollient, 7
Cyclomydril, 18
clocortolone pivalate, 7
cyclopentolate HCL, 18
clocortolone pivalate P.M., 7
cyclopentolate hydrochloride, 18
Diabeta, 10
Cloderm, 7
cyclophosphamide, 3
diazepam, 14, 16
Cloderm P.M., 7
cycloserine, 2
diclofenac potassium, 19
clomiphene citrate, 10
cyclosporine, 3
diclofenac sodium, 7, 18
clomipramine HCL, 14
cyclosporine modified, 3
diclofenac sodium DR, 19
clonazepam, 16
cyproheptadine HCL, 20
diclofenac sodium ER, 19
clonazepam ODT, 16
Cystadane, 11
diclofenac sodium/misoprostol, 19
clonidine HCL, 5
Cystagon, 13
dicloxacillin sodium, 1
clopidogrel, 14
Cystaran, 18
dicyclomine hci, 12
clorazepate dipotassium, 14
Cytomel, 11
dicyclomine HCL, 12
Clorpres, 5
D
didanosine, 2
clotrimazole, 14
Dificid, 1
Daklinza, 2
clotrimazole/betamethasone dipropionate, 7
diflorasone diacetate, 7
Daliresp, 21
diflunisal, 19
danazol, 9
clozapine, 15
digoxin, 4
dantrolene sodium, 17
clozapine ODT, 15
dihydroergotamine mesylate, 20
dapsone, 3
coal TAR, 8
Dilantin, 16
Daraprim, 2
Coartem, 2
Dilantin Infatabs, 16
darifenacin ER, 13
cocaine HCL, 8
Dilantin-125, 16
darifenacin hydrobromide ER, 13
Codar AR, 21
Dilatrate SR, 4
Daytrana, 16
codeine sulfate, 19
Dilaudid-HP, 19
Debacterol, 14
colchicine, 20
diltiazem CD, 4
Decon-a, 21
Colcrys, 20
diltiazem HCL, 4
Delestrogen, 9
colestipol HCL, 6
diltiazem HCL ER, 4
Delzicol, 13
colistimethate sodium, 3
dimenhydrinate, 12
Demadex, 6
Coly-mycin S, 18
Dipentum, 13
demeclocycline HCL, 1
Colyte-flavor Packs, 12
diphenhydramine HCL, 20
Demser, 5
Combigan, 18
diphenoxylate/atropine, 12
Denavir, 7
Combipatch, 9
dipyridamole, 14
Depakene, 16
Combivent Respimat, 21
disopyramide phosphate, 5
Depakote, 16
disulfiram, 17
Embeda, 19 ethyl chloride/mist, 8
Diuril, 5
Emcyt, 3 etidronate disodium, 10
divalproex sodium, 16
Emend, 12 etodolac, 19
divalproex sodium DR, 16
Emsam, 15 etodolac ER, 19
divalproex sodium ER, 16
Emtriva, 2 etoposide, 3
Divigel, 9
Emulsion SB, 8 Eurax, 8
donepezil HCL, 17
Emverm, 3 Evamist, 9
Doral, 15
enalapril maleate, 5 Evicel, 14
dorzolamide HCL, 18
enalapril maleate/hydrochlorothiazide, 5 Evithrom, 14
dorzolamide HCL/timolol maleate, 17
Enbrel, 20 Evotaz, 2
doxazosin, 5
Enbrel Sureclick, 20 Exalgo, 19
doxazosin mesylate, 5
Endometrin, 13 Exelderm, 7
doxepin HCL, 14
Enjuvia, 9 exemestane, 3
doxepin hydrochloride, 7
Enlon, 17 Exjade, 22
doxercalciferol, 11
enoxaparin sodium, 14
doxycycline, 1, 6
Enstilar, 7 Extavia, 17
doxycycline hyclate, 1
entacapone, 16 F
doxycycline hyclate DR, 1
entecavir, 2
Fabior, 6
doxycycline monohydrate, 1
Entereg, 13
Factive, 1
dronabinol, 12
Entresto, 6
Falessa, 9
droperidol, 14
Epaned, 5
famciclovir, 2
drospirenone/ethinyl estradiol, 9
ephedrine sulfate, 6
famotidine, 12
Droxia, 13
Epiceram, 8
Fanapt, 15
Duavee, 9
Epiduo Forte, 6
Duet DHA 400, 22
Epifoam, 7
Fareston, 3
Duet DHA 400EC, 22
epinastine HCL, 18
Farxiga, 10
Duet DHA 430, 22
epinephrine, 6
Farydak, 4
Duet DHA 430EC, 22
epinephrine HCL, 21
Fazaclo, 15
Duet DHA Balanced, 22
Epipen 2-PAK, 6
felbamate, 16
Dulera, 21
Epipen-JR 2-PAK, 6
Felbatol, 16
duloxetine HCL, 15
Epivir HBV, 2
felodipine ER, 4
eplerenone, 5
Femring, 13
Epogen, 13
fenofibrate, 6
eprosartan mesylate, 5
fenofibrate micronized, 6
Epzicom, 2
fenofibric acid DR, 6
Equagesic, 19
Fenoglide, 6
Equetro, 15
fenoprofen calcium, 19
ergoloid mesylates, 17
fentanyl, 19
Ergomar, 20
fentanyl citrate oral transmucosal, 19
Durezol, 18
Ery-TAB, 1
Fentora, 19
dutasteride, 13
Eryped 200, 1
Feriva 21/7, 13
dutasteride/tamsulosin hydrochloride, 13
Eryped 400, 1
Ferriprox, 22
Dutoprol, 5
Erythrocin Stearate, 1
Fetzima, 15
Dyanavel XR, 16
erythromycin, 1, 6, 17
Finacea, 6
Dymista, 21
erythromycin base, 1
finasteride, 13
Dyrenium, 6
erythromycin ethylsuccinate, 1
Firazyr, 14
Dysport, 17
erythromycin/benzoyl peroxide, 6
Firmagon, 3
Dyural-l, 9
