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CareSource Ohio Medicaid
10/01/2016
INTRODUCTION
We are pleased to provide the 2016 CareSource Medicaid Formulary as a useful reference and
informational tool. This document can assist medical providers in selecting clinically-appropriate and costeffective products for their patients. While all Ohio Medicaid drugs are covered by CareSource, this is a list
of preferred medications.
The drugs represented have been reviewed by a National Pharmacy and Therapeutics (P&T) Committee and
then approved by a local Pharmacy, Therapeutics and Technology (PT&T) Committee for inclusion. The
document is reflective of current medical practice as of the date of review.
The information contained in this document and its appendices is provided solely for the convenience of
medical providers. We do not warrant or assure accuracy of such information nor is it intended to be
comprehensive in nature. This document is not intended to be a substitute for the knowledge, expertise, skill
and judgment of the medical provider in his or her choice of prescription drugs. All the information in the
document is provided as a reference for drug therapy selection. Specific drug selection for an individual
patient rests solely with the prescriber.
The document is subject to state-specific regulations and rules, including, but not limited to, those regarding
generic substitution, controlled substance schedules, preference for brands and mandatory generics
whenever applicable.
We assume no responsibility for the actions or omissions of any medical provider based upon reliance, in
whole or in part, on the information contained herein. The medical provider should consult the drug
manufacturer's product literature or standard references for more detailed information.
National guidelines can be found on the National Guideline Clearinghouse site at http://www.guideline.gov,
on the websites listed under each therapeutic class and on the sites listed in the WEBSITES section of this
publication.
PREFACE
The document is organized by sections. Each section is divided by therapeutic drug class primarily defined
by mechanism of action. Products are listed by generic name with brand name for reference only. Unless the
cited drug is available as an injectable or an exception is specifically noted, generally, all applicable dosage
forms and strengths of the drug cited are included in the document.
PHARMACY AND THERAPEUTICS (P&T) COMMITTEE
The services of an independent National Pharmacy and Therapeutics (P&T) Committee are utilized to
approve safe and clinically effective drug therapies. The P&T Committee is an external advisory body of
experts from across the United States. The P&T Committee’s voting members include physicians,
pharmacists, a pharmacoeconomist and a medical ethicist, all of whom have a broad background of clinical
and academic expertise regarding prescription drugs. Employees with significant clinical expertise are invited
to meet with the P&T Committee, but no employee may vote on issues before the P&T Committee. Voting
members of the P&T Committee must disclose any financial relationship or conflicts of interest with any
pharmaceutical manufacturers.
In addition to the National P&T Committee review, the CareSource Pharmacy Therapeutics and Technology
(PT&T) Committee makes formulary recommendations based upon the needs of regional member
demographics. The CareSource PT&T Committee is comprised of the Plan’s Medical Directors, Pharmacy
staff and representatives from the medical community.
DRUG LIST PRODUCT DESCRIPTIONS
To assist in understanding which specific strengths and dosage forms on the document are covered, examples
are noted below. The general principles shown in the examples can usually be extended to other entries in the
document. Any exceptions are noted.
Listed products on the document generally include all strengths and dosage forms of the cited brandname product.
pregabalin
Lyrica
Oral capsules, oral solution and all strengths of Lyrica would be included in this listing.
When a strength, dosage or different formulation is specified, only that specific strength, dosage or
formulation may be covered. Other strengths/dosage/formulations, including injectable dosage forms of
the reference product, are not covered.
colestipol tabs
Colestid
The generic-name oral tablet formulation is on the document. From this entry, the oral packets and granules
cannot be assumed to be on the list unless there is a separate entry.
Extended-release and delayed-release products require their own entry.
metformin
Glucophage
The immediate-release product listing of Glucophage alone would not include the extended-release product
Glucophage XR.
metformin ext-rel
Glucophage XR
A separate entry for Glucophage XR confirms that the extended-release product is on the document.
Dosage forms on the document will be consistent with the category and use where listed.
neomycin/polymyxin B/hydrocortisone
Cortisporin
Since Cortisporin is listed only in the OTIC section, it is limited to the otic solution and suspension. From this
entry the topical cream cannot be assumed to be on the list unless there is an entry for this product in the
DERMATOLOGY section of the document.
GENERIC SUBSTITUTION
Generic substitution is a pharmacy action whereby a generic version is dispensed rather than a prescribed
brand-name product. Boldface type indicates generic availability. However, not all strengths or dosage
forms of the generic name in boldface type may be generically available. In most instances, a brand-name
drug for which a generic product becomes available will become non-formulary, with the generic product
covered in its place, upon release of the generic product onto the market. However, the document is subject
to state specific regulations and rules regarding generic substitution and mandatory generic rules apply
where appropriate.
Generic drugs are usually priced lower than their brand-name equivalents and should be considered the first
line of prescribing subject to applicable rules. Prescription generic drugs are:
•
•
•
Approved by the U.S. Food and Drug Administration for safety and effectiveness, and are
manufactured under the same strict standards that apply to brand-name drugs.
Tested in humans to assure the generic is absorbed into the bloodstream in a similar rate and
extent compared to the brand-name drug (bioequivalence). Generics may be different from the
brand in size, color and inactive ingredients, but this does not alter their effectiveness or ability to
be absorbed just like the brand-name drug.
Manufactured in the same strength and dosage form as the brand-name drugs.
When a generic drug is substituted for a brand-name drug, you can expect the generic to produce the same
clinical effect and safety profile as the brand-name drug (therapeutic equivalence).
PLAN DESIGN
The document represents a closed formulary plan design. The medications listed on the document are
covered by the plan as represented. Certain medications on the list are covered if utilization management
criteria are met (i.e. Step Therapy, Prior Authorization, Quantity Limits, etc); requests for use of such
medications outside of their listed criteria will be reviewed for medical necessity. If a medication is not listed
on the document, a formulary exception may be requested for coverage. Medical necessity or formulary
exception requests will be reviewed based on drug-specific prior authorization criteria or standard nonformulary prescription request criteria.
LEGEND
AL
Age Limit
OTC
Over the counter
PA
Prior Authorization; Prior Authorization includes but is not limited to therapeutic interchange
QL
Quantity Limit
SP
Specialty Drug
ST
Step Therapy
boldface
Indicates generic availability; boldface may not apply to every strength or dosage form under
the listed generic name
delayed-rel
Delayed-release (also known as enteric-coated), refer to the reference brand listed for
clarification
ext-rel
Extended-release (also known as sustained-release), refer to the reference brand listed for
clarification
NOTICE
The information contained in this document is proprietary. The information may not be copied in whole or in
part without written permission. ©2015. All rights reserved.
This document contains references to brand-name prescription drugs that are trademarks or registered
trademarks of pharmaceutical manufacturers.
CareSource does not operate the websites/organizations listed here, not is it responsible for the
availability or reliability of the websites’ content. These listings do not imply or constitute an endorsement,
sponsorship or recommendation by CareSource.
Please be advised that this document is updated periodically and changes may appear prior to their
effective date to allow for client notification.
CareSource Ohio Medicaid
10/01/2016
ANALGESICS........................................................................................................................................................................................................... 4
ANALGESICS, OTHER .................................................................................................................................................................................. 4
NSAIDs ........................................................................................................................................................................................................... 4
NSAIDs, COMBINATIONS ............................................................................................................................................................................. 4
NSAIDs, TOPICAL ......................................................................................................................................................................................... 4
COX-2 INHIBITORS ....................................................................................................................................................................................... 4
GOUT ............................................................................................................................................................................................................. 4
OPIOID ANALGESICS ................................................................................................................................................................................... 5
NON-OPIOID ANALGESICS.......................................................................................................................................................................... 6
VISCOSUPPLEMENTS ................................................................................................................................................................................. 6
ANTI-INFECTIVES ................................................................................................................................................................................................... 7
ANTIBACTERIALS ......................................................................................................................................................................................... 7
ANTIFUNGALS .............................................................................................................................................................................................. 8
ANTIMALARIALS ........................................................................................................................................................................................... 8
ANTIRETROVIRAL AGENTS ........................................................................................................................................................................ 9
ANTITUBERCULAR AGENTS ..................................................................................................................................................................... 10
ANTIVIRALS................................................................................................................................................................................................. 10
MISCELLANEOUS ....................................................................................................................................................................................... 11
ANTINEOPLASTIC AGENTS ................................................................................................................................................................................ 11
ALKYLATING AGENTS ............................................................................................................................................................................... 11
ANTIMETABOLITES .................................................................................................................................................................................... 11
HORMONAL ANTINEOPLASTIC AGENTS ................................................................................................................................................. 11
IMMUNOMODULATORS ............................................................................................................................................................................. 12
KINASE INHIBITORS ................................................................................................................................................................................... 12
TOPOISOMERASE INHIBITORS ................................................................................................................................................................ 13
MISCELLANEOUS ....................................................................................................................................................................................... 13
CARDIOVASCULAR .............................................................................................................................................................................................. 14
ACE INHIBITORS......................................................................................................................................................................................... 14
ACE INHIBITOR/CALCIUM CHANNEL BLOCKER COMBINATIONS ........................................................................................................ 14
ACE INHIBITOR/DIURETIC COMBINATIONS ............................................................................................................................................ 14
ADRENOLYTICS, CENTRAL....................................................................................................................................................................... 14
ALDOSTERONE RECEPTOR ANTAGONISTS .......................................................................................................................................... 14
ALPHA BLOCKERS ..................................................................................................................................................................................... 14
ANGIOTENSIN II RECEPTOR ANTAGONISTS/DIURETIC COMBINATIONS........................................................................................... 15
ANGIOTENSIN II RECEPTOR ANTAGONIST/CALCIUM CHANNEL BLOCKER COMBINATIONS ......................................................... 15
ANGIOTENSIN II RECEPTOR ANTAGONIST/CALCIUM CHANNEL BLOCKER/DIURETIC COMBINATIONS ....................................... 15
ANTIARRHYTHMICS ................................................................................................................................................................................... 15
ANTILIPEMICS............................................................................................................................................................................................. 15
BETA-BLOCKERS ....................................................................................................................................................................................... 16
BETA-BLOCKER/DIURETIC COMBINATIONS ........................................................................................................................................... 16
CALCIUM CHANNEL BLOCKERS .............................................................................................................................................................. 16
DIGITALIS GLYCOSIDES ............................................................................................................................................................................ 17
DIURETICS .................................................................................................................................................................................................. 17
NEPRILYSIN INHIBITOR/ANGIOTENSIN II RECEPTOR ANTAGONIST COMBINATIONS ..................................................................... 17
NITRATES .................................................................................................................................................................................................... 17
PULMONARY ARTERIAL HYPERTENSION .............................................................................................................................................. 17
MISCELLANEOUS ....................................................................................................................................................................................... 18
CENTRAL NERVOUS SYSTEM ............................................................................................................................................................................ 18
ANTIANXIETY .............................................................................................................................................................................................. 18
ANTICONVULSANTS .................................................................................................................................................................................. 18
ANTIDEMENTIA ........................................................................................................................................................................................... 19
ANTIDEPRESSANTS .................................................................................................................................................................................. 19
ANTIPARKINSONIAN AGENTS .................................................................................................................................................................. 20
ANTIPSYCHOTICS ...................................................................................................................................................................................... 21
1
ATTENTION DEFICIT HYPERACTIVITY DISORDER ................................................................................................................................ 21
HUNTINGTON'S DISEASE AGENTS .......................................................................................................................................................... 22
HYPNOTICS................................................................................................................................................................................................. 22
MIGRAINE .................................................................................................................................................................................................... 23
MOOD STABILIZERS .................................................................................................................................................................................. 23
MULTIPLE SCLEROSIS AGENTS .............................................................................................................................................................. 23
MUSCULOSKELETAL THERAPY AGENTS ............................................................................................................................................... 23
MYASTHENIA GRAVIS ............................................................................................................................................................................... 24
NARCOLEPSY/CATAPLEXY....................................................................................................................................................................... 24
PSYCHOTHERAPEUTIC-MISCELLANEOUS ............................................................................................................................................. 24
MISCELLANEOUS ....................................................................................................................................................................................... 25
ENDOCRINE AND METABOLIC ........................................................................................................................................................................... 25
ANDROGENS .............................................................................................................................................................................................. 25
ANTIDIABETICS .......................................................................................................................................................................................... 25
CALCIUM RECEPTOR ANTAGONISTS ..................................................................................................................................................... 27
CALCIUM REGULATORS ........................................................................................................................................................................... 27
CONTRACEPTIVES .................................................................................................................................................................................... 27
ENDOMETRIOSIS ....................................................................................................................................................................................... 29
ESTROGENS ............................................................................................................................................................................................... 29
ESTROGEN/PROGESTINS......................................................................................................................................................................... 29
ESTROGEN/SELECTIVE ESTROGEN RECEPTOR MODULATOR COMBINATIONS ............................................................................. 30
GAUCHER DISEASE ................................................................................................................................................................................... 30
GLUCOCORTICOIDS .................................................................................................................................................................................. 30
GLUCOSE ELEVATING AGENTS ............................................................................................................................................................... 30
HUMAN GROWTH HORMONES................................................................................................................................................................. 30
HYPERPARATHYROID TREATMENT, VITAMIN D ANALOGS ................................................................................................................. 30
INSULIN-LIKE GROWTH FACTOR ............................................................................................................................................................. 30
PHENYLKETONURIA TREATMENT AGENTS ........................................................................................................................................... 30
PHOSPHATE BINDER AGENTS ................................................................................................................................................................. 30
PROGESTINS .............................................................................................................................................................................................. 31
SELECTIVE ESTROGEN RECEPTOR MODULATORS ............................................................................................................................. 31
THYROID AGENTS ..................................................................................................................................................................................... 31
VASOPRESSIN RECEPTOR ANTAGONISTS............................................................................................................................................ 31
VASOPRESSINS ......................................................................................................................................................................................... 31
MISCELLANEOUS ....................................................................................................................................................................................... 31
GASTROINTESTINAL ........................................................................................................................................................................................... 31
ANTACIDS ................................................................................................................................................................................................... 31
ANTIDIARRHEALS ...................................................................................................................................................................................... 32
ANTIEMETICS ............................................................................................................................................................................................. 32
ANTISPASMODICS ..................................................................................................................................................................................... 32
CHOLELITHOLYTICS .................................................................................................................................................................................. 32
H2 RECEPTOR ANTAGONISTS .................................................................................................................................................................. 32
INFLAMMATORY BOWEL DISEASE .......................................................................................................................................................... 32
IRRITABLE BOWEL SYNDROME ............................................................................................................................................................... 33
LAXATIVES/STOOL SOFTENERS.............................................................................................................................................................. 33
PANCREATIC ENZYMES ............................................................................................................................................................................ 33
PROSTAGLANDINS .................................................................................................................................................................................... 33
PROTON PUMP INHIBITORS ..................................................................................................................................................................... 33
SALIVA STIMULANTS ................................................................................................................................................................................. 34
STEROIDS, RECTAL ................................................................................................................................................................................... 34
MISCELLANEOUS ....................................................................................................................................................................................... 34
GENITOURINARY .................................................................................................................................................................................................. 34
BENIGN PROSTATIC HYPERPLASIA ........................................................................................................................................................ 34
URINARY ANTISPASMODICS .................................................................................................................................................................... 34
VAGINAL ANTI-INFECTIVES ...................................................................................................................................................................... 34
MISCELLANEOUS ....................................................................................................................................................................................... 35
HEMATOLOGIC ..................................................................................................................................................................................................... 35
ANTICOAGULANTS .................................................................................................................................................................................... 35
ANTIHEMOPHILIC AGENTS ....................................................................................................................................................................... 35
HEMATOPOIETIC GROWTH FACTORS .................................................................................................................................................... 36
HEREDITARY ANGIOEDEMA AGENTS ..................................................................................................................................................... 36
IDIOPATHIC THROMBOCYTOPENIC PURPURA AGENTS ...................................................................................................................... 36
PAROXYSMAL NOCTURNAL HEMOGLOBINURIA (PNH) AGENTS ........................................................................................................ 36
PLATELET AGGREGATION INHIBITORS .................................................................................................................................................. 36
2
PLATELET SYNTHESIS INHIBITORS ........................................................................................................................................................ 36
MISCELLANEOUS ....................................................................................................................................................................................... 36
IMMUNOLOGIC AGENTS...................................................................................................................................................................................... 37
ALLERGENIC EXTRACTS .......................................................................................................................................................................... 37
BIOLOGIC DISEASE-MODIFYING AGENTS .............................................................................................................................................. 37
DISEASE-MODIFYING ANTIRHEUMATIC DRUGS (DMARDs) ................................................................................................................. 37
IMMUNE GLOBULINS ................................................................................................................................................................................. 37
IMMUNOMODULATORS ............................................................................................................................................................................. 37
IMMUNOSUPPRESSANTS ......................................................................................................................................................................... 38
NUTRITIONAL/SUPPLEMENTS............................................................................................................................................................................ 38
ELECTROLYTES ......................................................................................................................................................................................... 38
VITAMINS AND MINERALS ........................................................................................................................................................................ 38
RESPIRATORY ...................................................................................................................................................................................................... 40
ANAPHYLAXIS TREATMENT AGENTS ..................................................................................................................................................... 40
ANTICHOLINERGICS .................................................................................................................................................................................. 40
ANTICHOLINERGIC/BETA AGONIST COMBINATIONS............................................................................................................................ 40
ANTIHISTAMINES, LOW SEDATING.......................................................................................................................................................... 40
ANTIHISTAMINES, NONSEDATING ........................................................................................................................................................... 40
ANTIHISTAMINES, SEDATING ................................................................................................................................................................... 40
ANTIHISTAMINE/DECONGESTANT COMBINATIONS.............................................................................................................................. 41
ANTITUSSIVES............................................................................................................................................................................................ 41
ANTITUSSIVE COMBINATIONS ................................................................................................................................................................. 41
BETA AGONISTS ........................................................................................................................................................................................ 41
CYSTIC FIBROSIS ...................................................................................................................................................................................... 42
DECONGESTANTS ..................................................................................................................................................................................... 42
DECONGESTANT/EXPECTORANT COMBINATIONS .............................................................................................................................. 42
EXPECTORANTS ........................................................................................................................................................................................ 42
LEUKOTRIENE RECEPTOR ANTAGONISTS ............................................................................................................................................ 42
MAST CELL STABILIZERS ......................................................................................................................................................................... 42
MEDICAL SUPPLIES ................................................................................................................................................................................... 42
NASAL ANTIHISTAMINES .......................................................................................................................................................................... 43
NASAL STEROIDS ...................................................................................................................................................................................... 43
PHOSPHODIESTERASE-4 INHIBITORS .................................................................................................................................................... 43
PULMONARY FIBROSIS AGENTS ............................................................................................................................................................. 43
RESPIRATORY SYNCYTIAL VIRUS........................................................................................................................................................... 43
STEROID/BETA AGONIST COMBINATIONS ............................................................................................................................................. 43
STEROID INHALANTS ................................................................................................................................................................................ 43
XANTHINES ................................................................................................................................................................................................. 43
MISCELLANEOUS ....................................................................................................................................................................................... 44
TOPICAL ................................................................................................................................................................................................................ 44
DERMATOLOGY.......................................................................................................................................................................................... 44
MOUTH/THROAT/DENTAL AGENTS ......................................................................................................................................................... 47
OPHTHALMIC .............................................................................................................................................................................................. 47
OTIC ............................................................................................................................................................................................................. 49
WEBSITES ............................................................................................................................................................................................................. 50
INDEX ..................................................................................................................................................................................................................... 52
3
ANALGESICS
Practice guidelines of pain management are available at:
http://www.asahq.org
ANALGESICS, OTHER
Treatment recommendations for osteoarthritis are available at:
http://www.rheumatology.org
OTC, QL
acetaminophen
QL acetaminophen
QL acetaminophen liq, elixir
NSAIDs
OTC
OTC
QL
PA
TYLENOL
=
=
ibuprofen
naproxen sodium
diclofenac potassium
diclofenac sodium delayed-rel
diclofenac sodium ext-rel
diflunisal
etodolac
etodolac ext-rel
flurbiprofen
ibuprofen
indomethacin
indomethacin ext-rel
indomethacin supp
indomethacin susp
ketoprofen
ketorolac
ketorolac nasal spray
meloxicam
nabumetone
naproxen
naproxen sodium
oxaprozin
sulindac
QL ketorolac
Max 200 caps, tabs per month
Max 200 mL per month
ADVIL
ALEVE
INDOCIN
INDOCIN susp
SPRIX
MOBIC
NAPROSYN
ANAPROX
DAYPRO
=
Max 20 tabs per month
NSAIDs, COMBINATIONS
diclofenac sodium delayed-rel/misoprostol
ARTHROTEC
NSAIDs, TOPICAL
QL
diclofenac sodium gel 1%
VOLTAREN GEL
QL diclofenac sodium gel 1%
COX-2 INHIBITORS
celecoxib
GOUT
QL
ST
allopurinol
colchicine tabs
febuxostat
=
Max 100 grams per month
CELEBREX
ZYLOPRIM
COLCRYS
ULORIC
AL: Age Limit; OTC: Over the counter; PA: Prior Authorization; QL: Quantity Limit; SP: Specialty Drug; ST: Step Therapy
boldface: indicates generic availability; delayed-rel: delayed-release (also known as enteric-coated);
ext-rel: extended-release (also known as sustained-release)
4
probenecid
QL colchicine tabs
=
Max 30 tabs per month
OPIOID ANALGESICS
Practice Guidelines for Cancer Pain Management (includes WHO analgesic ladder) are available at:
http://www.asahq.org
http://www.nccn.org
Opioid guidelines in the management of chronic non-malignant pain are available at:
http://www.asipp.org/Guidelines.htm
QL
QL
QL
PA
PA
PA
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
PA
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
butalbital/acetaminophen/caffeine/codeine
butalbital/aspirin/caffeine/codeine
codeine/acetaminophen
fentanyl citrate buccal
fentanyl lozenge
fentanyl sublingual
fentanyl transdermal
hydrocodone/acetaminophen
hydrocodone/acetaminophen - Vicodin
hydrocodone/acetaminophen soln
hydrocodone/ibuprofen
hydromorphone
meperidine
methadone soln 5 mg/5 mL, 10 mg/5 mL, 10 mg/mL
methadone tabs 5 mg, 10 mg
morphine
morphine ext-rel
morphine ext-rel 10 mg, 20 mg, 30 mg, 50 mg, 60 mg,
80 mg, 100 mg
morphine ext-rel 40 mg, 200 mg
morphine supp
oxycodone
oxycodone
oxycodone ext-rel
oxycodone/acetaminophen
oxycodone/aspirin
oxymorphone ext-rel
tramadol
tramadol/acetaminophen
butalbital/acetaminophen/caffeine/codeine
butalbital/aspirin/caffeine/codeine
codeine/acetaminophen tabs
codeine/acetaminophen soln, susp
fentanyl transdermal
hydrocodone/acetaminophen tabs
hydrocodone/acetaminophen soln
hydrocodone/ibuprofen tabs
hydromorphone tabs
hydromorphone liq
meperidine tabs
meperidine soln
methadone tabs 5 mg
methadone tabs 10 mg
=
=
=
=
=
=
=
=
=
=
=
=
=
=
FIORICET w/CODEINE
FIORINAL w/CODEINE
TYLENOL w/CODEINE
FENTORA
ACTIQ
ABSTRAL
DURAGESIC
NORCO
HYCET
VICOPROFEN
DILAUDID
DEMEROL
DOLOPHINE
MS CONTIN
KADIAN
KADIAN
ROXICODONE
OXYCONTIN
PERCOCET
PERCODAN
OPANA ER
ULTRAM
ULTRACET
Max 48 caps per month
Max 48 caps per month
Max 300 tabs per month
Max 3750 mL per month
Max 10 patches per month
Max 300 tabs per month
Max 3750 mL per month
Max 150 tabs per month
Max 180 tabs per month
Max 180 mL per month
Max 12 tabs per month
Max 30 mL per month
Max 120 tabs per month
Max 60 tabs per month
AL: Age Limit; OTC: Over the counter; PA: Prior Authorization; QL: Quantity Limit; SP: Specialty Drug; ST: Step Therapy
boldface: indicates generic availability; delayed-rel: delayed-release (also known as enteric-coated);
ext-rel: extended-release (also known as sustained-release)
5
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
methadone (concentrate) soln 10 mg/mL
methadone soln 5 mg/5 mL
methadone soln 10 mg/5 mL
morphine soln 10 mg/5 mL, 20 mg/5 mL
morphine (concentrate) soln 20 mg/mL
morphine tabs
morphine ext-rel (generic for MS CONTIN)
15 mg, 30 mg, 60 mg
morphine ext-rel (generic for MS CONTIN)
100 mg, 200 mg
morphine ext-rel (generic for KADIAN)
10 mg, 20 mg, 30 mg, 50 mg, 60 mg, 80 mg
morphine ext-rel (generic for KADIAN) 100 mg
morphine supp
oxycodone caps, tabs
oxycodone (concentrate) soln 20 mg/mL
oxycodone soln 5 mg/5 mL
oxycodone/acetaminophen tabs
oxycodone/acetaminophen soln
oxycodone/aspirin
tramadol
tramadol/acetaminophen
KADIAN 40 mg
KADIAN 200 mg
OPANA ER 5 mg, 7.5 mg, 10 mg, 15 mg, 20 mg
OPANA ER 30 mg, 40 mg
=
=
=
=
=
=
=
Max 30 mL per month
Max 600 mL per month
Max 300 mL per month
Max 900 mL per month
Max 180 mL per month
Max 180 tabs per month
Max 120 tabs per month
=
Max 60 tabs per month
=
Max 60 caps per month
=
=
=
=
=
=
=
=
=
=
=
=
=
=
Max 30 caps per month
Max 180 supps per month
Max 180 caps, tabs per month
Max 180 mL per month
Max 180 mL per month
Max 300 tabs per month
Max 1385 mL per month
Max 308 tabs per month
Max 240 tabs per month
Max 40 tabs per month
Max 60 caps per month
Max 30 caps per month
Max 120 tabs per month
Max 60 tabs per month
NON-OPIOID ANALGESICS
QL
butalbital/acetaminophen/caffeine
QL
butalbital/aspirin/caffeine
QL butalbital/acetaminophen/caffeine
QL butalbital/aspirin/caffeine
VISCOSUPPLEMENTS
PA, SP
sodium hyaluronate
PA, SP
sodium hyaluronate
FIORICET
FIORINAL
=
=
Max 48 tabs per month
Max 48 tabs per month
GEL-ONE
SUPARTZ
AL: Age Limit; OTC: Over the counter; PA: Prior Authorization; QL: Quantity Limit; SP: Specialty Drug; ST: Step Therapy
boldface: indicates generic availability; delayed-rel: delayed-release (also known as enteric-coated);
ext-rel: extended-release (also known as sustained-release)
6
ANTI-INFECTIVES
Practice guidelines and statements developed and endorsed by the Infectious Diseases Society of America are available at:
http://www.idsociety.org
Hepatitis: CDC recommendations on the treatment of hepatitis are available at:
http://www.cdc.gov/hepatitis/Resources/
Guidelines for the management of chronic hepatitis by the American Association for the Study of Liver Disease are available at:
http://www.aasld.org
HIV/AIDS: Guidelines for the treatment of HIV patients by the U.S. Department of Health and Human Services are available at:
http://www.aidsinfo.nih.gov
Infective Endocarditis: American Heart Association recommendations for the prevention of bacterial endocarditis are available at:
http://www.myamericanheart.org
Influenza: Recommendations of the Advisory Committee on Immunization Practices are available at:
http://www.cdc.gov/ncidod/diseases/flu/fluvirus.htm
International Travel: CDC recommendations for international travel are available at:
http://www.cdc.gov/travel
Respiratory Tract Infection/Antibiotic Use/Community Acquired Pneumonia/Other: Principles of appropriate antibiotic use
for treatment of nonspecific upper respiratory tract infection in adults are available at:
http://www.cdc.gov/flu/
Sexually Transmitted Diseases: CDC Sexually Transmitted Diseases Guidelines are available at:
http://www.cdc.gov/std/treatment/default.htm
ANTIBACTERIALS
Aminoglycosides
neomycin
Cephalosporins
Cephalosporin Combinations
ceftolozane/tazobactam
First Generation
cefadroxil
cephalexin
Second Generation
cefaclor
cefprozil
cefuroxime axetil
Third Generation
ZERBAXA
KEFLEX
CEFTIN
cefdinir
Erythromycins/Macrolides
azithromycin
azithromycin ext-rel
clarithromycin
clarithromycin ext-rel
erythromycin base
erythromycin delayed-rel
ZITHROMAX
ZMAX
BIAXIN
AL: Age Limit; OTC: Over the counter; PA: Prior Authorization; QL: Quantity Limit; SP: Specialty Drug; ST: Step Therapy
boldface: indicates generic availability; delayed-rel: delayed-release (also known as enteric-coated);
ext-rel: extended-release (also known as sustained-release)
7
erythromycin ethylsuccinate
erythromycin ethylsuccinate
erythromycin stearate
E.E.S.
