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Priority Partners (690) Effective 10/01/2016 INTRODUCTION....................................................................................................................................................................................................... 4 PREFACE ................................................................................................................................................................................................................. 4 PHARMACY AND THERAPEUTICS (P&T) COMMITTEE ...................................................................................................................................... 4 PRODUCT SELECTION CRITERIA......................................................................................................................................................................... 4 GENERIC SUBSTITUTION ...................................................................................................................................................................................... 5 DRUG EFFICACY STUDY IMPLEMENTATION (DESI) DRUGS ............................................................................................................................ 5 NON-FORMULARY EXCEPTION REQUESTS ....................................................................................................................................................... 5 MANAGED DRUG LIMITATIONS (MDL)................................................................................................................................................................. 6 MARYLAND PREFERRED DRUG LIST .................................................................................................................................................................. 7 OVER-THE-COUNTER DRUG COVERAGE ........................................................................................................................................................... 7 PRIOR AUTHORIZATION ........................................................................................................................................................................................ 9 STEP THERAPY .................................................................................................................................................................................................... 10 SPECIALTY PHARMACY ...................................................................................................................................................................................... 10 EDITOR................................................................................................................................................................................................................... 11 LEGEND ................................................................................................................................................................................................................. 11 NOTICE................................................................................................................................................................................................................... 11 ANALGESICS......................................................................................................................................................................................................... 12 ANALGESICS, OTHER ................................................................................................................................................................................ 12 NSAIDs ......................................................................................................................................................................................................... 12 COX-2 INHIBITORS ..................................................................................................................................................................................... 12 GOUT ........................................................................................................................................................................................................... 12 OPIOID ANALGESICS ................................................................................................................................................................................. 12 NON-OPIOID ANALGESICS........................................................................................................................................................................ 13 ANTI-INFECTIVES ................................................................................................................................................................................................. 13 ANTIBACTERIALS ....................................................................................................................................................................................... 13 ANTIFUNGALS ............................................................................................................................................................................................ 14 ANTIMALARIALS ......................................................................................................................................................................................... 14 ANTIRETROVIRAL AGENTS ...................................................................................................................................................................... 15 ANTITUBERCULAR AGENTS ..................................................................................................................................................................... 15 ANTIVIRALS................................................................................................................................................................................................. 15 MISCELLANEOUS ....................................................................................................................................................................................... 15 ANTINEOPLASTIC AGENTS ................................................................................................................................................................................ 16 ALKYLATING AGENTS ............................................................................................................................................................................... 16 ANTIMETABOLITES .................................................................................................................................................................................... 16 HORMONAL ANTINEOPLASTIC AGENTS ................................................................................................................................................. 16 IMMUNOMODULATORS ............................................................................................................................................................................. 16 KINASE INHIBITORS ................................................................................................................................................................................... 16 MISCELLANEOUS ....................................................................................................................................................................................... 17 CARDIOVASCULAR .............................................................................................................................................................................................. 17 ACE INHIBITORS......................................................................................................................................................................................... 17 ACE INHIBITOR/CALCIUM CHANNEL BLOCKER COMBINATIONS ........................................................................................................ 17 ACE INHIBITOR/DIURETIC COMBINATIONS ............................................................................................................................................ 17 ADRENOLYTICS, CENTRAL....................................................................................................................................................................... 18 ALPHA BLOCKERS ..................................................................................................................................................................................... 18 ANGIOTENSIN II RECEPTOR ANTAGONISTS (ARBs)/DIURETIC COMBINATIONS .............................................................................. 18 ANGIOTENSIN II RECEPTOR ANTAGONIST (ARB)/CALCIUM CHANNEL BLOCKER COMBINATIONS .............................................. 18 ANGIOTENSIN II RECEPTOR ANTAGONIST (ARB)/CALCIUM CHANNEL BLOCKER/DIURETIC COMBINATIONS ............................ 18 ANTIARRHYTHMICS ................................................................................................................................................................................... 18 ANTILIPEMICS............................................................................................................................................................................................. 18 BETA-BLOCKERS ....................................................................................................................................................................................... 19 BETA-BLOCKER/DIURETIC COMBINATIONS ........................................................................................................................................... 19 CALCIUM CHANNEL BLOCKERS .............................................................................................................................................................. 19 DIGITALIS GLYCOSIDES ............................................................................................................................................................................ 20 DIRECT RENIN INHIBITORS ...................................................................................................................................................................... 20 DIURETICS .................................................................................................................................................................................................. 20 1 NEPRILYSIN INHIBITOR/ANGIOTENSIN II RECEPTOR ANTAGONIST COMBINATIONS ..................................................................... 20 NITRATES .................................................................................................................................................................................................... 20 NITRATE/VASODILATOR COMBINATIONS .............................................................................................................................................. 21 PULMONARY ARTERIAL HYPERTENSION .............................................................................................................................................. 21 MISCELLANEOUS ....................................................................................................................................................................................... 21 CENTRAL NERVOUS SYSTEM ............................................................................................................................................................................ 21 ANTIANXIETY .............................................................................................................................................................................................. 21 ANTICONVULSANTS .................................................................................................................................................................................. 21 ANTIDEMENTIA ........................................................................................................................................................................................... 22 ANTIDEPRESSANTS .................................................................................................................................................................................. 22 ANTIPARKINSONIAN AGENTS .................................................................................................................................................................. 22 ANTIPSYCHOTICS ...................................................................................................................................................................................... 22 ATTENTION DEFICIT HYPERACTIVITY DISORDER ................................................................................................................................ 22 HUNTINGTON'S DISEASE AGENTS .......................................................................................................................................................... 22 HYPNOTICS................................................................................................................................................................................................. 22 MIGRAINE .................................................................................................................................................................................................... 23 MOOD STABILIZERS .................................................................................................................................................................................. 23 MULTIPLE SCLEROSIS AGENTS .............................................................................................................................................................. 23 MUSCULOSKELETAL THERAPY AGENTS ............................................................................................................................................... 23 MYASTHENIA GRAVIS ............................................................................................................................................................................... 23 PSYCHOTHERAPEUTIC-MISCELLANEOUS ............................................................................................................................................. 24 ENDOCRINE AND METABOLIC ........................................................................................................................................................................... 