Esbriet, 21
E
Escavite, 22
Escavite D, 22
E.e.s. Granules, 1
escitalopram oxalate, 15
econazole nitrate, 7
estazolam, 15
Ecoza, 7
Estrace, 13
Edarbi, 5
estradiol, 9
Edarbyclor, 5
estradiol valerate, 9
Edecrin, 6
estradiol/norethindrone acetate, 9
Edurant, 2
Estrasorb, 9
Effient, 14
Estring, 13
Elestrin, 9
Estrogel, 9
Eletone, 8
Flagyl ER, 3
estropipate, 9
eszopiclone, 15
Elidel, 8
Flarex, 18
ethambutol HCL, 2
Eligard, 3
flavoxate HCL, 13
ethosuximide, 16
Elimite, 8
flecainide acetate, 5
ethyl chloride, 8
Eliquis, 14
Flector, 7
ethyl chloride/fine pinpoint, 8
Elixophyllin, 21
FLO-pred, 9
ethyl chloride/fine stream, 8
Ella, 9
Floriva, 22
ethyl chloride/medium jet stream, 8
Elmiron, 13
Flovent Diskus, 21
ethyl chloride/medium stream, 8
Emadine, 18
Flovent HFA, 21
fluconazole, 2
Gelclair, 14
flucytosine, 2
Gelnique, 13
fludrocortisone acetate, 8
gemfibrozil, 6
flunisolide, 20
Genotropin, 11 Humalog, 9
fluocinolone acetonide, 7, 18
Genotropin Miniquick, 11 Humalog Kwikpen, 9
fluocinolone acetonide ear drops, 18
gentamicin sulfate, 1, 6, 17 Humalog Mix 50/50, 9
fluocinonide, 7
gentamicin sulfate pediatric, 1 Humalog Mix 50/50 Kwikpen, 9
fluocinonide-e, 7
Genvoya, 2 Humalog Mix 75/25, 9
fluorometholone, 18
Geodon, 15 Humalog Mix 75/25 Kwikpen, 9
fluoxetine, 17
Gesticare DHA, 22 Humatrope, 11
fluoxetine DR, 15
Giazo, 13 Humatrope Combo Pack, 11
fluoxetine HCL, 15
Gilenya, 17 Humira, 20
fluphenazine decanoate, 15
Gilotrif, 4 Humira Pediatric Crohns Disease Starter Pack, 20
fluphenazine HCL, 15
Gilphex TR, 21
flurazepam HCL, 15
Giltuss PED-c, 21 Humira Pen, 20
flurbiprofen, 19
Giltuss TR, 21 Humira Pen-crohns Diseasestarter, 20
flurbiprofen sodium, 18
Gleevec, 4 Humira Pen-psoriasis Starter, 20
flutamide, 3
Glatiramer acetate , 17 Humulin R U-500 (concentrated), 9
fluticasone propionate, 7, 20
glimepiride, 10 Humulin R U-500 Kwikpen, 9
fluvastatin, 6
glipizide, 10 Hycamtin, 4
fluvastatin sodium ER, 6
glipizide ER, 10 hydralazine HCL, 5
fluvoxamine maleate, 15
glipizide/metformin HCL, 10 hydrochlorothiazide, 5
fluvoxamine maleate ER, 15
Glucagen Hypokit, 10 hydrocodone bitartrate/acetaminophen, 19
FML, 18
Glucagon Emergency Kit, 10
FML Forte, 18
glyburide, 10 hydrocodone bitartrate/chlorpheniramine maleate/PSE, 21
Focalgin 90 DHA, 22
glyburide micronized, 10
Focalgin CA, 22
glyburide/metformin HCL, 10 hydrocodone bitartrate/homatropine methylbromide, 21
Focalin, 16
glycolic acid, 7
Focalin XR, 16
glycolic acid 70% high purity, 7 hydrocodone polistirex/chlorpheniramine polistirex, 21
Folcaps Omega 3, 22
glycopyrrolate, 12
Folet DHA, 22
Glyset, 10 hydrocodone/acetaminophen, 19
folic acid, 13
Golytely, 11 hydrocodone/homatropine, 21
Folivane-OB, 22
Gonal-f, 10 hydrocodone/ibuprofen, 19
Folivane-prx DHA NF, 22
Gonal-f RFF, 10 hydrocortisone, 9, 12
Follistim AQ, 10
Gonal-f RFF Pen, 10 hydrocortisone acetate/aloe, 7
fondaparinux sodium, 14
Gonal-f RFF Rediject, 10 hydrocortisone acetate/lidocaine HCL,
Foradil Aerolizer, 21
Gordofilm, 8 hydrocortisone acetate/pramoxine, 12
Gordons Urea, 8 hydrocortisone butyrate, 7
Fortaz, 1
granisetron HCL, 12 hydrocortisone butyrate (lipid), 7
Forteo, 10
Granisol, 12 hydrocortisone butyrate (lipophilic), 7
Fortesta, 9
Granix, 13 hydrocortisone IN absorbase, 7
fortical, 10
griseofulvin microsize, 2 hydrocortisone valerate, 7
Fosamax Plus D, 10
griseofulvin ultramicrosize, 2 hydrocortisone/acetic acid, 18
fosinopril sodium, 5
guanfacine ER, 15 hydromorphone HCL, 19
fosinopril sodium/hydrochlorothiazide, 5
guanfacine HCL, 5 hydromorphone HCL dosette, 19
Fosrenol, 12
guanidine HCL, 17 hydromorphone HCL ER, 19
Fragmin, 14
Gynazole-1, 13 hydroxocobalamin, 13
Frova, 20
H hydroxychloroquine sulfate, 2
frovatriptan succinate, 20
hydroxyurea, 4
Fulyzaq, 12
hydroxyzine HCL, 14
halobetasol propionate, 7
furosemide, 5
hydroxyzine pamoate, 14