ERYPED
Fluoroquinolones
ciprofloxacin
ciprofloxacin ext-rel
levofloxacin
ST
moxifloxacin
QL
ofloxacin
QL ofloxacin 400 mg
Penicillins
=
Max 2 tabs per day
AUGMENTIN
AUGMENTIN XR
sulfadiazine
sulfamethoxazole/trimethoprim
sulfamethoxazole/trimethoprim DS
Tetracyclines
ANTIFUNGALS
QL
LEVAQUIN
AVELOX
amoxicillin
amoxicillin/clavulanate
amoxicillin/clavulanate ext-rel
ampicillin
dicloxacillin
penicillin VK
Sulfonamides
QL
CIPRO
BACTRIM DS
doxycycline monohydrate caps 50 mg, 75 mg, 100 mg
minocycline
tetracycline
MONODOX
MINOCIN
albendazole
clotrimazole troches
fluconazole
griseofulvin microsize
griseofulvin microsize susp
griseofulvin ultramicrosize
itraconazole caps
ketoconazole
nystatin
terbinafine tabs
ALBENZA
QL itraconazole caps
QL terbinafine tabs
DIFLUCAN
GRIS-PEG
SPORANOX
LAMISIL
=
=
ANTIMALARIALS
QL
artemether/lumefantrine
QL
atovaquone/proguanil
QL
chloroquine
QL
mefloquine
QL
primaquine
QL atovaquone/proguanil
QL chloroquine
QL mefloquine
Max 4 caps per day
Max 30 tabs per month
COARTEM
MALARONE
ARALEN
PRIMAQUINE
=
=
=
Max 12 tabs per 180 days
Max 10 tabs per 180 days
Max 6 tabs per 180 days
AL: Age Limit; OTC: Over the counter; PA: Prior Authorization; QL: Quantity Limit; SP: Specialty Drug; ST: Step Therapy
boldface: indicates generic availability; delayed-rel: delayed-release (also known as enteric-coated);
ext-rel: extended-release (also known as sustained-release)
8
QL COARTEM
QL PRIMAQUINE
=
=
Max 24 tabs per 180 days
Max 28 tabs per month
ANTIRETROVIRAL AGENTS
Antiretroviral Adjuvants
cobicistat
TYBOST
Antiretroviral Combinations
abacavir/dolutegravir/lamivudine
abacavir/lamivudine
abacavir/lamivudine/zidovudine
atazanavir/cobicistat
darunavir/cobicistat
efavirenz/emtricitabine/tenofovir
elvitegravir/cobicistat/emtricitabine/tenofovir
elvitegravir/cobicistat/emtricitabine/tenofovir alafenamide
emtricitabine/rilpivirine/tenofovir
emtricitabine/rilpivirine/tenofovir alafenamide
emtricitabine/tenofovir
emtricitabine/tenofovir alafenamide
lamivudine/zidovudine
TRIUMEQ
EPZICOM
TRIZIVIR
EVOTAZ
PREZCOBIX
ATRIPLA
STRIBILD
GENVOYA
COMPLERA
ODEFSEY
TRUVADA
DESCOVY
COMBIVIR
Chemokine Receptor Antagonists
maraviroc
SELZENTRY
Fusion Inhibitors
SP
enfuvirtide
FUZEON
Integrase Inhibitors
dolutegravir
elvitegravir
raltegravir
TIVICAY
VITEKTA
ISENTRESS
Non-nucleoside Reverse Transcriptase Inhibitors
delavirdine
efavirenz
etravirine
nevirapine
nevirapine ext-rel
RESCRIPTOR
SUSTIVA
INTELENCE
VIRAMUNE
VIRAMUNE XR
Nucleoside Reverse Transcriptase Inhibitors
abacavir soln
abacavir tabs
didanosine delayed-rel
didanosine soln
emtricitabine
lamivudine
stavudine
zidovudine
ZIAGEN soln
ZIAGEN
VIDEX EC
VIDEX soln
EMTRIVA
EPIVIR
ZERIT
RETROVIR
Nucleotide Reverse Transcriptase Inhibitors
tenofovir
VIREAD
Protease Inhibitors
atazanavir
darunavir
REYATAZ
PREZISTA
AL: Age Limit; OTC: Over the counter; PA: Prior Authorization; QL: Quantity Limit; SP: Specialty Drug; ST: Step Therapy
boldface: indicates generic availability; delayed-rel: delayed-release (also known as enteric-coated);
ext-rel: extended-release (also known as sustained-release)
9
QL
darunavir susp
fosamprenavir
indinavir
lopinavir/ritonavir
nelfinavir
ritonavir
saquinavir mesylate
tipranavir
QL PREZISTA susp
PREZISTA susp
LEXIVA
CRIXIVAN
KALETRA
VIRACEPT
NORVIR
INVIRASE
APTIVUS
=
ANTITUBERCULAR AGENTS
PA
bedaquiline
ethambutol
PA
ethionamide
isoniazid
pyrazinamide
rifabutin
rifampin
PA
rifapentine
Max 30 mL per month
SIRTURO
MYAMBUTOL
TRECATOR
MYCOBUTIN
RIFADIN
PRIFTIN
ANTIVIRALS
Cytomegalovirus Agents
ganciclovir inj
valganciclovir
VALCYTE
Hepatitis Agents
Hepatitis B
adefovir dipivoxil
entecavir
lamivudine
telbivudine
HEPSERA
BARACLUDE
EPIVIR-HBV
TYZEKA
Hepatitis C
PA, SP
PA, SP
PA, SP
PA, SP
PA, SP
PA, SP
elbasvir/grazoprevir
ledipasvir/sofosbuvir
ribavirin caps - Ribasphere
ribavirin oral soln
ribavirin tabs
sofosbuvir
ZEPATIER
HARVONI
REBETOL
REBETOL
COPEGUS
SOVALDI
acyclovir
famciclovir
valacyclovir
ZOVIRAX
FAMVIR
VALTREX
Herpes Agents
Influenza Agents
QL
oseltamivir
rimantadine
QL
zanamivir
QL
QL
QL
QL
RELENZA
TAMIFLU 30 mg
TAMIFLU 45 mg, 75 mg
TAMIFLU 6 mg/mL
TAMIFLU
FLUMADINE
RELENZA
=
=
=
=
Max 1 inhaler per 6 months
Max 20 caps per 6 months
Max 10 caps per 6 months
Max 180 mL per 6 months
AL: Age Limit; OTC: Over the counter; PA: Prior Authorization; QL: Quantity Limit; SP: Specialty Drug; ST: Step Therapy
boldface: indicates generic availability; delayed-rel: delayed-release (also known as enteric-coated);
ext-rel: extended-release (also known as sustained-release)
10
MISCELLANEOUS
atovaquone
clindamycin
dapsone
daptomycin
ivermectin
methenamine hippurate, prophylaxis
metronidazole
PA, QL
nitazoxanide
nitrofurantoin ext-rel
nitrofurantoin macrocrystals
nitrofurantoin susp
PA
pentamidine
PA
pentamidine
praziquantel
PA
rifaximin
tigecycline
trimethoprim
PA
vancomycin
QL ALINIA tabs
QL ALINIA susp
MEPRON
CLEOCIN
CUBICIN
STROMECTOL
HIPREX
FLAGYL
ALINIA
MACROBID
MACRODANTIN
FURADANTIN
NEBUPENT
PENTAM
BILTRICIDE
XIFAXAN
TYGACIL
VANCOCIN
=
=
Max 20 tabs per month
Max 540 mL per month
ANTINEOPLASTIC AGENTS
Clinical practice guidelines in oncology are available at:
http://www.asco.org
http://www.nccn.org
ALKYLATING AGENTS
altretamine
busulfan
chlorambucil
cyclophosphamide caps
PA, QL
mechlorethamine gel
melphalan
PA, SP
streptozocin
PA, SP, QL temozolomide
QL temozolomide
QL VALCHLOR
ANTIMETABOLITES
PA, SP
brentuximab vedotin
PA, SP
capecitabine
mercaptopurine
methotrexate
PA
thioguanine
HORMONAL ANTINEOPLASTIC AGENTS
Antiandrogens
PA, SP, QL abiraterone acetate
bicalutamide
PA, SP, QL enzalutamide
HEXALEN
MYLERAN
LEUKERAN
VALCHLOR
ALKERAN
ZANOSAR
TEMODAR
=
=
Max 15 days supply
Max 60 grams per month
ADCETRIS
XELODA
TREXALL
TABLOID
ZYTIGA
CASODEX
XTANDI
AL: Age Limit; OTC: Over the counter; PA: Prior Authorization; QL: Quantity Limit; SP: Specialty Drug; ST: Step Therapy
boldface: indicates generic availability; delayed-rel: delayed-release (also known as enteric-coated);
ext-rel: extended-release (also known as sustained-release)
11
PA
flutamide
nilutamide
QL XTANDI
QL ZYTIGA
Antiestrogens
=
=
fulvestrant
tamoxifen
toremifene
Aromatase Inhibitors
anastrozole
exemestane
PA
letrozole
Luteinizing Hormone-releasing Hormone (LHRH) Agonists
PA, SP
goserelin acetate
PA, SP
leuprolide acetate
PA, SP
leuprolide acetate
PA, SP
triptorelin pamoate
Gonadotropin Releasing Hormone (GnRH) Antagonists
PA, SP
degarelix acetate
Progestins
NILANDRON
megestrol acetate
Max 15 days supply
Max 15 days supply
FASLODEX
FARESTON
ARIMIDEX
AROMASIN
FEMARA
ZOLADEX
LUPRON DEPOT
TRELSTAR
FIRMAGON
MEGACE
IMMUNOMODULATORS
PA, SP
lenalidomide
PA, SP
pomalidomide
PA, SP
thalidomide
REVLIMID
POMALYST
THALOMID
KINASE INHIBITORS
PA, SP
afatinib
PA, SP, QL axitinib
PA, SP
cabozantinib
PA, SP
ceritinib
PA, SP
crizotinib
PA, SP
dabrafenib
PA, SP, QL dasatinib
PA, SP, QL erlotinib
PA, SP, QL everolimus
PA, SP, QL everolimus soluble tabs
PA, SP
ibrutinib
PA, SP, QL imatinib mesylate
PA, SP
lapatinib
PA, SP, QL lenvatinib
PA, SP
nilotinib
PA, SP, QL palbociclib
PA, SP, QL pazopanib
PA, SP, QL ponatinib
PA, SP, QL ruxolitinib
PA, SP, QL sorafenib
PA, SP, QL sunitinib
PA, SP
trametinib
GILOTRIF
INLYTA
COMETRIQ
ZYKADIA
XALKORI
TAFINLAR
SPRYCEL
TARCEVA
AFINITOR
AFINITOR DISPERZ
IMBRUVICA
GLEEVEC
TYKERB
LENVIMA
TASIGNA
IBRANCE
VOTRIENT
ICLUSIG
JAKAFI
NEXAVAR
SUTENT
MEKINIST
AL: Age Limit; OTC: Over the counter; PA: Prior Authorization; QL: Quantity Limit; SP: Specialty Drug; ST: Step Therapy
boldface: indicates generic availability; delayed-rel: delayed-release (also known as enteric-coated);
ext-rel: extended-release (also known as sustained-release)
12
PA, SP
PA, SP
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
vandetanib
vemurafenib
imatinib mesylate
AFINITOR
AFINITOR DISPERZ
IBRANCE
ICLUSIG
INLYTA
JAKAFI
LENVIMA
NEXAVAR
SPRYCEL
SUTENT
TARCEVA
VOTRIENT
CAPRELSA
ZELBORAF
=
=
=
=
=
=
=
=
=
=
=
=
=
Max 15 days supply
Max 15 days supply
Max 15 days supply
Max 15 days supply
Max 15 days supply
Max 15 days supply
Max 15 days supply
Max 15 days supply
Max 15 days supply
Max 15 days supply
Max 15 days supply
Max 15 days supply
Max 15 days supply
TOPOISOMERASE INHIBITORS
PA, SP
topotecan caps
HYCAMTIN
MISCELLANEOUS
SP
aldesleukin
PA, SP, QL bexarotene caps
PA, SP
bexarotene gel
etoposide
PA
hydroxyurea
hydroxyurea
leucovorin
mesna
mitotane
PA, SP
olaparib
PA, SP
panobinostat
procarbazine
PA
rituximab
PA, SP
romidepsin
tretinoin caps
PA, SP, QL vismodegib
PA, SP, QL vorinostat
QL bexarotene caps
QL ERIVEDGE
QL ZOLINZA
PROLEUKIN
TARGRETIN caps
TARGRETIN gel
DROXIA
HYDREA
MESNEX
LYSODREN
LYNPARZA
FARYDAK
MATULANE
RITUXAN
ISTODAX
ERIVEDGE
ZOLINZA
=
=
=
Max 15 days supply
Max 15 days supply
Max 15 days supply
AL: Age Limit; OTC: Over the counter; PA: Prior Authorization; QL: Quantity Limit; SP: Specialty Drug; ST: Step Therapy
boldface: indicates generic availability; delayed-rel: delayed-release (also known as enteric-coated);
ext-rel: extended-release (also known as sustained-release)
13
CARDIOVASCULAR
The Eighth Report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure
is available at:
http://jama.jamanetwork.com/article.aspx?articleid=1791497
Guidelines for the evaluation and management of cardiovascular diseases in adults are available at:
http://www.acc.org
http://www.heartfailureguideline.org
http://www.myamericanheart.org
ACE INHIBITORS
Guidelines for the use of ACE inhibitors are available at:
http://jama.jamanetwork.com/article.aspx?articleid=1791497
http://professional.diabetes.org
http://www.acc.org
http://www.myamericanheart.org
PA
benazepril
captopril
enalapril
enalapril oral soln
fosinopril
lisinopril
quinapril
ramipril
trandolapril
ACE INHIBITOR/CALCIUM CHANNEL BLOCKER COMBINATIONS
amlodipine/benazepril
ACE INHIBITOR/DIURETIC COMBINATIONS
benazepril/hydrochlorothiazide
captopril/hydrochlorothiazide
enalapril/hydrochlorothiazide
fosinopril/hydrochlorothiazide
lisinopril/hydrochlorothiazide
quinapril/hydrochlorothiazide
LOTENSIN
VASOTEC
EPANED
ZESTRIL
ACCUPRIL
ALTACE
MAVIK
LOTREL
LOTENSIN HCT
VASERETIC
ZESTORETIC
ACCURETIC
ADRENOLYTICS, CENTRAL
clonidine
clonidine transdermal
guanfacine
CATAPRES
CATAPRES-TTS
TENEX
ALDOSTERONE RECEPTOR ANTAGONISTS
eplerenone
spironolactone
INSPRA
ALDACTONE
ALPHA BLOCKERS
Guidelines for the use of alpha blockers in various patient populations are available at:
http://jama.jamanetwork.com/article.aspx?articleid=1791497
doxazosin
terazosin
CARDURA
AL: Age Limit; OTC: Over the counter; PA: Prior Authorization; QL: Quantity Limit; SP: Specialty Drug; ST: Step Therapy
boldface: indicates generic availability; delayed-rel: delayed-release (also known as enteric-coated);
ext-rel: extended-release (also known as sustained-release)
14
ANGIOTENSIN II RECEPTOR ANTAGONISTS/DIURETIC COMBINATIONS
Guidelines for the use of angiotensin II receptor antagonists in various patient populations are available at:
http://jama.jamanetwork.com/article.aspx?articleid=1791497
http://professional.diabetes.org
candesartan
candesartan/hydrochlorothiazide
irbesartan
irbesartan/hydrochlorothiazide
losartan
losartan/hydrochlorothiazide
telmisartan
telmisartan/hydrochlorothiazide
valsartan
valsartan/hydrochlorothiazide
ATACAND
ATACAND HCT
AVAPRO
AVALIDE
COZAAR
HYZAAR
MICARDIS
MICARDIS HCT
DIOVAN
DIOVAN HCT
ANGIOTENSIN II RECEPTOR ANTAGONIST/CALCIUM CHANNEL BLOCKER COMBINATIONS
amlodipine/telmisartan
TWYNSTA
amlodipine/valsartan
EXFORGE
ANGIOTENSIN II RECEPTOR ANTAGONIST/CALCIUM CHANNEL BLOCKER/DIURETIC COMBINATIONS
amlodipine/valsartan/hydrochlorothiazide
EXFORGE HCT
ANTIARRHYTHMICS
Guidelines for the use of antiarrhythmics and cardiac glycosides in various patient populations are available at:
http://www.acc.org
SP
amiodarone 200 mg
disopyramide
disopyramide ext-rel
dofetilide
flecainide
propafenone
propafenone ext-rel
sotalol
sotalol
NORPACE
NORPACE CR
TIKOSYN
RYTHMOL
RYTHMOL SR
BETAPACE
BETAPACE AF
ANTILIPEMICS
The 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults is
available at:
http://circ.ahajournals.org/content/early/2013/11/11/01.cir.0000437738.63853.7a
Bile Acid Resins
cholestyramine
colestipol tabs
QUESTRAN/QUESTRAN LIGHT
COLESTID
Cholesterol Absorption Inhibitors
ST
ezetimibe
ZETIA
Fibrates
fenofibrate
fenofibrate
gemfibrozil
HMG-CoA Reductase Inhibitors
atorvastatin
LOFIBRA
TRICOR
LOPID
LIPITOR
AL: Age Limit; OTC: Over the counter; PA: Prior Authorization; QL: Quantity Limit; SP: Specialty Drug; ST: Step Therapy
boldface: indicates generic availability; delayed-rel: delayed-release (also known as enteric-coated);
ext-rel: extended-release (also known as sustained-release)
15
lovastatin
pravastatin
rosuvastatin
simvastatin
MEVACOR
PRAVACHOL
CRESTOR
ZOCOR
Omega-3 Fatty Acids
omega-3 acid ethyl esters
LOVAZA
PCSK9 Inhibitors
PA, SP
evolocumab
REPATHA
Miscellaneous
PA, SP
lomitapide
PA, SP
mipomersen
JUXTAPID
KYNAMRO
BETA-BLOCKERS
Guidelines for the use of beta-blockers and beta-blocker combinations in various patient populations are available at:
http://jama.jamanetwork.com/article.aspx?articleid=1791497
http://www.acc.org
atenolol
bisoprolol
carvedilol
labetalol
metoprolol succinate ext-rel
metoprolol tartrate 25 mg, 50 mg, 100 mg
nadolol
propranolol
propranolol ext-rel
TENORMIN
ZEBETA
COREG
TRANDATE
TOPROL-XL
LOPRESSOR
CORGARD
INDERAL LA
BETA-BLOCKER/DIURETIC COMBINATIONS
Guidelines for the use of beta-blockers and diuretic combinations in various patient populations are available at:
http://jama.jamanetwork.com/article.aspx?articleid=1791497
http://www.acc.org
atenolol/chlorthalidone
bisoprolol/hydrochlorothiazide
metoprolol/hydrochlorothiazide
CALCIUM CHANNEL BLOCKERS
Dihydropyridines
amlodipine
felodipine ext-rel
nifedipine ext-rel
nifedipine ext-rel
PA
nimodipine oral soln
Nondihydropyridines
diltiazem
diltiazem ext-rel
diltiazem ext-rel
diltiazem ext-rel
diltiazem ext-rel
verapamil ext-rel
verapamil ext-rel
TENORETIC
ZIAC
LOPRESSOR HCT
NORVASC
ADALAT CC
PROCARDIA XL
NYMALIZE
CARDIZEM
CARDIZEM CD
CARDIZEM LA
TIAZAC
CALAN SR
VERELAN
AL: Age Limit; OTC: Over the counter; PA: Prior Authorization; QL: Quantity Limit; SP: Specialty Drug; ST: Step Therapy
boldface: indicates generic availability; delayed-rel: delayed-release (also known as enteric-coated);
ext-rel: extended-release (also known as sustained-release)
16
DIGITALIS GLYCOSIDES
digoxin
digoxin ped elixir
DIURETICS
Carbonic Anhydrase Inhibitors
acetazolamide
acetazolamide ext-rel
methazolamide
Loop Diuretics
bumetanide
furosemide
torsemide
LANOXIN
DIAMOX SEQUELS
LASIX
DEMADEX
Potassium-sparing Diuretics
amiloride
Thiazides and Thiazide-like Diuretics
chlorothiazide susp
chlorthalidone
hydrochlorothiazide
indapamide
metolazone
Diuretic Combinations
amiloride/hydrochlorothiazide
spironolactone/hydrochlorothiazide
triamterene/hydrochlorothiazide
triamterene/hydrochlorothiazide
DIURIL
ALDACTAZIDE
DYAZIDE
MAXZIDE
NEPRILYSIN INHIBITOR/ANGIOTENSIN II RECEPTOR ANTAGONIST COMBINATIONS
PA
sacubitril/valsartan
ENTRESTO
NITRATES
Oral
Sublingual
isosorbide dinitrate ext-rel tabs
isosorbide dinitrate oral
isosorbide mononitrate
isosorbide mononitrate ext-rel
nitroglycerin ext-rel
ISORDIL
isosorbide dinitrate sublingual
nitroglycerin sublingual
NITROSTAT
nitroglycerin transdermal
nitroglycerin transdermal
NITRO-DUR
PULMONARY ARTERIAL HYPERTENSION
Endothelin Receptor Antagonists
PA, SP
ambrisentan
PA, SP
bosentan
PA, SP
macitentan
LETAIRIS
TRACLEER
OPSUMIT
Transdermal
AL: Age Limit; OTC: Over the counter; PA: Prior Authorization; QL: Quantity Limit; SP: Specialty Drug; ST: Step Therapy
boldface: indicates generic availability; delayed-rel: delayed-release (also known as enteric-coated);
ext-rel: extended-release (also known as sustained-release)
17
Phosphodiesterase Inhibitors
PA, SP
sildenafil inj
PA, SP, QL sildenafil tabs
QL sildenafil tabs
REVATIO
REVATIO
=
Max 90 tabs per month
Prostaglandin Vasodilators
PA, SP
epoprostenol sodium
PA, SP
iloprost
PA, SP
treprostinil
PA, SP
treprostinil
FLOLAN
VENTAVIS
REMODULIN
TYVASO
Soluble Guanylate Cyclase Stimulators
PA, SP
riociguat
ADEMPAS
Miscellaneous
glycine diluent
MISCELLANEOUS
hydralazine
methyldopa
PA
metyrosine
midodrine
minoxidil
ranolazine ext-rel
STERILE DILUENT FOR FLOLAN
DEMSER
RANEXA
CENTRAL NERVOUS SYSTEM
Practice guidelines for psychiatric disorders are available at:
http://www.psych.org
ANTIANXIETY
Benzodiazepines
alprazolam
alprazolam ext-rel
chlordiazepoxide
clonazepam tabs
clorazepate
diazepam
lorazepam
oxazepam
Miscellaneous
buspirone
clomipramine
fluvoxamine
XANAX
XANAX XR
KLONOPIN
TRANXENE T-TAB
VALIUM
ATIVAN
ANAFRANIL
ANTICONVULSANTS
Practice guidelines for the treatment of epilepsy are available at:
http://www.aan.com
ST
carbamazepine
carbamazepine ext-rel
carbamazepine ext-rel
clobazam
diazepam rectal gel
TEGRETOL
CARBATROL
TEGRETOL-XR
ONFI
DIASTAT
AL: Age Limit; OTC: Over the counter; PA: Prior Authorization; QL: Quantity Limit; SP: Specialty Drug; ST: Step Therapy
boldface: indicates generic availability; delayed-rel: delayed-release (also known as enteric-coated);
ext-rel: extended-release (also known as sustained-release)
18
PA
QL
ST
ST
ST
ST
ST
QL
QL
QL
QL
QL
divalproex sodium delayed-rel
divalproex sodium ext-rel
ethosuximide
ethotoin
ezogabine
felbamate
gabapentin caps, tabs
gabapentin soln
lacosamide
lamotrigine
levetiracetam
levetiracetam ext-rel
levetiracetam inj
methsuximide
oxcarbazepine
oxcarbazepine ext-rel
perampanel
phenobarbital
phenytoin
phenytoin sodium extended
phenytoin sodium extended
pregabalin
primidone
rufinamide
tiagabine
topiramate sprinkle caps, tabs
valproic acid
zonisamide
gabapentin 100 mg
gabapentin 300 mg
gabapentin 400 mg
gabapentin 600 mg
gabapentin 800 mg
DEPAKOTE
DEPAKOTE ER
ZARONTIN
PEGANONE
POTIGA
FELBATOL
NEURONTIN
NEURONTIN
VIMPAT
LAMICTAL
KEPPRA
KEPPRA XR
KEPPRA
CELONTIN
TRILEPTAL
OXTELLAR XR
FYCOMPA
DILANTIN INFATABS
DILANTIN
PHENYTEK
LYRICA
MYSOLINE
BANZEL
GABITRIL
TOPAMAX
DEPAKENE
ZONEGRAN
=
=
=
=
=
Max 1080 caps per month
Max 360 caps per month
Max 270 caps per month
Max 180 tabs per month
Max 120 tabs per month
ANTIDEMENTIA
Practice guidelines for the management of dementia are available at:
http://www.aan.com
donepezil 5 mg, 10 mg
galantamine
galantamine ext-rel
memantine
rivastigmine
ARICEPT
RAZADYNE
RAZADYNE ER
NAMENDA
EXELON
ANTIDEPRESSANTS
Although these agents are primarily indicated for depression, some of these are also approved for other indications, including
bipolar disorder, obsessive-compulsive disorder, panic disorder and premenstrual dysphoric disorder.