24 ANDROGENS .............................................................................................................................................................................................. 24 ANTIDIABETICS .......................................................................................................................................................................................... 24 CALCIUM RECEPTOR ANTAGONISTS ..................................................................................................................................................... 26 CALCIUM REGULATORS ........................................................................................................................................................................... 26 CONTRACEPTIVES .................................................................................................................................................................................... 26 ENDOMETRIOSIS ....................................................................................................................................................................................... 27 ESTROGENS ............................................................................................................................................................................................... 28 ESTROGEN/PROGESTINS......................................................................................................................................................................... 28 GLUCOCORTICOIDS .................................................................................................................................................................................. 28 GLUCOSE ELEVATING AGENTS ............................................................................................................................................................... 28 HUMAN GROWTH HORMONES................................................................................................................................................................. 28 HYPERPARATHYROID TREATMENT, VITAMIN D ANALOGS ................................................................................................................. 28 PHOSPHATE BINDER AGENTS ................................................................................................................................................................. 28 PROGESTINS .............................................................................................................................................................................................. 29 SELECTIVE ESTROGEN RECEPTOR MODULATORS ............................................................................................................................. 29 THYROID AGENTS ..................................................................................................................................................................................... 29 VASOPRESSINS ......................................................................................................................................................................................... 29 MISCELLANEOUS ....................................................................................................................................................................................... 29 GASTROINTESTINAL ........................................................................................................................................................................................... 29 ANTACIDS ................................................................................................................................................................................................... 29 ANTIDIARRHEALS ...................................................................................................................................................................................... 29 ANTIEMETICS ............................................................................................................................................................................................. 29 ANTISPASMODICS ..................................................................................................................................................................................... 29 CHOLELITHOLYTICS .................................................................................................................................................................................. 30 H2 RECEPTOR ANTAGONISTS .................................................................................................................................................................. 30 INFLAMMATORY BOWEL DISEASE .......................................................................................................................................................... 30 IRRITABLE BOWEL SYNDROME ............................................................................................................................................................... 30 LAXATIVES/STOOL SOFTENERS.............................................................................................................................................................. 30 PANCREATIC ENZYMES ............................................................................................................................................................................ 30 PROSTAGLANDINS .................................................................................................................................................................................... 30 PROTON PUMP INHIBITORS ..................................................................................................................................................................... 30 SALIVA STIMULANTS ................................................................................................................................................................................. 31 STEROIDS, RECTAL ................................................................................................................................................................................... 31 ULCER THERAPY COMBINATIONS .......................................................................................................................................................... 31 MISCELLANEOUS ....................................................................................................................................................................................... 31 GENITOURINARY .................................................................................................................................................................................................. 31 BENIGN PROSTATIC HYPERPLASIA ........................................................................................................................................................ 31 URINARY ANTISPASMODICS .................................................................................................................................................................... 31 VAGINAL ANTI-INFECTIVES ...................................................................................................................................................................... 31 MISCELLANEOUS ....................................................................................................................................................................................... 31 2 HEMATOLOGIC ..................................................................................................................................................................................................... 32 ANTICOAGULANTS .................................................................................................................................................................................... 32 HEMATOPOIETIC GROWTH FACTORS .................................................................................................................................................... 32 IDIOPATHIC THROMBOCYTOPENIC PURPURA AGENTS ...................................................................................................................... 32 IRON CHELATING AGENTS ....................................................................................................................................................................... 32 PLATELET AGGREGATION INHIBITORS .................................................................................................................................................. 32 PLATELET SYNTHESIS INHIBITORS ........................................................................................................................................................ 32 MISCELLANEOUS ....................................................................................................................................................................................... 32 IMMUNOLOGIC AGENTS...................................................................................................................................................................................... 33 ALLERGENIC EXTRACTS .......................................................................................................................................................................... 33 BIOLOGIC DISEASE-MODIFYING AGENTS .............................................................................................................................................. 33 DISEASE-MODIFYING ANTIRHEUMATIC DRUGS (DMARDs) ................................................................................................................. 33 IMMUNOMODULATORS ............................................................................................................................................................................. 33 IMMUNOSUPPRESSANTS ......................................................................................................................................................................... 33 VACCINES ................................................................................................................................................................................................... 33 NUTRITIONAL/SUPPLEMENTS............................................................................................................................................................................ 33 ELECTROLYTES ......................................................................................................................................................................................... 33 VITAMINS AND MINERALS ........................................................................................................................................................................ 34 RESPIRATORY ...................................................................................................................................................................................................... 34 ANAPHYLAXIS TREATMENT AGENTS ..................................................................................................................................................... 34 ANTICHOLINERGICS .................................................................................................................................................................................. 35 ANTICHOLINERGIC/BETA AGONIST COMBINATIONS............................................................................................................................ 35 ANTIHISTAMINES, LOW SEDATING.......................................................................................................................................................... 35 ANTIHISTAMINES, NONSEDATING ........................................................................................................................................................... 35 ANTIHISTAMINES, SEDATING ................................................................................................................................................................... 35 ANTIHISTAMINE/DECONGESTANT COMBINATIONS.............................................................................................................................. 35 ANTITUSSIVES............................................................................................................................................................................................ 35 ANTITUSSIVE COMBINATIONS ................................................................................................................................................................. 35 BETA AGONISTS ........................................................................................................................................................................................ 36 DECONGESTANTS ..................................................................................................................................................................................... 36 EXPECTORANTS ........................................................................................................................................................................................ 36 LEUKOTRIENE RECEPTOR ANTAGONISTS ............................................................................................................................................ 36 MAST CELL STABILIZERS ......................................................................................................................................................................... 36 MEDICAL SUPPLIES ................................................................................................................................................................................... 36 NASAL ANTIHISTAMINES .......................................................................................................................................................................... 36 NASAL STEROIDS ...................................................................................................................................................................................... 36 PULMONARY FIBROSIS AGENTS ............................................................................................................................................................. 36 STEROID/BETA AGONIST COMBINATIONS ............................................................................................................................................. 37 STEROID INHALANTS ................................................................................................................................................................................ 