Halog, 7
Fuzeon, 2
Hylatopic, 8
Halonate, 7
Fycompa, 16
Hylatopic Plus, 8
haloperidol, 15
G
hyoscyamine sulfate, 12
haloperidol decanoate, 15
hyoscyamine sulfate ER, 12
gabapentin, 16
haloperidol lactate, 15
hyoscyamine sulfate ODT, 12
Gabavale-5, 14
Halotin, 7
hyoscyamine sulfate SR, 12
Gabazolamine, 14
Harvoni, 2
Hypersal, 21
Gabazolamine-0.5, 14
Helixate FS, 14
Hypertenevide-12.5, 4
Gabazolpidem-5, 15
Hemabate, 19
Hypertenipine-2.5, 4
Gabitidine, 12
heparin sodium, 14
Hypertensolol, 5
Gabitril, 16
heparin sodium dcu, 14
I
Gaboxetine, 15
heparin sodium/NACL 0.45%, 14
galantamine hydrobromide, 17
heparin sodium/NACL 0.9%, 14 ibandronate sodium, 10
ganirelix acetate, 11
heparin sodium/sodium chloride 0.9% premix, 14
Ibrance, 4
gatifloxacin, 17
ibuprofen, 19
Gattex, 13
Hexalen, 3
homatropine HBR, 18 IC 400, 19
IC 800, 19
Iclusig, 4
Keppra, 16 Leukeran, 3
Ilaris, 20
Keppra XR, 16 leuprolide acetate, 3
Ilevro, 18
Kerafoam, 8 Levacet, 19
imatinib mesylate, 3
Kerafoam 42, 8 levalbuterol, 21
Imbruvica, 4
Keralyt Scalp, 8 levalbuterol HCL, 21
imipramine HCL, 15
Ketek, 3 Levatol, 4
imipramine pamoate, 15
ketoconazole, 2, 7 Levemir, 10
imiquimod, 8
Levemir Flexpen, 10
Imitrex, 20
ketoprofen, 19 Levemir Flextouch, 10
Imuran, 3
ketoprofen ER, 19 levetiracetam, 16
Increlex, 11
ketorolac tromethamine, 18, 19 levetiracetam ER, 16
Incruse Ellipta, 21
Khedezla, 15 Levitra, 6
indapamide, 5
Kineret, 20 levobunolol HCL, 17
Inderal XL, 4
Kinlytic, 14 levocarnitine, 11
Indocin, 19
Kitabis PAK, 1 levocetirizine dihydrochloride, 20
indomethacin, 19
Kogenate FS, 14 levofloxacin, 1, 17
indomethacin ER, 19
Kogenate FS Bio-set, 14 levonorgestrel, 9
Infasurf, 21
Kombiglyze XR, 10 levonorgestrel and ethinyl estradiol, 9
Inlyta, 4
Korlym, 10 levonorgestrel/ethinyl estradiol, 9
Innopran XL, 4
Kovaltry, 14 levorphanol tartrate, 19
Intelence, 2
Kristalose, 12 levothyroxine sodium, 11
Intron A, 4
Kuvan, 11 levothyroxine sodium TAB 0.075MG, 11
Intron A W/Diluent, 4
Kynamro, 6 Levsin, 12
Invanz, 3
L Lexiva, 2
Invega Sustenna, 15
Lialda, 12
labetalol HCL, 4
Invega Trinza, 15
Lido-RX 4.1, 8
Lacrisert, 17
Invirase, 2
lidocaine, 8
lactic acid, 8
Invokamet, 10
lidocaine and tetracaine cream, 8
lactic acid e, 8
Invokana, 10
lidocaine HCL, 8, 14,
lactic acid w/vitamin e, 8
Iopidine, 18
lidocaine HCL jelly, 8
lactulose, 11, 12
ipratropium bromide, 20, 21
lidocaine HCL viscous, 14
Lamictal, 16
ipratropium bromide/albuterol sulfate, 21
lidocaine HCL-hydrocortisone acetate with aloe, 12
Lamictal Chewable Dispersible, 16
Iprivask, 14
Lamictal ODT, 16
irbesartan, 5
lidocaine HCL/hydrocortisone acetate,
irbesartan/hydrochlorothiazide, 5
lidocaine viscous, 14
Iressa, 4
lidocaine-prilocaine-cream base, 8
Isentress, 2
isoniazid, 2
lidocaine/prilocaine, 8
Isopto Carbachol, 18
Lincocin, 3
Isopto Homatropine, 18
lincomycin HCL, 3
Lamictal XR, 16
Isopto Hyoscine, 18
lincomycin/lidocaine, 3
Lamisil, 2
isosorbide dinitrate, 4
lindane, 8
Lamisil Spray, 7
isosorbide dinitrate ER, 4
linezolid, 3
lamivudine, 2
isosorbide mononitrate, 4
Linzess, 13
lamivudine/zidovudine, 2
isosorbide mononitrate ER, 4
liothyronine sodium, 11
lamotrigine, 16
isradipine, 4
lisinopril, 5
lamotrigine ER, 16
Isuprel, 21
lisinopril/hydrochlorothiazide, 5
lamotrigine ODT, 16
itraconazole, 2
lithium, 15
lamotrigine titration, 16
lithium carbonate, 15
lanoxin, 4
ivermectin, 2
lithium carbonate ER, 15
Lanoxin, 4
Ixinity, 14
Lithostat, 13
Lanoxin Pediatric, 4
J
Livalo, 6
lansoprazole, 12
LO Loestrin FE, 9
Jakafi, 4
lansoprazole/amoxicillin/clarithromycin, 12
Locoid, 8
Janumet, 10
lomustine, 3
Janumet XR, 10
Lantus, 9
Lonsurf, 4
Januvia, 10
Lantus Solostar, 9
lorazepam, 14
Jardiance, 10
Lastacaft, 18
Lortab, 19
Jentadueto, 10
latanoprost, 18
Juxtapid, 6
Latuda, 15
Lorzone, 17
K
Lazanda, 19
losartan potassium, 5