Guidelines for the evaluation and management of bipolar and depressive disorders are available at:
http://www.psych.org
Monoamine Oxidase Inhibitors (MAOIs)
tranylcypromine
PARNATE
AL: Age Limit; OTC: Over the counter; PA: Prior Authorization; QL: Quantity Limit; SP: Specialty Drug; ST: Step Therapy
boldface: indicates generic availability; delayed-rel: delayed-release (also known as enteric-coated);
ext-rel: extended-release (also known as sustained-release)
19
Selective Serotonin Reuptake Inhibitors (SSRIs)
citalopram
escitalopram
fluoxetine
paroxetine HCl
sertraline
CELEXA
LEXAPRO
PROZAC
PAXIL
ZOLOFT
Serotonin Norepinephrine Reuptake Inhibitors (SNRIs)
duloxetine delayed-rel
venlafaxine ext-rel
venlafaxine tabs
CYMBALTA
EFFEXOR XR
Tricyclic Antidepressants (TCAs)
amitriptyline
amoxapine
desipramine
doxepin
imipramine HCl
nortriptyline
trimipramine
NORPRAMIN
TOFRANIL
PAMELOR
SURMONTIL
Tricyclic Antidepressants/Benzodiazepine Combination
chlordiazepoxide/amitriptyline
Miscellaneous Agents
bupropion
bupropion ext-rel
QL
bupropion ext-rel
mirtazapine
QL
nefazodone
trazodone
QL
QL
QL
QL
QL
QL
bupropion ext-rel (generic for WELLBUTRIN XL)
nefazodone 50 mg
nefazodone 100 mg
nefazodone 150 mg
nefazodone 200 mg
nefazodone 250 mg
WELLBUTRIN SR
WELLBUTRIN XL
REMERON
=
=
=
=
=
=
Max 30 tabs per month
Max 360 tabs per month
Max 180 tabs per month
Max 120 tabs per month
Max 90 tabs per month
Max 60 tabs per month
ANTIPARKINSONIAN AGENTS
Practice guidelines for the diagnosis and treatment of Parkinson's disease are available at:
http://www.aan.com
amantadine
benztropine
bromocriptine
carbidopa/levodopa
carbidopa/levodopa ext-rel
carbidopa/levodopa/entacapone
entacapone
pramipexole
ropinirole
selegiline
trihexyphenidyl
PARLODEL
SINEMET
SINEMET CR
STALEVO
COMTAN
MIRAPEX
REQUIP
ELDEPRYL
AL: Age Limit; OTC: Over the counter; PA: Prior Authorization; QL: Quantity Limit; SP: Specialty Drug; ST: Step Therapy
boldface: indicates generic availability; delayed-rel: delayed-release (also known as enteric-coated);
ext-rel: extended-release (also known as sustained-release)
20
ANTIPSYCHOTICS
Atypicals
QL
aripiprazole
aripiprazole ext-rel inj
aripiprazole lauroxil ext-rel inj
ST
asenapine
clozapine
ST, QL
iloperidone
ST, QL
lurasidone
QL
olanzapine
ST, QL
paliperidone ext-rel
paliperidone palmitate ext-rel inj
paliperidone palmitate ext-rel inj
QL
quetiapine
QL, ST
quetiapine ext-rel
risperidone
risperidone long-acting inj
QL
ziprasidone
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
aripiprazole 2 mg
aripiprazole 5 mg, 10 mg, 15 mg, 20 mg, 30 mg
olanzapine
paliperidone ext-rel
quetiapine 25 mg
quetiapine 50 mg, 100 mg
quetiapine 200 mg, 300 mg, 400 mg
ziprasidone
FANAPT
LATUDA
SEROQUEL XR
Miscellaneous
ABILIFY
ABILIFY MAINTENA
ARISTADA
SAPHRIS
CLOZARIL
FANAPT
LATUDA
ZYPREXA
INVEGA
INVEGA SUSTENNA
INVEGA TRINZA
SEROQUEL
SEROQUEL XR
RISPERDAL
RISPERDAL CONSTA
GEODON
=
=
=
=
=
=
=
=
=
=
=
Max 60 tabs per month
Max 30 tabs per month
Max 30 tabs per month
Max 30 tabs per month
Max 120 tabs per month
Max 90 tabs per month
Max 60 tabs per month
Max 60 tabs per month
Max 60 tabs per month
Max 30 tabs per month
Max 30 tabs per month
chlorpromazine
fluphenazine
fluphenazine inj
haloperidol
loxapine
perphenazine
perphenazine/amitriptyline
pimozide
thioridazine
thiothixene
trifluoperazine
ORAP
ATTENTION DEFICIT HYPERACTIVITY DISORDER
Guidelines for the evaluation and management of attention deficit disorder are available at:
http://www.aacap.org
http://www.aap.org
QL
QL
ST, QL
QL
QL
QL
amphetamine/dextroamphetamine mixed salts
amphetamine/dextroamphetamine mixed salts ext-rel
atomoxetine
clonidine ext-rel
dexmethylphenidate
dexmethylphenidate ext-rel 5 mg, 10 mg, 15 mg, 20 mg,
30 mg, 40 mg
ADDERALL
ADDERALL XR
STRATTERA
KAPVAY
FOCALIN
FOCALIN XR
AL: Age Limit; OTC: Over the counter; PA: Prior Authorization; QL: Quantity Limit; SP: Specialty Drug; ST: Step Therapy
boldface: indicates generic availability; delayed-rel: delayed-release (also known as enteric-coated);
ext-rel: extended-release (also known as sustained-release)
21
QL
QL
QL
QL
QL
QL
QL
QL
dextroamphetamine ext-rel
dextroamphetamine tabs 5 mg, 10 mg
guanfacine ext-rel
lisdexamfetamine
methylphenidate
methylphenidate chew tabs, soln, tabs
methylphenidate ext-rel caps 20 mg, 30 mg, 40 mg
methylphenidate ext-rel tabs
QL amphetamine/dextroamphetamine mixed salts
5 mg, 7.5 mg, 10 mg, 12.5 mg
QL amphetamine/dextroamphetamine mixed salts
15 mg, 20 mg, 30 mg
QL amphetamine/dextroamphetamine mixed salts ext-rel
QL clonidine ext-rel
QL dexmethylphenidate
QL dexmethylphenidate ext-rel
QL dextroamphetamine ext-rel
QL dextroamphetamine tabs 5 mg, 10 mg
QL guanfacine ext-rel
QL methylphenidate
QL methylphenidate chew tabs
QL methylphenidate soln 5 mg/5 mL
QL methylphenidate soln 10 mg/5 mL
QL methylphenidate ext-rel caps 20 mg, 30 mg, 40 mg
(generic for RITALIN LA)
QL methylphenidate ext-rel tabs 10 mg, 20 mg
QL methylphenidate ext-rel tabs 18 mg, 27 mg, 36 mg, 54 mg
QL STRATTERA
QL VYVANSE
DEXEDRINE SPANSULE
INTUNIV
VYVANSE
RITALIN
METHYLIN
RITALIN LA
=
Max 90 tabs per month
=
Max 60 tabs per month
=
=
=
=
=
=
=
=
=
=
=
=
Max 30 caps per month
Max 60 tabs per month
Max 60 tabs per month
Max 30 caps per month
Max 60 caps per month
Max 90 tabs per month
Max 30 tabs per month
Max 90 tabs per month
Max 90 tabs per month
Max 2100 mL per month
Max 1050 mL per month
Max 30 caps per month
=
=
=
=
Max 90 tabs per month
Max 30 tabs per month
Max 30 caps per month
Max 30 caps per month
HUNTINGTON'S DISEASE AGENTS
PA, SP
tetrabenazine
XENAZINE
HYPNOTICS
Practice parameters for the treatment of sleep disorders and clinical guidelines for the evaluation and management of chronic
insomnia are available at:
http://www.aasmnet.org
Benzodiazepines
QL
estazolam
QL
flurazepam
QL
temazepam 15 mg, 30 mg
QL
triazolam
QL
QL
QL
QL
QL
estazolam
flurazepam
temazepam 15 mg, 30 mg
triazolam 0.125 mg
triazolam 0.25 mg
Nonbenzodiazepines
OTC
doxylamine
PROSOM
RESTORIL
HALCION
=
=
=
=
=
Max 30 tabs per month
Max 30 caps per month
Max 30 caps per month
Max 60 tabs per month
Max 30 tabs per month
UNISOM
AL: Age Limit; OTC: Over the counter; PA: Prior Authorization; QL: Quantity Limit; SP: Specialty Drug; ST: Step Therapy
boldface: indicates generic availability; delayed-rel: delayed-release (also known as enteric-coated);
ext-rel: extended-release (also known as sustained-release)
22
PA, SP
QL
tasimelteon
zolpidem
QL zolpidem
HETLIOZ
AMBIEN
=
Max 30 tabs per month
MIGRAINE
Guidelines for prevention and management of migraine headaches are available at:
http://www.aan.com
Ergotamine Derivatives
dihydroergotamine inj
QL
dihydroergotamine spray
ergotamine/caffeine
QL dihydroergotamine spray
D.H.E. 45
MIGRANAL
CAFERGOT
=
Max 8 vials (1 box) per month
Selective Serotonin Agonists
QL
almotriptan
QL
naratriptan
QL
rizatriptan
QL
rizatriptan orally disintegrating tabs
QL
sumatriptan
QL
sumatriptan inj
QL
sumatriptan nasal spray
QL
QL
QL
QL
QL
QL
QL
almotriptan
naratriptan
rizatriptan
rizatriptan orally disintegrating tabs
sumatriptan
sumatriptan inj
sumatriptan nasal spray
Miscellaneous
AXERT
AMERGE
MAXALT
MAXALT-MLT
IMITREX
IMITREX
IMITREX
=
=
=
=
=
=
=
Max 12 tabs per month
Max 9 tabs per month
Max 12 tabs per month
Max 12 tabs per month
Max 12 tabs per month
Max 10 inj per month
Max 12 doses (2 boxes) per month
acetaminophen/dichloralphenazone/isometheptene
MOOD STABILIZERS
carbamazepine ext-rel
lithium carbonate
lithium carbonate ext-rel tabs 300 mg
lithium carbonate ext-rel tabs 450 mg
lithium citrate
EQUETRO
LITHOBID
LITHIUM CITRATE
MULTIPLE SCLEROSIS AGENTS
Practice guidelines for multiple sclerosis are available at:
http://www.aan.com
PA, SP
ST, PA, SP
PA, SP
PA, SP
PA, SP
dalfampridine ext-rel
fingolimod
glatiramer 20 mg
interferon beta-1a
interferon beta-1b
MUSCULOSKELETAL THERAPY AGENTS
baclofen
QL
carisoprodol 350 mg
AMPYRA
GILENYA
COPAXONE
AVONEX
EXTAVIA
SOMA
AL: Age Limit; OTC: Over the counter; PA: Prior Authorization; QL: Quantity Limit; SP: Specialty Drug; ST: Step Therapy
boldface: indicates generic availability; delayed-rel: delayed-release (also known as enteric-coated);
ext-rel: extended-release (also known as sustained-release)
23
PA
carisoprodol/aspirin
chlorzoxazone
cyclobenzaprine 5 mg, 10 mg
dantrolene
methocarbamol
orphenadrine ext-rel
tizanidine tabs
QL carisoprodol 350 mg
PARAFON FORTE DSC
DANTRIUM
ROBAXIN
ZANAFLEX tabs
=
Max 120 tabs per month
MYASTHENIA GRAVIS
pyridostigmine
pyridostigmine ext-rel
MESTINON
MESTINON TIMESPAN
NARCOLEPSY/CATAPLEXY
PA
armodafinil
PA
modafinil
PA
sodium oxybate
NUVIGIL
PROVIGIL
XYREM
PSYCHOTHERAPEUTIC-MISCELLANEOUS
Alcohol Deterrents
acamprosate calcium
disulfiram
SP
naltrexone microspheres
ANTABUSE
VIVITROL
Opioid Antagonists
QL
naloxone inj
QL
naloxone nasal spray
naltrexone
QL naloxone inj
QL NARCAN
NARCAN
=
=
Max 2 mL per month
Max 2 doses (1 box) per month
Partial Opioid Agonists
PA
buprenorphine sublingual
Partial Opioid Agonist/Opioid Antagonist Combinations
PA
buprenorphine/naloxone buccal film
PA
buprenorphine/naloxone sublingual film
PA
buprenorphine/naloxone sublingual tabs
BUNAVAIL
SUBOXONE FILM
SUBOXONE
Pseudobulbar Affect
PA
dextromethorphan/quinidine
NUEDEXTA
Smoking Deterrents
Treating Tobacco Use and Dependence: 2008 Update-Clinical Practice Guideline is available at:
http://www.ahrq.gov/professionals/clinicians-providers/guidelines-recommendations/tobacco/index.html
OTC, QL
OTC, QL
OTC, QL
QL
nicotine polacrilex gum
nicotine polacrilex lozenge
nicotine transdermal
bupropion ext-rel
varenicline
QL nicotine polacrilex gum
QL nicotine polacrilex lozenge
NICORETTE
NICORETTE
ZYBAN
CHANTIX
=
=
Max 600 pieces per month , max 180 days per year
Max 500 lozenges per month, max 180 days per year
AL: Age Limit; OTC: Over the counter; PA: Prior Authorization; QL: Quantity Limit; SP: Specialty Drug; ST: Step Therapy
boldface: indicates generic availability; delayed-rel: delayed-release (also known as enteric-coated);
ext-rel: extended-release (also known as sustained-release)
24
QL nicotine transdermal
QL CHANTIX
=
=
Max 30 patches per month, max 180 days per year
Max 180 days per year
MISCELLANEOUS
PA
riluzole
RILUTEK
ENDOCRINE AND METABOLIC
ANDROGENS
Clinical practice guidelines for the treatment of hypogonadism are available at:
http://www.aace.com
PA
PA
PA
PA
oxandrolone
oxymetholone
testosterone cypionate
testosterone enanthate
testosterone gel
testosterone gel
OXANDRIN
ANADROL-50
DEPO-TESTOSTERONE
DELATESTRYL
ANDROGEL
FORTESTA
ANTIDIABETICS
Guidelines of treatment and management of diabetes are available at:
http://professional.diabetes.org
Alpha-glucosidase Inhibitors
acarbose
ST
miglitol
PRECOSE
GLYSET
Amylin Analogs
ST
pramlintide
SYMLINPEN
Biguanides
metformin
metformin ext-rel
GLUCOPHAGE
GLUCOPHAGE XR
Biguanide/Sulfonylurea Combinations
glipizide/metformin
QL
glyburide/metformin
QL glyburide/metformin
GLUCOVANCE
=
Max 300 tabs per month
Dipeptidyl Peptidase-4 (DPP-4) Inhibitors
alogliptin
ST
linagliptin
NESINA
TRADJENTA
Dipeptidyl Peptidase-4 (DPP-4) Inhibitor/Biguanide Combinations
alogliptin/metformin
ST
linagliptin/metformin
KAZANO
JENTADUETO
Dipeptidyl Peptidase-4 (DPP-4) Inhibitor/Insulin Sensitizer Combinations
alogliptin/pioglitazone
OSENI
Incretin Mimetic Agents
ST
exenatide
ST
exenatide ext-rel
ST
liraglutide
BYETTA
BYDUREON
VICTOZA
AL: Age Limit; OTC: Over the counter; PA: Prior Authorization; QL: Quantity Limit; SP: Specialty Drug; ST: Step Therapy
boldface: indicates generic availability; delayed-rel: delayed-release (also known as enteric-coated);
ext-rel: extended-release (also known as sustained-release)
25
Insulins
OTC, QL
OTC, QL
OTC, QL
OTC, QL
OTC, QL
OTC, QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
insulin human
insulin human
insulin isophane human
insulin isophane human
insulin isophane human 70%/regular 30%
insulin isophane human 70%/regular 30%
insulin aspart
insulin aspart protamine 70%/insulin aspart 30%
insulin glargine
insulin glargine
insulin glulisine
insulin glulisine
insulin lispro
insulin lispro protamine/insulin lispro
APIDRA
APIDRA SOLOSTAR
HUMALOG, NOVOLOG
HUMALOG, NOVOLOG FLEXPEN
HUMULIN, NOVOLIN pens
HUMULIN, NOVOLIN vials
HUMULIN R U-500 vials
LANTUS
LANTUS SOLOSTAR
=
=
=
=
=
=
=
=
=
HUMULIN R
NOVOLIN R
HUMULIN N
NOVOLIN N
HUMULIN 70/30
NOVOLIN 70/30
NOVOLOG
NOVOLOG MIX 70/30
LANTUS
LANTUS SOLOSTAR
APIDRA
APIDRA SOLOSTAR
HUMALOG
HUMALOG MIX
Max 4 vials per month
Max 15 pens per month
Max 4 vials per month
Max 15 pens per month
Max 15 pens per month
Max 4 vials per month
Max 2 vials per month
Max 4 vials per month
Max 15 pens per month
Insulin Sensitizers
pioglitazone
ACTOS
Insulin Sensitizer/Biguanide Combinations
pioglitazone/metformin
ST
pioglitazone/metformin ext-rel
ACTOPLUS MET
ACTOPLUS MET XR
Insulin Sensitizer/Sulfonylurea Combinations
ST
pioglitazone/glimepiride
DUETACT
Meglitinides
nateglinide
repaglinide
STARLIX
PRANDIN
Sodium-Glucose Co-transporter 2 (SGLT2) Inhibitors
ST
canagliflozin
INVOKANA
Sodium-Glucose Co-transporter 2 (SGLT2) Inhibitor/Biguanide Combinations
ST
canagliflozin/metformin
INVOKAMET
Sulfonylureas
QL
QL
glimepiride
glipizide
glipizide ext-rel
glyburide
glyburide micronized
QL glyburide 1.25 mg
QL glyburide 2.5 mg
QL glyburide 5 mg
AMARYL
GLUCOTROL
GLUCOTROL XL
GLYNASE
=
=
=
Max 480 tabs per month
Max 240 tabs per month
Max 120 tabs per month
AL: Age Limit; OTC: Over the counter; PA: Prior Authorization; QL: Quantity Limit; SP: Specialty Drug; ST: Step Therapy
boldface: indicates generic availability; delayed-rel: delayed-release (also known as enteric-coated);
ext-rel: extended-release (also known as sustained-release)
26
QL glyburide micronized 1.5 mg
QL glyburide micronized 3 mg
QL glyburide micronized 6 mg
Supplies
OTC, QL
OTC, QL
alcohol swabs
blood glucose monitoring kits, test strips
OTC, QL
blood glucose monitoring kits, test strips
OTC, QL
blood glucose monitoring kits, test strips
OTC, QL
blood glucose monitoring kits, test strips
OTC
OTC, QL
OTC, QL
OTC
glucose
insulin syringes, needles
lancets
urine glucose test strips
insulin delivery device
QL
QL
QL
QL
QL
alcohol swabs
insulin syringes, needles
lancets
FREESTYLE TEST STRIPS
PRECISION XTRA TEST STRIPS
=
=
=
Max 240 tabs per month
Max 120 tabs per month
Max 60 tabs per month
FREESTYLE FREEDOM LITE
KITS AND TEST STRIPS
FREESTYLE INSULINX
KITS AND TEST STRIPS
FREESTYLE LITE
KITS AND TEST STRIPS
PRECISION XTRA
KITS AND TEST STRIPS
V-GO INSULIN DELIVERY
DEVICE
=
=
=
=
=
Max 400 swabs per month
Max 400 per month
Max 400 units per month
Max 200 strips per month
Max 200 strips per month
CALCIUM RECEPTOR ANTAGONISTS
PA, SP
cinacalcet
SENSIPAR
CALCIUM REGULATORS
Guidelines of treatment and management of osteoporosis are available at:
http://www.aace.com
http://www.nof.org
Bisphosphonates
alendronate tabs
ibandronate tabs
Calcitonins
calcitonin-salmon
calcitonin-salmon
FOSAMAX
BONIVA
FORTICAL
MIACALCIN
CONTRACEPTIVES
EE = ethinyl estradiol
ME = mestranol
Monophasic
20 mcg Estrogen
PA
drospirenone/EE 3/20
drospirenone/EE/levomefolate 3/20 and levomefolate
levonorgestrel/EE 0.1/20
norethindrone acetate/EE 1/20
norethindrone acetate/EE 1/20 and iron
norethindrone acetate/EE 1/20 and iron - Lomedia 24 Fe
YAZ
BEYAZ
LOESTRIN 1/20
LOESTRIN FE 1/20
AL: Age Limit; OTC: Over the counter; PA: Prior Authorization; QL: Quantity Limit; SP: Specialty Drug; ST: Step Therapy
boldface: indicates generic availability; delayed-rel: delayed-release (also known as enteric-coated);
ext-rel: extended-release (also known as sustained-release)
27
30 mcg Estrogen
35 mcg Estrogen
50 mcg Estrogen
QL
desogestrel/EE 0.15/30 - Apri
drospirenone/EE 3/30
levonorgestrel/EE 0.15/30
norethindrone acetate/EE 1.5/30
norethindrone acetate/EE 1.5/30 and iron
norgestrel/EE 0.3/30
Triphasic
Progestin Only
LOESTRIN 1.5/30
LOESTRIN FE 1.5/30
ethynodiol diacetate/EE 1/35
norethindrone/EE 0.4/35
norethindrone/EE 0.5/35
norethindrone/EE 0.5/35
norethindrone/EE 1/35
norethindrone/EE 1/35
norgestimate/EE 0.25/35
OVCON 35
BREVICON
MODICON
NORINYL 1+35
ORTHO-NOVUM 1/35
ORTHO-CYCLEN
ethynodiol diacetate/EE 1/50 - Zovia 1/50
norethindrone/ME 1/50
norgestrel/EE 0.5/50 - Ogestrel
QL norgestrel/EE 0.5/50 - Ogestrel
Biphasic
YASMIN
NORINYL 1+50
=
Max 28 tabs per 28 days
desogestrel/EE
MIRCETTE
desogestrel/EE
levonorgestrel/EE
norethindrone acetate/EE and iron
norethindrone/EE
norethindrone/EE
norgestimate/EE
CYCLESSA
norethindrone
norethindrone
NOR-QD
ORTHO MICRONOR
ESTROSTEP FE
ORTHO-NOVUM 7/7/7
TRI-NORINYL
ORTHO TRI-CYCLEN
Emergency Contraception
OTC, QL
levonorgestrel - Next Choice One Dose
QL
levonorgestrel
ulipristal
QL levonorgestrel
Extended Cycle
Implant
SP
PLAN B ONE-STEP
ELLA
=
Max 6 tabs per year
levonorgestrel/EE 0.1/20 and EE 10
levonorgestrel/EE 0.15/30
levonorgestrel/EE 0.15/30 and EE 10
LOSEASONIQUE
etonogestrel implant
NEXPLANON
SEASONIQUE
AL: Age Limit; OTC: Over the counter; PA: Prior Authorization; QL: Quantity Limit; SP: Specialty Drug; ST: Step Therapy
boldface: indicates generic availability; delayed-rel: delayed-release (also known as enteric-coated);
ext-rel: extended-release (also known as sustained-release)
28
Injectable
QL
medroxyprogesterone acetate 150 mg/mL
QL medroxyprogesterone acetate 150 mg/mL
DEPO-PROVERA
=
Progestin Intrauterine Device
SP
levonorgestrel-releasing IUD
SP
levonorgestrel-releasing IUD
SP
levonorgestrel-releasing IUD
Transdermal
Vaginal
Max 1 inj per 3 months
LILETTA
MIRENA
SKYLA
norelgestromin/EE - Xulane
etonogestrel/EE ring
NUVARING
Miscellaneous
OTC, QL
condoms, male
diaphragm
QL condoms, male
=
ENDOMETRIOSIS
danazol
PA
nafarelin
Max 24 condoms per month
SYNAREL
ESTROGENS
Guidelines of treatment and management of hormone therapy and menopause are available at:
http://www.menopause.org
https://www.aace.com/files/menopause.pdf
Oral
Transdermal
QL
estradiol
estrogens, conjugated
estrogens, esterified
estrogens, esterified/methyltestosterone
estropipate
ESTRACE
PREMARIN
MENEST
estradiol
estradiol
ALORA
CLIMARA
QL ALORA
Vaginal
PA
=
estradiol vaginal crm
estradiol vaginal tabs
estrogens, conjugated crm
ESTROGEN/PROGESTINS
Oral
EE/norethindrone acetate
EE/norethindrone acetate - Jinteli
estradiol/norethindrone acetate
estradiol/norgestimate
estrogens, conjugated/medroxyprogesterone
Max 8 patches per month
ESTRACE CREAM
VAGIFEM
PREMARIN CREAM
FEMHRT
ACTIVELLA