37 XANTHINES ................................................................................................................................................................................................. 37 MISCELLANEOUS ....................................................................................................................................................................................... 37 TOPICAL ................................................................................................................................................................................................................ 37 DERMATOLOGY.......................................................................................................................................................................................... 37 MOUTH/THROAT/DENTAL AGENTS ......................................................................................................................................................... 40 OPHTHALMIC .............................................................................................................................................................................................. 40 OTIC ............................................................................................................................................................................................................. 41 WEBSITES ............................................................................................................................................................................................................. 43 INDEX ..................................................................................................................................................................................................................... 45 3 INTRODUCTION Priority Partners is pleased to provide the 2016 Priority Partners MCO Formulary. The Priority Partners Formulary is a guide for health care providers and plan members. The formulary is updated on a regular basis, including when a new generic or brand-name medication becomes available, and as discontinued drugs are removed from the marketplace. The Priority Partners Formulary is a closed formulary and only those drugs listed in this formulary are covered. The drugs selected for this formulary have been reviewed and approved by the Priority Partners Pharmacy and Therapeutics (P&T) Committee. Formulary drugs are clinically-appropriate and cost-effective for patients who have their drug benefit administered through Priority Partners. There may be occasions when an unlisted drug is desired for medical management of a specific patient. In those instances, the unlisted medication may be requested through the Non-Formulary request process, which is described on page 5 of this document. Please visit our website at www.jhhc.com for additional information regarding the Priority Partners MCO Formulary. PREFACE The Priority Partners MCO Formulary is organized by sections. Each section includes therapeutic groups identified by either a drug class or disease state. Products are listed by generic name. Brand names are included as a reference to assist in product recognition. Unless exceptions are noted, generally all applicable dosage forms and strengths of the drug cited are covered. This formulary covers selected over-the-counter (OTC) products upon prescription. A complete list is included in this formulary. You are encouraged to recommend OTC products when clinically-appropriate. The Priority Partners formulary is now available on line through the Epocrates system. Registration for Epocrates is free and is available at www.epocrates.com. PHARMACY AND THERAPEUTICS (P&T) COMMITTEE The Priority Partners P&T Committee is comprised of faculty physicians from the Johns Hopkins School of Medicine and other Priority Partners practicing physicians from a variety of medical specialties. Additional members of the Committee include Clinical Pharmacists and Allied Health Professionals. The actions of the Priority Partners P&T Committee are communicated in the Across the Board Newsletter, which is distributed via mail to Priority Partners network physicians. PRODUCT SELECTION CRITERIA The Priority Partners P&T Committee considers all new-to-market drugs for inclusion to the formulary. The evaluation includes a literature review and expert external opinion may also be sought. Formal reviews are prepared that typically address the following information: • • • • • • • • • Safety Efficacy Comparison studies Approved indications Adverse effects Contraindications/Warnings/Precautions Pharmacokinetics Patient administration/compliance considerations Medical outcome and pharmacoeconomic studies When a new drug is considered for formulary inclusion, it will be reviewed relative to similar drugs currently on formulary. In addition, entire therapeutic classes are periodically reviewed in an effort to continually provide the most clinically useful and cost-effective agents. All the information in the Priority Partners MCO Formulary is provided as a reference for drug therapy selection. Specific drug selection for an individual patient rests solely with the prescriber. 4 GENERIC SUBSTITUTION Generic substitution is a pharmacy action whereby a generic version is dispensed rather than the prescribed brand-name product. Products designated in the formulary drug list by boldface type have generic availability. 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. The U.S. Food and Drug Administration's (FDA) generic drug review and approval process assures the following requirements have been met: 1. 2. The generic drug must contain the same active ingredient(s), be the same strength and the same dosage form as the brand-name product. The FDA has given the generic an "A" rating compared to the branded product indicating bioequivalence, and has determined the generic is therapeutically equivalent to the reference brand. The ratings of generic drugs are available by referring to the FDA reference, Approved Drug Products with Therapeutic Equivalence Evaluations (Orange Book). When the above two criteria are met, a generic can be substituted with the full expectation that the substituted product will produce the same clinical effect and safety profile as the prescribed product. Drug products that have a narrow therapeutic index (NTI) can also be guided by these principles. It is not necessary for the health care provider to approach any one therapeutic class of drug products (e.g., NTI drugs) differently from any other class, when there has been a determination of therapeutic equivalence by the FDA for the drug products under consideration. Also, additional clinical tests or examinations by the physician are not needed when a therapeutically equivalent generic drug product is substituted for the brandname product. It is recommended that generic substitution not be exercised by the pharmacist with multisource products that appear in the Orange Book and carry a "B" rating, indicating that these products cannot be considered therapeutically equivalent to other products in the group. Also, state laws or regulations may dictate the ability to practice generic substitution for selected products or categories of drugs. It is also recommended that generic substitution not be undertaken for any unrated multisource products that might be considered narrow therapeutic index, or maintenance drugs where it is known that unrated products from different labelers are not bioequivalent. DRUG EFFICACY STUDY IMPLEMENTATION (DESI) DRUGS Drugs first marketed between 1938 and 1962 were approved as safe but required no showing of effectiveness for FDA approval. Beginning in 1962, all new drugs were required to be both safe and effective before they could be marketed. This legislation also applied retroactively to all drugs approved as safe from 1938-1962. The DESI program was established to review the effectiveness of these pre-1962 drugs, and a determination of fully effective was made for most of these products and they remain in the marketplace. A few DESI products remain classified as less than fully effective while awaiting final administrative disposition. Also, classified as DESI are many products listed as identical, similar, or related to actual DESI products. Some plans will not pay for DESI less-than-effective drug products. NON-FORMULARY EXCEPTION REQUESTS A medical exception must be requested for drug products not listed in the Priority Partners MCO Formulary. To request a Non-Formulary Exception Request form, call 1-800-654-9728, or download a copy from the Priority Partners website at www.jhhc.com. Fax the completed form to the Priority Partners Pharmacy Department at 1-410-424-4607. 5 MANAGED DRUG LIMITATIONS (MDL) Certain prescription medications have specific dispensing limitations for quantity and maximum dose. These dispensing limitations are based on generally accepted guidelines, drug label information approved by the Food and Drug Administration (FDA), current medical literature and input from a committee of physicians and pharmacists. The Priority Partners Pharmacy and Therapeutics Committee may place a limit on the quantity of drug a plan participant may receive based upon cost and/or clinical reasons. The list of medications subject to quantity limits may change. The most up-to-date listing of quantity limits is available on the website www.jhhc.com. Amerge (naratriptan) Aranesp (darbepoetin alfa) Atrovent (ipratropium) nasal spray 0.03% Atrovent (ipratropium) nasal spray 0.06% Celebrex (celecoxib) Combivent Respimat (ipratropium/albuterol) Depo-Provera (medroxyprogesterone acetate 150 mg/mL) Diflucan (fluconazole) 150 mg Dolophine (methadone) 5 mg Dolophine (methadone) 10 mg Duragesic (fentanyl transdermal) Elidel (pimecrolimus) Epipen, Epipen Jr. (epinephrine pen) Epogen (epoetin alfa) Fioricet (butalbital/acetaminophen/caffeine) caps, tabs Flovent Diskus (fluticasone) Flovent HFA (fluticasone) Freestyle or Precision XTRA diabetic test strips (birth through age 17) Freestyle or Precision XTRA diabetic test strips (age 18 and above) Granix (tbo-filgrastim) Humalog Humulin Imitrex (sumatriptan) tabs Imitrex (sumatriptan) spray Imitrex (sumatriptan) injections Kytril (granisetron) 1 mg Kytril (granisetron) 1 mg/5 mL suspension Lantus Leukine (sargramostim) Levonorgestrel 0.75 mg Lovenox (enoxaparin) all strengths Lysteda (tranexamic acid) Maxalt (rizatriptan) tabs Metrogel (metronidazole) 1% gel Mobic (meloxicam) 7.5 mg/5 mL suspension Mobic (meloxicam) tabs MS Contin (morphine ext-rel) Neulasta (pegfilgrastim) Neupogen (filgrastim) Nexium 24HR (esomeprazole magnesium delayed-rel) Next Choice One Dose (levonorgestrel) 1.5 mg Novolin Novolog Omeprazole delayed-rel caps, tabs (OTC) Oxycodone immediate-release 15 mg, 20 mg, 30 mg tabs Oxymorphone ext-rel Pantoprazole delayed-rel tabs Plan B One-Step (levonorgestrel) 1.5 mg (OTC only) Prevacid (lansoprazole delayed-rel) caps (Rx) 8 tabs/month 4 vials or syringes/month 30 mL/month 15 mL/month 60 caps/month 2 containers/month 1 mL injection/90 days 2 tabs/month 540 tabs/month 270 tabs/month 10 patches/month 100 gm/month 2 syringes/month 4 vials or syringes/month 8 caps or tabs/day 1 container (60 caps)/month 1 container/month 300 strips/month 150 strips/month 12 syringes/month 4 vials combined/month 4 vials combined/month 16 tabs/month 12 nasal sprays/month 8 injections/month 6 tabs/month 30 mL/month 4 vials/month 4 vials or syringes/month 4 tabs/year greater than 30 days of therapy requires Prior Authorization 30 tabs/month 12 tabs/month 60 gm/month 600 mL/month 60 tabs/month 90 tabs/month 4 vials or syringes/month 12 vials or syringes/month 2 caps or tabs/day 2 tabs/year 4 vials combined/month 4 vials combined/month 68 caps or tabs/month 180 tabs combined/month 60 tabs/month 30 tabs/month 1 tab/month 30 caps/month 6 Prevacid 24HR (lansoprazole delayed-rel) (OTC) Prevpac (lansoprazole 30 mg + amoxicillin 500 mg + clarithromycin 500 mg) Prilosec (omeprazole delayed-rel) 20 mg, 40 mg caps (Rx) Proair HFA (albuterol sulfate, CFC-free aerosol) Procrit (epoetin alfa) Protopic (tacrolimus) Relenza (zanamivir) 5 mg Spiriva Handihaler (tiotropium) Spiriva Respimat (tiotropium, CFC-free aerosol) Tamiflu (oseltamivir) caps Tamiflu (oseltamivir) oral suspension Valcyte (valganciclovir) 450 mg Ventolin HFA (albuterol sulfate, CFC-free aerosol) Zithromax (azithromycin) 250 mg Zithromax (azithromycin) 500 mg Zofran/Zofran ODT (ondansetron) 4 mg, 8 mg Zofran (ondansetron) 4 mg/5 mL solution Zomig/Zomig ZMT (zolmitriptan) 2.5 mg Zomig/Zomig ZMT (zolmitriptan) 5 mg Zyvox (linezolid) 600 mg 60 caps/month 1 pack/14 days 30 caps/month 2 containers/month 4 vials or syringes/month 100 gm/month 5 days therapy maximum/month 1 container/month 1 container/month 10 caps/180 days 180 mL/90 days 98 tabs/month 2 containers/month 6 tabs/month 3 tabs/month 12 tabs/month 60 mL/month 18 tabs/month 15 tabs/month 28 tabs/month MARYLAND PREFERRED DRUG LIST Maryland Department of Health and Mental Hygiene is responsible for formulary management of most drugs used for behavioral health purposes. Please refer to the Maryland Preferred Drug List for a complete listing of covered drugs at https://mmcp.dhmh.maryland.gov/pap/Pages/Preferred-Drug-List.aspx OVER-THE-COUNTER DRUG COVERAGE In addition to prescription benefits, all over-the-counter (OTC) medications on this list, up to a maximum 30-day supply, are covered by Priority Partners with a written or verbal prescription from a network provider. OTC products covered are restricted to generics when available. Brand names are provided as reference only. If both prescription and OTC products are available, you are encouraged to prescribe OTC products when clinically appropriate. Product Name Acetaminophen tabs, caps, chew tabs, susp, elixir, drops Acetic acid/Aluminum acetate otic solution Alumina/Magnesia Alumina/Magnesia/Simethicone Ammonium Lactate 12% crm, lotion Artificial tears oint, soln Aspirin tabs, chew tabs, buffered tabs, delayed-rel tabs Bacitracin topical oint Blood glucose monitoring kits, test strips MDL Blood ketone monitoring test strips Brompheniramine/Phenylephrine elixir 1 mg/2.5 mg/5 mL Budesonide spray - Rhinocort Allergy Butenafine crm Calcium Acetate/Aluminum Sulfate powder packet Cetirizine Cetirizine/Pseudoephedrine ext-rel Chlorpheniramine 4 mg tabs, syrup Cholecalciferol (D3) drops Cimetidine Clotrimazole crm Clotrimazole vaginal crm Condoms Dextromethorphan/Guaifenesin ext-rel Dextromethorphan/Guaifenesin liquid, solution, syrup Diabetic supplies: alcohol swabs, lancets, sharps container Brand Name Examples Tylenol Maalox Maalox, Mylanta Amlactin Artificial Tears Freestyle, Precision XTRA Precision XTRA Dimetapp Lotrimin Ultra Domeboro Zyrtec Zyrtec-D Chlor-Trimeton Vitamin D3 Tagamet HB 200 Lotrimin AF Gyne-Lotrimin 3-day, Gyne-Lotrimin 7-day Mucinex DM 7 Product Name Diphenhydramine 25 mg caps, elixir, tabs Docusate Sodium 100 mg caps, 150 mg/15 mL liquid Doxylamine 25 mg Electrolyte