leflunomide, 19
losartan potassium/hydrochlorothiazide, 5
K-phos NO 2, 13
Lenvima 10MG Daily Dose, 4
Lenvima 14MG Daily Dose, 4
Lotemax, 18
Kalbitor, 14
Lenvima 20MG Daily Dose, 4
lovastatin, 6
Kaletra, 2
Lenvima 24MG Daily Dose, 4
loxapine, 15
Kalydeco, 21
Letairis, 6
loxapine succinate, 15
Karbinal ER, 20
letrozole, 3
Lufyllin, 21
Kazano, 10
leucovorin calcium, 4
Lumigan, 18
methylphenidate HCL CD, 15 moxifloxacin HCL, 1
Lupaneta Pack, 11
methylphenidate HCL ER, 16 Mozobil, 13
Lupron Depot, 3
methylphenidate HCL SR, 16 Multaq, 5
Lupron Depot-PED, 11
methylphenidate hydrochloride, 15 mupirocin, 6
Luzu, 7
methylprednisolone, 9 mupirocin calcium, 6
Lycelle, 8
methylprednisolone acetate, 9 Muse, 6
Lynparza, 4
methylprednisolone dose pack, 9 mycophenolate mofetil, 3
Lyrica, 16
methylprednisolone PF, 9 mycophenolic acid DR, 3
Lysodren, 3
methylprednisolone sodiumsuccinate, 9 Mykidz Iron Fl, 22
methyltestosterone, 9 Myleran, 3
metipranolol, 18 Mynatal, 22
M
metoclopramide HCL, 12 Myobloc, 17
metoclopramide ODT, 12 Myrbetriq, 13
Makena, 9
metolazone, 5 Mysoline, 16
malathion, 8
metoprolol succinate ER, 4 N
maprotiline HCL, 15
metoprolol tartrate, 4
Marnatal-f, 22
nabumetone, 19
metoprolol/hydrochlorothiazide, 5
Marplan, 15
nadolol, 4
metronidazole, 3, 6
Matulane, 4
nadolol/bendroflumethiazide, 5
metronidazole vaginal, 13
Maxidex, 18
nafcillin sodium, 1
mexiletine HCL, 5
Maxipime, 1
Nafrinse Daily/Acidulated, 14
Miacalcin, 10
Mb Hydrogel, 8
Nafrinse Daily/Neutral, 14
midodrine HCL, 6
meclofenamate sodium, 19
Nafrinse Weekly, 14
Mifeprex, 11
Medi-derm/L-RX, 8
naftifine HCL, 7
Migergot, 20
Medrol, 9
naftifine hydrochloride, 7
Migral, 20
medroxyprogesterone acetate, 9
Naftin, 7
Millipred, 9
medroxyprogesterone/lidocaine, 9
nalbuphine HCL, 19
Millipred DP, 9
mefenamic acid, 19
Nalfon, 19
Minastrin 24 FE, 9
mefloquine HCL, 2
Namenda XR, 17
mineral oil heavy, 11
megestrol acetate, 3, 9
Minivelle, 9
Megrix, 8
Namzaric, 17
minocycline HCL, 1
Mekinist, 4
naphazoline HCL, 18
minocycline HCL ER, 1
meloxicam, 19
naproxen, 19
minoxidil, 5
Mirapex ER, 16
memantine HCL, 17
naproxen sodium, 19
Mircera, 13
memantine HCL titration PAK, 17
naproxen sodium ER, 19
mirtazapine, 15
memantine hydrochloride, 17
naratriptan HCL, 20
mirtazapine ODT, 15
Menest, 9
Nascobal, 13
misoprostol, 12
Menopur, 11
Nasonex, 21
Mitigare, 20
Menostar, 9
Natachew, 22
Mitosol, 17
Mentax, 7
Natacyn, 17
meperidine HCL, 19
Natalvirt 90 DHA, 22
Mobic, 19
meprobamate, 14
Natalvirt CA, 22
modafinil, 16
mercaptopurine, 3
Natalvit, 22
Moderiba, 2
mesalamine, 12
Natazia, 9
Mesnex, 4
nateglinide, 10
Natelle One, 22
moexipril HCL, 5
Metadate CD, 16
Nature-throid, 11
moexipril/hydrochlorothiazide, 5
metaproterenol sulfate, 21
Nature-throid Nt-2.5, 11
molindone hydrochloride, 15
metaxalone, 17
Nebupent, 3
mometasone furoate, 7, 20
metformin HCL, 10
Nebusal, 21
metformin HCL ER, 10
Neevo DHA, 22
methadone HCL, 19
nefazodone HCL, 15
methamphetamine HCL, 15
Nembutal Sodium, 15
methazolamide, 5
Neo-synalar, 6
methenamine hippurate, 13
neomycin sulfate, 1
methenamine mandelate, 13
neomycin/bacitracin/polymyxin, 17
methimazole, 11
neomycin/polymyxin/bacitracin zinc, 17
methocarbamol, 17
neomycin/polymyxin/bacitracin/hydrocortisone, 18
montelukast sodium, 21
methotrexate, 3
Monurol, 13
methotrexate sodium, 3
neomycin/polymyxin/dexamethasone, 18
morphine sulfate, 19
methoxsalen, 7
neomycin/polymyxin/gramicidin, 17
morphine sulfate ER, 19
methscopolamine bromide, 12
neomycin/polymyxin/HC, 18
Morphine Sulfate Powder, 19
methyclothiazide, 5
neomycin/polymyxin/hydrocortisone, 18(2)
Motofen, 12
methyldopa, 5
Movantik, 13
methyldopa/hydrochlorothiazide, 5
Neoral, 3
Moviprep, 11
methylergonovine maleate, 19
Neosalus, 8
Moxatag, 1
Methylin, 16
Neosalus CP, 8
Moxeza, 17
methylphenidate HCL, 15
neostigmine methylsulfate, 17