PREFEST
PREMPHASE
AL: Age Limit; OTC: Over the counter; PA: Prior Authorization; QL: Quantity Limit; SP: Specialty Drug; ST: Step Therapy
boldface: indicates generic availability; delayed-rel: delayed-release (also known as enteric-coated);
ext-rel: extended-release (also known as sustained-release)
29
Transdermal
ST
estrogens, conjugated/medroxyprogesterone
PREMPRO
estradiol/levonorgestrel
estradiol/norethindrone acetate
CLIMARA PRO
COMBIPATCH
ESTROGEN/SELECTIVE ESTROGEN RECEPTOR MODULATOR COMBINATIONS
ST
conjugated estrogens/bazedoxifene
DUAVEE
GAUCHER DISEASE
PA
miglustat
ZAVESCA
GLUCOCORTICOIDS
cortisone acetate
dexamethasone
PA
dexamethasone
fludrocortisone
hydrocortisone
hydrocortisone succinate
methylprednisolone
prednisolone sodium phosphate soln 5 mg/5 mL,
15 mg/5 mL
prednisolone syrup
prednisone
DEXPAK
CORTEF
SOLU-CORTEF
MEDROL
GLUCOSE ELEVATING AGENTS
QL
glucagon, human recombinant
QL
glucagon, human recombinant
QL GLUCAGEN HYPOKIT
QL GLUCAGON EMERGENCY KIT
GLUCAGEN HYPOKIT
GLUCAGON EMERGENCY KIT
=
=
Max 2 inj per month
Max 2 inj per month
HUMAN GROWTH HORMONES
Guidelines for use of growth hormone are available at:
http://www.aace.com/publications/guidelines
PA, SP
somatropin
NORDITROPIN
HYPERPARATHYROID TREATMENT, VITAMIN D ANALOGS
calcitriol (1,25-D3)
doxercalciferol
paricalcitol
ROCALTROL
HECTOROL
ZEMPLAR
INSULIN-LIKE GROWTH FACTOR
PA, SP
mecasermin
INCRELEX
PHENYLKETONURIA TREATMENT AGENTS
PA, SP
sapropterin
KUVAN
PHOSPHATE BINDER AGENTS
calcium acetate
calcium acetate
lanthanum
ELIPHOS
PHOSLO
FOSRENOL
AL: Age Limit; OTC: Over the counter; PA: Prior Authorization; QL: Quantity Limit; SP: Specialty Drug; ST: Step Therapy
boldface: indicates generic availability; delayed-rel: delayed-release (also known as enteric-coated);
ext-rel: extended-release (also known as sustained-release)
30
PROGESTINS
Oral
Vaginal
medroxyprogesterone acetate
norethindrone acetate
progesterone, micronized
PROVERA
AYGESTIN
PROMETRIUM
progesterone gel
progesterone supp
progesterone vaginal inserts
CRINONE
FIRST-PROGESTERONE VGS
ENDOMETRIN
SELECTIVE ESTROGEN RECEPTOR MODULATORS
raloxifene
EVISTA
THYROID AGENTS
Antithyroid Agents
methimazole
potassium iodide
propylthiouracil
TAPAZOLE
SSKI
Thyroid Supplements
levothyroxine
levothyroxine
levothyroxine - Levoxyl
liothyronine
QL
liotrix
thyroid
QL THYROLAR
SYNTHROID
CYTOMEL
THYROLAR
ARMOUR THYROID
=
Max 30 tabs per month
VASOPRESSIN RECEPTOR ANTAGONISTS
PA, SP
tolvaptan
SAMSCA
VASOPRESSINS
SP
desmopressin spray
desmopressin spray, tabs
STIMATE
DDAVP spray, tabs
MISCELLANEOUS
cabergoline
methylergonovine
PA, SP
nitisinone
PA, SP
octreotide acetate
PA, SP
pegvisomant
SP
tesamorelin
ORFADIN
SANDOSTATIN
SOMAVERT
EGRIFTA
GASTROINTESTINAL
Guidelines for the treatment and management of various gastrointestinal diseases/conditions are available at:
http://gi.org
http://www.gastro.org
ANTACIDS
OTC
OTC
OTC
alumina/magnesia
alumina/magnesia/simethicone
calcium carbonate
MAALOX
MAALOX
AL: Age Limit; OTC: Over the counter; PA: Prior Authorization; QL: Quantity Limit; SP: Specialty Drug; ST: Step Therapy
boldface: indicates generic availability; delayed-rel: delayed-release (also known as enteric-coated);
ext-rel: extended-release (also known as sustained-release)
31
ANTIDIARRHEALS
OTC
bismuth subsalicylate
OTC
loperamide
diphenoxylate/atropine
loperamide
ANTIEMETICS
OTC
PA
PA, QL
PA
QL
PA
PEPTO-BISMOL
LOMOTIL
meclizine
aprepitant 40 mg, 80 mg
aprepitant pack
dronabinol
granisetron tabs
meclizine
metoclopramide
netupitant/palonosetron
ondansetron
prochlorperazine
promethazine
trimethobenzamide
QL granisetron tabs
QL EMEND TRIPACK
EMEND
EMEND TRIPACK
MARINOL
REGLAN
AKYNZEO
ZOFRAN
TIGAN
=
=
ANTISPASMODICS
chlordiazepoxide
chlordiazepoxide/clidinium
dicyclomine
glycopyrrolate tabs
hyoscyamine sublingual
hyoscyamine sulfate
hyoscyamine sulfate ext-rel
hyoscyamine sulfate ext-rel caps
hyoscyamine sulfate orally disintegrating tabs
methscopolamine tabs 2.5 mg
CHOLELITHOLYTICS
ursodiol
ursodiol
H2 RECEPTOR ANTAGONISTS
OTC
cimetidine
OTC
famotidine
OTC
ranitidine
cimetidine
famotidine
nizatidine
ranitidine
INFLAMMATORY BOWEL DISEASE
Oral Agents
balsalazide
budesonide delayed-rel caps
mesalamine delayed-rel caps
mesalamine delayed-rel tabs
ST
mesalamine delayed-rel tabs
mesalamine ext-rel caps
Max 15 tabs per month
Max 1 pack per 15 days
BENTYL
ROBINUL
LEVSIN/SL
LEVSIN
LEVBID
ANASPAZ
PAMINE
ACTIGALL
URSO
TAGAMET HB
PEPCID AC
ZANTAC
PEPCID
ZANTAC
ENTOCORT EC
DELZICOL
ASACOL HD
LIALDA
APRISO
AL: Age Limit; OTC: Over the counter; PA: Prior Authorization; QL: Quantity Limit; SP: Specialty Drug; ST: Step Therapy
boldface: indicates generic availability; delayed-rel: delayed-release (also known as enteric-coated);
ext-rel: extended-release (also known as sustained-release)
32
ST
ST
Rectal Agents
mesalamine ext-rel caps
olsalazine
sulfasalazine
sulfasalazine delayed-rel
PENTASA
DIPENTUM
AZULFIDINE
AZULFIDINE EN-TABS
hydrocortisone acetate foam
hydrocortisone enema
mesalamine rectal susp
mesalamine supp
CORTIFOAM
ROWASA
CANASA
IRRITABLE BOWEL SYNDROME
Irritable Bowel Syndrome with Constipation
ST
linaclotide
ST
lubiprostone
LINZESS
AMITIZA
Irritable Bowel Syndrome with Diarrhea
PA
alosetron
LOTRONEX
LAXATIVES/STOOL SOFTENERS
OTC
bisacodyl
OTC
docusate calcium
OTC
docusate sodium
OTC
polyethylene glycol 3350
OTC
senna
OTC
sennosides
OTC
sennosides/docusate sodium
OTC
sodium phosphate/sodium bisphosphate enema soln
lactulose
lactulose
peg 3350/electrolytes
peg 3350/electrolytes
peg 3350/electrolytes
polyethylene glycol 3350
DULCOLAX
COLACE
MIRALAX
SENOKOT
SENNA PLUS
FLEET ENEMA-PEDIATRIC
KRISTALOSE
COLYTE
GOLYTELY
NULYTELY
PANCREATIC ENZYMES
pancrelipase
pancrelipase delayed-rel
pancrelipase delayed-rel
VIOKACE
CREON
ZENPEP
PROSTAGLANDINS
misoprostol
CYTOTEC
PROTON PUMP INHIBITORS
OTC, QL
esomeprazole magnesium delayed-rel
OTC, QL
lansoprazole delayed-rel
OTC, QL
omeprazole magnesium delayed-rel
OTC, QL
omeprazole magnesium delayed-rel caps
OTC, QL
omeprazole/sodium bicarbonate
QL
esomeprazole delayed-rel caps
QL
lansoprazole delayed-rel
QL
omeprazole delayed-rel
QL
pantoprazole delayed-rel tabs
QL
rabeprazole delayed-rel
QL esomeprazole delayed-rel caps
NEXIUM 24HR
PREVACID 24HR
PRILOSEC OTC
ZEGERID OTC
NEXIUM
PREVACID
PRILOSEC
PROTONIX
ACIPHEX
=
Max 60 caps per month
AL: Age Limit; OTC: Over the counter; PA: Prior Authorization; QL: Quantity Limit; SP: Specialty Drug; ST: Step Therapy
boldface: indicates generic availability; delayed-rel: delayed-release (also known as enteric-coated);
ext-rel: extended-release (also known as sustained-release)
33
QL
QL
QL
QL
QL
QL
QL
QL
lansoprazole delayed-rel
omeprazole magnesium delayed-rel caps
omeprazole/sodium bicarbonate
omeprazole delayed-rel
pantoprazole delayed-rel tabs
rabeprazole delayed-rel tabs
NEXIUM 24HR
PRILOSEC OTC
=
=
=
=
=
=
=
=
Max 60 caps per month
Max 60 caps per month
Max 60 caps per month
Max 60 caps per month
Max 60 tabs per month
Max 60 tabs per month
Max 120 caps per month
Max 60 tabs per month
SALIVA STIMULANTS
pilocarpine tabs
SALAGEN
STEROIDS, RECTAL
hydrocortisone crm
hydrocortisone crm
ANUSOL-HC 2.5%
PROCTOCORT 1%
MISCELLANEOUS
OTC
loperamide/simethicone
OTC
petrolatum/mineral oil/shark liver oil/phenylephrine oint
OTC
phenylephrine/shark liver oil/cocoa butter supp
OTC
pramoxine/phenylephrine/glycerin/petrolatum
PA
carglumic acid
PA, SP
cholic acid
PA
cromolyn sodium
PA
glycopyrrolate
PA
sacrosidase
PA, SP
sodium phenylbutyrate powder
PA, SP
sodium phenylbutyrate tabs
sucralfate
IMODIUM
PREPARATION H
PREPARATION H
PREPARATION H
CARBAGLU
CHOLBAM
GASTROCROM
CUVPOSA
SUCRAID
BUPHENYL
BUPHENYL
CARAFATE
GENITOURINARY
BENIGN PROSTATIC HYPERPLASIA
Guidelines for the management of BPH are available at:
http://www.auanet.org/guidelines
alfuzosin ext-rel
doxazosin
finasteride
tamsulosin
terazosin
URINARY ANTISPASMODICS
OTC
oxybutynin transdermal
flavoxate
oxybutynin
oxybutynin ext-rel
tolterodine
ST
tolterodine ext-rel
trospium
trospium ext-rel
VAGINAL ANTI-INFECTIVES
OTC
clotrimazole
OTC
miconazole
clindamycin crm
UROXATRAL
CARDURA
PROSCAR
FLOMAX
OXYTROL FOR WOMEN
DITROPAN XL
DETROL
DETROL LA
CLEOCIN
AL: Age Limit; OTC: Over the counter; PA: Prior Authorization; QL: Quantity Limit; SP: Specialty Drug; ST: Step Therapy
boldface: indicates generic availability; delayed-rel: delayed-release (also known as enteric-coated);
ext-rel: extended-release (also known as sustained-release)
34
clindamycin supp
clotrimazole
metronidazole
miconazole
terconazole
terconazole
CLEOCIN vaginal supp
METROGEL-VAGINAL
TERAZOL 3
TERAZOL 7
MISCELLANEOUS
PA
acetohydroxamic acid
bethanechol
hyoscyamine/methenamine/methylene blue/
phenyl salicylate/sodium phosphate
hyoscyamine/methenamine/methylene blue/
phenyl salicylate/sodium phosphate - Urelle
pentosan polysulfate sodium
phenazopyridine
potassium citrate ext-rel
potassium citrate/citric acid
potassium citrate/sodium citrate/citric acid
sodium citrate/citric acid
PA
sorbitol irrigation soln
LITHOSTAT
URECHOLINE
UROGESIC-BLUE
ELMIRON
PYRIDIUM
UROCIT-K
CYTRA-K
CYTRA-3
CYTRA-2
HEMATOLOGIC
Guidelines of treatment and management of hemophilia are available at:
http://www.hemophilia.org
ANTICOAGULANTS
CHEST guidelines are available at:
http://www.chestnet.org/Guidelines-and-Resources/Guidelines-and-Consensus-Statements/Antithrombotic-Guidelines9th-Ed
Injectable
PA
Oral
dalteparin
enoxaparin
FRAGMIN
LOVENOX
apixaban
dabigatran etexilate
rivaroxaban
warfarin
ELIQUIS
PRADAXA
XARELTO
COUMADIN
Synthetic Heparinoid-like Agents
PA, QL
fondaparinux
QL fondaparinux
ANTIHEMOPHILIC AGENTS
SP
antihemophilic factor (human)
SP
antihemophilic factor (human)
SP
antihemophilic factor (human)
SP
antihemophilic factor (human)
SP
antihemophilic factor (recombinant porcine)
SP
antihemophilic factor (recombinant)
SP
antihemophilic factor (recombinant)
SP
antihemophilic factor (recombinant)
ARIXTRA
=
Max 30 syringes per 6 months, unless PA is initiated
ALPHANATE
HEMOFIL M
KOATE-DVI
MONOCLATE-P
OBIZUR
ADVATE
ELOCTATE
HELIXATE FS
AL: Age Limit; OTC: Over the counter; PA: Prior Authorization; QL: Quantity Limit; SP: Specialty Drug; ST: Step Therapy
boldface: indicates generic availability; delayed-rel: delayed-release (also known as enteric-coated);
ext-rel: extended-release (also known as sustained-release)
35
SP
SP
SP
SP
SP
SP
SP
SP
SP
SP
SP
SP
SP
SP
antihemophilic factor (recombinant)
antihemophilic factor (recombinant)
antihemophilic factor (recombinant)
antihemophilic factor (recombinant)
antihemophilic factor (recombinant)
antihemophilic factor/von Willebrand factor complex (human)
antiinhibitor coagulant complex
antiinhibitor coagulant complex
coagulation factor VIIa, recombinant
factor IX complex, plasma-derived
factor IX complex, plasma-derived
factor IX concentrate
factor IX concentrate
factor IX concentrate
KOGENATE FS
KOVALTRY
NOVOEIGHT
RECOMBINATE
XYNTHA
HUMATE-P
FEIBA NF
FEIBA VH
NOVOSEVEN RT
BEBULIN VH
PROFILNINE SD
BENEFIX
MONONINE
RIXUBIS
HEMATOPOIETIC GROWTH FACTORS
Guidelines for the management of neutropenia are available at:
http://www.asco.org
Guidelines for the management of anemia associated with chronic kidney disease are available at:
http://www.kidney.org/professionals/kdoqi/guidelines_commentaries.cfm#guidelines
PA, SP
PA, SP
PA, SP
PA, SP
PA, SP
PA, SP
PA, SP
darbepoetin alfa
epoetin alfa
epoetin alfa
filgrastim
pegfilgrastim
sargramostim
tbo-filgrastim
ARANESP
EPOGEN
PROCRIT
NEUPOGEN
NEULASTA
LEUKINE
GRANIX
HEREDITARY ANGIOEDEMA AGENTS
PA, SP
C1 esterase inhibitor
CINRYZE
IDIOPATHIC THROMBOCYTOPENIC PURPURA AGENTS
PA, SP
eltrombopag
PROMACTA
PAROXYSMAL NOCTURNAL HEMOGLOBINURIA (PNH) AGENTS
PA, SP
eculizumab
SOLIRIS
PLATELET AGGREGATION INHIBITORS
OTC
aspirin
clopidogrel
dipyridamole
prasugrel
PA
ticagrelor
PLAVIX
PERSANTINE
EFFIENT
BRILINTA
PLATELET SYNTHESIS INHIBITORS
anagrelide
AGRYLIN
MISCELLANEOUS
aminocaproic acid
cilostazol
PA, SP
deferasirox
pentoxifylline ext-rel
succimer
ST
tranexamic acid
AMICAR
EXJADE
CHEMET
LYSTEDA
AL: Age Limit; OTC: Over the counter; PA: Prior Authorization; QL: Quantity Limit; SP: Specialty Drug; ST: Step Therapy
boldface: indicates generic availability; delayed-rel: delayed-release (also known as enteric-coated);
ext-rel: extended-release (also known as sustained-release)
36
IMMUNOLOGIC AGENTS
Guidelines for the management of rheumatic diseases are available at:
http://www.rheumatology.org
ALLERGENIC EXTRACTS
PA, SP
grass mixed pollen allergen extract
PA
ragweed pollen allergen extract
PA
timothy grass pollen allergen extract
ORALAIR
RAGWITEK
GRASTEK
BIOLOGIC DISEASE-MODIFYING AGENTS
PA, SP
adalimumab
PA, SP, QL etanercept
HUMIRA
ENBREL
QL ENBREL 25 mg kit, syringe
QL ENBREL 50 mg syringe
QL ENBREL SURECLICK
=
=
=
DISEASE-MODIFYING ANTIRHEUMATIC DRUGS (DMARDs)
hydroxychloroquine
leflunomide
methotrexate
IMMUNE GLOBULINS
PA, SP
cytomegalovirus immune globulin
PA, SP
hepatitis B immune globulin
PA, SP
immune globulin, gamma (IGG)
PA, SP
immune globulin, gamma (IGG)
PA, SP
immune globulin, gamma (IGG)
PA, SP
immune globulin, gamma (IGG)
PA, SP
immune globulin, gamma (IGG)
PA, SP
immune globulin, gamma (IGG)
PA, SP
immune globulin, gamma (IGG)
PA
lymphocyte immune globulin anti-thymocyte G
PA
rabies immune globulin
SP
rho D immune globulin
SP
rho D immune globulin
SP
rho D immune globulin
SP
rho D immune globulin
Max 8 inj per month
Max 4 inj per month
Max 4 inj per month
PLAQUENIL
ARAVA
CYTOGAM
HEPAGAM B
CARIMUNE NF
FLEBOGAMMA
GAMASTAN S/D
GAMMAGARD
GAMUNEX-C
HIZENTRA
PRIVIGEN
ATGAM
HYPERRAB S/D
HYPERRHO S/D
RHOGAM PLUS
RHOPHYLAC
WINRHO SDF
IMMUNOMODULATORS
CDC recommendations on the treatment of hepatitis are available at:
http://www.cdc.gov/hepatitis/Resources/
Guidelines for the management of hepatitis are available at:
http://www.aasld.org
Interferons
PA, SP
PA, SP
PA, SP
PA, SP
interferon alfa-2b
interferon gamma-1b
peginterferon alfa-2a
peginterferon alfa-2b
Miscellaneous
PA, SP
canakinumab
PA, SP
rilonacept
INTRON A
ACTIMMUNE
PEGASYS
SYLATRON
ILARIS
ARCALYST
AL: Age Limit; OTC: Over the counter; PA: Prior Authorization; QL: Quantity Limit; SP: Specialty Drug; ST: Step Therapy
boldface: indicates generic availability; delayed-rel: delayed-release (also known as enteric-coated);
ext-rel: extended-release (also known as sustained-release)
37
PA, SP
tocilizumab
ACTEMRA
IMMUNOSUPPRESSANTS
Antimetabolites
azathioprine
azathioprine
mycophenolate mofetil
mycophenolate sodium delayed-rel
AZASAN
IMURAN
CELLCEPT
MYFORTIC
Calcineurin Inhibitors
cyclosporine caps
cyclosporine soln
cyclosporine, modified
tacrolimus
SANDIMMUNE
SANDIMMUNE
NEORAL
PROGRAF
Rapamycin Derivatives
everolimus
sirolimus
ZORTRESS
RAPAMUNE
NUTRITIONAL/SUPPLEMENTS
ELECTROLYTES
Potassium
potassium chloride ext-rel
potassium chloride ext-rel
potassium chloride liquid
Potassium-Removing Agents
sodium polystyrene sulfonate
Miscellaneous
potassium phosphate
VITAMINS AND MINERALS
Folic Acid/Combinations
OTC
folic acid
OTC
folinic acid/vitamin B6/vitamin B12
folic acid
folic acid/vitamin B6/vitamin B12
folic acid/vitamin B6/vitamin B12 - Folbic
l-methylfolate/vitamin B6/vitamin B12
Prenatal Vitamins
OTC
prenatal vitamins/ferrous fumarate/
folic acid 27 mg/0.8 mg
prenatal vitamins without A/ferrous asparto glycinate/
l-methylfolate/folic acid/DHA
prenatal vitamins without A/ferrous asparto glycinate/
l-methylfolate/folic acid/DHA
prenatal vitamins without A/ferrous asparto glycinate/
iron carbonyl/methylfolate/folic acid/DHA
prenatal vitamins without A/ferrous asparto glycinate/
l-methylfolate/folic acid/DHA
K-TAB
KAYEXALATE
K-PHOS NEUTRAL
FOLINIC-PLUS
FOLGARD RX
METANX
PRENATAL TAB
PRENATE DHA
PRENATE ESSENTIAL
PRENATE MINI
PRENATE PIXIE
AL: Age Limit; OTC: Over the counter; PA: Prior Authorization; QL: Quantity Limit; SP: Specialty Drug; ST: Step Therapy
boldface: indicates generic availability; delayed-rel: delayed-release (also known as enteric-coated);
ext-rel: extended-release (also known as sustained-release)
38
prenatal vitamins without A/ferrous fumarate/
l-methylfolate/folic acid/DHA
prenatal vitamins without A/ferrous fumarate/
l-methylfolate/folic acid/DHA
prenatal vitamins/calcium/vitamin B6/vitamin B12/
folic acid/ginger
prenatal vitamins/carbonyl iron/docusate/folic acid Prenatal AD
prenatal vitamins/carbonyl iron/folic acid - Prenatabs Rx
prenatal vitamins/ferrous asparto glycinate/folic acid
prenatal vitamins/ferrous asparto glycinate/l-methylfolate/
folic acid
prenatal vitamins/minerals/l-methylfolate/folic acid
Miscellaneous
OTC
OTC
OTC
OTC
OTC
OTC
OTC
OTC
OTC
OTC
OTC
PA
calcium
calcium/vitamin D
ferrous fumarate
ferrous gluconate
ferrous sulfate
ferrous sulfate 160 mg - Slow Release Iron
multivitamins
multivitamins/iron tabs
omega-3 fatty acids
omega-3 fatty acids/vitamin E
pediatric multiple vitamin w/iron 15 mg chew tabs
cyanocobalamin inj
ergocalciferol (D2)
ferrous fumarate/folic acid - Hemocyte-F
fluoride drops
fluoride tabs
multiple vitamins/iron - Ferotrinsic
multiple vitamins/iron - Hematogen
multiple vitamins/minerals
multiple vitamins/minerals - Corvite Free
multiple vitamins/minerals - Vicap Forte
multiple vitamins/minerals/iron
multiple vitamins/minerals/iron - Ferrocite Plus
multivitamins/fluoride drops, tabs
multivitamins/fluoride/iron drops, tabs
phytonadione
sodium chloride
sodium fluoride/xylitol
vitamin ADC/fluoride drops
vitamin ADC/fluoride/iron drops
vitamin B complex/vitamin C/folic acid
zinc acetate
PRENATE ENHANCE
PRENATE RESTORE
PRENATE AM
PRENATE STAR
PRENATE ELITE
PRENATE CHEWABLE
FERGON
FEOSOL
ONE-A-DAY
GERITOL
FISH OIL
FISH OIL
LURIDE
LURIDE LOZI-TABS
HEMOCYTE PLUS CAPS
MEPHYTON
FLUOR-A-DAY
NEPHROCAPS
GALZIN
AL: Age Limit; OTC: Over the counter; PA: Prior Authorization; QL: Quantity Limit; SP: Specialty Drug; ST: Step Therapy
boldface: indicates generic availability; delayed-rel: delayed-release (also known as enteric-coated);
ext-rel: extended-release (also known as sustained-release)
39
RESPIRATORY
Guidelines to the management, prevention, or treatment of COPD and asthma are available at:
http://www.aaaai.org
http://www.ginasthma.com
http://www.goldcopd.com
http://www.nhlbi.nih.gov
The Allergy Report and guidelines for allergy-related conditions are available at:
http://www.aaaai.org
ANAPHYLAXIS TREATMENT AGENTS
QL
epinephrine
QL
epinephrine
QL
epinephrine pen
QL epinephrine pen
QL EPIPEN
QL EPIPEN JR.