rehydrating solution, oral Ergocalciferol (D2) drops Esomeprazole magnesium delayed-rel MDL Ferrous Gluconate tabs Ferrous Sulfate drops, elixir, tabs Fexofenadine Fexofenadine/Pseudoephedrine ext-rel Fluticasone spray - Flonase Allergy Relief Guaifenesin ext-rel Guaifenesin liquid, syrup Hydrocortisone crm, gel, lotion, oint, solution 1% Hydrocortisone oint 0.5% Hydrocortisone/Aloe Vera crm 0.5%, 1% Ibuprofen 200 mg tabs, 100 mg/5 mL susp Insulin human MDL Insulin isophane human MDL Insulin isophane human 70%/regular 30% MDL Insulin syringes and needles Ketotifen ophthalmic solution Lansoprazole delayed-rel MDL Levonorgestrel 1.5 mg (Prescription not required regardless of member's age.) MDL Loperamide tabs, liquid Loratadine liquid, orally disintegrating tabs, tabs Loratadine/Pseudoephedrine ext-rel Meclizine Miconazole crm, powder, spray Miconazole vaginal crm, suppository Multivitamins Multivitamins drops Multivitamins/Iron Multivitamins/Iron drops Multivitamins/Minerals Neomycin/Bacitracin/Polymyxin B Niacin tabs Omeprazole delayed-rel MDL Permethrin 1% (60 mL) Polyethylene Glycol 3350 powder Polysaccharide Iron Complex (renal patients only) Pseudoephedrine tabs, ext-rel tabs, 30 mg/5 mL syrup Pyrantel Pyridoxine 25 mg Ranitidine Salicylic Acid pad 2% Salicylic Acid/Urea oint 5-10% Spacer (respiratory) Triamcinolone acetonide spray Urea crm 10% Urea crm 20% Urea lotion 10% Vitamin E drops, caps Brand Name Examples Benadryl Colace Unisom Pedialyte Drisdol Nexium 24HR Fergon Feosol Allegra Allegra-D Mucinex Diabetic Tussin Cortizone-10 Advil Humulin R, Novolin R Humulin N, Novolin N Humulin 70/30, Novolin 70/30 Zaditor Prevacid 24HR Plan B One-Step Imodium A-D Claritin Claritin-D Micatin Monistat 3, Monistat 7 Poly-Vi-Sol Geritol Poly-Vi-Sol/Iron Centrum Silver Neosporin Prilosec OTC NIX Creme Rinse Miralax Nu-Iron 150 Sudafed Pin-X Vitamin B6 Zantac 75, Zantac 150 Kerasal Aerochamber Nasacort Allergy 24HR Atrac-tain Carmol 20 Carmol 10 8 PRIOR AUTHORIZATION Certain medications require prior authorization (PA) before coverage is approved, to assure medical necessity, clinical appropriateness and/or cost effectiveness. Coverage of these drugs is subject to specific criteria approved by the Priority Partners P&T Committee. Established criteria are based upon medical literature, physician expert opinion, and FDA-approved labeling information. To request a Non-Formulary Exception Request form, call 1-800-654-9728, or download a copy from the Priority Partners website at www.jhhc.com. Fax the completed form to the Priority Partners Pharmacy Department at 1-410-424-4607. The following drugs and generic versions, if available, require prior authorization. This list is subject to change. Adcirca Alecensa Amitiza Ampyra Androderm Androgel Avonex Betaseron Bosulif Celebrex Cimzia Claravis Copaxone Copegus Cosentyx Delatestryl Depo-Testosterone Differin Dificid Eligard Eliquis Enbrel Exjade Farydak Flolan Forteo Harvoni Humira Ibrance Imbruvica Intron A Jadenu Jakafi Lenvima Letairis Lovenox (for greater than 30 days of therapy) Lupron Lynparza Mekinist Ninlaro Norditropin Noxafil Ofev Oralair Oxandrin Pegasys Promacta Rebetol Rebif Remodulin Revatio Revlimid Santyl Sensipar Sovaldi Tagrisso Tafinlar Tecfidera Testim Tikosyn Tracleer Tykerb Tyvaso Xarelto Xeljanz Xeljanz XR Xenazine Zolinza Zydelig 9 STEP THERAPY For some plan members who receive the pharmacy benefit, certain covered medications are required to satisfy specific step therapy criteria. Step therapy criteria simply means that for certain drug products, members must first have tried one or more prerequisite medications to treat their condition before other medications are covered through their benefit. The following drugs and generic versions, if available, require step therapy. This list is subject to change and may not be all-inclusive. Advair Diskus Advair HFA Afinitor Anoro Ellipta Elidel Exforge Exforge HCT FirstLansoprazole Jardiance Kombiglyze XR levalbuterol nebulization solution Lialda Onglyza Ovide Protopic Serevent Diskus Sprycel Symbicort Synjardy Tanzeum Tasigna Tekturna Ulesfia Uloric Victoza Xopenex HFA Zetia Inhaled corticosteroid required before Advair or Symbicort Inhaled corticosteroid required before Advair or Symbicort Nexavar or Sutent required before Afinitor Spiriva required before Anoro Ellipta Topical steroid required before Elidel and tacrolimus (Protopic) amlodipine/benazepril or amlodipine with an ARB required before valsartan/amlodipine (Exforge) amlodipine/benazepril or amlodipine with an ARB required before valsartan/amlodipine/hydrochlorothiazide (Exforge HCT) ranitidine syrup required before First-Lansoprazole metformin or metformin combinations required before Jardiance metformin or metformin combinations required before Kombiglyze XR albuterol nebulization solution required before levalbuterol nebulization solution or Xopenex HFA Other Colitis drug required before Lialda metformin or metformin combinations required before Onglyza permethrin required before malathion (Ovide) for age > 6 Topical steroid required before Elidel and tacrolimus (Protopic) Inhaled corticosteroid required before Serevent Diskus imatinib (Gleevec) required before Sprycel or Tasigna Inhaled corticosteroid required before Advair or Symbicort metformin or metformin combinations required before Synjardy metformin or metformin combinations required before Tanzeum imatinib (Gleevec) required before Sprycel or Tasigna Two antihypertensives required before Tekturna permethrin required before Ulesfia for 6 years of age or younger allopurinol required before Uloric metformin or metformin combinations required before Victoza albuterol nebulization solution required before levalbuterol nebulization solution or Xopenex HFA Statin (HMG-CoA) required before Zetia SPECIALTY PHARMACY Most of the injectable products listed in this formulary for Priority Partners plan participants are available through CVS Specialty™. Prior Authorization is required for most injectables and may be requested by calling Priority Partners at 1-800-654-9728. In addition, CVS Specialty includes delivery services to the location of the plan participant's or the physician's choice. Other services include electronic claims processing and claims assistance designed to alleviate the administrative duties of physicians' offices. 10 EDITOR Your comments and suggestions regarding the Priority Partners Formulary are encouraged. Your input is vital to this formulary's continued success. Network providers may request Formulary changes by completing a Formulary Change Request Form. All responses will be reviewed and considered. Please send your comments or completed form to: Chairperson Pharmacy and Therapeutics Committee Priority Partners MCO 6704 Curtis Court Glen Burnie, MD 21060 Phone: 1-800-654-9728 Fax: 1-410-424-4607 LEGEND d DESI drug MDL Managed Drug Limitation OTC Over the counter PA Prior Authorization SP Specialty ST Step Therapy boldface Indicates generic availability 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 Priority Partners Formulary and its appendices is provided by Priority Partners solely for the convenience of medical providers. Priority Partners does not warrant or assure accuracy of such information, nor is it intended to be comprehensive in nature. The Priority Partners Formulary 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. Priority Partners assumes 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. 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. The information contained in this document is proprietary. The information may not be copied in whole or in part without the written permission of Priority Partners MCO. ©2016. All rights reserved. This document contains references to brand-name prescription drugs that are trademarks or registered trademarks of pharmaceutical manufacturers not affiliated with Priority Partners. Priority Partners does not operate the websites/organizations listed here, nor is it responsible for the availability or reliability of the websites' content. These listings do not imply or constitute an endorsement, sponsorship or recommendation by Priority Partners. 11 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 NSAIDs OTC MDL acetaminophen TYLENOL ibuprofen diclofenac sodium delayed-rel etodolac ibuprofen meloxicam nabumetone naproxen naproxen sodium oxaprozin sulindac ADVIL COX-2 INHIBITORS MDL, PA celecoxib GOUT ST allopurinol colchicine febuxostat probenecid MOBIC NAPROSYN ANAPROX DAYPRO CELEBREX ZYLOPRIM COLCRYS ULORIC ST = allopurinol required before Uloric 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 MDL MDL MDL MDL butalbital/acetaminophen/caffeine/codeine butalbital/aspirin/caffeine/codeine codeine sulfate codeine/acetaminophen fentanyl transdermal hydrocodone/acetaminophen 5/300 mg, 7.5/300 mg, 10/300 mg hydrocodone/acetaminophen 5/325 mg, 7.5/325 mg, 10/325 mg hydrocodone/acetaminophen solution 7.5/325 mg/15 mL hydromorphone methadone morphine ext-rel morphine immediate-release morphine supp oxycodone concentrate 20 mg/mL oxycodone immediate-release 5 mg, 10 mg oxycodone immediate-release 15 mg, 20 mg, 30 mg oxycodone oral solution 5 mg/5 mL FIORICET w/CODEINE FIORINAL w/CODEINE TYLENOL w/CODEINE DURAGESIC DILAUDID DOLOPHINE MS CONTIN 12 MDL oxycodone/acetaminophen oxycodone/aspirin oxymorphone ext-rel tramadol immediate-release tramadol/acetaminophen NON-OPIOID ANALGESICS MDL butalbital/acetaminophen/caffeine butalbital/aspirin/caffeine PERCOCET PERCODAN ULTRAM ULTRACET FIORICET FIORINAL ANTI-INFECTIVES 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 Sexually Transmitted Diseases: CDC Sexually Transmitted Diseases Guidelines are available at: http://www.cdc.gov/std/treatment/default.htm 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/ Practice guidelines and statements developed and endorsed by the Infectious Diseases Society of America are available at: http://www.idsociety.org ANTIBACTERIALS Aminoglycosides neomycin sulfate tabs Cephalosporins First Generation cephalexin Second Generation cefaclor cefprozil cefuroxime axetil Third Generation KEFLEX CEFTIN cefdinir Erythromycins/Macrolides MDL azithromycin clarithromycin ZITHROMAX BIAXIN 13 PA erythromycin base erythromycin delayed-rel erythromycin delayed-rel - Ery-tab erythromycin ethylsuccinate erythromycin stearate fidaxomicin Fluoroquinolones ciprofloxacin ciprofloxacin ext-rel levofloxacin moxifloxacin ofloxacin Penicillins Sulfonamides Tetracyclines * amoxicillin amoxicillin/clavulanate amoxicillin/clavulanate ext-rel ampicillin dicloxacillin penicillin VK E.E.S. DIFICID CIPRO LEVAQUIN AVELOX AUGMENTIN sulfadiazine sulfamethoxazole/trimethoprim DS doxycycline hyclate caps doxycycline hyclate tabs 20 mg, 100 mg doxycycline monohydrate caps 100 mg doxycycline monohydrate susp doxycycline monohydrate tabs minocycline caps tetracycline VIBRAMYCIN MONODOX VIBRAMYCIN ADOXA MINOCIN * doxycycline hyclate delayed-rel tabs 75 mg, 100 mg, 150 mg are not covered ANTIFUNGALS MDL PA clotrimazole troches fluconazole griseofulvin microsize susp, tabs griseofulvin ultramicrosize itraconazole caps itraconazole solution ketoconazole tabs nystatin posaconazole terbinafine tabs ANTIMALARIALS atovaquone atovaquone/proguanil chloroquine mefloquine primaquine pyrimethamine DIFLUCAN GRIS-PEG SPORANOX SPORANOX NOXAFIL LAMISIL MEPRON MALARONE ARALEN DARAPRIM 14 ANTIRETROVIRAL AGENTS These agents are carved-out from the MCO and are covered by Maryland Medicaid Fee-For-Service (FFS). ANTITUBERCULAR AGENTS ethambutol isoniazid pyrazinamide rifampin ANTIVIRALS Cytomegalovirus Agents foscarnet valganciclovir oral solution MDL valganciclovir tabs Hepatitis Agents Hepatitis B Hepatitis C PA, SP PA, SP PA, SP PA, SP Herpes Agents Influenza Agents MDL MDL, * MYAMBUTOL RIFADIN VALCYTE VALCYTE adefovir dipivoxil entecavir lamivudine HEPSERA BARACLUDE EPIVIR-HBV ledipasvir/sofosbuvir ribavirin caps ribavirin tabs sofosbuvir HARVONI REBETOL COPEGUS SOVALDI acyclovir caps, susp, tabs valacyclovir ZOVIRAX VALTREX amantadine caps, syrup oseltamivir zanamivir TAMIFLU RELENZA * Covered for individuals 7 years of age or older MISCELLANEOUS OTC pyrantel albendazole clindamycin dapsone tabs linezolid susp MDL linezolid tabs metronidazole 250 mg, 375 mg, 500 mg nitrofurantoin ext-rel nitrofurantoin macrocrystals paromomycin pentamidine aerosol rifabutin tinidazole trimethoprim tabs vancomycin PIN-X ALBENZA CLEOCIN ZYVOX ZYVOX FLAGYL MACROBID MACRODANTIN NEBUPENT MYCOBUTIN TINDAMAX VANCOCIN 15 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 lomustine melphalan SP temozolomide ANTIMETABOLITES SP capecitabine mercaptopurine thioguanine HORMONAL ANTINEOPLASTIC AGENTS Antiandrogens bicalutamide flutamide Antiestrogens tamoxifen toremifene HEXALEN MYLERAN LEUKERAN GLEOSTINE ALKERAN TEMODAR XELODA TABLOID CASODEX FARESTON Aromatase Inhibitors anastrozole exemestane letrozole ARIMIDEX AROMASIN FEMARA Luteinizing Hormone-releasing Hormone (LHRH) Agonists PA, SP leuprolide acetate PA, SP leuprolide acetate ELIGARD Progestins megestrol acetate MEGACE IMMUNOMODULATORS PA, SP lenalidomide REVLIMID KINASE INHIBITORS PA, SP alectinib PA, SP bosutinib PA, SP dabrafenib SP, ST dasatinib SP, ST everolimus PA, SP ibrutinib PA, SP idelalisib SP imatinib mesylate PA, SP lapatinib PA, SP lenvatinib SP, ST nilotinib PA, SP osimertinib PA, SP palbociclib PA, SP ruxolitinib ALECENSA BOSULIF TAFINLAR SPRYCEL AFINITOR IMBRUVICA ZYDELIG GLEEVEC TYKERB LENVIMA TASIGNA TAGRISSO IBRANCE JAKAFI 16 PA, SP PA, SP PA, SP sorafenib sunitinib trametinib NEXAVAR SUTENT MEKINIST ST = imatinib (Gleevec) required before Sprycel or Tasigna; Nexavar or Sutent required before Afinitor MISCELLANEOUS SP bexarotene caps doxorubicin liposomal etoposide hydroxyurea PA, SP ixazomib mitotane PA, SP olaparib PA, SP panobinostat procarbazine tretinoin caps PA, SP vorinostat TARGRETIN caps DOXIL HYDREA NINLARO LYSODREN LYNPARZA FARYDAK MATULANE ZOLINZA 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 benazepril captopril enalapril fosinopril lisinopril moexipril quinapril ramipril trandolapril ACE INHIBITOR/CALCIUM CHANNEL BLOCKER COMBINATIONS amlodipine/benazepril trandolapril/verapamil ext-rel ACE INHIBITOR/DIURETIC COMBINATIONS captopril/hydrochlorothiazide enalapril/hydrochlorothiazide fosinopril/hydrochlorothiazide lisinopril/hydrochlorothiazide moexipril/hydrochlorothiazide quinapril/hydrochlorothiazide LOTENSIN VASOTEC ZESTRIL ACCUPRIL ALTACE MAVIK LOTREL TARKA VASERETIC ZESTORETIC ACCURETIC 17 ADRENOLYTICS, CENTRAL clonidine clonidine transdermal guanfacine CATAPRES CATAPRES-TTS TENEX 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 prazosin terazosin CARDURA MINIPRESS ANGIOTENSIN II RECEPTOR ANTAGONISTS (ARBs)/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/hydrochlorothiazide valsartan valsartan/hydrochlorothiazide ATACAND ATACAND HCT AVAPRO AVALIDE COZAAR HYZAAR MICARDIS HCT DIOVAN DIOVAN HCT ANGIOTENSIN II RECEPTOR ANTAGONIST (ARB)/CALCIUM CHANNEL BLOCKER COMBINATIONS telmisartan/amlodipine TWYNSTA ST valsartan/amlodipine EXFORGE ST = amlodipine/benazepril or