Neotuss Plus, 21
Nutropin AQ Nuspin 10, 11 oxcarbazepine, 16
Nutropin AQ Nuspin 20, 11 Oxecta, 19
Nesina, 10
Nutropin AQ Nuspin 5, 11 oxiconazole nitrate, 7
Nestabs, 22
Nutropin AQ Pen, 11 Oxistat, 7
Nestabs Abc, 22
Nuvail, 8 Oxtellar XR, 16
Nestabs DHA, 22
Nuvigil, 16 oxybutynin chloride, 13
Neulasta, 13
Nuwiq, 14 oxybutynin chloride ER, 13
Nymalize, 4 oxycodone HCL, 19
Neumega, 13
nystatin, 2, 7, 14 oxycodone HCL ER, 19
Neupogen, 13
nystatin/triamcinolone, 7 oxycodone/acetaminophen, 19
Neupro, 16
O oxycodone/aspirin, 19
Neutrasal, 14
oxycodone/ibuprofen, 19
O-CAL Fa, 22
Neuvaxin, 8
Oxycontin, 19
O-CAL Prenatal, 22
Nevanac, 18
oxymorphone hydrochloride, 19
OB Complete, 22
nevirapine, 2
oxymorphone hydrochloride ER, 19
OB Complete 400, 22
nevirapine ER, 2
oxytocin, 19
OB Complete One, 22
Newgen, 22
P
OB Complete Petite, 22
Nexa Plus, 22
OB Complete Premier, 22 Paire OB, 22
Nexavar, 4
OB Complete/DHA, 22 paliperidone ER, 15
niacin ER, 6
Obstetrix DHA, 22 Pamine FQ, 12
nicardipine HCL, 4
octreotide acetate, 11 Panatuss Dxp, 21
Nicomide, 22
Ocudox, 1 Pancreaze, 12
nifedipine, 4
Ocuvel, 22 pancrelipase, 12
nifedipine ER, 4
Odefsey, 2 Pandel, 8
Nilandron, 3
Ofev, 21 pantoprazole sodium, 12
nimodipine, 4
ofloxacin, 1, 17, 18 papaverine HCL, 6
Ninlaro, 4
olanzapine, 15 paregoric, 12
nisoldipine, 4
olanzapine ODT, 15 paricalcitol, 11
nisoldipine ER, 4
olanzapine/fluoxetine, 17 Parnate, 15
Nitro-bid, 4
Oleptro, 15 paromomycin sulfate, 1
Nitro-dur, 4
olopatadine HCL, 18, 20 paroxetine HCL, 15
nitrofurantoin, 13
One Touch Test Strips 10 paroxetine HCL ER, 15
nitrofurantoin macrocrystals, 13
omega-3-acid ethyl esters, 6 Paser, 2
nitrofurantoin monohydrate, 13
omeprazole, 12 Pataday, 18
nitrofurantoin monohydrate/macrocrystals, 13
omeprazole/sodium bicarbonate, 12 Paxil, 15
Omnaris, 21 PCE, 1
nitroglycerin ER, 4
Omnitrope, 11
nitroglycerin lingual, 4
Omontys, 13 Pediaderm HC, 8
nitroglycerin transdermal, 4
ondansetron HCL, 12 Pediaderm Ta, 8
Nitromist, 4
ondansetron ODT, 12 Pediatex TDM, 21
Nitrostat, 4
Onfi, 16 peg 3350/electrolytes, 11
Niva-plus, 22
Onglyza, 10 peg-3350/electrolytes, 11
Nivatopic Plus, 8
Opana ER (crush Resistant), 19 peg-3350/NACL/NA bicarbonate/KCL,
nizatidine, 12
opium, 12 Peg-intron, 2
Norditropin Cartridge, 11
opium tincture, 12 Peg-intron Redipen, 2
Norditropin Flexpro, 11
Opsumit, 6 Peg-intron Redipen PAK 4, 2
Norditropin Nordiflex Pen, 11
Oracit, 13 Peganone, 16
norethindrone, 9
Orapred ODT, 9 Pegasys, 2
norethindrone & ethinyl estradiol ferrous fumarate, 9
Oravig, 14 Pegasys Proclick, 2
Orencia, 20 Pegintron, 2
norethindrone acetate, 9
Orenitram, 6 penicillin G potassium, 1
norethindrone acetate/ethinyl estradiol, 9(2)
Orfadin, 11 penicillin G procaine, 1
Orkambi, 21 penicillin G sodium, 1
norethindrone acetate/ethinyl estradiol/ferrous fumarate, 9
orphenadrine citrate, 17 penicillin v potassium, 1
orphenadrine citrate ER, 17 Pennsaid, 7
norgestimate/ethinyl estradiol, 9
orphenadrine/asa/caffeine, 17 Pentam 300, 3
Norinyl 1+50, 9
Oseni, 10 Pentasa, 12
Noroxin, 1
Osmoprep, 11 pentazocine/naloxone HCL, 19
Norpace CR, 5
Osphena, 10 pentetate calcium trisodium, 22
Northera, 6
Otezla, 20 pentetate zinc trisodium, 22
nortriptyline HCL, 15
Otiprio, 18 pentoxifylline ER, 14
Norvir, 2
Ovace Plus, 7 Perforomist, 21
Novoeight, 14
Ovidrel, 11 perindopril erbumine, 5
Noxafil, 2
oxacillin sodium, 1 permethrin, 8
Nplate, 13
oxandrolone, 9 perphenazine, 15
Nucynta, 19
oxaprozin, 19 perphenazine/amitriptyline, 17
Nucynta ER, 19
Oxaydo, 19 Pertzye, 12
Nuedexta, 17
oxazepam, 14 Pexeva, 15
phenazopyridine HCL, 13
Prenate, 22 Provida OB, 22
phenelzine sulfate, 15
Prenate AM, 22 Pruclair, 8
Phenergan Fortis, 20
Prenate DHA, 22 Prudoxin, 7
phenobarbital, 15
Prenate Elite, 22 Prumyx, 8
phenobarbital sodium, 15