EPIPEN
EPIPEN JR.
=
=
=
ANTICHOLINERGICS
QL
aclidinium bromide
QL
ipratropium soln
QL
ipratropium, CFC-free aerosol
QL
tiotropium
QL
tiotropium
QL
QL
QL
QL
QL
ipratropium soln
ATROVENT HFA
SPIRIVA HANDIHALER
SPIRIVA RESPIMAT
TUDORZA
TUDORZA
ATROVENT HFA
SPIRIVA HANDIHALER
SPIRIVA RESPIMAT
=
=
=
=
=
ANTICHOLINERGIC/BETA AGONIST COMBINATIONS
Short Acting
QL
ipratropium/albuterol inhalation spray
QL
ipratropium/albuterol soln
QL ipratropium/albuterol soln
QL COMBIVENT RESPIMAT
Long Acting
QL
Max 120 units per month
Max 5 inhalers per month
Max 1 inhaler per month
Max 1 inhaler per month
Max 1 inhaler per month
COMBIVENT RESPIMAT
=
=
tiotropium/olodaterol
QL STIOLTO RESPIMAT
Max 8 pens per year
Max 8 pens per year
Max 8 pens per year
Max 180 units per month
Max 1 inhaler per month
STIOLTO RESPIMAT
=
Max 1 inhaler per month
ANTIHISTAMINES, LOW SEDATING
OTC
cetirizine
levocetirizine
ZYRTEC
XYZAL
ANTIHISTAMINES, NONSEDATING
OTC
fexofenadine tabs
OTC
loratadine
ALLEGRA
CLARITIN
ANTIHISTAMINES, SEDATING
OTC
chlorpheniramine
AL: Age Limit; OTC: Over the counter; PA: Prior Authorization; QL: Quantity Limit; SP: Specialty Drug; ST: Step Therapy
boldface: indicates generic availability; delayed-rel: delayed-release (also known as enteric-coated);
ext-rel: extended-release (also known as sustained-release)
40
OTC
OTC
OTC
chlorpheniramine ext-rel
clemastine
diphenhydramine
carbinoxamine soln
clemastine
cyproheptadine
diphenhydramine
hydroxyzine HCl
hydroxyzine pamoate
BENADRYL
VISTARIL
ANTIHISTAMINE/DECONGESTANT COMBINATIONS
OTC
cetirizine/pseudoephedrine ext-rel
OTC
fexofenadine/pseudoephedrine ext-rel
OTC
loratadine/pseudoephedrine ext-rel
promethazine/phenylephrine
ZYRTEC-D
ALLEGRA-D
CLARITIN-D
ANTITUSSIVES
Clinical practice guidelines are available at:
http://journal.publications.chestnet.org/article.aspx?articleID=1084267
benzonatate
TESSALON
ANTITUSSIVE COMBINATIONS
Opioid
OTC
codeine/chlorpheniramine/pseudoephedrine liquid
OTC
codeine/guaifenesin liquid
OTC
codeine/guaifenesin/pseudoephedrine
codeine/chlorpheniramine/phenylephrine
codeine/guaifenesin liquid
codeine/guaifenesin/pseudoephedrine
codeine/phenylephrine/promethazine
codeine/promethazine
hydrocodone/homatropine
Non-opioid
OTC
OTC
OTC
OTC
OTC
PHENYLHISTINE DH
CAPCOF
dextromethorphan/guaifenesin ext-rel
dextromethorphan/guaifenesin syrup
dextromethorphan/guaifenesin/pseudoephedrine liq
10 mg/100 mg/30 mg/5 mL
dextromethorphan/brompheniramine/pseudoephedrine
dextromethorphan/guaifenesin/pseudoephedrine tabs
15 mg/400 mg/60 mg
dextromethorphan/promethazine
dextromethorphan/pyrilamine
BETA AGONISTS
Inhalants
Short Acting
QL
albuterol inhalation soln
QL
albuterol sulfate, CFC-free aerosol
QL albuterol inhalation soln 0.5%
QL albuterol inhalation soln 0.83%, 0.63 mg/3 mL,
1.25 mg/3 mL
QL VENTOLIN HFA
MUCINEX DM
CAPMIST DM
CAPRON DM
VENTOLIN HFA
=
=
Max 50 mL per month
Max 375 mL per month
=
Max 2 inhalers per month
AL: Age Limit; OTC: Over the counter; PA: Prior Authorization; QL: Quantity Limit; SP: Specialty Drug; ST: Step Therapy
boldface: indicates generic availability; delayed-rel: delayed-release (also known as enteric-coated);
ext-rel: extended-release (also known as sustained-release)
41
Long Acting
Hand-held Active Inhalation
QL
indacaterol
QL
olodaterol, CFC-free aerosol
QL
salmeterol xinafoate
QL ARCAPTA NEOHALER
QL SEREVENT
QL STRIVERDI RESPIMAT
Oral Agents
ARCAPTA NEOHALER
STRIVERDI RESPIMAT
SEREVENT
=
=
=
Max 1 inhaler per month
Max 1 inhaler per month
Max 1 inhaler per month
albuterol
albuterol ext-rel
metaproterenol
terbutaline
VOSPIRE ER
CYSTIC FIBROSIS
PA, SP
aztreonam lysine inhalation soln
SP
dornase alfa
PA, SP
ivacaftor
PA, SP
lumacaftor/ivacaftor
SP
tobramycin inhalation soln
CAYSTON
PULMOZYME
KALYDECO
ORKAMBI
TOBI
DECONGESTANTS
OTC
oxymetazoline
OTC, QL
pseudoephedrine
OTC, QL
pseudoephedrine ext-rel
AFRIN
SUDAFED
SUDAFED
QL pseudoephedrine
QL pseudoephedrine ext-rel
=
=
Max 180 tabs per month
Max 60 tabs per month
DECONGESTANT/EXPECTORANT COMBINATIONS
OTC
pseudoephedrine/guaifenesin ext-rel
OTC
pseudoephedrine/guaifenesin syp 30 mg/100 mg/5 mL
MUCINEX D
EXPECTORANTS
OTC
guaifenesin ext-rel
OTC
guaifenesin liq
OTC
guaifenesin liq, syp, tabs
MUCINEX
DIABETIC TUSSIN
LEUKOTRIENE RECEPTOR ANTAGONISTS
montelukast
zafirlukast
SINGULAIR
ACCOLATE
MAST CELL STABILIZERS
OTC
cromolyn sodium nasal spray
QL
cromolyn soln for inhalation
QL cromolyn soln for inhalation
NASALCROM
=
Max 120 vials per month
MEDICAL SUPPLIES
OTC, QL
mask
OTC
sodium chloride for inhalation
AL: Age Limit; OTC: Over the counter; PA: Prior Authorization; QL: Quantity Limit; SP: Specialty Drug; ST: Step Therapy
boldface: indicates generic availability; delayed-rel: delayed-release (also known as enteric-coated);
ext-rel: extended-release (also known as sustained-release)
42
OTC, QL
spacer
sodium chloride for inhalation
QL mask
QL spacer
AEROCHAMBER
=
=
NASAL ANTIHISTAMINES
azelastine spray
azelastine spray
ASTEPRO
NASAL STEROIDS
OTC, QL
fluticasone spray
OTC, QL
triamcinolone acetonide spray
QL
flunisolide spray
QL
fluticasone spray
QL
triamcinolone acetonide spray
QL flunisolide spray
QL fluticasone spray
QL triamcinolone acetonide spray
Max 2 per year
Max 2 per year
FLONASE ALLERGY RELIEF
NASACORT ALLERGY 24HR
=
=
=
Max 2 bottles per month
Max 1 bottle per month
Max 1 bottle per month
PHOSPHODIESTERASE-4 INHIBITORS
ST
roflumilast
DALIRESP
PULMONARY FIBROSIS AGENTS
PA, SP
nintedanib
PA, SP
pirfenidone
OFEV
ESBRIET
RESPIRATORY SYNCYTIAL VIRUS
PA, SP
palivizumab
SYNAGIS
STEROID/BETA AGONIST COMBINATIONS
QL
budesonide/formoterol
QL
fluticasone/salmeterol 100/50
QL
mometasone/formoterol
SYMBICORT
ADVAIR 100/50
DULERA
QL ADVAIR 100/50
QL DULERA
QL SYMBICORT
=
=
=
STEROID INHALANTS
QL
budesonide inh susp
QL
flunisolide, CFC-free aerosol
QL
mometasone
QL
mometasone, CFC-free aerosol
QL
QL
QL
QL
budesonide inh susp
AEROSPAN
ASMANEX
ASMANEX HFA
XANTHINES
theophylline ext-rel caps
theophylline ext-rel tabs
theophylline liquid
theophylline liquid
Max 1 inhaler per month
Max 1 inhaler per month
Max 1 inhaler per month
PULMICORT RESPULES
AEROSPAN
ASMANEX
ASMANEX HFA
=
=
=
=
Max 60 units per month
Max 2 inhalers per month
Max 1 inhaler per month
Max 2 inhalers per month
THEO-24
ELIXOPHYLLIN
AL: Age Limit; OTC: Over the counter; PA: Prior Authorization; QL: Quantity Limit; SP: Specialty Drug; ST: Step Therapy
boldface: indicates generic availability; delayed-rel: delayed-release (also known as enteric-coated);
ext-rel: extended-release (also known as sustained-release)
43
MISCELLANEOUS
OTC
sodium chloride nasal spray
ipratropium nasal spray
PA, SP
omalizumab
OCEAN
ATROVENT spray
XOLAIR
TOPICAL
DERMATOLOGY
Acne
Guidelines for the care and treatment of acne vulgaris are available at:
http://www.aad.org/education-and-quality-care/clinical-guidelines
Topical
ST
ST
AL, QL
adapalene crm, gel 0.1%
benzoyl peroxide, except foam
clindamycin gel, lotion, soln
erythromycin gel 2%
erythromycin pads
erythromycin soln
erythromycin/benzoyl peroxide
sulfacetamide lotion 10%
sulfacetamide/sulfur crm, gel, lotion, pads
sulfacetamide/sulfur pad, wash
sulfacetamide/sulfur susp
tretinoin
QL tretinoin
DIFFERIN
CLEOCIN T
BENZAMYCIN
KLARON
SUMAXIN
SUMAXIN TS
RETIN-A
=
Actinic Keratosis
fluorouracil
Antibiotics
OTC
OTC
OTC
OTC
Antifungals
OTC
OTC
QL
EFUDEX
bacitracin
bacitracin/polymyxin B
neomycin/polymyxin B/bacitracin
neomycin/polymyxin B/bacitracin/pramoxine
gentamicin
mupirocin
mupirocin oint
silver sulfadiazine
clotrimazole
miconazole
ciclopirox
clotrimazole
clotrimazole/betamethasone
econazole
ketoconazole crm, shampoo 2%
nystatin
QL clotrimazole/betamethasone crm
QL clotrimazole/betamethasone lotion
Max 45 grams per month
POLYSPORIN
NEOSPORIN
BACTROBAN
BACTROBAN NASAL
SILVADENE
ALEVAZOL
MICATIN
LOPROX
LOTRISONE
=
=
Max 45 grams per month
Max 30 mL per month
AL: Age Limit; OTC: Over the counter; PA: Prior Authorization; QL: Quantity Limit; SP: Specialty Drug; ST: Step Therapy
boldface: indicates generic availability; delayed-rel: delayed-release (also known as enteric-coated);
ext-rel: extended-release (also known as sustained-release)
44
Antipsoriatics
Guidelines of care for the management and treatment of psoriasis with topical therapies are available at:
http://www.aad.org
Oral
PA
methoxsalen
8-MOP
Topical
QL
PA
calcipotriene
methoxsalen
OXSORALEN
QL calcipotriene soln
QL calcipotriene crm, oint
=
=
Max 60 mL per month
Max 120 grams per month
Antiseborrheics
OTC
selenium sulfide shampoo 1%
ketoconazole shampoo 2%
selenium sulfide shampoo 2.5%
SELSUN BLUE
NIZORAL SHAMPOO
Corticosteroids
Low Potency
OTC
hydrocortisone crm, gel, lotion, oint, soln 1%
OTC
hydrocortisone oint 0.5%
alclometasone crm, oint 0.05%
desonide crm, oint 0.05%
fluocinolone acetonide oil 0.01%
fluocinolone acetonide soln 0.01%
hydrocortisone crm, lotion, oint 2.5%
Medium Potency
High Potency
QL
QL
CORTIZONE-10
ACLOVATE
DESOWEN
DERMA-SMOOTHE/FS
betamethasone valerate crm, lotion, oint 0.1%
fluocinolone acetonide crm, oint 0.025%
fluticasone propionate crm, lotion 0.05%, oint 0.005%
hydrocortisone butyrate crm, oint, soln 0.1%
hydrocortisone valerate crm 0.2%
mometasone crm, lotion, oint 0.1%
prednicarbate crm, oint 0.1%
triamcinolone acetonide crm, lotion, oint 0.025%
triamcinolone acetonide crm, lotion, oint 0.1%
betamethasone dipropionate augmented crm 0.05%
betamethasone dipropionate augmented lotion 0.05%
betamethasone dipropionate crm, lotion, oint 0.05%
desoximetasone crm 0.25%
diflorasone diacetate crm 0.05%
fluocinonide crm, gel, oint, soln 0.05%
triamcinolone acetonide crm, oint 0.5%
QL desoximetasone crm 0.25%
QL diflorasone diacetate crm 0.05%
=
=
CUTIVATE
LOCOID
WESTCORT
ELOCON
DERMATOP
DIPROLENE AF
DIPROLENE
TOPICORT
Max 1 tube per month
Max 1 tube per month
Very High Potency
betamethasone dipropionate augmented oint 0.05%
DIPROLENE
AL: Age Limit; OTC: Over the counter; PA: Prior Authorization; QL: Quantity Limit; SP: Specialty Drug; ST: Step Therapy
boldface: indicates generic availability; delayed-rel: delayed-release (also known as enteric-coated);
ext-rel: extended-release (also known as sustained-release)
45
QL
clobetasol propionate crm, gel, oint, soln 0.05%
diflorasone diacetate oint 0.05%
QL diflorasone diacetate oint 0.05%
Emollients
OTC
=
urea lotion 10%
ammonium lactate 12%
urea crm 40%
urea crm 50%
TEMOVATE
Max 1 tube per month
LAC-HYDRIN
REMEVEN
Immunomodulators
Guidelines for the treatment of atopic dermatitis are available at:
http://www.aad.org/education/clinical-guidelines
ST
pimecrolimus
tacrolimus
ELIDEL
PROTOPIC
Local Analgesics
QL
lidocaine patch
QL lidocaine patch
LIDODERM
=
Max 90 patches per month
Local Anesthetics
lidocaine lotion 3%
lidocaine/prilocaine crm
Rosacea
metronidazole crm 0.75%
metronidazole gel 0.75%
metronidazole lotion 0.75%
sulfacetamide/sulfur
METROCREAM
METROLOTION
Scabicides and Pediculicides
OTC
permethrin
ST, QL
benzyl alcohol
malathion
permethrin
spinosad
QL ULESFIA
ULESFIA
OVIDE
NATROBA
=
Miscellaneous Skin and Mucous Membrane
OTC
diphenhydramine/zinc acetate
OTC
docosanol
OTC
salicylic acid 17%
ST, QL
acyclovir
PA
alitretinoin
aluminum chloride
PA
becaplermin
QL
collagenase
PA
fluocinolone-hydroquinone-tretinoin
PA, QL
imiquimod crm 5%
ST, QL
penciclovir
QL
podofilox soln
PA
sinecatechins
Max 277 grams per month
BENADRYL
ABREVA
ZOVIRAX
PANRETIN
DRYSOL
REGRANEX
SANTYL
TRI-LUMA
ALDARA
DENAVIR
CONDYLOX
VEREGEN
AL: Age Limit; OTC: Over the counter; PA: Prior Authorization; QL: Quantity Limit; SP: Specialty Drug; ST: Step Therapy
boldface: indicates generic availability; delayed-rel: delayed-release (also known as enteric-coated);
ext-rel: extended-release (also known as sustained-release)
46
PA, QL
QL
QL
QL
QL
QL
QL
QL
trichloroacetic acid
trypsin/balsam/castor oil
acyclovir oint 5%
imiquimod crm 5%
podofilox soln
trypsin/balsam/castor oil
DENAVIR
SANTYL
ZOVIRAX cream 5%
TRI-CHLOR
=
=
=
=
=
=
=
Max 15 grams per month
Max 48 packets per month
Max 1 bottle per month
Max 120 grams per 3 months
Max 1 tube per dispense
Max 60 grams per 3 months
Max 5 grams per month
MOUTH/THROAT/DENTAL AGENTS
Anesthetics - Topical Oral
lidocaine viscous
Steroids - Mouth/Throat
triamcinolone paste
Miscellaneous
chlorhexidine
sodium fluoride
PERIDEX
PREVIDENT
OPHTHALMIC
Preferred Practice Pattern Guidelines for the treatment of various ophthalmic conditions are available at:
http://one.aao.org
Antiallergics
OTC
Antifungals
QL
ketotifen
azelastine
cromolyn sodium
ZADITOR
natamycin
NATACYN
QL NATACYN
Anti-infectives
ST
QL
QL ofloxacin
=
Max 15 mL per month
bacitracin
ciprofloxacin soln
erythromycin
gentamicin
moxifloxacin
neomycin/polymyxin B/gramicidin
ofloxacin
polymyxin B/bacitracin
polymyxin B/trimethoprim
sulfacetamide soln 10%
tobramycin soln
CILOXAN
VIGAMOX
NEOSPORIN
OCUFLOX
POLYTRIM
BLEPH-10
TOBREX
=
Max 10 mL per month
Anti-infective/Anti-inflammatory Combinations
gentamicin/prednisolone acetate
gentamicin/prednisolone acetate
neomycin/polymyxin B/bacitracin/hydrocortisone oint
neomycin/polymyxin B/dexamethasone
PRED-G
PRED-G SOP
MAXITROL
AL: Age Limit; OTC: Over the counter; PA: Prior Authorization; QL: Quantity Limit; SP: Specialty Drug; ST: Step Therapy
boldface: indicates generic availability; delayed-rel: delayed-release (also known as enteric-coated);
ext-rel: extended-release (also known as sustained-release)
47
neomycin/polymyxin B/hydrocortisone susp
sulfacetamide/prednisolone acetate oint 10%/0.2%
sulfacetamide/prednisolone phosphate 10%/0.25%
tobramycin/dexamethasone oint 0.3%/0.1%
tobramycin/dexamethasone susp 0.3%/0.05%
tobramycin/dexamethasone susp 0.3%/0.1%
Anti-inflammatories
Nonsteroidal
diclofenac sodium
QL
ketorolac 0.4%
ketorolac 0.5%
QL ketorolac 0.4%
Steroidal
QL
Antivirals
PA
Beta-blockers
Nonselective
Selective
TOBRADEX
TOBRADEX ST
TOBRADEX
ACULAR LS
ACULAR
=
dexamethasone sodium phosphate
fluorometholone 0.1% oint
fluorometholone 0.1% susp
prednisolone acetate 0.12%
prednisolone acetate 1%
prednisolone phosphate 1%
rimexolone
QL FML oint
BLEPHAMIDE SOP
Max 5 mL per month
FML
FML LIQUIFILM
PRED MILD
PRED FORTE
VEXOL
=
Max 3.5 grams per month
ganciclovir
trifluridine
ZIRGAN
VIROPTIC
levobunolol
metipranolol
timolol maleate
timolol maleate gel
BETAGAN
TIMOPTIC
TIMOPTIC-XE
betaxolol 0.5%
Carbonic Anhydrase Inhibitors
Topical
dorzolamide
TRUSOPT
Carbonic Anhydrase Inhibitor/Beta-blocker Combinations
dorzolamide/timolol maleate
COSOPT
Mydriatics
atropine sulfate oint
atropine sulfate soln
cyclopentolate
homatropine
tropicamide
Parasympathomimetic
pilocarpine
CYCLOGYL
ISOPTO HOMATROPINE
MYDRIACYL
ISOPTO CARPINE
AL: Age Limit; OTC: Over the counter; PA: Prior Authorization; QL: Quantity Limit; SP: Specialty Drug; ST: Step Therapy
boldface: indicates generic availability; delayed-rel: delayed-release (also known as enteric-coated);
ext-rel: extended-release (also known as sustained-release)
48
Prostaglandins
latanoprost
XALATAN
Sympathomimetics
brimonidine 0.2%
Sympathomimetic/Beta-blocker Combinations
brimonidine/timolol
COMBIGAN
Miscellaneous
OTC
artificial tears oint, soln
naphazoline 0.1%
PA, SP, QL ocriplasmin
JETREA
QL JETREA
=
Max 1 inj per lifetime
OTIC
Clinical practice guidelines for the treatment of otitis media are available at:
http://www.aap.org
Anti-infectives