amlodipine with an ARB required before valsartan/amlodipine (Exforge) ANGIOTENSIN II RECEPTOR ANTAGONIST (ARB)/CALCIUM CHANNEL BLOCKER/DIURETIC COMBINATIONS ST valsartan/amlodipine/hydrochlorothiazide EXFORGE HCT ST = amlodipine/benazepril or amlodipine with an ARB required before valsartan/amlodipine/hydrochlorothiazide (Exforge HCT) ANTIARRHYTHMICS Guidelines for the use of antiarrhythmics and cardiac glycosides in various patient populations are available at: http://www.acc.org PA, SP amiodarone disopyramide disopyramide ext-rel 100 mg dofetilide dronedarone flecainide propafenone CORDARONE NORPACE NORPACE CR TIKOSYN MULTAQ RYTHMOL 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 Antilipemic Combinations ezetimibe/simvastatin VYTORIN 18 Bile Acid Resins cholestyramine can colestipol Cholesterol Absorption Inhibitors ST ezetimibe QUESTRAN/QUESTRAN LIGHT COLESTID ZETIA ST = Statin (HMG-CoA) required before Zetia Fibrates fenofibrate fenofibrate, micronized fenofibric acid tabs gemfibrozil HMG-CoA Reductase Inhibitors atorvastatin lovastatin pravastatin simvastatin Niacins OTC niacin niacin ext-rel Omega-3 Fatty Acids omega-3 acid ethyl esters FIBRICOR LOPID LIPITOR MEVACOR PRAVACHOL ZOCOR NIASPAN LOVAZA 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 carvedilol labetalol metoprolol succinate ext-rel metoprolol tartrate nadolol pindolol propranolol propranolol ext-rel sotalol TENORMIN COREG TRANDATE TOPROL-XL LOPRESSOR CORGARD INDERAL LA BETAPACE, BETAPACE AF 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 TENORETIC ZIAC LOPRESSOR HCT NORVASC 19 nifedipine ext-rel nisoldipine ext-rel ADALAT CC SULAR Nondihydropyridines diltiazem ext-rel diltiazem ext-rel verapamil ext-rel verapamil ext-rel CARDIZEM CD TIAZAC CALAN SR VERELAN DIGITALIS GLYCOSIDES digoxin LANOXIN DIRECT RENIN INHIBITORS ST aliskiren TEKTURNA ST = Two antihypertensives required before Tekturna DIURETICS Carbonic Anhydrase Inhibitors acetazolamide acetazolamide ext-rel methazolamide Loop Diuretics bumetanide furosemide torsemide Potassium-sparing Diuretics amiloride spironolactone triamterene Thiazides and Thiazide-like Diuretics chlorothiazide susp chlorthalidone hydrochlorothiazide indapamide metolazone Diuretic Combinations amiloride/hydrochlorothiazide spironolactone/hydrochlorothiazide triamterene/hydrochlorothiazide 37.5/25 triamterene/hydrochlorothiazide 37.5/25 triamterene/hydrochlorothiazide 75/50 DIAMOX SEQUELS LASIX DEMADEX ALDACTONE DYRENIUM DIURIL ALDACTAZIDE DYAZIDE MAXZIDE-25 MAXZIDE NEPRILYSIN INHIBITOR/ANGIOTENSIN II RECEPTOR ANTAGONIST COMBINATIONS sacubitril/valsartan ENTRESTO NITRATES Oral isosorbide dinitrate ext-rel tabs isosorbide dinitrate oral isosorbide mononitrate isosorbide mononitrate ext-rel ISORDIL 20 Sublingual/Translingual isosorbide dinitrate sublingual nitroglycerin lingual spray nitroglycerin sublingual Transdermal nitroglycerin oint nitroglycerin transdermal NITROLINGUAL NITROSTAT NITRO-BID NITRO-DUR NITRATE/VASODILATOR COMBINATIONS isosorbide dinitrate/hydralazine BIDIL PULMONARY ARTERIAL HYPERTENSION Endothelin Receptor Antagonists PA, SP ambrisentan PA, SP bosentan LETAIRIS TRACLEER Phosphodiesterase Inhibitors PA, SP sildenafil PA, SP tadalafil REVATIO ADCIRCA Prostaglandin Vasodilators PA, SP epoprostenol sodium PA, SP treprostinil PA, SP treprostinil FLOLAN REMODULIN TYVASO MISCELLANEOUS hydralazine ivabradine methyldopa midodrine minoxidil reserpine CORLANOR CENTRAL NERVOUS SYSTEM Practice guidelines for psychiatric disorders are available at: http://www.psych.org ANTIANXIETY Refer to State D.H.M.H. Preferred Drug List for a complete listing at: https://mmcp.dhmh.maryland.gov/pap/docs/MMPP_MHF.pdf ANTICONVULSANTS Practice guidelines for the treatment of epilepsy are available at: http://www.aan.com Refer to State D.H.M.H. Preferred Drug List for a complete listing at: https://mmcp.dhmh.maryland.gov/pap/docs/MMPP_MHF.pdf ethosuximide phenobarbital phenytoin phenytoin sodium extended primidone ZARONTIN DILANTIN INFATABS DILANTIN MYSOLINE 21 ANTIDEMENTIA Practice guidelines for the management of dementia are available at: http://www.aan.com donepezil galantamine memantine rivastigmine ARICEPT RAZADYNE 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 Refer to State D.H.M.H. Preferred Drug List for a complete listing at: https://mmcp.dhmh.maryland.gov/pap/docs/MMPP_MHF.pdf ANTIPARKINSONIAN AGENTS Practice guidelines for the diagnosis and treatment of Parkinson's disease are available at: http://www.aan.com amantadine caps, syrup bromocriptine carbidopa/levodopa carbidopa/levodopa ext-rel carbidopa/levodopa/entacapone entacapone pramipexole ropinirole selegiline caps PARLODEL SINEMET SINEMET CR STALEVO COMTAN MIRAPEX REQUIP ANTIPSYCHOTICS Refer to State D.H.M.H. Preferred Drug List for a complete listing at: https://mmcp.dhmh.maryland.gov/pap/docs/MMPP_MHF.pdf 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 Intuniv and Kapvay: For recipients 6-17 years of age, Intuniv and Kapvay (and their generics) are part of the mental health formulary and billed fee-for-service. For individuals not in this age range, you may submit a non-formulary request form to Priority Partners. Refer to State D.H.M.H. Preferred Drug List for a complete listing at: https://mmcp.dhmh.maryland.gov/pap/docs/MMPP_MHF.pdf 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 in adults are available at: http://www.aasmnet.org Refer to State D.H.M.H. Preferred Drug List for a complete listing at: https://mmcp.dhmh.maryland.gov/pap/docs/MMPP_MHF.pdf 22 Nonbenzodiazepines OTC doxylamine 25 mg UNISOM MIGRAINE Guidelines for prevention and management of migraine headaches are available at: http://www.aan.com Ergotamine Derivatives ergotamine/caffeine CAFERGOT Selective Serotonin Agonists MDL naratriptan MDL rizatriptan MDL sumatriptan MDL sumatriptan inj MDL sumatriptan nasal spray MDL zolmitriptan MDL zolmitriptan orally disintegrating tabs AMERGE MAXALT IMITREX IMITREX IMITREX ZOMIG ZOMIG Miscellaneous d acetaminophen/dichloralphenazone/isometheptene MIDRIN MOOD STABILIZERS Refer to State D.H.M.H. Preferred Drug List for a complete listing at: https://mmcp.dhmh.maryland.gov/pap/docs/MMPP_MHF.pdf MULTIPLE SCLEROSIS AGENTS Practice guidelines for multiple sclerosis are available at: http://www.aan.com PA, SP PA, SP PA, SP PA, SP PA, SP PA, SP PA, SP PA, SP dalfampridine ext-rel dimethyl fumarate delayed-rel glatiramer 20 mg glatiramer 40 mg interferon beta-1a interferon beta-1a interferon beta-1b peginterferon beta-1a AMPYRA TECFIDERA COPAXONE COPAXONE AVONEX REBIF BETASERON PLEGRIDY MUSCULOSKELETAL THERAPY AGENTS baclofen carisoprodol cyclobenzaprine 5 mg, 10 mg dantrolene methocarbamol tizanidine tabs DANTRIUM ROBAXIN ZANAFLEX MYASTHENIA GRAVIS pyridostigmine pyridostigmine ext-rel MESTINON MESTINON TIMESPAN 23 PSYCHOTHERAPEUTIC-MISCELLANEOUS Alcohol Deterrents Opioid Antagonists Partial Opioid Agonists Partial Opioid Agonist/Opioid Antagonist Combinations These agents are carved-out from the MCO and are covered by Maryland Medicaid Fee-For-Service (FFS). A list of Substance Use Disorder medications can be found at: https://mmcp.dhmh.maryland.gov/pap/docs/Substance%20Use%20Disorder%20%20Medication%20Clinical%20Criteria %20Final%20.pdf Pseudobulbar Affect 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 These agents are carved-out from the MCO and are covered by Maryland Medicaid Fee-For-Service (FFS). A list of Substance Use Disorder medications can be found at: https://mmcp.dhmh.maryland.gov/pap/docs/Substance%20Use%20Disorder%20%20Medication%20Clinical%20Criteria %20Final%20.pdf ENDOCRINE AND METABOLIC ANDROGENS Clinical practice guidelines for the treatment of hypogonadism are available at: http://www.aace.com/publications/guidelines PA PA PA PA PA PA PA oxandrolone testosterone cypionate testosterone enanthate testosterone gel testosterone gel 25 mg/2.5 g testosterone gel, except 25 mg/2.5 g testosterone transdermal OXANDRIN DEPO-TESTOSTERONE DELATESTRYL TESTIM ANDROGEL ANDROGEL ANDRODERM ANTIDIABETICS Guidelines of treatment and management of diabetes are available at: http://professional.diabetes.org Alpha-glucosidase Inhibitors acarbose Biguanides metformin metformin ext-rel 500 mg PRECOSE GLUCOPHAGE GLUCOPHAGE XR Biguanide/Sulfonylurea Combinations glipizide/metformin glyburide/metformin METAGLIP GLUCOVANCE Dipeptidyl Peptidase-4 (DPP-4) Inhibitors ST saxagliptin ONGLYZA ST = metformin or metformin combinations required before Onglyza 24 Dipeptidyl Peptidase-4 (DPP-4) Inhibitor/Biguanide Combinations ST saxagliptin/metformin ext-rel KOMBIGLYZE XR ST = metformin or metformin combinations required before Kombiglyze XR Incretin Mimetic Agents ST albiglutide ST liraglutide TANZEUM VICTOZA ST = metformin or metformin combinations required before Tanzeum or Victoza Insulins OTC, MDL, * OTC, MDL, * OTC, MDL, * OTC, MDL, * OTC, MDL, * OTC, MDL, * MDL, * MDL, * MDL, * MDL, * MDL, * MDL, * 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 detemir insulin glargine insulin lispro 100 units/mL insulin lispro protamine/insulin lispro HUMULIN R NOVOLIN R HUMULIN N NOVOLIN N HUMULIN 70/30 NOVOLIN 70/30 NOVOLOG NOVOLOG MIX 70/30 LEVEMIR LANTUS HUMALOG HUMALOG MIX * Insulin vials are included in the formulary. Insulin pens require prior authorization for members > 18 years of age. Insulin Sensitizers pioglitazone ACTOS Insulin Sensitizer/Biguanide Combinations pioglitazone/metformin ACTOPLUS MET Insulin Sensitizer/Sulfonylurea Combinations pioglitazone/glimepiride DUETACT Meglitinides nateglinide repaglinide Sodium-Glucose Co-transporter 2 (SGLT2) Inhibitors ST empagliflozin STARLIX PRANDIN JARDIANCE ST = metformin or metformin combinations required before Jardiance Sodium-Glucose Co-transporter 2 (SGLT2) Inhibitor/Biguanide Combinations ST empagliflozin/metformin SYNJARDY ST = metformin or metformin combinations required before Synjardy Sulfonylureas glimepiride glipizide glipizide ext-rel glyburide glyburide, micronized AMARYL GLUCOTROL GLUCOTROL XL GLYNASE 25 Supplies OTC OTC, MDL, * alcohol swabs blood glucose monitoring kits, test strips OTC, MDL, * blood glucose monitoring kits, test strips OTC, MDL, * blood glucose monitoring kits, test strips OTC, MDL, * blood glucose monitoring kits, test strips OTC, * OTC OTC OTC blood ketone monitoring test strips insulin syringes and needles lancets sharps container 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 PRECISION XTRA * Abbott diabetes meters available at 1-866-224-8892 or www.ChooseFreeStyle.com 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 alendronate/vitamin D3 risedronate Calcitonins calcitonin-salmon spray Parathyroid Hormones PA, SP teriparatide FOSAMAX FOSAMAX PLUS D ACTONEL MIACALCIN FORTEO CONTRACEPTIVES EE = ethinyl estradiol ME = mestranol Monophasic 20 mcg Estrogen 30 mcg Estrogen # # drospirenone/EE 3/20 norethindrone acetate/EE 1/20 norethindrone acetate/EE 1/20 and iron desogestrel/EE 0.15/30 - Apri drospirenone/EE 3/30 levonorgestrel/EE 0.15/30 - Levora norethindrone acetate/EE 1.5/30 norethindrone acetate/EE 1.5/30 and iron norgestrel/EE 0.3/30 - Low-Ogestrel YAZ LOESTRIN 1/20 LOESTRIN FE 1/20 YASMIN LOESTRIN 1.5/30 LOESTRIN FE 1.5/30 # Only the reference brand name noted is on formulary. 35 mcg Estrogen # ethynodiol diacetate/EE 1/35 - Zovia 1/35 26 norethindrone/EE 0.4/35 norethindrone/EE 0.5/35 norethindrone/EE 1/35 norgestimate/EE 0.25/35 OVCON 35 MODICON ORTHO-NOVUM 1/35 ORTHO-CYCLEN # Only the reference brand name noted is on formulary. 50 mcg Estrogen # ethynodiol diacetate/EE 1/50 - Zovia 1/50 norethindrone/ME 1/50 # Only the reference brand name noted is on formulary. Biphasic Triphasic # desogestrel/EE norethindrone/EE MIRCETTE NECON 10/11 desogestrel/EE levonorgestrel/EE - Trivora norethindrone acetate/EE/iron norethindrone/EE norethindrone/EE norgestimate/EE norgestimate/EE CYCLESSA ESTROSTEP FE ORTHO-NOVUM 7/7/7 TRI-NORINYL ORTHO TRI-CYCLEN ORTHO TRI-CYCLEN LO # Only the reference brand name noted is on formulary. Extended Cycle Progestin Only levonorgestrel/EE 0.15/30 levonorgestrel/EE 0.15/30 and EE 10 SEASONIQUE norethindrone ORTHO MICRONOR Emergency Contraception OTC, MDL levonorgestrel 1.5 mg MDL levonorgestrel 0.75 mg MDL levonorgestrel 1.5 mg - Next Choice One Dose PLAN B ONE-STEP OTC = Prescription not required regardless of member's age. Injectable MDL Transdermal Vaginal medroxyprogesterone acetate 150 mg/mL DEPO-PROVERA norelgestromin/EE - Xulane etonogestrel/EE ring NUVARING Miscellaneous OTC condoms diaphragm ENDOMETRIOSIS danazol 27 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 Vaginal estradiol estrogens, conjugated estropipate ESTRACE PREMARIN estradiol CLIMARA estradiol crm estrogens, conjugated crm ESTRACE CREAM PREMARIN CREAM ESTROGEN/PROGESTINS Oral EE/norethindrone acetate EE/norethindrone acetate - Jinteli estrogens, conjugated/medroxyprogesterone estrogens, conjugated/medroxyprogesterone Transdermal estradiol/levonorgestrel GLUCOCORTICOIDS dexamethasone fludrocortisone hydrocortisone methylprednisolone prednisolone sodium phosphate oral solution prednisolone syrup prednisone GLUCOSE ELEVATING AGENTS glucagon, human recombinant FEMHRT PREMPHASE PREMPRO CLIMARA PRO CORTEF MEDROL PRELONE GLUCAGON EMERGENCY KIT HUMAN GROWTH HORMONES Guidelines for use of growth hormone are available at: http://www.aace.com/publications/guidelines PA, SP, # somatropin NORDITROPIN # Only the branded product noted is on formulary. HYPERPARATHYROID TREATMENT, VITAMIN D ANALOGS calcitriol (1,25-D3) doxercalciferol caps ROCALTROL HECTOROL PHOSPHATE BINDER AGENTS calcium acetate lanthanum sevelamer carbonate sevelamer HCl PHOSLO FOSRENOL RENVELA RENAGEL 28 PROGESTINS medroxyprogesterone acetate norethindrone acetate progesterone powder progesterone suppositories progesterone, micronized SELECTIVE ESTROGEN RECEPTOR MODULATORS raloxifene THYROID AGENTS Antithyroid Agents methimazole propylthiouracil Thyroid Supplements levothyroxine levothyroxine - Levoxyl liothyronine thyroid VASOPRESSINS desmopressin spray, tabs MISCELLANEOUS cabergoline methylergonovine succimer PROVERA AYGESTIN FIRST-PROGESTERONE VGS PROMETRIUM EVISTA TAPAZOLE SYNTHROID CYTOMEL ARMOUR THYROID DDAVP CHEMET 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 alumina/magnesia/simethicone ANTIDIARRHEALS OTC loperamide diphenoxylate/atropine loperamide ANTIEMETICS OTC MDL MDL meclizine aprepitant granisetron meclizine metoclopramide ondansetron prochlorperazine promethazine promethazine supp ANTISPASMODICS dicyclomine glycopyrrolate MAALOX MAALOX MYLANTA IMODIUM A-D LOMOTIL EMEND ANTIVERT REGLAN ZOFRAN BENTYL ROBINUL 29 hyoscyamine sulfate CHOLELITHOLYTICS ursodiol ursodiol H2 RECEPTOR ANTAGONISTS OTC cimetidine OTC ranitidine cimetidine ranitidine 150 mg, 300 mg ranitidine syrup INFLAMMATORY BOWEL DISEASE Oral Agents balsalazide budesonide delayed-rel caps mesalamine delayed-rel tabs ST mesalamine delayed-rel tabs mesalamine ext-rel caps sulfasalazine sulfasalazine delayed-rel LEVSIN ACTIGALL URSO TAGAMET HB 200 ZANTAC 75, ZANTAC 150 ZANTAC ZANTAC COLAZAL ENTOCORT EC ASACOL HD LIALDA PENTASA AZULFIDINE AZULFIDINE EN-TABS ST = Other