Prenate Enhance, 22 Pulmicort Flexhaler, 21
phenoxybenzamine hydrochloride, 5
Prenate Essential, 22 Pulmophylline, 21
phentolamine mesylate, 5
Prenate Mini, 22 Pulmozyme, 21
phenylephrine HCL, 6, 18
Prenate Pixie, 22 Purixan, 3
phenylephrine/guaifenesin, 21
Prenate Restore, 22 Pylera, 12
Phenytek, 16
Prenate Star, 22 pyrazinamide, 2
phenytoin, 16
Prepidil, 19 pyridostigmine bromide, 17
phenytoin sodium, 16
Prepopik, 12 pyrogallic acid, 8
phenytoin sodium extended, 16
Preque 10, 22 Q
Phoslyra, 13
Presera, 8
Qnasl, 21
Phospholine Iodide, 18
Prevacid Solutab, 12
Qnasl Childrens, 21
pilocarpine HCL, 14, 18
Quartette, 9
pilocarpine hydrochloride, 14
Prezcobix, 2
quazepam, 15
pimozide, 17
Prezista, 2
Quelicin 1000, 17
pindolol, 4
Priftin, 2
quetiapine fumarate, 15
pioglitazone HCL, 10
primaquine phosphate, 2
Quillivant XR, 16
pioglitazone HCL-glimepiride, 10
primidone, 16
quinapril HCL, 5
pioglitazone HCL/metformin HCL, 10
Primlev, 19
quinapril/hydrochlorothiazide, 5
piroxicam, 19
Primsol, 3
quinidine gluconate, 5
Plegridy, 17
Pristiq, 15
quinidine gluconate CR, 5
quinidine gluconate ER, 5
Pliaglis, 8
quinidine sulfate, 5
podofilox, 8
quinidine sulfate ER, 5
Poly-VI-flor, 22
quinine sulfate, 2
Poly-VI-flor/Iron, 22
Proair HFA, 21
Qutenza, 8
polyethylene glycol 3350, 11
Proair Respiclick, 21
Qvar, 21
polymyxin b sulfate, 3
probenecid, 20
R
polymyxin b sulfate/trimethoprim sulfate, 17
probenecid/colchicine, 20
procainamide HCL, 5
R-natal OB, 22
Pomalyst, 3
Procentra, 16
rabeprazole sodium, 12
potassium citrate ER, 13
prochlorperazine, 15
raloxifene hydrochloride, 10
potassium citrate-citric acid crystals, 13
prochlorperazine edisylate, 15
ramipril, 5
potassium citrate/citric acid, 13
prochlorperazine maleate, 15
Ranexa, 4
potassium citrate/sodium citrate/citric acid, 13
Procort, 13
ranitidine HCL, 12
Procrit, 13
Rapaflo, 13
Potiga, 16
Proctofoam HC, 12
Rapamune, 3
Pr Cream, 8
Procysbi, 13
Rasuvo, 20
Pradaxa, 14
progesterone, 9
Ravicti, 11
pramipexole dihydrochloride, 16
pramipexole dihydrochloride ER, 16
Prograf, 3
Pramosone, 8
Prolensa, 18
pravastatin sodium, 6
Prolia, 10
Prazolamine, 17
Promacta, 13
Rebetol, 2
prazosin HCL, 5
promethazine HCL, 20
Rebif, 17
Pred Mild, 18
promethazine HCL plain, 20
Rebif Rebidose, 17
Pred-G, 18
promethazine-DM, 21
Pred-G S.o.p., 18
promethazine/codeine, 21
prednicarbate, 7
promethazine/dextromethorphan, 21
Recombinate, 14
prednisolone, 9
promethazine/phenylephrine, 21
Recothrom, 14
prednisolone acetate, 18
promethazine/phenylephrine/codeine, 21
prednisolone sodium phosphate, 9, 18
Promiseb, 7
Rectiv, 13
prednisolone sodium phosphate ODT, 9
Promiseb Complete, 7
Recura, 7
prednisone, 9
propafenone HCL, 5
Relagard, 13
Prednisone Intensol, 9
propafenone HCL ER, 5
Relenza Diskhaler, 2
Prefera OB, 22
propantheline bromide, 12
Relhist, 21
Prefera OB + DHA, 22
proparacaine HCL, 18
Relistor, 13
Preferaob +dha, 22
propranolol HCL, 4
Relpax, 20
Preferaob One, 22
propranolol HCL ER, 4
Relyyt, 8
propranolol/hydrochlorothiazide, 5
Remodulin, 6
Prefol-DHA, 22
propylthiouracil, 11
Renagel, 12
Premarin, 9, 13
Prostin E2, 19
Renvela, 12
Premphase, 9
Protonix, 12
repaglinide, 10
Prempro, 9
protriptyline HCL, 15
repaglinide/metformin hydrochloride, 10
Prenata, 22
Proventil HFA, 21
Repronex, 11
Rescon-JR, 21
Selrx, 7 Spritam, 16
Rescon-MX, 21
Selzentry, 2 Sprix, 20
Rescriptor, 2
Semprex-d, 21 Sprycel, 4
Rescula, 18
senna plus, 11 Stalevo 100, 16
reserpine, 5
Sensipar, 11 Stalevo 125, 16
Restora RX, 12
Stalevo 150, 16
Revlimid, 3
Stalevo 200, 16
Reyataz, 2
Stalevo 50, 16
Rezira, 21
Stalevo 75, 16
Rezyst IM, 12
stannous fluoride oral rinse, 14
Rezyst SB, 12
stavudine, 2
Rheumatrex, 20
Stavzor, 16
Ribasphere Ribapak, 2
Staxyn, 6
ribavirin, 2
Sentroxatine, 15 Stelara, 7
Ridaura, 19
Serevent Diskus, 21 Stimate, 11
rifabutin, 2
Seroquel XR, 15 Stiolto Respimat, 21