acetic acid
acetic acid/aluminum acetate
ciprofloxacin otic
ofloxacin otic
CETRAXAL
Anti-infective/Anti-inflammatory Combinations
QL
acetic acid/hydrocortisone
ciprofloxacin/dexamethasone
neomycin/polymyxin B/hydrocortisone
QL acetic acid/hydrocortisone
CIPRODEX
CORTISPORIN OTIC
=
Max 10 mL per month
AL: Age Limit; OTC: Over the counter; PA: Prior Authorization; QL: Quantity Limit; SP: Specialty Drug; ST: Step Therapy
boldface: indicates generic availability; delayed-rel: delayed-release (also known as enteric-coated);
ext-rel: extended-release (also known as sustained-release)
49
WEBSITES
Agency for Healthcare Research and Quality
http://www.ahrq.gov
Alzheimer's Association
http://www.alz.org
American Academy of Allergy, Asthma and
Immunology
http://www.aaaai.org
American Academy of Child & Adolescent Psychiatry
http://www.aacap.org
American Academy of Dermatology
http://www.aad.org
American Academy of Neurology
http://www.aan.com
American Academy of Ophthalmology
http://www.aao.org
American Academy of Pediatrics
http://www.aap.org
American Association for the Study of Liver Disease
http://www.aasld.org
American Association of Clinical Endocrinologists
http://www.aace.com
American Association of Diabetes Educators
http://www.diabeteseducator.org
American Cancer Society
http://www.cancer.org
American College of Allergy, Asthma and Immunology
http://www.acaai.org
American College of Cardiology
http://www.acc.org
American College of Chest Physicians
http://www.chestnet.org
American Congress of Obstetricians and
Gynecologists
http://www.acog.org
American Diabetes Association
http://www.diabetes.org
American Gastroenterological Association
http://www.gastro.org
American Headache Society Committee for Headache
Education
http://www.achenet.org
American Heart Association
http://www.myamericanheart.org
American Lung Association
http://www.lung.org
American Medical Association
http://www.ama-assn.org
American Psychiatric Association
http://www.psych.org
American Society of Anesthesiologists
http://www.asahq.org
American Society of Clinical Oncology
http://www.asco.org
American Society of Interventional Pain Physicians
http://www.asipp.org
American Urological Association
http://www.auanet.org
Centers for Disease Control and Prevention
http://www.cdc.gov
Centers for Disease Control and Prevention
Guideline topics: AIDS
http://www.cdc.gov/hiv/default.html
American College of Gastroenterology
http://gi.org
Centers for Disease Control and Prevention
Guideline topics: Sexually Transmitted Diseases
http://www.cdc.gov/std/treatment/default.htm
American College of Physicians
http://www.acponline.org
CVS Caremark®
http://www.caremark.com
American College of Rheumatology
http://www.rheumatology.org
The Food and Drug Administration
http://www.fda.gov
50
Global Initiative for Asthma
http://www.ginasthma.com
National Foundation for Infectious Diseases
http://www.nfid.org
Infectious Diseases Society of America
http://www.idsociety.org
National Guideline Clearinghouse
http://www.guideline.gov
Institute for Safe Medication Practices
http://www.ismp.org
National Heart, Lung and Blood Institute
http://www.nhlbi.nih.gov
Johns Hopkins AIDS Service
http://www.thebody.com/content/art12096.html
National Institutes of Health
http://www.nih.gov
Juvenile Diabetes Research Foundation International
http://jdrf.org
National Kidney Foundation
http://www.kidney.org
MedWatch
http://www.fda.gov/Safety/MedWatch/default.htm
National Osteoporosis Foundation
http://www.nof.org
National Agricultural Library
http://www.nal.usda.gov
North American Menopause Society
http://www.menopause.org
National Cancer Institute
http://www.cancer.gov/cancertopics
United States Department of Health and Human
Services
http://www.hhs.gov
National Comprehensive Cancer Network
http://www.nccn.org
World Health Organization
http://www.who.int
51
INDEX
8
8-MOP, 45
A
abacavir soln, 9
abacavir tabs, 9
abacavir/dolutegravir/lamivudine, 9
abacavir/lamivudine, 9
abacavir/lamivudine/zidovudine, 9
ABILIFY, 21
ABILIFY MAINTENA, 21
abiraterone acetate, 11
ABREVA, 46
ABSTRAL, 5
acamprosate calcium, 24
acarbose, 25
ACCOLATE, 42
ACCUPRIL, 14
ACCURETIC, 14
acetaminophen, 4
acetaminophen/dichloralphenazone/isometheptene, 23
acetazolamide, 17
acetazolamide ext-rel, 17
acetic acid, 49
acetic acid/aluminum acetate, 49
acetic acid/hydrocortisone, 49
acetohydroxamic acid, 35
ACIPHEX, 33
aclidinium bromide, 40
ACLOVATE, 45
ACTEMRA, 38
ACTIGALL, 32
ACTIMMUNE, 37
ACTIQ, 5
ACTIVELLA, 29
ACTOPLUS MET, 26
ACTOPLUS MET XR, 26
ACTOS, 26
ACULAR, 48
ACULAR LS, 48
acyclovir, 10, 46
ADALAT CC, 16
adalimumab, 37
adapalene crm, gel 0.1%, 44
ADCETRIS, 11
ADDERALL, 21
ADDERALL XR, 21
adefovir dipivoxil, 10
ADEMPAS, 18
ADVAIR 100/50, 43
ADVATE, 35
ADVIL, 4
AEROCHAMBER, 43
AEROSPAN, 43
afatinib, 12
AFINITOR, 12
AFINITOR DISPERZ, 12
AFRIN, 42
AGRYLIN, 36
AKYNZEO, 32
albendazole, 8
ALBENZA, 8
albuterol, 42
albuterol ext-rel, 42
albuterol inhalation soln, 41
albuterol sulfate, CFC-free aerosol, 41
alclometasone crm, oint 0.05%, 45
alcohol swabs, 27
ALDACTAZIDE, 17
ALDACTONE, 14
ALDARA, 46
aldesleukin, 13
alendronate tabs, 27
ALEVAZOL, 44
ALEVE, 4
alfuzosin ext-rel, 34
ALINIA, 11
alitretinoin, 46
ALKERAN, 11
ALLEGRA, 40
ALLEGRA-D, 41
allopurinol, 4
almotriptan, 23
alogliptin, 25
alogliptin/metformin, 25
alogliptin/pioglitazone, 25
ALORA, 29
alosetron, 33
ALPHANATE, 35
alprazolam, 18
alprazolam ext-rel, 18
ALTACE, 14
altretamine, 11
alumina/magnesia, 31
alumina/magnesia/simethicone, 31
aluminum chloride, 46
amantadine, 20
AMARYL, 26
AMBIEN, 23
ambrisentan, 17
AMERGE, 23
AMICAR, 36
amiloride, 17
amiloride/hydrochlorothiazide, 17
aminocaproic acid, 36
amiodarone 200 mg, 15
AMITIZA, 33
amitriptyline, 20
amlodipine, 16
amlodipine/benazepril, 14
amlodipine/telmisartan, 15
amlodipine/valsartan, 15
amlodipine/valsartan/hydrochlorothiazide, 15
ammonium lactate 12%, 46
amoxapine, 20
amoxicillin, 8
amoxicillin/clavulanate, 8
amoxicillin/clavulanate ext-rel, 8
amphetamine/dextroamphetamine mixed salts, 21
amphetamine/dextroamphetamine mixed salts ext-rel, 21
ampicillin, 8
AMPYRA, 23
ANADROL-50, 25
ANAFRANIL, 18
anagrelide, 36
ANAPROX, 4
52
ANASPAZ, 32
anastrozole, 12
ANDROGEL, 25
ANTABUSE, 24
antihemophilic factor (human), 35
antihemophilic factor (recombinant porcine), 35
antihemophilic factor (recombinant), 35, 36
antihemophilic factor/von Willebrand factor complex (human), 36
antiinhibitor coagulant complex, 36
ANUSOL-HC 2.5%, 34
APIDRA, 26
APIDRA SOLOSTAR, 26
apixaban, 35
aprepitant 40 mg, 80 mg, 32
aprepitant pack, 32
APRISO, 32
APTIVUS, 10
ARALEN, 8
ARANESP, 36
ARAVA, 37
ARCALYST, 37
ARCAPTA NEOHALER, 42
ARICEPT, 19
ARIMIDEX, 12
aripiprazole, 21
aripiprazole ext-rel inj, 21
aripiprazole lauroxil ext-rel inj, 21
ARISTADA, 21
ARIXTRA, 35
armodafinil, 24
ARMOUR THYROID, 31
AROMASIN, 12
artemether/lumefantrine, 8
ARTHROTEC, 4
artificial tears oint, soln, 49
ASACOL HD, 32
asenapine, 21
ASMANEX, 43
ASMANEX HFA, 43
aspirin, 36
ASTEPRO, 43
ATACAND, 15
ATACAND HCT, 15
atazanavir, 9
atazanavir/cobicistat, 9
atenolol, 16
atenolol/chlorthalidone, 16
ATGAM, 37
ATIVAN, 18
atomoxetine, 21
atorvastatin, 15
atovaquone, 11
atovaquone/proguanil, 8
ATRIPLA, 9
atropine sulfate oint, 48
atropine sulfate soln, 48
ATROVENT HFA, 40
ATROVENT spray, 44
AUGMENTIN, 8
AUGMENTIN XR, 8
AVALIDE, 15
AVAPRO, 15
AVELOX, 8
AVONEX, 23
AXERT, 23
axitinib, 12
AYGESTIN, 31
AZASAN, 38
azathioprine, 38
azelastine, 47
azelastine spray, 43
azithromycin, 7
azithromycin ext-rel, 7
aztreonam lysine inhalation soln, 42
AZULFIDINE, 33
AZULFIDINE EN-TABS, 33
B
bacitracin, 44, 47
bacitracin/polymyxin B, 44
baclofen, 23
BACTRIM DS, 8
BACTROBAN, 44
BACTROBAN NASAL, 44
balsalazide, 32
BANZEL, 19
BARACLUDE, 10
BEBULIN VH, 36
becaplermin, 46
bedaquiline, 10
BENADRYL, 41, 46
benazepril, 14
benazepril/hydrochlorothiazide, 14
BENEFIX, 36
BENTYL, 32
BENZAMYCIN, 44
benzonatate, 41
benzoyl peroxide, except foam, 44
benztropine, 20
benzyl alcohol, 46
BETAGAN, 48
betamethasone dipropionate augmented crm 0.05%, 45
betamethasone dipropionate augmented lotion 0.05%, 45
betamethasone dipropionate augmented oint 0.05%, 45
betamethasone dipropionate crm, lotion, oint 0.05%, 45
betamethasone valerate crm, lotion, oint 0.1%, 45
BETAPACE, 15
BETAPACE AF, 15
betaxolol 0.5%, 48
bethanechol, 35
bexarotene caps, 13
bexarotene gel, 13
BEYAZ, 27
BIAXIN, 7
bicalutamide, 11
BILTRICIDE, 11
bisacodyl, 33
bismuth subsalicylate, 32
bisoprolol, 16
bisoprolol/hydrochlorothiazide, 16
BLEPH-10, 47
BLEPHAMIDE SOP, 48
blood glucose monitoring kits, test strips, 27
BONIVA, 27
bosentan, 17
brentuximab vedotin, 11
BREVICON, 28
BRILINTA, 36
brimonidine 0.2%, 49
brimonidine/timolol, 49
bromocriptine, 20
budesonide delayed-rel caps, 32
53
budesonide inh susp, 43
budesonide/formoterol, 43
bumetanide, 17
BUNAVAIL, 24
BUPHENYL, 34
buprenorphine sublingual, 24
buprenorphine/naloxone buccal film, 24
buprenorphine/naloxone sublingual film, 24
buprenorphine/naloxone sublingual tabs, 24
bupropion, 20
bupropion ext-rel, 20, 24
buspirone, 18
busulfan, 11
butalbital/acetaminophen/caffeine, 6
butalbital/acetaminophen/caffeine/codeine, 5
butalbital/aspirin/caffeine, 6
butalbital/aspirin/caffeine/codeine, 5
BYDUREON, 25
BYETTA, 25
C
C1 esterase inhibitor, 36
cabergoline, 31
cabozantinib, 12
CAFERGOT, 23
CALAN SR, 16
calcipotriene, 45
calcitonin-salmon, 27
calcitriol (1,25-D3), 30
calcium, 39
calcium acetate, 30
calcium carbonate, 31
calcium/vitamin D, 39
canagliflozin, 26
canagliflozin/metformin, 26
canakinumab, 37
CANASA, 33
candesartan, 15
candesartan/hydrochlorothiazide, 15
CAPCOF, 41
capecitabine, 11
CAPMIST DM, 41
CAPRELSA, 13
CAPRON DM, 41
captopril, 14
captopril/hydrochlorothiazide, 14
CARAFATE, 34
CARBAGLU, 34
carbamazepine, 18
carbamazepine ext-rel, 18, 23
CARBATROL, 18
carbidopa/levodopa, 20
carbidopa/levodopa ext-rel, 20
carbidopa/levodopa/entacapone, 20
carbinoxamine soln, 41
CARDIZEM, 16
CARDIZEM CD, 16
CARDIZEM LA, 16
CARDURA, 14, 34
carglumic acid, 34
CARIMUNE NF, 37
carisoprodol 350 mg, 23
carisoprodol/aspirin, 24
carvedilol, 16
CASODEX, 11
CATAPRES, 14
CATAPRES-TTS, 14
CAYSTON, 42
cefaclor, 7
cefadroxil, 7
cefdinir, 7
cefprozil, 7
CEFTIN, 7
ceftolozane/tazobactam, 7
cefuroxime axetil, 7
CELEBREX, 4
celecoxib, 4
CELEXA, 20
CELLCEPT, 38
CELONTIN, 19
cephalexin, 7
ceritinib, 12
cetirizine, 40
cetirizine/pseudoephedrine ext-rel, 41
CETRAXAL, 49
CHANTIX, 24
CHEMET, 36
chlorambucil, 11
chlordiazepoxide, 18, 32
chlordiazepoxide/amitriptyline, 20
chlordiazepoxide/clidinium, 32
chlorhexidine, 47
chloroquine, 8
chlorothiazide susp, 17
chlorpheniramine, 40
chlorpheniramine ext-rel, 41
chlorpromazine, 21
chlorthalidone, 17
chlorzoxazone, 24
CHOLBAM, 34
cholestyramine, 15
cholic acid, 34
ciclopirox, 44
cilostazol, 36
CILOXAN, 47
cimetidine, 32
cinacalcet, 27
CINRYZE, 36
CIPRO, 8
CIPRODEX, 49
ciprofloxacin, 8
ciprofloxacin ext-rel, 8
ciprofloxacin otic, 49
ciprofloxacin soln, 47
ciprofloxacin/dexamethasone, 49
citalopram, 20
clarithromycin, 7
clarithromycin ext-rel, 7
CLARITIN, 40
CLARITIN-D, 41
clemastine, 41
CLEOCIN, 11, 34
CLEOCIN T, 44
CLEOCIN vaginal supp, 35
CLIMARA, 29
CLIMARA PRO, 30
clindamycin, 11
clindamycin crm, 34
clindamycin gel, lotion, soln, 44
clindamycin supp, 35
clobazam, 18
clobetasol propionate crm, gel, oint, soln 0.05%, 46
54
clomipramine, 18
clonazepam tabs, 18
clonidine, 14
clonidine ext-rel, 21
clonidine transdermal, 14
clopidogrel, 36
clorazepate, 18
clotrimazole, 34, 35, 44
clotrimazole troches, 8
clotrimazole/betamethasone, 44
clozapine, 21
CLOZARIL, 21
coagulation factor VIIa, recombinant, 36
COARTEM, 8
cobicistat, 9
codeine/acetaminophen, 5
codeine/chlorpheniramine/phenylephrine, 41
codeine/chlorpheniramine/pseudoephedrine liquid, 41
codeine/guaifenesin liquid, 41
codeine/guaifenesin/pseudoephedrine, 41
codeine/phenylephrine/promethazine, 41
codeine/promethazine, 41
COLACE, 33
colchicine tabs, 4
COLCRYS, 4
COLESTID, 15
colestipol tabs, 15
collagenase, 46
COLYTE, 33
COMBIGAN, 49
COMBIPATCH, 30
COMBIVENT RESPIMAT, 40
COMBIVIR, 9
COMETRIQ, 12
COMPLERA, 9
COMTAN, 20
condoms, male, 29
CONDYLOX, 46
conjugated estrogens/bazedoxifene, 30
COPAXONE, 23
COPEGUS, 10
COREG, 16
CORGARD, 16
CORTEF, 30
CORTIFOAM, 33
cortisone acetate, 30
CORTISPORIN OTIC, 49
CORTIZONE-10, 45
COSOPT, 48
COUMADIN, 35
COZAAR, 15
CREON, 33
CRESTOR, 16
CRINONE, 31
CRIXIVAN, 10
crizotinib, 12
cromolyn sodium, 34, 47
cromolyn sodium nasal spray, 42
cromolyn soln for inhalation, 42
CUBICIN, 11
CUTIVATE, 45
CUVPOSA, 34
cyanocobalamin inj, 39
CYCLESSA, 28
cyclobenzaprine 5 mg, 10 mg, 24
CYCLOGYL, 48
cyclopentolate, 48
cyclophosphamide caps, 11
cyclosporine caps, 38
cyclosporine soln, 38
cyclosporine, modified, 38
CYMBALTA, 20
cyproheptadine, 41
CYTOGAM, 37
cytomegalovirus immune globulin, 37
CYTOMEL, 31
CYTOTEC, 33
CYTRA-2, 35
CYTRA-3, 35
CYTRA-K, 35
D
D.H.E. 45, 23
dabigatran etexilate, 35
dabrafenib, 12
dalfampridine ext-rel, 23
DALIRESP, 43
dalteparin, 35
danazol, 29
DANTRIUM, 24
dantrolene, 24
dapsone, 11
daptomycin, 11
darbepoetin alfa, 36
darunavir, 9
darunavir susp, 10
darunavir/cobicistat, 9
dasatinib, 12
DAYPRO, 4
DDAVP spray, tabs, 31
deferasirox, 36
degarelix acetate, 12
DELATESTRYL, 25
delavirdine, 9
DELZICOL, 32
DEMADEX, 17
DEMEROL, 5
DEMSER, 18
DENAVIR, 46
DEPAKENE, 19
DEPAKOTE, 19
DEPAKOTE ER, 19
DEPO-PROVERA, 29
DEPO-TESTOSTERONE, 25
DERMA-SMOOTHE/FS, 45
DERMATOP, 45
DESCOVY, 9
desipramine, 20
desmopressin spray, 31
desmopressin spray, tabs, 31
desogestrel/EE, 28
desogestrel/EE 0.15/30 - Apri, 28
desonide crm, oint 0.05%, 45
DESOWEN, 45
desoximetasone crm 0.25%, 45
DETROL, 34
DETROL LA, 34
dexamethasone, 30
dexamethasone sodium phosphate, 48
DEXEDRINE SPANSULE, 22
dexmethylphenidate, 21
55
dexmethylphenidate ext-rel 5 mg, 10 mg, 15 mg, 20 mg,
30 mg, 40 mg, 21
DEXPAK, 30
dextroamphetamine ext-rel, 22
dextroamphetamine tabs 5 mg, 10 mg, 22
dextromethorphan/brompheniramine/pseudoephedrine, 41
dextromethorphan/guaifenesin ext-rel, 41
dextromethorphan/guaifenesin syrup, 41
dextromethorphan/guaifenesin/pseudoephedrine liq
10 mg/100 mg/30 mg/5 mL, 41
dextromethorphan/guaifenesin/pseudoephedrine tabs
15 mg/400 mg/60 mg, 41
dextromethorphan/promethazine, 41
dextromethorphan/pyrilamine, 41
dextromethorphan/quinidine, 24
DIABETIC TUSSIN, 42
DIAMOX SEQUELS, 17
diaphragm, 29
DIASTAT, 18
diazepam, 18
diazepam rectal gel, 18
diclofenac potassium, 4
diclofenac sodium, 48
diclofenac sodium delayed-rel, 4
diclofenac sodium delayed-rel/misoprostol, 4
diclofenac sodium ext-rel, 4
diclofenac sodium gel 1%, 4
dicloxacillin, 8
dicyclomine, 32
didanosine delayed-rel, 9
didanosine soln, 9
DIFFERIN, 44
diflorasone diacetate crm 0.05%, 45
diflorasone diacetate oint 0.05%, 46
DIFLUCAN, 8
diflunisal, 4
digoxin, 17
digoxin ped elixir, 17
dihydroergotamine inj, 23
dihydroergotamine spray, 23
DILANTIN, 19
DILANTIN INFATABS, 19
DILAUDID, 5
diltiazem, 16
diltiazem ext-rel, 16
DIOVAN, 15
DIOVAN HCT, 15
DIPENTUM, 33
diphenhydramine, 41
diphenhydramine/zinc acetate, 46
diphenoxylate/atropine, 32
DIPROLENE, 45
DIPROLENE AF, 45
dipyridamole, 36
disopyramide, 15
disopyramide ext-rel, 15
disulfiram, 24
DITROPAN XL, 34
DIURIL, 17
divalproex sodium delayed-rel, 19
divalproex sodium ext-rel, 19
docosanol, 46
docusate calcium, 33
docusate sodium, 33