Colitis drug required before Lialda Rectal Agents hydrocortisone acetate foam hydrocortisone enema mesalamine rectal susp mesalamine supp IRRITABLE BOWEL SYNDROME Irritable Bowel Syndrome with Constipation PA lubiprostone LAXATIVES/STOOL SOFTENERS OTC docusate sodium OTC polyethylene glycol 3350 lactulose peg 3350/electrolytes peg 3350/electrolytes CORTIFOAM ROWASA CANASA AMITIZA COLACE MIRALAX GOLYTELY NULYTELY PANCREATIC ENZYMES pancrelipase delayed-rel pancrelipase delayed-rel CREON ZENPEP PROSTAGLANDINS misoprostol CYTOTEC PROTON PUMP INHIBITORS OTC, MDL esomeprazole magnesium delayed-rel OTC, MDL lansoprazole delayed-rel OTC, MDL omeprazole delayed-rel tabs OTC, MDL omeprazole magnesium delayed-rel OTC, MDL omeprazole magnesium delayed-rel caps MDL lansoprazole delayed-rel caps ST lansoprazole powder for suspension MDL omeprazole delayed-rel caps 20 mg, 40 mg NEXIUM 24HR PREVACID 24HR PRILOSEC OTC PREVACID FIRST-LANSOPRAZOLE PRILOSEC 30 MDL pantoprazole delayed-rel ST = ranitidine syrup required before First-Lansoprazole SALIVA STIMULANTS pilocarpine tabs SALAGEN STEROIDS, RECTAL hydrocortisone crm ANUSOL-HC ULCER THERAPY COMBINATIONS bismuth/metronidazole/tetracycline MDL lansoprazole + amoxicillin + clarithromycin PYLERA PREVPAC MISCELLANEOUS sucralfate CARAFATE GENITOURINARY BENIGN PROSTATIC HYPERPLASIA Guidelines for the management of BPH are available at: http://www.auanet.org/guidelines alfuzosin ext-rel finasteride 5 mg tamsulosin URINARY ANTISPASMODICS flavoxate oxybutynin oxybutynin ext-rel tolterodine tolterodine ext-rel trospium trospium ext-rel VAGINAL ANTI-INFECTIVES OTC clotrimazole crm 1% OTC clotrimazole crm 2% OTC miconazole crm 2%, supp 100 mg OTC miconazole crm 4%, supp 200 mg clindamycin crm clotrimazole MDL fluconazole 150 mg metronidazole miconazole terconazole crm 0.4% terconazole crm 0.8% terconazole supp 80 mg MISCELLANEOUS bethanechol phenazopyridine potassium citrate ext-rel potassium/sodium phosphates - Phospha 250 Neutral propantheline 15 mg sodium citrate/citric acid UROXATRAL PROSCAR FLOMAX DITROPAN XL DETROL DETROL LA GYNE-LOTRIMIN 7-DAY GYNE-LOTRIMIN 3-DAY MONISTAT 7 MONISTAT 3 CLEOCIN DIFLUCAN METROGEL-VAGINAL TERAZOL 7 TERAZOL 3 URECHOLINE PYRIDIUM UROCIT-K 31 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 MDL, PA* enoxaparin LOVENOX PA* Greater than 30 days of therapy requires Prior Authorization Oral PA PA apixaban rivaroxaban warfarin ELIQUIS XARELTO COUMADIN 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 SP, MDL SP, MDL SP, MDL SP, MDL SP, MDL SP, MDL SP, MDL darbepoetin alfa epoetin alfa epoetin alfa filgrastim pegfilgrastim sargramostim inj tbo-filgrastim ARANESP EPOGEN PROCRIT NEUPOGEN NEULASTA LEUKINE GRANIX IDIOPATHIC THROMBOCYTOPENIC PURPURA AGENTS PA, SP eltrombopag PROMACTA IRON CHELATING AGENTS PA, SP deferasirox PA, SP deferasirox tabs EXJADE JADENU PLATELET AGGREGATION INHIBITORS OTC aspirin clopidogrel dipyridamole dipyridamole ext-rel/aspirin vorapaxar PLAVIX PERSANTINE AGGRENOX ZONTIVITY PLATELET SYNTHESIS INHIBITORS anagrelide AGRYLIN MISCELLANEOUS aminocaproic acid pentoxifylline ext-rel MDL tranexamic acid AMICAR LYSTEDA 32 IMMUNOLOGIC AGENTS Guidelines for the management of rheumatic diseases are available at: http://www.rheumatology.org ALLERGENIC EXTRACTS PA grass mixed pollen extract ORALAIR BIOLOGIC DISEASE-MODIFYING AGENTS PA, SP adalimumab PA, SP certolizumab pegol PA, SP etanercept HUMIRA CIMZIA ENBREL DISEASE-MODIFYING ANTIRHEUMATIC DRUGS (DMARDs) hydroxychloroquine leflunomide methotrexate PA, SP tofacitinib PA, SP tofacitinib ext-rel PLAQUENIL ARAVA XELJANZ XELJANZ XR 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 interferon alfa-2b peginterferon alfa-2a INTRON A PEGASYS IMMUNOSUPPRESSANTS Antimetabolites azathioprine azathioprine mycophenolate mofetil AZASAN IMURAN CELLCEPT Calcineurin Inhibitors cyclosporine cyclosporine, modified tacrolimus SANDIMMUNE NEORAL PROGRAF Rapamycin Derivatives sirolimus RAPAMUNE VACCINES * * FLUMIST FLUZONE influenza vaccine influenza vaccine * For patients 18 years of age or older. Pediatric patients should receive VFC vaccine supply. NUTRITIONAL/SUPPLEMENTS ELECTROLYTES Potassium potassium bicarbonate/potassium citrate effervescent tabs 25 mEq potassium chloride ext-rel potassium chloride liquid 33 potassium chloride powder 20 mEq potassium chloride/potassium bicarbonate/citric acid effervescent tabs 25 mEq Potassium-Removing Agents sodium polystyrene sulfonate VITAMINS AND MINERALS Folic Acid Agents folic acid Prenatal Vitamins prenatal vitamins/DHA/docusate/folic acid/polysaccharide iron complex prenatal vitamins/DHA/folic acid prenatal vitamins/docusate/folic acid prenatal vitamins/ferrous fumarate/folic acid prenatal vitamins/folic acid prenatal vitamins/folic acid/omega 3 fatty acids Miscellaneous OTC OTC OTC OTC OTC OTC OTC OTC OTC OTC OTC OTC OTC cholecalciferol (D3) drops electrolyte rehydrating solution, oral ergocalciferol (D2) drops ferrous gluconate ferrous sulfate multivitamins multivitamins drops multivitamins/iron multivitamins/iron drops multivitamins/minerals polysaccharide iron complex - Nu-Iron 150 pyridoxine 25 mg vitamin E cyanocobalamin inj ergocalciferol (D2) caps multivitamins/fluoride drops, tabs multivitamins/fluoride/iron drops, tabs phytonadione vitamin ADC/fluoride drops vitamin ADC/fluoride/iron drops vitamin B complex/vitamin C/folic acid zinc acetate VITAFOL FE+ SELECT-OB + DHA CITRANATAL RX VITAFOL-OB VITAFOL GUMMIES VITAMIN D3 PEDIALYTE DRISDOL FERGON FEOSOL POLY-VI-SOL GERITOL POLY-VI-SOL WITH IRON CENTRUM SILVER VITAMIN B6 DRISDOL MEPHYTON NEPHRO-VITE RX GALZIN 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 MDL epinephrine MDL epinephrine MDL epinephrine pen EPIPEN EPIPEN JR. 34 ANTICHOLINERGICS ipratropium nebulization solution ipratropium, CFC-free aerosol MDL, * tiotropium MDL, * tiotropium, CFC-free aerosol ATROVENT HFA SPIRIVA HANDIHALER SPIRIVA RESPIMAT * Covered only for individuals older than age 12 ANTICHOLINERGIC/BETA AGONIST COMBINATIONS Short Acting ipratropium/albuterol nebulization solution MDL ipratropium/albuterol, CFC-free aerosol COMBIVENT RESPIMAT Long Acting ST ANORO ELLIPTA umeclidinium/vilanterol ST = Spiriva required before Anoro Ellipta ANTIHISTAMINES, LOW SEDATING OTC cetirizine levocetirizine ZYRTEC XYZAL ANTIHISTAMINES, NONSEDATING OTC fexofenadine OTC loratadine liquid, orally disintegrating tabs, tabs ALLEGRA CLARITIN ANTIHISTAMINES, SEDATING OTC chlorpheniramine OTC diphenhydramine cyproheptadine ANTIHISTAMINE/DECONGESTANT COMBINATIONS OTC brompheniramine/phenylephrine elixir 1 mg/2.5 mg/5 mL OTC cetirizine/pseudoephedrine ext-rel OTC fexofenadine/pseudoephedrine ext-rel OTC loratadine/pseudoephedrine ext-rel CHLOR-TRIMETON BENADRYL DIMETAPP ZYRTEC-D 12 HOUR 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 codeine/chlorpheniramine/pseudoephedrine codeine/guaifenesin codeine/guaifenesin/pseudoephedrine codeine/promethazine codeine/promethazine/phenylephrine hydrocodone/homatropine Non-Opioid OTC OTC dextromethorphan/guaifenesin ext-rel dextromethorphan/guaifenesin liquid, solution, syrup dextromethorphan/promethazine MUCINEX DM 35 BETA AGONISTS Inhalants Short Acting albuterol nebulization solution MDL albuterol sulfate, CFC-free aerosol MDL albuterol sulfate, CFC-free aerosol ST levalbuterol nebulization solution ST levalbuterol tartrate, CFC-free aerosol PROAIR HFA VENTOLIN HFA XOPENEX HFA ST = albuterol nebulization solution required before levalbuterol nebulization solution or Xopenex HFA Long Acting Hand-held Active Inhalation olodaterol, CFC-free aerosol ST salmeterol xinafoate STRIVERDI RESPIMAT SEREVENT DISKUS ST = Inhaled corticosteroid required before Serevent Diskus Oral Agents albuterol albuterol ext-rel terbutaline DECONGESTANTS OTC pseudoephedrine OTC pseudoephedrine ext-rel EXPECTORANTS OTC guaifenesin ext-rel OTC guaifenesin liquid OTC guaifenesin liquid, syrup, tabs LEUKOTRIENE RECEPTOR ANTAGONISTS montelukast VOSPIRE ER SUDAFED SUDAFED MUCINEX DIABETIC TUSSIN SINGULAIR MAST CELL STABILIZERS cromolyn nebulization solution MEDICAL SUPPLIES OTC spacer AEROCHAMBER NASAL ANTIHISTAMINES azelastine spray NASAL STEROIDS OTC budesonide spray - Rhinocort Allergy OTC fluticasone spray - Flonase Allergy Relief OTC triamcinolone acetonide spray budesonide spray flunisolide spray fluticasone spray * mometasone spray NASACORT ALLERGY 24HR RHINOCORT AQUA NASONEX * Covered for individuals 2-4 years of age PULMONARY FIBROSIS AGENTS PA, SP nintedanib OFEV 36 STEROID/BETA AGONIST COMBINATIONS ST budesonide/formoterol ST fluticasone/salmeterol ST fluticasone/salmeterol, CFC-free aerosol SYMBICORT ADVAIR DISKUS ADVAIR HFA ST = Inhaled corticosteroid required before Advair or Symbicort STEROID INHALANTS beclomethasone, CFC-free aerosol budesonide budesonide nebulization suspension MDL fluticasone propionate MDL fluticasone, CFC-free aerosol XANTHINES theophylline ext-rel tabs theophylline liquid MISCELLANEOUS MDL ipratropium nasal spray sodium chloride nebulization solution QVAR PULMICORT FLEXHALER PULMICORT RESPULES FLOVENT DISKUS FLOVENT HFA ELIXOPHYLLIN ATROVENT 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 Oral PA Topical OTC PA isotretinoin - Claravis salicylic acid pad 2% adapalene crm, gel, lotion benzoyl peroxide gel 2.5%, 5%, 10% clindamycin foam 1% clindamycin gel, lotion, solution 1% clindamycin/benzoyl peroxide erythromycin gel 2% erythromycin solution 2% erythromycin/benzoyl peroxide 3%/5% sulfacetamide/sulfur cleanser, crm, foam, lotion, wash 10-5% sulfacetamide/sulfur crm 10-2% tretinoin crm, gel DIFFERIN EVOCLIN CLEOCIN T BENZACLIN BENZAMYCIN RETIN-A PA required for individuals 35 years of age or older Actinic Keratosis fluorouracil crm 1% fluorouracil crm 5% fluorouracil solution 2%, 5% Antibiotics OTC OTC bacitracin neomycin/bacitracin/polymyxin B mupirocin oint 2% silver sulfadiazine crm 1% FLUOROPLEX EFUDEX NEOSPORIN BACTROBAN SILVADENE 37 Antifungals OTC OTC OTC butenafine clotrimazole miconazole ciclopirox crm, gel, shampoo, topical suspension ciclopirox nail lacquer clotrimazole ketoconazole crm 2% nystatin nystatin/triamcinolone LOTRIMIN ULTRA LOTRIMIN AF MICATIN PENLAC Antipsoriatics Guidelines of care for the management and treatment of psoriasis with topical therapies are available at: http://www.aad.org Injectable PA, SP Oral Topical Antiseborrheics secukinumab COSENTYX methoxsalen oral OXSORALEN-ULTRA calcipotriene tazarotene DOVONEX TAZORAC ketoconazole shampoo 2% selenium sulfide shampoo 2.5% NIZORAL SHAMPOO Corticosteroids Products are grouped based upon relative potency. The formulary generally includes all strengths and usual topical dosage forms for all the products cited. Low Potency OTC OTC OTC Medium Potency High Potency hydrocortisone crm, gel, lotion, oint, solution 1% hydrocortisone oint 0.5% hydrocortisone/aloe vera crm 0.5%, 1% desonide crm, lotion, oint 0.05% fluocinolone acetonide body oil 0.01% fluocinolone acetonide crm, oil, solution 0.01% fluocinolone acetonide scalp oil 0.01% hydrocortisone crm 2.5% hydrocortisone lotion 1% betamethasone valerate crm, lotion, oint 0.1% betamethasone valerate foam 0.12% desoximetasone crm, oint 0.05% fluocinolone acetonide crm, oint 0.025% fluticasone propionate crm 0.05% hydrocortisone valerate crm, oint 0.2% mometasone crm, lotion, oint 0.1% triamcinolone acetonide crm, lotion 0.025% triamcinolone acetonide crm, lotion, oint 0.1% betamethasone dipropionate augmented crm 0.05% betamethasone dipropionate augmented lotion 0.05% DESOWEN LUXIQ TOPICORT LP CUTIVATE WESTCORT ELOCON DIPROLENE AF DIPROLENE 38 betamethasone dipropionate crm, lotion, oint 0.05% desoximetasone crm, oint 0.25%, gel 0.05% fluocinonide crm, gel, oint, solution 0.05% triamcinolone acetonide crm 0.5% TOPICORT Very High Potency betamethasone dipropionate augmented gel, oint 0.05% clobetasol propionate crm, gel, oint, solution 0.05% clobetasol propionate foam 0.05% clobetasol propionate lotion, shampoo 0.05% halobetasol propionate crm, oint 0.05% DIPROLENE TEMOVATE OLUX CLOBEX ULTRAVATE Emollients OTC OTC OTC OTC AMLACTIN ATRAC-TAIN CARMOL 20 CARMOL 10 ammonium lactate 12% urea crm 10% urea crm 20% urea lotion 10% Immunomodulators Guidelines for the treatment of atopic dermatitis are available at: http://www.aad.org/education/clinical-guidelines MDL, ST MDL, ST, * pimecrolimus tacrolimus ELIDEL PROTOPIC ST = Topical steroid required before Elidel and tacrolimus (Protopic) * = tacrolimus 0.03%: In addition to clinical criteria, the member must be at least two years of age. tacrolimus 0.1%: In addition to clinical criteria, the member must be at least 15 years of age. Local Anesthetics lidocaine oint 5% lidocaine/prilocaine Rosacea MDL metronidazole crm 0.75% metronidazole crm 1% metronidazole gel 1% sulfacetamide/sulfur cleanser, crm, foam, lotion, wash 10-5% sulfacetamide/sulfur crm 10-2% Scabicides and Pediculicides OTC permethrin 1% ST benzyl alcohol ST* malathion permethrin crm 5% METROCREAM NORITATE METROGEL NIX CREME RINSE ULESFIA OVIDE ST = permethrin required before Ulesfia for 6 years of age or younger ST* = permethrin required before malathion (Ovide) for age > 6 Miscellaneous Skin and Mucous Membrane OTC calcium acetate/aluminum sulfate powder packet OTC salicylic acid/urea oint 5-10% acyclovir oint aluminum chloride solution 20% PA collagenase imiquimod podofilox solution salicylic acid foam 6% DOMEBORO KERASAL ZOVIRAX OINTMENT DRYSOL SANTYL ALDARA CONDYLOX SALVAX 39 salicylic acid liquid 27.5% salicylic acid lotion 6% MOUTH/THROAT/DENTAL AGENTS Anesthetics - Topical Oral lidocaine viscous Steroids - Mouth/Throat triamcinolone paste Miscellaneous chlorhexidine gluconate sodium fluoride 0.5 mg, 1 mg tabs sodium fluoride chew tabs sodium fluoride crm, gel 1.1% sodium fluoride dental rinse 0.2% sodium fluoride oral drops sodium fluoride/xylitol chew tabs PERIDEX LURIDE LOZI-TABS PREVIDENT PREVIDENT LURIDE FLUOR-A-DAY OPHTHALMIC Preferred Practice Pattern Guidelines for the treatment of various ophthalmic conditions are available at: http://one.aao.org Antiallergics OTC Anti-infectives ketotifen azelastine cromolyn sodium bacitracin ciprofloxacin solution erythromycin gentamicin moxifloxacin neomycin/polymyxin B/gramicidin ofloxacin polymyxin B/bacitracin polymyxin B/trimethoprim sulfacetamide solution 10% tobramycin oint tobramycin solution Anti-infective/Anti-inflammatory Combinations gentamicin/prednisolone acetate neomycin/polymyxin B/dexamethasone sulfacetamide/prednisolone phosphate 10%/0.25% tobramycin/dexamethasone susp 0.3%/0.1% Anti-inflammatories Nonsteroidal ketorolac 0.4% ketorolac 0.5% nepafenac Steroidal dexamethasone sodium phosphate fluorometholone 0.1% susp fluorometholone 0.25% ZADITOR CILOXAN VIGAMOX NEOSPORIN OCUFLOX POLYTRIM BLEPH-10 TOBREX TOBREX PRED-G MAXITROL TOBRADEX ACULAR LS ACULAR NEVANAC FML LIQUIFILM FML FORTE 40 Antivirals Beta-blockers Nonselective Selective fluorometholone oint loteprednol susp 0.5% prednisolone acetate 0.12% prednisolone acetate 1% prednisolone phosphate 1% rimexolone FML S.O.P. LOTEMAX PRED MILD PRED FORTE trifluridine VIROPTIC levobunolol timolol hemihydrate timolol maleate