Rifamate, 2
Serostim, 11 Stivarga, 4
rifampin, 2
sertraline HCL, 15 Strattera, 16
Rifater, 2
sevelamer carbonate, 12 Strazepam, 15
riluzole, 17
Sfrowasa, 13 streptomycin sulfate, 1
rimantadine HCL, 2
Signifor, 11 Striant, 9
Rimantalist, 2
Signifor Lar, 11 Stribild, 2
Riomet, 10
sildenafil, 6 Suboxone, 19
risedronate sodium, 10
sildenafil citrate, 6 Subsys, 19
risedronate sodium DR, 10
Simbrinza, 18 Suclear, 11
Risperdal Consta, 15
Simcor, 6 Sucraid, 12
risperidone, 15
Simponi, 20 sucralfate, 12
risperidone ODT, 15
simvastatin, 6 sulfacetamide sodium, 6, 17
Ritalin, 16
Sinelee, 8 sulfacetamide sodium/prednisolone sodium phosphate, 18
Ritalin LA, 16
sirolimus, 3
Sirturo, 2 sulfacetamide sodium/sulfur, 6
rivastigmine tartrate, 17
Sitavig, 2 sulfacetamide sodium/sulfur cleanser, 6
rivastigmine transdermal system, 17
Sivextro, 3 sulfadiazine, 1
rizatriptan benzoate, 20
Sklice, 8 sulfamethoxazole/trimethoprim, 3
rizatriptan benzoate ODT, 20
sulfamethoxazole/trimethoprim DS, 3
ropinirole ER, 16
sodium bicarbonate, 12 sulfasalazine, 12
ropinirole HCL, 16
sodium chloride, 21 sulfurated lime, 8
Roxicet, 19
sodium citrate/citric acid, 13 sulindac, 19
Rozerem, 15
sodium hyaluronate, 8 sumatriptan, 20
Rytary, 16
sodium phenylbutyrate, 11 sumatriptan succinate, 20
S
sodium sulfacetamide, 6, 7, 17 sumatriptan succinate refill, 20
sodium sulfacetamide wash, 7 Sumavel Dosepro, 20
Sabril, 16
sodium sulfacetamide/sulfur, 6 Supprelin LA, 11
Safyral, 9
sodium sulfacetamide/sulfur cleanser, 6 Suprax, 1
Saizen, 11
sodium sulfacetamide/sulfur cleanser IN urea, 6
Suprep Bowel Prep, 12
Saizen Click.easy, 11
Survanta Intratracheal, 21
salicylic acid, 8
sodium sulfacetamide/sulfur cleansing cloths, 6
Sustiva, 2
salicylic acid cream, 8
Sutent, 4
sodium sulfacetamide/sulfur green, 6 Sylatron, 4
sodium sulfacetamide/sulfur IN urea, 6 Symax Duotab, 12
salicylic acid lotion, 8
sodium sulfacetamide/sulfur wash, 6 Symbicort, 21
Salivamax, 14
Solaice, 8 Symlinpen 120, 10
salsalate, 19
Soltamox, 3 Symlinpen 60, 10
Salvax Duo Plus, 8
Solu-medrol, 9
Samsca, 11
Somatuline Depot, 11
Sancuso, 12
Somavert, 11 Synalar TS, 8
Sandimmune, 3
Sorilux, 7 Synalgos-DC, 19
Sandostatin Lar Depot, 11
sotalol HCL, 4 Synarel, 11
Saphris, 15
sotalol HCL (AF), 4 Synera, 8
Sarafem, 17
Sotylize, 4 Synthroid, 11
Savaysa, 14
Sovaldi, 2 T
Savella, 17
Spectracef, 1
Tabloid, 3
spinosad, 8
Scalacort DK, 8
Taclonex, 8
Spiriva Handihaler, 21
scopolamine hydrobromide, 12
tacrolimus, 3, 8
Spiriva Respimat, 21
Select-OB, 22
Tafinlar, 4
spironolactone, 5
Select-ob+dha, 22
Tagrisso, 4
spironolactone/hydrochlorothiazide, 5
selegiline HCL, 16
Taltz, 7
Sporanox, 2
selenium sulfide, 7
Tamiflu, 2
tamoxifen citrate, 3
Thyrolar-1/4, 11 triamcinolone IN orabase, 14
tamsulosin HCL, 13
Thyrolar-2, 11 triamterene/hydrochlorothiazide, 5
Tanzeum, 10
Thyrolar-3, 11 Trianex, 8
Tarceva, 4
tiagabine hydrochloride, 16 triazolam, 15
Targadox, 1
ticlopidine HCL, 14 Tribenzor, 5
Taron-bc, 22
Tikosyn, 5 Tricare Prenatal Compleat, 22
Taron-c DHA, 22
timolol maleate, 4, 17 Tricare Prenatal DHA One, 22
Tasigna, 4
timolol maleate ophthalmic gel forming, 17
tricitrates, 13
Tazorac, 7
trifluoperazine HCL, 15
Tecfidera, 17
trifluridine, 17
tinidazole, 3 trihexyphenidyl HCL, 16
Tegretol, 16
Tirosint, 11 Trileptal, 16
Tegretol-XR, 16
Tisseel, 14 trimethobenzamide HCL, 12
Tekamlo, 5
Tisseel VH, 14 trimethoprim, 3
Tekturna, 5
Tivicay, 2 trimethoprim sulfate/polymyxin b sulfate, 17
Tekturna HCT, 5
telmisartan, 5
tizanidine HCL, 17 trimipramine maleate, 15
telmisartan/amlodipine, 5
TL Triseb, 7 Triumeq, 2
telmisartan/hydrochlorothiazide, 5
Tobi Podhaler, 1 Triveen-duo DHA, 22
temazepam, 15
Tobradex, 18 Triveen-prx RNF, 22
temozolomide, 3
Tobradex ST, 18 Trokendi XR, 16
terazosin HCL, 5
tobramycin, 1 Tropazone, 8
terbinafine HCL, 2