dofetilide, 15
DOLOPHINE, 5
dolutegravir, 9
donepezil 5 mg, 10 mg, 19
dornase alfa, 42
dorzolamide, 48
dorzolamide/timolol maleate, 48
doxazosin, 14, 34
doxepin, 20
doxercalciferol, 30
doxycycline monohydrate caps 50 mg, 75 mg, 100 mg, 8
doxylamine, 22
dronabinol, 32
drospirenone/EE 3/20, 27
drospirenone/EE 3/30, 28
drospirenone/EE/levomefolate 3/20 and levomefolate, 27
DROXIA, 13
DRYSOL, 46
DUAVEE, 30
DUETACT, 26
DULCOLAX, 33
DULERA, 43
duloxetine delayed-rel, 20
DURAGESIC, 5
DYAZIDE, 17
E
E.E.S., 8
econazole, 44
eculizumab, 36
EE/norethindrone acetate, 29
EE/norethindrone acetate - Jinteli, 29
efavirenz, 9
efavirenz/emtricitabine/tenofovir, 9
EFFEXOR XR, 20
EFFIENT, 36
EFUDEX, 44
EGRIFTA, 31
elbasvir/grazoprevir, 10
ELDEPRYL, 20
ELIDEL, 46
ELIPHOS, 30
ELIQUIS, 35
ELIXOPHYLLIN, 43
ELLA, 28
ELMIRON, 35
ELOCON, 45
ELOCTATE, 35
eltrombopag, 36
elvitegravir, 9
elvitegravir/cobicistat/emtricitabine/tenofovir, 9
elvitegravir/cobicistat/emtricitabine/tenofovir alafenamide, 9
EMEND, 32
EMEND TRIPACK, 32
emtricitabine, 9
emtricitabine/rilpivirine/tenofovir, 9
emtricitabine/rilpivirine/tenofovir alafenamide, 9
emtricitabine/tenofovir, 9
emtricitabine/tenofovir alafenamide, 9
EMTRIVA, 9
enalapril, 14
enalapril oral soln, 14
enalapril/hydrochlorothiazide, 14
ENBREL, 37
ENDOMETRIN, 31
enfuvirtide, 9
enoxaparin, 35
entacapone, 20
56
entecavir, 10
ENTOCORT EC, 32
ENTRESTO, 17
enzalutamide, 11
EPANED, 14
epinephrine, 40
epinephrine pen, 40
EPIPEN, 40
EPIPEN JR., 40
EPIVIR, 9
EPIVIR-HBV, 10
eplerenone, 14
epoetin alfa, 36
EPOGEN, 36
epoprostenol sodium, 18
EPZICOM, 9
EQUETRO, 23
ergocalciferol (D2), 39
ergotamine/caffeine, 23
ERIVEDGE, 13
erlotinib, 12
ERYPED, 8
erythromycin, 47
erythromycin base, 7
erythromycin delayed-rel, 7
erythromycin ethylsuccinate, 8
erythromycin gel 2%, 44
erythromycin pads, 44
erythromycin soln, 44
erythromycin stearate, 8
erythromycin/benzoyl peroxide, 44
ESBRIET, 43
escitalopram, 20
esomeprazole delayed-rel caps, 33
esomeprazole magnesium delayed-rel, 33
estazolam, 22
ESTRACE, 29
ESTRACE CREAM, 29
estradiol, 29
estradiol vaginal crm, 29
estradiol vaginal tabs, 29
estradiol/levonorgestrel, 30
estradiol/norethindrone acetate, 29, 30
estradiol/norgestimate, 29
estrogens, conjugated, 29
estrogens, conjugated crm, 29
estrogens, conjugated/medroxyprogesterone, 29, 30
estrogens, esterified, 29
estrogens, esterified/methyltestosterone, 29
estropipate, 29
ESTROSTEP FE, 28
etanercept, 37
ethambutol, 10
ethionamide, 10
ethosuximide, 19
ethotoin, 19
ethynodiol diacetate/EE 1/35, 28
ethynodiol diacetate/EE 1/50 - Zovia 1/50, 28
etodolac, 4
etodolac ext-rel, 4
etonogestrel implant, 28
etonogestrel/EE ring, 29
etoposide, 13
etravirine, 9
everolimus, 12, 38
everolimus soluble tabs, 12
EVISTA, 31
evolocumab, 16
EVOTAZ, 9
EXELON, 19
exemestane, 12
exenatide, 25
exenatide ext-rel, 25
EXFORGE, 15
EXFORGE HCT, 15
EXJADE, 36
EXTAVIA, 23
ezetimibe, 15
ezogabine, 19
F
factor IX complex, plasma-derived, 36
factor IX concentrate, 36
famciclovir, 10
famotidine, 32
FAMVIR, 10
FANAPT, 21
FARESTON, 12
FARYDAK, 13
FASLODEX, 12
febuxostat, 4
FEIBA NF, 36
FEIBA VH, 36
felbamate, 19
FELBATOL, 19
felodipine ext-rel, 16
FEMARA, 12
FEMHRT, 29
fenofibrate, 15
fentanyl citrate buccal, 5
fentanyl lozenge, 5
fentanyl sublingual, 5
fentanyl transdermal, 5
FENTORA, 5
FEOSOL, 39
FERGON, 39
ferrous fumarate, 39
ferrous fumarate/folic acid - Hemocyte-F, 39
ferrous gluconate, 39
ferrous sulfate, 39
ferrous sulfate 160 mg - Slow Release Iron, 39
fexofenadine tabs, 40
fexofenadine/pseudoephedrine ext-rel, 41
filgrastim, 36
finasteride, 34
fingolimod, 23
FIORICET, 6
FIORICET w/CODEINE, 5
FIORINAL, 6
FIORINAL w/CODEINE, 5
FIRMAGON, 12
FIRST-PROGESTERONE VGS, 31
FISH OIL, 39
FLAGYL, 11
flavoxate, 34
FLEBOGAMMA, 37
flecainide, 15
FLEET ENEMA-PEDIATRIC, 33
FLOLAN, 18
FLOMAX, 34
FLONASE ALLERGY RELIEF, 43
fluconazole, 8
57
fludrocortisone, 30
FLUMADINE, 10
flunisolide spray, 43
flunisolide, CFC-free aerosol, 43
fluocinolone acetonide crm, oint 0.025%, 45
fluocinolone acetonide oil 0.01%, 45
fluocinolone acetonide soln 0.01%, 45
fluocinolone-hydroquinone-tretinoin, 46
fluocinonide crm, gel, oint, soln 0.05%, 45
FLUOR-A-DAY, 39
fluoride drops, 39
fluoride tabs, 39
fluorometholone 0.1% oint, 48
fluorometholone 0.1% susp, 48
fluorouracil, 44
fluoxetine, 20
fluphenazine, 21
fluphenazine inj, 21
flurazepam, 22
flurbiprofen, 4
flutamide, 12
fluticasone propionate crm, lotion 0.05%, oint 0.005%, 45
fluticasone spray, 43
fluticasone/salmeterol 100/50, 43
fluvoxamine, 18
FML, 48
FML LIQUIFILM, 48
FOCALIN, 21
FOCALIN XR, 21
FOLGARD RX, 38
folic acid, 38
folic acid/vitamin B6/vitamin B12, 38
folic acid/vitamin B6/vitamin B12 - Folbic, 38
folinic acid/vitamin B6/vitamin B12, 38
FOLINIC-PLUS, 38
fondaparinux, 35
FORTESTA, 25
FORTICAL, 27
FOSAMAX, 27
fosamprenavir, 10
fosinopril, 14
fosinopril/hydrochlorothiazide, 14
FOSRENOL, 30
FRAGMIN, 35
FREESTYLE FREEDOM LITE KITS AND TEST STRIPS, 27
FREESTYLE INSULINX KITS AND TEST STRIPS, 27
FREESTYLE LITE KITS AND TEST STRIPS, 27
fulvestrant, 12
FURADANTIN, 11
furosemide, 17
FUZEON, 9
FYCOMPA, 19
G
gabapentin caps, tabs, 19
gabapentin soln, 19
GABITRIL, 19
galantamine, 19
galantamine ext-rel, 19
GALZIN, 39
GAMASTAN S/D, 37
GAMMAGARD, 37
GAMUNEX-C, 37
ganciclovir, 48
ganciclovir inj, 10
GASTROCROM, 34
GEL-ONE, 6
gemfibrozil, 15
gentamicin, 44, 47
gentamicin/prednisolone acetate, 47
GENVOYA, 9
GEODON, 21
GERITOL, 39
GILENYA, 23
GILOTRIF, 12
glatiramer 20 mg, 23
GLEEVEC, 12
glimepiride, 26
glipizide, 26
glipizide ext-rel, 26
glipizide/metformin, 25
GLUCAGEN HYPOKIT, 30
GLUCAGON EMERGENCY KIT, 30
glucagon, human recombinant, 30
GLUCOPHAGE, 25
GLUCOPHAGE XR, 25
glucose, 27
GLUCOTROL, 26
GLUCOTROL XL, 26
GLUCOVANCE, 25
glyburide, 26
glyburide micronized, 26
glyburide/metformin, 25
glycine diluent, 18
glycopyrrolate, 34
glycopyrrolate tabs, 32
GLYNASE, 26
GLYSET, 25
GOLYTELY, 33
goserelin acetate, 12
granisetron tabs, 32
GRANIX, 36
grass mixed pollen allergen extract, 37
GRASTEK, 37
griseofulvin microsize, 8
griseofulvin microsize susp, 8
griseofulvin ultramicrosize, 8
GRIS-PEG, 8
guaifenesin ext-rel, 42
guaifenesin liq, 42
guaifenesin liq, syp, tabs, 42
guanfacine, 14
guanfacine ext-rel, 22
H
HALCION, 22
haloperidol, 21
HARVONI, 10
HECTOROL, 30
HELIXATE FS, 35
HEMOCYTE PLUS CAPS, 39
HEMOFIL M, 35
HEPAGAM B, 37
hepatitis B immune globulin, 37
HEPSERA, 10
HETLIOZ, 23
HEXALEN, 11
HIPREX, 11
HIZENTRA, 37
homatropine, 48
HUMALOG, 26
HUMALOG MIX, 26
58
HUMATE-P, 36
HUMIRA, 37
HUMULIN 70/30, 26
HUMULIN N, 26
HUMULIN R, 26
HYCAMTIN, 13
HYCET, 5
hydralazine, 18
HYDREA, 13
hydrochlorothiazide, 17
hydrocodone/acetaminophen, 5
hydrocodone/acetaminophen - Vicodin, 5
hydrocodone/acetaminophen soln, 5
hydrocodone/homatropine, 41
hydrocodone/ibuprofen, 5
hydrocortisone, 30
hydrocortisone acetate foam, 33
hydrocortisone butyrate crm, oint, soln 0.1%, 45
hydrocortisone crm, 34
hydrocortisone crm, gel, lotion, oint, soln 1%, 45
hydrocortisone crm, lotion, oint 2.5%, 45
hydrocortisone enema, 33
hydrocortisone oint 0.5%, 45
hydrocortisone succinate, 30
hydrocortisone valerate crm 0.2%, 45
hydromorphone, 5
hydroxychloroquine, 37
hydroxyurea, 13
hydroxyzine HCl, 41
hydroxyzine pamoate, 41
hyoscyamine sublingual, 32
hyoscyamine sulfate, 32
hyoscyamine sulfate ext-rel, 32
hyoscyamine sulfate ext-rel caps, 32
hyoscyamine sulfate orally disintegrating tabs, 32
hyoscyamine/methenamine/methylene blue/
phenyl salicylate/sodium phosphate, 35
hyoscyamine/methenamine/methylene blue/
phenyl salicylate/sodium phosphate - Urelle, 35
HYPERRAB S/D, 37
HYPERRHO S/D, 37
HYZAAR, 15
I
ibandronate tabs, 27
IBRANCE, 12
ibrutinib, 12
ibuprofen, 4
ICLUSIG, 12
ILARIS, 37
iloperidone, 21
iloprost, 18
imatinib mesylate, 12
IMBRUVICA, 12
imipramine HCl, 20
imiquimod crm 5%, 46
IMITREX, 23
immune globulin, gamma (IGG), 37
IMODIUM, 34
IMURAN, 38
INCRELEX, 30
indacaterol, 42
indapamide, 17
INDERAL LA, 16
indinavir, 10
INDOCIN, 4
INDOCIN susp, 4
indomethacin, 4
indomethacin ext-rel, 4
indomethacin supp, 4
indomethacin susp, 4
INLYTA, 12
INSPRA, 14
insulin aspart, 26
insulin aspart protamine 70%/insulin aspart 30%, 26
insulin delivery device, 27
insulin glargine, 26
insulin glulisine, 26
insulin human, 26
insulin isophane human, 26
insulin isophane human 70%/regular 30%, 26
insulin lispro, 26
insulin lispro protamine/insulin lispro, 26
insulin syringes, needles, 27
INTELENCE, 9
interferon alfa-2b, 37
interferon beta-1a, 23
interferon beta-1b, 23
interferon gamma-1b, 37
INTRON A, 37
INTUNIV, 22
INVEGA, 21
INVEGA SUSTENNA, 21
INVEGA TRINZA, 21
INVIRASE, 10
INVOKAMET, 26
INVOKANA, 26
ipratropium nasal spray, 44
ipratropium soln, 40
ipratropium, CFC-free aerosol, 40
ipratropium/albuterol inhalation spray, 40
ipratropium/albuterol soln, 40
irbesartan, 15
irbesartan/hydrochlorothiazide, 15
ISENTRESS, 9
isoniazid, 10
ISOPTO CARPINE, 48
ISOPTO HOMATROPINE, 48
ISORDIL, 17
isosorbide dinitrate ext-rel tabs, 17
isosorbide dinitrate oral, 17
isosorbide dinitrate sublingual, 17
isosorbide mononitrate, 17
isosorbide mononitrate ext-rel, 17
ISTODAX, 13
itraconazole caps, 8
ivacaftor, 42
ivermectin, 11
J
JAKAFI, 12
JENTADUETO, 25
JETREA, 49
JUXTAPID, 16
K
KADIAN, 5
KALETRA, 10
KALYDECO, 42
KAPVAY, 21
KAYEXALATE, 38
KAZANO, 25
KEFLEX, 7
59
KEPPRA, 19
KEPPRA XR, 19
ketoconazole, 8
ketoconazole crm, shampoo 2%, 44
ketoconazole shampoo 2%, 45
ketoprofen, 4
ketorolac, 4
ketorolac 0.4%, 48
ketorolac 0.5%, 48
ketorolac nasal spray, 4
ketotifen, 47
KLARON, 44
KLONOPIN, 18
KOATE-DVI, 35
KOGENATE FS, 36
KOVALTRY, 36
K-PHOS NEUTRAL, 38
KRISTALOSE, 33
K-TAB, 38
KUVAN, 30
KYNAMRO, 16
L
labetalol, 16
LAC-HYDRIN, 46
lacosamide, 19
lactulose, 33
LAMICTAL, 19
LAMISIL, 8
lamivudine, 9, 10
lamivudine/zidovudine, 9
lamotrigine, 19
lancets, 27
LANOXIN, 17
lansoprazole delayed-rel, 33
lanthanum, 30
LANTUS, 26
LANTUS SOLOSTAR, 26
lapatinib, 12
LASIX, 17
latanoprost, 49
LATUDA, 21
ledipasvir/sofosbuvir, 10
leflunomide, 37
lenalidomide, 12
lenvatinib, 12
LENVIMA, 12
LETAIRIS, 17
letrozole, 12
leucovorin, 13
LEUKERAN, 11
LEUKINE, 36
leuprolide acetate, 12
LEVAQUIN, 8
LEVBID, 32
levetiracetam, 19
levetiracetam ext-rel, 19
levetiracetam inj, 19
levobunolol, 48
levocetirizine, 40
levofloxacin, 8
levonorgestrel, 28
levonorgestrel - Next Choice One Dose, 28
levonorgestrel/EE, 28
levonorgestrel/EE 0.1/20, 27
levonorgestrel/EE 0.1/20 and EE 10, 28
levonorgestrel/EE 0.15/30, 28
levonorgestrel/EE 0.15/30 and EE 10, 28
levonorgestrel-releasing IUD, 29
levothyroxine, 31
levothyroxine - Levoxyl, 31
LEVSIN, 32
LEVSIN/SL, 32
LEXAPRO, 20
LEXIVA, 10
LIALDA, 32
lidocaine lotion 3%, 46
lidocaine patch, 46
lidocaine viscous, 47
lidocaine/prilocaine crm, 46
LIDODERM, 46
LILETTA, 29
linaclotide, 33
linagliptin, 25
linagliptin/metformin, 25
LINZESS, 33
liothyronine, 31
liotrix, 31
LIPITOR, 15
liraglutide, 25
lisdexamfetamine, 22
lisinopril, 14
lisinopril/hydrochlorothiazide, 14
lithium carbonate, 23
lithium carbonate ext-rel tabs 300 mg, 23
lithium carbonate ext-rel tabs 450 mg, 23
lithium citrate, 23
LITHIUM CITRATE, 23
LITHOBID, 23
LITHOSTAT, 35
l-methylfolate/vitamin B6/vitamin B12, 38
LOCOID, 45
LOESTRIN 1.5/30, 28
LOESTRIN 1/20, 27
LOESTRIN FE 1.5/30, 28
LOESTRIN FE 1/20, 27
LOFIBRA, 15
lomitapide, 16
LOMOTIL, 32
loperamide, 32
loperamide/simethicone, 34
LOPID, 15
lopinavir/ritonavir, 10
LOPRESSOR, 16
LOPRESSOR HCT, 16
LOPROX, 44
loratadine, 40
loratadine/pseudoephedrine ext-rel, 41
lorazepam, 18
losartan, 15
losartan/hydrochlorothiazide, 15
LOSEASONIQUE, 28
LOTENSIN, 14
LOTENSIN HCT, 14
LOTREL, 14
LOTRISONE, 44
LOTRONEX, 33
lovastatin, 16
LOVAZA, 16
LOVENOX, 35
loxapine, 21
lubiprostone, 33
60
lumacaftor/ivacaftor, 42
LUPRON DEPOT, 12
lurasidone, 21
LURIDE, 39
LURIDE LOZI-TABS, 39
lymphocyte immune globulin anti-thymocyte G, 37
LYNPARZA, 13
LYRICA, 19
LYSODREN, 13
LYSTEDA, 36
M
MAALOX, 31
macitentan, 17
MACROBID, 11
MACRODANTIN, 11
MALARONE, 8
malathion, 46
maraviroc, 9
MARINOL, 32
mask, 42
MATULANE, 13
MAVIK, 14
MAXALT, 23
MAXALT-MLT, 23
MAXITROL, 47
MAXZIDE, 17
mecasermin, 30
mechlorethamine gel, 11
meclizine, 32
MEDROL, 30
medroxyprogesterone acetate, 31
medroxyprogesterone acetate 150 mg/mL, 29
mefloquine, 8
MEGACE, 12
megestrol acetate, 12
MEKINIST, 12
meloxicam, 4
melphalan, 11
memantine, 19
MENEST, 29
meperidine, 5
MEPHYTON, 39
MEPRON, 11
mercaptopurine, 11
mesalamine delayed-rel caps, 32
mesalamine delayed-rel tabs, 32
mesalamine ext-rel caps, 32, 33
mesalamine rectal susp, 33
mesalamine supp, 33
mesna, 13
MESNEX, 13
MESTINON, 24
MESTINON TIMESPAN, 24
METANX, 38
metaproterenol, 42
metformin, 25
metformin ext-rel, 25
methadone soln 5 mg/5 mL, 10 mg/5 mL, 10 mg/mL, 5
methadone tabs 5 mg, 10 mg, 5
methazolamide, 17
methenamine hippurate, prophylaxis, 11
methimazole, 31
methocarbamol, 24
methotrexate, 11, 37
methoxsalen, 45
methscopolamine tabs 2.5 mg, 32
methsuximide, 19
methyldopa, 18
methylergonovine, 31
METHYLIN, 22
methylphenidate, 22
methylphenidate chew tabs, soln, tabs, 22
methylphenidate ext-rel caps 20 mg, 30 mg, 40 mg, 22
methylphenidate ext-rel tabs, 22
methylprednisolone, 30
metipranolol, 48
metoclopramide, 32
metolazone, 17
metoprolol succinate ext-rel, 16
metoprolol tartrate 25 mg, 50 mg, 100 mg, 16
metoprolol/hydrochlorothiazide, 16
METROCREAM, 46
METROGEL-VAGINAL, 35
METROLOTION, 46
metronidazole, 11, 35
metronidazole crm 0.75%, 46
metronidazole gel 0.75%, 46
metronidazole lotion 0.75%, 46
metyrosine, 18
MEVACOR, 16
MIACALCIN, 27
MICARDIS, 15
MICARDIS HCT, 15
MICATIN, 44
miconazole, 34, 35, 44
midodrine, 18
miglitol, 25
miglustat, 30
MIGRANAL, 23
MINOCIN, 8
minocycline, 8
minoxidil, 18
mipomersen, 16
MIRALAX, 33
MIRAPEX, 20
MIRCETTE, 28
MIRENA, 29
mirtazapine, 20
misoprostol, 33
mitotane, 13
MOBIC, 4
modafinil, 24
MODICON, 28
mometasone, 43
mometasone crm, lotion, oint 0.1%, 45
mometasone, CFC-free aerosol, 43
mometasone/formoterol, 43
MONOCLATE-P, 35
MONODOX, 8
MONONINE, 36
montelukast, 42
morphine, 5
morphine ext-rel, 5
morphine ext-rel 10 mg, 20 mg, 30 mg, 50 mg, 60 mg, 80 mg,
100 mg, 5
morphine ext-rel 40 mg, 200 mg, 5
morphine supp, 5
moxifloxacin, 8, 47
MS CONTIN, 5
MUCINEX, 42
MUCINEX D, 42
61
MUCINEX DM, 41
multiple vitamins/iron - Ferotrinsic, 39
multiple vitamins/iron - Hematogen, 39
multiple vitamins/minerals, 39
multiple vitamins/minerals - Corvite Free, 39
multiple vitamins/minerals - Vicap Forte, 39
multiple vitamins/minerals/iron, 39
multiple vitamins/minerals/iron - Ferrocite Plus, 39
multivitamins, 39
multivitamins/fluoride drops, tabs, 39
multivitamins/fluoride/iron drops, tabs, 39
multivitamins/iron tabs, 39
mupirocin, 44
mupirocin oint, 44
MYAMBUTOL, 10
MYCOBUTIN, 10
mycophenolate mofetil, 38
mycophenolate sodium delayed-rel, 38
MYDRIACYL, 48
MYFORTIC, 38
MYLERAN, 11
MYSOLINE, 19
N
nabumetone, 4
nadolol, 16
nafarelin, 29
naloxone inj, 24
naloxone nasal spray, 24
naltrexone, 24
naltrexone microspheres, 24
NAMENDA, 19
naphazoline 0.1%, 49
NAPROSYN, 4
naproxen, 4
naproxen sodium, 4
naratriptan, 23
NARCAN, 24
NASACORT ALLERGY 24HR, 43
NASALCROM, 42
NATACYN, 47
natamycin, 47
nateglinide, 26
NATROBA, 46
NEBUPENT, 11
nefazodone, 20
nelfinavir, 10
neomycin, 7
neomycin/polymyxin B/bacitracin, 44
neomycin/polymyxin B/bacitracin/hydrocortisone oint, 47
neomycin/polymyxin B/bacitracin/pramoxine, 44