BETAGAN BETIMOL TIMOPTIC betaxolol 0.25% BETOPTIC S VEXOL Carbonic Anhydrase Inhibitors brinzolamide dorzolamide AZOPT TRUSOPT Carbonic Anhydrase Inhibitor/Beta-blocker Combinations dorzolamide/timolol maleate COSOPT Mydriatics atropine solution 1% homatropine 5% Parasympathomimetics pilocarpine Prostaglandins bimatoprost 0.01% bimatoprost 0.03% latanoprost travoprost Sympathomimetics brimonidine 0.1% brimonidine 0.15% brimonidine 0.2% ISOPTO HOMATROPINE ISOPTO CARPINE LUMIGAN XALATAN ALPHAGAN P ALPHAGAN P Sympathomimetic/Beta-blocker Combinations brimonidine/timolol COMBIGAN Miscellaneous OTC artificial tears oint, soln ARTIFICIAL TEARS OTIC Clinical practice guidelines for the treatment of otitis media are available at: http://www.aap.org Anti-infectives OTC acetic acid/aluminum acetate acetic acid ciprofloxacin otic 41 ofloxacin otic 0.3% Anti-infective/Anti-inflammatory Combinations ciprofloxacin/dexamethasone neomycin/polymyxin B/hydrocortisone Miscellaneous CIPRODEX CORTISPORIN OTIC antipyrine/benzocaine 42 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 43 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 44 INDEX A acarbose, 24 ACCUPRIL, 17 ACCURETIC, 17 acetaminophen, 12 acetaminophen/dichloralphenazone/isometheptene, 23 acetazolamide, 20 acetazolamide ext-rel, 20 acetic acid, 41 acetic acid/aluminum acetate, 41 ACTIGALL, 30 ACTONEL, 26 ACTOPLUS MET, 25 ACTOS, 25 ACULAR, 40 ACULAR LS, 40 acyclovir caps, susp, tabs, 15 acyclovir oint, 39 ADALAT CC, 20 adalimumab, 33 adapalene crm, gel, lotion, 37 ADCIRCA, 21 adefovir dipivoxil, 15 ADOXA, 14 ADVAIR DISKUS, 37 ADVAIR HFA, 37 ADVIL, 12 AEROCHAMBER, 36 AFINITOR, 16 AGGRENOX, 32 AGRYLIN, 32 albendazole, 15 ALBENZA, 15 albiglutide, 25 albuterol, 36 albuterol ext-rel, 36 albuterol nebulization solution, 36 albuterol sulfate, CFC-free aerosol, 36 alcohol swabs, 26 ALDACTAZIDE, 20 ALDACTONE, 20 ALDARA, 39 ALECENSA, 16 alectinib, 16 alendronate tabs, 26 alendronate/vitamin D3, 26 alfuzosin ext-rel, 31 aliskiren, 20 ALKERAN, 16 ALLEGRA, 35 ALLEGRA-D, 35 allopurinol, 12 ALPHAGAN P, 41 ALTACE, 17 altretamine, 16 alumina/magnesia, 29 alumina/magnesia/simethicone, 29 aluminum chloride solution 20%, 39 amantadine caps, syrup, 15, 22 AMARYL, 25 ambrisentan, 21 AMERGE, 23 AMICAR, 32 amiloride, 20 amiloride/hydrochlorothiazide, 20 aminocaproic acid, 32 amiodarone, 18 AMITIZA, 30 AMLACTIN, 39 amlodipine, 19 amlodipine/benazepril, 17 ammonium lactate 12%, 39 amoxicillin, 14 amoxicillin/clavulanate, 14 amoxicillin/clavulanate ext-rel, 14 ampicillin, 14 AMPYRA, 23 anagrelide, 32 ANAPROX, 12 anastrozole, 16 ANDRODERM, 24 ANDROGEL, 24 ANORO ELLIPTA, 35 antipyrine/benzocaine, 42 ANTIVERT, 29 ANUSOL-HC, 31 apixaban, 32 aprepitant, 29 ARALEN, 14 ARANESP, 32 ARAVA, 33 ARICEPT, 22 ARIMIDEX, 16 ARMOUR THYROID, 29 AROMASIN, 16 ARTIFICIAL TEARS, 41 artificial tears oint, soln, 41 ASACOL HD, 30 aspirin, 32 ATACAND, 18 ATACAND HCT, 18 atenolol, 19 atenolol/chlorthalidone, 19 atorvastatin, 19 atovaquone, 14 atovaquone/proguanil, 14 ATRAC-TAIN, 39 atropine solution 1%, 41 ATROVENT, 37 ATROVENT HFA, 35 AUGMENTIN, 14 AVALIDE, 18 AVAPRO, 18 AVELOX, 14 AVONEX, 23 AYGESTIN, 29 AZASAN, 33 azathioprine, 33 azelastine, 40 azelastine spray, 36 azithromycin, 13 AZOPT, 41 AZULFIDINE, 30 AZULFIDINE EN-TABS, 30 45 B bacitracin, 37, 40 baclofen, 23 BACTROBAN, 37 balsalazide, 30 BARACLUDE, 15 beclomethasone, CFC-free aerosol, 37 BENADRYL, 35 benazepril, 17 BENTYL, 29 BENZACLIN, 37 BENZAMYCIN, 37 benzonatate, 35 benzoyl peroxide gel 2.5%, 5%, 10%, 37 benzyl alcohol, 39 BETAGAN, 41 betamethasone dipropionate augmented crm 0.05%, 38 betamethasone dipropionate augmented gel, oint 0.05%, 39 betamethasone dipropionate augmented lotion 0.05%, 38 betamethasone dipropionate crm, lotion, oint 0.05%, 39 betamethasone valerate crm, lotion, oint 0.1%, 38 betamethasone valerate foam 0.12%, 38 BETAPACE, BETAPACE AF, 19 BETASERON, 23 betaxolol 0.25%, 41 bethanechol, 31 BETIMOL, 41 BETOPTIC S, 41 bexarotene caps, 17 BIAXIN, 13 bicalutamide, 16 BIDIL, 21 bimatoprost 0.01%, 41 bimatoprost 0.03%, 41 bismuth/metronidazole/tetracycline, 31 bisoprolol/hydrochlorothiazide, 19 BLEPH-10, 40 blood glucose monitoring kits, test strips, 26 blood ketone monitoring test strips, 26 bosentan, 21 BOSULIF, 16 bosutinib, 16 brimonidine 0.1%, 41 brimonidine 0.15%, 41 brimonidine 0.2%, 41 brimonidine/timolol, 41 brinzolamide, 41 bromocriptine, 22 brompheniramine/phenylephrine elixir 1 mg/2.5 mg/5 mL, 35 budesonide, 37 budesonide delayed-rel caps, 30 budesonide nebulization suspension, 37 budesonide spray, 36 budesonide spray - Rhinocort Allergy, 36 budesonide/formoterol, 37 bumetanide, 20 busulfan, 16 butalbital/acetaminophen/caffeine, 13 butalbital/acetaminophen/caffeine/codeine, 12 butalbital/aspirin/caffeine, 13 butalbital/aspirin/caffeine/codeine, 12 butenafine, 38 C cabergoline, 29 CAFERGOT, 23 CALAN SR, 20 calcipotriene, 38 calcitonin-salmon spray, 26 calcitriol (1,25-D3), 28 calcium acetate, 28 calcium acetate/aluminum sulfate powder packet, 39 CANASA, 30 candesartan, 18 candesartan/hydrochlorothiazide, 18 capecitabine, 16 captopril, 17 captopril/hydrochlorothiazide, 17 CARAFATE, 31 carbidopa/levodopa, 22 carbidopa/levodopa ext-rel, 22 carbidopa/levodopa/entacapone, 22 CARDIZEM CD, 20 CARDURA, 18 carisoprodol, 23 CARMOL 10, 39 CARMOL 20, 39 carvedilol, 19 CASODEX, 16 CATAPRES, 18 CATAPRES-TTS, 18 cefaclor, 13 cefdinir, 13 cefprozil, 13 CEFTIN, 13 cefuroxime axetil, 13 CELEBREX, 12 celecoxib, 12 CELLCEPT, 33 CENTRUM SILVER, 34 cephalexin, 13 certolizumab pegol, 33 cetirizine, 35 cetirizine/pseudoephedrine ext-rel, 35 CHEMET, 29 chlorambucil, 16 chlorhexidine gluconate, 40 chloroquine, 14 chlorothiazide susp, 20 chlorpheniramine, 35 chlorthalidone, 20 CHLOR-TRIMETON, 35 cholecalciferol (D3) drops, 34 cholestyramine can, 19 ciclopirox crm, gel, shampoo, topical suspension, 38 ciclopirox nail lacquer, 38 CILOXAN, 40 cimetidine, 30 CIMZIA, 33 cinacalcet, 26 CIPRO, 14 CIPRODEX, 42 ciprofloxacin, 14 ciprofloxacin ext-rel, 14 ciprofloxacin otic, 41 ciprofloxacin solution, 40 ciprofloxacin/dexamethasone, 42 CITRANATAL RX, 34 clarithromycin, 13 CLARITIN, 35 CLARITIN-D, 35 CLEOCIN, 15, 31 46 CLEOCIN T, 37 CLIMARA, 28 CLIMARA PRO, 28 clindamycin, 15 clindamycin crm, 31 clindamycin foam 1%, 37 clindamycin gel, lotion, solution 1%, 37 clindamycin/benzoyl peroxide, 37 clobetasol propionate crm, gel, oint, solution 0.05%, 39 clobetasol propionate foam 0.05%, 39 clobetasol propionate lotion, shampoo 0.05%, 39 CLOBEX, 39 clonidine, 18 clonidine transdermal, 18 clopidogrel, 32 clotrimazole, 31, 38 clotrimazole crm 1%, 31 clotrimazole crm 2%, 31 clotrimazole troches, 14 codeine sulfate, 12 codeine/acetaminophen, 12 codeine/chlorpheniramine/pseudoephedrine, 35 codeine/guaifenesin, 35 codeine/guaifenesin/pseudoephedrine, 35 codeine/promethazine, 35 codeine/promethazine/phenylephrine, 35 COLACE, 30 COLAZAL, 30 colchicine, 12 COLCRYS, 12 COLESTID, 19 colestipol, 19 collagenase, 39 COMBIGAN, 41 COMBIVENT RESPIMAT, 35 COMTAN, 22 condoms, 27 CONDYLOX, 39 COPAXONE, 23 COPEGUS, 15 CORDARONE, 18 COREG, 19 CORGARD, 19 CORLANOR, 21 CORTEF, 28 CORTIFOAM, 30 CORTISPORIN OTIC, 42 COSENTYX, 38 COSOPT, 41 COUMADIN, 32 COZAAR, 18 CREON, 30 cromolyn nebulization solution, 36 cromolyn sodium, 40 CUTIVATE, 38 cyanocobalamin inj, 34 CYCLESSA, 27 cyclobenzaprine 5 mg, 10 mg, 23 cyclophosphamide caps, 16 cyclosporine, 33 cyclosporine, modified, 33 cyproheptadine, 35 CYTOMEL, 29 CYTOTEC, 30 D dabrafenib, 16 dalfampridine ext-rel, 23 danazol, 27 DANTRIUM, 23 dantrolene, 23 dapsone tabs, 15 DARAPRIM, 14 darbepoetin alfa, 32 dasatinib, 16 DAYPRO, 12 DDAVP, 29 deferasirox, 32 deferasirox tabs, 32 DELATESTRYL, 24 DEMADEX, 20 DEPO-PROVERA, 27 DEPO-TESTOSTERONE, 24 desmopressin spray, tabs, 29 desogestrel/EE, 27 desogestrel/EE 0.15/30 - Apri, 26 desonide crm, lotion, oint 0.05%, 38 DESOWEN, 38 desoximetasone crm, oint 0.05%, 38 desoximetasone crm, oint 0.25%, gel 0.05%, 39 DETROL, 31 DETROL LA, 31 dexamethasone, 28 dexamethasone sodium phosphate, 40 dextromethorphan/guaifenesin ext-rel, 35 dextromethorphan/guaifenesin liquid, solution, syrup, 35 dextromethorphan/promethazine, 35 dextromethorphan/quinidine, 24 DIABETIC TUSSIN, 36 DIAMOX SEQUELS, 20 diaphragm, 27 diclofenac sodium delayed-rel, 12 dicloxacillin, 14 dicyclomine, 29 DIFFERIN, 37 DIFICID, 14 DIFLUCAN, 14, 31 digoxin, 20 DILANTIN, 21 DILANTIN INFATABS, 21 DILAUDID, 12 diltiazem ext-rel, 20 DIMETAPP, 35 dimethyl fumarate delayed-rel, 23 DIOVAN, 18 DIOVAN HCT, 18 diphenhydramine, 35 diphenoxylate/atropine, 29 DIPROLENE, 38, 39 DIPROLENE AF, 38 dipyridamole, 32 dipyridamole ext-rel/aspirin, 32 disopyramide, 18 disopyramide ext-rel 100 mg, 18 DITROPAN XL, 31 DIURIL, 20 docusate sodium, 30 dofetilide, 18 DOLOPHINE, 12 DOMEBORO, 39 donepezil, 22 47 dorzolamide, 41 dorzolamide/timolol maleate, 41 DOVONEX, 38 doxazosin, 18 doxercalciferol caps, 28 DOXIL, 17 doxorubicin liposomal, 17 doxycycline hyclate caps, 14 doxycycline hyclate tabs 20 mg, 100 mg, 14 doxycycline monohydrate caps 100 mg, 14 doxycycline monohydrate susp, 14 doxycycline monohydrate tabs, 14 doxylamine 25 mg, 23 DRISDOL, 34 dronedarone, 18 drospirenone/EE 3/20, 26 drospirenone/EE 3/30, 26 DRYSOL, 39 DUETACT, 25 DURAGESIC, 12 DYAZIDE, 20 DYRENIUM, 20 E E.E.S., 14 EE/norethindrone acetate, 28 EE/norethindrone acetate - Jinteli, 28 EFUDEX, 37 electrolyte rehydrating solution, oral, 34 ELIDEL, 39 ELIGARD, 16 ELIQUIS, 32 ELIXOPHYLLIN, 37 ELOCON, 38 eltrombopag, 32 EMEND, 29 empagliflozin, 25 empagliflozin/metformin, 25 enalapril, 17 enalapril/hydrochlorothiazide, 17 ENBREL, 33 enoxaparin, 32 entacapone, 22 entecavir, 15 ENTOCORT EC, 30 ENTRESTO, 20 epinephrine, 34 epinephrine pen, 34 EPIPEN, 34 EPIPEN JR., 34 EPIVIR-HBV, 15 epoetin alfa, 32 EPOGEN, 32 epoprostenol sodium, 21 ergocalciferol (D2) caps, 34 ergocalciferol (D2) drops, 34 ergotamine/caffeine, 23 erythromycin, 40 erythromycin base, 14 erythromycin delayed-rel, 14 erythromycin delayed-rel - Ery-tab, 14 erythromycin ethylsuccinate, 14 erythromycin gel 2%, 37 erythromycin solution 2%, 37 erythromycin stearate, 14 erythromycin/benzoyl peroxide 3%/5%, 37 esomeprazole magnesium delayed-rel, 30 ESTRACE, 28 ESTRACE CREAM, 28 estradiol, 28 estradiol crm, 28 estradiol/levonorgestrel, 28 estrogens, conjugated, 28 estrogens, conjugated crm, 28 estrogens, conjugated/medroxyprogesterone, 28 estropipate, 28 ESTROSTEP FE, 27 etanercept, 33 ethambutol, 15 ethosuximide, 21 ethynodiol diacetate/EE 1/35 - Zovia 1/35, 26 ethynodiol diacetate/EE 1/50 - Zovia 1/50, 27 etodolac, 12 etonogestrel/EE ring, 27 etoposide, 17 everolimus, 16 EVISTA, 29 EVOCLIN, 37 EXELON, 22 exemestane, 16 EXFORGE, 18 EXFORGE HCT, 18 EXJADE, 32 ezetimibe, 19 ezetimibe/simvastatin, 18 F FARESTON, 16 FARYDAK, 17 febuxostat, 12 felodipine ext-rel, 19 FEMARA, 16 FEMHRT, 28 fenofibrate, 19 fenofibrate, micronized, 19 fenofibric acid tabs, 19 fentanyl transdermal, 12 FEOSOL, 34 FERGON, 34 ferrous gluconate, 34 ferrous sulfate, 34 fexofenadine, 35 fexofenadine/pseudoephedrine ext-rel, 35 FIBRICOR, 19 fidaxomicin, 14 filgrastim, 32 finasteride 5 mg, 31 FIORICET, 13 FIORICET w/CODEINE, 12 FIORINAL, 13 FIORINAL w/CODEINE, 12 FIRST-LANSOPRAZOLE, 30 FIRST-PROGESTERONE VGS, 29 FLAGYL, 15 flavoxate, 31 flecainide, 18 FLOLAN, 21 FLOMAX, 31 FLOVENT DISKUS, 37 FLOVENT HFA, 37 fluconazole, 14 fluconazole 150 mg, 31 48 fludrocortisone, 28 FLUMIST, 33 flunisolide spray, 36 fluocinolone acetonide body oil 0.01%, 38 fluocinolone acetonide crm, oil, solution 0.01%, 38 fluocinolone acetonide crm, oint 0.025%, 38 fluocinolone acetonide scalp oil 0.01%, 38 fluocinonide crm, gel, oint, solution 0.05%, 39 FLUOR-A-DAY, 40 fluorometholone 0.1% susp, 40 fluorometholone 0.25%, 40 fluorometholone oint, 41 FLUOROPLEX, 37 fluorouracil crm 1%, 37 fluorouracil crm 5%, 37 fluorouracil solution 2%, 5%, 37 flutamide, 16 fluticasone propionate, 37 fluticasone propionate crm 0.05%, 38 fluticasone spray, 36 fluticasone spray - Flonase Allergy Relief, 36 fluticasone, CFC-free aerosol, 37 fluticasone/salmeterol, 37 fluticasone/salmeterol, CFC-free aerosol, 37 FLUZONE, 33 FML FORTE, 40 FML LIQUIFILM, 40 FML S.O.P., 41 folic acid, 34 FORTEO, 26 FOSAMAX, 26 FOSAMAX PLUS D, 26 foscarnet, 15 fosinopril, 17 fosinopril/hydrochlorothiazide, 17 FOSRENOL, 28 FREESTYLE FREEDOM LITE kits and test strips, 26 FREESTYLE INSULINX kits and test strips, 26 FREESTYLE LITE kits and test strips, 26 furosemide, 20 G galantamine, 22 GALZIN, 34 gemfibrozil, 19 gentamicin, 40 gentamicin/prednisolone acetate, 40 GERITOL, 34 glatiramer 20 mg, 23 glatiramer 40 mg, 23 GLEEVEC, 16 GLEOSTINE, 16 glimepiride, 25 glipizide, 25 glipizide ext-rel, 25 glipizide/metformin, 24 GLUCAGON EMERGENCY KIT, 28 glucagon, human recombinant, 28 GLUCOPHAGE, 24 GLUCOPHAGE XR, 24 GLUCOTROL, 25 GLUCOTROL XL, 25 GLUCOVANCE, 24 glyburide, 25 glyburide, micronized, 25 glyburide/metformin, 24 glycopyrrolate, 29 GLYNASE, 25 GOLYTELY, 30 granisetron, 29 GRANIX, 32 grass mixed pollen extract, 33 griseofulvin microsize susp, tabs, 14 griseofulvin ultramicrosize, 14 GRIS-PEG, 14 guaifenesin ext-rel, 36 guaifenesin liquid, 36 guaifenesin liquid, syrup, tabs, 36 guanfacine, 18 GYNE-LOTRIMIN 3-DAY, 31 GYNE-LOTRIMIN 7-DAY, 31 H halobetasol propionate crm, oint 0.05%, 39 HARVONI, 15 HECTOROL, 28 HEPSERA, 15 HEXALEN, 16 homatropine 5%, 41 HUMALOG, 25 HUMALOG MIX, 25 HUMIRA, 33 HUMULIN 70/30, 25 HUMULIN N, 25 HUMULIN R, 25 hydralazine, 21 HYDREA, 17 hydrochlorothiazide, 20 hydrocodone/acetaminophen 5/300 mg, 7.5/300 mg, 10/300 mg, 12 hydrocodone/acetaminophen 5/325 mg, 7.5/325 mg, 10/325 mg, 12 hydrocodone/acetaminophen solution 7.5/325 mg/15 mL, 12 hydrocodone/homatropine, 35 hydrocortisone, 28 hydrocortisone acetate foam, 30 hydrocortisone crm, 31 hydrocortisone crm 2.5%, 38 hydrocortisone crm, gel, lotion, oint, solution 1%, 38 hydrocortisone enema, 30 hydrocortisone lotion 1%, 38 hydrocortisone oint 0.5%, 38 hydrocortisone valerate crm, oint 0.2%, 38 hydrocortisone/aloe vera crm 0.5%, 1%, 38 hydromorphone, 12 hydroxychloroquine, 33 hydroxyurea, 17 hyoscyamine sulfate, 30 HYZAAR, 18 I IBRANCE, 16 ibrutinib, 16 ibuprofen, 12 idelalisib, 16 imatinib mesylate, 16 IMBRUVICA, 16 imiquimod, 39 IMITREX, 23 IMODIUM A-D, 29 IMURAN, 33 indapamide, 20 INDERAL LA, 19 49 influenza vaccine, 33 insulin aspart, 25 insulin aspart protamine 70%/insulin aspart 30%, 25 insulin detemir, 25 insulin glargine, 25 insulin human, 25 insulin isophane human, 25 insulin isophane human 70%/regular 30%, 25 insulin lispro 100 units/mL, 25 insulin lispro protamine/insulin lispro, 25 insulin syringes and needles, 26 interferon alfa-2b, 33 interferon beta-1a, 23 interferon beta-1b, 23 INTRON A, 33 ipratropium nasal spray, 37 ipratropium nebulization solution, 35 ipratropium, CFC-free aerosol, 35 ipratropium/albuterol nebulization solution, 35 ipratropium/albuterol, CFC-free aerosol, 35 irbesartan, 18 irbesartan/hydrochlorothiazide, 18 isoniazid, 15 ISOPTO CARPINE, 41 ISOPTO HOMATROPINE, 41 ISORDIL, 20 isosorbide dinitrate ext-rel tabs, 20 isosorbide dinitrate oral, 20 isosorbide dinitrate sublingual, 21 isosorbide dinitrate/hydralazine, 21 isosorbide mononitrate, 