tobramycin sulfate, 1, 17 trospium chloride, 13
Terbinex, 2
tobramycin/dexamethasone, 18 trospium chloride ER, 13
terbutaline sulfate, 21
Tobrex, 17 Truvada, 2
terconazole, 13
tolazamide, 10 Tudorza Pressair, 21
Tersi Foam, 7
tolbutamide, 10
Testim, 9
tolcapone, 16
testosterone, 9
tolmetin sodium, 19
testosterone cypionate, 9
tolterodine tartrate, 13 Tuzistra XR, 21
testosterone enanthate, 9
tolterodine tartrate ER, 13 Tykerb, 4
testosterone P.M., 9
Topamax, 16 Tyvaso, 6
tetrabenazine, 17
Topamax Sprinkle, 16 Tyvaso Refill, 6
Topicort, 8 Tyvaso Starter, 6
tetracycline HCL, 1
topiramate, 16 Tyzeka, 2
Tetrix, 8
torsemide, 5 Tyzine, 21
Tev-tropin, 11
Toviaz, 13 Tyzine Pediatric Nasal Drops, 21
Teveten HCT, 5
Tracleer, 6 U
Texacort, 8
Tradjenta, 10
Uceris, 9, 13
Texavite LQ, 22
tramadol HCL, 19
Ulesfia, 8
Thalomid, 3
tramadol HCL ER, 19
Uloric, 20
Theo-24, 21
tramadol hydrochloride/acetaminophen, 19
theophylline, 21
theophylline CR, 21
trandolapril, 5
Ultresa, 12
theophylline ER, 21
trandolapril/verapamil HCL, 5
Umecta, 8
trandolapril/verapamil HCL ER, 5
Umecta PD, 8
tranexamic acid, 14
urea, 8
Transderm-scop, 12
tranylcypromine sulfate, 15
Travatan Z, 18
travoprost, 18
urea topical, 8
Trazamine, 15
Uretron D/S, 13
trazodone HCL, 15
Uroqid #2, 13
Trecator, 2
ursodiol, 12
Trelstar, 3
V
Trelstar Mixject, 3
Vagifem, 13
Thiola, 13
valacyclovir HCL, 2
thioridazine HCL, 15
Tretin-X, 6
Valchlor, 3
thiothixene, 15
tretinoin, 4, 6
tretinoin microsphere, 6
valganciclovir, 2
tretinoin microsphere P.M., 6
valproic acid, 16
Trexall, 3
valsartan, 5
Treximet, 20
valsartan/hydrochlorothiazide, 5
Trezix, 19
vancomycin HCL, 3
Thrombogen, 14
Tri-VI-flor, 22
Vantas, 3
Thyrolar-1, 11
triamcinolone, 9
Vascepa, 6
Thyrolar-1/2, 11
triamcinolone acetonide, 7, 14, 20
vasopressin, 11
Vecamyl, 5
Xeljanz, 20 Zyflo CR, 21
Vectical, 7
Xeljanz XR, 20 Zykadia, 4
Velphoro, 13
Xeomin, 17 Zylet, 18
Vemavite-prx 2, 22
Xerac Ac, 8 Zyprexa Relprevv, 15
venlafaxine HCL, 15
Xgeva, 10 Zytiga, 3
venlafaxine HCL ER, 15
Xifaxan, 3 8
Ventavis, 6
Xigduo XR, 10
8-mop, 7
Ventolin HFA, 21
Xolair, 21
Veramyst, 21
Xolegel, 7
verapamil HCL, 4
Xolegel Corepak, 7
verapamil HCL ER, 4
Xolegel Duo/Head & Shoulders, 7
verapamil HCL SR, 4
Xolegel Duo/Xolex, 7
Verdeso, 8
Xopenex, 21
Veregen, 8
Xopenex HFA, 21
Veripred 20, 9
Xrylix, 7
Versacloz, 15
Xtandi, 3
Vesicare, 13
Xuriden, 11
Vexol, 18
Viagra, 6
Xyntha, 14
Vibramycin, 1
Xyntha Solofuse, 14
Victoza, 10
Xyrem, 17
Victrelis, 2
Y
Videx Pediatric, 2
Yodoxin, 2
Vigamox, 17
Z
Viibryd, 15
zafirlukast, 21
Vimpat, 16
zaleplon, 15
Vinacal B, 22
Zamicet, 19
Vinate AZ Extra, 22
Zarontin, 16
Vinate Calcium, 22
Zatean-CH, 22
Vinate DHA RF, 22
Zatean-pn, 22
Viokace, 12
Zatean-pn DHA, 22
Viracept, 2
Zatean-pn Plus, 22
Viramune, 2
Zavesca, 13
Virazole, 2
Zelapar, 16
Viread, 2
Zelboraf, 4
Vita-pren, 22
Vitafol Ultra, 22
Zenpep, 12
Vitafol-nano, 22
Zenzedi, 16
Vitafol-ob+dha, 22
Zetia, 6
Vitafol-one, 22
Zetonna, 21
Vitamedmd One RX/Quatrefolic, 22
Ziagen, 2
Vitamedmd Plus RX/Quatre Folic, 22
zidovudine, 2
Vitamedmd Redichew RX, 22
Zioptan, 18
Vitamedmd Redichew RX/Quatrefolic, 22
ziprasidone HCL, 15
Vitapearl, 22
Zirgan, 17
Vitekta, 2
Zithranol, 7
Vituz, 21
Zithranol-rr, 7
Viva DHA, 22
Zmax, 1
Vogelxo, 9
Zoladex, 3
Vogelxo P.M., 9
Zolinza, 4
Voltaren, 7
zolmitriptan, 20
voriconazole, 2
zolmitriptan ODT, 20
Votrient, 4
zolpidem tartrate, 15
Vraylar, 15
zolpidem tartrate ER, 15
Vsl#3 DS, 12
Zolpimist, 15
Vusion, 7
Zomacton, 11
Vytorin, 6
Zomig, 20
Vyvanse, 16
Zomig Nasal Spray, 20
W
Zonalon, 7
zonisamide, 16
warfarin sodium, 14
Zorbtive, 11
Welchol, 6
Zortress, 3
Westhroid, 11
Zuplenz, 12
Wp Thyroid, 11
Zyclara, 8
X
Zyclara P.M., 8
Xalkori, 4
Zydelig, 4
Xarelto, 14
Zyflo, 21 RX-61479 Revised 04/01/2016
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