neomycin/polymyxin B/dexamethasone, 47
neomycin/polymyxin B/gramicidin, 47
neomycin/polymyxin B/hydrocortisone, 49
neomycin/polymyxin B/hydrocortisone susp, 48
NEORAL, 38
NEOSPORIN, 44, 47
NEPHROCAPS, 39
NESINA, 25
netupitant/palonosetron, 32
NEULASTA, 36
NEUPOGEN, 36
NEURONTIN, 19
nevirapine, 9
nevirapine ext-rel, 9
NEXAVAR, 12
NEXIUM, 33
NEXIUM 24HR, 33
NEXPLANON, 28
NICORETTE, 24
nicotine polacrilex gum, 24
nicotine polacrilex lozenge, 24
nicotine transdermal, 24
nifedipine ext-rel, 16
NILANDRON, 12
nilotinib, 12
nilutamide, 12
nimodipine oral soln, 16
nintedanib, 43
nitazoxanide, 11
nitisinone, 31
NITRO-DUR, 17
nitrofurantoin ext-rel, 11
nitrofurantoin macrocrystals, 11
nitrofurantoin susp, 11
nitroglycerin ext-rel, 17
nitroglycerin sublingual, 17
nitroglycerin transdermal, 17
NITROSTAT, 17
nizatidine, 32
NIZORAL SHAMPOO, 45
NORCO, 5
NORDITROPIN, 30
norelgestromin/EE - Xulane, 29
norethindrone, 28
norethindrone acetate, 31
norethindrone acetate/EE 1.5/30, 28
norethindrone acetate/EE 1.5/30 and iron, 28
norethindrone acetate/EE 1/20, 27
norethindrone acetate/EE 1/20 and iron, 27
norethindrone acetate/EE 1/20 and iron - Lomedia 24 Fe, 27
norethindrone acetate/EE and iron, 28
norethindrone/EE, 28
norethindrone/EE 0.4/35, 28
norethindrone/EE 0.5/35, 28
norethindrone/EE 1/35, 28
norethindrone/ME 1/50, 28
norgestimate/EE, 28
norgestimate/EE 0.25/35, 28
norgestrel/EE 0.3/30, 28
norgestrel/EE 0.5/50 - Ogestrel, 28
NORINYL 1+35, 28
NORINYL 1+50, 28
NORPACE, 15
NORPACE CR, 15
NORPRAMIN, 20
NOR-QD, 28
nortriptyline, 20
NORVASC, 16
NORVIR, 10
NOVOEIGHT, 36
NOVOLIN 70/30, 26
NOVOLIN N, 26
NOVOLIN R, 26
NOVOLOG, 26
NOVOLOG MIX 70/30, 26
NOVOSEVEN RT, 36
NUEDEXTA, 24
NULYTELY, 33
NUVARING, 29
NUVIGIL, 24
NYMALIZE, 16
62
nystatin, 8, 44
O
OBIZUR, 35
OCEAN, 44
ocriplasmin, 49
octreotide acetate, 31
OCUFLOX, 47
ODEFSEY, 9
OFEV, 43
ofloxacin, 8, 47
ofloxacin otic, 49
olanzapine, 21
olaparib, 13
olodaterol, CFC-free aerosol, 42
olsalazine, 33
omalizumab, 44
omega-3 acid ethyl esters, 16
omega-3 fatty acids, 39
omega-3 fatty acids/vitamin E, 39
omeprazole delayed-rel, 33
omeprazole magnesium delayed-rel, 33
omeprazole magnesium delayed-rel caps, 33
omeprazole/sodium bicarbonate, 33
ondansetron, 32
ONE-A-DAY, 39
ONFI, 18
OPANA ER, 5
OPSUMIT, 17
ORALAIR, 37
ORAP, 21
ORFADIN, 31
ORKAMBI, 42
orphenadrine ext-rel, 24
ORTHO MICRONOR, 28
ORTHO TRI-CYCLEN, 28
ORTHO-CYCLEN, 28
ORTHO-NOVUM 1/35, 28
ORTHO-NOVUM 7/7/7, 28
oseltamivir, 10
OSENI, 25
OVCON 35, 28
OVIDE, 46
OXANDRIN, 25
oxandrolone, 25
oxaprozin, 4
oxazepam, 18
oxcarbazepine, 19
oxcarbazepine ext-rel, 19
OXSORALEN, 45
OXTELLAR XR, 19
oxybutynin, 34
oxybutynin ext-rel, 34
oxybutynin transdermal, 34
oxycodone, 5
oxycodone ext-rel, 5
oxycodone/acetaminophen, 5
oxycodone/aspirin, 5
OXYCONTIN, 5
oxymetazoline, 42
oxymetholone, 25
oxymorphone ext-rel, 5
OXYTROL FOR WOMEN, 34
P
palbociclib, 12
paliperidone ext-rel, 21
paliperidone palmitate ext-rel inj, 21
palivizumab, 43
PAMELOR, 20
PAMINE, 32
pancrelipase, 33
pancrelipase delayed-rel, 33
panobinostat, 13
PANRETIN, 46
pantoprazole delayed-rel tabs, 33
PARAFON FORTE DSC, 24
paricalcitol, 30
PARLODEL, 20
PARNATE, 19
paroxetine HCl, 20
PAXIL, 20
pazopanib, 12
pediatric multiple vitamin w/iron 15 mg chew tabs, 39
peg 3350/electrolytes, 33
PEGANONE, 19
PEGASYS, 37
pegfilgrastim, 36
peginterferon alfa-2a, 37
peginterferon alfa-2b, 37
pegvisomant, 31
penciclovir, 46
penicillin VK, 8
PENTAM, 11
pentamidine, 11
PENTASA, 33
pentosan polysulfate sodium, 35
pentoxifylline ext-rel, 36
PEPCID, 32
PEPCID AC, 32
PEPTO-BISMOL, 32
perampanel, 19
PERCOCET, 5
PERCODAN, 5
PERIDEX, 47
permethrin, 46
perphenazine, 21
perphenazine/amitriptyline, 21
PERSANTINE, 36
petrolatum/mineral oil/shark liver oil/phenylephrine oint, 34
phenazopyridine, 35
phenobarbital, 19
phenylephrine/shark liver oil/cocoa butter supp, 34
PHENYLHISTINE DH, 41
PHENYTEK, 19
phenytoin, 19
phenytoin sodium extended, 19
PHOSLO, 30
phytonadione, 39
pilocarpine, 48
pilocarpine tabs, 34
pimecrolimus, 46
pimozide, 21
pioglitazone, 26
pioglitazone/glimepiride, 26
pioglitazone/metformin, 26
pioglitazone/metformin ext-rel, 26
pirfenidone, 43
PLAN B ONE-STEP, 28
PLAQUENIL, 37
PLAVIX, 36
podofilox soln, 46
polyethylene glycol 3350, 33
63
polymyxin B/bacitracin, 47
polymyxin B/trimethoprim, 47
POLYSPORIN, 44
POLYTRIM, 47
pomalidomide, 12
POMALYST, 12
ponatinib, 12
potassium chloride ext-rel, 38
potassium chloride liquid, 38
potassium citrate ext-rel, 35
potassium citrate/citric acid, 35
potassium citrate/sodium citrate/citric acid, 35
potassium iodide, 31
potassium phosphate, 38
POTIGA, 19
PRADAXA, 35
pramipexole, 20
pramlintide, 25
pramoxine/phenylephrine/glycerin/petrolatum, 34
PRANDIN, 26
prasugrel, 36
PRAVACHOL, 16
pravastatin, 16
praziquantel, 11
PRECISION XTRA KITS AND TEST STRIPS, 27
PRECOSE, 25
PRED FORTE, 48
PRED MILD, 48
PRED-G, 47
PRED-G SOP, 47
prednicarbate crm, oint 0.1%, 45
prednisolone acetate 0.12%, 48
prednisolone acetate 1%, 48
prednisolone phosphate 1%, 48
prednisolone sodium phosphate soln
5 mg/5 mL, 15 mg/5 mL, 30
prednisolone syrup, 30
prednisone, 30
PREFEST, 29
pregabalin, 19
PREMARIN, 29
PREMARIN CREAM, 29
PREMPHASE, 29
PREMPRO, 30
PRENATAL TAB, 38
prenatal vitamins without A/ferrous asparto glycinate/
iron carbonyl/methylfolate/folic acid/DHA, 38
prenatal vitamins without A/ferrous asparto glycinate/
l-methylfolate/folic acid/DHA, 38
prenatal vitamins without A/ferrous fumarate/l-methylfolate/
folic acid/DHA, 39
prenatal vitamins/calcium/vitamin B6/vitamin B12/
folic acid/ginger, 39
prenatal vitamins/carbonyl iron/docusate/folic acid Prenatal AD, 39
prenatal vitamins/carbonyl iron/folic acid - Prenatabs Rx, 39
prenatal vitamins/ferrous asparto glycinate/folic acid, 39
prenatal vitamins/ferrous asparto glycinate/l-methylfolate/
folic acid, 39
prenatal vitamins/ferrous fumarate/
folic acid 27 mg/0.8 mg, 38
prenatal vitamins/minerals/l-methylfolate/folic acid, 39
PRENATE AM, 39
PRENATE CHEWABLE, 39
PRENATE DHA, 38
PRENATE ELITE, 39
PRENATE ENHANCE, 39
PRENATE ESSENTIAL, 38
PRENATE MINI, 38
PRENATE PIXIE, 38
PRENATE RESTORE, 39
PRENATE STAR, 39
PREPARATION H, 34
PREVACID, 33
PREVACID 24HR, 33
PREVIDENT, 47
PREZCOBIX, 9
PREZISTA, 9
PREZISTA susp, 10
PRIFTIN, 10
PRILOSEC, 33
PRILOSEC OTC, 33
primaquine, 8
PRIMAQUINE, 8
primidone, 19
PRIVIGEN, 37
probenecid, 5
procarbazine, 13
PROCARDIA XL, 16
prochlorperazine, 32
PROCRIT, 36
PROCTOCORT 1%, 34
PROFILNINE SD, 36
progesterone gel, 31
progesterone supp, 31
progesterone vaginal inserts, 31
progesterone, micronized, 31
PROGRAF, 38
PROLEUKIN, 13
PROMACTA, 36
promethazine, 32
promethazine/phenylephrine, 41
PROMETRIUM, 31
propafenone, 15
propafenone ext-rel, 15
propranolol, 16
propranolol ext-rel, 16
propylthiouracil, 31
PROSCAR, 34
PROSOM, 22
PROTONIX, 33
PROTOPIC, 46
PROVERA, 31
PROVIGIL, 24
PROZAC, 20
pseudoephedrine, 42
pseudoephedrine ext-rel, 42
pseudoephedrine/guaifenesin ext-rel, 42
pseudoephedrine/guaifenesin syp 30 mg/100 mg/5 mL, 42
PULMICORT RESPULES, 43
PULMOZYME, 42
pyrazinamide, 10
PYRIDIUM, 35
pyridostigmine, 24
pyridostigmine ext-rel, 24
Q
QUESTRAN/QUESTRAN LIGHT, 15
quetiapine, 21
quetiapine ext-rel, 21
quinapril, 14
quinapril/hydrochlorothiazide, 14
64
R
rabeprazole delayed-rel, 33
rabies immune globulin, 37
ragweed pollen allergen extract, 37
RAGWITEK, 37
raloxifene, 31
raltegravir, 9
ramipril, 14
RANEXA, 18
ranitidine, 32
ranolazine ext-rel, 18
RAPAMUNE, 38
RAZADYNE, 19
RAZADYNE ER, 19
REBETOL, 10
RECOMBINATE, 36
REGLAN, 32
REGRANEX, 46
RELENZA, 10
REMERON, 20
REMEVEN, 46
REMODULIN, 18
repaglinide, 26
REPATHA, 16
REQUIP, 20
RESCRIPTOR, 9
RESTORIL, 22
RETIN-A, 44
RETROVIR, 9
REVATIO, 18
REVLIMID, 12
REYATAZ, 9
rho D immune globulin, 37
RHOGAM PLUS, 37
RHOPHYLAC, 37
ribavirin caps - Ribasphere, 10
ribavirin oral soln, 10
ribavirin tabs, 10
rifabutin, 10
RIFADIN, 10
rifampin, 10
rifapentine, 10
rifaximin, 11
rilonacept, 37
RILUTEK, 25
riluzole, 25
rimantadine, 10
rimexolone, 48
riociguat, 18
RISPERDAL, 21
RISPERDAL CONSTA, 21
risperidone, 21
risperidone long-acting inj, 21
RITALIN, 22
RITALIN LA, 22
ritonavir, 10
RITUXAN, 13
rituximab, 13
rivaroxaban, 35
rivastigmine, 19
RIXUBIS, 36
rizatriptan, 23
rizatriptan orally disintegrating tabs, 23
ROBAXIN, 24
ROBINUL, 32
ROCALTROL, 30
roflumilast, 43
romidepsin, 13
ropinirole, 20
rosuvastatin, 16
ROWASA, 33
ROXICODONE, 5
rufinamide, 19
ruxolitinib, 12
RYTHMOL, 15
RYTHMOL SR, 15
S
sacrosidase, 34
sacubitril/valsartan, 17
SALAGEN, 34
salicylic acid 17%, 46
salmeterol xinafoate, 42
SAMSCA, 31
SANDIMMUNE, 38
SANDOSTATIN, 31
SANTYL, 46
SAPHRIS, 21
sapropterin, 30
saquinavir mesylate, 10
sargramostim, 36
SEASONIQUE, 28
selegiline, 20
selenium sulfide shampoo 1%, 45
selenium sulfide shampoo 2.5%, 45
SELSUN BLUE, 45
SELZENTRY, 9
senna, 33
SENNA PLUS, 33
sennosides, 33
sennosides/docusate sodium, 33
SENOKOT, 33
SENSIPAR, 27
SEREVENT, 42
SEROQUEL, 21
SEROQUEL XR, 21
sertraline, 20
sildenafil inj, 18
sildenafil tabs, 18
SILVADENE, 44
silver sulfadiazine, 44
simvastatin, 16
sinecatechins, 46
SINEMET, 20
SINEMET CR, 20
SINGULAIR, 42
sirolimus, 38
SIRTURO, 10
SKYLA, 29
sodium chloride, 39
sodium chloride for inhalation, 42, 43
sodium chloride nasal spray, 44
sodium citrate/citric acid, 35
sodium fluoride, 47
sodium fluoride/xylitol, 39
sodium hyaluronate, 6
sodium oxybate, 24
sodium phenylbutyrate powder, 34
sodium phenylbutyrate tabs, 34
sodium phosphate/sodium bisphosphate enema soln, 33
sodium polystyrene sulfonate, 38
sofosbuvir, 10
65
SOLIRIS, 36
SOLU-CORTEF, 30
SOMA, 23
somatropin, 30
SOMAVERT, 31
sorafenib, 12
sorbitol irrigation soln, 35
sotalol, 15
SOVALDI, 10
spacer, 43
spinosad, 46
SPIRIVA HANDIHALER, 40
SPIRIVA RESPIMAT, 40
spironolactone, 14
spironolactone/hydrochlorothiazide, 17
SPORANOX, 8
SPRIX, 4
SPRYCEL, 12
SSKI, 31
STALEVO, 20
STARLIX, 26
stavudine, 9
STERILE DILUENT FOR FLOLAN, 18
STIMATE, 31
STIOLTO RESPIMAT, 40
STRATTERA, 21
streptozocin, 11
STRIBILD, 9
STRIVERDI RESPIMAT, 42
STROMECTOL, 11
SUBOXONE, 24
SUBOXONE FILM, 24
succimer, 36
SUCRAID, 34
sucralfate, 34
SUDAFED, 42
sulfacetamide lotion 10%, 44
sulfacetamide soln 10%, 47
sulfacetamide/prednisolone acetate oint 10%/0.2%, 48
sulfacetamide/prednisolone phosphate 10%/0.25%, 48
sulfacetamide/sulfur, 46
sulfacetamide/sulfur crm, gel, lotion, pads, 44
sulfacetamide/sulfur pad, wash, 44
sulfacetamide/sulfur susp, 44
sulfadiazine, 8
sulfamethoxazole/trimethoprim, 8
sulfamethoxazole/trimethoprim DS, 8
sulfasalazine, 33
sulfasalazine delayed-rel, 33
sulindac, 4
sumatriptan, 23
sumatriptan inj, 23
sumatriptan nasal spray, 23
SUMAXIN, 44
SUMAXIN TS, 44
sunitinib, 12
SUPARTZ, 6
SURMONTIL, 20
SUSTIVA, 9
SUTENT, 12
SYLATRON, 37
SYMBICORT, 43
SYMLINPEN, 25
SYNAGIS, 43
SYNAREL, 29
SYNTHROID, 31
T
TABLOID, 11
tacrolimus, 38, 46
TAFINLAR, 12
TAGAMET HB, 32
TAMIFLU, 10
tamoxifen, 12
tamsulosin, 34
TAPAZOLE, 31
TARCEVA, 12
TARGRETIN caps, 13
TARGRETIN gel, 13
TASIGNA, 12
tasimelteon, 23
tbo-filgrastim, 36
TEGRETOL, 18
TEGRETOL-XR, 18
telbivudine, 10
telmisartan, 15
telmisartan/hydrochlorothiazide, 15
temazepam 15 mg, 30 mg, 22
TEMODAR, 11
TEMOVATE, 46
temozolomide, 11
TENEX, 14
tenofovir, 9
TENORETIC, 16
TENORMIN, 16
TERAZOL 3, 35
TERAZOL 7, 35
terazosin, 14, 34
terbinafine tabs, 8
terbutaline, 42
terconazole, 35
tesamorelin, 31
TESSALON, 41
testosterone cypionate, 25
testosterone enanthate, 25
testosterone gel, 25
tetrabenazine, 22
tetracycline, 8
thalidomide, 12
THALOMID, 12
THEO-24, 43
theophylline ext-rel caps, 43
theophylline ext-rel tabs, 43
theophylline liquid, 43
thioguanine, 11
thioridazine, 21
thiothixene, 21
thyroid, 31
THYROLAR, 31
tiagabine, 19
TIAZAC, 16
ticagrelor, 36
TIGAN, 32
tigecycline, 11
TIKOSYN, 15
timolol maleate, 48
timolol maleate gel, 48
TIMOPTIC, 48
TIMOPTIC-XE, 48
timothy grass pollen allergen extract, 37
tiotropium, 40
tiotropium/olodaterol, 40
tipranavir, 10
66
TIVICAY, 9
tizanidine tabs, 24
TOBI, 42
TOBRADEX, 48
TOBRADEX ST, 48
tobramycin inhalation soln, 42
tobramycin soln, 47
tobramycin/dexamethasone oint 0.3%/0.1%, 48
tobramycin/dexamethasone susp 0.3%/0.05%, 48
tobramycin/dexamethasone susp 0.3%/0.1%, 48
TOBREX, 47
tocilizumab, 38
TOFRANIL, 20
tolterodine, 34
tolterodine ext-rel, 34
tolvaptan, 31
TOPAMAX, 19
TOPICORT, 45
topiramate sprinkle caps, tabs, 19
topotecan caps, 13
TOPROL-XL, 16
toremifene, 12
torsemide, 17
TRACLEER, 17
TRADJENTA, 25
tramadol, 5
tramadol/acetaminophen, 5
trametinib, 12
TRANDATE, 16
trandolapril, 14
tranexamic acid, 36
TRANXENE T-TAB, 18
tranylcypromine, 19
trazodone, 20
TRECATOR, 10
TRELSTAR, 12
treprostinil, 18
tretinoin, 44
tretinoin caps, 13
TREXALL, 11
triamcinolone acetonide crm, lotion, oint 0.025%, 45
triamcinolone acetonide crm, lotion, oint 0.1%, 45
triamcinolone acetonide crm, oint 0.5%, 45
triamcinolone acetonide spray, 43
triamcinolone paste, 47
triamterene/hydrochlorothiazide, 17
triazolam, 22
TRI-CHLOR, 47
trichloroacetic acid, 47
TRICOR, 15
trifluoperazine, 21
trifluridine, 48
trihexyphenidyl, 20
TRILEPTAL, 19
TRI-LUMA, 46
trimethobenzamide, 32
trimethoprim, 11
trimipramine, 20
TRI-NORINYL, 28
triptorelin pamoate, 12
TRIUMEQ, 9
TRIZIVIR, 9
tropicamide, 48
trospium, 34
trospium ext-rel, 34
TRUSOPT, 48
TRUVADA, 9
trypsin/balsam/castor oil, 47
TUDORZA, 40
TWYNSTA, 15
TYBOST, 9
TYGACIL, 11
TYKERB, 12
TYLENOL, 4
TYLENOL w/CODEINE, 5
TYVASO, 18
TYZEKA, 10
U
ULESFIA, 46
ulipristal, 28
ULORIC, 4
ULTRACET, 5
ULTRAM, 5
UNISOM, 22
urea crm 40%, 46
urea crm 50%, 46
urea lotion 10%, 46
URECHOLINE, 35
urine glucose test strips, 27
UROCIT-K, 35
UROGESIC-BLUE, 35
UROXATRAL, 34
URSO, 32
ursodiol, 32
V
VAGIFEM, 29
valacyclovir, 10
VALCHLOR, 11
VALCYTE, 10
valganciclovir, 10
VALIUM, 18
valproic acid, 19
valsartan, 15
valsartan/hydrochlorothiazide, 15
VALTREX, 10
VANCOCIN, 11
vancomycin, 11
vandetanib, 13
varenicline, 24
VASERETIC, 14
VASOTEC, 14
vemurafenib, 13
venlafaxine ext-rel, 20
venlafaxine tabs, 20
VENTAVIS, 18
VENTOLIN HFA, 41
verapamil ext-rel, 16
VEREGEN, 46
VERELAN, 16
VEXOL, 48
V-GO INSULIN DELIVERY DEVICE, 27
VICOPROFEN, 5
VICTOZA, 25
VIDEX EC, 9
VIDEX soln, 9
VIGAMOX, 47
VIMPAT, 19
VIOKACE, 33
VIRACEPT, 10
VIRAMUNE, 9
VIRAMUNE XR, 9
67
VIREAD, 9
VIROPTIC, 48
vismodegib, 13
VISTARIL, 41
vitamin ADC/fluoride drops, 39
vitamin ADC/fluoride/iron drops, 39
vitamin B complex/vitamin C/folic acid, 39
VITEKTA, 9
VIVITROL, 24
VOLTAREN GEL, 4
vorinostat, 13
VOSPIRE ER, 42
VOTRIENT, 12
VYVANSE, 22
W
warfarin, 35
WELLBUTRIN SR, 20
WELLBUTRIN XL, 20
WESTCORT, 45
WINRHO SDF, 37
X
XALATAN, 49
XALKORI, 12
XANAX, 18
XANAX XR, 18
XARELTO, 35
XELODA, 11
XENAZINE, 22
XIFAXAN, 11
XOLAIR, 44
XTANDI, 11
XYNTHA, 36
XYREM, 24
XYZAL, 40
Y
YASMIN, 28
YAZ, 27
Z
ZADITOR, 47
zafirlukast, 42
ZANAFLEX tabs, 24
zanamivir, 10
ZANOSAR, 11
ZANTAC, 32
ZARONTIN, 19
ZAVESCA, 30
ZEBETA, 16
ZEGERID OTC, 33
ZELBORAF, 13
ZEMPLAR, 30
ZENPEP, 33
ZEPATIER, 10
ZERBAXA, 7
ZERIT, 9
ZESTORETIC, 14
ZESTRIL, 14
ZETIA, 15
ZIAC, 16
ZIAGEN, 9
ZIAGEN soln, 9
zidovudine, 9
zinc acetate, 39
ziprasidone, 21
ZIRGAN, 48
ZITHROMAX, 7
ZMAX, 7
ZOCOR, 16
ZOFRAN, 32
ZOLADEX, 12
ZOLINZA, 13
ZOLOFT, 20
zolpidem, 23
ZONEGRAN, 19
zonisamide, 19
ZORTRESS, 38
ZOVIRAX, 10, 46
ZYBAN, 24
ZYKADIA, 12
ZYLOPRIM, 4
ZYPREXA, 21
ZYRTEC, 40
ZYRTEC-D, 41
ZYTIGA, 11
OH-MMED-1119
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