20 isosorbide mononitrate ext-rel, 20 isotretinoin - Claravis, 37 itraconazole caps, 14 itraconazole solution, 14 ivabradine, 21 ixazomib, 17 J JADENU, 32 JAKAFI, 16 JARDIANCE, 25 K KEFLEX, 13 KERASAL, 39 ketoconazole crm 2%, 38 ketoconazole shampoo 2%, 38 ketoconazole tabs, 14 ketorolac 0.4%, 40 ketorolac 0.5%, 40 ketotifen, 40 KOMBIGLYZE XR, 25 L labetalol, 19 lactulose, 30 LAMISIL, 14 lamivudine, 15 lancets, 26 LANOXIN, 20 lansoprazole + amoxicillin + clarithromycin, 31 lansoprazole delayed-rel, 30 lansoprazole delayed-rel caps, 30 lansoprazole powder for suspension, 30 lanthanum, 28 LANTUS, 25 lapatinib, 16 LASIX, 20 latanoprost, 41 ledipasvir/sofosbuvir, 15 leflunomide, 33 lenalidomide, 16 lenvatinib, 16 LENVIMA, 16 LETAIRIS, 21 letrozole, 16 LEUKERAN, 16 LEUKINE, 32 leuprolide acetate, 16 levalbuterol nebulization solution, 36 levalbuterol tartrate, CFC-free aerosol, 36 LEVAQUIN, 14 LEVEMIR, 25 levobunolol, 41 levocetirizine, 35 levofloxacin, 14 levonorgestrel 0.75 mg, 27 levonorgestrel 1.5 mg, 27 levonorgestrel 1.5 mg - Next Choice One Dose, 27 levonorgestrel/EE - Trivora, 27 levonorgestrel/EE 0.15/30, 27 levonorgestrel/EE 0.15/30 - Levora, 26 levonorgestrel/EE 0.15/30 and EE 10, 27 levothyroxine, 29 levothyroxine - Levoxyl, 29 LEVSIN, 30 LIALDA, 30 lidocaine oint 5%, 39 lidocaine viscous, 40 lidocaine/prilocaine, 39 linezolid susp, 15 linezolid tabs, 15 liothyronine, 29 LIPITOR, 19 liraglutide, 25 lisinopril, 17 lisinopril/hydrochlorothiazide, 17 LOESTRIN 1.5/30, 26 LOESTRIN 1/20, 26 LOESTRIN FE 1.5/30, 26 LOESTRIN FE 1/20, 26 LOMOTIL, 29 lomustine, 16 loperamide, 29 LOPID, 19 LOPRESSOR, 19 LOPRESSOR HCT, 19 loratadine liquid, orally disintegrating tabs, tabs, 35 loratadine/pseudoephedrine ext-rel, 35 losartan, 18 losartan/hydrochlorothiazide, 18 LOTEMAX, 41 LOTENSIN, 17 loteprednol susp 0.5%, 41 LOTREL, 17 LOTRIMIN AF, 38 LOTRIMIN ULTRA, 38 lovastatin, 19 LOVAZA, 19 LOVENOX, 32 lubiprostone, 30 LUMIGAN, 41 50 LURIDE, 40 LURIDE LOZI-TABS, 40 LUXIQ, 38 LYNPARZA, 17 LYSODREN, 17 LYSTEDA, 32 M MAALOX, 29 MACROBID, 15 MACRODANTIN, 15 MALARONE, 14 malathion, 39 MATULANE, 17 MAVIK, 17 MAXALT, 23 MAXITROL, 40 MAXZIDE, 20 MAXZIDE-25, 20 meclizine, 29 MEDROL, 28 medroxyprogesterone acetate, 29 medroxyprogesterone acetate 150 mg/mL, 27 mefloquine, 14 MEGACE, 16 megestrol acetate, 16 MEKINIST, 17 meloxicam, 12 melphalan, 16 memantine, 22 MEPHYTON, 34 MEPRON, 14 mercaptopurine, 16 mesalamine delayed-rel tabs, 30 mesalamine ext-rel caps, 30 mesalamine rectal susp, 30 mesalamine supp, 30 MESTINON, 23 MESTINON TIMESPAN, 23 METAGLIP, 24 metformin, 24 metformin ext-rel 500 mg, 24 methadone, 12 methazolamide, 20 methimazole, 29 methocarbamol, 23 methotrexate, 33 methoxsalen oral, 38 methyldopa, 21 methylergonovine, 29 methylprednisolone, 28 metoclopramide, 29 metolazone, 20 metoprolol succinate ext-rel, 19 metoprolol tartrate, 19 metoprolol/hydrochlorothiazide, 19 METROCREAM, 39 METROGEL, 39 METROGEL-VAGINAL, 31 metronidazole, 31 metronidazole 250 mg, 375 mg, 500 mg, 15 metronidazole crm 0.75%, 39 metronidazole crm 1%, 39 metronidazole gel 1%, 39 MEVACOR, 19 MIACALCIN, 26 MICARDIS HCT, 18 MICATIN, 38 miconazole, 31, 38 miconazole crm 2%, supp 100 mg, 31 miconazole crm 4%, supp 200 mg, 31 midodrine, 21 MIDRIN, 23 MINIPRESS, 18 MINOCIN, 14 minocycline caps, 14 minoxidil, 21 MIRALAX, 30 MIRAPEX, 22 MIRCETTE, 27 misoprostol, 30 mitotane, 17 MOBIC, 12 MODICON, 27 moexipril, 17 moexipril/hydrochlorothiazide, 17 mometasone crm, lotion, oint 0.1%, 38 mometasone spray, 36 MONISTAT 3, 31 MONISTAT 7, 31 MONODOX, 14 montelukast, 36 morphine ext-rel, 12 morphine immediate-release, 12 morphine supp, 12 moxifloxacin, 14, 40 MS CONTIN, 12 MUCINEX, 36 MUCINEX DM, 35 MULTAQ, 18 multivitamins, 34 multivitamins drops, 34 multivitamins/fluoride drops, tabs, 34 multivitamins/fluoride/iron drops, tabs, 34 multivitamins/iron, 34 multivitamins/iron drops, 34 multivitamins/minerals, 34 mupirocin oint 2%, 37 MYAMBUTOL, 15 MYCOBUTIN, 15 mycophenolate mofetil, 33 MYLANTA, 29 MYLERAN, 16 MYSOLINE, 21 N nabumetone, 12 nadolol, 19 NAMENDA, 22 NAPROSYN, 12 naproxen, 12 naproxen sodium, 12 naratriptan, 23 NASACORT ALLERGY 24HR, 36 NASONEX, 36 nateglinide, 25 NEBUPENT, 15 NECON 10/11, 27 neomycin sulfate tabs, 13 neomycin/bacitracin/polymyxin B, 37 neomycin/polymyxin B/dexamethasone, 40 neomycin/polymyxin B/gramicidin, 40 51 neomycin/polymyxin B/hydrocortisone, 42 NEORAL, 33 NEOSPORIN, 37, 40 nepafenac, 40 NEPHRO-VITE RX, 34 NEULASTA, 32 NEUPOGEN, 32 NEVANAC, 40 NEXAVAR, 17 NEXIUM 24HR, 30 niacin, 19 niacin ext-rel, 19 NIASPAN, 19 nifedipine, 19 nifedipine ext-rel, 20 nilotinib, 16 NINLARO, 17 nintedanib, 36 nisoldipine ext-rel, 20 NITRO-BID, 21 NITRO-DUR, 21 nitrofurantoin ext-rel, 15 nitrofurantoin macrocrystals, 15 nitroglycerin lingual spray, 21 nitroglycerin oint, 21 nitroglycerin sublingual, 21 nitroglycerin transdermal, 21 NITROLINGUAL, 21 NITROSTAT, 21 NIX CREME RINSE, 39 NIZORAL SHAMPOO, 38 NORDITROPIN, 28 norelgestromin/EE - Xulane, 27 norethindrone, 27 norethindrone acetate, 29 norethindrone acetate/EE 1.5/30, 26 norethindrone acetate/EE 1.5/30 and iron, 26 norethindrone acetate/EE 1/20, 26 norethindrone acetate/EE 1/20 and iron, 26 norethindrone acetate/EE/iron, 27 norethindrone/EE, 27 norethindrone/EE 0.4/35, 27 norethindrone/EE 0.5/35, 27 norethindrone/EE 1/35, 27 norethindrone/ME 1/50, 27 norgestimate/EE, 27 norgestimate/EE 0.25/35, 27 norgestrel/EE 0.3/30 - Low-Ogestrel, 26 NORITATE, 39 NORPACE, 18 NORPACE CR, 18 NORVASC, 19 NOVOLIN 70/30, 25 NOVOLIN N, 25 NOVOLIN R, 25 NOVOLOG, 25 NOVOLOG MIX 70/30, 25 NOXAFIL, 14 NUEDEXTA, 24 NULYTELY, 30 NUVARING, 27 nystatin, 14, 38 nystatin/triamcinolone, 38 O OCUFLOX, 40 OFEV, 36 ofloxacin, 14, 40 ofloxacin otic 0.3%, 42 olaparib, 17 olodaterol, CFC-free aerosol, 36 OLUX, 39 omega-3 acid ethyl esters, 19 omeprazole delayed-rel caps 20 mg, 40 mg, 30 omeprazole delayed-rel tabs, 30 omeprazole magnesium delayed-rel, 30 omeprazole magnesium delayed-rel caps, 30 ondansetron, 29 ONGLYZA, 24 ORALAIR, 33 ORTHO MICRONOR, 27 ORTHO TRI-CYCLEN, 27 ORTHO TRI-CYCLEN LO, 27 ORTHO-CYCLEN, 27 ORTHO-NOVUM 1/35, 27 ORTHO-NOVUM 7/7/7, 27 oseltamivir, 15 osimertinib, 16 OVCON 35, 27 OVIDE, 39 OXANDRIN, 24 oxandrolone, 24 oxaprozin, 12 OXSORALEN-ULTRA, 38 oxybutynin, 31 oxybutynin ext-rel, 31 oxycodone concentrate 20 mg/mL, 12 oxycodone immediate-release 15 mg, 20 mg, 30 mg, 12 oxycodone immediate-release 5 mg, 10 mg, 12 oxycodone oral solution 5 mg/5 mL, 12 oxycodone/acetaminophen, 13 oxycodone/aspirin, 13 oxymorphone ext-rel, 13 P palbociclib, 16 pancrelipase delayed-rel, 30 panobinostat, 17 pantoprazole delayed-rel, 31 PARLODEL, 22 paromomycin, 15 PEDIALYTE, 34 peg 3350/electrolytes, 30 PEGASYS, 33 pegfilgrastim, 32 peginterferon alfa-2a, 33 peginterferon beta-1a, 23 penicillin VK, 14 PENLAC, 38 pentamidine aerosol, 15 PENTASA, 30 pentoxifylline ext-rel, 32 PERCOCET, 13 PERCODAN, 13 PERIDEX, 40 permethrin 1%, 39 permethrin crm 5%, 39 PERSANTINE, 32 phenazopyridine, 31 phenobarbital, 21 phenytoin, 21 phenytoin sodium extended, 21 52 PHOSLO, 28 phytonadione, 34 pilocarpine, 41 pilocarpine tabs, 31 pimecrolimus, 39 pindolol, 19 PIN-X, 15 pioglitazone, 25 pioglitazone/glimepiride, 25 pioglitazone/metformin, 25 PLAN B ONE-STEP, 27 PLAQUENIL, 33 PLAVIX, 32 PLEGRIDY, 23 podofilox solution, 39 polyethylene glycol 3350, 30 polymyxin B/bacitracin, 40 polymyxin B/trimethoprim, 40 polysaccharide iron complex - Nu-Iron 150, 34 POLYTRIM, 40 POLY-VI-SOL, 34 POLY-VI-SOL WITH IRON, 34 posaconazole, 14 potassium bicarbonate/potassium citrate effervescent tabs 25 mEq, 33 potassium chloride ext-rel, 33 potassium chloride liquid, 33 potassium chloride powder 20 mEq, 34 potassium chloride/potassium bicarbonate/citric acid effervescent tabs 25 mEq, 34 potassium citrate ext-rel, 31 potassium/sodium phosphates - Phospha 250 Neutral, 31 pramipexole, 22 PRANDIN, 25 PRAVACHOL, 19 pravastatin, 19 prazosin, 18 PRECISION XTRA, 26 PRECISION XTRA kits and test strips, 26 PRECOSE, 24 PRED FORTE, 41 PRED MILD, 41 PRED-G, 40 prednisolone acetate 0.12%, 41 prednisolone acetate 1%, 41 prednisolone phosphate 1%, 41 prednisolone sodium phosphate oral solution, 28 prednisolone syrup, 28 prednisone, 28 PRELONE, 28 PREMARIN, 28 PREMARIN CREAM, 28 PREMPHASE, 28 PREMPRO, 28 prenatal vitamins/DHA/docusate/folic acid/polysaccharide iron complex, 34 prenatal vitamins/DHA/folic acid, 34 prenatal vitamins/docusate/folic acid, 34 prenatal vitamins/ferrous fumarate/folic acid, 34 prenatal vitamins/folic acid, 34 prenatal vitamins/folic acid/omega 3 fatty acids, 34 PREVACID, 30 PREVACID 24HR, 30 PREVIDENT, 40 PREVPAC, 31 PRILOSEC, 30 PRILOSEC OTC, 30 primaquine, 14 primidone, 21 PROAIR HFA, 36 probenecid, 12 procarbazine, 17 prochlorperazine, 29 PROCRIT, 32 progesterone powder, 29 progesterone suppositories, 29 progesterone, micronized, 29 PROGRAF, 33 PROMACTA, 32 promethazine, 29 promethazine supp, 29 PROMETRIUM, 29 propafenone, 18 propantheline 15 mg, 31 propranolol, 19 propranolol ext-rel, 19 propylthiouracil, 29 PROSCAR, 31 PROTOPIC, 39 PROVERA, 29 pseudoephedrine, 36 pseudoephedrine ext-rel, 36 PULMICORT FLEXHALER, 37 PULMICORT RESPULES, 37 PYLERA, 31 pyrantel, 15 pyrazinamide, 15 PYRIDIUM, 31 pyridostigmine, 23 pyridostigmine ext-rel, 23 pyridoxine 25 mg, 34 pyrimethamine, 14 Q QUESTRAN/QUESTRAN LIGHT, 19 quinapril, 17 quinapril/hydrochlorothiazide, 17 QVAR, 37 R raloxifene, 29 ramipril, 17 ranitidine, 30 ranitidine 150 mg, 300 mg, 30 ranitidine syrup, 30 RAPAMUNE, 33 RAZADYNE, 22 REBETOL, 15 REBIF, 23 REGLAN, 29 RELENZA, 15 REMODULIN, 21 RENAGEL, 28 RENVELA, 28 repaglinide, 25 REQUIP, 22 reserpine, 21 RETIN-A, 37 REVATIO, 21 REVLIMID, 16 RHINOCORT AQUA, 36 ribavirin caps, 15 ribavirin tabs, 15 53 rifabutin, 15 RIFADIN, 15 rifampin, 15 rimexolone, 41 risedronate, 26 rivaroxaban, 32 rivastigmine, 22 rizatriptan, 23 ROBAXIN, 23 ROBINUL, 29 ROCALTROL, 28 ropinirole, 22 ROWASA, 30 ruxolitinib, 16 RYTHMOL, 18 S sacubitril/valsartan, 20 SALAGEN, 31 salicylic acid foam 6%, 39 salicylic acid liquid 27.5%, 40 salicylic acid lotion 6%, 40 salicylic acid pad 2%, 37 salicylic acid/urea oint 5-10%, 39 salmeterol xinafoate, 36 SALVAX, 39 SANDIMMUNE, 33 SANTYL, 39 sargramostim inj, 32 saxagliptin, 24 saxagliptin/metformin ext-rel, 25 SEASONIQUE, 27 secukinumab, 38 SELECT-OB + DHA, 34 selegiline caps, 22 selenium sulfide shampoo 2.5%, 38 SENSIPAR, 26 SEREVENT DISKUS, 36 sevelamer carbonate, 28 sevelamer HCl, 28 sharps container, 26 sildenafil, 21 SILVADENE, 37 silver sulfadiazine crm 1%, 37 simvastatin, 19 SINEMET, 22 SINEMET CR, 22 SINGULAIR, 36 sirolimus, 33 sodium chloride nebulization solution, 37 sodium citrate/citric acid, 31 sodium fluoride 0.5 mg, 1 mg tabs, 40 sodium fluoride chew tabs, 40 sodium fluoride crm, gel 1.1%, 40 sodium fluoride dental rinse 0.2%, 40 sodium fluoride oral drops, 40 sodium fluoride/xylitol chew tabs, 40 sodium polystyrene sulfonate, 34 sofosbuvir, 15 somatropin, 28 sorafenib, 17 sotalol, 19 SOVALDI, 15 spacer, 36 SPIRIVA HANDIHALER, 35 SPIRIVA RESPIMAT, 35 spironolactone, 20 spironolactone/hydrochlorothiazide, 20 SPORANOX, 14 SPRYCEL, 16 STALEVO, 22 STARLIX, 25 STRIVERDI RESPIMAT, 36 succimer, 29 sucralfate, 31 SUDAFED, 36 SULAR, 20 sulfacetamide solution 10%, 40 sulfacetamide/prednisolone phosphate 10%/0.25%, 40 sulfacetamide/sulfur cleanser, crm, foam, lotion, wash 10-5%, 37, 39 sulfacetamide/sulfur crm 10-2%, 37, 39 sulfadiazine, 14 sulfamethoxazole/trimethoprim DS, 14 sulfasalazine, 30 sulfasalazine delayed-rel, 30 sulindac, 12 sumatriptan, 23 sumatriptan inj, 23 sumatriptan nasal spray, 23 sunitinib, 17 SUTENT, 17 SYMBICORT, 37 SYNJARDY, 25 SYNTHROID, 29 T TABLOID, 16 tacrolimus, 33, 39 tadalafil, 21 TAFINLAR, 16 TAGAMET HB 200, 30 TAGRISSO, 16 TAMIFLU, 15 tamoxifen, 16 tamsulosin, 31 TANZEUM, 25 TAPAZOLE, 29 TARGRETIN caps, 17 TARKA, 17 TASIGNA, 16 tazarotene, 38 TAZORAC, 38 tbo-filgrastim, 32 TECFIDERA, 23 TEKTURNA, 20 telmisartan/amlodipine, 18 telmisartan/hydrochlorothiazide, 18 TEMODAR, 16 TEMOVATE, 39 temozolomide, 16 TENEX, 18 TENORETIC, 19 TENORMIN, 19 TERAZOL 3, 31 TERAZOL 7, 31 terazosin, 18 terbinafine tabs, 14 terbutaline, 36 terconazole crm 0.4%, 31 terconazole crm 0.8%, 31 terconazole supp 80 mg, 31 54 teriparatide, 26 TESSALON, 35 TESTIM, 24 testosterone cypionate, 24 testosterone enanthate, 24 testosterone gel, 24 testosterone gel 25 mg/2.5 g, 24 testosterone gel, except 25 mg/2.5 g, 24 testosterone transdermal, 24 tetrabenazine, 22 tetracycline, 14 theophylline ext-rel tabs, 37 theophylline liquid, 37 thioguanine, 16 thyroid, 29 TIAZAC, 20 TIKOSYN, 18 timolol hemihydrate, 41 timolol maleate, 41 TIMOPTIC, 41 TINDAMAX, 15 tinidazole, 15 tiotropium, 35 tiotropium, CFC-free aerosol, 35 tizanidine tabs, 23 TOBRADEX, 40 tobramycin oint, 40 tobramycin solution, 40 tobramycin/dexamethasone susp 0.3%/0.1%, 40 TOBREX, 40 tofacitinib, 33 tofacitinib ext-rel, 33 tolterodine, 31 tolterodine ext-rel, 31 TOPICORT, 39 TOPICORT LP, 38 TOPROL-XL, 19 toremifene, 16 torsemide, 20 TRACLEER, 21 tramadol immediate-release, 13 tramadol/acetaminophen, 13 trametinib, 17 TRANDATE, 19 trandolapril, 17 trandolapril/verapamil ext-rel, 17 tranexamic acid, 32 travoprost, 41 treprostinil, 21 tretinoin caps, 17 tretinoin crm, gel, 37 triamcinolone acetonide crm 0.5%, 39 triamcinolone acetonide crm, lotion 0.025%, 38 triamcinolone acetonide crm, lotion, oint 0.1%, 38 triamcinolone acetonide spray, 36 triamcinolone paste, 40 triamterene, 20 triamterene/hydrochlorothiazide 37.5/25, 20 triamterene/hydrochlorothiazide 75/50, 20 trifluridine, 41 trimethoprim tabs, 15 TRI-NORINYL, 27 trospium, 31 trospium ext-rel, 31 TRUSOPT, 41 TWYNSTA, 18 TYKERB, 16 TYLENOL, 12 TYLENOL w/CODEINE, 12 TYVASO, 21 U ULESFIA, 39 ULORIC, 12 ULTRACET, 13 ULTRAM, 13 ULTRAVATE, 39 umeclidinium/vilanterol, 35 UNISOM, 23 urea crm 10%, 39 urea crm 20%, 39 urea lotion 10%, 39 URECHOLINE, 31 UROCIT-K, 31 UROXATRAL, 31 URSO, 30 ursodiol, 30 V valacyclovir, 15 VALCYTE, 15 valganciclovir oral solution, 15 valganciclovir tabs, 15 valsartan, 18 valsartan/amlodipine, 18 valsartan/amlodipine/hydrochlorothiazide, 18 valsartan/hydrochlorothiazide, 18 VALTREX, 15 VANCOCIN, 15 vancomycin, 15 VASERETIC, 17 VASOTEC, 17 VENTOLIN HFA, 36 verapamil ext-rel, 20 VERELAN, 20 VEXOL, 41 VIBRAMYCIN, 14 VICTOZA, 25 VIGAMOX, 40 VIROPTIC, 41 VITAFOL FE+, 34 VITAFOL GUMMIES, 34 VITAFOL-OB, 34 vitamin ADC/fluoride drops, 34 vitamin ADC/fluoride/iron drops, 34 vitamin B complex/vitamin C/folic acid, 34 VITAMIN B6, 34 VITAMIN D3, 34 vitamin E, 34 vorapaxar, 32 vorinostat, 17 VOSPIRE ER, 36 VYTORIN, 18 W warfarin, 32 WESTCORT, 38 X XALATAN, 41 XARELTO, 32 XELJANZ, 33 XELJANZ XR, 33 XELODA, 16 55 XENAZINE, 22 XOPENEX HFA, 36 XYZAL, 35 Y YASMIN, 26 YAZ, 26 Z ZADITOR, 40 ZANAFLEX, 23 zanamivir, 15 ZANTAC, 30 ZANTAC 75, ZANTAC 150, 30 ZARONTIN, 21 ZENPEP, 30 ZESTORETIC, 17 ZESTRIL, 17 ZETIA, 19 ZIAC, 19 zinc acetate, 34 ZITHROMAX, 13 ZOCOR, 19 ZOFRAN, 29 ZOLINZA, 17 zolmitriptan, 23 zolmitriptan orally disintegrating tabs, 23 ZOMIG, 23 ZONTIVITY, 32 ZOVIRAX, 15 ZOVIRAX OINTMENT, 39 ZYDELIG, 16 ZYLOPRIM, 12 ZYRTEC, 35 ZYRTEC-D 12 HOUR, 35 ZYVOX, 15 56
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